Some Thoughts on Neuropsychological Theory and Report Writing     The following notes are in a very crude form and are still under construction.  They include a mixture of theories, observations, plagiarisms, and opinions about cognitive processes and how to describe them in neuropsychological reports. My approach has been an attempt to apply functional organizational theory (mostly Lurian) to interpretation of other tests, particularly the Halstead- Reitan Battery.  Hopefully this approach will prove useful in rehabilitation efforts.  My purpose for assembling the current notes has been to provide structure for my neuropsychological reports and to help communicate the need for that structure to peers and to students.   Comments are welcome.    
  INDEX
Preliminary Conversation
Issues to Address in the BACKGROUND section
Luria's Three Principal Functional Units
Functional Systems in Neuropsychology
    Motor Systems: Overview and Sample Writeups
    Tactile/Kinesthetic: Overview and Sample Writeups
    Visual Functions: Overview and Sample Writeups
    Acoustic-Motor Coordination: Overview and Sample Writeups
    Speech Functions: Overview and Sample Writeups
    Attention and Concentration: Overview and Sample Writeups
    Memory Functions: Overview and Sample Writeups
    Intellectual Functions: Overview and Sample Writeups
    Acadmeic Abilities: Overview and Sample Writeups
Issues to Address in the SUMMARY Section:
Greg's Mailbox

 1. Twofold purpose:
      a. Get general idea of state of consciousness, personality, and awareness of  his
          situation
      b. Get principal complaints and identify pathological signs

 2. Use history questionnaire and WMS-R orientation section to determine
     orientation in time and space premorbid functioning, peculiar strengths, etc

 3. Slowness or inertia may suggest intracranial pressure or deep lesion near the
     ventricles

 4. Unexpressive face without "emotional depression" may suggest basal gan.

 5. Echopraxia of facial expression and intonation along with echolalia speech may
     suggest frontal lesion.

 6. Emotional immobility and rigidity can suggest lesion of subcortical formations.

 7. Primary difficulties involve disorientation to place and time. Can be seen in
     marked diencephalic or frontodiencephalic lesions. Secondary difficulties result
     from inactivity, disturbance of the discriminatory process, or pathological
     inertia. More common in frontal lesions.

 8. Determine the order of symptom appearance. Duration, constant, progressive,
     etc

 9. Inquire for details of memory, spatial, etc

10. Identify modalities to work around or exclude.

11. Effect of lesion on personality. Patient's awareness of changes. Interview
      family members or significant others.

1. etiology - make it clear that you looked at all common causes of brain damage:
    (eg. prenatal, developmental, genetic, illness, bodily injury, head injury, toxic
    exposure, substance abuse, anoxic events, STD, MVA

2. chronology: needs to be very detailed

3. educational/vocational/self-care issues.... premorbid functioning

4. Objective evidence: Brain scan, NMR, CT, EEG, LAB, professional consults

5. Recent history.. behavior on the ward, current meds, motivation on the tests

1. The Three Basic Units:
     a. Unit for regulating tone or waking. Primarily composed of brain stem,
         diencephalon, and medial regions of the cortex. Changes in this unit are
         gradual and relatively generalized.
     b. Unit for receiving, processing, and storing information. Consists of lateral,
         posterior regions of the neocortex on the convex surface of the hemispheres.
         Includes occipital, temporal, and parietal regions. Changes consist of
         relatively discrete neural impulses. High modal specificity is maintained
         (esp. visual, auditory vestibular, and general sensory input....gustatory and
         olfaction are mediated to a lesser degree in man.) Includes primary
         projection areas and systems of secondary (gnostic) cortical zones. The
         secondary zones serve a synthetic function by combining input into
         functional patterns.
     c. Unit for programming, regulating and verifying mental activity.

2. Each basic unit is hierarchical in structure and consists of at least three cortical
    zones.
     a. Primary (projection) area - receives impulses and sends impulses to the
         periphery.
     b. Secondary (projection-association) area - where incoming information is
         processed or programs are prepared
     c. Tertiary (zones of overlapping) - responsible for the most complex forms of
         mental activity requiring the concerted participation of many cortical areas.

3. Three principle sources of activation for the nervous system.
     a. Metabolic processes
     b. External sensory stimulation (orienting reflex)
     c. Intentions, plans, forecasts, and programs formed during man's conscious
         life, which are social in their motivation and are effected with the close
         participation of external and internal speech.

