---
name: "neuropsych-battery-selector"
description: "Domain-validated decision logic for selecting neuropsychological test batteries matched to suspected cognitive deficit profiles"
domain: "clinical-neuroscience"
authors:
 - "Claude Code Agent"
version: "1.0.0"
papers:
 - "Lezak et al., 2012"
 - "Strauss et al., 2006"
 - "Mitrushina et al., 2005"
 - "Heilbronner et al., 2010"
dependencies:
 required:
 - research-literacy
review_status: "ai-generated"
---

# Neuropsychological Battery Selector

## Purpose

Selecting a neuropsychological test battery is a clinical judgment task, not a checklist exercise. A competent programmer without clinical neuropsychology training will get this wrong because:

- **Not all "memory tests" test the same construct.** The CVLT-II/III assesses list learning with encoding strategies; Logical Memory tests narrative recall; the BVMT-R tests visual-spatial memory. Each is sensitive to different lesion profiles (Lezak et al., 2012, Ch. 11).
- **Test selection must match the referral question.** A dementia screen requires different instruments than a TBI return-to-work evaluation or a pre-surgical epilepsy workup.
- **Normative data are not interchangeable.** Age, education, cultural background, and premorbid ability all determine which norms to apply and whether a given score is actually impaired (Mitrushina et al., 2005).
- **Redundant tests waste time and fatigue patients.** Over-testing degrades performance and inflates apparent impairment, particularly in older adults and those with attentional deficits (Strauss et al., 2006).

## When to Use This Skill

Use this skill when you need to:

- Select neuropsychological tests matched to a suspected cognitive deficit profile
- Assemble a battery for a specific referral question (dementia differential, TBI, pre-surgical, forensic)
- Advise on which cognitive domains to assess given a neurological condition
- Evaluate whether a proposed battery has adequate domain coverage or problematic redundancy
- Choose between brief screening vs. comprehensive evaluation

Do NOT use this skill for:

- Interpreting test scores (that requires a different skill)
- Diagnosing neurological conditions from test results alone
- Administering tests (this requires licensed clinical training)

## Research Planning Protocol

Before executing the domain-specific steps below, you MUST:

1. **State the research question** -- What cognitive domain(s) are being assessed and why?
2. **Justify the method choice** -- Why neuropsychological testing (not neuroimaging, behavioral paradigm)? What alternatives were considered?
3. **Declare expected outcomes** -- What deficit pattern would support the clinical/research hypothesis?
4. **Note assumptions and limitations** -- What does this battery assume about the patient? Where could it mislead?
5. **Present the plan to the user and WAIT for confirmation** before proceeding.

For detailed methodology guidance, see the `research-literacy` skill.

---


## ⚠️ Verification Notice

This skill was generated by AI from academic literature. All parameters, thresholds, and citations require independent verification before use in research. If you find errors, please [open an issue](https://github.com/HaoxuanLiTHUAI/awesome_cognitive_and_neuroscience_skills/issues).

## Step 1: Clarify the Referral Question

The referral question determines everything. Map it to one of these categories:

| Referral Type | Primary Goal | Typical Battery Length |
|---|---|---|
| Dementia differential diagnosis | Distinguish AD vs. FTD vs. VaD vs. DLB | 3--4 hours |
| Mild cognitive impairment screening | Detect early decline, track progression | 1.5--2 hours |
| TBI evaluation (acute/subacute) | Document deficits, guide rehabilitation | 2--3 hours |
| TBI evaluation (chronic/forensic) | Quantify residual deficits, effort testing | 4--6 hours |
| Pre-surgical epilepsy workup | Lateralize/localize function, predict risk | 3--5 hours |
| Psychiatric differential | Distinguish cognitive vs. psychiatric etiology | 2--3 hours |
| Return-to-work/fitness-for-duty | Functional capacity in specific domains | 2--4 hours |

(Lezak et al., 2012, Ch. 5; Sweet et al., 2011 -- 78% of neuropsychologists use a flexible battery approach)

---

## Step 2: Identify Target Cognitive Domains

Based on the referral question and suspected condition, select domains to assess. Every battery MUST cover at least attention/processing speed, memory, and executive function. Add domains based on the clinical picture.

