Clinical Neuropsychology E-Book

• Herausgeber: John Wiley & Sons
• Kategorie: Geisteswissenschaft
• Sprache: Englisch

Seitenzahl: 1258

Veröffentlichungsjahr: 2012

Beschreibung

Featuring updates and revisions, the second edition of Clinical Neuropsychology provides trainee and practicing clinicians with practical, real-world advice on neuropsychological assessment and rehabilitation.

• Offers illustrated coverage of neuroimaging techniques and updates on key neuro-pathological findings underpinning neurodegenerative disorders
• Features increased coverage of specialist areas of work, including severe brain injury, frontotemporal lobar degeneration, assessing mental capacity, and cognitive impairment and driving
• Features updated literature and increased coverage of topics that are of direct clinical relevance to trainee and practicing clinical psychologists
• Includes chapters written by professionals with many years' experience in the training of clinical psychologists

Leseprobe

Contents

Cover

Title Page

Copyright

List of Contributors

Preface

Preface to the First Edition

Part 1: General Introduction

Chapter 1: General Introduction: What Is the Relevance of Neuropsychology for Clinical Psychology Practice?

Why Study Clinical Neuropsychology?

Common Issues Across Different Assessments

Case Examples

Clinical Neuropsychology as a Professional Specialty: Who is a Clinical Neuropsychologist?

Conclusions

Part 2: Neuroscience Background

Chapter 2: Neuroanatomy and Neuropathology

Introduction to Neuroanatomy

Cellular Organization

Neuroglia

Neurodevelopment

Meninges and Cerebrospinal Fluid

Blood Supply of the Brain

Regional Anatomy of the Brain

Introduction to Neuropathology

Chapter 3: Neurological Investigations

Introduction

Investigations for SystemicMedical Disorders

Neuroimaging

Summary

Part 3: Neuropsychological Assessment: General Issues

Chapter 4: Psychological and Psychiatric Aspects of Brain Disorder: Nature, Assessment and Implications for Clinical Neuropsychology

Prevalence

Assessment

Implications for Cognitive Function and Neuropsychological Assessment

Conclusions

Chapter 5: The Effects of Prescribed and Recreational Drug Use on Cognitive Functioning

Introduction

Specific Drugs

No Conclusions, but Some Issues to Consider …

Chapter 6: Quantitative Aspects of Neuropsychological Assessment

Introduction

Converting Test Scores to a Common Metric

Cautions in Interpreting Test Score Profiles

Reliability

Inferential Methods for the Single CaseWhen Reference Samples Are Small

Detecting Change in Neuropsychological Functioning in the Individual Case

Using Regression Equations Built from Summary Data in the Assessment of the Individual Case