1. Motor Functions: The investigation of motor functions seeks to evaluate and
    understand motoric activity with respect to eight hierarchical levels within this
    complex functional system. These include:
         Simple movement
         Kinesthetic basis of movement
         Optic spatial organization
         Dynamic organization
         Complex forms of praxis
         Integrative oral praxis
         Selectivity of motor acts
         Speech regulation of motor acts

2. Sensory Functions: This portion of the evaluation emphasizes performance
    within the tactile and visual modalities. The three areas of tactile functions
    examined are:
         Cutaneous sensation
         Muscle and joint sensation
         Stereognosis

     The visual processes examined include:
         Gross visual perception
         Visual discrimination and synthesis of relevant features
         Visual analytic skills
         Visual-spatial orientation
         Intellectual operation in space

3. Audiomotor Functions: These refer to the formation and coordination of motor
    acts based on nonverbal properties of auditory input, such as pitch, intensity,
    and rhythm.  They rely on a sequential, temporally organized synthesis of
    information (mediated in part by the temporal and frontotemporal regions), as
    contrasted with the tactile and visual systems, which rely on a simultaneous,
    spatially organized synthesis of input elements (mediated in part by the
    parieto-occipital region).

The significance of this portion of the evaluation is that many motor sequences have their origin in rhythm provided through acoustic signals. In time, the motor sequences become automated so that the individual no longer needs the acoustic signals as cues.

Melodic and rhythmic tasks are employed to examine the patient's ability to discriminate increasingly complex stimuli, ability to motorically reproduce melodic and rhythmic sequences following model stimulus patterns, and ability to spontaneously produce melodic and rhythmic sequences without the aid of a stimulus pattern.

4. Speech Functions:
    Evaluation of receptive speech skills includes:
         Perception of the sounds of speech (phonemic hearing)
         Word comprehension
         Understanding the meaning of simple phrases
         Understanding consecutive speech containing logical grammatical structures

    The expressive speech evaluation includes:
         Articulation of the sounds of speech
         Pronunciation of words or phrases (nominative and repetitive speech)
         Execution of spontaneous, consecutive speech (spontaneity, fluency,
             stability of  acoustic traces, ability to select and arrange words in a
             meaningful and grammatically correct manner)

    -begins with internal ideas and associations
    -passes through a stage of "internal" speech
    -then is translated into an external expression

5. Writing Skills: Three components of writing skills are assessed:
        Phonetic analysis
        Simple copying/writing
        Copying/writing complex verbal material

6. Reading Skills: Four components of reading skills are assessed:
        Phonetic synthesis
        Analysis and perception of letters
        Reading syllables and individual words
        Reading phrases and whole texts

7. Arithmetic Skills: This portion of the evaluation considers:
       Attention, concentration, memory, and ability to follow sequential rules.
       Comprehension of written material
       Conversion of oral material to its written equivalent
       Translation of verbal material to numbers in a logical manner

8. Memory Functions: This portion of the evaluation considers two primary forms of memory. The first is connected with general orientation in place and time (i.e. states of consciousness). The second form of memory is concerned with the complex activity of memorization and recall. The latter type of memory receives formal assessment using a variety of memory tasks within the auditory, visual, and kinesthetic modalities. The functions evaluated include:
      Direct retention of memory traces
      Range (or total number) of directly retained traces
      Stability of memory traces
      Selectivity of memory traces

9. Intellectual Functions: Assumes that intellectual activity takes place when a problem demands preliminary analysis and synthesis of a situation and special auxiliary operations by means of which it can be solved. To investigate, you create situations for which the individual has no ready-made or automatic, previously established means of responding. Functions evaluated include:
      Analysis of the situation/task
      Selection of essential task components
      Correlation of task components with one another
      Formulation of hypotheses
      Development of a strategy
      Selection of definite operations for responding to the task.

1. Prerequisites which must be met before voluntary movement can be effectively
    carried out.
     A. Adequate muscle strength and consistency of normal tone
     B. Adequate afferent (sensory) feedback from the musculature. Involves the
          postcentral regions of the cortex.
     C. Intact optic-spatial system to insure adequate spatial organization. Involves
          the occipito- parietal region.
     D. Complex movement involves a chain of discrete movements which require
          progressive innervation and inhibition of different muscle groups. Involves
          the premotor regions.
     E. Verbal direction is needed to mediate the goal of movement and the
          comparison of results to the original intention. This involves the
          temporoparietal area of the dominant hemisphere.
     F. Intentionality must be maintained throughout the activity and the appropriate
         actions  must be selected. The frontal lobes play a critical role in regulating,
         directing, and completing the intended action. The frontal lobes are also
          involved in making discriminations needed to compare results of movement
          with the original intention.

