Specialized N Eu Ropsych O Log Ical Assessment Methods

CHAPTER 1 2

SPECIALIZED N EU ROPSYCH O LOG ICAL ASSESSMENT METHODS

Glenn J. Larrabee, Ph.D.

Clinical neuropsychological assessment is the 1987). Indeed, the recently developed comprehen- measurement and analysis of the cognitive, behav- sive norms for the Halstead-Reitan Battery were ioral, and emotional consequences of brain damage co-normed with the WAIS and other measures of or dysfunction. Historically, neuropsychological memory and language (Heaton, Grant, & Mat- assessment has had a variety of influences includ- thews, 1991). The process, ability-focused ing behavioral neurology, psychometrics and test approaches typically include a standard core set of construction, and experimental psychology (chap- procedures, usually assessing memory and intelli- ter 10, this volume; Walsh, 1987). gence, which are augmented by additional flexible- Neuropsychological assessment has been char- adjustive exploration of cognitive deficits specific acterized by two basic approaches: (1) the fixed to the particular patient undergoing evaluation battery approach exemplified by the Halstead- (Hamsher, 1990; Lezak, 1995; Milberg, Hebben, Reitan battery and the Luria-Nebraska neuropsy- & Kaplan, 1996). chological battery (Reitan & Wolfson, 1993; More recently, Bauer (1994) has discussed an Golden, Purisch, & Hammeke, 1985); and (2) the approach which he characterizes as intermediate ability-focused, cognitive process, hypothesis-test- to the fixed and flexible battery approach: multi- ing approach, exemplified by the Benton-Iowa ple fixed batteries. Bauer distinguishes three Group (Benton, Sivan, Hamsher, Varney, & types of multiple fixed batteries, and provides Spreen, 1994), Lezak (1995), and the Boston group several examples of each type. The first, a gen- (Milberg, Hebben, & Kaplan, 1996). It is an over- eral "screening" battery, is comprised of items simplification to characterize these two general maximally sensitive to clinically significant orientations as (a) a fixed battery, without modifi- abnormalities requiring more detailed explora- cation, administered to all patients regardless of tion with additional testing. A second alternative complaint or reason of referral, versus (b) flexible, is the "population specific" battery for evalua- but inconsistent across patients. In actual practice, tion of specific patient populations or disease the core Halstead-Reitan battery and the Luria- entities (e.g., HIV seropositive status, cf. But- Nebraska are frequently administered in conjunc- ters, Grant, Haxby, Judd, Martin, McClelland, tion with measures of intelligence and memory Pequegnat, Schacter, & Stover, 1990), wherein such as the Wechsler Adult Intelligence Scale- the goal is to provide a selective but standard- Revised (WAIS-R) (Wechsler, 1981) or Wechsler ized evaluation of the cognitive functions most Memory Scale-Revised (WMS-R) (Wechsler, relevant to diagnosis and treatment of individu-

301 302 HANDBOOK OF PSYCHOLOGICAL ASSESSMENT als within the specific population. Finally, batter- Sivan, and colleagues (1994) typically set the cut- ies can be "domain specific," providing a off for performance abnormality to match the bot- detailed evaluation of particular neurobehavioral tom 5 percent of control-subject test performance. functions such as language (e.g., Boston Diag- Heaton and colleagues (1991) set this value at -1.1 nostic Aphasia Examination: Goodglass & SD (T score of 39 or less), which defines abnor- Kaplan, 1983) or memory (WMS-R: Wechsler, mality as performance lower than approximately 1987). 86 percent of normal control subjects. Various interpretive strategies have been A clinician utilizing the ability-focused, developed for distinguishing between normal and hypothesis-testing approach evaluates the pat- abnormal neuropsychological test performance. terns of cognitive strengths and weaknesses of a One strategy, which developed out of the fixed particular patient relative to one another, consid- battery approach, was the determination of an ers these patterns in light of the referral question optimal "brain-damage cutting score" that maxi- and other clinical/historical data, and integrates mally separated a brain-damaged sample from a these data to form a diagnostic impression and normal sample (cf. Reitan & Wolfson, 1993; clinical recommendations (Lezak, 1995). As Golden et al., 1985). Certainly, one would not Walsh (1995) has noted, the hypothesis-testing dispute the fact that a neuropsychological test approach is dependent on two major elements: should be sensitive to brain damage or dysfunc- (1) current familiarity with the body of knowl- tion; however, the "brain-damage cutting score" edge of neuropsychological findings in relation approach is dependent on a variety of factors to neurological disorders, and (2) personal expe- including demographic characteristics (age, edu- rience of the clinician with as wide a range of cation, gender) of the brain-damaged and control neurologic disorders as possible, seen at various groups, the nature and severity of brain damage stages of evolution and resolution. or dysfunction in the brain-damaged group, as well as on where the cutting score is set (Lezak, 1995). Again, it is an oversimplification to char- OVERVIEW OF SPECIALIZED acterize battery approaches as based only on NEUROPSYCHOLOGICAL PROCEDURES optimal "cutting scores;" for example, Reitan has supported a four-tiered method of analysis Lezak (1995) has characterized neuropsychol- including level of performance, pattern of perfor- ogy as one of the most rapidly evolving fields in mance, comparison of lateralized sensorimotor the clinical sciences. Despite the vast prolifera- processes, and analysis of pathognomonic signs tion of specialized tests that have been devel- (Reitan & Wolfson, 1993). oped since the first edition of Lezak's book An alternative approach, associated with the (Lezak, 1976), several reviews of the field on ability-focused, hypothesis-testing orientation, is neuropsychology (Lezak, 1995; Mapou & Spec- to evaluate each cognitive function relative to the tor, 1995; Spreen & Strauss, 1998), have identi- range of performance in a representative normal fied seven major functional areas: (1) language sample, adjusting for age, gender, education, and and related verbal and communicative functions, other relevant demographic factors. This approach (2) spatial/perceptual skills, (3) sensorimotor is analogous to the ranges of normality developed functions, (4) attention- and related information- for laboratory values in clinical medicine. This processing tasks, (5) memory (verbal, visual, approach, which references normality to a normal remote), (6) intellectual and problem-solving control sample, remains dependent on the repre- skills (including "executive" functions), and (7) sentativeness of the normal sample, as well as on emotional and adaptive functions. These ratio- the level of performance at which the interpretation nally defined areas are supported by recent fac- of abnormality is set (referred to as "abnormal-per- tor analyses of comprehensive test batteries formance cutting score"). The advantage of this conducted by Larrabee and Curtiss (1992) and approach over the more traditional "brain-damage Leonberger, Nicks, Larrabee, and Goldfader cutting score" approach, is that one is not depen- (1992). Table 12.1 displays the results of a fac- dent on the variability inherent in a mixed brain- tor analysis of the WAIS-R, the WMS-R, and the damaged population, and the "abnormal perfor- Halstead-Reitan Neuropsychological Battery mance cutting score" can be set at a value that (HRNB) (Leonberger et al., 1992). This analy- keeps the false positive error rate constant. Benton, sis, employing the delayed-recall WMS-R sub- SPECIALIZED NEUROPSYCHOLOGICAL ASSESSMENT METHODS 303

Table 12.1. Factor Loadings of the Wechsler Memory Scale-Revised, Wechsler Adult Intelligence Scale-Revised, and the Halstead-Reitan Neuropsychological Test Battery: Analysis of Delayed Recall Scores FACTOR MEASURE 1 2 3 4 5 Wechsler Memory Scale-Revised

Mental Control .06 .36 .17 .46 .31 Figural Memory .23 .04 .36 .04 .19 Digit Span .09 .31 .11 .69 .06 Visual Memory Span .50 .07 .12 .34 .28 Logical Memory II .10 .31 .67 .06 .02 Visual Paired Associate II .32 .10 .60 .09 .14 Verbal Paired Associates II .09 .10 .76 .19 .14 Visual Reproduction II .55 .04 .49 .15 .19

Wechsler Adult Intelligence Scale-Revised

Information .07 .82 .05 .15 .07 Vocabulary .07 .88 .13 .16 .09 Arithmetic .16 .56 -.01 .42 .09 Comprehension .22 .76 .10 .16 .04 Similarities .13 .74 .22 .14 .02 Picture Completion .62 .22 .17 .17 .07 Picture Arrangement .59 .22 .18 .18 .01 Block Design .76 .18 .02 .18 .24 Object Assembly .80 .13 .05 -.03 .15 Digit Symbol .42 -.08 .40 .12 .50

Halstead-Reitan Neuropsychological Test Battery

Category Test (VII) -.51 -.11 -.35 -.18 -.05 Tactual Performance Test (location) .54 -.06 .31 -.02 .11 Speech Sounds Perception Test -.16 -.17 -.34 -.42 -.32 Rhythm Test -.22 -.19 -.11 -.59 .06 Finger Tapping Test (dominant hand) .11 .08 .08 .01 .37 Trail Making Test (Part B) -.43 -.05 -.33 -.26 -.47 Note: n = 237, orthogonal rotation. From "Factor structure of the Wechsler Memory Scale-Revised within a comprehensive neuropsychological battery," by F.T. Leonberger, S.D. Nicks, G.J. Larrabee & P.R. Goldfader, 1992, Neuropsychology, 6, p. 245. Copyright 1992, Educational Publishing Foundation. Reprinted with permission of authors.

tests, and in an attempt to identify a memory Test, and Wide Range Achievement Test- component of the HRNB, Category Test subtest Revised (WRAT-R) (Jastak & Wilkinson, 1984). VII and TPT location, yielded five factors, iden- This factor analysis, employing delayed-recall tified by the authors as: (1) Nonverbal and Spa- memory tests, yielded six factors, identified by tial Reasoning, (2) Verbal Comprehension and the authors as (1) General Verbal Ability and Expression, (3) Memory, (4) Attention and Con- Problem Solving, (2) Visual/Nonverbal Problem centration, (and 5) Psychomotor Speed. Table Solving, (3) Memory, (4) Gross Motor Skills, (5) 12.2 displays the results of the factor analysis by Attention/Information Processing, and (6) Finger Larrabee and Curtiss (1992), employing several Localization. of the Benton-Iowa tests (Benton, Sivan, et al., Tables 12.1 and 12.2 demonstrate two note- 1994), selected HRNB sensorimotor procedures worthy findings. Concept-formation tasks con- (Heaton et al., 1991), specialized measures of sidered to be related to frontal lobe attention and memory from the head trauma functioning, such as the Categories Test, Wis- research literature (Levin, Benton, & Grossman, consin Card Sorting Test, and Trailmaking B 1982), the WAIS-R, Wisconsin Card Sorting are more closely associated with WAIS-R Per- 304 HANDBOOK OF PSYCHOLOGICAL ASSESSMENT formance IQ subtests than with a separate GENERAL CONSIDERATIONS IN "frontal cognitive" factor. Complex sensorim- THE USE AND INTERPRETATION OF otor tasks such as the Purdue Pegboard, SPECIALIZED NEUROPSYCHOLOGICAL Grooved Pegboard, Benton-Iowa Tactile Form ASSESSMENT PROCEDURES Perception, and HRNB Tactual Performance Test are more closely associated with WAIS- Selection of procedures for neuropsychological R Performance IQ subtests than with a separate assessment should provide appropriate breadth and sensorimotor factor. depth of evaluation. Some assessment should be

