American Academy of Clinical Neuropsychology (AACN) Practice Guidelines for Neuropsychological Assessment and Consultation

This document is the first set of practice guidelines to be formally reviewed and endorsed by the AACN Board of Directors and published in the official journal of AACN. They have been formulated with the assumption that guidelines and standards for neuropsychological assessment and consultation are essential to professional development. As such, they are intended to facilitate the continued systematic growth of the profession of clinical neuropsychology, and to help assure a high level of professional practice. These guidelines are offered to serve members of AACN, as well as the field of clinical neuropsychology as a whole.


INTRODUCTION
Clinical neuropsychology has experienced tremendous growth in recent years, whether measured in terms of the number of practitioners, scientific studies, meetings, journals, training programs, or assessment tools. Organizations devoted to neuropsychology have formed and have become well established, yet are still maturing. Within the American Psychological Association (APA), the Division of Clinical Neuropsychology (Division 40) was formed in 1980 and clinical neuropsychology was recognized as a specialty in 1996. Definitions of ''neuropsychology'' and core training requirements have been developed (Hannay et al., 1998) and a number of general approaches to performing valid and appropriate neuropsychological assessment are recognized as having common core features (cf. Lezak, Howieson, & Loring, 2004).
Identification of professional issues and explication of standards is essential to providing quality neuropsychological services to the public and to developing neuropsychology as a science and clinical specialty. Development of guidelines for neuropsychological assessment is the next logical step in the growth, development, and maturation of the field of clinical neuropsychology. In the era of evidence-based practice in psychology (EBPP), such guidelines should be ''. . . based on careful systematic weighing of research data and clinical expertise'' (APA, 2006). The present document is founded on the assumptions that standards for neuropsychological assessment and consultation are essential to professional development and protection of the public, and that such standards can be articulated as general aspirational guidelines despite theoretical and practical diversity within the field (APA, 2005). Consistent with its mission, the American Academy of Clinical Neuropsychology (AACN) is in a position to take on this responsibility. The present Guidelines are offered to serve members of AACN, as well as the profession of neuropsychology as a whole.
The American Board of Clinical Neuropsychology (ABCN) is a member specialty examining board under a unitary governing body, the American Board of Professional Psychology (ABPP). Founded in 1947, ABPP is the oldest peer-reviewed board for psychology and grants board certification in several specialty areas of psychology, including clinical neuropsychology. Within ABPP, ABCN is responsible for the examination process for clinical neuropsychology board certification candidates, with AACN being the membership organization for individuals who have been awarded board certification by ABCN. Inherent in this examination process are de facto and consensually accepted standards for training, knowledge, and clinical practice in neuropsychology (updated policy and procedures are available online at http://www.theabcn.org).
This document is intended to serve as a guide for the practice of neuropsychological assessment and consultation and is designed to promote quality and consistency in neuropsychological evaluations. Psychologists may use these Guidelines to evaluate their own readiness to perform neuropsychological evaluations and as a framework for performing this type of work. Psychologists who desire to upgrade skills, knowledge, and experience may also use these Guidelines as a reference. Other organizations, disciplines, professionals, entities, and individuals are encouraged to consider these Guidelines as principles for the provision of neuropsychological services. Because they apply to the current practice of clinical neuropsychology, these Guidelines will require periodic review and are intended to remain in effect until a point in time at which the AACN Board of Directors (BOD) determines that a revision is necessary.
The present Guidelines are intended to be compatible with the current APA (2002b) Ethical Principles of Psychologists and Code of Conduct (EPPCC) and follow the recommendations of other APA documents, including the Criteria for Practice Guideline Development and Evaluation (2002a) and Determination and Documentation of the Need for Practice Guidelines (2005). The EPPCC are intended to describe standards for competent and adequate professional conduct. In contrast to applicable codes of ethics, the present Guidelines are intended to describe the most desirable and highest level professional conduct for neuropsychologists when engaged in the practice of clinical neuropsychology. In the event of a conflict, the EPPCC or other AACN policy statements can inform the practical use of these Guidelines. Similarly, applicable federal and state laws supersede these guidelines.
The term ''guidelines'' refers to statements that suggest or recommend specific professional behavior, endeavors, or conduct for psychologists. The primary purpose of practice guidelines is to promote high-quality psychological services by providing the practitioner with well-supported practical guidance and education in a particular practice area. Practice guidelines also ''inform psychologists, the public, and other interested parties regarding desirable professional conduct'' (APA, 2005). Guidelines differ from ''standards'' in that standards are mandatory and may be accompanied by an enforcement mechanism, whereas guidelines are aspirational in intent. Guidelines are intended to facilitate the continued systematic development of the profession and to help assure a high level of professional practice (APA, 2005). They are not intended to be mandatory or exhaustive, and may not be applicable to every professional and clinical situation. They are not to be promulgated as a means of establishing the identity of a group or specialty area of psychology. Likewise, they are not created with the purpose of excluding any psychologist from practicing in a particular area, nor are they intended to take precedence over a psychologist's judgment.

DEFINITIONS
Clinical neuropsychology has been defined as ''an applied science concerned with the behavioral expression of brain function and dysfunction'' (Lezak et al., 2004). Vanderploeg (2000) noted that neuropsychology studies ''the impact of brain injury or disease on the cognitive, sensorimotor, emotional, and general adaptive capacities of the individual.'' In a similar vein, Prigatano (2002) offered that neuropsychology is ''the scientific study of how the brain produces mind and how disorders of the brain cause a variety of mental and personality disturbances.'' Integrating these statements, clinical neuropsychology is an applied science that examines the impact of both normal and abnormal brain functioning on a broad range of cognitive, emotional, and behavioral functions. The distinctive features of neuropsychological evaluations and consultations in assessing brain function and dysfunction include the use of objective neuropsychological tests, systematic behavioral observations, and interpretation of the findings based on knowledge of the neuropsychological manifestations of brain-related conditions. Where appropriate, these evaluations consider neuroimaging and other neurodiagnostic studies and inform neuropsychologically oriented rehabilitation interventions.

