What came to be known as the Halstead-Reitan Neuropsychological Battery (HRNB) Test developed in two parts. It was originally developed by Ward Halstead (and later extended by Ralph Reitan) in order to create a battery, or set of tests, that would be able to assess brain dysfunction. Along with two neurosurgeons, Percival Bailey and Paul Bucy, Halstead researched brain-behavior relationships. Halstead’s research in observing those with brain impairments in their everyday lives soon led him to realize that brain-damaged individuals displayed a wide range of impairments, but there was no one cognitive test that could accurately identify or evaluate these deficits. After realizing that those with brain dysfunction tend to struggle with “understanding complex situations and problems, analyzing circumstances, and reaching meaningful conclusions about situations in everyday life” (Mazur-Mosiewicz, 2011), Halstead worked to comprise a set of assessment procedures that would allow him to distinguish normal patients from those with brain dysfunction.
Halstead had several criteria in mind while developing relevant neuropsychological tests that would actually reflect the condition of the brain. He wanted to create a standardized procedure that could be used effectively enough to qualify for comparison of results between an individual’s results and the results obtained from a group of individuals (Reitan, 1994). The importance of choosing tests shown to be sensitive to specific brain areas was not lost on Halstead. With that in mind, he tried to develop a test battery with reasonably known validity so that variability among different individual subjects could be cross-checked with other data for interpretation.
In the 1940s when the HRNB was first developed by Halstead, it consisted of ten tests. Of the ten, three were excluded to leave seven tests, including: 1) the Category Test, 2) the Tactual Performance Test, 3) the Seashore Rhythm Test, 4) the Speech Sounds Perception Test, 5) the Finger Oscillation (or Tapping) Test, 6) the Critical Flicker Fusion Test, and 7) the Time Sense Test (Franzen, et al., 1954). According to Franzen, et al. (1954), these seven tests “were selected for their ability to discriminate between patients with frontal lobe lesions and patients with other lesions or other subjects.” However, further implementation of the HRNB by Reitan produced results where the last two tests did not effectively differentiate between neurologically impaired subjects and normal subjects. That being the case, the Critical Flicker Fusion Test and Time Sense Test are not included in today’s modified version of the HRNB. The remaining five tests, however, are used to obtain seven individual scores that are compared with designated cutoff scores, or “norms,” for each individual test to determine whether the subject has brain dysfunction. Three of the seven scores come from the Tactual Performance Test, measuring total time, memory, and location. The data from these three scores are used to calculate an Impairment Index for adults subjects, which “represents the proportion of the patient’s scores that fall within the impaired range” (Franzen, et al., 1954). The remaining four scores come from each of the other tests within the five still used today from Halstead’s original HRNB.
The Category Test is a “concept-identification procedure in which the patient must discover the concept or principle that governs the relationship between various series of geometric forms” (Hartlage, et al., 1987). Basically, this test primarily exercises the subject’s ability to formulate his/her own concepts and generate possible solutions based on his/her own problem-solving skills and situational feedback. Visual-spatial perception and color discrimination abilities are definitely required to administer this test, but despite the possible limitation, it is a very good discriminator of those that have brain dysfunction or impairment.
The Tactual Performance Test consists of a blindfolded subject, who is instructed to place each of ten blocks into their respective recesses in a foam board as quickly as possible three times- once with his/her dominant hand, once with his/her non-dominant hand, and once with both hands (Hartlage, et al., 1987). Then, once the blindfold is removed, the subject is given 35 minutes to draw a picture of the foam board, including the shape of each recess in its respective location. This particular test is also used to discriminate between those that are neurologically impaired versus those whose brains are intact. Completion time differences are used to determine lateralization and are also a strong indicator of parietal lobe dysfunction.
The Tactual Performance Test, as stated previously, is additionally used to calculate the Impairment Index. The Impairment Index represents the proportion of a particular individual’s scores that fall within the impaired range (Franzen, et al., 1954). The scores range from 0.0, which indicates no performance impairment, to 10.0, which indicates impairment. The cutting score for brain impairment is 0.5, which did not change when Reitan made his modifications to the original HRNB (Lezak, et al., 2004). The Impairment Index was also not based on normal distribution, but skewed distribution via nonparametric data handling (data that relies on ranking) and was described by Halstead to “‘reflect the empirical odds out of ten chances that a given individual has an impairment of cortical brain functions’” (Lezak, et.al., 2004).
