Assessment of memory in rehabilitation counseling.

The development of neuropsychology and the study of human memory have demonstrated that individuals with a number of different disabilities are at risk for memory deficits. Substance abuse, HIV infection/AIDS, mental retardation, schizophrenia, and diabetes mellitus are examples of clinical diagnoses that carry a risk for concomitant memory disturbances (Lezak, 1995).

Ruff and Schraa (2001) suggested that detecting the specific cognitive difficulties of clients not only assists in planning rehabilitation but also facilitates client awareness of such problems and engagement in participating more fully in the rehabilitation program. Stringer and Naldone (2000) described the role of neuropsychological assessment in rehabilitation settings and in planning of vocational/educational goals. They pointed out the importance of identifying cognitive and behavioral deficits to better understand their possible effects on the individual's ability to carry out activities of daily living. Also, by identifying such deficits, cognitive rehabilitation efforts can be designed to integrate with other rehabilitation programming. Memory deficits, for example, may compromise the learning of a work routine and adaptation to new contexts. The identification of memory difficulties allows the rehabilitation counselor to include mnemonic strategies and compensation procedures in the rehabilitation plan that may facilitate successful outcomes.

Traditionally, rehabilitation counselors have tended to refer clients for neuropsychological assessment only when their primary diagnoses have a clear and direct relation to neurological deficits. According to data from the Longitudinal Study of Vocational Rehabilitation Search Program (n.d.), counselors referred only 338 clients for neuropsychological assessment from a sample of 8,500 DVR clients, even though the sample included 170 clients with traumatic brain injury as the primary disability. It appears that potential memory deficits may often not be assessed, even when the risk of occurrence is substantial, which may lead to unrealistic goals and failure to achieve successful rehabilitation outcomes.

The present paper will focus on memory assessment in vocational rehabilitation for clients who may not have diagnosed neurological disorders but may be at risk for significant memory deficits. First, a summary of the major theoretical aspects of memory as a construct will be presented, along with studies of memory disorders in individuals with diagnoses of schizophrenia, substance abuse, and mental retardation, providing examples of groups of clients that may benefit from memory assessment. Later, a model of assessment will be suggested and major memory assessment tools will be presented as instruments to be used in the assessment of memory in rehabilitation settings.

Theoretical Models of Memory Function

Lezak (1995) defined memory as "the complex systems by means of which an organism registers, stores, retains, and retrieves some previous exposure to an event or experience" (p. 429). Memory is intertwined with learning and, consequently, is important to the successful implementation of many rehabilitation services and interventions.

There is agreement in the literature that memory cannot be regarded as a unitary faculty (Baddeley, 2002). Several classification systems have been proposed, for example, according to duration (short-term and long-term memory) and content (declarative and non-declarative memory). A thorough review of theories of memory is beyond the scope of the present paper, and only a few of the most relevant aspects of the psychology of memory to vocational rehabilitation will be considered here.

Memory is frequently viewed in terms of three stages: encoding (the processes by which information is registered), storage (the maintenance of information over time), and retrieval (the accessing of information). These processes are engaged by a variety of brain structures which are governed and regulated by mechanisms of facilitation and inhibition. Memory difficulties can be related to an array of circumstances linked to both anatomical and chemical changes in the brain and external/contextual features of events/stimuli.

From a mnemonic duration perspective, memory traces are distinguished based on the duration and the capacity of the storage (Sohlberg, & Mateer, 2001). Two major memory systems can be listed: working memory and long-term memory. Working memory has been defined as a limited capacity memory that is used for manipulating information while reasoning and learning (Baddeley, 1997). It comprehends the central executive (an attentional controller), a phonological loop (a store that holds memory traces for a couple of seconds using subvocal speech), and the visuospatial sketchpad (the temporary storage and manipulation of visual and spatial information) (Baddeley, 1997). The working memory system influences the following abilities: attending to current events, maintaining selected information, and integrating the information with experiences stored in long-term memory (Oram, Geffen, Geffen, Kavanagh, & McGrath, 2005).

Long-term memory would hold the information permanently and would also have an unlimited capacity of storage. It can be subdivided considering on the basis of content: explicit (declarative) and implicit (non-declarative) memory. Declarative memory concerns the capacity to recollect specific experiences from the past, called episodic memory, as well as the generic knowledge of the world, called semantic memory (Baddeley, 2002). Implicit memory refers to retention of the processes that are involved in performing tasks such as automatic skills and habits (Cermak, 1990). Furthermore, memory can also be classified according to a temporal perspective: retrospective memory, or recalling experiences and facts from the past, and prospective memory, or realizing delayed intentions to be performed in the future (Brandimonte, Einstein, & McDaniel, 1996).

The complexity of human mnemonic function becomes evident when underlying theoretical models are analyzed. The formulation of a theoretical construct of memory is of great relevance to achieving a better understanding of clinical cases; however, it is not sufficient. The identification of the different types of memory deficits prevalent in a specific group, and the development of assessment instruments that provide reliable and valid information, have been a focus of attention among researchers and practitioners (Backman, Jones, Berger, Laukka, & Small, 2005; Soutor, Chen, Streisand, 2004).

Ruff and Schraa (2001) suggested that understanding the dichotomy between declarative and procedural (implicit) memory can be extremely useful in the context of rehabilitation. As procedural memory is frequently preserved when cognitive dysfunction occurs, intervention plans should consider strategies based on this preserved function and should utilize compensatory procedures to address declarative deficits (e.g. therapist names, times medication should be taken). The identification of problems in the audio-verbal or visuospatial modes of memory and learning can also provide useful information, as rehabilitation interventions could prioritize the preserved mode of processing and storing information.

As previously noted, assessment of memory in vocational rehabilitation is seldom conducted with clients without a diagnosed neurological disease. Individuals with a variety of disabilities that are not primarily neurological disorders may also present memory deficits that compromise rehabilitation outcomes (Backman, Jones, Laukka, & Small, 2005; DeLuca, Christodoulou, Diramond, Rosestein, Kramer, Ricker, et al., 2004; Soutor, Chen, & Streisand, 2004).

Individuals at Risk of Developing Memory Deficits

Among the groups of clients who may be at particular risk for memory deficits are those with alcohol and other drug abuse (AODA) problems, schizophrenia, and mental retardation. The present paper will focus on these three disability groups, as these types of disabilities are often seen in vocational rehabilitation programs, and a considerable amount of research about the neurocognitive deficits associated with these disabilities has been conducted.

Memory and Alcohol and Other Drug Abuse

The National Institute on Alcohol Abuse and Alcoholism's 2001-2002 epidemiological study reported that approximately 12.9% of the 18-44 age group could be considered to meet the DSM-IV diagnostic criteria for alcohol abuse (National Institute on Alcohol and Alcoholism, n. d.). Chronic alcohol consumption is related to anatomical changes, such as shrinkage of brain tissue and changes in the white matter microstructure (Sullivan, & Pfefferbaum, 2003). Individuals who abuse alcohol frequently present cognitive and motor deficits (Lezak, 1995; Selby, & Azrin, 1998). Neuropsychological assessment of persons with chronic alcoholism provided evidence of persistent deficits, even after a period of sobriety (Munro, Saxton, & Buttes, 2000; Sullivan, Fama, Rosenbloom, & Pfefferbaum, 2002).