PURPOSE AND SCOPE
Clinical neuropsychologists conduct their professional activities in accord with the EPPCC (APA, 2002b), and any AACN position statements that apply to particular issues or areas of practice that are relevant to their professional activities. They are also aware of and may seek guidance from the standards of practice and principles of other relevant professional organizations (e.g., American Academy of Forensic Psychology, American Academy of Pediatrics).
While the professional standards for the ethical practice of psychology are addressed in the EPPCC, these principles are not fully inclusive with respect to the current aspirations of desirable professional conduct for clinical neuropsychologists. By design, none of the present Guidelines contradicts any of the principles of the EPPCC; rather, they exemplify those principles in the context of the practice of clinical neuropsychology, as herein defined. The Guidelines have been designed to be national in scope and are intended to conform to applicable state and federal law. In situations in which the clinical neuropsychologist believes that the requirements of law are in conflict with these Guidelines, attempts to resolve the conflict should be made in accordance with the procedures set forth in the EPPCC.
The present Guidelines specify the nature of desirable professional practice by clinical neuropsychologists within any sub-discipline of this specialty (e.g., child, forensic). The term ''psychologist'' designates any individual whose professional activities are defined by APA and by regulation of title by state registration or licensure, as the practice of psychology. ''Clinical neuropsychologist'' refers to psychologists who engage in the practice of clinical neuropsychology as defined above.

EDUCATION AND TRAINING
Early in the development of the field of clinical neuropsychology, neuropsychologists were in limited demand, and there were few formal training programs. By 1979, the International Neuropsychological Society (INS) had published broad guidelines indicating alternative pathways for obtaining competence in this discipline (Rourke & Murji, 2000). At one point, a formal re-specialization program of continuing education was suggested as one means of helping psychologists gain the necessary skills to practice neuropsychology. Continuing education, however, is only intended to expand or elaborate on established skills and is not regarded as an adequate modality for establishing competence in neuropsychology (Bornstein, 1988a). Formal training programs are now widely available (Cripe, 2000;Donders, 2002), and the nature of specialized neuropsychological training has been defined (Bornstein, 1988b;Hannay et al., 1998) and is the basis for the Guidelines proposed herein.

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As evident from the definition of neuropsychology, a neuropsychologist possesses skills beyond simply administering and scoring a particular set of tests (Matarazzo, 1990;Meyer et al., 2001). A neuropsychologist is ''a professional psychologist trained in the science of brain-behavior relationships'' (Hannay et al., 1998). Kane, Goldstein, and Parsons (1989) pointed out that ''the unique competence of the neuropsychologist is that of conceptualizing assessment results within a brain-behavior framework.'' The prefix ''neuro'' in neuropsychologist means that the psychologist is a specialist who has had explicit training in neuroscience and neurological bases of behavior. To fulfill this role, neuropsychologists must have specialized knowledge and training, a fact that is incorporated into the existing definitions of a neuropsychologist (Barth et al., 2003;Bieliauskas, 1999). Both APA Division 40 (Clinical Neuropsychology) and the National Academy of Neuropsychology (NAN) definitions require 2 years of specialized training. The APA Division 40 definition requires formal university training in neuropsychology and the neurosciences, and recommends a peer review process as an indicator of competency. The NAN definition (National Academy of Neuropsychology, 2001) requires, for individuals receiving training after 2001, ''the equivalent of two (fulltime) years of experience and specialized training, at least one of which is at the post-doctoral level, in the study and practice of clinical neuropsychology and related neurosciences. These two years include supervision by a clinical neuropsychologist.''

WORK SETTINGS
Clinical neuropsychologists comprise a relatively small group compared with other specialists in the healthcare marketplace. Indeed, according to recent SAMHSA Mental Health Information Center statistics (http://www.mentalhealth.samhsa.gov/ publications/allpubs/SMA01-3537/chapter20.asp), there are over 77,000 licensed doctoral-level psychologists in the United States. At present, there are roughly 4,000 individuals purporting to practice clinical neuropsychology in the United States as reflected by membership in APA Division 40. This is a small number relative to other organizations including the 7,000 members of Division 12 (Clinical Psychology) of APA, 17,000 members of the American Academy of Neurology (AAN), and over 150,000 members of APA. Nonetheless, from the beginning of its development in the United States in the 1950s and 1960s, clinical neuropsychology has flourished as a discipline because of its unique focus and clinical utility.
The settings in which clinical neuropsychologists practice are richly varied. To illustrate, a neuropsychological text edited by Lamberty, Courtney, and Heilbronner (2003) includes chapters from practitioners who work in independent practice, collaborate with physicians in a medical practice, forensic settings (e.g., civil and correctional), or have adult and child practices in rural or urban communities, universityaffiliated medical centers, university-based attention deficit-hyperactivity disorder (ADHD) and learning disorder clinics, Veterans Affairs medical centers, general hospital settings, medical rehabilitation units, or schools. Other practice environments include military bases, pharmaceutical companies, surgical centers, and practices in which patients for social security and disability benefits are evaluated (Sweet, Peck, Abramowitz, & Etzweiler, 2000). Neuropsychologists have established themselves and the utility of neuropsychology as a specialty practice, in a number of medical, legal, social service, and other professional settings (Prigatano & Pliskin, 2003).

