Module 5- Neuropsychological Assessment • Bender Gestalt Test • Benton’s Visual Retention Test • Principles of

Rehabilitation • Approaches to Rehabilitation • Planning, process and outcome of cognitive retraining.

A neuropsychological assessment is a comprehensive evaluation of cognitive, emotional,

and behavioural functioning, often used to understand the effects of brain injury, neurological
diseases, or psychological conditions on an individual's mental abilities.

Purpose:
-Diagnosis: The assessment helps in diagnosing conditions like Alzheimer's disease,
traumatic brain injury (TBI), strokes, epilepsy, and psychiatric conditions such as
schizophrenia. It can identify cognitive decline, differentiate between types of dementia, and
detect underlying neurological or psychological causes of dysfunction.

-Cognitive Functioning: It measures abilities such as memory, attention, language,

problem-solving, executive functions (planning, organising), and visuospatial skills
(understanding spatial relationships). This is crucial for identifying strengths and weaknesses.

-Treatment Planning: The assessment guides treatment decisions and helps with
rehabilitation plans, whether cognitive therapy, psychological treatment, or adjustments in
daily activities like returning to work or managing finances.

Approaches to Neuropsychological Tests:

-Battery Approach: - The battery approach to neuropsychological testing involves using a

wide variety of tests to assess different cognitive functions. All parts of the battery are
administered, regardless of the patient's specific complaints. -
Advantages: - Identifies problems that the patient may not complain about or be aware of.
Disadvantages: - Time-consuming, often taking 6 to 8 hours for a full assessment. -
Example: Halstead-Reitan Neuropsychological Test Battery (HRNTB)

-Hypothesis Testing Approach: - This approach focuses on a detailed evaluation of areas

related to the patient's specific complaints. It places relatively less emphasis on aspects of
functioning that are less likely to be impaired. It often aims to illuminate the differential roles
of the two hemispheres.
Advantages: - Provides a detailed description of deficits related to the patient's complaints. -
Disadvantages: - May overlook unexpected areas of deficits that were not specifically
assessed. - Example: Boston Process Approach

-Screening Approaches: - Screening approaches in neuropsychological testing are more

flexible and efficient. They are often driven by economic factors and aim to determine
whether a diagnosis can be made with less information or if additional testing is necessary to
identify more subtle problems. - Examples: Repeatable Battery for the Assessment of
Neuropsychological Status (RBANS)

Domains of Neuropsychological Assessments:

- Intelligence Tests: Assess cognitive abilities, including problem-solving, reasoning, and
overall intellectual functioning.

-Test of Perception: Evaluate how an individual processes and interprets sensory information
, including visual, auditory, and tactile perception.

- Language Tests: Examine language-related skills such as comprehension, expression, and

fluency in both spoken and written language.

-Memory Tests: Assess various aspects of memory, including short-term memory, long-term
memory, and memory recall.

-Visuo-Spatial Tests: Measure an individual's ability to perceive, analyse, and manipulate

visual information in space, which is essential for tasks like navigation and object
manipulation.

- Frontal Lobe (Executive Function) Tests: Evaluate executive functions, which involve
higher-level cognitive processes like planning, decision-making, and impulse control. These a

- Vigilance Tests: Assess an individual's sustained attention and ability to maintain focus on
a task for an extended period.

-Personality Assessment: Explore an individual's personality traits, emotional states, and

psychological well-being, often used in clinical or forensic contexts.

- Motor Functions: Examine an individual's motor skills, including fine and gross motor
abilities, coordination, and motor planning. This is particularly important for understanding
motor-related deficits due to neurological conditions.re associated with the frontal lobes of
the brain.

The Bender Gestalt Test

The Bender Gestalt was developed by psychiatrist Lauretta Bender. The Bender Gestalt Test,
or the Bender Visual Motor Gestalt Test, is a psychological assessment instrument used to
evaluate visual-motor functioning and visual perception skills in both children and adults.
Scores on the test are used to identify possible brain damage and the degree of maturation of
the nervous system. Age Limit- Typically meaningful for individuals above 12 years of age.

