Neuropsychological Features of Civil Litigators and Criminal Offenders: Comparative

Analyses of Brain, Behavior, and Cognitive Ability

By

Hannah Michelle Lindsey

University of North Carolina Wilmington

Wilmington, North Carolina

May 2012
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Table of Contents

List of Tables and Figures v

Abstract vi

Acknowledgements vii

Dedication viii

Introduction to Clinical and Forensic Neuropsychology 1

Personal Injury Litigation 5

Social Security Disability Determination 6

Worker’s Compensation Claims 7

Criminal Law 8

Criminal Competency 10

Mental Retardation 11

Assessment of Neuropsychological Domains 13

Motivation and Malingering 14

Rey 15-Item Test 15

Dot Counting Test 17

Intelligence 17

Wechsler Adult Intelligence Scale: Third Edition 19

Learning and Memory 20

Digit Span 22

Letter-Number Sequencing 22

Language and Verbal Ability 24

FAS test of phonemic fluency 24

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Vocabulary 25

Comprehension 25

Visual and Perceptual Function 25

Picture Completion 25

Hooper Visual Organization Test 26

Matrix Reasoning 28

Picture Arrangement 28

Attention and Concentration 28

Stroop Color-Word Interference Test 29

Trail Making Test 30

Digit Symbol Coding 30

Symbol Search 33

Ruff 2 & 7 Test of Selective Attention 33

Concept Formation, Abstraction, and Reasoning 35

The Category Test 35

Similarities 36

Arithmetic 36

Motor Function 36

Finger Tapping Test 37

Block Design 37

Object Assembly 37

Emotional Status 38

Beck Depression Inventory: Second Edition 39

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Academic Achievement and Aptitude 39

Wide Range Achievement Test: Fourth Edition 40

Information 40

Neuropsychological Features and Forensic Aspects of Behavior 42

Method 45

Participants 45

Materials 46

Procedure and Statistical Analyses 46

Results 48

Discussion 51

References 55

Footnotes 71
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List of Tables and Figures

Tables

Table 1 Proposed Table for Determination of Neuropsychological

Disability Using Test, Clinical, and Historical Data 9

Table 2 The Structure of the Wechsler Adult Intelligence Scale:

Third Edition 21

Table 3 Means and Standard Deviations for Significant Scores of

Individual Case Conditions 49

Table 4 Significant Differences Between Civil Cases and Between

All Forensic Cases 50

Table 5 Tukey’s HSD Pairwise Comparisons of Performance in

Neuropsychological Domains 52

Figures

Figure 1 Sample of Rey’s 15-Item Test for Malingering 16

Figure 2 Example of Stimulus Packets for the Dot Counting

Test for Malingering 18

Figure 3 Sample of the Digit Span subtest of WAIS-III 23

Figure 4 Sample of Stimulus Cards for the Hooper VOT 27

Figure 5 Sample of the Trail Making Test parts A and B 31

Figure 6 Sample of the Digit Symbol subtest of WAIS-III 32

Figure 7 Sample of the Symbol Search subtest of WAIS-III 34

Figure 8 Demonstration of the Closure Technique used for the

Sentence Comprehension subtest of the WRAT4 41

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Abstract

This study was conducted to determine neuropsychological performance across different types of forensic

cases. Participants (n = 160) ages 18-71 were collected from an archived database and are represented by

four forensic domains: personal injury (n = 36), Social Security disability (n = 43), worker’s compensation

(n = 37), and death penalty (n = 44). Ethnicities represented were Caucasian (n = 91), African American (n

= 15), and Hispanic (n = 54). Analyses involved a between-subjects design where ANOVAS and

MANOVAS of neuropsychological assessments and domains included data from 12 analyses. Differences

for death penalty were seen on measures of intelligence, verbal ability, memory, executive functioning, and

motor skills, (p < .017) and for Hispanics on measures of academic ability, verbal fluency, and attention (p

< .05). Personal injury performed significantly better on measures of intelligence, verbal ability, verbal

learning, memory, and executive function. The present findings support and extend prior literature.

Keywords: forensic, neuropsychological assessment, death penalty, civil litigation

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Acknowledgements

I would like to personally thank and acknowledge Margie I. Hernandez Mejia, Tara N.
Jackman, Keenan B. Withers, Aaron N. Dedmon, Davor N. Zink, Lee A. Wiegand, Robert
L. Hakan, Ph.D., Bryan Myers, Ph.D., and Michael O. Maume, Ph.D. for your gracious
support and meaningful contributions to my undergraduate education, research, and
particularly to the development of this, my undergraduate honors thesis.
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For Dr. Antonio E. Puente

Thank you for everything you have done for me over the past three years. I never dreamt
that I would have learned and accomplished so much at this point in my life. You have
been an incredible inspiration and a great motivational influence to me. I cannot give
you enough thanks for the time and energy you have sacrificed for my education and well
being as a student, and also for what you have taught me about what it means to give
back and to strive to reach my full potential in this world. I dedicate this to you, for
without you, I could not have accomplished so much. You have pushed me beyond the
limits that I once feared would hold me back, and you have made me realize that I can do
anything that I set my mind to. Thank you, once again, for everything, I have learned an
immense amount about myself and about life as well while under your guidance. I can
only hope that one day I am able to touch someone’s life as you have touched mine; I
would then be satisfied with the knowledge that I have accomplished my goal of making a
positive and meaningful difference in the life of another. Thank you.

“[A] Commitment to progress and improvement…in terms of furthering the advancement of the
evolutionary trend toward greater complexity, diversity, and improvement in the quality and
dimensions of life and the life experience. A sense of purpose is thus provided for the life of the
individual and for society as a whole, a critical feature of which involves furthering the evolution
of human understanding of the natural order… The practical consequences for action affected by
a value shift of this kind can be seen to stretch out endlessly…humanity needs to see itself in
terms of something greater and more important than itself to give meaning and purpose to human
existence… Science becomes a source and arbiter of values and belief systems at the highest level
and the most direct avenue to an intimate understanding and rapport with those ‘forces that move
the universe and created man.’” – Roger W. Sperry
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Neuropsychological Features of Civil Litigators and Criminal Offenders: Comparative Analyses of Brain,

Behavior, and Cognitive Ability

The field of Clinical Neuropsychology has its origins in the medical field, but fully developed out

of collaboration between neuroscience, neurology, psychiatry, and psychology. Physicians with an interest

in the location of brain lesions and the abnormal behavioral changes that seemed to result as a consequence,

such as Paul Broca and Karl Wernicke, were the earliest practitioners in the study of brain-behavior

relationships, and the addition of quantitative psychological assessment later on paved way for the

foundation of the field (Franzen, 1989; Goldstein, 1992). Assessments based on the subjective

interpretations of “correct” behavior and functioning were then able to rely on quantitative and objective

norm-based measurements of psychological functioning. The Division of Clinical Neuropsychology

(Division 40) of the American Psychological Association (APA) was established in 1980, and the Houston

Conference of 1988 redefined the specialties of the field of clinical neuropsychology to have the following

description:

A clinical neuropsychologist is a professional psychologist trained in the science of brain-

behaviour relationships. The clinical neuropsychologist specializes in the application of

assessment and intervention principles based on the scientific study of human behaviour

across the lifespan as it relates to normal and abnormal functioning of the human central

nervous system (Executive Commission of Division 40 of the APA; Definition of a

Clinical Neuropsychologist, 1989).

In the beginning of the field, neuropsychological tests, such as the Wechsler-Bellevue intelligence

scales (Wechsler, 1939), the Rorschach technique (Piotrowski, 1937), the Bender-Gestalt test (Bender,

1938), and tests of human figure drawings (Machover, 1948), weighed heavily on standard psychological

testing procedures and portions of the neurological and mental status examination (Goldstein, 1992).

Neuropsychological assessments are now based on a more quantitative and scientific approach to solving

problems and answering questions about the brain and behavior, versus the qualitative and subjective

methods utilized in the past (Franzen, 1989; Vanderploeg, 2000). When the scientific approach is applied

successfully through accurate use of measurement, observation, logic, and consideration of alternative

explanations, the descriptive abilities of neuropsychological assessment to correlate relationships between

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brain abnormalities, behavioral changes, and outcomes with implications for day-to-day functioning of an

individual have been shown to be addressed in greater depth and specificity than other psychological

testing procedures (Larrabee, 2000a; Martell, 1992). The field of clinical neuropsychology has undergone

incredible growth since the 1980s, and with its new scientific basis and instruments for objectively

measuring cognitive, behavioral, and emotional consequences of abnormal brain conditions, it is capable of

being applied to more areas than simply the clinical investigation of brain damage (Goldstein, 1992;

McCaffrey, Williams, Fisher, Laing, 1997; Martell, 1992).

The term forensic means, “pertaining to the courts of law” and refers to any information that can

appropriately be utilized for decision-making in a legal setting (McCaffrey, Williams, Fisher, & Laing,

1997; Giuliano, Barth, Hawk & Ryan, 1997). Hence, the field of forensic neuropsychology involves the

application of neuropsychological assessment of brain-behavior relationships in order to provide necessary

information for legal decision-making in cases involving civil litigation (e.g., personal injury suits, Social

Security disability determination, worker’s compensation claims) and criminal law (e.g., competency to

stand trial, criminal responsibility, competency for execution). This area of neuropsychology is complex

and requires not only a thorough knowledge of the field of neuropsychology itself, but also knowledge of

the relevant legal principles involved, for forensic evaluations are conducted for different reasons than

clinical evaluations and thus require different skills, such as the ability to communicate the relevance of

cognitive abnormalities in a way that relates to civil and criminal legal issues. The Ethical Principles of the

American Psychological Association (1992) emphasize the importance of understanding a patient in lieu of

the unique circumstances of his or her life. Performing scientifically correct but clinically sensitive

evaluations, while incorporating diversity in demographically relevant issues, poses a unique challenge to

the clinical neuropsychologist (McCaffrey & Puente, 1992), and the forensic neuropsychological

assessment involves the highest level of clinical and scientific aspects of the neuropsychological practice

(Larrabee, 2000a; McCaffrey et al., 1997; Puente, 1997).

In 1983, Curt Bartol stated,

Law is a practical, conservative, and traditional endeavor that is strongly influenced by

moral, social, and political pressures. And, perhaps, for good reason, law views the
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science of psychology with suspicion and skepticism, convinced that psychology must

prove its worth in ‘meaningful’ application before it can be accepted and trusted (p. ix).

Little has been published concerning the history of forensic neuropsychology and despite the skepticism

toward psychology, its eventual acceptance into the courtroom. However, appellate court decisions (e.g.,

People v. Hawthorne, 1940) concerning the allowance of special information regarding mental status,

competence, and criminal responsibility to be presented into the courtroom by a psychologist have been

documented (Giuliano et al., 1997). Later, the benchmark ruling by the District of Columbia Court of

Appeals in 1962 (Jenkins v. United States) stated that despite their lack of medical degree, psychologists

could be considered experts when providing testimony concerning the responsibility of a criminal. Perlin

(1977) states that the Jenkins decision “opened the doors to the admission of psychological testimony in a

multitude of legal areas” (p. 44). The first major case in the state of North Carolina was Horne v. Goodson

in 1986, where Puente (Puente & Gillespie, 1991) testified in a head injury case, but whose testimony was

rendered not admissible by the Industrial Commission of North Carolina because he was not a physician,

regardless of the clear evidence that the defendant’s behavioral changes were causally related to head

injury. The North Carolina Court of Appeals reversed the original ruling after extensive amicus briefs were

filed by the North Carolina Psychological Association (NCPA) and the APA, and allowed information

concerning neurocognitive changes to be provided by a neuropsychologist (Puente, 1992a; 1997). Judicial

appellate courts have held that the trier at fact determines the sole decision of whether or not a witness is

qualified to render an expert opinion. Rule 702 of the Federal Rules of Evidence states the following: “If

scientific, technical, or other specialized knowledge will assist the trier of fact to understand the evidence

or to determine a fact in issue, a witness qualified as an expert by knowledge, skill, experience, training, or

education may testify thereto in the form of an opinion or otherwise” (Richardson & Adams, 1992, p. 298).

Since initial acceptance into the courtroom, the value of neuropsychology to society has

increased indefinitely. It has been said that scientific testimony has “revolutionized the American lawsuit”

(Carlson, 1986, p. 589), and argued that neuropsychology’s value can be gauged by its acceptance into the

courtroom (Puente, 1997). Not only were questions of the court concerning cognitive competency and

direct effects of neuropathology now able to be addressed, but also attorneys were able to utilize this

neuropsychological evidence as potential sources of legal case support, especially in civil litigations
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(Giuliano et al., 1997; Larrabee, 2000a). The fact that forensic neuropsychologists have the unique ability

to characterize and quantify specific aspects of cognitive functioning in relation to behavioral changes and

dysfunction, their expert testimonies are now greatly excepted in both civil and criminal legal-proceedings

(Adams & Rankin, 1996; Martell, 1992; Van Gorp, 2007).

The potential relevance of neuropsychology to issues pertaining to civil litigations such as

determining disability for the Social Security Administration, in worker’s compensation claims, and in

personal injury lawsuits, as well as to those related to criminal competency and responsibility (Barth, Ryan,

Schear, & Puente, 1992; Puente, 1987, 1990a; Puente & Gillespie, 1991) has received much recent

attention (Giuliano et al., 1997). McMahon and Satz (1981) address three tasks of the forensic

neuropsychologist for civil and criminal litigation: (1) determinations of dysfunction, (2) the effect of

dysfunction on the individual, and (3) prognosis. Puente (1992b) explains that no matter what kind of

litigation the neuropsychologist is concerned with, their task remains the same, which is “to provide as

accurate, scientific data about the patient’s neurobehavioral function as allowable within the constraints of

the knowledge available at the time of the evaluation” (p. 428). It is imperative that the neuropsychologist

understands that their role in the courtroom is to provide the necessary information for decision-making by

the trier, especially when addressing criminal competencies (Larrabee, 2000b). The neuropsychologist must

rely on objective information, provide conclusions that directly reflect the data, and communicate the

information in an unambiguous manner so that the proper legal decision can be made (Puente, 1992b).

