Clinical Practice of Forensic Neuropsychology: An Evidence-Based Approach

One of the main attractions of Clinical Practice of Forensic Neuropsychology: An Evidence-Based Approach is that it is a single-author work and can be used either as a manual or read from cover to cover. It is a practical summary of the process of neuropsychological testing in a forensic setting that is both accessible to beginners and informative for forensic psychiatrists experienced in neuropsychological testing.

The text consists of eight chapters, beginning with “The Neuropsychological Exam” and ending with “Testimony,” that take the reader through each successive stage of a forensic neuropsychological consultation. The basics of the initial assessment are discussed, with chapters dealing with the “Assessment of Symptom Validity,” “PTSD,” and “The Special Problem of Mild Traumatic Brain Injury” that describe the how and the why of assessment. Tests are reviewed individually in a systematic manner. The presentation of the statistical data is clear and accessible.

After the first chapter dealing with the examination, Dr. Brauer Boone devotes three chapters to the topic of symptom validity testing. Here, as in other chapters, she takes us through the commonly used tests, summarizing how each test works and what the research shows for the test. Her reviews of how the tests measure up in sensitivity (a measure of the frequency with which true positives actually test positive) and specificity (a measure of the frequency with which true negatives are detected by a test) in particular remind us that even tests long in use in the field, such as the Structured Interview of Reported Symptoms (SIRS), can, depending on how the test is scored, yield results that are far less specific or sensitive than one might expect. Should this test be scored improperly under certain circumstances, the results would be rendered virtually worthless. Forensic psychiatrists in training and those unfamiliar with neuropsychological testing will find the summaries in the book helpful when using test results to support opinions in evaluations.

My one regret is that Bauer Boone did not address informed consent for neuropsychological testing in relation to validity testing and tests for malingering in more detail. This is a controversial area within neuropsychology. She elides the question of informed consent by stating on page 5 that when a person contracts with an attorney to represent him, decisions about participation in psychological testing are made by the attorney. This assertion took me by surprise. First, observers are not allowed to be present because of validity concerns in many if not all jurisdictions, and because most attorneys are not sufficiently knowledgeable about the relative strengths and weaknesses of specific tests, it is hard to see how they could be helpful even if they were present. Second, I was surprised to see the attorney characterized as the decision-maker in the attorney–client relationship. Consistent with experience in practice, review of Rule 1.2(a) of the American Bar Association's Model Rules of Professional Conduct places the authority for decision-making in the hands of the client. With respect to the client–lawyer relationship, in addressing the allocation of authority, the rule states that the lawyer must abide by the client's decisions, unless there are ethics-related or legal reasons why he cannot.¹

Bauer Boone's next point is that defense counsel has the right and indeed the obligation to obtain information useful to the defense, including conducting its own examination, and should the plaintiff refuse to undergo an examination arranged by the defense, defense counsel could reasonably request that the case be dismissed. Furthermore, in some jurisdictions, the consent of the subject is not required at all. All this is true of course, but, if anything, it suggests that more care, not less, be paid to informed consent. In Form 1.2 on page 6 of the book, there is no mention that validity testing should be conducted in a manner that would be easily understood by the average plaintiff. The form leaves one with the distinct impression that what one sees is all there is and that the only possible choice is for the subject to consent to all the tests or none. The unspoken fact is that subjects are not informed about specific tests, the predictive value of the results, and the uses to which the results can be and are put at trial, something any reasonable person would need to know in making an informed decision.

The author's points about validity are well taken, however, and the topic is worthy of more attention. I look forward to seeing how she addresses these concerns in the second edition.

Overall, the book is useful as a manual that provides a highly accessible overview of tests that will be useful for early-career and experienced forensic psychiatrists alike.

• © 2014 American Academy of Psychiatry and the Law