Critical Issues in Neuropsychology – serie

Neuropsychology has its roots in clinical neurology. Reading case de­ scriptions by 19th century neurologists, such as Wernicke's painstakingly detailed examinations of patients with the "aphasic symptom-complex," makes it obvious that neuropsychology is not a new discipline. Even the marriage with psychology is not new; the neurologist Arnold Pick, for example, was fully conversant with the developments in contemporary psychological as well as linguistic research. However, the primary focus of 19th and early 20th century psychology was on "general psychology," and only a small number of psychologists ventured into what then was called "differential psychology" (the psychology of individual dif­ ferences) including a few who became attached to neurological research and rehabilitation units after World War I. It remained until World War II for psychologists to establish a more solid working relationship with neurology. What psychology had to offer to neurology was its experimental skill, the development of a sophisticated methodology, and, for clinical work, the development of psychometrics. On the whole, the marriage between the two disciplines has been fruitful, leading to new insights, models, and discoveries about brain-behavior relationships, documented in several textbooks which appeared in rapid succession since the 1960s. In clinical practice, neuropsychology has been inventive in some respects, in others merely introducing psychometric rigor to already existing neurological examinations. As described in greater detail in this book, developmental neuropsy­ chology is of even more recent origin.

Over the past two decades researchers and clinicians in the neurosciences have witnessed a literal information explosion in the area of brain imaging and neuropsychological functioning. Until recently we could not view the nervous system except through the use of invasive procedures. Today, a variety of imaging techniques are available, but this technology has advanced so rapidly that it has been difficult for new information to be consolidated into a single source. The goal of this volume is to present information on technological advances along with current standards and techniques in the area of brain imaging and neuropsychological functioning. The quality of brain imaging techniques has improved dramatically. In 1975 one had to be content with a brain image that only offered a gross distinction between ventricular cavities, brain, and bone tissue. Current imaging techniques offer considerable precision and approximate gross neuroanatomy to such an extent that differentiation between brain nuclei, pathways, and white­ gray matter is possible. These technological advances have progressed so rapidly that basic and clinical research have lagged behind. It is not uncommon, particularly in longitudinal research, for the technical meth­ odology of a study to become obsolete while that study is still in progress. This has hampered certain aspects of systematic research and has also produced the need for a textbook that could address contemporary issues in brain imaging and neuropsychology.

This book is written for the clinician, students, and practitioners of neuropsychology, neuropsychiatry, and behavioral neurology. It has been my intent throughout to present a synthesis of ideas and research findings. I have reviewed thousands of articles and research reports and have drawn extensively from diverse sources in philosophy, psychol­ ogy, neurology, neurosurgery, neuropsychiatry, physiology, and neuroanatomy in order to produce this text. Of course I have also drawn from my own experience as a clinician and research scientist in preparing this work and in this regard some of my own biases and interests are represented. I have long sought to understand the human mind and the phenomena we experience as conscious awareness. After many years of studying a variety of Western and Eastern psychologists and philosophers, including the Buddhist, Taoist, and Hindu philosophical systems, I began, while still an undergraduate student, to formulate my own theory of the mind. I felt, though, that what I had come upon were only pieces of half the puzzle. What I knew of the brain was minimal. Indeed, it came as quite a surprise when one day I came across the journal Brain as I was browsing through the periodicals section of the library. I was awed. An entire journal devoted to the brain was quite a revelation. Nevertheless, although intrigued by the possibilities, I resisted.

This book is the outcome of a decade of research on the neu­ roanatomical mechanisms of learning in the young laboratory rat. It is essentially a discourse on the functional organization of the brain in relation to problem-solving ability and intelli­ gence. During the period between 1980 and 1989, well over 1000 weanling albino rats were subjected to localized brain damage (or sham operations in the case of the controls) under deep anesthesia and aseptic surgical conditions, were allowed tore­ cover, and subsequently were tested on a wide variety of prob­ lems designed to measure general learning ability. Since vir­ tually every part of the brain rostral to the medulla has been explored with lesions, it has become possible not only to map a number of "putative" brain systems underlying the acquisition of distinctive problem-solving tasks, but to isolate several neu­ roanatomical mechanisms that appear to be selectively in­ volved in the acquisition of particular kinds of goal-directed learned activities. Of particular interest was the discovery of a "nonspecific mechanism" (previously referred to in our re­ search reports as the "general learning system") inhabiting the interior parts of the brain. One objective of this volume was to make these maps available in a single source. Another was to provide a descrip­ tion of learning syndromes arising from local lesions to differ­ ent parts of the brain.

