Case studies Assessment
CHAPTER 10 Neuropsychological
Assessment and Screening
TOPIC 10A Neurobiological Concepts and Behavioral Assessment 10.1 The Human Brain: An Overview 10.2 Structures and Systems of the Brain 10.3 Survival Systems: The Hindbrain and Midbrain 10.4 Attentional Systems 10.5 Motor/Coordination Systems 10.6 Memory Systems 10.7 Limbic System 10.8 Language Functions and Cerebral Lateralization 10.9 Visual System 10.10 Executive Functions 10.11 Neuropathology of Adulthood and Aging
10.12 Behavioral Assessment of Neuropathology
In the practice of assessment, psychologists often discover that their clients need assistance with serious problems that are best understood from a neurobiological standpoint. These problems typically arise as a consequence of head injury, learning disability, memory impairment, language disorder, or attentional difficulties, to list just a few examples. Tens of millions of individuals are affected. For example, in the United States an estimated 5 to 8 million children struggle with a learning disability (Dey, Schiller, & Tai, 2004), about 13 to 16 million adults live with memory loss and other symptoms related to dementia (Alzheimer’s Disease and Related Disorders Association, 2000), and approximately 1.7 million people experience a head injury each year (Faul, Xu, Wald, & Coronado, 2010).
These numbers are staggering, and they provide an ongoing mandate for psychologists to develop specialized tests and procedures at the interface of psychology and medicine. The purpose of this chapter is to summarize pertinent tests, concepts, methods, and issues encountered in neuropsychological assessment and ancillary areas of appraisal such as substance abuse evaluation and screening for dementia. In Topic 10A, Neurobiological Concepts and Behavioral Assessment, we provide a condensed review of neurobiological concepts relevant to psychological testing and assessment. The emphasis in this topic is upon the various brain systems that underlie effective cognitive and emotional functioning. Understanding these brain systems is essential for those who study or use psychological tests. In this primer, the reader also will encounter several of the simpler approaches to assessment used by neuropsychologists. In the process, a good foundation will be set for Topic 10B, Neuropsychological Tests, Batteries, and Screening Tools, which reviews prominent
neuropsychological instruments, test batteries, and screening tools.
10.1 THE HUMAN BRAIN: AN OVERVIEW By convention the nervous system is divided into the central nervous system consisting of the brain and spinal cord, and the peripheral nervous system that includes the cranial nerves and the network of nerves emanating from the spinal cord. The brain is intimately involved in thinking, feeling, and behaving. For these reasons, our focus in this topic is the structure and function of the brain. The brain is beyond doubt the most protected organ in the human body. The first line of defense against physical trauma is the skull, consisting of several intermeshed, rigid bones that almost completely encase the brain. Beneath the skull, the brain is also surrounded by the meninges, a thin layering of three tough membranes that encases the brain and spinal cord, providing additional protection. The
middle spongy layer of the meninges is filled with another form of protection, cerebrospinal fluid, which buffers the brain against sudden acceleration and deceleration, such as from a blow to the head. The brain literally floats in a snugly fitting bath of cerebrospinal fluid. Buoyancy reduces the effective weight of the organ to a few ounces, vastly reducing pressure upon the base of the brain. Without the protection of this fluid, the brain would bruise easily from any rapid movement of the head. When unbouyed, the brain weighs less than three pounds. It is composed principally of five elements: gray matter, white matter, glial cells, cerebrospinal fluid (CSF), and the blood vessels of the vascular system that provide the brain with oxygen and nutrients. The 1011 or 100 billion neurons in the brain are arranged in complex networks that largely have defied understanding. In part, the inscrutability of the brain derives from its computational complexity. Neurons communicate by sending all-or-none electrochemical impulses to one another. Each neuron might send transmissions
to thousands, perhaps tens of thousands, of other neurons at near and distant sites called synapses. Chemical communications across the synapses can occur up to a thousand times a second. Even if we use a conservative estimate of a thousand synapses per neuron, in theory the number of neural transmissions that could occur in just one second is a staggering 1017 or 100,000,000,000,000,000 (one hundred quadrillion). No wonder that staid neuroscientists such as Sir John Eccles (who received a Nobel Prize for his work in neurophysiology) resort to hyperbole and describe the brain as “without qualification the most highly organized and most complexly organized matter in the universe” (Eccles, 1973). Considering how little we know of the universe, the truth of this statement is open to question. But it does effectively underscore the point that neuroscientists approach the study of the human brain with a sense of awe. Cerebrospinal Fluid and the Ventricular System
Cerebrospinal fluid (CSF) is a clear liquid that is continuously produced and replenished within the ventricles. The ventricles are hollow, interconnected chambers found in the middle of the brain. There are four ventricles: two side-by- side ventricles, called the lateral ventricles, and two midline ventricles known as the third and fourth ventricles. In rare cases, the normal flow of CSF can become constricted, such as when the aqueduct leaving the third or fourth ventricle becomes too small. This can be a congenital condition present at birth or a disease-related state observed in adulthood. In children, the increase in pressure can lead to enlargement of the ventricles and compression of the brain against the skull. In time, the skull can even enlarge. This condition is known as hydrocephalus or, literally, “water on the brain.” Untreated, the consequence of hydrocephalus can be mental retardation and early mortality. Fortunately, effective treatments are available, including the insertion of a shunt to drain the excess fluid
from the ventricles—usually into the child’s abdomen. The Vascular System of the Brain Metabolically, the brain is a highly active organ, needing substantial supplies of oxygen and glucose to function effectively. These energy sources are supplied by the flow of blood through the cardiovascular system. Hence, the general physical health of the client and the specific condition of his or her vascular system in the brain are essential to highlevel cognitive functioning. Two pairs of arteries carry blood to the brain. These are the left and right internal carotid arteries, found in the front of the neck, and the left and right vertebral arteries, found in the back of the neck. The vertebral arteries come together just below the base of the brain to form a single artery, the basilar artery. These three arteries—the left and right internal carotids and the basilar artery—all feed into a circular arterial structure at the base of the brain known as the circle of Willis. This circular network
ensures that the brain receives a continual supply of blood, even if one of the input arteries is compromised. From this circular arterial system at the base of the brain, three arteries branch upward on each side to the roughly symmetrical cerebral hemispheres of the brain. The anterior cerebral arteries supply blood to the left and right frontal lobes and some midline structures. The middle cerebral arteries provide blood to the vast majority of the lateral surface of each hemisphere, including the frontal, parietal, and temporal lobes, and to some internal structures as well. Finally, the posterior cerebral arteries supply blood to the left and right occipital lobes and to additional subcortical structures. Especially with advancing age, it is not unusual for one or more arteries in the brain to become completely obstructed by a condition known as atherosclerosis, the gradual buildup of fatty plaque. When an artery in the brain becomes completely obstructed—whether gradually or suddenly from a piece of dislodged plaque—the brain tissue supplied by that vessel dies because
it is deprived of oxygen. This event is called an infarct, which is one kind of stroke or cerebrovascular accident (CVA). Another kind of CVA occurs when a bulging area of arterial weakness, called an aneurysm, bursts open, allowing blood to spurt directly into the brain tissue. This is technically known as an arterial rupture. The effects of a CVA depend upon the size and location of the resulting damage to the brain. For example, an infarct occurring at the base of the left middle cerebral artery would have calamitous generalized effects (e.g., right- sided paralysis of the body, loss of speech), whereas an infarct occurring higher up, in a smaller offshoot from the artery, might have limited effects or even go unnoticed. One form of vascular impairment known as multi-infarct dementia (MID) occurs when the hardly noticeable individual effects of many small infarcts accumulate over a number of years. The symptoms of MID are varied but often impact the ability to perform everyday activities such as eating, dressing, and shopping. The symptoms might include forgetfulness, vague or
circumstantial speech, lack of concentration, loss of balance, physical weakness, difficulty following instructions, and problems handling money. Often the onset of MID is so gradual and insidious that relatives recognize only in retrospect that something has been wrong for months after the onset of problems. 10.2 STRUCTURES AND SYSTEMS OF THE BRAIN The organization of the human brain is difficult to comprehend because important structures are interwoven and folded over upon one another. As noted, the brain also contains an intricate system of fluid-filled caverns, the ventricles, further complicating the spatial arrangement of important brain structures. In addition, functional brain systems rarely obey any simple structural organization—they typically meander their way from one part of the brain to another. Hence, we will focus mainly on a functional systems approach to explaining the operation of the brain, alluding to structures when appropriate.
We begin with a quick overview of the central nervous system and its primary subdivisions. The most basic element of the nervous system is the cerebrum, consisting of the left and right cerebral hemispheres, which are connected by the corpus callosum, a band of fibers that transfers information from one hemisphere to the other. From the standpoint of evolution, the cerebrum is the most recent part of the brain to develop. This is where thought, perception, imagination, judgment, and decision occur. Some essential structures located beneath the cerebrum are the basal ganglia and the cerebellum (both important in coordinated movement), the diencephalon (including the thalamus), the midbrain (consisting of the cranial nerves and other important relay stations), the pons (connecting the cerebrum with the cerebellum and the spinal cord), and the medulla (mediating essential bodily functions). Corpus Callosum
The corpus callosum is the major commissure that serves to integrate the functions of the two cerebral hemispheres. This large bundle of subcortical nerve fibers is about four inches long and a quarter inch thick. The corpus callosum spans the brain from side to side just above the level of the thalamus. Although there are exceptions, the corpus callosum generally connects homologous brain sites in the left and right hemispheres. The function of the corpus callosum was poorly understood until the 1960s when Sperry, Gazzaniga, and others initiated sophisticated laboratory studies of so-called split-brain patients (Sperry, 1964; Gazzaniga, 1970; Gazzaniga & LeDoux, 1978). These patients were persons with epilepsy whose corpus callosa had been severed to prevent the transport of epileptic discharges from one hemisphere to the other. Although outwardly normal, split- brain patients revealed a striking isolation of consciousness when visual information was restricted to one hemisphere or the other. For example, when a picture of an apple was
tachistoscopically presented to the left side of the examinee’s fixation point, this stimulus was processed only in the right hemisphere (on account of the normal crossing over of neural connections). Furthermore, because the corpus callosum was severed, the image of the apple remained trapped in the right hemisphere. As the reader will discover later, the right hemisphere is usually mute and does not subserve important language functions. Thus, when asked, “What did you see?” the examinees, responding from the verbal left hemisphere, would honestly reply, “Nothing.” Yet, these patients could readily identify the object by pointing to it with the left hand (which is under the neural control of the right hemisphere). This suggests that although the right hemisphere cannot talk, it has a separate and independent capacity to perceive, learn, remember, and issue commands for motor tasks. In a normal individual with intact corpus callosum, consciousness appears unitary because the two halves of the brain can communicate and forge a compromise as
regards perception, thought, and action. Much of our knowledge of hemispheric specializations, discussed later, has been garnered from the detailed study of split-brain patients. Further insight has been gained from studies of persons living with the congenital absence of this structure, a condition known as agenesis of the corpus callosum (ACC). Present in about 1 in 4,000 live births, ACC manifests with a variety of deficits, superbly summarized by Paul, Brown, Adolphs, and others (2007). Even though overall IQ is minimally impacted, impairments are observed in abstract reasoning, problem solving, and category fluency (e.g., the ability to list multiple items in a category such as animals). One intriguing symptom that bears on current understanding of language function is that persons with ACC show marked difficulty in the verbal expression of emotional experience. Parents of children with the disorder consistently describe conversations that are meaningless or out of place (Paul et al., 2007). This corresponds well with known lateralization of brain function, in which logical components
of language are underwritten by the left hemisphere, whereas the emotional aspects of language are subserved by the right hemisphere. In the absence of a corpus callosum, individuals with ACC find it particularly difficult to synthesize these two elements of language. Cerebral Cortex The cerebral cortex, the outermost layer of the brain, is the source of the highest levels of sensory, motor, and cognitive processing. Also called the neocortex, the cerebral cortex is a very recent evolutionary development. It is the functional capacity of this brain system—a uniform six layers deep—that most dramatically separates humans from the lower animals. The tissue of the cerebral cortex is folded over into elaborate convolutions consisting of bulges and grooves. The prominent bulges are called gyri (singular gyrus), whereas the clefts, fissures, and grooves are called sulci (singular sulcus). This arrangement allows the brain to have a great deal more cerebral cortex than if the surface were smooth. Although the pattern
of gyri and sulci is subtly unique for each person, certain major landmarks such as the central sulcus and the lateral sulcus (Figure 10.1) are always discernible in a normal brain. A small portion of the cerebral cortex is committed cortex. These sites are dedicated to basic sensory processing of vision, hearing, touch, and motor control. Nonetheless, the specificity of committed cortex is relative, not absolute. For example, the precentral gyrus classically is regarded as the motor cortex (see Figure 10.1), but only a fraction of the neurons subserving voluntary movement are located there. This has been demonstrated through neurosurgical investigations of the exposed cortex in persons with epilepsy, beginning with the pioneering work of Wilder Penfield (1958). The fully conscious patient received local anesthesia while surgeons opened a skull flap to expose one side of the brain. Then a stylus was used to deliver a small, brief, harmless electrical charge to specific sites in the sensory, motor, and language areas. The purpose of this procedure was to map the topography of the
cortex so that vital brain sites were not excised. Using this approach, Uematsu, Lesser, Fisher, and others (1992) reconfirmed that a significant proportion—more than one-third—of motor responses originate outside the classic narrow cortical strip. Some motor responses emanate from the sensory strip, and others from adjoining brain sites. Furthermore, the motor strip contains a sizeable proportion of sensory cells, too. Thus, cells that subserve each specific sensory or motor function are highly concentrated in the respective committed area, but also thin out and overlap with nearby brain sites. In brief, the committed cortex of the frontal lobe is dedicated to motor control, the parietal lobe is concerned with the processing of touch and other somatosensory information, the occipital lobe is involved in visual perception, and the temporal lobe is essential to the processing of auditory information. Of course, these brain regions serve other functions as well, but part of each major lobe is dedicated to a specific motor or sensory function (Figure 10.2).
FIGURE 10.1 Major Landmarks of the Left Cerebral Hemisphere
FIGURE 10.2 The Structural Model of Left Hemisphere Language Functions 10.3 SURVIVAL SYSTEMS: THE HINDBRAIN AND MIDBRAIN The lowest part of the brain, located at the top of the spinal cord, consists of the hindbrain, which includes the medulla oblongata, the pons, the reticular formation, and the cerebellum. From the standpoint of evolution, the hindbrain was the first brain system to develop, which explains why so many vital bodily functions are
governed by this brain area. For example, the automatic control of breathing is mediated here —we breathe even when asleep, or for that matter, when in a deep coma. The lowest section of the hindbrain is the medulla oblongata, which mediates several essential bodily functions: breathing, swallowing, vomiting, blood pressure, and, partially, heart rate (Kandel, Schwartz, & Jessell, 1995). Aspects of talking and singing also are governed here, although higher brain sites are intimately involved in these functions as well. Significant damage to the medulla usually is fatal. In rare cases, a small stroke in the medulla causes one or more of the following symptoms: opposite-sided paralysis, partial loss of pain and temperature sense, clumsiness, dizziness, partial loss of the gag reflex, and same-sided paralysis and atrophy of the tongue. Thus, one reason why neurologists ask patients to stick out their tongue and move it from side to side is specifically to check for neurological damage in and around the medulla. The polio virus—
rampant in the 1950s but now well controlled— may attack the medulla, shutting down the neural control of breathing and necessitating a mechanical respirator. The pons and cerebellum are the highest structures in the hindbrain. Together they help coordinate muscle tone, posture, and hand and eye movement. The role of the cerebellum in motor control is discussed later. Lesions of the pons may render the individual incapable of making coordinated lateral eye movements. For this reason, neurologists and neuropsychologists commonly ask patients to demonstrate left-right and up-down eye movements. Located just above the hindbrain is the mid- brain, which includes a number of important relay stations involved in hearing and vision. In addition, the midbrain contains nuclei for many of the cranial nerves (some of which also emanate from the hindbrain). The 12 paired cranial nerves are major neural tracts whose functions are well understood and easily tested. Some are exclusively sensory, relaying information from the external world to the
brain; some are exclusively motor, serving to execute commands from the brain; about a third of the cranial nerves possess both sensory and motor functions. Neurologists refer to the cranial nerves by number. The numbers correspond roughly to the top to bottom sequence of the nerves’ emergence from the brain (Table 10.1). The reader will notice that many cranial nerves mediate aspects of vision and eye movement, basic sensory functions, and movement of jaw, tongue, face, and head. Over the centuries, neurologists have devised a variety of simple confrontational techniques to assess the cranial nerves. As peculiar as it may appear, asking the patient to stick out his or her tongue and move it left, right, up, or down can provide important information about the functioning of the hypoglossal (12th) cranial nerve. In like manner, various simple tests of hearing, balance, eye movement, and so on are used to complete the examination of the cranial nerves. TABLE 10.1 The Cranial Nerves and Their Functions
10.4 ATTENTIONAL SYSTEMS Attention has been likened to a “spotlight” that our brain uses to identify what is relevant and ignore what is irrelevant (Andreasen, 2001). Attention is often a primitive, automatic cognitive system that is essential for survival. Consider the variety of competing stimuli
1. Olfactory Sense of smell 2. Optic Vision 3. Oculomotor Horizontal and vertical eye
movement 4. Trochlear Vertical eye movement 5. Trigeminal Facial sensation, jaw
movement 6. Abducens Horizontal eye movement 7. Facial Facial movement and taste 8. Auditory/ vestibular
Hearing and balance
9. Glossopharyngeal
Taste, swallowing
10. Vagus Visceral reflexes 11. Accessory Head movement 12. Hypoglossal Tongue movement
encountered when you drive a car down the highway, perhaps with a friend sitting next to you. A realistic scenario is that your friend asks a question, an airplane flies low in the distant horizon, a billboard on the left lures your visual focus, a siren blares in the distance, your back aches from a strenuous workout—all these sources of stimulation compete for your attention. Then a car swerves into your lane. Instantly, without conscious forethought, your brain focuses every last fragment of attention on this one looming threat, ignoring all else. Neuropsychologists have identified several kinds of attention, including the following types: • Orienting • Selective • Divided • Sustained
Orienting attention is the simplest and most primitive form, related to the “fight” or “flight” reflex. This is the straightforward direction of all attentional resources to a single threatening stimulus, such as a car swerving into your lane.