ETHICAL AND CLINICAL ISSUES
The following section identifies four ethical and clinical issues that are particularly relevant to the practice of clinical neuropsychology and to the development of these guidelines. However, many other practice-related issues, such as effects of third-party observers and the use of psychometricians, are not covered. The reader is referred to relevant AACN position papers or documents from other membership organizations for discussion of these and other issues (see www.theaacn.org and www.nanonline.org).

A. Informed Consent
Neuropsychologists are aware of, and sensitive to, ethical and legal issues of informed consent, confidentiality, autonomy, and related human rights that arise in the context of evaluating children and adults. This is also true for ''vulnerable adults,'' such as patients with mental retardation, developmental disabilities, or dementia, including those who already have designated legal guardians. The limits of confidentiality are explained to all examinees (or to parents or guardians, when appropriate) at the outset of a neuropsychological evaluation. The neuropsychologist establishes a clear understanding of examiner-examinee relationship issues, and ensures that this understanding is shared with the examinee and, if necessary, with relevant third parties, such as a referring physician, social worker, special education administrator, or attorney, and in some cases with insurers (Johnson-Greene & NAN Policy & Planning Committee, 2005). Consideration of such relationships is critical in identifying the person legally entitled to consent to the evaluation and to a release of information about the examinee. The following questions might be asked in these situations: For a patient with dementia or mental retardation, is there a court-appointed guardian? For a child, if the parents are divorced, who has legal custody to give consent for the evaluation and who has a right to receive full disclosure of the findings?

B. Patient Issues in Third-Party Assessments
Neuropsychologists may evaluate someone at the request of a third party (e.g., insurance carrier, attorney, judge, or special education hearing officer), as part of a legal proceeding, a disability evaluation, or special education due process hearings. In such cases, the neuropsychologist clarifies the nature of the relationship with the referring third party by establishing that the neuropsychologist will provide a candid and objective opinion based on the evaluation results (Bush & NAN Policy & Planning Committee, 2005a). In a legal dispute, such an opinion is offered regardless of whether the referral comes from someone advocating for the examinee or for a different party.
At the outset of the evaluation, the neuropsychologist establishes the aims of the assessment, describes in clear language the sorts of information requested of the patient and types of testing procedures to be performed, the general information-gathering procedures to be followed (e.g., whether the evaluation will involve 214 AMERICAN ACADEMY OF CLINICAL NEUROPSYCHOLOGY formal standardized testing, interview, observation in the office, observations in natural settings such as school, home, or daycare, or collection of information from collateral sources where deemed appropriate, such as care providers, teachers, health aides, parents, spouse), the means of providing feedback (e.g., oral and=or written), and to whom and when a neuropsychological report will be sent. The neuropsychologist and referring parties discuss in advance who will pay for the evaluation, what costs are anticipated, and what payment arrangements can be made. In the case of a third-party referral, the neuropsychologist explains to the examinee (or guardians) that the party requesting the evaluation, rather than the patient being evaluated, is considered the ''client,'' at least in the sense that it is this party that will receive the evaluation findings and report. The examinee is helped to understand that his=her responses, and the neuropsychologist's opinions about him=her, will be shared with the referring party, and that the referring party will decide how to use the information (e.g., whether it will be given to opposing attorneys, read aloud in court, etc.). The information from the examination may also be used in future or separate legal or administrative proceedings. The examinee is entitled to decline to participate, but the neuropsychologist should advise him=her to consult with his=her attorney or agent to clarify the possible consequences of consenting, or refusing, to be evaluated. Written reports, in these circumstances, clearly avoid the implication of patienthood or ongoing treatment and identify the examinee as distinct from the name and social=legal identity of the referral source. In forensic cases, neuropsychologists are careful to distinguish between the role of an ''expert'' and the role of a ''clinician.'' The expert's role is to inform the attorney(s), as well as the ''trier of fact'' (e.g., a judge, jury, or hearing officer) of the neuropsychological findings and to present unbiased opinions and answers to specific questions pertinent to the case, based on relevant scientific and clinical evidence (i.e., to be an ''advocate of the facts'') of the case. In contrast, the treating clinician's role is to be an advocate for his=her patient. Taking on the role of a patient advocate in a forensic situation might be perceived as biasing the clinician's opinions in favor of the patient. The neuropsychologist acting as a forensic expert typically does not conduct a feedback and treatment-planning conference with examinees (or their representative). A neuropsychologist who has treated a patient generally will decline to serve as an expert with regard to that case. If called upon to testify, the treating clinician responds in a manner consistent with original role limitations and qualifies his=her role when answering questions about the patient.
Neuropsychologists may provide a ''second opinion'' based on a review of another neuropsychologist's report, at the request of a judge or an attorney, an insurance company, or another psychologist. In this situation, the neuropsychologist is careful to base such an opinion only on available data and to express caution when lacking the information to provide a more substantive basis for their opinion(s). For example, the neuropsychologist may not be certain about the quality of examinerexaminee rapport or the accuracy of test administration procedures for the evaluation under review, or may find it difficult to form opinions based on the tests administered. Therefore, the ''second opinion'' might be limited to statements regarding whether or not the other examiner chose appropriate tests, reported the scores accurately, and made inferences, conclusions, and recommendations that are supported by the data provided in the report; whether alternative conclusions or recommendations, not mentioned in the report, should be considered; and whether any further neuropsychological tests or other information gathering (e.g., medical examinations) should be carried out to answer questions relevant to the case.