The growth of clinical neuropsychology has been unprecedented. This growth has been oriented more toward the provision of than toward the foundation for services. Thus, while a greater number of psychologists are performing a greater number of neuropsychological procedures, there seems to us an uneven parallel growth between these services and the empirical foundations for them. It should come to no one's surprise that increasingly aggressive attacks on the field have been leveled. Despite these attacks, clinical neuropsychology con­ tinues to enjoy exceptional growth within psychology and acceptance by other health practitioners, insurance companies, legislators, judges, juries, and above all, consumers of our services. Growth without self-reflection is a dangerous enterprise, as is growth without directions. We find it disconcerting that existing and limited "self­ analysis" has assumed that neuropsychological dysfunction is immune to the same variables that affect psychological dysfunction. Some attention has been paid to the most obvious ones, such as age, but all others have been ignored and/ or misunderstood. This neglect has spawned a body of knowledge replete with questionable data and unfounded conclusions. Hence, it is surprising that clinical neuropsychologists consider themselves to be more scientifically sound than their regular clinical counterparts.

Providing a thorough collection of information regarding clinical aspects of head injury from acute care to recovery, this treatise interrelates a variety of neural specialties and broadens the rehabilitation process to include the family.

This was an exciting project to work on, and I attempted to obtain a broad sampling of current research on the neuropsychology of epilepsy. Because the emphasis of the book takes a neuropsychological perspective on epilepsy, the coverage is not redundant with previous texts on this topic. The book is organized around three themes, although individual chapters certainly often extend beyond the part in which they are located. The three major topics are the nature of epilepsy, cognitive and emotional consequences of epilepsy, and treatment approaches to epilepsy and outcome. In Part I, following a historical overview of epilepsy in Chapter 1 by Sandra D. Haynes and me, Gerald C. McIntosh presents a conceptualization of the epilepsies from a neurologist's perspective. The characteristics of seizure types are discussed, and the etiology of secondary epilepsies is described. Epileptic syndromes are considered. McIntosh outlines clinical seizure patterns associated with seizures originating from different cortical regions.

It is a privilege to be asked to write the foreword for so excellent a book, so timely and so much needed by the field. Not only is it most unusual these days to have a single­ authored volume on so broad a topic, but Dr. La Rue has done a superb job of providing both a scholarly treatise and a practical handbook. With a burgeoning elderly population and the corresponding increase in geriatric psychopathology, the needs of mental health services are exceeding by far the supply of appropriate providers. In an effort to meet this need, psychiatry, medicine, neurology, pharmacology, psychology, nursing, and social work have all made the provision of training in geriatrics and gerontology a high priority-but I fear we are losing the race. For example, multidisciplinary teams that assess, diagnose, and treat mental health disorders in elderly patients are incomplete without clinical psychologists and neuropsy­ chologists, and yet there is barely a handful of clinical psychologists trained in dealing with geriatric patients. We can count on our fingers the additional ones graduated each year. In hospitals, clinics, and private practices across the country, otherwise skilled psychologists are unprepared to respond to the special mental health needs of the elderly. A few CME programs are helping to address this need, but they are clearly not enough.

