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Brief Reliable Assessments

by George VonHilsheimer | October 5th, 2006

I’ve been amazed at how some notables in this field have ignored the enormous data base in neuropsychology and either invented their own tests or else used really dumb tests which have not been validated on populations like the ones we see, and have limited face validity, and poor reliability.

I got into psychology whilst running under-funded practical field programs in the slums and among migratory field farmers so I have always wanted quick, dirty, reliable tests that are easy to administer and to score. When you sift through the neuropsych
literature with such a hungry, poverty-stricken hand as mine has been then you come up with challenging studies. For example:

FILSKOV’S SHORT FORM OF THE HALSTEAD-REITAN

FILSKOV, Susan B., Prediction of Cerebral Impairment and Lateralization (of brain injury) from Figure Copying, Doctoral Dissertation, U of Vt., 1975, N=216

Test correctly selected:

  1. 92% of all impaired subjects;
  2. 89% with diffuse impairment;
  3. 97% of “normal” subjects less than 60 years of age.This method used only Cards 1,2,3, and 27 of the Blue Aphasia Screening Test Booklet (on the Halstead-Reitan it’s the square, cross, triangle and key). Scored well on degree of
    impairment, and R/L location of lesion.

Right lesions are characterized by 1. larger size; 2. asymmetry of the cross copy; 3. un-joined lines; 4. added or missing cross-points, crossovers; rotation of figures.

Left lesions are indicated by 1. smaller size; 2. shakiness; 3. rounded corners; 4. missing parts of the key.

Impairment is indicated by:

  • A rating of 3 or more on the triangle (0-5 degrees of impairment);
  • A rating of 3 or more on all figures;
  • size problem on the square and the triangle;
  • Consistent un-joined lines;
  • Crossovers and rotations.

I have a short form reviewing these rules, indicating I got it from T.H. Blau in 1975.

Principles of Behavioral Neurology, M-Marsel Mesulam, TESTS OF DIRECTED ATTENTION AND MEMORY, F.A. Davis Company. Permission is given to copy the tests:

p,86 “We have developed two simple methods that are amenable to use at the bedside as well as in the neuropsychological laboratory and that dissect several different components of the learning process.

“One of these, the Three Words-Three Shapes Test, is based on three simple designs and three words with low imagery value as test stimuli. The patient is first asked to copy the six test stimuli without being told that memory is to be tested. Immediately after copying, the stimuli are removed and the patient is asked to reproduce them from memory. This provides a measure of incidental recall.

“Patients who have complete incidental recall are then ready to proceed to tests of delayed memory. Patients who show any impairment in the incidental recall stage are allowed a 30-second examination of the six stimuli, this time being told that their memory for these will be tested. Following this second presentation (the first study period), immediate recall is tested. Patient who reproduce correctly five or all six of the items are then ready to enter the delayed retention period. Patients who do not succeed in doing so are allowed repeated study periods either until the criterion of five or six items is reached, or until five study periods have elapsed. Delayed recall is tested after 5 minutes, and again after 15 and 30 minutes. During the delay period, the patient is engaged in other distracting tasks. After the 30-minute delayed recall condition, multiple interactions can be evaluated.”

Cancellation tests are recommended particularly for testing Attention. Mesulam provides four, a randomized scatter of capital letters (the subject crosses out or circles the A’s); orderly rows of randomized capital letters (same task); a randomized scatter of shapes, squares, circles, triangles, star (both solidly blacked in and outline; a capitol building shape, black circles with a white star filling the circle, half circle, circle with diagonal line extending out of the circle and six radii, circle with four radii, star, open shape of L various rotated.

While I, myself, rely on Lezak’s (Muriel B.) NEUROLOGICAL ASSESSMENT (2nd Edition, Oxford U Press, 1983), her publisher is, like most, not generous with figures and illustrations. For example, NEUROPSYCHOLOGY FOR CLINICAL PRACTICE: Etiology, Assessment, and Treatment of Common Neurological Disorders, Russel L. Adams, Parsons, O.A., Culbertson, Jan L., and Sara Jo Nixon, American Psychological Association, 1986 is un-enriched by a single test image; there are only six figures in the entire 546 page book. Mesulam’s book is a wonderful exception to this niggardly habit of publishers.

ESTIMATION OF INTELLIGENCE: Rey’s LADY WHO IS WALKING IN THE RAIN

One of the most robust and widely used estimations of intelligence is taken from Andre Rey,

Une dame qui se promene et il pleut (A lady who is walking in the rain), Monographies de psychologies applique, No1, 1947. This was adapted by E.M. Taylor in PSYCHOLOGICAL APPRAISAL OF CHILDREN WITH CEREBRAL DEFECTS, Harvard U. Press, 1959, and is described in Lezak, M.D, Psychological Appraisal, Oxford U Pres, 1976, pp 252 ff, with a discussion at pp 327 ff.

I have several thousand copies of this drawing done by generations of Central Florida pupils and I encourage everyone to develop their own collection, and their own norms. Local norms are much more valuable and reliable than norms developed by folk remote to your own location. In my experience the scoring is reliable (and this is supported by the literature). Here are the score points; each gets one point.