Evidence of memory deficits in AODA. In the medical literature there is at least one well described alcohol related dementia, Wernicke-Korsakoff's syndrome (Victor, Adams, Collins, 1989). Korsakoff's syndrome is characterized by profound remote and anterograde memory impairment (Fama, Marsh, Sullivan, 2004). However, more subtle memory deficits have been recently described in groups with alcohol dependence (Bowden, 1990). Cermak (1990) reviewed a variety of studies that documented a high prevalence of memory deficits in individuals with chronic alcoholism. Premature cognitive aging was found to be common, with memory scores below same-aged controls. In addition, intrusion errors in verbal memory tasks were common, along with significant difficulties when tasks were complex and numerous. Also, a group of 12 persons with alcohol-dependence, without clinical diagnoses of Wernicke-Korsakoff syndrome, was given a working memory task (Ambrose, Bowden, & Whelan, 2001) and results suggested that both encoding and storage of information may be compromised.

Fals-Stewart and Bates (2003) identified several variables that correlated with memory, as measured by Wechsler Memory Scale learning and memory scores and the Rey-Osterrieth Complex Figure, in a group of individuals with substance abuse problems. As expected, the most robust predictors of ability were estimates of pre-morbid functioning and years of education. Nevertheless, the percentage of days of heavy drinking reported, numbers of years of alcohol use, and presence of head injury were important factors as well. In another study, Darke, Sims, McDonald, and Wickes (2000) also reported that individuals in methadone maintenance programs presented significantly lower scores on all neuropsychological measures tested (including memory), when compared to a control group. Darke et al. also pointed out that noncompliance with clinic routines and instructions, and other behaviors observed within this group, may reflect inability rather than lack of motivation or personality characteristics. In short, there is evidence indicating that individuals who abuse alcohol and other drugs frequently present memory deficits that may affect rehabilitation programming.

Rehabilitation and memory deficits in AODA. The role of neuropsychological impairment in rehabilitation outcome of persons with chronic alcohol dependence/abuse is still not well understood. Frequently, 30% or more of persons entering addiction treatment present mild to severe neuropsychological deficits (Meek, Clark, & Solana, 1989; O'Malley, Adamse, Heaton, & Gawin, 1992). Bates, Bowden, and Barry (2002) explored five possible models where neuropsychological impairment would have a direct impact on treatment outcome or roles as a moderator or mediator influencing the relationship of other risk factors on treatment outcome. The purpose of cognitive rehabilitation in AODA treatment would be to improve cognitive functioning, enhancing the recovery process. Literature suggests that individuals with time-limited impairment tend to improve after restorative techniques are used and that persons with persistent impairments benefit from compensatory strategies (Bates, Bowden, & Barry, 2002). Bates, Voelbel, Buckman, Labouvie, and Barry (2005) investigated short-term neuropsychological recovery in 197 persons in a program for substance abuse. After six weeks of treatment, memory showed a significant improvement which may have clinical relevance when considering overall treatment outcomes. Tapert, Ozyurt, Myers, and Brown (2004) studied the relationship between neuropsychological functioning and coping strategies in predicting outcome after 12 months of discharge from an alcohol treatment facility. Results appeared to indicate that neuropsycholgical abilities moderated the relationship between coping and recovery one year after treatment. In sum, the exact role of memory deficits in rehabilitation outcomes of persons with AODA is still not determined; there is evidence that cognitive rehabilitation strategies enhance treatment outcomes in this population.

Memory and Schizophrenia

According to the National Institute of Mental Health (NIMH, n. d.), approximately 1.1% of the American population, age 18 and older, have schizophrenia in a given year. Disorders of thought (e.g., content of thoughts and illogical thoughts) are one of the major characteristics of schizophrenia (Saddock, Saddock, & Kaplan, 2000). Palmer, Heaton, Kuck, and Braff (1997) assessed neurocognitive function in 171 persons with schizophrenia and found that 76% showed significant deficits. The presence of neuropsychological impairments in schizophrenia is already well documented, and some authors have suggested that memory is one of the most commonly affected functions (e.g., Wilk, Gold, Iannone, & Buchanan, 2005). Antipsychotic drugs have been effective in treating positive symptoms of schizophrenia (e.g., hallucinations and delusions), allowing many persons with schizophrenia to live in the community. However, pharmacological treatment (especially with first-generation antipsychotics) does not seem to improve cognitive deficits (Gold, 2004), and additional rehabilitation strategies appear to be necessary.

In April 2003, a panel of experts created the NIMH-Measurement and Treatment Research to Improve Cognition in Schizophrenia (MATRICS) initiative. This work group had as one of their objectives to determine the major separable cognitive impairments in schizophrenia (Nuechterlein, Barch, Gold, Goldberg, Green, & Heaton, 2004). The MATRICS group reviewed the literature and, using principal component analysis, identified seven cognitive factors affected in schizophrenia: Speed of Processing, Attention/Vigilance, Working Memory, Verbal Learning and Memory, Visual Learning and Memory, Reasoning and Problem Solving, and Verbal Comprehension. Research data suggested that impairment in cognition appears to be a stable feature of the illness and that memory deficits are commonly found.

Evidence of memory deficits in schizophrenia. McKenna, Ornstein, and Baddeley (2002) wrote an extensive review of the literature on memory deficits in schizophrenia. They concluded that the impairment of memory functions is frequently observed; however, some specific types of memory function may be affected more than others. For example, deficits in episodic long-term memory may occur, with procedural and implicit memory preserved. The disruption of memory occurs as a function of severity and chronicity of the disease, and the deficits seem to remain stable over time (Mockler, 1997).

Bilder, Goldman, Robinson, Reiter, Bell, Bates et al. (2000) published a study, based on 94 participants with first-episode schizophrenia after initial stabilization of the psychosis. After administering a comprehensive assessment battery, Bilder et al. concluded that the participants with schizophrenia were more impaired than a control group on every neuropsychological dimension measured. Furthermore, learning/memory deficits best distinguished participants with schizophrenia from healthy individuals in the control group. Also, this study found that such learning/memory deficits were observed even in participants with less severe generalized deficits. Heinrichs and Zakzanis (1998) conducted a meta-analysis of 204 studies published between 1980 and mid-1997 and also found that memory dysfunction was the neurocognitive domain that best differentiated individuals with schizophrenia from healthy control groups.

Aleman, Hijman, de Haan, and Kahn (1999) also conducted a meta-analysis of 70 published studies on recall and recognition memory performance between individuals with schizophrenia and control groups. In this study, memory deficits were found to be a significant and stable factor associated with schizophrenia. According to Aleman et al., the composite effect size for recall performance was large (d = 1.21). In recognition tasks, results showed a small improvement, but still in the impaired range, when compared to controls. An important finding was that potential moderator variables such as age, medication status, and duration and severity of the disease did not substantially affect memory.

