Critical evaluation of ``Assessment: neuropsychological testing of adults'' $

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1 Archives of Clinical Neuropsychology 16 (2001) 215±226 Critical evaluation of ``Assessment: neuropsychological testing of adults'' $ Abstract Ralph M. Reitan*, Deborah Wolfson Reitan Neuropsychology Laboratory This article presents a critical evaluation of a Special Article, provided as an ``educational service'' and prepared by an Expert Panel under the direction of the Technology and Therapeutic Assessment Subcommittee of the American Academy of Neurology. The chief author of the Special Article was Jeffrey L. Cummings, M.D. D 2001 National Academy of Neuropsychology. Published by Elsevier Science Ltd. The aim of this article on neuropsychological assessment was to consider ``the use of neuropsychological assessment of adults, including appropriate application and limitations of neuropsychological testing, specific disorders where evaluation is pertinent, and issues surrounding neuropsychological consultation to neurologists'' (p. 592). The principal author of the report was a neurologist, although the Expert Panel included several neuropsychologists and an additional number of physicians. The members of this panel will be referred to below as ``the authors.'' Points made and conclusions stated in the article will be selected, summarized, and commented upon in sequential order. (1) The authors state that some tests (WAIS and WAIS-R; WMS and WMS-R) although never developed as neuropsychological instruments, have become useful for neuropsychological assessment. They state that the Halstead±Reitan Battery (HRB) was developed specifically to detect brain dysfunction and to differentiate ``organic'' from functional disorders, but was never intended to be used for ``differential diagnosis of neurologic disorders or precise delineation of the underlying neuronal systems'' affected by brain disease or damage. ``Newer tests designed in concert with evolving information regarding the $ Neurology, 47, 592±599, * Corresponding author. Reitan Neuropsychology Lab, PO Box 66080, Tucson, AZ 85728, USA. address: reitanlab@aol.com (R.M. Reitan) /01/$ ± see front matter D 2001 National Academy of Neuropsychology. PII: S (00)

2 216 R.M. Reitan, D. Wolfson / Archives of Clinical Neuropsychology 16 (2001) 215±226 mediation of behavior by specific structures or circuits provide greater insight into the integrity or disintegration of neurologic function.'' Comment: The HRB was the first neuropsychological approach to demonstrate neuropsychological differences among different brain diseases or injuries (Reitan, 1959, 1964), and its effectiveness in this regard (Reitan & Wolfson, 1997) has yet to be matched by other neuropsychological procedures. (2) The authors state that tests are extremely variable with regard to their sensitivity to brain damage, but that tests that are timed usually are most sensitive to diffuse or multifocal cerebral changes. Comment: Except when tests have been routinely administered to the same braindamaged and control groups, there have been few, if any, rigorous tests of differential sensitivity. Thus, the authors' point is not well established. However, among tests in the HRB that are most generally sensitive to cerebral damage, two are summarical measures (GNDS and Impairment Index), two are not timed (Category Test and TPT-Localization), and one is timed (Trail Making Test-Part B). The authors have missed the main point with regard to sensitivity; namely, that summarical measures, which include a range of sensitive tests, represent by far the most sensitive indicators. Of course, such summarical indicators cannot be derived unless a standard set of tests, each of which is sensitive to brain damage, has been administered. (3) In their discussion of test reliability, the authors state that ``only a few studies have addressed the long-term reliability of neuropsychological assessments in stable patients'' (italics added), and then cite a study by Snow, Tierney, Zoritto, Fisher, and Reid (1989) that states explicitly in the title that it was based on a normal elderly sample! It is important to recognize that reliability of performances may differ, for valid reasons, among controls and brain-damaged subjects, even when brain damage is viewed as stable. With respect to evaluation of reliability in the literature, it must be stated that Franzen (1989) has devoted an entire book to the area of the reliability and validity of neuropsychological tests, which lists about 850 references. (4) In discussing the validity of neuropsychological testing, the authors state that ``neuropsychological tests have been shown to have high validity for distinguishing between abnormal and normal performances but have little capacity for distinguishing among different causes of performance impairment.'' Comment: This conclusion implies that there are no consistent differences, with respect to neuropsychological test performances, among patients with intrinsic tumors, extrinsic tumors, strokes, diffuse cerebrovascular disease, closed head injuries, penetrating head injuries, Parkinson's