This book is the culmination of a research program conducted in Colombia during the past several years. The fundamental aim of the program was to develop neuropsychological tests for Spanish speakers, especially elderly individuals and those with limited edu­ cational attainment. The lack of norms for these populations repre­ sents a significant practical problem not only in developing countries but also in more developed countries. For example, norms are usually obtained with middle-class Anglo-Saxon English-speaking popula­ tions, often university students, and such norms do not usually include individuals older than 65 years. Furthermore, very few neuro­ psychological tests have been developed for Spanish speakers; fre­ quently, tests are translated into Spanish (often poor translations at that), but the norms used are still those obtained from English­ speaking populations. This volume summarizes the normative results of this research program. We anticipate that these tests and norms will be particularly useful in the neuropsychological evaluation of Spanish speakers, especially those with limited educational attainment, and the elderly. The United States represents the fifth largest Spanish-speaking coun­ try in the world (after Mexico, Spain, Argentina, and Colombia), with over 20 million speakers. It is anticipated that by the year 2025 there will be as many Hispanics in the United States as members of all other ethnic minority groups combined. Further, about 10% of the U. S. population are considered functionally illiterate, with Hispanics rep­ resenting an unusually large segment.

Behavioral neuropsychology presents at once achallenge and an opportunity for the field ofbehavior analysis. A great diversity of problem areas-including education, classroom management, child rearing, retardation, and industry­ have been treated effectively by the behavior analytic approach, which has traditionally and quite deliberately chosen to deemphasize physiology and cognitive variables. Yet brain injury, by its nature, entails neurological insult that is often closely related to specific cognitive dysfunctions. The challenge for behavior analysis is to develop effective treatments for a disorder with such clearly defined tripartite characteristics. The opportunity exists for be­ havior analysis to expand its conceptual basis as well as to provide benefits to patients otherwise despairing of assistance. Case histories demonstrate over 20 years of successful applications of behavior analysis to brain-injured in­ dividuals, indicating that some applications are possible, but are these reports notable exceptions or the harbingers of a new general therapeutic approach? The present book describes an overall focused behaviaral program far dealing with the diversity of brain injury problems in a general brain injury rehabilitation setting. The authors describe what types of neurological damage are associated with specific types of cognitive/emotional dysfunction and in turn with specific types ofbehavioral dysfunction, thereby demonstrating how the choice ofbehavioral treatment is guided by the neurological and subjective assessment. The result is a conceptually unified approach. The distinctive value of this book lies in the detail as well as the pro­ grammatic guidelines for actual implementation ofthis behavioral approach.

This is the first volume to integrate neuropsychology and behavior therapy into a comprehensive, cohesive assessment and treatment methodology. Of particular value is a discussion of how to integrate multiple sources of information and criteria for selecting treatment techniques. The work will appeal to a wide audience including neuropsychologists, neurologists, psychiatrists, clinical psychologists, and special educators.

The author has written an easily accessible summary of neuropsychological tests, neuropsychiatric disorders, and the relationships of test performance to disorder and treatment strategy. This ready reference provides neuropsychologists with an understanding of the medical context within which neuropsychological evaluation and psychosocial therapy takes place.

Practicing neuropsychologists and students in clinical neuropsychology must increas­ ingly cross disciplinary boundaries to understand and appreciate the neuroanatomical, neurophysiological, and neuropharmacological bases of cognition and behavior, cur­ rent cognitive theory in many different domains of functioning, and the nature and tools of clinical assessment. Although the cognitive functions and abilities of interest are often the same, each of these fields has grappled with them from sometimes very different perspectives. Terminology is often specific to a particular discipline or ap­ proach, methods are diverse, and the goals or outcomes of study or investigation are usually very different. This book poises itself to provide a largely missing link between traditional approaches to assessment and the growing area of cognitive neuropsy­ chology. Historically, neuropsychology had as its central core the consideration of evidence from clinical cases. It was the early work of neurologists such as Broca, Wernicke, Hughlings-Jackson, and Liepmann, who evaluated and described the behavioral cor­ relates of prescribed lesions in individual patients and focused investigation on the lateralization and localization of cognitive abilities in humans. An outgrowth of those approaches was the systematic development of experimental tasks that could be used to elucidate the nature of cognitive changes in individuals with well-described brain lesions.

Greatly revised, the Second Edition presents an extended survey of this rapidly growing field. The book reviews the effects of industrial and pharmaceutical chemicals on human behavior, cognitive function, and emotional status. Features include two new chapters addressing key forensic issues and recent views on multiple chemical sensitivity, sick building syndrome, and psychosomatic disorders; current data on NIOSH and OSHA exposure levels for industrial toxins; and enhanced coverage of testing methods; studies of PET, SPECT, and BEAM imaging applied to neurotoxic exposure.

