Cognitive Assessment

Cognition

Cognition is “the mental action or process of acquiring knowledge and understanding

through thought, experience, and the senses”.

It encompasses many aspects of intellectual functions and processes such as attention, the
formation of knowledge, memory and working memory, judgment and evaluation, reasoning and
computation, problem solving and decision making, comprehension and production of language.
Cognitive processes use existing knowledge and generate new knowledge.

Psychological Assessment

“The gathering and integration of data to evaluate a person’s behavior, abilities, and other
characteristics, particularly for the purposes of making a diagnosis or treatment
recommendation” (APA Dictionary).

Psychologists assess diverse psychological problems (e.g., anxiety, substance abuse) and
other psychological concerns (e.g., intelligence, career interests) in a range of clinical,
educational, organizational, forensic, and other settings. Assessment data may be gathered
through interviews, observation, standardized tests, self-report measures, physiological or
psychophysiological measurement devices, or other specialized procedures and apparatuses.

Cognitive Assessment

A cognitive assessment is an examination conducted to determine someone's level of

cognitive function. The term cognitive functioning encompasses a variety of skills and abilities,
including intellectual capacity, attention and concentration, processing speed, language and
communication, visual-spatial abilities, and memory.

Sensorimotor and psychomotor functioning are often measured alongside neurocognitive

functioning to clarify the brain basis of certain cognitive impairments and are therefore
considered as one of the domains that may be included within a neuropsychological or
neurocognitive evaluation. These skills and abilities cannot be evaluated in any detail without
formal standardized psychometric assessment.
 A series of activities are administered by an accredited psychologist to assess various
areas of cognitive functioning including:

Verbal Comprehension – measures the individual’s range of vocabulary and their ability to
express general knowledge and explain concepts.

Visual Spatial – measures the verbal reasoning, understanding, concept formation and
knowledge of an individual.

Fluid Reasoning – measures the ability to solve novel problems independent of previous
knowledge.

Working Memory – measures a person’s ability to learn, manipulate and retain information to
complete new tasks.

Processing Speed – measures the individual’s ability to quickly process and make decisions
about visual inform.

In this type of assessment, the subject will be asked to complete a series of tasks that
require cognitive skills. Exams may be broken up into several different components to test things
like reasoning, understanding language, and so forth. Each section is scored separately, and the
results can be compared with those of other people who have taken the test to see where
someone falls on a scale of cognitive performance.

Use

Cognitive assessment is commonly used for the following reasons:

a) screening for cognitive impairment.

b) differential diagnosis of cause.
c) rating of severity of disorder or monitoring disease progression.

Ways of doing cognitive assessment

Psychologists can use different types of methods for evaluating cognitive functioning. Some
of them are:

1. by conducting assessment interviews

2. through observation
 3. by using different psychological tests to evaluate functioning

1. Assessment Interviews

Probably the single most important means of data collection during psychological evaluation
is the assessment interview. Without interview data, most psychological tests are meaningless.
The interview also provides potentially valuable information that may be otherwise unobtainable,
such as behavioral observations, idiosyncratic features of the client, and the person’s reaction to
his or her current life situation. In addition, interviews are the primary means for developing
rapport and can serve as a check against the meaning and validity of test results.

Interview vs Conversation

Sometimes an interview is mistakenly thought to be simply a conversation. In fact, the

interview and conversation differ in many ways. An interview typically has a clear sequence and
is organized around specific, relevant themes because it is meant to achieve defined goals.
Unlike a normal conversation, the assessment interview may even require the interviewer and
interviewee to discuss unpleasant facts and feelings. Its general objectives are to gather
information that cannot easily be obtained through other means, establish a relationship that is
conducive to obtaining the information, develop greater understanding in both the interviewer
and interviewee regarding problem behavior, and provide direction and support in helping the
interviewee deal with problem behaviors. The interviewer must not only direct and control the
interaction to achieve specific goals, but also have knowledge about the areas to be covered in
the interview.

Structured and Unstructured Interviews

A basic dimension of an interview is its degree of structure. Some interviews allow the
participants to freely drift from one area to the next, whereas others are highly directive and goal
oriented, often using structured ratings and checklists. The more unstructured formats offer
flexibility, possibly high rapport, the ability to assess how clients organize their responses, and
the potential to explore unique details of a client’s history. Unstructured interviews, however,
have received frequent criticism, resulting in widespread distrust of their reliability and validity.
As a result, highly structured and semistructured interviews have been developed that provide
sound psychometric qualities, the potential for use in research, and the capacity to be
administered by less trained personnel.

