Halstead-Reitan battery
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Contents |
Introduction
Poor performance on tests of neuropsychological assessment indicates either localized or widespread brain damage in an individual (Stirling, 24). Such tests provide the advantage of comparing a patient's test scores to standardized scores by other respondents. In addition, these scores show changes in cognition that may relate to progression of an illness or recovery after an injury (Stirling, 24). To test for these impairments or advances, a series of tests is usually administered and often referred to as a test battery. The Halstead-Reitan Battery (HRB) is the most commonly used and evaluates 'measures of verbal and nonverbal intelligence, language, tactile and manipulative skills, auditory sensitivity, and so on' (Stirling, 24).
History and Development
Dr. Ward Halstead and Dr. Ralph Reitan were responsible for the development of the HRB. As early as the 1930s, Dr. Halstead's use of research techniques enabled the accurate identification of localized lesions in the brain (Parsons, 156). During this time, a more holistic approach to neuropsychological assessment was taken, in that brain damage was thought to be more global, rather than attributable to impairments in specific cognitive functions and domains. At the University of Chicago, Ralph Reitan, was one of Halstead's doctoral students and later went on to publish an article, in which a study of 50 individuals proved to quantitatively separate nearly all of the brain-damaged participants from their age/sex matched controls, thereby confirming the validity of Halstead's initial findings (Parsons, 156).
At the time of this discovery, inferences about localized lesions came largely from the realms of neurology and neurosurgery, thus questioning the reliability of this battery as well as the ability to generalize the findings to other populations, including patients in psychiatry (Parsons, 157). Later, Dr. Reitan began to move beyond his original cases and extended his results to other participants and again was able to make accurate predictions about 'the lateralization, localization, and the nature of the disorder itself' (Parsons, 157). The growth and the development of the HRB continues to receive recognition throughout the scientific community and has gradually become the most widespread battery.
Tests Administered
Any interpretation of the results from the HRB should consider the variables of age, education, and sex, as well any indication of peripheral injuries. Additionally, hand and eye preference should also be documented, for these inclinations provide important implications in reference to laterality (Parsons, 163). Emotional reactions, attitudes, and any other limitations of the patient should be noted (i.e. a patient's drug administration), which may profoundly impact the interpretation of the results. An accurate interpretation of the test scores relies on a trained psychologist or a professional examiner due to its complex nature. This costly battery takes between five and six hours and requires patience and stamina from both the examiner and patient (Loring & Meador, 1995). The following measures most commonly assessed in neuropsychological evaluations are summarized. (*Note: the tests highlighted in bold indicate in-class administration and brief instructions are provided).
General Intelligence and Achievement
The general level of functioning is assessed using the Wechsler Adult Intelligence Scale-Revised (WAIS-R), where full scale, verbal, and performance IQs are reported. Also, the Wide Range Achievement Test (WRAT) scores on subtests of reading, spelling, and arithmetic indicate a participant's current level of performance (Parsons, 169).
Sensory-Perceptual and Sensory-Motor Functioning
To test for sensory-perceptual ability, Finger agnosia and impairments in finger tip writing recognition recordings provide important data for the visual, auditory, and tactile modalities (Parsons, 169). Sensory-Motor functioning is measured using the Finger Tapping test, the Purdue or Grooved Pegboard tests, or Grip Strength tests, which provide implications for data involving questions of lateralization and localization. Also, the Tactual Performance Test (TPT) requires an individual to place shapes in a board while being blindfolded. Following completion of this task, the patient is often asked to draw an illustration of the board from memory (St. John, 2008). Left or ride side deficits give insight about lateralization, whereas any suppressive impulses highlight widespread functionary impairments, instead of specific, or localized brain deficits (Parsons, 169).
Attention, Concentration, and Memory
The importance of these tests lies in their ability to detect brain dysfunction, including laterality. The Wechsler Memory Scale (WMS) or its revised version (WMS-R) is the most common subtest that is used to assess memory. The most prevalent subtests of this Scale include measures of Logical Memory, Visual Reproduction, and Paired Associate Learning (Loring & Meador, 1995). Despite the limitations, which refer to the inability to provide adequate normative data, it is still the most common measure administered.
