Advanced Clinical Solutions for WAIS-IV IV and WMS-IV

Advanced Clinical Solutions for WAIS-IV IV and WMS-IV Gloria Maccow, PhD Assessment Training Consultant Agenda Describe components of Advanced Clinical Solutions for WAIS-IV and WMS-IV (ACSW4W4). Select components of ACSW4W4 to answer specific referral questions; Analyze data from ACSW4W4 to determine if cognitive abilities are declining; and Analyze data from ACSW4W4 to determine if examinee s performance is consistent with the nature of the injury or clinical condition. 2 Copyright 2013. All rights reserved. 1

Advanced Clinical Solutions for WAIS-IV and WMS-IV is an individually administered array of tests, procedures, and scores addressing specific clinical questions and needs. Primary Goal of ACS... To expand and enhance the clinical utility of WAIS-IV and/or WMS-IV through... 4 Copyright 2013. All rights reserved. 2

Applications of ACS... additional assessments of: premorbid functioning effort social cognition executive function A separate instrument, Texas Functional Living Scale, linked with the WAIS-IV and WMS-IV, can be used to assess instrumental activities of daily living. 5 Copyright 2013. All rights reserved. Applications of ACS... and software that delivers: Demographically Adjusted Norms Additional scores for WAIS-IV and WMS-IV Reliable Change scores 6 Copyright 2013. All rights reserved. 3

Designed for Use... in forensic settings to measure pre-morbid function (insurance claims) and suboptimal effort (malingering). with older adults to assess current status, premorbid functioning, decline in cognitive functions, and reliable change. 7 Copyright 2013. All rights reserved. Designed for Use... with individuals who have traumatic brain injury to assess premorbid functioning, executive functions, and social cognition. with individuals with Autism/ Asperger s to evaluate social cognition. 8 Copyright 2013. All rights reserved. 4

Components of ACS 9 Copyright 2013. All rights reserved. Memory Grid Cards Word Choice Stimulus Book Record Forms/Booklets Additional Assessments 5

Premorbid Functioning Test of Pre-Morbid Functioning (TOPF) Revision of the Wechsler Test of Adult Reading (WTAR). Provides an estimate of premorbid intellectual functioning. 11 Copyright 2013. All rights reserved. Premorbid Functioning Test of Pre-Morbid Functioning (TOPF) Revised and re-normed with WAIS IV and WMS IV. Enhanced by the addition of more difficult words and an extended IQ range of predictability. 12 Copyright 2013. All rights reserved. 6

Test of Premorbid Functioning Uses Atypical Grapheme-Phoneme translation to measure word knowledge through reading. Relatively resistant to brain injury and dementia. 13 Copyright 2013. All rights reserved. Test of Premorbid Functioning Premorbid Prediction Models Demographics only (simple or complex) TOPF only Demographics with TOPF Predict WAIS-IV Indexes and WMS-IV IMI, DMI, and VWMI 14 Copyright 2013. All rights reserved. 7

Effort Assessing Suboptimal Effort Help determine if the examinee s level performance is consistent with the nature of his or her injury or clinical condition. Information on effort may be required for certain medical-legal and forensic evaluations. 15 Copyright 2013. All rights reserved. Effort Assessing Suboptimal Effort Available for Ages 16-69 External Measure New subtest: Word Choice Embedded Measures Reliable Digit Span Logical Memory Recognition Verbal Paired Associates Recognition Visual Reproduction Recognition 16 Copyright 2013. All rights reserved. 8

Social Cognition Assessing Social Cognition An assessment of an individual s ability to understand non-verbal communication and social interactions. Three new subtests (Social Perception, Faces - Supplemental, Names - Supplemental) provide assessments of emotion, face, and name recognition, as well as prosody and incidental recall of emotional expression. Audio files on CD- ROM. 17 Copyright 2013. All rights reserved. Social Perception Subtest Consists of 3 tasks Affect Naming (Happy, Sad, Angry, Surprise, Disgust, Fear, and Neutral) Prosody-Face Matching (includes Sarcasm) Prosody-Pairs Matching Listen to a pair of individuals interacting. Describe how tone of voice changes the meaning of what is said. 18 Copyright 2013. All rights reserved. 9

Executive Function Assessing Executive Function with selected tests from Delis-Kaplan Executive Function System (D-KEFS) Trail Making (Conditions 2, 3, & 4) Number Sequencing, Letter Sequencing, Number- Letter Switching Verbal Fluency Letter and Category Fluency, Category Switching Now correlated with WAIS IV and WMS IV 19 Copyright 2013. All rights reserved. Verbal Fluency Note- this is a language test. Deficits in executive functioning may be inferred if no significant language impairments are present. 20 Copyright 2013. All rights reserved. 10

