•   Identify/describe the nature and extent of any cognitive deficits and emotional changes

•   Determine the need for treatment and inform the development of an individualized treatment plan to address the cognitive, emotional, and behavioral deficits (e.g., cognitive rehabilitation, psychotherapy, medication)

•   Evaluate the effectiveness of interventions in terms of their immediate and long-term impacts on proximal (e.g., specific cognitive problems) or distal outcomes (e.g., return to work, social integration)

•   Description of the injury—Determine how the injury occurred, duration of any alteration in mental status (i.e., confusion, posttraumatic amnesia), or loss of consciousness. Inquire about symptoms that have begun since the injury occurred [2].

•   Description of current symptoms.

•   Comprehensive TBI history—In addition to information about the current injury, it is important to determine if a person has sustained multiple MTBIs, as the effects of these injuries can be additive.

•   Review of imaging studies—Inquire about what tests were done in the emergency room and whether the results are available. Studies show that only a small percentage of patients with MTBI show positive findings on CT scans [3].

•   Comorbid conditions that could account for the person’s symptoms.

•   Social, educational, and employment history.

•   Domains—Domains to be assessed following MTBI include attention/concentration, speed of information processing, learning/encoding of new information, motor speed, memory and learning, reading speed and comprehension, verbal fluency and language use, intellectual function, and executive functions (problem solving, planning, organization, decision making, prioritizing, etc.). Assessment of dysexecutive behaviors such as impulsivity, apathy, risk taking, irritability, and daily blunders should also be included.

•   Instrument selection—Select tests that are sensitive to the subtle cognitive changes that are characteristic of MTBI. Tests with a low ceiling or intended for use as screening tools (i.e., mini mental status examinations) are not useful in assessing persistent changes related to MTBI, as these gross measures are unlikely to detect the impairments in higher order cognitive abilities that are characteristic of MTBI.

•   Assessment of mood—Emotional distress may exacerbate the person’s perceptions of the extent of their cognitive deficits and compound their functional impairments [2]. Individuals with MTBI commonly experience depression, anxiety, and emotional dysregulation. These changes in mood may be related to the injury event itself, or may be secondary to functional impairments (e.g., absence from work or school), physical injuries, pain, and fatigue. Posttraumatic stress disorder (PTSD) can co-occur with MTBI, particularly when the circumstances leading to the injury were traumatic or combat related [4].

•   Functional relevance—Select tests to evaluate cognitive and behavioral domains that are particularly important for an individual’s day-to-day functioning. For example, it may be important to assess reading efficiency in college students, math calculation skills in accountants, sustained attention in truck drivers, and so on.

•   Quantitative versus qualitative data—Diagnostic and treatment planning decisions following MTBI should rely both on scores obtained from standardized tests, as well as detailed clinical observations. While quantitative test scores allow comparisons of an individual’s abilities to normative samples and estimates of preinjury function, qualitative data gained through clinical observation provide rich information that can support the interpretation of objective test scores. For example, an individual’s inability to arrive on time for a testing session may provide information that supplements tests of executive functioning or anxiety [1].

•   Relative versus absolute impairments—Absolute impairments are indicated by very low test scores. In contrast, relative impairments are reductions in functioning relative to the individual’s levels of premorbid functioning. Estimates of premorbid function are based on educational and vocational history and on tests designed to assess premorbid cognitive ability (e.g., Wechsler Adult Reading Test, Test of Premorbid Function, and National Adult Reading Test). Relative impairments are not necessarily reflected in objectively low (i.e., below average) test scores. However, both absolute and relative impairments may have significant impact on daily functioning, as well as occupational and social-role performance. Individuals with MTBI may show no absolute impairments, but show relative impairments that considerably affect their ability to function. For example, a person who performs within the “average” range following MTBI may have performed in the “high average” or “superior” range prior to his or her injury. Thus, this person’s current “average” range score does not reveal the extent of his or her current impairments [1].

•   Mitigating factors—Performance on NPA following MTBI can be affected by physical, cognitive, and emotional factors. For example, headaches, dizziness, fatigue, visual impairments, insomnia, and drowsiness due to medication may interfere with test performance. Anxiety, depression, and low motivation may affect test performance negatively. Incentive to manifest disability for secondary gain is an additional mitigating factor that may affect test performance. Effort and malingering tests should be included in NPAs, especially when there is current or future potential for secondary gain [1].