28 Portrait

 Neuropsychological
Assessment
Lingering Effects of Brain Trauma

Driving home from work one afternoon, in using environmental feedback to regu-
R.L., a 32-year-old nurse and mother of late or change their behavior. One mani-
four, stopped at a red light. The vehi- festation is response inhibition: patients
cle traveling behind rear-ended her car. with frontal-lobe lesions consistently per-
R.L.’s head snapped back and struck severate on responses in various test sit-
the headrest, then the side window uations, particularly those in which the
as she bounced forward. She blacked solution demands change. The Wisconsin
out for a few minutes, but by the time Card-Sorting Test exemplifies the predic-
the emergency vehicles arrived, she ament of a patient with frontal damage.
was conscious—albeit disoriented and A subject is given a deck of cards con-
dysphasic—and experiencing severe
­ taining multiple copies of those repre-
pain in her back and neck from the whip- sented here. Presented with a row of
lash. Several vertebrae were damaged. four cards selected from among them,
R.L. spent about a week in the hospi- the subject’s task is to place each card
tal. Neither a CT nor an MRI scan iden- from the deck in front of the appropriate
tified any cerebral injury. Nonetheless, card in the row, sorting by one of three
evidence of closed-head trauma (dia- possible categories: color, number of el-
grammed in Figure 26.4) was abun- ements, or shape. Subjects are not told
dant. An accomplished musician, R.L. could still play the correct sorting category but only whether their re-
the piano well from memory, but she could no lon- sponses are correct or incorrect. When a subject se-
ger read music. Her oral language skills remained im- lects the correct category ten consecutive times, the
paired, and she was completely unable to read. correct solution changes unexpectedly.
R.L.’s difficulties did not abate, and she had spells Shifting response strategies is particularly difficult
of apraxia. For example, she often found herself un- for people with frontal damage. R.L. eventually per-
able to figure out how to put on her makeup; she would formed the card-sorting task, but with great difficulty.
stare at her lipstick with no idea how to use it. When Our neuropsychological evaluation revealed a woman
she came to us a year after the accident, R.L. was de- of above-average intelligence with a significant loss
pressed because the neurologists could find no reason of verbal fluency and verbal memory as well as severe
for her continuing impairments. dyslexia even a year after the accident. Nearly 20 years
As described in Section 16.3, perhaps the most com- later, R.L. is still unable to read music and reads text
monly observed trait of frontal-lobe patients is difficulty only with great difficulty.

People with closed-head traumatic brain injuries often show little or no vis-
ible sign of cerebral injury on neuroimaging but still have significant cognitive
deficits, often so severe that they cannot resume their preinjury lifestyles. For
many, the extent of neurological disorder becomes clear only from the results
of neuropsychological tests.
This fundamentally diagnostic role of neuropsychological assessment
has changed radically since its heyday in the 1980s, when clinically trained
793
794  Part V  Plasticit y and Disorders

neuropsychologists and neuropsychological evaluation were regarded as es-

sential in neurological assessment. In this chapter, we describe this changing
role and the opportunities it presents, consider the rationale behind neuro­
psychological assessment and its goals, explain the problem of effort in testing
subjects, and summarize three actual case assessments.

28.1 ​The Changing Face of

Neuropsychological Assessment
Neuropsychological assessment is rooted in neurology and psychiatry. One of
its pioneers was Kurt Goldstein, a clinician who was expert in neurology, psy-
chology, and psychiatry. After World War II, Goldstein and others pushed the
development of psychological assessments for neurological patients, and espe-
cially returning veterans, leading to a divergence of psychological assessment
from traditional medicine by the late 1940s. The first neuropsychological tests
were designed to identify people with cerebral dysfunction attributable to or-
ganic disease processes (brain pathology), rather than to “functional disorders”
linked to behavior.
Although test designers originally believed that a single test for brain dam-
age could be constructed, with a cutoff point that separated the brain-damaged
from the non–brain-damaged patient, the task proved impossible. Gradually,
more-sophisticated testing procedures were developed, largely by teams work-
ing in a few far-flung locations, from Europe and North America to Australia,
and headed by Oliver Zangwill (Cambridge), Freda Newcombe (Oxford), Alex-
ander Luria (Moscow), Brenda Milner and Laughlin Taylor (Montreal), Edith
Kaplan and Hans-Leukas Teuber (Boston), Arthur Benton (Iowa City), and
Figure 28.1 . Kevin Walsh (Melbourne).
Presenting Problems By the early 1980s, neuropsychology was no longer confined to a few elite
Fully 70 percent of all patients laboratories focused on research, and the new field of clinical neuropsychology
undergoing neuropsychological blossomed in clinics and hospitals. Since that time, three factors have enhanced
assessment are referred either for
rehabilitation or in connection
the rate of change in neuropsychological assessment: functional brain imaging,
with medical or psychiatric prob- cognitive neuroscience, and managed health care. We consider each briefly.
lems. (Information from Zillmer and
Spiers, 2001.)
Functional Brain Imaging
Dementia 5% We emphasize the importance of functional imaging in the Snapshots through-
Forensic 7% out the preceding chapters. Whereas in earlier eras the effects of cerebral injury
or disease often had to be inferred from behavioral symptoms, neuroimaging
allows investigators to identify changes in cerebral functioning in a wide va-
Other 8% riety of disorders, including most of the neurological, developmental, and
Rehabilitation 29% behavioral disorders discussed in Chapters 23 through 27.
Learning With the advent of functional neuroimaging, the clinical neuro­
disabled 10%
psychologist’s main role has changed from diagnostician to participant
in rehabilitation, especially in cases of chronic disease such as stroke
Psychiatric 20% Neurological
and head trauma. As charted in Figure 28.1, by the early 2000s neuro­
disease 21%
psychologists were seeing about 3 in 10 patients for rehabilitation and an-
other 4 in 10 as medical referrals. The most common question relates to
general cognitive functioning.
 Chapter 28   Neuropsychological Assessment §28.1  795

