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Clinical neuropsychology 1970–1990: A personal view
Archives of Clinical Neuropgwhology, Vol. 6, pp. 105 I 11, 199 I Printed in tic USA. All rights reserved.
Clinical
Copyright
0887.6177/9153.M) + 00 Q 1991 National Academy of Neumpsycholcgy
Neuropsychology
1970-l
990:
A Personal View Oscar A. Parsons Oklahoma Center for Alcohol & Drug Related Studies, University of Oklahoma Health Sciences Center
In 1970, I assessed the status of a “new discipline”, clinical neuropsychology, and optimistically predicted growth and expansion over the next decades. A current assessment in 1990 indicates that the dramatic increase in the number of clinical neuropsychologists and in the scope and magnitude of their professional functioning far exceeds my expectations of two decades ago. Further, there is every indication that clinical neuropsychology will continue to be a challenging, vital, and expanding profession.
Since the early fifties of this century there has been an accelerating and exhilarating interest in neuroscience and human neuropsychology accompanied by a dramatic increase in research in these areas. As with the incorporation of all new scientific knowledge, universities gradually reorganized curricula to include these developments. In 1966 and 1967 when we started our Ph.D. program in Biological Psychology at the University of Oklahoma Health Sciences Center, we had one of the first courses in neuropsychology, by that specific name, ever given by any university. By 1970, the nascent field was established to the extent that when Charles Spielberger invited me to write a chapter for his edited series of books on Current Topics in Clinical and Community Psychology, I happily chose the topic of Clinical Neuropsychology (Parsons, 1970). I made a number of points in that paper of two decades ago which captured the status of neuropsychology at that time. This paper is based on an invited address given in response to the author’s receiving the “Distinguished Clinical Neuropsychologist Award” from the National Academy of Neuropsychology at its Tenth Annual Meeting, November 2, 1990, Reno, Nevada. Requests for reprints should be sent to Oscar A. Parsons, Ph.D., Executive Director, Oklahoma Center for Alcohol and Drug Related Studies, 800 N.E. 15th Street, Oklahoma City, OK 73 104. 105
IO6
0. A. Parsons
NEUROPSYCHOLOGY-1970 I described clinical neuropsychology as a new discipline and defined it as “that branch of psychology which applies knowledge derived from relevant experimental and clinical investigations to specific brain-behavior problems in humans.” I noted that the clinical neuropsychologist is concerned primarily with identifying, measuring and, describing changes in behavior that relate to brain dysfunction and that the clinical neuropsychologist’s activities contributed to a variety of important clinical problems: differential diagnosis; lateralization and localization of lesions; establishing baselines of sensory, motor, perceptual, cognitive, and intellectual functioning from which subsequent improvement or decline could be determined; identifying specific deficits from noxious agents such as drugs; developing methods for remediation of deficit: helping to determine competency in the aged; and, developing better diagnostic and remedial efforts for the minimally brain-damaged child. I predicted that these specific functions would grow in importance in that the society in which we lived was one
whose youth experiments with multifarious mind (brain) altering drugs, whose over-30 population is ridden with alcohol and tranquilizers, whose underprivileged frequently suffer from inadequate diets which directly in the neonate or indirectly in a pregnant mother affect the growing brain, and whose automobile drivers provide a toll of head injuries from accidents that outstrips wartime causalities. (Parsons, 1970)
In this 1970 chapter, I noted that the term “neuropsychology” was receiving increasing use in the literature and that two Journals established in the 6Os, Cortex and Neuropsychologia were devoted to studies explicitly neuropsyche logical in nature. Incidentally, these Journals were both European in origin and edited by neurologists with strong psychological interests, Ennio DeRenzi and the late Henri Hecaen. During the mid-60s the International Neuropsychological Society was formed, a society comprised mainly of psychologists, many of whom were beginning to call themselves “neuropsychologists.” I noted that at least one university (our program at the University of Oklahoma) offered a predoctoral specialization in neuropsychology, that four postdoctoral training programs in clinical neuropsychology had been established (our’s was one of these) and that summer workshops in neuropsychology were being offered. I concluded that “technical advances during the last decade have led to “breakthroughs” and to the accumulation of data far beyond the wildest expectations or fervent hopes of the neuroscientists or psychologists of 20 years ago. My recommendation for the education of the clinical neuropsychologist was that it should not only include usual sound training in clinical and experimental psychology but in addition, a thorough grounding in the modern concepts of the