The Memory Assessment Scales is another collaboration of subtests, although it is less popular and differs in content than those items provided on the WMS. However, it is still sufficient in detecting lateralized dysfunction in candidates for anterior temporal lobectomy. Overall, the Memory Assessment Scales is a series of tests quite similar to those administered for the WMS, but also provides a general memory measure as well as verbal and visual memory subtest scores (Loring & Meador, 1995).
The Trial making test and the Digit Span are measures that show sensitivity to attentional impairments. The Trial making test requires an individual to first make connections between a series of numbers, which is referred to as Trial A. For patients with frontal damage, Trial B is more sensitive, in that the individual is now asked to connect letters with a series of numbers (e.g. A to 1, B to 2, C to 3) and this switching of tasks now demands the use of a different set of 'thinking' skills (St. John, 2008). This transition has proven to be challenging for such patients. The Digit Span includes a series of tasks that are auditorily presented to the individual. Starting with a smaller set of randomly arranged numbers, these series are to be verbally repeated back in the original or reverse order to the experimenter. The set of numbers increases with each trial and subsequent lines do not use similar arrangements of numbers as the previous tasks (St. John, 2008).
Executive/ Frontal Functions
The Category Test, the Trial making test, and the Wisconsin Carding Sorting Test (WCST) provide accurate measures of executive or frontal lobe functioning. The WCST presents the patient with a deck of cards that are to be categorized (e.g. shape, color, number, etc), which is predetermined by the experimenter without the participant's knowledge of this choosing. As the cards are shown to the individual, he/she is required to guess which sorting principle the experimenter has chosen. After clear indication of the participant's discovery of the category, the sorting principle is changed without notifying the individual. Scores are based on the number of errors the participant makes in guessing which sorting principle is being used. Poor performance on such a task implies the failure to inhibit a motor program, a deficit termed perseverance (St. John, 2008).
Language and Communication Skills
The Reading and Spelling tests from the WRAT, the Aphasia Screening Test, as well as the Vocabulary subtest from the WAIS, provided with a patient's educational background, are all used to measure language skills and possible impairments (Loring & Meador, 1995). Additionally, a patient's nontest related verbal communicative skills (e.g. word finding difficulties) could provide very informative data in predicting relevant dysfunctions (Parsons, 170). For instance, the Controlled Oral Word Association allows the patient 60 seconds to name as many words as possible beginning with a chosen letter (e.g. 'C'). The second and third trials are conducted in the same manner, but two different letters are selected based on the reported difficulty to retrieve words that begin with those letters (e.g. 'F' and 'L'). An average of 15 words produced is sufficient in normal patients; however, the increasing difficulty of subsequent word associations results in an expected reduction of responses for patients with language and communication deficits (St. John, 2008).
Calculational Skills
On the Arithmetic subtest of the WAIS-R, the patient is required to retain information via memory when problems are presented to him/her orally. Conversely, the WRAT arithmetic allows the patient to use pencil and paper as a means of calculating problems that are presented visually (Parsons, 171). Difficulties with the use of symbols provide evidence of left-hemisphere lesions, whereas visual-spatial deficits predict right-hemisphere lesions. Finally, the Aphasia Screening Test presents two mathematical problems; one presented auditorily and the other requiring the participant to copy a problem and then solve it (Parsons, 171).
Spatial Relationships
Subtests of the WAIS-R including the Block Design test and Rey-Osterreith Complex Figure test are the most commonly administered assessments of visual spatial aptitude. The Block Design test presents an individual with a set of blocks that are to be arranged based upon a predetermined pattern. Scores are based on the amount of time it takes the participant to successfully recreate the design (St. John, 2008). The Rey-Osterreith Complex Figure test varies in instructional administration, with the participant being asked to draw the complex figure from memory, as a copy, or by section. Other times, the novel way in which the figure is reproduced can sometimes be of interest for researchers (St. John, 2008). Additional administrations of spatial ability may include the Bender Gestalt test; however, it has limitations of poor standardization and scoring criteria and is frequently used to evaluate visual motor functioning (Loring & Meador, 1995). Finally, the Visual Retention Test, Judgment of Line Orientation and Facial Recognition Tests (e.g. Benton and Hooper Visual Organization Test) are also commonly used tests to measure spatial aptitude (Loring & Meador, 1995).
