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Copyright <!:l 1989 Philadelphia Neuropsychology Society

Neuropsychology. Volume 3. pp. 17-22

Printed in the UK. All rights reserved.

A Proposal for the Use of Bayesian Probabilities in

Neuropsychological Assessment
W. PAUL JONES
University of Nevada, Las Vegas
Las Vegas, Nevada
Abstract A measurement model based on Bayesian probabilities is proposed as an
alternative to approaches based on classical measurement theory. The suggested
model includes use of interactive microcomputer programs to integrate clinical im~
pressions into the metric assessment procedure. The Bayesian model provides a new
focus in neuropsychological assessment for both cognitive and affective functioning.

Keywords:

Bayesian probabilities, microcomputer, neuropsychology.

Two major statistical measurement approaches are apparent in neuropsychological assessment. One, evident in the Halstead-Reitan Neuropsychological Test Battery (Reitan
& Wolfson, 1985) and the Luria-Nebraska Neuropsychological Battery (Golden, Purisch,
& Hammeke, 1985), uses a decision model based on cutting scores to differentiate statistically between neurologic and normal subjects. The other primary approach is based on
measuring of a functional area (e.g., language, visuospatial) as preserved or impaired and
then making inferences about neurobehavioral status (Goodglass & Kaplan, 1972;
Benton, Hamsher, Varney, & Spreen, 1983). In this second approach impairment is
referenced to the normal population, rather than to a brain-damaged group. For example,
an impaired population could be defined (Benton et al., 1983) as the bottom 5% of the
normative sample.
An increasing emphasis on the second approach has led to a growing consensus for
modification in focus of the neuropsychological examination. Townes et al. (1985) suggested that combining cognitive and affective measures provides a means of determining
compensation for neurologic deficits that is more valuable than one which correlates
diagnostic profiles with neurologic deficiencies. Chute, Conn, DiPasquale, & Hoag
(1988) agreed, noting further that continuing improvements in neuroradiological techniques have decreased the need for localization of brain dysfunction as a primary objective for neuropsychological testing. With specific references to psychiatric cases, Erickson and Binder (1986) advocated testing with a primary goal of enhancing the patient's functional skills. Mapou (1988) also questioned the value of tests designed
primarily to detect brain damage. He argued that continuing research to determine an
instrument's sensitivity to a unitary 'concept of brain damage is neither relevant nor
useful.
Address correspondence to: Paul Jones, Ed.D., Department of Counseling and Educational Psychology and Foundations, University of Nevada, Las Vegas, 4505 Maryland Parkway, Las Vegas,
NV 89154-3003.

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W. Paul Jones

Implementation of a broader focus would not be without cost. Neuropsychological

assessments with emphasis on cognitive function alone (Kiernan, Mueller, Langston, &
Van Dyke, 1987) often are already of such length as to limit applicability in many clinical
settings. Adding affective traits might be clinically advantageous but would only exacerbate this problem.
Mapou (1988) suggested that priority be given to the development of new instruments
focused on sensitivity to specific cognitive function. Toward such a goal, he provided a
listing of 11 steps in test development described as minimally necessary for instruments
to provide such information. These steps direct attention in neuropsychological test development back to basic concepts in classical measurement theory.
The purpose here is to propose consideration of an alternative approach, a model
which does not rest on the base of classical measurement theory. To the extent that
efficacy of this alternative model could be demonstrated, there is potential for meeting
several needs for change noted above. The model could allow both for focus on specific
cognitive function and the addition of the affective dimensions. Particularly in screening
applications, satisfactory precision of measurement could be provided within time limits
which would not limit use in typical clinical settings.

The Model
The alternative proposed here requires two primary shifts in perspective from traditional
thinking about neuropsychological evaluations. One is in the appropriate statistical model
for such an assessment. The other is in use of the microcomputer.

Bayesian Statistics
More than two centuries ago an English cleric, the Reverend Thomas Bayes, proposed an
elegantly simple probability theorem (Phillips, 1973). Although elements of Bayesian
thinking are becoming more evident in contemporary measurement, particularly the more
complex item response theory models (Wainer & Thissen, 1987), this model proposes a
return to the most basic Bayesian approach ..
To establish the probability of some condition, the basic Bayesian theorem begins
with a quantified prior belief, multiplies that belief by the likelihood of some observed
data, and divides that product by the sum of products of the likelihoods and priors to
obtain the posterior belief. This then becomes the prior belief to be modified, if desired,
by additional observation.
To illustrate, the clinician may need to determine if a patient's capability for retrieval
of vocabulary from stored memory should be described as high, average, or low in comparison to some designated normative group. The general population percentages (from
stanine conversions) for these categories are 23, 54, and 23, respectively. In Bayesian
terms, these are the prior beliefs. A response from the patient is elicited to a question (or
a set of questions) for which there are available percentage data for successful response in
each of these three groups. For example, available data may indicate that 90% of individuals with high facility in this cognitive area can define a certain word correctly, 50%
with average facility, and 25% with low cognitive facility. These are the likelihoods for
the Bayesian theorem.
Entering the beginning population figures and the patient's response into the formula,

Bayesian Model

19

the outcome is a simple probability statement about "belonging" to a certain group.

