Why is neuropsychology important

These skills are neurodevelopmental in nature. Problems with executive functioning may indicate subtle dysfunctions in brain circuitry. Many parents, students and adults are frustrated by these behaviors and view them as emotional in nature or as a moral failing on the part of the child, adolescent or adult.

These attitudes further reinforce low self-esteem and poor effort. It is important to understand that these are brain-based behaviors that are weak or deficient for particular people.

A neuropsychological evaluation should delineate the profile of strengths and weaknesses in executive functioning in order to build on assets and propose appropriate intervention for deficits. Timely intervention is important because executive functioning deficits can and do persist past the school years and can affect independent functioning on a job and in social interactions. This behavior is understandable in the face of fear of failure and difficulty in getting your child to change. Students with Autism Spectrum Disorders ASDs who are considered to be high functioning typically appear to be fluid with language.

They often have good vocabulary, remember lots of information, and have good oral speaking ability. They will often score well on tests of basic language skills. However, some of these students may have subtle but real difficulties with higher order language and pragmatics. Pragmatic language is the social aspect of language. For example, turn taking behaviors and topic maintenance in conversation are aspects of pragmatic language. Higher order language refers to abilities such as understanding inferences, nuance, and ambiguity.

It is important to assess these language abilities as they affect reading comprehension, written expression and social interactions. As students progress in their schooling, the ability to utilize higher order language skills becomes increasingly more important and some children with HFA may start to have academic problems.

It is well-known that children with ASDs often receive several misdiagnoses before being correctly diagnosed. Most neurodevelopmental problems reading disorders, learning disorders, attention deficit disorder etc. Without taking a thorough history and systematically sampling multiple domains, your child might receive a misdiagnosis. A neuropsychologist is trained to know the correct questions to ask and tasks to give to arrive at the best diagnostic formulation.

A neuropsychologist integrates the findings from the domains discussed above to arrive at an understanding of the brain behavior relationships and their impact on academic, behavioral, and life skills performance.

School-based evaluations are often performed by multiple evaluators within their area of specialty Speech, Education etc. However, the results are seldom integrated into a greater understanding of how one domain affects another. With this understanding, a neuropsychological evaluation should yield results that lead to an appropriate and effective educational plan or transition plan for an adolescent or young adult.

It should help adults with the transition into the work world, and help them understand their strengths and their limitations in terms of job and career choice. For example, a person might have difficulty with multi-tasking and should not take a job that involves the intense levels of multi-tasking that confronts a pilot.

A mere diagnosis is not sufficient. In the case of children and adolescents, an evaluation should give parents suggestions for how to help your child at home.

There is no point in having such an extensive evaluation without it resulting in a detailed plan of how to approach your child educationally and behaviorally. The plan should be based on the findings of the evaluation and should be of sufficient detail and clarity for parents, educators, and adults to understand the best methods to teach your individual child or to support independent adult functioning.

It should include information about:. Strengths and weaknesses How your child learns Recommended educational approaches Recommended strategies for abilities that support academic achievement and life skills such as social skills, pragmatic language, and executive function abilities.

These uses are presented in Table I. Some conditions are defined by the presence of cognitive impairment. These impairments must be in two domains: memory, and one other cognitive deficit.

For these conditions, therefore, neuropsychological assessment would serve to provide diagnostic information, because the presence of specific or multiple cognitive deficits, including memory, would provide information for a diagnosis. Similarly there are other conditions, such as postconcussion syndrome where the presence of cognitive impairments of various types is required as a part of the diagnosis. Further, mental retardation requires the presence of a certain level of current intellectual functioning that can only be obtained psychometrically.

The way the DSM-TV-TR is structured, however, there is no diagnosis that is confirmed simply as a function of the data obtained in a neuropsychological assessment.

In the case of dementia, for instance, there are multiple additional criteria that must be met as well, and many of these pieces of information are obtained from other sources. These include history eg, prior better levels of functioning , assessment of current adaptive deficits, and identification of a potential cause of the condition. As a result, neuropsychological assessments are only part of the diagnostic process.

Due to the way the DSM-TV-TR is set up, neuropsychological assessment does not provide information relevant to the diagnosis of most conditions where cognitive impairments are present. For example, many serious mental illnesses are marked by the presence of substantial cognitive impairments. Schizophrenia, 15 bipolar disorder, 16 and major depression 17 have substantial cognitive deficits as a common feature of their presentation, even in patients with current minimal levels of symptoms.

Since these impairments are not part of the diagnostic criteria, neuropsychological assessment does not provide diagnostically relevant information. As noted below, however, there is considerable information that can be obtained from neuropsychological assessments in these conditions, particularly in functional and prognostic domains. There are some conditions where neuropsychological assessment can be important for differential diagnosis.

As noted above, dementia requires memory deficits in the presence of other cognitive impairments, while amnesia is diagnosed by the presence of only deficits in memory. Detection of multiple cognitive impairments would therefore rule out the presence of amnesia and argue for a diagnosis of dementia in this case.