The permanent effects of traumatic brain injury (TBI) are not limited to the person who suffers the injury. People who care for the individual, particularly family members, suffer in various ways. Family members are often confused as to the behavioral and neuropsychological changes that they see in a brain-injured rela­ tive. They can become frustrated and angry when the individual does not return to premorbid levels of functioning. They can become tired and worn down from repeated problems in trying to manage the individual's difficulties while having only fragmented information regarding them. Drs. Smith and Godfrey have provided a useful service for family members by summarizing important neuropsychological changes associated with TBI and providing practical guidelines for coping with these problems. While the neuropsychological problems they describe are not completely understood, the authors provide a useful description of many of the neuro­ behavioral problems seen following TBI in young adults. They attempt to provide guidelines for family members that have practical utility in understanding and managing these patients. Theirs is a cognitive-behavioral approach that can have utility for this group of individuals. I applaud their efforts to provide something systematic and practical for family members.

Researchers who were influenced by Dr. Nelson Butters contribute articles to this volume to honor him and his thirty-year career. Their contributions reflect how Dr. Butters impacted their current work and offer an historical account of research theory and paradigmatic shifts within the field of cognitive neuropsychology. Researchers, clinicians, and students working in the neurosciences will appreciate this volume.

The Practice of Forensic Neuropsychology focuses the awareness of neuropsychologists on the critical areas of forensic practice that should be considered during each phase of a scientific neuropsychological examination/investigation. Written by three eminent neuropsychologists and a seasoned attorney, this important book contains practical information and guidelines for conducting valid and reliable forensic neuropsychological examinations that aid the 'trier-of-fact' in both civil and criminal settings. The authors also include vital information to help attorneys evaluate neuropsychological claims put forth by their own or opposing experts.

Leaders in neuropsychology, behavioral neurology, speech and language science, neuropsychiatry, and many other disciplines contribute to this volume, the first comprehensive review of knowledge in the field. They discuss a wide range of disorders, including areas of recent research - such as frontal lobe dementias and the neuropsychological aspects of late life depression - and clinical problems typically given insufficient consideration in other works, such as seizure disorder, head injury, and mental retardation. Normal aging is also covered in detail, and assessment procedures and clinical interventions are given thorough treatment. Other highlights include discussions of guardianship and caregiving personality and behavior, psychotic disorders, Alzheimer's, and head trauma.

This volume reflects, in part, an update of Clinical Application of Neuropsycho­ logical Test Batteries, edited by Theresa Incagnoli, Gerald Goldstein, and Charles Golden some 10 years ago. While the initial concept of the present editors involved doing a straightforward update of each chapter, it soon became apparent that the field of clinical neuropsychology had changed so dramatically and rapidly that substantial changes in the outline had to be made. It was our view that sufficient interest remained in the standard comprehen­ sive neuropsychological test batteries to make an update worthwhile. We asked four senior people to take on this assignment, James Moses, Jr. , andAmold Purisch in the case of the Luria-Nebraska Battery, and James Reed and Homer Reed for the Halstead-Reitan Battery. These individuals all have long-term associations with these procedures and can be viewed as pioneers in their development. How­ ever, it also seemed to us that there was an increasing interest in the psychometric aspects of the standard procedures and in assessment issues related to the relative merits of using standard or individualized assessment strategies. Thus, we have chapters by Elbert Russell and Gerald Goldstein that provide discussions of these current methodological and clinical issues. During the past 10 years, the cognitive revolution has made a strong impact on neuropsychology. The interest of cognitive psychologists in brain function has increased dramatically, and we now have an active field of cognitive neuropsy­ chology, something that was only beginning 10 years ago.

