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Childhood dementias are rare, occurring at an incidence rate of 5.6/100,000 (.0056% point prevalence) (Yeates et al., Pediatric neuropsychology: research, theory and practice, Guilford, New York, 2000). Many medical disorders can contribute to deterioration in children where a previously acquired skill is lost or negatively compromised. Such diseases would technically be termed a dementia or dementing illness; however, this term is controversial in children. The term΄s controversy stems from the opposing interactive forces of continued developmental progress in a child and the counter-developmental effect of ongoing or chronic illness. This controversy aside, this chapter discusses illnesses and issues of deterioration in childhood neuropsychological functioning. This is an often neglected issue in Neuropsychology and the interested reader is guided to in-depth descriptions of many of the diseases discussed found in comprehensive texts in pediatric neuropsychology (see Baron et al., Pediatric neuropsychology in the medical setting, Oxford Press, New York, 1995; Lezak et al., Neuropsychological assessment, 4th edn, Oxford University Press, New York, 2004; Yeates et al., 2000; Yeateset al., Pediatric neuropsychology: research, theory and practice, Guilford, New York, 2010. See also Heilman and Valenstein, Clinical neuropsychology, 4th edn, Oxford University Press, New York, 2003). [ABSTRACT FROM AUTHOR]

The singularly most uniquely human attribute is language. Such a bold statement is difficult to make, but profoundly true. Many species possess communication skill and communication among some species is elaborate and facilitates complex social relationships and interactions; however, the extent and sophistication of human use of representational language is truly unique. Language is so intertwined into what it is to be human that its complexity is often overlooked as a prerequisite skill in neuropsychological assessment. At its simplest, language can be conceptualized as expressive and receptive language functions. While typically residing in the left hemisphere (referred to as the dominant hemisphere because of the propensity of language to develop even if damage occurs to normal language centers), bilateral representation and right hemisphere representation of language occurs both naturally and secondarily in response to early cerebral injury that affects the typically dominant left hemisphere (see (Table 7.1) for relative frequencies of hemispheric language dominance). See also Chaps. 3 and 12. The evaluation of the patient with language deficits first requires a review of the assessment of language and the definition of some terms. We will first review the basic aspects to evaluate speech and define terms describing different types of speech problems. We will then return to evaluating various speech problems commonly encountered in the clinic. [ABSTRACT FROM AUTHOR]

Attention and concentration are simple concepts on the surface but become complex when asked to assess or differentiate among capacities. While, at its most basic, attention refers to an organisms ability to recognize and respond to changes in its environment. The concept of attention when applied in neuropsychology represents a range of behavior which is dependent on functional integrity of many anatomical regions. The range of behavior includes everything from autonomic and reflexive auditory and visual orientation to sound and movement, to the ability to process several stimuli simultaneously or alternate back and forth from competing stimuli (see Kolb B, Whishaw, 2009 for review). While a universally accepted definition of attention and concentration would be broad and potentially unusable, the models of attention typically have common features including orienting, selecting stimuli and maintenance for a necessary time or successful completion of a task. These factors are represented in Fig. 6.1. Attention is typically viewed as a sequence of processes that occur in several different regions of the brain, which are involved with the acquisition and sustaining of attention. Attention is organized hierarchically, usually modality-specific at its origin and then multi-modality or multi-cortically mediated as in rapid alternation or switching of attention or maintenance of concentration. In addition to attention, concentration refers to two elements: the capacity to sustain attention on relevant stimuli and the capacity to ignore irrelevant competing stimuli. Again, while simple, the concept of concentration is objectively difficult to differentiate in an orthogonal manner, several models of attention and concentration have been proposed and the interested reader is referred to Posner (1990) for elaboration. [ABSTRACT FROM AUTHOR]

