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Most neuropsychological tests are blatantly explicit. By this, we mean that most of the tests we administer focus upon the concept and assumption of conscious cognitive control . In addition, many of these tasks appear to be artificial, and the results of these measures are difficult to correlate with day-to-day activities. For example, during the course of the day, people are not repeating digits forwards and backwards; they are not sorting cards into categories or solving “tower” tests; they are not connecting circles in numerical order with a pencil line, etc. Nevertheless, based upon interpretations of test results, we attempt to identify symptoms and diagnose pathology. The neuropsychologist then attempts to predict how the patient may present the in the “real world,” making inferences from test interpretation. From this, the clinician attempts to devise meaningful interventions that will support the patient in treating and/or compensating for their deficiencies ; however, many of the tasks that are administered in a neuropsychological battery are not practical, and thus performance on the measure may not translate or generalize well in terms of a patient’s neurobehavioral presentation outside of the clinical setting. Some tests utilize game-like formats. Other tasks are administered conveying academic overtones, and still other tasks are administered within a question-answer format. So the inferences and predictions we make are always indirect.

A primary example of measures with academic overtones are the Wechsler scales, especially when a “group” of these tests is administered within a school setting; however, the Wechsler series has flaws with respect to the clinical utility of outcomes in a neuropsychological assessment. Although these “WIS” subtests were never originally intended to be used as neuropsychological instruments, this is not to say that the Wechsler series do not provide valuable information. And the Wechsler scales are perhaps the most “popular” tasks administered in neuropsychological testing [1]. Every set of tasks has limitations, and on nearly all WIS-like subtests, the examiner “guides” all of the activity. Similarly, these types of tasks are very explicit and based upon a static view of brain function [2]. And, as has been reviewed in The Compendium of Neuropsychological Tests, 3rd Edition [3], most examiners focus upon tests that are explicit, and the conclusion has been offered that considerable meaningful data is likely lost because of the lack of evaluating implicit procedures and processes.

A static view of brain function is inherent in current methodologies of neuropsychological assessment. ADHD as a Model of Brain-Behavior Relationships [49] and The Myth of Executive Functioning [50], this evaluation approach was referred to as the serial-order processing paradigm. This model is based upon the view that first, we perceive, second, we think in order to formulate a solution to a problem, and third, we finally act by implementing that solution. As reported by Cisek and Kalaska [4] and others [5, 6], there is very little evidence to support this type of serial order processing paradigm. It is certainly true that at times, we do engage in this type of problem-solving ; however, this type of serial-order processing methodology does not account for or explain how smoothly, quickly, and effectively people are generally able to coordinate and control their adaptive behavior. This also might be thought of as a “perceive-think-respond” methodology that represents a variation of convergent thinking. In simplified terms, this means that problems are presented or that questions are asked, and that there really is only one way of solving the problem or correctly answering the question. This is clearly an explicit and almost completely an examiner-directed approach toward assessment; it is believed that as much as 95 % of behavior occurs on a routine, regular, automatic, and habitual basis. Therefore, much of thought and behavior must be implicit. Every day of our lives we do things that need to be done, without really thinking about them or how to do them. This is the essence of the novelty-routinization principle . In this regard, it is essential for the neuropsychologist to know how people learn implicitly. Similarly, problem-solving behavior that occurs “on-the-fly” would appear to require efficient perception/idea-action coupling that occurs quickly and implicitly [7]. These adaptive behaviors can be outside of our conscious awareness when they initially occur, though we are often able to recall them explicitly, later, after the “event” occurred. For example, think about driving on the expressway, thinking about something else as we drive, but then quickly stopping or turning to avoid an accident when something occurred that must have captured our attention.

The world of neuropsychology is changing. We can no longer think of behavior as organized along a verbal versus non-verbal dichotomy . We cannot view behavior in terms of verbal-visual-spatial functional differences. Instead, the neuroscientific evidence [8, 9] supports a novelty-routinization principle of vertebrate brain organization. As such, human brain-behavior relationships need to be viewed within that context. Any new task, by definition, is novel. Inherent in novelty is a change in the visual-spatial characteristics of that set of circumstances. Visual-spatial functioning can be viewed as nothing more than representing a change in the “momentary geometry” of any given, changing situation [10, 11]. When we are faced with a novel problem, we learn the solution to that problem, and if it is relevant and adaptive, a neuropsychologically intact individual will engage in that behavior over and over again, so that the behavior in question becomes automatic or routine. As we discussed in ADHD as a Model of Brain-Behavior Relationships [49] and The Myth of Executive Functioning [50], when this “automatic” or routine level of functioning is achieved, the behavior becomes independent of conscious cognitive control. Therefore, we might think of any novel behavior as initially requiring cognitive input or cognitive control in order to achieve a solution, but as that behavior is practiced or learned, it becomes independent of higher-order cognitive control [12]. This is the basic, fundamental principle that was described in the previously mentioned volumes as well.