Post–Test Probabilities and Bayes’ Theorem

Quantitative AnalysisWithout Tears: The Use of Computers

Conclusion

Part 4: Adult Neuropsychology

Chapter 7: Disorders of Memory

Introduction

Memory Theory

Assessment of Memory

Rehabilitation of Memory

Summary

Chapter 8: Disorders of Language and Communication

Introduction

Non-Verbal Communication

Verbal Communication

Processing Auditory Input

Central Processes –Words and Sentences

Processing Verbal Output

Literacy

Remediation and Rehabilitation

Conclusions

Chapter 9: Executive Dysfunction

Introduction

Assessment of Executive Functions

Some Important Final Words Concerning Executive Function Assessment

Rehabilitation of the Dysexecutive Syndrome

Conclusions

Acknowledgements

Chapter 10: Acquired Disorders of Voluntary Movement

Introduction

Classification of Apraxia

Brain Localization of Apraxic Deficits

The Assessment of Apraxia

Management and Treatment of Apraxia

Conclusions

Chapter 11: Visuo-Spatial and Attentional Disorders

Introduction

Early Visual Processing and Visual Field Disorders

Disorders of Higher Visual Processing

Non-Spatial Forms of Attention

Summary and Conclusions

Chapter 12: Disorders of Number Processing and Calculation

Introduction

The Selective Preservation of Number Processing or Calculation

The Selective Impairment of Number Processing

The Selective Impairment of Calculation

Current Theoretical Models

Arithmetical Word Problem Solving

Assessment of Number Processing and Calculation

Rehabilitation

Conclusion

Part 5: Neuropsychology: Specialist Areas of Work

Chapter 13: Clinical Neuropsychological Assessment of Children

Introduction

Background

Foundations of Clinical Practice

Brain Development

Cognitive and Behavioural Development

The Development of Clinicians and Applied Practice

Designing and Conducing a Paediatric Neuropsychological Assessment

Neuropsychological Formulations

Treatment and Rehabilitation

Conclusions

Chapter 14: Neuropsychological Assessment of Older Adults

Introduction

The Purposes of Assessment

Special Considerations for Older Adults

Assessment Procedures

Screening Assessments

Comprehensive Neuropsychological Assessment

Assessment of Awareness of Neuropsychological Dysfunction

Computerized Assessment

Conclusions

Chapter 15: Neuropsychology of Frontotemporal Lobar Degeneration: Frontotemporal Dementia, Semantic Dementia and Progressive Non-Fluent Aphasia

Introduction

Frontotemporal Dementia

Semantic Dementia

Progressive Non–Fluent Aphasia

Conclusions

Chapter 16: Very Severe and Profound Brain Injury

Introduction

Measurement of Altered Consciousness

Incidence and Prevalence

Neuropsychological Assessment

Approaches to Rehabilitation

Ethical Issues

Chapter 17: Neuropsychology and the Law

Introduction

Professional Issues

The Assessment

The Report

After the Report: Preparation for Settlement or Judgement

The Courts

Concluding Comments

Chapter 18: Mental Capacity

The Mental Capacity Act (England andWales) 2005

Assessment of Capacity

Assessment Tools

Financial Decision-Making

Sexual Capacity and Consent

Lack of Capacity

Summary

Part 6: Rehabilitation

Chapter 19: Theoretical Approaches to Cognitive Rehabilitation

Introduction

What Is a TheoreticalModel?

Specific Domains Requiring Application of Models or Theories

Models for Guiding Delivery of Rehabilitation

Towards an All–Encompassing Theory of Cognitive Rehabilitation

Conclusion

Chapter 20: Planning, Delivering and Evaluating Services

Introduction

Information to Assist in Planning Services

Rehabilitation Models

Evaluation and Outcome

Quality and Standards of Care

Informed Consent and Risk Assessment

Service Development

Summary

Chapter 21: Research Design and Outcome Evaluation

Introduction

Outcome Measurement

Outcome Measures

Conclusions

Chapter 22: Interventions for Psychological Problems After Brain Injury

Introduction

Psychological Needs

Neuropsychological Assessment and Counselling

Individual Psychological Treatment

Facilitating Long-Term Adjustment

Conclusions

Chapter 23: Neurorehabilitation Strategies for People with Neurodegenerative Conditions

Introduction

Cognitive Neurorehabilitation

Pharmacological Intervention – the ‘Anti-dementia’ Drugs

Neurorehabilition in Dementia – Combining Cognitive and Drug Treatments

Chapter 24: Driving in Neurological Patients

Why Is Driving Important?

Crash Risk

Driving Regulations

Factors Affecting Driving Ability

Driver-Retraining Programmes

Role of Simulators

Advising Patients in Clinical Practice

color plates

Index

This edition first published 2013 © 2013 John Wiley & Sons Ltd

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Library of Congress Cataloging-in-Publication Data Clinical neuropsychology : a practical guide to assessment and management for clinicians / edited by Laura H. Goldstein and Jane E. McNeil. – 2nd ed. p. cm. Includes index. ISBN 978-0-470-68371-2 (pbk.) 1. Clinical neuropsychology. I. Goldstein, Laura H. (Laura Hilary), 1960– II. McNeil, Jane E. RC386.6.N48C52725 2012 616.8–dc23 2011035236

A catalogue record for this book is available from the British Library.