Arousal refers to the maintenance of an appropriate level of cerebral activity to successfully complete the task in which one is engaged. Arousal occurs on a continuum from hypoarousal to hyperarousal and may fluctuate quickly. Appropriate arousal is a necessary prerequisite for consciousness. Arousal is anatomically mediated through the ascending reticular activating system (RAS), which has projections arising from the medulla and pons, projecting to the midbrain, thalamus and hypothalamus (see Chap. 3 for more details). Stimulation of the RAS is essential for maintaining consciousness at a basic neurophysiologic level. Hyperarousal produces states of agitation. States of arousal vary from coma to normal and are typically classified or categorized clinically as below. Table 5.1 presents categorical classification of arousal, response to attempts to influence arousal and course of arousal with varying stimulation. [ABSTRACT FROM AUTHOR]

The assessment of language is an essential component to neuropsychological evaluations. One that is often quickly summarized as ˵speech was fluent and articulate, with normal rate, rhythm, intonation, and prosody.″ While this may describe some aspects of speech, it by no means offers clinicians enough information to determine if language functions are impaired. This chapter will approach the assessment of language from more of a diagnostic perspective. That is, we will approach language disorders based on well-described aphasia syndromes which are familiar to many. While this can be helpful, some readers uncertain of aphasia syndromes, but observing some disruption of language, are encouraged to review Chap. 7 , which explores diagnosis of language disorders from a symptomatic (behavioral observation) perspective. Aphasia syndromes denote an acquired language dysfunction due to neurological injury or disease. Aphasia syndromes are generally described by three language domains first detailed by Bensen and Geschwind: (1) fluent or nonfluent, (2) language comprehension, and (3) repetition. Additional components for assessing aphasia have been added, including naming, reading, and writing. Maintaining consistency with Chap. 7 , reference to ˵dominant hemisphere″ will refer to left hemisphere, since greater than 90% of people are left hemisphere dominant for language. Approximately 90–95% of the general population is right-handed. Rule of thumb: Left hemisphere dominance for language Right handed – 90–95% Left handed – 60–70% The clinical features of each aphasia syndrome are reviewed below along with neuroanatomical correlates. For rapid review, please see Tables 12.1 and 12.2 and Appendix. For more detailed discussion, please see Heilman and Valenstein (Clinical neuropsychology, 4th edn, Oxford University Press, New York, 2004), Kolb and Whishaw (Fundamentals of human neuropsychology, 6th edn, Worth, New York, 2008), Goodglass et al. (The assessment of aphasia and related disorders, 3rd edn, Pro-Ed, Austin, 2001), Lezak et al. (Neuropsychological assessment, 4th edn, Oxford University Press, New York, 2004), Mesulam (Principles of behavioral and cognitive neurology, 2nd edn, Oxford University Press, New York, 2000), and/or Victor and Ropper (Adams and Victor΄s principals of neurology, 7th edn, McGraw-Hill, New York, 2001) for reviews. [ABSTRACT FROM AUTHOR]

Emotions and mood play a central role both in the outcome and the management of neurologic illness. The importance is magnified when faced with differentiating between a primary emotional etiology for presenting complaints or neurocognitive symptoms and the possibility of emotional symptoms being the result of a neurologic injury, or a process of dysfunction as a result of an attempt to adjust to changes produced from neurologic injury or neurodegenerative process. Differentiating among these three possibilities is not easy and depends as much on eliciting a detailed psychiatric history as it does on knowledge of the possible emotional sequelae of neurologic injury and anatomical correlates of emotional functioning. This chapter outlines the currently used multi-axial system of the Diagnostic and Statistical Manual of Mental Disorders, 4th edition, Text Revised (DSM-IV-TR). This manual represents the currently accepted diagnostic criteria for mental disorders as outlined by the American Psychiatric Association and the American Psychological Association. While there is no shortage of controversy regarding the criteria for diagnosing mental illness, this system represents the best effort thus far to provide behavioral and objective criteria to a nosologically difficult area of medicine. The DSM-IV-TR uses a multi-axial approach to diagnosis which incorporates the primary diagnosis (Axis I), personality disorders and mental retardation (Axis II), general medical conditions affecting or potentially affecting the mental disorder (Axis III), psychosocial and environmental deficits/difficulties (Axis IV), and a rating of global functioning on a likert-type scale with descriptive anchors (Axis V). Each of these axes will be reviewed with an emphasis on neurologic disease and commonly associated emotional sequelae. The interested reader is referred to the DSM-IV-TR referenced at the end of this chapter for a more detailed description of both the multi-axial system and specific mental disorders. [ABSTRACT FROM AUTHOR]