Clinical Neuropsychology. 19704990
107
structure and function of the nervous system. I thought that postdoctoral training in clinical neuropsychology should be the culminating preparatory experience for a professional level of functioning and predicted that many such programs would be established in the next decades. Prognostications are always dangerous, but I felt sure that there would be foa major areas of investigation during the next decades: (i) there would be an increase in international cooperative studies on neuropsychological problems; (ii) the electrophysiological methods of the computer averaged evoked potentials and other psychophysiological measures would be emphasized; (iii) there would be a re-emphasis of an old approach, the intensive experimental analysis of a single subject; (iv) the fruitful application of knowledge and theories from the basic advances in psychology proper to the problems of neuropsychology would continue. Finally, I was enthusiastic about the future of neuropsychology,
the next decade promises to be even more exciting than the past... There is every indication that clinical neuropsychology is a vital and expanding field. The human mind remains one of the most fascinating of all scientific puzzles and the problems of brain-behavior relationships will be of increasing importance as time goes on. (Parsons, 1970)
NEUROPSYCHOLOGY-1990 Certainly during the 20 years since my overview of the area the growth that I anticipated has continued - far more, I must confess, than I envisioned. Journals in neuropsychology have proliferated. In addition to Newopsychofogiu and Cortex there are a dozen or more others devoted to neuropsychology, and these are, in the main, under the editorial leadership of neuropsychologists. There has been a corresponding increment in the number of books devoted to neuropsychology from the one or two volumes in 1970 to the current rate approaching two or three a month. Division 40, the Division of Clinical Neuropsychology of APA established in the 197Os, has been one of the most rapidly growing divisions. The International Neuropsychological Society has flourished, holding annual meetings both in the United States and Europe. The National Academy of Neuropsychology estab lished over a decade ago has had an equally impressive growth. The diplomate examination in clinical neuropsychology has been a specialty examination of the American Board of Examiners in Psychology for several years. There are countless workshops in neuropsychology offered at regional and national meetings, even on cruises to the Caribbean, China, or Russia! Postdoctoral training in neuroscience and in neuropsychology has been greatly expanded. In clinical neuropsychology there are now over 40 institutions offering postdoctoral training. Certainly my 1970 expectation of increased post-
108
0. A. Parsons
doctoral training has been fulfilled. In addition, in several dozen universities, neuropsychology has reached the status of being declared a specialized track for students, especially those in clinical psychology. In 1988, 36 internships in psychology provided learning experiences where neuropsychological assessment was emphasized (Cripe, 1989). Criteria for acceptable training in clinical neuropsychology in preparation for functioning at the professional level have been established (Reports of the INS- Division 40 Task Force on Education, Accreditation, and Credentialing, 1987; Reports of the Division 40 Task Force on Education, Accreditation, and Credentialing, 1988). Turning now to the substantive areas of current neuropsychology, I would first like to review with you how my prognostications of 20 years ago have fared. I think that three of the four predictions have been born out. The predicted increase in use of the electrophysiological methods using evoked and eventrelated potentials has been realized. Studies using these techniques have focused on normal cognitive processes, developmental and aging changes, psychopath@ logical and neuropathological conditions such as schizophrenia, depression, head injury, aphasia, dementia, alcohol, and drug effects. Surprisingly, however, there have been relatively few studies that have investigated the relationships between event-related potentials and nonconcurrently measured neuropsychological test performance (both putative measures of CNS functioning). This is an area which we have recently investigated (Parsons, Sinha, & Williams, 1990) alcoholics and controls with and without a positive