Les 1 10/09/2025
Neuropsychological assessment – introduction
There are different purposes of neuropsychological assessment (NPA)
1. The most well-known purpose is diagnosis.
- Meaning that you can discriminate between psychiatric and neurological disorders.
- You can identify a possible neurological disorder. This means that you already have a
suspicion of what a person might have, and then you look if the cognitive profile fits this
possible neurological condition.
- Distinguish between different neurological disorders (e.g., different forms of dementia).
It is important to remember that with a NPA you assess cognitive functions. Meaning you can’t say
anything about the location of brain damage. You might get an idea which parts of the brain are
involved through tests; however, you are not allowed to say anything about the site of a lesion with
neuropsychological assessment. For this, you need neurodiagnostic techniques (fMRI, EEG).
Contrastingly, neuroimaging will not identify the behavioural strengths and accompanying deficits, for
this you need neuropsychological assessment. These tools are complementary to each other. One
says something about the site of the lesion and the other about the behavioural and cognitive
deficits.
2. Patient care and planning.
- You identify cognitive strengths and weaknesses of a patient
- You identify behaviour alterations
- You identify personality characteristics
You identify this irrespective of a diagnosis (so, this can be used whether a patient has a diagnosis or
not, doesn’t matter). This information is needed for optimal and careful management of many
disorders.
3. Treatment planning and remediation
- Think about what the most appropriate cognitive rehabilitation treatment is
4. Treatment evaluation
- Did the treatment have an effect? (e.g., you test the person before and after treatment and
you can say something about whether the treatment was effective or not. You can think
about medication, CBT, all different kinds of treatments).
5. Research
- E.g., examine specific brain disorders and behavioural disabilities
- Development, standardization, and evaluation of NPA techniques
6. Forensic neuropsychology
- In the context of claims of injury and loss of function
- In criminal cases
o Is there reason to suspect brain dysfunction that contributes to the misbehaviour?
o Is the defendant’s mental capacity sufficient to stand trial?
Neuropsychological assessment makes use of a diagnostic cycle which consists of
several steps. It is a case study (n = 1). During each step you formulate a
hypothesis and reject or accept it. Why? Because you want a transparent and
well-considered diagnostic process. By formulating hypothesis, you don’t have to
,rely on your clinical experience only. This would be difficult if you don’t have much experience yet.
That is why you make use of hypothesis which you base on scientific literature.
If you don’t formulate hypotheses and go through the diagnostic cycle, there is a big risk that you
make interpretation errors. There are different errors, but we discuss 2 in the lecture (more in the
book):
- Confirmation bias: seek and value supportive evidence for the hypotheses at the expense of
contrary evidence
- Disregarding base rates of disorders: when a sign occurs more frequently than the condition
it indicates (e.g., if you work a lot with people with AD and notice a memory deficit, you have
the tendency to think that it is caused by AD. However, memory problems are common and
more often is not a sign of AD. E.g., more people have mild verbal retrieval problems than
have early AD. So, working with a patient group is also a risk because you are biased).
In NPA, we use evidence-based medicine consisting of three sources of information:
- Clinical judgement based on experience, you have an idea/feeling of what might be the
case with the patient
- Relevant scientific evidence you use scientific evidence; you know the literature, know
which symptoms are usually seen in a certain condition
- Patients values and preferences this is an important part to include in your decision; you
might decide to give a certain treatment but if the patient doesn’t agree, it wont work.
Neuropsychological assessment is originally derived from two classical approaches:
- Psychometric approach Reitan-Halstead test battery
- Behavioural neurological approach Luria
Psychometric approach: Reitan – Halstead test battery
This is standardized in assessment and scoring methods. It uses a quantitative test approach, and it
uses normative data and cut-off scores. Test included in this battery, e.g.,
- Tactual performance test: the patient is blind folded and must place blocks in their
appropriate space with the dominant hand. You can report how many blocks are put in the
direct hole.
