Applying Luria's Diagnostic Principles in the Neuropsychological Assessment of Children

The first part of this article examines the theoretical justification for applying Luria's approach in the assessment of children. It is concluded that Luria's concepts of functional systems and the principle of specifying primary and secondary deficits may be applied to children. However, the selection of functional components to assess should be based on traditions of child neuropsychology rather than on Luria's assessment of adults. In addition, the tendency for comorbid disorders, mechanisms of neural adaptation to damage, and the prevalent types of brain abnormality in children render brain–behavior relationships more complex in children than in adults. The second part of the article describes how Luria's methods were adapted for use with children. An assessment, NEPSY, was developed by integrating Luria's views with contemporary child neuropsychological traditions. The NEPSY includes 27 homogeneous and psychometrically developed subtests, standardized in the United States and Finland for the age range of 3 to 12 years. The rationale of analyzing disorders of cognitive processes through a comprehensive and systematic assessment of their components, characteristic of Luria's approach, was preserved, but more specific principles of diagnosis were modified. Research findings obtained with a previously published, Finnish NEPSY version are presented.     

Introduction: Neuropsychological Assessment Après Luria

Neuropsychological assessment since Alexander R. Luria's death in 1977 has demonstrated increased sophistication and advancement, and a number of models or approaches to neuropsychological assessment are available worldwide today. This article reviews, in the context of this special issue, Luria's influence on the further development of neuropsychological assessment approaches and methods. Contemporary approaches are summarized and contrasted, and a discussion of neo-Lurian adaptations and extensions of his neuropsychological model is presented. Brief comments about the succeeding articles in this issue help to demonstrate the wide influence sustained by Luria's ideas in various regions of the world.     

Quantitative and Qualitative Integration of Lurian Procedures

This article reviews contemporary Russian research aimed at integrating and combining qualitative and quantitative evaluation approaches using Luria's procedures of neuropsychological assessment. A scoring system for rating and evaluating cognitive disturbances in different functional areas is described. The advantages of application of this system are discussed, using as examples the neuropsychological follow-up of neurosurgical patients, as well as neuropsychological research into the cognitive disturbances in patients with Parkinsonism and in children who are mentally retarded. The effectiveness of these updates to Luria's approach is demonstrated.     

Russian Neuropsychology After Luria

It is now more than 20 years after Luria's death in 1977. His collaborators, disciples, and followers both in Russia and abroad continue to further develop his work. The development of Russian neuropsychology reflects the universal tendency to replace static neuropsychology, which relates individuals' behavior to fixed cerebral lesions, with dynamic neuropsychology, which analyzes the dynamics of brain-behavior interaction. Three types of Russian studies illustrate the latter approach: (1) neuropsychological follow-up of different nosological groups of patients in the process of medical or psychological treatment, (2) studies of cognitive evolution (developmental neuropsychology), and (3) studies of cognitive involution (neurogeriatrics). All studies focus on cortico-subcortical and interhemispheric relationships. Another change in modern Russian neuropsychology consists of combining the qualitative approach with the quantitative one, but the system of rating is based, following Luria's tradition, on the psychological evaluation of each task's structure and the qualitative analysis of the patients' performance and possibilities for its correction. Hence, Luria's creative and comprehensive approach stimulates the further development of neuropsychology in Russia.     

Comments on a standardized version of Luria's tests

Appreciation is expressed for the work of Golden's group in the selection of Luria's tests, the standardization of their administration, the collection of norms, and the evaluation of the reliability and validity of the Luria-Nebraska test battery. However, questions are raised concerning the ability of the test to efficiently handle topical diagnosis and to construct rehabilitation programs. Concern is expressed over the possible vulgarization of Luria's doctrine of functional systems and the loss of predictive power in Luria's tests through neglect of qualitative information and methodology. Suggestions are made as to how Luria's qualitative methodology might be incorporated in a standardized version of a neuropsychological examination.     