Purpose- The Bender Gestalt Test is used to evaluate visual maturity, visual motor
integration skills, style of responding, reaction to frustration, ability to correct mistakes,
planning and organizational skills, and motivation. Copying figures requires fine motor skills,
the ability to discriminate between visual stimuli, the capacity to integrate visual skills with
motor skills, and the ability to shift attention from the original design to what is being drawn.

Description & Method- The Bender Gestalt Test is an individually administered pencil and
paper test used to make a diagnosis of brain injury. The test consists of nine separate designs,
each printed on a white background. The patient is provided with unlined paper and a pencil.
The patient is then asked to copy each design from the card in front of them. Examinees are
allowed to erase but cannot use any mechanical aids (such as rulers). The popularity of this
test among clinicians is most likely the short amount of time it takes to administer and score.
The average amount of time to complete the test is five to ten minutes.

1. The Bender Gestalt Test lends itself to several variations in administration. One method
requires that the examinee view each card for five seconds, after which the card is removed.
The examinee draws the figure from memory.

2. Another variation involves having the examinee draw the figures by following the standard
procedure. The examinee is then given a clean sheet of paper and asked to draw as many
figures as he or she can recall.

3. Last, the test is given to a group, rather than to an individual (i.e., standard administration).
It should be noted that these variations were not part of the original test.

The Bender-II version includes 16 figures and a recall phase.

Based on Gestalt Effect: The test is based on the Gestalt effect, which is the brain's ability to
perceive whole forms rather than just collections of simpler and unrelated elements.

Precautions-
The Bender Gestalt Test should not be administered to an individual with severe visual
impairment unless his or her vision has been adequately corrected with eyeglasses. The test
should not be given to an examinee with a severe motor impairment, as it would affect his or
her ability to draw the geometric figures correctly. The test scores might thereby be distorted.

Psychometric testing requires a clinically trained examiner to administer and evaluate it.
When using a scoring system, the examiner should assess its reliability, validity, and
normative sample.

When making a diagnosis of brain injury, the Bender Gestalt Test should never be used in
isolation. When making a diagnosis, results from the Bender Gestalt Test should be used in
conjunction with other medical, developmental, educational, psychological, and
neuropsychological information.
Results: A scoring system does not have to be used to interpret performance on the test;
however, there are several reliable and valid scoring systems available. Many of the available
scoring systems focus on specific difficulties experienced by the test taker. (any 3)
● Angular difficulty: Altering or omitting angles in figures.
● Bizarre doodling: Adding unrelated components to drawings.
● Closure difficulty: Failing to close spaces or connect parts.
● Irregular line quality: Rough or tremor-like lines.
● Line extension: Extending parts not in the original.
● Superimposition: Overlapping figures.
● Workover: Reinforcing or overworking lines.
Total Score- If the subject rotates the card or paper and then draws correctly, it is correct.
Generally, 3 or fewer errors indicates an absence of visuo-constructive deficits; 4 errors is a
borderline score; and 5 or 6 errors provide some evidence for brain impairment.
Benton Visual Retention Test
The Benton Visual Retention Test (or simply Benton test/ BVRT) is an individually
administered test for people aged from eight years to adulthood that measures visual
perception and visual memory. It can also be used to help identify possible learning
disabilities among other conditions that might affect an individual's memory. The test is
untimed, and the results are professionally scored by form, shape, pattern, and arrangement
on the paper. Dr. Benton developed the test to provide a shorter assessment for immediate
nonverbal memory to supplement the popular digit span test. The test was published in 1946,
and is now currently in its 5th edition.

The Benton Visual Retention Test is composed of 3 sets, or forms, of 10 designs (each 8.5 ×
5.5 in.) that measure the examinee's visual and memory abilities. The examinee is given a
booklet containing 10 blank pages on which they reproduce the designs. These designs are
used to measure the examinee's visual perception and memory, and can be administered five
different ways. These five methods are as follows:

Method type-
A- The examinee views each design for 10 seconds before reproducing them
B- The examinee views each design for 5 seconds before reproducing them
C- The examinee views each design and is allowed to reproduce them while viewing the
designs for an indefinite amount of time
D- The examinee views each design for 10 seconds, and then waits 15 seconds before
reproduction begins
M- The examinee views each design for 10 seconds, and then chooses the correct design from
a multiple choice of four displays.
In every method except for Administration C, the original design is hidden before
reproduction begins.