Instrumental Activities of Daily Living 21 Copyright 2013. All rights reserved. About TFLS TFLS is a brief, ecologically valid, performance based measure to identify the level of care required by an individual. Authors: Munro Cullum, PhD, Myron F. Weiner, MD, and Kathleen C. Saine, PhD. Publication Date: April 2009 22 Copyright 2013. All rights reserved. 11

Overview of TFLS Brief assessment of functional competence 15 minutes to administer Assesses Instrumental Activities of Daily Living (IADL) Performance-based measure Direct assessment of skills Designed for Ages 16-90 23 Copyright 2013. All rights reserved. Use TFLS to... Assess functional abilities (Time, Money and Calculation Skills, Communication, Memory) Screen for dementia Monitor functional decline Monitor treatment/drug efficacy Determine level of care required Linked with WAIS-IV and WMS-IV 24 Copyright 2013. All rights reserved. 12

Interpretation of TFLS Total Score T-Score metric combines all 4 domains. T-Score above 40 points suggests individual can live independently. T-Score below 25 points often suggests individual may need to reside in a special care unit. T-score of 26-40 (mild, mild-to-moderate, and moderate impairment) suggests individual may need partial or fully assisted living. 25 Copyright 2013. All rights reserved. ACS Software Additional Scores 13

Demographically Adjusted Norms Enable clinician to refine hypothesis about the degree to which a specific score is unexpected when compared to individuals of similar background characteristics (e.g., education level). Norms approximate the unique demographic subgroup of an individual. 27 Copyright 2013. All rights reserved. Demographically Adjusted Norms Available for WAIS-IV and WMS-IV Subtest and Index Scores Education-only adjusted norms Full Demographically adjusted norms 28 Copyright 2013. All rights reserved. 14

29 Copyright 2013. All rights reserved. Use of Demographically Adjusted Norms Meant to minimize the impact of psychosocial variables on the diagnosis of cognitive impairment, such as estimating the degree of cognitive impairment after a brain injury or insult.... most appropriately applied in the context of a neurodiagnostic assessment. Use of Demographically Adjusted Norms NOT a replacement or substitute for WAIS-IV or WMS-IV conventional age-adjusted norms. NOT to be used for: psychoeducational evaluations, determination of intellectual deficiency, vocational assessment,.. any context in which the purpose of the evaluation is to determine the absolute functional level (IQ or Memory) of the examinee relative to a representative sample of the U.S. population (The Psychological Corporation, 2002). 30 Copyright 2013. All rights reserved. 15

Premorbid Function Software applies a regression equation to predict premorbid abilities using demographic characteristics and/or performance on the ACS Test of Premorbid Functioning (TOPF). Software Provides Estimate of Premorbid IQ (FSIQ, GAI, VCI, PRI, WMI, and PSI) Estimate of Premorbid Memory Ability (IMI, DMI, and VWMI) 31 Copyright 2013. All rights reserved. Reliable Change Assesses whether performance differences over time are due to actual changes in functioning, and not to the unreliability of the measure. Uses scores from the WAIS IV and/or WMS IV to compute a reliable change score between an assessment at Time 1 and Time 2. 32 Copyright 2013. All rights reserved. 16

Reliable Change Software uses regression based models to provide an indicator of a significant decline in performance between test sessions controlling for the impact of practice effects, ability level, and age where appropriate. Available for all WAIS-IV and WMS-IV subtest and index scores. 33 Copyright 2013. All rights reserved. Additional Subtest Scores Allow better identification and description of the nature and extent of observed memory problems. Additional WAIS-IV Subtest Scores Cancellation Additional WMS-IV Subtest Scores Logical Memory Verbal Paired Associates Designs Visual Reproduction 34 Copyright 2013. All rights reserved. 17

Additional Index Scores WMS-IV Indexes Auditory Immediate Auditory Delayed Auditory Recognition Visual Immediate Visual Delayed Visual Recognition Designs Spatial Designs Content 35 Copyright 2013. All rights reserved. Additional WMS-IV Contrast Scores Auditory Immediate vs. Delayed Recognition vs. Delayed Visual Immediate vs. Delayed Recognition vs. Delayed Designs: Spatial vs. Content 36 Copyright 2013. All rights reserved. 18