### Cognitive Domain Framework

**Attention / Processing Speed**
- WAIS-IV Processing Speed Index (Coding, Symbol Search): **~15 min** (Wechsler, 2008)
- Trail Making Test Part A: **~3 min** (Reitan, 1958; deficient if >78 sec, ages 25--54)
- Continuous Performance Test (CPT-3): **~14 min** (Conners, 2014)
- WAIS-IV Digit Span (Forward): **~5 min** (Wechsler, 2008)

**Executive Function**
- Wisconsin Card Sorting Test (WCST-64): **~15 min** (Heaton et al., 1993)
- Trail Making Test Part B: **~5 min** (Reitan, 1958; deficient if >273 sec, ages 25--54)
- Stroop Color-Word Test: **~5 min** (Golden, 1978)
- Tower of London/D-KEFS Tower: **~15 min** (Shallice, 1982; Delis et al., 2001)
- Verbal Fluency -- FAS: **~5 min** (Benton et al., 1994; mean ~36--44 words total for ages 25--54, education 12+ years)
- Verbal Fluency -- Animals: **~2 min** (Strauss et al., 2006; mean ~20--24 animals for ages 25--54)

**Memory**
- WMS-IV (Logical Memory I & II, Verbal Paired Associates I & II): **~30--45 min** including delay (Wechsler, 2009)
- CVLT-II/CVLT-3 (California Verbal Learning Test): **~30 min** (Delis et al., 2000/2017)
- RAVLT (Rey Auditory Verbal Learning Test): **~15 min** (Rey, 1964; Schmidt, 1996)
- BVMT-R (Brief Visuospatial Memory Test--Revised): **~25 min** including delay (Benedict, 1997)
- Logical Memory (WMS-IV): immediate and delayed recall; **sensitivity 90--95% for MCI when combined with CVLT** (Rabin et al., 2009)

**Language**
- Boston Naming Test (BNT-60): **~15--20 min** (Kaplan et al., 1983)
- Token Test (short form): **~10 min** (De Renzi & Vignolo, 1962)
- Controlled Oral Word Association (COWA/FAS): **~5 min** (listed above under executive; also indexes language)
- Western Aphasia Battery--Revised (WAB-R): **~30--60 min** (Kertesz, 2007; use for suspected aphasia)

**Visuospatial / Visuoconstructional**
- Rey Complex Figure Test -- Copy: **~5--10 min** (Osterrieth, 1944; Meyers & Meyers, 1995)
- WAIS-IV Block Design: **~10 min** (Wechsler, 2008)
- Judgment of Line Orientation (JLO): **~15 min** (Benton et al., 1994)
- Hooper Visual Organization Test (VOT): **~15 min** (Hooper, 1983)

**Motor Function**
- Grooved Pegboard: **~5 min per hand** (Klove, 1963; Ruff & Parker, 1993)
- Finger Tapping Test: **~10 min** (Halstead, 1947; Reitan & Wolfson, 1993)

---

## Step 3: Assemble the Battery

### Core Battery (~2--3 hours)

Every evaluation should include these unless contraindicated:

| Domain | Recommended Core Test(s) | Time |
|---|---|---|
| Premorbid estimate | TOPF or WTAR | ~10 min |
| Attention / Processing Speed | TMT-A + WAIS-IV Coding + Digit Span | ~20 min |
| Executive Function | TMT-B + Verbal Fluency (FAS + Animals) + Stroop | ~15 min |
| Verbal Memory | CVLT-II/III or RAVLT | ~30 min |
| Visual Memory | BVMT-R or RCFT recall | ~25 min |
| Language | BNT (30- or 60-item) | ~15 min |
| Visuospatial | RCFT Copy or Block Design | ~10 min |
| Motor | Grooved Pegboard (bilateral) | ~10 min |
| Effort/Validity | TOMM Trial 1 or embedded measures | ~10 min |
| **Total** | | **~145 min** |

### Extended Battery (~4--6 hours)

Add these for complex referrals (forensic, dementia differential, pre-surgical):

| Domain | Additional Tests | Time |
|---|---|---|
| Intelligence estimate | WAIS-IV (4 index scores) | ~70 min |
| Memory (expanded) | WMS-IV (full battery) | ~75 min |
| Executive (expanded) | WCST-64 + Tower | ~30 min |
| Language (expanded) | Token Test + WAB-R | ~40 min |
| Visuospatial (expanded) | JLO + Hooper VOT | ~30 min |
| Effort/Validity (expanded) | TOMM (full) + WMT or MSVT | ~30 min |
| **Added time** | | **~275 min** |

