Screening and Assessing for

Neuropsychological
Impairment
Chapter 5
• Introduction:
• The branch of medicine that focuses on the nervous system and its disorders is neurology. The
branch of psychology that focuses on the relationship between brain functioning and
behavior is neuropsychology.
• An important role in clinical practice is screening and assessing for the presence of possible
neuropsychological impairment.
 data indicating that 20% to 30% of assessment referrals to professional psychologists relate
to information regarding central nervous system (CNS) involvement .
• Neuropsychological assessment may be defined as the evaluation of brain and nervous
system functioning as it relates to behavior. Sub-specialty areas within neuropsychology
include pediatric neuropsychology , geriatric neuropsychology , forensic neuropsychology
and school neuropsychology an area well known to our guest test user. A subspecialty within
the medical specialty of neurology that also focuses on brain–behavior relationships (with
more biochemical and less behavioral emphasis) is behavioral neurology .
• referrals from psychiatric and neurological settings.
 assessments might serve as an early warning sign that, if positive, would then result in a more
in-depth medical or neuropsychological assessment.
 Examples of the types of situations where screening might be important would be among
substance-abusing populations, persons exposed to neurotoxic substances, or elderly
populations where the distinction between depression and organically based dementia
• our understanding of brain/behavior relationships has grown over the
past few decades, the field of school neuropsychology has
increasingly found a place in the schools. School neuropsychologists
bring their knowledge of brain– behavior relationships to bear in
their answers to questions raised about students’ academic and
social skills. The school neuropsychologist can help design evidence-
based interventions that complement students’ cognitive and social
strengths, while effectively addressing areas of challenge.
• HISTORY AND DEVELOPMENT:
• Neuropsychological assessment as a well-defined discipline began in
the 1950s with the work of Halstead, Reitan, and Goldstein in the
United States.
• Concurrent with the development of the early testing procedures and
batteries, there was also an emphasis on brief screening instruments.
• The Bender Visual Motor Gestalt was one of the earliest of these. It
was first developed by L. Bender in 1938 and comprises nine designs
that a client is requested to reproduce.
• Rey developed the Rey Auditory-Verbal Learning Test (Rey, 1964),
which primarily screens for difficulties with short-term auditory
memory. Clients are instructed to recall a series of words that are
read to them and then repeat back as many of the words as possible.
Some Brain–Behavior Characteristics for Selected Nervous System.

Temporal lobes: These lobes contain auditory reception areas as well as certain areas for the
processing of visual information.
Damage may affect sound discrimination, recognition, and comprehension; music appreciation;
voice recognition; and auditory or visual memory storage.
• Occipital lobes: These lobes contain visual reception areas.
Damage to this area could result in blindness to all or part of the visual field or deficits in object
recognition, visual scanning, visual integration of symbols into wholes, and recall of visual imagery.
• Parietal lobes These lobes contain reception areas for the sense of touch and for the sense of
bodily position.
Damage to this area may result in deficits in the sense of touch, disorganization, and distorted self-
perception.
• Frontal lobes These lobes are characteristically involved in ordering information and sorting out
stimuli.
Damage
• Concentration and attention, abstract-thinking ability, concept-formation ability, foresight, problem-
solving ability, and speech, as well as gross and fine motor ability, may be
• Thalamus The thalamus is a kind of communications relay station for all sensory information
transmitted to the cerebral cortex. Damage to the thalamus may result in transformed states of
arousal, memory defects, speech deficits, and disorientation.
• Hypothalamus is involved in the regulation of bodily functions such as eating, drinking, body
temperature, sexual behavior, and emotion. It is sensitive to changes in environment that call for a
“fight or flight” response from the organism. Damage to it may elicit a variety of symptoms ranging
from uncontrolled eating or drinking to mild alterations of mood states.
• Cerebellum Together with the pons (another brain site in the area of the brain referred to as the
hindbrain), the cerebellum is involved in the regulation of balance, breathing, and posture,
among other functions. Damage to the cerebellum may manifest as problems in fine motor
control and coordination.