Learning
General information from the WAIS-R is used as a means of providing data on a patient's ability to obtain information from his/her environment and to remember it. High scores on this measure predict pre-morbid attainment, whereas low scores indicate 'lack of attainment, learning disabilities as a child, poor educational opportunities, and brain dysfunction effects on memory and communication' (Parsons, 172). The WMS also provides paired associates of learning both new/difficult as well as old/easy paired associates, particularly in elderly patients, where dementia is suspected. The WAIS Digit-Symbol test, improvement or lack of on the Luria words, and scores on the Tactual Performance Test (TPT) also reflect issues of learning, particularly the ability to retain new information (Parsons, 172).
Abstracting
Performance on the WAIS that refers to verbal abstracting ability is able to predict left-hemisphere or generalized brain dysfunction. The Category Test, in which a stimulus set is given to the participant and then required to organize it by obeying a set of rules, is used as a measure of nonverbal abstracting aptitude. This task has proven to be particularly sensitive to all types of brain dysfunctions (Parsons, 172).
Problem Solving
The TPT test is commonly used to measure problem-solving skills, which assesses the patient's strategy usage and approaches to solving problems. The Category test, the Block Design Test, and the Trial making test are other instruments that test for problem solving as well as set flexibility and perseverance. These tests coupled with the Digit Symbol Test and the TPT test reveal that most sensitivity to brain damages and aging in patients (Parsons, 173).
Personality
The Minnesota Multiphasic Personality Inventory (MMPI) provides useful information in diagnosis and treatment. However, this test, along with others, is inadequate in determining whether depressive scores are the cause or the reaction to brain injury (Parsons, 173). While personality tests are not always employed, they are often administered more times than not, particularly to evaluate if personality characteristics are significant factors, and more specifically in patients who report back pain prior to or following back surgery (Loring & Meador, 1995). Overall, personality tests are used as a means of assessing which treatment approach will produce the most effective results (Parsons, 173).
Limitations
The original norms for the Halstead tests are based on a relatively small and young sample, resulting in diagnostic issues and potential faulty conclusions (Lezak, 710). However, age-graded norms are now available for means of comparison that include gender and education variables. Also, these tests have been questioned in the elderly population, as they have been shown to be too lengthy and challenging for these individuals (Lezak, 710). Thus, Halstead's core scores have not been included in batteries that evaluate such patients. Nevertheless, the HRB's accuracy and validity still relies on its ability to predict the nature, the presence, as well as the site of a lesion by employing statistical relationships between test scores (Lezak, 710).
Neuropsychological Findings
Interpretations of the HRB have proven to be highly accurate in correct predictions. However, the battery has been questioned for its lengthy administration and lack of diagnostic efficiency (Loring & Meador, 1995). While, the mere length of the HRB has shown to be less appropriate for patients in whom attentional issues are present, its most significant contribution comes from its ability to address a variety of behaviors in relation to neuropsychological functioning (Lezak, 712). Variations of the HRB have been used in studies in an effort to indicate more specific brain dysfunctions, for they provide greater sensitivity to test performance of patients (Lezak, 713). More plainly stated, specific tests are selected to test for particular hypotheses about an individual (Stirling, 25). Overall, batteries provide information about changes in cognitive functioning that are helpful for diagnostic purposes, but more importantly, in the efficacy of treatment and recovery.
References
Lezak, M. D. (1995). Batteries for assessment of brain damage. In, Neuropsychological assessment (3rd ed., pp. 686-735). New York: Oxford University Press.
Loring, D. W., & Meador, K. J. (1995, May 12). Neuropsychology for neurologists.
Paper presented at the Annual Meeting of the American Academy of Neurology,
Seattle, Washington. Retrieved April 24, 2008, from http://www.nldontheweb.org
/loring-meador.htm
Parsons, O. A. (1986). Overview of the halsted-reitan battery. In T. Incagnoli, G. Goldstein, & C. J. Golden (Eds.), Clinical application of neuropsychological test batteries (pp. 155-192). New York and London: Plenum Press.
Stirling, J. (2002). Introducing neuropsychology. New York, NY: Psychology Press.
St. John, S. (2008). Neuropsychological tests. Retrieved April 24, 2008, from Rollins College, Blackboard Web site: http://blackboard.rollins.edu/webapps/portal/ frameset.jsp?tab=course&url=bin/common/course.pl?course_id=5963_1