family history of alcoholism. Perceptual-motor test performance (e.g., Digit Symbol, Trails, Pegboard) and the P300 amplitudes were significantly lower in the alcoholics and were significantly correlated, especially in family history positive alcoholics, illustrating not only the brain-behavior relationship but also suggesting importance of controlling for family history of alcoholism in neuropsychological research. As called for by the third prediction, there has been a vast increase in sophisticated clinical case studies (especially at professional meetings) which contribute to our neuropsychological theory and practice. Examples of these include Martin’s (1987) illuminating analysis of different Alzheimer patients’ patterns of cognitive functioning and our recent case studies of contributions of the Tact& Performance Test performance to issues of lateralization and cognitive style (Heilbronner & Parsons, 1989). The fourth prediction stated that basic advances in psychological theory would continue to be fruitfully applied to the problems of neuropsychology, a rather safe prediction. And, indeed, we have seen that cognitive theory, linguistic theory, artificial intelligence, developmental theory, information theory, learning theory, perceptual theory, systems theory, and so on, have been applied and useful information obtained. This first prediction, that there would be an increase in international cooperative studies has not been born out to the extent I had envisioned. Reasons for this probably have to do with difficulties in arriving at translations for test mate-
Clinical Neuropsychology,
1970-l 990
109
rials and instructions which convey the same meaning across different languages as well as achieving consensus about selection of tests and/or methods. Well, three out of four predictions fulfilled is not too bad. Of course what I failed to predict could fill pages. For example, I would never have dreamed that a President of the United States would declare the 1990s to be the “decade of the brain” as President Bush has done. More specifically, I did not predict the great rise of interest in rehabilitation of the brain-injured, especially in closed head injury cases. I thought aging would be studied but badly underestimated the tremendous increase in dementia research. I knew that biomedical techniques would be refined but had no inkling that we would have magnetic resonance imagery that enables us to see lesions that we cannot see by CAT scans, or positron emission tomography (PET) or single photon emission computerized tomography (SPECT) that can give us a functional metabolic image of brain processes in different structures; all are biomedical improvements which can lead to more definitive criteria against which to validate our neuropsychological tests. Indeed, the progress of cognitive neuroscience has far exceeded my anticipations. Posner et al.‘s (1988) inferences about brain localization of attention and language processes, as derived from PET scans taken during behavioral tasks, is a good example of the direction this work has taken at present and will take in the future. I had little suspicion that we would be seriously applying neuropsychological principles to the assessment of psychiatric disorders such as the neuropsycho logical characteristics of schizophrenics versus depressed patients in terms of left hemispheric versus right hemispheric or frontal versus temporal lobe types of disorders. I certainly had no idea that the neuroendocrine system would be investigated with respect to differential neuropsychological patterns of performance, e.g., we have recently found that testosterone levels and follicle stimulating hormone levels are significantly correlated with visual-spatial performance in normal males (Errico, Parsons, Kling, & King, submitted), confirming previous relationships reported by Christiansen and Knussmann (1987) and Gordon and Lee (1986). I did not realize the case for environmental toxins causing neuropsychological changes would be made repeatedly (Hartman, 1988). I would never have predicted that in epilepsy research, behavioral and EEG predictors, about equally weighted, would result in successful prediction of outcome of resection of brain tissue to control epilepsy (Dodrill et al., 1986 ). I did not envision the application of operant methods in teaching amnesic patients to learn tasks even though they cannot remember coming to the laboratory to be taught (Glisky, Schachter, & Tulving, 1986)! Nor did I foresee the stimulating theoretical developments of types of memory, e.g., implicit versus explicit, procedural versus declarative, and episodic versus knowledge based. Indeed, the latter has provided the theoretical basis for one of our current projects in which we are attempting to identify the specific processes in memory and problemsolving affected by alcoholism (Nixon & Parsons, in press).