Note that the characteristics of brain injury in free drawings are:

1. Lack of details;

2. Parts loosely joined;

3. Parts noticeably shifted;

4. Shortened and thin arms and legs;

5. Inappropriate size and shape of other parts (except the head);

6. Petal-like or scribbled fingers.

SCORE ONE POINT FOR EACH CHARACTERISTIC:

1. Human form (head with legs).

2. Body distinct from arms and legs.

3. Some clothing (buttons, scribbles on body).

4. A female figure (if the child is 14 then hips and breasts should be noticeable.

5. Profile: head and at least one other part of the body in profile (body, feet, arms).

6. Motion indicated by gait or posture.

7. Rain roughly indicated.

8. Rain properly indicated (touching ground, regularly distributed, rain drops, on umbrella and lower parts of the picture).

FOR A DRAWING FEATURING AN UMBRELLA

9. Umbrella roughly indicated.

10. Umbrella in two lines (round, oblong, top, handle).

11. Umbrella clearly shown (ribs, points, scallops).

12. Umbrella dimensions are 1/3 to 2/3 of the body length.

13. Umbrella is positioned to cover at least half of the body.

14. Umbrella is attached to a hand at the end of an arm.

15. Position of the arm is adequate.

FOR DRAWING FEATURING A RAINCOAT, CAPE, HOOD, NO UMBRELLA

16. Hood indicated (if hood and umbrella count only 42, clothing).

17. Head well covered by the hood.

18. Raincoat or cape.

19. Shoulders, arms covered by coat or cape, hands only showing.

20. Shoulders not shown, but indicated when you ask subject, “Where are the arms?”

21. Arms fully covered by cape, with shoulders clearly indicated.

22. Eyes shown (one line, dot).

23. Eyes in double lines, several parts.

24. Nose shown

25. Mouth shown (one line).

26. Mouth shown in double lines, lips front or profile.

27. Ears shown.

28. Chin shown (front or profile).

29. Neck or collar shown clearly. If a lady’s face is covered by the umbrella, or if her back is turned, give credit for nose, mouth, eyes etc. Credit 2 points if the quality of the picture suggests the more mature form of these details.

30. Hands (credit one point if the hands are in pocket).

31. Arms shown (one line)

32. Arms in double lines.

33. Arms attached to body at shoulder level.

34. Arms are in proportion to the body or slightly longer.

35. Legs shown (one line).

36. Legs in double lines.

37. Legs properly attached. (Credit if a long dress is appropriately drawn on body).

38. Legs are in proportion to the body.

39. Feet are shown.

40. Shoes shown clearly.

41. Clothing: 2 articles (skirt and blouse, jacket and skirt, if the hood goes with an open umbrella it is considered clothing).

42. No transparency if such could be possible.

For a picture that shows a definite artistic trend or technique (silhouette, etching, skilled schematization, etc) credit the total number of points to here, 42.

43. A baseline, a road, a path, in one line or dots.

44. Figure clearly positioned on the baseline or road.

45. Road or path shown.

46. Pavement or gravel shown.

47. Flower border, tree, doorway, house shown.

48. Special details showing imagination.

Rey’s estimation can be used to discern all the variabilities of brain injury, and development in the drawing is well documented as being coordinated with the general development of the individual.

I also use the FULL RANGE PICTURE VOCABULARY TEST, which is an easy-to-use, reliable intelligence test based on verbal comprehension, normed for age 2 through adult. It requires only 5 to 10 minutes to administer. The person taking the test does not have to read or write. The FRPVT is useful in testing physically handicapped subjects and aphasics.

TRAIL MAKING TASKS A & B

Halstead first described the Trail Making Tasks, A & B. The comparison of the two performances is often highly useful. Trails B particularly assesses cognitive flexibility. Of course, this test does not lend itself to computerization, which is a particular problem of all the figure copying, manipulating and remembering tasks. However, tasks are generally more productive of useful information about brain function than are checklists, verbal performances and questionnaires. IMO and IME it is useful for the professional to be fluent in assessing drawing, copying and manipulative skills.

SBORDONE ATTENTION BATTERY

ROBERT J. SBORDONE, PH.D., created his Attention List and distributed it in the early 1980s. This is a one-page list, easily administered and performances on it are significantly reliable and valid. Sbordone has a book on neuropsychology for lawyers and is a gifted speaker, but I cannot find a website for him. His last known address is 7700 Irvine Center Drive, Ste 750, Irvine, CA 92718.

Record the client’s responses, and time required to completion.

