The Boston process approach


The Boston process approach is an approach to neuropsychological assessment, which was developed at the Boston Veterans Medical Center by the American psychologist, Dr. Edith Kaplan, along with her colleagues, Drs. Harold Goodglass, Nelson Butters, Laird Cermak, and Norman Geschwind.[1] It focuses on qualitative measurements of behavior[2] and arises from the premise that “equal performance on any given mental task can be accomplished by different processes or strategies”.[3] That is, because different sorts of errors by different patients may attain the same total score on a test, it is important to look at underlying processes in order to understand the particular difficulties of the individual. The goal of the approach is to create an understanding of the cognitive strengths and weaknesses of a patient.[4] It is a flexible-battery approach to neuropsychological testing, meaning the set of standardized tests given to the patient is chosen according to the patient's specific deficits.[5] In 1976, Dr. Kaplan began training neuropsychology interns to allow them to apply what she referred to at the time as the Boston approach to neuropsychological assessment of their patients.[6] The first fairly formalized and comprehensive description of Dr. Kaplan’s methods was published in the original 1986 version of her book chapter with Drs. Nancy Hebben and William Milberg,[7][8] and it was here that the term “Boston process approach” was first used. There are no overall descriptions of the approach and no instances of that term used before that chapter. The Boston process approach is currently used as a method of neuropsychological assessment, with experience in its use being considered by some to be essential or very important for applicants to internships in clinical neuropsychology.[9]

Administration

The neuropsychologist performing the assessment chooses a set of standardized tests to be administered based on the behaviors and complaints of the patient.[10] On completion, the neuropsychologist analyzes the problem-solving method that the patient used to address each question. Any unusual errors are further investigated by re-administration of modified versions of the standardized tests, with the focus of identifying the specific problem area.[11]

Qualitative analysis

The qualitative analysis focuses on closely observing the process by which a patient arrives at a final answer.[12] An example of qualitative analysis is in regard to the Block design test, which measures spatial visualization ability and motor skills. During the task the patient is asked to recreate a viewed pattern by arranging a set of blocks that have colored patterns on each side, The examiner observes the method by which the patient approaches and solves the problem, focusing, for example, on what quadrant the patient started at, which hand was used to arrange the blocks, whether the patient rotated the blocks on the table or had to lift them into space, if the image produced was either a mirror image or reversal of the pattern that the patient was supposed to create, and which side the patient made more errors on,.[13][14] This is considered qualitative analysis because it focuses on how the patient came to their final design, rather than the final design itself.[15]

Modifications

The modifications made to standardized tests can include repetition of test questions, and allowing more time than allotted in the standardized version.[16] Many standardized tests have been subject to process-based modifications including the Wechsler Adult Intelligence Scale Revised as a Neuropsychological Instrument (WAIS-R NI), Wechsler Intelligence Scale for Children (WISC-IV), Raven's Progressive Matrices (RPM), Shipley Institute of Living Scale, Wisconsin Card Sorting Test (WCST), Proverbs Test, Visual Verbal Test, Wechsler Memory Scale-Revised (WMS-R), California Verbal Learning Test (CVLT), Rey-Osterrieth Complex Figure (ROCF), Benton Visual Retention Test (BVRT) (multiple choice form), Consonant Trigrams Test, Cowboy Story Reading Memory Test, tests involving verbal fluency, narrative writing sample, Boston Naming Test (BNT), Cow and Circle Experimental Puzzles, Automobile Puzzle, Spatial Quantitative Battery, Judgment of Line Orientation (JLO), Wide Range Achievement Test (WRAT4), Porteus Maze Test (PMT), Stroop Task, Luria Three-Step Motor Program, Grooved Peg Board, California Proverb Test, Boston Evaluation of Executive Function, Boston/Rochester Neuropsychological Screening Test, Geriatric Evaluation of Mental Status.[17]

Interpretation

The results obtained from using the Boston process approach allow the clinician to make inferences about what brain areas have been affected in the patient. The interpretation of the data focuses more on the errors made during the examination, rather than the overall score on the test.[18] The exhibition of either low-level or higher-level deficits of cognitive processing allows for inference about what level the damage occurred.[19]

Critiques

Critiques of the Boston process approach are that there are no supporting norms and no standardized methods of assessing the patient’s deficits.[20] Although these critiques have been addressed in part by standardizing methods of administration and scoring to allow the findings to be replicated,[21] in fact there are so many potential qualitative variables that not all of Dr. Kaplan’s original observations have been captured in norms or standardized. Dr. Poreh’s methods were an attempt at standardizing a part of those of Dr. Kaplan.[22] The California Verbal Learning Test and the Delis–Kaplan Executive Function System (D-KEFS) are examples of standardized tests that capture some of Dr. Kaplan's qualitative observations in the form of multiple test conditions, but still there are open questions about the empirical validity of some of her claims.