- Speech sound perception test: the psychologist says something, the patient must underline
the syllable that he/she hears.
- Trail making test: the patient must draw lines between the numbers and letters. This requires
cognitive flexibility.
Scoring/conclusion based on this test. For each subtest you collect a score and see if the patient
scores above/below the cut-off score. So, whether it is
impaired or not. Then you calculate a summary index of brain
damage:
You get a score between 0-1. They originally said that the higher the impairment score, the more
severe the impairment is. However, for each test you see whether it is impaired or not, not the
severity. So, the impairment index is more about the consistency of impairment that is found (on how
many test is the impairment found). We don’t have to learn the cut-off score.
You decide whether the patient is (not) impaired based on cut-off scores. There are four possibilities:
- If a patient has an impairment and the score indicates impairment =
correct the test has a high sensitivity
- If a patient is recognized as having no impairment and the score also
indicates no impairment test has a high specificity
, - The score indicates an impairment however there is none false positive
- The score indicates no impairment however there is one false negative
There is criticism on the Reitan – Halstead test battery
- It is a-theoretical (not based on theories about the brain)
- It is not a flexible test battery (you can’t adjust it to an individual)
- It only focuses on ‘abilities’, not on ‘dysfunctions’. So, you don’t get insight into the nature or
cause of the problem. Therefore, it gives no direction for rehabilitation
Behavioural neurological approach: Luria
This was developed after the second world war when there were many patients with brain injury. He
developed a test battery based on his view/theory about the brain. He thought that the brain
consisted of several functional units (he assigned functions to certain parts of the brain):
- Attention – regulated by the brain stem
- Perception – posterior part of the brain
- Organization and planning – anterior part of the brain
He also distinguished within each unit in different levels (hierarchy)
- Primary (image – you see something but don’t give an interpretation to it)
- Secondary (interpretation – you interpret what you see)
- Tertiary (cross-modal integration – meaning that you use e.g., your taste, smell, vision,
hearing (integrating different senses) to reach a conclusion).
This approach is based on observation. It is a flexible test battery; it can be adjusted to the individual
patient (based on the patient you decide which tests you want to use). Therefore, you can test
specific hypothesis. It is a qualitative assessment, meaning that you give a description about the
behaviour during the test. This gives direction to rehabilitation.
He used mostly simple tasks with the goal to provoke symptoms. E.g.,
- Motor functions – the psychologist makes some movements with the hand and after the
patient has to recreate those movements together with the psychologist.
- Higher order visual functions (present pictures to patient who must describe it; or figures
which you have to fill in or say how many times it is in the bigger picture)
Criticism on this approach
- The theory is strongly focused on the left hemisphere and less on the right hemisphere (so he
measures more the analytic part rather than the emotional part).
- No empirical testing of theory – there were no brain imaging techniques, so it was just an
idea about how the functions were related to brain damage but there were not tests to
confirm this
- No standardization, normative data or data about the reliability and validity of the tests
- No insight into the severity of disorders (you describe the performance and whether that is
impaired or not, nothing about the severity)
Neuropsychological assessment – current situation
In the past, the focus was to determine whether someone had brain damage or not. Currently, the
focus is more on knowing what is wrong. So, we speak about differential diagnostic thinking.
Differential diagnostic thinking
- Which of two or more diagnostic pigeonholes best suits the patient’s behaviour?
, - To do this, it is important to listen to complaints of patients in an unjudgmental manner. So,
without a bias and open to different kind of conditions. Not have something in your mind
already before you start
- Try to cluster syndromes, symptoms and impairments because the whole picture says
something about the condition, not only one symptom
- Successive elimination of alternative hypotheses to come to a differential diagnosis
Example: child comes to a psychologist because of a low performance in school. You can think about
what could be associated with this, e.g., ADHD or a learning disorder. You have these two hypotheses
but how do you determine which one it is? You must look at the different characteristics/impairments
of both conditions. E.g., in ADHD you expect impairments in attention, hyperactivity-impulsivity. In a
learning disorder you expect impairments in arithmetic, reading. These are very different from each
other and thus, you can distinguish which diagnosis fits the complaints of the child best.
