Test selection and administration Next, the neuropsychologist decides which tests to administer to answer the referral question. Many tests are selected to assess cognitive abilities, but neuropsychologists also measure emotions, psychopathology, behavior, and everyday function. Tests are given in a variety of modalities – some are performance-based, some are verbal, some nonverbal, some auditory, and some visual. Some tests are timed, and others have no time limits. Some tests are self-report questionnaires. There are a number of ways to select a cognitive test battery. There are fixed batteries , which are comprehensive collections of tests that are always administered together, such as the Luria-Nebraska and Halstead-Reitan batteries. Most neuropsychologists do not adhere to a rigid fixed battery because the batteries tend to be long, not all the tests are needed to answer some referral questions, and some areas of cognition may not be adequately assessed by components of the batteries. Instead, most neuropsychologists select tests in a somewhat flexible manner, based on the patient and the referral question. Included in most batteries are tests that assess attention, processing speed, learning and memory, visuospatial abilities, language, intelligence, and executive functions (Harvey, 2019). Assessments of emotion, adaptive functioning, personality, and psychopathology are included as indicated by the referral question, clinical interview, or behavioral observations during testing. Sometimes tests of motor and sensory function are included in an assessment. Academic achievement testing is useful for evaluations of learning disabilities and some other developmental disorders. Many neuropsychologists have a core set of tests that they administer to most persons, and then they supplement these measures with Behavioral observations Neuropsychologists observe behavior carefully, beginning with the first contact and continuing through the final feedback session. Emotional tone, speech patterns and inflections, body language, and motor movements (e.g., tremor) can be important sources of data. For example, during the intake interview, verbal descriptions of the presenting problem provide valuable information about the fluency (e.g., rate) of speech and how a person can organize a narrative around events in his or her life. Signs of anxiety and dysphoria are noted, as well as signs of potentially more severe psychopathology, such as hallucinations and delusions. Eye contact and body postures are noted, as well as clothing, grooming, and hygiene. Neuropsychologists also consider whether the patient is open and willingly engaged in the evaluation or is a reluctant or even hostile participant, because these factors might have an important bearing on test interpretation. Test scoring and interpretation After tests are administered, the neuropsychologist scores them. Raw scores on tests are usually converted to standard score s, which are scores that are based on a standard, normal distribution that is derived from normative data. For example, most intelligence tests use standard scores that have an average score of 100 and a standard deviation of 15. Thus, an IQ score of 115 is one standard deviation above mean, which is at the 84th percentile. That means that the individual scored higher than 84% of those who were given the test as part of the normative group (see below). Standard scores help neuropsychologists apply a common metric across a wide range of tests, which allows for cross-test comparisons of performance (Guilmette et al., 2020). For many tests, a patient’s scores are compared to scores from a normative group – a sample of individuals from a comparison population of interest. Ideally, normative data provide a reasonable estimation of how an average individual similar to the patient would perform on the neuropsychological tasks. For example, if a 72-year-old patient is evaluated for a suspected neurocognitive disorder, it would not be fair or useful to compare
extra tests as indicated for a particular referral. This is called a flexible-battery approach to test selection. As stated earlier, test administration can take place in one or several sessions. There are advantages to both scenarios. Testing in one day is efficient and is minimally disruptive to the work and school schedules of patients. However, extensive testing in one day can cause fatigue and might adversely affect performance on tests that occur later in the day. Testing across multiple occasions allows for shorter sessions and thus minimizes the effects of fatigue. It also allows the neuropsychologist to observe behavior on multiple occasions and lets the patient build a stronger relationship with the neuropsychologist, which facilitates rapport and lessens anxiety, both of which help to maximize functioning in the testing sessions. However, multiple appointments can be inconvenient and disruptive to school and work schedules, and the assessment also takes longer overall, which is a disadvantage when time is of the essence. Neuropsychological tests are administered in a standardized fashion. That is, there are standard directions and procedures to follow. However, this does not mean that testing is a rigid process. Although the neuropsychologist needs to adhere to some standards and conventions in administration, interpersonal interactions are not stilted and there is room for rapport, positive reinforcement of effort, breaks, and flexibility within limits. No feedback about test performance is provided during testing sessions; feedback is reserved for the feedback session, allowing the neuropsychologist time to administer and score all the tests and consider all behavioral and historical information before coming to any substantive conclusions. During test administration, neuropsychologists monitor behaviors and reactions. Is a person made nervous by some tasks and not others? What happens on easy versus difficult tasks? How do the patient’s moods and emotions change? All these factors are critical to consider when interpreting test scores. They may be windows into areas of difficulty or strength and may help the neuropsychologist make recommendations to optimize function. For example, if anticipatory anxiety appears to have an adverse effect on performance during some tasks, the neuropsychologist might provide some education to the patient as to how to anticipate and minimize anxious feelings in certain contexts to maximize cognitive resources. Or if the patient engages in frequent negative self-talk during testing (e.g., “I’m so stupid,” “I bet I got that one wrong”), some interventions to challenge negative self-appraisal might be warranted. her scores to memory performance scores for persons in their 20s because there are normal age-related changes in memory that occur with age. It would be more appropriate to compare her to cognitively intact persons of similar age. In addition to age, many normative comparisons account for test score differences due to biological sex or education (e.g., Stricker et al., 2021). Most normative data in clinical neuropsychology were derived from native English-speaking European American samples. Whereas there are normative datasets for persons from other races or ethnicities, and/or who speak a different language, they are limited in size and/or in the number of test scores they address (e.g., Werry et al., 2019). Locating the most appropriate comparison sample for a patient is essential to ensure that over- or under- diagnosis of neuropsychological disorders does not occur and that patients from underrepresented groups are not harmed by use of inappropriate normative data. Test score interpretation does not rest solely on normative comparisons, which are comparisons across persons. It also is important to compare performances on tasks within a person, which is an intra-individual comparison (Halliday et al., 2018).
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