Table 12.2. FactorStructure of Neuropsychology Battery With Delayed Recall Memory Tests FACTORS VARIABLES 1 2 3 4 5 6 Visual Naming .63 Controlled Oral Word Assoc. .35 .40 Visual Form Discrimination .34 Judgment of Line Orientation .31 Facial Recognition .41 WMS Mental Control .48 Trailmaking B -.74 -.31 PASAT-Trial 4 .47 Serial Digit Learning .55 Expanded Paired Assoc.-Delay .54 Selective Reminding-Delay .81 Visual Reproduction-Delay .55 Continuous Recog. Mere-Delay .57 Continous Visual Mem-Delay .55 Finger Tap-DOM .73 .34 Finger Tap-N DOM .74 .35 Grip-DOM .89 Grip-N DOM .92 Purdue Pegs-DOM .39 .33 .42 Purdue Pegs-N DOM .69 .34 Grooved Pegs-DOM -.39 -.40 Grooved Pegs-N DOM -.84 Tactile Form-DOM .77 Tactile Form-N DOM .76 Finger Localiz-DOM .77 Finger Localize-N DOM .71 WAIS-R Information .84 Digit Span .38 .54 Vocabulary .92 Similarities .68 Comprehension .80 Arithmetic .64 Picture Completion .47 Picture Arrangement .49 .50 Block Design .55 Object Assembly .62 Digit Symbol .50 .31 Wisconsin Persev. Errors -.55 WRAT-R Reading .78 .35 Spelling .68 .43 Arithmetic .61 .36 Note: n = 151, Oblique rotation. Range of factor intercorrelations is .02 (3 with 6) to -.45 (2 with 3). Loadings of .30 or higher are reported. From Larrabee and Curtiss, 1992. SPECIALIZED NEUROPSYCHOLOGICAL ASSESSMENT METHODS 305 made of each of the key neurobehavioral domains, in neuropsychology are critical for effective use of including language, spatial processes, sensorimo- the hypothesis-testing approach to clinical neurop- tor processes, attention, memory, intelligence/ sychological assessment. Aphasia following stroke problem solving, and emotional/adaptive pro- evolves over time; post-traumatic amnesia resolves cesses. Selection of tests should be based upon over time; cognitive functions sensitive to Alzhe- proven reliability and validity, utilizing procedures imer' s-type dementia follow a pattern of differen- with sufficient normative data, which are corrected tial decline over time. Evaluation of the language- for demographic factors when these are empiri- disordered patient following "dominant"-hemi- cally related to test performance in the normative sphere cerebrovascular accident (CVA) requires sample. The present author follows the Benton- particular skill and experience, because aphasics Iowa tradition of interpreting performance as can fail so-called "non-verbal" tasks (Benton, "impaired" when exceeded by 95 percent of the Sivan, et al., 1994; Hamsher, 1991), including normative sample and as "borderline" when falling WAIS-R Performance IQ subtests (Larrabee, between the 6th to 16th percentiles relative to nor- 1986), in spite of an intact "nondominant" hemi- mal controls. sphere. Patients suffering fight hemisphere cere- The examination should start with an interview brovascular accident can display impaired verbal- of the patient. This serves several purposes includ- memory test performance due to generalized atten- ing establishing rapport, gathering relevant history tional problems during the subacute stages of regarding symptomatic complaints, and providing recovery, despite having an "intact" left hemi- an initial assessment of the patient's degree of sphere (Trahan, Larrabee, Quintana, Goethe, & awareness of their problems. The complaints of the Willingham, 1989). Additionally, patients with malingerer of massive cognitive impairment fol- history of nondominant CVA may present with lowing whiplash without head trauma (with bilateral impairment on stereognostic tasks such as detailed examples given of past memory and cog- the Benton-Iowa Tactile Form Perception, despite nitive failures) are just as important as the denial of a perfectly normal left parietal lobe (Semmes, deficit made by the patient with suspected Alzhe- 1965). Persons with premorbid history of learning imer-type dementia, when these deficits are only disability can appear to have persistent focal left- too apparent to the examiner and to the patient's hemisphere cognitive problems, including poor spouse. Careful interviewing and observation can verbal learning and lower Verbal relative to Perfor- yield clinical data on language function, spatial mance IQ, following the typical recovery period abilities, motor function, attention, memory, intel- for minor closed head injury. An elderly patient lectual function, and emotional status. These with a focal vascular lesion in the area of the angu- observations, symptomatic complaints, and clini- lar gyrus in the "dominant" (left) hemisphere can cal history provide the initial hypotheses regarding appear to have Alzheimer-type dementia (Cum- a patient's neurobehavioral status. These hypothe- mings & Benson, 1992). ses can then be tested by formal psychometric procedures, sampling the seven neurobehavioral domains. Observations of normal language func- SPECIALIZED NEUROPSYCHOLOGICAL tion during the clinical interview, followed by nor- ASSESSMENT PROCEDURES mal performance on sensitive measures of word- finding ability, with Verbal IQ within the range of The ability-focused, flexible-adjustive examina- premorbid estimation, would preclude the need for tion can be considered in a more or less hierarchi- more detailed language evaluation. In the same cal fashion ranging from assessment of basic skills patient, decreased Performance IQ in the context (language ability) to more complex skills (mem- of normal language, preserved Verbal IQ, and nor- ory, intellectual and problem-solving ability). This mal verbal memory would indicate the need for hierarchy presumes a conscious and alert patient. assessment of more basic spatial perceptual and spatial constructional skills, as well as manual motor and manual tactile assessment, for evalua- Language and Related Functions tion of a potential focal non-dominant hemisphere problem. In a patient with a history significant for aphasia, Walsh's (1995) caveats regarding extent of the neuropsychological evaluation should begin supervised, didactic, and experiential knowledge with a comprehensive examination of language 306 HANDBOOK OF PSYCHOLOGICAL ASSESSMENT function. This can be conducted by a speech and Moreover, category-fluency tasks correctly classi- language pathologist or can be conducted by the fied more Alzheimer's and elderly control subjects neuropsychologist if she or he has particular exper- than did letter-fluency tasks. Mickanin, Grossman, tise and training in language assessment. Modern Onishi, Auriacombe, and Clark (1994) have also language-assessment batteries such as the Boston reported greater impairment in semantic relative to Diagnostic Aphasia Examination (Goodglass & letter fluency in Alzheimer' s disease. Kaplan, 1983), Western Aphasia Battery (Kertesz, In neuropsychological examination of the apha- 1982), and Multilingual Aphasia Examination sic patient, the impact of the language disturbance (Benton, Hamsher, & Sivan, 1994) typically on so-called "nonverbal" functions is important. include measures of word-finding skills (eg., con- As Benton, Sivan, and collaborators (1994) have frontation naming of objects; fluency tasks requir- reported, up to 44 percent of left-posterior aphasics ing generation of words beginning with a certain with comprehension impairment fail the Facial letter; or generation of names in a semantic cate- Recognition Test, a "nonverbal" measure requiring gory such as animal names), repetition (of words, discrimination and matching of shaded photo- sentences, digit sequences), auditory comprehen- graphs of non-familiar persons (to be discussed sion (of serial commands; appropriate yes-no further in the next section). Larrabee (1986) responses to brief questions; matching a picture to reported significant associations of global lan- a word or phrase spoken by the examiner; follow- guage impairment in left-hemisphere damaged ing commands to manipulate objects), reading patients with WAIS-R Performance IQ (r=.74) and comprehension (of words, sentences or para- with all the Performance subtests, (range: r=.72 graphs), writing (to dictation or from copy), and with Object Assembly to r=.44 with Block ratings of the fluency and articulatory features of Design). Hence, an aphasic with demonstrated the patient's spontaneous speech. Modern lan- auditory-comprehension impairment who passes guage evaluation generally follows the classifica- the Facial Recognition Test and performs normally tion scheme developed by clinicians at the Boston on WAIS-R Block Design might be expected to Veterans Administration (VA), utilizing analysis have a better prognosis than another aphasic with of the fluent/non-fluent aspects of speech and equal degree of comprehension impairment who whether repetition is preserved or impaired to yield fails both of these "nonverbal" tasks, presumably seven major types: Broca, Wernicke, Global, because the first patient is able to better monitor Anomic, Conduction, Transcortical Motor, and the disruptive effects of his disordered language Transcortical Sensory (Benson, 1993). Additional system. types/features of aphasic disorders have been Given the ubiquitous nature of word-finding related to lesions of subcortical structures in the problems in all aphasic disorders, tests of word- language dominant hemisphere (Crosson, 1992). finding are good screens for aphasia. The Multilin- Language evaluation can contribute to differen- gual Aphasia Examination (MAE) (Benton, Ham- tial diagnosis as well as provide information on sher, et al., 1994) contains a Visual Naming prognosis following development of aphasia. In subtest, requiting confrontation naming of pictures Alzheimer-type dementia, language deficits and parts of pictures (eg., elephant, ear, tusk). The progress from anomic aphasia to transcortical sen- MAE also contains a word-fluency task, Con- sory aphasia (impaired comprehension, fluent trolled Oral Word Association, which requires the speech, preserved repetition) to Wernicke's apha- subject to produce as many words as possible, with sia (impaired comprehension, fluent speech, three different letters, 60 seconds per letter. This impaired repetition), to echolalia, palilalia (invol- type of task is also sensitive to non-aphasic, frontal untary repetition during speech), dysarthria, and lobe dysfunction (Benton, 1968; Butler, Rorsman, terminal mutism (Cummings & Benson, 1992). Hill, & Tuma, 1993), is related to level of social Comparison of performance on phonemic (let- skill following very severe closed head injury ter) versus semantic (category) fluency tasks may (Marsh & Knight, 1991), and is predictive of com- show different patterns for different dementing petency to consent to medical procedures in nor- syndromes. Monsch and colleagues (1994) found mal elderly patients and patients with Alzheimer's that patients with Alzheimer' s-type dementia were disease (Marson, Cody, Ingram, & Harrell, 1995). disproportionately impaired on category-fluency The MAE Controlled Oral Word Association Test relative to letter-fluency tasks, whereas patients is part of the three tests of the Iowa Battery for with Huntington's disease were equally impaired. Mental Decline in the elderly (Eslinger, Damasio, SPECIALIZED NEUROPSYCHOLOGICAL ASSESSMENT METHODS 307

Benton, & VanAllen, 1985). Spreen and Strauss graphically or constructionally reproduce stimuli. (1998) present an earlier variant (F,A,S) of the Visuoperceptual or pattern analysis can be dissoci- MAE Controlled Oral Word Association Test. ated from spatial processing. The former under- Kaplan, Goodglass, and Weintraub (1983) have goes end-stage processing in the inferior temporal published a widely used measure of visual- con- lobe ("what" an object is) whereas the latter under- frontation naming, the Boston Naming Test goes end-stage processing in the posterior parietal (BNT). The BNT is highly correlated with the cortex ("where" an object is located in space) MAE Visual Naming Test (r=.86) and both share (Capruso, Hamsher & Benton, 1995; Mishkin, significant variance with the WAIS-R Verbal Ungerleider, & Macko, 1983). Additionally, per- Comprehension factor (Axelrod, Ricker, & ceptual and constructional skills can be dissoci- Cherry, 1994). Table 12.2 shows a high loading for ated. Perceptual and spatial tasks may involve no MAE Visual Naming on a factor defined by motor response, such as the Benton-Iowa Visual WAIS-R Verbal IQ subtests, consistent with the Form Discrimination, Facial Recognition or results of Axelrod and colleagues (1994). MAE Judgement of Line Orientation tasks (Benton, Controlled Oral Word Association shows a com- Sivan, et al., 1994), or they may involve construc- plex pattern of loadings, sharing loadings with the tional skills such as two- or three-dimensional puz- General Verbal Ability factor and the Attention/ zle or object assembly (WAIS-R Block Design and Information processing factor. This is not surpris- Object Assembly subtests, Benton-Iowa Three ing given the timed component of this task. Dimensional Block Construction; Benton, Sivan, Certain caveats are important in evaluating per- et al., 1994), drawing from copy (Rey-Osterrieth formance on word-finding tasks. Tests of visual- Complex Figure copy administration; Lezak, confrontation naming can be failed due to modal- 1995; Meyers & Meyers, 1995) or line bisection ity-specific impairments, which disconnect visual and line cancellation. input from preserved language functions (Bauer, As Kane (1991) observed, patients or their fam- 1993; Larrabee, Levin, Huff, Kay, & Guinto, ilies do not often spontaneously complain of 1985). These non-aphasic patients suffering from impaired spatial skills. The exception, of course, is visual-verbal disconnection, "optic aphasia," or the patient with profound neglect, resulting in inat- associative visual agnosia are able to demonstrate tention, usually to the left hemi-space. Although normal word-finding skills on tasks not involving patients with neglect do not frequently complain of visual processing (eg., naming to verbal descrip- this problem due to their anosognosia (denial or tion). Also, non-aphasic patients with left frontal minimization of deficit), the neglect is readily or bilateral frontal lobe disease or injury had apparent to family members and professional staff. reduced performance on letter fluency (Benton, Perceptual-spatial tasks can vary from assessing 1968). Lastly, recent investigation by Jones and the angular orientation between pairs of lines such Benton (1994) raised questions about the superior as on the Benton-Iowa Judgment of Line Orienta- sensitivity of word-finding tasks to aphasic distur- tion task (Benton, Sivan, et al., 1994), to the com- bance. These authors contrasted the performance plex problem-solving requirements of WAIS-R of 48 aphasics with 15 normal controls. In this Block Design. Impaired spatial problem-solving is sample, the Token Test (a variant of the procedure one of the impairments seen in the earlier stages of originally devised by DeRenzi and Vignolo Alzheimer' s-type dementia (Cummings & Benson, (1962), requiting the subject to follow commands 1992; Ska, Poissant, & Joanette, 1990). of increasing complexity to manipulate colored The Benton-Iowa Facial Recognition Test eval- plastic tokens) was the most discriminating, fol- uates the patient's ability to discriminate and lowed by Sentence Repetition, Controlled Oral match shaded black and white photographs of Word Association, and Visual Naming. unfamiliar persons (Benton, Sivan, et al., 1994). In non-aphasic patients, only those with disease of the fight hemisphere show an excessively high number Visuoperceptual and Visuospatial Skills of impaired performances. Moreover, among patients with right hemisphere disease, there is a Measures of visuoperceptual and spatial skills high failure rate for those with posterior lesions. evaluate the patient's ability to visually analyze Failure is independent of visual field impairment. (e.g., match or discriminate) stimuli, make judg- In patients with left hemisphere disease, only those ments about the spatial aspects of stimuli, and with impaired auditory comprehension had a high 308 HANDBOOK OF PSYCHOLOGICAL ASSESSMENT rate of failure on the Facial Recognition Test. Her- measure of consistency of retrieval for spatial mann, Seidenberg, Wyler, and Haltiner (1993) memory (Larrabee & Levin, 1984). found significant postoperative decline in Facial The Rey-Osterrieth Complex Figure Test can be Recognition performances for both left and right utilized to evaluate constructional skills, organiza- temporal lobectomy patients, whereas their sub- tional skills sensitive to frontal cognitive functions jects improved on the Judgment-of-Line-Orienta- and memory (Lezak, 1995). Recently, Meyers and tion performance. The authors explained this Meyers (1995) have provided extensive normative dissociation on the basis of Mishkin's two-compo- data for the Complex Figure Test. nent theory of visual processing contrasting Visuospatial or visuoperceptual neglect is fre- "where an object is located" versus "what an object quently discussed in reviews of spatial and percep- is" (Mishkin, et al., 1983). Benton, Sivan, and tual assessment (cf. Lezak, 1995) although it is coworkers (1994) review a number of other inves- more appropriately considered as a disorder of tigations which have employed the Facial Recog- attention (Heilman, Watson, & Valenstein, 1993). nition Test for analysis of perceptual abilities of a Neglect or inattention to one hemi-space can be variety of patients. Table 12.2 demonstrates an assessed via analysis of a patient's drawings, association of Facial Recognition performance which may appear on one-half (usually the fight- with the visual/non-verbal problem-solving factor. hand side) of the paper, by line-cancellation The Visual Form Discrimination Test requires (patients are presented with a page covered by matching-to-sample of complex geometric pat- lines which they must cross out), or by line bisec- terns (Benton, Sivan, et al., 1994). This task tion (they must bisect horizontal lines of differing requires both spatial perceptual skills as well as width) (Lezak, 1995; Heilman, Watson, et al., sustained attention. Patients who are impulsive 1993). Neglect is most often the consequence of a will perform poorly on this task because the dis- fight hemisphere lesion and is not due to primary criminations required are often subtle. Benton, sensory impairment (i.e., it is a cognitive deficit, Sivan, and colleagues (1994) report a high failure not a sensory deficit secondary to hemianopsia). It rate in both left- and right-hemisphere-lesioned is not uncommon for patients suffering neglect to patients, attesting to the multifactorial nature of be unaware of this problem (Heilman, Watson, et this task. al., 1993). The Judgment of Line Orientation Test requires Other less commonly employed measures of the patient to visually judge the angle between two lines, which is compared to a multiple-choice dis- perception have also been utilized in evaluating play of 11 lines varying in their degree of angular neuropsychological functions in specialized popu- orientation (Benton, Sivan, et al., 1994). This test lations. These include measures of stereopsis and is particularly sensitive to focal disease of the right measures of color discrimination. Hamsher (1991) posterior hemisphere. Moreover, the test is typi- explains stereopsis as the ability to ascertain that cally passed by patients who have left hemisphere two objects lie at different distances from the disease, even by those who have auditory-compre- observer, based on the fact that each eye receives hension impairment. Hence, the Judgment of Line slightly different retinal images of these objects. Orientation Test can provide useful information on Global stereopsis is the ability to perceive, binocu- the differential diagnosis of an aphasic syndrome larly, in a stereoscope (which presents separate secondary to unilateral stroke, from patterns of images to each eye), a form in space that cannot be impaired language and spatial/perceptual skills seen by either eye, individually. Hamsher notes resulting from bilateral or diffuse brain disease due that performance on this type of task can be to multi-infarct or Alzheimer's-type dementia. In impaired for persons with fight hemisphere the evaluation of dementia, the Judgment of Line lesions, but stereopsis is unimpaired in left-hemi- Orientation Test appears to be more sensitive than sphere-lesioned patients, including those with evi- Facial Recognition, although performance dissoci- dence of auditory comprehension impairment. ations can occur (Eslinger & Benton, 1983). Hence, performance on global stereopsis and on Although Judgment of Line Orientation does not the Judgment of Line Orientation task may be use- show any sizable loadings in Table 12.2, a prior ful in differentiating bilateral from unilateral dom- factor analysis of neuropsychological tests in a inant hemisphere dysfunction, particularly when normal elderly sample showed a high loading on a dominant hemisphere dysfunction is accompanied factor defined by WAIS-R Block Design and a by auditory comprehension impairment. SPECIALIZED NEUROPSYCHOLOGICAL ASSESSMENT METHODS 309

