1 Outline 1. Neuropsychological Assessment a.Goals of neuropsychological assessment b.Psychometric approach – advantages c.Psychometric approach – interpretation 2. IQ and Neuropsychological Testing 3. Malingering

2 Outline 4. Neuropsychological Test Batteries a. Halstead-Reitan 5. Functions of interest to neuropsychologists a.Laterality b.Visual Perception c.Language d.Memory e.Attention & Executive Control

3 1. Neuropsychological Assessment Goals Diagnosis What happened that damaged the patient’s brain?

4 1. Neuropsychological Assessment Goals Description What went wrong cognitively, emotionally, or behaviorally as a result?

5 1. Neuropsychological Assessment Goals Tracking changes Observe changes in patient’s performance over time, to monitor healing/worsening and effects of treatment

6 1. Neuropsychological Assessment – advantages Standardized: Repeatable instructions, presentation, and tasks Norms Intensive: Multiple measures within and among wide range of domains

7 1. Neuropsychological Assessment – advantages Sensitive Valid indicators of skills, capable of detecting abilities and deficits Scaled Hierarchical items Start/stop rules

8 1. Neuropsychological Assessment – advantages Precise Allows reliable, exacting quantification of relative abilities Allows comparison within/over time

9 1. Neuropsychological Assessment Interpretation Quantitative observations: Many tests give standardized scale scores (like Wechsler tests) based on norms

10 1. Neuropsychological Assessment Interpretation Actuarial results (e.g., Boston Aphasia Battery) – profile of subtest scores indicates nature of disorder

11 1. Neuropsychological Assessment Interpretation Cut-off scores used to make decisions How are cut-offs set? Norm-referenced? Criterion-referenced?

12 1. Neuropsychological Assessment Interpretation Neuropsychologists also make up tests as needed – these typically are not standardized, so interpretation may be problematic.

13 1. Neuropsychological Assessment Interpretation Example: line-crossing task used to detect “neglect” following right-hemisphere brain damage

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15 1. Neuropsychological Assessment What do we know about the line-crossing test? What cognitive operations are involved in test performance? Why do neglect patients fail at this test? Is this test valid? Reliable?

16 2. IQ and neuropsychological testing Estimating pre-morbid IQ may be necessary to determine whether there is actual loss of function or capacity. Often difficult to use a regular IQ test with patients

17 2. IQ and neuropsychological testing Estimating pre-morbid IQ – Clinical approaches Education Vocabulary Occupation, farm size Functional capacities

18 2. IQ and neuropsychological testing Actuarial & psychometric approaches Demographic formulas Reading level Subtest pattern

19 3. Malingering Faking a disorder or deficit. Important for legal and financial reasons – people sometimes fake a deficit in order to collect insurance payments, or to fraudulently obtain narcotics

20 3. Malingering Tests to catch malingering usually based on fact malingerers don’t know what real deficits look like – they often show too much loss of function. Munchausen Syndrome – psychopathology involves faking illness, but not for money or drugs Rarely treated successfully

21 4. Neuropsychological test batteries Test batteries – large sets of tests Wide variety of tests to tap many different skills and abilities Developed before the era of brain scanning, in part to help locate site of brain damage

22 To use test batteries or not? On the plus side: Many batteries have known psychometric properties (e.g., reliability, validity). Use of standardized procedure permits comparison of one patient with others, even if the others are tested by different clinicians. Tests cover a wide range of cognitive functions and behaviors

23 To use test batteries or not? On the minus side: Test-centered rather than patient-centered Time-consuming Patient may fail a test for many different reasons Batteries are developed for general purposes – may lack flexibility to assess any given patient’s idiosyncratic deficits. May reduce clinician’s potentially useful curiosity, lead to “cookie-cutter reports.”

24 4a. HRNTB Ward Halstead Ph.D. psychologist, taught in U Chicago Medical School Through 1940s, devised and tried out many tests for use with brain-damaged patients With his student Ralph Reitan, settled on a battery of tests that allowed comprehensive evaluation of BD patients

25 Reitan’s four-fold approach Inferential decision- making using the HRNTB based on: Level of performance Pattern of performance Specific behavioral deficits Comparison of two sides of the body (right- left comparisons)

26 Reitan’s four-fold approach Level of performance Comparison of individual with normative groups of impaired and non- impaired persons

27 Reitan’s four-fold approach Pattern of Performance Examination of intra- test performance and subtest scores

28 Reitan’s four-fold approach Specific Behavioral Deficits Sensitivity to deviant or deficient performance which, of itself, points to impairment

29 Reitan’s four-fold approach Comparison of Two Sides of the Body Looking for discrepancies in test performance which may reveal weakness or lateralized impairment

