Van Zandvoort, M. (2019). Chapter 7: Neuropsychological questions and methods. In F. Luteijn & D. Barelds (Eds.), Psychological diagnostics in health care (4th ed., pp. 145-168). Amsterdam: Boom uitgevers.

What is the history of neuropsychology?

The history of neuropsychology is characterized by fluctuations of periods in which the focus is on localization or on holism. Localization refers to specific behavioral effects of several disorders in individual parts of the brain, and holism refers to the general behavioral effects of disorders in the brain as a whole. Gall’s phrenology is the best-known period of localization. After Gall, the emphasis was on holism. Later, because of the studies of Broca and Wernicke, the emphasis was on localization again. Broca and Wernicke discovered aphasia, a language disorder which is the consequence of brain damage. Around the First World War, holism started to gain the upper hand again, which was especially due to Goldstein’s search for one common and fundamental psychological disorder. This holistic period led to tests and tests batteries. The goal of these tests was to determine and measure the psychological consequences of brain damage. These tests were called ‘organic tests’.

Later, a struggle arose in the field of neuropsychology between the clinical, more qualitative approach and the methodological, statistical, quantitative approaches. The Dutch neuropsychology is currently dominated by Lurian and experimental influences. Also, insights, theories, and facts obtained through localization and lateralization research are also important. However, there is a lot of interest in ‘holistic issues’, such as ‘quality of life’. The current view is that brain dysfunctions have consequences that stem from both selective, localization-related disorders as well as more general consequences.

What are the possible misconceptions about neuropsychology?

One important misconception is that neuropsychology involves only the examination of functional cognitive disorders and intellectual deterioration. However, emotional disorders and personality changes also occur as a direct result of damage to for example the frontal lobes. It is also important to note that neuropsychologists also determine which of the patient’s functions are intact or relatively intact.

Another misconception is the idea that the explanation question (Chapter 1) requires an answer in terms of a medical diagnosis. This is not part of the job for a neuropsychologist. Instead, he draws conclusions on the basis of cognitive functional domains and their influence on the behavior.

A final misconception is the idea that the neuropsychologist should limit his or her examination entirely to the question of the initiator. This is not the case: sometimes new and more important questions can arise, which the neuropsychologist then should try to answer.

What are the types of questions?

Neuropsychological questions can be divided into three types:

The first type of question is the most general and basic: What is the cognitive profile of the patients? To answer this question, behavioral, cognitive, and emotional disorders should be identified. An example of this type of question is: Can the memory complaints reported by the patient be attributed to underlying memory disorders and/or is there an indication of underperformance, aggravation or mood-related problems?

The second and third type of questions address the relationship between behavior and the brain. The second type refers to damage and/or abnormalities that have already been identified, while the third involves asking the question of whether there may be other brain abnormalities, and if so, which ones.

What are measurement instruments in neuropsychology?

The diagnostic methods that have been discussed in other chapters of the book are also used during neuropsychological examination: anamnesis and heteroanamnesis, the interview, observation, questionnaires, tests, and experiments. In this section, the instruments that are most frequently used and that are psychometrically the most favorable will be discussed. The current available neuropsychological tests can be classified into four groups: 1) general level tests and screening tests, 2) specific tests for cognitive functioning, divided into functional domains, 3) tests for emotional functioning, personality and attitudes, and 4) clinimetric methods.

Level tests and screening tests

The most common used intelligence tests are the WAIS (Wechsler Adult Intelligence Scale), the GIT (Groninger Intelligence test), the Raven’s Progressive Matrices, the KAIT NL (Dutch adaptation of the Kaufman Adolescent and Adult Intelligence Test), and the SON-R (Snijders-Oomen Non-verbal Intelligence Test). Intelligence tests should not be used as a screener for possible disorders in cognitive functioning.

Screening tests are tests used to screen for dementia. For example, the Mini-Mental State Examination (MMSE), the Cognitive Screening Test, the MoCA (Montreal Cognitive Assessment), and the Amsterdamse Dementie Screeningtest. It is advisable to have a low cut-off score when using these questionnaires. The goal should be to refer the client to an experienced neuropsychologist, who can then conduct a full neuropsychological examination.

During an examination of the cognitive functions, the following cognitive domains should be examined: attention, information processing speed, perception, memory, and learning, language, spatial functions, and executive functions (planning, behavioral regulation). The neuropsychologist will focus on the ‘higher’ brain functions, which means that he or she will ensure that there is no evidence of lower sensory dysfunctions, such as deafness, blindness, or dyslexia.