Based upon this information, how can we make neuropsychological instruments that were developed and utilized years ago relevant to the significant advancements in our understanding of brain-behavior relationships and have these instruments align with what is known in the neurosciences? We now need to think in terms of the operations of the ventral and dorsal attention networks , the fronto-parietal network, the default mode network, the limbic network, and how all of these systems interact with the sensory and motor networks for the purpose of constantly interacting within a dynamically changing environment. We also need to think about how these networks operate in a segregated and in an integrated manner to support adaptive decision making. This is truly a daunting, formidable task. Furthermore, these networks interact with the gating mechanisms of the basal ganglia for the proper selection of behaviors [13–16], and they similarly interact with the cerebellar circuitry system in order to properly refine, automate, and adapt behavior as circumstances change. In fact, although we can understand certain test results and behaviors in terms of the cortico-basal ganglia gating mechanisms, such as the commission errors on a continuous performance test described in the previous chapter, practical clinical neuropsychology has no measures that assess the integrity of the cerebellum . Nevertheless, we believe that by altering certain methods of administration of currently available tests, we can just now begin to tap certain of these processes and functions. Similarly, perhaps we can revisit and revise certain traditional concepts in order to make them more applicable to current clinical neuropsychological practice.

Practice Effect: What Is It and Should It Always Be Avoided?

“Practice effect” refers to a general test-taking benefit in which test performance is enhanced after repeated administrations of the same test [17]. In fact, practice effects can also occur with different test items, because from one test administration to the next, the patient seems to learn how to approach a task more efficiently. In other words, the patient sometimes “learns ” how to take the test. It has been suggested that practice effects are to be avoided, particularly because they interfere with the measurement of any given person’s “true ability ;” however, there is absolutely no universal agreement about whether or not “true ability” exists, nor is there agreement as to how this should be measured. People adjust to situations. This essentially means that the brain adjusts to situations. In fact, this is exactly what we expect a human brain to do. The brain takes a novel set of circumstances and it attempts to efficiently manage those circumstances by becoming more familiar with them, and by identifying methods of effective adaptation. The brain is continuously in a state of making what is unfamiliar or novel more familiar or even automatic to reduce the neurocognitive demands of the given behavior. This is how the human brain problem-solves. Even in normal control subjects, considerable test score variability is common from one test administration to another test administration even after relatively brief periods of time [18]. If our purpose is to study and understand brain-behavior relationships , then the concept of practice effect may not be a “bad thing” and, in fact, may be a valuable tool in terms of understanding an individual’s neurocognitive status. Practice effects may, in fact, be a measure of the individual’s learning efficiency or ability to take a novel process and make it automatic. We completely understand that this is our “novel,” controversial opinion; we are asking neuropsychologists to stop and to think about the importance of what most practitioners were taught to avoid; at the same time, we are uncompromising in proposing that this viewpoint has relevance with respect to the study of brain-behavior relationships.

It is useful to break practice effect down into at least two different types. All cognitive tests consist of two basic elements, which comprise the broad categories of content and procedures [19]. All tasks simply must contain stimulus content, and most problem-solving tasks will also feature procedures. If these procedures are known, this will facilitate efficient solutions. Therefore, in some cases, it might be useful to separate practice effects into these two broad dimensions. In general, the neuroanatomic substrate for task content is the medial temporal lobe memory system, which requires the integrity of the hippocampus and related structures. This allows for the conscious recollection of the task, and more often than not, it is influenced by recognition recall and/or conscious awareness. The learning and memory of procedures recruits the cortico-basal ganglia system, often referred to under the “umbrella-like” category of the fronto-striatal system.

One task with both content and procedure that is extremely obvious is the Wisconsin Card Sorting Test (WCST) . For example, the stimulus items consist of the shapes, colors, and the number of geometric forms. This is the explicit content. The procedural aspect concerns learning how to sort these cards along the proper dimensions in response to the informational “feedback” provided by the examiner as to whether the response is “correct” or “incorrect.” If the task is re-administered on one or perhaps on several occasions, it is certainly true that the original intention of the task is no longer being measured, which is to “discover” the three organizing principles of color, form, and number; however, by comparing test performances after repeated administrations of the WCST , the neuropsychologist could effectively measure and assess if the patient learned the content and the procedure. Although this clearly changes the usual purpose or intent of the task, it also provides diagnostic information about the particular patient’s ability to remember the content and learn the procedure. Although it is beyond the scope of this brief manuscript to discuss the purpose and administration of the WCST in greater detail, the fact that significant improvements are made across trials would be clinically relevant and of diagnostic import. In our view, overall view, the WCST is a problem-solving task that requires an individual to discover the stimulus-based properties that govern the problem in question. This viewpoint should not be surprising, because The Myth of Executive Functioning [50] was devoted to that topic; all problem solving requires an individual to discover the stimulus-based properties of the problem; however, if the task is re-administered without improvement in performance variables, this might indicate that the individual was unable to learn about the task characteristics. The ability or inability to learn the stimulus-based characteristics of the test would be of considerable clinical value. Presently there are no normative standards for making this type of judgment; therefore, this conclusion would need to be made with extreme caution.

