This article is an attempt to present a picture of some of Ralph Reitan's contributions to neuropsychology. The context for this picture is the Neuropsychology Laboratory at Indiana University Medical Center during the 1960s. Each of the authors worked there during those years, and for some 3 years, both authors worked there simultaneously.
The Laboratory was a component of the Department of Neurology. Earlier, neuropsychology had been located in the Department of Surgery, but there the full professional acceptance of psychology and psychologists could not be attained. In Neurology, however, those issues never arose. Reitan and his staff were warmly accepted, the ready availability of patients was assured, and a happy home was instantly created. Scientific and professional acceptance for neuropsychology quickly developed with other services including pediatrics and neurosurgery. Smooth administrative arrangements are not usually listed among Reitan's accomplishments, but their importance should not be overlooked. They in fact facilitated the interdisciplinary research and, to an even greater degree, the interdisciplinary training that became hallmarks of Reitan's efforts in neuropsychology.
The research efforts of the Neuropsychology Laboratory were based on data that were collected each day. These data were generated by the evaluations of individual patients. Specifically, technicians were trained to administer and score all of the tests and to make specific behavioral observations. A technician also provided a summary of the relevant information in the patient's medical chart. Later Reitan or one of his associates critically reviewed the test data and the medical summary data, and then the data were available for use in specific research studies. It should be noted, in this context, that the Neuropsychology staff had no assigned clinical responsibilities. Reitan and all of his staff were supported by grant funds that he had been awarded. Nevertheless, clinical responsibilities were assumed when necessary. Referring physicians and surgeons not infrequently faced difficult clinical decisions involving diagnosis and treatment. At those times, the concerned physician might call Neuropsychology and inquire about clinical concerns. Did the neuropsychological test data point to a disturbance in brain functions and, if so, where was it, what was it, etc.? Under those conditions, the opinion of the neuropsychologist was given orally and was entered into the patient's medical chart. This kind of clinical application, namely the specification of type and location of a brain lesion based on a blind analysis of neuropsychological test data, was something Reitan and his staff routinely did. To the best of the authors' knowledge, this was rarely if ever the case at other centers. Clinical concerns became a major part of the short training programs (workshops) Reitan established, which are discussed in a later section of this article.
Reitan's core research thrust was the analysis of the role of the Halstead–Reitan Battery of Neuropsychological Tests in the performances of adult patients with brain lesions. This analysis encompassed many different lines of inquiry, and it must be noted as these are reviewed that the battery was not an unchanging entity but was, instead, an evolving structure. To illustrate this point, the Halstead battery earlier included two Critical Flicker Fusion measures and a measure of one's ability to estimate a short time interval (the Time Sense test). These measures were dropped because the data did not discriminate adequately between groups of patients with and without brain lesions. Measures that were added to the Halstead battery included a screening test for aphasia based closely on a similar test developed by Halstead and Wepman and two measures of sensory perceptual functions, a finger agnosia test and a fingertip number writing test. The Halstead–Reitan battery was supplemented by the Wechsler–Bellevue test, the Trail Making Test, and the Minnesota Multiphasic Personality Inventory.
To summarize the data-gathering phase of the ongoing research effort of the Neuropsychology Laboratory that Reitan directed, for each and every patient referred for evaluation the data included results of the Halstead–Reitan Battery (with its supplements), the Wechsler–Bellevue test, the Trail Making Test, and the MMPI. The data also included relevant medical data taken from the patient's medical chart. The individual research studies included factor analyses, the relationships of the different procedures to various neurological criteria, and the differential sensitivity of each and every test to specific patient variables other than neurological status (e.g., age, education, etc.). Many of these studies were undertaken to validate the battery: “One of the contributions [of the Indianapolis group] was very comprehensive studies of validation of the tests. … The discriminating power, not only of every test, but also of every item—from drawing a cross to the total score on the category test—[came to be] known” (Reed, 1985).
In addition to these validation efforts, many of the studies were conceptually refined, looking at highly specific aspects of both behavioral variables and neurological variables. This degree of conceptual refinement both for neurological variables and for behavioral variables enlarges awareness of what brain–behavior relationships are all about. The increased awareness is based on quantitative, replicable procedures and it anchors a critical advance in neuropsychology. As one of the authors (Reed, 1985) explained:
[I]f a single principle emerges, it pertains to the appreciation of the complexity of brain–behavior relationships. The research has th[o]roughly demonstrated that brain–behavior relationships will be affected by: (1) the nature or type of lesion. Intrinsic tumors have different effects from closed head injuries which, in turn, have different effects from cerebral vascular lesions. (2) the effect of a brain lesion will vary along an acuteness-chronicity dimension including age of onset; and (3) the hemisphere involved will also have different effects including locus within the hemisphere. (p. 292)
The sophistication of Reitan's research efforts is paralleled by his efforts in education and training that are specifically related to neuropsychology. He began giving invited speeches in 1954, and he spoke frequently thereafter to graduate training programs where there was a high level of interest in his activities. Additionally, he regularly participated at the regional and national meetings of the American Psychological Association, either presenting research or participating in seminars. Interest in neuropsychology was increasing exponentially, and Reitan was a very effective speaker. Beginning in the mid-60s, he directed 3-day workshops focusing on the presentation and analysis of test data on individual patients he and his staff had evaluated. These workshops continued for several years with Reitan's staff joining him in the presentations. The workshops typically concluded with Reitan meeting individually with workshop participants who were invited to present patients they had evaluated. Participation in the first workshop was by invitation only, and participants included clinicians and researchers from the United States and Canada that had some prior relationship with Reitan. Later workshops were not so restricted. These workshops were very popular and provided brief but highly focused training for neuropsychologists. Reitan also provided prolonged training for at least a small group of psychologists, including his own staff. The authors worked with Reitan for several years. A significant part of their time was spent in training that closely resembled the training provided the residents and fellows in neurology and neurosurgery. Participation in daily in-patient rounds, short courses in neuroanatomy, regularly scheduled conferences in neuropathology, and problems in diagnostic assessment illustrate the kinds of experiences in which staff members were actively involved. The same kind of training was available to postdoctoral fellows. Neuropsychologists were frequent visitors to the Indiana Laboratory through the 1960's. Some would stay for a few days, others for a much longer period of time. Their training was not standardized but was on a self-selected basis. Some wanted to observe testing; others had highly specific interests in defined patient groups.