Color-discrimination and color-association tasks ipsilateral impairment overall, than did left hemi- have also been evaluated in specialized neuropsy- sphere lesions. chological populations. Alexia without agraphia Sensorimotor examination can encompass (the unique presentation of a patient who can write motor and tactile ability, basic visual processes, but not read what they have written), resulting olfaction, and audition. Schwartz and collaborators from posterior cerebral artery infarction of the left (1990) reported a dose-dependent decrement in occipital lobe and splenium of the corpus callo- olfactory discrimination in nonsmoking paint- sum, is frequently associated with the inability to manufacturing workers. Varney (1988) reported name colors, although color matching may be pre- poor prognosis for patients developing posttrau- served (Benson, 1979). This is primarily a linguis- matic anosmia due to personality changes second- tic deficit (anomia) in contrast to the perceptual ary to damage to the orbital frontal cortex. impairment reflected by color-matching deficits in The Sensory Perceptual Examination, frequently persons with posterior fight hemisphere disease performed as part of the Halstead-Reitan Battery, (Hamsher, 1991). includes assessment of finger-tip number writing, Braun, Daigneault, and Gilbert (1989), reported finger localization, and single versus double simul- sensitivity of color discrimination to solvent neu- taneous stimulation in the visual, tactile, and audi- rotoxicity. In an investigation of printshop work- tory modalities (Jarvis & Barth, 1994). As noted in ers exposed to toxic solvents, these authors found the preceding section, unilateral (usually left- that performance on the Lanthony D-15 desatu- sided) extinction to double simultaneous stimula- rated panel test of chromatopsia significantly dis- tion, especially across several modalities, can be criminated solvent-exposed workers from controls, seen with focal hemispheric lesions contralateral to and reflected a dose effect, with a significant asso- the neglected hemispace (Heilman, Watson, & ciation of impairment with greater solvent expo- Valenstein, 1993). As with any neuropsychological test, adequate normative data are important. sure. By contrast, performance on 20 Thompson, Heaton, Matthews, and Grant (1987) neuropsychological tests, including the Wisconsin reported significant age, gender, and education Card Sort, Rey Auditory Verbal Learning, Trail- effects for several HRNB sensorimotor tasks (e.g., making Test and Grooved Pegboard Test, did not Tapping, Tactual performance, Grip Strength, discriminate the solvent-exposed workers from Grooved Pegboard) that varied in magnitude and nonexposed controls. direction, depending on the task, and upon the subjects' preferred hand. Considerable inter-manual variability was found in these normal subjects, Sensorimotor Function suggesting caution in the interpretation of a lateralized lesion based on differences in right- and left- The examination of sensorimotor functions has a hand performance. long tradition in neurology and neuropsychology. Because of the effects of motivation on manual The evaluation of motor and tactile functions of the motor tasks (Binder & Willis, 1991; Heaton, hands is of particular importance given the known Smith, Lehman, & Vogt, 1978), assessment across contralateral representation of motor and tactile a range of tasks is recommended for evaluation of areas in the cerebral hemispheres. consistency of performance. Heaton et al. (1991) Hom and Reitan (1982) investigated the effects provide age, gender, and education-adjusted nor- of left and right hemisphere lesions due to either mative data for the Halstead-Reitan Finger Tap- head trauma, cerebrovascular event, or tumor, on ping Test (requiring repetitive tapping of a sensorimotor measures from the HRNB (Finger- telegraph-like key for 10 seconds), hand dyna- tapping; Grip Strength; Tactual Performance Test; mometer, and the Grooved Pegboard Test (requir- Suppressions in tactile, auditory and visual modal- ing the subject to rapidly place small grooved pegs ities; Finger Agnosia; Finger Tip Number Writing; in sequential rows). The Purdue Pegboard Test is and Tactile Form Recognition). All three etiologies also widely used. This requires the subject to place produced greater impairment for the hand con- small metal pegs in a columnar array, by 30-sec- tralateral to the lesion, with greatest effects for ond trials, first with the dominant, then nondomi- cerebrovascular, less for tumor, with trauma pro- nant hand, followed by a bimanual trial. Normative ducing the least-pronounced effects. Right hemi- data are provided for younger adults by Yeudall, sphere lesions produced greater contra and Fromm, Redden, and Stefanyk (1986) and for mid- 310 HANDBOOK OF PSYCHOLOGICAL ASSESSMENT