Summary ACS: Construct Coverage Refined assessment of memory functions Error scores Additional indexes Suboptimal Effort - Word Choice - Embedded Measures Social Cognition Affect Recognition, Prosody Faces Names Executive Function Trail-Making Verbal Fluency Change in cognitive function Demographic Adjustments to Norms Premorbid Ability estimation Reliable Change Scores (regression based) 37 Copyright 2013. All rights reserved. Are Cognitive Abilities Declining? 19

Many Factors can Influence Performance Acuity Attention Executive Functioning Global Intellectual Functioning Working Memory Language Impairment (Auditory Memory subtests) Visual-Spatial Processing (Visual Memory subtests) Fatigue Poor Effort Impulsivity 39 Copyright 2013. All rights reserved. Intake Information Mabel is an 82-year old female. She attended college but did not complete degree. She was married for 50 years until her husband died 10 years ago. She was a homemaker and never worked outside the home. 40 Copyright 2013. All rights reserved. 20

Referral Concerns Her children referred Mabel for evaluation. They are concerned about declines in her cognitive abilities and about her living alone. 41 Copyright 2013. All rights reserved. Referral Concerns According to her children, Mabel evidences word retrieval difficulties, and difficulty sequencing complex information. She is forgetful and easily overwhelmed with instrumental daily activities. 42 Copyright 2013. All rights reserved. 21

Intake Information Mabel is relatively physically healthy. She was diagnosed with atrial fibrilation and osteoporosis - both being treated with medication. She takes Namenda to treat cognitive decline. 43 Copyright 2013. All rights reserved. Dementia or Mild Cognitive Impairment Clinical concepts concerning this referral: Change in cognitive status from a previous level Mental Status Memory impairment Self-care Depression 44 Copyright 2013. All rights reserved. 22

Clinical Questions Is Mabel experiencing dementia? Does she evidence deficits in two or more areas of cognition? Does she manifest a decline in memory and other cognitive functions relative to premorbid cognitive ability? If cognitive abilities are impaired, what is the impact on daily living? 45 Copyright 2013. All rights reserved. WAIS-IV Procedures Utilized WMS-IV + Brief Cognitive Status Exam ACS: Additional Scores ACS: Test of Premorbid Functioning Reliable Change Scores (Serial Assessment) Texas Functional Living Scales 46 Copyright 2013. All rights reserved. 23

Evaluation Results Mini Mental Status Exam = 19 (middle stage/moderate Alzheimer s disease) BDI-II=1 (no indication of depression) 47 Copyright 2013. All rights reserved. WAIS-IV: IV: Probable Dementia of Alzheimer s s Type-Mild Composite Clinical Mean Control Mean Mean Diff. p value Effect Size VCI 86.2 103.0 16.84 <.01 1.04 PRI 85.8 101.5 15.72 <.01 1.01 WMI 84.3 100.9 16.66 <.01 1.12 PSI 76.6 102.6 26.06 <.01 1.70 FSIQ 81.2 102.0 20.87 <.01 1.25 48 Copyright 2013. All rights reserved. n = 44 24

WAIS-IV: IV: Mild Cognitive Impairment Composite Clinical Mean Control Mean Mean Diff. p value Effect Size VCI 99.0 106.1 7.13 <.01.49 PRI 93.9 102.4 8.43 <.01.61 WMI 96.6 104.7 8.13 <.01.54 PSI 94.9 102.2 7.33.05.53 FSIQ 94.8 104.8 10.00 <.01.72 n = 53 49 Copyright 2013. All rights reserved. WAIS-IV IV Scores Composite Score/ Composite Score/ Index/Subtest Scaled Score Index/Subtest Scaled Score Verbal Comprehension 98 Perceptual Reasoning 92 Similarities 11 Block Design 9 Vocabulary 10 Matrix Reasoning 9 Information 8 Visual Puzzles 8 Working Memory 97 Processing Speed 74 Digit Span 10 Coding 6 Arithmetic 9 Symbol Search 4 Full Scale IQ = 89 General Ability Index = 95 50 Copyright 2013. All rights reserved. 25

Index-Level Discrepancy Comparisons Comparison Score 1 Score 2 Diff. Critical Value.05 Significant Difference Y / N Base Rate Overall Sample VCI - PRI 98 92 6 9.75 N 32.5 VCI - WMI 98 97 1 8.82 N 48.1 VCI - PSI 98 74 24 9.75 Y 7 PRI - WMI 92 97-5 10.99 N 37.1 PRI - PSI 92 74 18 11.75 Y 12.1 WMI - PSI 97 74 23 10.99 Y 7.3 FSIQ - GAI 89 95-6 3.19 Y 12.4 51 Copyright 2013. All rights reserved. PSI: Weakness Mabel s ability to mentally process routine information rapidly without making errors is a weakness relative to her verbal reasoning and nonverbal reasoning abilities. 52 Copyright 2013. All rights reserved. 26