2 2013

List of Contributors

Professor Nick Alderman

Consultant Clinical Neuropsychologist and Specialty Lead

National Brain Injury Centre

St Andrew's Healthcare

Billing Road

Northampton NN1 5DG

Professor J. Graham Beaumont

Honorary Professor, University of Roehampton

Consultant Neuropsychologist

Department of Clinical Psychology

Royal Hospital for Neuro-disability

West Hill

London SW15 3SW

Ms Karen Bonham

Lead Speech and Language Therapist (Brain Injury)

Rookwood Hospital

Llandaff

Cardiff CF5 2YN

Dr Rebecca L. Brookes

Stroke and Dementia Research Centre

St George’s, University of London

Cranmer Terrace

London SW17 0RE

Professor Richard G. Brown

Professor of Neuropsychology and Clinical Neuroscience

King's College London

Department of Psychology (PO77)

Institute of Psychiatry

De Crespigny Park

London SE5 8AF

Professor Paul W. Burgess

Professor of Neuroscience

UCL Institute of Cognitive Neuroscience

Alexandra House

17 Queen Square

London WC1N 3AR

Dr Nigel J. Cairns

Research Associate Professor

Departments of Neurology and Pathology & Immunology

Washington University School of Medicine

Saint Louis

Missouri 63110

USA

Professor John R. Crawford

School of Psychology

College of Life Sciences and Medicine

King's College

University of Aberdeen

Aberdeen AB24 2UB

Professor Jonathan J. Evans

Professor of Applied Neuropsychology

University of Glasgow

Mental Health & Wellbeing, Institute of Health & Wellbeing

Gartnavel Royal Hospital

1055 Great Western Road

Glasgow G12 0XH

Dr Jessica Fish

Medical Research Council Cognition and Brain Sciences Unit

15 Chaucer Road

Cambridge CB2 7EF

Professor Laura H. Goldstein

Professor of Clinical Neuropsychology

King's College London

Department of Psychology (PO77)

Institute of Psychiatry

De Crespigny Park

London SE5 8AF

Dr Fergus Gracey

Consultant Clinical Neuropsychologist

Oliver Zangwill Centre for Neuropsychological Rehabilitation

Princess of Wales Hospital

Lynn Road

Ely CB6 1DN

Dr Camilla Herbert

Consultant in Neuropsychology and Rehabilitation

Brain Injury Rehabilitation Trust

Kerwin Court

Horsham RH13 0TP

Dr Nigel S. King

Consultant Clinical Neuropsychologist and Clinical Tutor

Community Head Injury Service

Buckinghamshire Healthcare NHS Trust

The Camborne Centre

Jansel Square

Aylesbury HP21 7ET

Professor Nadina B. Lincoln

Professor of Clinical Psychology

Institute of Work, Health & Organisations

University of Nottingham, International House

Jubilee Campus

Wollaton Road

Nottingham NG8 1BB

Dr Pat McKenna

174 Kings Road

Pontcanna

Cardiff CF11 9DG

Dr Jane E. McNeil

Consultant Clinical Neuropsychologist

Neuropsychology Department

Queen Alexandra Hospital

Cosham

Portsmouth PO6 3LY

Dr Tom Manly

Clinical Psychologist and Scientist

MRC Cognition and Brain Sciences Unit

Box 58

Addenbrooke's Hospital

Hills Road

Cambridge CB2 2QQ

Professor Jason B. Mattingley

Foundation Chair in Cognitive Neuroscience

Queensland Brain Institute and School of Psychology

University of Queensland

St Lucia 4072

Australia

Dr John D. C. Mellers

Consultant Psychiatrist

Neuropsychiatry Unit

Room 32, Outpatients Dept

Maudsley Hospital

Denmark Hill

London SE5 8AZ

Professor Esme Moniz-Cook

Professor of Clinical Psychology

Consultant Clinical Psychologist

Institute of Rehabilitation

University of Hull  

c/o 39-41 Coltman Street

Hull HU3 2PG

Professor Robin G. Morris

Professor of Neuropsychology

King's College London

Department of Psychology (PO78)