Even the most sophisticated functional-imaging techniques often do not

predict the extent of behavioral disturbance observed in people with certain
types of brain injury, especially head trauma, as R.L.’s case illustrates. And
as the Portrait recounts, for people with closed-head injury, often the only
way to document the nature and extent of disability is by a thorough neuro­
psychological assessment (see Christensen and Uzzell, 2000; Zillmer, 2004;
Zillmer et al., 2008). This is where experience in assessment can make a signifi-
cant difference, for neurology as well as for neuropsychology, and ultimately,
for the patient.
In his presidential address to the National Academy of Neuropsychology
on “The Future of Neuropsychology,” Eric Zillmer (2004) argues that neuro­
psychology is the primary method for studying the brain by examining its be-
havioral product. Although certainly useful as a complementary assessment tool,
neuroimaging measures structure, not function. Neurologist Allan Ropper and
Brian Burrell (2014) argue that clinicians and physicians experienced in using
their eyes and ears and brains can diagnose neurological problems as effectively
as those using complex technology. The advantage of neuropsychological as-
sessment for cognitive function is that its measures are quantified objectively,
whereas imaged-based neurology measures are qualitative and subjective.

Cognitive Neuroscience
The growth of clinical neuropsychology promoted a diversification of methods
used by individual practitioners. The choice of tests varies with the disorder
being investigated and the question being asked. From the early 1950s through
the early 1990s, batteries of tests were developed, each with a different focus
(Table 28.1). Many, such as the Halstead–Reitan Battery, retain the concept
of cutoff scores, although performance below a particular level cannot always
be taken as indicative of brain damage.
Among the difficulties with cutoff scores is cerebral organization, which var-
ies with such factors as sex, handedness, age, education, culture, and life experi-
ence. Another is problem-solving strategy: test problems can be solved by using
different strategies and can thus entail different cortical regions. Symptoms of
cortical injury can be highly specific (see the case of J.I., the color-blind painter,

Table 28.1 ​Overview of neuropsychological test batteries

Test Battery Type Basic Reference
Benton’s neuropsychological investigation Composite Benton et al., 1983
Boston Process Approach Composite Kaplan, 1988
Oxford neuropsychological procedures Composite Newcombe, 1969
Montreal Neurological Institute approach Composite Taylor, 1979
Frontal-lobe assessment Composite Stuss and Levine, 2002
Western Ontario procedures Composite Kimura and McGlone, 1983
Halstead–Reitan Battery Standardized Reitan and Davison, 1974
Luria’s neuropsychological investigation Standardized Christensen, 1975
Luria–Nebraska Battery Standardized Golden, 1981
CANTAB Computerized Robbins et al., 1998
796  Part V  Plasticit y and Disorders

described in Section 13.4). Finally, because many tests require various kinds of
problem solving, we might expect task performance to vary with intelligence.
All these factors make the use of cutoff scores difficult to justify.
A serious handicap in developing test batteries was the absence of neuro­
logical theory in test construction or use. Knowledge of brain function was
based largely on clinical observation, and few clinicians other than Alexander
Luria had tried to formulate a general theory of how the brain functions to pro-
duce cognition (shown in Figure 10.17).
The emergence of cognitive neuroscience in the 1990s brought a dramatic
change in the theoretical understanding of brain and cognition. Case studies
once again became popular, each directed by sophisticated cognitive theory and
assisted by structural- and functional-imaging technologies (see Shallice, 1988).
These more-cognitive approaches also use multivariate statistical methods, such
as structural equation modeling, to attempt to understand how the neural net-
works and the connectome are disrupted, both in individual cases and in groups.
Test design now incorporates this knowledge, and the cognitive approach will
continue to change neuropsychological assessment in the future.
Perhaps the greatest influence of cognitive neuroscience is in clarifying
the functions of the right frontal lobe (see a review by Stuss and Levine,
2002). Historically, the right frontal lobe proved remarkably unresponsive
to neuropsychological assessment. The combination of functional imaging
and ­neuropsychological test development has now led to an understanding of
the right frontal lobe’s role in formerly inaccessible functions such as social
cognition (see Section 20.6).