PSI: Functional Implication A weakness in the speed of processing routine visual information may make the task of comprehending novel and/or nonroutine information more timeconsuming and difficult for Mabel. 53 Copyright 2013. All rights reserved. PSI: Functional Implication A weakness in simple visual scanning and tracking may leave her less time and mental energy for the complex task of understanding new material. 54 Copyright 2013. All rights reserved. 27

WMS-IV: Probable Dementia of Alzheimer s s Type-Mild WMS-IV Index Clinical Mean Control Mean Mean Diff. p value Effect Size AMI 68.5 107.1 38.60 <.01 2.24 VMI 69.7 102.5 32.85 <.01 2.00 IMI 71.7 107.4 35.71 <.01 2.16 DMI 63.6 104.6 40.98 <.01 2.39 GAI 86.9 110.4 23.57 <.01 1.64 n = 48 (ages 65-89) 55 Copyright 2013. All rights reserved. WMS-IV Index WMS-IV: Mild Cognitive Impairment Clinical Mean 56 Copyright 2013. All rights reserved. Control Mean Mean Diff. p value Effect Size AMI 89.9 105.6 15.65 <.01 1.05 VMI 89.3 102.1 12.84 <.01 0.89 VWMI 91.6 107.2 15.54 <.01 1.22 IMI 90.8 105.8 15.00 <.01 1.09 DMI 87.5 103.5 16.00 <.01 1.01 GAI 97.2 106.9 9.73 <.01 0.78 n = 50 (ages 55-84) 28

WMS-IV Scores: BCSE Mabel s global cognitive functioning, as measured by the BCSE, was in the Low range, compared to others, ages 70 to 90, with a similar educational background. This classification level represents 2 4% of cases within her age and education group. 57 Copyright 2013. All rights reserved. WMS-IV Scores: BCSE Functioning in this range has a moderately high probability of being considered atypical, though not necessarily diagnostic. 58 Copyright 2013. All rights reserved. 29

WMS-IV Scores Index/Subtest Index Score/ Scaled Score Index/Subtest Index Score/ Scaled Score Auditory Memory 78 Visual Memory 66 Logical Memory I 9 Visual Reproduction I 3 Logical Memory II 2 Visual Reproduction II 5 Verbal Paired Associates I 7 Verbal Paired Associates II 7 Symbol Span 6 Immediate Memory 77 Delayed Memory 67 Logical Memory I 9 Logical Memory II 2 Verbal Paired Associates I 7 Verbal Paired Associates II 7 Visual Reproduction I 3 Visual Reproduction II 5 59 Copyright 2013. All rights reserved. Ability Memory Analysis Ability Score Type: GAI (= 95) Predicted Difference Method Index Predicted WMS IV Index Score Actual WMS IV Index Score Difference Critical Value Significant Difference Y / N Auditory Memory 97 78 19 9.33 Y Base Rate 5-10% Visual Memory 97 66 31 7.72 Y <1% Immediate Memory 97 77 20 10.41 Y 4% Delayed Memory 97 67 30 10.86 Y 1% 60 Copyright 2013. All rights reserved. 30

Retention of Information WMS IV Indexes Index Score 1 Score 2 Immediate Memory Index vs. Delayed Memory Index Contrast Scaled Score 77 67 5 61 Copyright 2013. All rights reserved. Auditory Memory Relative to WAIS-IV IV Abilities Contrast Scaled Scores Score Score 1 Score 2 General Ability Index vs. Auditory Memory Index Contrast Scaled Score 95 78 5 Verbal Comprehension Index vs. Auditory Memory Index Working Memory Index vs. Auditory Memory Index 98 78 5 97 78 6 62 Copyright 2013. All rights reserved. 31

GAI vs. AMI The clinical groups that significantly differ from the controls and have large effect sizes on the GAI vs. AMI are Probable Dementia of the Alzheimer s Type-Mild Severity, Mild Cognitive Impairment, Mild and Moderate Intellectual Disability, Schizophrenia, and Moderate-to-Severe TBI groups. 63 Copyright 2013. All rights reserved. Auditory Process Scores Auditory Memory Process Score Summary Score LM II Recognition VPA II Recognition VPA II Word Recall Raw Score Scaled Score Percentile Rank Cumulative Percentage (Base Rate) 15 - - 17-25% 22 - - 10-16% 5 7 16-64 Copyright 2013. All rights reserved. 32