Selective attention refers to the identification of a single, personally relevant stimulus embedded within a flow of extraneous information. This is exemplified when, for example, a young boy who seems absorbed in solitary play nonetheless turns his head when he overhears his name spoken quietly in the background. Divided attention, also known as distributed attention, pertains to the ability to shift back and forth between two or more tasks. An example might be when a partygoer tries to follow two conversations at the same time. Sustained attention, also known as vigilance, refers to the ability to sustain attention over relatively long periods of time. This involves the capacity to resist distraction and stay on task for a prolonged period. A good example is the air traffic controller who must monitor radar images carefully to keep airplanes at a safe distance from one another. The exact neurological mechanisms of attention are not well understood. Kandel, Schwartz, and Jessell (1995) note that the “neuronal mechanisms of focused attention and conscious
awareness are now emerging as one of the great unresolved problems in perception and indeed in all of neurobiology” (p. 402). Neurologically, attention is a complex function that involves the collaborative effort of several brain sites. Furthermore, different forms of attention appear to invoke different brain systems. For example, sustained attention or vigilance is mediated by the reticular formation, a network of ascending and descending nerve cell bodies and fibers, which begins in the spinal cord and extends through the medulla all the way up to the thalamus. Specific nuclei within the reticular formation project through the thalamus to wide areas of the brain and thereby help mediate attention. Based upon the classic studies of Moruzzi and Magoun (1949) demonstrating that ascending nerve tracts within the reticular formation govern general arousal or consciousness, portions of this structure are also known as the reticular activating system. Damage to the reticular activating system gives rise to global diminution of consciousness
ranging from chronic drowsiness to stupor or coma (Carpenter, 1991). Selective attention appears to invoke brain sites in addition to the reticular formation. For example, based upon functional imaging studies that highlight active brain sites, it appears that the cingulate gyrus is essential for focusing upon relevant aspects of the environment while ignoring irrelevant information. One finding is that, when asked to perform complex attentional tasks, persons who suffer from schizophrenia and who, therefore, reveal deficits in selective attention also show dysfunction in the cingulate gyrus (Carter, Mintun, Nichols, & Cohen, 1997). 10.5 MOTOR/ COORDINATION SYSTEMS Although many brain sites are involved in motor control, three areas are of special significance: the cerebellum, the basal ganglia, and the motor cortex. The cerebellum sits just below the cerebrum at the back of the brain. Together with other brain structures, it helps coordinate muscle
tone, posture, and hand and eye movements. Lesions in or near the cerebellum may render the individual incapable of making coordinated lateral eye movements. For this reason, neurologists and neuropsychologists commonly ask patients to demonstrate left-right and up- down eye movements. An individual with damage to the cerebellum might not be able to move his or her eyes with facility in all directions. The cerebellum receives sensory information from every part of the body and coordinates the details of automatic skilled movements. Damage to the cerebellum may cause a variety of motor disturbances, depending upon the specific sites affected (Manto & Pandolfo, 2002). Slurred, hesitant speech known as dysarthria may be a symptom of cerebellar damage. Muscles may become flabby and tire easily. Rapid, coordinated tapping of the index finger may prove difficult. Measures of finger-tapping speed (Reitan & Wolfson, 1993) are, therefore, an important component of neuropsychological test batteries.
Bodily movements may lose their coordination in cerebellar disease, becoming spasmodic and jerky. Even a simple gesture such as reaching for a cup may result in the inadvertent thrusting of cup and contents halfway across the room. The characteristic wide-based gait of alcoholics —called ataxia—is a consequence of cerebellar degeneration (Ghez, 1991). Another symptom of cerebellar damage is intention tremor, so named because it is not present at rest but arises during voluntary, intentional movements of the hands. Nystagmus also is common in cerebellar disease. In this symptom, the eyes appear to jitter back and forth even when the individual attempts to hold a steady gaze. In conjunction with the vestibular center in the inner ear, the cerebellum also helps coordinate the vestibuloocular reflex (VOR). The VOR acts to maintain the eyes on a fixed target when the head is rotated. Without the VOR, vision would be incredibly blurred whenever the head moved even a fraction of an inch. Instead, a small area of the cerebellum coordinates a rapid refixation of the eyes to compensate for head movements.
The basal ganglia consist of a collection of nuclei in the in the forebrain that makes connections with the cerebral cortex above and the thalamus below. The basal ganglia are traditionally considered as part of the motor system. The main constituents of the basal ganglia are three large subcortical nuclei: the caudate, the putamen, and the globus pallidus. Some authorities also consider the amygdala to be part of the basal ganglia (Carpenter, 1991). These structures are interconnected with and functionally related to the subthalamic nucleus and the substantia nigra. Along with the cerebellum, the corticospinal system, and the motor nuclei in the brain stem, the basal ganglia participate in the control of movement. Unlike the other components of the motor system, the basal ganglia do not have direct connections with the spinal cord. The motor functions of the basal ganglia are indirect and are mediated via neural connections with the frontal cerebral cortex. The most common syndrome caused by damage to the basal ganglia is Parkinson’s disease (PD)
(Factor & Weiner, 2008). In Parkinson’s disease, three characteristic types of motor disturbances are observed: involuntary movement, including tremor; poverty and slowness of movement without paralysis; and changes in posture and muscle tone. In its later stages, this disease is typified by an immobile, masklike facial expression, an extreme difficulty initiating movements, and a fine tremor that may disappear once a movement is under way. Patients with Parkinson’s disease also reveal specific cognitive deficits, suggesting that the basal ganglia contribute not just to movement but to thinking as well. Deficits observed in these patients include problems formulating goals and evaluating progress, difficulties with attention, limitations in word-finding, and slowed thinking. Some patients with PD report that their brain feels “swampy” (Tröster, 2012). A loss of spontaneity and a lack of initiative also are observed (La Rue, 1992). The motor cortex is found on the precentral gyrus of the frontal lobe. Primary motor cells that subserve voluntary movement are located
here and in adjoining brain sites. Motor control is substantially but not exclusively contralateral (opposite-sided), meaning that the left precentral gyrus subserves the right side of the body, and vice versa. Thus, when an individual makes a decision, say, to lift his right hand, motor neurons in the left precentral gyrus will be activated. For obvious reasons, this area is also known as the motor strip. The fact that motor control is substantially opposite-sided is the basis for several neuropsychological procedures that compare the function of the two sides of the body as a means of determining the integrity of the left and right motor strips. Consider the finger-tapping test, employed with many neuropsychological test batteries (e.g., Reitan & Wolfson, 1993). In a typical finger-tapping procedure, the examiner uses standardized procedures with repeated trials to determine the maximal tapping rates of the left and right index fingers over a 10-second span. Of course, the preferred hand will have a slight advantage, with a normative expectation of a rate that is 10 percent higher. For example,
in a right-handed person, a tapping rate of 55 for the right index finger and 50 for the left index finger might be typical. Any significant deviation from this expected pattern may suggest impairment in the opposite- sided motor strip. For example, suppose a right- handed examinee has a tapping rate of 47 for the right index finger and 50 for the left index finger. Because the right-sided tapping rate is comparatively slower than expected (i.e., 6 percent slower instead of 10 percent faster than the left-sided tapping rate), this would suggest impairment in the left motor strip. 10.6 MEMORY SYSTEMS Although the lay public thinks of memory as a single thing, psychologists have known for more than a century that there are many types of memory and also several stages of memory (Ebbinghaus, 1885/1913). We can provide only a cursory review here. The importance of reviewing these basic distinctions is that different brain systems may be involved in different kinds of memory.
As to types of memory, Andreasen (2001) posits the existence of at least four different polarities of memory: episodic versus semantic, working versus associative, declarative versus procedural, and explicit versus implicit. To this list, we would add a fifth dimension: short-term versus long-term memory. These dimensions are not completely separate and distinct from one another. Episodic memory refers to memory of events or experiences, such as recalling that you had oatmeal for breakfast. In contrast, semantic memory is general knowledge not tied to a specific learning experience, such as knowing that a butterfly is an insect, not a bird. Working memory is the retention of information that we need only briefly, such as remembering the digits of a phone number just long enough to complete the call. Associative memory involves memories that are invoked because of their association with particular cues, for example, recalling the smell and taste of popcorn when hearing the sound of it popping in the microwave. Declarative memory involves the “what” of memory (e.g., knowing that a bicycle
has two wheels) whereas procedural memory involves the “how” of memory (e.g., knowing how to ride a bicycle). Another way of dividing memory is explicit versus implicit, which defines the difference between memories that are immediately accessible and obvious (e.g., knowing your name) compared to those that are latent, beneath the surface (e.g., surprising yourself when you are able to recall the name of your first-grade teacher). Another important distinction is between short- term and long-term memory. Short-term memory is synonymous with working memory and is very short in duration, lasting from perhaps 10 seconds to a minute. If short-term memories are not “refreshed” through rehearsal, they disappear after this brief duration. Long- term memory refers to memories that have been consolidated in some way so that they are more lasting in duration—hours or years—although not necessarily permanent. Describing the brain systems involved in memory is challenging because multiple brain sites are typically involved and different types
of memory utilize different pathways. Even so, there is substantial evidence that structures within the temporal lobes are essential to many important features of memory. In particular, the hippocampus and the amygdala appear to be involved in various aspects of memory and learning. Specifically, these brain sites are involved in the consolidation of short-term memories into long-term memories. The amygdala may play a special role in integrating memories from different modalities and, especially, in consolidating memories with strong emotional meaning (Andreasen, 2001). Humans have both a left hippocampus and right hippocampus (plural: hippocampi), located subcortically within the left and right temporal lobes. The same is true for the amygdala (plural: amygdalae), which is also a bilateral structure. The crucial role of these structures in the consolidation of memory was revealed by the case of H.M., a patient with intractable epilepsy who was treated by the surgical removal of the forward section of the temporal lobe on both sides of his brain (Milner, 1968). Prior to this
case, many individuals with epilepsy had been successfully treated by the removal of the diseased portion of one temporal lobe. The goal of this kind of surgery is to remove the diseased brain areas that serve as the “trigger” or focus point for seizure activity. The cognitive consequences of single-sided temporal lobe surgery had proved to be minimal. H.M. was the first carefully studied case of bilateral temporal lobe surgery. The consequences of his surgery were devastating, which was a shocking revelation to everyone involved. Put simply, H.M. proved incapable of forming any new memories from the point of the surgery onward (Milner, 1968). His old long-term memories remained intact, so he could recall where he attended high school, and so forth. And his short-term memory was intact, so he could remember a phone number briefly, for example. But his ability to consolidate new long-term memories was completely annihilated. He could read the same magazine from day to day, unaware that he had read it, cover to cover, the day before. A new
doctor remained a new doctor on each new visit. He was essentially a prisoner of the moment, able to converse and interact with apparent normality but unable to remember anything new for more than a few minutes. Structured testing of H.M. confirmed that different forms of memory are subserved by different brain systems. Consider procedural memory, for example, the recollection of how to do something. H.M. was asked to undertake repeated trials of mirror drawing—a complex procedural task in which the examinee traces a path on a sheet of paper while looking in a mirror. This is a daunting assignment in which directionality—left and right—are effectively reversed. With practice, normal individuals typically show slow improvement, tracing the path more quickly and with fewer errors. Intriguingly, H.M. likewise showed normal improvement on this task from day to day— indicating that his procedural memory remained intact—even though he had no realization that he had seen the puzzle before (Corkin, 1968). Most likely, this kind of procedural memory is
subserved by the cerebellum. Clearly, it is not underwritten by the temporal lobes. 10.7 LIMBIC SYSTEM The limbic system is a “primitive” central brain system that is involved in emotions and basic survival drives. This system overlaps with other brain sites, especially those involved in memory. The structures of the limbic system are involved in emotions, such as fear and aggression, as well as in the acquisition of memory. The pleasure centers of the brain are located here, too, within the nucleus acumbens. In addition to the hippocampus and amygdala, other limbic structures are the cingulate gyrus, mammillary bodies, and the fornix. Andreasen (2001) points out that the exact boundaries of what constitutes the limbic system are not well established because our understanding of this brain system has been steadily growing. In evolutionary terms, the limbic system is very old and, consequently, involved in primitive survival functions. Because of its proximity to and connections with the hypothalamus, the
limbic system indirectly exerts autonomic nervous system control over crucial bodily functions needed for continued existence. The hypothalamus is a deceptively small structure that sits just below and in front of the thalamus. Even though it composes only about 0.3 percent of the brain’s weight, the hypothalamus is involved in numerous aspects of motivated behavior and bodily regulation: blood pressure, feeding, sexual behavior, sleep/ wake cycle, temperature regulation, emotional behavior, and movement. Well studied in lower animals, the functions of the hypothalamus are less well known in humans (Kolb & Whishaw, 2011). It is known that the hypothalamus exerts proprietary control over the pituitary gland, thereby modulating a wide range of endocrine functions. The most common cause of a hypothalamic lesion is a severe head injury. Hypothalamic lesions often lead to disturbances of pituitary function, including excessive or deficient intake of food or water and temperature and blood pressure dysregulation (Kupfermann, 1991a). Dysfunction of the
hypothalamus also can lead to emotional dysregulation (especially fear or rage) and sleep disturbance (hypersomnolence or insomnia). 10.8 LANGUAGE FUNCTIONS AND CEREBRAL LATERALIZATION Language Functions of the Left Hemisphere Language is primarily (but not exclusively) a left hemisphere function that involves widely separated cortical and subcortical structures. Because so many regions of the left hemisphere are involved in language, virtually any significant left hemisphere lesion will produce some kind of disturbance in the production or comprehension of language. For this reason a detailed profile of language skills offers a window to the integrity and functioning of the left hemisphere. Yet, we need to keep in mind that virtually any high-level intellectual activity, including language expression and comprehension,
requires the synthetic interaction of the entire brain. Speech is a case in point. While primarily subserved by the left hemisphere in most individuals, the right cerebral hemisphere does provide the intonation patterns for speech. As a result, patients with right-sided lesions (particularly in the frontal area) may speak in an eerie monotone (Kalat, 2012). Modern conceptions of brain-language correlations actually stem from the late nineteenth century. In 1861, Paul Broca observed that damage to a small region just in front of the motor cortex of the left hemisphere caused a language disorder originally called expressive aphasia and now more typically known as nonfluent aphasia. Persons with damage to this left hemisphere premotor area— aptly named Broca’s area—speak in a slow, labored manner. They have difficulty enunciating words correctly; the act of speaking seems to be torturous for them. Speech takes on a frankly telegrammatic nature; adjectives, adverbs, articles, and conjunctions—the words that add color to speech—frequently are
omitted. Writing also is difficult for these persons. Fortunately, persons who experience Broca’s aphasia have little difficulty understanding either spoken or written language. In its pure form, the disorder involves expressive language only. In 1874, Wernicke announced that damage to the upper and rearward portion of the left temporal lobe—a region now known as Wernicke’s area—was linked to a language disorder originally called receptive aphasia and now more typically known as fluent aphasia. Affected individuals appear unable to comprehend spoken or written language. Apparently, persons with Wernicke’s aphasia have no difficulty perceiving words but cannot associate the words with their underlying meaning. As a consequence, the written and verbal expressions of persons with this aphasia are fluent but meaningless. For example, when asked to define book, a patient might respond, “Book, a husbelt, a king of prepator, find it in front of a car ready to be directed.” The same person might define scarecrow as, “We’ll call
that a three-minute resk witch, you’ll find one in the country in three witches” (Williams, 1979). Building on the observations of Broca and Wernicke, Geschwind (1972) proposed a structural, neurological model of left hemisphere language functions that has been highly influential in neuropsychological assessment. This model bears directly upon the assessment of language skills; the major elements are outlined next and depicted in Figure 10.2. Geschwind postulated the following: 1. Spoken language is perceived in the left
auditory cortex at the top of the temporal lobe and then transferred to Wernicke’s area.
2. In Wernicke’s area, the meanings of words are activated and the auditory codes are transported to a subcortical bundle of transmission fibers called the arcuate fasciculus.
3. The arcuate fasciculus sends the auditory codes directly to Broca’s area.
4. Upon reaching Broca’s area, the auditory code activates the corresponding articulatory
code that specifies the sequence of muscle actions required to pronounce a word.
5. In turn, the articulatory code is transmitted to the portions of the motor cortex governing tongue, lips, larynx, and so forth in order to produce the desired spoken word.
Comprehending or speaking a written word involves most of the previously outlined pathways, but with a different starting point: 6. Written words are first registered in the
visual cortex, then relayed through the visual association cortex to the angular gyrus.
7. In the angular gyrus, the visual form of the word is mapped into the auditory code stored in Wernicke’s area, thereby gaining access to the meaning of the written word, which can also be spoken (steps 2 through 5 previously).
The Geschwind model is helpful in explaining a number of clinical syndromes caused by discrete left hemisphere brain damage (Gregory, 1999): • Lesions to Broca’s area will cause slow,
labored, telegraphic speech, but the
comprehension of spoken or written language will not be affected.
• Damage to Wernicke’s area will have more serious and pervasive implications for language comprehension; namely, the patient will be unable to understand spoken or written communications.
• Damage to the angular gyrus will cause serious reading disability, but there will be little problem in comprehending speech or in speaking.
• Impairment limited to the left auditory cortex will result in serious disruption of verbal comprehension. However, such persons will be able to speak and read normally.