2. The investigation of motor functions seeks to evaluate and understand motoric activity with respect to eight hierarchical levels within this complex functional system. These include:
     A. Simple movement
     B. Kinesthetic basis of movement
     C. Optic spatial organization
     D. Dynamic organization
     E. Complex forms of praxis
     F. Integrative oral praxis
     G. Selectivity of motor acts
     H. Speech regulation of motor acts

a. MOTOR FUNCTIONS: Screening for "release reflexes" commonly found in degenerative disease (i.e., snout, glabellar, palmomental, rooting, and grasp) was negative. There was no gross disturbance of gait or station. There was no significant asymmetry of upper or lower facial musculature or of the upper extremities. Measures of facial motor impersistence were negative. There was no disturbance of voluntary or reflex conjugate eye movement.

The patient demonstrated adequate muscular tone, power, and accuracy of movement for completion of routine manual motor tasks. Manual motor speed and strength were mildly impaired with respect to age norms and right-left comparisons revealed relatively greater impairment for the dominant (left) hand. However, these motor deficits are likely due to arthritis. No disturbance was evident in the patient's use of kinesthetic feedback to control voluntary movement.

Visual-spatial organization of motor acts was very mildly impaired as evidenced by a tendency use the wrong hand when attempting to mimic actions modeled by the examiner. Simple repetitive movements of the hands were performed slowly, but were smoothly integrated and coordinated. There was no evidence of ideational, ideomotor, or motor apraxia. Skill at the level of selectivity of motor acts appeared mildly impaired as evidence by weak constructional ability on drawing tasks. Speech regulation of motor acts was mildly impaired as evidenced by a failure to disrupt a pattern of movement in response to verbal cues.
 
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b. MOTOR FUNCTIONS: This patient demonstrated adequate muscular tone, power, and accuracy of movement for routine manual motor tasks. Although motor speed was within normal limits, right-left comparisons revealed mild impairment of left hand speed on tasks requiring manipulation of the digits. The protruded tongue deviated slightly to the left. Tonus of upper and lower facial musculature appeared symmetrical. The patient demonstrated adequate appreciation for kinesthetic feedback in the control of movement. At the level of optic-spatial organization of motor acts, the patient demonstrated the ability to accurately reproduce gross hand/arm movements from a visual model. Although inaccurate responses were obtained for relatively complex visual stimuli, performance improved when similar tasks were prompted verbally. These findings suggest an inability to plan and carry out goal-directed behavior mediated by internal speech. Other evidence of this impairment came from the patient's inability to integrate multiple, simple movements into a complex pattern. Performance was similarly impaired on tasks requiring the patient to imagine and carry out symbolic actions. This deficit in the use of internal speech to regulate behavior precluded the patient's ability to comprehend relational words in regulation of behavior.
 
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c. MOTOR FUNCTIONS: Screening for "release reflexes" commonly found in degenerative disease (i.e., snout, glabellar, palmomental, rooting, and grasp) was negative. There was no gross disturbance of gait or station. There was no asymmetry of upper or lower facial musculature or of the upper extremities. Measures of facial motor impersistence were negative. There was no disturbance of voluntary or reflex conjugate eye movement.

The patient demonstrated adequate muscular tone, power, and accuracy of movement for completion of routine manual and oral motor tasks. Manual motor speed and strength were mildly impaired with respect to age norms, but right-left comparisons revealed normal differences in these measures. No disturbance was evident in the patient's use of kinesthetic feedback to control voluntary movement. Visual-spatial organization of motor acts was sufficiently intact to duplicate modeled hand movements, though mirror-image responding suggested mild impairment.

Simple repetitive movements of the hands were smoothly integrated and coordinated. Tasks designed to assess motor praxia revealed oversimplified approximations to the target behavior, largely due to the patient distracting herself with rambling speech. Though basic drawing/constructional skills were intact, the patient tended to embellish drawings and had marked organizational difficulty with more complex tasks (such as drawing a clock face). These latter problems appeared to be primarily due to difficulty staying focussed on the task at hand. Speech regulation of motor acts was mildly impaired.
 
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d. MOTOR FUNCTIONS: Compared with results of previous assessment (in 1988) the patient displayed increased motor speed on the Finger Tapping Test. However, this motor speed remained well below the normal range. Dominant hand motor speed was relatively slow compared with the nondominant hand. Muscular strength in the upper extremities was within normal limits, showed no significant change from prior assessment, and showed normal right-left differences. Extreme athetoid movements were evident in the hands, arms, and feet. However, the fingers were not deformed or rigid. The patient demonstrated awkward, but functional, voluntary control of her hands and fingers. She was able to sequentially touch the tips of her fingers to her thumb, but did so very slowly. Control appeared more impaired for relatively gross movements of the hands than for discrete movements. For example, the patient was unable to perform a task requiring alternating opening and closing of her hand.