Forgetting and Retrieval: Auditory Modality Logical Memory Score Score 1 Score 2 LM II Recognition vs. Delayed Recall LM Immediate Recall vs. Delayed Recall Contrast Scaled Score 17-25% 2 1 9 2 1 65 Copyright 2013. All rights reserved. Forgetting and Retrieval: Auditory Modality Verbal Paired Associates Score Score 1 Score 2 Contrast Scaled Score VPA II Recognition vs. Delayed Recall 10-16% 7 9 VPA Immediate Recall vs. Delayed Recall 7 7 10 66 Copyright 2013. All rights reserved. 33

Visual Memory Relative to Other Abilities Score Score 1 Score 2 General Ability Index vs. Visual Memory Index Contrast Scaled Score 95 66 2 Perceptual Reasoning Index vs. Visual Memory Index 92 66 2 67 Copyright 2013. All rights reserved. Visual Process Scores Visual Memory Process Score Summary Score Raw Score Scaled Score Percentile Rank Cumulative Percentage (Base Rate) VR II Recognition 2 - - 17-25% VR II Copy 43 - - >75% 68 Copyright 2013. All rights reserved. 34

Forgetting and Retrieval: Visual Modality Visual Reproduction Score Score 1 Score 2 VR II Recognition vs. Delayed Recall VR Copy vs. Immediate Recall VR Immediate Recall vs. Delayed Recall Contrast Scaled Score 17-25% 5 6 >75% 3 2 3 5 8 69 Copyright 2013. All rights reserved. Modality-Specific Memory Strengths and Weaknesses WMS IV Indexes Index Score 1 Score 2 Contrast Scaled Score Auditory Memory Index vs. Visual Memory Index 78 66 5 70 Copyright 2013. All rights reserved. 35

Visual Working Memory Mabel s ability to keep in mind a mental image of a symbol and its relative spatial position on the page is below average (Symbol Span scaled score = 6). 71 Copyright 2013. All rights reserved. Immediate Memory Relative to WAIS-IV IV GAI Score Score 1 Score 2 General Ability Index vs. Immediate Memory Index Contrast Scaled Score 95 77 4 72 Copyright 2013. All rights reserved. 36

GAI vs. IMI The clinical groups that significantly differ from the controls and have large effect sizes on the GAI vs. IMI are Probable Dementia of the Alzheimer s Type-Mild Severity, Mild Cognitive Impairment, Mild and Moderate Intellectual Disability, Right Temporal Lobectomy, Moderate-to-Severe TBI groups, and Autistic Disorder groups. 73 Copyright 2013. All rights reserved. Delayed Memory Relative to WAIS-IV IV GAI Score General Ability Index vs. Delayed Memory Index Score 1 Score 2 Contrast Scaled Score 95 67 3 74 Copyright 2013. All rights reserved. 37

GAI vs. DMI The clinical groups that significantly differ from the controls and have large effect sizes on the GAI vs. DMI are Probable Dementia of the Alzheimer s Type-Mild Severity, Mild Cognitive Impairment, Mild and Moderate Intellectual Disability, Right Temporal Lobectomy, Autistic Disorder, Schizophrenia, and Moderate-to-Severe TBI groups. 75 Copyright 2013. All rights reserved. Additional Scores-AMI WMS-IV Index Auditory Immediate Auditory Delayed Auditory Recognition Index Score Percentile Rank Qualitative Description 89 23 Low Average 67 1 Extremely Low 76 5 Borderline 76 Copyright 2013. All rights reserved. 38

Additional Scores-AMI Score Score 1 Score 2 Auditory Immediate Index vs. Auditory Delayed Memory Index Auditory Recognition Index vs. Auditory Delayed Memory Index Contrast Scaled Score 89 67 1 76 67 5 77 Copyright 2013. All rights reserved. Test of Premorbid Functioning Uses Atypical Grapheme-Phoneme translation to measure word knowledge through reading. Relatively resistant to brain injury and dementia. 78 Copyright 2013. All rights reserved. 39