In practice, few patients reveal aphasic symptoms that fall neatly into one or another of the preceding categories. Furthermore, modern conceptions of aphasia point to weaknesses in the classical model (e.g., its overly simplistic view of the structure of language) and propose a complex, nonlinear model of aphasia that is beyond the scope of coverage here (Bonner,
Ash, & Grossman, 2010). Nonetheless, a thorough assessment of language functions is an essential part of every neuropsychological evaluation and the classical model of Broca, Wernicke, and Geschwind provides a useful starting point. Additional perspectives on aphasia and the structural model of language can be found in Benson (1994) and Mayeux and Kandel (1991). Specialized Functions of the Right Hemisphere Based on thousands of studies of normal and braindamaged persons, it is now well established that the right hemisphere is dominant for a variety of cognitive and perceptual skills. However, a detailed discussion of specialized right hemisphere functions is beyond the scope of this section. Competent reviews of the extensive literature on this topic can be found in Bradshaw and Mattingley (1995), Fonseca, Scherer, de Oliviera, and others (2009), Springer and Deutsch (1997), and Witelson (2007). In general, the right
hemisphere appears to be dominant for the analysis of geometric and visual space, the comprehension and expression of emotion, the processing of music and nonverbal environmental sounds, the production of nonverbal and spatial memories, and the tactual recognition of complex shapes. A frequent symptom of right hemisphere damage is constructional dyspraxia, the impaired ability to deal with spatial relationships either in a two- or three- dimensional framework (Reitan & Wolfson, 1993). This symptom is commonly exhibited by an impaired ability to copy simple shapes such as a cross. Left hemisphere lesions can also cause constructional dyspraxia, but the correlation is less consistent. Most neuropsychological test batteries include one or more copying tasks to screen for constructional dyspraxia. We include a summary of findings on cerebral lateralization in Table 10.2. 10.9 VISUAL SYSTEM
The primary sensory areas for vision are located in the occipital lobes; much of this projection area is on the mesial or midline surface that separates the two cerebral hemispheres. Each occipital lobe sees the opposite side of the visual world. Thus, all visual stimuli to the left of the reader’s fixation point are ultimately processed in the right occipital lobe, and vice versa. The split visual world is shared across the splenium, the rearward portion of the corpus callosum, producing a unified perception of the entire visual field. Damage to the primary visual area produces a corresponding loss of visual field on the opposite side. For example, an extensive lesion in the left occipital lobe would render a person blind to the right half of the visual world. A very small lesion might produce a scotoma or blind spot. TABLE 10.2 A Summary of Findings on Cerebral Lateralization
Funct ional Syste m
Left Hemisphere Dominance
Right Hemisphere Dominance
Vision Processing of the right visual field Recognition of letters, words
Processing of the left visual field Recognition of faces
Auditi on
Processing of right ear Processing of language-related sounds
Processing of left ear Processing of music and environmental sounds
Somat osens ory
Sensory input from the right side
Sensory input from the left side
Move ment
Motor output to the right side Complex voluntary movement, including speech
Motor output to the left side
Langu age
Speech, reading, writing, and arithmetic
Intonation and emotional patterning to speech
The forward portion of each occipital lobe is unimodal association cortex. These regions synthesize visual stimuli and produce meaning from them. This is where the high-level processing of visual information occurs. Damage to the association cortex of the occipital lobes may cause visual agnosia, a difficulty in the recognition of drawings, objects, or faces (Kandel, 1991). Luria (1973) described a typical case of a patient with such a lesion: The patient carefully examines the picture of a
pair of spectacles shown to him. He is
Memo ry
Verbal memory Pictorial memory
Spatia l proces ses
Analysis of geometric and visual space
Emoti on
Comprehension and expression of emotion
Olfact ion
Smell in left nostril Smell in right nostril
confused and does not know what the picture represents. He starts to guess. “There is a circle . . . and another circle . . . and a stick . . . a crossbar . . . why, it must be a bicycle?”
The visual agnosias are especially linked to right-sided lesions of occipital association cortex, but may also involve impairment of the parietal and temporal lobes as well. A particularly dramatic form of visual agnosia is prosopagnosia, the inability to recognize familiar faces. Benson (1994) cites the example of a 70-year-old man who suffered a series of strokes affecting the forward portions of the occipital lobes. The patient’s chief complaint was that he could not recognize his wife or his daughter by sight, although he immediately recognized them by their voices. In another case of visual agnosia known as object agnosia, a patient reproduced a drawing of a train with great skill but had no idea what he had drawn. Benson (1988) describes the many fascinating symptoms of visual agnosia.
10.10 EXECUTIVE FUNCTIONS The executive functions of the brain provide the ability to respond to novel situations in an adaptive manner. Lezak, Howieson, and Loring (2004) propose that the executive functions consist of four components: • Volition • Planning • Purposive action • Effective performance
Volition is the capacity for intentional behavior, the ability to conceptualize a goal. Planning is the identification of the steps needed to achieve the goal. Purposive action is the capacity to take action and sustain it in an orderly manner. Effective performance requires the ability to monitor one’s activities in light of the original goals and shift strategies as needed. Thus, executive functions are implicated in a wide range of cognitive, emotional, and social skills. An intriguing paradox of psychological testing is that few instruments are sensitive to
impairments of executive functions. When provided with the structure of a typical psychological test, individuals with impaired executive functions often rise to the occasion and perform well. However, in the perplexity of real life, personal functioning may reveal catastrophic disability. For example, a successful financial planner who sustained a brain injury . . . can no longer formulate plans well because
of an inability to take all aspects of a situation into account and integrate them. This disability is further aggravated by his lack of awareness of his mistakes. Problems occasioned by the man’s emotional lability and proneness to irritability are overshadowed by the crises resulting from his efforts to carry out inappropriate and sometimes financially hazardous plans. (Lezak, 1995, p. 650)
Yet, cognitive test scores for this individual— and others like him with impaired executive functions—might well be normal.
Executive functions are substantially but not exclusively underwritten by the frontal lobes. Although it is true that disturbances in executive functions can arise from a variety of neurological conditions that involve diverse brain sites, in the vast majority of cases damage to the frontal lobes is implicated. It is with the frontal lobes that humans create intentions, form plans, and regulate their behavior by comparing the effects of their actions with their original intentions. In short, the frontal lobes are essential for the programming, regulation, verification, and motor performance of executive functions. Enacting a plan requires a bodily movement of some kind. People pursue their goals by physically manipulating the environment, whether with their hands or through the motor activity of speech. It is not surprising, then, to find that the primary motor cortex is located in the frontal lobes—where plans and intentions are also formed. The primary motor cortex is found on the precentral gyrus, at the rear of the frontal lobe,
just in front of the central sulcus. Motor control is opposite-sided, with the left motor cortex controlling bodily movements on the right, and vice versa. The topical organization of the motor strip was first mapped by Penfield (1958) during a series of operations to remove damaged cortical tissue in persons with epilepsy. He stimulated different areas of the motor cortex with a harmless electrical current to map the correspondence between cortex and different body parts. Penfield found that those areas of the body requiring precise control, such as fingers and mouth, occupy a disproportionately large amount of cortical space. Just in front of the primary motor cortex is the supplementary motor cortex. The supplementary motor cortex is involved in the serial ordering of complex motor chains, that is, movement programming. A portion of the frontal lobes just below the supplementary motor cortex is involved in the control of voluntary eye gaze. The left frontal lobe also mediates expressive language, discussed in detail later.
Damage to the primary motor cortex causes opposite-sided deficits in fine motor control and also reduces the speed and strength of limb movements. These effects are easily detected with simple motor tests such as finger-tapping speed. Severe damage to the motor cortex causes total paralysis of the affected bodily parts. Damage to the supplementary motor cortex causes deficits in the execution of motor sequences such as copying a series of arm or facial movements (Kolb & Milner, 1981). The most common cause of frontal lobe damage is closed head injury, which is one type of traumatic brain injury. In a closed head injury, acceleration/deceleration forces are instantly applied to the entire brain, as when a person’s head strikes the dashboard in an automobile accident. Because of the irregular surfaces of the surrounding skull, the forward underside surfaces of the frontal lobes are almost always damaged (Jennett & Teasdale, 1981). The front ends of the temporal lobes also are highly vulnerable in closed head injury.
Nauta (1971) summarizes the effects of frontal lobe dysfunction as a “derangement of behavioral programming.” Lezak (1983, 1995) has catalogued the behavioral disturbances that can result from generalized, bilateral frontal lobe damage: 1. Motivational-like problems involving
decreased spontaneity, decreased productivity, reduced rate of behavior, and lack of initiative
2. Difficulties in making mental shifts and perseveration of activities and responses
3. Problems in stopping that are often described as impulsivity, overreactivity, and difficulty in holding back a wrong or unwanted response
4. Deficits in self-awareness resulting in an inability to perceive performance errors or to size up social situations appropriately
5. A concrete attitude (Goldstein, 1944) in which objects, experiences, and behavior are all taken at their most obvious face value
Curiously, frontal lobe lesions may have little effect on old learning and well-established
skills. Both Hebb and Penfield reported that surgical removal of frontal lobe tissue caused little change in IQ scores (Hebb, 1939; Penfield & Evans, 1935). Early studies of prefrontal lobotomy demonstrated much the same finding: no change in IQ or even a slight improvement after disconnection of the frontal lobes. Devising adequate measures of frontal lobe function has proved to be difficult. Lezak et al. (2004) note that frontal lobe disorders change how a person responds, whereas most tests measure what a person knows. Lezak (1982) has devised an ingenious method called the Tinkertoy® Test, discussed in the next topic, to assess the programming difficulties experienced by persons with frontal lobe lesions. More commonly, clinicians rely upon observation and checklists to diagnose frontal lobe dysfunction. A generic example of a checklist for executive functions is provided in Figure 10.3.
FIGURE 10.3 Example of a Structured Checklist for the Assessment of Executive Functions 10.11 NEUROPATHOLOGY OF ADULTHOOD AND AGING Although most individuals age gracefully and maintain good health into old age, an unfortunate minority experience one or more neurological syndromes such as brain injury, dementia, or Parkinson’s disease. In this section we provide a brief synopsis of a number of more common neurological problems encountered in adulthood and old age. Because neuropsychological tests excel in the evaluation of these syndromes, a brief survey will provide an important backdrop to the selected instruments discussed in the second half of the chapter. Traumatic Brain Injury Traumatic brain injury or TBI is an inclusive term that encompasses everything from a “mild” concussion to severe brain injury (Silver, McAllister, & Yudofsky, 2011). TBI is most
commonly the consequence of a blow to the head, and concussion is probably the most common form of TBI. The classic example of a concussion is the football player who receives a hard hit (“sees stars”), is rendered briefly unconscious and immobile, and then gradually walks off the field with assistance. Within hours or a few days, he is back to normal. The symptoms of concussion include a brief loss of consciousness followed by a low-grade headache, difficulty concentrating, fatigue, irritability, and other emotional symptoms. Although some concussions can have serious, lasting effects, most patients appear to make a full recovery in a few days or weeks. A concussion is one example of a closed head injury (CHI)—a trauma to the head and brain in which the skull remains intact. But closed head injury is a broader term than concussion and potentially signifies a greater level of impairment than typically found in a concussion. Closed head injury is often contrasted with open head injury or OHI—a trauma to the head and brain in which the skull
is penetrated. OHI is also known as penetrating head injury. Typically, the consequences of OHI are focal or localized in and near the site of impact, whereas the effects of CHI are more diffuse, affecting areas throughout the brain. The neurological consequences of TBI depend upon the nature and severity of the injury, but any or all of the following are possible: • a contusion or bruising of the brain
underneath the site of impact known as a coup injury
• a contusion opposite the side of the impact, caused by rebound, and known as a contrecoup injury
• frequent contusions in the undersurfaces of the frontal lobes and the tips of the temporal lobes because of the bony skull protrusions located there
• diffuse axonal injury or nonspecific brain cell damage from shear-strain effects on neural pathways
• brain tissue damage due to obstructed blood flow when cerebral arteries are ruptured
• hematoma or bleeding into the brain between the skull and the surface of the brain
• edema or swelling of the brain, which can lead to secondary brain damage
• in the long term, possible shrinkage of the brain and enlargement of the ventricular system
As to the neurobehavioral effects of TBI, the most common and reliable complaints are of concentration and memory problems. This is why tests of concentration and memory are found in virtually every test battery used in neuropsychological assessment. Other generalizations about TBI are difficult because the nature and severity of the brain damage will not be the same in any two patients. Focal damage may lead to specific symptoms (e.g., damage to the left hemisphere language areas may cause expressive aphasia). Many studies suggest that TBI patients are more seriously handicapped by personality and emotional disturbances than by cognitive and physical disabilities (Lezak & O’Brien, 1990).
Modern warfare constitutes a major source of TBI cases. Beginning just after the stunning and devastating attacks of September 11, 2001, more than two million U.S. troops have been deployed to Afghanistan and Iraq. Almost half of these soldiers have been deployed more than once, totaling in excess of three million tours of duty (Marine Corps Times, December 18, 2009). In these contemporary war theatres, blast injuries from roadside bombs known as improvised explosive devices (IEDs) comprise a common source of TBI. The detonation of an IED produces a pressure shock wave that reverberates through the brain and body, often causing neuronal changes that include diffuse axonal injury. TBI from these deadly devices is recognized as the “signature injury” of the wars in Afghanistan and Iraq (Dixon, 2011). Even a “mild” blast can produce subtle deficits that are difficult to detect and measure. The prevalence of troop exposure to IED blasts is not well appreciated by the public. In a study of 2,525 U.S. Army infantry soldiers conducted three to four months after a year-long
deployment to Iraq (Hoge, McGurk, Thomas, and others, 2008), fully 62 percent of the sample reported that an IED had exploded near them on two or more occasions! From the large subsample of IED-exposed soldiers (N = 1,556), 7 percent reported an injury with loss of consciousness, 15 percent told of injury with altered mental status, and 18 percent reported other injury. Emotional and health consequences likewise were common, with many troops demonstrating Post-Traumatic Stress Disorder (PTSD), depression, and health problems such as stomach pain, headache, fatigue, and sleep disturbance. Overall, 15 percent of the original sample met the criteria for mild TBI (mTBI). The presence of mTBI was especially correlated with IED blasts that caused a loss of consciousness. Neoplastic Disease (Tumor) Neoplastic disease or brain tumor encompasses many different forms of tumorous growth (Reitan & Wolfson, 1993). For example, gliomas are tendrillike tumors of the glial cells
that infiltrate the brain over a period of weeks or months; meningiomas are slower-growing, globular-shaped tumors of the meninges (membranes encasing the brain) that press down upon the brain. Brain tumors produce a variety of effects, depending upon their location, size, and rate of growth. A rapidly infiltrating tumor such as a glioma quickly may compromise many skills. For example, if the tumor is on the left side of the brain, motor and sensory functions on the right side of the body may be severely impacted, as well as language and problem-solving abilities. If the tumor is on the right side of the brain, constructional abilities (e.g., drawing, assembling three-dimensional objects) will be impaired as well as motor and sensory functions on the left side. A slower-growing meningioma may produce no symptoms for years and then create focal symptoms that relate to the site of encroachment on the brain. For example, if the right parietal area is affected, deficits in spatial ability may be observed.
Chronic Alcohol Abuse Chronic alcohol ingestion leads to neuronal changes that include a loss of dendritic branches and dendritic spines, especially in areas important for memory such as the hippocampus. Over time, enlargement of the ventricles and widening of the cerebral sulci also are observed. In severe cases, atrophy of the medial thalamus and mamillary bodies is found, leading to the pronounced memory problems that characterize Wernicke-Korsakoff’s syndrome (Davila, Shear, Lane, Sullivan, & Pfefferbaum, 1994). The neuropathology of alcoholism often is exacerbated by vitamin and nutritional deficiencies. In those tragic cases of severe alcohol abuse in which the medial thalamus and mamillary bodies are damaged, the profound anterograde amnesia of Wernicke-Korsakoff’s syndrome is noted. Patients show an inability to retain memory of events for more than a short time even though immediate memory is intact and remote memory is only mildly impaired. The
falsification of memory known as confabulation, in the presence of clear consciousness, is noted. Other symptoms of severe abuse include gait disturbance and gaze difficulties. In neurologically intact alcoholics, neurobehavioral effects are more elusive and controversial but may include subtle memory deficits and difficulties with novel problem solving (e.g., Waugh, Jackson, Fox, Hawke, & Tuck, 1989). Recent research indicates that the brain changes and neurocognitive impairments caused by prolonged alcohol abuse can be partially reversed. A common problem observed in chronic alcoholics is, literally, shrinkage of brain tissue and enlargement of the ventricles. The ventricles are fluid-filled caverns at the center of the brain. The relationship is linear, with greater alcohol intake predicting greater brain shrinkage and larger ventricular enlargement (Anstey, Jorm, Reglade-Méslin, and others, 2006). Using sophisticated imaging techniques, Bartsch, Homola, Biller, and others (2007) studied longitudinal changes in brain
volume in 15 alcoholics and 10 matched controls. After 6-7 weeks of abstinence, the alcoholics revealed a 2 percent gain in volume of brain tissue, compared to no change among the controls. While a 2 percent improvement may not seem like much, it could foretell even more dramatic gains with long-term abstinence. The common metric among substance abuse professionals is that full cognitive recovery takes at least a year. In the Bartsch et al. study (2007), pretest versus posttest scores on the d2- test, a measure of attention and concentration, also improved in the recovery group but showed no change in the control group. Several other studies confirm improvement in neuropsy- chological test results after abstinence in recovering alcoholics, as summarized by Walker (2006). Normal Pressure Hydrocephalus Hydrocephalus is a build-up of cerebral spinal fluid (CSF) inside the skull, which causes brain swelling. In normal pressure hydrocephalus (NPH), which mainly affects individuals aged
60 or older, there is an increase in CSF, but the pressure of the fluid remains normal. Even so, brain function is affected, leading to a classic triad of symptoms: gait ataxia, incontinence, and dementia. Conn (2011) describes his own case of NPH from a unique perspective (he is a physician) and suggests that many cases of dementia caused by NPH are misdiagnosed with potentially tragic consequences. NPH is highly treatable, whereas other forms of dementia resist intervention. His story is a warning against complacency and fatalism among health care workers who deal with assessment and diagnosis, including psychologists. His case of NPH . . . began in about 1992 as a trivial abnormality
of gait that was misdiagnosed as Parkinson’s disease (PD). Over the next 10 years, during which I was being unsuccessfully treated with dopaminergic drugs for PD, the illness gradually progressed until I could barely walk with a walking frame, had become incontinent of urine and, sometimes, faeces and began to
show signs of cognitive loss. In the process of obtaining a motorised wheelchair I was referred to a younger neurologist who recognised that I had run the whole classic course of NPH, a disease of which I had never heard. I had a ventriculoperitoneal shunt (VPS) implanted in 2003 and was miraculously restored virtually to normal (p. 162).
A VPS shunt is a catheter extending beneath the skin from the ventricles of the brain to the abdominal cavity, allowing excess CSF to drain off. The prevalence of NPH is difficult to ascertain because it resembles other forms of diffuse dementia. Many cases likely are overlooked. Based on his evaluation of published studies, Conn (2011) estimates that 1 percent of the population will develop NPH by the age of 80. Alzheimer’s Disease The most common degenerative neurological disease is Alzheimer’s disease (AD), which features an insidious degeneration of the brain.