• Reticular formation In the core of the brain stem, the reticular formation contains fibers en route
to and from the cortex. Because stimulation to this area can cause a sleeping organism to awaken
and an awake organism to become even more alert,. Damage to this area can cause the organism
to sleep for long periods of time.
• Limbic system Composed of the amygdala, the cingulate cortex, the hippocampus, and the septal
areas of the brain, the limbic system is basic to the expression of emotions. Damage to this area
may profoundly affect emotional behavior.
• Spinal cord Many reflexes necessary for survival (such as withdrawing from a hot surface) are
carried out at the level of the spinal cord. In addition to its role in reflex activity, the spinal cord is
integral to the coordination of motor movements. Spinal cord injuries may result in various
degrees of paralysis or other motor difficulties.
• Some brain-damaged persons might have specific signs such as
aphasia, neglect of a portion of their visual field, or word-finding
difficulties.
• In contrast, others might have general impairments such as a
cognitive abilities or difficulty regulating their behavior.
• The practical implication is that any one screening test for
neuropsychological impairment is likely to assess for a narrow range
of abilities.
• If a client has deficits outside this range, the test is not suitable to that
particular area of difficulties. The result is a high number of false
negatives. Indeed, this problem has plagued most screening devices.
• For example, a test such as the Bender Gestalt is primarily a test of
visuo-constructive abilities.
Recommended screening batteries
/tests for neuropsychological
impairment
• Visuoconstructive Abilities • Memory and Learning
1. Bender (Standard or 1. Rey Auditory Verbal Learning
Background Test
2. Interference Procedure)
2. Bender memory
3. Block Design, Object Assembly
3. Digit Symbol, Information
4. Free Drawing Procedures (Draw-
A-Person, etc.) • Verbal Functions and Academic
Skills
• Mental Activity (Attention and
Speed of 1. Controlled Oral Word
Association (FAS)
1. Information Processing)
2. Trail Making
2. Information, Vocabulary,
Comprehension
3. Digit Span
3. Similarities (Arithmetic)
4. Arithmetic
5. Digit Symbol
• Motor Performance
• Finger Tapping
• Executive Functions
1. (Behavioral observations, reports by significant
others)
2. Emotional Status
3. Minnesota Multiphasic Personality Inventory
4. (MMPI-2/MMPI-A)
5. Beck Depression Inventory (BDI )
 CLASS ACTIVITY
A patient complains of problems maintaining
balance. At what site in the brain might a
neuropsychologist “work backward” from
this complaint and identify a problem?
• Any neuropsychological history should provide a careful
documentation of present complaints and current overall life
situation. Each symptom should be described along with its onset,
frequency, duration, intensity, and any changes over time. Asking
the client when the symptom first appeared and how it has changed
over time frequently can access much of this information.
 TESTS FOR SCREENING AND
ASSESSING FOR
NEUROPSYCHOLOGICAL
IMPAIRMENT

Bender Visual Motor Gestalt Test

• The Bender Visual Motor Gestalt Test (Bender, 1938), usually referred to as the
Bender Gestalt or simply the Bender, has been extensively used as a screening
device for neuropsychological impairment by assessing a client’s visuo-
constructive abilities. It consists of nine designs that are sequentially presented
to subjects with the request that they reproduce them on a blank, 8.5-by-11-
inch sheet of paper.
• History a psychological test first developed by child neuro-psychiatrist Bender
The test is used to evaluate "visual-motor maturity", to screen for
developmental disorders, or to assess neurological function or brain damage.
• Bender first described her Visual Motor Gestalt Test in an 1938 monograph
entitled: A Visual Motor Gestalt Test and Its Clinical Use. The test has been used
as a screening device for brain damage. It measures perceptual motor skills,
perceptual motor development, and gives an indication of neurological
intactness. It has been used as a personality test and a test of emotional
problems.
• The Bender-II contains 16 figures versus 9 in the original. The new or revised
scoring system for the Bender-II was developed based on empirical
investigation of numerous scoring systems.
• Purpose: The Bender Gestalt Test is used to:
1. evaluate visual maturity, visual motor integration skills,
2. style of responding, reaction to frustration,
3. ability to correct mistakes,
4. planning and organizational skills,
5. and motivation.