Memory difficulties in schizophrenia appear to be caused by inefficient use of strategies in encoding and retrieval (Muller, Ullsperger, Hammerstein, Sachweh, & Becker, 2005). Such deficits are related to reduced working memory capacity (Stone, Gabrieli, Stebbins, & Sullivan, 1998). Fuller, Luck, McMahon, and Gold (2005) found evidence that persons with schizophrenia require at least twice as long as other control participants in consolidating items into visual working memory. Moreover, there is some evidence that deficits in working memory are related to difficulties in other functions such as problem solving (Gold, Carpenter, Randolph, Goldberg, & Weinberg, 1997), language comprehension (Condray, Steinhauer, van Kammen, & Kasparek, 1996), and planning (Hutton, Puri, Duncan, Robbins, Barnes, & Joyce, 1998).

Another important aspect of memory impairment that may be associated with schizophrenia is disturbance in semantic memory, which is expressed through distorted knowledge about some aspects of the world. Moelter, Hill, Hughett, Gur, and Ragland (2005) investigated semantic memory in 27 individuals with schizophrenia and 30 controls. After analyzing the clustering strategies of participants, Moelter et al. noticed that the group with schizophrenia used strategies that relied on isolated, non-overlapping clusters while the control group used overlapping semantic clusters. This result suggests that persons with schizophrenia have difficulties in using higher order categorization strategies, which may account in part for limited semantic retrieval abilities.

Turetsky, Moberg, Mozley, Moelter, Agrin, Gur, et al. (2002) used the California Verbal Learning Test (CVLT) to investigate the variability of memory deficits in 116 persons with diagnoses of schizophrenia. On the basis of a cluster analysis, participants were divided into three groups with different types of memory profiles (cortical, subcortical, and unimpaired). The authors suggested that categorizing individuals on the basis of type of memory deficit could provide important data in understanding neurobiological differences among individuals with schizophrenia. Those differences would also be important in planning rehabilitation interventions.

Rehabilitation and memory deficits in schizophrenia. Impairments in social and occupational functioning are frequently observed in schizophrenia. A literature review by Green (1996) indicated that there is a strong relationship between cognitive symptoms and these impairments. Marder and Fenton (2004) have suggested that improving cognition may lead to improvement of functional outcomes in schizophrenia.

Finch and Wheaton (1999) studied the pattern of services provided to vocational rehabilitation clients with mental illness and found that counseling had a positive effect on client wages. In addition, they also found that clients who had assessment and counseling as part of services provided tended to have higher wages, even when compared with other groups of clients, suggesting that assessment services may be a key component in achieving successful employment outcomes, such as higher wages.

McGurk and Mueser (2004) conducted a review of the literature to investigate relationships among cognitive functioning, symptoms, and competitive employment in clients with severe mental illness. Their study indicated a strong relationship between cognitive functioning, symptoms, and employment and also indicated that vocational rehabilitation may compensate for the effects of cognitive impairments and symptoms on work. However, McGurk and Mueser suggested that, although supported employment services are related to positive employment outcomes, cognitive function and symptoms are also important.

Learning and memory abilities appear to predict employment outcomes. Evans, Bond, Meyer, Kim, Lysaker, Gibson, et al. (2004) evaluated cognitive functioning and clinical symptoms in a group of persons with schizophrenia spectrum diagnoses enrolled in vocational services. In a four months follow-up, learning and memory were the only significant predictors of integrated employment. In addition, Fiszdon, Bryson, and Wexler (2004) studied the stability of outcomes after cognitive remediation training and found significant improvements in participants in the cognitive training group, when compared to a control group, and the improvements were sustained after 6 and 12-month follow-ups. Therefore, addressing possible memory deficits during the rehabilitation process can be beneficial for assisting clients in overcoming obstacles, including obstacles to successful vocational rehabilitation.

Memory and Mental Retardation

It is estimated that 9% of working age people in the United States have mental retardation (Center for Disease Control, n. d.), and it is another type of disability in which memory deficits are commonly observed (Turnure, 1991). As the etiology of mental retardation varies considerably and Down syndrome is the most frequent genetic cause of mild to moderate mental retardation (National Institute of Child Health and Human Development), the present paper will mainly review research conducted with persons with Down syndrome. In a review of the literature, Vicary and Carlesimo (2002) identified substantial variations in memory function among persons with mental retardation. In the context of long-term memory, individuals with mental retardation show difficulties in finding efficient encoding strategies, but once the material has been successfully stored, recovering the memory trace may be achieved.

Evidence of memory deficits in mental retardation. Vakil, Shelef-Reshef, Levy-Shift (1997) investigated declarative and procedural memory in a group of adults with mild mental retardation and found lower performance when compared to a group of school children with comparable mental age. Minsky, Spitz, and Besselieu (1985) previously had found similar results. Working memory components present some interesting differences when individuals with mental retardation are compared to individuals without intellectual deficits; more specifically, the phonological loop tends to be affected and the visuospatial sketchpad shows comparable performance. Rosenquist, Conners, and Roskos-Ewoldsen (2003) suggested that individual with mental retardation appeared to have specific difficulty in the rehearsal phase of the phonological loop.

Vicary (2004) compared individuals with Down syndrome and Williams syndrome regarding explicit and implicit memory function. Vicary found that the participants with Williams syndrome showed a similar profile during an explicit memory task, when compared to a group of individuals matched for mental age. On the other hand, individuals with Down syndrome performed more poorly on an explicit memory task as compared to both groups. When considering an implicit memory task, the group with Williams syndrome showed impairment in the ability to learn new procedures but comparable results in repetition priming tasks. In another study, Vicary, Bellucci, and Carlesimo (2005) examined visual (object characteristics) and spatial (position/motion of object) long-term memory in the groups with these same two syndromes. Results showed that individuals with Williams syndrome had greater difficulty in the learning of spatial material (memory for position/motion of objects) and individuals with Down syndrome had greater difficulties with visuo-object materials (memory for objects physical characteristics). Deficits in verbal short-term memory, with preserved visual and spatial short-term memory, have often been found in persons with Down syndrome (Kittler, Krinsky-Mchale, Devenny, 2004; Jarrold, Cowan, Hewes, Riby, 2004; Numminen, Service, Ahonen, & Ruoppila, 2001). In contrast, people diagnosed with Williams syndrome tended to present preserved functioning of the phonological loop, but considerable deficits in the visual-spatial sketchpad (Vicary, & Carlesimo, 2002).

Krinsky-Mchale, Devenny, Kittler, and Silverman (2003) examined effects of age and IQ scores on implicit memory in adults with mild and moderate mental retardation with and without Down syndrome. Krinsky et al. found that, in an implicit memory task, participants with Down syndrome were functionally equivalent to adults with unspecified mental retardation. However, when comparisons were made between persons with and without mental retardation, intelligence level was also a significant factor in implicit memory performance.