disease, Alzheimer's disease, multiple sclerosis, etc. The conclusion does imply that neuropsychological testing can detect abnormal performances, but that any inferences regarding etiology, type of lesion, location of lesion, lateralization of major involvement, etc. are without validity. Obviously, this conclusion is ludicrous, either in terms of published studies in the literature or in terms of the clinical experience of any neuropsychologist who has competently examined such patients. The literature has included studies for more than a third of a century, which indicate, both in formal studies and as explicated in case illustrations, the significant predictive validity of neuropsychological testing in differential identification of patients who fall in these various categories

3 R.M. Reitan, D. Wolfson / Archives of Clinical Neuropsychology 16 (2001) 215± (Bornstein & Brown, 1991; Reitan, 1959, 1962; Reitan & Fitzhugh, 1971; Reitan & Wolfson, 1993). Admissibility of legal testimony by experts apparently is moving in the direction of requiring a scientific basis for opinions offered (see Daubert vs. Merrill Dow Pharmaceuticals). This means, in turn, that evidence must be based, to an increased extent, on both sensitivity and specificity of the neuropsychological test data with respect to the condition in question. How will a neuropsychologist deal with an attorney who uses this article in cross-examination to indicate that results of the neuropsychological examination of a headinjured person have no specificity with regard to traumatic brain injury? If you were using tests that had been validated with regard to differential identification of the adverse neuropsychological effects of traumatic brain injury vs. many other possible conditions of brain disease or damage, you might be able to support your position to a degree. You would still have to deal with explaining that the conclusions of this highly respectable group of neuropsychologists and neurologists (the authors of the Neurology report) had neglected much of the relevant literature with which you happened to be familiar and on which you had based your own conclusions. (5) The authors state that aging affects a number of neuropsychological functions including fluid intellectual abilities, complex attentional processes, some aspects of memory, psychomotor speed, accessing word knowledge, visuospatial skills, some forms of reasoning, and complex problem solving. They also point out that education has a marked effect on neuropsychological test performance. To support these conclusions, the authors cite a number of references, based mainly on non-brain-damaged subjects. Comment: The literature on the effects of age and education on neuropsychological (and even intelligence) test results indicates quite clearly that while the effects are definite among normals, the effects are strikingly diminished or even obliterated among brain-damaged groups (Reitan & Wolfson, 1995). This result stands to reason. If the tests are sensitive to brain damage, brain damage will determine the variance, at least to a large degree, and the variance normally associated with age and education will be diminished. Age and education influences will not protect the individual from the impairing effects of significant brain damage. In fact, in one sense, the person with an exceptionally able brain may be the person who has the most to lose. A number of recent studies have added information to the older literature regarding the differential relationships of age and education to neuropsychological and intelligence test results, and have shown that the diminished relationships among brain-damaged groups occur both with adults and children, and extend even to children with learning disabilities (Reitan & Wolfson, 1996). (6) The authors also cite the effects on neuropsychological test results of ethnicity and cultural factors, gender, psychiatric disorders, and substance abuse, noting that these variables may influence how well the individual subject performs. Comment: While any of a host of factors that differ among human beings may influence test performances, it is again necessary to point out that the variance of interest and clinical concern in neuropsychology stems from the biological condition of the brain. Thus, our methodology must be sensitive to brain status, regardless of the host of other factors that might be of influence in non-brain-damaged persons. The HRB was developed with this requirement in mind, and the use of various methods of inference, over and beyond level of

