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Neuropsychological Assessment
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Kessels R.P.C., and Hendriks M.P.H., Neuropsychological Assessment. In: Howard S. Friedman (Editor in Chief),
Encyclopedia of Mental Health, 2nd edition, Vol 3, Waltham, MA: Academic Press, 2016, pp. 197-201.
Copyright © 2016 Elsevier Inc. unless otherwise stated. All rights reserved.
Author's personal copy
Neuropsychological Assessment
RPC Kessels, Radboud University, Nijmegen, The Netherlands; Radboud University Medical Center, Nijmegen, The Netherlands; and
Vincent van Gogh Institute for Psychiatry, Venray, The Netherlands
MPH Hendriks, Radboud University, Nijmegen, The Netherlands and Academic Centre for Epileptology Kempenhaeghe, Heeze, The
Netherlands
r 2016 Elsevier Inc. All rights reserved.
Neuropsychological assessment refers to the measurement of Although such a test typically involves attention, encoding,
cognitive functions and processes with the aim to establish consolidation, storage and retrieval of information, it also re-
whether cognitive dysfunction or cognitive impairment is lies on auditory perception and speech. By definition, a sub-
present in individuals, typically in patients with (suspected) division in cognitive domains is arbitrary, and many different
brain disease, psychiatric disorder or information-processing classifications exist. The following broad classification of cog-
complaints. Neuropsychological assessment is preferably per- nitive domains is often used: memory and learning, executive
formed by clinical neuropsychologists who have expertise in function, attention and speed of information processing,
the study of the neural correlates of behavior and cognition. praxia, motor function, language and perception. In addition,
The cognitive processes that are being investigated include intelligence is often considered as a separate domain for
functions that are involved in thinking, planning, walking, heuristic reasons, but in fact it reflects the overall cognitive
remembering, talking, seeing and feeling. These cognitive ability based on the aforementioned individual domains
processes can be impaired after brain disease or dysfunction, (Lezak et al., 2012; Kessels and Brands, 2009). Selecting which
and these deficits may have great effect on everyday function of cognitive tools should be used depends on the assessment’s
patients. Moreover, these deficits may also provide further aim, but it is basically a process of hypothesis testing.
insight into theoretical aspects of human information pro-
cessing and the workings of the human brain in relation to
pathophysiological processes. Diagnostic versus Descriptive Aim of the Assessment
In assessing cognitive deficits, two important questions must
be answered. First, the question is whether an individual pa-
Assessment of Cognitive Function
tient, or a patient group, has cognitive impairments compared
with a reference group. Second, we need to interpret the pat-
Tests versus Cognitive Domains
tern of impairment: whether selective deficits of one or more
Tests that are used in clinical neuropsychology in most cases cognitive processes – or domains – exist. By establishing this
examine one or more aspects of cognitive domains, which are pattern of cognitive deficits, we can subsequently relate this
theoretical constructs in which a multitude of cognitive pro- information to cerebral dysfunction in general (diffuse) or
cesses are involved. For example, a memory test in which a specific brain lesions (focal). Although neuropsychological
series of words has to be remembered aims to assess verbal assessment in isolation can neither determine whether patients
memory function as part of the cognitive domain memory. have ‘organic’ lesions nor accurately identify the side or site of
the lesion, it provides information about cognitive function effects into account, although age and education levels are
that can be interpreted in conjunction with other diagnostic important predictors of cognitive performance. Furthermore,
tools, such as neuroimaging findings or clinical history. the psychometric properties of cognitive screening instruments
Two approaches can be distinguished for performing a are often suboptimal, as they have been designed as diagnostic
neuropsychological assessment. In the first approach, a cog- instruments, but are often used for other purposes, such as
nitive screening instrument is used, with the aim to dis- monitoring changes over time.
criminate cognitively healthy people from patients with a Thus, some caution is required when using cognitive
specific disorder, such as Alzheimer’s dementia, frontal-lobe screeners in clinical practice. A low (below cut-off) perform-
dysfunction or aphasia. A second approach is to administer a ance is usually indicative of cognitive impairment, but it may
number of neuropsychological tests, each tapping a specific also be the result of poor motivation, low education level or
cognitive function to examine cognitive strengths and weak- illiteracy. A larger risk is that of false-negative results, that is, a
nesses that may be due to a specific brain disease, develop- ‘normal’ performance on a cognitive screener, which makes the
mental disorder or psychiatric syndrome. clinician conclude that there are no cognitive deficits, where in
fact the test’s sensitivity is too low to detect impairments.