Several studies have found that individuals with Down syndrome show cognitive deterioration related to age and increased risk of developing Alzheimer's disease at an early age (Burt, Primeaux-Hart, Loveland, Cleveland, Lewis, Lesser et al., 2005; Hon, Huppert, & Holland, 1998; Krinsky-McHale, Devenny, Silverman, 2002). Oliver, Crayton, Holland, Hall, and Bradbury (1998) followed prospectively a group of persons with Down syndrome for 50 months and found that the degree of pre-existing cognitive impairment was positively associated with a faster rate of deterioration in cognitive functions, mainly orientation, learning, and memory. Consequently, assessment of memory in individuals 30 years or older with Down syndrome could play an important role in the diagnosis of degeneration (Holland, Hon, Huppert, Stevens, 2000). Recently, Krinsky-Mchale, Kitter, Brown, Jenkins, Devenny (2005) also found evidence that Williams syndrome can be associated with precocious aging and loss of cognitive abilities. Krinsky-Mchale et al. (2005) investigated implicit and explicit memory in adults with Williams syndrome. Krinsky-Mchale et al. found that Williams syndrome group performance on an implicit memory task (repetition priming) did not change with age, but their performance on an explicit memory task (free recall) was significantly reduced with age.

Rehabilitation and memory deficits in mental retardation. Individuals with mental retardation show poorer performance on memory tasks when compared to chronological age matched peers. Two methods used to enhance memory performance of individuals with mental retardation have been reported in the literature: the instructional approach and the generative approach (Carlin, Soraci, & Strawbridge, 2005). The instructional approach refers to providing instruction or external prompts which include physical cues, verbal prompts, and suggestion of strategies while performing a memory task (Bray, Saarnio, Borges, & Hawk, 1994). For example, Belmont and Butterfield (1973) reported that rehearsal strategies can significantly improve the memory of individuals with mental retardation. The generative approach encompasses the design of encoding contexts that naturally induce generative processing. Carlin, Sorac, Dennis, Chechle, and Loiselle (2001) proposed that the generative approach allowed individuals to generate multiple potential solutions during the encoding phase of a task, and later to select the best solution. Carlin et al. (2005) found that this approach can enhance memory performance of individuals with different intelligence levels and ages. Memory assessment could facilitate the development of rehabilitation plans, to the extent that patterns of learning could be evaluated, and this information could assist in the design of specific training strategies (for example, implicit vs. explicit training).

In summary, there are several types of disabilities that present an increased risk of memory deficits. Thus, it may often be important to assess the presence and nature of such difficulties and to include questions in assessment referrals to investigate such possible deficits in memory.

Assessment of Memory Problems

Several purposes of neuropsychological assessment have been identified in the literature (e.g., Byrne, Clafferty, Cosway, Grant, Hodges, Whalley et al., 2003; Gerry, 2004). Heinrichs (1990) pointed out the importance of neuropsychological assessment strategies that address rehabilitation issues, not only describing client profiles but also predicting the likely success of different interventions. In the following section, a few of the more common models of neuropsychological assessment will be described in order to, later, present the importance of the ecological model to rehabilitation.

Models of Neuropsychological Assessment

Wilson (2002) identified five models of neuropsychological assessment: psychometric, localizational, theoretical, exclusion, and ecological. The psychometric method is based on principles of standardization and the establishment of reliability, validity, norms for scoring, and interpretation. However, limitations associated with disabilities can pose difficulties in following standard administration procedures and identifying appropriate normative comparisons (Berven, 2004; Bolton, 2001; Ekstrom, & Smith, 2002). In addition, Cermak (1990) pointed out that "although standardized memory tests and batteries can assess adequately the degree of a patient's memory problem, the type of processing that leads to the problem currently cannot be assessed" (p.136). Hence, the psychometric method generally provides a classification of individual variability but tends to be much less informative regarding consequences useful for rehabilitation interventions.

The second model of neuropsychological assessment described by Wilson (2002) attempts to identify the location of damage in a particular brain region. Localization of lesions can provide important information for research purposes. Considering brain plasticity, the localization of damage may provide little information about practical memory function and may not be helpful in guiding rehabilitation. Furthermore, the development of neuroimaging techniques has reduced the need for neuropsychological tests to localize lesions in the brain (Mapou, 1988).

The third model of neuropsychological assessment described by Wilson (2002) is based on cognitive neuropsychology theories. This model provides explanations for assessment results through integrative theories that may be useful in providing guidelines for treatment design. Nevertheless, as the present understanding of memory function is still limited, so is the empirical support for rehabilitation procedures that are derived from these theoretical constructs.

The fourth model of neuropsychological assessment involves defining a condition through the exclusion of other possible explanations (Wilson, 2002). For example, when assessing memory deficits, it is common to exclude confounding factors such as poor attention, perceptual deficits, and language problems. However, understanding logically what is not related to a client cognitive deficit does not necessarily lead to a better understanding of cognitive functioning, so this approach also has limitations in facilitating the accomplishment of rehabilitation objectives.

The ecological model of assessment is the final model identified by Wilson (1993, 2002), focusing on the prediction of problems that are likely to occur in everyday life. A person's score in the impaired range of a standardized memory test does not necessarily provide information on the types of rehabilitation problems that can be expected. Sbordone (1996) defined this issue as "the functional and predictive relationship between the patient's performance on a set of neuropsychological tests and the patient's behavior in a variety of real-world settings" (p. 16). The ecological model of assessment suggests that information from the client's different environments should be gathered to facilitate interpretation of test data. Moreover, different sources of influence are recognized as interfering with a client performance, which should also be considered (e.g., socio-economic status, education, emotional distress, physical pain). Hence, an ecological assessment would consist of an investigation of the detailed history of injury, complaints of the individual and family, medical, academic, and vocational records, neurodiagnostic tests, behavioral observations, and neuropsychological testing. The test battery would include a variety of tools, such as questionnaires, inventories, and more traditional neuropsychological tests. This approach to assessment seems to follow the current trend in deriving case formulations from assessment procedures. Westmeyer (2003) described this process as the construction and test of idiographic hypotheses by referring to the problems and characteristics of the client and the reasons and conditions that contributed to the occurrence of problems, while also providing treatment recommendations.

After identifying the five assessment models and some of their limitations, it can be suggested that the assessment process should be tailored according to specific questions about the rehabilitation of a particular individual, providing the basis for the selection of assessment tools (Wilson, 2002). Such an approach can provide a flexible individualized assessment procedure, which recognizes the contributions of the various sources of information and prioritizes the individual needs of clients. Moreover, the formulation of comprehensive assessment questions is a crucial step toward the implementation of an effective assessment plan and subsequent rehabilitation interventions.

Assessment of Memory

An important component of assessment is the creation of tools that directly establish the relationship between test scores and the behavior to be predicted. In conducting research, at least two points are necessary: to understand the relationship between various cognitive functions and the specific behaviors of interest and to clarify the relationships between individual cognitive functions and specific test scores and patterns of test scores (Long, 1996). In the practice of memory assessment, Larrabee and Crook (1996) identified the procedures as falling into three distinct groups: behavioral rating scales, direct measurement of the person in his or her environment, and specific performance tests or general batteries constructed to simulate everyday tasks.