The pathophysiology includes clumplike deposits in the brain known as neuritic plaques and neurofibrillary tangles (Koss, 1994). Additional brain changes include neuronal loss, shrinkage or atrophy of the brain, depletion of acetylcholine neurotransmitters involved in memory, and accumulation of foreign deposits in the cerebral vasculature; the course of the disease invariably is downhill. First described in 1907, Alois Alzheimer portrayed his initial case as follows: The first noticeable symptom of illness shown
by this 51-year-old woman was suspicious- ness of her husband. Soon, a rapidly increasing memory impairment became evident; she could no longer orient herself in her own dwelling, dragged objects here and there and hid them, and at times, believing that people were out to murder her, started to scream loudly. On observation at the institution, her entire demeanor bears the stamp of utter bewilderment. She is completely
disoriented to time and place. (La Rue, 1992)
Although Alzheimer’s disease is not part of normal aging, advanced age is an important risk factor. Rare before age 65, the disease afflicts 3 percent of persons 65 to 74 years of age, 18 percent of persons 75 to 84 years of age, and nearly half of those 85 years and older (Evans, Funkenstein, Albert, and others, 1989). Symptoms and examples suggestive of Alzheimer’s disease are listed in Table 10.3. These examples characterize other forms of dementia as well. TABLE 10.3 General Symptoms and Specific Examples Suggestive of Alzheimer’s Disease
Significant memory problems that extend beyond benign forgetfulness Fails to recall what was eaten for breakfast Difficulty with everyday tasks and commonplace activities No longer balances the checkbook, prepares the same meal Loss of orientation to date, time and/or place Significantly off as to date or time, loses the way going home Gradual and insidious onset Onset is hard to identify, problem is recognized in retrospect Language and word finding difficulties Conversation characterized by circumlocution and vagueness Problems with abstract thinking Difficulty following the rules of simple card games Deterioration of social judgment Dresses inappropriately, neglects personal hygiene Misplaces or loses important items Car keys disappear, eyeglasses are found in a kitchen drawer Changes in Personality:
Note: These examples characterize other forms of dementia as well. Source: A synthesis based on Alzheimer’s disease websites. As detailed by Storandt and Hill (1989), difficulty with the acquisition of new information (short-term memory dysfunction) is generally the most salient symptom in the early stages. As the disease progresses, patients may also show a prominent language dysfunction (e.g., pronounced word finding difficulty) or a striking visuospatial disturbance. Reports of personality change, including delusions and agitation, also are common. The late stages are characterized by severe, pervasive disability. Vascular Dementia (Stroke) The second most common cause of dementia in the elderly is vascular dementia, caused by blockage of an artery and subsequent death of brain tissue due to insufficient blood supply (infarction) or bleeding into or around the brain (hemorrhage). Sudden onset is the rule, but the accumulation of small strokes over time, known as multi-infarct dementia (MID), may produce
an apparently progressive disorder. The Hachinski Ischemic Score was developed to distinguish multi-infarct dementia from Alzheimer’s disease (Hachinski, Iliff, Zilha, and others, 1975). Using this index, MID is indicated by the presence of several of the following factors: abrupt onset, somatic complaints, stepwise deterioration, emotional incontinence, fluctuating course, history of hypertension, nocturnal confusion, history of strokes, personality preserved, atherosclerosis present, depression, and focal neurological signs. Because MID may be treatable to some degree, the differential diagnosis of MID versus Alzheimer’s disease is more than academic. The stroke syndrome is defined by the acute onset of a focal deficit involving the central nervous system. The specific symptoms depend upon the site of infarction but may include motor weakness and impaired sensibility in the limbs on the opposite side; nonfluent aphasia if the dominant hemisphere is affected; partial loss of the visual field if the stroke occurs in the rear of the brain. The acute symptoms of stroke often
subside in some measure and lead to a plateau of stable functioning. Parkinson’s Disease (PD) Parkinson’s disease (PD) is almost nonexistent before age 40 and affects only 1 or 2 in 1,000 persons ages 70 and over (La Rue, 1992). Primarily identified as a movement disorder, cognitive and emotional problems are common in PD. In fact, the late stages of PD may entail a clear dementia. The symptoms include slowness of movement (bradykinesia), tremor at rest, shuffling gait, and postural rigidity. The neuropathology includes depletion of dopamine and neuron loss in the basal ganglia. Tremor is the most common and the least debilitating early symptom in PD. The rate of progression is quite variable, but movement disability in PD can become pronounced and lead to confinement; 10 to 20 percent of PD patients develop a clear dementia. Patients with PD reveal a deficit on neuropsychological tests requiring speed (e.g., Digit Symbol, Trail Making, reaction time measures). Surprisingly,
tests of visual discrimination and paired- associate learning—which do not require speed —also differentiate patients with moderate to severe PD from matched controls (Pirozzolo, Hansch, Mortimer, Webster, & Kuskowski, 1982). About 40 to 60 percent of PD patients also experience depression (La Rue, 1992). 10.12 BEHAVIORAL ASSESSMENT OF NEUROPATHOLOGY Psychological testing can be essential in the evaluation of neuropathology, as we will see in the next topic. Yet, it is easy for psychologists to become enamored of tests and to overlook the value of simple observation, interview, and behavioral evaluation. In medicine, the field of behavioral neurology has recognized the merit of these straightforward approaches for at least 150 years, dating back to the pioneering observations of Paul Broca and Carl Wernicke on syndromes of aphasia (Pincus & Tucker, 2003). Psychologists make use of this long-
established tradition when they conduct a mental status examination at the beginning of assessment (Sonne, 2012). Assessment of Mental Status The mental status examination (MSE) is a loosely structured interview that usually precedes other forms of psychological and medical assessment. The purpose of the evaluation is to provide an accurate description of the patient’s functioning in the realms of orientation, memory, thought, feeling, and judgment. The MSE is the psychological equivalent of the general physical examination: Just as the physician reviews all the major organ systems, looking for evidence of disease, the psychologist reviews the major categories of personal and intellectual functioning, looking for signs and symptoms of psychopathology (Gregory, 1999). Although there is some latitude as to the scope of the MSE, certain mental functions are almost always investigated. A typical evaluation touches upon the areas listed in Table 10.4.
TABLE 10.4 Major Areas of a Typical Mental Status Exam
Appearance and Behavior Grooming Facial expressions Gross motor behavior Eye contact Speech and Communication Processes Speech content, rate, tone, volume Word difficulty, confusion, misuse Thought content Logic, clarity, appropriateness Delusions Cognitive and Memory Functioning Calculating ability Immediate recall Recent and remote memory Fund of information Abstracting ability Emotional Functioning Predominant mood Appropriateness of affect Insight and Judgment Awareness of problems Orientation Day, date, time, location
Source: Based on Gregory, R. J. (1999). Foundations of intellectual assessment: The WAIS-III and other tests in clinical practice. Boston: Allyn and Bacon. Some of the elements in this list can be assessed with short screening tests. In particular, cognition, memory, and orientation are intellectual functions that can be tested in a formal, structured manner (Hodges, 1994). These measures are most commonly used in the mental status evaluation of the elderly, especially when the client appears to have a dementia such as Alzheimer’s disease, as discussed later in this chapter. Formal tests of mental status are also helpful in the assessment of certain brain-impairing conditions such as head injury, schizophrenia, severe depression, and drug-induced delirium. It is important to emphasize that screening tests are supplementary—they do not replace clinical judgment in the evaluation of mental status. Some areas covered by the MSE are simply impossible to quantify. For example, the evaluation of a patient’s insight requires keen
observation and sensitive interviewing skills. An MSE screening test for insight does not exist. Behavioral Rating Scales Another approach in the behavioral tradition is to utilize observations from persons familiar with the patient, such as a spouse, parent, close friend, or caretaker. Asking them questions about the patient is a good starting point. But a more efficient method is to employ a relevant behavior rating scale tied to the specific behaviors of the individual. This allows for reliable assessment and provides access to normative data. Hundreds of behaviorally based scales exist (Tate, 2010). These can be broad- spectrum (such as establishing the likelihood of dementia) or narrow in focus (such as verifying the presence of the syndrome of disinhibition). For purposes of illustration, we will summarize two instruments here, one for the evaluation of dementia in general, and another for the appraisal of specific frontal lobe syndromes. The Behavioral and Psychological Assessment of Dementia (BPAD) is a proxy-report rating
scale designed to assess dementia-related changes in behavior among adults 30 years of age and older (Schmidt & Gallo, 2007). In completing the BPAD, the informant rates the client on 78 items Within the past four weeks (current), and also five years ago (past). Items are rated on a four-point scale. The BPAD assesses the symptoms for each of the two time periods (current and past) and also computes a change score. The change score reflects changes in mood and behavior that might signal the onset of dementia. Thus, three sets of scores emerge: Current, Past, and Change. For each of the three sets of scores, the BPAD yields a total score and seven domain scores. All scores are reported as T-scores with a mean of 50 and standard deviation of 10, relative to the standardization sample. The test was standardized and validated on a large sample of men and women 30 to 90 years of age. The sample was matched to U.S. census proportions in regard to racial/ethnic makeup, educational backgrounds, and geographic regions.
The seven domains of the test are grouped into three clusters, as follows: • Psychopathological Symptom Cluster • Perceptual Delusions • Positive Mood/Anxiety • Negative Mood/Anxiety • Behavioral Symptom Cluster • Aggressive • Perseverative/Rigid • Disinhibited • Biological Symptom Cluster • Biological Rhythms
The instrument also yields a total score based on the sum of all seven domains. The BPAD items are at a grade 6 reading level. The test can be used in a variety of settings (inpatient, outpatient, assisted living) with patients suspected of having Alzheimer’s disease, vascular dementia, and psychiatric problems. The BPAD is a promising test, but there is scant validity research at this time. Certainly the domains exemplify good content validity, insofar as they overlap with the consensus of experts on the behavioral and psychological
symptoms of dementia. For example, a prominent international group provides the following authoritative statement on the behavioral manifestations of dementia: • Behavioral symptoms: Usually identified on
the basis of observation of the patient, including physical aggression, screaming, restlessness, agitation, wandering, culturally inappropriate behaviors, sexual disinhibition, hoarding, cursing and shadowing.
• Psychological symptoms: Usually and mainly assessed on the basis of interviews with patients and relatives; these symptoms include anxiety, depressive mood, hallucinations and delusions. A psychosis of Alzheimer’s disease has been accepted since the 1999 conference (International Psychogeriatric Association, 2002).
Although terminology is not identical, the BPAD domains possess a clear commonality with the above description of dementia. A test that embodies a more specific application is the Frontal Systems Behavior Scale (FrSBe)
(Grace & Malloy, 2001). The purpose of this instrument is to provide a behaviorally oriented assessment of three frontal lobe syndromes: apathy, disinhibition, and executive dysfunction. The scale consists of 46 items rated on a 5-point Likert scale by either the patient or a family member. Results from a family member are considered more reliable and valid. Items are written at a 6th grade level. Separate norms are provided for the patient and family form. The scale also attempts to quantify behavioral changes over time by including a baseline (retrospective) and a current assessment. A highly desirable feature of the form is that it takes only 10 minutes to administer and 10-15 minutes to score. The subscales include Apathy (14 items), Disinhibition (15 items), and Executive Dysfunction (17 items), which are reported as T- scores (mean of 50, SD of 10) derived from a community-based sample of 436 men and women with two levels of education. Comparison data also are provided for several clinical groups: frontotemporal dementia,
frontal lesions, nonfrontal stroke, head injury, Alzheimer’s disease, Parkinson’s disease, and Huntington’s disease. The construct validity of the FrSBe is firmly upheld by an exploratory factor analytic study of results for 324 neurological patients and research participants, the majority diagnosed with neurodegenerative disorders such as Alzheimer’s, Parkinson’s, and Huntington’s disease (Stout, Ready, Grace, Malloy, & Paulsen, 2006). The three-factor solution revealed that 83 percent of the items from the Apathy, Disinhibition, and Executive Dysfunction scales loaded prominently on the corresponding factors from the analysis. These results highly support the utility of the scale in assessment of the three frontal syndromes. In a study of 66 individuals with a history of traumatic brain injury, Reid-Arndt, Nehl, and Hinkebein (2007) found that the FrSBe was a better predictor of community integration than neuropsychological tests. Mendez, Licht, and Saul (2008) reported that the scale differentiates patients with frontotemporal dementia (FTD)
from those with Alzheimer’s disease (AD) and vascular dementia (VaD). Specifically, the FTD patients had significantly greater scores on Disinhibition than the AD patients and the VaD patients. Chiaravalloti and DeLuca (2003) testify that the FrSBe is sensitive to the behavioral changes observed in patients with Multiple Sclerosis. In sum, this simple, brief scale is an excellent measure for use with patients who display frontal lobe manifestations related to a variety of neurodegenerative disorders. TOPIC 10B Neuropsychological Tests, Batteries, and Screening Tools 10.13 A Conceptual Model of Brain-Behavior Relationships 10.14 Assessment of Sensory Input 10.15 Measures of Attention and Concentration 10.16 Tests of Learning and Memory 10.17 Assessment of Language Functions 10.18 Tests of Spatial and Manipulatory Ability 10.19 Assessment of Executive Functions 10.20 Assessment of Motor Output
10.21 Test Batteries in Neuropsychological Assessment 10.22 Screening for Alcohol Use Disorders
The purpose of this topic is to review a diverse collection of neuropsychological tests, batteries, and screening tools. We focus here on representative tests, prominent batteries, and useful screening tools, recognizing that comprehensive coverage is well beyond the scope of the book. For a complete treatment of neuropsychological assessment, the reader is referred to the authoritative tome amassed by Lezak, Howieson, Bigler, and Tranel (2012), which runs to an amazing 1,200 pages in length. By necessity, the coverage here is more discerning and emphasizes better-known tests and batteries. Neuropsychologists and other clinicians often encounter clients who struggle with alcoholism or other types of substance abuse. For this reason, we also review a few simple but
practical tools for rapid screening of clients with possible alcohol problems. This issue is vital because, at any given time, 10 percent of the adult population manifests an alcohol disorder (Yalisove, 2004). Although it might appear a straightforward matter to identify patients with alcohol problems—just ask them how much and how often they drink—in reality this is a vexing diagnostic challenge due to the active façade of denial maintained by most alcoholics. However, a number of screening tools summarized later are useful for this task. Finally, it is important to emphasize that neuropsychological assessment involves more than the administration and scoring of specialized tests and screening tools. An essential component of any assessment is the evaluation of a client’s mental status. This is particularly true with elderly clients who may experience Alzheimer’s disease or other forms of dementia. Accordingly, we close this chapter with a focus upon mental status assessment in the elderly. In this concluding topic, we pay special attention to the Mini-Mental Status
Exam (Tombaugh, McDowell, Kristjansson, & Hubley, 1996), one of the most widely used screening tools in existence. Neuropsychological tests and procedures encompass an eclectic assortment of methods and purposes. At one end of the spectrum are simple, 10-minute screening tests used to probe the need for further assessment. At the other end of the spectrum are exhaustive, six-hour test batteries designed to provide a comprehensive assessment. In between are hundreds of specialized instruments developed to measure particular neuropsychological abilities. At first glance, this multitude of tests would appear to resist simple categorization, as if researchers in this area had followed an incoherent philosophy of trial and error in the development of new instruments and procedures. However, with closer scrutiny it is evident that most neuropsychological tests fit within a simple, logical model of brain-behavior relationships. We will use this model as a framework for discussing well-known neuropsychological tests and procedures.
10.13 A CONCEPTUAL MODEL OF BRAIN-
BEHAVIOR RELATIONSHIPS Bennett (1988) has proposed a simplified model of brain-behavior relationships that is helpful in organizing the seemingly chaotic profusion of neuropsychological tests (Figure 10.4). His conceptualization is a slight expansion of the model presented by Reitan and Wolfson (1993). According to this view, each neuropsychological test or procedure evaluates one or more of the following categories: 1. Sensory input 2. Attention and concentration 3. Learning and memory 4. Language 5. Spatial and manipulatory ability 6. Executive functions:
• Logical analysis • Concept formation • Reasoning • Planning
• Flexibility of thinking 7. Motor output
The order of the categories listed corresponds roughly to the order in which incoming information is analyzed by the brain in preparation for a response or motor output. In the remainder of this topic, the discussion of neuropsychological tests and procedures is organized around these seven categories. Within each category we will review established tests and also introduce new instruments that show promise of extending the horizons of neuropsychological assessment. However, the reader needs to know that neuropsychological assessment commonly involves a battery of tests. One approach is flexible or patient- centered testing in which an individualized test battery is fashioned for each client. These batteries are based upon the presenting complaints, referral issues, and an initial assessment (Kane, 1991; Larrabee, 2008). More typically, neuropsychologists employ a fixed battery of tests for most referrals. One of the most widely used fixed batteries, the Halstead-
Reitan Neuropsychological Battery, is outlined in Table 10.5. Even though the HRNB is an old test—the elements of the battery have not been changed since its inception in the 1950s—many neuropsychologists still regard this battery as the “gold standard” in the field (Horton, 2008; Sweeney, et al., 2007). In large measure, this is because of the steadily accumulating body of affirming research on the battery, which includes 267 publications by its developer, Ralph Reitan, and literally hundreds of additional articles from the dozens of neuropsychologists mentored by him. Yet, the HRNB is not without competition. The chapter closes with a presentation of two other batteries, namely, the Neuropsychological Assessment Battery and the Luria-Nebraska Neuropsychological Battery.
