Common Approaches To Neuropsychological Evaluation

Neuropsychological assessment approaches fall broadly into three categories: (i) the fixed battery (or cognitive-metric) approach; (ii) the process (or hypothesis-testing) approach; and (iii) the flexible battery approach. These approaches can readily be conceptualized as differing along two dimensions: test selection and administration/interpretation. Test selection may be fixed or flexible; administration and interpretation are characterized, respectively, as standardized and actuarial at one extreme, and as nonstandardized and qualitative at the other extreme. Each approach has strengths and weaknesses (Table 1).

The fixed battery approach falls at the extremes of fixed test selection, standardized administration, and actuarial interpretation. It is best exemplified by the Halstead-Reitan Battery (4). The process, or hypothesis-testing, approach emphasizes qualitative aspects of neuropsychological functions, which are found in developmental and cognitive psychology. Champions of the process approach promote "testing the limits" with patients and assessing the component processes of cognition, rather than relying exclusively upon summary scores. In other words, the process approach views critically how a task is solved and how the solution unfolds over time, rather than the achievement score quantifying the quality of the end product.

Although the fixed battery and process approaches dominated neuropsychol-ogy, initially, the flexible battery has recently emerged as the most commonly used approach to neuropsychological evaluation (5). Flexible batteries benefit from the strengths of the fixed battery and process approaches by striving to quantify the qualitative aspects of cognition and task performance (6). In this way, the flexible battery approach capitalizes on advances in cognitive neuroscience while remaining firmly grounded in psychometric theory. In addition, the flexible battery approach incorporates a standard battery of tests from which the clinician can tailor the evaluation to address particular patients' needs and/or explore given domains of function in

TABLE 1 Advantages and Disadvantages of the Three Major Approaches to Neuropsychological Assessment

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