By: Shahal Rozenblatt, Ph.D., Clinical Neuropsychologist
Advanced Psychological Assessment, P.C.
People are highly complex organisms whose problems are of equal complexity. In order to effectively treat the problems with which people present, we need to have a way of understanding the nature of this complexity, breaking it down so that targeted solutions can be implemented. The neuropsychological evaluation is one such method. This article is meant to serve as an introduction to neuropsychology and neuropsychological evaluations and how they can be helpful to physical, occupational, and speech therapists in developing and guiding interventions.
Neuropsychology is a branch of psychology where the focus is on understanding brain-behavior relationships, using a variety of tests that tap into multiple brain functions in order to gain insight into a person’s difficulties. Most clinicians who do this type of work are licensed clinical psychologists with specialized training in and understanding of brain-behavior relationships. Unlike neuroimaging techniques, such as MRI and CT scans, that look at structural defects (e.g., tumors), neuropsychology relies on paper-and-pencil and computer based methods to evaluate how specific areas of the brain perform their functions. The goal of a neuropsychological evaluation is not necessarily to determine if a brain injury or other neurological disorder is present, although this certainly can be a component, but to delineate the impact that such a condition can have on the individual’s ability to function in his or her environment. For children this will most likely be related to school, for adults at work and in relationships. When someone is referred for a neuropsychological evaluation, their level of functioning is usually below that which we expect from them. A parent will complain that their child is struggling academically or a spouse will report that their partner is becoming increasingly forgetful. The battery of tests used by neuropsychologists are well-standardized based on age, education level, and gender enabling comparisons to be made between the patient’s performance and that of the “typical” person. The goal of the evaluation is to determine the person’s areas of cognitive and emotional strengths and weaknesses, helping to develop a treatment plan that will focus on improving the areas of weakness and use the areas of strength to compensate.
In the hospital the most common referrals for a neuropsychological evaluation are following brain injuries acquired in motor vehicle accidents, stroke or brain tumor resection, or dementia. As part of a treatment team that involves medical doctors (e.g., physiatrists, neurologists, and surgeons) and rehabilitation specialists (e.g., speech, occupational, and physical therapists) all of whom play crucial roles in the evaluation and treatment of the patient, the neuropsychologist’s role is to clarify the extent of the patient’s cognitive deficits, determine if there are mental health issues such as anxiety and depression that are impacting the person, and refining the interventions that are being implemented. For instance, the evaluation will clarify the extent of receptive and expressive language deficits following a left-hemisphere injury (the side of the brain that is usually dominant for language). The evaluation can determine if the problems are motor-based or due to cognitive limitations (i.e., comprehension), assess the cognitive capacity of the patient and how this impacts treatment, and provide specific recommendations that will improve speech, memory, and other related cognitive functions.
In the community setting, the type of patients that are seen by a neuropsychologist will be more varied. With children, the most common reasons for referral involve problems with academics and behavior, often times including Attention-Deficit/Hyperactivity Disorder (ADHD), learning disorders, and Autism spectrum disorders. With adults, work and social problems are the most common reasons for referral, followed by the need for accommodations in college or on entrance examinations (e.g., LSAT and GRE). When working with children, the neuropsychological evaluation is geared towards helping parents, teachers, and other professionals understand why the child is struggling academically, emotionally, and socially and developing an intervention plan that will work towards remitting the areas of difficulty. When dealing with adults, problems with work and relationships are common. In this case, the neuropsychological evaluation provides insight into the person’s ability to contend with the demands placed on him or her, including why they are less successful in their pursuits.
What is involved in the neuropsychological evaluation? Depending on the setting and purpose of the evaluation, approximately 8 hours of face-to-face testing is involved (in inpatient hospital settings a brief evaluation 1 hour in length may be used due to time constraints). Multiple areas are assessed by the neuropsychologist including intelligence, academic abilities, executive functions, learning and memory, speech and language, motor skills, and personality and adaptive functioning. Within each domain, the assessment breaks down the processes involved into their components so that we are better able to understand the point of weakness and implement appropriate interventions. For example, when evaluating someone for a Reading Disorder impairments in any of the following aspects can occur: decoding, fluency/accuracy, and comprehension. Decoding skills refer to the ability to read the actual word and requires phonological awareness – the ability to accurately manipulate the sounds of the language. Fluency/accuracy refers to the amount of effort required to read and comprehension refers to how well one understands what he or she reads. Interventions will depend on which aspect or combination thereof serves as the point of weakness.
Once the evaluation is completed a comprehensive report is put together that includes what the test findings mean, the diagnoses, and specific recommendations. A case example will serve to illustrate this process. A 13-year old girl is brought by her parents to be evaluated due to poor academic performance, social difficulties, and behavior problems at home and school. She presents with an unremarkable medical history and is not currently taking prescription medications, although she uses melatonin to help her sleep at night. Her work in school is sloppy and she is having difficulty with peers. The test results show that she is of average intelligence, verbal and nonverbal, and has well developed language skills. However, she struggles on measures of executive functioning, presenting with limited attention span, distractibility, impulsivity, and deficits in problem solving and working memory. Results of the academic portion show inconsistent performance, with careless errors, particularly in math. Her ability to learn and retain information is also below average. The test findings and clinical history all point to a diagnosis of ADHD, Combined Type, meaning that she presents with attention problems and limited impulse control. Now what?
Typical recommendations for someone with ADHD involve follow-up with their primary care physician or referral to a neurologist to determine if medication management is an appropriate intervention. In addition, psychological interventions will focus on skill building and learning to monitor and deal with one’s attention and emotional states. However, there are many other problems that affect individuals with ADHD. They often have difficulty communicating appropriately with others, meaning that they tend to be less mature and often do not understand or attend to many of the pragmatic components of social communication (e.g., dealing with the more subtle aspects such as body language, intonation, etc.). The speech therapist is an ideal person to deal with this component, helping the person to communicate more effectively and take into account the needs of those with whom they are interacting. Planning and organizational problems are ubiquitous for children and adults with ADHD, ranging from poor handwriting to disorganized thinking and work. Occupational therapists help remediate fine motor problems, but also help the person to become more aware of how they are using their body, slowing things down and providing an opportunity to think through one’s actions. By breaking complex tasks into smaller steps, things are simplified, allowing the individual with ADHD to master one step at a time, eventually developing the ability to take on the complex task. Individuals with ADHD are often clumsy and prone to injury. Physical therapists can help the person develop better strength and muscle tone when such issues arise. However, they also aid in a more delicate component- helping the person with ADHD to be mindful of their environment, teaching them how to attend to what is going on around them more effectively, including use of their body.
The complexity of the human nervous system is beyond questions. Although our understanding of the brain is far from complete, we have developed ways that enable us to gain greater insight into its functioning and how it relates to our ability to interact with the world around us. Neuropsychological assessment is one such tool, enabling a collaborative approach that deconstructs complex processes and enables interventions to be targeted to the areas of weakness.
The Neuropsychological Evaluation as a Guide to Intervention.
By: Shahal Rozenblatt, Ph.D., Clinical Neuropsychologist