The Seashore Rhythm Test is a standardized test that utilizes 30 pre-recorded pairs of rhythmically patterned sounds. The subject simply determines whether each pair sounds the same or different, which measures the subject’s attention and concentration abilities as well as recognition and perception skills. This particular study does not determine lateralization. The Speech Sounds Perception Test is an auditory verbal test that requires a subject to match the sound of one out of 60 nonsense syllables to a presented stimulus. This test is affected by dominant-hemisphere involvement and determines the ability to discriminate between similar sounding syllables (Hartlage, et al., 1987). The last of the five tests in Halstead’s original HRNB is the Finger Oscillation, or Tapping, Test. For this test, the subject is instructed to tap as fast (or much) as possible with their forefinger on a lever. The subject will do this twice— once with the forefinger on their dominant hand and the other with their nondominant. The average number of taps for each hand is then used as an indicator of motor speed and coordination, as well as lateralization.
Around the 1950s, Ralph Reitan, one of Halstead’s doctoral students, re-examined the original HRNB created by Halstead. Although it was widely known for its clinical usefulness at the time, Reitan conducted further research related to brain-behavior relationships and modified it to make it “specifically designed to examine neurological conditions” (Vanderploeg, 1994). Any test that did not experimentally prove the existence of brain damage was either modified, removed, or replaced. The addition of new tests to the original five led to the development of the HRNB known and used today. Because he believed that neurological tests should be balanced between both hemispheres of the brain, the tests that he added were specifically picked to cover all areas of brain functioning. Some of the added tests were: 1) the Trail Making Test, 2) the Aphasia Screening Test, 3) Grip Strength, 4) Sensory-Perceptual Examination, 5) Tactile Form Recognition. It is important to note though, that the Wechsler Adult Intelligence Scale (WAIS) and Minnesota Multiphasic Personality Inventory (MMPI) are also utilized when deemed necessary (Lezak, et.al., 2004).
The Trail Making Test is a two-part test. Part A requires the subject to sequentially connect a series of randomly circled numbers without taking their pencil off of the paper. Part B is similar but requires the subject to connect circled numbers and letters in alternating serial order (ex. 1-A-2-B, etc.) (Hartlage, et al., 1987). Overall, this test measures attention, concentration, sequencing skills, and cognitive flexibility. The Aphasia Screening Test measures major language functions such as spelling, naming, reading, writing, enunciation, etc., as well as motor apraxia to discern how well the right and left hemispheres function for the individual. The Grip Strength Test is very self-explanatory— the individual holds a hand dynamometer straight down at his/her side and squeezes as hard as he/she is capable of to assess motor strength and measure lateralization. The Sensory-Perceptual Examination basically uses neurological techniques to test the subject’s senses and perceptions. Lastly, the Tactile Form Recognition Test determines if the subject is able to recognize the shape of four different geometrically shaped plastic pieces by touch. In addition, the WAIS and MMPI tests were given to subjects as deemed necessary.
Initially, there was a lot of skepticism regarding early HRNB research. Reitan’s norms are, in this case, a quantitative value to which one can compare an individual’s behavior or test score to because it is considered normal. It is important to note here, then, that norms may be established by experiential, learned, or clinical means (Vanderploeg, et al., 1994). According to Lezak, et al. (2004), Halstead developed his cutting scores based on 28 “normal” individuals who, in truth, had various limitations due to some being diagnosed with psychiatric problems, some awaiting jail sentencing, and some awaiting lobotomies for behavioral problems. That being said, research has been done over the years to provide better normative information for the HRNB.
One of the variables that accrued criticism was the HRNB’s unaccountability of different age groups. In the normative group, subjects’ age ranged from 14-50 years old, which was not very inclusive. Franzen (1954) states that research results from various researchers have shown that performance on subtests decreased with age, leading to possibly erroneous diagnostic conclusions. This is especially the case with more complex subtests that involve immediate adaptive ability or memory recall activities, such as the Category Test, Trail Making Test Part B, and the Tactual Performance Test (Leckliter, et al., 1989). In an attempt to rectify this issue, age-related norms have been established by creating means and standard deviations for five different age groups (ages 19-27, 28-36, 37-45, 46-57, and 58-76) and comparing results to a data set specific to an individual’s age group. In addition, there are different test batteries and versions of batteries available that are designed specifically for children or specifically for adults. For older children, there is the Halstead-Reitan Neuropsychological Test Battery for Older Children; younger children use the Reitan-Indiana Neuropsychological Test Battery for Younger Children (Preiss, et al., 2003). The HRNB discussed thus far is specifically for adults.
