Neuropsychology investigates the relationship between the brain and behavior, which can vary

due to brain injury or disease. Neuropsychologists study this relationship; the changes that occur
in different thought processes in association with the structure of the brain and cognitive
integration.

In recent years, the focus of clinical neuropsychological evaluation has moved from detection
and localization of lesions to tests that measure the cognitive strengths and weaknesses of an
individual, so as to know about a patient’s neurobehavioral competencies.

Neuropsychological assessment is the process of gathering information about a client’s brain

functioning on the basis of performance on psychological tests. Clinicians use NA to determine
the functional correlates of brain damage by comparing a client’s performance on a particular
test with normative data from individuals who are known to have certain types of injuries or
disorders. It maps the relationship between brain functioning and behavior in the realms of
cognitive, motor, sensory, and emotional functioning.

The three main aims of a neuropsychological assessment are: to identify the cognitive deficit, to
locate the associated brain lesions, and to devise suitable rehabilitation training. A
neuropsychological assessment typically involves an interview and a series of paper-pencil tests.
Various tests assesses a variety of domains like mental activity (attention and speed of
information processing); visuo-constructive abilities; memory and learning; verbal functions,
including academic skills; executive functions (observing, directing, and regulating behaviour);
motor performance; and emotional status.

The data obtained from mental and neurological assessments may fill in as an early cautioning
sign that, clients who do poorly on such a test would most likely be experiencing
neuropsychological impairment. The test results reveal the functional status of the different brain
networks, and how it would affect a person’s daily life, diagnose a condition if appropriate, and
make recommendations for intervention and/or accommodation for any problem areas.

GOALS:

Integrity of cognitive functions: It helps to determine which functions of the brain have been
disrupted and providing evidence that a brain injury has caused cognitive and behavioural
deficits. The evaluation is also helpful to determine the presence, nature, and severity of
cognitive dysfunction. It provides a baseline to monitor future changes in cognitive abilities,
mood and personality, including treatment effects.

Differential diagnosis. Neuropsychological assessment can provide tools for differential

diagnosis where clear cognitive decline is apparent, despite the absence of neurological deficits.
It is helpful when a person exhibiting mild cognitive impairment, wherein the memory of these
individuals is poorer than that of individuals matched for age and education, yet they do not
reach the impairment level of patients diagnosed with dementia. It is also helpful in providing
differential diagnosis of a range of neurodegenerative disorders such as Alzheimer’s dementia,
frontotemporal dementia, and various mental disorders like schizophrenia, depression, anxiety,
epilepsy, and autism.

Diagnosis. To evaluate neurological and psychiatric disorders, one unique contribution of the
neuropsychological assessment is the detection and evaluation of cerebral dysfunction in the
absence of clear anatomical evidence of alterations. The results of a neuropsychological
evaluation can help clarify diagnoses related to a range of learning and psychological concerns,
develop specific recommendations and accommodations to address a person’s needs and
problem areas. It also assist in better understanding a person’s strengths and weaknesses and
address related concerns. It also identifies psychological factors such as depression that
contribute to cognitive dysfunction.

Treatment planning and design rehabilitation programs. To provide treatment suggestions

for cognitive disorders as well as psychological adjustment, along with a profile of strengths and
weaknesses to provide rehabilitation, educational, vocational, or other services. It also
determines the levels of cognitive functioning as they relate to work, school, and independent
living. Not only does a rehabilitation program attempt to mitigate deficits or teach the patient
how to deal with them; it also allows the patient to cultivate and optimize spared skills for use as
compensatory mechanisms that enable optimal functioning despite their disabilities. The
evaluation can serve to assess whether a person is able, from a mental ability perspective, to
make a successful return to major life roles. It is also used for the evaluation of the effectiveness
of pharmacological treatment or any other interventions to track changes in patients’
performance over time and monitor their healing.
Functional Assessment. The most popular reason for referral for neuropsychological evaluation
is not to determine if there is impairment, but rather to evaluate its consequences on the person’s
functioning. In order to fully appreciate the meaning and consequences of an injury, it is not
enough to measure the current level of function of a person compared to some standard, but it is
also necessary to estimate the premorbid capabilities of the person and predict their future
functioning outcome.