110
0. A. Parsons
I did not anticipate the rapid growth of forensic neuropsychology and the increasingly important role of neuropsychologists in litigation. I did not realize the degree of enrichment that focusing upon the processes involved in performance might bring to our neuropsychological evaluative procedures as Edith Kaplan (1988) has so forcefully demonstrated. Stimulated by her work, in part, we have recently developed “efficiency” indexes (accuracy divided by time) for all of our test procedures and shown that alcoholics are far less efficient than controls even though in some instances they do not differ in accuracy (Glenn & Parsons, in press). Finally, neither I nor anyone in 1970 could have anticipated that our world would be confronted with a deadly plague such as AIDS, in which 60% to 70% of the persons afflicted will show evidence of dementia, with 10% or more having dementia as the first symptoms (Navia, Jordon, & Price, 1986), or that we would be confronted with hundreds and possibly thousands of babies with central nervous system dysfunction born to mothers who were addicted to crack or suffered from AIDS. These changes and the many others that I did not anticipate and have not commented on, have diminished my 1970, middle-aged ardor for making specific predictions for the future. In my later maturity, it is clear to me that empirical, theoretical and biomedical technical innovations, many of which cannot be specified at the present, together with the emergence of new biological and environmental hazards will determine the new directions and in-depth accomplishments of the next decade. Rather than predictions, I would like to issue a plea to all clinical neuropsychologists to consider the following as a goal for the decade of the 9Os, the “decade of the brain.” Recent surveys have indicated that the highest percentage of the practicing neuropsychologists’ work remains in the area of evaluation (Putnam & DeLuca, 1990), the “bread and butter” of neuropsychology. It is my firm conviction that the most pressing need is for the development of a battery of tests that would be standardized on a national sample, much like the WAIS-R and the WAIS were standardized (i.e., where age, education, gender, socioeconomic status, and race are taken into consideration). Please understand I am not arguing for a standardized as opposed to flexible battery approach. Rather that we develop a core battery of say 1 l/2 to 2 hours length that receives a national standardization. This would provide time for another several hours of flexible test administration. I recognize the enormity of the problems in such an endeavor: gaining agreement as to composition of the core battery tests; gaining the cooperation of neuropsychologists throughout the nation; and obtaining the funds to underwrite the enterprise. But the advantages are self-evident as any one who has ever been in practice or involved in a legal case can appreciate. In closing, it is clear in 1990 that clinical neuropsychology has achieved a scientific maturing and a professional respectability that signals a long life ahead. I can do no better than paraphrase what I said 20 years ago: This decade
Clinical Neuropsychology,
1970-l
990
111
of the 9Os, the “decade of the brain” promises to be even more exciting than the past decades. There is every indication that clinical neuropsychology will continue to be a challenging, vital, and expanding field. The human mind remains one of the most fascinating of all scientific puzzles and the problems of brainbehavior relationships will be of increasing importance as time goes on. REFERENCES Christiansen,
K., & Knussmann, R. (1987) Sex hormones and cognitive functioning in men. 18,27-36. Gripe, L. (1989). Listing of training programs in clinical neuropsychology 1988. The Clinical Neuropsychologist. 3, 116-128. Dodrill, C., et al. (1986). Multidisciplinary prediction of surgical relief from cortical resection surgery. Annals of Neurology, 20, l-12. Errico, A. L., Parsons, 0. A., Kling, 0. R., & King, A. C. (submitted.) Alcoholics visual-spafial Nemopsychobiology,
deficits: Are sexual hormones implicated?
Glenn, S. W., & Parsons, 0. A. (in press). Efficiency measures in male and female alcoholics. Journal of Studies on Alcohol.
Glisky, E. L., Schachter, D., & Tulving, E. (1986). Learning and retention of computer-related vocabulary in memory-impaired patients: Method of vanishing cues. Journal of Clinical and Experimental Psychology, 8,292-3 12.
Gordon, H.W. & Lee, PA. (1986). A relationship between gonadouopins and visuospatial function. Neuropsychologia, 24.563-576.
Hartman, D. (1988). Neuropsychological roxicology: IdenQication and assessment of human neurotoxic syndromes. New York: Pergamon Press Heilbronner, R., & Parsons, 0. A. (1989). The clinical utility of the Tactual Performance Test (TPT): Issues of Iateralization and cognitive style. The Clinical Neuropsychologist, 3,2X%264. Kaplan, E. (1988). A process approach to neuropsychological assessment. In T. Boll & B. K. Bryant (Eds.), Clinical neuropsychology and brain function (pp. 125-167). Washington, D.C.: American Psychological Association. Martin, A. (1987). Rcprescntation of semantic and spatial knowledge in Alzheimer’s patients: Implications for models of preserved learning in amnesia. Journal of Clinical and Experimental Psychology, 9,191-224.