4 218 R.M. Reitan, D. Wolfson / Archives of Clinical Neuropsychology 16 (2001) 215±226 performance, is well known. The authors of the report, however, fail to mention the value and need for a multiple-inferential approach in analyzing the test results for individual subjects and appear to recognize only a level-of-performance approach. It is no wonder that they are so concerned about the host of variables that may influence test scores among normals, but it is unfortunate that they do not seem to recognize that the requirement of competent neuropsychological evaluation is first to recognize the effects of brain impairment rather than the effects of normal variation. (7) The authors also consider the value of neuropsychological assessment of patients with traumatic brain injury, cerebrovascular disease, dementia, Parkinson's disease, HIV infection, epilepsy, neurotoxic exposure, and chronic pain. The role and contributions of neuropsychology in each of these conditions, in the view of the authors, is summarized below, followed by a comment. 1. Traumatic brain injury Neuropsychological assessment is useful. With severe TBI, in the acute posttraumatic period, only brief direct testing is recommended. More detailed evaluation is appropriate when recovery has largely plateaued. Neuropsychological assessment can contribute to the rehabilitative program when the testing has identified deficits that can be addressed in the individual's specific rehabilitative program Comment The initial testing, even with severe TBI, should be performed at about the time the patient is ready for discharge from the hospital and should be comprehensive in nature. Brain-injured persons show great intraindividual variability in areas of impairment, and it is important to know the patient's areas of comparative strengths and weaknesses (Reitan & Wolfson, 1988). Secondly, cognitive rehabilitation should be started promptly after this comprehensive evaluation, with the results of the examination serving as a basis for prescribing the elements and plan of the cognitive retraining program. Such aims cannot be achieved if only ``brief directed assessment'' is performed. Spontaneous recovery should not be permitted to plateau before a facilitated recovery program is initiated. Spontaneous recovery should be facilitated and augmented as much as possible, using a cognitive retraining program based on a comprehensive evaluation of the full range of neuropsychological functions, in order to achieve maximal functional recovery. 2. Cerebrovascular disease The authors state that ``neuropsychological assessment has little role in the assessment of patients with acute stroke,'' but may be helpful in ``patients who have largely recovered but may still evidence cognitive impairment,'' guiding rehabilitation and assisting families in planning home management.

5 2.1. Comment R.M. Reitan, D. Wolfson / Archives of Clinical Neuropsychology 16 (2001) 215± Neuropsychology has shown that general impairment, as well as specific deficits, vary with the individual patient who has sustained a stroke, and knowledge of the nature and degree of general impairment adds greatly in understanding the overall picture of neuropsychological deficits (as contrasted with the evaluation of specific deficits performed by the behavioral neurologist in cases of acute stroke) (Bornstein & Brown, 1991; Reitan & Wolfson, 1993). The potential for functional recovery may, in fact, be more dependent on the degree of general impairment than on specific deficits, and only neuropsychological testing can reveal and assess the nature and degree of generalized impairment. It is difficult to understand a recommendation that neuropsychological assessment should be restricted essentially to patients who have largely recovered and who may show only subtle indications of impairment. The complete picture of impairment in stroke patients should be identified as soon as possible after the stroke so that the existing deficits can be identified and a reasonable plan can be developed for achieving recovery. 3. Dementia The authors state that neuropsychological assessment can aid in assessment of patients with Alzheimer's disease and other dementias, and is especially valuable in distinguishing between normal aging and early Alzheimer's disease Comment Our clinical work with persons who have Alzheimer's disease shows that when the diagnosis can be made definitively, even in the early stages, the patient is severely impaired on the HRB. In fact, many older persons, who do not qualify clinically for any type of diagnosis of dementia, are significantly impaired on the HRB, as might well be expected from findings of senile plaques and neurofibrillary tangles in the brains of many older persons who were not demented in a clinical sense. Dementia, as defined by neurologists, is based largely on clinical observation and judgment, whereas neuropsychological impairment with aging (as shown on the HRB) begins much earlier and gradually progresses as the subject grows older (Reitan & Wolfson, 1986). There is a great deal of interindividual variability on the HRB of older non-alzheimer's subjects, with some persons retaining neuropsychological functions much better than others. In many cases, however, the HRB results suggest that the diagnosis of Alzheimer's disease should have been made, even though clinical observation and judgment have not been adequate to support the diagnosis. 4. Parkinson's disease The authors conclude that neuropsychological assessment can be of value in Parkinson's disease when there is a question of subtle cognitive deficits, but that overt dementia can be observed by the clinician, thus making neuropsychological testing unnecessary.