The first time I walked onto a neurology ward during my graduate training I was shocked (much as family members of people with brain illnesses probably are). I had learned a great deal in class about aphasia, amnesia, agnosia, apraxia, and other cognitive disorders, but I had not been prepared for the behavioral disorders I was to encounter, for the severe physical disabilities, for the indignities of the patient role. Bit by bit I overcame this shock. I learned to look people in the eye who seemed to have more tubes than the New York subway system, people whose faces had been scraped off the pavement and who were drooling, incontinent, and severely dysarthric. I learned to see beyond what frightened and repulsed me to the human beings within. I wish I could say that I saw in each person a deep human soul yearning to breathe free and to love, an essence, an intrinsic goodness, a wholeness; I did not. Rather, it seems like each and every unique element of human behavior, one's abilities, and one's desires can be destroyed by some brain lesion, while leaving a uniquely human person behind. Not only are there losses, but behaviors emerge at times that are not seen in people with intact brains but which still reveal a human attempting to cope. I do feel that I saw and still see in each such person something intrinsically human, but not the same thing in each.

I am extraordinarily pleased to have been asked by Drs. Christensen and Uzzell to write the foreword for this handbook. This handbook is the result of the most recent of a series of con­ ferences held in Copenhagen, Denmark, at five-year intervals over the past 15 years, under the guidance and leadership of Dr. Anne-Lise Christensen, and under the sponsorship of the Egmont Foundation, which must be acknowledged as well for its constant support of this in­ ternational effort. The participants in these conferences are all internationally renowned clinicians and sci­ entists. These experts represent not only the area of neuropsychology, but disciplines ranging from fundamental neurophysiology and neuroanatomy, to medical and financial perspectives on neurological injury and recovery. The participants have, to a significant extent, remained re­ markably constant over this period, and this has allowed increasing intimacy among them both professionally and personally. One felicitous result of this camaraderie has been that the con­ ferences have evolved with an increased focus on topics of the broadest interest across disci­ plines. One aspect of such a continuing dialogue across disciplines is that specific areas of mutual interest are explored in depth, allowing cross-fertilization of ideas to occur.

The inter-comparison of specific skills as represented by performance on neu- psychological tests is at the heart of the neuropsychological assessment process. However, there is a tendency to regard the interpretation of single tests as a process that is independent of performance on other tests, with integration of test information representing a summary of these individual test performances. As neuropsychology has become increasingly sophisticated, it has been recognized that many factors influence the performance on any given test. The meaning of the same score may vary considerably from one person to another, depending on his or her performance on other neuropsychological tests. Thus, a low score on the Halstead Category Test may indeed reflect frontal lobe damage, but only if we first rule out the influence of visual-spatial problems, emotionality, attentional issues, motivation, fatigue, and comprehension of the instructions. Simplistic interpre- tions that assume a common interpretation based on a specific score will inva- ably lead to errors in interpretation and conclusions. The purpose of this book is to provide each test that is described with a compendium of the possible interpretations that can be used with a variety of common tests that are often included in a neuropsychological test battery. The first chapter discusses some of the pitfalls and cautions when comparing the tests, while the second chapter examines administrative and scoring issues that may be unclear or unavailable for a given test.

Historically, relatively few investigations in neuropsychology have been sensitive to the analysis of cultural variables. This handbook will assist the neuropsychologist interested in cultural competence and help increase understanding of the link between cultural competence in assessment and intervention and good treatment outcomes. The handbook authors provide an in-depth discussion of the current status of multicultural training in neuropsychology; specific information on diverse groups (age, gender, ethnicity, etc.), assessment instruments, and clinical populations (HIV infected, seizure disorders, brain injuries); and unique analysis of immigration patterns, forensics, and psychopharmacology. This volume is the first to summarize the cultural data available in neuropsychology. A valuable resource for clinical neuropsychologists, school psychologists and rehabilitation professionals.

In this revised and updated 2nd edition, the concepts and methods of psychometric neuropsychology are presented as a framework by which to evaluate current instruments. Newer methodologies and statistical techniques are discussed, such as meta analysis, effect size, confirming factor analysis, and ecological validity. The research in this area since the publication of the first edition in 1989, has been incorporated, including a greatly expanded chapter on child assessment instruments. This volume should complement the bookshelf of every clinical neuropsychologist as well as researchers and students. Anyone conducting forensic evaluations should find especially useful the information on reliability and validity when preparing for court appearances. It may also be of value to those who, in the future, may have to deal with environmental disputes or to write dispute settlement clauses into environmental treaties.