C. Test Security
Appropriate test security is the assumed responsibility of any practicing neuropsychologist and reflects several different levels for maintaining the safekeeping and utility of any test. Likewise, how the test results are disseminated to patients also falls under the guidelines for test security (NAN, 2000c) and for copyright protection. It is inappropriate and unethical to make copies of actual tests for patients or other parties as a means of providing feedback on assessment findings (EPPCC; APA, 2002b). Because of the time and expense in properly standardizing psychological and neuropsychological instruments, the clinician is entrusted to safeguard and protect the proprietary aspects of such tests to the fullest degree possible. Test publishers routinely include a section on their recommendations for test security and these should be strictly followed in the best manner possible by each clinician. Unique pressures may arise in certain forensic settings, but again the responsibility of the clinician is to maintain the integrity and security of test materials as far as the law and practice guidelines of psychology apply in the relevant jurisdiction(s) of service or practice. In particular, neuropsychologists are aware of the EPPCC and federal, state, provincial, or local policies that govern the content, security, and release of psychological and neuropsychological reports, test protocols, and raw test data or responses, including mandates from state boards of psychology, the Health Insurance Portability and Accountability Act (HIPAA) and the Centers for Medicare and Medicaid Services (CMS).

D. Underserved Populations/Cultural Issues
The present guidelines augment the ''cultural competence'' provisions of the EPPCC by defining the issues to be considered and recommending some specific competencies for the neuropsychological evaluation of individuals belonging to minority and underserved populations. Consistent with these provisions, neuropsychologists are aware that cultural, linguistic, disability, and other demographic and socioeconomic factors influence individuals' participation in the process of neuropsychological assessment, and may alter the meaning of the information obtained from testing (see, for example, Artiola i Fortuny et al., 2005;Brauer, 1993;Cohen, Mounty, & Martin, 2005;Manly et al., 1998;Mason, 2005;Ortiz, 2001;Perez-Arce & Puente, 1998;Vernon, 2005;Wong & Fujii, 2004). Neuropsychologists are also aware of the risks inherent in administering and interpreting tests with individuals from groups for whom there are insufficient or limited test adaptations, normative data, or validity studies (see Artiola i Fortuny, Heaton, & Hermosillo, 1998;Manly, 2005). These groups include individuals with unusually low levels of education (in the United States or elsewhere), those whose primary language is other than English and who belong to distinctive cultural or sociodemographic groups, and those with physical or mental disabilities that limit the ability to participate meaningfully in the examination as originally intended.
Neuropsychologists who agree to evaluate members of special populations are specifically educated about issues and have experience in administering and interpreting procedures relevant to the patient in question (Echemendia & Westerveld, 2006;Hauser, Wills, & Isquith, 2006;Ortiz, 2001;Vernon, 2005;Wong & Fujii, 2004). Alternatively, neuropsychologists show (1) that they have sought a local colleague better qualified to accomplish the task, (2) that the potential harm to the patient of deferring or declining the referral has been assessed and is considered to outweigh the potential dangers of proceeding with an evaluation, notwithstanding acknowledged limitations in the neuropsychologist's population-specific competencies, and (3) that they have attempted to ameliorate or compensate for all such limitations by consulting appropriate colleagues and research literature.
Neuropsychologists describe in their report how well they have communicated with the patient, their own level of fluency in the patient's language, and their uncertainty about the fidelity of interpreter-mediated translation and quality of interpersonal communication, including not only literal content, but also culturally mediated meanings, affective tone, and nonverbal ''body language.'' They further note the inevitable effects of using an interpreter on the validity of the test results and interview data (Dean & Pollard, 2005;Glickman & Gulati, 2003;Harvey, Artiola i Fortuny, Vester-Blockland, & De Smedt, 2003;Hindley, Hill, & Bond, 1993;Marcos, 1979). Interpreters are employed in a manner that respects the patient's autonomy and competence (Artiola i Fortuny et al., 2005;Cohen et al., 2005;Dean & Pollard, 2005). Neuropsychologists avoid using family members, friends, or other untrained individuals as interpreters, whenever possible, to preserve patient confidentiality and autonomy as well as to optimize the fidelity of translation.
Neuropsychologists recognize the threats to validity that can occur with the introduction of cultural bias in both translated and adapted instruments. These threats may occur at three levels: item, method, and construct ( Van de Vijver & Hambleton, 1996). When working with populations for whom tests have not been standardized and normed, neuropsychologists place particular emphasis on using direct observation and relevant supplementary information about a patient's adaptive functioning within his or her ''real-world'' community. They may employ assessment strategies that do not require a standardized normative approach, including, but not limited to, direct observation, charting of behavioral changes over time, criterion-referenced testing, direct comparisons with a group of demographically similar peers, or comparison with demographically similar groups in published research studies (Manly, 2005;Simeonsson & Rosenthal, 2001).

A. The Decision to Evaluate
Before initiating neuropsychological testing, the neuropsychologist clarifies the referral source and the referral questions, determines that he or she is competent to evaluate the patient and answer the referral question(s), concludes that it is ethically acceptable to do so, and decides that a neuropsychological evaluation is pertinent to the issues raised. Otherwise, the neuropsychologist contacts the referral source and discusses whether some other type of evaluation may be better to address the referral questions, such as a psychodiagnostic evaluation, functional behavior assessment, clinical interview, psychiatric evaluation or other medical assessment. Alternatively, the neuropsychologist suggests that the evaluation may be more appropriately conducted by a different neuropsychologist owing to conflict of interest or the fit of the patient's needs to the neuropsychologist's clinical competencies or cultural or language expertise.