Institute of Psychiatry

De Crespigny Park

London SE5 8AF

Dr Graham E. Powell

Consultant Clinical Psychologist

Powell Campbell Edelmann

9 Devonshire Place

London WC2E 9DJ

Professor Jane Powell

Pro-warden (Research & Enterprise)

Professor of Psychology

Goldsmiths’ College

Lewisham Way

London SE14 6NW

Dr Kate A. Radford

Senior Lecturer (Research)

Clinical Practice Research Unit

Faculty of Health

Brook Building 417

University of Central Lancashire

Preston PR1 2HE

Professor Jennifer M. Rusted

Professor of Experimental Psychology

School of Psychology

Pevensey 1

Sussex University

Brighton BN1 9QH

Dr Naomi A. Sibtain

Consultant Neuroradiologist

King's College Hospital and South London and Maudsley NHS Foundation Trusts

Denmark Hill

London SE5 9RS

Professor Julie Snowden

Consultant Neuropsychologist

Salford Royal Foundation Trust and University of Manchester

Cerebral Function Unit

Greater Manchester Neuroscience Centre

Salford Royal Foundation Trust

Salford

Greater Manchester M6 8HD

Dr Andy Tyerman

Consultant Clinical Neuropsychologist & Head of Service

Community Head Injury Service

Buckinghamshire Healthcare NHS Trust

The Cambourne Centre

Jansel Square

Aylesbury HP21 7ET

Dr Jody Warner-Rogers

Consultant Paediatric Neuropsychologist

Paediatric Neurodisability Service

Newcomen Centre

Guy's and St Thomas's NHS Foundation Trust

St Thomas's Street

London SE1 9RT

Professor Barbara A. Wilson OBE

Senior Scientist (Visitor Status)

MRC Cognition & Brain Sciences Unit

15 Chaucer Road

Cambridge CB2 7EF

Dr Andrew Worthington

Consultant in Neuropsychology and Rehabilitation

Headwise

Innovation Centre

Longbridge Technology Park

Birmingham B31 2TS

Preface

Although often viewed as a speciality within Clinical Psychology, we continue to feel that knowledge of neuropsychology (and its applications) is relevant to all areas of clinical work where people (across the age span) might be showing some change in their cognitive functioning. Thus, a working knowledge of neuropsychology and the assessment and management of cognitive impairment may be necessary for the delivery of a competent clinical service by even those practitioners who do not wish to see themselves as experts in the field of clinical neuropsychology, and who may well have had little or no experience of clinical neuropsychology during their training as Clinical Psychologists. Historically, psychometric testing (underpinned by knowledge of psychometric principles) has been a cornerstone of the skills making psychologists unique as a professional group and it remains a core, essential skill of clinical neuropsychologists. In recent years there have been increasing and multiple threats to clinical psychology: from non-psychologist IAPT practitioners providing CBT, other neuro-professionals claiming skills in cognitive assessment and the move from self-management under the British Psychological Society to external regulation by non-psychologists with the Health Professions Council. We, more than ever before, need to protect our expertise and ensure the next generation of psychologists have the same breadth and depth of skills if the profession is to continue to exist and if the public is to be protected. While we would argue that neuropsychological assessment should form part of the core competencies acquired by all trainee clinical psychologists, our compilation of this second edition is based on the more realistic appreciation of the training opportunities available to those who are both pre- and post-qualification, an appreciation gained through many years of being actively involved in both pre- and post-qualification training of clinical psychologists at the Institute of Psychiatry and elsewhere.