With the example data above, beginning with prior probabilities for high, average, and
low of .23, .54, and .23, if the person answers the question correctly, the posterior
probabilities are .30, .50, and .11, respectively. An incorrect answer results in probabilities of .05, .58, and .37. These now become the prior beliefs for additional questions.
This model, rather than the traditional underlying latent trait concepts, assumes that
most often the clinician's question is not concerned with where measurement might be on
some underlying continuum, but rather what is the probability of a given patient's measurement belonging to a trait cluster with identifiable behavioral correlates. Although the
computational direction is different, this concept is not inconsistent with Torgerson's
classical position on ideal type structures. Differentiating this model from the categories
approach, he noted (1983) that both the stereotypes of everyday language and many
typologies in personality structure; for example, medicaUpsychiatric diagnoses correspond to his ideal type model.
Traditional measurement theory generally assumes an underlying normality in the
distribution of traits being measured. Although inherent in the theory, this assumption is
often violated. The Bayesian model thus appears more reality-based in making no such
assumption.
Different from the confidence intervals of classical theory, the obtained posterior
beliefs are interpreted simply as probability statements (Jones & Newman, 1971). This
allows the length of a subtest to be driven not by classical reliability theory, but instead
by the degree of certainty required by the assessment.
Given a large data base, the clinician can continue providing stimuli and modifying
posterior probabilities until the desired level of certainty is obtained. In some instances, a
sufficient certainty level can be achieved with administration of only a very few questions
in a trait area. This feature of the model is particularly important given the time constraints in many clinical settings. Cattell, Eber, and Tatsuoka (1970, p. 40) emphasize
that with limited testing time it is advantageous to measure a variety of factors with less
reliability, rather than to use time on only a few factors with high classical reliability
coefficients.
Although traditional neuropsychological assessments have been focused on the cognitive area, there is growing awareness (Nussbaum et aI., 1988) of the importance of
personality and behavioral correlates of various neuropsychological profiles. Thus, the
issue of time utilization may become even more crucial for the clinician. The Bayesian
model proposed here makes feasible the assessment of a much broader spectrum of cognitive and affective traits in a given time period.

Microcomputer Applications

A reasonable question is: If this assessment model is in fact appropriate, why has it not
been more frequently used in measurement applications? The answer may simply be that
the computational complexity necessitated a resource like the microcomputer. The task of
calculating posterior beliefs after each patient response precludes use of the model in
clinical assessments without such a resource.
The microcomputer in use as proposed in this model also offers the potential for
facilitating clinical input to the assessment process. Issues about the relative role of the
clinician in diagnosis are of long standing (Meehl, 1957). The increasing use of clinical

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Paul Jones

test interpretations, generated by microcomputer without clinician input (Matarazzo,

1986) has only added to the controversy.
In this model an opportunity for clinician input is provided first in the prior belief. If
clinical impressions preceding test administration are equivocal, population percentages
provide the quantification to begin observation and analysis. But the clinician has the
opportunity, when supported by other data, to integrate clinical impressions into the
metric analysis.
Consider a menu-driven computer program which provides for administration and
timing of test items, calculates the posterior probabilities, and is interactive in clinician
decision-making functions. For example, the clinician may be asked first for an impression about whether there is reason to suspect elevated anxiety. A "yes" response modifies the prior probabilities of high-average-low from the population percentages of
20-60-20 to 30-55-15. After clinician input, the patient's responses to test questions
are elicited with cumulative posterior probabilities computed and displayed after each
item. Testing continues until the clinician is satisfied with the certainty level. Assessment
of another trait then begins.
After the testing is completed, the Bayesian model again provides for clinician interaction. Results in each area are first presented in the form of category probabilities, for
example, high, average, and low verbal facilities of .44, .45, and .01, respectively. A
clinician on the basis of impressions from the complete interview could elect to change
the metric assignment from average to high (or even low) before proceeding with additional analysis and report. A computer program could then provide additional data analysis and, if desired, 'Y-rite a draft report to a text file.
Once verbal facility has been evaluated, one could then proceed to spatialJperceptual,
attentional, verbal memory, visual memory, intellectual, and problem-solving areas.
Testing time for each area can be greatly reduced by such application of the Bayesian
approach.
This Bayesian model can also be applied to affective areas, including assessing the
presence/absence of anxiety, depression, reality contact, thought disorder, and so forth.
Item data for affective instruments, although not typically reported, are routinely obtained in normative studies.
For example, the Clinical Analysis Questionnaire (Krug, 1980) reports personality
trait and pathology scores using responses to 272 items. Krug (1981) has proposed a
coding model for second-order personality traits (e.g., extraversion, anxiety) with categories of low, average, and high for each factor. From the normative data, the differential
item responses by assigned category could be made available. These data then would be
applied in the Bayesian model for prediction of category assignment as in the cognitive
areas.

Conclusion
The Bayesian model presented here can provide a framework for data gathering which
could enhance quality and utility of the neuropsychological assessment. Particularly in
screening applications, this model, using a basic Bayesian analysis in concert with the
microcomputer, holds promise for effective assessment of a variety of relevant traits
within reasonable time constraints. With assignment only in categories of highaverage-low, there would seem to be a loss in measurement precision, but this loss may

Bayesian Model

21

be more apparent than real. Differential intervention decisions are seldom made on
small scale differences. In fact, interpretation in only three such categories is often recommended, even with tests designed using traditional scaling procedures.
In order to implement the model, especially with attention to the interaction of specific cognitive and affective functions, an extensive amount of data will be needed regarding population base rates of particular disorders and behavioral correlates. Such data
are not now readily available. But the premise here is that the relevant data often have
been gathered. With no model to serve as a framework for use, the needed data are just
seldom reported. Test publishers and clinicians do obtain performance data on given
stimuli and could provide sufficient description of the individuals and groups to enable
Bayesian analysis.
Directing more attention to the tenets of classical measurement theory could certainly
enhance the quality of neuropsychological instrumentation. But either instead of or in
addition to such direction, consideration seems warranted for a model perhaps better
suited to meet contemporary needs with contemporary tools.

References
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questionnaire. Champaign, IL: IPAT.
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software supporting the activities of daily living. Neuropsychology, 2, 41-57.
Erickson, R.C., & Binder, L.M. (1986). Cognitive deficits among functionally psychotic patients:
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