The impetus for this volume began with our research in the 1980's involving serial neuropsychological evaluation with various patient populations. At that time, reports on the practice effects associated with routinely utilized clinical neuropsychological instruments were sparse. While test-retest data were available for almost all assessment instruments, this was usually in the form of correlation coefficients and not changes in mean performance between or across assessment periods (see McCaffrey & Westervelt, 1995 for a detailed discussion of these and related issues). Clinical neuropsychological practitioners had few guidelines to assist them in determining if a change in a patient's performance across assessments was due to an intervention, maturation, practice effects, or a combination of factors. This volume represents our efforts at reviewing the literature between 1970 and 1998 and extracting the reported information on practice effects. The tables include the assessment instrument used, information on the subject/patient groups, the sample size (n}, gender, age, intervention, interval between the assessments, scores at both assessment points, and the citation. Those studies that reported data on more than two assessment points are indicated by a notation~ however, any data beyond the second assessment are not reported and the interested reader should refer to the original article. The tables are arranged alphabetically for the most widely used assessment instruments. Those instruments for which there was limited data on practice effects are grouped by "domain" (e. g.

Neuropsychologists have an important role in potentiating the psychosocial adjustment and quality of life of patients through effective diagnosis and rehabilitation of cognitive and psychomotor deficits caused by acute and chronic disease. Thoroughly updated and expanded, this second edition of the highly acclaimed "Medical Neuropsychology" contains a complete review of the rapidly developing literature pertaining to the association between cognition and medical diseases. As a compendium of the empirical literature documenting the neuropsychological sequelae of organ and system pathology, this volume will be of interest of all practitioners interested in the integration of neuropsychology into the mainstream of health service delivery.

While conducting research on intellectual and neuropsychological perfonnance of various patient populations across time, we became aware of the lack of information concerning practice effects associated with many widely used assessment instruments. Although test-retest data were available for almost all of these instruments, it typically came in the form of correlation coefficients and mean changes in performance between assessments was often absent. In a 1995 article (McCaffrey & Westervelt, 1995), we discussed a number of issues relevant to serial neuropsychological and intellectual assessment and concluded that clinical neuropsychological practitioners had few guidelines to assist them in interpreting change in a patient's performance across assessments. This volume represents our efforts at reviewing the literature between 1970 and 1998 and extracting the reported information on practice effects. The tables include the assessment instrument used, information on the subject/patient groups, the sample size fu}, gender, age, intervention, interval between the assessments, scores at both assessment points, and the citation. The tables reflect the existing published literature within intellectual assessment and, therefore, some instruments (e.g., Wechsler tests) comprise a majority of the tables whereas others (e.g., Raven's Progressive Matrices, Stanford-Binet) do not. The test index is arranged by the name of the test as reported in the specific article. We caution readers to refer to the original articles if additional or more specific information is needed.

Learning disabilities is a subject that is usually associated with school-aged children where the research and intervention strategies are well known. Much less research has been done for assessing and diagnosing older adolescents and adults in this area. This work is an effort to provide a comprehensive review of what we know about certain of these disorders, specifically: language-based learning disorders; nonverbal learning disorders; high-functioning autism; attention-deficit/hyperactivity disorder; and mathematics disorders and how they manifest themselves in the later years of development and maturity. A chapter addresses each one of these disorders of learning. Included in each chapter is a discussion of historical perspectives, definitions and diagnostic criteria, incidence and prevalence data, comorbidity studies, pertinent research from all relevant fields of study, reasonable accommodations in academia as well as the workplace, and outcome data. This much-needed review will be of interest to clinicians in neuropsychology, educational psychology, and psychopharmacology.

This volume is intended to serve as an aid in the process of differential diagnosis which frequently confronts neuropsychologists. The guide is a compendium of information of the base rates of symptoms across a variety of disorders which neuropsychologists encounter. In addition to serving as a convenient source of information on symptom base rates, this volume also contains detailed cross referencing of symptoms across disorders.This book is intended for use by clinical neuropsychologists and psychologists.