Neuropsychological Assessment Chapter28

Total Page:16

File Type:pdf, Size:1020Kb

Neuropsychological Assessment Chapter28 Neuropsychological Assessment chapter 28 R. L. was a 32-year-old nurse and mother of four. Driving home from work one afternoon, she stopped at a red light and was rear-ended by another vehicle. R. L.’s head snapped back and struck the head rest and then the side window as she bounced forward. She blacked out for a few minutes, but, when the emergency vehicles arrived, she was con- scious, although disoriented and dysphasic, in addition to having severe pain in her back and neck from the whiplash. R. L. spent about a week in the hospital, where neither CT nor MRI scans identified any cerebral injury, although several vertebrae were damaged. An accomplished musician, she could still play the piano well from memory, but she could no longer read music. In addi- tion, her oral language skills remained impaired and she was completely unable to read. R. L.’s difficulties did not abate, and she had spells of apraxia. For example, she often found herself unable to figure out how to put on her makeup; she would stare at her lip- stick and have no idea how to use it. When R. L. came to us, she was depressed because, although the neurologists could find no reason for her impairments, she continued to have significant difficulties. Our neuropsychological evaluation revealed a woman of above- average intelligence who had a significant loss of verbal fluency and verbal memory, as well as severe dyslexia even a year after the accident. Now nearly 10 years later, she is still unable to read music and reads text only with great difficulty. L.’s case illustrates one of the remaining problems in clinical neurology. R People with closed-head injuries often have no sign of cerebral injury vis- ible on neuroimaging but still have significant cognitive deficits, often so se- vere that they cannot resume their preinjury life styles. For many, the only evidence of neurological disorder comes from neuropsychological tests. The 1980s were the heyday of neuropsychological assessment. Clinically trained neuropsychologists were in demand and neuropsychological evaluation was regarded as an essential tool in neurological assessment. The role of neu- ropsychological assessment has changed radically, however, and it has begun to develop a new face that is likely to continue changing for some time. In this chapter, we describe this changing role for neuropsychological assessment, consider the rationale behind assessment, and present summaries of six actual case assessments. 751 CHAPTER 28 NEUROPSYCHOLOGICAL ASSESSMENT 752 The Changing Face of Neuropsychological Assessment The roots of neuropsychological assessment lie in neurology and psychiatry. Clinician Kurt Goldstein, for example, was expert in neurology, psychology, and psychiatry. The psychological basis of assessment began to diverge from medicine in the 1940s. The first neuropsychological tests were designed to identify people suffering from cerebral dysfunction attributable to some type of organic disease process (brain pathology), rather than to “functional disor- ders” linked to behavior. Although test designers originally believed that it would be possible to con- struct a single test for brain damage and to establish a cutoff point that sepa- rated the brain-damaged from the non-brain-damaged patient, the task proved to be impossible. Gradually, more-sophisticated testing procedures were de- veloped, largely in a few locations in Europe and North America, including Cambridge (Oliver Zangwill), Oxford (Freda Newcombe), Moscow (Alexander Luria), Montreal (Brenda Milner and Laughlin Taylor), Boston (Edith Kaplan and Hans-Leukas Teuber), and Iowa City (Arthur Benton). By the early 1980s, neuropsychology was no longer confined to a few elite laboratories, and the new field of clinical neuropsychology blossomed in clin- ics and hospitals. Since that time, three factors have enhanced the rate of change in neuropsychological assessment: functional imaging, cognitive neu- roscience, and managed health care. We consider each briefly. Functional Imaging Perhaps the biggest change in both neurology and neuropsychology in the past 25 years has been the development of functional imaging. Indeed, we have em- phasized the importance of functional imaging in the Snapshots in Chapters 6 through 27. Thus, whereas in earlier eras the effects of cerebral injury or dis- ease often had to be inferred from behavioral symptoms, neuroimaging has al- lowed investigators to identify changes in cerebral functioning in a wide variety of disorders, including most of the neurological and behavioral disorders dis- cussed in Chapters 26 and 27. The main role of the clinical neuropsychologist therefore has changed from one of diagnosis to one of participating in rehabilitation, especially in cases of chronic disease such as stroke and head injury. An important point to bear in mind, however, is that even the most sophisticated