Test scoring-
First method: The number of correct scores is calculated based on an all-or-nothing
approach; points are awarded if the reproduction of the design matches the original.
Second method: The number of error score, on the other hand, is calculated based on the
number and type of errors made for each design. The major categories for these errors are
omissions, distortions, perseverations, rotations, misplacements, and size errors. These scores
are then compared to normative data available in the manual and conclusions can be drawn
by the examiner. The two different methods of scoring allow for both quantitative and
qualitative analysis of an individual's test.

Uses: It is sensitive to many forms of brain impairments and diseases, but it is difficult to
diagnose a particular disease through the test. In fact, according to the test manual, a high
number of a single category of error should not be used as a diagnosis, but should lead to
further testing. High amounts of perseverations, for example, suggests frontal lobe damage,
while the omission of peripheral designs suggests potential brain trauma in the right parietal
lobe. Learning disabilities among children are able to be identified through the Benton Test.

Psychometric properties: According to the Benton Test manual, test-retest reliability of the
Benton Test is 0.85.

Criticisms and validity: The Benton Test has been criticised for needing an IQ estimate,
which can be tough to obtain if a person is in poor condition. Research on retesting shows
mixed results; some studies find no change in scores over time, while others do see
differences. Despite these concerns, the Benton Test has several advantages. It offers a clearer
scoring system compared to other visual memory tests. Additionally, it has reliable results
with different versions and is quick to administer.

Cognitive retraining
Cognitive retraining is a therapeutic strategy that seeks to improve or restore a person's skills
in the areas of paying attention, remembering, organizing, reasoning and understanding,
problem-solving, decision making, and higher level cognitive abilities. These skills are all
interrelated. Cognitive retraining is one aspect of cognitive rehabilitation, a comprehensive
approach to restoring such skills after brain injury or other disability.

-Purpose
The purpose of cognitive retraining is the reduction of cognitive problems associated with
brain injury, other disabilities or disorders, and/or aging. The primary aim of CRT is to
reinforce, strengthen, or even establish cognitive abilities that may have been compromised
due to brain injury or cognitive impairment. This includes improving memory, attention,
reasoning, and problem-solving skills. It aims to help individuals establish new patterns of
cognitive abilities, allowing them to adapt to their cognitive disabilities and find alternative
ways to perform tasks and activities. The goal of CRT is to enhance overall functioning. By
improving cognitive skills and developing effective strategies, individuals can regain
independence and improve their quality of life.

Professionals from a variety of fields, such as psychology, psychiatry, occupational therapy,

and speech-language pathology may be involved in cognitive retraining. Cognitive retraining
has also been used to treat dementia, schizophrenia , attention-deficit disorder, learning
disabilities, and cognitive changes associated with ageing. Cognitive retraining includes a
considerable amount of repetitive practice that targets the skills of interest. In fact, it is
essential for the newly retrained skills to become automatic. Regular feedback is another
important element of cognitive retraining, as is the use of such rewards as money. Retraining
usually begins with simpler skills and proceeds to more complicated skills. The therapist may
address cognitive skills while the person is practicing real-life tasks, in an effort to improve
their performance of these tasks. The length of time for cognitive training varies according to
the type and extent of the injury and the type of retraining skills used.
Types of cognitive retraining DEMO AP