The level of education that an individual has received also acts as a variable in all subtest results as a confounding variable. Research has found that even though an individual may have brain dysfunction or impairment, if he/she was well-educated, it would be possible for him/her to obtain higher scores than an individual who may not have any brain deficits but is less educated. While limiting the confounding variable of age, Finlayson, Johnson, and Reitan evaluated the effects of education on HRB performance for those under 50 years old in 1997 (Leckliter, et.al, 1989). The subjects were grouped into 3 groups of educational classifications. The HRB results showed that the Category Test, the Seashore Rhythm Test, the Speech Sounds Perception Test, and the Trails Making Test Parts A and B showed discrepancies due to different educational levels (Leckliter, et al., 1989). In addition, those of different genders showed better performance on certain subtests. For example, Leckliter, et al. (1989), states that a study done by Pauker in 1977 showed that women performed finger tapping more slowly than men, women made fewer errors on the Speech Sounds Perception Test, and men had stronger grip strengths.
Throughout the years, there have been questions regarding the reliability and validity of the HRNB as well. To establish the reliability of the HRNB, the focus has been on test-retest reliability (Franzen, 1954). Generally, researchers have reported correlations in studies that have assessed test-retest reliability. For example, Franzen (1954) notes that Matarazzo, et al. (1974)’s test-retest study obtained results that were consistent with another researcher, Dodrill and Troupin’s results, which supported the reliability of the HRNB. In addition, a general consensus made by other conducted studies is that individuals with stable brain conditions will produce test-retest reliabilities that are different from those that have severe brain impairments, but those with mildly impaired brain functions may produce a change in results due to practice efforts (Franzen, 1954). As far validity goes, Filskov (1974) states that various research efforts have indicated “a perfect hit rate for the Halstead-Reitan Neuropsychological Battery when it comes to discriminating cerebral impairment.” In fact, because those that walk into a clinical setting for an assessment generally have cerebral impairment already, it is likely that false negative determinations will not be found. Previous validity studies also conclude that the HRNB is efficient at making diagnoses regarding brain impairments at a level consistent with the test results.
Clinically, the HRNB is considered a very important and useful assessment. However, it is not a procedure commonly used in everyday practice because it requires a lot of resources and time to conduct it in its entirety. For the HRNB, there are three different screening batteries for three distinct age categories used to determine which individuals truly need a detailed assessment such as the HRNB (Preiss, et.al, 2003). In the screening battery for adults, the Trail Making Test Part A and B, Tactile Form Recognition Test, and Finger Tapping Test is administered to determine neurological impairment. The screening battery for older children is called the Halstead-Reitan Neuropsychological Test Battery for Older Children, and the one for younger children is called the Reitan-Indiana Neuropsychological Test Battery for Younger Children. However, no study is without limitations. In a research study where an individual with a neurological illness, such as Huntington’s disease, and an individual with a psychiatric disorder, such as schizophrenia, were studied using HRNB and the Luria-Nebraska Neurological Battery (LNNB) testing procedures, the results for the individual with Huntington’s disease provided “the impression of a significantly impaired patient with a severe movement disorder, but relatively well preserved tactile function” (Incagnoli, et al., 1986) by both batteries. In addition, both batteries adequately reflected the manifestations in the brain related to the disease. However, in the patient with schizophrenia, both procedures performed “in a range consistent with the presence of brain damage, but no brain damage [was] found using conventional neurodiagnostic methods and historical data” (Incagnoli, et al., 1986). This means that neuropsychological assessments for psychiatric disorders highlighted the individual’s cognitive and perceptual abilities but did not discriminate a psychiatric disorder from brain damage. This conclusion indicates that a set neuropsychological test battery, such as the HRNB, may be inefficient in detecting brain impairments in those with psychiatric disorders compared to a set of tests that are customized for an individual.
In conclusion, the Halstead-Reitan Neuropsychological Battery, created by the joint effort of Ward Halstead and Ralph Reitan, is one of the most efficient and significant batteries used in neuropsychology today. A set of tests with their respective procedures are used to obtain scores that indicate whether an individual suffers from brain dysfunction or impairment. Although the norms that initially were used for this assessment required additional research to validate its procedures over the years, the assessment is known to be quite accurate in providing results regarding brain impairment, dysfunction, and lateralization. Unfortunately, it cannot be used in everyday clinical practice because of the time and resources necessary to run the lengthy test. However, screening tests allow the opportunity for children or adults that truly need the assessment to be able to get it. In addition, despite some limitations of the HRNB present today, it is nevertheless widely used and recognized in the field of psychology.