The capacity to encode, retain and retrieve information is essential to the evolution of all living animals. From the ameba to ourselves, learning from interaction with our environment is critical to adaptation to the stimuli that influence our well being. The human brain is masterful at recognizing patterns of recurrence, be they sensory, motor or cognitive. This process of pattern recognition produces engrams which are the building blocks of concepts and organization which facilitate retrieval. Through this chapter, we will discuss models of processing and outline the essential elements for memory. We will discuss the anatomical correlates of memory and discuss how damage to many parts of the brain can have a direct or secondary effect on memory functioning. Several syndromic patterns of memory loss are reviewed below and recommendations given regarding possible etiologies for these observed memory scores. The factors which influence memory including encoding, storage and retrieval will be addressed. Finally, in this chapter we will discuss how to perform an assessment of memory functions which will allow the clinician to determine if problems in memory are present and if more detailed assessment of memory functions is indicated. Additional detailed information regarding the impact that different etiologies can have on memory functioning are discussed throughout this text. As with many cognitive functions beyond the basic sensory, perceptual and motor systems, memory is dependent on prerequisite skills for accurate assessment and determination of the etiology of a deficit. Accurate assessment of memory hinges on the adequacy of sensory input, perceptual skill, motor output and attentional capacity. Factors which influence these prerequisite skills can produce a profound impact on memory. In addition, some internal cognitive aspects of functioning such as reasoning and organization produce secondary effects on measured memory skills. In addition to these factors, assessment of memory must consider the emotional functioning of the person being assessed. Severe psychopathology such as schizophrenia or bipolar disorder can have an obvious and profound effect on memory; however, even mild depression and situational anxiety can produce subtle but predictable effects on memory performance which may be detrimental or enhancing. [ABSTRACT FROM AUTHOR]

The frontal lobes represent a large area, consuming approximately -one-third of the cortical surface of the brain. This area is involved directly and indirectly across a wide spectrum of human thought, behavior and emotions. The irony of the frontal lobes may best be described as the area of the brain we know the most about but understand the least. For example, frontal lobe functioning involves simple motor skills (both gross and fine), complex motor skills, sequenced motor skills, inhibition of motor skills and automatic motor skills, and these may be the simplest of the functions of the frontal lobes. The frontal lobes also subsume what is collectively referred to as executive skills. These functions include attention, reasoning, judgment, problem solving, creativity, emotional regulation, impulse control and awareness of aspects of one΄s and others΄ functioning. In this chapter, we will briefly discuss the anatomy of the frontal lobes, the basic and complex functions of the frontal lobes, and the informal assessment of frontal lobe functions. [ABSTRACT FROM AUTHOR]

Visuospatial and visuoperceptual skills play a role in every day -functioning; however, they are typically automatic. We process information visually and make identifications and analyze complex visual stimuli and are largely unaware of the visuoperceptual process involved or complexities of the stimuli that were analyzed. As an example, assume that you have purchased a new car and now suddenly that make and model seems to be everywhere. You suddenly notice the different colors in which the car comes, the different trim packages, and optional equipment (i.e., roof racks, spoiler, etc.). Soon you find yourself distinguishing among similar year models based on detail changes such as tail light configuration or color-matching door hardware. You can also identify this car from multiple angles (front, side, rear, corner, etc.) These complex stimuli are typically automatically perceived, poorly verbally labeled, yet precisely and accurately analyzed and identified. The centers in the brain that process such information are ever vigilant to visual and visuospatial stimuli and organized to simultaneously and sequentially take that information and transform it into usable, salient information or associated knowledge. All this occurs in a split second and typically below our level of awareness. While this process can certainly be consciously controlled, typically in novel learning or acquisition stages, our nature is to use repetition, familiarity or repeated recurrence to allow for more automatic processing and save the conscious and effortful processing capacities for the novel or necessary tasks at hand. If this process is impaired, many types of deficits occur, from failure to process basic elements in the visual stimuli (i.e., color, lines, orientation) to more complex and integrative features such as object identification, faces or familiar scenes. These deficits can include phenomena such as visual neglect and hemi-inattention or more dramatic visual agnosias or prosopagnosia. This impairment may include what is referred to as disconnection syndromes in which centers of basic visual sensory functions are dissociated or disconnected from association cortex areas that allow for synthesis or analysis necessary to recognize the sensory stimuli as a specific object. [ABSTRACT FROM AUTHOR]

