Neuropsychological Evaluation
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Neuropsychological evaluation (NPE) is a testing method through which a neuropsychologist can acquire data about a subject’s cognitive, motor, behavioral, linguistic, and executive functioning. In the hands of a trained neuropsychologist, these data can provide information leading to the diagnosis of a cognitive deficit or to the confirmation of a diagnosis, as well as to the localization of organic abnormalities in the central nervous system (CNS). The data can also guide effective treatment methods for the rehabilitation of impaired patients.
NPE provides insight into the psychological functioning of an individual, a capacity for which modern imaging techniques [1, 2] have only limited ability. However, these tests must be interpreted by a trained, experienced neuropsychologist in order to be of any benefit to the patient. These tests are often coupled with information from clinical reports, physical examination, and increasingly, premorbid and postmorbid self and relative reports. Alone, each neuropsychological test has strengths and weaknesses in its validity, reliability, sensitivity, and specificity. However, through eclectic testing and new in situ testing, the utility of NPE is increasing dramatically. [3, 4]
NPE is useful for measuring many function categories, including the following:
Intellectual functioning
Academic achievement
Language processing
Visuospatial processing
Attention/concentration
Verbal learning and memory
Visual learning and memory
Executive functions
Speed of processing
Sensory-perceptual functions
Motor speed and strength
Motivation/symptom validity
Personality assessment
Table 1. Examples of Commonly Used Neuropsychological Tests [5, 6, 7, 8] (Open Table in a new window)
Domain
Neuropsychological Test
Intellectual functioning
Wechsler Scales
Wechsler Adult Intelligence Scale-Revised (WAIS-R)
Wechsler Adult Intelligence Scale-III (WAIS-III)
Wechsler Intelligence Scale for Children-IV (WISC-IV)
Stanford-Binet Intelligence Scale-IV
Academic achievement
Wechsler Individual Achievement Test (WIAT)
Woodcock-Johnson Achievement Test
Language processing
Boston Naming Test
Multilingual Aphasia Examination
Boston Diagnostic Aphasia Examination
Token Test
Visuospatial processing
Rey-Osterrieth Complex Figure – Copy condition
WAIS Block Design Subtest
Judgment of Line Orientation
Hooper Visual Organization Test
Attention/ concentration
Digit Span Forward and Backward
Trail Making Tests
Cancellation Tasks (Letter and symbol)
Paced Auditory Serial Addition Test (PASAT)
Vanderbilt Assessment Scale
Behavior Assessment System for Children (BASC)
Serial Sevens
Verbal learning and memory
Wechsler Memory Scale (WMS)
Logical Memory I and II – Contextualized prose
Verbal Paired-Associates
WMS-III Verbal Memory Index
Rey Auditory Verbal Learning Test – Rote list learning (unrelated words)
California Verbal Learning Test – Rote list learning (related words)
Verbal Selective Reminding Test – Selective reminding (unrelated words)
Hopkins Verbal Learning Test
Visual learning and memory
WMS
Visual Reproduction I and II
WMS-III Visual Memory Index
Rey-Osterrieth Complex Figure – Immediate and delayed recall
Nonverbal Selective Reminding Test
Continuous Recognition Memory Test
Visuo-Motor Integration Test – Block design
Executive functions
Wisconsin Card Sorting Test
Category Test
Stroop Test
Trail Making Test-B
WAIS Subtests of Similarities and Block Design
Porteus Maze Test
Multiple Errands Test (MET)
Serial Sevens
Mini-Mental State Exam
Speed of processing
Simple and Choice Reaction Time
Symbol Digit Modalities Test – Written and oral
Sensory-perceptual functions
Halstead-Reitan Neuropsychological Battery (HRNB) Tactual Performance Test and Sensory Perceptual Examination
Motor speed and strength
Index Finger Tapping
Grooved Pegboard Task
Hand Grip Strength
Thurstone Uni- and Bimanual Coordination Test
Motivation
Rey 15 Item Test
Dot Counting
Forced-Choice Symptom Validity Testing
Personality assessment
Minnesota Multiphasic Personality Inventory (MMPI)
Millon Clinical Multiaxial Inventory
Beck Depression Inventory (BDI)
Rorschach Test
Myers-Briggs Type Indicator (MBTI)
Thematic Apperception Test for Children or Adults
NPE is used to quantitatively measure the cognitive and behavioral capabilities of a patient. The data from neuropsychological tests can then be compared with normative data based on a number of different demographic criteria, including (but not limited to) age, race, gender, and socioeconomic status. NPE can include testing of intelligence, attention, memory, and personality, as well as of problem solving, language, perceptual, motor, academic, and learning abilities.