Evaluation of the training programs Reitan led must rely largely on the reports of those involved. The workshop participants frequently provided written evaluations, and they were routinely very favorable. The authors happily report that their training was a vital part of their careers. A broad evaluation can be inferred from a poll taken a number of years ago that asked APA Division 40 (neuropsychology) members to identify the individual having the most influence on their training. By an extremely wide margin, Reitan headed the list of names that the poll generated.
It is beyond the scope of this paper to identify all of the research and training activities in neuropsychological functioning in the Reitan-Indiana Laboratory during the decade of the 1960s. The preceding material has identified the activities involving adults. There was a definite but secondary interest in programs for children. Reitan modified the Halstead tests to make them suitable for children from 9 or 10 years of age through the teen years. For still younger children, tests superficially resembling those designed for older subjects were identified and developed. The children's form of the Wechsler test was used. New tests involving concept formation and psychomotor abilities were developed and added. Research soon made it clear that the conceptual framework that evolved from the research with adult patients having recently acquired insults to the brain was of very little use in understanding the problems presented by children. The types of neurological impairment in the groups of children that could be composed bore little resemblance to the impairing conditions in the adult groups. Furthermore, when groups of children could be compared with adults having presumably similar lesions (e.g., traumatic brain lesions), the effects of the impairing conditions were necessarily mixed with the effects associated with growth and development.
The research with children that Reitan directed demonstrated that the tests that were used separated the experimental and control groups and demonstrated specifically that age of onset and chronicity were critical variables. It was not possible, however, to do the kinds of sophisticated research that had been possible with adults.
One can argue that skill sets useful in working with brain-injured children must necessarily emphasize rehabilitation and long-term education and management. Reitan's personal training and research skills led to his visibility and importance in advancing adult neuropsychology. His uniqueness as a psychologist did not develop in his work with children.
The preceding material provides a snapshot of Reitan's research and training programs in the 1960s. Those years mark the beginning of the explosive growth in the number of psychologists who chose neuropsychology as their specialty. As one of the authors (Reed, 1985) wrote in the 1980s:
The standards for sophisticated neuropsychological assessment of the individual patients were set at Indiana. The Halstead–Reitan Battery or parts of it are [in the 1980s] probably used in more hospitals throughout the United States and Canada than any other neuropsychological battery in existence. … [T]his battery has been used in investigations of drug abuse, alcoholism, head injuries, learning disabilities, mental retardation, acute lymphocytic leukemia, juvenile delinquency and, while not a neurological disease state, it has even been used in a study pertaining to the selection of major league baseball players. (pp. 292–293)
Similarly, Dean (1985) concluded that “numerous batteries have been offered as wide-band measures of the integrity and functioning of the brain,” but “the HRB remains the most widely researched and widely utilized measure in the United States,” while Meier (1985) offered the following observations:
[The Halstead–Reitan] comprehensive neuropsychological test battery has a long and illustrious history of clinical research and application in American clinical neuropsychology. Following its inaugural presentation to the psychological community [by Halstead in 1947], and the careful nurturance of concept and application by Reitan …, the battery has had perhaps the most widespread impact of any approach in clinical neuropsychology. It seems reasonable to state that in the first half of the period since World War II, during which neuropsychology expanded so remarkably, this approach was the primary force in stimulating clinical research and application in this country. (p. 646)
Today, how intense is the training of current neuropsychologists in the standards of evidence employed in the neurological specialties? How intense is their day-to-day involvement with neuropsychological tests and can they critically evaluate those tests? The authors believe it would not be possible today to identify a group of psychologists using the Halstead–Reitan Battery, but this negative finding may well be without significance. Of greater importance is the question what kinds of demands are neuropsychologists facing. If those demands require both a sophisticated understanding of cerebral pathology and a sophisticated understanding of psychological tests, then Reitan's work in research and training retains its significance.
The authors acknowledge the editorial assistance of Patrick C. Reed in preparing this article.