Managed Care
Economics is perhaps the greatest challenge faced by practicing psychologists in
recent decades (see Zillmer, 2004). With the high cost of medical care, clinicians
often face pressure to reduce the time and money spent on neuropsychological
services, which are time consuming and expensive. In particular, the perception
that medical imaging can provide faster and more accurate assessments of cere-
bral dysfunction sometimes fosters unreasonable pressure to reduce the number
of neuropsychological tests given to individual patients.
Clearly, imaging has changed the way in which neuropsychological assessment
will be used, but in head-trauma cases, as R.L. and the many examples of TBI
throughout this book demonstrate, neuropsychological assessment is often the
only way to document cognitive disturbances. Gary Groth-Marnat (1999) sug-
gests that psychologists must develop and promote assessment procedures that:
• Focus on diagnostic matters most clearly linked to treatment choice and
outcomes
• Identify conditions likely to result in cost savings
• Are time efficient
• Integrate treatment planning, progress monitoring, and outcome evaluation
Clearly, clinical assessment has to adapt if it is to survive the challenge of
health care costs. But we emphasize once more that many diagnoses remain
invisible to neuroimaging and can be reached only by careful observation. Im-
proving patient outcomes thus requires teamwork—a combination of medical
 Chapter 28   Neuropsychological Assessment §28.2  797

tests, from blood work to neuroimaging, and neuropsychological assessment—

along with a collaborative effort among practitioners expert in medical, psycho-
logical, and administrative specialties.

28.2 ​Rationale Behind
Neuropsychological Assessment
By the 1990s, neuropsychologists had an impressive choice among tests, as sum-
marized in Table 28.1. At one end of the spectrum are standardized test bat-
teries with fixed criteria for organicity, atypical behavior assumed to have a
biological (organic) basis. Thus, organicity criteria are used to distinguish be-
havioral symptoms from those not directly related to brain pathology. These
tests have in common the advantage of straightforward administration, scoring,
and interpretation. There is little need to understand the theoretical bases
of the tests or the nuances of cerebral organization to administer them. Such
Table 28.2 ​Representative
understanding is necessary for interpretation, however. Examples include
tests used in the Boston
the Halstead–Reitan Battery and the Luria–Nebraska Battery. Process Approach battery
More recently, Trevor Robbins and his colleagues at the University of
Cambridge devised a computerized version of a standardized battery, the Intellectual and Conceptual Functions
Cambridge Neuropsychological Test Automated Battery (CANTAB), that Wechsler Adult Intelligence Scale IV
has the advantage of being administered in a highly structured manner (e.g., Raven’s Standard Progressive Matrices
Robbins et al., 1994; 1998). CANTAB has been used extensively for research Shipley Institute of Living Scale
and increasingly in clinical practice. At last count, over 600 publications were Wisconsin Card-Sorting Test
using the CANTAB, although to date it has not been directly compared to Proverbs test
older comprehensive test batteries (see Smith et al., 2013, for a discussion). Memory Functions
At the other end of the testing spectrum are individualized test ­batteries Wechsler Memory Scale IV
that require particular theoretical knowledge to administer and interpret. Rey Auditory Verbal Learning Test
These assessments are more qualitative than quantitative. The testing of each Rey Complex-Figure Test
patient is tailored both to that person’s etiology and to the qualitative nature Benton Visual-Recognition Test
of his or her performance on each test. An example is Luria’s neurological Consonant trigrams test
approach, which is not really so much a test battery as a strategy for examin- Cowboy Story-Reading Memory Test
ing patients. (The Luria–Nebraska Battery was an attempt to make Luria’s
Language Functions
procedure more structured and quantitative, but the process made the battery
Narrative writing sample
into a completely different analysis.)
Tests of verbal fluency
Composite test batteries occupy a middle ground between the standard-
Visual-perceptual functions
ized and individualized batteries. Each test is administered in a formalized way
Cow-and-circle experimental test
and may have comparison norms, but qualitative performance and the pattern
Automobile puzzle
of test results are considered. An example is the Boston Process Approach
Parietal-lobe battery
(Table 28.2). Arthur Benton and his colleagues (Benton et al., 1983; Benton,
Hooper Visual Organization Test
1994) have described other composite batteries that can be tailored to indi-
viduals, as have Muriel Lezak et al. (2012), Pat McKenna and Elizabeth War- Academic Skills
rington (1986), William Milberg and his colleagues (1986), Freda Newcombe Wide Range Achievement Test
(1969), Aaron Smith (1981), Laughlin Taylor (1979), and Kevin Walsh (1991). Self-Control and Motor Functions
Across this spectrum, each battery is constantly changing in response to Proteus Maze Test
test revisions and developments as well as to the clinical population being Stroop Color-Word Interference Test
evaluated. One constraint on the choice of any test, however, is the clinical Luria Three-Step Motor Program
neuropsychologists’ training. The use of tests based on theory requires an Finger tapping
understanding of the theory of cerebral organization.
798  Part V  Plasticit y and Disorders

