Forensic Neuropsychology: A Scientific Approach. Glenn J. Larrabee, ed. New York: Oxford University Press, 2005. 479 pages, $68.50, hardcover: ISBN 0-195-15899-7.

For many decades, clinical neuropsychology has been characterized by a 2-party system-ie, a schism between practitioners of the "battery" approach (Halstead-Reitan, Luria-Nebraska) and those who adhere to the "flexible" principles propounded most forcefully by Edith Kaplan and Muriel Lezak (Early full disclosure-This reviewer was weaned on the latter Weltanschauung, with minimal exposure to the former.) This great divide has produced a number of heated exchanges in the literature, and one might come to think that the sides resembled the Montagues and the Capulets. However, surveys have shown that most neuropsychologists actually practice something of a blend of the two approaches, using what has been called a "flexible battery" methodology, with a core set of tests supplemented by additional measures as dictated by the specifics of the patient across the testing table. Furthermore, there have been occasional attempts at rapprochement between the two camps, extending to a failed effort to merge the two competing specialty boards.

However, as neuropsychological activity in the legal realm has expanded (becoming the largest revenue-producer for neuropsychologists in independent practice), the debate between the two groups has taken on renewed fervor. A recent article by Russell,1 a long-time proponent of the battery approach and creator of the Halstead Russell Neuropsychological Evaluation System, Revised (HRNES-R; Western Psychological Services), reaches the unequivocal conclusion that

[horizontal ellipsis] in forensic situations, the expert witness using a standardized battery is the only psychologist who can provide dependable testimony interpreting psychometric test data as a whole to the court. The expert witness who utilizes a flexible battery cannot provide dependable evidence derived from the battery as a whole, though they may present the results of individual tests.1(p792)

One should not overlook the importance of the phrase "as a whole," as Russell seems to be arguing for the greater value of batteries simply in distinguishing brains that are dysfunctional from those that are intact, raising the dichotomanic specter of the "organic vs functional" distinction that many thought had been left behind. Not having read the HRNES-R manual, I leave aside my perplexity at how Russell would advise users of the multicomponent instrument who follow the catalogue's advice ("You can select measures according to the patient's needs and the purpose of testing.") to respond to an attorney's inquiry, "So your validated fixed battery is really pretty elastic after all, isn't it?" If a reasonable response exists, an eminent clinician/researcher like Russell likely has it.

Nonetheless, as an expression of the fixed battery advocates' views, Russell's position would effectively disenfranchise the majority of neuropsychologists from participating in the legal process. Forensic Neuropsychology: A Scientific Approach provides a useful and effective counterargument, offering (as the book's subtitle indicates) a scientific framework that captures the thinking and tactics of proponents of the flexible approach. This point of view is most clearly taken in the first 2 chapters, but it is detectable throughout. The remainder of the book consists largely of tutorials on conditions that the forensic neuropsychologist is likely to encounter in civil and criminal contexts. The closing pair of chapters by Denney constitute a concise primer on the major issues and perspectives relevant to criminal cases. Denney delves especially into the concept of "competence" in its various forms, offering a critical synopsis of available instruments. He also addresses the notion of "responsibility" and the factors that can limit it, giving a nice summary of the evolution of views on insanity.

Larrabee will be familiar to the readers of this journal as the editor of the 2000 issue on forensic neuropsychology, several articles in which may be seen as precursors of chapters in the present volume. He has been a major contributor to this literature for at least the past 15 years. Here, he contributes 3 chapters, including an introductory "framework" chapter in which he lays out the basic tenets and practices of the proposed "scientific approach," revisiting his 4-pronged "consistency analysis" of neuropsychological test data as a means of identifying suboptimal effort. Larrabee makes his case against the superiority of fixed batteries, arguing that what is important is not that particular measures should be used but that testing encompass the core neuropsychological domains using valid instruments. He also provides a scholarly critical review of the booming area of evaluation of malingering.

Larrabee's third chapter on mild head trauma is 1 of 4 that are likely to be of most interest to head trauma rehabilitation clinicians; two others are by Donders on pediatric traumatic brain injury and by Sherer and Madison on moderate-severe traumatic brain injury. The authors are extremely well-qualified, the writing is scholarly yet accessible, and each chapter should satisfy both researchers seeking current reviews of relevant literature and clinicians looking for insight into the presenting problems of their patients. The fourth chapter (by Ricker) presents a sophisticated treatment of dynamic imaging techniques, with substantive discussion of the value of each in assessment of brain injury. While there is little discussion directly linked to forensic practice, the material in these chapters provides readers with concise reviews of their topics.

The chapters by Bolla (on neurotoxic injury) and Binder (on medically unexplained symptoms) equip the newcomer with a fundamental grasp of the condition(s) and issues in assessment. Patients with complaints of these sorts (eg, effects of mold exposure, chronic fatigue, multiple chemical sensitivity) can present the most vexing diagnostic problems, given, among other factors, the nonspecificity of many of the symptoms and relative paucity of research on neurobehavioral consequences. The work by Marson and Hebert will likely be passed over by many head trauma clinicians, as it deals with older adults with dementia. This is regrettable, as the chapter summarizes Marson's elegant extensive work in formulating models of competencies and empirical development of assessment methods, efforts that have recently been extended to traumatic brain injury.

Greiffenstein (a neuropsychologist) and Cohen (an attorney) offer a rich guide to collaboration containing a wealth of practical knowledge clearly gleaned in the trenches. The authors discuss the opposing frameworks (vocabularies, goals, methods) of the legal system and the scientist/practitioner model, which can stand in such diametric contrast that one may wonder how representatives of the two can work together. Greiffenstein and Cohen take the reader through the phases of a legal case, offering sage advice to both novices and experienced practitioners to help them negotiate the tricky forensic terrain. Thorny issues such as release of raw data and requests for third-party observers are given up-to-date treatments. The authors offer further rebuttal to Russell and other fixed battery advocates, arguing that Russell has failed to grasp the "liberal thrust" of the Daubert decision. A clear awareness of potential ethical pitfalls pervades this chapter, but readers would be well-advised also to digest the succeeding chapter by Grote, which goes into some detail about changes in the 2002 APA Ethical Principles and also discusses how the Health Insurance Portability and Accountability Act (HIPAA) (quite new at the time the chapter was written) is likely to affect forensic neuropsychological practice. Grote closes with some wise advice about possible ethical traps to be avoided.

Although I have no data to support this opinion, it is my strong impression that the vast majority of neuropsychologists working in rehabilitation settings gravitate toward flexible methods for at least 2 reasons: (1) limitations of time and resources that mandate emphasis on assessments of immediate value and (2) impatience of other staff members if all one offers is confirmation of the fact (usually already established by magnetic resonance imaging) that a patient does, indeed, have (eg) a right parietal lesion. The flexible approach is more likely to elicit practical, functionally relevant information of the sort that is relevant to the rehabilitation process. Thus, I expect that most rehabilitation neuropsychologists will find Forensic Neuropsychology's point of view to be "ego syntonic" and a valuable tool should they elect to enter the legal lists.

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