Regardless of the degree of structure, any interview needs to accomplish specific goals, such
as assessing the client’s strengths, level of adjustment, the nature and history of the problem,
diagnosis, and relevant personal and family history. Techniques for accomplishing these goals
vary from one interviewer to the next. Most practitioners use at least some structured aids, such
as intake forms that provide identifying data and basic elements of history. Obtaining
information through direct questions on intake forms frees the clinician to investigate other
aspects of the client in a more flexible, open-ended manner. Clinicians might also use a checklist
to help ensure that they have covered all relevant areas. Other clinicians continue the structured
format throughout most of the interview by using one of the formally developed structured
interviews, such as the Schedule for Affective Disorders and Schizophrenia (SADS) or
Structured Clinical Interview for the DSM-IV (SCID).

2. Assessment through Observation

“Observation is a visual method of gathering information on activities: of what happens,

what your object of study does or how it behaves”.

Observations of the person being referred in their natural setting can provide additional
valuable assessment information. In the case of child, how do they behave in school settings, at
home, and in the neighborhood? Does the teacher treat them differently than other children?
How do their friends react to them? The answers to these and similar questions can give a better
picture of a child and the settings in which they function. It can also help the professional
conducting the assessment better formulate treatment recommendations.

To assess and understand behavior, one must first know what one is dealing with. It comes as
no surprise, then, that behavioral assessment employs observation as a primary technique. A
clinician can try to understand a phobic's fear of heights, a student's avoidance of evaluation
settings, or anyone's tendency to overeat. These people could be interviewed or assessed with
self-report inventories. But many clinicians would argue that unless those people are directly
observed in their natural environments, true understanding will be incomplete. To determine the
frequency, strength, and pervasiveness of the problem behavior or the factors that are
maintaining it, behavioral clinicians advocate direct observation.

Of course, all this is easier said than done. Practically speaking, it is difficult and expensive
to maintain trained observers and have them available. This is especially true in the case of
adults who are being treated on an outpatient basis. It is relatively easier to accomplish with
children or those with cognitive limitations. It is likewise easier to make observations in a
sheltered or institutional setting.

In some cases, it is possible to use observers who are characteristically part of the person's
environment (such as spouse, parent, teacher, friend, or nurse). In certain instances, it is even
possible to have the client do some self-observation. Of course, there is the ever-present question
of ethics. Clinical psychologists must take pains to make sure that people are not observed
without their knowledge or that friend and associates of the client are not unwittingly drawn into
the observational net in a way that compromises their dignity and right to privacy.

Observational data can be gathered from different areas of an individual’s life e.g.

 Home observation

 School observation

 Hospital or clinical observation

 Workplace observation

3. Cognitive tests to evaluate Cognitive Functioning

In contrast to testing that relies on self-report, evaluating cognitive functioning relies on

measures of task performance to establish the severity of cognitive impairments. Such tests are
commonly used in clinical neuropsychological evaluations in which the goal is to identify a
patient’s pattern of strengths and weaknesses across a variety of cognitive domains. These
performance-based measures are standardized instruments with population-based normative data
that allow the examiner to compare an individual’s performance with an appropriate comparison
group (e.g., those of the same age group, sex, education level, and/or race/ethnicity).
 Cognitive testing is the primary way to establish severity of cognitive impairment and is
therefore a necessary component in a neuropsychological assessment. Clinical interviews alone
are not sufficient to establish the severity of cognitive impairments, for two reasons: (1) patients
are known to be poor reporters of their own cognitive functioning (Edmonds et al., 2014; Farias
et al., 2005; Moritz et al., 2004; Schacter, 1990) and (2) clinicians relying solely on clinical
interviews in the absence of neuropsychological test results are known to be poor judges of
patients’ cognitive functioning (Moritz et al., 2004).

There are numerous performance-based tests that can be used to assess an individual’s level
of functioning within each domain identified below for both adults and children.