The patient was unable to complete the Tactual Performance Test due to slowness and restricted range of movement for the upper extremities. Upper and lower facial musculature was symmetrical in tone and showed no deficits on tests of motor imperception. The protruded tongue deviated to the right. Pronounced "slurping" and loud, involuntary swallowing was observed throughout the session.

1. Three areas of tactile functions are examined on the LNNB.
     A. Cutaneous sensation
     B. Muscle and joint sensation
     C. Stereognosis

2. Errors can result from attentional deficits, cortical or subcortical damage, spinal
    cord or peripheral nerve injuries.

3. Limitations to interpretation:
     A. Functional relations between tactile skills are not well defined.
     B. Complex tactile skills can be intact even with impaired primary perception.
     C. Hemispheric differences exist in how somatosensory information is
          represented.
     D. Bilateral and ipsilateral deficits can also follow unilateral lesions

4. Item failure on complex tactile tasks can result from:
     A. Loss of integrity of primary tactile perception
     B. Impairment of spatial synthesis
     C. Inability to assign a verbal label to the stimulus

a. SENSORY FUNCTIONS: Tactile sensory functions were examined in the areas of gross perception and capacity to meaningfully integrate tactile stimuli. Unilateral stimulation of the hands and face revealed intact primary perception of simple pressure stimuli. Bilateral, simultaneous stimulation of the face and hands (which is sensitive to relatively subtle deficits in tactile perception) revealed no evidence of cortical suppression. Sharpness and pressure discrimination were intact. There was no significant impairment of tactile finger localization. Assessment of graphesthesia as assessed by numbers written on the fingertips revealed mild impairment for the right hand. Appropriate responses to proprioceptive stimulation suggested intact muscle and joint sensation for both sides of the body. Assessment of stereognostic skills suggested mild impairment of tactile integration skill.

Assessment of gross auditory perception revealed significant, bilateral hearing loss, particularly for the right ear. Visual acuity appeared impaired. The patient also complains of macular degeneration and diminished sensory perception in the forth and fifth digits of her left hand.
 
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b. SENSORY FUNCTIONS: Tactile sensory functions were examined in the areas of gross perception and capacity to meaningfully integrate tactile stimuli. Unilateral stimulation of the hands and face revealed intact primary perception of simple pressure stimuli. Bilateral, simultaneous stimulation of the face and hands (which is sensitive to relatively subtle deficits in tactile perception) revealed a tendency to suppress perception of stimulation to the hands in the presence of competing tactile stimulation of the patient's face.

Sharpness and pressure discrimination were intact and responses suggested hyper-sensitivity to these stimuli. There was mild impairment of tactile finger localization, with relatively more errors for the right hand. Similar findings were evident upon test of graphesthesia, as assessed by numbers written on the fingertips. Appropriate responses to proprioceptive stimulation suggested intact muscle and joint sensation for both sides of the body. Assessment of stereognostic skills also produced no evidence of impaired tactile integration skill.

Assessment of gross auditory perception revealed possible diminished acuity, but no impairment for unilateral or bilateral, simultaneous stimulation. Peripheral visual fields were full as assessed by finger confrontation, but revealed very mild right-left confusion. There were no subjective reports of impaired sensory perception for the tactile, visual, or auditory modalities.

1. Examination of visual processes includes:
    a. Gross visual perception
    b. Visual discrimination and synthesis of relevant features
    c. Visual analytic skills
    d. Visual-spatial orientation e. Intellectual operation in space

2. Some factors to consider:
Items which depend upon verbal naming and sensitive to temp. lobe damage so errors may be due to visual agnosia OR impaired verbal naming:
     Name 4 common objects (pencil, eraser, rubber band, quarter)
     Identify blurred objects
     Identify high contrast photos

From superimposed drawings pick out relevant cues and synthesize relevant features into a recognizable pattern. Assesses visual-spatial perception visual recognition, and naming skills. These secondary visual processes are generally localized in the right parieto-occipital area. This also requires the ability to separate parts from the gestalt, which can be impaired by deficit in either hemisphere.

Items from Ravens Progressive matrices require visual analytic and synthesizing skills. This is sensitive to right hemisphere functioning and assesses a broad range of visual-spatial skills.

