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Aphasiology
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The process approach to

neuropsychological assessment
a
Edith Kaplan
a
Departments of Neurology and Psychiatry , Boston
University School of Medicine
Published online: 29 May 2007.

To cite this article: Edith Kaplan (1988) The process approach to neuropsychological
assessment, Aphasiology, 2:3-4, 309-311, DOI: 10.1080/02687038808248930

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 APHASIOLOGY, 1988, VOL.. 2, NO. 314, 309-312

The process approach to neuropsychological

assessment

EDITH KAPLAN
I>cpartmcnts of Neurology and Psychiatry, Boston University School of
Medicine.

Most standardized tests, designed to assess cognitive functioning are predicated o n the
notion that thc final solution to a problcm is an objective measure o f s o m e underlying
unitary mechanism. In a paper entitled Process and achievement: a basic problem of
Downloaded by [York University Libraries] at 14:14 13 August 2014

education and dcvclopmental psychology, Hcinz Werncr (1937) dcnionstratcd that a

given final solution may bc arrivcd at via diverse proccsscs which thernselvcs may
rcflect the activity of distinctly diffcrcnt structures in the central nervous system.
Further, Werncrs assumption that any cognitivc act involvcs microgcnesis, 1.e. an
unfolding proccss over timc (1956), warrants closc obscrvation o f behaviour en
route to a solution. To illustratc thc rclcvancc of such a process orientation for
neuropsychological a ~ s e ~ s n i c n tKaplan
, (1983) prcscntcd rxarnples drawn from
observations of patients with verified focal lesions, normal children and normal
and pathological elderly individuals.
T h e distinction bctwecn the process and achicvcmcnt approachcs is underscorcd
by the results o f a study o f the pcrforniancc of twenty-two paticnts with focal lesions
(verified by CAT scan) on thc Block dcsign subtcst of the Wcchsler adult intelligence
scale-reviscd (Kaplan, Palmcr, Weinstein and Bakcr 1981). An analysis of the flow
charts, i.c. a record of thc succcssivc moves CII routc to thc final solution, yielded the
following results: though right (RH) and lcft heniispherc (LH) lesion patients made a
comparable nunibcr o f crrors, the strategies thcy eniploycd and the nature o f the
crrors thcy made wcrc significantly diffcrcnt; RH lcsion paticnts had significantly
more instances o f broken configuration, i.c. thcy did not maintain the 3 x 2 o r 3 x 3
inatris o f the dcsign, whcrcas no LH lcsion paticnt had morc than one non-self
correctcd final solution and no inorc than two cn routc to thc final solution; LH lesion
patients prcfcrcntially startcd thcir dcsigns in thc lcft hcmiattcntional field and made
more crrors in the right hcmiattcntional ficld, whcrcas RH lesion patients
prcferentiall y started thcir dcsigns in the right hcmiattcntional ficld and made m o r e
crrors in the left hcmiattcntional ficld.
Generally speaking, wc may concludc that paticnts with focal lesions prefercntial-
1y begin to work on thcir block dcsigns in t h r hcmiattcntional ficld ipsilatcral to thc
lesion and make more errors in thc hemiattcntional ficld contralatcral to the lesion. In
addition, by totalling thc numbcr of crrors cn routc to a solution as wcll as the total
numbcr ofblock surfaces that arc correct in the final solution the therapist is better able
to monitor the course of rccovcry and/or thc cffcctivcncss of an intervention.
Obviously using the standard scoring of right/wrong would not rcflect improved
performance sincc a paticnt would carn a zero if his or hcr final solution was correct
except for one block surface, o r if all block surfaccs wcrc incorrect. Conversely, if a
paticnt made a numbcr o f significant crrors en routc to a solution but sclf-corrected
Address for corrcspondeiicr: Edith Kaplaii. Boston University, Medical School, M-9, 85 E.
Newton Street. Boston, MA 071 18, USA.
 310 Edith Kaplan

within thc allotted time, full crcdit for thc item would bc given and the
pathognomonic crrors would bc obscured.
The stratcgics that aphasic paticnts, with antcrior lesions, cmploy in assembling
puzzles (c.g. thc Objcct asscmbly subtest of the Wcchsler adult intelligence
scale-rcviscd) arc distinctly different from thosc cmploycd by paticnts with antcrior
lesions latcrlizcd to thc right hcmisphcrc. Whcreas aphasics show a predilcction for
contour, i.c. usc an cdgc alignmcnt stratcgy, paticnts with right frontal lesions tcnd to
be morc focuscd on thc intcrnal fcaturcs of thc puzzle. O n two cxpcrimcntal object
assemblies, a circlc jigsaw puzzlc which can only bc solvcd by edge alignmcnt, and a
cow which prccludcs thc use of such a strategy (all junctures bcing equal), LH lesion
paticnts tcnd to solvc thc circlc morc effcctivcly than the cow, and RH lesion paticnts
arc bcttcr at solving thc cow than the circlc.
Monitoring the evolution of a drawing, for cxamplc thc copy of the Rey complex
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figurc (Ostcrricth 1944), providcs another opportunity to cxamine the differential