30 4a. HRNTB Category test Tests abstraction and reasoning Tactual performance test Manual dexterity, spatial memory, tactile discrimination Seashore rhythm test & Speech-sounds perception test Attention, concentration, auditory discrimination Finger tapping test Motor speed and manual dexterity

31 4a. HRNTB Trail making (see below) Reitan-Indiana Aphasia Screening Examination Reitan-Klove Sensory Perceptual Examination Version of standard neurological screening test for sensory processes Strength of Grip Test Uses hand dynamometer Lateral Dominance Examination

32 Functions of interest to neuropsychologists a. Laterality b. Visual Perception c. Language d. Memory e. Attention & Executive Control

33 5a. Laterality Compares functions of the L and R hemispheres of the cortex Especially important if neurosurgery is planned: where are language functions? Language functions are in left hemisphere in most people, bilateral in some Annett Handedness Questionnaire

34 Annett Handedness Questionnaire Please indicate which hand you habitually use for each of the following: (R, L or E) 1. Writing 2. Throwing a ball 3. Holding a racquet 4. Striking a match 5. Cut with scissors 6. Threading a needle 7. At top of broom 8. At top of shovel 9. To deal cards 10. To hammer a nail 11. To hold a toothbrush 12. To unscrew a lid There are several ways to score this test

35 5b. Visual Perception Visual field deficits Informal assessment by clinician More precise assessment requires special optometry equipment.

36 5b. Visual Perception Agnosia – inability to recognize familiar objects visually. To test – ask patient to name various objects Meaning of objects has not been lost –it’s a deficit of visual recognition.

37 Visual agnosias visual object agnosia – inability to identify common visual objects prosopagnosia – inability to recognize familiar faces color agnosia – inability to discriminate between colors and to name colors simultanagnosia – visual perception of simultaneously presented objects is impaired

Figure/ground discrimination – separate figure from background

The embedded figures test – task is to find all the objects in this figure.

The objects in the embedded figures test stimulus

41 Visual Memory Rey-Osterrieth figure complicated, abstract figure (next slide) patient looks at it briefly then asked to reproduce the figure from memory scoring is quite complex assesses visual memory, visual construction skill

The Rey-Osterrieth Complex Figure (Osterrieth, 1946)

43 5c. Language A very important function for humans, typically mediated by left hemisphere Expressive and receptive language can be independently lost or spared

44 5c. Language Batteries include Boston Diagnostic Aphasia Examination and Western Aphasia Battery (developed at UWO School of Medicine) Task-specific tests used with patients having comparatively isolated dysfunctions

45 Boston Diagnostic Aphasia Examination Oral Expression – word repetition, body part naming, visual confrontation naming Writing Auditory comprehension: Body part identification Understanding written language: Word picture matching.

46 Task-specific tests Graded Naming Test or Boston Naming Test - both assess ability to name objects. Token Test - detects non-obvious loss of receptive language Pyramid & Palm Trees Test - tests the understanding of words

Graded Naming Test examples – test has 30 of these, presented in order of increasing difficulty Boston Naming Test examples

Pyramid Palm Tree Fir Tree 3 Picture Version 3 Word Version Pyramid and Palm Trees Test – which one of the two lower items goes with the upper item?

49 5d. Memory Amnesia is loss of episodic (personal) memory, which may include knowledge of public people/events Two distinct kinds of amnesia: Retrograde Anterograde

50 5d. Memory Retrograde loss of memory for events from patient’s past patient asked to retrieve old events Anterograde loss of ability to store new memories. patient exposed to new information, then memory for that information tested

51 Retrograde amnesia Boston Remote Memory test 2 types of questions Easy vs. hard 2 types of material Famous faces (hints given if needed) Events – asked to recall information about them

52 Anterograde amnesia Warrington’s Recognition Memory Test 50 faces and 50 words presented separately 2AFC test administered immediately after learning phase Severely impaired patients may perform at chance. Then, it’s hard to tell what’s wrong with their memory

53 Anterograde amnesia Wechsler Memory Scale III Separate short-term and long-term retention scores Tries to differentiate between verbal and non- verbal elements of memory Includes recall and recognition tests 2+ hours to administer

54 5e. Attention & Executive Control Spatial attention: Line bisection, cancellation tasks Sustained attention / vigilance: Continuous performance test (CPT) Focused attention: Dichotic listening / visual search Divided attention: Trail making, task combinations

55 Trails A Trails B A 2 4 B 1 C D E 3 5 Trails A and Trails B – from Halstead-Reitan test battery

56 5. Attention & Executive Control Executive functions Assess higher cortical functions such as planning, response inhibition, controlled functions (e.g., new task, or new environment). Wisconsin Card Sort Task used frequently

Sort according to unspoken rule; examiner changes rule – can patient adapt to new rule? Sort by number Sort by color