Test of Premorbid Functioning Premorbid Prediction Models Demographics only (simple or complex) TOPF only Demographics with TOPF Predict WAIS-IV Indexes and WMS-IV IMI, DMI, and VWMI 79 Copyright 2013. All rights reserved. Premorbid Functioning Test of Premorbid Functioning Score Summary Raw Score Standard Score Percentile Rank Qualitative Description Test of Premorbid Functioning 61 119 89.7 High Average 80 Copyright 2013. All rights reserved. 40

Premorbid Functioning WAIS IV IV Actual Predicted Comparison Composite Actual Equated Difference Critical Value Significant Difference Base Rate FSIQ 89 117-28 6.11 Y 3.4% VCI 98 117-19 7.3 Y 9.3% PRI 92 117-25 11.12 Y 17.9% WMI 97 118-21 9.77 Y 16.1% PSI 74 118-44 11.04 Y 5.7% Actual Predicted Comparison based on Test of Premorbid Functioning Equated Model 81 Copyright 2013. All rights reserved. Premorbid Functioning WMS IV Actual Predicted Comparison Index Actual Equated Difference Critical Value Significant Difference Base Rate IMI 77 117-40 9.65 Y 2.2% DMI 67 118-51 10.36 Y 3.9% Actual Predicted Comparison based on Test of Premorbid Functioning Equated Model 82 Copyright 2013. All rights reserved. 41

Reliable Change Score Used to determine if there has been a change in cognitive functioning between 2 time periods Decline associated with dementia or other progressive neurological condition Improved function related to intervention such as rehabilitation or medication effects 83 Copyright 2013. All rights reserved. Reliable Change Score Applies multivariate hierarchical regression method to control for practice effects and other factors associated with change in performance. 84 Copyright 2013. All rights reserved. 42

Reliable Change Score Predictors Time 1 performance GAI (or VCI or PRI) Age Education Sex Test interval 85 Copyright 2013. All rights reserved. Reliable Change Score Compare actual time 2 performance to predicted time 2 performance Statistically significant difference Base rate If difference is significant and rare, may indicate a decline or improvement in functioning. 86 Copyright 2013. All rights reserved. 43

Reliable Change Score Serial Assessment Report for WAIS-IV and WMS-IV Mabel Sample82 Test-Retest Interval 6 months 0 days 87 Copyright 2013. All rights reserved. WAIS-IV IV Serial Assessment 88 Copyright 2013. All rights reserved. 44

WMS-IV Serial Assessment 89 Copyright 2013. All rights reserved. Clinical Questions Is Mabel experiencing dementia? Progressive and long-term decline in cognitive function. Perceptual reasoning ability, speed of processing visual information, and memory, especially long-term memory. 90 Copyright 2013. All rights reserved. 45

Diagnosis and Treatment Evaluate all data to determine if Mabel s current functioning is consistent with a diagnosis of Dementia. Establish the impact of cognitive impairment on Mabel s performance of instrumental activities of daily living? 91 Copyright 2013. All rights reserved. Instrumental Activities of Daily Living Texas Functional Living Scale Score Time Total Money and Calculation Total Communication Total Memory Total TFLS Total Raw Score 8 6 26 3 43 Subscale Cumulative Percentage 51-75 17-25 26-50 3-9 TFLS T-Score 40 92 Copyright 2013. All rights reserved. 46

Instrumental Activities of Daily Living Impairments in cognitive functions adversely impact Mabel s ability to perform instrumental activities of daily living. T-score of 40 on the TFLS indicates mild impairment. 93 Copyright 2013. All rights reserved. Diagnosis On initial assessment, Mabel s performance indicated a possible decline in functioning from previous levels of performance with a clear memory impairment present. On re-evaluation, Mabel showed significant declines in general intellectual and memory functioning. 94 Copyright 2013. All rights reserved. 47

Diagnosis The data indicate a progressive and long-term decline in cognitive function. The clinician diagnosed Mabel with Alzheimer s Disease. 95 Copyright 2013. All rights reserved. Living Arrangements It was determined that Mabel required an assisted living environment due to her significant difficulties with memory and daily functioning. Mabel was placed in an assisted living facility close to her children. She functioned relatively independently and did well with structured routines. 96 Copyright 2013. All rights reserved. 48

Interventions: Encoding Given her relative strength in higher-order conceptualization and reasoning, Mabel may benefit from using associative linkages when encoding information. By linking new information to what has been previously learned, she may be able to gain a more global understanding of the information and improve recall. 97 Copyright 2013. All rights reserved. Interventions: Encoding When she first encounters new information, she should link it in as many ways as possible to already known information. This strategy creates several avenues for remembering the information later. 98 Copyright 2013. All rights reserved. 49