A. General Cognitive/Intellectual Ability

General cognitive/intellectual ability encompasses reasoning, problem solving, and meeting

cognitive demands of varying complexity. It has been identified as “the most robust predictor of
occupational attainment and corresponds more closely to job complexity than any other ability”
(OIDAP, 2009). Intellectual disability affects functioning in three domains: conceptual (e.g.,
memory, language, reading, writing, math, knowledge acquisition); social (e.g., empathy, social
judgment, interpersonal skills, friendship abilities); and practical (e.g., self-management in areas
such as personal care, job responsibilities, money management, recreation, organizing school and
work tasks) (American Psychiatric Association, 2013). Tests of cognitive/intellectual
functioning, commonly referred to as intelligence tests, are widely accepted and used in a variety
of fields, including education and neuropsychology. Prominent examples include the Wechsler
Adult Intelligence Scale, fourth edition (WAIS-IV; Wechsler, 2008) and the Wechsler
Intelligence Scale for Children, fifth edition (WISC-V; Wechsler, 2014).

i. The Wechsler Adult Intelligence Scale (WAIS-IV)

The Wechsler Adult Intelligence Scale (WAIS) is an IQ test designed to measure intelligence
and cognitive ability in adults and older adolescents. The original WAIS (Form I) was published
in February 1955 by David Wechsler, as a revision of the Wechsler–Bellevue Intelligence Scale,
released in 1939. It is currently in its fourth edition (WAIS-IV) released in 2008 by Pearson, and
is the most widely used IQ test, for both adults and older adolescents, in the world.
 The current version of the test and is comprised of the 10 core subtests and five supplemental
subtests listed in the table below. In addition, a new index was added which was the General
Ability Index, or GAI. This index consists of the scores from the Similarities, Vocabulary,
Information, Block Design, Matrix Reasoning, and Visual Puzzles subtests.

WAIS-IV Test Measures

The Wechsler Adult Intelligence Scale returns scores on four separate indexes of adult
intelligence, each with its own subsets:

 The Perceptual Reasoning Index (PRI) contains several subsets. Block design tests an
adult’s visual motor construction, visual spatial processing, and visual problem solving.
Matrix reasoning measures inductive reasoning and one’s ability to solve problems in
nonverbal, abstract ways. Visual puzzles reveal the subject’s visual spatial reasoning.
Through picture completion, psychologists measure how quickly the subject can perceive
visual details. And quantitative reasoning is tested using figure weights.
 The Verbal Comprehension Index (VCI) the test takers must describe how various
concepts and words are similar. They also define vocabulary words and answer general
knowledge questions. These tests are used to evaluate semantic knowledge, verbal
comprehension, abstract verbal reasoning, and verbal expression.
 The Working Memory Index (WMI) essentially evaluates how well you can remember
things. To measure WMI, participants will be asked to recall a list of numbers in the
order that they were given (digit span) and a series of numbers and letters in order (letter-
number sequencing). These tests evaluate attention, mental control, auditory processing,
and working memory. The WMI also uses arithmetic to measure concentration,
quantitative reasoning, and mental manipulation.
 The Processing Speed Index (PSI) is essentially a measure of how fast your brain
works. Through symbol search, cancellation, and coding, the test evaluates graphomotor
speed, associative memory, and processing speed. Graphomotor skills combine
perceptual, cognitive, and motor skills and enable a person to write.
Calculation of Scores

Scores are calculated on each of the four indices of the Wechsler Adult Intelligence
Scale. They are then combined to create a Full-Scale IQ (FSIQ). Test takers will also be given a
score on the General Ability Index (GAI), which uses the six subsets of the PRI and VCI:
similarities, vocabulary, information, block design, matrix reasoning, and visual puzzles.

Good Score on the WAIS-IV IQ Test

The Wechsler Adult Intelligence Scale is normed so that 100 is the median score for the adult
population. Scores of 90-109 are in the average range, and the average IQ of all high school
graduates is 105. College graduates have an average IQ of 115, which means that people in the
“high average” range of IQ, 110-119, have a good chance of succeeding in college. Scores of
120-129 are considered “superior,” and this is the average IQ range for most successful Ph.D.
candidates. A full-scale IQ score of 130 or above on the WAIS-IV will qualify you for Mensa,
the high IQ society for people in the top 2% of intelligence.