Navia, B. A., Jordon, B. D., & Price, R. W. (1986). The AIDS dementia complex: I. Clinical features. Annals of Neurology, 19,517-524. Nixon, S. J., & Parsons, 0. A. (in press). Alcohol-related efticiency deficits using an ecologically valid test. Alcoholism: Clinical and Experimemal Research. Parsons, 0. A. (1970). Clinical neuropsychology. In C. D. Spielberger (Ed.), Current ropics in clinical and communifypsychology (Vol. II) (pp. l-601. New York: Academic Press. Parsons, 0. A., Sinha, R., & Williams, H. L. (1990). Relationships between neuropsychological test performance and event-related potentials in alcoholics and nonalcoholic samples. Alcoholism: Clinical and Experimental Research, 14,746755. Putnam, S. H., & DeLuca, J. W. (1990). The TCN professional practice survey. Part 1: General practices of neuropsychologists in primary employment and private practice setting. The Clinical Neuropsychologist. 4, 199-244. Posner, M. I., Peterson, S. E., Fox, P T., & Raichle, M. E. (1988). Localization of cognitive opemtions in the human brain. Science, 240, 1627-1631. Reports of the INS-Division 40 Task Force on Education, Accreditation, and Credentialing (1987). Guidelines for doctoral training programs in clinical neuropsychology. The Clinical Neuropsychologist, 1.29-34. Reports of the Division 40 Task Force on Education, Accreditation, and Credentialing (1988). Guidelines regarding the use of nondoctoral personnel in clinical neuropsychological assessment. The Clinical Neuropsychologisl, 25-29.
Clinical
Copyright
0887.6177/9153.M) + 00 Q 1991 National Academy of Neumpsycholcgy
Neuropsychology
1970-l
990:
A Personal View Oscar A. Parsons Oklahoma Center for Alcohol & Drug Related Studies, University of Oklahoma Health Sciences Center
In 1970, I assessed the status of a “new discipline”, clinical neuropsychology, and optimistically predicted growth and expansion over the next decades. A current assessment in 1990 indicates that the dramatic increase in the number of clinical neuropsychologists and in the scope and magnitude of their professional functioning far exceeds my expectations of two decades ago. Further, there is every indication that clinical neuropsychology will continue to be a challenging, vital, and expanding profession.
Since the early fifties of this century there has been an accelerating and exhilarating interest in neuroscience and human neuropsychology accompanied by a dramatic increase in research in these areas. As with the incorporation of all new scientific knowledge, universities gradually reorganized curricula to include these developments. In 1966 and 1967 when we started our Ph.D. program in Biological Psychology at the University of Oklahoma Health Sciences Center, we had one of the first courses in neuropsychology, by that specific name, ever given by any university. By 1970, the nascent field was established to the extent that when Charles Spielberger invited me to write a chapter for his edited series of books on Current Topics in Clinical and Community Psychology, I happily chose the topic of Clinical Neuropsychology (Parsons, 1970). I made a number of points in that paper of two decades ago which captured the status of neuropsychology at that time. This paper is based on an invited address given in response to the author’s receiving the “Distinguished Clinical Neuropsychologist Award” from the National Academy of Neuropsychology at its Tenth Annual Meeting, November 2, 1990, Reno, Nevada. Requests for reprints should be sent to Oscar A. Parsons, Ph.D., Executive Director, Oklahoma Center for Alcohol and Drug Related Studies, 800 N.E. 15th Street, Oklahoma City, OK 73 104. 105
IO6
0. A. Parsons
NEUROPSYCHOLOGY-1970 I described clinical neuropsychology as a new discipline and defined it as “that branch of psychology which applies knowledge derived from relevant experimental and clinical investigations to specific brain-behavior problems in humans.” I noted that the clinical neuropsychologist is concerned primarily with identifying, measuring and, describing changes in behavior that relate to brain dysfunction and that the clinical neuropsychologist’s activities contributed to a variety of important clinical problems: differential diagnosis; lateralization and localization of lesions; establishing baselines of sensory, motor, perceptual, cognitive, and intellectual functioning from which subsequent improvement or decline could be determined; identifying specific deficits from noxious agents such as drugs; developing methods for remediation of deficit: helping to determine competency in the aged; and, developing better diagnostic and remedial efforts for the minimally brain-damaged child. I predicted that these specific functions would grow in importance in that the society in which we lived was one
whose youth experiments with multifarious mind (brain) altering drugs, whose over-30 population is ridden with alcohol and tranquilizers, whose underprivileged frequently suffer from inadequate diets which directly in the neonate or indirectly in a pregnant mother affect the growing brain, and whose automobile drivers provide a toll of head injuries from accidents that outstrips wartime causalities. (Parsons, 1970)
