Trends in Neuropsychological Test Usage

Terri Horowitz, M.S., Drexel University, Psychology Department
Philip Schatz, Ph.D., Saint Joseph's University, Psychology Department
Douglas L. Chute, Ph.D., Drexel University University, Psychology Department

Abstract

This retrospective survey explored current trends in neuropsychological test utilization. We provide a descriptive analysis of tests used by neuropsychologists (including original vs. revised versions), and when and where the evaluations were performed. Previous surveys have employed self-report inventories, in which psychologists were asked to report in hindsight the type and frequency with which they use neuropsychological tests. Instead, we reviewed 134 (110 adult, 24 child) actual neuropsychological evaluations from Pennsylvania Head Injury Program files. Mose evaluations were conducted in rehabilitation settings. Findings indicate that the Wechsler scales (Intelligence and Memory) and parts of the Halstead-Reitan Battery remain the most frequently used tests, and that a substantial number of neuropsychoogists continue to use the original versions of the WAIS and WMS. Strikingly, "traditional" psychological measures, such as personality, projective, and mood assessment measures were virtually absent in current evaluations. Tables are provided to explicate the changing trends in neuropsychological test usage since 1980.

Introduction

Increasing numbers of psychologists are defining themselves as "neuropsychologists," although their training and credentials vary considerably. It can be expected that this diversity of educational background may result in a comparable variability of assessment procedures used by the current practitioners. Most of the surveys of neuropsychological test utilization in the literature are limited by their reliance on self-report inventories; psychologists were asked to report in hindsight the type and frequency with which they use neuropsychological tests. Furthermore, the psychologists surveyed were asked to describe frequency of test usage in vague, qualitative terms such as "frequently," "moderately," or "occasionally." As is the case with most survey research, previous studies were also confounded by a generally low-to-moderate response rate.

This study's aim was to explore the current trends in neuropsychological test utilization by retrospective analysis rather than traditional survey measures. We surveyed the actual neuropsychological tests used with a population of moderate-to-severe traumatic brain injury survivors. Our primary goal was to provide a descriptive analysis of what tests examiners use, and when and where (e.g., rehabilitation hospital) the evaluations are being performed. In addition, we were interested in identifying the percentage of practitioners who choose to use the older, original versions of certain tests (e.g. WAIS, WMS) rather than their current revised versions. Practitioners are often ambivalent to switch to current (revised) versions of tests after they have become familiar with the older versions and find them reliable.


Methods

Subjects: Subjects were 94 individuals enrolled in the Pennsylvania Head Injury Program (PHIP) who underwent a neuropsychological evaluation between 1986 and 1995. All subjects were considered to be domiciled in the state of Pennsylvania at the time of their head injury, had applied to the Pennsylvania Head Injury Program for funding, and showed evidence of having sustained a traumatic brain injury according to PHIP criteria.

Twenty-seven subjects had multiple (two or more) neuropsychological assessments, yielding a total of 134 neuropsychological assessments evaluated for this study. Of these 134 neuropsychological evaluations, 110 were performed on adults (age 16+) and 24 on children.

Procedures: Individual PHIP files were examined for complete neuropsychological evaluations. Evaluations were not used if they appeared to have been conducted for primarily vocational purposes. Three types of information were recorded:

  1. setting where the evaluation was performed (e.g., hospital, private practice),
  2. time post-injury the neuropsychological evaluation was performed,
  3. tests used (including original or revised versions).

Results:

Neuropsychological evaluations included in this study were predominantly conducted in rehabilitation hospitals or units (48%), followed by acute care hospitals (18%), private practice (16%), psychiatric facilities (8%), educational programs (6%), and "other" (4%) settings.

For adults, the mean time between injury and evaluation was approximately one year and five months, with a standard deviation of 1.5. For children the mean was approximately one year and one month with a standard deviation of 1.2.

The rank order for each test administered to adults is displayed in Table 1. Tests are arranged in descending order from most to least frequently administered (alphabetically when percentages are equivalent). Tests were excluded if they were used in less than 5% (n=6) of the adult neuropsychological evaluations.

Due to the relatively small number of child evaluations, the rank order for child assessments only includes test administered in at least 15% (n=4) of the evaluations. These results are displayed in Table 2.


Discussion:

This study surveyed the actual neuropsychological tests used with traumatic brain injury survivors. In contrast to most previous surveys, this study did not rely on neuropsychologistÕs recall or estimation of the frequency with which they use their measures. Although we were only able to sample a small number of child assessments, other surveys have not previously included tests used with children in their reports.