Attention

To assess selective attention, distractibility and the ability to inhibit responses, the Stroop test can be used. The Stroop test is based on the principle that reading is an automated process and that there is inference (distraction) between naming the color of the ink and the name of the color that is read aloud. An example of this is the word green, which is printed in red ink. The correct response would be ‘red’. Thus, the dominant response (‘green’) must be inhibited and selective attention must be focused on the naming of the color. This produces a delay, and the extent of the delay provides insight into the ability to selectively focus attention and to inhibit responses. Another test used to assess sustained attention is The Bourdon test. This test involves a sheet of paper that shows fifty lines with groups of dots, which contain either three, four, or five dots. The patient must cross out each group of four dots. Then, the following elements are scored: the average time that the patient spends on each line, the consistency of the time taken, and the number of errors. This test reflects how well the patient can concentrate for long periods of time (10 to 15 minutes). When a patient experiences neglect or hemineglect, the patient pays no attention to the stimuli from the contralesional side. This can be tested with tests such as the Behavioural Inattention Test, and with so-called crossing-out (cancellation) tasks.

Information processing speed

Among patients with brain damage, inertia is a common complaint. It is good to have information of the processing speed, because this may have an impact on the additional test profile of the patient. Information processing speed can be assessed in different ways. A distinction should be made between psychomotor speed, simple information processing, and complex information processing. However, a good reaction time instrument with corresponding norms is not available.

Perception and visuospatial functions

If there are doubts about the functioning of sensory organs such as the eyes and the ears, one can use The Cortical Vision Screenings Test (CORVIST). This is a short screening instrument. One can also use the Visual Object and Space Perception Battery (VOSP). When combining these tests, underlying disorders can be examined in more detail. For evaluating facial recognition abilities, one can use The Benton Facial Recognition Test. To assess visuospatial functions, one can use the Benton Line Orientation Test and maze tests. To assess auditory recognition, one can use The Seashore Test.

Memory and Learning

To assess procedural memory, one can only use experiments, because there are no normed tests. There are different tests for declarative memory, in which there is a distinction between ‘registering information’, ‘learning new information’, ‘retaining information’, and ‘recognizing information’ for both verbal and non-verbal materials. Some famous neuropsychological task for verbal memory are the 15-Woordentest (15-Word test) and the 8-Woordentest (8-Word test). Repeating the verbally or non-verbally offered sequences in reverse order shows the capacity of the working memory.

The semantic memory is often assessed using semantic fluency tests, in which the subject must recall as many examples of a category as possible (animals, fruits, words that begin with a certain letter).

Language

Tests that look at aphasia, problems in language, make a distinction between utterances (expression, production) and language comprehension (reception, comprehension) and between disorders at the word or sentence level. The test battery from the Stichting Afasie Nederland (Dutch Aphasia Foundation) is used to assess language that is both spoken and hear. The Akense Afasie (Aachen Aphasia Test) Test contains subtests for reading and writing. The Amsterdam-Nijmegen Test voor Alledaagse Taalvaardigheid (Amsterdam-Nijmegen Everyday Language Test) focuses on verbal communication skills in everyday life. The Semantische Associatie Test (Semantic Association Test) is a newcomer which focusses on the accessibility and availability of an adequate semantic network. The Token Test can also be used for screening for aphasia.

Executive functions

The term ‘executive functions’ refers to things such as coordination, controlling, and planning. Common tests to assess executive functions are the Wisconsin Card Sorting Test, the Tower of London test, the Trail Making Test and the Stroop test.

Praxis

Sometimes, practiced purposeful actions such as using a comb, putting on a coat, and waving goodbye are impaired in patients with brain damage. The most common tasks that are used for this purpose in clinical practice are the Luria tasks and the Goldberg tasks. However, there are no adequate norms for these tasks.

Emotional and personality problems

To assess emotional and personality problems, the neuropsychologist is often limited to observations, interviews and questionnaires. An example of a questionnaire is The Hospital Anxiety and Depression Scale (HADS). Tests that assess the tendency to aggravate and simulate (‘malingering’) are for example the Amsterdam Short-Term Memory test. The Test of Memory Malingering is also used.

Clinimetric methods

Clinimetrics focuses on instruments that measure the effects of illness and abnormalities. Initially, the focus was on rating scales for illness-specific and generic symptoms and general limitations in everyday life. Later, more complex concepts such as functional health and quality of life were introduced.

What are the common interpretation problems?

The most common problems in the interpretation of neuropsychological data are test conditions, premorbid functioning, multiconditionality, and the relationship between sensitivity and specificity.

Test conditions

When one carries out measurements using tests or other measurements, it is assumed that the person undergoing this test meets basic conditions. For example, we assume that the person understands and remembers the instruction, that he or she is able to respond to, etcetera. However, patients with brain damage sometimes do not meet the conditions. It is even the goal of diagnostics to find out whether the patient is ‘testable’ or not.