FIGURE 10.4 Conceptual Model of Brain Behavior Relationships Source: Adapted with permission from Reitan and Wolfson (1993). 10.14 ASSESSMENT OF SENSORY INPUT The accuracy of sensory input is crucial to the proficiency of perception, thought, plans, and action. An individual who does not see stimuli correctly, hear sounds accurately, or process touch reliably may encounter additional handicaps at higher levels of perception and cognition. Neuropsychological assessment always incorporates a multimodal examination of sensory capacities. TABLE 10.5 Tests and Procedures of the Halstead-Reitan Test Battery Test Description Categ ory Test*
Measures abstract reasoning and concept formation; requires examinee to find the rule for categorizing pictures of geometric shapes
Tactu al Perfor mance Test*
Measures kinesthetic and sensorimotor ability; requires blindfolded examinee to place blocks in appropriate cutout on an upright board with dominant hand, then nondominant hand, then both hands; also tests for incidental memory of blocks
Speec h Sound s Perce ption Test*
Measures attention and auditory-visual synthesis; requires examinee to pick from four choices the written version of taped nonsense words
Seash ore Rhyth m Test*
Measures attention and auditory perception; requires examinee to indicate whether paired musical rhythms are same or different
Finger Tappi ng Test*
Measures motor speed; requires examinee to tap a telegraph keylike lever as quickly as possible for 10 seconds
Grip Streng th
Measures grip strength with dynamometer; requires examinee to squeeze as hard as possible; separate trials with each hand
Trail Makin g, parts A, B
Measures scanning ability, mental flexibility, and speed; requires examinee to connect numbers (part A) or numbers and letters in alternating order (part B) with a pencil line under pressure of time
Tactil e Form Recog nition
Measures sensory-perceptual ability; requires examinee to recognize simple shapes (e.g., triangle) placed in the palm of the hand
Senso ry- Perce ptual Exam
Measures sensory-perceptual ability; requires examinee to respond to simple bilateral sensory tasks, e.g., detecting which finger has been touched, which ear has received a brief sound; assesses the visual fields
*Strictly speaking, these five measures constitute the Halstead-Reitan Test Battery. However, in common parlance reference to the Halstead-Reitan includes all of the measures listed in the table. Sensory-Perceptual Exam The procedures developed by Reitan and Klove are entirely typical of sensory-perceptual procedures (Reitan, 1984, 1985). The Reitan- Klove Sensory-Perceptual Examination consists of several methods for delivering unilateral and bilateral stimulation in the modalities of touch, hearing, and vision. The tasks are so simple that normal persons seldom make any errors at all. For example, the examinee is asked to say which hand has been touched (with eyes
Aphas ia Scree ning Test
Measures expressive and receptive language abilities; tasks include naming a pictured item (e.g., fork) repeating short phrases; copying tasks (not a measure of aphasia) included here for historical reasons
Suppl ement ary
WAIS-III, WRAT-3, MMPI-2, memory tests such as Wechsler Memory Scale-III or Rey Auditory Verbal Learning Test
closed), or to report which ear has received a barely audible finger snap, or to identify which number has been traced on the fingertip. The results of this test are especially diagnostic if the examinee consistently makes more errors on one side of the body than the other. The reader will recall from the previous chapter that neural innervation is almost exclusively opposite- sided. Furthermore, certain areas of the cerebral cortex are devoted to primary processing of touch, hearing, and vision. Thus, an examinee who finds it difficult to process touch in the right hand may have a lesion in the postcentral gyrus of the left parietal lobe. Similarly, difficulty processing sound in the right ear may indicate a lesion in the superior portion of the left temporal lobe, and right-sided visual defects may indicate brain impairment in the left occipital lobe. Finger Localization Test Finger localization is a venerable procedure developed by neurologists to evaluate possible sensory losses caused by impairment of brain
functions. Most neuropsychological test batteries employ a variant of this test, in which examinees must identify those fingers that have been touched (without benefit of sight). Benton has developed a well-normed 60-item test of finger localization that consists of three parts: (1) with the hand visible, identifying single fingers touched by the examiner with the pointed end of a pencil (10 trials each hand); (2) with the hand hidden from view, identifying single fingers touched by the examiner (10 trials each hand); (3) with the hand hidden from view, identifying pairs of fingers simultaneously touched by the examiner (10 trials each hand). The method of response is left to the patient: naming, touching, or pointing to fingers on a diagram (Benton, Sivan, Hamsher, Varney, & Spreen, 1994). Each stimulus presentation is scored right or wrong, and normal adults typically make very few errors in the 60 trials. Mean scores for normal adults are near perfect, ranging from 56 to 60 in various samples. In contrast, patients with brain disease find finger
localization to be a challenging task, particularly on the second and third parts of the test. 10.15 MEASURES OF ATTENTION AND CONCENTRATION The attentional capacity of the brain makes it possible to attend to meaningful stimuli, screen irrelevant sensory input from the profusion of incoming stimuli, and flexibly shift to alternative stimuli when conditions demand it (Kinsbourne, 1994). While in theory it might be possible to make subtle distinctions between simple attention, concentration, mental shifting, mental tracking, vigilance, and other variants of attention/concentration, in practice these skills are difficult to separate. Only one attentional measure—the Test of Everyday Attention (TEA) —has succeeded in partitioning attention into its component sources. We discuss the TEA and other prominent measures of attentional impairment in the following sections. Test of Everyday Attention
The Test of Everyday Attention (TEA) is a promising measure devised in Great Britain by Robertson, Ward, Ridgeway, and NimmoSmith (1994, 1996). The TEA measures the subcomponents of attention, including sustained attention, selective attention, divided attention, and attentional switching. The subtests of the TEA are outlined in Table 10.6. The test has three parallel versions and has been well validated with closed head injury clients, stroke patients, and persons with Alzheimer’s disease. Normative data are based upon the performance of 154 healthy individuals between the ages of 18 and 80. Examinees enjoy the real-life scenarios of the TEA, which adds to the ecological validity of the instrument. The TEA is highly sensitive to normal age effects in the general population and is, therefore, well suited to geriatric assessment. With the exception of the Elevator Counting subtest, the eight subtests were standardized to yield equivalent scores with a common mean of 10 and standard deviation of 3. Thus, the TEA allows for subtest analysis as a means of identifying an
individual’s particular strengths and weaknesses (Crawford, Sommerville, & Robertson, 1997). The TEA is highly sensitive to the effects of closed head injury (Chan, 2000), with the Map Search and Telephone Search subtests revealing the largest deficits from brain injury (Bate, Mathias, & Crawford, 2001). Chan and his colleagues developed a Cantonese version of the TEA and report favorably on its use with clinical and nonclinical Chinese participants (Chan, Lai, & Robertson, 2006; Chan & Lai, 2006). A children’s version (TEA-ch) is also available (Manly, Nimmo-Smith, Watson, and others, 2001). Continuous Performance Test The Continuous Performance Test (CPT) is not really a single test but rather a family of similar procedures that dates back to the pathbreaking research of Rosvold, Mirsky, Sarason, and others (1956). These authors devised a measure of sustained attention (also called vigilance) that involved continuous presentation of letters on a screen. In some cases, examinees were to press
a key when a certain letter appeared (e.g., x). In other instances, examinees were to press a key when a certain letter appeared after another letter (e.g., x when it occurs after a). Errors of omission are noted when the examinee fails to press for a target stimulus. Errors of commission are noted when the examinee presses the key for a nontarget stimulus. Normal subjects make few errors. TABLE 10.6 Subtests of the Test of Everyday Attention (TEA)
Map Search: A two-minute speeded search for 80 symbols on a colored map; measures selective attention. Elevator Counting: Simulation of elevator floor counting from tape-presented tones; measures sustained attention. Elevator Counting with Distraction: Same as above but with auditory distractors; measures sustained attention. Visual Elevator: Visual simulation of elevator floor counting with up-down reversals; measures attentional switching. Auditory Elevator with Reversal: Same as visual elevator, except it is presented on tape; measures attentional switching. Telephone Search: Search for key symbols while searching entries in a simulated classified telephone directory; measures divided attention. Telephone Search Dual Task: Combines Telephone Search with simultaneous counting of auditory tones; measures divided attention. Lottery: Subject listens for winning numbers known to end in 55 and then writes down preceding stimuli; measures sustained attention.
Although CPT tests are sensitive to a wide variety of brain-impairing conditions including hyper-activity, drug effects, schizophrenia, and overt brain damage, these tests are not a panacea for the diagnosis of attention-deficit disorders. For example, in one study of the popular Conners (1995) CPT, children with diagnosed Attention-Deficit/Hyperactivity Disorder (ADHD) did not score worse than clinical controls; on the other hand, children with diagnosed reading disorders showed impaired performance on the CPT (McGee, Clark, & Symons, 2000). In general, reviewers recommend that CPT tests should be interpreted in the context of a comprehensive test battery, especially when they are used in the assessment of persons with suspected attentional problems (Riccio, Reynolds, & Lowe, 2001). The CPT is ideal for computerized adaptation, and dozens of different versions of it have appeared in the literature (e.g., Conners, 1995; Gordon & Mettelman, 1988). Unfortunately, the proliferation of similar but not identical tests has hindered research on the practical utility of this
promising measure of attention. Sandford and Turner (1997) have published a computerized CPT that uses both visual and auditory stimuli. The Intermediate Visual and Auditory Continuous Performance Test (IVA) is normed on 781 normal persons ranging from 5 to 90 years of age and screened for attention deficit, learning difficulties, emotional problems, and medication use. In one analysis, the IVA showed 92 percent sensitivity (i.e., an 8 percent rate of false negatives) and 90 percent specificity (i.e., a 10 percent rate of false positives) in differentiating children diagnosed with Attention-Deficit/Hyperactivity Disorder (ADHD) from normal children. Research by Tinius (2003) further endorses the validity of the IVA. He found that adults with mild traumatic brain injury or ADHD performed significantly lower than normal controls on IVA subtests assessing reaction time, inattention, impulsivity, and variability of reaction time. This instrument is just one of many promising neuropsychological tests that takes advantage of microcomputer technology.
10.16 TESTS OF LEARNING AND MEMORY Learning and memory are intertwined processes that are difficult to discuss in isolation. Learning new material usually requires the exercise of memory. Furthermore, many tests of memory incorporate a learning curve through repeated administrations. The separation of learning and memory processes is theoretically possible but of little practical value in clinical assessment. We make no tight distinction between these processes. Memory tests can be categorized according to several dimensions, including short term versus long term, verbal versus pictorial, and learning curve versus no learning curve. These dimensions reflect neurological factors discussed in the previous section. For example, verbal memory is significantly lateralized to the left hemisphere, whereas pictorial memory is largely underwritten by the right hemisphere. The interested reader can consult Lezak et al. (2012) for more detailed analyses of the neural
substrates for different types of memory. Here we will concentrate on the psychometric characteristics of four quite dissimilar memory tests. Wechsler Memory Scale-IV The Wechsler Memory Scale-IV (Wechsler, 2009) is a monumental revision of the previous edition. The latest version is barely recognizable as the offspring of the original one-page test published more than 60 years ago (Wechsler, 1945). The fourth edition is an extensive, multiphasic memory test consisting of nine subtests, although seven are sufficient for the Standard Battery. The nine subtests are described in Table 10.7. The first seven subtests constitute the basis for obtaining age-adjusted scaled scores (mean of 100 and SD of 15) for five standard indices: • Immediate Memory Index • Delayed Memory Index • Auditory Memory Index • Visual Memory Index • Visual Working Memory Index
If the ancillary subtests (Logos and Names) are employed, five additional index scores can be computed. We confine our discussion here to the Standard Battery, although it is worth noting that the WMS-IV provides for five flexible batteries (e.g., Older Adult/Abbreviated Battery, Logical Memory/Designs Battery) using different combinations of the nine subtests. The standard battery requires about 75 minutes to administer, while the abbreviated battery can be completed in 35-40 minutes. TABLE 10.7 WMS-IV Subtests Immediate Recall Subtests
Brief Cognitive Status Exam: Brief assessment for significant cognitive impairment. Logical Memory I: Verbal recall of essential elements from brief stories read to the examinee. Verbal Paired Associates I: Verbal recall for a list of 10 to 14 paired terms (e.g., bicycle— arrow) when only the first term is presented (e.g., bicycle—?). Designs I: Visual recall for specific elements in a 4 × 4 puzzle grid exposed for 10 seconds; examinee must select small cards with the proper designs and place them correctly within a blank 4 × 4 grid. Visual Reproduction I: Visual reproduction (drawing) of five (easy to hard) simple geometric designs each exposed for 10 seconds. Spatial Addition: Visual spatial recall for locations of dots on two separate 4 × 4 grids, adding or subtracting the locations. Symbol Span: Visual recall for symbols viewed briefly by selecting correct options in the proper order from a large array of symbols. Logos I: Visual recognition for unique logos paired with fictitious company names by
*30-minute delayed recall for stimuli in administration I. The WMS-IV was co-normed with the WAISIV in 2009. The standardization of the new instrument is superb. Based on 2005 census data, the 2,200 participants were stratified as to age (13 age bands spanning 16 to 90), gender, race/ethnicity, educational level, and geographic region. Because the WMS-IV is a relatively new version, there is currently little external research on its reliability and validity. Even so, the WMS- IV Technical and Interpretive Manual (Pearson, 2009) provides a mountain of supportive data. Subtests internal consistencies range from a low of .74 (Visual Reproduction I) to highs of .94 to .97 (Verbal Paired Associates I and Visual
Delayed Recall Subtests* Logical Memory II Verbal Paired Associates II Designs II Visual Reproduction II Logos II Names II
Reproduction II, respectively). Internal consistencies of the index scores were excellent, consistently in the mid-to high-90s. Test-retest reliabilities for the index scores were lower, in the low .80s. Validity of the battery appears strong, based on a variety of approaches, including confirmatory factor analysis, correlations with other measures, and test profiles for special groups (Pearson, 2009). In general, the index scores reveal good convergent validity (high correlations with similar measures) and good discriminant validity (low correlations with dissimilar measures). Test profiles for special groups (e.g., intellectual disability, traumatic brain injury, Alzheimer’s disease, and schizophrenia) likewise make theoretical sense in light of the aims of the test battery. An important disclaimer with any multiphasic battery like the WMS-IV is that distinctive profiles should not be used in isolation for diagnosis. If A implies B, it does not follow that B implies A. This is a logical fallacy. A specific example will illustrate the point. If Alzheimer’s
disease, on average, yields a distinctive WMS- IV profile, it does not follow that the presence of that profile in a new patient signifies that the patient has Alzheimer’s disease. Proper diagnosis always entails the synthesis of many sources, including interview with patient and informants. Likewise, isolated low scores on a WMS-IV index should not be overinterpreted. Accessing the original standardization data, Brooks, Holdnack, and Iverson (2011) found that healthy people often obtain low scores on one or more index scores, especially when they had lower education levels or intelligence. Moderating influences need to be considered in test interpretation. Rey Auditory Verbal Learning Test In the early 1900s, the Swiss psychologist Edouard Claparede (1873-1940) proposed a memory test consisting of the free-recall of a 15-item word list. This test evolved into the Rey Auditory Verbal Learning Test (RAVLT), making it one of the oldest mental tests in
continuous use (Boake, 2002). The test first appeared in French (Rey, 1964), but an English- language adaptation has been provided by Lezak (1983, 1995) and others. The RAVLT is a very popular test of memory, especially for purposes of clinical research. A search of PsychINFO from 1950 onward revealed more than 400 published articles using this simple instrument. In administering the RAVLT, the examiner reads a list of 15 concrete nouns at the rate of one per second. The examinee recalls as many as possible in any order. Forewarning the examinee to recall all the words, including those previously recalled, the examiner reads the entire list a second time. A third, fourth, and fifth administration and recall then ensue; these are followed by an interference trial with a new list of words. Next, immediate recall of the original list is tested (without benefit of a new presentation). Finally, a recognition trial is included in which the examinee must underline the administered words from a longer written paragraph. The test yields a number of scores, including the number recalled (of 15) for each
of the initial five trials, the total for the five trials (75 possible), the immediate recall after the distractor list is read, and the recognition score. Rosenberg, Ryan, and Prifitera (1984) concluded that the RAVLT performs well in the identification of patients known to be memory impaired by other criteria. In addition to an overall reduction in performance, memory- impaired patients showed a reduced rate of improvement across the five learning trials. Abundant norms for the RAVLT can be found in Strauss, Sherman, and Spreen (2006). Schoenberg, Dawson, Duff, and others (2006) provide normative data for 392 individuals with documented neurological dysfunction. The RAVLT is available in at least seven parallel versions, which is both a strength and a weakness of the test (Hawkins, Dean, & Pearlson, 2004). It is a strength because clinicians often employ repeat testing as they follow patients with memory difficulties. Of course, this raises the specter of practice effects: examinees will do better on second, third, and
ensuing administrations to some degree because of their prior exposure to the specific items, regardless of whether their clinical condition is improving or getting worse. With parallel versions of a test, the impact of practice effects can be mitigated by using a different form for each administration. Yet, this is a potential weakness, too, because the equivalence of the seven parallel forms is not well established. In reviewing studies of the seven forms of the RAVLT, Hawkins, Dean, and Pearlson (2004) could locate only six studies, and four of these were limited to comparisons of the original test against one other form. Although differences between forms likely are minor, their exact magnitude is simply unknown. Fuld Object-Memory Evaluation The Fuld Object-Memory Evaluation is a useful test of memory impairment in the elderly (Fuld, 1977). The test begins by presenting the examinee with a bag containing 10 common objects (ball, bottle, button, etc.). The task is not described as a memory test. The examinee is
asked to determine whether he or she can identify objects by touch alone. Each object is felt and then named; the examinee then pulls it out of the bag to see if he or she was right. After all 10 items have been correctly identified, a distractor task is administered: rapidly naming words in a semantic category (e.g., names, foods, things that make people happy, vegetables, or things that make people sad). Then the examinee is asked to recall as many of the objects as possible. After each recall, the subject is slowly and clearly reminded verbally of each item omitted on that trial, a procedure called selective reminding (Buschke & Fuld, 1974). The examinee is then administered four more chances to recall the list by selective reminding, with a distractor task after each trial. Delayed recall is tested after a 5-minute interval. Finally, the test closes with a multiple-choice recognition test. The Fuld test is often used to help confirm a diagnosis of Alzheimer’s disease, a degenerative neurological disorder described in the previous topic. In the early stages of
Alzheimer’s disease the most prominent symptom is memory loss. Elderly persons with memory impairment not only score lower than control subjects on the Fuld Object-Memory Evaluation, but they also benefit very little from the selective reminding. Fuld (1977) has provided norms for community-active and healthy nursing-home residents in their 70s and 80s. Fuld, Masur, Blau, Crystal, and Aronson (1990) describe a prospective study in which the Fuld Object-Memory Evaluation demonstrated promise as a predictor of dementia in cognitively normal elderly. Lichtenberg, Manning, Vangel, and Ross (1995) describe a program of neuropsychological research using the Fuld test with older urban medical patients. Chung (2009) reports very favorably on the validity of the Fuld test as a screening measure of dementia in Chinese elderly. In a sample of 192 community-dwelling individuals, 57 with confirmed dementia, the optimal cut-off on the total retrieval score yielded an amazing 93 percent sensitivity and 90 percent specificity. In other words, 93 percent of the individuals with
dementia were correctly spotted, and 90 percent of the normal individuals were appropriately classified. These are impressive findings for a simple screening test. Chung and Ho (2009) report similarly favorable results in a Chinese nursing-home sample. Rivermead Behavioral Memory Test The Rivermead Behavioral Memory Test (RBMT) is a measure of everyday memory such as route finding, remembering names, and recalling information (Wilson, Cockburn, & Baddeley, 1991). The instrument includes the following subtests: • Names: A photograph is shown along with
the first and second names of the person in the photograph. The examinee is tested on both the first and the second names.
• Belonging: At the beginning of the test, the examinee is required to hand over a personal belonging (e.g., wallet), which is then hidden while the examinee observes. Later
Later the examinee must remember to ask for the item and then also to find it.
• Appointment: The examinee is asked to remember to ask the date of the next appointment when he or she hears the sound of an alarm timer.
• Pictures: The examinee is shown 10 cards with simple pictures or drawings and later is asked to recognize them among a set of 20 cards.
• Immediate Story: The examiner reads a short paragraph and immediately afterward asks the examinee to recall as many elements of the brief story as possible.
• Delayed Story: After completing a number of additional subtests, the examinee is asked to recall as many elements of the story as possible.
• Faces: The examinee is shown 5 cards with a face on them and then asked to recognize them among a set of 10 cards.
• Immediate Route: The examiner demonstrates a short route with the examinee and leaves an envelope with a
written message at the destination. The examinee is asked to reproduce the route and to recall the message.
• Immediate Message: This item is linked to Immediate Route (above). The examinee is asked to recall the written message.
• Delayed Message: After completing a number of intervening tasks, the examinee is asked to recall the written message again.