Luria's Neuropsychological Evaluation in the Nordic Countries

The publication of Luria's Neuropsychological Investigation (LNI) by Christensen in 1975 introduced Luria's evaluation procedures to worldwide neuropsychology. The LNI demonstrated the benefit of a thorough qualitative analysis of an individual patient's functioning as well as the usefulness of a comprehensive theory of brain functioning. This article reviews the experiences that led to the development of the LNI, discusses its use and extension in Scandinavian countries, and presents clinical and research applications of the LNI in diagnosis and rehabilitation. A series of case examples provides justification and validity for the continued use of the LNI and related procedures. Discussion of the advantages and disadvantages of the LNI and consideration of possible modifications of the procedures and interpretative methods provide the rationale for continued development of Luria's approach.     

The neuropsychological assessment of dementia

It has become standard practice to base the diagnosis of dementia on the combination of neuropsychological and non-behavioral findings. The present article provides a short, clinically oriented synopsis of the targets, investigational procedures, and difficulties of the modern neuropsychological approach to the diagnosis of dementia. Over the years, neuropsychology has developed assessment tools to evaluate the cognitive and behavioral abnormalities of many dementias. Validated tests of memory, language, executive, and other cognitive functions are used to screen for dementia and identifying certain dementia profiles. Behavioral assessment procedures are available for non-cognitive neurodegenerative alterations. At present, problems arise mainly with the behavioral heterogeneity of certain dementia syndromes. Especially problematic are discrimination of age-associated or mild cognitive impairments from incipient dementia and the impact of psychiatric symptoms on cognitive functions. It is concluded that neuropsychology offers a valuable contribution to the diagnosis and differential diagnosis of dementia.     

Standardized and flexible batteries in neuropsychology: An assessment update

This article summarizes current literature relevant to commonly used tests and test batteries in clinical neuropsychology. The first section contains a discussion of the philosophy and relative advantages of standardized and flexible battery approaches in neuropsychology. The second contains historical background and a literature review of the two major standardized test batteries: the Halstead-Reitan and Luria-Nebraska. The third section includes reviews of tests that are frequently used in the flexible battery approach. Various tests of intellectual functioning, attention, memory, language, and spatial analyses are critiqued in this section. Contributions of the process approach are noted. The article ends by underscoring the need for continued research into the nature of neuropsychological measures and the abilities they assess.     

The impact of culture and education on non-verbal neuropsychological measurements: a critical review

Clinical neuropsychology has frequently considered visuospatial and non-verbal tests to be culturally and educationally fair or at least fairer than verbal tests. This paper reviews the cross-cultural differences in performance on visuoperceptual and visuoconstructional ability tasks and analyzes the impact of education and culture on non-verbal neuropsychological measurements. This paper compares: (1) non-verbal test performance among groups with different educational levels, and the same cultural background (inter-education intra-culture comparison); (2) the test performance among groups with the same educational level and different cultural backgrounds (intra-education inter-culture comparisons). Several studies have demonstrated a strong association between educational level and performance on common non-verbal neuropsychological tests. When neuropsychological test performance in different cultural groups is compared, significant differences are evident. Performance on non-verbal tests such as copying figures, drawing maps or listening to tones can be significantly influenced by the individual's culture. Arguments against the use of some current neuropsychological non-verbal instruments, procedures, and norms in the assessment of diverse educational and cultural groups are discussed and possible solutions to this problem are presented.     

Cognitive Event-Related Potentials in Neuropsychological Assessment

Neuropsychology is a behavioral approach to studying the brain, and an integration of neuropsychology with on-line processing measures of brain function is important for advancing the understanding of brain–behavior relationships. Cognitive event-related potentials (ERPs) are on-line processing measures that are of interest to neuropsychologists because they are linked to familiar neuropsychological test paradigms and because they have reached a degree of standardization sufficient to make them applicable in individual assessment. A selective review of cognitive ERPs is given, focusing on studies of attention in the oddball paradigm and arguing that an adequate assessment of attention is basic in understanding higher order cognitive functions. General principles for using ERP data to supplement and clarify neuropsychological analysis are discussed, and available evidence on dementia and traumatic head injury is reviewed. It is concluded that ERPs are a useful supplement to neuropsychological assessment. Although diagnostic use of ERPs must be guarded because of limited standardization and validation, information-processing analysis with ERPs may aid significantly in interpretation of behavioral data.     

