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, cost-effective 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 (e.g., driving simulators, on the road tests). This general strategy is endorsed throughout the text and across different skill areas.
One relative weakness in this section and with regard to the book, in general, is the relatively scant attention paid to the topic of money management. This is an extremely important and complex set of skills that neuropsychologists are frequently asked to address in their assessments. There has been considerable research in this area (e.g., Marson et al., 2009) with only brief mention made of this work. An entire chapter devoted to this topic would have enhanced the comprehensiveness of the text.
The second part of the book addresses the relationship between specific neurological and psychiatric conditions and everyday functioning. Among the conditions reviewed are normal aging, MCI/Alzheimer's disease, TBI, sports-related concussions, MS, HIV, depression, and schizophrenia. Each chapter begins with a brief review of the disorder, which in virtually every case I found to be concise and up to date. This is followed by a synopsis of the existing research concerning the disorder and real-world functioning. Some of the areas where research is limited are surprising. For example, despite the growing evidence regarding the efficacy of disease modifying medications in treatment of MS, there has been little research exploring the relationship between MS-related cognitive deficits and capacity to adhere to medication regimens. The authors appropriately highlight this as an area which should receive a high priority in terms of future research.
These chapters reviewing the relationship between cognitive skills and real-world behavior in specific populations are among the most interesting and reveal the areas of both convergence and discrepancy. For example, the critical role played by prospective memory in adherence to medication regimens is highlighted across multiple clinical disorders. Unfortunately, this type of memory is not captured by most traditional assessment techniques, nor included in most assessment batteries.
This disorder-specific approach also highlights the fact that relationships between cognitive skills and real-world performance do not necessarily generalize from one clinical population to another. In the case of driving, for example, aspects of executive functioning appear to be most highly correlated with difficulties within the HIV+ population, whereas deficits in information processing speed and attentional capacity were most relevant in patients with MS. These types of contrasts highlight the need for clinicians to familiarize themselves with the research specific to each clinical population they work with.
In conclusion, this is an extremely impressive book which fills a great void in the field. It should be required reading for all clinical neuropsychology students/trainees as well as for all of us who strive on a daily basis to provide useful recommendations to patients and their families. I am hopeful that future editions will expand the coverage of clinical disorders to include stroke, epilepsy, and other populations. From the perspective of a practicing clinician, I do wish that more specific advice was provided regarding strategies for assessing specific functional areas, like that provided in Rizzo and Kellison's chapter on driving. On the other hand, I also understand that the lack of such advice reflects the current state of the art. Great progress has been made with a great distance yet to be travelled. This excellent book represents a significant milestone in this journey.