The “low average” IQ range is 80-89, and people in this range will likely struggle with
academics. Those scoring in the 71-80 range tend to exhibit what is called “borderline
intellectual functioning.” Moderate retardation occurs from about 50-70, and severe retardation
at IQs below 50.

ii. Wechsler Intelligence Scale for Children (WISC-V)

The Wechsler Intelligence Scale for Children (WISC) has been around since 1949 as an
adaptation of David Wechsler’s 1939 Wechsler-Bellevue Intelligence Scale. This version of the
Wechsler test is a psychological assessment that measures different aspects of intelligence and is
designed for children between the ages of 6 to 16. The test has undergone several updates and the
current version of the test is the fifth edition WISC-V which was released in 2014.

Uses

Though this test can be used as an IQ test for children, it is most often used as a clinical
tool to measure individual cognitive abilities. The WISC is often used among a battery of other
tests to assess and identify cognitive function and ability ranges which can help identify
giftedness, learning disabilities, or general strengths and weaknesses a child may have in their
cognitive abilities. Learning disabilities can be identified by comparing results from an
intelligence test like the WISC with the scores from an achievement test like the Wechsler
Individual Achievement Test to identify gaps between academic achievement and a child’s level
of intellectual functioning.

The developers of this intelligence test recognize that a child’s performance must be
compared to individuals like them, and each version of the WISC uses normative samples to
compare a child’s score to. Age has the most significant effect on how a child performs on a
certain task. Therefore, raw scores of each subtest are calculated and then compared to the
normative sample with children of the same age.

This test relies on the idea that cognitive skills, or intelligence, are normally distributed
throughout the population. Normal distribution means that most people fall within the average
range and less people perform at a range that is above or below average.

Scoring system

Scores for this test are determined based on statistical values such as the mean (the
average) and standard deviation (a calculation that determines a significant distance of a score
from the average). Once a child’s performance on a subtest is compared to the normative sample,
subtest scores are converted into scaled scores that serve as one of the universal metrics for this
test.

A scaled score of 10 is the mean and scaled scores that deviate 3 units reflect a standard
deviation. Similar subtests are then combined into Primary Index Scales that have a mean of 100
and standard deviation of 15. These numbers help determine the classification for performance.

Classification of performance for scaled index scores are as follows:

 Below Average – scaled score 1 to 5

 Low Average – scaled score 6 to 7

 Average – scaled score 8 to 11

 High Average – scaled score 12 to 13

 Superior – 14 to 15
  Very Superior – 16 to 20

Descriptors of performance for standard WISC score ranges are as follows:

 Below Average – standard score below 79

 Low Average – standard score 80 to 89

 Average – 90 to 109

 High Average – 110 to 119

 Superior – 120 to 129

 Very Superior – above 130

Administration

The fifth version of this test is done individually with the child and clinician and can be
done in standard paper-and-pencil administration or on a tablet, digital format. This test includes
a total of 16 subtests; however, the standard number of subtests given is 7. Raw scores on these
subtests are converted into scaled scores and then the sum of scaled scores of similar tests is
converted into a Primary Index Scale.

WISC Index Scores

There is a total of five Primary Index Scores that make up the Full-Scale IQ score: Verbal
Comprehension, Visual Spatial, Fluid Reasoning, Working Memory, and Processing Speed. The
Verbal Comprehension Index reflects the ability to access and apply word knowledge. The core
subtests include Similarities (how to words are similar) and Vocabulary.

 The Visual Spatial Index reflects the ability to understand visual details and
relationships to solve puzzles and construct geometric designs. The core subtests are
Block Design (orienting blocks to match a picture) and Visual Puzzles (visual spatial
integration).

 The Fluid Reasoning Index reflects the ability to detect relationships among visual
objects. The core subtests are Matrix Reasoning (reasoning with continuous and discrete
visual patterns) and Figure Weights (quantitative reasoning).
  The Working Memory Index reflects the ability to register, maintain, and manipulate
visual and auditory information. The core subtests are Digit Span (repeating number
sequences) and Picture Span (auditory and visual attention and working memory,
respectively).

 The Processing Speed Index reflects the speed at which a child can accurately make
decisions. The core subtests are Coding (matching symbols to associated numbers) and
Symbol Search (visual scanning and graphomotor speed of matching symbols).

 Verbal Comprehension Index measures a child’s ability to verbally reason, which can
be heavily influenced by their semantic knowledge. This index score is derived from the
Similarities, Vocabulary, Information, and Comprehension subtests.

