Prior to the advent of modern neuroimaging techniques, detecting and localizing brain lesions was a principal focus of clinical neuropsychology. As witnessed by early efforts involving the Halstead–Reitan and Benton–Iowa batteries, neuropsychological tests were largely validated to identify whether a lesion was present and, if so, where was it located. Presently, however, neuropsychologists are no longer unique in their ability to localize a lesion, and many physicians may prefer to subject their patients to 40min in a scanner instead of 4h in a testing room.
Yet, assertions of impending obsolescence are premature. Clinical neuropsychology fulfills a role shared by few disciplines. Namely, we determine the presence and severity of cognitive impairment. Based on our findings, we are often asked to make inferences regarding a patient's capacity for activities of daily living. As the large number of baby boomers age, these referral questions will only increase. Nonetheless, few neuropsychologists receive training to address such issues, and compilations of relevant research, models, or practice recommendations are uncommon.
Thus, Demakis’ edited volume, “Civil Capacities in Clinical Neuropsychology,” partially fills an important void. With 15 chapters authored by well-established experts from clinical neuropsychology and the law, the text commences with an overview of psychological models concerning capacity to manage personal affairs. Legal concepts regarding competence are defined, and the process by which courts make competency decisions is outlined. After laying this foundation, specific capacities are discussed. In particular, the text addresses ability to make medical treatment decisions, execute a last will and testament, drive an automobile, execute financial matters, and manage personal care activities. The authors delineate an underlying model of each capacity, discuss methods to assess the capability, and review research concerning the relationship between neuropsychological functions and the specific capability. Each of these chapters concludes with an illustrative case example.
In addition to specific capacities, one chapter delineates how neuropsychologists may assist the court in appointing a guardian. The volume concludes with suggestions how to conduct capacity evaluations and how to communicate their results in a meaningful and ethical manner. In particular, officers of the court make recommendations regarding the content of reports. In a related chapter, rules of evidence and legal requirements for reports to the court are reviewed. Neuropsychologists, noted for their independence, are somewhat prone toward idiosyncratic report styles. With such guidance, this material will likely enhance the ability of neuropsychologists to facilitate competency decisions of the court.
The scope of this text is admirable, and it addresses relevant and important aspects of competency. The expertise of the authors is indisputable, and they have written clear and thoughtful chapters. Neuropsychologists and lawyers contribute as authors, thereby ensuring that the roles and responsibilities of the practitioners and consumers are elaborated. In each chapter, the psychological and legal literatures of each capacity are discussed, and important nuances are elaborated. For instance, the important distinction between capacity and competency is clarified (the former being a psychological construct and the latter being a legal concept). The case examples help to solidify important concepts and provide a reasonable idea how to conduct evaluations and render reports. The topics progress in a logical and sequential manner that build upon each other. The foundation and assumptions concerning functional capacities are clearly stipulated, and a basic familiarization with measures and report requirements is provided. In addition, an example of a capacity report is included in the chapter by Wood and O'Bryan. Moreover, continuing education credits are available for reading this book.
Although capacity measures are described, their relative merits are not evaluated, and their validity and reliability are not elaborated. For a clinician to conduct a capacity evaluation, it would be helpful if the authors made recommendations regarding best practices and instruments. For example, in the chapter concerning driving capacity, it would have been useful for the authors to summarize the best neuropsychological predictors for each clinical population. Indeed, across each of the chapters, the reader is left wondering. What is the recommended battery of tests to use? What are the best practices?
Related to this issue, classification validity of the instruments is generally neglected, and the authors offer no clear recommendations regarding what scores constitute incapacity. In part, this may be due to limitations of the existing research concerning the instruments. Few of the measures discussed in the text have empirically validated cutoffs. Indeed, Moberg and Shah acknowledge that few capacity measures have demonstrated evidence of their ecological validity. Nonetheless, this vagary should be clarified as a void in the literature. Additionally, with few exceptions, the authors leave unresolved such important issues as when should incapacity be evaluated and who should request such evaluations. This is discussed in general terms by Sullivan, but indications for specific capacities are lacking.
A further limitation of the text concerns its coverage of capacities. For example, testamentary capacity is an important capability and is discussed in the book. However, it may also have been helpful to address ability to enter into contracts or business activities. For instance, individuals with neurocognitive compromise may sign contracts with potential personal or financial liability, and this may ultimately lead to legal proceedings. Likewise, with the advent of the Americans with Disability Act, capacity to continue employment subsequent to neuropsychological impairment is arguably a relevant and important topic to address.
A further criticism concerns the empirical basis of capacity evaluations. In particular, from the chapter concerning testamentary capacity, there is no meaningful research pertaining to this topic. As such, some of the capacities are insufficiently defined and barely researched, thereby leaving confident assertions wanting. This is a shortcoming of the literature rather than the authors. Nonetheless, it highlights the fact that scientific evaluation of civil capacities has only begun, and some capacities are better delineated than others. If the text is to be criticized in this regard, it is because the authors offer inadequate acknowledgement of this weakness.
These shortcomings notwithstanding, this is an essential text for the clinician. It clarifies basic assumptions, models, roles, and responsibilities, and it provides a rudimentary framework for conducting capacity evaluations. Furthermore, owing to the scientific blindspots it highlights, this text will also serve as a catalyst for subsequent research.