Factors Affecting Test Choice

Throughout this book, you have seen that circumscribed lesions in different
cortical regions can produce discrete behavioral changes. Working backward
from this knowledge to localize unknown brain damage seems reasonable. That
is, given a particular behavioral change, we should be able to predict the site or
sites of the disturbance most likely to be causing the change.
Problems emerge in working backward in such a manner, however. Re-
search patients are often chosen for specific reasons. For example, whereas
patients with rapidly expanding tumors would not be chosen for research be-
cause their results are so difficult to interpret, neurosurgical patients are neuro­
psychologists’ ideal research subjects because the extent of their damage is
known. Therefore, we might expect differences in the neurological disorder’s
etiology to make assessment difficult. Indeed, people with diffuse dysfunction,
as in head trauma, likely would perform very differently from people with sur-
gical removals.
Even after the practitioner has chosen tests appropriate for a specific etiol-
ogy, significant questions must be resolved. First, how sensitive are the tests?
If a large brain region is dysfunctional, the assessment test need not be par-
ticularly sensitive to demonstrate the dysfunction. If the lesion is small, on the
other hand, the behavioral effect may be rather specific. For example, a lesion
in the right somatosensory representation of the face may produce very subtle
sensory changes, and unless specific tests of nonverbal fluency are used (see,
for example, Figure 16.9), the cognitive changes may go unnoticed, even with
dozens of tests.
A related problem is that various factors may interact with brain pathology
to make interpreting test results difficult. Both age and ethnic or cultural back-
ground can influence test performance. Therefore, as noted in Section 28.1, test
scores with strict cutoff criteria cannot be interpreted.
Intelligence also alters an investigator’s expectations of test performance:
someone with an IQ score of 130 may be relatively impaired on a test of ver-
bal memory but may appear typical compared with someone with an IQ score
of 90. Thus, unlike standard, quantitative psychometric assessment, neuro­
psychological assessment must be flexible. This flexibility makes interpretation
difficult and requires extensive training in fundamental neuropsychology and
neurology as well as in neuropsychological assessment. (For an interesting legal
discussion related to flexible batteries, see Bigler, 2008.)
Finally, significant differences in test performance are related to factors such
as sex and handedness, both detailed in Chapter 12. In addition, test perfor-
mance is often biased by demographics. For example, in one three-city study
of the effects of head trauma, investigators found that healthy participants in
one city performed as poorly as brain-damaged subjects in another. Significant
demographic differences influenced test performance and thus had to be con-
sidered in interpreting test results.

Goals of Neuropsychological Assessment

The goal of assessment in general clinical psychology is diagnosing a disorder
for the purpose of changing behavior. For example, to aid in teaching, intel-
ligence and achievement tests may be given to schoolchildren with the goal of
 Chapter 28   Neuropsychological Assessment §28.2  799

identifying particular problem areas (poor short-term memory, for example, or

slow reading). Similarly, personality tests are used with an eye toward defining
and curing a behavioral disorder, such as generalized anxiety.
The goals of clinical neuropsychology are different in some respects. Neuro­
psychological assessment:
• Aims to determine a person’s general level of cerebral functioning
and to identify cerebral dysfunction and localize it where possible. In
doing so, the assessment attempts to provide an accurate and unbiased esti-
mate of a person’s cognitive capacity.
• Facilitates patient care and rehabilitation. Serial assessments can pro-
vide information about the rate of recovery and the potential for resuming
a former lifestyle.
• Identifies mild disturbances when other diagnostic studies have pro-
duced equivocal results. Examples are the effects of head trauma or the
early symptoms of a degenerative disease.
• Identifies unusual brain organization that may exist in left-handers
or in people who have had a childhood brain injury. This informa-
tion is particularly valuable to surgeons, who would not want, for example,
to remove primary speech zones inadvertently while performing surgery.
Such information is likely to be obtained only from behavioral measures.
• Corroborates an abnormal EEG in disorders such as focal epilepsy.
Indeed, the primary evidence may emerge from behavioral assess-
ment, because radiological procedures, including noninvasive imaging,
can fail to identify specifically the abnormal brain tissue giving rise to
the seizures.
• Documents recovery of function after brain injury. Because some
recovery may be expected, documentation aids not only in planning for
rehabilitation but also in determining the effectiveness of medical treat-
ment, particularly for neoplasms (tumors) or vascular abnormalities.
• Promotes realistic outcomes. Assisting a patient and the patient’s family
in understanding the patient’s possible residual deficits facilitates setting
realistic life goals and planning rehabilitation programs.