6 220 R.M. Reitan, D. Wolfson / Archives of Clinical Neuropsychology 16 (2001) 215± Comment The above conclusion fails to represent an understanding of the neuropsychology of Parkinson's disease. It is imperative in neuropsychological evaluation of Parkinson's patients that (1) both specific and general tests be used (the specific tests usually confirm and quantify the neurologist's observations of dyskinesia, whereas the general tests reveal significant higher-level deficits in adaptive abilities), and (2) a comprehensive neuropsychological test battery be used which covers the full range of neuropsychological functions (thus permitting an assessment of intraindividual differences in neuropsychological functions, which represent the critical information in understanding the patient's functional impairment) (Reitan & Boll, 1971). Neurologists frequently comment that persons with Parkinson's disease, for some unknown reasons(s), fail to take advantage of their ``cure'' when treatment is effective in relieving movement disorders, and explanations relating to ``learned invalidism'' are frequently invoked. Recent neuropsychological studies of Parkinson's disease have focused on specific deficits that are readily observed. These experiments have shown that Parkinson's patients have deficits, but mainly only confirm the existence of the readily observed signs and symptoms. The HRB has been developed through a long-term study to measure the full range of neuropsychological functions which are dependent on the brain. Many clinicians who favor a flexible battery (which is also recommended by the authors of the report being reviewed) feel that it is not only clinically appropriate but economically reasonable to select tests that are designed to evaluate the patient's specific complaints and/or the referring questions. Thus, the tests administered relate to the signs and symptoms reported by the patient rather than to the patient's brain Ð and such signs and symptoms are often far from synonymous with brain status. The HRB has been developed through testing thousands of controls and brain-damaged patients across the full range of neurological diagnoses. The criterion for selection of tests was whether the test added uniqueness in both the neurological and neuropsychological understanding of the patient's brain functions. Thus, in our studies of Parkinson's patients, we did not select tests to focus on specific signs and symptoms, but instead used the HRB to evaluate each patient's brain functions. (There is a great advantage in using a standard, comprehensive battery when the requirement is to understand the condition of the brain as contrasted with assessing observed symptomatology.) The results of published studies have shown that Parkinson's patients not only have specific motor deficits (as already shown by neurological examination), but also reveal striking deficits in complex problem-solving tasks regardless of whether they involve motor functions. In our first study, for example, we found Parkinson's patients to have a mean Wechsler IQ of 107 and a mean number of Category Test errors of 83! (Reitan & Boll, 1971). Although treatment methods of neurologists may ``cure'' the motor deficits, and the patient appears to be intelligent in casual contact, Parkinson's patients are frequently significantly impaired in basic aspects of reasoning, organizing, and gaining the necessary insight and grasp of problems to be able to make headway in practical, everyday situations. The motor deficits may be cured, but the neuropsychological deficits may be the ``weak link,'' defeating the prospect of again picking up premorbid activities and responsibilities.

7 R.M. Reitan, D. Wolfson / Archives of Clinical Neuropsychology 16 (2001) 215± Individual subjects with Parkinson's disease vary in their neuropsychological impairment, but the neuropsychological definition of Parkinson's disease is quite different from the neurological definition of Parkinson's disease, and every patient with Parkinson's disease should have the benefits implicit in a comprehensive and competent neuropsychological evaluation. 5. Human immunodeficiency virus encephalopathy The authors state that ``neuropsychological deficits are not more positive in seropositive individuals than in those who are seronegative, and routine neuropsychological assessment does not need to be performed in persons with HIV.'' However, when deficits do occur in the course of the disease, they may be prognostic implications for rapid decline and death, and may influence the decision to use antiviral agents Comment It is difficult to understand why the authors feel that neuropsychological testing is not needed in patients with HIV. First, there are conflicting reports in the literature regarding the presence of neuropsychological deficits in persons infected with HIV who do not have clinical signs of AIDS. Some studies have reported significant deficits and other studies have not. When the infection has progressed to a diagnosis of AIDS, clinical neuropsychological evaluation has been shown to reveal unique information. Heaton and his colleagues at the University of California-San Diego have conducted detailed studies which Heaton reported in his Presidential Address of the Division of Clinical Neuropsychology of APA in 1994 and subsequently published in The Clinical Neuropsychologist (Heaton et al., 1996). Anyone who doubts the clinical value of neuropsychological assessment in patients with HIV infection should read this comprehensive publication. Neuropsychological evaluation provides unique information regarding neuropsychological strengths and weaknesses in the individual patient. 6. Multiple sclerosis The authors recognize that cognitive functions are often impaired in patients with MS, that neuropsychological testing identifies the deficits even when the patient is felt to have normal clinical neurological findings, and that cognitive impairment correlates with reduced effectiveness in many daily activities Comment The conclusions of the authors are quite appropriate, although they are oriented toward sensitivity of neuropsychological test results rather than specificity for MS. It is important to realize that the neurological definition of MS and the neuropsychological definition of MS are complementary but quite different (Reitan, Reed, & Dyken, 1971). Reitan showed the