Scores on the five Primary Index Scales are then combined and converted into a Full-Scale
Intelligence Quotient (FSIQ), which is designed to measure overall intelligence.

B. Language and Communication

The domain of language and communication focuses on receptive and expressive language
abilities, including the ability to understand spoken or written language, communicate thoughts,
and follow directions (American Psychiatric Association, 2013; OIDAP, 2009). The
International Classification of Functioning, Disability and Health (WHO, 2001) distinguishes the
two, describing language in terms of mental functioning while describing communication in
terms of activities (the execution of tasks) and participation (involvement in a life situation). The
mental functions of language include reception of language (i.e., decoding messages to obtain
their meaning), expression of language (i.e., production of meaningful messages), and integrative
language functions (i.e., organization of semantic and symbolic meaning, grammatical structure,
and ideas to produce messages).

Abilities related to communication include receiving and producing messages (spoken,

nonverbal, written, or formal sign language), carrying on a conversation (starting, sustaining, and
ending a conversation with one or many people) or discussion (starting, sustaining, and ending
an examination of a matter, with arguments for or against, with one or more people), and use of
communication devices and techniques (telecommunications devices, writing machines) (WHO,
2001). In a survey of historical governmental and scholarly data, Ruben (1999) found that
communication disorders were generally associated with higher rates of unemployment, lower
social class, and lower income.

A wide variety of tests are available to assess language abilities; some prominent examples
include the Boston Naming Test (Kaplan et al., 2001), Controlled Oral Word Association
(Benton et al., 1994a; Spreen and Strauss, 1991), the Boston Diagnostic Aphasia Examination
(Goodglass and Kaplan, 1983).

i. The Boston Naming Test (BNT)

The Boston Naming Test (BNT), introduced in 1983 by Edith Kaplan, Harold Good glass
and Sandra Weintraub, is a widely used neuropsychological assessment tool to measure
confrontational word retrieval in individuals with aphasia or other language disturbance caused
by stroke, Alzheimer's disease, or other dementing disorder. A common and debilitating feature
is anomic aphasia, an impairment in the ability to name objects. The BNT contains 60-line
drawings graded in difficulty. Patients with anomia often have greater difficulties with the
naming of not only difficult and low frequency objects but also easy and high frequency objects.
Naming difficulties may be rank ordered along a continuum. Items are rank ordered in terms of
their ability to be named, which is correlated with their frequency. This type of picture-naming
test is also useful in the examination of children with learning disabilities and the evaluation of
brain-injured adults.

Brain’s areas associated with naming

Research has found that several specific brain regions that showed greater gray and white
matter volume and integrity were associated with better task performance on the BNT. The
classically known language areas are Broca’s and Wernicke’s areas in the frontal and temporal
lobes, respectively, of the left hemisphere (for most people). Additional areas that are activated
for language processes are outside those areas in the left hemisphere—especially anterior to
Broca’s area- as well as in right hemisphere regions. Naming tasks seem to be associated with
the left triangularis in the frontal lobe and superior temporal-lobe regions. Whereas Broca’s and
Wernicke’s areas in the left hemisphere are mainly responsible for language production and
comprehension, respectively, the right hemisphere regions are known to play a different role in
language processing including discourse planning, comprehension, understanding humor,
sarcasm, metaphors and indirect requests.

Instructions for Administration

The examiner begins with Item 1 and continues through Item 60, unless the patient is in
distress or refuses to continue. The patient is told to tell the examiner the name of each picture
and is given about 20 seconds to respond for each trial. The examiner writes down the patient’s
responses in detail, using codes. If the patient fails to give the correct response, the examiner at
her or his discretion may give the patient a phonemic cue, which is the initial sound of the target
word. After the patient completes the test, the examiner scores each item + or – according to the
response coding and scoring procedures.

C. Learning and Memory

This domain refers to abilities to register and store new information (e.g., words, instructions,
procedures) and retrieve information as needed (OIDAP, 2009; WHO, 2001). Functions of
memory include “short-term and long-term memory; immediate, recent and remote memory;
memory span; retrieval of memory; remembering; [and] functions used in recalling and learning”
(WHO, 2001, p. 53). However, it is important to note that semantic, autobiographical, and
implicit memory are generally preserved in all but the most severe forms of neurocognitive
dysfunction (American Psychiatric Association, 2013; OIDAP, 2009).