Intelligence Testing in Neuropsychological

Assessment
Most neuropsychological assessments begin with a measure of general intel-
ligence, most often one of the Wechsler scales, which have proved invaluable
in determining a base level of cognitive functioning. The most recent version,
released in 2008, is the Wechsler Adult Intelligence Scale—Fourth Edition
(WAIS-IV), which is normed on people aged 16 to 90. The WAIS-IV has 10
core subtests and 5 supplemental subtests.
The 10 core subtests comprise the Full Scale IQ (FSIQ). Earlier editions of
the Wechsler Scale (Wechsler-Bellevue, WAIS-R, and WAIS-III) used sepa-
rate scales to establish a verbal and a performance IQ score. In the WAIS-IV,
these two scales have been replaced by five index scores: General Ability Index
(GAI), Verbal Comprehension Index (VCI), Perceptual Reasoning Index (PRI),
800  Part V  Plasticit y and Disorders

Working Memory Index (WMI), and Processing Speed Index (PSI). The FSIQ
has a mean of 100 and a standard deviation of 15, and the manual states that for
clinical decision making, the VCI and PRI indexes now substitute for the Verbal
and Performance IQ scores (Hartman, 2009).
An advantage of the WAIS-IV is that it can be given more quickly than the
WAIS-III (about 70 versus 80 or more minutes, respectively), an important im-
provement for testing patients who might fatigue easily. A briefer test can be
given by using only the GAI, which yields a composite score based on three VCI
subtests and three PRI subtests. The GAI correlates at 0.97 with the FSIQ and
may provide a “purer” estimate of intelligence in older or disabled adults with
compromised memory and/or motor function (Hartman, 2009).
Sufficient studies have not as yet been conducted to determine the usefulness
of the five WAIS-IV indexes in neuropsychological assessment, although there
are hints that they might prove useful. For example, adults with ADHD show sig-
nificant decrements in WMI and PRI relative to matched controls (Theilling &
Petermann, 2014). Similarly, TBI patients show a specific decrement in process-
ing speed relative to neurologically healthy controls (Donders & Strong, 2014).
Although the verbal and performance scales of earlier WAIS versions were
not designed to measure left- and right-hemisphere functions, respectively, the
FSIQ core subtests have proved useful as a rough measure. FSIQ scores ob-
tained on both the VCI and PRI have a mean of 100 and a standard deviation
of 15. A difference of more than 10 points between the verbal comprehension
and the perceptual reasoning index scores is usually taken as clinically signifi-
cant, although statistically this interpretation is liberal.
The results of numerous studies on earlier editions of the Weschler Scales
demonstrate that well-defined left-hemisphere lesions produce a relatively low
verbal IQ score compared with performance score, whereas well-defined right-
hemisphere lesions produce a relatively low performance score. Diffuse damage,
on the other hand, tends to produce a low performance score, leading to the er-
roneous belief that the verbal–performance IQ difference was not diagnostically
useful. Although a reduced performance score was not definitive, study results
reveal that obtaining a relatively low verbal IQ was rare and that its appearance
should not be ignored.
Elizabeth Warrington and her colleagues (1986) evaluated the WAIS-R sub-
scales and IQ values in a retrospective study of 656 unselected patients with
unilateral brain damage. Overall, their results showed that left-hemisphere le-
sions depress verbal IQ scores, whereas right-hemisphere lesions depress per-
formance IQs. The exception in both cases is occipital lesions.
However, the verbal–performance discrepancy score was fewer than 10 points
in 53 percent of left-hemisphere cases and in 43 percent of right-hemisphere
cases. A small number of patients had discrepancy scores greater than 10 points
in the opposite direction: 6 percent of those with left-hemisphere lesions and
3 percent with right-hemisphere lesions. (It is curious that the patients with left
parietal or temporoparietal lesions did not show a large drop in IQ score, con-
sidering, presumably, that they would be dysphasic. Because language skills were
not mentioned in the Warrington study, her analysis could have excluded apha-
sic subjects. In our experience, dysphasic patients have very depressed verbal IQ
scores, as would be expected.)
 Chapter 28   Neuropsychological Assessment §28.2  801

Warrington also analyzed a subset of WAIS-R subtests, including four

verbal instruments (arithmetic, similarities, digit span, and vocabulary) and
three performance (nonverbal) tests (picture completion, block design, and
picture arrangement). Overall, the performance of left-hemisphere frontal,
temporal, and parietal patients was significantly poorer on the four verbal
tests. No differences appeared between these left-hemisphere groups on the
tests, however. The performance tests were less predictive of lesion side be-
cause only the right parietal patients were significantly poorer on block de-
sign and picture arrangement. These conclusions will likely prove true of the
WAIS-IV as well.
Postinjury intelligence testing is useless without a premorbid estimate of in-
tellectual level. A relatively low IQ score cannot be ascribed to a brain injury
unless there is some idea of what the score was before the injury. Such esti-
mates usually are informal and based on a patient’s education, occupation, and
socioeconomic background. Robert Wilson and his colleagues (1979) describe
a statistical procedure for estimating premorbid IQ scores.
Other related Wechsler scales are the Wechsler Memory Scale (WMS‑IV)
and Wechsler Intelligence Scale for Children (WISC-IV). Although the
WMS‑IV and WAIS-IV both measure memory, each measures distinct mem-
ory functions and should be seen as complementary (e.g., Lepach et al., 2013).