Premorbid functioning

Often, there is no data available from the time before the illness or accident. When psychologists then want to draw conclusions about acquired brain injury, they need to use reasoning and reconstructions. There are different types of reasoning. First, they can use the anamnesis and heteroanamnesis and ask the patient’s inner circle about his or her functioning. Second, they could assume that the patient functioned ‘average’. Third, they could estimate the premorbid intellectual level on the basis of the Dutch Reading Test for Adults and on the basis of the patient’s age and education.

Multiconditionality

Test scores on neuropsychological tests are not only influenced by brain damage, but also by other conditions and factors such as age, level of education, gender, genetic differences, etc. Therefore, psychologists must always ask themselves which factors aside brain damage may have affected the results. So, the interpretation of both the recognition and explanation of neuropsychological problems consists of three steps. First, an unexpected outcome leads to a hypothesis. Second, there is a search for confirmation of this in other data. Third, the psychologist will go through all the available data in search of a contradiction.

Sensitivity and specificity

These terms refer to the distinctiveness of a test score with regards to an external criterion. Sensitivity reflects how often low test score (below a cut-off score) is obtained by people with the relevant diagnosis, and specificity refers to how often a good test score (above a cut-off score) is obtained by people without that diagnosis. For example, 100% or almost 100% of patients with a diagnostic amnestic (memory loss) syndrome should obtain a low score on a memory test, and around 100% of the healthy patients should obtain a high score. Raising the cut-off score would increase sensitivity, but decrease the specificity. The patient’s individual question will determine whether there should be more value attached to sensitivity or specificity.

Barry CH15 Psychological Assessment in Child Mental Health Settings

What is this article about?

Psychological principles can be used to guide interventions and treatments. But, to be able to do this, we need scientifically grounded and comprehensive assessment. However, relative to the literature on evidence-based treatment, there is not a lot of research on evidence-based assessment. This chapter discusses important issues in providing an evidence-based assessment of child and adolescent emotional, behavioral, and social functioning (which is called psychological assessment).

How does evidence-based assessment with children and adolescents take place?

An assessment is successful when it answers the referral question. This type of assessment often consists of a clear description of the types of problems that a child or adolescent is experiencing and the potential causes of these problems. This is called a ‘case conceptualization’. A correct assessment also leads to recommendations for interventions based on this conceptualization. To be an effective clinician, one should have knowledge about assessment techniques. To aid clinicians in this process, there have been models developed for evidence-based assessment. There is a call for evidence-based assessment because this can help professionals conduct psychological assessments, communicate their findings to others, and evaluate assessment results from other professionals.

In this chapter, the focus is on an evidence-based assessment of children and adolescents. The model that is described is guided by three principles:

Every decision made during an assessment with a child or adolescent should be guided by the most current and best available research.
Results from tests should be used only for making interpretations for which they have been validated.
The assessment process should be guided by a hypothesis-testing approach. That is, one should address the referral question (e.g., Why is this child doing poorly in school?) by developing possible hypotheses based on research (e.g., the child has a learning disability; the child has problems sustaining attention) and then collect data to determine which hypothesis is most consistent with the available data.

What is the difference between evidence-based and traditional approaches to psychological assessment?

In evidence-based assessment, it is important to include an assessment of the child or adolescent’s psychological context. This is because, to understand a child, it is important to take a ‘meta-systems’ approach. A meta-systems approach refers to the various systems involved with the child. The literature on this indicates that the ratings of a child’s personality and behavior in different contexts are only modestly correlated. These modest correlations suggest that different assessors provide different views of the child’s personality and adjustment. By understanding the characteristics of various contexts, the child’s behavior can be explained. In traditional approaches, the focus is not on the context and instead only on the child’s emotional and behavioral functioning.

Another characteristic of evidence-based assessment is that it should be ‘construct-centered’. For example, the literature on child or adolescent depression can inform the assessor about the important constructs to assess, which is not only ‘looking sad’, but also ‘loss of interest in activities’ and ‘thoughts of death’.

Another principle of evidence-based assessment is that the assessment process is like a scientific manuscript: the clinician engages in hypothesis testing and arrives at a conclusion that informs interventions based on the data collected during the evaluation.

How does the assessment of treatment outcome take place?

Assessing change during treatment leads to more treatment fidelity and improves treatment outcomes. Therefore, this should become routine in child mental health settings. Evidence-based assessment is possible for this type of assessment, too. First, the criteria by which treatment progress is evaluated should be measurable. Second, only measures that have proven to be sensitive to change should be used for the purpose of treatment monitoring. Third, the criteria for evaluating treatment outcomes should be meaningful. Fourth, the criteria for evaluating treatment outcomes must be feasible: this is client-specific.