There are various types of cases that involve forensic neuropsychological evaluation, however

certain types of cases are presented more frequently, and these are the ones in which neuropsychologists

specialize in: personal injury suits, Social Security disability determination, worker’s compensation claims,

and criminal competency (to a lesser frequency than civil litigations) to stand trial and/or for execution.

Cases involving civil litigation occur more frequently than those involving criminals, and they tend to be

resolved prior to trial. Mild head injury cases involve a higher likelihood of expert appearance in the

courtroom (versus writing a deposition) due to the possibility that the behavioral consequences are results

of a mild head injury with no detectable neurological or neuroradiological deficits, and the

neuropsychologist would be requested to translate these deficits from the injury in a way in which the trier

can understand, as well as to demonstrate that the injured was not faking his or her mental disability, or
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malingering (Puente, 1992b; 1997; Sbordone, 1991). The question at hand in civil cases is what the

sustained injuries mean for the victim’s day-to-day functioning relative to their premorbid abilities (Adams

& Rankin, 1996). These cases include neuropsychological evaluation to determine if the injured is in need

of guardianship, is competent to work, to consent to treatment, to consent to research, and their capacity to

testify (Larrabee, 2000a). The burden on proof in civil cases requires “the preponderance of evidence” or

the probability that a fact is more true than not true. As a practitioner of a science based on probability

(Puente, 1997), it is the forensic neuropsychologist’s role to demonstrate how the defendant’s behavioral

implications are probably caused by the injury received.

Personal Injury Litigation

Personal Injury cases involve neuropsychological assistance in determining damages sustained as

a result of some incident of negligence between two parties. The litigation resulting from the injury can

result from wide array of situations (Grote, Kaler, & Meyer, 1986; Kurke & Meyer, 1986). Research has

indicated that the primary cause of head injury is from automobile accidents (Kreutzer, Leininger, &

Harris, 1990; Levin, Benton, & Gossman, 1983; Rimel, Jane, & Bond, 1990) and that these make up the

majority of personal injury cases for a forensic neuropsychologist (Adams & Rankin, 1996; Kreutzer,

Marwitz, & Myers, 1991). If the injurious event was inflicted willfully and/or maliciously, the litigation

will be considered an assault, however if this is not the case, it is necessary to determine if the defendant is

legally responsible for the injuries sustained by the plaintiff (Kurke & Meyer, 1986). The injured party will

typically be represented by an attorney, and seeking a financial compensation and treatment for the injuries

sustained and the resulting disabilities. Attorneys often call upon forensic neuropsychologists to

determining the cognitive and emotional status of the parties involved in the litigation at the time of the

injurious incident, which is directly relevant to determining the cause of the event and consequently to

determining liability (Kurke & Meyer, 1986; Laing & Fisher, 1997a).

Juries best appreciate and base their accusations on information concerning how the injury affects

the victim’s day-to-day functioning relative to their abilities before the injury was sustained (Kreutzer et al.,

1990). A traditional neuropsychological evaluation in a personal injury suit requires information regarding

the victim’s premorbid functional abilities and the resulting behavioral and neurological consequences of

the accident, with emphasis on intelligence, communication, memory, social ability, executive functioning,
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emotional functioning, personality, vocational, and academic ability (Adams & Rankin, 1996; Kreutzer et

al, 1990; Lynch & McCaffrey, 1997). The goal in personal injury lawsuits is to determine if the current

mental, emotional, and physical states of the appellant party pre-existed the injury or if they were results of

the incident (Grote et al., 1986; Kurke & Meyer, 1986), and the role of the forensic neuropsychologist is to

demonstrate this in an ethical, objective, and scientifically valid manner (Laing & Fisher, 1997b; Lynch &

McCaffrey, 1997).

Social Security Disability Determination

For the purpose of occupational disability insurance for those who are unable to work, the term

disability is a legal, rather than psychological or medical term (Piechowski, 2011). The Social Security Act

(42 U. S. C. § 423) defines disability as “the inability to engage in any substantial gainful activity by reason

of any medically determinable physical or mental impairment(s) which can be expected to result in death or

which has lasted or can be expected to last for a continuous period of not less than 12 months.” The

determination of disability results from a judicial decision based on evidence provided by an expert’s

opinion concerning an applicant’s psychological and physical status (Williams, 2010). The careful

assessment in determining disability is essentially tied to determination of functional capacity which has

been described as “that which a person knows, understands, believes, or can do” (Grisso, 2003, p. 39), and

the ultimate goal of the forensic neuropsychologist is in determining whether or not the patient is disabled

to such extent that he or she cannot sustain gainful employment (e.g., Americans with Disabilities Act,

1990), can not access educational resources (e.g., The Individuals with Disabilities Education Improvement

Act, 2004), and should be entitled to monetary benefits as a result (Piechowski, 2011; Puente, 1997).

The Social Security Administration (SSA) typically refers an applicant to a neuropsychologist for

examination. As described by the Social Security Act and the Code of Federal Regulations (20 C.F.R. §§

404.1500-404.1599), determination of disability follows a prescribed evaluation process, which was upheld

by the U. S. Supreme Court in decisions including Heckler v. Campbell (1983) and Bowen v. Yuckert

(1987) (Piechowski, 2011). There are two major issues that dictate the evaluation for SSA cases. First, to be

eligible for benefits, the claimant must (1) directly meet or fit a listing, (2) have a combination of

impairments, (3) have limited medical improvements related to employments, or (4) not be able to perform

a previous or related work. Mental impairment is categorized in nine separate listings which are as follows:
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organic mental disorders, schizophrenia, paranoid or other psychotic disorders, affective disorders, mental

retardation and autism, anxiety-related disorders, somatoform disorders, personality, and substance

addiction disorders (Social Security Administration, 2006). In the field of forensic neuropsychology,

evaluations are most applicable for organic mental disorders (Puente, 1997), which is defined by the Social

Security Administration (2006) as “Psychological or behavioral abnormalities associated with a

dysfunction of the brain. History and physical examination or laboratory tests demonstrate the presence of a

specific organic factor judged to be etiologically related to the abnormal mental state and loss of previously

acquired functional abilities.” In order to qualify for disability, both presentation of the basic symptoms of

“organicity” (e.g., memory impairment), and a negative effect of these symptoms on one’s functioning in

daily activities must be present in the individual (Piechowski, 2011; Puente, 1997).

The second issue that dictates evaluation of SSA claimants is the fact that the Social Security

Administration approved only specific neuropsychological tests for use in the evaluation of disability,

which are the following: Boston Diagnostic Aphasia Examination, McCarthy Scale of Children’s Abilities,

the Standford—Binet Intelligence Scale (3rd ed.) Wechsler Intelligence Scale for Children-Revised,

Wechsler Adult Intelligence Scale-Revised, the Luria—Nebraska Neuropsychological Battery, the Millon

Behavioral Health Inventory, and the Kaufman Assessment Battery for Children (Social Security

Administration, 2006). Unlike worker’s compensation or personal injury suits, evaluations for Social

Security disability require an assessment of mental health without reference to causation or premorbid

levels of functioning (Williams, 2010). However, due to the strict guidelines of the SSA, the assessment

can be very complex (Puente, 1997).

Worker’s Compensation Claims

Worker’s compensation cases can be described as being more of a legal process than medical

(Glass, 2004). Laws pertaining to worker’s compensation in the United States were first enacted at the

beginning of the twentieth century with the Federal Employers Liability Act in 1908, which covered those

involved in hazardous occupations, such as certain federal employees and railroad workers. Like personal

injury suits, to qualify for worker’s compensation, one must present differences in functional ability before

and after some injury, which in this case must have occurred as a direct result of one’s job. However, it is a

“no fault” system of compensation, where the injured employee is not required to demonstrate negligence
   8  

in his employer (Piechowski, 2011). In these cases, forensic neuropsychologists are required to provide an

expert opinion regarding the development or aggravation of some psychological dysfunction or impairment

due to a direct causal relationship with the work-related accident (Williams, 2010). For such reasons, it is

imperative that the clinician obtains a thorough evaluation of the claimant’s premorbid neuropsychological

functioning. This can be accomplished through records of school records, as well as an emphasis on the

individual’s vocational history (Puente, 1997).

The neuropsychological report that is required by the court for worker’s compensation claims

should place special emphasis on the resulting post-injury symptoms and functional abilities pertaining to

work-related capabilities (Puente, 1997). A rating, or percentage of impairment, is required to be in the

report, and is based on guidelines that have been published by the American Medical Association (AMA)

in 1994. The variables that are factored into establishing a rating include levels of intelligence, thinking

ability, perceptual skills, judgment, affect, and behavior, along with activities of daily living and potential

for rehabilitation and treatment. Special emphasis should be placed on the role that severity of the accident,

age, education, and other psychosocial and psychobiological variables have on rating (Puente, 1997; Puente

& McCaffrey, 1992b). This rating can pose serious difficulties for the neuropsychologist (and

consequentially for the court) because, unlike other types of injuries, “quantifying” loss (extent of

disability/impairment) for head injuries is not methodologically clarified. However, Puente (1997)

developed Table 1 as an alternative method for evaluating the disability associated with worker’s

compensation.1

Criminal Law

The function of forensic neuropsychologists in criminal settings has traditionally involved

addressing major issues of mental illness (e.g., mental retardation; traumatic brain injury) and the impact of

such illness on the defender’s behavior as it relates to the requirements of the law. Acts or omissions that

violate the societal norms are established in the societies penal laws, and in order for a defense attorney to

argue that the defendant’s brain damage is a mitigating factor of his criminal behavior, he must establish

with reliable evidence that the behavioral alterations committed were directly linked to the dysfunctional

status of the brain (Martell, 1992; Rehkopf & Fisher, 1997). This direct link between brain and behavior is

the burden of proof required for criminal law. For this is the reason, neuropsychologists have increasingly
   9  
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been summoned for their participation as expert witnessed in these cases, especially in relation to the issues

of criminal competency and responsibility (Larrabee, 2000a). The courts rely on the objective results of

neuropsychological assessment when determining the neurocognitive deficits related to neurological

impairments that could result in the behavioral junctures associated with capital offenses (Hanlon, Rubin,

Jensen, & Daoust, 2010). Therefore in those cases where there is sufficient reason to believe that a brain

lesion could be causally linked to having adverse effects on the accused’s behavior, the neuropsychologist

is able to assist on either the defense or the prosecution in determining if there is scientific evidence for this

claim through neuropsychological evaluation of the criminal. However, according to the APA Code of

Ethics (2002), the first of five general principles of ethical standards requires that the psychologist “strive

to benefit those with whom they work and care to do no harm.” Under this principle, it would be unethical

to assist in the prosecution of the accused through neuropsychological evaluation.

Criminal Competency. If the defense counsel suspects that the defendant suffers from one or

more neurological impairment, the question of the client’s competency to stand trial must be addressed.

The Dusky v. United States trial in 1960 designated that the test for competency to stand trial “must be

whether the defendant has sufficient present ability to consult with his lawyer with a reasonable degree of

rational understanding, and whether he has a rational, as well as factual, understanding of the proceedings

against him” (p. 402, quoting United States Solicitor General Rankin). Dusky was among the first of many

landmark Supreme Court rulings toward fairness and in support of the rights of those on trial in criminal

proceedings. These cases concerning competency led to the establishment of a two-pronged test of

competency: The first prong is related to the cognitive abilities of the defendant, addressing his capacity to

understand the proceedings around him, where basic functions such as orientation, comprehension,

memory, and understanding of his situation must be evaluated. The neuropsychologist is especially helpful

in assessing the cognitive component of competency, for the mental abilities required reflect a direct

relevance to neuropsychological evidence (Martell, 1992; Rehkopf & Fisher, 1997).

The second prong is related to interpersonal/behavioral cooperation and involves the abilities of

the defendant to communicate and participate effectively with his or her defense. This involves his ability

to successfully speak to and communicate with the counsel, as well as listen and understand the

occurrences in his case. Many mental disorders or deficits, such as those involved in speech comprehension
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(i.e., aphasias) or attention and concentration (e.g., Attention Deficit Disorder), can directly impair one’s

capacity to communicate and cooperate in the courtroom. The neuropsychologist also can assess this in

order to provide substantial objective data to the judiciaries, for in this case, “sufficient present ability” is

ultimately their decision (Martell, 1992; Reynolds, Price, & Niland, 2003).

In death penalty cases, an assessment of competency is also necessary in order to determine that

the condemned understand that he is sentenced to death. Otherwise, according to the Supreme Court ruling

in Ford v. Wainwright (1986), it is considered cruel and unusual punishment to execute an incompetent

individual, and it is a violation of the Eighth Amendment. In regard to their new ruling, the Supreme Court

wrote, “Whether its aim be to protect the condemned from fear and pain without comfort of understanding,

or to protect the dignity of society itself from the barbarity of exacting mindless vengeance, the restriction

finds enforcement in the Eighth Amendment” (p. 2602). Further, it has also been ruled by the Supreme

Court (Atkins v. Virginia, 2002) that it is also considered cruel and unusual punishment to execute a person

who is mentally retarded. Sullivan and Denney (2003) state that this case is very important to the

neuropsychologist who performs death penalty related evaluations, and he should not perform those

evaluations unless he is thoroughly aware of the details of this case and subsequent ruling.

Mental retardation. Perlin (2006) states that the role of the expert opinion concerning cases in

which competency for death is dependent on whether or not the defendant has a disabling mental condition,

“is perhaps greater than virtually any other area of criminal law” (p. 343). The role of the

neuropsychologist in death penalty cases is especially important in the determination of mental retardation.

The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR;

American Psychiatric Association, 2000) defines mental retardation as follows:

The essential feature of Mental Retardation is significantly subaverage general

intellectual functioning (Criterion A) that is accompanied by significant limitations in

adaptive functioning in at least two of the following skill areas: communication, self-care,

home living, social/interpersonal skills, use of community resources, self-directions,

functional academic skills, work, leisure, health and safety (Criterion B). The onset must

occur before age 18 years (p. 41).

