1

Neuropsychological Assessment

William P. Wattles, Ph.D.

Francis Marion University

2

Practicum Log

• Supervision Hours (coaching, feedback sessions, etc.) (S),

• Student-contact Hours (i.e. assessment, intervention) (ST),

• Consultation Hours (i.e. direct contact with consultees, interviews, meetings) (C )

• Research Hours (projects, program evaluation, etc.) (R)

• Administrative Hours (i.e. scheduling, record review, scoring, report writing) (A),

• Other Hours (e.g. staff meetings, in-service, conferences) (O)

3

Neuropsychology

• Nothing more than the study of human brain/behavior relationships.

Neuropsychology goals

•  Diagnosis determine the nature of the underlying problem.

• Understand the effects of any brain injury

• measure change in functioning over time, such as to determine the consequences of treatment

4

5

Neurologist

• A physician specializing in diseases and disorders of the brain, spinal cord, nerves, and muscles, including stroke, Parkinson's disease, epilepsy, Alzheimer's disease, and muscular dystrophy

6

Neuropsychologist

• A psychologist with specialized training in the evaluation of cognitive functions. Neuropsychologists use a battery of standardized tests to assess specific cognitive functions and identify areas of cognitive impairment

7

8

9

• Classically, brain/behavior relationships have been inferred from the study of individuals with head injuries, tumors, neurological disease, and other unpleasant brain pathologies.

10

Phineas Gage

• Amazingly, he was talking and could walk. He lost a lot of blood, but after a bout with infection, he not only survived to the ghastly lesion, but recovered well, too.

11

Phineas Gage

• He became extravagant and anti-social, a fullmouth and a liar with bad manners, and could no longer hold a job or plan his future.  "Gage was no longer Gage",

12

Phineas Gage

• His skull was recovered and in 1994 researchers discovered that most of the damage was done to the ventromedial region of the frontal lobes on both sides

• The part of the frontal lobes responsible for speech and motor functions was apparently spared, so they concluded that the changes in social behavior observed in Phineas Gage were probably due to this lesion

13

Phineas Gage

• "Gage's story was the historical beginnings of the study of the biological basis of behavior

14

Methods of Neuropsych Assessment

• Medical History• Clinical Interview• Behavioral

Observations• Psychometric

Tests

15

Neuropsych assessment

• Major cognitive domains typically assessed include

• Attention• Memory• Intelligence• Visual-Spatial-

Perceptual functions

• Psychosensory and Motor abilities

• "Executive" or "Frontal Lobe" functions

• Personality or Emotional Functioning.

16

Executive Functioning

• Elaborated functions of

• logic,• strategy,• planning, • problem solving • reasoning.

• These capacities help us solve problems of all sizes in our lives.

17

Executive Functioning

• Executive Functioning difficulties relate to planning, organizing and strategizing behaviors.

18

Executive Functioning

• Analyze the context and the expected objective in order to formulate hypotheses on the probable outcomes of a decision

19

• Behavioral changes are assumed to be due to this brain tissue damage.– For instance, stroke

damage to the back of brain results in visual difficulties even though eyes are intact.

20

CNS involvement

• Behavioral manifestation of CNS deficits is highly heterogeneous.

• Thus, a battery is often called for.

21

Organic Mental Disorders

• Prior to DSM-IV we had a category called organic mental disorders for those with a physical or organic cause. – Suggest mind body separation– Most disorders involve a mix of biological and

psychological factors

22

Dysfunctions of the Brain

• Cause– Head injuries

– Diseases of the brain

– Endocrinological disorders

– Exposure to toxins

• Symptom– Depression

– Anxiety

– Delusions

– Mental impairment

– aggressiveness

23

Substance Abuse

• One Tequila• Two Tequila• Three Tequila• Floor

24

Goal of Neuropsychological assessment

• Originally to Differentiate between organic and functional

25

Distinguishing Brain Damage

• Lesion Detection

• Localization

• Lateralization

26

Neuropsychologist

• A Neuropsychologist is a psychologist who specializes in studying brain behavior relationships.

27

Two approaches

• Comprehensive Battery Approach

• Qualitative hypothesis-testing approach

28

Detect Impairment

• The first method is to use an assessment technique in which a fixed battery of tests is given and in which we only want to know what functions are impaired and what functions are not impaired.