functional imaging tech- niques often do not predict the extent of behavioral disturbance observed in people with certain types of brain injury, especially in head trauma, as R. L.’s case illustrates. For people with closed-head injury, the only way to document the nature and extent of their disabilities is by a thorough neuropsychological assessment (see Christensen and Uzzell). Cognitive Neuroscience One effect of the growth of clinical neuropsychology is the diversification of methods used by individual neuropsychologists, the choice of tests varying with the disorder being investigated. Indeed, there are now two texts that CHAPTER 28 NEUROPSYCHOLOGICAL ASSESSMENT 753 summarize the various tests available (one by Lezak and the other by Spreen and Strauss). From the early 1950s through the early 1980s, batteries of tests were devel- oped, each with a different focus (Table 28.1). Many of these test batteries, such as the Halstead-Reitan Battery, retained the concept of cutoff scores, although this assumption presents difficulties because performance below a particular level cannot always be taken as being indicative of brain damage. For one thing, cerebral organization varies with such factors as sex, handedness, age, educa- tion, and experience. Furthermore, test problems can be solved by using differ- ent strategies and can thus entail different cortical regions. Symptoms of cortical injury can be highly specific (recall the color-blind painter’s case de- scribed in Chapter 13). Finally, because many tests require problem solving of various kinds, we might expect task performance to vary with intelligence. All these factors make the use of cutoff scores difficult to justify. A serious handicap in the development of test batteries was the absence of theory in test construction or use. Knowledge of brain function was based largely on clinical observation, and few clinicians other than Alexander Luria had tried to formulate a general theory of how the brain functions to produce cognition. The emergence of cognitive neuroscience in the 1990s produced a dramatic change in the theoretical understanding of brain and cognition. Case studies once again became popular, each directed by sophisticated cognitive theory and assisted by structural and functional imaging technologies (see Shallice). These more-cognitive approaches also use multivariate statistical methods such as structural equation modeling to attempt to understand the way in which neural networks are disrupted in both individual cases and in groups. Test design has begun to incorporate this knowledge, but the emerging field of cognitive neuroscience will certainly change the way in which neuropsycho- logical assessment is conducted in the future. Perhaps the area most influenced to date is in understanding the functions of the right frontal lobe (see a review by Stuss and Levine). Historically, the right frontal lobe proved remarkably unresponsive to neuropsychological assessment. The combination of functional imaging and neuropsychological test develop- ment has now led to an understanding of the role of the right frontal lobe in previously inaccessible functions such as social cognition (see Chapter 22). Table 28.1 Overview of neuropsychological test batteries Test battery Type Basic reference Benton’s neuropsychological investigation Composite Benton et al., 1983 Boston Process Approach Composite Kaplan, 1988 Oxford neuropsychological procedures Composite Newcombe, 1969 Montreal Neurological Institute approach Composite Taylor, 1979 Frontal lobe assessment Composite Stuss and Levine, 2002 Western Ontario procedures Composite Kimura and McGlone, 1983 Halstead-Reitan Battery Standardized Reitan and Davison, 1974 Luria’s neuropsychological investigation Standardized Christensen, 1975 Luria-Nebraska Standardized Golden, 1981 CanTab Computerized Robbins et al., 1998 CHAPTER 28 NEUROPSYCHOLOGICAL ASSESSMENT 754 Managed Care Perhaps economics is the greatest challenge faced by practicing psychologists in the past decade. In the era of managed health care, clinicians are pressured to reduce the time and money spent on neuropsychological services. In particular, there is sometimes unreasonable pressure to reduce the number of tests given to individual patients, especially in view of the perception that medical imaging can provide faster and more accurate assessments of cerebral dysfunction. As already noted, imaging has changed the way in which neuropsychologi- cal assessment will be used, but, in cases of head trauma, as R. L.’s case demon- strates, neuropsychological assessment is often the only way to document cognitive disturbances. Groth-Marnat
Recommended publications
  • Neuropsychological Testing