Items which specifically focus on visual spatial skill include telling time from a standard clock and appreciation of map directions. There are heavy visual spatial and visual-analytic components...so any posterior damage can cause impairment, as can damage to the right hemisphere.

Good performance on earlier items but impairment toward the end suggests intact primary and secondary visual processes but impaired visual-spatial and spatial reasoning skills. This pattern is often seen with anterior right hemisphere damage and relatively intact posterior areas.

a. VISUAL FUNCTIONS: Assessment of visual functions suggested integrity of primary visual projection areas as evidenced by accurate recognition of objects and pictures. Although the patient had marked difficulty naming items, his gestures and verbal descriptions communicated intact perception. Visual discrimination appeared similarly intact. Performance on tasks requiring synthesis of visual information was poor, but reliability of these measures was markedly impaired by verbal deficits. Complex visual-spatial skills were markedly impaired on tasks requiring mental rotation of images, and visualizing "hidden" objects in a 3-dimensional drawing. The patient was unable to tell time or draw the hands on a clock which had no printed numbers. However, he was able to tell time accurately from a standard clock.

b. VISUAL FUNCTIONS:  ......Gross visual perception was intact as measured by confrontational techniques, with no evidence of errors upon unilateral and bilateral, simultaneous stimulation. However, performance on complex visual tasks suggested evidence of perceptual fragmentation and poor perceptual integration of complex visual detail. The patient's performance on visual-spatial reasoning tasks was suggestive of the sort of passive visual analysis and impulsive responding commonly associated with damage to the right anterior cerebral hemisphere.

1. Assesses the formation and coordination of motor acts based on the nonverbal properties of auditory input, including:
     a. pitch
     b. intensity
     c. rhythm

2. Based on integrity of the auditory afferent system, which relies on sequential, temporally organized synthesis of stimuli. (as opposed to the tactile and visual systems, which rely on simultaneous, spatially organized synthesis of stimuli.

3. Sequential information is mediated in the temporal and frontotemporal regions. (Spatial information is processed in the parieto-occipital regions.)

4. The concept is that motor acts have a "melody" in the sense that they are based on a series of time intervals. In fact, Luria proposed that the original "rhythm" for many motor sequences is provided through acoustic signals. As the sequence becomes automated, the individual no longer needs the acoustic cues.

5. Acoustic-motor functions are evaluated using melodic and rhythmic tasks. which include:
     -perception of pitch relationships
     -reproduction of pitch relationships and musical melodies
     -perception and evaluation of acoustic signals
     -motor performance of rhythmic patterns

6. These tasks are particularly sensitive to attentional difficulties. Be sure to make qualitative notes to help distinguish whether poor performance is partially due to attentional problems. Note such things as drowsiness, lethargy, instability, restlessness, excitability, or distractibility.) In extreme cases these may preclude a valid examination of acoustic-motor skills. Also, note whether the client appears aware of his mistakes.

a. ACOUSTIC-MOTOR COORDINATION:  (not yet available)

1. Evaluation of receptive speech skills includes:
     A. Perception of the sounds of speech (phonemic hearing)
     B. Word comprehension
     C. Understanding the meaning of simple phrases
     D. Understanding consecutive speech containing logical grammatical structures

2. The processes which underlie receptive speech include acoustic analysis articulation, pitch discrimination, and stability of acoustic traces.

3. The expressive speech evaluation includes:
     A. Articulation of the sounds of speech
     B. Pronunciation of words or phrases (nominative and repetitive speech)
     C. Execution of spontaneous, consecutive speech (spontaneity, fluency,
          stability of acoustic traces, ability to select and arrange words in a
          meaningful and grammatically correct manner)

a. SPEECH FUNCTIONS: Receptive speech functions were severely impaired. Repeated prompting failed to elicit accurate verbal repetition or written representations of most basic phonemic sounds. Rather, the patient tended to transform the stimuli into related sounds or words, such as saying "muf or puf" in place of "muh or tuh." Most of these errors maintained the correct initial consonant sounds. Performance deteriorated markedly in response to mild increases in stimulus complexity or when correct responses required mediation of behavior by internal speech. Adequate comprehension of isolated words was evident in the patient's correct selection of objects and pictures of objects in response to simple verbal prompts and by correct definitions of selected words. The patient was capable comprehending very simple phrases and sentences, but was unable to appreciate subtleties of grammatical structure. Despite adequate retention of verbal memory traces, the patient had difficulty comprehending the meaning of verbal material. He was also unable to inhibit premature conclusions regarding meaning.

