From stigma to science: Rethinking "Intelligence" in the neuropsychology of epilepsy

To review the historical, conceptual, and ethical foundations of intelligence testing in neuropsychology and to consider whether alternative cognitive performance labels offer greater conceptual precision while reducing stigma.

We conducted a narrative review of early twentieth century cognitive assessments, tracing the evolution of intelligence testing and its intersections with eugenic ideology. Key examples include the Army Alpha and Beta tests administered during World War I and Ellis Island immigration assessments, which were frequently interpreted without consideration of cultural or educational influences. We examine how these practices informed early interpretations of neuropsychological performance, particularly in individuals with epilepsy, and shaped initial characterizations of neurologically based cognitive abilities.

Early intelligence testing was grounded in the belief that intelligence was a fixed and directly genetically determined trait. Test performance was interpreted as an index of biological superiority, lending scientific legitimacy to eugenic ideologies and reinforcing stigma toward individuals with epilepsy. Although modern frameworks emphasize multidimensional cognitive abilities, intelligence-based characterization persists and continues to be frequently reported as a primary outcome of neuropsychological testing.

In contexts that require a single summary indicator of cognitive performance, labels such as Total Cognitive Composite are recommended since they avoid implying a fixed or unitary capacity. Continued reliance on the construct of "intelligence" is inconsistent with contemporary models of cognition, reflects outdated theoretical assumptions, and carries enduring psychosocial stigma. Moreover, its circular and internally inconsistent definitions substantially limit its validity and appropriateness within contemporary adult clinical neuropsychological practice.