B. Review of Records
Having access to information from sources other than the patient and their family members usually allows for a more comprehensive neuropsychological evaluation. Memories may be inaccurate or historical reports distorted, previous information may have been misunderstood or pieced together from the recollections of others, or patients simply may not know important facts. When conducting a comprehensive evaluation, the neuropsychologist attempts to obtain relevant background information from written records whenever possible. By gathering historical information, the neuropsychologist may improve diagnostic predictive accuracy, better describe cognitive and behavioral functioning, and assist treatment planning. In the case of an injury, medical condition, or neurological event, medical records from emergency personnel, hospitals, and outpatient facilities help to establish facts related to the time frame of the presenting problems, presence or absence of critical medical factors, type and degree of injury or impairment, and circumstances under which problems may have become manifest. Historical information is also relevant in assessing patients with histories of psychiatric illness, developmental disabilities, or learning or attentional disorders, and for whom the time sequence of the problems and interventions used to manage these problems may be important in clinical decision making.
In the case of suspected cognitive changes, an attempt to obtain a patient's earlier medical records is advisable in most cases. Although not a common practice in adult neuropsychological assessment, information gathered from available childhood health records helps to determine if pre-existing difficulties may account, in part, for a patient's current level of functioning. In the evaluation of children, adolescents, and young adults, information contained in the school records often enhances understanding of the child's past and current cognitive and behavioral functioning. Records of school or work histories for adults may be similarly useful in providing information on premorbid level of functioning, but are often unavailable.
The aims of the evaluation typically determine the extent to which the neuropsychologist gathers information from collateral sources. Extensive review of records may be a worthwhile goal in conducting some assessments, but may not be warranted in all cases and will depend on the nature of the referral questions. In many routine clinical scenarios, such as evaluations undertaken to facilitate ongoing medical care, the patient's best interests may be better served when an interpretive report is provided expeditiously, without the delays that often accompany a request to complete a review of external records. Writing a subsequent addendum summarizing a review of obtained records may be considered as a means to supplement information not available at the time of the original report.

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Finally, the nature of the questions asked of a neuropsychologist in a forensic evaluation may require a more extensive review of records than is typically required for a clinical evaluation. In a forensic case, the neuropsychologist reviews as much relevant information about the past and present functioning of the patient as can be made available to him=her. Neuropsychologists do not, when conducting an examination for a forensic purpose, assume primary responsibility for the discovery and production of historical records.

C. Interview of Patient and Significant Others
A neuropsychological evaluation consists of more than a review of records and the administration of psychological and neuropsychological tests. Indeed, some information critical to the evaluation may only be available via a patient interview. Information from the patient may enable the clinician to gain perspective on the patient's experience, including self-perceptions of problems and stresses, and to integrate this information with data from other sources (e.g., test results, record reviews, interviews with significant others). In this way, the clinician may come to a more complete understanding of the patient's history and current situation and be better able to apprehend how the patient or examinee views his=her life circumstances.
Neuropsychologists may employ actuarial (i.e., purely data-driven) approaches to understanding and interpreting brain-behavior relationships, including those that focus solely on lateralization and=or localization of brain dysfunction (Russell, Russell, & Hill, 2005). However, a comprehensive neuropsychological evaluation generally entails identification and description of the cognitive and behavioral correlates of brain disease or neurodevelopmental disorder, opinions regarding prognosis, and formulation of treatment plans. A clinical interview and gathering of historical information, often including neuroimaging or other medical findings, is critical to this process.
When interviewing a patient, the neuropsychologist typically considers the events that led to the referral for an evaluation, the duration of the presenting problems or condition, the primary symptoms and changes in symptom presentation over time, the effect of the presenting symptoms or condition on daily functioning, the results of previously conducted tests and procedures, and the patient's strengths and interests. Relevant historical details may include prenatal history, birth and developmental background, educational history (including any history of learning disabilities or weaknesses), work history, current and past medical and psychiatric history, history of alcohol or substance abuse, current and past medications, legal history, and family medical, psychiatric, and substance abuse history.
Although interviewing a family member or friend of the patient is not always possible, doing so may yield useful information not otherwise available. Because of problems with motivation, memory, language, reduced awareness of their illness, or other neurobehavioral symptoms, patients may not always be reliable informants for past or current events. Information from a person who knows the patient and who can talk about the patient's premorbid history, and the effects that the illness=injury has had on the patient and family, can be critical in understanding the functional consequences of the illness=injury. Such individuals may sometimes be the only source of information regarding the onset, clinical course, and magnitude of deficits. However, it is important to communicate to the family or significant other that a doctor-patient relationship does not exist; thus, issues such as confidentiality, release of records, etc., should be discussed in advance. Whether used in evaluating the patient or to obtain information from other informants, a structured interview can help to reduce bias and ensure thoroughness and consistency across examinations. It may also provide a means for standardizing data collection of potential use in clinical research.

