Essentials of Neuropsychological Assessment

Nancy Hebben, William Milberg

• Publisher: Wiley
• Year: 2009
• ISBN:
  9780470535899
• Edition: 2
• Topic: Psychology
• Subtopic: Research & Methodology in Psychology
• Index: Psychology

Quickly acquire the knowledge and skills you need to confidently administer, score, and interpret the most popular neuropsychological assessment instruments

Neuropsychological testing can identify changes in cognition, behavior, and emotion; aid in determining the cause of a disorder or developmental problem; and assist clinicians in planning treatment and rehabilitation. To use these tests properly, professionals need an authoritative source of advice and guidance on how to administer, score, and interpret them. Now fully revised and in a second edition, Essentials of Neuropsychological Assessment is that source.

Completely updated to include the most current instruments, including the Delis-Kaplan Executive Function System (D-KEFS), the Wechsler Intelligence Scale for Children-Fourth Edition (WISC-IV), the Wechsler Adult Intelligence Scale-Fourth Edition (WAIS-IV), and the Wechsler Memory Scale-Fourth Edition (WMS-IV), Essentials of Neuropsychological Assessment, Second Edition presents an overview of the assumptions, logic, knowledge base, and skills underlying the practice of neuropsychological assessment. Neuropsychological experts Nancy Hebben and William Milberg describe how clinical history, behavioral observations, and formal test results are used to make inferences about the contribution of brain dysfunction to psychological functioning.

Like all the volumes in the Essentials of Psychological Assessment series, this book is designed to help busy mental health professionals quickly acquire the knowledge and skills they need to make optimal use of major neuropsychological assessment instruments. Each concise chapter features numerous callout boxes highlighting key concepts, bulleted points, and extensive illustrative material, as well as test questions that help you gauge and reinforce your grasp of the information covered.

Essentials of Neuropsychological Assessment, Second Edition provides comprehensive instruction on neuropsychological test administration, scoring, interpretation, and report writing. It also addresses practical and conceptual issues related to neuropsychological assessment in geriatric, pediatric, forensic, and other specialized settings.

Other titles in the Essentials of Psychological Assessment series:

• Essentials of Assessment Report Writing
  
  

• Essentials of WAIS-IV Assessment
  
  

• Essentials of WISC-IV Assessment, Second Edition
  
  

• Essentials of WIAT-II and KTEA-II Assessment
  
  

• Essentials of WJ IIITM Cognitive Abilities Assessment
  
  

• Essentials of WJ IIITM Tests of Achievement Assessment
  
  

• Essentials of School Neuropsychological Assessment
  
  

• Essentials of Cross-Battery Assessment, Second Edition
  
  

• Essentials of KABC-II Assessment
  
  

• Essentials of NEPSY Assessment
  
  

• Essentials of Executive Function Assessment
  
  

• Essentials of Processing Assessment
  
  

Four

ESSENTIALS OF TEST SELECTION, ADMINISTRATION, AND SCORING

OVERVIEW

This chapter covers the basic conditions and logistics of the neuropsychological examination. Some of the advice dispensed in this chapter may seem the paragon of common sense to an experienced clinician. Expertise with such issues as optimizing test performance, monitoring of clinical test behavior, recording data, using standard procedures of test administration, and understanding the logic of test selection, however, can mean the difference between obtaining valid, clinically useful test results and malpractice. Even experienced clinicians can be taken by surprise by malingering or by patients with somatization disorders or conversion reactions if these phenomena are not part of their typical practice.

OPTIMIZING PERFORMANCE

In most cases the interpretation of neuropsychological tests is based on the central assumption that the performance measured by those tests represents the best effort of the patient delivered under conditions as close to optimal as possible. The exclusion of nonneurological causes is the first logical step in making the decision that a lower than expected test score or the presence of an unusual behavioral symptom is related to dysfunction of the central nervous system. This task may be undermined if the patient is unusually anxious, too hot or cold, or subjected to unusual or unpredictable sights or sounds. For example, it would not be unusual for an otherwise normal adult to perform poorly on a test of attention if during the test, voices can be heard arguing or (as sometimes is the case on a busy hospital ward) other patients are being examined, trays are being dropped, announcements are blaring from the overhead paging system, and so forth. Patients who are extremely anxious, ruminative, or distracted by internal thoughts may perform poorly on a number of neuropsychological tests, especially those requiring intense or sustained attention. Although these factors may be significant in predicting cognitive performance in other situations, they often preclude drawing inferences about brain function. Most patients who are referred for neuropsychological testing want to do their best, particularly if they understand the reasons for the testing and their effort’s possible benefits to their treatment, job, or school performance.