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In the assessment of who is “subaverage”, the IQ score of the defendant will very often be the

critical determining factor in competency for execution. The results of intelligence evaluations should be

carefully explained to the court in plain, comprehensible common sense that an average person who lacks

knowledge of the field or the disorder could understand. Courts tend to lean toward verdicts that seem

“morally right” and need clear, scientific evidence that the verdict should be otherwise (Perlin, 2006;

Rehkopf & Fisher, 1997). Of utmost importance is the ability of the neuropsychologist to contextualize the

meaning of “IQ” as well as the functional consequences of whatever the score may be.

Early researchers in intelligence testing generally considered intelligence to relate the concepts of

learning from experience and adapting to one’s environment (Reynolds et al., 2003). One of the general

categorizations of mental retardation is that it corresponds to approximately the bottom 2% of the

population in regards to intellectual functioning. Assuming a normalized mean of 100 with a standard

deviation of 15, mental retardation as designated by an IQ of 70 or below, which implies the fact that one

with such an IQ is less capable of learning from experience and adapting to their environment than 98% of

the population. Although this is true, the DSM-IV-TR (American Psychiatric Association, 2000) explains

that when measurement error is considered, an IQ of 70 is considered to represent an IQ of approximately

65 to 75, thus leading to the conclusion that any persons with an IQ of 75 or below can be considered

mentally retarded when exhibiting significant deficits in adaptive behavior. Law, however, does not

appreciate this lack of a “bright line” distinguishing mental retardation from borderline intellectual

functioning, nor the idea that statistically, considering those with an IQ of 75 and lower as mentally

retarded doubles the percentage of the population (from 2.28% to 5.48%) that can be deemed incompetent

for execution (Reynolds et al., 2003).

The importance that the expert explain the functional role of IQ scores and, as such, the statistical

meaninglessness of differences between scores of 68 (within the definition on mental retardation) and 72

(outside the definition of mental retardation), for example, is emphasized to the highest degree when

regarding to criminal competency (Perlin, 2006). The DSM-IV-TR (American Psychiatric Association,

2000) explicitly states,

When there is significant scatter in the subtest scores, the profile of strengths and
   13  

weaknesses [developed by the expert based on factors that may limit test performance,

i.e., sociocultural background or native language], rather than the mathematically derived

full-scale IQ, will more accurately reflect the person’s learning abilities (p. 42).

Unfortunately, a large part of the problem concerning the “bright line”, is the fact that those involved in the

legal system have been trained in such a way that emphasizes a dyadic universe (e.g., retarded/not

retarded), and historical cases such as Walters v. Johnson (2003, p. 695) and State v. Kelly (2002, p. 11)

which hold the Wechsler Adult Intelligence Scales as “the gold standard of testing” do not make the task of

the neuropsychologist any easier in influencing their view of intelligence scores (Perlin, 2006; Reynolds et

al., 2003).

Assessment of Neuropsychological Domains

The neuropsychological evaluation relies heavily on its ability to objectively present relevant

information concerning biological functioning in relation to a patient’s subjective experience and resulting

behavior, especially when concerning legal issues requiring a forensic assessment. Neuropsychological

evaluations are important for establishing a wide array of physical, cognitive, perceptual, and intellectual

abilities that may relate to the accused’s behavior or some liability in the courtroom in a significantly

influential way.

The typical functional capabilities addressed in neuropsychological assessment usually include

domains such as (1) motivation, (2) intelligence, (3) learning and memory, (4) language and verbal fluency

(5) visual and perceptual function, (6) attention and concentration, (7) concept-formation, abstraction, and

reasoning, (8) motor function, (9) emotional function, and (10) academic achievement and aptitude.

Specialized testing batteries such as the Halstead-Reitan Neuropsychological Test Battery (HRNB;

Halstead, 1947; Reitan & Wolfson, 1993) are commonly utilized in neuropsychological assessment due to

their standardization of measures and comprehensive norms (Bauer, 2000; Russell, 2000). Further, there is

a general agreement among neuropsychologists and psychometricians in the high validity and reliability

associated with this battery (Hevern, 1980; Robbins, 1989).

Individual tests can be utilized as well, or incorporated within a standard battery in order to tailor
   14  

the evaluation to the specific client’s situation (Van Gorp, 2007). It is imperative that the assessments

selected have well documented norms, adjusted when necessary for demographic and situational factors

such as age, sex, education level, ethnicity, race, and handedness (Franzen, 1989; Heaton, Grant, &

Matthews, 1991; Martell, 1992; McCaffrey & Puente, 1992; Strauss, Sherman, & Spreen, 2006). The APA

code of ethics has placed recent emphasis on the importance of understanding the client in the context of

his or her life (American Psychological Association, 2002) in order to make appropriate and valid

conclusions from neuropsychological assessment.

Motivation and Malingering. Malingering is defined by the Diagnostic and Statistical Manual of

Mental Disorders – Fourth addition – Text revision as “the intentional production of false or grossly

exaggerated physical or psychological symptoms, motivated by external incentive such as avoiding military

duty, avoiding work, obtaining financial compensation, evading criminal prosecution, or obtaining drugs”

(American Psychiatric Association, 2000, p. 739). The DSM-IV-TR explains that under some conditions,

malingering may represent adaptive behavior (e.g., feigning illness while captive of the enemy during

wartime), however in the neuropsychological context, malingering seems to be most often associated with

monetary compensation (Binder, 1992). Assessment of malingering is as important in criminal as in civil

cases; only the motivational sources differ. Malingering of psychosis is more frequently seen in criminal

settings, versus the malingering of impairment due to head injury typical of civil cases (Resnick, 1997). For

the criminal, motivational factors are encompassed more so by the avoidance of prosecution and

punishment (Larrabee, 2000a).

It is wisely suggested that a clinician attend to the possibility of malingering anytime financial

issues or other external incentives are present. Van Gorp (2007) addresses the importance of a formal

assessment of motivation to perform to one’s best functional ability. He argues that sufficient effort made

by the physician toward providing a formal assessment should be of standard neuropsychological practice

in any evaluation that has any direct or indirect incentives for the examinee to malinger, which, in forensic

neuropsychology, tends to be the case.

Studies by Binder and Willis (1991; Binder ,1992) have found that patients with mild head trauma

and resulting financial incentive performed much worse on forced-choice tests than those who had well-
   15  

documented brain dysfunction. Forced-choice techniques have been demonstrated (Pankratz, 1979;

Pankratz, Binder, & Wilcox, 1987; Pankratz, Fausti, & Peed, 1975) to be an effective means of assessing

questionable sensory deficits. In 1983, Pankratz suggested that forced-choice techniques could clarify

questions concerning complaints of feigned memory and other neuropsychological issues. Forced-choice

strategies assess specific abilities through a large number of multiple-choice items where a person’s

performance is compared to likelihood based on chance alone, where the probability of correctly guessing

one of the two choice responses is 50%. Any score that is significantly lower than 50% can only be

explained by suggesting that the patient chose not to report the correct answer, although he or she must

have perceived the sensory cues, and therefore was motivated to perform poorly for some unknown reason

(Pankratz & Binder, 1997; Rogers, Harrell, & Liff, 1993). An implication that can be derived from these

results on forced-choice tests is the role of sensory-perception and motor performance in detecting

malingering. Demonstrated by brain injury simulation studies of malingering (Benton & Spreen, 1961;

Bruhn & Reed, 1975; Heaton, Smith, Lehman, & Vogt, 1978), more deficits seem to be associated with

sensorimotor measures than assessments of cognitive ability when brain injury is being faked in testing.

Rey’s 15-Item Test. Other tests that have been reviewed as strategies for detecting malingering in

neuropsychological testing (Binder, 1992; Lezak, 1995), such as Rey’s 15-Item Test (Rey-15), appear to be

difficult, when in reality are performed easily when motivated, even by those with significant impairment;

these are most likely the best measures of effort and motivation in testing (Pankritz & Binder, 1997). The

Rey-15 is made up of 15 different items, from five commonly used elements (i.e., numbers, letters,

symbols) arranged in their typical and familiar sequential order (Figure 1). In terms of how to interpret a

patient’s results on this test, Rey (1964) stated the following, “If the patient is not intellectually weak, if he

is not suffering serious mental deterioration, and especially if he is sincere and cooperates faithfully, he will

reproduce the 15 signs without difficulty” (p. 122). However, a cutoff score should be determined for

assessing malingering, and Frederick (2000) utilized several methods in order to estimate that the cut-off of

fewer than nine items was “moderately sensitive (58% to 89%)”, “highly specific (96% to 98%)” and

applicable to forensic settings with a reasonably low base rate of significant neuropsychological injury or

impairment, such as mild head trauma cases, which have been shown to be more likely to malinger (Binder,

1992). The test is commonly used in neuropsychological practice as a test of effort due to its ease of
   16  

 
 

E
 

L  
 
 
R
 
 

MP E   F O
A  U G  
 
S
S
 

T
 
 
O I N
 
  N ST
 
 
  DO T E
 
 
Figure   1.   A   sample   of   the   Rey’s   15-­‐item   Test   for   malingering.   These   are  15   commonly  
used  items   for   the   test   of   effort;  includes  five   groups   of   three   commonly   seen   symbol  
sequences.  Individual  under  evaluation  is  asked  to  recall  these  from  memory,   a  task  
that   should   be   very   easily   accomplished  by   even   those  with   severe   brain   impairment.  
Adapted  from  Rey  A.  (1964).   L’Examen  clinique  en  psychologie.   Paris,  France:   Presses  
Universitaires  de  France.  
   17  

administration, however it has been know to frequently report false-positives (e.g., classifying genuine

effort as malingering) and thus is argued to not be the solely relied on method (Pankratz & Binder, 1997).

Dot Counting Test. Binks, Gouvier, & Waters (1997) introduced the idea of bringing in new and

more standardized tests for measuring motivation and malingering. Rey’s Dot Counting Test (DCT: Rey,

1964) has been argued as useful for detecting malingering (Lezak, 1983), and involves the test-taker to

count as many dots on a 3x5 index card as quickly as possible. The methodology behind the test is in the

fact that malingerers (and often psychopaths) will respond to stimuli without any relationship between the

intensity of their response and the intensity of the perception (Rey, 1941). The test involves two packets of

6 cards, the first packet with ungrouped dots, and the second with grouped dots (Figure 2). The subject is

presented, in an irregular order, tasks of increasing difficulty (Rey, 1941). A study by Binks et al. (1997)

demonstrated that malingering can be suspected when there is an atypical differences between response

times for counting grouped versus ungrouped dots, as well as when deviations from linearity occur in

counting time association with number of dots, which is supportive of Rey’s methodology concerning

malingerer’s irregular response patterns (Rey, 1941; Lezak, 1983). However, they found that the most

important predictor for malingering is gauged by the total sum of incorrect dot counts, which is a quick and

easy result to determine.

Intelligence. Although the concept and measurement of intelligence is extremely important,

especially in the world of clinical and forensic neuropsychology, there has historically been several issues

defining what exactly intelligence is (Reitan & Wolfson, 1993). Psychological concepts of intelligence

were typically centered within the realm of academic and social ability, but Halstead (1947) stated that this

standard conceptualization of intelligence was too variable and too often related to equally poorly defined

and overlapping criteria. The task of defining intelligence has been difficult for psychologists for as long as

the field has been in existence, and some say that there is no hope in ever doing so explicitly, not only

because of the nature of what the concept of intelligence is, as well as the nature of concept (Neisser,

1979). The lack of an objectively defined theory of intelligence obviously creates problems concerning its

measurement, thus the reliability and validity of standard psychological measurements of intelligence need

to be questioned (Reitan & Wolfson, 1993).

   18  

 
 
 

E
 
 

L  
 

R
 

P
 

O
 

F
 

 
M
 

E  
 

A  U G
S
 
 

S
 
 

T N
 

O I
 

N EST
 

 
 
 

O
 

T
 

D
 
 
 
 
 
 
 
 
 
 
 
Figure  2.  Example  of  the  stimulus  packets   for  the  Dot   Counting  Test   for  malingering.  The  
top   card   shows   19   ungrouped   dots   and   represents   the  first   packet   of   dot   counting   stimuli,  
and   the   card   below   shows   four   groups   of   five   dots   and   represents   the   second   packet.  
Adapted   from   Boone,   K.,   Lu,   P.,   &   Herzberg,   D.   (1997).   The   Dot   Counting   Test   Stimulus  
Booklet.  Torrance,  CA:  Western  Psychological  Services.  
   19  

Meanwhile, the field of clinical neuropsychology has maintained their basic conceptual orientation

of intelligence and adaptive ability toward the biological adequacy of brain functions (Reitan & Wolfson,

1993). In 1947, Halstead argued that the approach to defining intelligence would be more meaningful if a

relationship could be established between what is seen as intelligible performance and the underlying

biological function and structure. It is believed by many that the added dimension of biological adequacy in

brain function would greatly benefit the long-lived issue of measuring intelligence in an objective and valid

manner. Unfortunately, little effort has been made to develop theories of brain mechanism and intelligence,

however results from some studies have suggested that neuropsychological measures and brain-related

criterion may be able to broaden our concept of intelligence and contribute to a better understanding of its

nature (Halstead, 1947; Hebb, 1939; 1941; Reitan, 1959; Reitan & Wolfson, 1988;1993)

Wechsler Adult Intelligence Scale: Third Edition. Wechsler originally defined intelligence as the

“capacity of the individual to act purposefully, to think rationally, and to deal effectively with his

environment” (1944, p. 3). He believed that intelligence should be measured both by verbal and

performance task, for both measured ability in different ways in which they could accumulate to form a

general, global construct of intellectual ability. Wechsler knew from scientific experience that there were

additional variables playing a role in the unexplained variance of intelligence, and he believed them to be

made up of basic human motivations, personality traits, attitudes, and other connotative dispositions that

are only indirectly relevant to one’s intellectual ability through cognition (Wechsler, 1944).