1. Count backwards from 20: 20,19,18,17,16,15,14,13,12,11,10,9,8,7,6,5,4,3,2,1

2. SERIAL 1,4,5,9… or 10,13,16,19,22,25,28,31,34,37,40

3. ALTERNATING SERIAL 3 AND 5 ADDITION (3,8,11,16,19,24,27,32,35,40)

4. SERIAL 7 SUBTRACTION (93, 86, 79, 72, 65, 58, 51, 44, 37, 30)

5. SERIAL 13 SUBTRACTION (87, 74, 61, 48, 35, 22, 9)

6. ALTERNATING 3 AND 5 SUBTRACTION (97,92, 89, 84, 81, 76, 73, 68, 65, 60, 57, 52)

7. RECITE THE ALPHABET

(A,B,C,D,E,F,G,H,I,J,K,L,M,N,O,P,Q,R,S,T,U,V,W,X,Y,Z)

8. INDICATE WHICH LETTERS IN THE ALPHABET CONTAIN ONLY STRAIGHT LINES

A, E, F, H, I, K, L, M, N, T, V, W, X Y, Z

9. NAME THE LETTERS WHICH RHYME WITH “TREE”

B, C, D, E, G, P, T, V, Z

10. RECITE THE LETTERS OF THE ALPHABET AND TELL ME THE NUMBER OF THE LETTER AFTER EACH LETTER (viz. A1, B2 , C3, ….Z26)

11. NOW RECITE AND TELL ME THE NUMBER OF THE LETTER AND THEN TELL ME THE LETTER (viz., 1A, 2B, 3C, …..26Z)

SBORDONE’S ATTENTION BATTERY NOTES

Poor performance on Tasks 1 (count backwards from 20), 2 (serial 3 add) and 7 (serial 3 and 5 addition) indicate sub-cortical injury.

Many patients with a good education but who have frontal injuries can do well on Tasks 3 and 4 (serial alternating 3 and 5 addition and serial 7 subtracting)

When Tasks 3 and 4 are done poorly first rule out poor pre-morbid arithmetic skills and a limited education; then consider poor visual imagery and poor memory. The skills used in Tasks 3 and 4 are strongly affected by age, anxiety and depression.

When performance is poor on task 4 and 6 (serial seven subtraction, and serial 3 and 5 subtraction) consider frontal injury. Even a good pre-morbid education and good arithmetic skills will not protect the client against error in these tasks after frontal injury.

Combine serial seven subtraction (4) and indicating which capital letters contain only straight lines (8) to localize injury to the right.

When there are some errors on 4 (serial 7 sub) but more on 5 (serial 13 sub) then the injury is right and posterior.

The posterior hemisphere is indicated when Tasks 4, 5 and 8 (serial seven subtraction, serial thirteen subtraction and indicate the capital letters of the alphabet made with only straight lines) are done poorly and poor visual imagery is indicated.

Patients who make a high proportion of loss of set and intrusion errors are likely to have bilateral frontal lobe damage.

High omission errors (as in counting backwards) and high arithmetic and slow responses suggest sub-cortical brain damage.

Psychological Assessment Products (PAR) has a simple, portable Booklet Category Test (BCT ) in two easel binders that contain all 208 Category Test (CT) designs. See http://www3.parinc.com/products/product.aspx?Productid=BCT

The skills needed on the BCT are essentially equivalent to those needed on the CT. Unlike the CT the BCT has no need for expensive, complex projection equipment. The BCT incorporates instructions on the backs of the Stimulus Plates and in the Response Form, which tends to standardize administration of the BCT. It also helps that the BCT Response Form is easy to use. The stimuli for each subtest are presented on a single page, which also helps to make the administration of the test easy and facilitates reviewing the client responses. A Score Summary section of the form makes it easier to use the demographically corrected normative data included in the expanded BCT Professional Manual. This data improves diagnostic accuracy and interpretation of error scores. The revised Manual also provides information about current research findings related to the clinical utility of the BCT.

Dodrill, Carl B., (1978) proposed a neuropsychological Battery for Epilepsy, which was typical of most neuropsychological recommendations in that it totally ignored practicality, time and expense. Dodrill proposed using the entire Halstead battery as revised by Reitan; to which he added his own Aphasia Screening Test (Dodrill and Troupin, 1977); the Wechsler Memory Scale (Form I); the Seashore Tonal Memory Test; a modification of the Stroop Color-Word Test (Stroop, 1935); the Wonderlic Personnel Test; and a host of others. Dodrill did finally exclude all of the Coin Recognition portion of the Reitan-Kloeve Perceptual Exam, and all of the Wechsler Memory Scale except for Logical Memory and Visual Reproduction. Dodrill also reduced the total number of proposed tests from 100 to a mere 35!

Convincingly, when a group of us graduate students persisted in an all night social evening with Reitan, his final recommendation to our persistent question – “Dr. Reitan, if you were STUCK in the jungle with only 5 tests, which 5 would you prefer to have?” No neuropsychologist likes this question, but ethanol reduced inhibition and Reitan (according to rumor perpetrated for >30 years by von Hilsheimer) agreed with Dodrill’s study (before Dodrill made it) and the Tactual Performance Task (TPT) (which requires a fairly large set of geometrical forms which fit into cutouts), especially with the non-preferred hand [t = 6.61]; finger tapping [t=8.5 males, 7.12 females, both p=www.minddisorders.com/flu-Inv/Halstead-ReitanBattery.html

www.reitan/abs.com/reitan%20biblio.htm

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