The exact same overall principles would be applicable to other tasks, such as the traditional and well-known Block Design subtest. The stimulus-based characteristics are both observed in the content and the procedural elements of the task; the content concerns the different items which are essentially perceptions of the various configurations or patterns of the blocks; the procedural principles include the “discovery” that the 4 blocks make a square, and that this same “square” can be constructed without a framed outline; on 9-block items, the organizing principle changes to learning the underlying principle that all the solutions concern a 3 × 3 configuration, and that the stimulus “outline” can be removed, while even rotating the stimulus figures at a 90° angle, taking on a more abstract appearance. “Logical intuition” informs us that the understanding of these principles can be either explicit or implicit, although to our knowledge, this has never been formally investigated. In any event, the concept of practice effect is based upon the idea that the individual is capable of benefiting from the experience of interacting within his or her environment. This is what the human brain is supposed to do as its primary functional goal! With multiple administrations of the same task, we would expect that everyone’s performance improves. Aspects of this type of learning can be implicit, which is seldom, if ever, measured through contemporary neuropsychological measures. Practice effects indicate that an individual has learned and can execute a set of procedures, without really having a conscious intention to do so when the task was initially administered. “Conscious awareness ” might be necessary to initially discover these stimulus-based characteristics, but improved performance no longer requires the guidance of goal-directed thinking. We consider it essential that the field begin to develop and implement measures of procedural and implicit learning . However, the WCST and the Block Design subtest are relatively “easy,” since the content of these tasks arguably out-weighs the “procedures.” Nevertheless, people with certain pathologies might find these tests extremely difficult. It is sufficient to demonstrate that these tasks consist of both content and procedures, and that both explicit and implicit learning can be demonstrated through the effects of “practice,” which is nothing more than repeated administration and performance.

The most widely known, classic case of medial temporal lobe anterograde amnesia is H.M. In 1953, in an effort to relieve severe epilepsy, he received a bilateral medial temporal lobe resection [20]. Since the time of his surgery, he was unable to learn and retain any new memories for events and information. However, as reviewed by Banich and Compton [21], H.M. was capable of learning new skills, such as the mirror tracing task, the rotary pursuit task, a mirror-reading task, and the Tower of Hanoi, a version of which is available on the DKEFS [22]. These tasks appear to be dependent upon perceptual-action coupling [23]. Although to our knowledge, it has never been conceptualized this way before, the dissociation between the declarative memory system and procedural learning system reveal the distinction between knowing “what” and knowing “how.” And, we assess the medial temporal lobe system through a type of “practice effect,” which is a way of thinking about the learning and memory assessed by administering the CVLT [24]. What neuropsychology is missing, and needs, is an evaluation of the learning and memory of the “how” system, in other words, the procedural learning system.

In our opinion, the original Trail Making Tests (TMT) , which are in the public domain, represent an ideal candidate for evaluating an individual’s ability to benefit from interacting with a task, traditionally known as practice effect; however, according to our proposed administration, we are evaluating implicit learning. This is the “how” system of procedural learning. Before introducing our methodology of administration, it is critical to examine the component brain systems that support successful task completion of the trail making tests. (The reader who is not familiar with the TMT should consult Strauss, et al., [3] and Lezak, et al., [1]).

The assumption that is made in order to complete TMT Part A is that the patient in question understands numerical sequence. It is also assumed that that the patient is able to recognize the numbers. The test consists of numbers within circles that are randomly distributed on a standard size sheet of paper. The test requires the patient to connect all of the numbers in proper ascending serial order with a pencil line as quickly as possible. The standard administration of this test consists of a single trial. The variable of interest concerns the speed with which the task is completed. If errors are made, this is pointed out to the subject for correction, and the errors negatively impact the patient’s completion time.

Based upon current theoretical neuropsychological principles, we would expect this task to recruit the ventral attention network (VAN) . The purpose of this brain region activation would be necessary for identifying the numbers. This is the case because the ventral attention network supports object identification, which is sometimes referred to as the “what” pathway [25]. In addition, it would be predicted that successful completion of this task activates the dorsal attention network (DAN) . The dorsal attention network, consisting of connections between the frontal eye fields and the parietal lobes, would be activated for the purpose of locating the various numbers or, in other words, generating a meaningful visual-search strategy in order to locate the position of the numbers on the page. In this regard, aspects of the dorsal attention network have been referred to as the “where” pathway [25]. Holding the pencil in order to connect the numbers activates the sensory-motor network . Finally, in order to coordinate these operations, activation of the fronto-parietal network (FPN) would be expected as well. This would provide the appropriate cognitive control or guidance [26].

In our proposed administration, TMT Part A would be presented in five consecutive trials , rather than in a single trial based upon standard administration procedures. From the first trial to the last trial, we would expect improved performance as measured by a decrease in time to completion. Because the same stimulus page would be presented five times consecutively, all factors would remain constant. We would essentially be measuring the implicit learning of a novel, visual-search strategy which is dependent upon interactions between the VAN, DAN, and the FPN. The patient serves as his or her own normative control. During the course of completing this task over five trials, the prediction mechanisms of the cerebellum would be activated so that the hand would almost be guided by itself, motorically, becoming independent of conscious cognitive control and moving on the basis of “prediction.” The cerebellum would learn the position of the numbers from prediction through repetition so that the final, best performance would be retained within the premotor cortex. Cerebro-cerebellar interactions would “learn” the implicit visual-search strategy, and the most efficient representation of that strategy, as measured by a decrease in time to completion, would be stored within the premotor cortex, because the cortex retains what the cerebellum learns [27]. This would represent the implicit learning function of the cerebellum, reflecting the brain’s potential to develop automatic behaviors. This type of administration would be particularly useful and beneficial for patients who initially perform slowly, and/or with initial errors; however, if the subject immediately performs well within the range of normal limits with respect to speed and accuracy parameters on the initial, or perhaps even more quickly than expected, then the administration of five consecutive trials would not be necessary.