Example: severe depression and dementia are both related with memory
impairments. How do you distinguish between these? One difference is that
with severe depression you don’t expect severe memory impairment which
you do expect for early dementia. You must think about characteristics of
each condition and determine what profile fits the complaints best.
In NPA we focus on different cognitive domains (there are a lot)
- Cognitive domain = broad category (overarching terms, e.g., executive
functions, intelligence, attention, etc.)
- Cognitive function = specific function within a broad domain (e.g.,
planning, cognitive flexibility, etc.)
We would like to assess each domain, but this is not possible due to limited time, resources, load
ability of a patient etc. Based on the hypothesis, you determine which cognitive domain you assess.
Prior to the assessment you must make decisions:
- A fixed or a flexible test battery?
- Quantitative or qualitative approach?
- Which cognitive domains should be tested?
- Which test do you choose?
There is a problem with neuropsychological tests which you should consider. They are aimed to
measure a specific cognitive function or domain; however, neuropsychological tests rarely measure
only the function they are supposed to measure! Often, they also measure other cognitive functions.
- The verbal fluency test: you must mention as many words as possible form a specific category
within one minute. This does not only measure verbal fluency, but also vocabulary size,
lexical access speed, updating, inhibition/switching ability.
- Rey Osterrieth complex figure: you measure psychomotor abilities but also other abilities
such as attention, planning, etc.
More problems…
- Tests require intact visual and auditory perception (make sure to ask prior to the test if the
patient has his/her glasses etc. because this could give a wrong impression of performance)
- Tests always rely partly on attention, memory, executive functions, language, and motor skills
- Motivation, mood, speed of information processing, fatigue, etc. can have a significant
negative influence
If you find impaired performance, there are two options
Neuropsychological assessment – introduction
There are different purposes of neuropsychological assessment (NPA)
1. The most well-known purpose is diagnosis.
- Meaning that you can discriminate between psychiatric and neurological disorders.
- You can identify a possible neurological disorder. This means that you already have a
suspicion of what a person might have, and then you look if the cognitive profile fits this
possible neurological condition.
- Distinguish between different neurological disorders (e.g., different forms of dementia).
It is important to remember that with a NPA you assess cognitive functions. Meaning you can’t say
anything about the location of brain damage. You might get an idea which parts of the brain are
involved through tests; however, you are not allowed to say anything about the site of a lesion with
neuropsychological assessment. For this, you need neurodiagnostic techniques (fMRI, EEG).
Contrastingly, neuroimaging will not identify the behavioural strengths and accompanying deficits, for
this you need neuropsychological assessment. These tools are complementary to each other. One
says something about the site of the lesion and the other about the behavioural and cognitive
deficits.
2. Patient care and planning.
- You identify cognitive strengths and weaknesses of a patient
- You identify behaviour alterations
- You identify personality characteristics
You identify this irrespective of a diagnosis (so, this can be used whether a patient has a diagnosis or
not, doesn’t matter). This information is needed for optimal and careful management of many
disorders.
3. Treatment planning and remediation
- Think about what the most appropriate cognitive rehabilitation treatment is
4. Treatment evaluation
- Did the treatment have an effect? (e.g., you test the person before and after treatment and
you can say something about whether the treatment was effective or not. You can think
about medication, CBT, all different kinds of treatments).
5. Research
- E.g., examine specific brain disorders and behavioural disabilities
- Development, standardization, and evaluation of NPA techniques
6. Forensic neuropsychology
- In the context of claims of injury and loss of function
- In criminal cases
o Is there reason to suspect brain dysfunction that contributes to the misbehaviour?
o Is the defendant’s mental capacity sufficient to stand trial?