What are ethical and professional issues in the assessment of children and adolescents?

When working with children and adolescents, it is important to determine who has the right to consent for the assessment to be conducted. Also, the clinician must be effective in communicating and maintaining rapport with parents, children, and teachers. Confidentiality should also be discussed with all the relevant parties.

Frick developed a self-examination for professionals, that can help to determine whether their assessments meet the ethical and competent criteria. So, professionals should:

ensure that they have appropriate training for the assessment methods to be used,
consider the client’s background in interpreting assessment results,
receive informed consent before initiating the assessment,
consider to whom assessment feedback should be provided,
take appropriate steps to maintain the client’s confidentiality,
obtain releases to provide information from the assessment to outside parties

What are general issues in selecting measures?

When selecting methods and measures, the clinicians should keep in mind the child’s developmental context. For example, hyperactivity takes on a different meaning when the child is 2, 10 or 16 years old. The clinician should also be able to compare the child to same-aged peers, with the use of norms. When selecting measures for evaluation, the clinician must look at whether the scores from the test are proven to be valid and reliable for the population that he or she wants to use it.

Another issue in selecting measures is evaluating the clinical utility of a particular tool. This is defined as ‘the extent to which a measure will make a meaningful difference in relation to diagnosis accuracy, case formulation considerations, and treatment outcomes’. Lastly, it is best to use an assessment battery (multiple tests) instead of just one test, because every test has strengths and weaknesses.

What are some of the most common assessment methods?

There are different assessment methods: interviews, behavioral observations, intelligence tests, behavior rating scales, and laboratory tasks.

Clinical Interviews

In an interview, a description of the problem and impairments are discussed. Interviews can be structured or unstructured. Unstructured interviews do provide information about the client, but are often unreliable and do not permit conclusions about the extent to which the child’s difficulties are significant relative to same-aged peers. Structured interviews provide the interviewer with a script to follow. They also include guidelines on how a child’s responses are to be scored. These interviews have shown to be more reliable and valid. Therefore, structured interviews can be helpful in determining whether the child meets the criteria for a particular diagnosis.

Behavioral Observations

Children and adolescents can be observed when they are tested, during interactions with their parents, in the classroom, when they are alone, or all of these. These observations can take place informally or through structured observational systems, such as the Behavior Assessment System for Children and the Test Observation Form. When conducting observations, the clinician must be aware of ‘reactivity’: the person knows that he or she is being watched and changes his/her behavior accordingly.

Intelligence Tests and Academic Functioning

There are well-normed standardized intelligence tests, for example, the Wechsler Intelligence Scale for Children. These tests have clear procedures for administration and scoring, but they require specialized training to administer and score.

Behavior Rating Scales

Rating scales are scales for different domains relevant to a child’s psychological adjustment. They are often standardized and thus allow for age-based comparisons on constructs of interest. Broadband or omnibus scales are scales that have a lot of subscales that assess different domains of functioning. Examples are the Achenbach System of Empirically Based Assessment, the Behavior Assessment System for Children, and the Conners-3.

Laboratory Tasks

These tasks are designed to elicit performance that will help to confirm or disconfirm the presence of a specific problem or disorder. For example, one can use behavioral avoidance tasks for anxiety.

What are the benefits and challenges of an assessment battery?

There is not a single best method for assessing all important constructs. Therefore, an assessment battery should include procedures that provide data from multiple informants who interact with the child in different settings. It is also important that different methods are used so that the strengths of one method can compensate for limitations in another. Informants can be parents, teachers, children themselves or peers. A parent is thought to be the most useful and critical informant. For teachers, they are especially useful when the child is young and has only one teacher. Children themselves can provide information about internalizing symptoms, which are invisible to others.

How is information across different informants integrated?

To integrate information across informants, one can use the attributions bias context (ABC) model.

First, the clinician should document all significant findings across constructs and informants. Then, any areas in which convergence is evident are noted and likely point to an area of concern. Third, the clinician should try to determine the reasons behind any discrepancies. In this step, he should consider cultural or systemic influences on the information obtained as well as other potential influences on the responses. In the fourth step, the clinician should develop a hierarchy of problems from primary to secondary. Secondary problems are apart from the clinical issue or may be considered additional manifestations of the primary problem. In the fifth and last step, the clinician determines all the relevant information that should be in the assessment report.

To get an overview of all the articles, please visit https://www.joho.org/en/article-summaries-psychological-assessment-uva.