Neuropsychological testing provides diagnostic clarification and grading of clinical severity for patients with obvious or supposed cognitive deficits. Often these include patients with a history of any of the following problems:
Failure to achieve developmental milestones
Learning or attention deficits [9, 10]
Exposure to drugs, alcohol, or maternal illness in utero
Exposure to chemicals, toxins, or heavy metals
Neurodegenerative diseases
Cerebral palsy
Genetic disorders including, but not limited to, trisomies, monosomies, and trinucleotide repeat disorders
Psychiatric disorders
NPE is of limited value if a patient is severely compromised, as in advanced dementia or early in recovery from serious brain injury (eg, TBI, stroke, anoxia, infection), although brief serial assessment with measures such as the Galveston Orientation and Amnesia Test, high-velocity lead therapy (HVLT), digit span, and motor speed and dexterity is very useful in tracking recovery. NPE’s value is also limited if a patient has other serious medical complications or psychiatric disorders.
Neuropsychological tests are a series of measures that identify cognitive impairment and functioning in individuals. They provide quantifiable data about the following aspects of cognition:
Reasoning and problem-solving ability
Ability to understand and express language
Working memory and attention
Short-term and long-term memory
Processing speed
Visual-spatial organization
Visual-motor coordination
Planning, synthesizing, and organizing abilities
Applications of NPE include the following:
Provide a differential diagnosis of organic and functional pathologies
Assess for dementia versus pseudodementia [11, 12, 13, 14]
Determine the presence of epilepsy versus somatoform disorder (that is, nonepileptic seizures or pseudoseizures)
Determine the presence of traumatic brain injury (TBI) sequelae [16] versus malingering or unconscious highlighting
Distinguish between cognitive deficiency caused by indifference (as is occasionally seen in depression patients) and that caused by other diseases and disorders
Guide rehabilitation programs and monitor patient progress
Guide the therapist in referring to specialists
An NPE also provides data to guide decisions about the patient’s condition, such as the following:
Competency to manage legal and financial affairs
Capacity to participate in medical and legal decision making
Ability to live independently or with supervision
Ability to return to work and school affairs
Candidacy for transplantation [17]
In addition, data from an NPE can be used to guide the following assessments and procedures:
Evaluation of the cognitive effects of various medical disorders and associated interventions
Assessment of tests for diabetes mellitus, chronic obstructive pulmonary disease (COPD), hypertension, human immunodeficiency virus (HIV) infection, coronary artery bypass graft (CABG), and clinical drug trials
Assessment of CNS lesions and/or seizure disorders before and after surgical interventions, including corpus callosotomy, focal resection (eg, topectomy, lobectomy), and multiple subpial transection
Monitoring of the effects of pharmacologic interventions
Documentation of the cognitive effects of exposure to neurotoxins
Documentation of adverse effects of whole brain irradiation in children
Comparison with guidelines for electroconvulsive therapy (ECT) influenced by standardized evaluation of memory
Standard protocols for assessment of specific disorders, such as dementia of the Alzheimer type (DAT), multiple sclerosis (MS), TBI, and stroke [11, 12, 13, 14, 15, 16, 17, 18]
Developmental disorders (eg, specific learning disabilities) require detailed assessment of cognition, academic achievement, and psychosocial adjustment for proper identification and as a guide to their management. Academic placement in special education and resource classrooms may be needed.
Results of an NPE must be considered in the context of the patient’s age, education, sex, and cultural background. These factors can affect test performance and limit the conclusions that can be drawn from the evaluation. In addition, issues such as reliability, validity, sensitivity, and specificity need to be considered.