• Orientation: This subtest consists of 10 items tapping knowledge of personal and societal information.
• Date: The examinee is asked the date of the examination.
The RBMT is highly popular in geriatric and rehabilitation settings because of its robust ecological validity—the subtests parallel the tasks and activities of everyday life (Guaiana, Tyson, & Mortimer, 2004). Another strong point of the instrument is that it assesses many elements of memory. For example, the test evaluates all of the following aspects: short- term, long-term, verbal, spatial, retrospective, and prospective memory. The focus on
prospective memory—remembering to do something in the future—is a rare but welcome addition to the appraisal of memory. Man, Chung, and Mak (2009) developed an online version of the RBMT for use with Chinese examinees. They compared scores of 30 stroke patients on the original, face-to-face version of the test versus the online version, and found exceptionally strong correlations on the 12 subtests, with rs ranging from .84 to .93. The new version also was highly successful in distinguishing stroke patients from controls. In sum, the online adaptation looks highly promising as a replacement for the more cumbersome face-to-face edition. Wide Range Assessment of Memory and Learning-2 The original version of the Wide Range Assessment of Memory and Learning (WRAML) was the first comprehensive memory scale designed for use with children (ages 5 to 17 years). The second edition of the test, the WRAML-2 (Sheslow & Adams, 2004),
retains the pediatric focus but also extends the norms upward to 90 years of age. The WRAML-2 is, therefore, unique as the only memory scale that can be used with both children and adults. In addition to examiner convenience (no need to buy and learn several memory tests), there is clinical value as well in using a single test across a wide range of ages. Specifically, when clinicians desire to do follow-up testing on a child or teenage client who subsequently transitions into adulthood, using a single test avoids the pitfall of introducing measurement error associated with different tests. The WRAML-2 consists of six core subtests that contribute to three Index scores: Verbal Memory, Visual Memory, and Attention/ Concentration. Collectively, these Index scores establish the overall General Memory Index. A description of the core memory tasks is provided in Table 10.8. In addition to the core memory subtests, the WRAML-2 also utilizes delayed memory tasks and recognition memory tasks. The delayed
memory tasks require free recall of previously presented material whereas the recognition memory tasks involve mere recognition of the material. The two formats (delayed and recognition) help distinguish between storage and retrieval problems in memory. In particular, a client who performs poorly on delayed memory but who excels at recognition memory most likely has a problem with retrieval rather than storage. This is somewhat similar to not remembering a test item when a fill-in-the blank format is used but succeeding when a multiple- choice format is used. In fact, retrieval memory requires a different neurological substrate than recognition memory. Although capable functioning in both retrieval and recognition memory is typical throughout life, distinct differences (favoring recognition) are observed in old age, with certain neurological conditions such as Alzheimer’s disease, and in some forms of brain injury. TABLE 10.8 Description of core WRAML-2 Subtests
Verbal Memory Subtests Story Memory: Two short stories are read to the participant who, following each, is asked to recall as many parts of the story as can be remembered. This task measures immediate verbal memory. Verbal Learning: The examinee is read a relatively long list of simple words followed by an immediate free-recall trial. Three additional presentation/recall trials are used. This task evaluates the ability to actively learn verbal information and yields a verbal learning curve over the four trials.
Visual Learning Subtests
Design Memory: A card with a simple geometric array is presented for a 5-second exposure. Following a 10-second delay, the participant is asked to draw what is remembered about the card. This procedure is used for five separate cards of increasing difficulty. Picture Memory: The examinee visually scans a complex but common meaningful scene for 10 seconds. Then the examinee is presented with a second similar scene and asked to indicate which elements “have been moved, changed, or added” in the second picture. The procedure is used with four separate scenes.
Attention/Concentration Subtests Finger Windows: The participant demonstrates memory of a visual pattern using a vertically resting card containing asymmetrically located holes or “windows.” The examiner points out a sequence of windows, and then the participant is asked to duplicate the sequence. Number Letter: The examinee is asked to verbally repeat a random series of numbers and letters orally presented at one per second.
Note: All subtests listed contribute to the General Memory Index. The WRAML-2 also includes optional subtests that can be used to evaluate a relatively new area of memory measurement, namely, working memory (Baddeley, 1986). Working memory is a complex form of short-term memory. In addition to simply holding on to rote information for several seconds, when using working memory the client is also “working” with a part of the memory trace without distorting the whole trace. For example, try to read the following sentence only once (i.e., do not reread the sentence to answer the question): If in a bag you had two red balls, three yellow balls, and one green ball, what is the probability the ball would be yellow if you reached into the bag and randomly chose one ball? To answer this question, the short-term verbal memory processor must hold on to all the words in the sentence until the last phrase containing the question. Then it must reproduce the sentence, remembering how many red balls there were, and so on, then hold that information secure,
returning to accumulate all the numbers in order to compute the answer. There are two working memory subtests on the WRAML-2, one that examines verbal working memory and another that examines a combination of verbal and visual working memory. The adult standardization age bands used in norming the WRAML-2 are similar to those of the WMS-III, with similar attention given to stratification variables such as age, gender, ethnicity, geographic region, and educational level. “Tighter” age bands exist for the 5- to 14- year-old samples because there is more change in memory abilities across these ages than in adulthood (except for the oldest age groups). For the WRAML-2, factor-analytic studies show strong support for the three discrete domains being measured (Verbal Memory, Visual Memory, and Attention/Concentration) as well as the newly introduced domain of Working Memory. Especially impressive are the analyses showing extremely low item bias for gender as well as ethnicity. As with the WMS-III, validity studies show clinical groups with neurological
disorders scoring significantly lower than nonclinical groups on all WRAML-2 Indexes. The correlation of the WRAML-2 with WAIS- III Full Scale IQ is moderate, supporting the claim that it measures something different from, although related to, intelligence. Of interest, though, a much lower correlation with the WISC-III suggests that there is less correlation between intelligence and memory ability among children than among adults. Because both tests claim to be memory tests and show some similarities across tasks used to assess memory, it is reasonable to wonder if the WMS-III and WRAML-2 yield similar scores (i.e., if there is reasonable concurrent validity). Using 79 adults from ages 17 through 74 years, the test developers showed that overall memory indexes of the two measures differed by only 4.7 points. However, the correlations between scores on the two memory instruments ranged from .29 to .60. These moderate correlations suggest that they are measuring somewhat different aspects of memory and are not interchangeable instruments.
Additional Tests of Learning and Memory Because of space limitations, we can do no more than briefly mention several other useful tests of learning and memory. The California Verbal Learning Test-II is patterned after the Rey AVLT but provides software to quantify and analyze the pattern of results (Delis, Kramer, Kaplan, & Ober, 2000). The Benton Visual Retention Test is a design-copying test of visual memory (Sivan, 1991). Good reviews of memory tests can be found in Lezak et al. (2012) and Strauss, Sherman, and Spreen (2006). 10.17 ASSESSMENT OF LANGUAGE FUNCTIONS As noted in a previous section, language functioning offers a window to the integrity of the left cerebral hemisphere. Thus, neuropsychologists are keenly interested in an examinee’s ability to speak, read, write, and comprehend what others say. Little wonder that a comprehensive neuropsychological
examination always includes one or more methods for assessing language functions. Neuropsychologists exhibit a special interest in a variety of language dysfunctions known collectively as aphasia. Briefly stated, aphasia is any deviation in language performance caused by brain damage. In testing for aphasia, a neuropsychologist might use any or all of three approaches: (1) a nonstandardized clinical examination, (2) a standardized screening test, or (3) a comprehensive diagnostic test of aphasia. We will provide examples of each in our brief review of assessment methods in aphasia. Clinical Examination for Aphasia A clinical examination for aphasia has the advantages of simplicity, flexibility, and brevity. These are important attributes when assessing a severely impaired patient who may require bedside testing. Every practitioner has a slightly different version of the brief clinical exam (Lezak et al., 2012; Reitan, 1984, 1985).
Nonetheless, certain elements commonly are assessed: • Spontaneous speech: The examiner looks
for distinctive symptoms of aphasia such as word-finding difficulty or neologisms (e.g., referring to a comb as a “planker”).
• Repetition of sentences and phrases: The examiner asks the patient to repeat stimuli such as “No ifs, ands, or buts,” and “Methodist Episcopal.” The repetition tasks are so simple that normal subjects almost never fail them.
• Comprehension of spoken language: The examiner asks questions (“Does a car have handlebars?”) and issues commands (“Take this paper, fold it in half, and put it on the floor”). Again, the tasks are so simple that normal subjects almost never fail them.
• Word finding: The examiner points to common, easily recognized objects and asks, “What’s this?” Typical items include watch, pen, pencil, glasses, ring, and shoes. The examiner may ask the patient to name numbers, letters, or colors.
• Reading: The examiner requests the patient to read and explain a short paragraph suited to prior level of education and intelligence. The examiner may ask the patient to follow written instructions (e.g., “Close your eyes” or “Clap your hands three times”).
• Writing and copying: The examiner asks the patient to write spontaneously and from dictation. Also, the examiner may ask the patient to copy written matter and geometric shapes. The examiner is interested in grossly ungrammatical written productions and significant distortions in copying.
• Calculation: The examiner asks the patient to perform very simple mathematical calculations (e.g., 17 × 3) with and without aid of scratch paper. The tasks are so simple that normal subjects rarely fail.
Based on the clinical assessment, the examiner may fill out a rating scale for severity of aphasia. For example, the rating scale used in the Boston Diagnostic Aphasia Exam (Goodglass, Kaplan, & Barresi, 2000) includes the following speech characteristics: melodic
line, phrase length, articulatory agility, grammatical form, word finding, and auditory comprehension. Screening and Comprehensive Diagnostic Tests for Aphasia Standardized screening tests for aphasia closely resemble the brief clinical exam. The essential difference is that standardized screening tests incorporate objective and precise instructions for administration and scoring. The weakness of screening tests is that they will not detect subtle forms of aphasia. Comprehensive diagnostic tests for aphasia are quite lengthy and used mainly when a patient is known to experience aphasia. These tests provide a profile of language skills that is helpful in treatment planning. We provide a brief description of several aphasia tests in Table 10.9. 10.18 TESTS OF SPATIAL AND MANIPULATORY ABILITY Tests of spatial and manipulatory ability are also known as tests of constructional performance. A
constructional performance test combines perceptual activity with motor response and always has a spatial component (Lezak et al., 2012). Because constructional ability involves several complex functions, even mild forms of brain dysfunction will result in impaired constructional performance. However, careful observation is needed to distinguish the cause of the failed performance, which may include spatial confusion, perceptual deficiency, attentional difficulties, motivational problems, and apraxias. The term apraxia refers to a variety of dysfunctions characterized by a breakdown in the direction or execution of complex motor acts (Strub & Black, 2000). For example, a patient who could not demonstrate how to use a key would be diagnosed as suffering from ideomotor apraxia. TABLE 10.9 Brief Description of Several Aphasia Tests
Multilingual Aphasia Examination (Benton, Hamsher, Rey, & Sivan, 1994) This respected, comprehensive battery consists of 11 subtests and rating scales that assess visual naming, repetition, fluency, articulation, spelling, and other language variables; available in a Spanish edition, too. Western Aphasia Battery—Revised (Kertesz, 2000) Comprehensive test of verbal fluency, auditory comprehension, and repetition that aims to identify aphasia syndromes and determine their severity. Boston Diagnostic Aphasia Examination (Goodglass, Kaplan, & Barresi, 2000) Comprehensive test with 46 subscales that include music, spatial, computation, and seven types of writing skill in addition to traditional aphasia measures, available in French and Hindi versions, too. Porch Index of Communicative Ability— Revised (porch, 2001) A battery containing eighteen 10-item subtests, four verbal, eight gestural, and six graphic. Very reliable test often used to measure small
Tests of constructional performance embrace two large classes of activities: drawing and assembling. Owing to limitations of space, we will review only a few prominent instruments in each category. Design Copying Tests Drawing a copy of simple geometric shapes such as two overlapping pentagons is a complex activity that requires accurate visual perception, correct spatial analysis, as well as intact motor functions and the executive ability to make mid- course corrections in the drawing. Because the activity of copying a design involves so many cognitive capacities, it is sensitive to a wide variety of brain impairing conditions. For this reason, design copying has been a mainstay of cognitive screening for brain impairment. One of the most widely used design copying tests—indeed, one of the most widely used individual tests of any kind—is the Bender Visual-Motor Gestalt Test (Bender, 1938), more commonly known as the Bender Gestalt Test (BGT). In the last half of the twentieth century,
the BGT consistently ranked among the top four or five most frequently used tests in clinical psychology (Piotrowski, 1995). The original version consisted of nine stimulus drawings similar to those in Figure 10.5. The test is simple to explain and administer. The examinee is instructed to copy one drawing at a time on a sheet of blank paper. Erasures are discouraged. If needed, additional sheets of paper are provided. The examinee is told “this is not a test of artistic ability, but try to copy the drawings as accurately as possible. Work as fast or as slowly as you wish” (Hutt, 1977). Use of a ruler or straight edge is not permitted. For the original version of the BGT, a number of complex scoring systems have been developed for adults (Hain, 1964; Hutt & Briskin, 1960; Lacks, 1999). In addition, Koppitz (1963, 1975) produced an elaborate scoring system for children aged 5 to 11. The Koppitz system yielded a raw score (total errors) that could be converted to an age-equivalent score as well. In contrast to the use of the BGT with adults— where the examiner is looking for signs of brain
impairment—when used with children, the primary purpose of the test is to assess the level of developmental maturity. Several interesting variations on the original BGT are discussed in Gregory (1999).
FIGURE 10.5 Stimuli Similar to Those From the Bender Gestalt Test-II. Note: The Bender-Gestalt-II consists of sixteen stimuli similar to these. A revised and expanded version of the BGT was published by Brannigan and Decker (2003). The BGT-II adds to the original test rather than revamping it. Specifically, it includes the
original nine stimulus cards supplemented by seven new drawings (four very easy drawings, and three that provide substantial challenge). The four additional “easy” cards are administered only to younger examinees 4 through 7 years of age, whereas the three “difficult” cards are administered only to older examinees 8 through 851 years of age. Unlike previous editions of the test which lacked serious efforts at standardization, the BGT-II norms are based on more than 4,000 individuals, ages 4 through 85, stratified on important demographics according to the 2000 census. These new stimulus cards are intended to extend the measurement scale at the lower and higher extremes of ability. The authors also provide an explicit scoring system whereby each reproduction is scored on a 5-point scale from 0 (no resemblance) to 4 (nearly perfect). Of course, comprehensive, census-based norms are provided by way of standard scores, T scores, percentile ranks, confidence intervals, and classification labels. The standard score is called the Visual Motor Integration (VMI) and is
anchored to a mean of 100 and standard deviation (SD) of 15. This is a useful feature of the BG-II because it allows for comparisons of the VMI score with IQs, memory quotients, and other indices normed to mean of 100 and SD of 15. Marnic (2011) found that the test is valuable in the diagnosis of attention-deficit/ hyperactivity disorder in referred children and adolescents. Decker (2008) provides a sophisticated analysis of subtle changes in BGT- II protocols across the life span, suggesting that visual-motor skills mature rapidly from childhood into middle adolescence, decline steadily through adulthood, and drop steeply in old age. The Greek Cross (Reitan & Wolfson, 1993) is a very simple drawing task that is surprisingly sensitive to brain impairment. The examinee is requested to carefully copy the figure without lifting the pencil, that is, by tracing the perimeter. The stimulus figure and examples of defective performance are shown in Figure 10.6. This test is most often evaluated on a qualitative
basis, although scoring guides do exist (Gregory, 1999). Assembly Tests In his classic book on the parietal lobes, Critchley (1953) provided the rationale for including three-dimensional construction tasks in a neuropsychological test battery: It is possible, and indeed useful, to proceed to
problems in three-dimensional space though tests of this character are only too rarely employed. This is a more difficult undertaking, and patients who respond moderately well to the usual procedures with sticks and pencil-and-paper may display gross abnormalities when told to assemble bricks according to a three- dimensional pattern.
Benton, Sivan, Hamsher, Varney, and Spreen (1994) present a three-dimensional block construction test with excellent norms and scoring guide. The two forms of the test (Form A and Form B) consist of three block models that are presented one at a time to the patient.
The patient is requested to construct an exact replica of the model by selecting the appropriate blocks from a set of loose blocks on a tray. Based on omissions, additions, substitutions, and displacements, the three models are scored from 0 to 6, 8, and 15 points, respectively. This test is quite sensitive to brain impairment, especially when the left or right parietal area is affected. Lezak et al. (2012) discusses other assembly tasks. We should mention that the Tactual Performance Test from the Halstead- Reitan battery is, in part, an assembly task that measures spatial and manipulatory abilities (see Table 10.4). 10.19 ASSESSMENT OF EXECUTIVE FUNCTIONS Executive functions include logical analysis, conceptualization, reasoning, planning, and flexibility of thinking. The assessment of executive functions presents an unusual quandary to neuropsychologists: A major obstacle to examining the executive
functions is the paradoxical need to
structure a situation in which patients can show whether and how well they can make structure for themselves. Typically in formal examinations, the examiner determines what activity the subject is to do with what materials, when, where, and how. Most cognitive tests, for example, allow the subject little room for discretionary behavior, including many tests thought to be sensitive to executive— or frontal lobe—disorders . . . The problem for clinicians who want to examine the executive functions becomes how to transfer goal setting, structuring, and decision making from the clinician to the subject within the structured examination. (Lezak, 1995)
FIGURE 10.6 The Greek Cross Stimulus Figure and Reproductions from Persons with Known Brain Damage (a) Stimulus figure. (b) Clerical worker with diffuse right hemisphere dysfunction of
unknown origin. (c) College professor two years after a right hemisphere stroke. (d) Patient with generalized, diffuse dementia. Source: From Gregory, Robert J. Foundations of intellectual assessment: The WAIS-III and other tests in
clinical practice, p. 197. Published by Allyn and Bacon, Boston, MA. Copyright © 1999 by Pearson Education. Adapted by permission of the publisher. Many neuropsychologists resolve this quandary by using the clinical method to evaluate executive functions rather than administering formal tests (Cripe, 1996). For example, Pollens, McBratnie, and Burton (1988) use interview and observations to fill out the structured checklist on executive functions mentioned in the previous topic. Only a limited number of neuropsychological tests tap executive functions to any appreciable degree. Useful instruments in this regard include the Porteus Mazes, Wisconsin Card Sorting Test, and a novel approach known as the Tinkertoy® Test. We remind the reader that the Category Test from the Halstead-Reitan battery also captures executive functions to some extent (Table 10.4). The Porteus Maze Test was devised as a culture- reduced measure of planning and foresight (Porteus, 1965). Without lifting the pencil and attempting to avoid dead ends, the examinee
must trace a line through a series of increasingly difficult mazes. This underused instrument is quite sensitive to the effects of brain damage, particularly in the frontal lobes (Smith & Kinder, 1959; Smith, 1960). Krikorian and Bartok (1998) have published contemporary Porteus Maze norms for children and young adults 7 to 21 years of age; these researchers also demonstrated that test scores are minimally related to IQ scores. Mack and Patterson (1995) investigated the Porteus test as a useful measure of executive function in elderly patients with Alzheimer’s disease. In a study of 276 pediatric patients who had sustained a traumatic brain injury (TBI), Levin, Song, Ewing-Cobbs, and Roberson (2001) found that the Porteus test was highly sensitive to TBI severity as measured by the volume of tissue damage in the prefrontal areas of the brain. The Wisconsin Card Sorting Test (WCST) is a good measure of executive functions, although its differential sensitivity to frontal lobe damage is debated (Mountain & Snow, 1993). The
instrument was devised to study abstract thinking and the ability to shift set (Berg, 1948; Heaton, Chelune, Talley, and others, 1993). The examinee is given a pack of 64 cards on which are printed one to four symbols (triangle, star, cross, or circle) in one of four colors (red, green, yellow, or blue). No two cards are identical. Thus, each card embodies a number, a particular shape, and a specific color. The examinee must sort these cards underneath four stimulus cards according to an unknown principle (Figure 10.7). For example, the unknown principle might be “sort according to color.” As the examinee places cards, the examiner says “right” or “wrong.” After the examinee has sorted a run of 10 correct placements in a row, the examiner shifts the principle without warning. The test continues until the examinee has made six runs of 10 correct placements. The test can be scored in several different ways, including total number of trials to criterion (Axelrod, Greve, & Goldman, 1994). A common use of the WCST is to gauge ongoing recovery in patients with brain trauma of recent onset.