Impaired memory functioning can arise from a variety of internal or external factors, such as
depression, stress, stroke, dementia, or traumatic brain injury (TBI), and may affect an
individual’s ability to sustain work, due to a lessened ability to learn and remember instructions
or work-relevant material. Examples of tests for learning and memory deficits include the
Wechsler Memory Scale (Wechsler, 2009) and California Verbal Learning Test (Delis, 1994;
Delis et al., 2000).

i. The Wechsler Memory Scale (WMS-IV)

The original WMS was published by Wechsler in 1945 and revised in 1987, 1997, and again
in 2009. The Wechsler Memory Scale (WMS) is a psychological test designed to measure
different memory functions in a person. Anyone ages 16 to 90 is eligible to take this test. The
current version is the fourth edition (WMS-IV) which was published in 2009 and which was
designed to be used with the WAIS-IV. WMS-IV is made up of seven subtests: Spatial Addition,
Symbol Span, Design Memory, General Cognitive Screener, Logical Memory (I & II), Verbal
Paired Associates (I & II), and Visual Reproduction (I & II). A person's performance is reported
as five Index Scores: Auditory Memory, Visual Memory, Visual Working Memory, Immediate
Memory, and Delayed Memory.

The WMS-IV also incorporates an optional cognitive exam (Brief Cognitive Status Exam)
that helps to assess global cognitive functioning in people with suspected memory deficits or
those who have been diagnosed with a various neural, psychiatric and/or developmental disorder.
This may include conditions such as dementias or mild learning difficulties.

There is clear evidence that the WMS differentiates clinical groups (such as those
with dementias or neurological disorders) from those with normal memory functioning and that
the primary index scores can distinguish among the memory-impaired clinical groups.

ii. The California Verbal Learning Test (CVLT)

The California Verbal Learning Test (CVLT) is one of the most widely used
neuropsychological tests. It is a relatively new approach to clinical psychology and computer
science. It is a measure of episodic verbal learning and memory, which demonstrates sensitivity
to a range of clinical conditions. The test does this by attempting to link memory deficits with
impaired performance on specific tasks. It assesses encoding, recall and recognition in a single
modality of item presentation (auditory-verbal). The CVLT is a more sensitive measure of
episodic memory than other verbal learning tests. It was designed to not only measure how much
a subject learned but also show the strategies they used and ultimately what kind of errors they
made. The CVLT measures free and cued recall, serial position effects (including primacy and
recency), semantic clustering, intrusions, interference and recognition.

Administration

The experimenter reads a list of 16 nouns aloud, at one-second intervals, in fixed order,
over five learning trials (list A). After each trial, the subject is asked to recall as many words as
they can in any order (i.e., free recall). A big feature, compared to other verbal learning tests, is
that the words are drawn from four semantic categories (tools, fruits, clothing, spices and herbs),
with no consecutive words from the same category. If a subject 'clusters' words from a category
together, it is probable that they are using semantic organization.

An interference list (list B) is presented that shares two categories from List A (e.g., fish and
tools) and has two unshared categories (e.g., fruit and kitchen utensils). However, neither list
uses common words for a specific category (e.g., apples used rather than
bananas). Free and cued recall of list A are tested immediately (short-delay), and again after 20
minutes (long-delay). In cued recall, the experimenter prompts the subjects with the word
category.

D. Attention and Vigilance

Attention and vigilance refer to the ability to sustain focus of attention in an environment
with ordinary distractions (OIDAP, 2009). Normal functioning in this domain includes the ability
to sustain, shift, divide, and share attention (WHO, 2001). Persons with impairments in this
domain may have difficulty attending to complex input, holding new information in mind, and
performing mental calculations. They may also exhibit increased difficulty attending in the
presence of multiple stimuli, be easily distracted by external stimuli, need more time than
previously to complete normal tasks, and tend to be more error prone (American Psychiatric
Association, 2013).