TMT Part B makes two assumptions. First, the same assumption is made that the individual in question knows the automated numeric sequence. The second assumption that is made relates to assuming that the individual has automated the alphabetic sequence. TMT Part B requires the individual to learn a new sequence by alternating between numbers and letters, letters to numbers, numbers to letters, and so on while maintaining ascending numeric and alphabetic ordering. The new sequence becomes 1-A-2-B-3-C-4-D and so on. This new sequence stops with the number 13 (on the adult version of the task). In the performance of this task, the same VAN, DAN, FPN, and SMN networks are presumably activated, for the same reasons as described above; however, TMT Part B introduces an additional requirement. From a global perspective, this additional requirement can perhaps describe the emphasis upon “working memory” functions ; however, upon closer examination, in a neuroanatomic sense, there are more processes being recruited than just those thought to comprise working memory.

For example, the numeric sequence of 1-2-3-4-5 represents an extremely robust motor and well-established pattern. Similarly, the alphabetic sequence of A-B-C-D-E is just as robust. When we use the word “robust,” we literally mean very strong and difficult to break. These types of cognitive/motor sequences are robust because they typically run their course. Once they start, they typically run through to their natural ending points, of course with the exception of numbers, which are infinite. Therefore, in the performance of TMT Part B, the “working memory” component actually consists of starting a robust sequence, breaking or interrupting the familiar sequence in favor of a novel sequence, and repeating this process over and over again until completion of the task. This is why summarizing this task as being one that is related to only working memory is inadequate. The initial breaking of the known sequences and integrating the new sequence is initially under cortical “conscious control ” as frontal systems interact with the starting, stopping, and “chunking” processes of the basal ganglia ([28], see chapters 2, 4, 8, and 9). There is substantial mental tracking required while completing TMT Part B. While mental tracking is involved, our additional point concerns the breaking of the automated numeric and alphabetic sequences for the insertion of an aspect of another sequence, and then, breaking and combining aspects of both sequences on a continual basis in order to complete the task. In other words, we are describing a completely new perception-action coupling. The individual must interrupt a robust, automatic sequence constantly, while combining a perception with a new action. Since the cerebellum copies the content of working memory, in this case, the cortical-striatal interactions for the new sequence, and the locations of the numbers and letters, the cerebellum has the information it needs in order to “predict” and “automate.” In our opinion, this is the essence of working memory—specifically, the coupling of a perception or idea with a new action. This is exactly how working memory functions guide behavior. Additionally, this is an extremely unique task because it is unlike other working memory testing tasks that are typically explicit. Once again, the uniqueness of this procedure concerns the perception-action coupling. This is the type of coupling that is necessary to engage in new behavior as we adjust to task novelty, while interacting within a dynamically changing environment.

It is true that the terms “shifting,” “mentally tracking,” and “working memory” can be terms that are used to describe TMT Part B; however, our emphasis upon this type of detail makes it considerably more clear as to what is actually required, which is consistent with our description of problem-solving processes that are described within the the previously mentioned volumes. In our administration protocol , we present TMT Part B over the course of five consecutive trials. Improved performance is measured by the elimination of errors and decreased time to task completion. By the time the fifth trial is administered, the normal control subject should be well on his or her way toward automating a new sequence of behavior (i.e., alternating an ascending numeric-alphabetic sequence). This represents a motor sequence that is actually cognitive in nature. When understood in this way, we argue that TMT Part B represents an extremely important tool for the practicing neuropsychologist, much more useful than it is right now in current administration practice, but only if we change administration standards by providing multiple, consecutive, and repetitive trials. Another way to administer this task would be to use as many trials as might be necessary to demonstrate task acquisition, indicating performance consistent with the majority of the individual’s age-matched cohorts. However, the “5 trials” model controls for the number of stimulus presentations, while a “trials to acquisition” model might not be appropriate for all subjects while it introduces an additional variable which further complicates interpretation.

With respect to interpretation of the TMT task, a review of the normative standards provides little reason to believe that performance on TMT Part A and TMT Part B would be “normally distributed.” We do not think there reason to believe that performance on these subtests follow a bell-shaped curve; however, regardless of this assumption, which has yet to be proven, we have already indicated that this task can be administered and interpreted according to an individual comparison standard. The goal is to ascertain how long it might take for any given individual to automate the novel sequence through the processes of implicit learning required in the completion of both TMT Part A and Part B; therefore, just as we have pointed out with respect to the measurement of anterograde amnesia, this type of implicit procedural learning process should be interpreted on an intra-individual comparison basis. It may be useful to know how an individual performs relative to a group standard on the initial trial of TMT Part A and Part B; however, in terms of implicit learning, the primary relevant variable concerns how the individual performs relative to himself or herself. When employing this methodology, the subject is literally acting as his or her own control. We also believe that administering the TMT over multiple trials provides considerably more information to the clinical examiner than a single administration trial could. In fact, while the term “processing speed ” has always been elusive in terms of difficulties in finding a universally agreed upon definition, we believe that this type of perception-action coupling actually represents the essence of processing speed, making this term much easier to understand as a manifestation of executive, cognitive control in comparison to automaticity. Furthermore, this way of administering the TMT is completely consistent with the novelty-routinization principle. Multiple administrations of the TMT start with cognitive control and theoretically end with automaticity.

