This post is meant to give readers of neuropsychology reports – especially family members, and teachers – a guide to what to look for and expect from such reports.
Neuropsychology reports should not be full of jargon, or overly long (6 – 8 pages maximum, often does it). They should strive to be comprehensive, yet concise, speaking directly to the referral question. They should only offer the most necessary and useful information (including relative strengths and limitations found on testing; clear diagnostic impressions; and clear, practical recommendations for addressing any neuropsychological deficits found).
We will proceed section by section, following the outline of a good neuropsychology report, and what should be contained there
This first report section should contain such basic background and demographic information as the client’s name, date of birth, age, ethnicity, and handedness. Ethnicity is important because different ethnic backgrounds can be associated with different expression of psychiatric symptoms, and specific treatment approaches, etc. Handedness is important because it helps us understand what is called “lateralization” of function (for example, in about 95% of right-handers, and over 50% of left-handers, language function is located primarily in the brain’s left hemisphere). The referral question should also be clearly stated here (such as, evaluation to rule out the presence of ADHD, learning disability, dementia, etc.).
This section should include the primary symptoms that prompted the referral, including cognitive (that is, thinking and memory), emotional-behavioral, and/or physical complaints. The neuropsychologist should always seek to include the client’s perspective. For clients who tend to lack insight, information from collaterals – parents, spouses, other family members, friends or other professionals such as primary care physicians – is crucial. Still, one should always ask, and put into the report, chief complaints from the client’s perspective, even if they only say “There’s nothing wrong with my thinking or memory”, etc.
Here, one should note the onset and course for each key symptom described in the previous chief complaints section. For example, if a memory problem is cited, this section will ideally state 1) when memory problems were first noticed; 2) whether the onset of memory deficits was gradual, or more abrupt, etc.; 3) what the course has been (for example, has memory gradually worsened? Has there been instead a step-wise course, wherein there is a steep decline, then leveling off of the problem, then another decline, and so on)? In addition, there should be information on other evaluations done as regards symptoms, and treatments attempted. Finally, one should note which medications, if any, the client is taking. This is so because certain medications can have cognitive and other effects, which should be taken into account when interpreting evaluation findings.
This section should include the client’s other medical and psychiatric history, not yet addressed through the chief complaints section (for example, history of diabetes, past depressive episodes, treatment for such conditions, etc.).
This section should include notable medical and psychiatric conditions in at least 1st-degree relatives (such as heart disease or Alzheimer’s disease in mother; mood symptoms or substance abuse or ADHD in a brother, etc.).
This section should include basic information about birth history (whether normal or complicated), level of education attained and typical performance in school (average, below average, etc.), any special education services or apparent learning disability, and what type of work, if any, the individual has done (including typical occupation, longest-held job, whether full or part-time, etc.). Armed service, if any, should be included, along with what type of discharge was obtained.
In this section, even an outside reader should get a good sense of how the client looked and behaved during testing, as if they were actually meeting them. Key items to include here are: level of alertness; orientation to time, place, person and situation; quality of gross motor movement (gait, posture, psychomotor agitation, tremor, etc.); eye contact; quality of dress/grooming (since being poorly dressed/groomed can indicate lack of self-care, etc.); quality of speech (its volume, fluency, intonation); affect (range of emotional expression); mood (client’s report on emotional status, including any symptoms of depression such as sadness, plus poor sleep or appetite); quality of thought process, and thought content; apparent level of motivation and effort on testing; and any notable difficulties with test completion (for example, did the client tend to give up easily as tests became even moderately difficult?, etc.).
Every full neuropsychology report should include a table of test results. This can be put into the middle or end of the report. We advise the middle, right after the mental status/behavioral observations section. This table should include columns for the tests used, the standard score achieved on each test, the corresponding score percentile, and the score descriptor (for example, Superior, Average, Borderline, Extremely Low, etc.). There should be an emphasis on precision in reporting results. For example, the descriptor “Below Average” is very imprecise, as many scores are technically below average (that is, anything below 25th percentile). “Low Average”, “Borderline” and “Extremely Low” are better descriptors in this case, as they have more specific ranges assigned to them (such as 9th to 24th percentile for the Low Average range). The table should also include row markers for test domains (for example, Learning/Memory marker above all tests for that specific domain) A good table should give the reader a quick and comprehensive sense of which domains and tests are most problematic, and which are areas of relative strength.
This section need not resume the client’s entire history in detail. A line or two of summary background, plus a simple restatement of the referral question often suffices.
Next, the relevant mental status/behavioral observation findings and test results should be described.
One simple way to describe the test results starts with key mental status findings and behavioral observations, followed by brief descriptions of tests in order from the table. One could also review relative strengths first, then any areas of significant weakness (e.g., in attention, or in verbal learning and memory).
In any case, a line or two for each test will usually suffice. The neuropsychologist should think of what the client and/or collaterals want to know. Typically, they do not need or want detailed descriptions of the procedures for each test. Rather, they want to know in clear and understandable language how the client performed in specific test domains, and what the overall pattern of results suggests. Clients and collaterals want the bottom neuropsychological line, without too many trappings.
To that end, there should be a summary paragraph that states the overall cognitive pattern (in terms of limitations and strengths), the diagnostic impression(s), prognosis, and basic treatments needed going forward. Such treatments can be detailed in the recommendation section, at the end of the report.
The neuropsychologist should use standard DSM-5 or ICD-10 diagnostic codes, as applicable (except in school settings, when state Department of Education diagnoses are sometimes preferable). It is often helpful to add some descriptive elements, such as primary neuropsychological domains affected, and suspected cause (for example, “Cognitive Disorder, with prominent memory dysfunction, probably due primarily to concussion”).
A basic rule concerning recommendations: if a particular weakness is significant enough to highlight in the summary, then a recommendation should be written for it.
Recommendations should be clear, focused on the primary problems, and carefully tailored to the particular client involved.
If you receive a report that does not include recommendations with enough detail to address the problem areas cited in the report, ask the neuropsychologist if more specific content can be added to that particular recommendation(s) on a revised report, or to fill-in such detail during a feedback session.
Finally, feedback should be given to the client and/or family on results of the report. In feedback, the neuropsychologist should strive for clarity as concerns results, their interpretation, and suitable recommendations. Importantly, the neuropsychologist should also make every effort to ensure that the client and any collaterals feel respected and supported, throughout the evaluation process.
Thank you for reading this blog post!
Jeffrey J. Gaines, Ph.D., ABPP-CN
Board Certified in Clinical Neuropsychology