Demystifying the Neuropsychological Assessment: How to use the assessment as an effective tool for evaluation and treatment Jeff Snell, Ph.D. Director, Psychology and Neuropsychology Services, QLI Omaha, NE 2014 South Dakota Workers' Compensation Summit Psychology Psychology is the study of the mind and behavior. The discipline embraces all aspects of the human experience from the functions of the brain to the actions of nations, from child development to care for the aged. In every conceivable setting from scientific research centers to mental health care services, the understanding of behavior is the enterprise of psychologists. American Psychological Association (APA). APA Web Site, Q&A, Retrieved August 16, 2012 from http ://www.apa.org/support/about/apa/psychology.aspx#answer Neuropsychology Clinical neuropsychology is a specialty that applies principles of assessment and intervention based upon the scientific study of human behavior as it relates to normal and abnormal functioning of the central nervous system. The specialty is dedicated to enhancing the understanding of brain-behavior relationships and the application of such knowledge to human problems. Division 40 of the American Psychological Association, the Division of Clinical Neuropsychology. Retrieved August 16, 2012 from http://www.div40.org/pdf/archival%20description%20of%20clinical%20neuropsychology.pdf 1
Psychological Assessment A process of using samples of behavior and ability, reports of personal and medical history, symptoms or problems reported by self or others, in order to make inferences regarding an individual s capabilities, general personality functioning, intellectual capability, psychiatric functioning, etc The integration of various sources of information using a concise information-gathering process to make generalizations and conclusions Neuropsychological Assessment Emphasis on assessment of cognition and behavior as relates to underlying brain structure and function Identifying and diagnosing disturbances of cognition and behavior Projecting the functional impact of the findings on the individual Assisting in the design of clinical treatment Heavy emphasis on standardized, structured, highlycontrolled test administration, and interpretation of findings Process-oriented versus rigid battery or system Typical Populations of interest Cerebrovascular accidents (CVAs) Brain injury Neoplasms Infections, or inflammatory diseases Demyelinating disease Dementia / Pseudodementia General med./surg. patients with deficits that may complicate medical or surgical management Developmental disabilities..and many more 2
Typical Referral Issues Differential diagnoses between psychogenic and neurogenic syndromes Differential diagnoses between two or more suspected etiologies of cerebral dysfunction Evaluation of spared versus impaired functions secondary to a cortical or subcortical event Establishment of baseline Pre / Post pharmacological, surgical, or behavioral interventions Assessment of higher cortical functions for formulation of rehabilitation interventions Typical Referral Questions Is this individual experiencing depression, or the onset of dementia? Can this individual return to work? Is guardianship needed in this case? Is this patient safe to return to driving? Is this patient safe to discharge home? What academic/work accommodations are recommended? As compared to their previous functioning, are they better/worse? Intellectual Assessment Wechsler Adult Intelligence Scales, Fourth Edition (WAIS-IV) Wechsler Abbreviated Scale of Intelligence, Second Edition (WASI-II) Wechsler Intelligence Scales for Children, Fourth Edition (WISC-IV) Stanford-Binet Intelligence Scales, Fifth Edition (SB5) Test of Nonverbal Intelligence, Fourth Edition (TONI-4) 3
http://www.pearsonassessments.com/haiweb/cultures/en-us/productdetail.htm?pid=015-8980-808&mode=summary Academic Assessment Wechsler Individual Achievement Test Second Edition (WIAT-II) Woodcock-Johnson Tests of Achievement Third Edition (WJ-III) Wide Range Achievement Tests Fourth Edition (WRAT-4) Language Assessment Boston Naming Test (BNT) Controlled Oral Word Association Test (COWAT) Semantic Fluency - Animal Naming Test Peabody Picture Vocabulary Test Fourth Edition (PPVT-IV) Test of Premorbid Functioning (TOPF) Wide Range Achievement Test Fourth Edition (WRAT-4) Reading Subtest 4
Motor / Visual-Motor Assessment Grip Strength Test Finger Tapping Test Grooved Pegboard Test Line Bisection Task Cancellation Tasks Visual Search and Attention Test (VSAT) 5
Memory Assessment Wechsler Memory Scales Fourth Edition (WMS-IV) California Verbal Learning Test Second Edition (CVLT-II) Hopkins Verbal Learning Test Revised (HVLT-R) Brief Visuospatial Memory Test Revised (BVMT-R) Rey Complex Figure Test (RCFT) Wide Range Assessment of Memory and Learning Second Edition (WRAML2) Test of Memory Malingering (TOMM) 6
Executive Functioning Assessment Delis-Kaplan Executive Function System (D-KEFS) Stroop Color and Word Test (Stroop) Trail Making Test (TMT) Wisconsin Card Sorting Test (WCST) Continuous Performance Tasks (CPT) Clock Drawing Task Behavioural Assessment of the Dysexecutive Syndrome (BADS).. for children, BADS-C Red Blue Green Blue Yellow Green Blue Red Yellow Green Red Blue Green Blue Red Green Red Yellow Yellow Red Green Blue Green Green Blue Green Blue Yellow Blue Red Red Yellow Green Red Blue Green Red Blue Green Blue Yellow Green Blue Red Yellow Green Red Blue Green Blue Red Green Red Yellow Yellow Red Green Blue Green Green Blue Green Blue Yellow Blue Red Red Yellow Green Red Blue Green 7