Case 7

This vignettes concerns a Caucasian female who was seen on two separate occasions. She presents with rather unique neurologic pathology. For example, her MRI findings include an absence of the cerebellar vermis , a fusion of the cerebellar hemispheres, and an absence of the primary fissure of the cerebellum. While these findings are compatible with romboencephalitis , the potential involvement of the trigeminal nerve suggests the possibility of an extremely rare disorder called Gomez-Lopez-Hernandez Syndrome , of which there are only 34 such cases on documented record [29]. MRI data also revealed fusion of the cerebellar tonsils , which extended 6 mm below the level of the foramen magnum, which met criteria for a diagnosis of Chiari I Malformation as well. Figure 6.1 illustrates the MRI findings. She was seen for neuropsychological evaluation on two separate occasions, initially at the age of 7 years old, and again when she was 11 years old. The data presented here are restricted to the TMT Parts A and B, Child Version.

Fig. 6.1
figure 1

MRI findings demonstrating a fusion of the cerebellar hemispheres , the absence of the primary fissure of the cerebellum, and agenesis of the cerebellar vermis. There is also a fusion of the cerebellar tonsils. The patient’s presentation was confirmed as the 35th case on record with a diagnosis of Gomez-Lopez-Hernandez Syndrome

Full size image

Test results

7 years old

Trail making test

Time

Errors

Trial A1

40″

2

Trial A2

22″

1

Trial A3

20″

0

Trial A4

19″

1

Trial A5

26″

0

Trial B1

66″

0

Trial B2

37″

0

Trial B3

66″

0

Trial B4

29″

0

Trial B5

71″

0

Test results

11 years old

Trail making test

Time

Errors

Trial A1

21″

0

Trial A2

13″

0

Trial A3

11″

0

Trial A4

12″

0

Trial A5

11″

1

Trial B1

24″

0

Trial B2

21″

1

Trial B3

16″

1

Trial B4

14″

0

Trial B5

29″

3

These case data sets were not presented because of the rarity of the disorder. Instead, it needs to be kept in mind that the “easy” child version of TMT was administered on both occasions. This individual’s general level of intellectual functioning was never a question, so that in order to satisfy anyone’s curiosity about possible “cognitive referencing ,” global cognitive capacity has always been well within the range of expected, normal limits; however, at the age of seven, this child’s performance did not give evidence that she was able to automate the very simple version of TMT Part A. On TMT Part B, though her performance was error-free, her functioning with respect to speed parameters was indicative of a lack of automaticity of the visual-search strategy. Scores ranged from average to two- and three-standard deviations below the mean, with unpredictable speed of performance from one trial to the next trial.

When she was seen at again at 11 years old, she performed much more quickly on TMT Part A, as might be expected, given her age at that time; however, it is difficult to argue whether the visual field search strategy was automated in light of the fact that, on the final trial, a very simple counting error was made. On TMT Part B, although speed of performance might be considered well within the range of expected limits, she made errors, and the mistakes she made were unpredictable from one trial to the next trial. This child made different mistakes each time she committed an error; therefore, once again, there was no persuasive evidence that this child was able to learn a visual search strategy. In our opinion, these data represent dramatic evidence of a lack of automatize, especially in view of the fact that serial test results were obtained, separated by a time frame of almost exactly 4 years. However, even without knowing about the cerebellar abnormalities within this individual’s presentation, this type of performance can be observed in any patient that might walk into any clinician’s office, on any given day. This young lady’s neurocognitive profile reveals a certain level of cognitive control, although this was unreliable as evidenced in her committing errors. When reviewing the speed of her performance one may infer that the “DAN network ” was unable to assist in automating the behavior. This is suggested by the fact that the cortex and cerebellum function as an ensemble, while vermal and lateral cerebellar regions would support performance. By definition, her condition includes difficulties in controlling reflexive eye movements; this does not invalidate the data but instead, it emphasizes the role of the FEF within the DAN. Therefore, this presentation illustrates the potential value of consecutive administrations of the TMT, which, in fact, is the only point we wish to make.

Perception/Idea-Action Coupling

What is perception-action coupling ? At base, we are referring to perception-action coupling as an element of “working memory.” In The Myth of Executive Functioning [50], it was described how working memory cannot possibly be a unitary entity, while it was also characterized as a process that is comprised of both explicit and implicit components that interact [30]. Perception-action coupling is similarly a multiple-component process [31, 32]. For example, many clinical tests that require the subject to copy geometric forms/designs are described as “visual-motor” tests. An aspect of executive functioning, in this case “working memory,” implicitly lies in the “dash” between these two words [33]. The Rey Complex Figure Test [34] is a “visual-motor test ” that requires the self-generation of organization. In order to draw the figure properly (and obtain the required 34–35 raw score points), the subject must ask himself/herself, either explicitly or implicitly, “how” to best draw the stimulus figure. This determination or manipulation of perceptions and/or ideas “occurs” within working memory. And these are the explicit, or implicit ideas that “guide” the drawing of the figure. And this literally is perception-action coupling, an aspect of working memory. The term “visual-motor” tells us nothing at all specific; but considering the term “visual-motor” within the framework of perception-action coupling, we are beginning to understand any given subject’s “executive functioning” in the performance of this copying task.