The Wechsler Adult Intelligence Scale: Third Edition (WAIS-III)2 began with the Wechsler-

Bellevue Intelligence Scale (Wechsler, 1939)—the first of David Wechsler’s scales of intelligence—and is

based on the idea that intelligence is a global entity; it can characterize an individual’s behavior as whole,

while intelligence simultaneously is a specific concept that is comprised of unique, individual parts of

cognitive functioning. Research supports the notion that a composition of several specific functional

abilities appear to come together in a gestalt-like fashion to make up the higher-order cognitive domains

which result in intelligence (Carroll, 1993; Keith, 1990). Wechsler’s scales for assessing intelligence are

viewed by many psychologists as constituting the core measures of neuropsychological assessment

(Crawford, 1992).
   20  

The WAIS-III was published in 1997 with updated normative data that was stratified by age, sex,

ethnicity, education, and geographical area of residence (Wechsler, 1997). Some of the main advantages of

the Wechsler Scales are its extensive standardization sample that is highly representative of the U.S.

population, its psychometrically sound properties, such as scaling, reliability, and validity, as well as its

wide range of coverage over a high number of cognitive functions through 14 distinct subtests (Crawford,

1992; Golden, 1981). Upon evaluation by the WAIS-III, one will receive a Full-scale IQ (FSIQ) score,

which is a reliable representation of global intellectual functioning and determined by one’s Verbal IQ

(VIQ) and Performance IQ (PIQ), the two measurements Wechsler believes to be the most important for

determining intelligence. Four useful indices of cognitive ability are offered in the WAIS-III, which include

Verbal Comprehension (VCI) Perceptual Organization (POI), Working Memory (WMI), and Processing

Speed (PSI). Further, each of these indices are composed of up to four subtest (14 total) regarding specific

abilities within each domain, as well as relations to certain gross functional areas in the central nervous

system (Van Gorp, 2007; Wechsler, 1997). These subtests that make up the WAIS-III are the following:

Picture Completion, Vocabulary, Digit Symbol-Coding, Similarities, Block Design, Arithmetic, Matrix

Design, Digit Span, Information, Picture Arrangement, Comprehension, Symbol Search, Letter-Number

Sequencing, and Object Assembly. The composite structure of the individual measures of the WAIS-III

parallels Wechsler’s ideas about the structure of intelligence itself. The structure of the test, along with

corresponding measurement and functional relations between subtests and cognitive abilities are

represented in Table 2.

Learning and Memory. Difficulty with memory is the most common complaint of individuals

with neuropsychological dysfunction (Butters, Soety, & Glisky, 1998). Memory is not a unitary construct

(Berg, Franzen, & Wedding, 1987), therefore a memory screening should cover all of the functional areas.

Some of these parts include verbal memory, visual memory, immediate memory, the addition of

information to recent memory, the extent of recent memory, and the capacity of the individual for new

learning (Lezak, 1983). Relatively poor performances on tests of immediate memory may indicate

depression and result in the need for a differential diagnosis. Immediate memory impairment is also an

early sign of several neurological conditions that can lead to overall cognitive deterioration. (Berg et al.,

1987).
   21  

Table  2  
 
The  Structure  of  the  Wechsler  Adult  Intelligence  Scale:  Third  Edition  
   22  

Most nonverbal memory tests will utilize visual memory, and thus require some sort of visual

stimuli such as designs or nonsense figures. The Visual Reproduction subtest of the Wechsler Memory

Scale tests immediate visual memory and requires the examinee to draw a briefly viewed design from

memory as accurately as possible. Impaired design reproductions have been shown to be associated with

right hemisphere lesions, regardless of specific lesion site (McFie, 1960). Mayes (1988) demonstrated that

damage to the posterior association cortex is involved in a variety of material-specific short-term memory

processes, as well as impairments in previously well-established memories and semantic memory. Frontal

associations cortex lesions are suggested to result in impairments of the types of memory involved in

planning and information processing.

Digit Span. The most widely used test of verbal immediate memory is the Digit Span Subtest of

the WAIS-III, which makes up part of the WMI and is calculated as part of VIQ (Wechsler, 1997). The test

involves the recollection of an orally stated series of numbers both forward and backward (Figure 3). This

task provides a measure auditory short-term memory, meanwhile accessing functions of working memory,

memory span, immediate auditory memory, and auditory sequential processing.

The Digit Backward segment also provides a good measure of the individual’s ability to juggle

information mentally, as well as their capacity to simultaneously use their working memory and a reversing

operation to effectively reverse the verbal sequences (Lezak, 1983). The immediate memory assessed by

the Digit Span tends to me most vulnerable to left hemisphere dysfunction (Berg et al., 1987). In a study by

McFie (1975) subjects with left frontal lesions typically performed worse on the Digit Span (forward).

Scores on this subtest tend to be at their lowest point immediately following a brain injury; they will

typically increase over time, however, but will usually remain relatively lower than other subtest scores,

which often resulted in a reduced VIQ and was associated with impairment in verbal associative learning of

the WAIS-III (Wheeler & Reitan, 1963).

Letter-Number Sequencing. Although the Letter-Number sequencing subtest of the WAIS-III is

only a supplementary task, it makes up part of the WMI. The test can only supplement for the Digit Span

test if necessary, and if so, will contribute to VIQ. The assessment involves the reading of a sequence of

letters and numbers (e.g., L-3-H-8-T-4) where the test-taker is instructed to recall the sequence, however to
   23  

 
 
 

L E R  
MP E   F O
S T A  U G  
I N
S
NO T
O   E S
 
 
D T  

Figure  3.  A  sample  of  the  Digit  Span  Subtest  of  the  WAIS-­‐III.  The  subtest  involves  an  oral  reading  
of   number   sequences   followed   by   the   recollection   of   these   sequences   by   the   examinee.   The  
Digits   Forward   section   requires   recollection   of   the   numbers   in   the   same   order   to   which   they  
were   initially   stated.   Digits  Backward  requires  the   sequence  of   numbers   to   be   recalled   in   the  
reverse   order   to   which   they   were   initially   reported,   for   example   the   correct   response   on   the  
first   sequence   of   item  two   would   be   “9   –   2   –   6”.   Adapted   from  Wechsler,   D.   (1997).   Wechsler’s  
Adult  Intelligence  Scale:  Third  Edition,  Testing  Booklet.  San  A ntonio,  TX:  PsychCorp.  
   24  

report it back in numerical (lowest to highest) and alphabetical order (i.e., 3-4-8-H-L-T). This task involves

cognitive processes such as short-term auditory memory and auditory sequential processing (Hernandez,

2012). Other functional aspects of memory are reflected through this assessment, such as memory span,

immediate auditory memory, concentration, and numerical ability. Impairment in these areas has been

associated with dysfunction of the left hemisphere (Butters, Soety, & Glisky, 1998).

Language and Verbal Ability. Tests of verbal fluency should allow one to evaluate the readiness

with which subjects are able to produce variable behavior (Parker & Crawford, 1992) Language abilities

are essential to assess because evaluating the dominant hemisphere is important for determining the

presence of damage. Language abilities also play a necessary role in conceptual reasoning and effective

verbal communication, which is especially important in forensic neuropsychological cases involving

question of a defendant’s competency in understanding the legal proceedings of his or her case (Van Gorp,

2007). Evaluations involving semantic and phonemic fluency are often utilized in determining one’s verbal

functioning as it relates to the brain.

FAS test of phonemic fluency. Tasks of phonemic fluency involve saying as many words as

possible beginning with a specific letter, within a specified time period. The FAS is one of the best known

phonemic fluency tests and involves the saying of words beginning with the letters F, A, and S one at a

time for one minute each (Benton, 1968). Studies have shown tests of phonemic fluency to have a direct

correlation with activity in the frontal lobes, especially in the left prefrontal areas (Machado et al., 2009;

Parker & Crawford, 1992; Ravnkilde, Videbach, Rosenberg, Gjedde, & Gade, 2002). Based on several

PET-studies, it has been suggested that the left prefrontal cortex is involved with the gathering of

information from semantic memory (Posner, Peterson, Fox, & Raichie, 1988). The semantic memory’s

function is in providing general knowledge of the world as well as contributing to the encoding process into

episodic memory, which provides a person with his or her memory of consciously recollecting some

personally experienced event (Nyberg, Cabeza, & Tulving, 1996). Tests of Verbal Fluency have been

shown to entail both of these events simultaneously. For in order to generate different words beginning

with the same letter, these new words must be retrieved from semantic memory, and meanwhile the event

that a word has been generated must be stored into episodic memory so that it is not repeated (Ravnkilde et
   25  

al., 2002). Dysfunction or lesions of the left dorsolateral prefrontal cortex can directly result in changes in

an individual’s functioning in response initiation, strategy planning, and attention (Milner, 1964; Perret,

1974).

Vocabulary. The Vocabulary subtest of the WAIS-III is part of the VCI and is involved with

calculation of VIQ. This test of verbal ability involves the individual under evaluation to orally define

words. Performance on this test is known to be associated with disorders of following instruction and of

general deterioration, such as Alzheimer’s disease. However it is primarily used to measure crystallized and

lexical knowledge, verbal comprehension, verbal fluency, and richness of ideas (Hernandez, 2012).  This

subtest often serves as a baseline level of functioning against which other tests of verbal ability can be

compared to. If performance on the comparative tests is significantly lower than Vocabulary scores, brain

dysfunction is a good possibility (Golden, 1981).

Comprehension. The Comprehension subtest of the WAIS-III makes up part of the VIQ score.

This test assesses the individual’s ability to understand everyday situations. It is sensitive to abilities

involved in practical reasoning and judgment, their application to social situations, as well as to moral and

ethical judgment. The Comprehension test is also a measure of language development and verbal

comprehension (Hernandez, 2012). Several studies have found this subtest to be one of the most stable and

reliable of all the WAIS-III evaluations of brain-injured patients (Golden, 1977).

Visual and Perceptual function. Many functions of visual and perceptual function can be

affected by brain damage, including recognition of words, faces, colors, and symbols (Berg, Franzen, &

Wedding, 1987). Important functions such as the ability to orient one’s self in space, work with spatial

coordinates, discriminating between colors, attending symmetrically to objects in space, and see the left

visual field are associated with the right hemisphere of the brain (Joint & Goldstein, 1975; Levy, 1974). As

with the variety of visual and perceptual abilities that can be affected through brain  damage, many

neuropsychological assessments are available to assess these.

Picture Completion. The Picture Completion subtest of the WAIS-III is part of the POI and is

calculated into PIQ. This subtest measures visual discrimination via assessing one’s ability to differentiate
   26  

between important details, and it assesses crystallized knowledge of visual processing and visual-perceptual

organization as well as attention, nonverbal reasoning, and nonverbal ability (Hernandez, 2012; Wechsler,

1997). Poor performance on this subtest has been associated with right Frontal Lobe lesions (Golden,

1981).

Hooper Visual Organization Test. The Hooper Visual Organization Test (HVOT) is a brief

screening instrument that is capable of measuring the ability of the test-taker to organize visual stimuli, a

skill that is often impaired by certain neurological dysfunction. The test is also used to assess one’s

concrete response style, and ability to integrate fragmented pieces into a gestalt (Golden, 1981). The exam

involves 30 line drawings that depict simple or familiar objects. The drawings have been cut into pieces

and are randomly arranged in a puzzle-like fashion (Figure 4). The individual under assessment is asked to

state what the drawing would identify if the drawings were arranged correctly. It has been demonstrated

that successful performance on the task depends on the heavily one’s visual analytic and synthetic abilities,

as well as on the individual’s capacity to label objects either verbally or in writing (Hooper, 1983). The test

was designed for administration without any time limit, however it typically requires about 15 minutes to

be administered and scored. Sternberg and Salter (1982) demonstrated that the amount of time it takes a

particular individual to respond on certain cognitive tasks is influenced by many factors, such as rate of

information processing, manual dexterity, and sensory acuity, and these factors can be easily influenced by

transitory disruptions or inefficiencies caused by the individual’s current level of arousal. The absence of

time limits for the HVOT avoids inflicting anxiety or increasing the biochemical state of arousal in the

individual, thus making the test a more specific measure of visual integration ability (Hooper, 1983).

The HVOT has shown to be a sensitive indicator of both right- and left-hemisphere dysfunction

(Boyd, 1981; Wang, 1977). However, it is meant to be used as a screening instrument or to measure an

individual’s cognitive ability for visual integration specifically, and should be used alongside other tests of

cognitive functioning for more specific ideas about dysfunction. This instrument appears to reflect both

general and specific cognitive functions, including arousal, visual analysis and synthesis, concept

formation, short- and long-term memory, and written or verbal labeling of familiar objects. It provides a

measure of perceptual organization and perceptual aspects of performance deficits on complex tasks (e.g.,
   27  

SAMPLE  
DO  NOT  USE  FOR  
TESTING  
 
SAMPLE  
DO  NOT  USE  FOR  
TESTING  
Figure   4.   Sample   of   stimulus   cards   for   the   Hooper   Vistual   Organization   Test.   This   is   for   an  
assessment   of   visual   organizational   ability.   Individual   under   evaluation   is   instructed   to   identify  
what  the  objects  within  the  pictures  would  be  if  they  were  not  cut  up  and  rearranged.  Adapted  
from   Hooper,   H.   E.   (1983)   Hooper   Visual   Organization   Test:   Manual.   Beverly   Hills,   CA:   Western  
Psychological  Services.  
 
   28  

block design or object assembly tasks). The HVOT is a relatively specific assessment of impaired

conceptualization or structure dependency, and is independent of verbal ability, short-term memory

impairment, and deficits in sensorimotor functioning (Hooper, 1983).

Matrix Reasoning. The Matrix Reasoning Subtest is involved in the calculation of PIQ, and it

makes up part of the POI. The assessment consists of the individual identifying one of five options for what

best completes a visual pattern matrix that is missing some part. This test measures visual analogic

reasoning and assesses abilities such as spatial relations, fluid reasoning ability, mental transformation and

visual-perceptual discrimination (Hernandez, 2012).  