D. Measurement Procedures
Neuropsychological evaluations vary in content depending on their purpose but they typically assess multiple neurocognitive and emotional functions. Primary cognitive domains include: intellectual functions; academic skills (e.g., reading, writing, math); receptive and expressive language skills (e.g., verbal comprehension, fluency, confrontation naming); simple and complex attention; learning and memory (e.g., encoding, recall, recognition); visuospatial abilities; executive functions, problem-solving and reasoning abilities; and sensorimotor skills. Ideally, assessments should also include measures designed to assess personality, social-emotional functioning, and adaptive behavior. In some settings (e.g., testing the acutely medically ill), comprehensive testing may be contra-indicated; in such situations, measurement of selected neurocognitive domains and=or a screening of cognitive skills is preferred. Additional guidelines for test selection can be found in APA's Standards for Educational and Psychological Testing (1999).
Neuropsychological tests and measures used for clinical purposes must meet standards for psychometric adequacy (with exceptions as noted below). These standards include: (1) acceptable levels of reliability, (2) demonstrated validity in relation to other tests and=or to brain status, including evidence that the test or measure assesses the process, ability, or trait it purports to assess, and (3) normative standards that allow the clinician to evaluate the patient's scores in relation to relevant patient characteristics, such as age, gender, and sociodemographic or cultural=linguistic background. In general, tests published with large, stratified normative samples-''Heaton norms'' (Heaton, Avitabile, Grant, & Matthews, 1999); Mayo's Older Americans Normative Studies (MOANS; Ivnik et al., 1992Ivnik et al., , 1996, and Mayo's Older African Americans Normative Studies (MOAANS; Lucas et al., 2005)-provide a sound foundation for accurate interpretation. Comparisons of results from tests that are co-normed are advantageous in examining differences between two or more cognitive domains. The neuropsychologist is aware of the source of normative data and is cautious about using tests for which sample sizes are small or restricted (e.g., by geographic region or sociodemographic characteristics). Sample size considerations are particularly important in child assessments, where developmental changes in skills demand adequate sampling across a variety of ages.
Measures that show promise, but have not met the most rigorous standards, may be considered to assess skills, behaviors, or influences that are deemed important to elucidate patients' or others' concerns. However, these more ''provisional'' tests and measures are selected to complement rather than replace those with betterestablished properties. Preliminary evidence for psychometric adequacy is needed even for measures considered provisional in nature; and the neuropsychologist is aware of the level of support for their use in interpreting the findings.

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Some common conditions that justify exceptions to the general principles elucidated above include: the need to evaluate an individual whose neuropsychological functioning falls at the extremes of the normal distribution (e.g., those with mental retardation or the exceptionally gifted), individuals with sensory or motor disabilities that require modifications to standardized test administration (e.g., creating a bedside assessment for a patient with neglect following a right hemisphere stroke), and individuals from linguistic or cultural groups for whom no normed test exists. In such cases, the neuropsychologist recognizes the importance of ecologic validity or external ''real-world'' validation of the test findings and for determining the reliability of the findings across multiple tests. The neuropsychologist also explicitly acknowledges in the report the modifications of test administration and scoring and their potential effect on the validity of the assessment results.
A comprehensive neuropsychological evaluation should be thorough but also efficient and respectful of a patient's time and resources. Some patients, such as those who fatigue easily, may require more than one session. Furthermore, in clinical practice, clinical neuropsychologists often find it necessary and advisable to administer a selected set of subtests instead of the complete test battery or test. An advantage of using multiple tests from single or co-normed test batteries is that patient strengths and weaknesses, including levels or laterality of performance, can be assessed relative to the same normative sample. A further advantage is that administration of test batteries can provide for the assessment of a broad range of functions. Disadvantages include a predetermined number and restricted selection of subtests in the existing test batteries, and associated time constraints, which may preclude administration of complete batteries when given in combination with other measures of interest. Breadth of assessment can be provided by administering multiple individual tests and=or combinations of subtests from different test batteries, depending on the goals of the evaluation. The practice of using selected subtests or individually developed tests can be justified by reference to research literature employing these measures and the availability of appropriate normative standards (e.g., Baron, 2004;Heaton et al., 1999;Lucas et al., 2005;Steinberg & Bieliauskas, 2005).

E. Assessment of Motivation and Effort
A growing literature suggests that the assessment of motivation and effort is critical when conducting a neuropsychological evaluation (Bush & NAN Policy & Planning Committee, 2005b). This area has received the greatest emphasis in forensic assessment, in which symptom magnification, impression management, or even feigning of impairment can occur (Mittenberg, Patton, Canyock, & Condit, 2002). However, the assessment of effort and motivation is important in any clinical setting, as a patient's effort may be compromised even in the absence of any potential or active litigation, compensation, or financial incentives. Approaches for assessing motivation and effort include: behavioral observations from interview or testing of behaviors such as avoidance, resistance, hostility, and lack of cooperation; examination of the pattern of performance among traditional neuropsychological measures; identification of unexpected or unusually slow and=or impaired levels of performance; identification of cognitive profiles that do not fit with known patterns typical of brain disorders; and consideration of suspect performance on objective measures of effort. Clinicians utilize multiple indicators of effort, including tasks and paradigms validated for this purpose, to ensure that decisions regarding adequacy of effort are based on converging evidence from several sources, rather than depending on a single measure or method.
Neuropsychologists utilize commonsense methods to optimize patient performance, such as attending to the lighting, seating, and other aspects of physical comfort during testing; treating patients respectfully; establishing rapport; asking the patient about his=her understanding and acceptance of the evaluation process; and encouraging and reinforcing effort. The purpose of these methods is to establish a physically and interpersonally comfortable testing environment, with the goal of minimizing anxiety, resistance, physical discomfort, or other factors that may interfere with optimal motivation and effort.

F. Assessment of Concurrent Validity
The neuropsychologist typically draws inferences about a given skill or ability from more than one test or test score, and considers the influences of the patient's state of engagement, arousal, or fatigue on test performance. To illustrate, issues of test validity may be raised when performance on an attention measure early in a test battery is better than performance on another attention task toward the end of the battery. Cultural and language-mediated effects on test performance are also considered, and caution is exercised in administering and interpreting tests to individuals from a demographic, linguistic, or cultural group for which the tests have not been appropriately normed, validated, and translated (see section 5C). The neuropsychologist should be aware of limitations of making comparisons among standard scores arising from different normative samples and should make efforts to include norms that are most similar to the demographics of the patient being examined.