Interventions: Encoding Encourage her to use external memory sources, for example, leaving verbal messages on her telephone answering machine, to remind herself to pay bills, take medication, schedule/keep appointments, etc. 99 Copyright 2013. All rights reserved. Interventions: Retention of Information To increase her ability to retain information, build on her relative strength in verbal comprehension. Encourage her to verbalize the steps she will use to complete a daily routine (e.g., dressing) or to complete an assigned task. This self-talk can reinforce the sequencing of all necessary steps for successful task completion. 100 Copyright 2013. All rights reserved. 50

Interventions: Retention of Information To increase her ability to retain information, build on her relative strength in verbal comprehension. To complete extensive or complex tasks, ask her to break down these larger tasks into shorter, simpler tasks with feasible deadlines. 101 Copyright 2013. All rights reserved. Interventions to Improve Skills Her short-term memory and vocabulary skills could be improved at home while playing games that require memory, concentration, and recall of information. 102 Copyright 2013. All rights reserved. 51

Interventions to Improve Skills Computer-assisted educational programs may be of benefit to her. If she enjoys video games, learning can be integrated into this fun activity. Numerous commercial educational software packages exist to meet her needs. 103 Copyright 2013. All rights reserved. Is Performance Consistent with the Nature of the Injury or Clinical Condition? 52

Background Information Blake is a 23 year old, single, white male, with a bachelor s degree in political science. In 2009, he was working as an assistant store manager when he sustained a moderate TBI as a result of a motor vehicle accident. Upon admission to the hospital, his Glasgow Coma Scale was 7. 105 Copyright 2013. All rights reserved. Background Information He sustained hemorrhagic contusions with depressed skull fracture in right frontal area. Blood was noted in anterior temporal tip. 106 Copyright 2013. All rights reserved. 53

Frontal Lobe Damage associated primarily with executive dysfunction possible impaired flexibility in problemsolving or in adaptability (Lezak, et al., 2004). http://www.neuroskills.com/tbi/bfrontal.shtml 107 Copyright 2013. All rights reserved. Background Information Blake s orientation and language functions returned to normal after 3 4 hours. He experienced on going headaches, sleepiness, and fatigue for several days. He was released from the hospital after 3 days. 108 Copyright 2013. All rights reserved. 54

Background Information Blake continued to struggle with fatigue. He struggled to concentrate especially when reading. He returned to work after 3 weeks but had to leave early because of headaches and difficulty focusing and sustaining his attention. 109 Copyright 2013. All rights reserved. Background Information His parents encouraged Blake to seek legal counsel regarding the accident because the accident had been caused by a car whose driver had failed to stop at the red light. The lawyer observed that they had a good chance of winning a claim against the company given the on-going difficulties Blake was experiencing after the accident. 110 Copyright 2013. All rights reserved. 55

Background Information As part of the legal case, Blake was sent for neuropsychological evaluation of ongoing attention problems. The evaluation was conducted 12 months post injury. 111 Copyright 2013. All rights reserved. Traumatic Brain Injury Acquired brain injury caused by external physical force May lead to temporary or permanent impairment of cognitive, physical, and psychosocial functions. http://emedicine.medscape.com/article/326510-overview 112 Copyright 2013. All rights reserved. 56

Moderate TBI Clinical Concepts TBI associated with deficits in memory (including working memory) attention/executive functioning processing speed theory of mind and social perception (more recently) language problems perceptual problems See TBI special group studies in WAIS-IV and WMS-IV Technical and interpretive manual. 113 Copyright 2013. All rights reserved. Moderate TBI Clinical Concepts Higher-level cognitive skills, commonly referred to as executive functions, have been ascribed primarily to dorsolateral prefrontal regions. Emotional and behavioral regulation and control have been attributed primarily to ventromedial prefrontal cortex. 114 Copyright 2013. All rights reserved. 57

Moderate TBI Clinical Concepts Loss of cognitive functioning from a previous level. Secondary gain introduced by the medical legal case against the company responsible for the accident. Medical evidence for the presence of a moderate TBI. 115 Copyright 2013. All rights reserved. Procedures Utilized Record Review Clinical Interview WAIS IV WMS IV ACS: Demographically Adjusted Norms D KEFS: Trail Making, Verbal Fluency ACS: Social Perception ACS: Suboptimal Effort 116 Copyright 2013. All rights reserved. 58