There are of course different ways in which to present information on clinical neuropsychological knowledge and practice. One is to focus on specific neurological disorders, and their assessment and management. Within the scope of a relatively short book, however, we feel that this may limit the apparent relevance and generalizability of the skills, which we feel it is important for clinicians to possess. Thus, for the current volume we have again chosen to focus on broad areas of cognitive function (including those such as praxis and number processing and calculation which are perhaps less well-developed areas of clinical neuropsychology in the United Kingdom) which may be relevant to assess across a wide range of neurological and psychiatric disorders. We have also chosen to include chapters that deal with important background information relevant to those being assessed (such as the effects of medication and the interaction between neurological and psychiatric presentations) and, because so much of clinical neuropsychologists’ work does involve test interpretation, an overview of key psychometric concepts underpinning neuropsychological assessment. There is also a consideration of the impact of cognitive deficits on driving skills, an area that has developed considerably since our first edition.

In addition to addressing specific cognitive functions, it is of course obvious that clinical neuropsychology may be somewhat differently applied at different ends of the age spectrum, where different factors may assume particular importance. For this reason, we have chosen to include specific chapters that address the issue of neuropsychological practice with children and older adults as well as a new chapter addressing frontotemporal lobar degeneration. We have also covered the specific difficulties encountered in working with individuals with very severe and profound brain injury, an area brought to the public's attention through some recent dramatic neuroimaging studies as well as cases questioning the issues of life prolongation in situations reflecting potentially poor quality of life. At any point in the age range, neuropsychologists may be required to have an input into the medicolegal system, and for this reason we have again included a very practical chapter dealing with the way in which such work should be undertaken as well as a chapter on the assessment of mental capacity. The latter area has become increasingly relevant to clinical neuropsychologists with the passing of new legislation.

Clinical neuropsychology is by no means all about assessment, as the chapters on specific cognitive functions will indicate, and the delivery of good rehabilitation services requires every bit as much the generic skills acquired during clinical psychology training as well as neuropsychology-specific ones. However, given the considerable development of neuropsychological rehabilitation, it is important to review again the theoretical basis for effective cognitive rehabilitation, in an attempt to maintain an evidence-based approach to clinical practice, as well as considering how psychotherapeutic interventions designed for use with non-brain-damaged people might be modified and applied to those with acquired brain injury. While most attempts at cognitive rehabilitation have been developed for patients with acquired but non-progressive brain injury, the growing literature on such approaches for adults with dementia, possibly supplemented by the so-called ‘antidementia’ drugs, opens up further areas of work for clinical psychologists. Finally, psychologists, with their knowledge of outcome evaluation, should increasingly see themselves as being in a position to inform the process of service planning and should have a good understanding of the service delivery models that may bring about effective care to their patients with neurological impairments. With increasing emphasis on clinical governance, effective evaluation of neuropsychological interventions has assumed increasing importance, and we have therefore included a chapter that addresses both the relevant methodology and possible measures that may be used.

We believe, however, that clinical neuropsychological practice is most effective when set in the context of more general neuroscientific knowledge, and thus feel strongly that clinical neuropsychologists should have at least a basic understanding of neuropathology and the neurological investigations that their patients may well undergo. It is for this reason that two of the early chapters in this book present a relatively concise overview of the central nervous system and some of its common disorders, and how these are investigated. While psychologists should never work outside their own area of clinical expertise, an understanding of how medical investigations can inform the design and interpretation of neuropsychological assessments and interventions can only benefit the service psychologists provide to their patients.

We are grateful to the contributors to this volume, the majority of whom contributed to the first edition, as well those newly contributing to this book. For those contributors employed in the university sector, where book-chapter writing is not encouraged in the climate of the forthcoming Research Evaluation Framework, their time and diligence are greatly appreciated. We continue to believe that books of this type make a broader contribution to the profession and have an impact that is not captured by the formal university assessment metrics that govern many of the contributors’ activities. Many of our contributors have been actively involved over many years in different aspects of the training of clinical psychologists, and attach, as do we, considerable importance to such training and the dissemination of good practice.