dle-aged and older adults by Agnew, Bolla-Wil- ATTENTION, INFORMATION son, Kawas, and Bleecker (1988). PROCESSING, AND Tactile functions can be evaluated with the IMMEDIATE MEMORY Benton-Iowa Tactile Form Perception Test, which requires the subject to palpate 10 different Measures of attention, information processing, sandpaper geometric forms, one at a time, with and immediate memory are grouped together due vision obscured, and match these forms to their to factor-analytic evidence that these tasks are visual referents on a multiple-choice card con- assessing a common underlying construct (Larra- taining 12 different stimuli. Each hand is exam- bee & Curtiss, 1995; Larrabee, Kane, & Schuck, ined individually, using a different set of forms. 1983; Larrabee, & Curtiss, 1992; see Table 12.2). This procedure is sensitive to unilateral as well Although these measures are discussed separately as bilateral brain disease (Benton, Sivan, et al., from memory in this chapter, measures of attention 1994). Unilateral impairment is associated with a are frequently included in memory batteries such lesion in the contralateral hemisphere. Bilateral as the WMS-R (Wechsler, 1987) and Larrabee and impairment can occur with bilateral lesions or Crook (1995) have included this domain as part of a five-component model for assessment of mem- with fight (nondominant) hemisphere lesions (cf. ory including: (1) orientation, (2) attention/con- Semmes, 1965). centration information-processing and immediate Several procedures exist for evaluating finger memory, (3) verbal learning and memory, (4) localization skills. As noted, earlier, there is a fin- visual learning and memory, and (5) recent and ger localization task on the Halstead-Reitan bat- remote memory. tery. Benton, Sivan, and colleagues (1994) have Tables 12.1 and 12.2, which include measures of also published a test of Finger Localization. This attention as well as sensorimotor function, mem- utilizes a model of the left and fight hands which is ory, and verbal and visual intellectual ability, also placed on top of a screen, in free vision of the suggest a high degree of shared variance in atten- patient, with each finger identified by a number. tional tasks. Other factor analyses which have ana- By utilizing the model, demands on language are lyzed attentional tasks in the absence of measures minimized. The dominant hand is examined first, of memory, verbal, and visual intelligence, have beginning with touching individual fingers in free yielded multiple dimensions of performance vision. This task is repeated for the nondominant including visuo-motor scanning, sustained selec- hand. Then, alternating from dominant to nondom- tive attention and visual/auditory spanning (Shum, inant, the examiner touches individual fingers with McFarland, & Bain, 1990), visuo-motor scanning the hand hidden, followed by double simultaneous and visual/auditory spanning (Schmidt, Trueblood, stimulation of two fingers with the hand hidden. Merwin, & Durham, 1994) and focus/execute, Benton, Sivan, et al. (1994) provide data demon- shift, sustain, and encode (Mirsky, Anthony, Dun- strating the sensitivity of this task to bilateral and can, Ahearn, & Kellam, 1991). unilateral cerebral disease. Bilateral impairment in Various definitions of attention exist. Lezak finger localization can be seen with either bilateral (1995) has observed that a universally accepted disease, or unilateral left cerebral disease. Finger definition of attention has yet to appear. She localization skills have also been related to reading defines attention as several different capacities or achievement in children (Satz, Taylor, Friel, & processes by which the subject becomes receptive Fletcher, 1978). to stimuli and begins to process incoming or Tablel2.2 presents data demonstrating a disso- attended-to excitations. Attention is ascribed a cer- ciation in factor loadings. The Purdue Pegboard tain limited capacity, and is related to sustained and Grooved Pegboard show more complex load- effort and shifting of focus. Cohen (1993) also ings with the spatial/perceptual factor. The Fin- highlights the multidimensional nature of atten- ger Tapping and hand dynamometer load tion. Attention is described as facilitating cognitive together on a relatively pure motor factor. Of and behavioral performance by reducing or particular interest, the Purdue Pegboard and expanding the amount of information which is to Grooved Pegboard show an association of left- receive further processing by the brain, and assess- hand skill with the nonverbal/problem solving ing the saliency of information. Cohen relates factor and also with dominant and nondominant these processes, metaphorically, to the aperture Tactile Form Recognition scores. and lens system of a camera. Cohen also describes SPECIALIZED NEUROPSYCHOLOGICAL ASSESSMENT METHODS 31 1 other features of attention, including evaluating the rators (1992; see Table 12.1) found a closer spatial and temporal characteristics of a particular association of WMS-R Visual Memory span with a context, analogous to a "spotlight." He synthesizes spatial cognitive factor than with an attentional various theoretical conceptualizations of attention factor. This raises questions regarding the interpre- into 4 components: sensory selection, response tation of this particular test as a measure of atten- selection, attentional capacity, and sustained per- tion on the WMS-R. formance. Mirsky and coworkers (1991) take a One of the most widely used measures of atten- more psychometric approach, based on the factors tional tracking and sequencing is the Trailmaking identified in their factor analysis of purported mea- Test, in particular, Trailmaking B, which requires sures of attention. the subject to perform a divided attention- task and A variety of neuropsychological tests have been alternately connect numbers and letters in increas- utilized as measures of the various aspects of atten- ing order of value (e.g., 1 to A to 2 to B, etc.). The tion and information processing, including the factor analyses by Leonberger and colleagues Arithmetic and Digit Symbol subtests of the (1992) (see Table 12.1) suggest that performance WAIS-R, the Digit Span subtest of the WAIS-R on this test is determined by both spatial cognitive and WMS-R, and Mental Control and Visual as well as attention and psychomotor speed abili- Memory Span measures of the WMS-R (Larrabee ties. Normative data corrected for age, education, et al., 1983; Larrabee & Curtiss, 1992, 1995; Mir- and gender, are provided by Heaton and coworkers sky et al., 1991; Schmidt et al., 1994; Shum et al., (1991). Stuss, Stethem, and Poirer (1987) also pro- 1990). Other procedures related to attentional provide normative data for Trailmaking, which was cesses include the Seashore Rhythm Test, Speech co-normed with the Paced Auditory Serial Addi- Sounds Perception Test, and Trailmaking Test tion Test (PASAT) (Gronwall, 1977) and Conso- from the Halstead-Reitan (Leonberger et al., 1992; nant Trigrams procedure (Brown, 1958; Peterson Schmidt et al., 1994; see Table 12.1). The Stroop & Peterson, 1959). In a recent meta-analytic Test (Golden, 1978; Trenerry, Crosson, DeBoe, & review of the sensitivity of neuropsychological Leber, 1989), measures of letter cancellation, serial tests to brain damage, Trailmaking B and WAIS-R subtraction, and the Knox Cube (Shum et al., Digit Symbol were among the most sensitive mea- 1990) have been utilized as measures of attention. sures (Chouinard & Braun, 1993). Mirsky and colleagues (1991) include scores from The PASAT was originally developed to investi- the Wisconsin Card Sorting Test as an assessment gate information-processing rate after closed head of the "shift" aspect of attention, and the Continu- trauma (Gronwall, 1977). In this task, the subject ous Performance Test as a measure of sustained has to perform rapid serial addition across four attention. blocks of numbers, with the time between numbers Attentional measures from the WAIS-R and decreasing from 2.4 seconds to 2.0, 1.6 and 1.2 WMS-R will not be reviewed in detail. The respec- seconds. Two versions of the test exist. The origi- tive test manuals provide adequate normative data nal version developed by Gronwall uses 61 num- for these measures, which can be extended into the bers (Gronwall, 1977). Normative data for this upper age ranges with the Mayo Older Adult Nor- version are provided by Stuss and colleagues mative Studies (Ivnik et al., 1992a, 1992b). These (1987). A revised version has been developed uti- procedures can also provide important information lizing computer-synthesized speech and 50 num- on the motivation of the subject being evaluated, bers per trial block (Levin, Mattis, et al., 1987). particularly if there is disproportionate impairment Normative data for this version of the PASAT are of attention relative to other memory and intellec- provided by Brittain, LaMarche, Reeder, Roth, and tual functions (Mittenberg, Azrin, Millsaps, & Boll (1991) and by Roman, Edwall, Buchanan, and Heilbronner, 1993; Mittenberg, Theroux-Fichera, Patterson (1991). Zielinski, & Heilbronner, 1995). Forward digit The PASAT is sensitive to the information- pro- span has a weaker association with age than cessing deficits seen in the early stages of recovery reversed digit span (Craik, 1984; Wechsler, 1987). from mild closed head injury (Gronwall, 1977; There is some evidence that reversed digit span Levin, Mattis, et al., 1987). This sensitivity is may be related to visual scanning and visuospatial related to the speeded nature of the task as well as skill (Costa, 1975; Larrabee & Kane, 1986), the demands the task places on working memory although, this has not been demonstrated consis- (i.e., in the sequence, "2, 8, 4, and 6," the subject tently (Wechsler, 1987). Leonberger and collabo- must provide the response "10" to the numbers "2" 312 HANDBOOK OF PSYCHOLOGICAL ASSESSMENT and "8," then following hearing the number "4," familiar to general clinicians is based on an omni- add it to the preceding number heard, "8," rather bus battery, such as the Wechsler Memory Scale- than the preceding sum, producing the response Revised (Wechsler, 1987) or the Memory Assess- "12," followed by hearing "6," then adding it to the ment Scales (Williams, 1991). These omnibus bat- preceding number, "4," etc.). teries typically include a variety of measures of Gronwall (1977) also recommended utilizing attention, verbal and visual learning, and memory. the pattern of responding to evaluate level of moti- The second approach is based on utilizing a vation of a particular patient. Gronwall described selection of specialized, individually developed the case of a 14-year-old girl who, following mod- measures of various components of memory erate concussion, was making satisfactory recov- (Erickson & Scott, 1977; Larrabee & Crook, ery. On the 28th day post-trauma, the girl's 1995). For a comprehensive assessment, Larrabee PASAT results were completely inconsistent, with and Crook (1995) have recommended assessing as many correct at the fast trial as at the slow trial. five components: (1) Orientation; (2) Attention/ Gronwall noted that the girl had been a mediocre Concentration, Information Processing, and Imme- student and was reluctant to return to school full- diate Memory; (3) Verbal Learning and Memory; time. The week following the girl' s agreement that (4) Visual Learning and Memory; and (5) Recent she had no choice but to return to school, her and Remote Memory function. Larrabee and PASAT scores were consistent and normal. Crook also recommend analysis of forgetting Variations of the Consonant Trigrams Procedure scores, which can be particularly sensitive to have been utilized to evaluate sensitivity of short- amnestic and dementing conditions (Butters et al., term memory to interference in research on alco- 1988; Ivnik, Smith, Malec, Kokmen, & Tangalos, holic Korsakoff syndrome, schizophrenics who 1994; Larrabee, Youngjohn, Sudilovsky, & Crook, had undergone frontal leukotomy, and patients 1993; Martin, Loring, Meador, & Lee, 1988). who had sustained mild or severe closed head Although appropriate age-based normative data trauma (Butters & Cermak, 1980; Stuss, Kaplan, are important for any neuropsychological-test pro- Benson, Weir, Chirilli, & Sarazin, 1982; Stuss, cedure, age-based norms are particularly critical in Stethem, Hugenholtz, & Richard, 1989). In this assessment of learning and memory. Effects of age procedure, subjects are provided with three conso- on level of performance are much less pronounced nants, for example, C, F, L, then must engage in an for immediate memory-span measures such as the interfering activity, counting backwards by threes WAIS-R Digit Span or for measures of recent and for either 3, 9 or 18 seconds, following which they remote memory such as the Presidents Test (Ham- are asked to provide the letters. In their original sher, 1982) than they are for supraspan (i.e., research (Stuss et al., 1982), Consonant Trigrams beyond immediate memory span) learning of ver- was the only test out of several measures of learn- bal and visual materials (Craik, 1984; Davis & ing and memory that was sensitive to residual Bernstein, 1992). Aging effects are also much less effects of orbito frontal leucotomy. pronounced for forgetting rates (amount lost on In subsequent research utilizing longer delay delay as a function of material originally acquired) periods of 9, 18 and 36 seconds, Stuss and collabo- in normal subjects (Trahan & Larrabee, 1992, rators (1989) found that the Trailmaking Test, 1993). Normative data on forgetting rates have PASAT, and Consonant Trigrams all discrimi- been published for the Rey Auditory Verbal Learn- nated control subjects from severe closed head ing Test (RAVLT) (Geffen, Moar, O'Hanlon, trauma patients, whereas Consonant Trigrams Clark, & Geffen, 1990; Ivnik et al., 1992c); and the alone discriminated patients with mild closed head original (form 1) WMS Visual Reproduction Test trauma from controls. Normative data for the 9-, with delayed recall (Trahan, 1992). Table A3 of 18-, and 36-second version of Consonant Trigrams the California Verbal Learning Test manual also are provided by Stuss and colleagues (1987). provides normative data relative to analysis of forgetting (Delis, Kramer, Kaplan, & Ober, 1987).

SPECIALIZED ASSESSMENT OF LEARNING AND MEMORY Assessment of Orientation

There have been two basic approaches to the Orientation, typically evaluated in four spheres: evaluation of learning and memory. The one most time, place, person and situation, is a common SPECIALIZED NEUROPSYCHOLOGICAL ASSESSMENT METHODS 31 3 component of the mental status examination (Strub Assessment of Verbal & Black, 1985). Disorientation to time frequently Learning and Memory suggests the presence of some type of abnormal condition such as amnesia, dementia, or confusion A variety of methods exist for evaluating verbal learning and memory, including immediate and (Benton, Sivan, et al., 1994), for orientation to time delayed recall of brief passages of prose (Logical and place are actually measures of recent memory Memory subtest of the WMS-R), digit supraspan because they evaluate a patient's ability to learn learning (rote memorization, in sequence, of an and remember continuing changes in these spheres eight- or nine-digit number, exceeding immediate (Strub & Black, 1985). memory span, such as the Benton-Iowa Serial Perhaps the best standardized measure of orien- Digit Learning Test; Benton, Sivan, et al., 1994), tation to time is the Temporal Orientation Test of forced-choice recognition memory for words pre- the Benton-Iowa group (Benton, Sivan, et al., viously seen (Recognition Memory Test) (War- 1994). This procedure requires the subject to iden- rington, 1984), and supraspan word-list learning tify the month, date, day of the week, year and to (multiple-trial list-learning tasks, such as the Rey estimate the time of day. Specific error points are Auditory Verbal Learning Test (RAVLT), Califor- associated with varying magnitudes of error (e.g., nia Verbal Learning Test (CVLT), and Verbal being incorrect on the month is weighted more Selective Reminding Test (VSRT) (cf. Lezak, heavily than misidentifying the day of the week). 1995; Delis et al., 1987; Buschke, 1973). Paired Normative data are available on over 400 subjects, Associate Learning is another modality of verbal and there is limited association of performance memory testing in which the patient on the presentation trial hears a list of pairs of words, followed with age (Benton, Sivan, et al., 1994). by a test trial in which the first word of the pair is Failure on the Temporal Orientation Test is presented, to which the patient must provide the more common with bilateral hemispheric disease second word (Paired Associate Learning of the (Benton, Sivan, et al., 1994). A screening battery WMS-R: Wechsler, 1987; Expanded Paired Asso- which included the Temporal Orientation Test, the ciate Test [EPAT]: Trahan et al., 1989). Benton Visual Retention Test (Sivan, 1992), and Three of the more widely used supraspan verbal Controlled Oral Word Association Test (Benton, list-learning procedures in clinical and research Sivan, et al., 1994) correctly discriminated 89 per- applications of neuropsychology are the RAVLT, cent of normal and demented elderly (Eslinger et CVLT, and VSRT. All three require the subject to al., 1985). learn a supraspan list of words over several trials, The questions from the Temporal Orientation with testing of delayed recall and testing of recog- Test are also a major component of the nition. Galveston Orientation and Amnesia Test The RAVLT requires the subject to learn a list of (GOAT) (Levin, O'Donnell, & Grossman, 1979). 15 unrelated words over five trials, followed by a The GOAT, developed to evaluate presence and second list to serve as interference and subsequent duration of posttraumatic amnesia (e.g, the short- and long-delay recall of the original list period of confusion and disorientation following (Lezak, 1995; Spreen & Strauss, 1991). Lezak significant closed head trauma), contains a brief (1995) has also provided a 50-word list (containing series of questions assessing orientation to time, the acquisition list, interference list, and 20 more words) for recognition testing following the place, and person, as well as questions related to delayed-recall trial (testing delays vary, 20 to 30 retrograde (recall of events prior to trauma) and minutes after acquisition depending on the particu- anterograde (recall of events subsequent to lar laboratory: Lezak, 1995; Spreen & Strauss, trauma) amnesia. High, Levin, and Gary (1990) 1998). Analysis of patterns of performance can analyzed the pattern of recovery of components yield information on serial-position effect, proac- of orientation on the GOAT following head tive interference, retroactive interference, and for- trauma of varying severity and found that the getting over time (Larrabee & Crook, 1995; Lezak, most common pattern, in 70 percent of patients 1995). studied, was return of orientation to person, fol- Performance on the RAVLT is affected by a lowed by orientation to place, with orientation to variety of conditions including temporal lobec- time the last component to recover. tomy (Ivnik et al., 1993), hydrocephalus (Ogden, 314 HANDBOOK OF PSYCHOLOGICAL ASSESSMENT

