Neuropsychology of Everyday Functioning

In 1981, Heaton and Pendleton published a prescient article addressing the discrepancy between the types of predictions that neuropsychologists were being asked to make and the lack of scientific research supporting the use of our assessment tools for this purpose.They pointed out the difficulties inherent in using the standardized tasks to predict real-world behavior and highlighted the great need for research in this area.It was around this time that I completed my post-doctoral fellowship and began work in an acute rehabilitation hospital.I quickly learned that this disparity was not simply an academic issue; the type of information that was being requested from me in this setting was quite different from the type that I had been trained to give.Most training programs at that time placed a strong emphasis on identification and localization of brain lesions.In the world of rehabilitation, the presence of brain damage was well-established and localization of lesions of limited interest.What was needed was information that would help predict both how this damage would impact participation in rehabilitation and functioning in the real world following discharge.To say that I was ill-prepared to provide this guidance would be an understatement, and as noted by Heaton and Pendleton, the body of research needed to guide the clinician simply did not exist.Marcotte and Grant's new book, Neuropsychology of Everyday Functioning, represents a milestone in neuropsychology's response to Heaton and Pendleton's early call to action.This edited work is impressive in both scope and depth.The first part of the book provides a framework for exploring relationships between cognitive skills and everyday functioning as well as an overview of the research pertaining to several key functional skills.Marcotte and colleagues' first chapter includes an overview of the field as well as a succinct discussion of major issues complicating prediction of real-world functioning from neuropsychological tests.The authors note the persisting disparity between the large numbers of neuropsychologists who conduct evaluations that focus on prediction or real-world behaviors versus the small number who use assessment instruments specifically designed for this purpose.Among the numerous excellent points made is the conclusion that many neuropsychologists continue to attempt to predict complex, real-world behaviors solely on the basis of highly structured tasks administered in an environment which minimizes distracters and uses other methods to elicit optimum performance.Several subsequent chapters examine prediction of everyday behaviors from the perspective of other professions (e.g.Human Factors/Ergonomics, Occupational Therapy).Having worked closely with occupational therapists for the past 28 years, this chapter was of particular interest to me.Although long impressed with the practical, functionally based focus of their assessments, I have harbored concerns regarding the reliability and validity of the assessments utilized as well as concern regarding a perceived lack of empiricism with regard to the evaluation of testing instruments and interventions.Baum and Katz's chapter on occupational therapy is illuminating in terms of the growing sophistication of this profession both in terms of establishing a scientific underpinning for assessment instruments and interventions, but also in terms its willingness to incorporate approaches developed by other professions.Should neuropsychology fail to develop useful, costeffective methods for predicting real-world behaviors, other professions appear poised to fill this void.The second section of Part 1 deals primarily with assessment of several key components of everyday functioning (instrumental activities of daily living, driving, medication management, and vocational functioning) and reviews the considerable research that has been conducted in these areas.I was left with an increased appreciation of the difficulty involved in predicting complex real-world behaviors as well as an improved understanding of both the unique contributions and limitations of neuropsychological testing with regard to the prediction process.Rizzo and Kellison's chapter on driving is representative of the useful information provided in this section; first, it provides an excellent review of how specific types of cognitive difficulties are associated with specific types of driving errors.This may help the practicing clinician derive more precise hypotheses regarding the specific types of driving difficulties a cognitively impaired driver might exhibit.Secondly, it stresses that prediction of complex behaviors such as driving cannot be made on the basis of cognitive skills alone, but must also consider multiple other variables such as mood state, personality factors, fatigue levels, drug effects, and so on.Third, it promotes a broad-based approach to assessment combining neuropsychological tests with more functionally based measures