Picture Arrangement. Another subtest of the WAIS-III that contributes to PIQ is the Picture

Arrangement Task where individuals are to sequence several cartoon-like pictures in such a way that they

are to tell some kind of story. Higher scores are give to those whose pictures are arranged logically, and

done so within the allotted time period, which ranges from 30 to 120 seconds depending on the item. The

test involves sequencing, social sophistication, visual recognition, and processing. Ability to organize and

integrate visual and perceptual information is measured, and utilization of general information and

reasoning, along with speed of mental processing, spatial perception, and visual processing is required

(Hernandez, 2012).

Attention and Concentration. Unlike other domains of functioning that can be localized,

disorders of attention occur following damage to a variety of different cortical and subcortical regions and

can even arise from external neurophysiological factors such as metabolism or mood. For these reasons of

ambiguity, attention is best studied through assessment of certain aspects of behavior in which there is an

interest in the behavior’s attentional component (Van Zomeren & Brouwer, 1992). Attentional impairments

occur in people who are able to perceive sensory input, comprehend language, form and retrieve memories,

and perform other cognitive functions, however these abilities occur inconsistently. Attentional processes

influence other core cognitive functions, such as perception and memory, through facilitation,

enhancement, or inhibition of their standard activity (Cohen, Malloy, & Jenkins, 1998). A primary function

of attention is to facilitate the selection of sensory information that is relevant to a specific task, in order for

it to be processed. Attention is also capable of influencing the way in which we respond to certain
   29  

demanding stimuli, a function referred to as response bias or control, which can be conceptualized as

intentional focus. Focus is a direct function of one’s attentional capacity, which can be reduced greatly

upon brain damage (Cohen, 1993; Kahneman, 1973). It is clear that attention cannot be defined with a

single sentence, nor cannot it be localized to a specific brain region, thus it seems reasonable that attention

cannot be assesse with only one test (Van Zomeren & Brower, 1992). Several neuropsychological tests

have implications for certain aspects of attention, but in order to get a relatively good idea of an

individual’s attentional abilities, more than one single test need be applied.

The Stroop Color-Word Interference Test. The Stroop Color-Word Interference Test (Stroop)

monitors the capacity to maintain a uniform course of action independent of intruding stimuli. It requires

patients to demonstrate flexibility by shifting their perceptual set to adapt to changing situations. It can be

used as a measure of verbal fluency, effortful processing, attention, and response inhibition, as well as a

general test of cognitive efficiency (Berg et al., 1987; Ravnkilde et al., 2002). The Stroop consists of five

columns of 20 words in a largely random order, where the words “red” printed in green or blue ink, “green”

printed in red or blue ink, or “blue” printed in red or green ink. The examinee is instructed to start at the

beginning of the leftmost column and move down it before moving to the next column to the right. The

examinee is allotted 45 seconds to state the color of ink that each word is printed in, and not to read the

word itself.

Poor performance on this test may be indicative of frontal lobe dysfunction (Perret, 1974), which

is mainly involved in higher-order, or executive, cognitive processes (Berg et al., 1987; Golden, 1978).

However more recent studies have consistently demonstrated the roles of the anterior cingulate gyrus and

prefrontal cortex (Carter, Mintun, Nichols, & Cohen, 1997; Peterson et al., 1999; Ravnkilde et al., 2002).

Activation of the anterior cingulate gyrus has been reported in studies of divided attention (Corbetta,

Miezin, Dobmeyer, Shulman, & Peterson, 1991), motor action (Paus, Petrides, Evans, & Meyer, 1993),

emotion (Devinsky, Morrel, & Vogt, 1995), and expectation (Murtha, Chertkow, Beauregard, Dixon, &

Evans, 1996). A more recent study by Ravnkilde et al., (2007) demonstrated activation of the

supplementary motor cortex, which is involved in visuospatial attention and with the temporal orienting of

attention, which is exemplified by “the ability to focus resources in order to optimize behavior at a
   30  

particular moment in time” (p. 542).

Trail Making Test. The Trail Making Test (TMT) of the Halstead-Reitan Neuropsychological

Battery has been shown to be a good identifier of over all brain function, and demonstrated to be is

significantly correlated with IQ scores (Boll & Reitan, 1973; Lezak, 1983; Golden, 1981; Smith, 1963) The

test consists of parts A (TMTA) and parts B (TMTB), where TMTA involves randomly placed circled

numbers (1-25) on a sheet of paper, and TMTB involves randomly placed circled numbers (1-13) and

letters (A-L) (Figure 5). The examinee is instructed to draw a connecting line between numbers (TMTA) or

alternating between numbers and letters (TMTB). The TMT requires the ability to immediately recognize

the symbolic significance of letters and numbers, to visually scan the page to identify the next number or

letter in a sequence, flexibility in alternating number and letter sequences, and doing so under the pressure

of time. Because the ability to quickly and efficiently perform well on this test, adequate brain functioning

is required, thus making the TMT (parts A and B) a good measure of overall brain function (Reitan, 1958).

TMTB monitors planning ability as well as visuo-motor speed and concentration. When time to complete

TMTB is significantly longer than time to complete part A, it is likely that the patient suffers a deficit in

complex conceptual tracking or sequencing (Berg et al., 1987). The ability to deal with symbols of

numerical and alphabetical value is a function of the left cerebral hemisphere, while the visual scanning

task involved in perception of spatial distribution is sustained by the right cerebral hemisphere (Reitan &

Wolfson, 1993).

Digit Symbol coding. The Digit Symbol subtest of the WAIS-III is part of the PSI and

consequently involved in PIQ. The task consists of a task of decoding a series of symbols for which a key is

provided that corresponds each symbol to a certain letter between 1 and 9 (Figure 6). The individual is

instructed to decode as many consecutive symbols as he can within 120 seconds, and score is based on

accuracy and completion. This subtest requires rapid processing of symbolic information and is used to

evaluate visual scanning ability, processing speed, short-term memory, visuomotor coordination,

attentional capacity and concentration.

   31  

LE  
MP R  
SA
T   U S E   F O
  NO N G  
DO S T I
TE
Figure  5.  Sample  of  the  Trail  Making  Test  parts  A  and  B.  The  picture  on  the  left  demonstrates  part  A  
of  the  Trail  Making  Test,  where  examinee  is  instructed  to  connect  the  circles  in  sequential  order,  
beginning  at   number  1  and   ending  at  number  25.  The  picture  on  the  right  demonstrates  part  B  of  
the   Trail   Making   Test,   where   examinee   is   instructed   to   draw   a   line   connecting   the   numbers   and  
letters   sequentially,   while  alternating  between   the  two  (e.  g.,  1-­‐A-­‐2-­‐B-­‐3-­‐C),  beginning   at  number  1  
and  ending  at  number  13.  Adapted  from  Reitan,  R.  M.,  &  Wolfson,  D.  (1993).  The  Halstead-­‐Reitan  
nd
neuropsychological   test   battery:   Theory   and   clinical   interpretation   (2   ed.).   Tucsan,   Arizona:  
Neuropsychology  Press.  
   32  

SAMPLE  
DO  NOT  USE  FOR  
TESTING  
SAMPLE  
DO  NOT  USE  FOR  
TESTING  
                                                           

 
 
Figure  6.   Sample  of   Digit   Symbol   subtest   of   the  WAIS-­‐III.   A   coding   task  where  the   symbols  from  
the  key  on  top  are  used  to  fill  in  the   block  with  its  corresponding  number  in  the  rows  below.  
Adapted   from   Wechsler,   D.   (1997).   Wechsler’s   Adult   Intelligence   Scale:   Third   Edition,   Testing  
Booklet.  San  A ntonio,  TX:  PsychCorp.  
   33  

Symbol Search. The Symbol Search task is a supplementary subtest of the PIQ scale of the WAIS-

III, but required for determining the WMI score. This subtest involves a visual task of 60 items, where the

examinee is instructed to determine if either of two symbols is present amongst a group of five similar

symbols (Figure 7). Performance on this task provides measures of visual perceptual discrimination and

scanning ability, and reflects abilities concerning perceptual speed, processing speed, psychomotor speed,

and speed of mental processing (Hernandez, 2012).

Ruff 2 & 7 Selective Attention Test. Two overlapping aspects of visual attention are sustained

attention and selective attention; the Ruff 2 & 7 Selective Attention Test (Ruff 2 & 7) was developed to

measure these. In the user’s manual, Ruff and Allen (1995) define sustained attention as “the ability to

maintain a consistent level of performance over an extended period” and selective attentions as “the ability

to select relevant stimuli (targets) while ignoring salient but irrelevant stimuli (distractors)” (p. 1). The task

consists of a series of twenty 15-second trials in which the individual is performing a visual search and

cancellation task. The task is to detect and eliminate various target 2s and 7s, which are intermingled within

a row of distractor symbols (e.g., O X C 7 M T K 2 G I). The duration of each trial is five minutes, which is

the minimum amount of time it takes to measure one’s ability to sustain attention (Broadbent, 1971;

Parasuraman & Davies, 1984). The test is scored by totaling the speed and accuracy of target detection.

The Ruff 2 & 7 requires detection of external stimuli, rather than internal information processing,

and thus maximum efficiency on the test requires self-initiated activity and “a high level of vigilance to

external stimuli across a sustained period of time” (Ruff & Allen, 1995, p. 3). Studies have demonstrated

(Roland, 1982; Tucker & Williamson, 1984) that the right hemisphere largely regulates the ability to

sustain attention toward external stimuli, and activity in the visual association cortex (frontal eye fields,

right posterior cortex, and superior posterior cortex) is correlated with sustained attention to a targeted

visual modality. Sustained attention for visual tasks is influenced by motivation and incentive, and can also

be greatly affected by one’s energetic capacity or level of arousal. This has been shown to be related to the

fact the two functions are controlled by associations within midbrain systems, such as the mesenchephalic

reticular system which is involved in the production of arousal (Cohen, 1993; Pribram & McGuinnes,

1975) and its relation to the midbrain nuclei involved in the control of saccadic movement for visual search
   34  

E    
P L   F OR
M E
A  U G  
S
S NO T
TI N
O   E S
D T  
Figure   7.  Sample   of  the   Symbol  Search   subtest  of  the  WAIS-­‐III.  Individual  is  
required  to  determine  if  either  of  the  two  symbols  on  the  far  left  side  are  
present   in   the   group   of   five   symbols   on   the   right   side,   and   indicate   their  
response  by  crossing  through  the  YES  or   NO  box.  Adapted  from  Wechsler,  
D.  (1997).  Wechsler’s  Adult  Intelligence  Scale:  Third  Edition,  Testing  Booklet.  
San  A ntonio,  TX:  PsychCorp.    
 
   35  

(Cohen et al., 1998).

Concept Formation, Abstraction, and Reasoning. Higher cognitive (executive) functions are

not associated with any specific process or localized area of the brain, rather cognitive abilities always

involve at least (1) the integrity of neuronal interconnections and interaction patterns that make up our

“thought” (2) the capacity to process at least two mental events simultaneously, (3) an extensive and easily

accessed data base of remembered learned material, and (4) in intact system for organizing perceptual

information (Berg et al., 1987). Concrete thinking is the most common indicator of cognitive impairment,

but is also often seen in individuals with limited education; it involves concept formation, generalizing

from a single instance, categorizing, and applying procedural rules and general principles to remembered

situations (Reitan & Wolfson, 1993). Cognitive rigidity often occurs in association with concrete thinking,

and can appear as the inability to shift and adapt perceptual organization, train of thought, or ongoing

behavior to current environmental situations. This can lead to inflexibility of concepts impairing one’s

ability to plan ahead, initiate activity, think creatively, or adapt to the demands of changing situations (Berg

et al., 1987; Malloy, Cohen, & Jenkins, 1998).

The Category Test. The Category Test of the Halstead-Reitan Neuropsychological Battery has

been known to be one of the best indicators of general brain function (Heaton, Miller, Taylor, & Grant,

2004) and appears to be closely associated with the brain-related potential for efficiency in practical

situations of one’s everyday experience. This test is mainly a test of concept formation ability as well as a

highly complex monitor of abstract thinking and logical analysis. The consequences to impairment in these

functions impact all aspects of living (Reitan & Wolfson, 1993). The test involves a projection apparatus to

present a series of 208 slides of “stimulus figures”, which are divided into seven subtests. The projection

apparatus has an answer panel below the screen with four levers numbered 1 to 4, which are used by the

examinee to select an answer; when answered correctly, a bell sounds, and incorrect answers receive a loud

buzzer. Examinees are instructed to determine principles that relate stimulus subsets by observing sets of

stimulus figures that vary in shape, size, number, intensity, color, and location, and are grouped by abstract

principles. Correct responses on the first two subsets are likely to occur on most items, unless the examinee

has severe brain damage and cannot recognize a pattern of correct and incorrect responses and adapt their
   36  

reasoning accordingly (Berg, et al., 1987).

Reitan and Wolfson (1993) describe the Category Test as unique compared to many other tests for

the following reasons: it is a complex test measuring concept formation, which requires the ability (1) to

recognize recurring similarities and differences among the stimuli material, (2) to hypothesize reasonable

ideas about the similarities and differences, (3) to test those hypotheses through reinforcement feedback,

and (4) to adapt one’s hypotheses based on the feedback following each response. Performance on the

Category test demonstrates the subject’s ability to change their behavior/decisions based on positive and

negative experiences, and involves the memory’s role in cognitive functions of organization and planning.

The Category Test has been shown to be sensitive to cerebral and frontal lobe damage as well as to reflect

damage to the left prefrontal regions, and on occasion to the right (Golden, 1981; Reitan & Wolfson, 1993).

Similarities. The Similarities Subtest of the WAIS-III is part of the VCI and is involved in

determining the VIQ. This subtest measures the test-taker’s ability to categorize two objects (e.g.,

Orange—Banana), as well as abstract thinking abilities, such as separating nonessential from essential

details, and concept formation. Although this is clearly a test of verbal ability, it doesn’t correlate highly

with VIQ scores, but is very sensitive to brain injury in the left temporal and parietal areas (Golden, 1981;

McFie, 1975).