1986), vertebrobasilar insufficiency (Ponsford, with severe closed head trauma from control sub- Donnan, & Walsh, 1980) and early Alzheimer- jects in both level and pattern of performance type dementia (Mitrushina, Satz, & Van Gorp, (Crosson, Novack, Trenerry, & Craig, 1988; Millis 1989). Powell, Cripe, and Dodrill (1991) found & Ricker, 1994). A discriminant function analysis that the RAVLT, particularly trial 5, was more sen- classified over 76 percent of cases of Huntington's sitive to discriminating a group of normal subjects disease, AD and Parkinson's disease (Kramer, from a mixed neurologic group than any other sin- Levin, Brandt, & Delis, 1989). Delis and collabo- gle test on the Halstead-Reitan or Dodrill (Dodrill, rators (1991) have developed an alternate form of 1978) batteries. In a factor analysis of the RAVLT the CVLT. and other neuropsychological measures, Ryan, The Verbal Selective Reminding Test (VSRT) Rosenberg, and Mittenberg (1984) identified a fac- was originally developed by Buschke (1973), in an tor on which the RAVLT and WMS verbal mem- attempt to separate the components of storage and ory scores loaded. Normative data are provided by retrieval inherent in verbal-list learning tasks. Ivnik and coworkers (1992c); Geffen and col- Unlike the RAVLT and CVLT, the only time the leagues (1990); and Wiens, McMinn, and Crossen subject hears the examiner present all of the VSRT (1988). Crawford, Stewart, and Moore (1989) have words is the first trial; thereafter, the examiner pre- developed alternate, parallel forms for the original sents only those words which were omitted on the List A and List B. immediately preceding trial, yet the subject is still The CVLT is, on the surface, similar in general expected to provide all of the words (those format to the RAVLT, with a five-trial supraspan reminded and those not reminded) on the list. Sev- learning task, followed by an interference list and eral different word lists exist for various versions short- and long-delay free recall; however, the of the VSRT (Spreen & Strauss, 1998). One of the CVLT was designed by Delis and colleagues to most widely used versions is the 12- unrelated- evaluate the process of verbal learning using an word-12-trial version developed by Levin and col- "everyday" task of learning and remembering a leagues (Hannay & Levin, 1985; Larrabee, Trahan, shopping list (Delis et al., 1987). The subject is Curtiss, & Levin, 1988; Levin, Benton, & Gross- presented with a "Monday" list of 16 items (four man, 1982). Normative data are provided by Larra- each, in the categories of tools, clothing, fruits, and bee and coworkers (1988), which are reprinted in spices/herbs), over five trials, followed by a second Spreen and Strauss, (1998). Additional normative "Tuesday" list to serve as interference, short-delay data are provided by Ruff, Light, and Quayhagen and long-delay free recall and category-cued (1989). recall, followed by delayed multiple-choice recog- As discussed in Larrabee and colleagues (1988), nition. By design, the CVLT allows for evaluation the scoring criteria for the VSRT assume that once of multiple dimensions of performance including a word has been recalled at least once, without semantic clustering versus serial-learning strate- reminding, it is in long-term storage (LTS). If it is gies, vulnerability to proactive and retroactive then recalled to criterion (correct recall of the interference, retention of information over time, entire list for three consecutive trials or to the final and free versus cued recall versus recognition trial of the test), the word is considered to be in memory. Indeed, a factor analysis of the CVLT consistent long-term retrieval (CLTR). There is yielded several factors including general verbal some debate about the validity of these assump- learning, response discrimination, proactive effect, tions (Loring & Papanicolaou, 1987). Larrabee and and serial position effect (Delis, Freeland, Kramer, collaborators (1988) found that the various VSRT & Kaplan, 1988). This factor structure has been scores (CLTR, LTS, Short-Term Storage, Short- replicated by Wiens, Tindall, and Crossen (1994), Term Recall, Random Long-Term Retrieval) who have also provided additional normative data. defined only one factor when factor analyzed in the Interestingly, these normative data yielded lower absence of any other test scores. Larrabee and values than those published in the CVLT manual Levin (1986) found separate verbal learning and (Delis et al., 1987). The CVLT test manual con- retrieval factors when a reduced set of VSRT tains normative data on a variety of clinical popu- scores was factored with other memory-test mea- lations including Alzheimer's disease (AD), sures. More recently, Beatty and coworkers (1996) Korsakoff amnestic syndrome, multiple sclerosis demonstrated predictive validity for the various and head trauma (Delis et al., 1987). Research on retrieval and storage indices in a sample of patients the CVLT has shown discrimination of patients with multiple sclerosis. Words in CLTR were more SPECIALIZED NEUROPSYCHOLOGICALASSESSMENT METHODS 31 5 consistently recalled at delay than were words in highest) loading on a factor assessing spatial- intel- Random Long-Term Retrieval or Short-term Stor- lectual skills, with lower loadings on a memory age. factor (Larrabee, Kane, & Schuck, 1983; Leon- The Levin VSRT exists in four forms. In normal berger et al., 1992, see Table 12.1). This poses a adult subjects, forms 2, 3, and 4 are equivalent and problem psychometrically, for when a purported approximately 10 percent easier than form 1 (Han- measure of visual memory shows a stronger asso- nay & Levin, 1985). Because the normative data ciation with visuospatial intelligence and problem are based on form 1, this led Larrabee and col- solving than with memory, the test is better leagues (1988) to recommend reducing the raw described as a spatial problem-solving task. This score on Forms 2, 3, or 4 by 10 percent prior to uti- problem is more pronounced when visual memory lizing the normative tables; however, Westerveld, is assessed via immediate reproduction from mem- Sass, Sass, and Henry (1994) found no form differ- ory (Larrabee & Curtiss, 1995; Larrabee, Kane, et ence in patients with seizure disorders. al., 1985; Leonberger, et al., 1992). When delayed The VSRT has been widely used in research on reproduction scores are factored, the loading for closed head trauma (Levin et al., 1982). The proce- the purported visual-memory tasks increases on dure is sensitive to the effects of severe closed the memory factor (Larrabee, Kane, et al., 1985; head injury in adults (Levin, Grossman, Rose, & Larrabee & Curtiss, 1995; Leonberger et al., 1992). Teasdale, 1979), children and adolescents (Levin For some visual-memory tasks, the strength of the et al., 1988). The VSRT is also sensitive to the loading pattern may actually reverse such that memory decline in early-stage Alzheimer-type when immediate visual reproduction scores are dementia (Larrabee, Largen, & Levin, 1985; factored, the strongest loading is with spatial intel- Masur, Fuld, Blau, Crystal, & Aronson, 1990) and ligence with a secondary loading on memory, Sass and colleagues (1990) have correlated VSRT whereas when delayed visual reproduction scores performance with hippocampal cell counts. Factor are factored, the strongest loading is with memory analyses of the VSRT show it loads on a general with a secondary loading on spatial intelligence memory factor independent of intellectual and (Larrabee & Curtiss, 1995; Larrabee, Kane, et al., attentional processes (Larrabee & Curtiss, 1995; 1985). The factorial confound of spatial intelli- Larrabee, Trahan, & Curtiss, 1992; also see Table gence and problem solving with purported tasks of 12.2). visual memory may be attenuated by use of visual- recognition memory tests (Larrabee and Curtiss, 1992, and Tablel2.2; Larrabee and Curtiss, 1995). Visual Memory Performance The Benton Visual Retention Test (Sivan, 1992) is also widely used as a measure of immediate A variety of methodologies have been devel- design reproduction from memory. Advantages oped for evaluation of visual learning and memory include a large normative database for adults and including forced-choice recognition memory for children, three alternate forms, and several pub- facial photographs (Warrington, 1984), yes/no rec- lished studies supporting sensitivity of the proce- ognition memory for recurring familiar pictures dure to brain damage (see Spreen & Strauss, 1998, (Hannay, Levin, & Grossman, 1979) or geometric for a review). Factor analysis has demonstrated forms (Kimura, 1963; Trahan & Larrabee, 1988), loadings on attention, memory, and spatial ability and drawing previously seen designs from memory (Larrabee, Kane, et al., 1985). The design of the (Meyers & Meyers, 1995; Sivan, 1992; Trahan, task, with 10 separate geometric patterns (six of Quintana, Willingham, & Goethe, 1988; Wechsler, which contain three figures per card), precludes 1945, 1987). Other methodologies have included administration of a delayed reproduction trial. recall of object placement in a spatial array for The Complex Figure Test (Lezak, 1995; Meyers abstract symbols (Malec, Ivnik, & Hinkeldey, & Meyers, 1995; Osterrieth, 1944; Rey, 1941; 1991) or marbles (Levin & Larrabee, 1983) or Spreen & Strauss, 1998) requires the subject to learning a supraspan spatial sequence (Milner, copy a spatially complex figure comprised of mul- 1971, describing a task developed by P. Corsi). tiple geometric components. There are 18 scorable Factor analyses of purported measures of visual components which can be scored 0, .5, 1, or 2, for memory, including other cognitive tasks of atten- a total score-range of 0 to 36. Following a copy tion, verbal and visuospatial intelligence, and ver- phase, the patient reproduces the complex figure bal memory, frequently show high (sometimes the from memory, with subsequent visuographic 316 HANDBOOK OF PSYCHOLOGICAL ASSESSMENT reproduction at anywhere from a 20-to-45-minute is paired with a forced-choice word-recognition delay, depending on the laboratory (Lezak, 1995; task. Both tasks require the subject to make a Spreen & Strauss, 1998). Various sets of norma- judgement regarding how pleasant/unpleasant a tive data have been archived, through accrual word or face is. Following presentation of 50 dif- (Lezak, 1995; Spreen & Strauss, 1998). Loring, ferent words, the subject is presented with 50 pairs Martin, Meador, and Lee (1990) found that 30- of words and forced to choose which of the pair of minute-delayed scores were higher when the copy words was previously seen. The same format is trial was followed by an immediate reproduction followed for the face memory test, that is, 50 faces trial than delayed recall without a preceding imme- presented, followed by 50 pairs of faces, with the diate recall trial. This calls for caution in applica- subject required to specify which of the pair of tion of the appropriate delayed reproduction faces was previously seen. Warrington (1984) pro- norms. vides data showing the expected double dissocia- Recently, Meyers and Meyers (1995) published tion in performance, with fight hemisphere- a comprehensive test manual for the Complex Fig- lesioned patients performing lower on faces refer- ure Test. This manual contains normative data on able to words, with the opposite pattern seen with 601 normal subjects ranging from 18 to 89 years of left hemisphere lesions. age. Administration involves a copy trial, immedi- Two other measures of visual memory are the ate trial (administered three minutes after the copy Continuous Recognition Memory Test (CRM) trial is completed), and a delayed reproduction trial (Hannay et al., 1979) and the Continuous Visual completed 30 minutes after the copy trial has Memory Test (CVMT) (Trahan & Larrabee, ended. Meyers and Meyers have also developed a 1988). Both require the subject to detect and dis- recognition trial which is administered following criminate recurring from perceptually similar but the 30-minute-delayed trial. Specific scoring crite- nonrecurring figures in a yes-no recognition mem- ria are provided for the 18 different units, and the ory format. The CRM utilizes recognizable objects Appendix presents three fully scored examples. (eg., insects, seashells) whereas the CVMT The explicit scoring criteria led to a median inter- employs abstract geometric patterns. ater reliability of .94. The CRM was developed for research on visual- Lezak (1995), Spreen and Strauss (1998), and memory deficits following closed head trauma Meyers and Meyers (1995) have reviewed the sen- (Hannay et al., 1979). In this original investigation, sitivity of performance on the Complex Figure performance on the CRM differentiated persons Test to a variety of neurologic conditions including with moderate closed head trauma from persons closed head trauma, stroke, and dementia. Dia- with mild head trauma and from non-neurological mond and Deluca (1996) found that ten patients medical control patients. Levin and colleagues with amnesia secondary to ruptured anterior-com- (1982), found that patients with mass lesions in the municating-artery aneurysms demonstrated pro- left temporal lobe performed defectively on the found loss of information on delayed reproduction VSRT, but normally on the CRM. Hannay and of the Complex Figure, despite copy scores that Levin (1989) found that CRM performance varied were within normal limits. Lezak (1995) reviews as a function of head-trauma severity in adoles- factor-analytic data showing both a memory as cents who had sustained mild, moderate, or severe well as a spatial component to Complex Figure closed head injury. Trahan, Larrabee, and Levin performance. To date, there have been no pub- (1986) reported significant effects of normal aging lished studies factoring immediate and delayed on CRM performance for 299 persons ages 10 to scores separately, with marker variables for verbal 89 years. and visual intelligence, attention, and memory. The CVMT, in addition to an acquisition trial, The test manual published by Meyers and Meyers also includes a 30-minute-delay multiple-choice (1995) reports significant correlations of immedi- recognition task, followed by a match-to-sample ate and delayed Complex Figure scores with sev- discrimination task to rule out gross perceptual- eral WAIS-R PIQ subtests, the BVRT, and the spatial deficits (Trahan & Larrabee, 1988). Norma- RAVLT. Hence, the Complex Figure Test may be tive data are presented for 310 adults ages 18 to 91 susceptible to the same spatial cognitive confounds years, with additional data on failure rates for as other design-reproduction-from-memory tasks. patients with amnestic disorder, AD, and severe Warrington (1984) has developed a forced- TBI. One hundred percent of the amnestic, 92 per- choice measure of facial recognition memory. This cent of the AD subjects, and 68 percent of the trau- SPECIALIZED NEUROPSYCHOLOGICAL ASSESSMENT METHODS 31 7 matic-brain-injury (TBI) subjects were impaired memory. Larrabee and Crook (1995) distinguish on at least two CVMT scores (Trahan & Larrabee, between Tulving's (1972) constructs of episodic or 1988). Patients with right hemisphere CVA per- context dependent memory as opposed to semantic formed at a significantly poorer level on the memory (memory for facts). Using the example of CVMT than did patients with left hemisphere recall of the identity of the "Enola Gay," Larrabee CVA (Trahan, Larrabee, & Quintana, 1990). Tra- and Crook note that for a 65-year-old person who han, Larrabee, Fritzsche, and Curtiss (1996) have recalls the precise context of seeing a newspaper reported on the development of an alternate form headline concerning the dropping of the atom of the CVMT. bomb, this information is in episodic memory. By Larrabee and collaborators (1992), in a factor contrast, for the teen-aged history and trivia buff, analysis of CVMT performance in normal sub- this material is more likely in semantic memory. jects, found that the CVMT acquisition score for Larrabee and Crook (1995) highlight the impor- sensitivity loaded on attentional and intellectual tance of making this distinction, which is exempli- factors. By contrast, the delayed-recognition fied by the normal performance of Korsakoff CVMT score loaded on a visual-memory factor amnestic patients on the WAIS Information subtest that was independent of the intellectual factors, as (Butters & Cermak, 1980) contrasted with the well as independent of a verbal memory factor. marked retrograde amnesia evident on the Albert, Larrabee and Curtiss (1995), in a factor analysis of Butters, and Levin (1979) Remote Memory Bat- a variety of measures of attention, memory, and tery assessing memory for famous faces and intelligence, using a mixed group of neurologic famous events. and psychiatric patients, found that both the acqui- There are far fewer procedures available for sition and delayed scores of the CVMT and CRM evaluation of remote episodic memory. The origi- loaded on a general (verbal and visual) memory nal Remote Memory Battery of Albert and collab- factor, in separate factor analyses of acquisition orators (1979) evaluated memory for famous faces and delayed scores (also see Larrabee & Curtiss, and famous events from the 1920s through the 1992, and Table 12.2). 1970s. Using this approach with Korskoff amnes- Altogether, the factor analyses conducted by tic patients, Albert and colleagues demonstrated a Larrabee and coworkers (1992), Larrabee and Cur- gradient of impairment in remote memory, which tiss (1992, 1995), and Leonberger and coworkers followed Ribot's (1881) law of regression, in (1992) demonstrate two important points. First, which memories from the remote past were better visual-recognition memory-testing procedures preserved than those acquired during the more appear to have less of a spatial confound (with recent past. Administration of this battery to per- visuospatial problem solving) than drawing-from- sons with dementing conditions has not yielded the memory visual-memory tasks. Second, as noted by gradient of impairment found in amnesia; rather, a Larrabee and Crook (1995), on a factor-analytic global impairment is seen in remote memory for basis, the original WMS Visual Reproduction fig- patients with Huntington's disease (Albert, But- ures, utilizing a modified immediate and delayed ters, & Brandt, 1981) and for patients with Alzhe- reproduction format (Russell, 1975; Trahan et al., imer's-type dementia (Wilson, Kaszniak, & Fox, 1988) are a better measure of memory in delayed- 1981). White (1987) has published a short form of recall format than are the WMS-R Visual Repro- the Remote Memory Battery, and Beatty, Salmon, duction designs (also, compare the loadings for the Butters, Heindel, and Granholm (1988) have uti- WMS-R Visual Reproduction in Table 12.1 to the lized a version which has been updated with mate- loadings for WMS Visual Reproduction in Table rial from the 1980s in an investigation of 12.2). retrograde amnesia in Alzheimer's and Hunting- ton's diseases. Hamsher (1982) has published a brief measure Recent and Remote Memory of recent and remote memory: the Presidents Test. This test, derived from common mental-status As already noted, Temporal Orientation can be examinations concerning memory for recent U.S. considered to be a measure of recent memory for Presidents, has four parts: (1) Verbal Naming, material the patient "brings with" them to the requiring free recall of the current and five previ- examination (Strub & Black, 1985). It is also ous U.S. Presidents; (2) Verbal Sequencing, important to consider more remote aspects of requiring sequencing of six cards imprinted with 318 HANDBOOK OF PSYCHOLOGICAL ASSESSMENT the names of the last six presidents (presented in chology. Tulsky, Zhu, & Prifitera (chapter 5, this quasi-random order) in the actual order of office; volume) provide a comprehensive review of the (3) Photo Naming, requiting confrontation naming evaluation of intelligence in adults. Lezak (1995) of photographs of each of the last six presidents provides a thorough review of measures of concept (presented in the same quasi-random order as Ver- formation and reasoning, which includes tests of bal Sequencing); and (4) Photo Sequencing, proverbs, similes, verbal abstraction, and visual- requiring sequencing of the photographs in the concept formation such as the Proverbs Test of actual order of office. Verbal Naming and Photo Gorham (1956), various subtests of the WAIS-R, Naming are scored in terms of number correct. the Halstead Category Test (Reitan & Wolfson, Verbal and Photo Sequencing are scored by com- 1993), Raven's Progressive Matrices (Raven, puting the Spearman rho between the patient's 1982), and the Wisconsin Card Sorting Test (Grant sequence and the actual sequence of office. & Berg, 1948; Heaton, Chelune, Talley, Kay, & The Presidents Test was normed on 250 hospi- Curtiss, 1993). Lezak (1995) devotes a separate talized non-neurologic, nonpsychiatric medical chapter to evaluation of executive functions, which patients, with corrections for age and education are identified as having four components: (1) voli- (Hamsher, 1982). Initial data suggest there is no tion, (2) planning, (3) purposive action, and (4) need to re-norm the procedure each time a new self-monitoring and regulation of performance. president enters office. Hamsher and Roberts Goldstein and Green (1995) view problem solving (1985) found that the Verbal Naming Test was the and executive functions as separate, though related most difficult, whereas Photo Naming was the eas- constructs. Problem solving is described as more iest, and patients with diffuse neurological disease specific (e.g., hypothesis generation, shifting and/or dementia performed the poorest on the var- response sets, divergent thinking, etc.) whereas ious subtests. Roberts, Hamsher, Bayless, and Lee executive functions are broader. Common to both (1990) found that 88 percent of patients with dif- are motivation, planning, execution, and evalua- fuse cerebral disease and control subjects were cor- tion of performance (Goldstein & Green, 1995). rectly classified on the basis of their Presidents Lezak's discussion of tasks requiting executive Test performance. In this same investigation, functions covers tests also considered by others to patients with right hemisphere disease demon- be measures of intellectual and problem-solving strated a selective impairment in temporal skills, such as the Porteus Maze Test (Porteus, sequencing, whereas patients with left-sided 1965). Although it is not uncommon to see a disso- lesions demonstrated selective impairment on the ciation of function with preserved-intellectual and Verbal Naming and Photo Naming subtests. The problem-solving skills in the context of impaired construct validity of the Presidents Test was sup- executive-function abilities related to frontal lobe ported by the factor analysis of Larrabee and Levin functions, shared impairments are frequently seen, (1986), who found a factor that was defined by particularly with severe diffuse brain damage or self-rated change in remote memory, the Verbal disease. Tables 12.1 and 12.2 demonstrate that Naming subtest of the Presidents Test and the measures identified as requiting executive func- Levin version (Levin et al., 1985) of Squire and tions (e.g., the Category Test, Wisconsin Card Slater's (1975) Recognition Memory Test for can- Sorting Test, and Trailmaking B) show a high celed television shows. degree of association with WAIS-R Performance In their review, Larrabee and Crook (1995) IQ subtests. noted that the advantages of the Presidents Test The Wechsler Adult Intelligence Scale, in its included good standardization and brief adminis- various revisions (i.e., Wechsler-Bellevue, WAIS, tration time. The major disadvantage was that per- WAIS-R) is one of the most widely used measures formance could not be analyzed for the presence of of adult intelligence. Factor analyses of the WAIS- a temporal gradient of impairment. R and its predecessor, the WAIS, have yielded three factors: (1) Verbal Comprehension (loadings from Information, Comprehension, Vocabulary, Assessment of Intellectual and and Similarities subtests); (2) Perceptual Organiza- Problem-Solving Skills tion (loadings from Picture Completion, Picture Arrangement, Block Design, and Object Assembly Measures of intelligence and problem solving subtests); and (3) Freedom from Distractibility have a long history in psychology and neuropsy- (loadings from Arithmetic and Digit Span subtests: SPECIALIZED NEUROPSYCHOLOGICAL ASSESSMENT METHODS 31 9