Table 1 Summary of the main cognitive domains and examples of tests that can be used for their assessment (commonly used abbreviations
in parentheses)
Memory and learning The ability to acquire new information, to store this Rey Auditory Verbal Learning Test (RAVLT), California
information in the long term and to retrieve previously Verbal Learning Test (CVLT-II), Location Learning Test
stored information (LLT-R), and Wechsler Memory Scale (WMS-IV)
Executive function The updating (working memory), planning, monitoring, Digit Span, Tower of London test, Trail Making Test
shifting, and inhibition of behavior (TMT), Wisconsin Card Sorting Test (WCST), and
Stroop Color Word Test
Attention and speed of Selection of relevant information, dual tasking, sustaining Reaction-time tests, Symbol Digit Modalities Test
information processing a state of alertness and the ‘mental speed’ with which (SDMT), Paced Serial Addition Test (PASAT), and
information is processed Continuous Performance Task (CPT)
Praxis and motor function Cognitive processes that underlie basic motor functions Pegboard tests, Rey–Osterrieth Complex Figure test, and
and complex actions Beery–Buktenica Developmental Test of Visual–Motor
Integration
Language Communication skills, understanding others, and verbal Boston Diagnostic Aphasia Battery, Token Test, and
expressing Verbal Fluency tests
Perception Both low-level and higher-order processing of visual, Ishihara Test for Color Blindness, Visual Object and
auditory and tactile stimuli Space Perception battery (VOSP), and Benton Test of
Facial Matching
Overall cognition Screening for cognitive decline regardless of cognitive Mini-Mental State Examination (MMSE), Cambridge
domains; intelligence Cognitive Examination (CAMCOG-R), Montreal
Cognitive Assessment (MoCA), and Wechsler Adult
Intelligence Scale (WAIS-IV)
Source: Adapted from Kessels, R.P.C., Brands, A.M.A., 2009. Neuropsychological assessment. In: Biessels, G.J., Luchsinger, J.A. (Eds.), Diabetes and the Brain. Totowa, NJ: Humana
Press, pp. 77−102.
neuropsychological test to be used. For assessment of the of words correctly recalled, the average reaction time in
memory domain, tests typically require a patient to memorize milliseconds or the number of errors made during the task.
numbers, words, pictures or short stories that have to be These performance measures are referred to as raw scores. For
recalled after a long or short delay or recognized among dis- decision making in clinical practice, raw scores are mean-
tracters. Higher-order cognitive processes, such as planning, ingless when there are no reference values available. That is,
self-monitoring, task switching and response inhibition are neuropsychological tests are designed in such a way that ceil-
grouped under the label executive functions. Executive func- ing or floor effects do not occur, meaning that even cognitively
tions are examined by tasks that are novel to the patient or unimpaired individuals usually do not obtain the maximum
require controlled (as opposed to automatic) processing (e.g., number of points on a test (in contrast to a screening instru-
planning a route on a map following a set of rules). Attention ment on which healthy individuals usually perform at or near
and speed of information processing are usually being exam- ceiling). As a result, developing fixed cut-off points for raw
ined using reaction-time tests or other timed tasks that require scores of neuropsychological tests is not possible. To deter-
the participant to respond as quickly as possible. If such a mine whether a given raw score indicates an impaired per-
task has to be performed over a longer period of time, it formance, a statistical comparison has to be made with a
taps concentration (sustained attention). In the language normative sample. Such a sample consists of a large group
domain, comprehension, speech production, picture naming, (i.e., hundreds) of cognitively healthy individuals. The nor-
and repetition are usually examined, as well as language- mative sample should also be representative for the general
related functions such as reading and writing. Praxia and population, in that it must include participants of a wide age
motor function can be assessed using tasks that require the range (with often separate norms for those younger than 18
patient to perform actions on verbal command (show me how years), both men and women, a variety of educational back-
you brush your teeth) or by drawing tasks (often used in de- grounds and levels of intelligence, and a good representation
velopmental assessment, such as free drawings or copying of the geographic and ethnic diversity of the culture in which
from an example). Perception is in most cases assessed using the test is being used. Normative datasets for neuro-
visual tasks in which pictures of common and uncommon psychological tests are language and country specific, as even
objects are shown that have to be recognized, which can also direct translations of the same neuropsychological test may
be overlapping or presented from unusual views to assess ag- result in smaller or larger performance differences. These
nosia (the inability to recognize objects or scenes). normative data sets are usually made available by the test’s
publisher, but additional normative data can also be found in
the public domain or in handbooks (e.g., Lezak et al., 2012;
Normative Data and Classification Strauss et al., 2006; Mitrushina et al., 2005).
To compare an individual performance to a normative
The performance of an individual on a neuropsychological test sample, a raw score must be converted into a standard score.
is usually expressed in a performance measure such as number The way this is done is determined by the performance of the
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200 Neuropsychological Assessment
normative sample on a specific test. That is, for most neuro- are often considered to be ‘below average’ or ‘borderline’
psychological tests, age and years of education (and to a lesser (Lezak et al., 2012).
extent ethnicity and gender) are important predictors of an
individual’s performance. For instance, the average raw score
of an 85-year-old man with 7 years of education on a word-list Interpretation
learning test may be 25, whereas the average score of a 21-year-
old female college student on the same test may be 40. The After administration and scoring of a set of neuropsychological
conversion of raw scores into standard scores takes these pre- tests, and the conversion of raw scores into standard scores, the
dictors into account, and test publishers provide tables or results have to be interpreted from a clinical perspective.
software tools to do this. Standard scores are age- or edu- At the level of a single test, classification can be done using
cation-corrected performance measures that have a direct re- the standard scores, but note that the aforementioned cut-off
lation to the mean and standard deviation (SD) of the scores are based on convention rather than external criteria.