The findings from this study indicate that the Wechsler scales (Intelligence and Memory) remain the most frequently used tests in both adult and child assessments. In contrast with the 1994 ranking, a sufficient amount of neuropsychologists continue to use the unrevised versions of the WAIS and WMS. While both the 1994 survey and our survey sample similar time periods (1987-1994 and 1986-1995, respectively), ours was a regional sample limited to the state of Pennsylvania. Therefore, common training and/or membership in regional organizations may explain this discrepancy. The Halstead-Reitan battery, or parts thereof, has remained high in the ranks throughout the years, with the most prominent subtests being the Trail Making, Finger Tapping, and Category Tests.

Perhaps the most notable discrepancies between the current survey and all of the previous surveys are the virtual disappearance of "traditional" psychological measures, such as personality, projective, and emotional assessment measures. While the MMPI and Beck Depression Inventory are the only measures ranked our list, other ranks have all included the Rorschach and other projective measures.


Table 1. Rank Order of Neuropsychological Tests used with Adult Patients, Followed by Percent of Evaluations (n=110)
  1. WAIS-R and WAIS (86%) (WAIS-R, WAIS)
  2. WMS-R and WMS (65%) (WMS-R, WMS)
  3. Trail Making Test (61%)
  4. Finger Tapping (48%)
  5. Category Test (all forms) (45%)
  6. WRAT-R (43%)
  7. Grip Strength (37%)
  8. Seashore Rhythm Test (36%)
  9. Reitan-Klove Sensory Perceptual Exam (34%)
  10. Tactual Performance Test (34%)
  11. Speech Sounds Perception Test (33%)
  12. Aphasia Screening Test (Reitan) (31%)
  13. Verbal Fluency (various forms) (28%)
  14. Grooved Pegboard (27%)
  15. Boston Naming Test (18%)
  16. California Verbal Learning Test (18%)
  17. Digit Vigilance / Cancellation Tasks (various forms) (18%)
  18. Stroop Color-Word Test (18%)
  19. MMPI and MMPI-2 (16%)
  20. Rey Auditory Verbal Learning Test (16%)
  21. Wisconsin Card Sorting Test (16%)
  22. Peabody Picture Vocabulary Test (14%)
  23. Bender Gestalt (13%)
  24. Hooper Visual Organization Test (13%)
  25. Lateral Dominance Examination (13%)
  26. Beck Depression Inventory (12%)
  27. Rey-Osterrieth Complex Figure Design Test (11%)
  28. Clock Drawing (9%)
  29. Luria-Nebraska Neuropsychological Battery (9%)
  30. Peabody Individual Achievement Test (9%)
  31. Woodcock-Johnson Psychoeducational Battery-Revised (8%)
  32. Knox Cube (7%)
  33. Rey Fifteen-Item Test (7%)
  34. Continuous Performance Test (6%)

Table 2. Rank Order of Neuropsychological Tests used with Child Patients, Followed by Percent of Evaluations (n=24)

  1. WISC-III and WISC-R (75%) (WISC-III, WISC-R)
  2. Trail Making Test (33%)
  3. Wide Range Assessment of Memory and Learning (33%)
  4. WRAT-R (33%)
  5. Category Test (all forms) (29%)
  6. Finger Tapping (29%)
  7. Boston Naming Test (25%)
  8. Rey Auditory Verbal Learning Test (25%)
  9. Grooved Pegboard (25%)
  10. Peabody Picture Vocabulary Test (25%)
  11. Wisconsin Card Sorting Test (25%)
  12. Grip Strength (21%)
  13. Lateral Dominance Examination (21%)
  14. Tactual Performance Test (21%)
  15. Aphasia Screening Test (Reitan) (17%)
  16. Digit Vigilance / Cancellation Tasks (various forms) (17%)
  17. Verbal Fluency (various forms) (17%)
  18. Woodcock-Johnson Psychoeducational Battery-Revised (17%)

Table 3. Ranking of Measures in Prior Studies of Neuropsychological Test Use

1980a

1990b

1994c

1996

WAIS/WAIS-R

1

1

1

1

WMS/WMS-R

8

2

3

2

Trail Making

N/A

3

4

3

WRAT/WRAT-R

3

5

12

6

MMPI/MMPI-2

10

4

2

19

Wisconsin Cards

N/A

11

9

21

Bender Gestalt

4

6

7

23

Rorschachd

N/A

7.5

23

0

Benton VRTe

6

9

42

0

aHartlage & Telzrow, (1980).
bGuilmette, Faust, Hart, & Arkes, (1990).
cLees-Haley, Smith, Williams, and Dunn (1996).
dRorschach was used in 4.5% (n=5) of our sample, and therefore, did not appear on our rank order.
eBenton Visual Retention Test was used in 1% (n=1) of our sample, and therefore, did not appear on our rank order.