    Medical Coverage Policy Effective Date ............................................. 8/15/2021 Next Review Date ....................................... 8/15/2022 Coverage Policy Number .................................. 0258 Neuropsychological Testing Table of Contents Related Coverage Resources Overview .............................................................. 1 Attention-Deficit/Hyperactivity Disorder: Assessment Coverage Policy ................................................... 1 and Treatment General Background ............................................ 2 Autism Spectrum Disorder/Pervasive Developmental Medicare Coverage Determinations .................. 15 Disorders: Assessment and Treatment Coding/Billing Information .................................. 16 Cognitive Rehabilitation Lyme Disease Treatment— Antibiotic Treatment References ........................................................ 28 INSTRUCTIONS FOR USE The following Coverage Policy applies to health benefit plans administered by Cigna Companies. Certain Cigna Companies and/or lines of business only provide utilization review services to clients and do not make coverage determinations. References to standard benefit plan language and coverage determinations do not apply to those clients. Coverage Policies are intended to provide guidance in interpreting certain standard benefit plans administered by Cigna Companies. Please note, the terms of a customer’s particular benefit plan document [Group Service Agreement, Evidence of Coverage, Certificate of Coverage, Summary
    [Show full text]
  • Atlanta Dist Career
    INS Distinguished Career Award Atlanta Alexandre Castro-Caldas Alexandre Castro-Caldas has had a prolific scientific career, and has made important contributions in several areas of investigation in the areas of Behavioral Neurology and Neuropsychology including Parkinson ’s Disease, illiteracy, and the effects of dental amalgam. He has published nearly 200 papers and book chapters. He has had a major leadership role within INS as well as other national and international organizations. Dr. Castro-Caldas was a member of the INS Board of Governors from 1984-1986; organizer of the 1983 meeting in Lisbon and the 1993 mid-year meeting in Madeira, and was elected president of INS from 2001-2002. Dr. Castro-Caldas has also been highly influential in the field of Behavioral Neurology in Portugal and internationally. He has held positions of leadership in numerous organizations including: Director of the Institute of Health Sciences of Portuguese Catholic University; President of the College of Neurology (Ordem dos Médicos) (1994-97); Member of the International Committee of the International Neuropsychiatric Association; Member of Advisory Board of Portuguese Society of Cognitive Sciences; Advisory Board member The European Graduate School of Child Neuropsychology; President of the Portuguese Society of Neurology (1989-92); board member of the Portuguese Association of Psychology; Board member of the International Association for the Study of Traumatic Brain Injury; and the advisory board for the European Association of Neuropharmacology. Martha Denckla Gerald Goldstein Kenneth Heilman In 1938, parents Samuel and Rosalind Heilman and big brother Fred, welcomed baby boy Kenneth Martin Heilman at what is now Maimonides Hospital.
    [Show full text]
  • Neuropsychology and Rehabilitation Focusing on Individual Needs in the Home, the Community and Wider Society Pearsonclinical.Co.Uk
    Neuropsychology and Rehabilitation Focusing on individual needs in the home, the community and wider society pearsonclinical.co.uk i Welcome to our Neuropsychology and Rehabilitation brochure As the UK’s leading publisher of standardised assessments you can depend on our easy-to-use, well-researched assessments to help you identify cognitive impairments and assist you in the evaluation of your clients; helping you to plan intervention strategies and enhance your evidence-based practice. On the following pages you can navigate through our neuropsychology and rehabilitation decision-tree to explore our portfolio of assessments, interventions and training tools that focus on: general cognition, memory, executive function, speech, language and communication, independent living and adaptive behaviour, motor/visual-motor skills, and social-emotional needs. With the power of our comprehensive digital system Q-interactive™, you can streamline the entire assessment process of some of our popular titles such as the; WAIS–IVUK, WMS-IVUK, CVLT- IIUK and the D-KEFS. Create client profiles, choose and develop batteries, and review scored data through a secure web-portal. Visit our website to view our full range of assessments and tools for both adults and children. pearsonclinical.co.uk XXXXXXX ii Q-interactive™ Leading the way in digital assessment Q-interactive™ is our revolutionary new digital platform that delivers the world’s most advanced assessment tools you can take with you anywhere. Q-interactive saves you time, while adding unprecedented flexibility, portability, convenience and efficiency. It’s simple. You use one iPad, while Q-interactive guides you through test administration instructions, scoring and recording of responses, and controlling of visual stimuli.