The Rey-Osterreith Complex Figure Test , now usually referred to as the Rey Complex Figure Test (RCFT) , which was once within the public domain, can therefore be utilized and interpreted as a measure that demonstrates how thought guides action. We have adopted a modified version of the RCFT test administration to demonstrate the process of perception-action coupling. Through this process, we have noticed that, even for normal control subjects, the “immediate memory” condition of this test tolerates or allows for considerable error. For example, normal control subjects can generate a reasonably accurate “copy” of the figure, earning a raw score between 35 and 36 points; however, just a few minutes later when the individual is asked to draw the complex figure from memory, a raw score of approximately 23–24 remains a satisfactory test performance. Therefore, even normal control subjects are seemingly allowed to “forget” considerable information in their reproductions and still obtain scores that would be considered representative of adequate recall. This most likely occurs because the subject has one limited exposure when copying the figure, and the “immediate memory” trial , which is not “immediate” at all because it occurs 3 min after the figure was copied, is an incidental learning and recall task, highly dependent upon how the subject initially organized and paid attention to what they were doing as they drew the figure. All practitioners who use this test must have noticed that subjects frequently approach the copy phase in a disorganized manner. Poor planning increases the likelihood of a poor copying score, and increases the likelihood of significant “forgetting” on the immediate memory and delayed recall conditions. More often than not, these types of performances are labeled as “visual-spatial” deficits ; however, in our opinion, nothing could be further from the truth. Again, the manner in which the RCFT is administered is really an incidental learning task. The raw score data may imply that normal control subjects did not necessarily “pay attention” to what they are doing when copying the figure. When a disorganized approach towards copying is observed, how can anyone expect the individual to demonstrate an acceptable performance after just a few minutes, let alone in a lengthier delay condition? In this case, a false positive error would have been committed if one diagnosed “visual-spatial” deficits based upon a poorly planned and organized approach to the copy portion which resulted in poor encoding and retrieval of information.

In our view, difficulties in copying the RCFT may result from problems in perception-action coupling , when the subject does not ask himself/herself the relevant questions, either explicitly in consciousness or implicitly, about how to efficiently copy the figure. Therefore, when a disorganized approach at copying is observed, and after we complete the administration of the test in the standardized way, we proceed with a modified method of administration. This consists of the examiner drawing the figure for the subject. The figure is drawn in an organized way, and the examiner names every element for the subject, through active demonstration as the subject observes the copying. For example, as we draw the figure, we initially point out that perhaps the most obvious feature concerns the rectangle. We then proceed over to the right side of the page, and indicate that the portion of the figure on the right seems to resemble a triangle. We then proceed to draw the details of the figure, starting with the largest details and working to the smallest details. We draw the vertical line and the horizontal line, and we label these lines as such. We count the number of lines in the upper left hand quadrant and we draw that. We then count the number of lines that bifurcate the lower right corner diagonal, and we proceed to draw them as we name them. As we move to the upper right hand quadrant, we draw the circle with three dots, informing the subject that sometimes people might refer to this as a face, while at other times, some people refer to this as what might look like a bowling ball. We proceed to draw the figure in an organized fashion, labeling every element, until the figure is complete.

After this demonstration, we ask the subject to draw the figure in the exact same way that we drew it. We ask them to copy the figure again, and to silently talk themselves through the drawing process while silently labeling each aspect of the design. When the subject completes the drawing in this organized fashion, we then ask which way of drawing the figure was easier: the patient’s original way, or the more organized approach demonstrated by the examiner. Most patients agree that they preferred the examiner’s method for organizing the drawing. Then, we distract the patients by engaging in another task for approximately 3 min. We then present the subject with a blank sheet of paper, and we ask the subject to recall as much of the figure as possible. In this phase of the test administration , we almost always obtain a significantly improved drawing. We then present the patient with a blank sheet of paper approximately 3 min later, and we ask them to draw the figure again. We observe that nearly all patients are, again, capable of reproducing a dramatically improved design. We then administer a 30 min recall. In fact, some of the authors of this manuscript have asked the patients for a 24-h recall when the patient is seen on two consecutive days. Once again, we find that most of the figure is retained. So in this modified administration methodology, the patient generates five sample “products ”: standard copy administration and immediate recall; this is followed by another copy phase after the patient observes a systematic drawing of the figure, followed again by immediate and delayed recall trials, all for purposes of comparison. A sixth recall after 24 h is optional, dependent upon circumstances. These multiple trials are all interpreted according to an individual comparison standard, so that the subject acts as his/her own control or “baseline.”

By administering the task in this modified way, several important points are clarified. First, the “traditional,” and often “knee-jerk” interpretation of “visual-spatial deficit ” is immediately taken off the table. An improved performance after using the “demonstration methodology ” illustrates the person can draw, that the subject paid attention to what they were doing, and that he/she “retained” a good approximation of the stimulus figure. This must mean the VAN and DAN were recruited for perception and analysis, and that the FPN and SMN were recruited for successful execution of the task. A lack of integrity within these systems, if properly identified and interpreted, would not be transient in the vast majority of cases; instead, a stable but poor level of functioning in these areas would be predicted. Second, the individual demonstrated that memory for that type of material is intact. If this interpretation was incorrect, whether or not every aspect of the design was labeled, poor information retrieval would be expected, evidenced by poor performance in spite of the demonstrated, planned approach. Therefore, in this modified administration, false positive error can often be reduced or even eliminated. Interpretatively useful information is easily obtained. Furthermore, the integrity of perception-action coupling, the critical “linkage system ” within working memory, is demonstrated by inference. To prove these points, the individual’s cognitive control system is initially supported by the examiner. Through the utilization of this process of administration, the examiner supports the examinee in coupling a perception with the appropriate action. Once that linkage is established, the patient is able to function at a level consistent with the majority of normal control subjects. The individual learns how to guide action, or behavior. In delayed recall conditions, this methodology also mimics how the subject recruits the Default Mode Network (DMN) , for drawing upon prior experiences to guide current “actions,” or behaviors.