Behavioral ratings. Behavioral rating scales for evaluating everyday memory function can be used to compare client self-perceptions with the results of other tests or the perceptions of significant others (Lezak, 1995). The discrepancies between client perceptions and an observer's report have been used to differentiate exaggerated memory complaints of clients with depression, from underestimated deficits commonly found in dementia; however, they clearly cannot be used as the sole means of evaluating memory in general (Larrabee, & Crook, 1996). For example, the Memory Functioning Questionnaire (MFQ; Gilewski, Zelinski, & Schaie, 1990) was created to examine memory complaints in older people. This questionnaire has 64 items, rated on seven-point scales, divided into seven sections: frequency of common memory problems, frequency of poor reading recall, quality of recall, rating of seriousness of memory problems, comparison of current memory status to different timeframes, and usage of compensatory techniques. Zelinsky, Gilewski, and Antony-Berstone (1990) evaluated evidence corroborating the validity of the MFQ. They found that the General Frequency of Forgetting factor predicted immediate and delayed list recall, and the Seriousness of Forgetting factor predicted list recognition. Zelinski et al. (1990) pointed out the advantage of having a family member also rate client memory function, which could enhance the yield of standardized neuropsychological evaluation.

Direct measurement of everyday memory. The development of direct measurement of everyday memory in the client's environment has also been an important achievement. The major instrument created from this perspective is the Rivermead Behavioural Memory Test (RBMT; Wilson, Cockburn, & Baddeley, 1985, 2003). This instrument was created to provide measures that would directly relate to the practical effects of impaired memory and for monitoring change with treatment for memory disorders. Validity is evident to non-psychologists due to the type of tasks used (Lezak, 1995). The test comes in four parallel forms that differ for every subtest except Orientation and Date. The parallel form reliability was estimated by correlating performance on Forms B, C, or D with Form A. Reliability estimates of B (.83) and C (.88) forms were higher than the estimate found for D (.67) which suggests advantages in the use of forms A, B, and C (Lezak, 1995). Subtest means for raw scores and standard deviations are provided for persons in the adult range (16-69) (Wilson, Cockburn, Baddeley, & Hiorns, 1989). Wilson et al. also examined ecological validity of the RBMT by correlating the performance on the test with memory failures observed by therapists during a client's daily rehabilitation program. The authors also reported the inter-scorer agreement to be 100%. Additional norms for individuals in the 70-94 year age range have also been developed (Lezak, 1995), and Aldrich and Wilson(1991) developed a version of the test adapted for children from 5 to 10 years of age. Van Balen, Westzaan, and Mulder (1996) later included stratified norms for the adult group which suggested that the older adult group (more than 69 years) scored lower than two younger age groups (45-59 and 60-69). In a longterm follow-up study, Wilson (1991) found that RBMT scores discriminated between clients who were independent (operationally defined as paid employment or full time student status or living alone) and those who were not independent.

The RBMT, an atheoretical test, developed on the basis of clinical experience with memory impaired individuals has been criticized as lacking sensitivity at high and low end memory functioning. However, Wills, Clare, Shiel, and Wilson (2000) investigated the performance of individuals with brain injuries, who had obtained RBMT scores within the normal range, when assessed at least 6 months previously, on an extended version of the test. This extended version allowed a finer classification of individual memory performance. Martin, West, Cull, and Adams (2000) studied a group of individuals with mild intellectual disabilities, using the RBMT, and found that the tests relying on verbal memory were considered the most difficult, while those relying on visual memory were considered the easiest. The authors suggested that the RBMT provides useful clinical information. Hon, Huppert, and Holland (1998) used the RBMT-children with older adults with Down syndrome and found that name learning, face recognition, and remembering an appointment were the most difficult subtests for this group.

The RBMT has been adapted for people with restricted mobility, which extends its usage to different groups that previously could not complete the route and message subtests (Clare, 2000). Kelly (2000) also used the RBMT as part of a cognitive assessment of deficits in a group of individuals with diagnoses of schizophrenia and related the findings to community functioning. Morgan (1999) used the RBMT while studying immediate and delayed recall in a group of drug users and found that participants showed significant impairment. In conclusion, the RBMT has been used with different populations, and this ecological instrument is currently well accepted within rehabilitation settings. Limitations are found when determining specific problems that require isolation for cognitive treatment; however, such limitations can be alleviated through the use of additional measures.

Adaptation of clinical tests. The third approach to the validity of memory tests is addressed by adapting everyday tasks to clinical test paradigms. An example of this procedure is the California Verbal Learning Test (CVLT; Spreen, & Strauss, 1991). The individual is required to learn a list of 16 items over five trials, followed by a second list to serve as interference. Short delay, with free and category-cued recall, and long delay, with free and cued recall, and yes-no recognition of the original list items are assessed. The test manual provides normative data for ages 17 to 80. The CVLT showed a split-half reliability estimate of .92. According to Sbordone (1996), the CVLT also demonstrates factor structure representing several underlying cognitive processing domains. This test has also been used with samples with different diagnoses.

Importance of Memory Assessment in Successful Rehabilitation Programs

After briefly reviewing memory deficits related to three disabling conditions and some of the research on rehabilitation of cognitive deficits, it was suggested that an ecological model of assessment should be used in rehabilitation, as an approach to gathering neuropsychological assessment data that are ecologically relevant. Snyder and Nussbaum(1998) pointed out that "to develop and initiate an effective memory rehabilitation program, determination of both the nature and the level of memory deficits through a thorough assessment is critical" (p. 452).

Rehabilitation programs for individuals with neurological disorders have consistently highlighted the need to continually monitor the initial condition of cognitive function and the post-treatment outcomes using a variety of measures (Farmer, & Eakman, 1995; Quemada, Claspedes, Ezkerra, Ballesteros, Ibarra, & Urruticoechea, 2003; Ross, Millis, & Rosenthal, 1997). It is suggested that mnemonic ability is an important variable that interferes with rehabilitation outcome.

The main goal of this paper was to enhance the assessment procedures adopted by rehabilitation counselors by showing that the assessment of memory may be an important part of assessment with clients with a number of types of disabilities that do not primarily represent neurological disorders. The addition of memory assessment to comprehensive assessment procedures may facilitate the development of more successful rehabilitation interventions and programs. By promoting a comprehensive individualized assessment plan at least two advantages can be achieved: barriers for achieving rehabilitation goals and client learning needs can be better identified and specific rehabilitation strategies can be suggested facilitating more effective interventions.

References

Aldrich, F. K., & Wilson, B. A. (1991). Rivermead Behavioural Memory Test for Children: A preliminary evaluation. British Journal of Clinical Psychology, 30, 161-168.

Aleman, A., Hijman, R., de Haan, E. H. F., Kahn, R. S. (1999). Memory impairment in schizophrenia: A meta-analysis. American Journal of Psychiatry, 156, 1358-1366.

Ambrose, M. L., Bowden, S.C., & Whelan, G. (2001). Working memory impairments in alcohol-dependent participants without clinical amnesia. Alcoholism: Clinical and Experimental Research, 25, 185-191.

Backman, L., Jones, S., Berger, A.K., Laukka, E.J., & Small, B. (2005). Cognitive impairment in preclinical Alzheimer's disease: A meta-analysis. Neuropsychology, 19, 520-531.

Baddeley, A. D. (1997). Human memory: Theory and practice (rev. ed.). East Sussex, UK: Psychology Press.