    [Show full text]
  • Medical Policy Neuropsychological and Psychological Testing
    Medical Policy Neuropsychological and Psychological Testing Table of Contents • Policy: Commercial • Coding Information • Information Pertaining to All Policies • Policy: Medicare • Description • References • Authorization Information • Policy History Policy Number: 151 BCBSA Reference Number: N/A Related Policies N/A Policyi Commercial Members: Managed Care (HMO and POS), PPO, and Indemnity Neuropsychological Testing Neuropsychological testing is MEDICALLY NECESSARY when conditions are met using McKesson InterQual® criteria for medical necessity reviews. Neuropsychological testing for Attention Deficit Hyperactivity Disorder (ADHD) may be MEDICALLY NECESSARY for the following: • when routine treatment for ADHD has not improved patient outcomes and there is well documented evidence of treatment failure, and • when psychological testing has been completed and further clinical information is needed to rule out a medical or psychiatric diagnosis. Neuropsychological testing for the routine diagnosis of ADHD is NOT MEDICALLY NECESSARY. Neuropsychological testing is considered NOT MEDICALLY NECESSARY when used primarily for: • educational or vocational assessment or training (to diagnose specific reading disorders, developmental disorders of scholastic skills, dyslexia and alexia), or • determining eligibility for special needs programs, • assessment or diagnosing of pervasive developmental disorders or other disorders or psychological development, • improving academic performance, • baseline assessment of function, • monitoring of chronic
    [Show full text]
  • Neuropsychological Testing Crosswalk for 2019 Neuropsychological Testing and Evaluation CPT® Codes CPT® Codes and Descriptors Effective January 1, 2019
    Neuropsychological Testing Crosswalk for 2019 Neuropsychological Testing and Evaluation CPT® Codes CPT® Codes and Descriptors Effective January 1, 2019 Professional and Technical Activities Performed by the Neuropsychologist Please note that the new codes do not cross-walk on a one-to-one basis with the deleted codes. The single code, 96118, will now be billed using up to four (4) codes; two (2) codes for Neuropsychological Evaluation Services (96132, 96133) and two (2) for Test Administration and Scoring (96136, 96137). • Evaluation services include interpretation of test results and clinical • Evaluation services must always be performed by the professional prior data, integration of patient data, clinical decision making, treatment to test administration, and may be billed on the same or different days. planning, report generation, and interactive feedback to the patient, • Test administration and scoring services performed by the family member(s) or caregiver(s). neuropsychologist includes time spent to administer and score a - The first hour of neuropsychological evaluation is billed using minimum of two (2) neuropsychological tests. 96132 and each additional hour needed to complete the service • The time spent scoring tests is now considered to be billable time. is billed with code 96133. - The first 30 minutes of test administration and scoring is billed - CPT Time Rules allow an additional unit of a time-based code using 96136 and each additional 30-minute increment needed to be reported as long as the mid-point of the stated amount to complete the service is billed with code 96137. of time is passed. Beyond the first hour (96132), at least - CPT time rules apply to the add-on code if, beyond the first 30 an additional 31 minutes of work must be performed to bill minutes, at least an additional 16 minutes of work is performed.
    [Show full text]
  • Neuropsychological Testing*
    Neuropsychological and Psychological Testing Corporate Medical Policy File Name: Neuropsychological and Psychological Testing File Code: UM.DIAG.04 Origination: 07/2011 (NAME CHANGE - Replaces Neuropsychological Testing section of BCBSVT Policy on Neurodevelopmental Assessment & Neuropsychological Testing which is now an archived policy) Last Review: 01/2020 Adaptive Maintenance Cycle Only Next Review: 05/2020 Effective Date: 04/01/2020 (Adaptive Maintenance Changes Only) Neuropsychological Testing* *If the testing proposed is primarily Psychological Testing, please see section “Psychological Testing” below. Description/Summary Neuropsychological testing (including higher cerebral function testing) consists of the administration of reliable and valid tests to identify the presence of brain damage, injury or dysfunction and any associated neuropsychological deficits. Findings are documented in a written report and help to determine the patient’s prognosis and assist with long-term treatment planning. Neuropsychological testing is typically covered under the medical benefit and will be covered up to eight cumulative hours without the need for prior authorization. • Neuropsychological testing differs from that of psychological testing in that neuropsychological testing generally consists of the administration of measures that sample cognitive and performance domains sensitive to the functional integrity of the brain, such as memory and learning, attention, language, problem solving, sensorimotor functions, etc. Neuropsychological tests are objective and quantitative in nature and tend to be specific to determining function in certain cortical regions, whereas psychological testing may test for broader cortical function, such as personality traits, and include self-report questionnaires, rating scales or projective techniques. The length of the evaluation depends upon a number of factors. These include not only the nature of the specific diagnosis, but also the patient's level of impairment, motivation, endurance and ability to cooperate with examination requests.