Neuropsychological evaluation examines brain–behavior relationships as they pertain to cognitive, emotional and behavioral manifestations of central nervous system trauma, disease or dysfunction. Neuropsychological evaluation includes examination of sensory, motor and perceptual functioning as prerequisite for evaluation of increasingly complex cognitive, emotional and behavioral functions. Evaluation is typically on an ordinal scale (i.e., impaired/non-impaired) for sensory and perceptual skills and progresses to an integral scale for more complex functions (i.e., percentile relative to normative group). Rapid bedside or interview assessment of functions such as attention, language and memory can be done; however, it is important to note a brief evaluation will yield less precise information than formal testing. Brief evaluation has several advantages. These evaluations are quick to perform and can be repeated as necessary to mark progress or suspected deterioration. Information from such evaluations are typically used to assist in patient management, set immediate goals and assist in treatment planning. In later chapters, we discuss brief assessment methods in each domain of cognition. Further details regarding the interpretive process, prerequisite knowledge base for adequate neuropsychological evaluations, psychometric principles guiding interpretation of neuropsychological psychometrically-derived data, and common errors in interpretation can be found throughout this book, but particularly Chapters. 1 , 2 , and 29 – 31 ). Sample neuropsychological reports are provided in Chapter. 1 , Appendix A. [ABSTRACT FROM AUTHOR]

Neuropsychological evaluations provide a wealth of information to the referring clinician and patient, offering a host of answers to important diagnostic and treatment-related questions. The range of questions a neuropsychological evaluation can answer are broad, but generally fall under six broad categories (e.g., Lezak et al., Neuropsychological assessment, 4th edn. Oxford University Press, New York, 2004): 1. Diagnoses: Identifying the existence of brain dysfunction [and differentiating brain dysfunction from non-lesional psychiatric diagnosis or otherwise reversible causes of cognitive dysfunction (e.g., depression)]. Example: Distinguishing dementia from depression or identifying the presence of mild cognitive impairment (MCI). 2. Describing neuropsychological status: Detailing how a disease or lesion(s) is expressed from cognitive, behavioral and affective perspectives. Example: Describing how a traumatic brain injury (TBI) has affected a patient΄s cognitive and emotional functioning, including the severity and extent of neuropsychological deficits. 3. Treatment planning, treatment facility placement or evaluating for resource utilization. Example: Identifying if a patient meets inclusion/exclusion criteria for placement in a rehabilitation facility. An increasing emphasis within neuropsychology is predicting neuropsychological outcome from proposed medical treatment (e.g., temporal lobectomy for intractable epilepsy or DBS for Parkinson΄s disease). 4. Identifying the effects of treatment (often includes measuring change in function over time). Example: Evaluation of effects of a speech/language therapy program for a patient. 5. Research evaluation tool: Identifying basic and central nervous system processes and/or the effects of other agents on the central nervous system. Example: Evaluating the neuropsychological effects of a medication to treat epilepsy in a randomized controlled trial. 6. Forensic applications: Neuropsychological evaluations are increasingly being used to assist fact-finding bodies to determine if, or the extent to which, an alleged event resulted in damage to the CNS. Another use is to assist courts in evaluating if a defendant is capable of managing his/her affairs independently. Also used forensically to evaluate mental state/competence/decision making capacity of individuals, particularly those alleged to be involved in -criminal activities [ABSTRACT FROM AUTHOR]