Large, population-based norms are available for relatively few measures. Those measures that do boast such norms, such as major intellectual and academic instruments, are of limited usefulness within a neuropsychological test battery. Ideally, patients should be compared with population-based norms, as well as with local norms and subgroup norms (ie, specific patient populations) to examine strengths and weaknesses. However, significant gaps can be found in the normative data for all age, educational, and intellectual ranges. Major deficiencies have also existed in the development of appropriate measures and norms for minority populations. [19]
A study by Hansson et al indicated that taking a collaborative and therapeutic (CTA) approach to NPE of pediatric patients with neurodevelopmental disorders can reduce the number of psychiatric symptoms reported by these patients. The study, of children with suspected neurodevelopmental disorders, utilized the Beck Youth Inventories (BYI). The investigators found that fewer psychiatric symptoms were reported on most BYI subscales by those children who were assessed with the CTA approach (11 patients) than by those whose needs were addressed through parent support measures (11 patients) and those on a waiting list for help (9 patients). At 6-month follow-up, the decrease in self-reported symptoms was still seen on the BYI anger and anxiety subscales. [20]
Reliability refers to the consistency with which the same information is obtained via the test or set of tests. In the absence of intervening variables (eg, illness, injury, new learning), scores should remain stable even in the event of certain other variables, such as the following:
Interrater reliability – Administration of the test by different examiners
Intrarater reliability – Administration of the test by the same examiner on more than 1 occasion
Test-retest reliability – Administration of the test to the same patient on different occasions
Validity refers to how well the test measures what it purports to measure. Specific types of validity that may be questioned include the following:
Construct validity – Does the test measure what it is supposed to measure
Concurrent validity – Do new tests correlate highly with existing tests or independent measures of the construct in question
Face validity – Does the test appear to measure what it is supposed to measure
Localization validity – Does the test localize focal lesions accurately
Ecologic validity – Does the test predict real-life ability
Generally, findings suggest that performance on tests of motor function, speed of cognitive processing, cognitive flexibility, complex attention, and memory are related positively to real-world success.
The amount of variance accounted for by cognitive factors alone, however, is typically quite small. Exceptions occur when comparisons made between results of formal NPE and real-world criteria are limited to very simple, very circumscribed, and/or very well-defined functions. Consequently, situational assessment is seen as a critical adjunct to neuropsychological assessment, especially at higher levels of cognitive functioning.
Neuropsychological tests, with very few exceptions, were not developed with an eye toward ecologic validity. They were developed as indicators of brain function or dysfunction and generally were validated against neurosurgical, neurologic, and neuroradiologic data. Nevertheless, many tests have proven to be good predictors of future behavior and, therefore, have demonstrated ecologic validity.
A qualitative process approach may improve the ecologic validity of the neuropsychological test battery. For example, testing the limits with measures of memory and executive functioning allows the examiner to understand better what a person can do under relatively ideal circumstances (not “what,” but “how”). The test itself may have little demonstrable ecologic validity, but an accurate analysis and insightful interpretation of findings can be highly valid from an ecologic perspective.
Using a survey of 654 members of the National Academy of Neuropsychology (NAN) and the International Neuropsychological Society, Hirst et al found evidence that neuropsychologists are not equally consistent in employing validity testing practices recommended by the NAN and the American Academy of Clinical Neuropsychology in neuropsychological assessments. The survey indicated that neuropsychologists who work with pediatric and geriatric patients tend to follow the recommendations less frequently than do those who work with nongeriatric adults. In addition, longer-practicing neuropsychologists tended more often not to follow validity testing recommendations than did those who have not been practicing as long. [21]
Sensitivity refers to a test’s ability to detect the slightest abnormalities in CNS function and is a reflection of the test’s true positive rate, that is, its ability to identify persons with a disorder. Specificity refers to the ability to differentiate patients with a certain abnormality from those with other abnormalities or with no abnormality, as indicated by the true negative rate. A score on any test can be a true positive, false positive, true negative, or false negative. Such results signify the following:
True positive – Requires high sensitivity to dysfunction, allowing dysfunctions to be detected
False positive- Indicates sensitivity to dysfunction, but lacks specificity to a particular dysfunction
True negative- Requires high specificity, allowing negative to be distinguished from others
False negative- Indicates a lack of sensitivity, without regard to specificity of the test
For any evaluation, it is important to understand the rates of each of the 4 result categories. The Stroop Test, for example, shows a relatively high level of specificity, with a high true negative rate (95.7%) and low false positive rate (4.3%). However, its sensitivity is questionable, as it has a relatively low true positive rate (30.8%) and high false negative rate (69.2%).
Each test has strengths and weaknesses in its ability to detect a minimal CNS dysfunction (sensitivity) while being able to indicate a specific CNS dysfunction (specificity). Timed measures of cognitive and/or motor processing are generally sensitive to diffuse cerebral dysfunctions, although the specificity of these tests is generally poor to moderate. Measures of cognitive and/or motor processing that are not timed are generally less sensitive to diffuse dysfunctions but are very useful in identifying specific brain lesions.