Categories of Neuropsychological Assessment

Eric Zillmer and Mary Spiers (2001) reviewed a survey of 2000 neuro­
psychologists and identified the 10 most frequently used categories of neuro­
psychological assessment tests, summarized in Table 28.3. Several volumes
catalogue the range of neuropsychological tests available, the two most ex-
tensive being those by Muriel Lezak and her colleagues (2012) and by Otfried
Spreen and Esther Strauss (1991).
Deborah Waber and her colleagues (2007) published a landmark longitudi-
nal study of neuropsychological performance in children aged 6 to 18 years in
which normative data are presented for a wide range of measures. For many
measures, raw scores improved steeply from 6 to 10 years of age before decel-
erating during adolescence. Household income predicted IQ and achievement

Table 28.3 ​Ten commonly assessed neuropsychological categories

Abstract reasoning and conceptualization (e.g., problem solving, executive functions)
Attention (e.g., selective, sustained, shifting, or neglect)
Daily activities (e.g., toileting, dressing, eating)
Emotional or psychological distress (e.g., depression, impulsivity)
Language (e.g., receptive or expressive speech, aphasia)
Memory (e.g., verbal, visual, working)
Motor (e.g., dexterity, speed, strength)
Orientation (e.g., awareness of place, time)
Sensation and perception (e.g., visual acuity, taste/smell, tactile)
Visuospatial (e.g., construction, route finding, facial recognition)
Data from Zillmer and Spiers, 2001.
802  Part V  Plasticit y and Disorders

scores but not other test performance. The neuropsychological scores are linked
to an MRI developmental database.
Sports medicine is a growing area for neuropsychological assessment. Of
particular interest is tracking athletes with concussions. Alison Cernich and
colleagues (2007) describe a test battery (the Automated Neuropsychological
Assessment Metrics Sports Medicine Battery, ASMB) specifically designed for
use in concussion surveillance and management. The ASMB is currently being
refined with the development of appropriate norms and with the goal of pre-
testing athletes in sports with high incidence of concussion (for example, U.S.
football and ice hockey). This type of battery has a clear utility, given the num-
ber of athletes in professional football and university hockey who experience
lingering effects from head injuries (see Chapter 25 Portrait and Section 26.3).

28.3 ​Neuropsychological Tests and

Brain Activity
Neuropsychological tests have been developed to identify cerebral dysfunc-
tion under the presumption that they actually measure the activity of specific
cerebral regions. However, cognitive processes correspond to the activity of
widely distributed neural networks (see Section 19.3 for examples in language
processing). One means for examining the question of what brain regions are
active during specific tests employs noninvasive imaging as control participants
perform one or more tests.
The most common studies focus on brain activation during frontal-lobe tests
such as the Wisconsin Card-Sorting Task. Julie Alvarez and Eugene Emory’s
meta-analysis (2006) of such studies reveals clearly reliable activation of frontal
regions when subjects perform tasks such as the Wisconsin Card-Sorting Test,
Stroop Test, and Chicago Word-Fluency Test (see Section 16.3 for test details).
But activation always appears in other cerebral regions too, even when studies
use subtraction methods (see Figure 7.15) to reduce general activity related to
noncognitive functions such as sensory processing. This more extended acti-
vation presumably occurs because the frontal cortex participates in several ex-
tended brain networks. Preceding chapters illustrate a wide range, for example
in Figures 16.17, 17.3, and 20.12.
Such results suggest that the interpretation of neuropsychological test per-
formance should move away from the historical anatomical localization ap-
proach, in which anatomy and function are inseparable, to an approach more
consistent with the developing view of connectivity and extended neural net-
works. Indeed, we have seen dozens of cases in which patients with verified lo-
calized brain injuries fail to show symptoms that we would expect on the basis
of our experience and cases that may actually show some symptoms that we
would not predict.
Neuropsychologists must remain cognizant of the facts: considerable inter­
subject variation exists in brain organization; the effects of education and spe-
cific experiences (for example, playing video games or not) are great; and large
individual differences emerge in how cognitively engaged aging people remain.
All of these factors will influence both test performance and the specificity of
brain activation.
 Chapter 28   Neuropsychological Assessment §28.4  803