G. Test Administration and Scoring
Standard procedures are followed in test administration and scoring (see Standards for Educational and Psychological Testing, APA, 1999). Tests are administered, scored, and interpreted in ways that are consistent with evidence regarding the utility and appropriate application of these methods. The clinician attempts to prevent misuse of the test materials, and to determine and report circumstances in which norms may have limited applicability or test procedures may be inapplicable or require modification (EPPCC). Neuropsychologists may ''test limits'' (e.g., by changing test demands or providing extra time) to investigate the effects of accommodations on test performance, but findings from such procedures are clearly labeled as such and norms that apply to standard administrations are not used to describe the results. The presence of third-party observers during test administration is also strongly discouraged (AACN, 2001;NAN, 2000a). If a third party or monitoring device is present, the neuropsychologist states how and to what extent this circumstance may have affected the test results.
Accuracy of scoring is essential for appropriate interpretation of test results. The neuropsychologist is familiar with scoring methods and criteria for specific items, procedures for aggregating scores, and the meaning of the scores (i.e., the normative base used for converting raw to standard, or derived scores). Scoring is  (APA, 1992;NAN, 2000b).

H. Interpretation
Accurate interpretation of neuropsychological test data requires extensive relevant training and experience, and knowledge of current empirically based professional opinions gathered from continuing education and the published literature. A neuropsychologist's clinical interpretation of the evaluation findings is based on information regarding the patient's history and problems, direct observation of the patient, levels or patterns of test performance associated with specific clinical presentations, and the current theory and knowledge regarding the neurological and psychosocial=cultural influences on test performance and daily functioning. This interpretation is highly individualized and does not follow a ''cookbook'' approach. Results from computer scoring and interpretation programs are also considered within the context of the individual patient; the neuropsychologist does not exclusively use automated computer printout interpretation as a substitute for a carefully considered and individually tailored clinical interpretation.
Information about the patient's sociodemographic status, cultural and linguistic background, and work, school, and family characteristics can be obtained through interview or formal measures. These factors are taken into consideration in making judgments as to the extent to which the test performance deviates from expected levels (see section 5C). This information is also useful in determining if environmental or motivational factors are contributing to or exacerbating the patient's problems.
The inferences made by neuropsychologists in interpreting the evaluation findings include judgments regarding: (1) the nature of the cognitive deficits or patterns of strengths and weaknesses, (2) the likely sources of, or contributors to, these deficits or patterns, and (3) their relation to the patient's presenting problems and implications for treatment and prognosis. The first type of inference is based on knowledge of the cognitive constructs measured by neuropsychological tests. Judgments regarding relative strengths and weaknesses also rely on knowledge of expected levels of test performance relative to background patient characteristics or to the patient's performance on other tests (as in making judgments regarding inter-test score discrepancies). In rendering conclusions regarding a patient's strengths and weaknesses, the clinician considers the consistency of findings across multiple tests and alternative explanations for high or low test scores (e.g., development of compensatory test-taking strategies, poor effort) or the overall pattern and profile of neuropsychological test scores.
The second type of inference, regarding causal or contributing factors, relies on knowledge of the cognitive, behavioral, and emotional consequences of brain insults or constitutional-genetic anomalies. If a brain insult or neurodevelopmental anomaly is known, a judgment is made as to whether the insult or anomaly has contributed in some way to the patient's problems. The insult or anomaly may be a primary cause of the problems. In circumstances in which several causal factors are potentially contributory, it may be difficult to conclude with reasonable certainty that a particular event or disease is the primary cause, or to isolate the specific influence of a particular condition on a behavior or learning problem. Inferences regarding causation take into account not only the pattern of the test results, but also the history of the patient's problems, the nature of the potential causal event and its relation to symptom presentation, the strength of research supporting a relation between the type of brain insult or anomaly of the patient and the test findings, the base rate of the problem in the general population, and alternative explanations for the patient's test findings. These same considerations apply if the brain insult or anomaly is unknown. In this latter instance, the judgment to be made involves the extent to which the problems are consistent with or suggest the presence, nature, or localization of a neurological abnormality. Inferences in this regard are again based on the degree of consistency of the patient's test results to those of other patients with similar insults or anomalies, the likelihood of a neurological insult or anomaly as having occurred, the patient's history and timing of symptoms in relation to a potential insult or anomaly, and consideration of other possible causes for the patient's problems.
In making judgments regarding brain insult or anomaly as a cause for the patient's presenting problems, co-morbidities, or ability deficits, the neuropsychologist considers factors that may ameliorate or exacerbate these effects. Such moderating variables may include patient behavior and background characteristics, environmental supports or stressors, the effects of various medications, and the patient's current level of cognitive functioning. Environmental and maturational influences on outcomes of brain insult or anomaly are also considered in making judgments regarding causation.
The third type of inference pertains to the validity of neuropsychological test results in identifying and forecasting social-behavioral or learning problems and in predicting responsiveness to different interventions. Test validity in this sense is supported to the extent that the patient's identified deficits, or patterns of strengths and weaknesses, have been related in past research to problems similar to the patient's. Further support for validity comes from studies indicating that specific deficits or patterns of strengths and weaknesses predict other difficulties or future outcomes, or inform treatment for the patient's problems. In drawing conclusions about the relevance of cognitive skills to identification and management of a patient's problems, the neuropsychologist considers the possible contributions of non-cognitive factors (e.g., the effects of pain, sleep disruption, medication effects, psychological distress or history of maladaptive behavior unrelated to the patient's cognitive deficits, social or educational supports).
New technologies for evaluating brain-behavior relationships are emerging, including advances in neuroimaging, genetic analyses, metabolic tests, and other measures that reflect physiological and psychological functions. All of the major areas of clinical psychometric assessment, as defined earlier in these guidelines, are being standardized for research and clinical purposes using an array of neuroimaging methods, such as functional magnetic resonance imaging (fMRI). To illustrate, APA

AMERICAN ACADEMY OF CLINICAL NEUROPSYCHOLOGY
Division 40 has endorsed the role of neuropsychologists in clinical use of fMRI (APA, 2004). In the coming years, standardized assessment protocols for assessing a broad spectrum of neuropsychiatric and cognitive disorders are likely to be developed wherein clinical neuropsychologists will use neuroimaging as part of their neuropsychological evaluation and assessment.