• The most commonly used representative of this type of test is the Halstead - Reitan Neuropsychological Battery.

29

Advantages of Battery Approach

• Advantages• Easier to use for

research• Better norms• Easier to learn

• Disadvantages• Time consuming• Can overlook reasons• Difficult to tailor to

client

30

Assess level of impairment

• The second method is to assess a hierarchical arrangement of items within each subtest so that if a function is impaired, the level at which it is impaired can be determined.

• The most common representative of this type of test is the Luria - Nebraska.

31

Advantages of Qualitative approach

• Advantages• Tailor to individual• Emphasizes process• Time efficient• More depth

• Disadvantages• Focuses on

weaknesses• More difficult to

research• Requires extensive

experience

32

Specificity & Sensitivity

• Specificity means when we measure "A" with our test, we know that the test does not measure "B", "C," or "D."

• If we wish to measure a thing "A" then the test has to be able to measure "A" even when very little of "A" is present; this is sensitivity.

33

Specificity and Sensitivity

• Specificity- the ability to rule out those without the condition

• Sensitivity the ability to provide a definitive diagnosis

34

Screening Battery

• Visuoconstructive Abilities

• Mental Activity (Attention and speed of information processing)

• Memory and Learning• Verbal Functions and

Academic skills

• Motor Performance• Executive Functions• Emotional Status

35

Interviewing for Brain Impairment

• The strongest tool for a clinician is still a clear, thorough and well-informed history.

36

Bender Gestalt

• Developed 1938• Narrow focus resulting

in low sensitivity and high number of false negatives (misses)

37

Bender Gestalt

• The Bender test is a brief, non-verbal assessment consisting of nine stimulus cards, each showing a figure.The client is asked to reproduce the figures.

• The task requires visual association, motor coordination,and the ability to integrate perceptual and motor skills to achieve accurate reproductions

38

Bender Gestalt

• The results of the Bender Gestalt alone are rarely sufficient to make a differential diagnosis between neuropsychological impairment and emotional disturbance.

RBANS

• Repeatable Battery for Assessment of Neuropsychological Status (1998)

• Focuses on Verbal skills, attention, visual memory, and visuoconstruction.

• 11 subtests• 5 indices

39

RBANS

• Broad band (Assesses multiple domains)

• Brief (under 30 mins)• Portable• alternate forms• moderate difficulty

40

RBANS

• Standard scores with mean of 100 and standard deviation of 15.

• Thus, 70 represents the 2nd percentile.

41

• Utility of the RBANS in detecting cognitive impairment associated with Alzheimer’s disease: Sensitivity, specificity, and positive and negative predictive powers

• Duff, et al 2009

• Each patient with AD was matched to a comparison patient on variables shown to affect cognitive functioning (i.e., age, education, and gender) (In matching patients, age was considered first, followed by education, followed by gender

42

•  Results suggest that RBANS scores yield excellent estimates of diagnostic accuracy and that the RBANS is a useful screening tool in detection of cognitive deficits associated with AD.

43

44

45

Training

• Neuropsychologists have extensive training in the anatomy, physiology, and pathology of the nervous system.

46

Changes is Neuropsych Assessment

• Emphasis more on application than measurement.– Employability

– Treatability

– Need for support

47

Impairment vs. Disability

• Impairment reflects normative comparisons and test data.

• Disabilty considers context including circumstances, environment, interests.

48

Functional assessment

Identifies the vocational and everyday impact of cognitive disability, and the real life obstacles related to work, school, and daily living.

Through functional assessment individuals gain a better understanding of strengths and needs, and the effect these have on career choice

49

Executive Functions

• Ability to effectively regulate and direct self-behavior.

• Most often involves frontal lobe damage.

• Volition• Planning• Purposive action• Effective performance

50

Verbal Functions

• Most frequently associated with left hemisphere brain damage– Aphasia

– Speech production.

• Six Major Functions• Spontaneous speech• Speech repetition• Speech

comprehension• Naming• Reading• Writing

51

The name for the yellow organism shown below is:

a. Yellow Jessaminea. Gelsemium sempervirens

b. Witch's buttera. Tremella mesenterica,

c. King Boletea. Boletus edulis

d. Dog Vomit Slime Molda. Fuligo Septica

52

The End

53

Aphasia

loss or impairment of the power to use or comprehend words usually resulting from brain damage

back