28.4 ​The Problem of Effort

A major challenge for neuropsychologists is determining whether subjects are
performing tests as requested or are malingering, typically by exaggerating their
cognitive deficits. The American Psychiatric Association’s DSM-5 (2013) de-
fines malingering as “the intentional production of false or grossly exaggerated
physical or psychological symptoms, motivated by external incentives such as
avoiding work, obtaining financial compensation, evading criminal prosecution,
or obtaining drugs.”
Paul Green and his colleagues (2001) gave 904 consecutive patients a bat-
tery of neuropsychological tests, including a test of effort. Suboptimal effort
suppressed the overall test-battery performance four and a half times as much
as moderate to severe brain injury did. Their conclusion: effort has a greater
effect on test performance than brain damage. In a follow-up study, Green
(2007) also found that poor performance on tests of effort not only affects
memory performance but actually influences performance across the entire
test battery.
Although we would like to hope that expert clinicians would be able to detect
malingering, the consensus is that clinical judgment is not impressive. The only
valid method of assessing a lack of effort appears to be the use of specific tests
of effort. Among the variety of tests published over the years, the most sensi-
tive is consistently found to be the Forced Choice Digit Memory Test devised
by Merille Hiscock (see, for example, Guilmette et al., 1994).
The test is extremely simple: subjects are shown a number (for example,
56093) and are then immediately shown two numbers, including the first one
and a novel one (for example, 56093 and 82104) and asked which of the two
they have already seen. Jeanette McGlone at Dalhousie University has shown
that even severely amnesic patients usually score nearly perfectly on a series of
32 trials, provided that they are not distracted (McGlone, 2007). People faking
memory problems may score as low as chance, indicating a lack of effort and
invalidating the entire assessment. A cutoff of no lower than 90 percent correct
is generally used in scoring the Forced Choice Digit Memory Test.
Although the actual incidence of malingering is unknown, at least 20 percent
of people with head traumas or alleged exposure to toxic substances are likely
to exert low effort intentionally. Such estimates emphasize the need to employ
testing measures such as the Forced Choice Digit Memory Test in any assess-
ment in which an advantage accrues to the test subject, such as in cases involv-
ing potential financial compensation.
The question of motivation in test performance is perhaps most clearly
shown in a comparison of neuropsychological test performance between people
with mild head injury seeking compensation from the Workers’ Compensation
Board and people ordered by a court to undergo a parenting assessment. The
former group gains financially by doing poorly and the latter group by doing
well: they retain custody of their children. Lloyd Flaro and his colleagues (2007)
found that the group seeking compensation was 23 times as likely to fail a test
of effort as those in the parenting group. In fact, the mild TBI group was twice
as likely to fail the test as the more severe TBI group. Such effects cannot be
explained by differences in cognitive skills, but they are explainable by differ-
ences in external incentives.
804  Part V  Plasticit y and Disorders

  28.5 ​Case Histories
Having surveyed the basic principles of neuropsychological theory and assess-
ment, we now apply the tests and the theory in considering the case histories
and test results of three patients. This sampling of clinical problems illustrates
the use of neuropsychological tests in neuropsychological assessment.
Because of our affiliation with the Montreal Neurological Institute, our com-
posite assessment battery is based on tests derived from the study of neuro­
surgical patients by Brenda Milner, Laughlin Taylor, and their colleagues. Most
of the tests have been discussed elsewhere in the text, especially in Chapters 14
through 16 in relation to neuropsychological assessment of parietal-, temporal-,
and frontal-lobe function.

Case 1: Epilepsy Caused by

Left-Hemisphere Tumor
This 33-year-old man had a history of seizures beginning 4 years before his ad-
mission to the hospital. His neurological examination on admission was nega-
tive, but his seizures were increasingly frequent and characterized by his head
and eyes turning to the right, a pattern that suggests supplementary motor cor-
tex involvement. The results of radiological and EEG studies suggested a left-
frontal-lobe lesion (Figure 28.2 at left), which was confirmed at surgery when
a poorly differentiated astrocytoma was removed.
The only difficulty that the patient experienced before surgery was in doing
the Wisconsin Card-Sorting Test, where he made numerous perseverative
­errors and sorted only one category correctly. Two weeks after surgery, all of
the intelligence ratings, memory quotients, and delayed verbal-recall scores de-
Figure 28.2 .
creased, but they remained in essentially the same ratio to one another. Other
Neuropsychological Test tests were unchanged, the only significantly low score again being on the card-
Results Before and After sorting test.
Surgery in Two Cases

Case 1 Left-frontal- Case 2

lobe lesion
Right-face-area lesion
extending into frontal lobe

Preop Postop Preop Postop

Full-scale IQ 115 102 Full-scale IQ 97 97
Verbal IQ 111 103 Verbal IQ 100 106
Performance IQ 117 99 Performance IQ 94 88*
Memory quotient 118 108 Memory quotient 94 92
Verbal recall 20 14 Verbal recall 13.5 14.0
Nonverbal recall 10.5 10 Nonverbal recall 3.5* 7.0
Card sorting 1 category* 1 category* Card sorting 0 category* 1 category*
Finger-position sense Left Right Left Right Finger-position sense Left Right Left Right
60/60 60/60 60/60 60/60 55/60* 59/60 54/60* 60/60
Drawings: Copy 36/36 35/36 Drawings: Copy 28/36* 26.5/36*
Recall 21/36 24/36 Recall 4/36* 9.5/36*
* Significantly low score. * Significantly low score.
 Chapter 28   Neuropsychological Assessment §28.5  805

If this patient was like other patients with similar lesions, on follow-up a year
after surgery, his intelligence ratings and memory scores would likely have re-
turned to the preoperative level. His card sorting, however, would be unlikely
to show any improvement.