Sherman, Strauss, Spellacy, & Hunter, 1995; severity. This effect extended to the most spatially Smith et al., 1992). The Digit Symbol subtest "pure" WAIS subtest, Block Design. shared loadings with Perceptual Organization and Cautions are also indicated when considering Freedom from Distractibility (Larrabee et al., subtest scatter. Ryan, Paolo, and Smith (1992) 1983; Matarazzo, 1972), and Arithmetic has also found that subtest scatter was no greater for brain- demonstrated shared loadings with Verbal Com- damaged than for normative subjects, when both prehension (Larrabee et al., 1983; Matarazzo, samples were equivalent on IQ. Fuld (1984) has 1972). The Mayo group has advocated interpreta- identified a pattern of WAIS-subtest performance tion of the WAIS-R by factor scores rather than the she found to be more common in patients with traditional VIQ, PIQ, FIQ analyses (Ivnik et al., Alzheimer-type dementia than in patients with 1994; Smith et al., 1992; Smith, Ivnik, Malec, multi-infarct dementia or other types of neurologi- Petersen, Kokmen, & Tangalos, 1994; Smith, cal dysfunction. Recently, Massman and Bigler Ivnik, Malec, & Tangalos, 1993). (1993) conducted a meta-analytic review of 18 dif- Various short forms of the WAIS-R have been ferent studies coveting over 3,700 subjects, and recommended. Smith and colleagues (1994) dem- found that the sensitivity of the Fuld profile to onstrated adequate prediction of the Verbal Com- Alzheimer-type dementia was low, 24.1 percent, prehension factor by Vocabulary and Information, although the specificity was much better, at 93.3 and adequate prediction of the Perceptual Organi- percent compared to normals and 88.5 percent zation factor by Block Design and Picture Comple- compared to non-Alzheimer patients. tion. A seven-subtest short form comprised of the Larrabee, Largen, and colleagues (1985) found WAIS-R Information, Digit Span, Arithmetic, that of a combination of memory and WAIS- intel- Similarities, Picture Completion, Block Design ligence subtests, the VSRT was the most sensitive and Digit Symbol subtests has been proposed by test in discriminating patients with AD from age, Ward (1990). This seven-subtest short form pre- education, and gender-matched controls; however, dicts well VIQ, PIQ, and FIQ scores based on the in spite of its superiority in discriminating these full WAIS-R administration, with composite reli- two groups, the VSRT did not correlate at all with dementia severity. By contrast, WAIS Information abilities and standard errors of estimate compara- and Digit Symbol were not only sensitive to the ble to the standard administration of the complete presence of dementia (albeit not as sensitive as the battery (Paolo & Ryan, 1993; Schrelten, Benedict, VSRT), but both of these WAIS subtests were also & Bobholz, 1994). correlated with severity of dementia. This sug- The sensitivity of the WAIS-R to cerebral dys- gested that the primary utility of memory testing function is widely established (Matarazzo, 1972; was in establishing the presence of dementia, while McFie, 1975; Reitan & Wolfson, 1993). Scores on assessment of intellectual skills was useful in char- the Wechsler scales are reduced in Alzheimer-type acterizing the severity of AD and determining the dementia (Fuld, 1984; Larrabee, Largen, et al., functional correlates of dementia. 1985), and in the context of moderate-to-severe One important outgrowth of the established sen- closed head trauma (Dikmen, Machamer, Winn, & sitivity of the WAIS-R to dementia is the need to Temkin, 1995; Levin et al., 1982). Sherer, Scott, estimate pre-morbid intellectual function. One Parsons, and Adams (1994) found that the WAIS- original method of analyzing the pattern of age and R was as sensitive as the HRNB in discriminating disease resistant ("hold") tests such as Vocabulary, brain-damaged from non-brain-damaged controls. relative to age and disease sensitive ("don't hold") Lower Verbal IQ (VIQ) scores relative to Per- tests such as Block Design and Digit Symbol, has formance IQ (PIQ) scores have been associated not been supported in subsequent research. with left hemisphere disease, with lower PIQ than Although the "hold" tests show less of a decline VIQ scores associated with fight hemisphere dis- relative to the "don't hold" tests in AD, basing the ease (Bornstein & Matarazzo, 1982). Some caveats assessment of premorbid function on "hold" tests are in order, because PIQ can be reduced in diffuse can underestimate premorbid IQ by as much as a brain disease (Lezak, 1995) as well as in the con- full standard deviation (Larrabee, Largen, et al., text of aphasia (Hamsher, 1991; Larrabee, 1986). 1985). Indeed, Larrabee (1986) found that patients with Investigators have taken advantage of the well- left and fight hemisphere CVA did not differ on documented association of demographic factors PIQ until PIQ was statistically adjusted for aphasia such as educational and occupational status with 320 HANDBOOK OF PSYCHOLOGICAL ASSESSMENT intelligence-test performance to develop regres- function (Adams et al., 1995; Heaton et al., 1993), sion equations for estimation of premorbid IQ. but performance is also affected by non-frontal These have been developed based on the WAIS dysfunction (Anderson, Damasio, Jones, & Tranel, standardization data (Wilson, Rosenbaum, Brown, 1991; Reitan & Wolfson, 1995). The Category Rourke, Whitman, & Grisell, 1978) and based on Test is described in greater detail in chapter 10. the WAIS-R-standardization data (Barona, Rey- The Wisconsin Cart Sorting Test (WCST) requires nolds, & Chastain, 1984). Recently, Paolo, Ryan, the patient to sort cards containing colored geo- Troster, and Hilmer (1996) have extended this metric forms of different shape and number to 4 regression-estimation approach to estimation of target cards. The only examiner feedback is WAIS-R-subtest-scales scores. Although these whether each sort is correct or incorrect. After the regression formulae can be quite useful, the stan- patient has reached a certain number correct in a dard errors of estimate are quite high (range of 12 row, the examiner changes the rule and the subject to 13 IQ points: cf., Barona et al., 1984; range of must switch conceptual sets. A number of scores 2.31 to 2.66 for subtest scaled scores: cf., Paolo et can be computed, but the most sensitive scores are al., 1996). the number of perseverative responses and number Nelson and colleagues (Nelson, 1982; Nelson & of perseverative errors made (Heaton et al., 1993). O'Connell, 1978) have developed an estimate of Tables 12.1 and 12.2 demonstrate an association pre-morbid IQ based on the ability of the patient to of Category Test and WCST performance with a pronounce irregular words (e.g., "debt"), entitled factor that is also defined by the WAIS-R PIQ sub- the National Adult Reading Test (NART). The tests; however, Perrine (1993) found that the Cate- NART was originally standardized in comparison gory Test and WCST shared only 30 percent to the WAIS, on a sample in Great Britain. It is less common variance when analyzed in the context of sensitive to the effects of dementia than WAIS other concept-formation tasks. WCST perfor- Vocabulary, but can be affected by aphasia and mance was associated with attribute identification moderate-to-severe dementia (Crawford, 1992). whereas Category Test scores were related to mea- One safeguard recommended by Crawford (1992) sures of rule learning and deduction of classifica- is to insure that the obtained NART score is within tion rules. More recently, Adams and coworkers the expected range of a NART value estimated on (1995) found that performance on Subtest VII of the basis of demographic factors, prior to using the the Category Test was correlated with local cere- NART to estimate premorbid IQ. Obviously, if bral metabolic rate for glucose (LCMRG) in the there is evidence that the NART has been affected cingulate, dorsolateral, and orbitomedial aspects of by aphasia or dementia, the clinician must rely on the frontal lobes in older alcoholic patients. By the demographic-regression equations for estima- contrast, the Categories-achieved Score on the tion of premorbid IQ. WCST was related to LCMRG in the cingulate Blair and Spreen (1989) have developed a revi- region alone. Hence, the findings of Perrine (1993) sion of the NART for a North American sample, and Adams and collaborators (1995) suggest that the NART-R, for predicting WAIS-R IQ. This the Category Test and WCST are not interchange- revised version or North American Adult Reading able measures of problem solving and concept for' Test (NAART) was significantly associated with mation related to frontal cognitive skills. VIQ (r = .83), PIQ (r = .40) and FIQ (r = .75), with Lezak (1995) discusses other measures of standard errors of estimate ranging from 6.56 for abstraction and frontal executive skills including VIQ to 10.67 for FIQ. Addition of demographic maze problem-solving, the Tinkertoy Test, and variables accounted for a 3 percent increase in IQ measures of design generation. The design fluency variance, which was non-significant. Berry and measure developed by Jones-Gotman and Milner colleagues (1994) published the first study to con- (1977) was intended as a nonverbal counterpart to firm the retrospective accuracy of the NART-R in the word-fluency procedure (see earlier discussion predicting WAIS-R IQs obtained 3.5 years earlier of Controlled Oral Word Association in the Lan- in a group of normal older persons. guage section of this chapter). This task requires Two of the more widely used measures of con- the subject to "invent" nonsense drawings (i.e., cept formation and problem solving are the HRNB without identifiable or recognizable meaning), Category Test (Reitan & Wolfson, 1993) and the under time constraints. Testing is conducted under Wisconsin Card Sorting Test (Heaton et al., 1993). a "free condition," and under a "fixed" condition Both are thought to reflect aspects of frontal lobe (acceptable drawings are limited to four straight or SPECIALIZED NEUROPSYCHOLOGICAL ASSESSMENT METHODS 321 curved lines). Jones-Gotman and Milner (1977) terns also have reliable extra-test correlates. originally reported an association of test impair- Fletcher (1985) found the first subgroup (reading ment with right frontal excision. and spelling impaired) had impaired verbal relative Ruff (1996) has published the Ruff Figural Flu- to nonverbal learning and memory-test perfor- ency Test. This test is a modification of an earlier mance, whereas the converse was true for sub- procedure devised by Regard, Strauss, and Knapp group 3 (impaired math, normal reading and (1982) to provide a measure of design fluency that spelling), who performed poorer on nonverbal was more reliable than the original Jones-Gotman learning and memory relative to their verbal learn- and Milner (1977) procedure. Ruff's version ing and memory. Rourke (1995) has reported requires the subject to produce multiple designs, extensively on the cognitive and emotional charac- connecting five symmetric and evenly spaced dots. teristics of the arithmetic-impaired subgroup, who Five different five-dot patterns are presented (two frequently suffer from nonverbal learning disabil- with interference). Ruff (1996) presents normative ity. data, corrected for age and education, on 358 vol- Table 12.2 displays a complex loading pattern unteers aged 16 to 70 years. The Ruff Figural Flu- for the WRAT-R subtests. The primary loading of ency Test loads on multiple factors including Reading, Spelling, and Math is on the first factor, complex intelligence, planning, and arousal in nor- which is also defined by the WAIS-R VIQ sub- mals and on planning and flexibility factors in tests. The three achievement tests also show a sec- head-injured patients (Baser & Ruff, 1987). ondary loading on the attention and information- It is also important to evaluate academic processing factor. achievement. Decline in calculational functions can be seen in dementing conditions (Cummings & Benson, 1992). As already discussed, oral reading tests have been used to predict pre-morbid ability ASSESSMENT OF PERSONALITY, in dementia (Blair & Spreen, 1989; Crawford, ADAPTIVE FUNCTIONS, 1992; Wiens, Bryant, & Crossen, 1993). Achieve- AND MOTIVATION ment testing is also important in evaluating for Assessment of personality function is an impor- learning disability. Assessment of learning disabil- tant part of any comprehensive psychological or ity