8 222 R.M. Reitan, D. Wolfson / Archives of Clinical Neuropsychology 16 (2001) 215±226 specificity of the HRB to MS years ago when, on the basis of test results alone, it was possible to correctly identify 15 of 16 MS patients who were included in a total sample of 112 patients being studied (Reitan, 1964). The importance of specificity of test results has been relatively neglected in clinical neuropsychology, but specificity is an inescapable requirement if conclusions are to be clinically relevant to the patient in question. 7. Epilepsy, neurotoxic exposure, and chronic pain The authors comment separately on each of these areas, essentially noting that neuropsychological deficits may occur in each of these conditions and evaluation may be helpful. With respect to epilepsy, however, the authors' comments are essentially restricted to performing brief testing during the Wada procedure and fail to note that evaluation of overall neuropsychological status of patients with epilepsy frequently is of great help in understanding and dealing with higher-level impairment of neuropsychological functions (Dodrill, 1984), in evaluating possible behavioral consequences of antiepileptic drugs, and the important work done in assessing the psychosocial problems of individuals with epilepsy (Dodrill, 1986). 8. Personality assessments in patients with neurologic disease The authors note that personality tests are often used to supplement neuropsychological assessments, but warn that tests such as the MMPI should be interpreted with caution. They go on to say that ``the behavioral and personality changes that occur in patients with frontal lobe or temporal lobe pathology are not readily characterized by responses to standard personality inventories.'' 8.1. Comment While a recommendation of caution in interpretation of tests such as the MMPI among braindamaged patients is well taken (inasmuch as the complaints of patients with brain impairment may have a different basis than similar complaints of the psychiatric patients on whom the norms were based), the references cited by the authors must be questioned regarding their cautionary statement concerning patients with frontal or temporal lobe pathology. They cite an article to support the statement quoted above that was based on subjects with closed head injuries and which did not include any subjects with specific frontal or temporal lobe damage. 9. Neuropsychological consultation The authors begin this section of their report with a review of a number of circumstances in which neuropsychological consultation may be helpful. They conclude this listing with a cautionary statement that ``neuropsychological assessment is not intended to provide a diagnosis or to indicate the precise localization of a focal brain lesion.''

9 R.M. Reitan, D. Wolfson / Archives of Clinical Neuropsychology 16 (2001) 215± The authors emphasize that the neuropsychological evaluation should not only be responsive to referral questions, but should be ``guided by the preliminary mental status assessment by the clinician'' (presumably the referring neurologist). In fact, the authors state that the evaluations (presumably the tests used) should be commensurate in extent with the question being asked and the status of the patient. It would appear that the authors feel that the neuropsychological testing should be determined by specific referral questions suggested by the neurologist rather than by the need to assess the status of the patient's brain. They explicitly state that more severely impaired patients or those in the acute phase of brain insults should have only brief and targeted assessments. The authors seem to feel that the neuropsychological strengths and weaknesses of such patients do not need to be assessed, or that if testing is done, it will only confirm clinically obvious impairment. This conceptualization of brain±behavior relationships is apparently based on a belief that the aim in neuropsychological testing is only to rank the patient's scores on a series of tests rather than to perform an assessment of intraindividual variations (personal strengths and weaknesses) of the patient. In competent neuropsychological evaluation, using tests of known relationships to each other, one may learn more about the patient's neuropsychological status from relationships between test scores than from how well the patient has performed on each test. Of course, such an approach cannot be employed unless the tests used have known relationships that permit them to complement each other in supporting clinical conclusions, and the authors preclude this possibility by stating that ``neuropsychological assessments should flexibly respond to the question being asked by the clinician'' rather than being selected by the neuropsychologist to describe the unique aspects of brain± behavior relationships for the patient. Thus, the position of the authors is that only brief assessments should be done with the more severely impaired patients, and that more extensive evaluations may be required for patients with mild or subtle deficits, but the authors caution that ``detailed testing tends to over-identify cognitive impairments, and referring clinicians should be aware that neuropsychological testing will often provide an exaggerated estimate of the possibility of brain dysfunction.'' It is difficult to discern the thinking behind this comment regarding ``detailed testing.'' Perhaps it is based on the notion that if one keeps giving tests, sooner or later, some of them will fall way below the average level and thus support a conclusion of ``brain dysfunction.'' However, if this is the model of thinking that the authors use to infer brain damage or dysfunction, one can only conclude that they have not compared brain-damaged and non-brain-damaged patients routinely on a set of tests composed to evaluate not only level of performance but patterns and relationships among test results, pathognomonic deficits, and comparisons of the same sensory and motor skills on the two sides of the body. Use of these methods in a complementary fashion represents the necessary methodology not only to evaluate neuropsychological ability structure, but also to relate deficits to the biological condition of the brain. The authors next state the neuropsychological reports should be brief because ``brevity in reporting often serves the clinician better than an extended report.'' No mention is made that sometimes a report must be relatively long in order to describe the patient's brain status and the resulting behavioral consequences.

