The Halstead-Reitan Neuropsychological Test Battery is a fixed set of eight tests used to evaluate brain and nervous system functioning in individuals aged 15 years and older. Children’s versions are the Halstead Neuropsychological Test Battery for Older Children (ages nine to 14) and the Reitan Indiana Neuropsychological Test Battery (ages five to eight).
Neuropsychological functioning refers to the ability of the nervous system and brain to process and interpret information received through the senses. The Halstead-Reitan evaluates a wide range of nervous system and brain functions, including visual, auditory, and tactual input; verbal communication; spatial and sequential perception; the ability to analyze information, form mental concepts, and make judgments; motor output; and attention, concentration, and memory.
The Halstead-Reitan is typically used to evaluate individuals with suspected brain damage. The battery also provides useful information regarding the cause of damage (for example, closed head injury, alcohol abuse, Alzheimer’s disease, stroke ), which part of the brain is damaged, whether the damage occurred during childhood development, and whether the damage is getting worse, staying the same, or getting better. Information regarding the severity of impairment and areas of personal strengths can be used to develop plans for rehabilitation or care.
Because of its complexity, the Halstead-Reitan requires administration by a professional examiner and interpretation by a trained psychologist. Test results are affected by the examinee’s age, education level, intellectual ability, and—to some extent—gender or ethnicity, which should always be taken into account. Because the Halstead-Reitan is a fixed battery of tests, some unnecessary information may be gathered or some important information may be missed. Overall, the battery requires five to six hours to complete, involving considerable patience, stamina, and cost. The battery has also been criticized for not including specific tests of memory; rather, memory is evaluated within the context of other tests.
Ward Halstead and Ralph Reitan are the developers of the Halstead-Reitan Battery. Based on studies of patients with neurologic impairments at the University of Chicago, Halstead recognized the need for an evaluation of brain functioning that was more extensive than intelligence testing. He began experimenting with psychological tests that might help identify types and severity of brain damage through observation of a person’s behavior in various tasks involving neuropsychological abilities. Initially he chose a set of ten tests; all but three are in the current Halstead-Reitan Battery.
Ralph Reitan, one of Halstead’s students, contributed to the battery by researching the tests’ ability to identify neurological problems. In a remarkable study, Reitan diagnosed 8,000 patients using only their test results—without meeting the patients or knowing anything about their background. This provided strong support for the battery’s effectiveness. Reitan adapted the original battery by including additional tests.
The Halstead-Reitan has been researched more than any other neuropsychological test battery. Research continues to support its ability to accurately detect impairment in a large range of neuropsychological functions.
A series of 208 pictures consisting of geometric figures are presented, sorted in groups according to some underlying principle, which the test subject is asked to determine. For each picture, individuals are asked to decide which of four principles they believe is represented and to press a key that corresponds to the number of choice. If they chose correctly, a chime sounds. If they chose incorrectly, a buzzer sounds. The pictures are presented in seven subtests.
The key to this test is that one principle, or common characteristic, underlies each subtest. The numbers 1, 2, 3, and 4 represent the possible principles. If individuals are able to recognize the correct principle in one picture, they will respond correctly for the remaining pictures in that subtest. The next subtest may have the same or a different underlying principle, and individuals must again try to determine that principle using the feedback of the chime and buzzer. The last subtest contains two underlying principles. The test takes approximately one hour to complete, but individuals with severe brain damage may take as long as two hours.
The Category Test is considered the battery’s most effective test for detecting brain damage, but does not help determine where the problem is occurring in the brain. The test evaluates abstraction ability, or the ability to draw specific conclusions from general information. Related abilities are solving complex and unique problems, and learning from experience. Children’s versions consist of 80 items and five subtests for young children, and 168 items and six subtests for older children.
Scoring involves recording the number of errors. Based on traditional scoring using cutoff values (cutoff scores are scores that indicate the borderline between normal and impaired functioning), scores above 41 are considered indicative of brain impairment for ages 15 to 45. For ages 46 and older, scores above 46 indicate impairment. Reitan has suggested a cutoff of 50 or 51 errors. Recommended cutoffs also vary depending on age and education level.
Tactual Performance Test
A form board containing 10 cutout shapes, and 10 wooden blocks matching those shapes are placed in front of a blindfolded individual. Individuals are then instructed to use only their dominant hand to place the blocks in their appropriate space on the form board. The same procedure is repeated using only the non-dominant hand, and then using both hands. Finally, the form board and blocks are removed, followed by the blindfold. From memory, individuals are asked to draw the form board and the shapes in their proper locations. The test usually takes anywhere from 15 to 50 minutes to complete. There is a time limit of 15 minutes for each trial, or each performance segment.
Other names for this test are the Form Board Test and the Seguin-Goddard Formboard. It evaluates sensory ability, memory for shapes and spatial location, motor functions, and the brain’s ability to transfer information between its two hemispheres. In addition to simple detection of brain damage, this test also helps determine the side of the brain where damage may have occurred. For children under the age of 15, only six shapes are used.
