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Chapter 6

PSYC31 - Neuropsychological Assessment chapter 6

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University of Toronto St. George
Pare, Dwayne

PSYC31 – Chapter 6: The Neuropsychological Examination: Interpretation The Nature of Neuropsychological Examination Data  The basic data of psychological examinations are behavioral observations Different Kinds of Examination Data  Background Data o Essential for providing the context in which current observations can be best understood o Requires knowledge of developmental and medical history, family background, educational and occupational accomplishments, and the patient’s current living situation and level of social functioning o Sensory and motor status, alertness cycles and fatigability, medication regimen, and likelihood of drug or alcohol dependency o Contributions of background variables have not always been appreciated in the interpretation of many different kinds of tests  Behavioral Observations o Naturalistic observations can provide very useful info about how the patient functions outside the formalized examination setting o Value of naturalistic observations may be most evident when formal examination findings alone would lead to conclusions that patients are more or less capable than they actually are o Behavioral characteristics that compromise their adequate and sometimes even excellent cognitive skills are not elicited in the usual neuropsychiatric or neuropsychological examination o How patients conduct themselves in the course of the examination is another source of useful info  Test Data o Testing differs from other sources of psychological data gathering in that it elicits behavior samples in a standardized, replicable, and more or less artificial and restrictive situation o Strengths: sameness of the test situation for each subject, the sameness that enables the examiner to compare behavior samples between individuals o Weakness: psychological test observations are limited to the behaviors prompted by the test situation o Psychological examination extrapolates from a limited set of observations to the patient’s behavior in real-life situations o Extrapolations are likely to be as accurate as the observations on which they are based are pertinent, precise, and comprehensive, as the situations are similar and as the generalizations are apt. o Examiners rely on their common sense judgments and practical experiences in making test-based predictions about their patient’s real-life functioning Quantitative and Qualitative Data  Every psychological observation can be expressed either numerically as quantitative data or descriptively as qualitative data  2 different approaches to neuropsychological assessment  An actuarial system exemplifies the quantitative method. It relies on scores, derived indices, and score relationships for diagnostic predictions  Clinical approach is built upon richly described observations without objective standardization. These clinicians document their observations in careful detail  Conditions necessary for actuarial predictions to be more accurate than clinical ones o There be only a small number of probable outcomes o Prediction variables be known o Data from which formula was derived be relevant to the questions asked  Actuarial evaluations overlook the realities of neuropsychological practice in an era of advanced neuroimaging and medical technology  Fixed versus flexible approaches  Quantitative data o Scores are summary statements about observed behavior o Scorer evaluates each behavior sample to see how well it fits a predetermined category and then it gives it a place on a numerical scale o Scored tests with more than one item produce a summary score that is the simple sum of the scores for all the individual items o Final test scores may misinterpret the behavior under examination on 2 counts:  It’s based on a narrowly defined aspect of a set of behavior samples and it’s 2 or more steps removed from the original behavior  Global or full scale scores calculated by summing or averaging a set of test scores are 3-4 steps removed from the behavior they represent o Standard scoring systems provide the means for reducing a vast array of different behaviors to a single numerical system  This enables the examiner to compare the score of any one test performance of a patient with all other scores of that patient or with any group or performance criteria  Problems in the Evaluation of Quantitative Data o It is important to keep in mind the abstract and artificial nature when interpreting test scores o Reification of test scores can cause the examiner to overlook or discount direct observations o A test score approach to psychological assessment that minimizes the importance of qualitative data can result in serious distortions in the interpretations, conclusions, and recommendations drawn from such a one-sided data base o To be neuropsychologically meaningful, a test score should represent as few kinds of behavior or dimensions of cognitive functions as possible o It is often difficult to know what functions contribute to a score obtained on a complex, multidimensional test task without appropriate evaluation based on search for commonalities in patients’ performance on different tests o If a score is over-inclusive it becomes virtually impossible to know just what behavioral or cognitive characteristic it represents o Range of observations an examiner can make is restricted by the test o Multiple-choice and automated tests offer no behavior alternatives beyond the prescribed set of responses o For most paper-and-pencil or automated tests, how the patient solves the problem or goes about answering the question remains unknown or is, at best, a matter of conjecture based on such relatively insubstantial info as heaviness or neatness of pencil marks, test-taking errors, patterns or nonresponse, erasures, and the occasional pencil- sketched spelling tryout or arithmetic computations in the margin o The fine-grained scaling provided by the most sophisticated instruments for measuring cognitive competence is not suited to the assessment of many of the behavioral symptoms of cerebral neuropathology o Behavioral aberrations due to brain dysfunction can be so highly individualized and specific to the associated lesion that their distribution in the population at large, or even in the brain impaired population, does not lend itself to actuarial prediction techniques o Evaluation of test scores in the context of direct observations is essential when doing
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