Case 8

This is a case vignette of a 14 year old female who was seen for an evaluation of ADHD . The copy phase of the RCFT was reasonably accurate, but when observing her performance, the approach to drawing the figure seemed poorly organized. She first drew the upper left external detail; this was followed by the horizontal line on the bottom of the figure; next came the “box” in the lower left aspect of the design and the horizontal line from it; this was followed by the top horizontal line, and then the vertical line extending throughout the figure and connecting to the horizontal line that runs from the lower left corner “box.” All of the quadrants were drawn as independent segments—this can easily be determined by inspecting the final product, since the horizontal, vertical, and diagonal lines do not properly intersect, usually a tell-tail sign of a disorganized drawing approach. From our observational experience, we have concluded that unless an individual draws the outline initially, which provides a Gestalt framework, it is very difficult to recall the figure, even upon “immediate recall,” without even providing a 3-min interval before recall. However, just as Shorr and colleagues found in neuropsychiatric populations, fragmentary recall, and/or aspects of “configurations” or perceptual clustering on recall trials is a significantly better predictor of memory performance than is initial copy accuracy [35]. This proved to be the case for this patient’s recall. The figures for “CASE II” illustrate this, as well as the fact that this individual was able to benefit from the “demonstration approach ,” which improved the copying of the figure, while dramatically demonstrating notably improved recall, both after 3 min and after 24 h. These data provide a classic example of how the “textbook” administration would have inevitably generated a false positive error, not to mention the omission of the substantive information that was gained by modifying the administration. This clinical information includes the fact this adolescent demonstrated disorganization when completing a novel, problem-solving drawing task independently, that she was capable of “learning” the “working memory” and perception-action coupling necessary for task completion, while suggesting she would benefit from structured, directed treatment and management approaches.

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In this regard, we are well aware of the controversy concerning the evidence to support the use of the RCFT in the measurement of executive functioning in children [36]. However, many studies use children from young school age through adolescence in their samples, and we cannot expect such a broad age-range to execute the task with the same level of skill sets [37]. Studies also correlate RCFT performance with other measures of executive function task performance and find weak relationships, but this should be expected. In our view, and as presented in ADHD as a Model of Brain-Behavior Relationships [49] and The Myth of Executive Functioning [50], executive functions are not a monolithic entity. Cole [38] found that tasks always recruit multiple and different brain regions, and we posit that there is no “executive function” per se, but instead, FPNs that flexibly recruit whatever brain regions are required to complete any given task. This consists of a dynamically changing functional neuroanatomic substrate that is always task dependent. In this way, executive functioning can never be defined or understood apart from the task which is used to assess it. And, to the extent that the RCFT requires perception-action linkages, either explicitly or implicitly, it is dependent upon a process of working memory, in which perceptions/ideas guide action, or test performance. And, this requires a paradigm shift in the way in which we understand terms such as “executive function ” and “working memory .”

Case 9: RCFT Evidence of Compromised Functioning Within the VAN, DAN, FPN, AND SMN Systems

This is a case presentation of a 13 year old girl with poorly functioning brain systems, most likely within the VAN, DAN , FPN, and SMN systems. These inferences are derived on the basis of her RCFT drawings Based upon this deficit, we would predict deficits in novel problem-solving. She obtained an average range score on the VCI; this is in very sharp contrast to her other composite index scores which typically are not as useful or revealing as they are in her case. She obtained impaired-range scores, all between the second and fifth percentile rankings, on the PRI, WMI, and PSI WISC-IV indices. This child’s history includes attention and executive function deficiencies, mixed dyslexia, dyscalculia, dysgraphia, and developmental coordination disorder. She presented with a “mixed bag” of clinical findings. She behaved in a socially out-of-step manner, but was not diagnosed with autism. Her behavior was often petulant and she failed to see her role in the negative outcomes of her decision making. This is an absolutely “perfect” presentation from which the clinical practitioner can gain important insights for understanding her adaptive difficulties.

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The patient earned a <0.02 percentile rank on the RCFT Copy task. Her approach to the task was very disorganized. For example, she started by drawing the circle with three dots. The examiner then taught the child how to copy the drawing. Her performance improved from five correct items to 15, which only yielded a 0.04 percentile. Information she encoded was available for recall on the 30-min delayed recall trial (0.3 percentile). This performance shows how the child did not appreciably benefit from teaching, but that information she encoded was available for recall. The net outcome of this RCFT clearly points to the suspicion of a lack of integrity within the brain systems presumably measured, even though the examiner deviated from the above described modified administration, which omitted the patient’s first immediate recall sample. But why are these behavioral samples still important?

There are three specific reasons, all of equal importance. First, as described in The Myth of Executive Functioning [50], the right hemisphere can be considered a novelty detector. It is critical for problem-solving, which, by definition, is novel. In ambiguous, novel situations, the human brain makes choices and decisions not only by applying information learned from prior experiences (the DMN), but instead, adaptive behaviors are also defined by the momentary “geometry ” of the immediate environment and change during continuously ongoing activity, or dynamically changing interactions [39]. Second, the right hemisphere is not irrelevant to language. Input from this hemisphere is clearly necessary for processing linguistic information such as the resolution of ambiguity when words have multiple meanings, metaphorical understanding, appreciation of humor, judgment and expression of affective language prosody, as well as the processing of the figurative and pragmatic aspects of language; all of these linguistic properties are driven by external factors that change dynamically as an inherent property of ongoing conversational discourse [9, 40]. Third, Vakalopoulos presented a very comprehensive, detailed, compelling neurodevelopmental review about how “visual-motor ” ability and motor skills contribute to empathic dysfunction, again affecting social, interactive behaviors [41]. So once again, as was emphasized in the previously mentioned volumes [49, 50], it is not at all feasible to isolate “visual-spatial” skills as relegated to some sort of artificial compartment, and therefore relatively unimportant because we live in a “verbal world.” Any fixed hemispheric assignment as in the “traditional” verbal versus visual-spatial dichotomy is unequivocally false, overly simplistic, and diagnostically misleading. Regardless of what any practitioner may have been taught, we need two functional, interacting cerebral hemispheres in order to achieve practical, successful adjustment. There is absolutely no evidence with which to generate a contrary neuroscientific viewpoint.