● Attention and concentration retraining- This cognitive retraining focuses on

enhancing abilities like focusing, dividing attention, sustaining attention to combat
boredom and fatigue, and resisting distractions. Attention is viewed as the foundation
for other cognitive skills.
● Memory retraining- Memory retraining involves teaching the patient several
strategies that can be used to recall certain types of information. For example, rhymes
or series of numbers, such as a phone number, broken down into smaller groups.
● Organisational skills retraining- This approach is used for individuals who struggle
with tracking or locating items, completing tasks in order, or managing tasks in a
timely manner. Strategies may include having one identified place for an item. In
addition, the person can be taught to keep the items that are used most frequently
closer to him. Items may be put into categories (Christmas decorations or diwali).
● Problem solving- Problem-solving retraining aims to help people define a problem;
come up with possible solutions to it ,discuss the solutions with others and listen to
their advice , review the various possible solutions from many perspectives and
evaluate whether the problem was solved after going through these steps. This
sequence may be repeated several times until the problem is solved. This process is
referred to as "SOLVE," from the first letter of the name of each step: Specify;
Options; Listen; Vary; and Evaluate. The "SOLVE" technique is more appropriate for
use with individuals at a higher level of functioning.
● Decision making- Decision-making retraining is used when a person must choose
among a number of options. The goal of this retraining is to help him or her consider
the decision thoroughly before taking any action. Factors considered may include
practical aspects like money, people, rules, policies, as well as personality influences.
● Executive skills- Executive skills retraining refers to teaching individuals how to
monitor themselves, control their thinking and actions, think in advance, set goals,
manage time, act in socially acceptable ways, and transfer skills to new situations.
Charts and videotapes may be used to monitor behavior. Eg - A student struggling
with time management learns to set realistic goals, break tasks into smaller steps.
They monitor progress with weekly reviews using charts.

Aftercare- The therapist will try to promote the transfer of skills learned using cognitive
retraining techniques to the patient's everyday life and demands. Training may be continued
until the patient's skills are improved, transferred to, and maintained in real world activities.

WHAT IS REHABILITATION?: Rehabilitation is a comprehensive approach that

encompasses a range of interventions designed to enhance individuals' functioning and
minimise disability caused by health conditions. It focuses on empowering individuals to
achieve their maximum potential in daily activities while considering the interactions
between their health status and environmental factors. It focuses on addressing impairments,
disabilities, and handicaps. Impairment: Refers to any loss or abnormality of body structure
or physiological or psychological function. Eg- Loss of vision or cognitive deficits.
Disability refers to the functional limitations or restrictions that result from an impairment,
affecting an individual’s ability to perform certain activities. Eg- Difficulty walking or
inability to perform daily tasks. Handicap refers to a social or environmental disadvantage
that results from a disability. Eg- Barriers to accessibility in public spaces, or limitations in
employment opportunities.

Principles that underlie a rehabilitation program:

1.. Timing: Rehabilitation should start as soon as tolerated to minimise the negative effects of
rest and immobilisation.
2. Compliance: Patients should adhere to prescribed exercises and perform them correctly
and at the appropriate intensity.
3. Person-Centered Care: Rehabilitation should prioritize the individual’s needs,
preferences, and goals, involving them actively in their own treatment process.
4. Holistic Approach: Effective rehabilitation considers the physical, emotional, social, and
environmental aspects of the individual’s life, aiming for overall wellbeing and quality of life.
5. Interdisciplinary Collaboration: A successful rehabilitation program involves a team of
professionals from various disciplines, including medical, psychological, and social services,
to provide comprehensive care.
6. Empowerment and Self-Management: Rehabilitation should empower individuals with
the skills and knowledge to manage their own conditions, promoting self-efficacy.

Approaches to Rehabilition
1. Institution-Based Rehabilitation (IBR): Conducted in specialized settings like
hospitals and rehabilitation centers, this approach focuses on providing clinical care
and structured training to individuals with disabilities. It offers access to professional
support, therapy, and resources necessary for recovery and skill development.
2. Outreach Programs for Rehabilitation: This approach delivers rehabilitation
services directly to individuals in their homes or local communities. Professionals
provide personalized support and interventions, making rehabilitation more accessible
and tailored to the unique circumstances of each individual.
3. Community-Based Rehabilitation (CBR): CBR involves a collaborative strategy
that includes individuals with disabilities, their families, and community members. It
aims to create inclusive rehabilitation services that promote social integration, equal
opportunities, and the development of community resources. This approach
emphasizes the importance of local involvement and support.
4. Home-Based Rehabilitation: In this approach, rehabilitation services are provided in
the individual's home environment, allowing for personalized care and support. It
focuses on practical strategies to enhance daily living skills and independence while
addressing specific challenges related to the home setting.
5. Vocational Rehabilitation: This approach aims to assist individuals with disabilities
in gaining employment or improving their work skills. It includes job training,
counseling, and support in finding suitable job placements, fostering independence
and economic self-sufficiency.