The Brain and Behavior: Assessing Cortical Dysfunction Through Activities of Daily Living.

The Brain and Behavior: Assessing Cortical Dysfunction Through Activities of Daily Living Arnadottir G. St Louis, MO 63146, CV Mosby & Year Book Medical Publishers Inc, 1990, hardback, 322 pp, illus, 36.95,

The rationale, development, description, and implications of the Arnadottir OTADL Neurobehavioral Evaluation (A-ONE), which integrates functional performance of activities of daily living with underlying neurobehavioral deficits, are presented in this text. It is written for occupational therapists and students, with the hope that it will be supplemented with a training course to ensure reliable test administration and interpretation.

The eight chapters in part I build the theoretical basis for the test assessment and interpretation, which is then described in detail in part 2. The scope of the book is both its strength and its weakness. The author describes a clinical need, explores a new theoretical framework, expands upon current techniques, and then presents results of interrater reliability and a normative study of the A-ONE. Even an order form has been included. Less than one third of the hook is devoted to the specifics of the A-ONE. Another third of the book is devoted to chapters on the gross anatomy and function of the cerebral hemispheres, neuronal processing, and causes of "cortical CNS [central nervous systeml dysfunctions." Although the synopses are conveniently located, it seems that extracting critical information for theory development would suffice, as the intended readers should have the ability to explore the subject in the original sources.

The A-ONE instrument is designed to focus on individuals over 16 years of age with neurobehavioral dysfunction and cortical deficits. The potential causes listed (eg, head injury, infection), however, would not limit impairment to the cortex. Part I of the assessment yields two types of information: level of independence with type of assistance needed and type and severity, of neurobehavioral deficits that affect independence. The test is performed as realistically as possible, in the morning at bedside. Five categories of function: dressing, grooming/hygiene, transfers/mobility, feeding, and communication are assessed, with two to six tasks for each category. Task specificity ranges from dressing-socks to communication-comprehension. All tasks are scored on a 4-to-0 scale, with an explanation of each grade of independence and a brief description of common scoring mistakes as a guide. A score of 4, independent, includes the ability to carry over performance to different situations.

The second part of the assessment explores 9 or 10 neurobehavioral characteristics for each category of function. These categories include motor apraxia, somatoagnosia, and abnormal tone; each is measured on a four-point scale of impairment, ranging from no deficit to physical assistance required to understand how to perform the task. To enable a reliable and consistent test, there is an 11-page neurobehavioral "Specific Impairment Checklist" that guides the assessor's observation through examples or descriptions of deficits for many of the behavioral characteristics.

Item content is validated through the literature and through the opinion of three experts in the fields of occupational therapy and neurology. An interrater reliability, study was conducted on 20 subjects, with a kappa coefficient for rater agreement for all items and all scales of .84. Normative data are derived from 79 individuals (ie, patients with nonneurologic disorders and staff from four hospitals in Iceland).

Part 2 of the A-ONE, lesion localization, is perhaps the more controversial section and not a requirement for the use of this tool. The Neurobehavioral Scale summary displays in columns the scores for behaviors tested (eg, ideomotor, ideational, and oral apraxia) during each function, with adjacent columns for marking the possible lesion sites gleaned from a localization chart constructed from the information of four experts in the field. When complete, a pattern may implicate certain cortical regions. Interrater reliability of 20 case studies yielded a total average kappa of .76.

In the style of A Jean Ayers, the author has offered a comprehensive presentation. There appears to be much to assess simultaneously, but this may be feasible with training and practice. The author acknowledges that although specific locales of the cortex have been linked with behavior, many areas have not, and the system is more pliable than once thought. it will be interesting to see if this provides meaningful, corroborated information, especially when patients seldom exhibit discrete lesions and when many also have subcortical involvement. At the same time, it is hopeful that the normative and reliability studies will be expanded.

Relating cognitive-perceptual deficits to specific functional performance is helpful for the physical therapy practitioner in understanding the meaning of reports often derived in the past from table-top tests. What seems to be missing for practitioners, however, is an explanation of how to implement treatment according to A-ONE results.

Barbara Hanley, PT

Helen Hayes Hospital

West Haverstraw, NY