In this 1970 chapter, I noted that the term “neuropsychology” was receiving increasing use in the literature and that two Journals established in the 6Os, Cortex and Neuropsychologia were devoted to studies explicitly neuropsyche logical in nature. Incidentally, these Journals were both European in origin and edited by neurologists with strong psychological interests, Ennio DeRenzi and the late Henri Hecaen. During the mid-60s the International Neuropsychological Society was formed, a society comprised mainly of psychologists, many of whom were beginning to call themselves “neuropsychologists.” I noted that at least one university (our program at the University of Oklahoma) offered a predoctoral specialization in neuropsychology, that four postdoctoral training programs in clinical neuropsychology had been established (our’s was one of these) and that summer workshops in neuropsychology were being offered. I concluded that “technical advances during the last decade have led to “breakthroughs” and to the accumulation of data far beyond the wildest expectations or fervent hopes of the neuroscientists or psychologists of 20 years ago. My recommendation for the education of the clinical neuropsychologist was that it should not only include usual sound training in clinical and experimental psychology but in addition, a thorough grounding in the modern concepts of the
Clinical Neuropsychology. 19704990
107
structure and function of the nervous system. I thought that postdoctoral training in clinical neuropsychology should be the culminating preparatory experience for a professional level of functioning and predicted that many such programs would be established in the next decades. Prognostications are always dangerous, but I felt sure that there would be foa major areas of investigation during the next decades: (i) there would be an increase in international cooperative studies on neuropsychological problems; (ii) the electrophysiological methods of the computer averaged evoked potentials and other psychophysiological measures would be emphasized; (iii) there would be a re-emphasis of an old approach, the intensive experimental analysis of a single subject; (iv) the fruitful application of knowledge and theories from the basic advances in psychology proper to the problems of neuropsychology would continue. Finally, I was enthusiastic about the future of neuropsychology,
the next decade promises to be even more exciting than the past... There is every indication that clinical neuropsychology is a vital and expanding field. The human mind remains one of the most fascinating of all scientific puzzles and the problems of brain-behavior relationships will be of increasing importance as time goes on. (Parsons, 1970)
NEUROPSYCHOLOGY-1990 Certainly during the 20 years since my overview of the area the growth that I anticipated has continued - far more, I must confess, than I envisioned. Journals in neuropsychology have proliferated. In addition to Newopsychofogiu and Cortex there are a dozen or more others devoted to neuropsychology, and these are, in the main, under the editorial leadership of neuropsychologists. There has been a corresponding increment in the number of books devoted to neuropsychology from the one or two volumes in 1970 to the current rate approaching two or three a month. Division 40, the Division of Clinical Neuropsychology of APA established in the 197Os, has been one of the most rapidly growing divisions. The International Neuropsychological Society has flourished, holding annual meetings both in the United States and Europe. The National Academy of Neuropsychology estab lished over a decade ago has had an equally impressive growth. The diplomate examination in clinical neuropsychology has been a specialty examination of the American Board of Examiners in Psychology for several years. There are countless workshops in neuropsychology offered at regional and national meetings, even on cruises to the Caribbean, China, or Russia! Postdoctoral training in neuroscience and in neuropsychology has been greatly expanded. In clinical neuropsychology there are now over 40 institutions offering postdoctoral training. Certainly my 1970 expectation of increased post-
108
0. A. Parsons
doctoral training has been fulfilled. In addition, in several dozen universities, neuropsychology has reached the status of being declared a specialized track for students, especially those in clinical psychology. In 1988, 36 internships in psychology provided learning experiences where neuropsychological assessment was emphasized (Cripe, 1989). Criteria for acceptable training in clinical neuropsychology in preparation for functioning at the professional level have been established (Reports of the INS- Division 40 Task Force on Education, Accreditation, and Credentialing, 1987; Reports of the Division 40 Task Force on Education, Accreditation, and Credentialing, 1988). Turning now to the substantive areas of current neuropsychology, I would first like to review with you how my prognostications of 20 years ago have fared. I think that three of the four predictions have been born out. The predicted increase in use of the electrophysiological methods using evoked and eventrelated potentials has been realized. Studies using these techniques have focused on normal cognitive processes, developmental and aging changes, psychopath@ logical and neuropathological conditions such as schizophrenia, depression, head