Arithmetic. This subtest of the WAIS-III is associated with the WMI and is a factor in VIQ.

Individuals are required to solve simple and complex math problems without the use of pencil and paper

and under the pressure of time. This test measures functional cognitive properties involved in problem

solving such at fluid reasoning ability, working memory, attention, concentration, planning, and

mathematical ability, however this is not a test of mathematical potential (such as seen in tests of academic

achievement), but of quantitative reasoning skills and practical thought processes (Golden, 1981).

Motor function. Neuropsychological tests that measure manual motor functioning have been

useful in the detection of lateralized brain dysfunction (Berg et al., 1987). The HRNB identifies lateralized

cerebral damage by comparing performances of the same type (i.e., the Finger Tapping Test) on the two

sides of the subject’s body. This allows inferences to be made concerning the functional status of
   37  

homologous areas of the two cerebral hemispheres (Reitan & Wolfson, 1993). Assessments comparing

motor performance between the two sides of the body has been said to permit inferences about functional

efficiency of the hemispheres (Henninger, 1992).

Finger Tapping Test. Probably the most widely used test of motor functioning is the Finger

Tapping Test of the Halstead-Reitan Neuropsychological Battery (Reitan & Davidson, 1974). This test is a

measure of finger agility and tapping speed. It consists of a tapping key with a device for recording the

number of taps. Performance is measured by averaging amount of taps for five trials, for each hand, and

performance levels are expected to be affected by age and sex (Berg et al., 1987; Reitan & Wolfson, 1993).

The presence of cortical damage tends to result in a slowing in the rate of finger tapping at any age, and

lateralized lesions may show a marked decrease in tapping rate for the hand contralateral to the lesion (Berg

et al., 1987; Golden, 1981). The Finger Tapping test has been demonstrated as quite sensitive to damages of

frontal regions of the brain on both sides (Reitan, 1979), except when the deficits are limited to prefrontal

regions alone (Golden, 1981).

Block Design. Tests of block designs have been demonstrated to be some of the best indicators of

brain damage, especially that of the right hemisphere (McFie, 1975), but it also can be sensitive to lesions

associated with the left hemisphere, especially when they are involving the parietal lobe (McFie, 1960).

This subtest of the WAIS-III contributes to the PIQ and is involved in the POI. Individuals are required to

produce designs with six-sided blocks while looking at a model picture located in the stimulus book. The

ability to perform this task successfully and efficiently reflects one’s capacity for nonverbal reasoning and

visual spatial organization, a long with a measure of special abilities such as planning, fine-motor

coordination, spatial relations, and visual-motor coordination (Hernandez, 2012).

Object Assembly. The Object Assembly subtest of the WAIS-III is an optional measure of

Performance, but if taken will not contribute to PIQ. This task requires the assembly of ambiguous jigsaw

puzzle-like pieces to form commonly seen objects within a given time limit. This test involves visual-

perceptual organization and processing, but is less sensitive to it than the Block Design subtest is (Golden,

1981). Other functions involved include perception of meaningful stimuli, motor activity, motivation, and

persistence.
   38  

Emotional Status. Emotion is an observable, public event that represents an interaction between

the individual expressing the emotion and the relevant environmental situation or their cognitive

representation of the environmental situation. Their functional role is to signal the presence of a personally

relevant event in the environment and to prepare the individual for a specific action in response to salient

stimuli (Starratt, 1998). The assessment of emotional status in an individual with possible brain impairment

is necessary due to the influence emotions may potentially have on performance on neuropsychological

assessments (Miller, 1975; Newman & Sweet, 1992). Literature suggests that in response to loss of

function, or as a result of damage to the brain structures involved in the mediation of emotion,

neurologically impaired individuals will suffer from depression at some time in their illness (Reifler,

Larson, & Hanley, 1982; Robinson, Starr, Kubos, & Price, 1983; Starratt, 1998). According to Newman

and Sweet (1992), there three major areas of impairment that seem to be associated with clinical

depression: (1) psychomotor speed, (2) motivation and attention (sustained effort and concentration), and

(3) memory and learning.

Slowed motor and mental functioning are some of the most consistently demonstrated findings in

studies of depression (Blackburn, 1975; Miller, 1975; Nelson & Charney, 1981; Newman & Sweet, 1986),

a deficit that may indicate an association between poor visuospatial task performance and right parietal lobe

impairment (Abrams & Taylor, 1987). However, this is arguably not the case, for psychomotor slowing is a

symptom of depression, in and of itself, and may be the factor that results in slowed performance on tasks,

and only framing the right hemisphere as the source (Newman & Sweet, 1992).

The primary symptoms of depression involve a lack of energy and motivation, negative self-

assessment, and poor attention (particularly sustained attention) and concentration, and have been

suggested to significantly affect performance on neuropsychological assessment. (Heaton & Heaton, 1981;

Lezak, 1983; Newman & Sweet, 1992). Cohen, Weingartner, Smallberg, Pickar, and Murphy (1982) argue

that the neuropsychological deficits associated with depression, such as motivational and attention deficits

result from impairment in the “central motivational state”, which is primarily motivated by neurochemicals.

Their viewpoint on depression is that because depressed individuals perform worse on tasks of sustained

effort and concentration, they will perform better on tasks with minimal demand.
   39  

Studies of depression have shown that individuals suffering from the emotional deficit tend to

perform worse on tasks of memory than brain damaged (Kopelman, 1986) and even schizophrenic

individuals (Malec, 1978). Interestingly, memory test performance will actually fluctuate along with major

depressive episodes, becoming worse when depressed, and returning to normal levels when not depressed

(Johansen, Gustafson, & Risberg, 1985; Sternberg & Jarvik, 1976; Sweet, 1983). However some studies of

memory have not shown significant differences in performance on memory tasks for depressed, as opposed

to non-depressed, samples (Gass & Russel, 1986) and thus findings of research concerning memory deficits

are not yet conclusive (Newman & Sweet, 1992).

Beck Depression Inventory-II. The Beck Depression Inventory: Second edition (BDI) is a self-

assessment questionnaire used as a tool in determining an individual’s level of depression. There are 21

items concerning common characteristics and symptoms of depression, which are as follows: Mood,

Pessimism, Sense of Failure, lack of Satisfaction, Guilty Feeling, Sense of Punishment, Self-hate, Self

Accusation, Self Punitive Wishes, Crying Spells, Irritability, Social Withdrawal, Indecisiveness, Body

Image, Work Inhibition, Sleep Disturbance, Fatigability, Loss of Appetite, Weight Loss, Somatic Pre-

occupation, Loss of Libido. The individual is required to rate himself on a scale of 0 to 3, where 0 implies

lack of symptom/characteristic and 3 implies that that symptom/characteristic is fully present in the

individual. The ratings are totaled for all 21 items and level of depression is determined based on ranges

specified in the administration manual (Beck, Steer, & Brown, 1996). Scores ranging between 0 and 13

demonstrate minimal depression; 14 to 19 as mild depression; 20 to 28 as moderate depression; and 29 to

63 as severe depression. A study by Beck et al., (1961) demonstrated that the BDI was able to discriminate

between depressed and non-depressed groups of individuals effectively, as well as reflect changes in the

intensity of depression after an interval of time.

Academic Achievement and Aptitude. It is important to assess a patient’s premorbid intellectual

functioning in order to determine if a deficit is caused by brain damage, or if it is due to organic brain

dysfunction. One of the common ways of doing this is through tests of academic skills or achievement and

aptitude. These tests assess the examinee’s functional level in skills such as reading, writing, and

arithmetic. Performance in these areas can have important implications on a patient’s vocational
   40  

competence and ability to adjust to real-world situations (Berg et al., 1987).

The Wide Range Achievement Test: 4th Edition. The Wide Range Achievement Test: Fourth

edition (WRAT4) derived from the original version (i.e., WRAT), which was developed over 70 years ago

by Joseph F. Jastak (1984) as a supplement to the Wechsler-Bellevue Scales (Wechsler, 1938). The

WRAT4 was standardized on a representative national sample according to age, sex, level of education,

geographic region, and socioeconomic status. This assessment of academic skill monitors educational

achievement in reading, arithmetic, and spelling and provides a measure of the basic academic skills

necessary for effective learning, communication, and thinking. These skills are important to consider when

screening neuropsychological functioning of individual’s referred for learning, behavioral, or vocational

difficulties (Wilkinson & Robertson, 2006). Indication of impairment in these areas of academic skill has

implications of an individual’s vocational competence and overall adjustment abilities (Berg, Franzen, &

Wedding, 1987).

The WRAT4 is composed of four subtests, including Word Reading, Sentence Comprehension,

Spelling, and Math Computation. Word Reading provides a measure of ability to decode letters and words

through tasks involving the identification of letters and recognition of words. Sentence Comprehension

involves the use of a modified cloze (shortened form of closure) technique, where individuals are required

to fill in missing words from sentences (Figure 8). This subtest is used as a measure of one’s ability to

comprehend and gain meaning from the words, ideas, and information contained in sentences. Spelling

assess the ability to encode auditory information into written format through a task that requires the

individual to write out words and letters that are orally stated by the testing technician. Math Computation

measures basic mathematical skills and ability to perform computations through counting, identifying

numbers, solving simple oral problems, and calculating written mathematics problems. In addition to

deriving scores from the four subtests, the standard scores from Word Reading and Sentence

Comprehension are combined to form a highly reliable Reading Composite score, which indicates a

comprehensive measures of reading achievement (Wilkins & Robertson, 2006).

Information. The Information subtest of the WAIS-III measures the individual’s store of general

knowledge about the world (e.g., important historical dates or facts), and contributes to the VIQ as a
   41  

E    
P L   F OR
M E  
A  U G
S
S O T
N EST
I N
O  
   
D T  
 
Figure   8.   A  demonstration   of   the  closure   technique  used   for   the   Sentence  Comprehension  
subtest   of   the   WRAT4.   Individual   being   assessed   must  fill   in   the   blank   with   whatever  word  
is   missing   from   the   sentence.   Adapted   from   Wilkinson,   G.   S.,   &   Robertson,   G.   J.  
(2006).  Wide   Range   Achievement   Test   4   professional   manual.   Lutz,   FL:   Psychological  
Assessment  Resources.  
 
   42  

component of the VCI. The test-taker is required to answer questions regarding history, geography, time,

and science, and the results reflect his or her educational knowledge through measurements of fundamental

information and long-term memory capacity for factual information (Hernandez, 2012). This kind of

general knowledge tends to remain as stable in brain injury as vocabulary (Golden, 1977).

Neuropsychological Features and Forensic Aspects of Behavior

Despite the demand for forensic neuropsychological evaluation of criminals and especially of

those involved in civil litigations and disabilities, only a few studies have taken into account the

relationship between neuropsychological performance, neurocognitive characteristics, and behavioral

patterns within these different groups (Hanlon, Rubin, Jensin, & Daoust, 2009; Rassmussen, Almvik, &

Levander, 2001; Reitan & Wolfson, 1996), and even fewer, if any, for the differences of those between the

groups.

A study of differences between litigators and non-litigators (Reitan & Wolfson, 1996)

demonstrated that those involved in litigation, and thus could possibly receive compensation for their head

injury, were less likely to perform consistently on retesting. Also, those who were not involved in litigation

had better (not necessarily statistically significant) means on every retest. Litigants not only performed

worse on tests that are shown to reflect brain function (i.e. CAT), but also on those that are not closely

related to brain function (i.e. Vocabulary subtest of WAIS-III). This finding suggests that individuals

involved in litigation are more likely to exert less effort in testing than those who are not involved in

litigation.

In a study assessing performance on neuropsychological tests and its relationship with personality,

criminality and violence by Rasmussen, Almvik, and Levander (2001) criminal versatility and violence

were significantly related to deficits in verbal ability as well as dysfunction in attentional ability and

executive function, which were manifested in childhood and persistent ADHD. Spellacy (1978) conducted

a study involving violent and non-violent males from a penitentiary population and found that violent

prisoners performed worse on assessments for language, perceptual, and psychomotor abilities, which he

attributed to cognitive dysfunction as causing an inability to control aggression. Other studies of this type
   43  

have related TMT performance to aggression (Gudjonsson & Roberts, 1981), and have demonstrated that

psychopaths have similar performance patterns of frontal lobe dysfunction as to patients with frontal

lesions (Gorenstein, 1982). However, the most vigorous findings about mental function have been made

concerning verbal and attentional deficits among delinquents (Rassmussen et al., 2001).

In 1984, Hare conducted a study of dichotic listening (DL) and determined that psychopaths had a

small right-ear-advantage in verbal DL when compared to non-psychopaths. It is reasoned that this could

imply that psychopaths could “have a left hemisphere that is not strongly or consistently dominant for

language or that is underaroused” (Rasmussen et al., 2001, p. 40). This “under-arousal” hypothesis is

consistent with ideas about the underlying basis of attentional and executive dysfunctioning in those with

ADHD, where language ability in psychopaths is ineffective in regulating behavior (Rassmussen et al.,

2001; Schalling, 1978). Fischer, Barkley, Edlebrock, and Smallish (1990) conducted a longitudinal study

with children exhibiting symptoms of ADHD and concluded that they remained chronically impaired in

academic achievement, inattention, and behavioral disinhibition well into late adolescence. Other studies

have shown that young adults with ADHD-like deficits were significantly impaired on aspects of executive

functioning such as vigilance, semantic encoding for verbal memory, and written arithmetic, as well as

Stroop performance (Siedman, Biederman, Faraone, Weber, & Oullette, 1997; Siedman, Biederman,

Weber, Hatch, & Faraone, 1998).

Hanlon, Rubin, Jensen, and Daoust (2009) conducted a study concerning the crime-related

neuropsychological features of indigent murder defendants and death row inmates. The authors explain that

murder defendants tend to manifest a larger frequency of neurological impairment, involving attentional

disturbance, language dysfunction and intellectual impairment, and executive dysfunction, as well as

differences in neuropsychological status (as opposed to nonhomicidal, less violent criminals) involving

language, memory, and psychomotor speed. Neuropsychological deficits, such as executive dysfunction,

have been demonstrated by many studies (Foster, Hillbrand, & Silverstein, 1993; Morgan & Lillenfield,

2000) to associate with characteristics that increase the likelihood of violent impulsive aggression.