    [Show full text]
  • The Assessment of Executive Function in Children
    City Research Online City, University of London Institutional Repository Citation: Henry, L. and Bettenay, C. (2010). The assessment of executive functioning in children. Child and Adolescent Mental Health, 15(2), pp. 110-119. doi: 10.1111/j.1475- 3588.2010.00557.x This is the accepted version of the paper. This version of the publication may differ from the final published version. Permanent repository link: https://openaccess.city.ac.uk/id/eprint/12074/ Link to published version: http://dx.doi.org/10.1111/j.1475-3588.2010.00557.x Copyright: City Research Online aims to make research outputs of City, University of London available to a wider audience. Copyright and Moral Rights remain with the author(s) and/or copyright holders. URLs from City Research Online may be freely distributed and linked to. Reuse: Copies of full items can be used for personal research or study, educational, or not-for-profit purposes without prior permission or charge. Provided that the authors, title and full bibliographic details are credited, a hyperlink and/or URL is given for the original metadata page and the content is not changed in any way. City Research Online: http://openaccess.city.ac.uk/ [email protected] Left running head: Lucy A. Henry & Caroline Bettenay Right Running Head: Assessing Executive Functioning The Assessment of Executive Functioning in Children Lucy A. Henry & Caroline Bettenay Child and Adolescent Mental Health, 2010, 15(2), pp. 110-119. Department of Psychology, London South Bank University, 103 Borough Road, London SE1 0AA, UK. E-mail: [email protected] Background: Executive functioning is increasingly seen as incorporating several component sub-skills and clinical assessments should reflect this complexity.
    [Show full text]
  • Norman Geschwind
    Norman Geschwind When a scholar dies after long years of productivity, the intellectual contributions are more readily assessed than when death occurs in the ascendancy of a brilliant but foreshortened career. Then, the passage of time may temper or verify the optimistic predictions voiced at the acute loss. With his exceptional powers of astute clinical observation, extensive knowledge of the neurological literature, verve and creative imagination, Norman Geschwind generated countless lively ideas that challenged himself and colleagues world-wide. Now, a decade and a half after his passing, we can savor the fact that many of his ideas have matured, benefiting from the development of new experimental techniques and the subsequent work of his successors. Norman Geschwind, MD, ’51 died on 4 November 1984 at the age of 58. He had been ill at home but a few minutes, and suffered irretrievable cardiac arrest in the presence of a physician calling on him. A native of New York City, Dr. Geschwind was tutored at Harvard College in two stretches that sandwiched a pair of years in the United States Army Infantry. Following graduation, magna cum laude, in 1947, he studied at Harvard Medical School, receiving his medical degree cum laude in 1951. After internship in medicine at Boston’s Beth Israel Hospital, he began specialty training in neurology with three years at National Hospital, Queen’s Square, London under a Moseley Traveling Fellowship, then as a USPHS Research Fellow. Chief residency followed under Derek Denny-Brown in the neurological unit, Boston City Hospital, then two years of research on axonal physiology with Francis O.
    [Show full text]
  • 10: Tests Used in Diagnosing Dementia
    Dementia Q&A 10 Tests used in diagnosing dementia This sheet explains the more common tests and assessments doctors currently use to diagnose dementia. Those who are being assessed for dementia will find it helpful to be prepared for what, for some people, can be a long and emotionally difficult process. What does assessment for dementia involve? There is no one diagnostic test for Alzheimer’s disease or for most other causes of dementia. Instead, doctors use a number of different tests and assessments to determine whether symptoms fit certain criteria and to rule out other possible causes of these symptoms. The first step towards a diagnosis is to talk to your doctor about your concerns. It is a good idea to take a close family member or friend along to the appointment to assist in providing additional information. It is also a good idea to take along a list of the memory changes or any other changes in mode, thinking or behaviour that have been concerning you, including when you first noticed them and how often you notice them. You should also take a list of the medications you are taking or bring your medications with you to the appointment. Your doctor may assess you or may make a referral to a specialist doctor such as a geriatrician (a specialist in illnesses and disabilities in older people), a neurologist (a specialist in disorders of the brain and nerve pathways), or a psychiatrist (a specialist in disorders of thinking, emotion and behaviour). For language assistance National Dementia Helpline 1800 100 500 call 131 450 Dementia Q&A 10 Assessment for dementia includes the following: Personal history The doctor usually spends some time discussing your medical history and gathering information about your changes in memory and thinking.