I. The Evaluation Report
Neuropsychological findings generally are summarized in a written report to be provided to the referral source or responsible party (Axelrod, 1999), except in special circumstances (e.g., certain forensic or research contexts). The EPPCC (APA, 2002b, 6.01: Documentation of Professional and Scientific Work) notes that the written report serves ''. . . to facilitate provision of services later; to ensure accountability; and to meet other requirements of institutions or the law.'' Report-writing styles vary with the purpose of the report, background and training of the neuropsychologist, requirements of the work setting, and even, on occasion, the specific guidelines established by the referring party. Neuropsychological evaluations are typically requested for a specific purpose or to answer specific referral questions. The purposes of the assessment may include provision of differential diagnoses, documentation of cognitive strengths and weaknesses, delineation of functional implications of the identified deficits, and recommendations regarding interventions. Generally speaking, the aims of the report are (1) to describe the patient and record the findings, (2) to interpret the patient's performance on tests in light of other assessment information, (3) to answer questions and make judgments regarding the nature and sources of the presenting complaints=concerns, (4) to assess prognosis and make recommendations for future care, and (5) to communicate the results to the patient or significant others with permission, to the referral source, and other service providers such as teachers and therapists (Axelrod, 1999).
Despite the absence of a universally accepted outline or format, the report usually is organized to assist the reader in identifying the patient and learning of the reason for referral and presenting problems, the patient's history and level of functioning, the patient's behavior during the evaluation, the test results, and the clinician's impressions, interpretations, and recommendations. Some of the most commonly used report sections include: Identifying Information and Reason for Referral; Background Information=History; Tests Administered; Behavioral Observations; Test Results=Interpretations; Summary & Conclusions; Diagnostic Impressions; and Recommendations. Consultations or short reports are more annotated versions of the above format, typically consisting of a few paragraphs describing the test results and recommendations. Abbreviated reports are more common when evaluating patients whose background is already known to the referral source (e.g., primary physician) or when the assessment is being conducted for more circumscribed reasons (e.g., to assess cognitive function as part of a multidisciplinary inpatient assessment). Test reports contain information regarding the patient's age, gender, educational level, occupational background, need for special services or accommodations in conducting the assessment, racial identity=ethnicity, the persons who conducted the assessment (neuropsychologist, psychometrist) and others present during testing (e.g., translator, student trainee), and (as appropriate) the language(s) in which testing was conducted and the examiner's and patient's fluency in the language(s).
One recommended practice in clinical neuropsychology is to include numerical data (including scaled scores or percentile ranks) in reports (Donders, 2001;Friedes, 1993). Neuropsychologists may choose to append test scores in a summary sheet, or insert scores in the report text. Including test scores allows for the comparison of a patient's performance over repeated evaluations, minimizes the need for obtaining multiple releases of information, and increases the efficiency with which raw data can be shared with other professionals for the purpose of further assessment or management of the patient. Inclusion of scores also increases accountability and may even minimize and clarify any interpretation biases or idiosyncrasies on the part of the writer (Matarazzo, 1995). Finally, in certain situations, such as documenting a learning disability or ADHD for higher education, the guidelines issued by testing organizations and used by academic institutions universally require the reporting of test scores (Educational Testing Service (1998a, 1998b. When used in conjunction with scores, use of words describing test scores (e.g., ''below average,'' ''impaired'') may facilitate understanding of test data.
Multiple normative data sets are available for many neuropsychological instruments, and test score percentiles or standard scores may differ depending on which norms are employed. As appropriate, citations may be provided for the normative sets, which can assist the reader in understanding how specific standard scores were derived. Further, because some test norms allow adjustment for age, while others also correct for additional factors, such as education, gender, and=or ethnicity, some practitioners may choose to specify the demographic characteristics that were considered in deriving norm-based scores (e.g., 10th percentile for age and education; Selnes et al., 1991).

J. Providing Feedback
Although documentation of the results from a neuropsychological evaluation usually takes the form of a written summary or report, feedback is often provided directly (i.e., in a face-to-face meeting or phone call) to referral sources, patients, families, third-party payers, and the legal system. Feedback to clinical referral sources is provided in a timely manner and addresses the relevant referral questions and concerns. The neuropsychologist also makes additional inferences and recommendations as appropriate for the benefit of the patient or referral source. For example, the need for patient counseling or special school placements may be advised, even if questions regarding these matters were not raised by the referral source.
Feedback regarding the evaluation findings and recommendations are provided in a manner that is comprehensible to intended recipients and which respects the well-being, dignity, and rights of the individual examinee. Ethical and legal guidelines pertaining to the provision of feedback should be identified and followed. As noted earlier (section 5B), feedback typically is not given in forensic evaluations, but it is part of most clinical evaluations. The neuropsychologist adheres to professional ethics (EPPCC) and federal, state, and local laws related to the autonomy 226 AMERICAN ACADEMY OF CLINICAL NEUROPSYCHOLOGY and decision-making capacities of patients who are legally competent. When cognitive impairments interfere with the patient's ability to understand the implications of the test results, or in the case of a child examinee, feedback may be provided to a responsible party (legal guardian or parent), with or without the patient present. The neuropsychologist consults with the responsible party to decide whether or not to provide direct feedback to a minor child or vulnerable adult. In some such cases, sensitive and developmentally appropriate discussion of results and recommendations may enhance the person's well-being; in other cases, direct feedback about test findings could be detrimental, particularly if the child or vulnerable adult misconstrues what is said.