Baddeley, A. D. (2002). The psychology of memory. In A. D. Baddeley, M. D. Kopelman, & B. A. Wilson (Eds.), The handbook of memory disorders (2nd ed., pp. 3-15). West Sussex, UK: Wiley.

Bates, M. E., Bowden, S. C., & Barry, D. (2002). Neurocognitive impairment associated with alcohol use disorders: Implications for treatment. Experimental and Clinical Psychopharmaccology, 10, 193-212.

Bates, M. E., Voelbel, G. T., Buckman, J. F., Labouvie, E. W., & Barry, D. (2005). Short-term neuropsychological recovery in clients with substance abuse disorders. Alcoholism: Clinical and Experimental Research, 29, 367-377.

Belmont, J. M., & Butterfield, E. C. (1973). On the theory and practice of improving short-term memory. American Journal of Mental Deficiency, 77, 458-465.

Berven, N. L. (2004). Assessment. In T. F. Riggar and D. R. Maki (Eds.), Handbook of rehabilitation counseling (pp. 199-217). New York: Springer.

Bilder, R. M., Goldman, R. S., Robinson, D., Reiter, G., Bell, L., Bates, J. A., et al. (2000). Neuropsychology of first-episode schizophrenia: Initial characterization and clinical correlates. American Journal of Psychiatry, 157, 549-559.

Bolton, B. F. (2001). Handbook of measurement and evaluation in rehabilitation (3rd ed.). Gaithersburg, MD: Aspen.

Bowden, S.C. (1990). Separating cognitive impairment in neurologically asymptomatic alcoholism from Wernicke-Korsakoff Syndrome: Is the neurological distinction justified? Psychological Bulletin, 107, 355-366.

Brandimonte, M., Einstein, G. O., & McDaniel, M. A. (1996). Prospective memory: Theory and applications. Mahwah, NJ: Erlbaum.

Bray, N. W., Saarnio, D. A., Borges, L. M., & Hawk, L. W. (1994). Intellectual and developmental differences in external memory strategies. American Journal on Mental Retardation, 99, 19-31.

Burt, D. B., Primeaux-Hart, S., Loveland, K. A., Cleveland, L. A., Lewis, K. R., Lesser, J., et al. (2005). Aging adults with intellectual disabilities. American Journal on Mental Retardation, 110, 268-284.

Byrne, M. Clafferty, B. A., Cosway, R., Grant, E., Hodges, A. Walley, H. et al. (2003). Neuropsychology, genetic liability, and psychotic symptoms in those at risk of schizophrenia. Journal of Abnormal Psychology, 112, 38-48.

Carlin, M. T., Soraci, S. A., Dennis, N. A., Chechle, N. A., & Loiselle, R. C. (2001). Enhancing free recall rates of individuals with mental retardation. American Journal on Mental Retardation, 106, 314-326.

Carlin, M. Y., Soraci, S. A., & Strawbridge, C. (2005). Generative learning during visual search for scene changes: Enhancing free recall of individuals with and without mental retardation. American Journal on Mental Retardation, 110, 13-22.

Center for Disease Control. (n. d.). Retrieved February 20, 2006, from http://www.cdc.gov/ncbddd.

Cermak, L. S. (1990). Cognitive-processing deficits in chronic alcohol abusers. Alcohol Health and Research World, 14, 130-136.

Clare, L. (2000). Adapting the Rivermead Behavioural Memory Test Extended Version for people with restricted mobility. British Journal of Clinical Psychology, 39, 363-369.

Condray, R., Steinhauer, S. R., van Kammen, D. P., Kasparek, A. (1996). Working memory capacity predicts language comprehension in schizophrenic patients. Schizophrenia Research, 20, 1-13.

Darke, S., Sims, J., McDonald, S., & Wickers, W. (2000). Cognitive impairment among methadone maintenance patients. Addiction, 95, 687-695.

DeLuca, J., Christodoulou, C., Diamond, B.J., Rosenstein, E.D., Kramer, N., et al. (2004). The nature of memory impairment in chronic fatigue syndrome. Rehabilitation Psychology, 49, 62-70.

Ekstrom, R. B., & Smith, D. K. (2002). Assessing individuals with disabilities in educational, employment, and counseling settings. Washington, DC: American Psychological Association.

Evans, J. D., Bond, G. R., Meyer, P. S., Kim, H. W., Lysanker, P. H., Gibson, P. J. et al. (2004). Cognitive rehabilitation and clinical predictors of success in vocational rehabilitation in schizophrenia. Schizophrenia Research, 70, 331-342.

Fals-Stewart, W., & Bates, M. E. (2003). The neuropsychological test performance of drug-abusing patients: An examination of latent cognitive abilities and associated risk factors. Experimental and Clinical Psychopharmacology, 11, 34-45.

Fama, R., Marsh, L., & Sullivan, E. V. (2004). Dissociation of remote and anterograde memory impairment and neural correlates in alcoholic Korsakoff syndrome. Journal of the International Neuropsychological Society, 10, 427-441.

Farmer, J. E., & Eakman, A. M. (1995). The relationship between neuropsychological functioning and instrumental activities of daily living following acquired brain injury. Applied Neuropsychology, 2, 107-115.

Finch, J. R., & Wheaton, J. E. (1999). Patterns of services to vocational rehabilitation consumers with serious mental ill ness. Rehabilitation Counseling Bulletin, 42, 214-228.

Fiszdon, J. M., Bryson, G. J., & Wexler, B. E. (2004). Durability of cognitive remediation training in schizophrenia: Performance on two memory tasks at 6-month and 12-month follow-up. Psychiatry Research, 125, 1-7.

Fuller, R. L., Luck, S. J., McMahon, R. P., & Gold, J. M. (2005). Working memory consolidation is abnormally slow in schizophrenia. Journal of Abnormal Psychology, 114, 239-290.

Gerry, T. H. (2004). Research on outcomes of pediatric traumatic brain injury: Current advances and future directions. Developmental Neuropsychology, 25, 199-225.

Gilewski, M. J., Zelinski, E. M., & Schaie, K. W. (1990). The memory functioning questionnaire for assessment of memory complains in adulthood and old age. Psychology and Aging, 5, 482-490.

Gold, J. M. (2004). Cognitive deficits as treatment targets in schizophrenia. Schizophrenia Research, 72, 21-28.

Gold, J. M., Carpenter, C., Randolph, C., Goldberg, T. E., Weinberger, D. R. (1997). Auditory working memory and Wisconsin Card Sorting Test performance in schizophrenia. Archives of General Psychiatry, 54, 159-165.

Green, M. F. (1996). What are the functional consequences of neurocognitive disorder? American journal of Psychiatry, 153, 321-330.

Heinrichs, R. W. (1990). Current and emergent applications of neuropsychological assessment: problems of validity and utility. Professional Psychology; Research and Practice, 21, 171-176.

Heinrichs, R. W., & Zakzanis, K. K. (1998). Neurocognitive deficit in schizophrenia: A quantitative review of evidence. Neuropsychology, 12, 426-445.

Holland, A. J., Hon, J., Huppert, F. A., & Stevens, F. (2000). Incidence and course of dementia in people with Down's syndrome: Findings form a population-based study. Journal of Intellectual Disability Research, 44, 138-146.

