British Psychological Society Chartered Psychologist    Registered with the Health Professions Council

Neuropsychological Assessments

What is a neuropsychological assessment?

Many clients are referred to me for neuropsychological assessment without having been told what it means. Equally unless you have watched one or experienced such an assessment you may even refer people all the time without completely understanding what's involved. The neuropsychological assessment I will describe here gives a flavour of the neuropsychological assessment which I carry out and which clients would have at BrainCurve. Different clinicians conduct assessments in different ways.

What questions is the assessment intending to answer?

A neuropsychological assessment is planned in consideration of what areas or information the assessment is being asked to explore or find out. Thus a neuropsychological assessment carried out to find out whether an individual is ready to try to return to work is different from one where the intention is to find out whether there is any evidence of neuropsychological impairment as a result of a mild head injury. This is why at BrainCurve communication prior to the referral is so important. It determines what kind of assessment will be conducted and ensures that the report answers the questions the person making the referral or indeed the client needs/wants to know.

I use a wide definition of neuropsychological assessment, but one which I hold to be in keeping with the complexity of what one is setting out to investigate.This can be summed up as how the person performs on the range of cognitive tasks which are designed to measure the person's intellectual functioning. The first point to note is that intellectual functioning does not mean academic ability. In this context it relates to the range of tasks which a person might need to carry out in everyday life and establishing what are their cognitive strengths and weaknesses. Thus a neuropsychological assessment should have what is known as 'ecological validity' meaning that it should have as much relevance as possible to how the person would perform in real life tasks, e.g. reading a book, cooking a meal, planning a new project at work. However to some extent neuropsychological assessment can only ever give an estimate or opinion of this and some tests are more ecologically valid than others. I usually tell clients some tests will probably feel a bit like being at school. Others however will be more like puzzles.

The second point to stress is that in assessing cognitive function one should also be trying to determine what factors other than impairment might be influencing performance on a task. After all, the person I am assessing may be very worried or preoccupied, may be extremely fatigued, or may be under the effect of alcohol or drugs. Part of my assessment therefore involves trying to decide to what extent other factors are interfering with or contributing to performance. Thus I will always assess mood and will always find out the person's status with regard to drug /alcohol use. This includes prescribed medication. It is also why a vital part of the assessment preparation is relaxing the person as much as possible. On the other hand however there may be times or tests where one wants to discover how the person performs under pressure. I will for example never assess a person all day without allowing for breaks. If however I need to actually find out how well the person's cognitive function will withstand the effects of fatigue, e.g. the person's occupation may require almost constant alertness and the ability to sustain performance despite fatigue; then I may need to deliberately limit breaks.

What are the main areas of cognitive function assessed?

  • language, expressing oneself and comprehension; reading
  • visuospatial function: visual perception, understanding relationships between shapes and patterns, copying
  • calculation; arithmetic
  • speed of processing and psycho motor speed, e.g. carrying out a task while timed or being timed while responding in a way involving quick motor speed, copying a series of symbols as quickly as possible.
  • problem solving and reasoning, ability to use abstraction and think in a complex way, integrating information, whether verbal or visual.
  • memory, including all areas of memory, e.g. from the ability to repeat a series of numbers, to the ability to remember to carry out certain tasks at a certain time, despite possible interference
  • atttention - across different aspects of attention, such as switching attention and holding attention over time.
  • executive function, e.g. the ability to plan and organise an approach to a task, carry out different aspects of a task while not losing sight of the main goal. Executive function is too complex to describe in detail here.

No test measures one of the above areas in isolation from other cognitive functions. Thus arithmetic involves the ability to reason about the meaning of the problem as well as being able to remember the figures and the relevant information. Neuropsychologists however know that some tasks are weighted much more towards one area of cognitive function than others. This is part of designing a test.

The neuropsychologist must choose a test which is well-designed in being based upon how a wide enough sample of people from a population without known impairment has performed. If a wide range of different tests are not to be used which assess the same area of function, e.g. memory, then the tester must decide which to use based upon the person's estimated ability before brain injury. For one person this may mean a relatively easy memory test, for another one much more challenging.

The neuropsychologist will want to determine other information, such as the person's premorbid or before-injury level of ability. It is usual to carry out an assessment of how well the person is trying.

To return for a moment to the importance of ecological validity, no test can completely replicate the complexity of everyday cognitive function. Certain impairments exist where a person may be able to plan and detail how they will carry out a task, and yet when the time comes to do so, be unable to translate intent into action. In addition, the diversity of tasks a person may perform in everyday life we can only gain a snapshot of in an assessment. Thus neuropsychological assessment involves asking the person and usually a significant other how well the person performs in real life in everyday terms. Again the reliability of this will vary. Some people make much better observers than others.

Another vital point to be made here is that one should not make sweeping, far-reaching conclusions on the basis of neuropsychological assessment alone. Thus I may suspect from a person's performance that it is too early to attempt a return to work. But this depends upon my information about the nature of that work, if there is a major impairment it is obviously easier. But imagine finding average performance in someone where background history suggests above average ability and imagine their job does not leave room for error. A safer way to approach this question would therefore be to then arrange a work trial, which may be, but need not be in the person's real job. With observation and enough time and planning, a much truer picture will emerge of how the person will actually be likely to cope with a return to work.

The final thing a neuropsychologist observes from the assessment is the person's behaviour during testing, during conversations between tests, and when the person may not realise I am still observing their behaviour. This means noticing attitude to testing, motivation, perseverance, insight into their performance, what strategies they may use to help them.

If this all seems rather daunting to a client, my experience and approach ensure that I never forget that to them it is not a matter of scores and test results, but yet another procedure they are participating in because they have been affected in a multitude of ways by their injury. It is another symbol of what has happened, a reminder that in some ways they may be different as a result of the brain injury. Thus it may be threatening to them and anxiety-provoking. It may to them be as daunting as a brain scan. In a very real way though, that is what a neuropsychological assessment is, a way of observing brain function while it is happening, observing behaviour and areas like personality, insight, and mood, and comparing all of this with what should be expected for that particular person, if no impairment or interference with performance had occurred. I will always share as much information with the client as is appropriate.

coffee

Finally there will always be tea or coffee, and usually biscuits!

 
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