Neuropsychological Assessment of Mental Capacity

The assessment of mental capacity to assist legal determinations of competency is potentially a growth area for neuropsychology, although to date neuropsychologists have published relatively little in this area. In this paper a systematic review of methods used to assess capacity is presented, including coverage of specialized tests and interviews used for this purpose. A neuropsychological model for conducting capacity assessments is proposed. This model involves comprehensive assessment of a wide range of cognitive abilities as well as assessment of specific skills and knowledge related to the type of capacity being assessed. The purpose of proposing this model is to stimulate further discussion and debate about the contribution neuropsychologists might make in this area.     

Emotional and pain-related factors in neuropsychological assessment following mild traumatic brain injury

A critical issue in the field of clinical neuropsychology is the idea that emotional or pain-related factors may compromise the validity of neuropsychological assessment. In this study, 53 individuals suffering from mild traumatic brain injury related to motor vehicle accident injury completed commonly used measures of emotional and pain-related functioning. A battery of commonly used neuropsychological tests, assessing attention, learning and memory, language, visuospatial and visuomotor functions, speeded processing, fine-motor skill, and symptom validity, was administered concurrently. Findings revealed a significant and negative correlation between anxiety and impaired delayed verbal memory, suggesting that as anxiety increased, delayed verbal memory decreased. The results otherwise provided little support for the idea that emotional or pain-related factors are detrimental to neuropsychological test performance following mild traumatic brain injury.     

Emotional disturbances and their interaction with neuropsychological deficits

The interaction and relationships between neuropsychological tests (which are principally oriented to intellectual and cognitive abilities) and tests of personality and emotional status are complex, but nevertheless important in the clinical assessment of brain-damaged persons. Are indications of emotional disturbances to be expected as a direct consequence of brain damage? If so, how can the indications of emotional disturbances be differentiated from results obtained with psychiatrically disturbed (non-brain-damaged) subjects? Some authors have presumed that emotional disturbances, such as depression, acute anxiety, etc., in their own right cause impaired performances on neuropsychological tests, whereas other authors have proposed that brain damage predisposes the individual to demonstrate evidence of emotional disturbances. If emotional disturbances cause impairment on neuropsychological tests, why is it that so many emotionally disturbed persons without brain damage tend to perform normally on neuropsychological tests? This review of relevant publications considers (1) different general approaches to these questions and their implications for neuropsychology, (2) evidence of differential sensitivity to brain damage of neuropsychological and emotional instruments, (3) the sensitivity and specificity of self-assessments and complaints of head-injured subjects, (4) MMPI findings among head-injured subjects and in interaction with neuropsychological measurements, and (5) principles and guidelines that may be of value in clinical application of findings reported in the literature.     

Luria in Uzbekistan: The Vicissitudes of Cross-Cultural Neuropsychology

If the material conditions of culture shape cognitive structures, as Luria and Vygotsky argued, the extraordinarily deep and rapid restructuring of historical forms (Luria, 1971, 265) in the Soviet Republics that followed the Bolshevik revolution of 1917 provided a natural laboratory to determine whether processes of modernization changed traditional ways of thinking. This was the purpose of Luria's 1931 expedition to the Soviet Republic of Uzbekistan in central Asia. Luria's initial reports attracted vitriolic criticism because he had allegedly belittled primitive Uzbeki culture. The lasting importance of the Uzbek expedition is its emphasis on culture as a determinant of cognitive processes that remains valid to the present: in 1984, Gilbert replicated Luria's field studies in South Africa with near-identical results. Yet current neuropsychology has been slow to recognize the need for culturally sensitive assessment.     

Integrative neuropsychological characteristics of subcortical-frontal brain regions as a schizophrenia liability factor

In order to study neuropsychological characteristics of subcortical-frontal brain regions function and assessment of their relation with vulnerability to schizophrenia 59 patients and 23 controls were investigated using Luria's neuropsychological methods. The analysis established bilateral abnormalities of the function of prefrontal and profound frontal lobe zones in patients as compared with controls. These abnormalities were more predominate in the left hemisphere. Point biserial correlation coefficients of determined integrative neuropsychological indicators with liability to schizophrenia were 0.39 +/- 0.11 and 0.28 +/- 0.09, for the left and right brain zones respectively. The obtained data permits discussion of the integrative neuropsychological indicators of subcortical-frontal brain regions as potential markers of liability to schizophrenia and confirms the role of structural and functional brain asymmetry in the pathogenesis of schizophrenia.     

