Neuropsychology in the Courtroom
Problem 1 Neuropsychological assessment
1. What is a neuropsychological assessment?
Neuropsychological assessment is used to assess the extent of impairment of
cognitive skills and to attempt to determine the brain area that may have been
damaged due to a neurological disease or brain injury.
2. What is the general procedure of neuropsychological assessment?
Most neuropsychological assessments start with a semi-structured clinical interview
that aims to gain details about the patient’s history, the accident and the post-accident
problems. In this interview, the clinician will observe the behavior, the manner of
answering questions and the reaction to the accident and the problems of the patient.
This gives the clinician neuropsychologically relevant information. It is also
important to interview a friend or family member of the patient to get information
about the pre-injury condition.
After the interview, the assessment usually starts with a test of general intelligence.
3. Which cognitive domains are there and in which order are they used?
There are multiple domains that are assessed during a neuropsychological evaluation.
There is no prescription for which tests to use, but usually the assessment starts with
measuring general intelligence, because general intelligence can influence the
performance on other tests.
- Intelligence is not an indicator of impairment. The most used intelligence test is
the WAIS-III, which produces a verbal and performance score. The verbal scale
is associated with the left hemisphere of the brain. It tests acquired knowledge,
verbal reasoning and comprehension. The performance scale is associated with
the right hemisphere of the brain. It tests nonverbal reasoning, spatial-processing
skills, attentiveness to detail and visuomotor integration. Unilateral lesions to the
left hemisphere decrease verbal scores; unilateral lesions to the right hemisphere
decrease performance scores (exception of occipital lesions). Diffuse damage
decreases performance scores, because of the effect on attention and information
processing speed. Clinical difference is established when there is a difference of
10 or more point between these scores.
, - Attention and information processing is often tested after intelligence, because
this can also influence performance on other cognitive domains. The amount of
information processing depends on the attentional capacity of a person. Different
types of attention include focused, sustained, and divided attention. If someone is
unable to pay attention to a stimulus, he/she will not encode or process the
information. Impairment in attention contributes to diminished insight. In turn,
insight predicts the quality of long-term psychosocial recovery.
- Memory problems are the most frequent symptom of brain injury. An example of
a test battery for memory is the Wechsler Memory Scale III. Some patients might
score normal on memory tests, while they do report memory impairments in
everyday life. This might be due to the advantageous circumstances in which the
memory tests are conducted (quiet and relaxed). Everyday life is not like that in
reality.
- Executive functions are different abilities that allow a person to organize and
plan actions, structure and sequence activities, reason and form judgments. The
BADS is a measurement often used for this domain (Key test/Zoo map). Mild
impairment of executive functions may be easily overlooked by the interview and
tests. Patients can perform well on intelligence and memory tests, but relatives
will report a loss of effectiveness in everyday life.
Problem 1 Neuropsychological assessment
1. What is a neuropsychological assessment?
Neuropsychological assessment is used to assess the extent of impairment of
cognitive skills and to attempt to determine the brain area that may have been
damaged due to a neurological disease or brain injury.
2. What is the general procedure of neuropsychological assessment?
Most neuropsychological assessments start with a semi-structured clinical interview
that aims to gain details about the patient’s history, the accident and the post-accident
problems. In this interview, the clinician will observe the behavior, the manner of
answering questions and the reaction to the accident and the problems of the patient.
This gives the clinician neuropsychologically relevant information. It is also
important to interview a friend or family member of the patient to get information
about the pre-injury condition.
After the interview, the assessment usually starts with a test of general intelligence.
3. Which cognitive domains are there and in which order are they used?
There are multiple domains that are assessed during a neuropsychological evaluation.
There is no prescription for which tests to use, but usually the assessment starts with
measuring general intelligence, because general intelligence can influence the
performance on other tests.
- Intelligence is not an indicator of impairment. The most used intelligence test is
the WAIS-III, which produces a verbal and performance score. The verbal scale
is associated with the left hemisphere of the brain. It tests acquired knowledge,
verbal reasoning and comprehension. The performance scale is associated with
the right hemisphere of the brain. It tests nonverbal reasoning, spatial-processing
skills, attentiveness to detail and visuomotor integration. Unilateral lesions to the
left hemisphere decrease verbal scores; unilateral lesions to the right hemisphere
decrease performance scores (exception of occipital lesions). Diffuse damage
decreases performance scores, because of the effect on attention and information
processing speed. Clinical difference is established when there is a difference of
10 or more point between these scores.
, - Attention and information processing is often tested after intelligence, because
this can also influence performance on other cognitive domains. The amount of
information processing depends on the attentional capacity of a person. Different
types of attention include focused, sustained, and divided attention. If someone is
unable to pay attention to a stimulus, he/she will not encode or process the
information. Impairment in attention contributes to diminished insight. In turn,
insight predicts the quality of long-term psychosocial recovery.
- Memory problems are the most frequent symptom of brain injury. An example of
a test battery for memory is the Wechsler Memory Scale III. Some patients might
score normal on memory tests, while they do report memory impairments in
everyday life. This might be due to the advantageous circumstances in which the
memory tests are conducted (quiet and relaxed). Everyday life is not like that in
reality.
- Executive functions are different abilities that allow a person to organize and
plan actions, structure and sequence activities, reason and form judgments. The
BADS is a measurement often used for this domain (Key test/Zoo map). Mild
impairment of executive functions may be easily overlooked by the interview and
tests. Patients can perform well on intelligence and memory tests, but relatives
will report a loss of effectiveness in everyday life.