Tests for deficits in attention and vigilance include a variety of continuous performance tests
(e.g., Conners Continuous Performance Test, Test of Variables of Attention), and the WAIS-IV
working memory index, Digit Vigilance (Lewis, 1990).

i. Conners continuous performance task (CPT-II)

A continuous performance task, continuous performance test, or CPT is any of several kinds
of neuropsychological test that measures a person's sustained and selective attention. Sustained
attention is the ability to maintain a consistent focus on some continuous activity or stimuli and
is associated with impulsivity. Selective attention is the ability to focus on relevant stimuli and
ignore competing stimuli. This skill is associated with distractibility.
Administration

In the Conners CPT-II clients are told to click the space bar when they are presented with
any letter except the letter "X". The person must refrain from clicking if they see the letter "X"
presented.

Scoring

There are four main scores that are used:

 Correct Detection: This indicates the number of times the client responded to the target
stimulus. Higher rates of correct detections indicate better attentional capacity.
 Reaction times: This measures the amount of time between the presentation of the
stimulus and the client's response.
 Omission errors: This indicates the number of times the target was presented, but the
client did not respond/click the mouse. High omission rates indicate that the subject is
either not paying attention (distractibility) to stimuli or has a sluggish response.
 Commission errors: This score indicates the number of times the client responded but
no target was presented. A fast reaction time and high commission error rate points to
difficulties with impulsivity. A slow reaction time with high commission and omission
errors, indicates inattention in general.

A client's scores are compared with the normative scores for the age, group and gender of the
person being tested.

E. Processing Speed

Processing speed refers to the amount of time it takes to respond to questions and process
information, and “has been found to account for variability in how well people perform many
everyday activities, including untimed tasks”. This domain reflects mental efficiency and is
central to many cognitive functions Tests for deficits in processing speed include the WAIS-IV
processing speed index, Trail Making Test Part and Stroop Effect test (Reitan, 1992).
 i. Stroop color-word interference test (SCWT)

The Stroop Color and Word Test (SCWT) is psychological test extensively used for both
experimental and clinical purposes. It assesses the ability to inhibit cognitive interference, which
occurs when the processing of a stimulus feature affects the simultaneous processing of another
attribute of the same stimulus (Stroop, 1935).

In the most common version of the SCWT, which was originally proposed by Stroop in the
1935, subjects are required to read three different tables as fast as possible. Two of them
represent the “congruous condition” in which participants are required to read names of colors
(henceforth referred to as color-words) printed in black ink (W) and name different color patches
(C). Conversely, in the third table, named color-word (CW) condition, color-words are printed in
an inconsistent color ink (for instance the word “red” is printed in green ink). Thus, in this
incongruent condition, participants are required to name the color of the ink instead of reading
the word. In other words, the participants are required to perform a less automated task (i.e.,
naming ink color) while inhibiting the interference arising from a more automated task (i.e.,
reading the word; MacLeod and Dunbar, 1988; Ivnik et al., 1996). This difficulty in inhibiting
the more automated process is called the Stroop effect (Stroop, 1935

F. Executive Functioning

Executive functioning is generally used as an overarching term encompassing many complex

cognitive processes such as planning, prioritizing, organizing, decision making, task switching,
responding to feedback and error correction, overriding habits and inhibition, and mental
flexibility (American Psychiatric Association, 2013; Elliott, 2003). It has been described as “a
product of the coordinated operation of various processes to accomplish a particular goal in a
flexible manner” (Funahashi, 2001).

Impairments in executive functioning can lead to disjointed and disinhibited behavior;

impaired judgment, organization, planning, and decision making; and difficulty focusing on
more than one task at a time (Elliott, 2003). Patients with such impairments will often have
difficulty completing complex, multistage projects or resuming a task that has been interrupted
(American Psychiatric Association, 2013). Because executive functioning refers to a variety of
processes, it is difficult or impossible to assess executive functioning with a single measure.
However, it is an important domain to consider, given the impact that impaired executive
functioning can have on an individual’s ability to work. Some tests that may assist in assessing
executive functioning include the Trail Making Test Part B (Reitan, 1992), the Wisconsin Card
Sorting Test (Heaton, 1993), and the Delis-Kaplan Executive Function System (Delis et al.,
2001).

i. Raven's Progressive Matrices (RPM)

Raven's Progressive Matrices (often referred to simply as Raven's Matrices) or RPM is a

nonverbal group test typically used in educational settings. It is usually a 60-item test used in
measuring abstract reasoning and regarded as a non-verbal estimate of fluid intelligence. It is the
most common and popular test administered to groups ranging from 5-year-olds to the elderly. It
is made of 60 multiple choice questions, listed in order of difficulty. This format is designed to
measure the test taker's reasoning ability, the educative ("meaning-making") component
of Spearman's g (g is often referred to as general intelligence). The tests were originally
developed by John C. Raven in 1936. In each test item, the subject is asked to identify the
missing element that completes a pattern. Many patterns are presented in the form of a 6×6, 4×4,
3×3, or 2×2 matrix, giving the test its name.

