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Neuropsychological Evaluation and Brain Injury
Victor Zelek, Ph.D.
Northeast Center for Special Care
Typically, neuropsychological evaluations are given to
individuals who have suffered some form of brain injury, for example,
traumatic head injury, strokes and brain tumors. Different types of brain
- Traumatic brain
injury (TBI), concussion, acceleration-deceleration injury.
accident (CVA) which includes stroke and ruptured aneurysm.
- Brain tumor,
which may originate in the brain or metastasize into the brain
from other parts of the body.
- Anoxia (lack of
oxygen), as in drowning, chocking or strangulation. Anoxic
brain injury may occur if the heart stops breathing for a brief
period of time.
- Toxic injury,
which is caused by neurotoxins, such as carbon monoxide, lead,
mercury and certain illicit drugs.
- Infection may
damage the brain, as in encephalitis, meningitis, abscess or
chronic brain Lyme disease.
diseases that affect the brain include Alzheimer's Disease,
Pick's Disease, Huntington's Disease, Lewy Body Disease and sometimes
Multiple Sclerosis and Guillome-Barr Disease.
Individuals with less obvious
brain/neurological dysfunction may also benefit from a neuropsychological
evaluation. These include persons with developmental disorders, ADD, a
learning disability and psychiatric disorder.
Clinical neuropsychologists are psychologists who are
trained in a variety of disciplines that include clinical psychology,
neuroanatomy, neurochemistry, neurophysiology and psychometrics. They
attempt to understand how the brain functions by using objective
psychometric measures (tests). These measures are used to analyze and
interpret an individuals responses to cognitive tasks by comparing those
responses to a Normative Sample. Typically, Normative Samples for each
test are comprised of large groups of people with similar characteristics
(age, education and cultural background) as the test-taker.
Testing results are often reported in percentiles. For example, a
score of 75th percentile on a memory test means that an individual did as
well or better than 75 percent of the people in the Normative Sample did on
that particular test. 50th percentile is average. A score of the
5th percentile indicates serious impairment.
A neuropsychologist makes inferences about what a person is able to do in
his/her environment based on how that individual performs on a set of tasks,
relative to how other people in the population perform on the tasks.
The tests have usually been validated by clinical research studies that
assess the specific relationships between performance on test measures,
neurological and cognitive functions. Tests typically consist of paper
and pencil tests, verbal tasks, structured and unstructured interviews, computerized
tasks and constructional tasks.
and Purpose of the Neuropsychological Evaluation
A neuropsychological evaluation may be
conducted for a variety of reasons. Some of these include:
- Clarification of diagnosis by assessing the cognitive profile and degree
of cognitive impairment in suspected cases of brain injury.
- Establishing a baseline from which comparisons of the
effectiveness of therapeutic interventions or changes in cognitive status
can be made.
- Using the evaluation
results to design a specific and targeted cognitive treatment plan.
- Assisting social workers
and discharge planners by providing a realistic picture of cognitive
strengths and goals for community placement and development of
rehabilitation and training programs.
- Predicting prognostic outcomes with respect to
community reintegration after brain injury.
- Documentation of cognitive status for vocational
& educational, forensic or litigation proceedings.
While imaging techniques
such as MRI, CT scan, PET or SPECT, can show damage to the brain's
structural integrity, blood flow or metabolism, however, they cannot measure
the amount of memory loss or capacity to sustain attention.
Neurological testing evaluates such impairments of cognitive
functioning. The types of cognitive deficits that are typically
encountered after brain injury are diverse but tend to include impairments
- Executive functioning:
planning, initiation, follow-through and organization.
- Speech, language and
- Memory: visual,
auditory, sort-tern memory, long-term memory.
- Speed of information processing.
- Mental flexibility,
reasoning, Problem solving and Judgment.
The rational behind providing neuropsychological assessment services in a
rehabilitation setting is to provide a better understanding of
brain-behavior relationships so that the Interdisciplinary Treatment Team
can focus on utilizing and individual's particular strengths to compensate
for limitations in cognitive functions associated withy their brain
injury. In the larger context of an individual's own life, it
provides the person with a sense of what he or she can do and how he or
she can most effectively attain the things they have difficulty doing.
is it so important that the patient has a good understanding of his/her
cognitive problems? Letís imagine that a personís car was damaged in
an accident. The mechanic fixed it the best he could and it is usable, but
there were two things that could not be fixed: the brakes are a little
loose and every time you break it slightly veers to the left. Knowing this
could be invaluable to the driver, since he/she could compensate for these
problems by braking earlier and slightly turning the wheel to the right.
Similarly, having good and continuous awareness of oneís cognitive
problems allows for evasive actions. When cognitive problems cannot be
completely fixed and one has to live with them, compensatory strategies
can go a long way.
Does a Neuropsychological Evaluation Include?
A comprehensive neuropsychological evaluation typically takes between
6-12 hrs to complete. Shorter 2-4 hour screens may be conducted. A
comprehensive evaluation may be conducted over several days. The length of
time taken is usually determined by factors such as an individualís age,
attention span, motivation and endurance, nature of the impairment and
referral reason. The evaluation includes obtaining data from a variety of
sources: background history, behavioral observations and objective testing
At intake, a complete history of developmental, medical/psychological,
educational, occupational and social concerns is obtained during the
interview with client, family members and review of records. Inferences
about premorbid characteristics are obtained using background information.
Structured Testing: Formal neuropsychological evaluation may be conducted
using a fixed battery of tests or a flexible series of tests geared towards
extrapolating information about an individualís ability to function in a
variety of areas. The areas most commonly assessed include:
- Gross Cognitive/Intellectual functioning:
Overall ability/aptitude. This gives an overall sense of a personís
ability to handle his/her environment. It gives an estimate of overall
cognitive functioning and may be helpful in detecting diffuse cognitive
decline noted in head and acquired brain injuries.
- Conceptual/abstract reasoning/executive
ability/judgment: The way in which a person is able to put together
information to formulate hypotheses about a situation. Problem solving,
planning/decision making, self awareness/insight, error correction or
trouble shooting, anticipate & responding to novel situations/future
needs, attention/interference control, regulate impulses &
drives/inhibition of inappropriate actions, flexibility.
ability to focus mental resources on a task. These are important in
monitoring what is going on in the environment and adapting to change.
Sustained and shifting attention. Levels of arousal are important here.
- Language: The
ability to communicate with others by using symbolic systems, such as
speech (expressive), and ability to interpret such systems (receptive).
Articulation, speech prosody, reading comprehension.
- Learning/Memory: The
way in which an individual acquires information/knowledge about the
world, and their ability to retain and retrieve such information when
required to do so. It includes the dynamic process of encoding and
categorizing information, storage and retrieval.
- Academic/achievement (optional depending on
purpose): Basic skills of reading spelling, writing and mathematics may
be assessed to get a sense of essential skills required to perform
everyday tasks, and employment readiness.
- Motor Functioning:
Psychomotor coordination. Speed & Style of Processing: The way
in which information is encoded (taken in) and utilized. Factors, such
as speed of processing, the strategies used (piecemeal/holistic). Adaptive
Functioning/Emotional/personality: Daily living, social and
communication skills. Emotional states, such as anxiety & depression
affect how the brain processes information. Personality styles which
affect how information is processed.
- MOTIVATION/MALINGERING: Occasionally,
inclusion of explicit measures of task motivation is used to determine
whether a personís performance is motivated by financial or emotional
gain (e.g., need for attention).
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