In practical terms, we are very grateful to Eleanor Janega, who helped us, in the latter stages, bring together the new and revised chapters. Dr Tracey Newell compiled the Index. We have retained the excellent line drawings prepared by Alex Dionysiou for our first edition, and are grateful to the chapter authors for the provision of additional original figures for this edition. Finally, we continue to express our considerable appreciation to our many colleagues, psychologists and non-psychologists alike, who over the years have set us good examples of how to work effectively as clinicians in our respective clinical settings.

LHG JMcN

Preface to the First Edition

Although often viewed as a speciality within Clinical Psychology, it should be immediately apparent that knowledge of neuropsychology (and its applications) is relevant to all areas of clinical work where people (across the age span) might be showing some change in their cognitive functioning. Thus, a working knowledge of neuropsychology and the assessment and management of cognitive impairment may be necessary for the delivery of a competent clinical service by even those practitioners who do not wish to see themselves as experts in the field of clinical neuropsychology, and who may well have had little or no experience of clinical neuropsychology during their training as Clinical Psychologists. While we would argue that neuropsychological assessment should form part of the core skills acquired by all trainee clinical psychologists, our compilation of this volume is based on the more realistic appreciation of the training opportunities available to those who are both pre- and post-qualification, an appreciation gained through many years of being actively involved in both pre- and postqualification training of clinical psychologists at the Institute of Psychiatry.

There are of course different ways in which to present information on clinical neuropsychological knowledge and practice. One is to focus on specific neurological disorders, and their assessment and management. Within the scope of a relatively short book, however, we feel that this may limit the apparent relevance and generalizability of the skills, which we feel it is important for clinicians to possess. Thus, for the current volume, we have chosen to focus on broad areas of cognitive function (including those such as praxis and number processing and calculation that are perhaps less well-developed areas of clinical neuropsychology in the United Kingdom), which may be relevant to assess across a wide range of neurological and psychiatric disorders. We have also chosen to include chapters that deal with important background information relevant to those being assessed (such as the effects of medication and the interaction between neurological and psychiatric presentations) and, because so much of clinical neuropsychologists’ work does involve test interpretation, an overview of key psychometric concepts underpinning neuropsychological assessment.

In addition to addressing specific cognitive functions, it is of course obvious that clinical neuropsychology may be somewhat differently applied at different ends of the age spectrum, where different factors may assume particular importance. For this reason, we have chosen to include specific chapters that address the issue of neuropsychological practice with children and older adults. At any point in the age range, neuropsychologists may be required to have an input into the medicolegal system, and for this reason we have included a very practical chapter dealing with the way in which such work should be undertaken.

Clinical neuropsychology is by no means all about assessment, as the chapters on specific cognitive functions will indicate, and the delivery of good rehabilitation services requires every bit as much the generic skills acquired during clinical psychology training as well as neuropsychology-specific ones. However, given the considerable development of neuropsychological rehabilitation, it is important to review the theoretical basis for effective cognitive rehabilitation, in an attempt to maintain an evidence-based approach to clinical practice, as well as considering how psychotherapeutic interventions designed for use with non-brain-damaged people might be modified and applied to those with acquired brain injury. While most attempts at cognitive rehabilitation have been developed for patients with acquired but non-progressive brain injury, the growing literature on such approaches for adults with dementia, possibly supplemented by the so-called ‘antidementia’ drugs, opens up further areas of work for clinical psychologists. Finally, psychologists should increasingly see themselves as being in a position to inform the process of service planning and should have a good understanding of the service delivery models that may bring about effective care to their patients with neurological impairments.

We believe, however, that clinical neuropsychological practice is most effective when set in the context of more general neuroscientific knowledge, and thus feel strongly that clinical neuropsychologists should have at least a basic understanding of neuropathology and the neurological investigations that their patients may well undergo. It is for this reason that two of the early chapters in this book present a relatively concise overview of the central nervous system and some of its common disorders, and how these are investigated. While psychologists should never work outside their own area of clinical expertise, an understanding of how medical investigations can inform the design and interpretation of neuropsychological assessments and interventions can only benefit the service psychologists provide to their patients.