Hon, J., Huppert, F. A., & Holland, A. J. (1998). The value of the Rivermead Behavioural Memory Test (children's version) in an epidemiological study of older adults with Down syndrome. British Journal of Clinical Psychology, 37, 15-29.

Hutton, S. B., Puri, B. K., Duncan, L. J., Robbins, T. W., Barnes, T. R. E., & Joyce, E. M. (1998). Executive function in first-episode schizophrenia. Psychological medicine, 28, 463-473.

Jarrold, C., Cowan, N., Hewes, A. K., Riby, D. M. (2004). Speech timing and verbal short-term memory: Evidence for contrasting deficits in Down syndrome and Williams syndrome. Journal of Memory and Language, 51, 365-380.

Kelly, C. (2000). Cognitive function in a catchment-area-based population of patients with schizophrenia. British Journal of Psychiatry, 177, 348-353.

Kittler, P., Krinsky-McHale, S. J., & Devenny, D. A. (2004). Semantic and phonological loop effects on verbal working memory in middle-age adults with mental retardation. American Journal of Mental Retardation, 109, 467-480.

Krinsky-McHale, S. J., Devenny, D. A., Kittler, P., & Silverman, W. (2003). Implicit memory in aging adults with and without Down syndrome. American Journal on Mental Retardation, 108, 219-233.

Krinsky-McHale, S. J., Devenny, D. A., & Silverman, W. P. (2002). Changes in implicit memory associated with early dementia in adults with Down's syndrome. Journal of Intellectual Disability Research, 46, 198-208.

Krinsky-Mchale, S. J., Kittler, P., Brown, W. T., Jenkins, E. C., Devenny, D. A. (2005). Repetition priming in adults with Williams syndrome: Age-related dissociation between implicit and explicit memory. American Journal on Mental Retardation, 110, 482-496.

Larrabee, G. J., & Crook, T. H. (1996). The ecological validity of memory testing procedures: Developments in the assessment of everyday memory. In R. J. Sbordone & C. J. Long (Eds.), Ecological validity of neuropsychological testing (pp. 225-242). Delray Beach, FL: St. Lucie.

Lezak, M. D. (1995). Neuropsychological assessment (3rd ed.). New York: Oxford University Press.

Long, C. J. (1996). Neuropsychological tests: A look at our past and the impact that ecological issues may have on our future. In R. J. Sbordone & C. J. Long (Eds.), Ecological validity of neuropsychological testing (pp. 1-14). Delray Beach, FL: St. Lucie.

Longitudinal Study of Vocational Rehabilitation Search Program. (n.d.). Retrieved February 20th, 2006, from http://www.ilr .cornell.edu/ped/lsvrsp/Application

Mapou, R. L. (1988). Testing to detect brain damage: An alternative to what may no longer be useful. Journal of Clinical and Experimental Neuropsychology, 10, 271-278.

Marder, S. R., & Fenton, W. (2004). Measurement and treatment research to improve cognition in schizophrenia: NIMH MATRICS initiative to support the development of agents for improving cognition in schizophrenia. Schizophrenia Research, 72, 5-9.

Martin, C., West, J., Cull, C., & Adams, M. (2000). A preliminary study investigating how people with mild intellectual disabilities perform on the Rivermead Behavioural Memory Test. Journal of Applied Research in Intellectual Disabilities, 13, 186-193.

Mc Gurk, S. R., & Mueser, K. T. (2004). Cognitive functioning, symptoms, and work in supported employment: A review and heuristic model. Schizophrenia Research, 70, 147-173.

McKenna, P., Ornstein, T., & Baddeley, A. D. (2002). Schizophrenia. In A. D. Baddeley, M. D. Kopelman, & B. A. Wilson (Eds.), The handbook of memory disorders (2nd ed., pp. 413-435). West Sussex, UK: Wiley.

Meek, P. S., Clark, H. W., & Solana, V. L. (1989). Neurocognitive impairment: The unrecognized component of dual diagnosis in substance abuse treatment. Journal of Psychoactive Drugs, 21, 153-160.

Minsky, S. K., Spitz, H. H., & Besselieu, C. L. (1985). Maintenance and transfer of training by mentally retarded young adults on the Tower of Hanoi problem, American Journal of Mental Deficiency, 90, 190-197.

Mockler, D. (1997). Memory and intellectual deficits do not decline with age in schizophrenia. Schizophrenia Research, 26, 1-7.

Moelter, S. T., Hill, S. K., Hughett, P., Gur, R. C., Gur, R. E., Ragland, D. J. (2005). Organization of semantic category exemplars in schizophrenia. Schizophrenia Research, 78, 209-217.

Morgan, M. J. (1999). Memory deficits associated with recreational use of 'ecstasy'. Psychopharmachology, 141, 30-36.

Muller, U., Ullsperger, M., Hammerstein, E., Sachweh, S., & Becker, T. (2005). Directed forgetting in schizophrenia: Prefrontal memory and inhibition deficits. European Archive of Psychiatry and Cinical Neuroscience, 255, 251-257.

Munro, C. A., Saxton, J., & Butters, M.A. (2000). The neuropsychological consequences of abstinence among older alcoholics: A cross-sectional study. Acoholism: Clinical and Experimental Research, 24, 1510-1516.

National Institute on Alcohol Abuse and Alcoholism. (n. d.). 2001-2002 epidemiological study. Retrieved February 4, 2006, from http://www.niaaa.nih.gov/Publications/Alcohol Research

National Institute of Child Health and Human Development. (n. d.). Retrieved February 20, 2006, from http://www.nichd.nih .gov/publications/pubs.cfm.

National Institute of Mental Health. (n. d.). The numbers count: Mental disorders in America. Retrieved February 20th, 2006, http://www.nimh.nih.gov/publicat/numbers.cfm

Nuechterlein, K. H., Barch, D. M., Gold, J. M., Goldberg, T. E., Green, M. F., & Heaton, R. K. (2004). Identification of separable cognitive factors in schizophrenia. Schizophrenia Research, 72, 29-39.

Numinen, H. Service, E., Ahonen, T., & Ruoppila, I. (2001). Working memory and everyday cognition in adults with Down syndrome. Journal of Intellectual Disability Research, 45, 157-168.

Oliver, C., Crayton, L., & Holland, A. (1998). A four-year prospective study of age-related cognitive change in adults with Down syndrome. Psychological Medicine, 28, 1365-1377.

O'Malley, S., Adamse, M. Heaton, R. K., & Gawin, F. H. (1992). Neuropsychological impairment in chronic cocaine abusers. American Journal of Drug and Alcohol Abuse, 18, 131-144.

Oram, J., Geffen, G. M., Geffen, L. B., Kavanagh, D. J., & McGrath, J. J. (2005). Executive control of working memory in schizophrenia. Psychiatric Research, 135, 81-90.

Palmer, B., Heaton, R. K., Kuck, J., & Braff, D. (1997). Is it possible to be schizophrenic yet neuropsychologically normal? Neuropsychology, 11, 437-446.