References

  1. ↑ name="Hebben, N., Kaplan, E. and Milberg, W. P." >"The Boston Process Approach to Neuropsychological Assessment." Neuropsychological Assessment of Neuropsychiatric and Neuromedical Disorders Ed. I. Grant & K. M. Adams. New York: Oxford Press 2009. 42–65. Print
  2. ↑ Ashendorf L., Libon D., and Swenson, R. The Boston Process Approach to Neuropsychological Assessment: A Practitioner’s Guide. New York: Oxford University Press, 2013. Print
  3. ↑ Milberg, W. and Hebben, N. Historical Foundations of the Boston Process Approach In Ashendorf, L., Libon, D.J., & Swenson, R. (Eds.) The Boston Process Approach to Neuropsychological Assessment.New York: Oxford 2013
  4. ↑ Milberg, W. and Hebben, N. Historical Foundations of the Boston Process Approach in Ashendorf, L., Libon, D.J., & Swenson, R. (Eds.) The Boston Process Approach to Neuropsychological Assessment.New York: Oxford 2013
  5. ↑ Sherman E. MS., Spreen, O., and Strauss, E. A Compendium of Neuropsychological Tests: Administration, Norms, and Commentary, Third Edition. 3rd ed. New York: Oxford UP, 2006. Print.
  6. ↑ Milberg, W. and Hebben, N. Historical Foundations of the Boston Process Approach in Ashendorf, L., Libon, D.J., & Swenson, R. (Eds.) The Boston Process Approach to Neuropsychological Assessment.New York: Oxford 2013
  7. ↑ Hebben, N., Kaplan, E. and Milberg, W. P. "The Boston Process Approach to Neuropsychological Assessment." Neuropsychological Assessment of Neuropsychiatric and Neuromedical Disorders Ed. I. Grant & K. M. Adams. New York: Oxford Press 2009. 42–65. Print
  8. ↑ Milberg WP, Hebben NA, Kaplan E. The Boston process approach to neuropsychological assessment. In: I. Grant (Ed.), Neuropsychological Assessment of Neuropsychiatric Disorders. New York: Oxford University Press, 1986.
  9. ↑ Mittenberg, W., Odland, A.P., Ritchie, A.S., and Ritchie, D. “Selection Criteria for Internships in Clinical Neuropsychology.” The Clinical Neuropsychologist, 26.8 (2012):, 1245–1254.Web.
  10. ↑ Rose, F., and White, R. "The Boston Process Approach." Contemporary Approaches to Neuropsychological Assessment. Ed. G. Goldstein & T. M. Incagnoli. Springer US, 1997. 171–211. Print.
  11. ↑ Hebben, N., Kaplan, E. and Milberg, W. P. "The Boston Process Approach to Neuropsychological Assessment." Neuropsychological Assessment of Neuropsychiatric and Neuromedical Disorders Ed. I. Grant & K. M. Adams. New York: Oxford Press 2009. 42–65. Print
  12. ↑ Kaplan, E. "The Process Approach to Neuropsychological Assessment." Aphasiology 2.3–4 (1988): 309–311. Web.
  13. ↑ Hebben, N., Kaplan, E. and Milberg, W. P. "The Boston Process Approach to Neuropsychological Assessment." Neuropsychological Assessment of Neuropsychiatric and Neuromedical Disorders Ed. I. Grant & K. M. Adams. New York: Oxford Press 2009. 42–65. Print
  14. ↑ Geschwind N, Kaplan E: A human cerebral deconnection syndrome: A preliminary report .Neurology 1962;12:675–685.
  15. ↑ Erickson, R. C. "A Review and Critique of The Process Approach in Neuropsychological Assessment." Neuropsychology Review 5.4 (1995): 223–243. Web.
  16. ↑ Sherman E. MS., Spreen, O., and Strauss, E. A Compendium of Neuropsychological Tests: Administration, Norms, and Commentary, Third Edition. 3rd ed. New York: Oxford UP, 2006. Print.
  17. ↑ Hebben, N., Kaplan, E. and Milberg, W. P. "The Boston Process Approach to Neuropsychological Assessment." Neuropsychological Assessment of Neuropsychiatric and Neuromedical Disorders Ed. I. Grant & K. M. Adams. New York: Oxford Press 2009. 42–65. Print
  18. ↑ Kaplan, E. "The Process Approach to Neuropsychological Assessment." Aphasiology 2.3–4 (1988): 309–311. Web.
  19. ↑ Hebben, N., Kaplan, E. and Milberg, W. P. "The Boston Process Approach to Neuropsychological Assessment." Neuropsychological Assessment of Neuropsychiatric and Neuromedical Disorders Ed. I. Grant & K. M. Adams. New York: Oxford Press 2009. 42–65. Print
  20. ↑ Milberg, W. and Hebben, N. Historical Foundations of the Boston Process Approach In Ashendorf, L., Libon, D.J., & Swenson, R. (Eds.) The Boston Process Approach to Neuropsychological Assessment.New York: Oxford 2013
  21. ↑ Poreh, Amir M. “ A Brief Introduction to The Quantified Process Approach" The Quantified Process Approach to Neuropsychological Assessment. Ed. A. M. Poreh. London: Psychology Press, 2012. 3–16. Print.
  22. ↑ Poreh, Amir M. “ A Brief Introduction to The Quantified Process Approach" The Quantified Process Approach to Neuropsychological Assessment. Ed. A. M. Poreh. London: Psychology Press, 2012. 3–16. Print.


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