Thus, the longitudinal constancy of test scores in patients with stabilized conditions is a reassuring characteristic of this test (Greve, Love, Sherwin, and others, 2002). Lezak (1982) devised the Tinkertoy® Test to give patients the opportunity to demonstrate executive capacities within the structured format of an examination. Fifty pieces of a standard Tinkertoy® set are placed on a clean surface and the examinee is told, “Make whatever you want with these. You will have at least five minutes and as much more time as you wish to make something.” The test is scored from − 1 to 112 based on several variables including the number of pieces used, the mobility of the construction, symmetry, and the naming of the construction. Head-injured patients produce impoverished designs consisting of a small number of pieces. These individuals often are unable to provide a name for their constructions.
FIGURE 10.7 Cards and Sorting Piles Similar to the Wisconsin Card Sorting Test Bayless, Varney, and Roberts (1989) studied the predictive validity of the Tinkertoy® Test by comparing the results of 50 patients with closed- head injuries versus 25 normal controls. Half of the head-injured individuals had returned to work while half had not. Whereas all but one of the head-injured who returned to work scored normally on the Tinkertoy® Test, nearly half of the nonreturnees performed below the level of the worst control subject. The researchers conclude: The test seems particularly well suited for
demonstrating the presence of deficits in executive functioning, which have proven
to be difficult to demonstrate with clinical tests even though they have catastrophic sequelae in daily vocational or psychosocial endeavors. (Bayless et al., 1989)
The Tinkertoy® Test also shows promise in the assessment of individuals with Alzheimer’s disease (Koss, Patterson, Mack, Smyth, & Whitehouse, 1998). Neuropsychologists still need additional measures of executive functions. One promising approach in the early stages of development is real-world assessment of route finding. The ability to find an unfamiliar location in the city requires strategy, self-monitoring, and corrective maneuvers. These are executive functions applied to a realistic problem (Boyd & Sauter, 1993). Another promising approach to the assessment of executive functions is embodied in a recent battery called the Behavioral Assessment of the Dysexecutive System (BADS; Wilson, Alderman, Burgess, and others, 1996). The BADS battery consists of six novel
situational tests that resemble real-life daily activities: • Temporal Orientation: The examinee is
asked to estimate how long various common activities take, such as a routine dental checkup.
• Rule Shift Cards: This test measures the ability to shift set after establishing a card- sorting pattern according to a simple rule.
• Action Program: This test of practical problem solving involves a task in which a cork must be extracted from a test tube by planning the use of available materials.
• Key Search: In this analogue test, examinees are required to demonstrate how they would search a field for a set of lost keys.
• Zoo Map: This is a test of planning and route finding in which the examinee is asked to plan a route to visit six of a possible 12 locations in a zoo.
• Six Elements: This is a multitasking subtest in which the examinee must complete six activities (two naming, two dictation, two
dictation, two mental arithmetic) in 10 minutes.
The battery also includes a 20-item dysexecutive questionnaire with items rated on a 5-point (0 to 4) Likert scale. The items involve likely changes when executive functions are impaired, for example, “I have difficulty thinking ahead and planning for the future.” The questions are in four broad areas: personality/ emotional changes, motivational changes, behavioral changes, and cognitive changes. Spreen and Strauss (1998) provide a helpful review of this battery. Norris and Tate (2000) compared the BADS with six other commonly used tests of executive functioning. In a sample of 36 neurological patients, they demonstrated the ecological superiority of this new instrument in predicting competency in everyday role functioning. Simon, Giacomini, Ferrero, and Mohr (2003) found that the BADS was a fair measure of social adjustment in patients with schizophrenia, correlating r = .34 with an index of psychosocial adjustment. The BADS outperformed the Wisconsin Card Sorting Test
and the Trail Making Test (part B) in this context. In a study comparing healthy controls, patients with mild cognitive impairment, and patients with mild Alzheimer’s disease, the BADS was highly sensitive to the impact of mild Alzheimer’s disease, but did not differentiate the other two groups (da Costa Armentano, Porto, Brucki, & Nitrini, 2009). 10.20 ASSESSMENT OF MOTOR OUTPUT Most neuropsychological test batteries include measures of manipulative speed and accuracy. Lezak et al. (2012) provides a comprehensive review. We will briefly summarize three approaches: finger tapping, pegboard performance, and line tracing. Perhaps the most widely used test of motor dexterity is the Finger-Tapping Test from the Halstead-Reitan battery. This test consists of a tapping key that extends from a mechanical counting device attached to a flat board. With the index finger of each hand, the examinee completes a series of 10-second trials until five
trials in a row are within a 5-point range. The score for each hand is the average of these five trials, rounded to the nearest whole number. With the dominant hand, males typically score about 54 taps (SD of 4), whereas females typically score about 51 taps (SD of 5; Dodrill, 1979; Morrison, Gregory, & Paul, 1979). In general, the absolute level of performance is of less interest than the relative abilities on the two sides of the body. Normative expectation is that the nondominant hand will yield a tapping rate about 90 percent of the dominant hand. Significant deviations from this pattern are thought to indicate a lesion in the hemisphere opposite that of the slowed hand (Haaland & Delaney, 1981). However, such inferences must be made with great caution owing to the very low reliability of the ratio score. Although test- retest and interexaminer reliabilities for either hand alone approach .80, the reliability of the ratio score is a dismal .44 to .54 (Morrison, Gregory, & Paul, 1979). The ratio score should be used with extreme caution in making clinical inferences about lateralization of damage.
The Purdue Pegboard Test requires the examinee to place pegs in holes with the left hand, right hand, and then both hands. Each trial lasts only 30 seconds, so the entire test can be administered in a matter of minutes. Tiffin (1968) reports normative scores for work applicants. Relative slowing in one hand suggests a lesion in the opposite hemisphere, whereas bilateral slowing indicates diffuse or bilateral brain damage. Using the Purdue Pegboard Test in isolation, one study found an 80 percent accuracy in identifying brain impairment among a large group of normal subjects and neurological patients (Lezak, 1983). Other studies report much less favorable findings (Heaton, Smith, Lehman, & Vogt, 1978). The Purdue Pegboard Test is a useful addition to a comprehensive battery but should not be used in isolation for screening purposes. Spreen and Strauss (1998) provide an excellent summary of norms for this widely used test. Klove has developed a variation on the pegboard test in which the pegs have a ridge along one side (Klove, 1963). Because each peg
must be rotated into position, the Grooved Pegboard requires complex coordination in addition to motor dexterity. The Grooved Pegboard test is an excellent instrument for assessing lateralized brain damage (Haaland & Delaney, 1981). Finally, we should mention that useful motor tests need not require sophisticated equipment. Lezak (1995) recommends a line tracing task to assess difficulties in motor regulation (Figure 10.8). The examinee is given a brightly colored felt-tipped pen and a sheet of paper with several figures and told to draw over the lines as rapidly as possible. Difficulties with motor regulation show up in overshooting corners, perseveration of an ongoing response, and inability to follow the reduced curves in the bottom figure. Because this task is easily completed by most 10-year-olds, any noticeable deviations are suggestive of difficulties in motor regulation.
10.21 TEST BATTERIES IN NEUROPSYCHOLOGICAL ASSESSMENT We remind the reader that the Halstead-Reitan Neuropsychological Battery (Reitan & Wolfson, 1993), discussed earlier, is a respected and widely used battery in neuropsychological assessment. Here we summarize competing approaches. The Luria-Nebraska Neuropsychological Battery
FIGURE 10.8 A Typical Line-Tracing Task (Reduced Size) Now that we have completed a tour of some individual neuropsychological tests and procedures, it is time once again to remind the reader that many neuropsychologists prefer to use a fixed battery rather than an ever-shifting, individualized assortment of instruments. Certainly, one of the most widely used fixed batteries is the Luria-Nebraska Neuropsychological Battery (LNNB; Golden,
2004; Golden, Purish, & Hammeke, 1980, 1986), now in its third edition (LNNB-III; Teichner, Golden, Bradley, & Crum, 1999). The test consists of 269 discrete items, chosen from the work of Luria (1966) and formally standardized. These items are scored 0, 1, or 2 according to precise criteria in the administration and scoring manual. Similar items are grouped into 11 clinical scales, C1 through C11 (Table 10.10). Raw scores on each scale are converted into T scores, with a mean of 50 and a standard deviation of 10. Higher scores reflect more psychopathology; scores above 70 are especially suggestive of brain impairment. TABLE 10.10 Tests and Procedures of the Luria-Nebraska Neuropsychological Battery
Ability Scale: Tasks Included
C1 Motor: Coordination, speed, drawing, complex motor abilities C2 Rhythm: Attend to, discriminate, and produce verbal and nonverbal rhythmic stimuli C3 Tactile: Identify tactile stimuli, including stimuli traced on the wrists C4 Visual: Identify drawings, including overlapping and unfocused objects; solve progressive matrices and other visuospatial skills C5 Receptive Speech: Discriminate phonemes and comprehend words, phrases, sentences C6 Expressive Speech: Articulate sounds, words, and sentences fluently; identify pictured or described objects C7 Writing: Use motor writing abilities in general; copy and write from dictation C8 Reading: Read letters, words, and sentences; synthesize letters into sounds and words C9 Arithmetic: Complete simple mathematical computations; comprehend mathematical signs and number structure C10 Memory: Remember verbal and nonverbal stimuli under both interference and noninterference conditions
Three summary scales are also derived from test performance: S1 (Pathognomonic), S2 (Left Hemisphere), and S3 (Right Hemisphere). The Pathognomonic scale reflects the degree of compensation that has occurred since an injury, such as functional reorganization of the brain as well as actual physical recovery. Higher scores reflect less compensation. The Left Hemisphere and Right Hemisphere scales can be used to help determine whether an injury is diffuse or lateralized. A number of other scales and interpretive factors are also available (Golden, Purish, & Hammeke, 1986). We cannot review the voluminous literature on the LNNB, but brief mention of a few key studies certainly is merited. The reliability of the LNNB has been evaluated from the usual perspectives (split-half, internal consistency, and test-retest), with excellent results. For example, the mean test-retest reliability for the clinical scales was near .90 (Bach, Harowski, Kirby, Peterson, & Schulein, 1981; Plaisted & Golden, 1982; Teichner et al., 1999). In various validity studies of classification of braindamaged
persons versus other criterion groups, the LNNB has shown hit rates of 80 percent or better (Golden, Moses, Graber, & Berg, 1981; Hammeke, Golden, & Purish, 1978; Moses & Golden, 1979; Teichner et al., 1999). In spite of the positive appraisals of the LNNB reported by Golden and his colleagues, some neu-ropsychologists remain skeptical of the test (e.g., Lezak, 1995). One concern is that the heterogeneity of the scales is so great that the individual scale scores do not quantify specific neuropsychological deficits but instead serve only to differentiate normal persons from brain- damaged patients (Snow, 1992; Van Gorp, 1992). Early reviewers also expressed concern that the speech scales were not oriented to syndromes of aphasia and could therefore misdiagnose language deficits (Delis & Kaplan, 1982). In defense of the LNNB, Purish (2001) contends that initial criticisms were based on misconceptions as to the theoretical basis for the instrument. Furthermore, in his view, these criticisms have been largely negated by an
expanding body of empirical research supporting the test. Yet, it is possible that the LNNB and its chief rival, the Halstead-Reitan Neuropsychological Battery, have reached their peak of popularity and clinical utility (Davis, Johnson, and D’Amato, 2005). New batteries emerge every few years. A promising addition is the Neuropsychological Assessment Battery. The Neuropsychological Assessment Battery (NAB) The Neuropsychological Assessment Battery or NAB (Stern & White, 2003ab) is a recent and promising entry in the field that is remarkable for its breadth and sophistication. Suitable for adults 18 to 97 years of age, the NAB is a comprehensive battery of 24 individual tests in five modular areas: attention, language, memory, spatial, and executive functions. Twelve of the subtests also can be used as a separate screening module. The instrument comes in two parallel and psychometrically equivalent versions, Form 1 and Form 2. Norms
are based on data from 1,448 neurologically healthy individuals matching the U.S. population on educational level, gender, ethnicity, and geographic region. The five major modules, each consisting of four to six subtests, are listed in Table 10.11. Subtests used in the Screening Module are indicated with an asterisk. One feature evident in this table is that each module contains one subtest designed to possess ecological validity as well as psychometric validity. Ecological validity refers to the congruence between testing situations and analogous real-world circumstances. A test with strong ecological validity is one that highly resembles practical behaviors required in the real world. Among the NAB subtests with ecological validity are Driving Scenes, Bill Payment, Daily Living Memory, Map Reading, and Judgments. Each resembles a real world situation of importance in daily life. Ecological validity is beneficial because it increases the acceptability of testing to examinees.
The modular nature of the NAB allows for fixed administration of the entire battery (which takes about three hours), or flexible administration of the Screening Module followed by full administration of one or more of the five modules, depending on screening results. Once the test has been administered, software is available to compute a large array of output scores in a highly user-friendly computerized report. The module scores are reported as standard scores (M = 100, SD = 15), whereas the subtest scores are rendered as T-scores (M = 50, SD = 10). The reliability of test scores is highly variable across the different modules and subtests, and is influenced by the examinee’s age as well. The average coefficient alphas for the subtests in the five major modules revealed the following ranges (Stern & White, 2003b): Attention Module: .78 to .79 Language Module: .48 to .84 Memory Module: .47 to .86 Spatial Module .65 to .67 Executive Functions Module: .45 to .77
Test-retest reliability was evaluated with 95 individuals who were tested twice over an average span of 6 months. Understandably, these average coefficients were somewhat lower and more variable:
These relationships between test and retest NAB scores are respectable, given the lengthy test- retest interval. The validity of the NAB is difficult to summarize concisely, because of the complexity of the instrument. The authors provide extensive documentation on validity, as evaluated from the traditional perspectives, including content validity, factor-analytic evidence of construct validity, and convergent and divergent correlations with similar and dissimilar external measures (all supportive). The authors conclude: Although the data presented in this chapter
support the validity of the NAB, these data
Attention Module: .44 to .87 Language Module: .23 to .70 Memory Module: .41 to .61 Spatial Module .13 to .68 Executive Functions Module: .43 to .64
and analyses should be considered only the beginning steps in the ongoing process of test validation. (Stern & White, 2003b, p. 141)
TABLE 10.11 Modules and Subtests of the NAB
Attention Orientation *
Questions about orientation to self, time, place, and situation
Digits Forward*
Repetition of orally presented digit sequences of increasing length
Digits Backward*
Orally presented digit sequences recalled in reverse order
Dots Delayed recognition of the “new” dot in visual presentation of dots
Numbers & Letters*
Timed tests of letter cancellation, letter counting, serial addition
Driving Scenes
Recognition of what is “new” in presentation of a second driving scene
Language Oral Production
Speech output when the examinee orally describes a picture
Auditory Comprehen sion
Comprehension of orally presented commands and instructions
Naming* Ability to name a pictured object, with cues if necessary
Reading Comprehen sion
Reading comprehension of single words and sentences
Writing Writing sample scored for delivery, legibility, syntax, spelling
Bill Payment
Real world task of writing a check to pay a utility bill
Memory List Learning
Verbal learning of 12-word list with interference trial
Shape Learning*
Visual learning of 9 shapes with delayed recognition
Story Learning*
Verbal learning of a short narrative story of five sentences
Daily Living Memory
Verbal learning of medication instructions, address, phone number
Spatial
*Subtests used on the Screening Module. Temple and Zgaljardic (2009) provide independent evidence for the validity of the Screening Module of the NAB. They note strong associations with a measure of functional
Visual Discriminati on
Matching of stimuli presented visually from an array
Design Constructio n
Assembling a tangram design from individual pieces
Figure Drawing
Drawing task involving copy and recall of geometric shapes
Map Reading
Answering practical questions based on the map of a city
Executive Functions Mazes* Solving paper-and-pencil mazes of
increasing complexity Categories Classifying and categorizing task
based on photos of six people Word Generation*
Creating three-letter words from two vowels and six consonants
Judgment Answering practical questions about home safety and health
independence in a sample of 70 individuals with moderate-to-severe traumatic brain injury at a residential post-acute rehabilitation facility. Yet, Iverson, Williamson, Ropacki, and Reilly (2007) come down on the other side of the fence. In their study of 37 outpatients with neurological problems, results on the Screening Module were better than expected. In other words, in their sample the instrument did not show good sensitivity. We need to keep in mind that the establishment of test validity is a dynamic process, not something set in stone when a test is released. The meaning of tests scores is sharpened and refined by ongoing research. Several recent reports support the validity of the NAB. For example, in a study of 54 patients with TBI and 54 matched controls, Donders and Levitt (2012) found that the Attention, Executive Functions, and Memory modules were highly sensitive to brain impairment. Gavett et al. (2012) reported that the Daily Living memory subtest provided the greatest accuracy in identifying patients with Alzheimer’s Disease. It will prove interesting in
the years ahead to see how additional studies bear on the validity of the NAB. Baseline Testing With Brief Neuropsychological Test Batteries As with most human attributes, variability in neu-rocognitive abilities from one person to the next is substantial. Some people are quick with reaction times, strong in memory skills, and facile with mathematical processing; others innately possess lower levels of ability; and, most of us are somewhere in between. Individual differences present a quandary in assessment, especially when the objective is to identify mild or subtle neuropsychological deficits such as mild traumatic brain injury (mTBI). When do low scores indicate mTBI and when do they signify a typical level of functioning? Access to baseline testing can prove invaluable in making this distinction. For at least two areas of assessment, the acquisition of baseline test data has become the expected practice.