Some patients, however, do not give their best effort when tested. This may be because they do not understand the reason for the assessment, have been referred involuntarily, or are involved in a situation in which they may gain or be rewarded for poor performance. It is the task of the neuropsychologist to arrange the testing conditions so that a patient can take advantage of the opportunity to work to potential. In this chapter, we discuss issues concerning the optimization of a patient’s performance and motivation, as well as the steps required for administration and scoring in neuropsychological assessment.

DON’T FORGET

It is the obligation of the examiner to arrange the testing conditions so that the patient can take advantage of the opportunity to work to potential.

Appropriate Testing Conditions

Optimally, neuropsychological testing should be undertaken in conditions that are reasonably quiet, with no foot traffic or distracting views. In most cases, this environment is an examination room that has sufficient artificial light (without glare and reflection), is kept at a comfortable temperature, and has adequate ventilation. It is usually best to seat the patient facing away from windows and doors from which activity can be seen and to prevent glare. When this is not possible, it may be necessary to keep shades drawn and doors closed, particularly if much visible activity is outside the room. The seating plan should also take into account wall spaces containing distracting pictures. If the external environment is noisy, it may be necessary to use a white-noise generator or to take steps to soundproof walls and doors. Many clients are not affected by external distractions, but even healthy adults may find themselves turning toward unusual sounds and conversation that divert their attention, particularly when they are anxious about being tested.

The office should appear welcoming and friendly. It probably should be conservatively decorated, however, reflecting the standards of the community in which the clinician works. As discussed in Chapter 3, the office should be a professional space with minimal personal mementos but should not be sterile and devoid of all personal touches. Comfortable seating should be available to both examiner and patient. When administering the tests, most examiners prefer that patients sit opposite them at a sufficiently large table or desk. In some instances, however, because of particular test materials that require a viewing stand, the examiner may sit at the end of a rectangular table while the patient sits on the side. The examiner should also arrange the room so that test materials are close at hand and available for easy access. However, to limit possible distractions, test materials should not be presented before they are necessary. Organization and readiness of test materials permit a smooth transition from one test to the next, thereby decreasing the overall time in testing. Knowing your materials and being practiced in a particular test also keeps the test session flowing, leaving less time for the patient to become bored or lose interest. In addition, a familiarity with administration rules and scoring allows the examiner to administer tests in an automatic fashion so that more time can be devoted to observing a patient’s behavior. Rapid Reference 4.1 summarizes the features important for appropriate testing conditions.

Rapid Reference 4.1

Appropriate Testing Conditions

• Quiet, nondistracting environment

• Well-lit room surfaces without glare

• Welcoming and friendly (but not overdone) room with comfortable seating

• Test materials organized and at hand, but out of sight, if possible, while not in use

Testing must often be done in less than optimal conditions under which the examiner has little control over environment. For example, a hospitalized patient may have to be tested at bedside on a hospital ward, or an incarcerated individual may have to be tested in whatever space is available at the prison. In these instances, the examiner should orchestrate whatever details possible to ensure the best possible testing environment. The examiner should also keep a record of the conditions under which testing took place and include the information in the test report, particularly when the conditions may have had a direct impact on the performance of a particular task.

Establishing Rapport

To optimize the patient’s performance, the examiner should try to gain the cooperation and trust of the person being tested. As discussed in the previous chapter, the way an examiner establishes rapport is a matter of personal style. You should introduce yourself to the patient and acknowledge adults by their titles and surnames. This maintains the formality of the professional situation and communicates your respect for the patient. Some casual conversation may be necessary to break the ice initially, but one of the first issues addressed should be an explanation of the purpose of the testing and a discussion of how the session will progress. Issues of confidentiality should be discussed with adults. All patients, both children and adults, need to know that the tasks they will be doing range from easy to hard and that their job is to do their best.

