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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 neuropsy- chological 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
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