Forensic Determination. Neuropsychological assessments are used in determinations of

workers ' compensation and personal injury litigation cases that involve determining whether the
injured individual is malingering or exaggerating the effects of the injury for getting an external
reward, such as financial advantage or exemption from military service or work.

HISTORY:

Neuropsychological assessment as a well-defined discipline began in the 1950s with the work of
Halstead, Reitan, and Goldstein in the United States; Rey in France; and Luria in the Soviet
Union. In the United States, the experimental and statistical orientation of American psychology
was reflected in test design and use. Norms were refined and used for comparison with an
individual patient’s performance. Optimal cutoff scores were developed to distinguish impaired
from normal performances.

Early success was achieved with the HRNTB in distinguishing not only the presence of brain
damage but also the location and nature of lesions. During the days before sophisticated neuro-
radiological techniques, this information was extremely useful. These efforts emerged into an
emphasis on what has sometimes been referred to as the three Ls of neuropsychology: lesion
detection, localization, and lateralization.

Concurrent with the developments in the United States was the work of Alexander Luria in the
Soviet Union and André Rey in France. They relied extensively on close patient observation and
in-depth case histories. They were not so much interested in what score a person might have
obtained but rather why the individual performed in a certain manner. Their work epitomized the
flexible, qualitative approach. Although somewhat controversial, these procedures were
formalized and standardized into the Luria-Nebraska Neuropsychological Battery.
From these early beginnings, two distinct strategies of approaching neuropsychological
assessment emerged. One was the comprehensive battery approach pioneered by Halstead and
Reitan and formalized into the HRNTB; the other was a more flexible, qualitative, hypothesis-
testing strategy as represented by Goldstein and Luria.

There are certain advantages and disadvantages of both the strategies. A comprehensive battery
assesses both strengths and weaknesses for a broad spectrum. Easier to use for research, more
extensively normed and can be administered by trained technicians. It is easier for students to
learn but is quite time consuming. It may overlook the underlying reasons for a client’s specific
test score. Is more difficult to tailor or change according to the needs of the client.

On the other hand hypothesis testing strategy can be tailored to the specifics of the client and
referral question. It emphasizes the processes underlying a client’s performance, rather than a
final score. It is time efficient and allows scope for close examination of ambiguous responses.
Focuses on a client’s weaknesses. It relies too, extensively on clinician expertise, is more
difficult to research, is not as extensively researched and provides a narrower slice of a client’s
domains of functioning.

Concurrent with the development of the early testing procedures and batteries, there was also an
emphasis on brief screening instruments. The Bender Visual-Motor Gestalt Test was one of the
earliest of these. It was first developed by Lauretta Bender in 1938 and included nine designs
that a client was requested to reproduce. A similar but more complex visuo-constructive test was
devised by Rey in 1941 and expanded by Osterrith in 1944. It has since become refined and
referred to as the Rey-Osterrith Complex Figure Test

In addition to these procedures, several short batteries have been developed for reviewing
possible neuropsychological impairment with specific types of disorders. Batteries for the
evaluation of neurotoxicity include the California Neuropsychological Screening Battery,
Pittsburgh Occupational Exposure Test, and Individual Neuropsychological Testing for
Neurotoxicity Battery. Each of these uses a combination of previously developed tests, such as
Trail Making and portions of the Wechsler intelligence scales. Assessment and monitoring of
some of the more important domains of dementia might be achieved with the Consortium to
Establish a Registry for Alzheimer’s Disease (CERAD) Battery or the Dementia Assessment
Battery. A similar specialized battery for detecting the early signs of AIDS-related dementia is
the NIMH Core Neuropsychological Battery.

Although tests can be quite useful, the strongest tool for a clinician in assessing brain impairment
can often be a clear, thorough, and well-informed history. One of the major factors guiding such
a history is, understanding the types of behavior that are likely to reflect neuropsychological
impairment. Attention, language, memory, emotional behaviors are some of the areas that can
give information related to neuropsychological impairment. It may provide an important
indicative value. It is more robust when a checklist is used, formally or informally developed.

A family history, Prenatal and early personal history, occupational history, medical history and
any neuropsychological history should carefully document current complaints and current overall
life situation. Onset, frequency, duration, intensity, and any changes over time must be recorded.
Example, Neuropsychological History Questionnaire and Neuropsychological Status
Examination.