Processing Speed Assessment Paced Auditory Serial Addition Test (PASAT) Processing Speed Index of WAIS-IV (PSI) Timed aspects of many of the previously-noted tests Personality Assessment / Symptom Reporting Minnesota Multiphasic Inventory 2 Restructured Form (MMPI-2RF) Millon Clinical Multiaxial Inventory Third Edition (MCMI-III) 16PF Fifth Edition Questionnaire Symptom Checklist 90 Revised (SCL-90-R) Beck Depression Inventory Second Edition (BDI-II) Beck Anxiety Inventory 8
Brief Screening or Battery Mini Mental Status Examination (MMSE) COGNISTAT (Neurobehavioral Cognitive Status Examination) Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) Military Acute Concussion Evaluation (MACE) Automated Neuropsychological Assessment Metrics (ANAM) Dementia Rating Scales Second Edition (DRS-2) The Neuropsychological Report Organization of a typical report Background information Procedures utilized Behavioral observations Results of assessments Summary/Recommendations Ranges and Percentiles 25% 75% Cumulative Percentile 2% 9% 91% 98% % within Range Range of Performance Standard Score (Composite/Index/IQ) Standard Deviation -2-1 0 +1 +2 9
The Neuropsychological Report Summary/Recommendations. Mr. Popeye T. Sailorman is a 46-year-old single Caucasian man from Sweethaven who recently was hospitalized following an assault in which he sustained a concussion. The current assessment was conducted in order to identify his cognitive strengths and needs, and to assist in the design of his treatment program. Within his current assessment Mr. Sailorman demonstrated many areas of functioning that appear to reflect performance that are at or his near pre-morbid estimates of ability. In particular, his language functioning (expressive and receptive) appears intact. His speech contains some errors of articulation and neologistic content, however friends report this as reflecting pre-injury characteristics (relative to this most recent concussion). Deficits were noted in the area of frontal executive functioning, particularly in measurements of impulsivity, reasoning, and emotional regulation. According to his history, Mr. Sailorman has sustained a number of concussive events, some requiring medical attention. It is therefore not surprising that some cumulative effect of his The Neuropsychological Report Referral Questions: 1) Is Mr. Sailorman able to return to his previous employment as a sea captain? At this point in his recovery, Mr. Sailorman is demonstrating functional abilities that are considered to be at or near his pre-injury status in most aspects of cognitive functioning. The over-learned and familiar aspects of the operation of his boat are not substantially impacted by the frontalexecutive deficits that were observed in the course of this examination, though his safe operation of a vessel could be compromised by his emotional/behavioral status (as was the case which resulted in his most recent injury). In terms of recovery from his recent concussion, however, Mr. Sailorman appears to be back to his pre-injury baseline of ability. What is the Question??? Broad questions How is this individual functioning after the injury? What is the ability level of this individual? Is there evidence of decline? Specific questions Does this person need a guardian? (This is a capacity question ) Can this individual return his previous job? What academic accommodations does need once she returns to school? Is the memory loss that is experiencing associated with the onset of dementia, or some other process? Is this patient safe to return home? 10
Situations where assessed/actual abilities may differ The artificial environment of testing The role of prior learning (familiarity) Novel/abstract tasks versus previously-developed routines The real world has natural cues and prompts, but also more distractions (and dangers!) The Advantages of Real World Performance Assessment Ecological validity Over-learned and crystallized information/abilities versus fluid/novel information/abilities Knowledge versus ability Incorporation of the familiar, or challenges of the new Leads to identification of remediation strategies Development of routines to use in natural environment Important to Remember! Neuropsychological assessment allows for a standardized comparison of performance with an appropriate normative population Results of a single assessment represents a point in time Serial testing can document change It is an artificial environment, with controls for extraneous variables that can affect performance Those extraneous variables in the real world can help, hinder, or have no effect Ecological/External validity can be limited 11
Important to Remember! You generally get a better answer when you have a question The questions to be answered by an assessment can be very specific, or more general As a referrer, you may have some questions come up after the report has been generated CALL! Selected Resources A Parent s Guide to Neuropsychological Evaluations: http://bianj.org/websites/bianj/images/parentsguidetoneur opsychologicalevaluations.pdf The American Psychological Association: www.apa.org Division 40 of the American Psychological Association, the Division of Clinical Neuropsychology: http://www.div40.org/ Assessment Psychology Online: http://www.assessmentpsychology.com/ Questions/Discussion 12
Contact Information Jeff Snell, Ph.D. Director, Psychology and Neuropsychology Services, QLI jeff.snell@qliomaha.com 13