10 224 R.M. Reitan, D. Wolfson / Archives of Clinical Neuropsychology 16 (2001) 215±226 The authors indicate that the report should contain data corrected for age and education. They apparently are unaware that relationships of neuropsychological test scores are quite different for brain-damaged vs. normal subjects; that corrections for age and education are generally based on normals; and that use of data based on normals for alteration of test scores of brain-damaged persons, in effect, tends to introduce error to otherwise valid measurements. The authors list a number of tests that they say are ``typically used'' to do neuropsychological assessments, separating them by areas of function. Apparently, the intent is solely to cover a number of areas of function. This ``typical'' battery makes no allowances for use of complementary inferential approaches, and seems to be based only on adequacy of performances, essentially ignoring intraindividual variations as a basis for interpretation. The authors next consider the competence of neuropsychologists, emphasizing such factors as having been certified by one or both Boards, having completed postdoctoral training, and holding a professional license. No mention is made of the great variability in the competence of neuropsychologists who do meet such criteria. The use of technicians for test administration is implicitly criticized by the authors. They warn that ``technicians may be less likely to identify spurious data or to modify their procedures to optimize information collection, and this may lead to interpretive errors.'' They then caution the referring clinician ``to be aware of whether technicians are in use in the neuropsychological laboratories to which they refer.'' Our experience indicates that technicians who are carefully trained and supervised are capable of following standard procedures in test administration quite reliably and accurately. Finally, with respect to consultation with neuropsychologists, the authors again emphasize that neurologists perform their own mental status examinations and perform screening tests as a basis for the referral. ``This initial assessment guides the questions to be asked of the neuropsychologist'' and the referring clinician should be as specific as possible in communicating to the psychologist the questions that need to be answered. The authors complete the paper with a brief summary, indicating that neuropsychological testing can be helpful when done by an individual with competence and experience. The authors again emphasize that ``neuropsychological evaluation is usually able to distinguish between normal and abnormal but cannot determine the cause of neurologic disease. Lesion localization should be inferred with caution on the basis of neuropsychological test results. Neuropsychological assessment is particularly valuable in patients with subtle deficits and provides less unique information when used with severely impaired patients.'' Finally, the authors again advise neurologists to base referral questions, which should be quite specific, on preliminary mental status assessment, and that neuropsychologists should focus on the referring question and should not offer medical advice. 10. Final comment There is little doubt that in many respects this article understated and downgraded the contribution that clinical neuropsychology can make in the evaluation and care of neurological patients. The emphasis on composing the neuropsychological examination in accordance with the instructions (preliminary findings, referral questions) of the neurologist

11 R.M. Reitan, D. Wolfson / Archives of Clinical Neuropsychology 16 (2001) 215± fails to recognize that clinical neuropsychology is a separate and independent discipline and that the consulting relationship should recognize the competence and expertise of the neuropsychologist in determining the content, nature, length, etc. of the examination that is required. The caution given to neurologists to be ``aware'' of laboratories that use technicians for testing represents another imposition on how we, as neuropsychologists, manage our practices. As neuropsychologists, we must recognize that this article will be read and used in many contexts beyond consultation with neurologists. Lawyers will almost certainly use the Neurology article to question individual neuropsychologists about the use