Neuropsychological assessment makes use of a diagnostic cycle which consists of
several steps. It is a case study (n = 1). During each step you formulate a
hypothesis and reject or accept it. Why? Because you want a transparent and
well-considered diagnostic process. By formulating hypothesis, you don’t have to
,rely on your clinical experience only. This would be difficult if you don’t have much experience yet.
That is why you make use of hypothesis which you base on scientific literature.
If you don’t formulate hypotheses and go through the diagnostic cycle, there is a big risk that you
make interpretation errors. There are different errors, but we discuss 2 in the lecture (more in the
book):
- Confirmation bias: seek and value supportive evidence for the hypotheses at the expense of
contrary evidence
- Disregarding base rates of disorders: when a sign occurs more frequently than the condition
it indicates (e.g., if you work a lot with people with AD and notice a memory deficit, you have
the tendency to think that it is caused by AD. However, memory problems are common and
more often is not a sign of AD. E.g., more people have mild verbal retrieval problems than
have early AD. So, working with a patient group is also a risk because you are biased).
In NPA, we use evidence-based medicine consisting of three sources of information:
- Clinical judgement based on experience, you have an idea/feeling of what might be the
case with the patient
- Relevant scientific evidence you use scientific evidence; you know the literature, know
which symptoms are usually seen in a certain condition
- Patients values and preferences this is an important part to include in your decision; you
might decide to give a certain treatment but if the patient doesn’t agree, it wont work.
Neuropsychological assessment is originally derived from two classical approaches:
- Psychometric approach Reitan-Halstead test battery
- Behavioural neurological approach Luria
Psychometric approach: Reitan – Halstead test battery
This is standardized in assessment and scoring methods. It uses a quantitative test approach, and it
uses normative data and cut-off scores. Test included in this battery, e.g.,
- Tactual performance test: the patient is blind folded and must place blocks in their
appropriate space with the dominant hand. You can report how many blocks are put in the
direct hole.
- Speech sound perception test: the psychologist says something, the patient must underline
the syllable that he/she hears.
- Trail making test: the patient must draw lines between the numbers and letters. This requires
cognitive flexibility.
Scoring/conclusion based on this test. For each subtest you collect a score and see if the patient
scores above/below the cut-off score. So, whether it is
impaired or not. Then you calculate a summary index of brain
damage:
You get a score between 0-1. They originally said that the higher the impairment score, the more
severe the impairment is. However, for each test you see whether it is impaired or not, not the
severity. So, the impairment index is more about the consistency of impairment that is found (on how
many test is the impairment found). We don’t have to learn the cut-off score.
You decide whether the patient is (not) impaired based on cut-off scores. There are four possibilities:
- If a patient has an impairment and the score indicates impairment =
correct the test has a high sensitivity
- If a patient is recognized as having no impairment and the score also
indicates no impairment test has a high specificity
, - The score indicates an impairment however there is none false positive
- The score indicates no impairment however there is one false negative
There is criticism on the Reitan – Halstead test battery
- It is a-theoretical (not based on theories about the brain)
- It is not a flexible test battery (you can’t adjust it to an individual)
- It only focuses on ‘abilities’, not on ‘dysfunctions’. So, you don’t get insight into the nature or
cause of the problem. Therefore, it gives no direction for rehabilitation
Behavioural neurological approach: Luria
This was developed after the second world war when there were many patients with brain injury. He
developed a test battery based on his view/theory about the brain. He thought that the brain
consisted of several functional units (he assigned functions to certain parts of the brain):
- Attention – regulated by the brain stem
- Perception – posterior part of the brain
- Organization and planning – anterior part of the brain
He also distinguished within each unit in different levels (hierarchy)
- Primary (image – you see something but don’t give an interpretation to it)
- Secondary (interpretation – you interpret what you see)
- Tertiary (cross-modal integration – meaning that you use e.g., your taste, smell, vision,
hearing (integrating different senses) to reach a conclusion).