normative sample of healthy participants (i.e., the normal Clinical interpretation also includes interpretation of other
distribution). Figure 1 shows an overview of widely used data that are available to a neuropsychologist, such as an
standard scores in relation to the normal distribution, such as individual’s medical history, results of magnetic resonance
Z-scores (with a mean of 0 and an SD of 1), T-scores (mean 50; imaging, qualitative observations of test behavior made during
SD 10), IQ scores (mean 100; SD 15), Wechsler scores (mean the assessment and the person’s intellectual and cognitive
10; SD 3) and percentile scores (reflecting the percentage of functioning before the onset of the cognitive complaints, brain
healthy subjects that perform worse than an individual; i.e., a disease or disorder (the latter referred to as premorbid level of
score percentile score of 3 means that only 3% of the normal functioning). For the assessment of children with develop-
population would obtain a lower performance). mental disorders, it is also crucial to relate the individual’s
Using statistical probabilities, standard scores can be in- performance to the expected developmental milestones for a
terpreted. For a performance to be classified as impaired, a cut- specific age and take the overall level of intelligence into ac-
off score of 1.5, 1.65 or 2SD below the normative mean is count. For instance, the reading or motor abilities of a 6-year-
often considered to be indicative of an impaired performance, old child differ greatly from those of a 10-year-old child.
as an age- and education-adjusted performance lower than Furthermore, a diagnosis is rarely made on the basis of a single
these cut-off-scores is highly unlikely in the normal popu- test performance; it is the result of the aggregate interpretation
lation (i.e., only 5.8, 5, or 2.3% of the normative sample, of multiple neuropsychological tests, test behavior, infor-
respectively). Standard scores lower than 1SD below the mean mation from the clinical interview with the patient and
34.13% 34.13%
Percentage of people
under normal curve 13.59% 13.59%
0.13% 2.14% 2.14% 0.13%
Percentiles
1 5 10 20 30 40 50 6070 80 90 95 99
Z scores
−4 −3 −2 −1 0 +1 +2 +3 +4
T scores
20 30 40 50 60 70 80
Wechsler
standard scores 1 4 7 10 13 16 19
IQ scores
55 70 85 100 115 130 145
Figure 1 The normal distribution in relation to standard scores that are used to classify neuropsychological test performance.
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Neuropsychological Assessment 201
developmental history. Also, apparent inconsistencies may be hand and their psychometric properties as well as under-
present in an individual’s test profile (e.g., an average per- standing of the quality of the available normative data (see
formance on one memory test but an impaired performance Vanderploeg, 2000, for a more detailed description of the
on another memory test), which can make the interpretation interpretation process). Neuropsychologists usually describe
of the test results complicated. Note that a poor test per- the interpretation of the results and their main conclusion
formance is never direct proof of brain dysfunction, as such in a neuropsychological report, which may support the medi-
a performance can also be driven by other factors, such as cal diagnostic process, or guide treatment, care or other
developmental disorders, personality factors, depressed mood, interventions.
inability to comprehend complex test instructions or motiv-
ation. Lack of motivation may result in insufficient mental
effort being displayed during neuropsychological assessment, See also: Attention-Deficit/Hyperactivity Disorder. Depression.
affecting the symptom validity of the assessment (i.e., poor test Intelligence and Mental Health. Psychological Testing. Traumatic
performances that do not reflect the actual level of cognitive Brain Injury
abilities of that individual). Specific tests exist to measure
symptom validity, which can detect underperformance be-
cause of lack of motivation or because of feigned cognitive
symptoms (malingering, which can be seen in some com- References
pensation-seeking individuals). Note also that subjective re-
ports of cognitive complaints are not necessarily substantiated Kessels, R.P.C., Brands, A.M.A., 2009. Neuropsychological assessment. In: Biessels,
by an impaired performance on neuropsychological tests, but G.J., Luchsinger, J.A. (Eds.), Diabetes and the Brain. Totowa, NJ: Humana Press,
pp. 77–102.
that such complaints can also be the result of rumination or
Lezak, M.D., Howieson, D.B., Bigler, E.D., Tranel, D., 2012. Neuropsychological
worrying, false beliefs that one’s memory has to be perfect all Assessment, fifth ed. New York, NY: Oxford University Press.
the time or psychological distress. Mitrushina, M.N., Boone, K.B., Razani, J., D’Elia, L.F., 2005. Handbook of Normative
In clinical practice, interpretation of neuropsychological Data for Neuropsychological Assessment. New York, NY: Oxford University Press.
test results requires knowledge of cognitive theories on brain– Strauss, E., Sherman, E.M.S., Spreen, O., 2006. A Compendium of
Neuropsychological Tests: Administration, Norms, and Commentary, third ed.
behavior function, understanding of normal and pathological New York, NY: Oxford University Press.
development, knowledge of neurological diseases and mental Vanderploeg, R.D. (Ed.), 2000. Clinician’s Guide to Neuropsychological Assessment,
disorders, experience with the neuropsychological tests at second ed. Hillsdale, NJ: Lawrence Erlbaum.