The patient demonstrated clear articulation of basic speech sounds, but (as noted above) he had trouble comprehending the task requirements with respect to repeating isolated sounds, tending instead to substitute complete words. This type of responding was particularly evident for written prompts, such as saying "plus or sham" for "pl" or "sh." The patient was able to accurately repeat most simple and complex words and phrases. Expressive speech in response to written stimuli was moderately impaired, particularly for unfamiliar words requiring phonemic analysis. Repetition of phrases and groups of words was largely intact, suggesting sufficient stability of memory traces for immediate repetition. Severe impairment of nominative speech was evident. Responses were significant for dysnomia and substitution of same-category nouns on object identification tasks. Performance was equally impaired for tasks requiring object identification from pictures and from verbal descriptions of the objects. These responses reveal an inability to inhibit alternative associations.

Evaluation of narrative speech revealed adequacy of basic verbal spontaneity and fluency. Accurate repetition of habitual word series items was observed. Ability to reverse these series items revealed stability of acoustic traces. Although rate of speech was adequate, quality of speech was markedly circumstantial/tangential suggesting a pathological associative process. The patient's ability to select and arrange words in a meaningful, grammatically correct manner was severely impaired.

b. SPEECH FUNCTIONS: Receptive speech functions were mildly impaired as evidenced on a task which required matching the correct written symbols to audible speech sound stimuli. Impaired phonemic analysis was also evident on a task which required the spelling of complex, unfamiliar words. The patient demonstrated adequate word comprehension as evidenced by correctly associating groups of sounds and the objects, qualities, actions, and relationships denoted by them. This skill was evident in the correct identification of objects and pictures of objects in response to both simple and complex verbal prompts. Accurate word comprehension was further evident in the patient's ability to provide definitions for selected words on a variety of tasks. However, the range of his vocabulary was limited. Comprehension of simple sentence structure was evident in the patient's rapid understanding of instructions and requirements on most tasks presented.

Expressive speech functions were impaired with respect to both repetitive and nominative speech. However, these deficits were so mild that they were not evident in casual conversation. Expressive speech functions were intact with respect to categorical associations. There was no disturbance of prosody, meter, or rate of speech. No paraphasic deficits were observed in routine speech. However, impaired phonemic analysis of unfamiliar words was again evident. Intact narrative speech functions were evident in the patient's verbal fluency skills, ability to reproduce a series of verbal stimuli, and adequate dialogic speech demonstrated throughout the test.

c. SPEECH FUNCTIONS: Receptive speech functions were intact with respect to phonemic hearing, word comprehension, and understanding of simple phrases. The patient's ability to comprehend the meaning of sentences containing complex grammatical structure was moderately impaired, but appeared consistent with his IQ scores and attained educational level. Expressive speech was intact with respect to accurate articulation of speech sounds and pronunciation of common words. Repetition of phonetically complex, unfamiliar words was mildly impaired. There was no impairment of the nominative function of speech. Narrative speech was fluent but showed mild impairment of spontaneity. The Aphasia Screening Exam revealed very poor spelling skills and appreciation of phonetic structure. Reading of simple material was adequate, but very slow. Basic math skills also showed mild impairment. These reading and mathematic skills appeared consistent with the patient's educational and vocational background.

Directly...Rhythm, Digit Span, "A" Test, PASAT, WMS-R, CVLT, complex
     commands
Qualitatively... Category, Trails, Interview... Orientation, psychomotor,
      distractibility, verbal comprehension, alertness, immediate and recent recall,

a. ATTENTION/CONCENTRATION: No gross deficits in basic attention were evident upon casual intervieew, though concentration (i.e., sustained attention) appeared to be moderately imparied. Objective assessment of attention and concentration as measured by the WMS-R revealed no significant impairment. Other measures revealed very mild impairment of ability to selectively attend to and discriminate nonverbal auditory stimuli (i.e., Rhythm Test). Measures of conceptual tracking and complex conceptual tracking (i.e., Trails A & B) were moderately impaired, suggesting that performance declines considerably as attentional demands increase beyond elementary tasks. This impairment of complex tracking skills was also evident in repetition errors on a serial recall task (i.e., CVLT), which suggested impairment of the the patient's ability to recall items from memory while simultaneously monitoring items she had already recalled.
 
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b. ATTENTION/CONCENTRATION: Significant deficits in attention and concentration were evident upon casual interview. The patient had great difficulty staying on task for more than a few seconds, unless re-directed by the examiner. However, objective assessment of attention and concentration as measured by the WMS-R revealed scores equivalent to the patient's full scale IQ. Other measures revealed impaired ability to selectively attend to and discriminate nonverbal auditory stimuli (i.e., Rhythm Test). Performance was intact, but extremely slow on measures of conceptual tracking and complex conceptual tracking (i.e., Trails A & B), suggesting difficulty staying focussed on the task. Performance was relatively intact, however, on a serial recall task which required the patient to produce items from memory while simultaneously monitoring herself for items she had already recalled.