All the questions on the Raven's progressives consist of visual geometric design with a
missing piece. The test taker is given six to eight choices to pick from and fill in the missing
piece. Raven set this test to measure two main components of Spearman's “g”: the ability to
think clearly and make sense of complexity (known as educative ability) and the ability to store
and reproduce information (known as reproductive ability).

Versions

The Matrices are available in three different forms for participants of different ability:

 Standard Progressive Matrices: These were the original form of the matrices, first
published in 1938. The booklet comprises five sets (A to E) of 12 items each (e.g., A1
through A12), with items within a set becoming increasingly difficult, requiring ever greater
cognitive capacity to encode and analyze information. All items are presented in black ink on
a white background.
 Colored Progressive Matrices: Designed for children aged 5 through 11 years-of-age, the
elderly, and mentally and physically impaired individuals. This test contains sets A and B
from the standard matrices, with a further set of 12 items inserted between the two, as set Ab.
Most items are presented on a colored background to make the test visually stimulating for
participants. However the very last few items in set B are presented as black-on-white; in this
way, if a subject exceeds the tester's expectations, transition to sets C, D, and E of the
standard matrices is eased.
 Advanced Progressive Matrices: The advanced form of the matrices contains 48 items,
presented as one set of 12 (set I), and another of 36 (set II). Items are again presented in
black ink on a white background and become increasingly difficult as progress is made
through each set. These items are appropriate for adults and adolescents of above-average
intelligence.

Neurocognitive Assessment Labs in different areas

i. BBS Labs - Clinical and Cognitive Neuroscience Laboratory

The Clinical and Cognitive Neuroscience Laboratory is a collaborative effort based in the
Department of Psychology at the University of Georgia, Athens (Greece). Under the direction of
Drs. Brett Clementz and Jennifer McDowell, members of the laboratory are engaged in a variety
of experimental and theoretical inquires within the realm of cognitive neuroscience. Research is
conducted using sophisticated brain imaging technologies, such as high-density EEG, whole-
head MEG, and fMRI. With these technologies at their disposal, CCNL researchers can address
diverse research interests from multiple perspectives.

Primary ongoing areas of research include studies of:

 basic sensory operations (visual and auditory processing) and motor performance
(saccadic eye movements)
 the differences in basic and higher-level cognitive operations between normal and
psychiatric groups, most notably those with schizophrenia
 brain plasticity associated with repeated practice
 brain changes that occur during aging
  prospective memory

Personnel at the CCNL also collaborate with other UGA researchers in programs within and
outside the Psychology Department on studies involving topics ranging from physical exercise,
to judgment and decision making, and social rejection.

ii. Assistive Technologies and Cognitive Testing Research

This research is being conducted at University of Michigan, USA. Traditional methods of

testing cognition are not accessible to children with significant physical and speech impairments.
Investigators with the Adapted Cognitive Assessment Laboratory (M-ACAL) develop alternative
testing methods by using Assistive Technology (AT) with adapted versions of cognitive tests. We
then investigate the neuropsychology of specific congenital neurodevelopmental conditions.
Current studies focus on working memory, processing speed, attentional impairment, sleep
disorder, and quality of life in children with cerebral palsy.

Findings have the potential to provide accurate information about cognitive and academic
abilities that could then be used in clinical or school settings to better support medical,
educational, and life planning.

iii. Neurocognitive Assessment Lab (University of Virginia, USA)

At the Neurocognitive Assessment Lab, they see adults and adolescents ages 14 and up. They
provide specialized evaluations for patients with brain injuries and measure your cognitive and
behavioral strengths and weaknesses.

The lab specializes in assessing the neurocognitive aspects of disorders such as:

 Sports-related concussion
 Central nervous system infection
 Substance abuse
 Mild age-associated memory impairment
 Seizure disorders
 Stroke
 Attention deficit and hyperactivity disorder
 Closed head injury and other neurologic trauma