Copying figures requires
6. fine motor skills,
7. the ability to discriminate between visual stimuli,
8. the capacity to integrate visual skills with motor skills, and
9. the ability to shift attention from the original design to what is being drawn.
• Precautions
The Bender Gestalt Test should not be:
1. administered to an individual with severe
2. visual impairment unless his or her vision
3. has been adequately corrected with eyeglasses.
• Additionally, the test should not be given to
• an examinee with a severe motor impairment, ( as the impairment would affect his
or her ability to draw the geometric figures correctly.
• The test scores might thereby be distorted.
• The Bender Gestalt Test should never be used in isolation. When making a
diagnosis, results from the Bender Gestalt Test should be used in conjunction
with other medical, developmental, educational, psychological, and
neuropsychological information. Finally, psychometric testing requires
administration and evaluation by a clinically trained examiner. If a scoring system
used, the examiner should carefully evaluate its reliability and validity, as well as
the normative sample being used
• Description
The Bender Gestalt Test is an individually administered pencil and paper test
used to make a diagnosis of brain injury. There are nine geometric figures
drawn in black. These figures are presented to the examinee one at a time; then,
the examinee is asked to copy the figure on a blank sheet of paper. Examinees
are allowed to erase, but cannot use any mechanical aids (such as rulers).
The average amount of
1. time to complete the test is no time limits but examiner records how long it
takes the examinee reproduce the designs.
after which the card is removed. The examinee draws the figure from memory.
Another variation involves having the examinee draw the figures by following the
standard procedure.
The examinee is then given a clean sheet of paper and asked to draw as many
figures as he or she can recall. Last, the test is given to a group, rather than to an
individual (i.e., standard administration).
Observational forms
• Examinee Information Name, gender, hand preference Physical
Observations
• Sensory impairments or movement restrictions Test-Taking
Observations
• Carelessness, in difference, inattentiveness, unusual or unique
behaviors Copy Observations
Examinee’s approach, drawing process Recall Amount of time needed
to recall designs and the order in which designs are recalled.
• Administration of the Bender-Gestalt II consists of two phases:
1. Copy Phase
• Examinee is shown stimulus cards with designs and asked to copy each of the designs
on a sheet of paper
2. Recall Phase
• Examinee is asked to redraw designs from memory
• Motor and Perception supplemental tests screen for specific motor and perceptual
abilities/difficulties.
• Kit consists of Examiner’s manual, 16 stimulus cards, observation form, motor test, and
a perception test. (Visual-Motor Skills and Visual-Motor Memory
• Materials needed: Two pencils with erasers, 10 sheets of drawing paper, and a
stopwatch (not included in test kit).
• Administer test on a table, seated across from the
• examinee if possible Supply one pencil and one sheet of paper (vertically in front of
examinee) Show the stimulus cards to the examinee one at time (associated with the
top of drawing paper)
• Administer stimulus cards in the correct numeric sequence and do not allow
examinee to turn or manipulate them.
• Copy Phase:
Inconspicuously measure how long the examinee takes to complete the items – record
time in minutes and seconds Document your observations – carefully note the
examinee’s approach to drawing each design
• Recall Phase:
Administered immediately following the copy phase. Examinee is given a new sheet of
paper an asked to draw as many of the designs that were previously shown.
Instruction:

• I am going to show you these cards, one at a time. Each card has a simple drawing
on it. I would like you to copy the drawing on the paper, as well as you can. Work in
any way that is best for you. This is not a test of artistic ability, but try to copy the
drawings as accurately as you possibly can. Work as fast or as slowly as you wish.
• Recall Phase:
• Administered immediately following the copy phase
• Examinee is given a new sheet of paper an asked to draw as many of the
designs that were previously shown.
1. Motor Test:
• 2 – 4 minutes
• Draw a line between the dots in each figure without touching the borders
• Perception Test:
• 2 – 4 minutes
• Circle or point to a design in each row that best matches the design in the
boxes
Administration and scoring
FORMS
Bender Visual Motor Gestalt
Test

CARDS
SCORING
Results/Scoring
1. Angular difficulty: This includes increasing, decreasing, distorting, or omitting an
angle in a figure.