1. This portion of the evaluation considers two primary forms of memory. The first is connected with general orientation in place and time (i.e. states of consciousness). The second form of memory is concerned with the complex activity of memorization and recall. The latter type of memory receives formal assessment using a variety of memory tasks within the auditory, visual, and kinesthetic modalities. The functions evaluated include:
     A. Direct retention of memory traces
     B. Range (or total number) of directly retained traces
     C. Stability of memory traces
     D. Selectivity of memory traces

2. Additional factors to consider when interpreting results of memory assessment include:
     A. Look for evidence of confabulation and for proactive or retroactive
          interference.
     B. Does the learning process follow a learning curve?
     C. Are logical, active memorization strategies being used?
     D. Look for inhibitory effects of homogenous and heterogenous interference.
     E. Compared cued vs. uncued recall.
     F. Is recall significantly better on recognition tasks than on free recall?
     G. Does recall decline excessively for delayed trials as compared to immediate
          trials?
     H. What type of information is not being recalled... events vs. factual
          information.... recent vs remote data

a. MEMORY FUNCTIONS: Memory functions were assessed with respect to general orientation and to the complex activities of memorization and recall. This patient displayed full awareness of time and date. She accurately stated her current location. She was confused about the duration of her hospitalization, stating she had been here for 1-1.5 weeks (she had actually been admitted for about 3 weeks). However, she was able to accurately estimate the length of the assessment session. Objective assessment of mnestic functions with the WMS-R revealed a General Memory score which was slightly lower than predicted by her IQ scores, with no significant difference between verbal and visual memory skills. Performance was equivalent on measures of immediate vs delayed recall.

The patient demonstrated very poor selectivity of recall, tending to make intrusion errors in which she mixed portions of verbal paragraphs or word lists together. However, there was no significant tendency to confabulate in her responses. On serial measures of associative recall and on serial word lists the patient demonstrated a slow, but positive learning curve. There was no spontaneous use of semantic strategies of facilitate recall of word lists, suggesting a passive or poorly organized approach to memory tasks. However, recall of word lists improved considerably in a recognition trial, suggesting that any existing weaknesses were a matter of memory retrieval, rather than impaired storage functions.
 
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b. MEMORY FUNCTIONS: Memory functions were assessed with respect to general orientation and to the complex activities of memorization and recall. This patient displayed full awareness of time and date. She accurately stated her current location. She was confused about the duration of her hospitalization, stating she had been here for 1-1.5 weeks (she had actually been admitted for about 3 weeks). However, she was able to accurately estimate the length of the assessment session. Objective assessment of mnestic functions with the WMS-R revealed a General Memory score which was slightly lower than predicted by her IQ scores, with no significant difference between verbal and visual memory skills. Performance was equivalent on measures of immediate vs delayed recall.

The patient demonstrated very poor selectivity of recall, tending to make intrusion errors in which she mixed portions of verbal paragraphs or word lists together. However, there was no significant tendency to confabulate in her responses. On serial measures of associative recall and on serial word lists the patient demonstrated a slow, but positive learning curve. There was no spontaneous use of semantic strategies of facilitate recall of word lists, suggesting a passive or poorly organized approach to memory tasks. However, recall of word lists improved considerably in a recognition trial, suggesting that any existing weaknesses were a matter of memory retrieval, rather than impaired storage functions.

Assumes that intellectual activity takes place when a problem demands preliminary analysis and synthesis of a situation and special auxiliary operations by means of which it can be solved. To investigate, you create situations for which the individual has no ready-made or automatic, previously established means of responding. Functions evaluated include: Analysis of the situation/task Selection of essential task components Correlation of task components with one another Formulation of hypotheses Development of a strategy Selection of definite operations for responding to the task

a. INTELLECTUAL FUNCTIONS: To evaluate the patient's intellectual functions a variety of tasks were employed to create situations for which he had no automatic responses. Successful performance required preliminary task analysis, identification of preliminary task components, restraint of impulsive responses, formulation of hypotheses, strategy development, selection of responses, and verification of accuracy.

The patient demonstrated impairment of the ability to perform a preliminary task analysis and identify essential components in a variety of tasks involving pictorial, verbal, and nonverbal stimuli. He tended to become easily frustrated and had difficulty restraining premature conclusions. He was able to generate alternative hypotheses but had difficulty developing consistent strategies for evaluating his ideas. Further, when correct responses were made by "trial and error", he had difficulty evaluating his success and generalizing conclusions to other items on the test.