Scoring involves recording the time to complete each of the three blindfolded trials and the total time for all trials combined (time score), the number of shapes recalled (memory score), and the number of shapes drawn in their correct locations (localization score). Generally, the trial for the non-dominant hand should be 20-30% faster than the trial for the dominant hand, due to the benefit of practice. If the non-dominant hand is slower than the dominant hand—it should be slower, but is a question of how much slower—or more than 30% faster than the dominant hand, brain damage is possible. However, some people without brain damage do not exhibit this typical improvement rate. Injuries of the arms, shoulders, or hands can also affect performance. Scores should be adjusted depending on education level and may vary depending on age.
Trail Making Test
This test consists of two parts. Part A is a page with 25 numbered circles randomly arranged. Individuals are instructed to draw lines between the circles in increasing sequential order until they reach the circle labeled “End.” Part B is a page with circles containing the letters A through L and 13 numbered circles intermixed and randomly arranged. Individuals are instructed to connect the circles by drawing lines alternating between numbers and letters in sequential order, until they reach the circle labeled “End.”If individuals make mistakes, the mistakes are quickly brought to their attention, and they continue from the last correct circle. The test takes approximately five to 10 minutes to complete.
This test was originally known as Partingon’s Pathways, or the Divided Attention Test, which was part of the Army Individual Test Battery. The test evaluates information-processing speed, visual-scanning ability, integration of visual and motor functions, letter and number recognition and sequencing, and the ability to maintain two different trains of thought. The test can be administered orally if an individual is incapable of writing. The Color Trails Test, designed for children and individuals of different cultures, uses colors instead of numbers and letters.
Scoring is simply the time to complete each part. Errors naturally increase the total time. Some have argued that the time taken to alert individuals of errors may vary depending on the person giving the test. For adults, scores above 40 seconds for Part A and 91 seconds for Part B have traditionally indicated brain impairment. Current research discourages the use of such traditional cutoffs, preferring ranges depending on age, education, and gender. For example, one study reported that for ages 15 to 19, the average time to complete Part A was 25.7 seconds and the time to complete Part B was 49.8 seconds. For ages 80 to 85, however, the average time to complete Part A was 60.7 seconds and the time to complete Part B was 152.2 seconds. This demonstrates the importance of considering other variables when scoring.
Finger Tapping Test
Individuals place their dominant hand palm down, fingers extended, with the index finger resting on a lever that is attached to a counting device. Individuals are instructed to tap their index finger as quickly as possible for ten seconds, keeping the hand and arm stationary. This trial is repeated five to 10 times, until the examiner has collected counts for five consecutive trials that are within five taps of each other. Before starting the test, individuals are given a practice session. They are also given brief rests between each 10-second trial, and one- to two-minute rests after every third trial. This entire procedure is repeated with the nondominant hand. The test takes approximately 10 minutes to complete.
This test is also called the Finger Oscillation Test. The children’s version uses an electronic tapper instead of a manual one, which was difficult for children to operate. The test measures motor speed and helps determine particular areas of the brain that may be damaged. Scoring involves using the five accepted trials to calculate an average number of taps per trial for each hand. In general, the dominant hand should perform 10% better than the nondominant hand. Yet this is not always the case, especially with left-handed individuals. Men and younger people tend to perform better than women and older people. Interpretation should also consider education level, intelligence, fatigue , general weakness or lack of coordination, depression , and injuries to the shoulders, arms, or hands. This test should only be interpreted in combination with other tests in the battery.
Thirty pairs of tape-recorded, nonverbal sounds are presented. For each pair, individuals decide if the two sounds are the same or different, marking “S” or “D” respectively on their answer sheets. The pairs are grouped into three subtests. This test is also called the Seashore Rhythm Test, and is based on the Seashore Tests of Musical Ability. It evaluates auditory attention and concentration, and the ability to discriminate between nonverbal sounds. The test helps detect brain damage, but not the location of damage. Adequate hearing and visual abilities are needed to take this test. Scoring is based on the number of correct items, with higher scores indicating less damage or good recovery. Scores should be interpreted along with information from other tests. Some researchers consider this test unreliable and simplistic. The children’s version does not include this test.
Speech Sounds Perception Test
Sixty tape-recorded nonsense syllables containing the sound “ee” (for example, “meer” and “weem”) are presented. After each syllable, individuals underline, from a set of four written syllables, the spelling that represents the syllable they heard. This test evaluates auditory attention and concentration and the ability to discriminate between verbal sounds. It provides some information regarding specific areas of brain damage, and may also indicate attention deficits or hearing loss. Scoring and interpretation are similar to that used for the Rhythm Test. The children’s version contains fewer syllable choices.
Reitan-Indiana Aphasia Screening Test
Aphasia is the loss of ability to understand or use written or spoken language, due to brain damage or deterioration. In this test, individuals are presented with a variety of questions and tasks that would be easy for someone without impairment. Examples of test items include verbally naming pictures, writing the name of a picture without saying the name aloud, reading printed material of increasing length, repeating words stated by the examiner, simple arithmetic problems, drawing shapes without lifting the pencil, and placing one hand to an area on the opposite side of the body.
