CAPlANANDSHKtlERsional creativity, observational expertise, flexibility, and ingenuity in the service of developing a multidimensional understanding of patientstheir abilities and deficits, their emotional state, self-regulatory functions, the impact of environmental variables on test performance, and so forth.Thus, Although the merits of unvarying standardized procedures are unarguable for some purposes, we contend that clinical assessment of cognitively compromised or emotionally distressed patients frequently demands a more flexible approach. In this, we concur with the statement of two experienced neuropsychologists who wrote:In evaluating clinical patients, however, the neuropsychological examiner encounters a wide range of emotional and physical problems that can interfere with testing and sometimes cause the results to be invalid. Through sensitive handling of the patient and appropriate minor adjustments in testing procedures (emphasis added), such problems can usually be overcome, while still adhering to the essential standardized aspects of the test. (Heaton & Heaton, 1981, p. 526) Other authors have made similar points. In setting forth guidelines for the evaluation of stroke patients, Hibbard and Gordon (1992) explicitly stated, "Testing procedures should be modified to test maximal functioning and learning abilities" (p. 14). Barbara Wilson, a pediatric neuropsychologist, wrote There are situations in which the test administration procedures must be modified in order to obtain meaningful information . . . the whole issue of goals of an assessment enters here. For some, adherence to standardized procedures is important and a "cannot do" score is felt to be sufficient information. For others-and we generally find ourselves in this group-the goal of the assessment is to obtain all information possible about the functioning capacities of the child and to facilitate the production of maximum performance (pp. 157-158).A focal concept of this chapter is that cognitive, emotional, or physical limitations, though certainly worthy of assessment in their own right, may undercut the validity of certain tests, thereby forcing examiners to choose between (a) by-the-book administration that yields data of questionable meaning and (b) procedural modification in an attempt to derive some useful information from the measures. A major objective of this chapter is to suggest ways that clinicians may avoid this kind of psychometric showdown by viewing the evaluation process in a less constrained manner.By way of illustration, consider the hazards of attempting to assess verbal memory in a patient with expressive aphasia. The typical format for testing this function requires the individual to repeat material (e.g., story content, word lists, digit strings) that is read by the examiner. That

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M. M. (1984). Construct validity for measures of childhood depression: Application of multitrait-multimethod methodology. Journal of Consulting and Clinical Psychology, 52, 911-985. SELIGMAN, M. E. P., KASLOW, N. J., ALLOY, L. B., PETERSON, C., TANENBAUM, R. L., & ABRAMSON, L. Y. (1984). Attributional style and depressive symptoms among children. Journal of AbnormalPsychology, TERI, L. (1982). Depression in adolescence: Its relationship to assertion and various aspects of self-image. 93, 235-238.Impulsivity is a common consequence of brain damage, one with negative prognostic implications. To attempt to study the incidence of impulsivity after lateralized cerebral lesions, 93 patients (50 RBD, 43 LBD) and 24 normal controls were administered the Matching Familiar Figures Test, a visual match-to-sample task in a multiple-choice format. The groups differed significantly (RBD < LBD < Controls) with respect to accuracy (visualperceptual skill). Average response latency scores of the brain-damaged groups were slightly, but not significantly, lower than that of Controls. Although more than one-third of the RBD showed a tendency to respond rapidly, reduced response latency in RBD patients may be due, not to impulsivity per se, but, rather, to incomplete visual scanning characteristic of neglect. The present results illustrate the hazards of interpreting neuropsychological test scores without consideration of pertinent processing variables.A number of authors (e.g., Bond

Obtaining accurate information about the neuropsychological functioning of elderly individuals with physical or sensorimotor limitations may be fostered by judicious use of nonstandard testing strategies. We review professional documents that support this position and discuss selected "flexible" testing techniques that can serve this goal. These approaches may permit assessment of skills that might otherwise go unmeasured (e.g., naming ability or executive function in persons with visual impairment). This perspective is particularly critical when clinicians are asked to assess an older adult's capacity and competence in daily life functions.

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