Perhaps the major drawback of NPE is the lack of ecologic validity when assessing executive functioning. [22] NPE is generally conducted within calm and quiet testing rooms where the subject is clearly presented with the task to be completed, is informed of time restrictions, and is prompted to start and stop behaviors. Under these conditions, a subject may achieve a score that indicates no executive dysfunctions, although the individual may be particularly drained from the mental exertion. Completing tasks in the real world, however, requires several executive functions that are not tested in traditional NPE, including recognizing that a task must be completed, starting the task, switching tasks, adapting to changes, and stopping a task.
However, changes in executive tests have dramatically increased the environmental validity of executive NPE. These changes include a growing emphasis on subject self reporting of premorbid and postmorbid functioning, as well as premorbid and postmorbid reports from relatives and significant others in the subject’s life. Often, however, the self report is not sufficient, for executive dysfunctions may be unknown to the subject, or else they may be ego-syntonic.
A dramatic approach to overcoming the problem of ecologic validity is found in the Multiple Errands Test (MET). The test takes place in a shopping mall and requires the subject to conduct 3 tasks simultaneously, such as buying an item, meeting at a certain location at a certain time, and acquiring available information (such as a foreign currency exchange rate). This evaluation tests the subject’s abilities in planning, task initiation, and task switching, and even requires the subject to interact with other individuals in an effective manner. The test has shown considerable sensitivity and specificity, and subjects with neurologic deficits have performed considerably worse than controls. A version of this test has also been created for the hospital setting.
Lassonde M, Sauerwein HC, Gallagher A, et al. Neuropsychology: traditional and new methods of investigation. Epilepsia. 2006. 47 Suppl 2:9-13. [Medline].
Schunk JE, Rodgerson JD, Woodward GA. The utility of head computed tomographic scanning in pediatric patients with normal neurologic examination in the emergency department. Pediatr Emerg Care. 1996 Jun. 12(3):160-5. [Medline].
Arffa S, Knapp JA. Parental perceptions of the benefits of neuropsychological assessment in a neurodevelopmental outpatient clinic. Appl Neuropsychol. 2008. 15(4):280-6. [Medline].
Wilson BA, Rous R, Sopena S. The current practice of neuropsychological rehabilitation in the United Kingdom. Appl Neuropsychol. 2008. 15(4):229-40. [Medline].
Heaton RK, Grant I, Mathews CG. Comprehensive Norms for an Expanded Halstead-Reitan Battery: Demographic Corrections, Research Findings, and Clinical Applications. Odessa, Fla: Psychol Assess Resources; 1991.
Spreen O, Strauss E. A Compendium of Neuropsychological Tests. 2nd ed. New York, NY: Oxford Univ Press; 1988.
Lacritz LH, Barnard HD, Van Ness P, et al. Qualitative analysis of WMS-III Logical Memory and Visual Reproduction in temporal lobe epilepsy. J Clin Exp Neuropsychol. 2004 Jun. 26(4):521-30. [Medline].
Heled E, Hoofien D, Margalit D, et al. The Delis-Kaplan Executive Function System Sorting Test as an evaluative tool for executive functions after severe traumatic brain injury: A comparative study. J Clin Exp Neuropsychol. 2011 Nov 25. [Medline].
Carlson CL, Mann M. Sluggish cognitive tempo predicts a different pattern of impairment in the attention deficit hyperactivity disorder, predominantly inattentive type. J Clin Child Adolesc Psychol. 2002 Mar. 31(1):123-9. [Medline].
Weiler MD, Bernstein JH, Bellinger DC, et al. Processing speed in children with attention deficit/hyperactivity disorder, inattentive type. Child Neuropsychol. 2000 Sep. 6(3):218-34. [Medline].
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Saxton J, Lopez OL, Ratcliff G, et al. Preclinical Alzheimer disease: neuropsychological test performance 1.5 to 8 years prior to onset. Neurology. 2004 Dec 28. 63(12):2341-7. [Medline].