This approach is based on observation. It is a flexible test battery; it can be adjusted to the individual
patient (based on the patient you decide which tests you want to use). Therefore, you can test
specific hypothesis. It is a qualitative assessment, meaning that you give a description about the
behaviour during the test. This gives direction to rehabilitation.
He used mostly simple tasks with the goal to provoke symptoms. E.g.,
- Motor functions – the psychologist makes some movements with the hand and after the
patient has to recreate those movements together with the psychologist.
- Higher order visual functions (present pictures to patient who must describe it; or figures
which you have to fill in or say how many times it is in the bigger picture)
Criticism on this approach
- The theory is strongly focused on the left hemisphere and less on the right hemisphere (so he
measures more the analytic part rather than the emotional part).
- No empirical testing of theory – there were no brain imaging techniques, so it was just an
idea about how the functions were related to brain damage but there were not tests to
confirm this
- No standardization, normative data or data about the reliability and validity of the tests
- No insight into the severity of disorders (you describe the performance and whether that is
impaired or not, nothing about the severity)
Neuropsychological assessment – current situation
In the past, the focus was to determine whether someone had brain damage or not. Currently, the
focus is more on knowing what is wrong. So, we speak about differential diagnostic thinking.
Differential diagnostic thinking
- Which of two or more diagnostic pigeonholes best suits the patient’s behaviour?
, - To do this, it is important to listen to complaints of patients in an unjudgmental manner. So,
without a bias and open to different kind of conditions. Not have something in your mind
already before you start
- Try to cluster syndromes, symptoms and impairments because the whole picture says
something about the condition, not only one symptom
- Successive elimination of alternative hypotheses to come to a differential diagnosis
Example: child comes to a psychologist because of a low performance in school. You can think about
what could be associated with this, e.g., ADHD or a learning disorder. You have these two hypotheses
but how do you determine which one it is? You must look at the different characteristics/impairments
of both conditions. E.g., in ADHD you expect impairments in attention, hyperactivity-impulsivity. In a
learning disorder you expect impairments in arithmetic, reading. These are very different from each
other and thus, you can distinguish which diagnosis fits the complaints of the child best.
Example: severe depression and dementia are both related with memory
impairments. How do you distinguish between these? One difference is that
with severe depression you don’t expect severe memory impairment which
you do expect for early dementia. You must think about characteristics of
each condition and determine what profile fits the complaints best.
In NPA we focus on different cognitive domains (there are a lot)
- Cognitive domain = broad category (overarching terms, e.g., executive
functions, intelligence, attention, etc.)
- Cognitive function = specific function within a broad domain (e.g.,
planning, cognitive flexibility, etc.)
We would like to assess each domain, but this is not possible due to limited time, resources, load
ability of a patient etc. Based on the hypothesis, you determine which cognitive domain you assess.
Prior to the assessment you must make decisions:
- A fixed or a flexible test battery?
- Quantitative or qualitative approach?
- Which cognitive domains should be tested?
- Which test do you choose?
There is a problem with neuropsychological tests which you should consider. They are aimed to
measure a specific cognitive function or domain; however, neuropsychological tests rarely measure
only the function they are supposed to measure! Often, they also measure other cognitive functions.
- The verbal fluency test: you must mention as many words as possible form a specific category
within one minute. This does not only measure verbal fluency, but also vocabulary size,
lexical access speed, updating, inhibition/switching ability.
- Rey Osterrieth complex figure: you measure psychomotor abilities but also other abilities
such as attention, planning, etc.
More problems…
- Tests require intact visual and auditory perception (make sure to ask prior to the test if the
patient has his/her glasses etc. because this could give a wrong impression of performance)
- Tests always rely partly on attention, memory, executive functions, language, and motor skills
- Motivation, mood, speed of information processing, fatigue, etc. can have a significant
negative influence
If you find impaired performance, there are two options