A Neo-Lurian Approach to Assessment and Remediation

The first part of this article presents an operational battery of tasks for measuring the four cognitive processes of Planning, Arousal–Attention, and Simultaneous and Successive processing (PASS) not only based on the qualitative data provided in Luria's syndrome analysis, but also taken from tasks in experimental cognitive psychology and neuropsychology. The second part of the article presents a remedial program based on PASS for enhancement of reading. Because this part provides in some detail the efficacy of the remedial procedure, it simultaneously validates the PASS constructs as well. In both parts of the article, I have been unmistakably guided by Luria's views: Tests are approaches to investigating cognitive functions, and the purpose of testing is to guide rehabilitation.     

Behavioral neuropsychology: Past,present, and future direction with organically based affect/mood disorders

Affective/mood disturbances have been widely described in association with central nervous system dysfunction. There have been multiple divergent viewpoints regarding the origin of these disorders, however. This is not surprising, as theories evolve in relation to our degree of technological advancement. This review describes the evolution of some of these views, and discusses the advantages of behavioral neuropsychology as an effective approach to assessment/treatment in this context. Although there have been few articles published describing the use of behaviorally based approaches to treat these disorders, it is thought that this approach shows promise, particularly when combined with information based on neuropsychological assessment data. Future directions for the continued evolution of this field are outlined.     

Neuropsychological predictors of conversion to probable Alzheimer disease in elderly with mild cognitive impairment

In the field of neuropsychology, it is essential to determine which neuropsychological tests predict Alzheimer's disease (AD) in people with mild cognitive impairment (MCI) and which cut‐off points should be used to identify people at greater risk for converting to dementia. The aim of the present study was to analyse the predictive value of the cognitive tests included in a neuropsychological battery for conversion to AD among MCI participants and to analyse the influence of some sociodemographic variables – sex, age, schooling – and others, such as follow‐up time and emotional state. A total of 105 participants were assessed with a neuropsychological battery at baseline and during a 3‐year follow‐up period. For the present study, the data were analysed at baseline. During the follow‐up period, 24 participants (22.85%) converted to dementia (2.79 ± 1.14 years) and 81 (77.14%) remained as MCI. The logistic regression analysis determined that the long delay cued recall and the performance time of the Rey figure test were the best predictive tests of conversion to dementia after an MCI diagnosis. Concerning the sociodemographic factors, sex had the highest predictive power. The results reveal the relevance of the neuropsychological data obtained in the first assessment. Specifically, the data obtained in the episodic verbal memory tests and tests that assess visuospatial and executive components may help to identify people with MCI who may develop AD in an interval not longer than 4 years, with the masculine gender being an added risk factor.     

Extending neuropsychological assessments into the primary mental ability space

A battery of 17 neuropsychological tests (including the CERAD battery) and 17 psychometric ability tests were administered to a sample of 499 participants of the Seattle Longitudinal study who had been given the psychometric ability tests seven and 14 years earlier. The neuropsychological tests were projected into a 5-factor psychometric ability space by means of extension analysis. The concurrent regressions of the neuropsychology tests on the psychometric ability tests were then used to estimate neuropsychology test scores from the psychometric ability tests administered in 1984, 1991 and 1998. Neuropsychologists then rated the study participants as either normal, suspect or cognitively impaired in 1998. Changes in estimated test scores were computed over seven and fourteen years. Significant odds ratios between normal and cognitively impaired groups were found for all neuropsychological tests over the proximal period and for most tests over the 14-year period. Similar findings occurred for the odds ratios between the normal and suspect groups for the most proximal 7-year changes.     

The neuropsychology of aging

Summary Luria's clinical neuropsychological approach and analysis of frontal lobe syndromes are applied to the study of aging. Brain damage produces both functional deficits and positive signs. The functional deficits seen in association with the aging process resemble those of patients with frontal system pathology. In the present study, performance of normal aging subjects is examined qualitatively for the positive signs associated with damage to frontal structures, namely perseveration and segmentation. Significant positive correlation is found between increasing prevalence of these frontal features and increasing age. Significant sex differences are also found, with males exhibiting more of these frontal features than females.