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Domain
Neuropsychological Test
Intellectual functioning
Wechsler Scales
Wechsler Adult Intelligence Scale-Revised (WAIS-R)
Wechsler Adult Intelligence Scale-III (WAIS-III)
Wechsler Intelligence Scale for Children-IV (WISC-IV)
Stanford-Binet Intelligence Scale-IV
Academic achievement
Wechsler Individual Achievement Test (WIAT)
Woodcock-Johnson Achievement Test
Language processing
Boston Naming Test
Multilingual Aphasia Examination
Boston Diagnostic Aphasia Examination
Token Test
Visuospatial processing
Rey-Osterrieth Complex Figure – Copy condition
WAIS Block Design Subtest
Judgment of Line Orientation
Hooper Visual Organization Test
Attention/ concentration
Digit Span Forward and Backward
Trail Making Tests
Cancellation Tasks (Letter and symbol)
Paced Auditory Serial Addition Test (PASAT)
Vanderbilt Assessment Scale
Behavior Assessment System for Children (BASC)
Serial Sevens
Verbal learning and memory
Wechsler Memory Scale (WMS)
Logical Memory I and II – Contextualized prose
Verbal Paired-Associates
WMS-III Verbal Memory Index
Rey Auditory Verbal Learning Test – Rote list learning (unrelated words)
California Verbal Learning Test – Rote list learning (related words)
Verbal Selective Reminding Test – Selective reminding (unrelated words)
Hopkins Verbal Learning Test
Visual learning and memory
WMS
Visual Reproduction I and II
WMS-III Visual Memory Index
Rey-Osterrieth Complex Figure – Immediate and delayed recall
Nonverbal Selective Reminding Test
Continuous Recognition Memory Test
Visuo-Motor Integration Test – Block design
Executive functions
Wisconsin Card Sorting Test
Category Test
Stroop Test
Trail Making Test-B
WAIS Subtests of Similarities and Block Design
Porteus Maze Test
Multiple Errands Test (MET)
Serial Sevens
Mini-Mental State Exam
Speed of processing
Simple and Choice Reaction Time
Symbol Digit Modalities Test – Written and oral
Sensory-perceptual functions
Halstead-Reitan Neuropsychological Battery (HRNB) Tactual Performance Test and Sensory Perceptual Examination
Motor speed and strength
Index Finger Tapping
Grooved Pegboard Task
Hand Grip Strength
Thurstone Uni- and Bimanual Coordination Test
Motivation
Rey 15 Item Test
Dot Counting
Forced-Choice Symptom Validity Testing
Personality assessment
Minnesota Multiphasic Personality Inventory (MMPI)
Millon Clinical Multiaxial Inventory
Beck Depression Inventory (BDI)
Rorschach Test
Myers-Briggs Type Indicator (MBTI)
Thematic Apperception Test for Children or Adults
Atif B Malik, MD Director of Pain Management, Orthopedic Wellness
Atif B Malik, MD is a member of the following medical societies: American Pain Society, International Spine Intervention Society, North American Spine Society
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Abdullah Shuaib Arizona College of Osteopathic Medicine at Midwestern University
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Megan E Turner West Virginia University School of Medicine
Megan E Turner is a member of the following medical societies: American Medical Student Association/Foundation
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Stephen Kishner, MD, MHA Professor of Clinical Medicine, Physical Medicine and Rehabilitation Residency Program Director, Louisiana State University School of Medicine in New Orleans
Stephen Kishner, MD, MHA is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Association of Neuromuscular and Electrodiagnostic Medicine
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Maaz Sohail St George’s University School of Medicine, New York
Disclosure: Nothing to disclose.
Patrick J Potter, MD, FRCP(C) Associate Professor, Physical Medicine and Rehabilitation, The University of Western Ontario; Consulting Staff, Department of Physical Medicine and Rehabilitation, St Joseph’s Health Care Centre
Patrick J Potter, MD, FRCP(C) is a member of the following medical societies: American Paraplegia Society, Canadian Association of Physical Medicine and Rehabilitation, Canadian Medical Association, College of Physicians and Surgeons of Ontario, Ontario Medical Association, and Royal College of Physicians and Surgeons of Canada
Disclosure: Nothing to disclose.
Craig Sadler Research Assistant, Center for the Study of Traumatic Stress, The Henry M Jackson Foundation for the Advancement of Military Medicine
Disclosure: Nothing to disclose.
Richard Salcido, MD Chairman, Erdman Professor of Rehabilitation, Department of Physical Medicine and Rehabilitation, University of Pennsylvania School of Medicine
Richard Salcido, MD is a member of the following medical societies: American Academy of Pain Medicine, American Academy of Physical Medicine and Rehabilitation, American College of Physician Executives, American Medical Association, and American Paraplegia Society
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