    [Show full text]
  • Development of Clinical Neuropsychology As A
    Development of Clinical Neuropsychology as a Psychological Specialty: A Timeline of Major Events By Corwin Boake, Ph.D., ABPP (CN) Memorial Hermann/The Institute of Rehabilitation & Research, University of Texas-Houston Medical School and Linas A. Bieliauskas, Ph.D., ABPP (CL, CN) Department of Psychiatry, University of Michigan Health System first president was Harold sponsored by the Philadelphia he development of clinical Goodglass. Clinical Neuropsychology Group. neuropsychology as a psychological T 1980 Presentation of the first Division 1988 Formation of the Midwest specialty in North America is based on 40 programming during an APA Neuropsychology Consortium of the contributions of many persons and convention. Nelson Butters served Postdoctoral Program in Clinical organizations. With the anniversary of as program chair. Neuropsychology, a membership ABPP, it is timely to recognize some of organization of postdoctoral the major contributions. The timeline 1981 Report of the Division 40/INS residencies. The first president was below includes many of the major Joint Task Force on Education, Kerry Hamsher. milestones of clinical neuropsychology Accreditation and Credentialing in in the USA and Canada, leading to the Clinical Neuropsychology. 1988 Approval by Division 40 of the definition of a clinical formation of the American Board of 1981 Meeting in Minneapolis of the neuropsychologist (Journal of Clinical Neuropsychology (ABCN) and planning group for ABCN, Clinical Neuropsychology, 1989). the growth of specialty organizations that attended by Linas Bieliauskas, uphold standards for training and Louis Costa, Edith Kaplan, 1989 Designation by ABPP of ABCN as practice. The timeline is an extension of Muriel Lezak, Charles Matthews, the specialty council in clinical the one published by Yeates and Steven Mattis, Manfred Meier, neuropsychology.
    [Show full text]
  • Neuropsychological Testing Under the Medical Benefit
    UnitedHealthcare® Commercial Medical Policy Neuropsychological Testing Under the Medical Benefit Policy Number: 2021T0152W Effective Date: September 1, 2021 Instructions for Use Table of Contents Page Related Commercial Policy Coverage Rationale ....................................................................... 1 • Maximum Dosage Definitions ...................................................................................... 2 Applicable Codes .......................................................................... 3 Community Plan Policy Description of Services ................................................................. 3 • Neuropsychological Testing Under the Medical Benefit Benefit Considerations .................................................................. 5 Clinical Evidence ........................................................................... 5 Medicare Advantage Coverage Summary U.S. Food and Drug Administration ........................................... 18 • Neuropsychological Testing References ................................................................................... 19 Policy History/Revision Information ........................................... 23 Related Optum Guideline Instructions for Use ..................................................................... 24 • Psychological and Neuropsychological Testing Coverage Rationale See Benefit Considerations Neuropsychological testing is proven and medically necessary for evaluating individuals with the following conditions when the results
    [Show full text]
  • Verbal Fluency: Norms for the Lakota Population in Semantic and Phonemic Fluency Tasks
    VERBAL FLUENCY: NORMS FOR THE LAKOTA POPULATION IN SEMANTIC AND PHONEMIC FLUENCY TASKS by Larissa M. Jordan, CCC-SLP Bachelor of Arts, John Brown University, 2007 Master of Science, University of Central Missouri, 2010 A Thesis Submitted to the Graduate Faculty of the University of North Dakota in partial fulfillment of the requirements for the degree of Master of Arts Grand Forks, North Dakota August 2014 © 2014 Larissa M. Jordan ii This thesis, submitted by Larissa M. Jordan in partial fulfillment of the requirements for the Degree of Master of Arts from the University of North Dakota, has been read by the Faculty Advisory Committee under whom the work has been done and is hereby approved. _________________________________ Dr. Regina Blass, Chairperson _________________________________ Dr. Alycia Cummings _________________________________ Dr. Mark E. Karan This thesis is being submitted by the appointed advisory committee as having met all the requirements of the School of Graduate Studies at the University of North Dakota and is hereby approved. _____________________________________ Dr. Wayne Swisher Dean of the School of Graduate Studies _____________________________________ Date iii PERMISSION Title Verbal Fluency: Norms of the Lakota Population in Semantic and Phonemic Fluency Tasks Department Linguistics Degree Master of Arts In presenting this thesis in partial fulfillment of the requirements for a graduate degree from the University of North Dakota, I agree that the library of this University shall make it freely available for inspection. I further agree that permission for extensive copying for scholarly purposes may be granted by the professor who supervised my thesis work or, in her absence, by the Chairperson of the department or the dean of the School of Graduate Studies.
    [Show full text]