Therefore, the practitioner can readily extrapolate this information to her “real life” circumstances, without “bending,” or “stretching,” one single aspect of the data, while “reviewing” the neurobiologic substrates of her presentation with information derived from what we know about large scale brain systems. Although reading is first and foremost a language based skill, perceptual skills are also an early basic underpinning, although presently most likely in a minimal way as demonstrated through numerous investigations reviewed by Mann [42, 43]. Mathematics recruits a wide variety of skills, and a range of functional connectivity patterns between brain networks to support them, in order to execute computation problems and engage in borrowing, carrying, and division, etc. [44–46]. The neuroanatomic underpinnings can also be extrapolated, or inferred, from Voogd and colleagues [47], who identified the comprehensive, detailed neuroanatomy of “visual-motor” behavior . This child was also notably clumsy, which also reflects deficits in spatial-motor functioning. The neuroanatomic underpinning involves integrating information from the VAN and DAN with the sensori-motor network, or SMN ([26, 48]; Please see ADHD as a Model of Brain-Behavior Relationships [49] and The Myth of Executive Functioning [50], for additional information to provide the appropriate framework.) In short, by understanding the requirements of existing neuropsychological tests, and by possessing a working knowledge of large scale brain systems, considerable information can be derived about a subject’s presentation, as well as practically useful, predictive information about the likely course of outcome, all of which can assist in dictating treatment planning and implementation (Unfortunately, additional intervention data are beyond the scope of this chapter).

Case 10: “Everything that Counts Cannot Be Counted”

This 10 year old boy was evaluated for Attention Deficit Hyperactivity Disorder . The examiner deviated from the modified administration procedure described above. First, the standard copy version was administered, followed by the boy’s copying the figure again, followed by 3 and 30 min recall administrations. These drawings are depicted below. Upon initial administration, the patient’s product was decent upon visual inspection, but in observing him draw, his approach was markedly disorganized. After he observed a systematic drawing of the RCFT, a subtle but significant improvement in his drawing was observed, and his copying approach was considerably improved. His immediate and delayed recall of the RCFT were both intact, although admittedly, a baseline of an initial immediate recall was not available for comparison purposes.

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This case presentation remains important because the direction in which patients deploy or allocate attention while copying a figure informs the examiner about how the person analyzes and solves “spatial” problems. In other words, novel problem solving approaches are often revealed. To a large extent, we are all dependent upon the visual system. This should already be obvious, since the visual network (VN) supports the functions of both the VAN and DAN, as well as providing support for brain systems to inhibit responding to distracting influences ([26]; see the previously mentioned volumes for additional discussion). Even a seemingly common, basic task such as using a pencil and paper can provide the examiner with useful information about any given individual’s integrity of brain systems functioning [19].

Summary

In the above examples we have demonstrated that inefficient or ineffective executive functioning/cognitive control can be mediated through structure, observation, and the cognitive guidance of an examiner. We demonstrated that patients were able to learn from the experience of interacting with both the examiner and the activity in which they were engaged. We also demonstrated that explicit learning processes may translate to implicit memory processes. The RCFT cases illustrated how the process of demonstration can be useful in “pinpointing” areas of deficit, and in predicting possibly expected behaviors and general principles about structuring treatment/management. Therefore, during this administration, we acquired considerably more information about the patients than we would have by simply relying upon a standardized administration methodology. Finally, within this type of administration, the performance of a normal control subject has nothing to do with the outcome we attempted to demonstrate. Instead, we were able to use the patient as his or her own control, and then utilize an individual comparison standard in order to obtain clinically useful conclusions. We reviewed how it is possible to avoid false positive errors.

Overall, this chapter revealed how commonly available neuropsychological tests can be made more clinically useful. By going against the status quo which we believe assesses cognition from a static viewpoint, we modified current test administration practices in order to evaluate a person’s neuropsychological status from a dynamic perspective. We proposed a paradigm for assessing the individual’s ability to adapt and automate behaviors. We firmly believe that the primary purpose of thinking is to guide interactive behavior within a dynamically changing environment. This requires perception/idea—action coupling, an element of “working memory,” and we demonstrated that the Trail Making Tests and the RCFT can be administered and interpreted in an attempt to evaluate different aspects of this type of linkage. The next step in this process should be comprised of two critical components. First, systematic investigations need to be geared towards obtaining data from large groups of subjects in order to determine if our hypotheses are correct. Second, these studies need to be correlated not with other neuropsychological tests, but instead, with controlled observations, through the development of appropriate questionnaires, in order to determine whether or not what we have measured really is associated with practical, daily behaviors such as routines, as well as minor changes in these routines to determine if these paradigms are ecologically valid.