Differential diagnosis is much more challenging for most conditions, however. For example, studies attempting to differentiate between dementing conditions of different etiologies, such as vascular dementia as compared with AD, have found little evidence of differential diagnostic utility from neuropsychological assessment. Their meta-analysis includes all of the research published on neuropsychological test differences between healthy controls and several neuropsychiatric target populations during the years As a result, there is a wealth of detail on how much information each of these neuropsychological tests provides for test-based differential diagnosis of the target populations compared with healthy comparison subjects.

It is important in this area to consider the differences between differential diagnosis and statistically significant differences in performance across different conditions.

An effect size of. Many statistically significant differences between samples would fare poorly as candidates for differential diagnosis. For example, people with schizophrenia routinely have more significant cognitive deficits than people with bipolar disorder, regardless of the mood state of the bipolar patients.

In contrast to the differences between people with AD and healthy populations on delayed recall memory, there is little discrimination between bipolar and schizophrenia populations. The distributions of patients with severe mental illness and healthy people have substantial overlap. As can be seen in Figure 1 , there is considerable overlap in the distributions of scores on neuropsychological assessments of people with schizophrenia and healthy people, even if the means of the distributions are two full standard deviations apart.

The r-BANS 21 is an abbreviated neuropsychological assessment that examines multiple ability domains in a repeatable format. It is scaled like an IQ test, with a mean of and standard deviation of 15 in healthy populations. As can be seen in Figure 1 , 22 people with schizophrenia have a mean level of performance that is 2. While a score of would be much more rare for someone with schizophrenia than a healthy individual, a score of 85 would be at the 67th percentile for someone with schizophrenia and at the 17th for the healthy population; both of these are clearly within not outlying scores.

An additional intriguing result of the Zakzanis et al analyses is that many of the tests that are often described as capturing fundamental characteristics of illnesses such as schizophrenia fare relatively poorly when evaluated with differential diagnostic standards. These tests would provide essentially no data useful for differential diagnosis. There are some areas where there a number of excellent differential diagnostic candidates.

Similarly, the difference between schizophrenia patients and AD patients on delayed recall memory was found to be similar to differences between healthy controls and AD patients. One of the more robust correlations in research in mental health is the association between cognitive performance and achievements in everyday functioning.

This relationship has been appreciated for over 30 years and has been replicated across multiple neuropsychiatric conditions. Table II shows multiple examples of exactly this type of relationship. There are also several additional important points about these findings. These findings tend to be most robust for global aspects of cognitive performance, as indexed by performance on composite measures. In fact, in one recent study in severe mental illness the predictive power of a composite score for correlation with functional deficits was 2 to 3 times as great as any individual neuropsychological measure.

Although it is quite possible to have functional deficits originating from a single residual cognitive deficit, on average more wide-ranging cognitive deficits, even if moderate in nature, leader to broader functional deficits. There will always be individual cases where a single, apparently delineated, cognitive deficit leads to gross impairment in functioning.

The most important clinical implication of what we know about cognition and functioning is this: when individuals affected by a neuropsychiatric condition are found to have current cognitive abilities congruent with pre-illness functioning they are least likely to have functional deficits.

This is particularly true in conditions such as HIV neuropathology 31 or traumatic brain injury TBI 32 where changes can occur in the context of unimpaired previous functioning. They tend to be from the domains of executive functioning and processing speed, but some studies also suggest that memory measures may be important see ref 33, p It has proven difficult to establish absolute standards for how much impairment in cognitive functioning will definitely lead to functional changes.

In addition, the search for specific cognitive to functional relationships has also proven challenging in conditions other than TBI. The group average data do suggest some general guidance, but clinical prediction will require analyses of specific cases.

What is clear, however, is that neuropsychological assessment is an excellent tool for the prediction of recovery. Assessment of changes in cognition in progressive degenerative conditions requires a different approach than required for the initial diagnosis of dementia or the assessment of improvement following TBI. If delayed recall performance is at a level that is close to 0 at the time that dementia is detected, this ability will not be a feature of the illness with the potential to change over time.

In fact, research comparing individuals with AD at different levels of illness duration and progressive course have suggested that there is a pattern of progression in the worsening of cognitive impairments, with delayed recall nearly completely absent at the time of diagnosis, with other changes occurring in close temporal proximity, including reductions in rate of learning, executive functioning, and processing speed.

Later on in the course, changes in longterm memory such as confrontation naming are detected and spatial and perceptual deficits become more severe. What is clear from research, however, is that in individuals with AD and considerable cognitive impairments, functional performance tends to worsen quite markedly. There is major interest in treatment of cognitive deficits in degenerative conditions, attention-deficit disorder, and severe mental illness.

These approaches have ranged from in person and computerized cognitive remediation efforts to multiple pharmacological interventions. It makes sense that the same measures of cognitive functioning used to identify functionally relevant deficits across different neuropsychiatric conditions would be used to measure treatment outcomes. This approach has been used in multiple different studies, although there are some issues that require attention in interpreting the results of the studies.

These include changes in performance that are due to random variation and practice effects and the fact that certain cognitive measures are more vulnerable to these effects than others, limiting their utility as outcome measures. One of the things that will render neuropsychological assessment consistently important is the new development of rehabilitation therapies.