injury, aphasia, dementia, alcohol, and drug effects. Surprisingly, however, there have been relatively few studies that have investigated the relationships between event-related potentials and nonconcurrently measured neuropsychological test performance (both putative measures of CNS functioning). This is an area which we have recently investigated (Parsons, Sinha, & Williams, 1990) alcoholics and controls with and without a positive family history of alcoholism. Perceptual-motor test performance (e.g., Digit Symbol, Trails, Pegboard) and the P300 amplitudes were significantly lower in the alcoholics and were significantly correlated, especially in family history positive alcoholics, illustrating not only the brain-behavior relationship but also suggesting importance of controlling for family history of alcoholism in neuropsychological research. As called for by the third prediction, there has been a vast increase in sophisticated clinical case studies (especially at professional meetings) which contribute to our neuropsychological theory and practice. Examples of these include Martin’s (1987) illuminating analysis of different Alzheimer patients’ patterns of cognitive functioning and our recent case studies of contributions of the Tact& Performance Test performance to issues of lateralization and cognitive style (Heilbronner & Parsons, 1989). The fourth prediction stated that basic advances in psychological theory would continue to be fruitfully applied to the problems of neuropsychology, a rather safe prediction. And, indeed, we have seen that cognitive theory, linguistic theory, artificial intelligence, developmental theory, information theory, learning theory, perceptual theory, systems theory, and so on, have been applied and useful information obtained. This first prediction, that there would be an increase in international cooperative studies has not been born out to the extent I had envisioned. Reasons for this probably have to do with difficulties in arriving at translations for test mate-
Clinical Neuropsychology,
1970-l 990
109
rials and instructions which convey the same meaning across different languages as well as achieving consensus about selection of tests and/or methods. Well, three out of four predictions fulfilled is not too bad. Of course what I failed to predict could fill pages. For example, I would never have dreamed that a President of the United States would declare the 1990s to be the “decade of the brain” as President Bush has done. More specifically, I did not predict the great rise of interest in rehabilitation of the brain-injured, especially in closed head injury cases. I thought aging would be studied but badly underestimated the tremendous increase in dementia research. I knew that biomedical techniques would be refined but had no inkling that we would have magnetic resonance imagery that enables us to see lesions that we cannot see by CAT scans, or positron emission tomography (PET) or single photon emission computerized tomography (SPECT) that can give us a functional metabolic image of brain processes in different structures; all are biomedical improvements which can lead to more definitive criteria against which to validate our neuropsychological tests. Indeed, the progress of cognitive neuroscience has far exceeded my anticipations. Posner et al.‘s (1988) inferences about brain localization of attention and language processes, as derived from PET scans taken during behavioral tasks, is a good example of the direction this work has taken at present and will take in the future. I had little suspicion that we would be seriously applying neuropsychological principles to the assessment of psychiatric disorders such as the neuropsycho logical characteristics of schizophrenics versus depressed patients in terms of left hemispheric versus right hemispheric or frontal versus temporal lobe types of disorders. I certainly had no idea that the neuroendocrine system would be investigated with respect to differential neuropsychological patterns of performance, e.g., we have recently found that testosterone levels and follicle stimulating hormone levels are significantly correlated with visual-spatial performance in normal males (Errico, Parsons, Kling, & King, submitted), confirming previous relationships reported by Christiansen and Knussmann (1987) and Gordon and Lee (1986). I did not realize the case for environmental toxins causing neuropsychological changes would be made repeatedly (Hartman, 1988). I would never have predicted that in epilepsy research, behavioral and EEG predictors, about equally weighted, would result in successful prediction of outcome of resection of brain tissue to control epilepsy (Dodrill et al., 1986 ). I did not envision the application of operant methods in teaching amnesic patients to learn tasks even though they cannot remember coming to the laboratory to be taught (Glisky, Schachter, & Tulving, 1986)! Nor did I foresee the stimulating theoretical developments of types of memory, e.g., implicit versus explicit, procedural versus declarative, and episodic versus knowledge based. Indeed, the latter has provided the theoretical basis for one of our current projects in which we are attempting to identify the specific processes in memory and problemsolving affected by alcoholism (Nixon & Parsons, in press).