2. Bizarre doodling: This involves adding peculiar components to the drawing that
have no relationship to the original Bender Gestalt figure.
3. Closure difficulty: This occurs when the examinee has difficulty closing open
spaces on a figure, or connecting various parts of the figure. This results in a gap
in the copied figure.
4. Cohesion: This involves drawing a part of a figure larger or smaller than shown on
the original figure and out of proportion with the rest of the figure. This error may
also include drawing a figure or part of a figure significantly out of proportion
with other figures that have been drawn.
5. Collision: This involves crowding the designs or allowing the end of one design to
overlap or touch a part of another design.
6. Contamination: This occurs when a previous figure, or part of a figure, influences
the examinee in adequate completion of the current figure. For example, an
examinee may combine two different Bender Gestalt figure.
7. Omission: This involves failing to adequately connect the parts of a figure or
reproducing only parts of a figure.
8. Overlapping difficulty: This includes problems in drawing portions of the figures that
overlap, simplifying the drawing at the point that it overlaps, sketching or redrawing the
overlapping portions, or otherwise distorting the figure at the point at which it overlaps.
9. Perseveration: This includes increasing, prolonging, or continuing the number of units
in a figure. For example, an examinee may draw significantly more dots or circles than
shown on the original figure.
10. Fragmentation: This involves destroying part of the figure by not completing or
breaking up the figures in ways that entirely lose the original design.
11. Impotence: This occurs when the examinee draws a figure inaccurately and seems to
recognize the error, then, he or she makes several unsuccessful attempts to improve the
drawing. Irregular line quality or lack of motor coordination: This involves drawing rough
lines, particularly when the examinee shows a tremor motion, during the drawing of the
figure.
12. Line extension: This involves adding or extending a part of the copied figure that was
not on the original figure.
13. Retrogression: This involves substituting more primitive figures for the
original design—for example, substituting solid lines or loops for circles, dashes
for dots, dots for circles, circles for dots, or filling in circles. There must be
evidence that the examinee is capable of drawing more mature figures.
14. Rotation: This involves rotating a figure or part of a figure by 45° or more.
This error is also scored when the examinee rotates the stimulus card that is
being copied.
15. Scribbling: This involves drawing primitive lines that have no relationship to
the original Bender Gestalt figure.
16. Simplification: This involves replacing a part of the figure with a more
simplified figure. This error is not due to maturation. Drawings that are primitive
in terms of maturation would be categorized under
17."Retrogression." Superimposition of design: This involves drawing one or
more of the figures on top of each other.
18. Work-over: This involves reinforcing, increased pressure, or overworking a
line or lines in a whole or part of a figure.
 Interpretation
Bender Visual Motor Gestalt Test
Reporting
1. Bio Data of Normal Person
2. Background Information
3. Test Administration:
• FOR EXAMPLE: The Bender Gestalt Test was administered on the normal person
at his classroom . The environment of the room was moderate. He was seated
comfortably and he was not looking tensed rather he was relaxed.
4. Instructions The normal person was given several instructions. He was asked to
sit normally and be relaxed. He was instructed to draw the diagram as it is but if
he deviated from the actual design he was not instructed to correct it. Firstly, he
was instructed to draw diagrams by seeing it and then he was asked to make
second unseen attempt.
5.General observation
6. Quantitative Analysis
7. Qualitative Analysis:
8. Summary
Types of neuropsychological
Tests
1. Ammons Quick Test This test has been used for many years to help assess premorbid
intelligence. It is a passive response picture-vocabulary test.
2. Aphasia Test (various) Several aphasia and language tests examine level of competency
in receptive and expressive language skills (e.g. Reitan-Indiana Aphasia Screening Test.
3. Beck Depression or Anxiety Scales These scales provide quick assessment of subjective
experience of symptoms related to depression or anxiety.
4. Bender Visual Motor Gestalt Test This test evaluates visual-perceptual and visual-motor
functioning, yielding possible signs of brain dysfunction, emotional problems, and
developmental maturity.