Development and marketing of computerized cognitive remediation interventions has not always been accompanied by the systematic assessment of their efficacy and long-term usefulness. It seems likely the performance on structured neuropsychological measures will continue to be the gold standard for selection of patients for these interventions and evaluation of their efficacy.

Essentially, a statistic is calculated that takes test scores at two different times and examines the difference between them, establishing a range of scores that could be attributed to practice effects or unreliability of measures.

Differences that exceed this range are then considered to be reliable. Thus, measures with greater test-retest reliability and smaller practice effects in healthy controls would be better candidates for detection of small amounts of change that would still be clinically meaningful. Previous results in severe mental illness have suggested that changes in typically administered cognitive assessment batteries would need to be in the vicinity of 1. Reduction, or at least the clear recognition, of practice effects is an important goal, because large practice effects in treatment studies on the part of the patients in the inactive treatment group can make it impossible to detect change in the treatment group.

Episodic memory tests are particularly vulnerable to practice effects, because of the possibility of learning of the content. However, it is critical to have alternate forms of such measures be closely equivalent, because if the alternate forms are different in their difficulty, an apparently improvement effect can be spuriously detected.

Problem-solving tests are quite vulnerable to changes with retesting, because if there is only one problem, like in the widely used Wisconsin Card Sorting Test, once it is solved the test is no longer a problem-solving test.

As a result, systematic efforts to develop problem-solving tests with similarly problems like mazes but with alternative stimuli have been conducted. One of the major issues in using neuropsychological assessment as a sole outcome measure to measure either spontaneous recovery or treatment response is the lack of definitive information as to how much change is required to be important. In a sense, this is the converse of how much worsening due to illness or injury is significant, because both are equally hard to define without additional reference points.

For an adequately powered randomized trial, separation of active treatment from inactive treatment is certainly one standard; one that will be applied by regulatory agencies. A third strategy, which is optimal in certain circumstances where it can be applied, is that of using concurrent assessment of functional outcomes. As improvement in functioning is the goal of treatment of cognition, whenever possible improvements in functioning occur, accompanying cognitive improvements should be measured.

For instance, in a study of cognitive remediation in schizophrenia published a few years ago, the level of improvement in neuropsychological test performance on the part of patients was less than 0. The above study is different from many other studies because of its duration and because of the fact that patients who entered were all receiving a psychosocial intervention: supported employment. Such concurrent interventions have been shown to be a prerequisite for functional gains in cognitive remediation studies in severe mental illness.

A suggested approach has been to use performance-based measures of functional capacity, 41 which have shown considerable validity in terms of prediction of everyday outcomes and sensitivity to functional decline in very elderly patients with severe mental illness. These measures, because they capture ability and not everyday outcomes, do not require environmental opportunities to perform skills and have been shown to be sensitive to the effects of short-term behavioral interventions.

Among the exciting developments in medical technology has been the advent of high-resolution structural and functioning imaging of the brain. The role of neuropsychology or a neuropsychologist is to understand how brain components and structures function, and how these functions affect human behavior and cognition.

A psychologist is someone who can diagnose and treat psychological disorders and mental health issues such as schizophrenia, depression, and anxiety. A psychologist is concerned with how we think, how we feel, and how will behave from a theoretical and scientific perspective and uses this knowledge to prevent, relieve, and diagnose psychological distress and dysfunctions. With neuropsychology, a doctor can identify and treat psychological disorders caused by the brain such as Alzheimer's disease, multiple sclerosis, and Epilepsy.

A neuropsychologist is focused on understanding how the brain works, and neuropsychology examines the brain for malfunctions that may lead to mental disorders or a breakdown of the nervous system.

Besides conducting a neuropsychological assessment and evaluation, a neuropsychologist may also recommend the appropriate treatment to resolve whatever neuropsychological disorders or dysfunctions that the patient may be dealing with. A neuropsychologist can determine if a person suffers from a developmental, behavioral, or neurological impairment and ascertain the severity of their condition. With neuropsychology, a neuropsychologist works closely with other healthcare professionals, especially psychologists and neurologists, when conducting an assessment.

A neuropsychologist may consider various types of diagnoses that relates with the brain and nervous system. In arriving at a diagnosis, a neuropsychologist would need to conduct a neuropsychological evaluation using imaging techniques such as magnetic resonance imaging MRI , computed topography CT scans, and electroencephalogram EEG.

In the United States, the hourly wage of a neuropsychologist generally depends on location, level of education, certifications, years of experience, and additional expertise. However, a neuropsychologist can also earn more or less than that estimate base on where they work.

A comprehensive neuropsychological evaluation generally takes between two or four hours to be completed, although more time may be required depending on how complex the issues under assessment are.

In some instances, a neuropsychology evaluation may require more than one session, with a typical session often comprising interviews and questions, brain scans, and different types of standardized tests.

Since neuropsychology is regarded as a specialize branch of psychology, aspiring neuropsychologists do not need a degree in medicine. However, in the same way other healthcare professionals require specialized medical training, a neuropsychologist must obtain formal education through graduate school.