Case 2: Epilepsy Caused by

Right-Hemisphere Infection
This 26-year-old man had an 8-year history of seizures dating to an episode
of meningitis in which he was thought to have an intracerebral abscess. Sub-
sequently, he developed seizures beginning in the left side of his face and left
hand. He was referred as a candidate for surgery because his seizures were un-
controlled by medication.
Before surgery, the patient scored within normal limits on tests of intelli-
gence and general memory, although he did have difficulty with delayed recall
of verbal material. He had slight defects of finger-position sense on the left
hand, which, together with some weakness in the left arm and leg, pointed to
damage in the right central area of the cortex. In addition, he had difficulty
copying and recalling the Rey Complex Figure and was unable to perform the
Wisconsin Card-Sorting Test, suggesting that his lesion might extend into the
frontal and temporal areas as well.
The right facial area and a region extending into the right frontal lobe were
removed at surgery (Figure 28.2 at right). Afterward, some residual epilep-
tiform abnormality in both the frontal lobe and the superior temporal gyrus
remained. Postoperative testing showed improvement in both verbal IQ score
and long-term verbal memory, but the patient had persistent difficulties on the
card-sorting test, with finger-position sense on the left hand, and on the copy
and recall of the Rey Complex Figure. His performance (perceptual reasoning
index) IQ score also declined.
The difficulty with finger position would be expected in such a case, but the
continuing difficulties with card sorting and the Rey Complex Figure imply that
areas in his right hemisphere remain dysfunctional. This dysfunction is seen in
residual abnormalities in the EEG recordings from the frontal and temporal
regions.

Case 3: Rehabilitation
This 37-year-old man had been in a traffic accident some 15 years earlier. He
was in a coma for 6 weeks and had secondary injury from brain infection. At
the time of his accident, he was a student in a graduate program in journal-
ism, having previously obtained a bachelor’s degree with honors in English
literature.
When we first met him, he had severe motor problems, used canes to walk,
and was both apraxic and ataxic. He had great difficulty in pronouncing words,
especially when hurried or stressed, but careful language testing on the Token
Test revealed no aphasic symptoms; his language problems were entirely due to
a difficulty in coordinating the muscles of the mouth (anarthria).
Since the time of his accident, this man had lived at home with his parents
and had not learned the social skills necessary to cope with his handicap. In
short, he was being treated as though he were intellectually disabled and was
806  Part V  Plasticit y and Disorders

being completely looked after by his family. Indeed, the patient believed himself
to be intellectually disabled and was very reluctant to attempt rehabilitation.
At his family’s urging, we administered a thorough assessment to evaluate his
intellectual potential. The results were surprising, even to us. His intellect was
superior (WAIS verbal IQ score of 127) and although he had deficits on some
tests, especially those requiring motor skills, his performance on most tests was
average or above average. Despite his obvious motor handicaps, this man clearly
was not intellectually disabled.
One significant cognitive loss, however, was his nonverbal memory, which
was very poor. Armed with our test results, we were able to show him—and his
family—that he could look after himself and should seek occupational therapy.
He is now a chartered accountant in Canada, equivalent to a certified public
accountant (CPA) in the United States.

SUMMARY
28.1 ​The Changing Face of of assessment varying with the particular clinical question
Neuropsychological Assessment being asked. Analysis of test results must consider a range
Developments in functional and structural brain imaging of variables including age, sex, handedness, cultural back-
have had a significant impact on the fields of neurology and ground, IQ score, and life experience.
clinical neuropsychology. Whereas neuropsychological as- 28.3 ​Neuropsychological Tests and Brain Activity
sessment had promised a way to localize focal cerebral injury,
One way to validate neuropsychological tests is to measure
medical imaging techniques now have largely replaced this
brain activity as subjects perform them. Although activity in
function. But imaging cannot detect all neurological dysfunc-
the expected regions is usually enhanced, activity elsewhere
tion. Rather, the most sensitive measure of cerebral integrity
in the brain increases as well, corresponding to the wide-
is behavior, and behavioral analysis using neuropsychological
spread neural networks within the connectome that underlie
assessment can identify dysfunction invisible to MRI or CT,
cognition. Such results remind us that test performance does
especially in cases of TBI, epilepsy, and mild stroke.
not necessarily equate to focal neural anatomy.
The tests used in neuropsychological assessment and the
use of test results have changed, owing in part to the con- 28.4 ​The Problem of Effort
tinuing development of cognitive neuroscience and enhanced Lack of effort poses a serious problem for assessing people
neuroimaging. Tests remain useful for diagnosis and have ex- who might benefit from doing poorly on neuro­psychological
panded to become integral to rehabilitation. This changing tests. If subjects are seeking compensation of some sort, for
role has economic implications as managed health care chal- instance, lack of effort invalidates the entire assessment.
lenges the cost of extensive neuropsychological evaluations, Several tests that are simple to administer can detect a lack
especially when adequate imaging data are available, regard- of effort.
less of its effectiveness.
28.5 ​Case Histories
28.2 ​Rationale Behind Despite technological advances, case histories demonstrate
Neuropsychological Assessment that neuropsychological assessment remains an important tool
A wide range of clinical neuropsychological assessment tools for demonstrating functional localization after discrete func-
is now available, the factors affecting test choice and the goals tional injury and for assisting in planning for rehabilitation.

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