### Assembly Rules

1. **One verbal learning test**: Choose CVLT-II/III OR RAVLT, not both. They measure overlapping constructs (Strauss et al., 2006--778).
2. **One copy figure**: RCFT copy OR Block Design for visuoconstruction screening. Use both only if visuospatial function is the primary question.
3. **Delay intervals**: Schedule verbal memory delay recall (~20--30 min after learning) during non-memory tasks. Same for visual memory delay.
4. **Fatigue management**: Place demanding tests (WCST, CVLT) early. Place motor tests as breaks. Offer rest periods every 60--90 min (Lezak et al., 2012, Ch. 6).
5. **At least one validity measure**: Mandatory. Use TOMM Trial 1 (sensitivity 83%, specificity 93% at cutoff <=40; Denning, 2012) as a minimum. For forensic cases, use two or more PVTs from different modalities (Sweet et al., 2011).

---

## Step 4: Select Appropriate Norms

### Normative Data Decision Tree

1. **Age**: Always match. Most tests provide age-stratified norms.
2. **Education**: Use education-corrected norms when available (e.g., Heaton et al., 2004 norms for TMT, WCST, verbal fluency).
3. **Premorbid IQ**: For patients with estimated IQ far from average, IQ-adjusted norms improve accuracy over education alone. MOANS norms found BNT, Token Test, and JLO correlate more strongly with IQ (r = .47--.61) than with education (r = .24--.31) (Steinberg et al., 2005).
4. **Cultural/linguistic background**: US-normed tests may overestimate impairment in non-English speakers or culturally diverse populations (Lucas et al., 2005; Pena-Casanova et al., 2009). Use population-specific norms when available (e.g., NP-NUMBRS for Spanish speakers).
5. **Sex**: Match when norms are available. Grooved Pegboard shows significant sex differences: women faster than men (Ruff & Parker, 1993). Finger Tapping: men faster, especially in older groups.

### Premorbid Estimation

- **TOPF** (Test of Premorbid Functioning): 70 irregular words, co-normed with WAIS-IV/WMS-IV, IQ range 53--141 (Pearson, 2009). Preferred for current use.
- **WTAR** (Wechsler Test of Adult Reading): predecessor to TOPF, co-normed with WAIS-III/WMS-III (Wechsler, 2001). Acceptable if TOPF unavailable.
- **Caution**: Both underestimate premorbid IQ in high-functioning individuals and overestimate in low-functioning individuals (Bright & van der Linde, 2020). Supplement with demographic-based estimates.

---

## Step 5: Address Common Pitfalls

### Practice Effects in Serial Assessment

- Practice effects average **d = 0.24--0.28** on composite scores at 6--12 month retest intervals (Calamia et al., 2012).
- No consensus on minimum retest interval; effects persist for **2+ years** on some measures (Heilbronner et al., 2010).
- Tests most susceptible: PASAT, Stroop interference, verbal fluency, TMT-B (Beglinger et al., 2005).
- Tests least susceptible: Digit Span, Letter-Number Sequencing (Beglinger et al., 2005).
- **Mitigation**: Use alternate forms (CVLT-II has alternate form; RAVLT has multiple lists). Apply reliable change indices (RCIs) or standardized regression-based norms to interpret change (Chelune et al., 1993).

### Ceiling and Floor Effects

- **Ceiling effects**: TMT-A and simple attention tests may miss mild deficits in high-functioning individuals. Add more demanding measures (e.g., PASAT, D-KEFS verbal fluency switching) (Strauss et al., 2006).
- **Floor effects**: WCST and complex tests may be too difficult for moderate-to-severe dementia. Substitute with simpler tasks (e.g., clock drawing, category fluency) (Lezak et al., 2012, Ch. 18).

### Ecological Validity

- Neuropsychological tests have modest correlations (**r = .3--.5**) with real-world functioning (Chaytor & Schmitter-Edgecombe, 2003).
- Supplement with functional measures (e.g., Independent Living Scales, IADL checklists) when the referral question concerns everyday competence.
- Executive function tests have particularly limited ecological validity; consider adding the Behavioral Assessment of the Dysexecutive Syndrome (BADS) or real-world task simulations (Wilson et al., 1996).