may be the primary focus of a particular neu- neuropsychological evaluation. The reader is ropsychology referral. Alternatively, it is referred to the chapters on personality assessment important to rule out learning disability when eval- in this volume for more detailed consideration of uating young adults who have sustained closed this topic (see chapters 16 and chapter 17). head injury. Persons with learning disability can produce profiles suggestive of neuropsychological In neuropsychological settings, personality and emotional factors can relate to current status in a impairment that could be misinterpreted as secondary to trauma when these patterns actually repre- number of ways. Persons with preexisting psychi- sent preexisting problems (Larrabee, 1990). atric problems can have exacerbations of these Several measures of achievement exist (see problems post-injury or following disease of the chapter 7, this volume). The Woodcock-Johnson central nervous system. Patients can develop per- Psycho-Educational Battery-Revised (Woodcock sonality change that is directly attributable to brain & Mather, 1989) is probably one of the more com- damage or disease, particularly if the frontal lobes, prehensive measures. Perhaps the most widely temporal lobes, or limbic system is involved (Heil- used battery in neuropsychological settings, which man, Bowers, & Valenstein, 1993). Persons sus- is more of a screening examination and shorter taining brain injury or disease can develop than the more Comprehensive Woodcock- secondary emotional reactions to their disabilities Johnson, is the Wide Range Achievement Test or can sustain traumatic emotional reactions such (WRAT-3) (Wilkinson, 1993). Several studies as posttraumatic stress disorder in the course of have shown that learning-disabled persons perform sustaining their original physical injury. in three reliably distinct patterns: (1) impaired oral As discussed in this volume, personality and reading and written spelling with preserved written emotional processes can be assessed via objective calculations; (2) impaired reading, spelling, and and projective instruments. In neuropsychological arithmetic, and (3) impaired arithmetic but normal assessment, objective personality tests such as the spelling and reading (Rourke, 1991). These pat- MMPI or MMPI-2 are more frequently utilized 322 HANDBOOK OF PSYCHOLOGICAL ASSESSMENT than projective measures (Butler, Retzlaff, & 1 and 3 at values over T scores of 80, secondary to Vanderploeg, 1991). exaggerated somatic complaints. One way of Personality evaluation in patients who have addressing these extreme elevations on the somatic brain injury or brain disease poses some unique scales is to compare them to Heaton and colleagues problems. One potential consequence of signifi- scale 1 and 3 data for simulated malingerers on the cant frontal lobe trauma or degenerative conditions MMPI, or to similar data for the Berry and cowork- such as Alzheimer-type dementia is denial or min- ers, MMPI-2 malingerers. Elevations on scales 1 imization of deficit, termed anosognosia (Priga- and 3 on the MMPI-2 can also be compared to the tano & Schacter, 1991). Consequently, persons Keller and Butcher (1991) data on chronic-pain with anosognosia may not endorse any personal- patients, particularly if pain is a feature of the pre- ity-test or depression-test items in the clinically senting problems (a frequent occurrence in mild significant range, when indeed, symptoms are very closed head trauma cases). Larrabee (1998) has significant. On the other hand, some (Alfano, Neil- demonstrated a pattern consistent with somatic son, Paniak, & Finlayson, 1992; Gass, 1991) have malingering demonstrated by T scores at least 80 advocated "neuro-correcting" the MMPI to on scales 1 and 3, accompanied by an elevated remove those items related to neurologic factors, score on the Lees-Haley Fake/Bad scale (Lees- arguing that spurious elevations on MMPI scales Haley, 1992). Elevations on scales 1 and 3 that may occur due to endorsing neurologically based exceed the Keller-Butcher pain group values by complaints. Other research demonstrating a closer over one standard deviation should be viewed as association of cognitive complaint with depression suspicious for exaggeration. than with actual cognitive performance (Williams, Clinician-based rating scales such as the Brief Little, Scates, & Blockman, 1987; Larrabee & Psychiatric Rating Scale (BPRS) (Overall & Levin, 1986) would argue against the need for such Gorham, 1962), and the Neurobehavioral Rating a correction. Indeed, Brulot, Strauss, and Spellacy Scales (NBRS) (Levin, High, et al., 1987) can be (1997) recently reported that endorsement of employed when the reliability and validity of a MMPI Head Injury Scale items was related to the self-report instrument are suspect due to the MMPI-2 Depression Content Scale, but not related patient's impaired neuropsychological status. The to performance on neuropsychological tests or to BPRS was developed for use with psychiatric measures of head-trauma severity such as loss of patients and was also employed by Levin, Gross- consciousness or posttraumatic amnesia. man, Rose, and Teasdale (1979) in an outcome One major advantage of the MMPI/MMPI-2 is study of patients with severe traumatic brain that it allows an assessment of the validity of a par- injury. Subsequently, Levin, High, and colleagues ticular patient's response pattern. Heaton and (1987) developed the NBRS as a measure more coworkers (1978) presented data on malingering suited to the neurobehaviorally impaired head- which included the MMPI. Berry and colleagues injured patient. Factor analysis of the NBRS has (1995) present similar data on the MMPI-2. Both yielded 4 factors: (1) Cognition/Energy, (2) Meta- Heaton and collaborators (1978) and Berry and cognition, (3) Somatic/Anxiety, and (4) Language. colleagues (1995) found that traditional MMPI/ Factors 1, 2, and 4 were related to head-trauma MMPI-2 validity scales (eg., F) were sensitive to severity, as well as to longitudinal recovery over malingering in normal subjects attempting to sim- time. ulate brain injury. Recently, Nelson and collaborators (1989) and One particular problem with the MMPI or Nelson, Mitrushina, Satz, Sowa, and Cohen (1993) MMPI-2 is that the validity scale most often relied have developed the Neuropsychology Behavior upon to detect malingering is the F scale. This and Affect Profile (NBAP). The NBAP is com- author (Larrabee, 1998) has seen patients who pleted by relatives rating pre-illness behavior and have been identified as malingerers by current emotional status as well as current functioning, on objective measures of malingering (e.g., Portland 106 items comprising five scales: (a) Indifference, Digit Recognition Test: Binder & Willis, 1991), (b) Inappropriateness, (c) Depression, (d) Mania, who have "valid" MMPIs, with F scales below sig- and (e) Pragnosia (a defect in the pragmatics of nificant elevations, but have extreme elevations on communications; e.g., "My relative often seems to scales 1 and 3. This is due to the fact that only 1 F- miss the point of a discussion"). Nelson and scale item is on either scales 1 or 3. What results is coworkers (1989) provide evidence for high inter- an extremely elevated "Conversion V" with scales nal consistency and good discriminative validity SPECIALIZED NEUROPSYCHOLOGICAL ASSESSMENT METHODS 323 between normal elderly and dementia patients and based on the binomial distribution, the assumption between normal subjects and stroke patients. is made that they had to know the correct answer to Measures of adaptive functioning assess the perform at such an improbably poor level. patient's capacity to function effectively in their This interpretation is rationally and statistically own environment. These measures include the appealing. Unfortunately, many persons whose more comprehensive rating scales such as the Cog- behavior is suspicious for malingering may not nitive Behavioral Rating Scale (Williams, 1987) perform at worse-than-chance level on forced- which assesses a variety of functional areas, via choice symptom-validity procedures. Hence, family or friend ratings of the patient, including Binder and Willis (1991) performed a study con- areas such as language, higher cognitive functions, trasting the performance of persons with docu- orientation, skilled motor movement, agitation and mented brain damage who were not seeking memory, to the more specifically focused scales compensation, with a similar group seeking com- such as the Memory Assessment Clinic's Self and pensation, a group without brain damage but suf- Family rating scales (MAC-S) (Crook & Larrabee fering major affective disorder, a group of minor 1990, 1992), (MAC-F) (Feher, Larrabee, Sud- head-trauma patients seeking compensation, a ilovsky, & Crook, 1994). Scales such as the MAC- group of non-patient control subjects, and a group S and MAC-F, which include parallel self- and of non-patient subjects instructed to feign brain family-appraisal rating forms, allow for assess- impairment, on the Portland Digit Recognition test ment of the patient's awareness of deficit and can (PDRT), a two-alternative forced-choice recogni- allow quantification of anosognosia in patients tion-memory task. The lowest performance of all who under-report difficulties (Feher et al., 1994). the groups was achieved by the non-patient simu- By contrast, greater self-report of impairment com- lators who averaged 50 percent correct on the 30- pared to ratings by relatives could suggest a poten- second-delay (Hard) condition of the PDRT. Using tial depressive pseudo-dementia or a somatoform a cutoff of below the worst performance of the basis to cognitive complaint. documented brain-damage group, up to 26 percent Assessment of motivation and cooperation has of the minor head trauma (MHT) group seeking assumed an increasingly important role in the med- compensation performed more poorly than all of ico-legal arena. Over the past several years, there the subjects who had documented brain damage. has been a significant increase in research on Binder and Willis also contrasted the performance malingering, or the intentional production of false of MHT subjects divided on PDRT performance or exaggerated symptoms for secondary gain into extreme groups (high vs. low motivation), on (American Psychiatric Association, 1994). Brandt a variety of standard neuropsychological tests. (1988) has indicated that the only way a clinician They found significantly poorer performance for can be certain of malingering is if the patient con- the low-motivation group on a variety of cognitive fesses. Obviously, confession rarely occurs. (eg., IQ, Digit Span), motor (eg., Fingertapping; Malingering can involve both symptom report Grooved Pegboard), and personality (SCL-90-R) (Berry et al., 1995) and/or neuropsychological test measures. Subsequently, Binder, Villanueva, performance (Brandt, 1988). Howieson, and Moore (1993) demonstrated that Several procedures have been developed to MHT patients with poor PDRT performance also assist in detection of malingering. Malingering of performed poorly on the Recognition trial of the symptom report has been discussed relative to the RAVLT (mean score was 8, just above chance). MMPI/MMPI-2. One of the major advances in Lee, Loring, and Martin (1992) established cut- detection of malingered neuropsychological test off scores for performance on the Rey-15 Item performance has been the application of forced- Test, an older measure of motivation developed by choice methodology and the binomial theorem to the French Psychologist Rey (1964). This task pre- assess malingering (Binder, 1990; Binder & sents the subject with 15 items arranged in three Pankratz, 1987; Hiscock & Hiscock, 1989). In a columns by five rows. These items are presented forced-choice task (e.g., identifying whether one for 10 seconds, then withdrawn with instructions to was touched once or twice; identifying which of reproduce them from memory. Although there are two five-digit numbers was previously presented), 15 items, they can be grouped and clustered rather it is conceivable that someone with severe brain easily (eg., upper and lower case letters; Roman damage could perform at chance level; however, if and Arabic numerals) so that even patients with someone does significantly worse-than-chance significant brain injury can perform normally. 324 HANDBOOK OF PSYCHOLOGICAL ASSESSMENT

