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Necessary Steps to Neuropsychological Evaluation

Dr. Tony Dugbartey
Psychiatry and Behavioral Sciences
Harborview Medical Center
Seattle, WA
March 1998

Neuropsychology is, quite simply, the study of brain-behavior relationships. Clinical Neuropsychologists are primarily involved in the diagnostic evaluation (and rehabilitation treatment) of cognitive difficulties associated with a wide variety of neurological, psychiatric, and medical conditions. Most neuropsychologists in the United States have a rather limited ability to fully evaluate the cognitive abilities of non English speaking individuals from culturally diverse backgrounds. However, strong attempts are being made by many to improve their clinical service delivery to immigrants whose primary language is one other than English.

Since neuropsychologists are specialists who do not typically assume primary care responsibilities of the client, it is vital for clients to have health care professionals (usually family practice physicians) who maintain care continuity beyond the immediacy of the neuropsychological consultation. Doing so can assist in the diagnosis and treatment of physical and mental conditions associated with cognitive impairments shown on the neuropsychological evaluation.

Illiteracy is not ipso facto evidence of a neurocognitive disability. However, illiteracy arising from a neurocognitive disorder, does provides a compelling reason for the neuropsychologist to certify that the individual may not be expected to demonstrate knowledge of the requirements for U.S. naturalization.

If you suspect that an individual has a cognitive difficulty that prevents him/her from successfully taking the English language or U.S. civics and history tests in order to become a naturalized citizen, a number of options may be considered prior to (or in tandem with) instituting the neuropsychological referral:

• Have the client undergo a medical/physical examination or other relevant diagnostic radiologic or laboratory tests, if necessary, in order to determine the extent and severity of the underlying medical (or neuropsychiatric) condition. If this information is already documented (e.g., hypertension, chronic obstructive pulmonary disease, seizure disorder, etc), then make it available to the assessing neuropsychologist. Doing so helps in the determination of both a tailored cognitive evaluation, and in the clarification of prognostic indicators regarding the extent to which one can reasonably expect the individual suffering from those conditions to learn and remember information necessary for success on the U.S. naturalization requirements.
• If the physical or mental condition is imminently treatable, then the question arises as to: 1) whether with successful intervention, an amelioration in cognitive status can be expected to follow, and importantly, 2) whether even with adequate treatment, the client's residual (or anticipated) cognitive abilities are significantly compromised enough to preclude the expectation of success on the U.S. naturalization test requirements.
• You may conduct a preliminary investigation of the cognitive status of the individual using any of a number of measures at your disposal (e.g., Mini Mental State Examination, interview of client, etc.). Below are a number of cognitive symptoms you may wish to query the client and/or collateral sources.

1. Frequently getting lost, even in familiar surroundings
2. Inability to follow simple directions not due to a primary communication deficit (e.g., instructions given in an unfamiliar language, hearing loss, etc.)
3. Disorientation (to person, place, or time)
4. Inability to focus, sustain, or shift attention even for brief periods of time
5. Wide fluctuations in attention and clarity of awareness during the day
6. Unable to recognize familiar people
7. Short term memory loss
8. Frequently losing your train of thought
9. Asking the same questions repeatedly
10. Difficulty coming up with the right word in conversations
11. Forgetting the names of common objects
12. Mind frequently goes blank
13. Forgetting to do things and misplacing things
14. Difficulty using utensils (cutlery, shaving kit, keys) and tools (scissors, garden equipment) that could previously be manipulated with relative ease
15. Neglect of personal hygiene
16. Loss of interest in previously enjoyable activities
17. Chronic sadness, anxiety, or unconcern
18. Irritability and anger outbursts
19. Difficulty making correct change for purchases
20. Making crude or socially inappropriate comments or actions