One application of baseline testing is the Automated Neuropsychological Assessment Metrics (ANAM) Traumatic Brain Injury (TBI) Battery used in the armed forces. U.S. military troops deployed to war zones are administered the latest version, the ANAM4 TBI Battery, to obtain baseline neurocognitive performance levels. In situations where a soldier has been exposed to trauma such as an IED blast, retesting with the ANAM4 TBI Battery will help identify the presence of TBI, even if it is mild in severity. The battery was designed to minimize retesting effects by providing a nearly endless source of potential stimuli within each test module. Developed under the guidance of the U.S. Army, the battery is widely available and used in diverse settings worldwide. The full ANAM4 consists of 22 assessments that can be grouped into flexible or standardized batteries. The subtests include measures of reaction time, learning, memory, mathematical processing, spatial processing, executive functions, and symptoms. Based on decades of study by dozens of neuropsychological and
human performance researchers, the subtests are highly sensitive to the impact of brain injury, degenerative disease, toxin exposure, medication effects, and rehabilitation efforts. All modules are administered with a personal laptop computer. For the performance-based measures, stimuli are presented visually, and the left-right mouse buttons are used for the forced-choice options. The ANAM4 TBI Battery consists of eight assessments that can be administered in about 20 minutes, making it highly feasible as a follow-up test when a soldier has been exposed to trauma such as an IED blast. The eight modules are listed in Table 10.12. The ANAM4 software generates a full report providing the examiner with the current neurocognitive status of the soldier, comparisons to previous testing sessions, and comparisons to selected reference and norm groups. Researchers can transfer data in spreadsheet format to preferred statistical packages. Normative data based on extraordinarily large samples are available for the ANAM4 TBI
Battery. Vincent, Roebuck-Spencer, Gilleland, and Schlegel (2012) collected test data from over 107,500 active duty service members 17 to 65 years of age. The norms are carefully stratified by age and gender. The main criticism of ANAM4 is the lack of research on its effectiveness in identifying mTBI in soldiers (Kennedy & Moore, 2010). While it is clear that the individual subtests possess strong psychometric qualities, there is surprisingly little research on such matters as sensitivity and specificity of the overall battery in the identification of mTBI. Another laptop-based neurocognitive battery is ImPACT (Immediate Post-Concussion Assessment and Cognitive Testing), developed in the 1990s by Mark Lovell and Joseph Maroon (Lovell, 2006; Lovell, Iverson, Collins, and others, 2006). ImPACT is intended for sports settings to help in making return-to-play decisions following concussions. The 20-minute battery is widely used in clinical management of concussions for athletes ages 10 through adulthood. The instrument is intended for use
when baseline results are available for individual team members. Impact is a highly popular computer-based testing program that is used in high school, college, and professional sports programs. It should be given only by persons trained in its administration and interpretation. The test developers caution that the battery should never be used as a “standalone” device for diagnosis or decision- making. TABLE 10.12 Subtests of the ANAM4 TBI Battery
Sleepiness scale: A self-assessment of the soldier’s sleepiness/fatigue level on a 7-point scale from “very alert” to “very sleepy.” Mood scale: A self-assessment of the user’s mood state in seven categories (Vigor, Happiness, Depression, Anger, Fatigue, Anxiety, and Restlessness). A number of adjectives related to these mood categories are rated on a 7-point scale. Simple reaction time (SRT): The user clicks the left mouse button when an asterisk appears on the screen at random intervals. A measure of attention and reaction time. Code substitution: A display of digits 1 through 9 appears in a row at the top of the screen with a different symbol above each digit. A series of 72 individual probes appears at the bottom of the screen, each showing a pairing of a digit and symbol. The soldier clicks the left or right mouse button to signify a match or non-match, respectively, with the static display at the top of the screen. A measure of visual search, sustained attention, and encoding. Procedural reaction time: A series of single digits (2, 3, 4, or 5) is presented in 32 trials. The
Source: Based on Eonta, S. E., Carr, W., McArdle, J. J., and others (2011). Automated Neuropsychological Assessment Metrics: Repeated assessments with two military samples. Aviation, Space, and Environmental Medicine, 82, 34-39. ImPACT typically is administered from a laptop computer by an athletic trainer, school nurse, team doctor, or psychologist to help determine when a player is ready to return to the field after a possible concussion from a hard “hit” or other head trauma. The six modules are described in Table 10.13. Dozens of published studies pertain to the reliability and validity of ImPACT. See impacttest.com for a listing of references. We will summarize here two studies on the sensitivity and specificity of test scores in predicting certain outcomes. The reader will recall that sensitivity refers to the percentage of respondents with a known condition who are correctly detected, whereas specificity refers to the percentage of respondents without the condition who are correctly designated. Lau, Collins, and Lovell (2011) followed 108 male
high school football players who sustained a concussion and then divided the group into protracted recovery (14 or more days) before returning to play, and short recovery (less than 14 days) before returning to play. A combination of four symptom clusters and four ImPACT scores yielded a sensitivity of 65 percent and specificity of 80 percent. Schatz, Pardini, Lovell, Collins, and Podell (2006) tested 12 recently concussed athletes with ImPACT and compared the data to results for 66 high school athletes with no history of concussion. The best discriminant function analysis correctly classified 82 percent of participants in the concussion group (sensitivity) and 89 percent of participants in the control group (specificity). These two studies support the overall utility of ImPACT. TABLE 10.13 The Six Modules from the ImPACT Test Battery
Word Discrimination: A measure of attention and verbal recognition memory. Twelve target words are presented for 750 milliseconds each on the computer screen. The list is presented twice. The athlete is tested for recall with the presentation of a 24-word list that includes the 12 target words and 12 non-target words from the same semantic category. For example, if the target word was “carrot” the non-target word might be “celery.” Using the mouse, the examinee clicks “yes” or “no” for each of the 24 stimuli. Design Memory: A measure of attention and visual recognition memory. Twelve target designs are presented for 750 milliseconds each on the computer screen. The designs are presented twice. The athlete is tested for recall with the presentation of 24 designs that include the 12 target designs and 12 non-target designs consisting of the original designs rotated in space. Using the mouse, the examinee clicks “yes” or “no” for each of the 24 designs. X’s and O’s: A measure of visual working memory and visual processing speed. The athlete views a screen of randomly placed X’s
Source: Based on descriptions from impacttest.com and Lovell (2006). But the battery is not without its critics. ESPN contributor Peter Keating (2012) cites a concern about the high false positive rate, and notes the conflict of interest in which the test developers, who have published the vast majority of research on the battery, also are involved in marketing the battery for profit. Further, he notes that . . . in practice, it’s hard for any neuropsychological test to get good data. Some athletes intentionally try to perform poorly on baselines so their post-injury tests won’t keep them out of play. Peyton Manning [Denver Broncos quarterback] admitted to this practice, which players call sandbagging, in April 2011 (ESPN The Magazine, “Concussion Test May Not Be Panacea,” August 26, 2012). After reviewing the available research, Mayers and Redick (2012) conclude that the empirical evidence does not support the use of the battery for making return-to-play decisions. ImPACT likely serves a positive purpose by sensitizing
players, coaches, and others to the dangers of repeated concussion. But as the test developers acknowledge, test results alone should never be the basis for important decisions like returning to play after head trauma. The stakes are high for athletes and their families. In the long-term, repeated blows to the head are known to cause chronic traumatic encephalopathy (CTE), a degenerative brain disease associated with memory loss, confusion, aggression, impulse control problems, Parkinsonian symptoms (tremor, gait abnormalities, slurred speech), and, eventually, progressive dementia (Saulle & Greenwald, 2012). Even “minor” blows to the head that do not result in serious symptoms can lead to CTE if they occur with sufficient frequency, as in boxing or football (McKee, Cantu, Nowinski, and others, 2009). In a recent post-mortem analysis of brain tissue in 85 former football players, hockey players, and military veterans, McKee, Stein, Nowinski, and others (2012) concluded that “for some athletes and war fighters, there may be severe and devastating
long-term consequences of repetitive brain trauma that has traditionally been considered only mild (p. 20).” As a society, we may want to reconsider the glamorization of contact sports like football, boxing, and hockey. 10.22 SCREENING FOR ALCOHOL USE DISORDERS The ways in which people can abuse alcohol include a spectrum of misfortune and tragedy ranging from an occasional hangover to, literally, drinking oneself to death. But clinicians and researchers generally recognize two diagnoses: alcohol abuse and alcohol dependence (American Psychiatric Association, 2000). Loosely speaking, the more generic syndrome of alcoholism refers to either diagnosis. A full discussion of these syndromes is not justified here, but a brief summary is warranted. Interestingly, neither alcohol abuse nor dependence is defined by ingestion of a particular amount of alcohol, although substantial quantities typically are involved. The criteria for alcohol abuse refer to the functional
impact of drinking on the life of the patient. In particular, if an individual meets one or more of four criteria, a diagnosis of alcohol abuse is defensible. Briefly, the criteria are: • Drinking interferes with important life
responsibilities at work, home, or school. • Drinking leads to unsafe behavior such as
driving while intoxicated. • Drinking causes persistent legal problems
such as arrests for fighting. • Drinking leads to conflict with a spouse or
significant other. In addition to meeting one or more of these criteria, the patient must not meet the criteria for a diagnosis of substance dependence, which often entails a more serious and chronic syndrome. Specifically, if a patient meets three or more of seven criteria, a diagnosis of alcohol dependence is warranted. Briefly, the criteria are: • Tolerance or needing increasingly more
alcohol to get the same effect. • Withdrawal symptoms such as tremor when
drinking ceases.
• Drinking in greater quantities or for longer periods than intended.
• Desire to cut down but unsuccessful efforts to control drinking.
• Spending large amounts of time using alcohol or recovering from use.
• Giving up important social, occupational, or recreational activities to drink.
• Continued use in spite of demonstrable health problems such as an ulcer.
Given the high prevalence of alcohol use disorders in the United States, it is nearly inevitable that psychologists and other clinicians will encounter patients who experience problems in this spectrum. Fortunately, there are several simple devices useful for screening and assessment, which we review here. In some cases, these tools are pristinely simple and consist of the clinician casually asking a handful of “yes-no” questions. In other cases, a more traditional paper-and-pencil questionnaire is needed. The CAGE questionnaire is a short screening instrument that consists of the practitioner
asking if the client has thought about Cutting down on drinking, become Annoyed by criticism of his or her drinking, felt Guilty about his or her drinking, or had an Eye-opener drink in the morning. A simple “yes-no” question pertinent to each symptom is asked as part of a general health history. The exact wording of this copyrighted instrument can be found in Ewing (1984). The endorsement of even a single item suggests the presence of an alcohol use disorder, whereas saying “yes” to two or more items virtually guarantees that the patient will meet the criteria for alcohol abuse or dependence. Research indicates that the tool is more effective when it is not preceded by questions about how much or how often the patient drinks (Steinweg & Worth, 1993). Apparently, questions about quantity and frequency trigger denial in the patient, making accurate assessment nearly impossible. The CAGE questionnaire has proved valuable as a screening tool in numerous locations, including general psychological practice and medical settings. In one study of a “walk-in” or immediate-care Veterans hospital
clinic, the test correctly identified 86 percent of patients later confirmed to have alcoholism and accurately ruled out 93 percent of patients later confirmed not to have alcohol problems. Astonishingly, the prevalence rate for alcoholism was determined to be 22 percent for this largely male clinic population (Liskow, Campbell, Nickel, & Powell, 1995). A recent epidemiological study conducted in and around Paris, France, casts doubt on the usefulness of the CAGE test as a screening device for alcoholism (Messiah, et al., 2007). In 2005, the researchers conducted a follow-up to a 1991 study of 1,991 participant responses to the Cut-down, Annoyed, Guilt, and Eye-opener (CAGE) questionnaire through telephone interview of 5,382 residents. The time period in question, 1991 to 2005, was an era in which alcohol consumption was known to be in decline, so it was surprising to the researchers when they found that the percentage of respondents endorsing each of the symptoms had increased substantially. In fact, the magnitude of the paradoxical increase
astonished the researchers. For example, when asked whether they had thought about cutting down on their drinking, the percentage of respondents who answered “yes” increased from 4.3 percent in 1991 to 16.6 percent in 2005. The researchers speculate that the results might indicate the emergence of a temperance movement in France. Whether or not this is true, the findings most certainly cast doubt on the value of the CAGE in general population surveys. Some researchers find that the CAGE questionnaire is more effective for screening with men than women (Cherpitel, 2002). In response to this shortcoming, a similar instrument called the TWEAK questionnaire was developed specifically for women. The acronym refers to Tolerance for drinking, Worried friends or relatives, Eye-opener to get going in the morning, Amnesia for things done or said while drinking, and feeling the need to Kut down on intake (Russell, Martier, Sokol, and others, 1994). TWEAK is scored on a 7- point scale, with the first two items earning two
points each, the last three items earning one point each. A total score of two or more points indicates the likelihood of an alcohol problem. TWEAK is highly accurate in screening for alcohol problems in women (Bradley, Boyd- Wickizer, Powell, & Burman, 1998). CAGE and TWEAK are by no means the only acronymic screening tools for alcohol problems. Other instruments include the five-item RAPS questionnaire or Rapid Alcohol Problems Screen (Cherpitel, 1995) and the 10-item AUDIT questionnaire or Alcohol Use Disorders Identification Test (Saunders, Aasland, Babor, and others, 1993). A huge amount of effort was invested in the development and validation of the AUDIT questionnaire. Research on this instrument was underwritten by the World Health Organization (WHO), and the scale has been translated into many languages. Dozens of additional screening tests could be mentioned, but we want to close this section by reviewing an interesting scale that embodies some appealing methods of test construction. The Substance Abuse Subtle Screening
Inventory-3 or SASSI-3 (Miller, Roberts, Brooks, & Lazowski, 1997) consists of two types of questions: obvious and subtle. The obvious questions include 26 behaviors that are endorsed on a 4-point Likert-type continuum ranging from never to repeatedly. These questions embody high face validity and are on a par with “I have taken drugs to improve how I feel” and “I have had more to drink than I planned.” The subtle questions consist of 67 true-false items that are more indirect and indicative of the attitudes and behaviors that commonly accompany substance abuse. These questions are on par with “I probably break the law more than others” and “I tend to be a responsible person” [reverse scored]. Both types of items—obvious and subtle—were carefully validated during test construction. Test construction consisted of administering a large group of preliminary items to three groups of individuals: substance abusers, non-substance abusers, and substance abusers instructed to “fake good.” The SASSI-3 emerged after this large pool of items was winnowed down to a
smaller number, based on group contrasts. The resulting instrument includes the direct items— those that discriminated substance abusers from non-substance abusers, and the indirect items— those that discriminated the “fake-good” substance abusers from non-substance abusers. In addition to the adult scale, an adolescent version now has been published, and the instrument is available for supervised online administration. A Spanish version also is available. The test developers report excellent reliability for the SASSI-3, with two-week test-retest stability coefficients for 40 respondents ranging from .92 to 1.00 for the subscales and coefficient alpha of .93 for the test overall. A validity study of 419 respondents revealed a 95 percent rate of correct classification for substance abusers and a 93 percent correct classification rate for non-substance abusers— very impressive results for a short screening test (Miller & Lazowski, 1999). Laux, Salyers, and Kotova (2005) found strong test-retest reliability with the SASSI-3 in a sample of 103 college
students, reporting r = .94 over a one-week period. Feldstein and Miller (2007) reviewed 36 studies on all editions of the SASSI and weigh in skeptically, citing high rates of false positives. They propose that public domain instruments (e.g., CAGE, AUDIT) perform just as well and have the added advantage of being free. The SASSI-3 appears to be a capable tool. Yet, given the frequency of its use—the instrument has been administered millions of times—it is disconcerting that few independent studies have been published (Gray, 2001). A search of PsychInfo yielded only 15 studies on the test, and the majority of these were unpublished doctoral dissertations. More research is needed to corroborate the value of this promising inventory. Mini-Mental State Exam The most widely used mental status tool with the elderly is the Mini-Mental State Examination (MMSE), a 5- to 10-minute screening test that yields an objective global
index of cognitive functioning (Folstein, Folstein, & McHugh, 1975; Tombaugh, McDowell, Kristjansson, & Hubley, 1996). The test contains 30 scorable items having to do with orientation, immediate memory, attention, calculation, language production, language comprehension, and design copying. The items are so easy that normal adults almost always obtain scores in the range of 27 to 30 points (Figure 10.9). The reliability of this simple instrument is excellent. Folstein et al. (1975) report a 24-hour test-retest reliability of .89 for 22 patients with varied depressive symptoms. Reliability over a 28-day period for 23 clinically stable patients with diagnoses of dementia, depression, and schizophrenia was an impressive .99. Normative data are available from several sources (e.g., Lindal & Stefansson, 1993; Tombaugh, McDowell, Kristjansson, & Hubley, 1996). Using a cutting score of 23 or below as abnormal and 24 or above as normal, the MMSE is about 80 to 90 percent accurate in identifying elderly patients with suspected
Alzheimer’s disease or other dementia. This cutting score produces few false-positives (normal patients classified as having dementia). The sensitivity of the instrument depends on a number of factors, including the cutting score used, the educational level of the examinee, the extent of the dementia, the nature of the underlying pathology, and the type of setting in which assessments are undertaken (Anthony, LeResche, Niaz, Von Korff, & Folstein, 1982; Tombaugh, McDowell, Kristjansson, & Hubley, 1996; Tsai & Tsuang, 1979). In spite of its limitations, the MMSE remains the most reliable and practical screening test for dementia in the elderly (Ferris, 1992). Drebing, Van Gorp, Stuck, and others (1994) recommend its use as part of a short screening battery for cognitive decline in the elderly.
FIGURE 10.9 Scoring Weights and Domains of the Mini-Mental State Examination Research on the MMSE continues unabated. A search of PsychINFO for articles with “MMSE” in the title yielded 128 hits with 27 of them published since 2010. A final caution is worth mentioning. The MMSE has become so popular that some practitioners use MMSE total scores as a shortcut toward a diagnosis of dementia (Nieuwenhuis-Mark, 2010). Tests should never be used as a substitute for clinical judgment.