5. Boston Diagnostic Aphasia Examination Broad diagnosis of language impairment in
adults
6. Boston Naming Test Assessing the ability to name pictures of objects through
spontaneous responses and need for various types of cueing inferences can be drawn
regarding language facility and possible localization of cerebral damage
7. California Verbal learning Test This procedure examines several aspects of verbal
learning, organization, and memory forms for adults and children
8. Cognitive Symptom Checklists Self-evaluation of areas of cognitive impairment for
9. Continuous performance Test this test require intense attention to a visual-motor task are used in
assessing sustained attention and freedom from distractibility(e.g. vigil, Connors Continuous
performance Test)
10. Controlled Oral Word Association Test Different forms of this procedure exist most frequently
used for assessing verbal fluency and the ease with which a person and think f words that begin with a
specific letter.
11. The neurobehavioral Cognitive Status Examination This screening test examines language,
memory, arithmetic, attention, judgment, and reasoning. It is typically used in screening individuals
who cannot tolerate more complicated or lengthier neuropsychological tests.
12.Delis-Kaplan Executive Function System Assesses key areas of executive function (problem-solving,
thinking flexibility, fluency, planning, and deductive reasoning in both spatial and verbal modalities,
norm for ages 8.89 Dementia Rating Seale: Provides measurement of attention, initiation, construction,
conceptualization, and memory to assess cognitive status in older adults with cortical impairment.
13.Digit Vigilance Test A commonly used test of attention, alertness and mental processing capacity,
using a rapid visual tracking task. Figural Fluency Test: Different forms of this procedure exist,
evaluating nonverbal mental flexibility, often compared with tests of verbal fluency.
14. Rorschach Projective Technique This familiar inkblot test is used to evaluate complex psychological
dynamics. Persons with brain injury have been shown to produce certain kinds of response that can
complement other test and help to understand personality changes associated with brain injury.
15. Test of Memory and Learning (TOMAL) This test for children and
adolescents measures numerous aspects of memory, assessing learning,
attention and recall.
16. Word Memory Test A validity procedure designed to detect response
bias that might indicate exaggeration of impairment or symptom feigning.
17. Test Batteries The Test Battery serves as a screening device.The Test
Battery consists of several paper and pencil tests suitable for adults and
adolescents with at least a 6th grade reading level.
i. They are Minnesota multi-phasic Personality inventory 2 (MMPI-2) or
MACL (adolescent),
ii. Substance Abuse Subtle Screening inventory (SASSI)
iii. Adult or Adolescent Questionnaire (contains sentence completion,
questions regarding parenting knowledge and skills and family back
ground).
• Advantages of Neuropsychological Tests
• It can clarify the reasons for the difficulties and will help in providing a foundation for an
effective treatment plan. It is important to keep in mind that psychological testing is only
one part of a complete assessment process which may include information provided by
physicians, teachers, parents and counselors.
• Testing may also be helpful when there is ongoing discrepancy between parents and the
school regarding the reason for a child’s difficulties and behavior Testing an provide a new
understanding about why a child is experiencing difficulties in school.
• Psychosis’s, counselors and therapists use psychological assessments as a supplement to
clinical interviews. Through testing, a lot of information is gathered in a relatively short
period of time.
• Psychological testing allows the evaluator not only to corroborate interview data and clinical
impressions, but also to go beyond the interview and collect information of broader
psychotically complexity Information obtained from assessment has scientific basis as it
compares the individual against normative data. It allows the evaluator to determine how
similar or dissimilar this person is to others. Neuropsychological testing may be indicated in
persons with epilepsy or hydrocephalus.
• Neuropsychological testing is also used to assess post-surgical changes in cognitive
Disadvantages of Neuropsychological Tests
• Lack of correct training is also a significant danger in the use of
psychometric testing or neuropsychological assessment.
• Another important danger with neuropsychological testing is the use
of questionnaires that try to assess person’s ability or skills in a
particular area
• It is difficult to accurately estimate the percentage of clinicians who
employ each of these assessments approaches in a fixed versus
flexible manner.