The hazards of strict reliance on neuropsychological tests

The overwhelming majority of neuropsychologists rely on standardized neuropsychological tests when they evaluate patients who have frontal-lobe damage as a result of a moderate or severe traumatic brain injury. Unfortunately, these tests were never designed to assess the neurobehavioral symptoms of these patients and are poor at doing this. Neuropsychologists typically spend relatively little time with brain-damaged patients because they often rely on questionnaires that are completed by the patient rather than take a comprehensive face-to-face clinical history and assistants who administer neuropsychological tests. The ecological validity of the neuropsychological tests that are administered to these patients is frequently ignored. As a consequence, neuropsychologists often base their predictions about whether these patients can work, return to school, or function independently in the community on the patient's quantitative test scores that were never designed for this purpose and have little ecological validity. Although patients with frontal-lobe damage may not show any cognitive deficits when they are administered standardized neuropsychological tests in an office setting, particularly when the anterior and ventral areas of their frontal lobes are damaged, they frequently exhibit cognitive difficulties, neurobehavioral symptoms, and executive dysfunction in unstructured real-world settings. Because standardized neuropsychological tests are generally poor at assessing these problems and symptoms, neuropsychologists may not be aware that a patient has these symptoms if they rely solely on their neuropsychological test results-particularly if they have never observed these patients function in real-world settings or interviewed the significant others of these patients.