We are grateful to the contributors to this volume, many of whom have been actively involved over many years in different aspects of our training of clinical psychologists, for the importance that they, like us, attach to such training and dissemination of good practice. In practical terms, we are very grateful to Gail Millard who has, good-humouredly, enabled us to convert very differently prepared manuscripts into a more consistent style, and coped with our many revisions. Alex Dionysiou has helped us with the preparation of many of the figures. Finally, we express our appreciation to our many colleagues, psychologists and non-psychologists alike, who over the years have set us good examples of how to work effectively as clinicians in our respective clinical settings.

LHG JMcN

Part 1

General Introduction

1

General Introduction: What Is the Relevance of Neuropsychology for Clinical Psychology Practice?

Laura H. Goldstein and Jane E. McNeil

Why Study Clinical Neuropsychology?

At this early stage in the 21st century, clinical neuropsychology is rightly finding its feet as a well-delineated and expanding clinical specialty within clinical psychology. It has moved away from the purely diagnostic role it acquired after the Second World War, to one in which the characterization of a person's functional strengths and weaknesses, and the explanation of their behaviour have become central in extending the range of meaningful questions that can be posed about an individual patient's presentation. The history of neuropsychology, and its development into a clinical specialty, has depended heavily on theoretical innovation and the constant need to develop a rigorous evidence base (Marshall and Gurd, 2010). Clinical neuropsychology is now very much valued as not simply involving the assessment of cognitive abilities in patients with cerebral pathology, but also as playing a major role in the rehabilitation of such people. It is also contributing to the understanding of the impact on cognitive functioning of disorders hitherto conceptualized as psychiatric or functional (rather than organic), for example depression or schizophrenia, and is being used to understand and hence possibly conceptualise in neuropsychological terms a variety of antisocial or maladaptive behaviours. Neuropsychology has expanded its area of enquiry beyond the testing room, and into the implications of cognitive impairment for everyday life, with a range of tests that are striving to be more ecologically valid (e.g., Wilson et al., 1996) as well as environmentally based (Shallice and Burgess, 1991; Alderman et al., 2003).

It is therefore important that all clinical psychologists, and not just those working in specialist neuropsychological settings, have a basic grounding in neuropsychology. Perhaps the simplest way of illustrating the widespread application of neuropsychological skills comes from the types of questions that clinical psychologists might need to answer about their patients. Thus, a clinical psychologist working in a primary-care setting, being the first person to undertake a formal assessment of a patient, might need to determine whether their patient's complaint of poor memory represents a condition that merits referral for further investigation by a neurologist or is likely to represent the consequences of anxiety or depression. In an adult mental-health setting, just as in a neuropsychiatry service, there may be the need to decide whether a newly developed memory disorder is psychogenically determined, perhaps even characteristic of factitious disorder or malingering. A clinical psychologist working with people with learning disabilities might need to be able to assess whether their patient's cognitive profile is indeed characteristic of a particular disorder (e.g., Down's Syndrome), or whether it represents the likely onset of the dementia that is often found in older adults with Down's Syndrome or points to the impact of some additional, acquired neuropathology (e.g., a recent head injury). In a forensic setting, the question for the clinical psychologist to address may well take the form of whether the person's offending behaviour could be accounted for by a previous head injury leading to impulsive behaviour characteristic of executive dysfunction. Working with older adults, the clinical psychologist may not only be trying to clarify whether the person's cognitive decline is representative of dementia rather than affective disorder but also may need to detail the precise nature of any dementia (e.g., Alzheimer's disease or fronto-temporal dementia). In an alcohol-abuse service, the evaluation of a person's memory and executive dysfunction may have implications for their future treatment or placement. In child-psychology settings, the need may well be to clarify the impact of developmental as well as acquired neuropathology on educational and social development.