### Symptom Validity Testing

- **TOMM** standard cutoff (<45 Trial 2): specificity .96--1.00 but sensitivity only .15--.50 (Tombaugh, 1996). Use Trial 1 cutoff <=40 for better sensitivity (.83) at .93 specificity (Denning, 2012).
- **WMT** (Word Memory Test): more sensitive than TOMM but higher false-positive rate in genuine MCI/dementia -- 67% of MCI patients classified as "poor effort" at standard cutoffs (Green, 2003). Use hard-easy comparison scores instead (sensitivity/specificity ~95%).
- **Embedded PVTs**: Reliable Digit Span (RDS >= 7 as cutoff; Greiffenstein et al., 1994), CVLT-II Forced Choice <=15 (Delis et al., 2000). Use multiple embedded measures to supplement standalone PVTs.
- **Rule**: In forensic and disability evaluations, include at least **two standalone PVTs and two embedded PVTs** (Larrabee, 2012).

---

## Step 6: Condition-Specific Battery Recommendations

For expected deficit profiles by condition, see `references/deficit-profiles.md`. Below are summary battery modifications:

| Condition | Add to Core | Remove/De-emphasize | Key Rationale |
|---|---|---|---|
| Alzheimer's (suspected) | WMS-IV full, CVLT-3 intrusion analysis, BNT-60 | May shorten executive battery | Memory encoding/storage is primary deficit (Weintraub et al., 2012) |
| FTD (behavioral variant) | WCST, D-KEFS, social cognition measures, personality inventory | De-emphasize visuospatial | Executive/behavioral profile dominates (Rascovsky et al., 2011) |
| Vascular dementia | Processing speed emphasis (Coding, Symbol Search), TMT-A/B, verbal fluency | May abbreviate language | Processing speed and executive function most affected (Sachdev et al., 2014) |
| TBI (moderate-severe) | CPT-3, PASAT, verbal fluency, motor tests bilateral | None -- broad battery needed | Diffuse deficits: attention, speed, memory, executive (Rabinowitz & Levin, 2014) |
| Temporal lobe epilepsy | Verbal/visual memory (laterality-specific), BNT, verbal fluency | May abbreviate motor | Memory lateralization critical for surgical planning (Jones-Gotman et al., 2010) |
| Parkinson's disease | Verbal fluency (semantic + phonemic), JLO, clock drawing, Grooved Pegboard | None | Dual-syndrome: frontostriatal vs. posterior cortical (Kehagia et al., 2013) |
| Multiple sclerosis | SDMT, PASAT, CVLT-II/III, BVMT-R | May abbreviate language | BICAMS recommended minimum battery (Langdon et al., 2012): SDMT + CVLT-II + BVMT-R |

---

## Quick Reference: Test-to-Domain Mapping

For a comprehensive catalog of tests with administration times, normative samples, and sensitivity data, see `references/test-catalog.md`.

---

## Key References

- Benton, A. L., Sivan, A. B., Hamsher, K., Varney, N. R., & Spreen, O. (1994). *Contributions to Neuropsychological Assessment* (2nd ed.). Oxford University Press.
- Delis, D. C., Kaplan, E., & Kramer, J. H. (2001). *Delis-Kaplan Executive Function System*. Pearson.
- Heaton, R. K., Miller, S. W., Taylor, M. J., & Grant, I. (2004). *Revised Comprehensive Norms for an Expanded Halstead-Reitan Battery*. PAR.
- Heilbronner, R. L., Sweet, J. J., Attix, D. K., Krull, K. R., Henry, G. K., & Hart, R. P. (2010). Official position of the AACN on serial neuropsychological assessments. *The Clinical Neuropsychologist*, 24, 1267--1278.
- Lezak, M. D., Howieson, D. B., Bigler, E. D., & Tranel, D. (2012). *Neuropsychological Assessment* (5th ed.). Oxford University Press.
- Mitrushina, M., Boone, K. B., Razani, J., & D'Elia, L. F. (2005). *Handbook of Normative Data for Neuropsychological Assessment* (2nd ed.). Oxford University Press.
- Strauss, E., Sherman, E. M. S., & Spreen, O. (2006). *A Compendium of Neuropsychological Tests* (3rd ed.). Oxford University Press.
- Sweet, J. J., Nelson, N. W., & Moberg, P. J. (2011). The TCN/AACN 2010 "salary survey." *The Clinical Neuropsychologist*, 25, 218--245.