Indeed, 42 of 100 patients with temporal lobe epi- (Mittenberg, et al., 1993, 1995; Mittenberg, lepsy and documented memory impairment per- Rotholc, Russell, & Heilbronner, 1996). Although formed perfectly in the Lee and colleagues' (1992) Mittenberg and colleagues derived discriminant study. Rey (1964) originally suggested that a score functions for these various different tests, they also of nine or less was suggestive of malingering. found that simple difference scores between Based on the distribution of performance for the WMS-R Attention Concentration (AC) and Gen- temporal lobe epilepsy group, Lee and coworkers eral Memory (GM) (AC lower than GM) and determined a cutoff of seven or less items for iden- WAIS-R Digit Span significantly lower than tification of malingered performance (only 4 per- Vocabulary, were nearly as effective as the com- cent of their memory-impaired epileptics plete discriminant functions in differentiating the performed this poorly). Six of 16 outpatient sub- experimental malingerers from head-injured subjects in litigation, the majority with history of mild jects. head trauma, performed at a level of seven or less correct. More recently, Greiffenstein, Baker, and Gola (1996) have provided data suggesting that SCREENING BATTERIES Rey's original cutoff of nine or less, was both sensitive and specific to malingering, provided that a Earlier, in the discussion of test batteries such as true organic amnestic disorder could be excluded the HRNB versus ability-focused, flexible on the basis of medical records. approaches to neuropsychology, the issue of Millis (1992) found that 50 percent of minor screening or core batteries was raised. As noted, head-trauma patients performed more poorly than Bauer (1994) recommended development of multi- patients with moderate-to-severe closed head ple fixed batteries, depending on the population trauma on the Word Recognition subtest of the being assessed. Earlier, Benton (1992) recom- Warrington Recognition Memory Test. The MHT mended development of a core battery of neurop- mean score approached chance, but was not worse- sychological tests that could be administered in an than-chance. Obviously, given the two-alternative hour or less. Subsequently, Parsons (1993a), as forced-choice format, particularly poor perfor- President of Division 40 (the Neuropsychology mance on the Warrington Recognition Memory division of the APA), invited input from the mem- Test can also be evaluated with the binomial theo- bership regarding development of a 1 1/2-to-2 hour rem, and the current author has seen two patients core test battery. Due to a primarily negative who performed at a significantly worse-than- response, further investigation into the develop- chance level who also failed the Rey-15 Item Test ment of a core battery was dropped (Parsons, and PDRT. 1993b). Other methodologies used in establishing pat- Since this time, the practice of clinical psychol- terns suspicious for malingering include compari- ogy in general, and neuropsychology specifically, son of normal persons instructed to feign has come under significant economic pressure impairment on standard psychological and neurop- from the impact of managed care companies on sychological tests with performance of persons reimbursement for services. In a recent survey, having sustained moderate-to-severe traumatic Sweet, Westergaard, and Moberg (1995) found brain injury (Heaton et al., 1978; Mittenberg et al., that 64 percent of respondents believed that 1993; Mittenberg et al., 1995). Heaton and collab- national health-care reform would reduce patient orators (1978) found that experimental malingerers evaluation time. Hence, it appears timely to recon- performed more poorly than head-injured subjects sider Benton and Parson's previous recommenda- on selected cognitive (eg., Digit Span), motor (tap- tions for development of a core battery. ping speed, grip strength), and personality (MMPI One of the biggest concerns regarding establish- F scale, and scales 1, 3, 7, and 8) variables, despite ment of a core battery is that clinicians will be out-performing the head injured on several sensi- "forced" by insurance companies to administer a tive tasks, including the Category Test and Tactual limited set of procedures to each patient, and there Performance Test. will be insufficient examination of the complexity Mittenberg and colleagues have contrasted the of brain functions; however, it is quite possible to performance of normal subject (i.e., noninjured) establish a core battery that is flexible and adapt- simulators with that of non-litigating head- injured able to the patient' s needs by developing statistical patients on the WAIS-R, WMS-R, and HRNB and psychometric guidelines based on an integra- SPECIALIZED NEUROPSYCHOLOGICAL ASSESSMENT METHODS 325 tion of Bauer's "screening," "population specific" An ideal patient population for test development and "domain-specific" multiple battery approach, would be patients who have suffered moderate-to- with what he terms a "tiered" approach (also severe closed head trauma. This population would described as a step battery by Tarter and Edwards, encompass both diffuse central nervous system 1986). For example, in a patient with a history of function as well as cases of focal injury superim- left hemisphere stroke, one is already alerted to a posed on diffuse damage. This population would population-specific need for screening of language also have known biological markers of severity and sensorimotor abilities. If this patient scores (Glasgow Coma Scale; duration of posttraumatic above average on screening measures of semantic amnesia) which can be correlated with test perfor- and phonemic fluency, and visual-confrontation mance (cf., Dikmen et al., 1995). Subgroups can be naming, there may be no need for more compre- formed of subacute and chronic samples, and hensive, "domain specific" aphasia examination. patients with and without mass lesions. Similarly, if the patient demonstrated average to The over-inclusive battery would be adminis- above average dominant-hand fine-motor skills on tered to the subacute and chronic groups of the Grooved Pegboard, and normal dominant-hand patients. Validity could be established in a variety performance on the Benton Tactile Form Percep- of fashions. Construct validity would be estab- tion Test, there may be no further testing required lished through factor analysis. Criterion validity of more basic manual motor and manual tactile could be established through demonstration of associations of test performance with initial admis- functions. sion Glasgow Coma scale values, and by evaluat- Several recent investigations are pertinent to the ing the association of different tests with relative- establishment of a core battery. The meta-analysis rating scales such as the Cognitive Behavior Rat- of Chouinard and Braun (1993), contrasted the rel- ing Scales (CBRS) (Williams, 1987), and/or self- ative sensitivity of various neuropsychological and family-rating scales such as the MAC-S or procedures in cases of diffuse cerebral dysfunc- MAC-F (Crook & Larrabee, 1990, 1992; Feher et tion. Several investigators have shown that the al., 1994). Discriminant validity could be evalu- WAIS-R can be reduced from the original eleven ated by contrasting patient versus control-subject subtests to seven or fewer, with little appreciable performance on the different tasks. Internal consis- loss in diagnostic or descriptive information (Paolo tency and test-retest reliability would also be & Ryan, 1993; Smith et al., 1994; Ward, 1990). examined. Sherer and colleagues' (1994) research, demon- The above procedure would ideally result in strating equivalent sensitivity of the WAIS-R sub- identification of the most valid and reliable mea- tests to the HRNB in detecting brain dysfunction, sures of each of the major neurobehavioral areas. and recent factor analyses of complex test batteries Tests could be ranked by the size and purity of fac- (Tables 12.1, 12.2) suggest a model for developing tor loadings, by sensitivity to trauma severity, by a core neuropsychological battery. ecological validity (prediction by relative ratings) A core battery should cover the basic domains and by reliability. Certain inherently less reliable outlined in the current chapter as well as by other domains such as attention/information processing authors (eg., Chouinard & Braun, 1993; Lezak, may require two measures. 1995;), including language, perceptual/spatial, Concurrently, subtests from "domain-specific" sensorimotor, attention, verbal and visual memory, batteries could be directly compared in patient and intellectual and problem-solving skills. In populations with left and right hemisphere CVA. addition, multi-factorial tests such as WAIS-R Hence, the Multilingual Aphasia Examination, the Digit Symbol or Trailmaking B should be Boston Diagnostic Aphasia Examination, and the included, which are sensitive (i.e., to the presence Western Aphasia Battery subtests could be directly of impairment), but not necessarily specific (i.e., as compared as to their respective sensitivities to lan- to which of several cognitive functions might be guage impairment in lefthemisphere CVA. The impaired). Initial development would require an Benton Visual Form Discrimination, Facial Rec- over-sampling of each domain (e.g., for verbal ognition, Line Orientation, and 3-Dimensional memory, including several supraspan list-learning Constructional Praxis Test could be compared with tasks such as the CVLT, AVLT, Selective measures such as the Hooper Visual Organiza- Reminding, paired-associate learning, prose recall, tional Test, the Boston Parietal Lobe Battery, and and verbal recognition memory). the Gollin Figures as to sensitivity in right hemi- 326 HANDBOOK OF PSYCHOLOGICAL ASSESSMENT sphere CVA. Both left and right- hemisphere CVA The above discussion suggests an approach for patients would be administered multiple measures developing a core examination, in three groups of of motor and tactile function, with determination patients most frequently seen for neuropsychologi- of the most sensitive measures. Factor analyses cal evaluation. The resultant core battery would could be conducted of performance on these not pose unnecessarily restrictive limitations on domain-specific batteries. Cluster analysis could the evaluation of a particular patient. For clinicians also be conducted on patterns of performance employing a fixed battery approach such as the within each subgroup, followed by discriminant HRNB or LNNB, or domain-specific batteries function analysis to identify the tasks contributing such as the WMS-R, failure on subtests of the core the most to cluster definition (c.f., Larrabee and examination would justify administration of the Crook, 1989). Of additional interest would be anal- more comprehensive battery. For clinicians ysis of the spatial/perceptual tasks that best dis- employing an individualized approach, additional criminate left and right CVA patients, given the assessment can also be justified on the basis of per- known association of aphasic comprehension defi- formance patterns on core battery subtests. cit with performance on "nonverbal" tests, to Assume that in addition to the RAVLT, the core establish which of these procedures were least battery contains Controlled Oral Word Associa- likely to be failed by patients with left hemisphere tion, the Grooved Pegboard, Trailmaking B, the CVA. PASAT, Rey-Osterrieth Complex Figure Test The domain-specific tests established as the (CFT), WAIS-R Block Design and Digit Symbol. most sensitive and having the best construct valid- The head-injured patient who fails RAVLT would ity in the CVA groups could then be administered also need to be examined on the less sensitive ver- with the core procedures established in the head- bal memory measures to explore completely their trauma sample to explore interrelationships and verbal learning difficulties. By contrast, the patient contingencies of performance. Hence, it could be who performs normally on COWA, Grooved Peg- determined that a left CVA patient with normal board, Trailmaking B, PASAT, RAVLT, CFT, WAIS-R Vocabulary and Boston Naming would Block Design, and Digit Symbol, would not need not need to be evaluated further for language more detailed exploration of other language, per- impairment and that same patient who has normal ceptual, sensorimotor, attentional, memory, or Block Design would not have to be administered intellectual and problem-solving skills. Line Orientation. Finally, the contingencies of performance on the core battery could be examined in probable Alzhe- AUTHOR NOTES imer-type dementia. For example assume the core- battery study identified the RAVLT as the most Glenn J. Larrabee, Center for Neuropsychologi- appropriate supraspan learning test relative to the cal Studies, University of Florida, and Sarasota CVLT and Selective Reminding. Further, assume a Memorial Hospital. measure of paired-associate learning and the War- The author gratefully acknowledges the assis- rington Word Recognition Memory score also tance of Susan Towers and Kristin Kravitz in the loaded on the verbal memory factor, but were not preparation of this chapter. as sensitive to impairment as the RAVLT. These Correspondence concerning this chapter should contingencies could be evaluated in the Alzheimer be addressed to Glenn J. Larrabee, Ph.D., 630 group, such that if the RAVLT was failed, one South Orange Avenue, Suite 202, Sarasota, FL would need to explore in addition, paired-associate 34236. learning and word-recognition memory. If a certain level of recognition memory was necessary for possible success on RAVLT or paired-associate REFERENCES learning, then on reassessment a year later, the recognition memory test alone would need to be Adams, K. 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