cffccts of latcralizcd lesions. Again, aphasics tcnd to first copy the extcrnal contour
and crr on thc intcrnal details, with distortions, whcn thcy occur, restricted to the
right sidc of the figurc. Immcdiatc and dclaycd rccall of the figurc typically show
prcscrvation of thc contour with a falling out of the intcrnal dctails. Thc copies
cxccutcd by the RH lesion paticnts, on the othcr hand, arc drawn in a more picccmeal
fashion with contour most notably distorted.
Consistcnt with thc abovc observations arc thc results of a study of the recall and
copy of global lcttcrs and shapes composcd of small dissonant or local lcttcrs and
shapcs, c.g. a largc lcttcr W madc u p ofsmall lcttcr Z s . Thc stimuli are prcscnted in
pairs (lcttcr and shape) and countcrbalanccd for lcft and right sidc (Dclis, Kicfner and
Fridlund, in prcss). Aphasic paticnts correctly rcproduccd thc global lcttcrs and shapcs
with a continuous linc cithcr omitting or misrcprcscnting thc local lcttcr. RH lesion
paticnts focuscd on thc local aspcct with thc global lcttcr or shape severely
compromiscd. A commissurotomizcd paticnt showcd this samc dissociation (Delis,
Kramcr, Efron and Kicfncr, 1987). Thc paticnt with his lcft hand, i.c. his right
hcmisphcrc opcrating in isolation, drew thc global aspcct of thc lcttcrs and shapcs just
as thc aphasics did; with his right hand, (proccssing now rcstrictcd to thc lcft
hcrnisphcrc), his pcrformancc was consistent with that of thc RH lcsion paticnts.
Pcrformancc on thc visuo-spatial tasks dcscribcd abovc obviously requires thc
intcgrity of both ccrcbral hcmisphcrcs. Lacking such intcgrity, sccondary to a lesion
in cithcr hcmisphcrc, visuo-spatial functioning will bc compromised in vcry
distinctivc ways, This has important implications for rehabilitation. By manipulating
stimulus paramctcrs to favour thc non-compromiscd hcmisphcrc, pcrformancc can
bc improvcd. In addition, attcnding to thcsc aspccts of visually prcscntcd stimuli
clinicians and rcscarchcrs will bc lcss likely to draw incorrcct conclusions about
functions in qucstion. T w o cxamplcs scrvc to undcrscorc thc importancc of closcly
attcnding to thc constraints of visuo-spatial dcmands. First, bccausc the Pcabody
picture vocabulary tcst (Dunn 1965) was dcsigncd to scrvc as a non-vcrbal mcasurc of
an individuals vocabulary, it is frcqucntly administcrcd to aphasics.
Bccausc thc four picturcd stimuli arc prcscntcd in a 2 x 2 matrix, a poor scorc may
not rcprcscnt an impovcrishcd prcmorbid vocabulary or an auditory comprchcnsion
problcm but rathcr a rcsponsc bias to thc stimuli in thc lcft hcmiattcntional ficld. To
corrcct for this thc stimulus choiccs could be cut up and prcscntcd vcrtically. Thc
sccond cxamplc was brought to my attcntion by Dr Nancy Hclm-Estabrooks. In
conducting a study to cxamine thc ability of aphasic paticnts to apprcciatc cartoon
 Process approach to neuropsycholo~icalassessment 31 1

humour, she found that a few of the cartoons that she and her co-workers had selected
generally eluded some of the patients. O n close examination it became apparent that
the critical humorous aspect was an internal detail or feature located in the right
hcmiattcntional field. Examination of the cartoons that elicited a humorous response
it became clear that the humour was conveyed by the global configuration which was
primarily located on the left side (Emory, Helm-Estabrooks, Albert and Di Napoli
1987).
Fifty years have passed since Werner first expressed his concern about the hazards
of an achievement approach to the assessment of intellectual and cognitive
functioning. With the burgeoning of tests in the rapidly advancing discipline of
clinical neuropsychology the concerns are as vital today as they were then.
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