CAUTION

Maintain a professional environment and respect for adult patients by addressing them by their titles and surnames.

Patients should be encouraged to try on all test items and, in some cases, to take a chance by guessing while the examiner remains supportive and encouraging. To avoid giving information about the correctness or incorrectness of an answer, praise should be given for effort, not for the answer itself. To avoid discouraging the patient early, the examiner should start with simpler tasks, and as tasks become more difficult, acknowledge that an item may have been difficult but that no one gets all the answers right. Also, praise should be given judiciously instead of for every answer; this also helps the patient avoid becoming discouraged.

Structure of the Test Session

The scheduling of a test session depends on the referral question, the nature of the tests being used, and the focus and stamina of the patient. In general, test sessions are limited by the severity of patients’ presenting problems, their general health, and their age. In some instances, shorter test sessions are necessary to achieve reliable samples of optimal cognitive ability. For patients whose symptomatology includes distractibility and for patients whose energy level has been compromised by nonneurological health conditions, it may be unwise to attempt testing in only 1 day if the goal is to obtain the patient’s best performance across many tasks. On the other hand, if the goal is to assess cognition and mental stamina over the course of a day, then administering the tests in a 1-day session would be more appropriate than dividing up the tasks over several sessions. Other patients who may be unable to work consistently well in one session include older adults, very young children, and patients who suffer from physical pain that is exacerbated by long periods of sitting.

In general, the clinician should try to complete the interview and testing in 1 day. This increases the likelihood that the tests are given under similar circumstances. When test sessions are given on different days, differences in sleep, illness, anxiety, and other situational factors may confound the results and make them difficult to interpret. For example, if in the first session a patient is in a good mood and does well on an intelligence test but at the time of a second session does poorly on memory because the patient is sleepy due to a problem with insomnia, the examiner is limited in the ability to conclude that a deficit in memory is the result of brain dysfunction. When it does become necessary to test on different days, the examiner must always make sure that multiple-part tests are given in a single session when validity is dependent on the test being administered in a given time frame; information about circumstances that could affect test performance should also be investigated. The latter is usually done by finding out whether any events that may be influencing the results have occurred in the interval between test sessions. Also, if symptom validity tests (SVTs) are necessary in the assessment, then different SVTs should be administered at each session.

DON’T FORGET

It is generally preferable to complete the testing session in 1 day to eliminate potential confounds.

The length of a test session varies according to the examiner’s skill, the test battery chosen, and patient characteristics. An examiner who knows the tests well and is organized can connect tasks with smooth transitions that facilitate an efficient test session. The more tests administered, the longer the time required for testing. Some patients work quickly, whereas others work slowly. Some patients need encouragement and multiple follow-up questions, whereas others work efficiently from start to finish.

When tests are given in a single session, the patient should be offered a reasonable number of breaks and time for lunch. Some patients may need few breaks, and others may need many. Breaks should be taken only between, not during, tests or subtests. Any signs of fatigue or variations in efforts should be noted. If a brief break with a moment for a small snack is not enough to restore the patient to sufficient levels of concentration and cooperation to return to testing, then the session may need to be terminated and rescheduled.

Balancing Test Order

Most clinicians who give fixed batteries of tests administer these tests in a fixed order for the majority of patients. In addition, some tasks such as the Wechsler intelligence tests have an inherently fixed order of administration. Even clinicians who giv...

Table of contents

• Essentials of Psychological Assessment Series
• Title Page
• Copyright Page
• Dedication
• Series Preface
• One - INTRODUCTION TO NEUROPSYCHOLOGICAL ASSESSMENT
• Two - THE DISCIPLINE OF NEUROPSYCHOLOGICAL ASSESSMENT
• Three - ESSENTIALS OF THE INTERVIEW AND CLINICAL HISTORY
• Four - ESSENTIALS OF TEST SELECTION, ADMINISTRATION, AND SCORING
• Five - ESSENTIALS OF INTERPRETATION
• Six - SPECIAL ISSUES IN NEUROPSYCHOLOGICAL ASSESSMENT
• Seven - ESSENTIALS OF REPORT WRITING
• Appendix A - A General Guide for Neuropsychological Assessment
• Appendix B - Essentials of the Neurobehavioral Syndromes
• References
• Annotated Bibliography
• Index
• About the Authors