Quemada, J. I., Claspedes, J. M. M., Ezkerra, J., Ballesteros, J., Ibarra, N., & Urruticoechea, I. (2003). Outcome of memory rehabilitation in traumatic brain injury assessed by neuropsychological tests and questionnaires. Journal of Head Trauma Rehabilitation, 18, 532-540.

Rosenquist, C., Conners, F. A., & Roskos- Ewoldsen, B. (2003). Phonological and visuo-spatial working memory in individuals with intellectual disability. American Journal on Mental Retardation, 108, 403-413.

Ross, S. R., Millis, S. R., & Rosenthal, M. (1997). Neuropsychological prediction of psychosocial outcome after traumatic brain injury. Applied Neuropsychology, 4, 165-170.

Ruff, R. M., & Schraa, J. C. (2001). Neuropsychological assessment. In B. F. Bolton (Ed.), Handbook of measurement and evaluation in rehabilitation (3rd ed., pp. 233-254). Gaithersburg, MD: Aspen.

Saddock, B. J., Sadock, V. A., & Kaplan, H. I. (2000). Kaplan and Sadock's comprehensive textbook of psychiatry. Philadelphia: Lippincott, Williams, & Wilkins.

Selby, M. J. & Azrin, R. L. (1998). Neuropsychological functioning of drug abusers. Drug and Alcohol Dependence, 50, 39-45.

Sbordone, R. J. (1996). Ecological validity: Some critical issues for the neuropsychologist. In R. J. Sbordone & C. J. Long (Eds.), Ecological validity of neuropsychological testing (pp. 15-41). Delray Beach, FL: St. Lucie.

Snyder, P. J., & Nussbaum, P. D. (Eds.). (1998). Clinical neuropsychology: A pocket handbook for assessment. Washington, DC: American Psychological Association.

Sohlberg, M. M., & Mateer, C. A. (2001). Cognitive rehabilitation: An integrative neuropsychological approach. New York: Guilford.

Spreen, O., & Strauss, E. (1991). A compendium of neuropsychological tests: Administration, norms, and commentary. New York: Oxford University Press.

Soutor, S. A., Chen, R., Streisand, R. (2004). Memory matters: Developmental differences in predictors of diabetes care behaviors. Journal of Pediatric Psychology, 29, 493-505.

Stone, M., Gabrieli, J. D., Stebbins, G. T., Sullivan, E. V. (1998). Working and strategic memory deficits in schizophrenia. Neuropsychology, 12, 278-288.

Stringer, A. Y., & Nadolne, M. J. (2000). Neuropsychological assessment: Contexts for contemporary clinical practice. In G. Groth-Marnat (Ed.), Neuropsychological assessment in clinical practice: A guide to test interpretation and integration (pp. 26-47). New York: Wiley.

Sullivan, E.V., Fama, R., Rosebloom, M.J., & Pfefferbaum, A. (2002). A profile of neuropsychological deficits in alcoholic women. Neuropsychology, 16, 74-83.

Sullivan, E.V., & Pfefferbaum, A. (2003). Diffusion tensor imaging in normal and neuropsychiatric disorders. European Journal of Radiology, 45, 244-255.

Tapert, S. F., Pulido, C., Paulus, M. P., Schuckit, M. A., Burke, C. (2004). Level of response to alcohol and brain response during visual working memory. Journal of Studies on Alcohol, 65, 692-700.

Turetsky, B. I., Moberg, P. J., Mozley, L. H., Moelter, S. T., Agrin, R. N., Gur, R. C. et al. (2002). Memory-delineated subtypes of schizophrenia: Relationship to clinical, neuroanatomical, and neurophysiological measures. Neuropsychology, 16, 81-490.

Turnure, J. E. (1991). Long-term memory and mental retardation. In N. W. Bray (Ed.), International research in mental retardation (Vol. 17, pp.193-217). New York: Academic Press.

Vakil, E., Shelef_Reshef, E., & Levy-Shift, R. (1997). Procedural and declarative memory processes: Individuals with and without mental retardation. American Journal on Mental Retardation, 102, 147-160.

Van Balen, H. G. G., Westzaan, P. S. H., & Mulder, T. (1996). Stratified norms for the Rivermead Behavioural Memory Test. Neuropsychological Rehabilitation, 6, 203-217.

Vicari, S. (2004). Memory development and intellectual disabilities. Acta Peadiatrica, 445, 60-64.

Vicari, S., & Carlesimo, G. A. (2002). Children with intellectual disabilities. In A. D. Baddeley, M. D. Kopelman, & B. A. Wilson (Eds.), The handbook of memory disorders (2nd ed., pp.617-636). West Sussex, UK: Wiley.

Vicari, S., Bellucci, S., & Carlesimo, G. A. (2005). Visual and spatial long-term memory: Differential pattern of impairments in Williams and Down syndromes. Developental Medicine and Child Neurology, 47, 305-311.

Victor, M., Adams, R.D., Collins, G.H. (1989). The Wernicke-Korsakoff syndrome (2nd ed.). Philadelphia, PA: Davis.

Westmeyer, H. (2003). On the structure of case formulations. European Journal of Psychological Assessment, 19, 210-216.

Wilk, C. M., Gold, J. M., Iannone, V. N., & Buchanan, R. W. (2005). No, it is not possible to be schizophrenic yet neuropsychologically normal. Neuropsychology, 19, 778-786.

Wills, P., Clare, L., Shiel, A., & Wilson, B. A. (2000). Assessing subtle memory impairments in the everyday memory performance of brain injured people: exploring the potential of the Extended Rivermead Behavioural Memory Test. Brain Injury, 14, 693-704.

Wilson, B. A. (1991). Theory, assessment and treatment in neuropsychological rehabilitation. Neuropsychology, 5, 281-291.

Wilson, B. A. (1993). Ecological validity of neuropsychological assessment: Do neuropsychological indexes predict performance in everyday activities? Applied and Preventive Psychology, 2, 209-215.

Wilson, B. A. (2002). Assessment of memory disorders. In A. D. Baddeley, M. D. Kopelman, & B. A. Wilson (Eds.), The handbook of memory disorders (2nd ed., pp.617-636). West Sussex, UK: Wiley.

Wilson, B. A., Cockburn, J., & Baddeley, A. (1985). The Rivermead Behavioural Memory Test. Reading, England: Thames Valley Test Co.

Wilson, B. A., Cockburn, J., & Baddeley, A. (2003). The Behavioural Memory Test- Second edition. San Antonio, TX: PsychCorp.

Wilson, B. A., Cockburn, J., Baddeley, A. & Hiorns, R. (1989). Development and validation of a test battery for detecting and monitoring everyday memory problems. Journal of Clinical and Experimental Neuropsychology, 11, 855-870.

Zelinsky, E. M., Gilewski, M. J., & Anthony-Bergstone, C. R. (1990). Memory functioning questionnaire: Concurrent validity with memory performance and self-reported memory failures. Psychology and Aging, 5, 388-399.

Ana Paula A. Pereira

University of Wisconsin-Madison

Universidade Federal do Parana

Ana Paula A. Pereira, Departmento de Psicologia-UFPR, Praca Santos Andrade, 50, Curtiba, Parana 80060-240, Brazil. Email: [e-mail]