Assessment of additional aspects of intellectual functioning revealed impaired capacity for abstractive reasoning. Assessment of complex sequential reasoning suggested adequate ability to maintain item components in memory but impaired ability to sequentially manipulate those components sufficiently to solve complex problems. The patient displayed appropriate levels of confidence in items he had answered correctly and was generally able to assess the accuracy of his performance sufficiently to know when he had missed an item. With respect to more traditional "IQ testing", the patient obtained a WAIS-R Full Scale IQ score of 78 (Borderline Range). His Performance IQ score of 76 (Borderline Range) was markedly lower than his Verbal IQ score of 82 (Low Average Range). Evaluation of subscale scores reveal little scatter and no significant strengths or weaknesses relative to his overall performance were identified. Comparison of these results with achievement scores on the WRAT-R and with the patient's educational and vocational attainment suggest that he has experienced a mild decline in overall intellectual capacity relative to his premorbid level of functioning.

b. INTELLECTUAL FUNCTIONS: The patient displayed severe impairment of ability to perform a preliminary task analysis and identify essential components on a variety of items involving pictorial, verbal, and nonverbal stimuli. He tended to provide impulsive responses based on premature conclusions without fully considering the test items. Abstractive reasoning was severely impaired, as was the ability to appreciate logical relationships between objects and concepts. These impairments of elementary intellectual functions precluded successful performance on more demanding tasks involving problems solving tactics or complex sequential reasoning.

With respect to traditional "IQ testing" the patient obtained a Full Scale WAIS-R IQ score of 65, a Verbal IQ score of 70, and a Performance IQ score of 61. There was no significant subtest scatter on either the verbal or performance scales.

c. INTELLECTUAL FUNCTIONS: The patient obtained a Full Scale WAIS-R IQ score of 73, a Verbal IQ Score of 77, and a Performance IQ Score of 71. Each of these scores fell within the Borderline Range of intellectual ability. There were no significant differences between verbal and nonverbal measures and no significant subtest scatter was obtained.

The patient's performance on a simple sequential reasoning task was slow, but within normal limits. Performance deteriorated on a task requiring complex sequential tracking. Upon assessment of abstractive reasoning and problem solving skills, the patient demonstrated an average level of mental flexibility and ability to benefit from his errors. However, his capacity for abstraction was poor and his mental flexibility deteriorated markedly under frustrating conditions. His approach to complex constructional tasks followed a disorganized, piecemeal approach which did not improve when prompted with spatial aids.

d. INTELLECTUAL FUNCTIONS: The patient's performance suggested severely impaired ability to perform a preliminary task analysis or to identify the essential components of novel tasks. The patient did demonstrate the ability to recognize very simple concepts and to respond to contingent feedback. However, she was unable to generalize across even very simple concepts. She also tended to make impulsive responses based on premature conclusions and faulty associations without fully considering test items. The patient obtained a WAIS-R Full Scale IQ Score of 61, a Performance IQ Score of 63, and a Verbal IQ Score of 63. All scores were within the Mild Mental Retardation range of intellectual ability. There was no significant difference between the verbal and performance sections and no significant subscale scatter was evident. These results were consistent with an administration of the WAIS in 1983 and revealed no significant change in IQ.

a. On the WRAT-R the patient obtained standard scores on the Reading, Spelling, and Arithmetic subtests of 55, 54, and 52, respectively. These scores are slightly but not significantly lower than expected based on her IQ scores. They suggest the patient has the potential for a modest gain in academic ability with sufficient training.
 
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b. Screening for academic achievement was accomplished using the WIAT. The patient obtained standard scores of Reading 94, Mathematics 79, Language 97, and Writing 85. In comparison to IQ scores, these academic test results support the impression that she functioned at a higher adaptive level premorbidly; this is particularly evident in her reading and language scores. Evaluation of individual subtests reveals that the patient currently has particular difficulty organizing her thoughts in written statements. Though she has a good understanding of basic mathematical operations, she has particular difficulty with more advanced concepts such as dealing with fractions. This contrasts with her report that her best subjects in high school were algebra, geometry and physics.

a.  presence / absence of cognitive impairment
b.  diffuse, lateralized, localized dysfunction
c.  specific abilities impaired (compared to estimates of premorbid functioning)
d.  acute, rapidly progressive, chronic, static
e.  presumed etiology
f.  degree of impairment
g.  prognosis / treatment / management recommendations

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