Lewis and his colleagues (1986; 1988) conducted neurological studies in adults and juvenile

delinquents condemned to death, and through CT or MRI scans revealed that 80% of adults and 50% of
   44  

juveniles evidenced neurological abnormality, whereas 33% of adult inmates and 9 of the 14 juveniles

manifested major neurological impairment. Studies involving the use of positron emission tomography

(PET scan) have demonstrated reduced activity in lateral and medial prefrontal cortex, as well as

hemispheric laterality effects involving increased activity in subcortical measures of the right hemisphere

(i.e., amygdale, hippocampus, and thalamus) in murderers relative to non-murderers (Raine, Buchsbaum, &

LaCasse, 1997).

In a follow up study with the same sample, Raine and colleagues (1998) classified the murderers

as either impulsive or controlled/planned based on the nature of their homicide, and found that impulsive

murderers had reduced prefrontal activity and increased activity in the right hemisphere subcortical

structures, whereas controlled/planned-type murderers demonstrated the same increase of activity in

subcortical structures of the right hemisphere, however lacked a decrease in prefrontal cortex activation.

History of head trauma has also been associated with aggression and criminal behavior (Hanlon et al.,

2009), where one study, although limited by small sample size (n = 15), demonstrated that 100% of death

row inmates in the sample had a history of severe head injury (Lewis et al, 1986).

This present study will be one of few that attempts to determine differences in neuropsychological

functioning and structure as it is related to behavior and test performance across the broad range of forensic

neuropsychological case-types, including: personal injury litigants, worker’s compensation claimants,

Social Security disability applicants, and death penalty inmates. Based on the literature concerning the

structure and function of behavior within these cases, the largest performance deficits should be

demonstrated in the death penalty subjects, and should include (at least) measures of executive functioning,

verbal ability, decreased intellectual functioning, and attentional deficits. This will most likely occur due to

the fact that all death penalty inmates were on trial in order to determine if they were competent for

execution based on the fact that they were mentally retarded (i.e., having an IQ of less than 70).

Impairments of right hemisphere and frontal lobe function will most likely be indicated, as well as possible

deficits in subcortical structures of the right hemisphere, such as the amygdala, hippocampus, and/or

thalamus.
   45  

Civil disability determination and liability cases should vary in performance depending on

litigational factors due to the decreased effort associated with compensatory opportunities. Social Security

disability applicants will likely score lower on the measures of cognitive function and crystallized ability,

whereas personal injury litigators and worker’s compensation claimants may perform lower on perceptual

and motor assessments, as is suggested in the literature concerning effort and compensation. Overall,

personal injury litigations are hypothesized to perform better on most tasks than the other cases, due to the

fact that they are least likely to have severe impairment in any specific area of premorbid functioning since

they make up a better representation of the general population than any other case, all of which exhibit bias

in some characteristic.

Method

Participants

A total of 160 participants (105 males, 55 females) were selected from an archived database of

individuals who presented at University Neuropsychology, a clinical neuropsychology practice in

Wilmington, North Carolina. The participant’s files were from the year 1972 to present, and were only

included in this study if Antonio E. Puente, Ph.D. or one of the qualified neuropsychological testing

technicians at his practice administered and scored the individual’s tests. Participants’ ages ranged from 18-

71 years (M = 39.15, SD = 12.52), those whose ages were more than two standard deviations from the

mean were excluded from the study. Participants’ ethnicities were Caucasian (n = 91), African American (n

= 15), or Hispanic (n = 54), and years of education3 ranged from 0-19 (M = 11.54, SD = 4.40). Participants

were divided into four types of case conditions (independent variables) based on their reason for receiving

neuropsychological testing (see Table 3, for case scores on individual tests): (1) Personal Injury (PI: n = 36,

18 male, 18 female; Mage = 43.50, SDage = 13.86, age range: 18-71; 29 Caucasian, three African American,

four Hispanic; Medu = 13.05, SDedu = 2.45, education range: 7-16 years) which included those who received

testing for litigational purposes regarding head injury liability, (2) Social Security Disability applicants and

recipients (SS: n = 43, 19 male, 24 female; Mage = 43.19, SDage = 12.20, age range: 24-63; 33 Caucasian,

nine African American, one Hispanic; Medu = 14.49, SDedu = 2.62, education range: 12-22 years), (3)

worker’s compensation claimants (WC: n = 37, 29 male, eight female; Mage = 40.22, SDage = 10.13, age

range: 18-62; 24 Caucasian, two African American, 11 Hispanic; Medu = 11.35, SDedu = 2.69, education
   46  

range: 6-16 years), and (4) capital offenders on trial for the Death Penalty (DP: n = 44, 40 male, four

female; Mage = 30.75, SDage = 9.28, age range: 18-58; five Caucasian, one African American, 38 Hispanic;

Medu = 6.67, SDedu = 4.24, education range: 0-15 years).

Materials

Data was gathered regarding each individual’s age, sex, ethnicity, handedness, reason for testing

(personal injury, social security disability, worker’s compensation, or death penalty), and their scores on 15

neuropsychological tests. The neuropsychological tests included were the following: the Wechsler’s Adult

Intelligence Scale: Third Edition (WAIS-III, see Footnote 2; including VIQ, PIQ, FSIQ, VCI, POI, WMI,

and PSI) from Wechsler (1997); the Trail Making Test (TMT; parts A [TMT-A] and B [TMT-B]) from

Reitan & Wolfson (1993). Normative data were derived from Tombaugh (2004); the Finger Tapping Test

(FTT; dominant hand [FTD] and non-dominant hand [FTD]) from Reitan & Wolfson (1993). Normative

data were derived from Mitrushina, Boone, Razani, and D’Elia (2005); the Hooper Visual Organization

Test (HVOT) from Hooper (1983). Normative data were derived from Mitrushina, et al. (2005); the Wide

Range Achievement Test: Fourth Edition (WRAT4; Reading [WRATR], Spelling [WRATS], and

Arithmetic [WRATA] subtests) from Jastak and Wilkinson (1984); the Beck Depression Inventory-II (BDI)

from Beck et al. (1996); The Ruff 2 & 7 Selective Attention Test (R27; including Total Speed [R27S] and

Total Accuracy [R27A]) from Ruff and Allen (1995); the FAS test of verbal phonemic fluency (Benton,

1968; Spreen & Benton, 1977). Normative data were derived from Mitrushina, et al. (2005). The Category

Test (CAT; Halstead & Settlage, 1943; Reitan, 1959; Reitan & Wolfson, 1993). Normative data were

derived from Heaton, Grant, and Matthews (1991); the Stroop Color-Word Test (Stroop CW; Golden,

1978; Stroop, 1935). Normative data were derived from Mitrushina, et al (2005); The Rey 15-item Test for

memory malingering (Rey-15; Rey, 1964); the Dot Counting Test for malingering (DCT; Lezak, 1995);

The Mini Mental Status Exam (MMSE) from Folstein, Folstein, and McHugh (1975); Dementia Rating

Scale: 2nd edition (DRS) from Jurica, Leitten, & Mattis (2011); and The Hopkins Verbal Learning Test—

Revised (HVLT) from Brandt and Benedict (2001).

Procedure and Statistical Analysis

Raw data from all tests were corrected for age, sex, and education (see Footnote 3) according to

the normative data provided by the tests’ publisher or the appropriate comprehensive norm handbook
   47  

(Heaton et al., 1991; Mitrushina et al., 2005) and then standardized as T scores by way of a standard

psychometric conversion table. Any scores above or below three standard deviations from the mean were

not included in analyses in order to dismiss outliers and to assume equal variances. The MMSE, DRS, and

HVLT were not included in analyses because less than 40% of the individuals in the sample completed

them, resulting in analysis of 12 assessments. Descriptive statistics were initially calculated for the entire

sample, however because of the large percentage of Hispanic participants included in the Death Penalty

case, a second set of descriptive statistics was calculated for only those involved in civil litigations (PI, SS,

and WC) in order to control for possible ethnic influence on the result interpretation. Two one-way

analyses of variance (ANOVAs) were calculated to determine differences, first between the individual test

scores among those only in the civil litigation cases, and a second for those between all four cases.

Raw scores for the Rey-15 and the DCT tests of effort and malingering were transformed into

dichotomous variables of Good Effort (Rey 15-item score ≥ 13; DCT score of ≤ 13) and Suspect Effort

(Rey 15-item Test score ≤ 12; DCT score of ≥ 14). Descriptive statistic calculations were performed to

determine the percentage of Good and Suspect Effort subjects there were for each group.

Based on the construct being measured by each of the tests, as determined by their respective

manuals, the 12 neuropsychological assessments were then grouped into ten functional-testing domains

(assessments included in parentheses): Academic Ability (WRATR, WRATS, WRATA); General

Intelligence (PIQ, VIQ, CAT); Learning and Memory (WMI, VIQ, FAS); Executive Functioning (CAT,

CW, TMTB); Language and Verbal Ability (VIQ, VCI, WMI, FAS); Perceptual and Visual Function

(HVOT, PIQ, POI, TMTB); Attention and Concentration (PIQ, R27A, TMTA); Abstraction and Reasoning

(POI, WMI, CAT); Concept Formation (VCI, HVOT, CAT); Motor Function (PIQ, TMTA, FTD)

Two Factorial Multivariate Analyses of Variance (MANOVAs) were performed on each of the 10

domains, one between only the civil cases, and the second on the entire sample. This was done in order to

determine if any significant differences were due to type of case, ethnicity, or an interaction between the

two. An alpha level of p < .05 was used on all analyses, excluding the tests of between-subjects effects

within the MANOVAs, where alpha level was determined by number of dependent variables (i.e., two DV

= p < .025; three DV = p < .017; four DV = p < .013). Tukey’s post hoc test was conducted for all

(M)ANOVAS, with an alpha level of p < .05.

   48  

Results

The results of the ANOVA and Tukey’s post hoc tests for civil litigation case scores demonstrated

statistically significant differences (refer to Table 3 for means and standard deviations) in the following

tests: Full Scale IQ, Verbal Comprehension Index, Perceptual Organization Index, Beck Depression

Inventory-II, Ruff 2 & 7 Test for Total Accuracy, and the Category Test: (FSIQ: F(2, 103) = 5.23, p =

.001); (VCI: F(2, 98) = 4.43, p = 0.014); (POI: F(2, 99) = 3.67, p = .029); (BDI: F(2, 68) = 5.13, p = .008);

(R27-A: F(2, 53) = 4.54, p = .015); (CAT: F(2, 67) = 4.89, p = .010).

When DP was included in the ANOVA, several more significant differences are found between

case assessment scores (See Table 3 for means and standard deviations). Significant differences occur

between cases for the following: Verbal IQ, Performance IQ, Full Scale IQ, Verbal Comprehension Index,

Perceptual Organization Index, WRAT Reading, Writing, and Arithmetic, Beck Depression Inventory-II,

Ruff 2 & 7 Test for Total Speed and Total Accuracy, Category Test, and Stroop Color-Word Test. Refer to

Table 4 for psychometric properties.

Descriptive statistics were performed for frequency of malingers in each case. Out of those who

received the tests of effort (Rey-15, or DCT) during their evaluation, suspect/poor effort was reported for

33% of Personal Injury suits, 70% of Worker’s compensation claimants, 60% of Social Security applicants,

and 43% of Death Penalty cases, totaling in 52% of the overall sample.

The first factorial MANOVA was conducted for civil cases only (SS, WC, PI) on all of the ten

domains and demonstrated significant main effects for case in Attention and Concentration, Wilks’s

lambda = 0.61, F(6, 50) = 2.32, p = .047, as well as for case in Concept Formation, Wilks’s lambda = .59,

F(6, 54) = 2.75, p = .021. No other significant main effects or interactions were found for case or ethnicity

when civil litigations were analyzed alone.