of technicians, about ``over-identifying cognitive impairments'' by having given too many tests, and about conclusions which, in the individual case at hand, go beyond the very modest capabilities ascribed to neuropsychologists by the authors of this article. Your judgment and practice as an individual neuropsychologist may well be questioned if they conflict with the published conclusions of this Expert Panel. Neuropsychologists might be inclined to ask themselves a number of questions about this report. Why would a neurologist be the chief author of a report concerned with what neuropsychologists can contribute? Why did the neuropsychologists on the panel not represent their field more adequately? These neuropsychologists might well say that the worst thing they could have done was to over-represent the field Ð to promise more than could be delivered. In reality, the worst thing was to understate the merits of neuropsychology and to minimize its potential contribution as a discipline. In fact, a report written by a neurologist, which tends to downgrade neuropsychology, lays the seeds for contention in relationships between the fields when a common interest in the brain and the welfare of patients should be a basis for complementary and harmonious interactions. References Bornstein, R. A., & Brown, G. (1991). Neurobehavioral aspects of cerebrovascular disease. New York: Oxford Univ. Press. Dodrill, C. B. (1984). Neuropsychological implications of epilepsy. In: R. Stevens (Ed.), Aspects of consciousness: clinical issues, vol. 4 (pp. 103±116). New York: Academic Press. Dodrill, C. B. (1986). Psychosocial consequences of epilepsy. In: S. B. Filskov, & T. J. Boll (Eds.), Handbook of clinical neuropsychology, vol. 2 ( pp. 338 ±363). New York: Wiley. Franzen, M. D. (1989). Reliability and validity in neuropsychological assessment. New York: Plenum. Heaton, R. K., Marcotte, T. D., White, D. A., Ross, D., Meredith, K., Taylor, M. J., Kaplan, R., & Grant, I. (1996). Nature and vocational significance of neuropsychological impairment associated with HIV infection. The Clinical Neuropsychologist, 10, 1 ±14. Reitan, R. M. (1959). The effects of brain lesions on adaptive abilities in human beings. Tucson, AZ: Neuropsychology Press. Reitan, R. M. (1962). Psychological deficit. Annual Review of Psychology, 13, 415± 444. Reitan, R. M. (1964). Psychological deficits resulting from cerebral lesions in man. In: J. M. Warren, & K. A. Akert (Eds.), The frontal granular cortex and behavior (pp. 295 ±312). New York: McGraw-Hill. Reitan, R. M., & Boll, T. J. (1971). Intellectual and cognitive functions in Parkinson's disease. Journal of Consulting and Clinical Psychology, 37, 364 ± 369. Reitan, R. M., & Fitzhugh, K. B. (1971). Behavioral deficits in groups with cerebral vascular lesions. Journal of Consulting and Clinical Psychology, 37, 215 ± 223.

12 226 R.M. Reitan, D. Wolfson / Archives of Clinical Neuropsychology 16 (2001) 215±226 Reitan, R. M., Reed, J. C., & Dyken, M. L. (1971). Cognitive, psychomotor, and motor correlates of multiple sclerosis. Journal of Nervous and Mental Disease, 153, 218 ± 224. Reitan, R. M., & Wolfson, D. (1986). The Halstead ± Reitan Neuropsychological Test Battery and aging. Clinical Gerontologist, 5, 39 ±61. Reitan, R. M., & Wolfson, D. (1988). Traumatic brain injury. Recovery and rehabilitation, vol. 2. Tucson, AZ: Neuropsychology Press. Reitan, R. M., & Wolfson, D. (1993). The Halstead ± Reitan Neuropsychological Test Battery: theory and clinical interpretation (2nd ed.). Tucson: Neuropsychology Press. Reitan, R. M., & Wolfson, D. (1995). Influence of age and education on neuropsychological test results. The Clinical Neuropsychologist, 9, 151 ± 158. Reitan, R. M., & Wolfson, D. (1996). The diminished effect of age and education on neuropsychological performances of learning-disabled children. Child Neuropsychology, 2, 11 ± 16. Reitan, R. M., & Wolfson, D. (1997). Theoretical, methodological, and validational bases of the Halstead ±Reitan Neuropsychological Test Battery. In: I. Grant, & K. M. Adams (Eds.), Neuropsychological assessment of neuropsychiatric disorders (2nd ed., pp. 3 ±42). New York: Oxford Univ. Press. Snow, W. G., Tierney, M. C., Zoritto, M. L., Fisher, R. H., & Reid, D. W. (1989). WAIS-R test±retest reliability in a normal elderly sample. Journal of Clinical and Experimental Neuropsychology, 11, 423 ±428.