This test is a modification of the Halstead-Wepman Aphasia Screening Test. It evaluates language-related difficulties, right/left confusion, and nonverbal tasks. A typical scoring procedure is not used because this is a screening test; its purpose is to detect possible signs of aphasia that may require further evaluation. Subtle language deficits may not be detected.
Reitan-Klove Sensory-Perceptual Examination
This test detects whether individuals are unable to perceive stimulation on one side of the body when both sides are stimulated simultaneously. It has tactile, auditory, and visual components involving the ability to (a) specify whether touch, sound, or visible movement is occurring on the right, left, or both sides of the body; (b) recall numbers assigned to particular fingers (the examiner assigns numbers by touching each finger and stating the number with the individual’s eyes closed); (c) identify numbers “written” on fingertips while eyes are closed; and (d) identify the shape of a wooden block placed in one hand by pointing to its shape on a form board with the opposite hand.
In addition to the core tests, examiners may choose to administer other tests based on the difficulties that individuals experience. Tests commonly used in combination with the Halstead-Reitan Battery include the Grip Strength Test, the Grooved Pegboard Test, the Reitan-Klove Lateral Dominance Examination, the Wechsler Memory Scale, the California Verbal Learning Test, the Buschke Selective Reminding Test, the Rey Auditory Verbal Memory Test, the Rey Complex Figure Test, the Test of Memory and Learning, the Wide Range Achievement Test , the Minnesota Multiphasic Personality Inventory , and the Wechsler Adult Intelligence Scale or Wechsler Intelligence Scales for Children. Some of these tests expand on these measures of functioning in the latest revision of the battery.
Interpretation of the Halstead-Reitan involves analysis of various factors:
- overall performance on the battery. The Halstead Impairment Index (HII) and the General Neuropsychological Deficit Scale (GNDS) are commonly used to obtain an overall score, although the latest revision now facilitates calculation of a global deficit score that reflects the number and severity of deficits or impairments and incorporates more test measures than were used in previous versions. This summary score weighs deficits more heavily than strengths, which reduces the chance that better performance on a few components of the test will hide impairments. The HII is calculated by counting the total number of tests in the impaired range, and dividing that number by the total tests administered, resulting in a decimal between zero and one (0.0-0.2: normal functioning; 0.3-0.4: mild impairment; 0.5-0.7: moderate impairment; and 0.8-1.0: severe impairment). The GNDS is calculated by assigning a value between zero and four to 42 variables contained in the tests, then summing those values (0-25: normal functioning; 26-40: mild impairment; 41-67: moderate impairment; and 68 and higher: severe impairment).
- performance on individual tests. Each test must be interpreted in relation to other tests in the battery. Significantly poor performance on one test may be due to various factors. However, if a pattern of poor performance occurs on three or more tests, or if significant discrepancies occur on two or more tests, impairment is likely.
- indications of lateralization and localization. This refers to the particular region of the brain that is damaged. Performance on sensory and motor tasks provides the necessary clues.
Abstraction —Ability to think about concepts or ideas separate from specific examples.
Aphasia —Loss of previously acquired ability to understand or use written or spoken language, due to brain damage or deterioration.
Cutoff scores —In psychological testing, scores that indicate the borderline between normal and impaired functioning.
Dominant hand —The hand that one prefers to use when performing various tasks such as writing or throwing an object.
Lateralization —The control of specific neurological functions by one side of the brain or the other; for example, in most right-handed people, language functions are controlled by the left side of the brain and spatial and visual functions are controlled by the right side of the brain.
Localization —The control of specific neurological functions by specific areas in the brain.
Motor —Involving muscle movement.
Neurologic —Pertaining to the nervous system (brain and nerve cells).
Neuropsychological functioning —The ability of the nervous system and brain to process and interpret information received through the senses.
Nondominant hand —The hand that one does not typically use when performing various tasks such as writing or throwing an object.
Tactile/tactual —A pulse rate above 100 beats per minute.
With the above information, a psychologist can diagnose the type of condition present, predict the course of the impairment (staying the same, getting better, or getting worse), and make recommendations regarding treatment, care, or rehabilitation.
In 2004, a revision in the norms used to make determinations about results on the battery was published.
This revision includes corrections based on ethnicity in addition to age, gender, and education. The results can be adjusted to demographic components, including African American or Caucasian ethnicity. Also updated is the global deficit score, which reflects the severity and number of deficits on more test measures than previously assessed. The sample used to determine the norms for this 2004 revision also was larger, including more than 1,000 adults, ages 20 to 85, for most test endpoints. The revision also has expanded measures of psychological functioning, including Wechsler scores.
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International Neuropsychology Society.700 Ackerman Road, Suite 550, Columbus, OH 43202. Telephone: (614) 263-4200. Web site: <http://www.osu.edu/ins>.
Heaton, R. K., and others. “Revised Comprehensive Norms for an Expanded Halstead-Reitan Battery: Demographically Adjusted Neuropsychological Norms for African American and Caucasian Adults.” Lutz, FL: Psychological Assessment Resources, 2004. Available online at: <http://www3.parinc.com/products/product.aspx?Productid=RCNAAC>.
Sandra L. Friedrich, MA
Emily Jane Willingham, PhD