However, upon inclusion of DP, significant main effects of case occurred for the domains of

General Intelligence, Learning and Memory, Language and Verbal Ability, Abstraction and Reasoning,

Concept Formation, and Motor Function: (GI: Wilks’s lambda = 0.71, F(12, 135) = 0.31, p =

.031), (LM: Wilks’s lambda = .54, F(9, 95) = 2.99, p = .003), (VC: Wilks’s lambda = .48, F(12, 100) =

2.69, p = .003), (AR: Wilks’s lambda = .70, F(9, 124) = 2.21, p = .026), (CF: Wilks’s lambda = .39, F(9,

76) = 4.00, p = .000), (MF: Wilks’s lambda = .72, F(9, 139) = 2.27, p = .021). A significant main effect for
   49  

Table  3  
 
Means  and  Standard  Deviations  for  Significant  Scores  of  Individual  Case  Conditions  
 
PI:   SS:   WC:   DP:  
Measure   M  (SD)   M  (SD)   M  (SD)   M  (SD)  
VIQ   47.70  (13.68)   39.84  (10.95)   44.14  (15.32)   31.83  (5.42)  
PIQ   47.03  (13.93)   40.36  (12.31)   43.52  (11.50)   32.37  (8.82)  
FSIQ   48.38  (13.76)   38.85  (11.97)   41.62  (12.19)   29.93  (9.12)  
VCI   47.93  (12.74)   39.45  (11.24)   44.13  (11.93)   32.69  (7.68)  
POI   49.52  (12.02)   41.23  (13.92)   44.75  (11.79)   31.07  (7.76)  
WRATR   46.42  (5.65)   47.74  (3.14)   47.50  (4.85)   37.59  (8.71)  
WRATS   46.05  (5.09)   45.87  (2.70)   45.04  (4.49)   37.78  (6.86)  
WRATA   45.19  (4.76)   45.78  (1.59)   46.25  (2.19)   41.70  (5.43)  
BDI   16.30  (11.07)   23.30  (15.91)   28.67  (9.96)   30.91  (9.28)  
R27S   40.06  (16.06)   34.79  (9.53)   42.65  (14.21)   32.72  (11.59)  
R27A   32.47  (16.32)   44.29  (11.68)   44.60  (12.94)   42.78  (13.39)  
CAT   38.43  (20.99)   27.42  (15.85)   24.00  (10.74)   20.46  (8.81)  
CW   46.89  (19.59)   43.38  (17.81)   43.38  (9.79)   29.54  (19.33)  
Note.   PI   =   Personal   Injury;   SS   =   Social   Security   Disability;   WC   =   Worker’s   Compensation;   DP   =   Death  
Penalty;  VIQ  =  Verbal  IQ;  PIQ  =  Performance  IQ;  FSIQ  =  Full  Scale  IQ;  VCI  =  Verbal  Comprehension  Index;  
th
POI   =   Perceptual   Organization   Index;   WRATR   =   Wide   Range   Achievement   Test   (4   ed.)   –   Reading   subtest;  
th
WRATS  =  Wide  Range  Achievement  Test  (4  ed.)  –  Spelling  subtest;  WRATA  =  Wide  Range  Achievement  
th nd
Test   (4   ed.)   –   Arithmetic   subtest;   BDI   =   Beck   Depression   Inventory   (2   ed.);   R27S   =   Ruff   2   &   7   Test   –  
Total   Speed;   R27A   =   Ruff   2   &   7   Test   –   Total   Accuracy;   CAT   =   Category   Test;   CW   =   Stroop   Color-­‐Word  
Interference  Test.  
   50  

Table  4  

Significant  Differences  Between  Civil  Cases  and  Between  All  Forensic  Cases  determined  by      Two  one-­‐way  
ANOVAs  
                               Civil________                        All  Forensic  Cases_____  
Measure   F   (df)      p   F   (df)      p  
VIQ   2.70   (2,  92)   0.073   7.47   (3,  114)   0.000***  
PIQ   2.43   (2,  98)   0.094   7.88   (3,  124)   0.000***  
FSIQ   5.23   (2,  103)   0.007**   15.31   (3,  142)   0.000***  
VCI   4.43   (2,  98)   0.014*   9.68   (3,  123)   0.000***  
POI   3.67   (2,  99)   0.029*   12.48   (3,  125)   0.000***  
WRATR   0.46   (2,  63)   0.633   17.16   (3,  94)   0.000***  
WRATS   0.38   (2,  63)   0.688   16.44   (3,  94)   0.000***  
WRATA   0.66   (2,  65)   0.520   7.87   (3,  97)   0.000***  
BDI   5.13   (2,  68)   0.008**   5.05   (3,  78)   0.003**  
R27S   1.71   (2,  53)   0.190   3.00   (3,  84)   0.035*  
R27A   4.54   (2,  53)   0.015*   3.22   (3,  84)   0.027*  
CAT   4.89   (2,  67)   0.01*   6.26   (3,  90)   0.001**  
CW   0.26   (2,  50)   0.771   2.84   (3,  62)   0.045*  
Note.   VIQ   =   Verbal   IQ;   PIQ   =   Performance   IQ;   FSIQ   =   Full   Scale   IQ;   VCI   =   Verbal   Comprehension   Index;   POI  
th
=   Perceptual   Organization   Index;   WRATR   =   Wide   Range   Achievement   Test   (4   ed.)   –   Reading   subtest;  
th
WRATS  =  Wide  Range  Achievement  Test  (4  ed.)  –  Spelling  subtest;  WRATA  =  Wide  Range  Achievement  
th nd
Test   (4   ed.)   –   Arithmetic   subtest;   BDI   =   Beck   Depression   Inventory   (2   ed.);   R27S   =   Ruff   2   &   7   Test   –  
Total   Speed;   R27A   =   Ruff   2   &   7   Test   –   Total   Accuracy;   CAT   =   Category   Test;   CW   =   Stroop   Color-­‐Word  
Interference  Test.  
*p  <  .05;  **p  <  .01;  ***p  <  .001.    
   51  

ethnicity was found for Academic Ability, Wilks’s lambda = .79, F(6, 168) = 3.60, p = .002, and a

significant interaction between case and ethnicity was found for Attention and Concentration, Wilks’s

lambda = .52, F(15, 108) = 1.91, p = .029. Refer to Table 5 for between-subjects effects of case and

ethnicity.

Discussion

The criminal mind is something that has been of interest to psychologists for as long as the field

has been in existence. It is difficult for the average person to understand why and/or how someone could

commit such heinous crimes as kidnapping, rape, or murder, and people tend to assume that all of these

criminals are simply sociopaths who are not capable of empathy or compassion and perform these evil acts

out of desire to do harm. However, the field of forensic neuropsychology may be able to provide insight

into the minds, or brains, of not only criminals, but of others involved in civil legal issues as well.

In terms of motivation and effort, the resulting percentages are indicative of what we expected,

such as a high percentage of suspect effort in worker’s compensation claimants and Social Security

disability applicants, and a lower percentage of criminals on trial for the death penalty. However, personal

injury was hypothesized to be likely to malinger because they probably represent the highest functioning

group in the study, but need to prove impairment on assessments in order to receive the desired

compensation from liability. This was not the case at all in this study’s results, in fact this group had the

lowest percentage of suspected malingerers. This could be due to the fact that only about 50% of our entire

sample was tested for effort, and within personal injury specifically, only 15 out of the entire group were

tested. The results of all groups for malingering are based on very small ns and should not be considered as

statistically valid.

Our data analyses determined that our sample of death penalty inmates, regardless of being of

majorly different ethnicity, performed significantly worse than the civil case groups on measures of general

intelligence, memory and learning involving verbal intelligence, overall language and verbal ability,

executive functioning involving verbal concept formation, abstraction and reasoning abilities, motor

function, and abilities to focus and sustain attention. These results support the initial hypothesis of this

study that the criminal offenders would have the largest neuropsychological test performance deficits in

mainly executive functioning, verbal ability, intellectual functioning, and attention.

   52  

Table  5  
 
Tukey’s  HSD  Pairwise  Comparisons  of  Performance  in  Neuropsychological  Domains,  Significant  at  Alpha  
.05,  .01,  and  .001  (differences  between  means  are  in  parenthesis)  
p  =  
Tukey's  HSD  Pairwise  Comparisons  
Measures   F   .017  
VIQ   5.53   0.002   (DP  <  PI)**   (DP  <  WC)**   (SS  <  PI)*  
General    
PIQ   5.66   0.002   (DP  <  PI)***   (DP  <  WC)*   (SS  <  PI)*  
Intelligence    
CAT   4.05   0.011   (DP  <  PI)***   (SS  <  PI)*   (WC  <  PI)**  
 
               
Memory  and   WMI   4.25   0.011   (SS  <  PI)*  
     
Learning   VIQ   7.63   0.000   (DP  <  PI)***   (SS  <  PI)**   (WC  <  PI)*  
 
             
VIQ   7.63   0.000   (DP  <  PI)***   (SS  <  PI)**   (WC  <  PI)*  
Language  and    
VCI   8.86   0.000   (DP  <  PI)***   (SS  <  PI)**   (WC  <  PI)*  
Verbal  Ability    
WMI   4.25   0.011   (DP  <  PI)***   (SS  <  PI)*  
   
             
Abstraction   POI   5.21   0.003   (DP  <  PI)***   (DP  <  WC)*   (SS  <  PI)*  
 
and  Reasoning   CAT   3.76   0.016   (DP  <  PI)***   (SS  <  PI)*   (WC  <  PI)**  
 
             
Concept   VCI   5.55   0.001   (DP  <  PI)**   (DP  <  WC)*  
   
Formation   CAT   4.81   0.003   (DP  <  PI)**   (WC  <  PI)*  
   
               
Motor  
PIQ   5.05   0.003   (DP  <  PI)***   (DP  <  WC)*  
Function      
               
Attention  and  
PIQ   3.62   0.008   (DP  <  PI)*  
Concentration        
               
Academic   WRATR   9.83   0.000   (H  <  C)***   (H  <  A)**  
   
Ability   WRATS   4.18   0.016   (H  <  C)***   (H  <  A)**          
 Note.  VIQ  =  Verbal  IQ;  PIQ  =  Performance  IQ;  CAT  =  Category  Test;  VCI  =  Verbal  Comprehension  Index;  
WMI  =  Working  Memory  Index;  POI  =  Perceptual  Organization  Index;  DP  =  Death  Penalty;  PI  =  Personal  
Injury;   WC   =   Worker’s   Compensation;   SS   =   Social   Security   Disability.   H   =   Hispanic;   C   =   Caucasian;   A   =  
African   American;   Significant   main   effect   of   p   <   .013   when   analyzing   four   variables   (e.g.,   Language   and  
Verbal   Ability);   Significant   main   effect   of   p   <   .017   when   analyzing   three   variables.  
*p  <  .05;  **p  <  .01;  ***  p  <  .001.    
   53  

The specific deficits of the death penalty case individuals associated with individual test score

imply that there is significant impairment in verbal abilities, attention, and executive functioning, which is

greatly supported by the literature suggesting that criminality is primarily associated with those domains

(Rassmussen et al., 2001). Although our data did not involve collection of information concerning whether

or not subjects had specific disorders, we may suspect, with good reason, the possibility that our death

penalty sample included a significant amount of individuals with ADHD; this assumption is based on the

results in literature that associate our findings of deficits in executive function, verbal memory, and

impaired Stroop performance with the presence of ADHD (Siedmen et al., 1997; 1998). Hanlon et al.,

(2000) indicates similar findings of attentional disturbance, language dysfunction and intellectual

impairment, and executive dysfunction, all of which he and others (Foster et al., 1993; Morgan &

Lillenfield, 2000) believes to be associated characteristics that increase the likelihood of aggressive

behavior. Unfortunately, access to specific and objective measures of neurological activity was unavailable

in this study, however localization of function through neuropsychological measures seems to indicate that

prefrontal regions are involved (due to poor performance on tasks of executive functioning, attention, and

interference, as seen, for example, on the Stroop). Also of interest is the result involving death penalty’s

high level of depression ratings along with impairments in attention, memory and learning, and motor

speed, for this confirms the aforementioned major areas associated with clinical depression described by

Newman and Sweet in 1992.

The finding that Hispanics scored significantly lower on skills of academic achievements

involving word and sentence comprehension than both Caucasians and African Americans makes logical

sense, for those who do not speak English, or speak it as a second language, will obviously be at a

disadvantage in these areas.

Personal injury litigation subjects scored significantly better than Social Security applicants and

worker’s compensation claimants on measures of general intelligence, verbal learning and memory, verbal

ability, abstraction, and concept formation. This is supportive of our hypothesis that overall, the personal

injury group was a better representation of the general population, which are adequately functioning in

these areas, especially relative to those who are disabled to the extent that they cannot work. It was

hypothesized that the three civil cases would vary depending on litigational purposes, however this was not
   54  

the case. Social Security disability and worker’s compensation groups seemed to not differ significantly on

any domains. They both typically remained at a status of performing worse than the personal injury

litigators, but better than the individuals on trial for the death penalty. It is always important to question the

validity behind results of neuropsychological assessment for someone involved with litigation or

compensation in any sense. However, the worker’s compensation group performed significantly worse in

domains and on tests that are better measures of cognitive function than of sensorimotor and perceptual

ability, which according to Pancratz and Binder (1997), is typically associated with actual effort and true

performance ability. Malingerers are able to fake their responses and actions on tests, but abilities in

cognition are much more difficult to consciously manipulate. Social security also seemed to score worse on

assessments of cognitive functioning, however there are slightly more significantly lower scores associated

with Social Security applicants, and those are moderately involved in sensorimotor performance, such as

the tasks that make up the WMI and the PIQ.

Overall, this study provided generally supportable and expected results across the four categories

of forensic cases evaluated. This is good news for a study involving as many variables as were involved in

this present study, for too many variables can often be of a limiting nature. In order to further extend this

study, more specific information regarding individual differences between subjects, such as neurological or

neuropsychological disorders (e.g., ADHD, agnosias, neglect, Alzheimer’s type dementia). A report of

mood disorder diagnoses will also be beneficial, especially for depressed individuals since we have seen

how depression may be related to so many different aspects of cognitive functioning (Gass & Russel, 1986;

Kopelman, 1986; Malec, 1978; Newman & Sweet, 1992). Also, an important limitation to this study is the

fact that educational data was not collected for the sample from the archived database, but was collected

from a sample of currently active patients within the same cases. Most importantly, it is important to

mention the skewed distribution of ethnicities between and within the four conditions, and the possibility of

ethnic bias in our sample. Although we did our best to control for this, it still may have had some influence

in our findings. In the future this data set will be extended to include these variables for the actual sample

involved. With a more detailed and informative data set, a closer look at the differences between the most

common forensic neuropsychological foci can occur, and will shed more light on a deep understanding of

the underlying correlates of brain, behavior, and the law.

   55  

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Footnotes
1
From “Forensic Clinical Psychology as a Paradigm for Clinical Neuropsychological Assessment:

Basic and Emerging Issues,” by A. E. Puente, 1997, In The Practice of Forensic Neuropsychology:

Meeting Challengings in the Courtroom (pp. 171-172), by R. J. McCaffrey, A. D. Williams, J. M. Fisher, &

L. C. Laing (Eds.). New York, NY: Plenum Press. Copyright [1997] by Plenum Press. Reprinted with

permission.
2
The most recent version of the Wechsler Adult Intelligence Scale is the Fourth Edition, which

was published in 2008 by Pearson, Inc. The archived database from which this study’s sample was

collected consisted of subjects who received neuropsychological evaluation before the newest edition of the

WAIS was released, and thus we were required to rely on the previous version.
3
Educational data were not available for individual participants in the Personal Injury, Social

Security Disability, or Worker’s Compensation groups. Data were collected from 40 random subjects in

each of the three civil litigation groups outside of those used in our sample, and mean years of education

was applied to our three groups from the post hoc sample for normative demographic purposes. The years

of education for the individuals in the Death Penalty group were recorded, however.