110
0. A. Parsons
I did not anticipate the rapid growth of forensic neuropsychology and the increasingly important role of neuropsychologists in litigation. I did not realize the degree of enrichment that focusing upon the processes involved in performance might bring to our neuropsychological evaluative procedures as Edith Kaplan (1988) has so forcefully demonstrated. Stimulated by her work, in part, we have recently developed “efficiency” indexes (accuracy divided by time) for all of our test procedures and shown that alcoholics are far less efficient than controls even though in some instances they do not differ in accuracy (Glenn & Parsons, in press). Finally, neither I nor anyone in 1970 could have anticipated that our world would be confronted with a deadly plague such as AIDS, in which 60% to 70% of the persons afflicted will show evidence of dementia, with 10% or more having dementia as the first symptoms (Navia, Jordon, & Price, 1986), or that we would be confronted with hundreds and possibly thousands of babies with central nervous system dysfunction born to mothers who were addicted to crack or suffered from AIDS. These changes and the many others that I did not anticipate and have not commented on, have diminished my 1970, middle-aged ardor for making specific predictions for the future. In my later maturity, it is clear to me that empirical, theoretical and biomedical technical innovations, many of which cannot be specified at the present, together with the emergence of new biological and environmental hazards will determine the new directions and in-depth accomplishments of the next decade. Rather than predictions, I would like to issue a plea to all clinical neuropsychologists to consider the following as a goal for the decade of the 9Os, the “decade of the brain.” Recent surveys have indicated that the highest percentage of the practicing neuropsychologists’ work remains in the area of evaluation (Putnam & DeLuca, 1990), the “bread and butter” of neuropsychology. It is my firm conviction that the most pressing need is for the development of a battery of tests that would be standardized on a national sample, much like the WAIS-R and the WAIS were standardized (i.e., where age, education, gender, socioeconomic status, and race are taken into consideration). Please understand I am not arguing for a standardized as opposed to flexible battery approach. Rather that we develop a core battery of say 1 l/2 to 2 hours length that receives a national standardization. This would provide time for another several hours of flexible test administration. I recognize the enormity of the problems in such an endeavor: gaining agreement as to composition of the core battery tests; gaining the cooperation of neuropsychologists throughout the nation; and obtaining the funds to underwrite the enterprise. But the advantages are self-evident as any one who has ever been in practice or involved in a legal case can appreciate. In closing, it is clear in 1990 that clinical neuropsychology has achieved a scientific maturing and a professional respectability that signals a long life ahead. I can do no better than paraphrase what I said 20 years ago: This decade
Clinical Neuropsychology,
1970-l
990
111
of the 9Os, the “decade of the brain” promises to be even more exciting than the past decades. There is every indication that clinical neuropsychology will continue to be a challenging, vital, and expanding field. The human mind remains one of the most fascinating of all scientific puzzles and the problems of brainbehavior relationships will be of increasing importance as time goes on. REFERENCES Christiansen,
K., & Knussmann, R. (1987) Sex hormones and cognitive functioning in men. 18,27-36. Gripe, L. (1989). Listing of training programs in clinical neuropsychology 1988. The Clinical Neuropsychologist. 3, 116-128. Dodrill, C., et al. (1986). Multidisciplinary prediction of surgical relief from cortical resection surgery. Annals of Neurology, 20, l-12. Errico, A. L., Parsons, 0. A., Kling, 0. R., & King, A. C. (submitted.) Alcoholics visual-spafial Nemopsychobiology,
deficits: Are sexual hormones implicated?
Glenn, S. W., & Parsons, 0. A. (in press). Efficiency measures in male and female alcoholics. Journal of Studies on Alcohol.
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