Moderate TBI and Cognition Is there evidence of impairment in general cognitive functioning? Is there evidence of a deficit in memory? 117 Copyright 2013. All rights reserved. TBI and WAIS-IV IV Composite Clinical Mean Control Mean Mean Diff. p value Effect Size VCI 92.1 100.8 8.73.03.52 PRI 86.1 100.7 14.64 <.01.94 WMI 85.3 97.9 12.59 <.01.78 PSI 80.5 97.6 17.09 <.01.97 FSIQ 83.9 99.4 15.50 <.01.93 n = 22 118 Copyright 2013. All rights reserved. 59

WAIS-IV IV Scores Index/Subtest Composite Score/ Scaled Score Index/Subtest Composite Score/ Scaled Score Verbal Comprehension 114 Perceptual Reasoning 98 Similarities 13 Block Design 10 Vocabulary 13 Matrix Reasoning 9 Information 12 Visual Puzzles 10 Working Memory 100 Processing Speed 102 Digit Span 10 Coding 10 Arithmetic 10 Symbol Search 11 Full Scale IQ = 105 General Ability Index = 106 119 Copyright 2013. All rights reserved. Index-Level Discrepancy Comparisons Comparison Score 1 Score 2 Difference Critical Value.05 Significant Difference Y / N Base Rate Overall Sample VCI - PRI 114 98 16 9.29 Y 12.2 VCI - WMI 114 100 14 10.18 Y 14.1 VCI - PSI 114 102 12 10.99 Y 22.2 PRI - WMI 98 100-2 10.99 N -- PRI - PSI 98 102-4 11.75 N -- WMI - PSI 100 102-2 12.46 N -- FSIQ - GAI 105 106-1 3.5 N -- 120 Copyright 2013. All rights reserved. 60

What is the GAI? The WAIS IV GAI provides the practitioner with a summary score that is less sensitive than the FSIQ to the influence of working memory and processing speed. GAI = sum of scaled scores for VCI subtests and PRI subtests. 121 Copyright 2013. All rights reserved. What is the GAI? WAIS IV GAI should be used for discrepancy comparisons Ability and Memory Ability and achievement GAI is NOT a replacement for FSIQ 122 Copyright 2013. All rights reserved. 61

General Ability Index Consider* using the GAI if a significant and unusual discrepancy exists between VCI and WMI; or PRI and PSI; or WMI and PSI, or between subtests within WMI and/or PSI. Note: The FSIQ is the most valid measure of overall cognitive ability and WM and PS are vital to comprehensive evaluation of cognitive ability. 123 Copyright 2013. All rights reserved. General Ability Index - Note! The GAI is used when neuropsychological deficits adversely impact performance on WM and PS. Impaired performance on WM and/or PS may mask actual differences between general cognitive ability (FSIQ) and other cognitive functions (e.g., memory). The GAI does not replace the FSIQ. Report and interpret GAI along with FSIQ. [see WAIS-IV Technical Manual] 124 Copyright 2013. All rights reserved. 62

Moderate TBI and Ability (WAIS-IV) IV) Relative to others his age, Blake s intellectual functioning is within the Average range. Verbal comprehension is a strength relative to perceptual reasoning, working memory, and processing speed. 125 Copyright 2013. All rights reserved. TBI and WMS-IV n = 32 (ages 19-45) Index Clinical Mean Control Mean Mean Diff. p value Effect Size AMI 80.0 101.0 21.00 <.01 1.25 VMI 82.5 101.2 18.64 <.01 1.07 VWMI 85.5 104.6 19.06 <.01 1.26 IMI 80.7 102.2 21.53 <.01 1.24 DMI 77.8 100.4 22.64 <.01 1.24 GAI 92.2 104.8 12.65 <.01.92 126 Copyright 2013. All rights reserved. 63

WMS-IV Scores Index/Subtest Index Score/ Scaled Score Index/Subtest Index Score/ Scaled Score Auditory Memory 105 Visual Memory 96 Logical Memory I 13 Visual Reproduction 10 Logical Memory II 16(S) Visual Reproduction II 10 Verbal Paired Associates I 7(W) Designs I 8 Verbal Paired Associates II 8(W) Designs II 10 Visual Working Memory 100 Spatial Addition 12 Symbol Span 8 127 Copyright 2013. All rights reserved. WMS-IV Scores Index/Subtest Index Score/ Scaled Score Index/Subtest Index Score/ Scaled Score Immediate Memory 96 Delayed Memory 107 Logical Memory I 13 Logical Memory II 16 Verbal Paired Associates I 7 Verbal Paired Associates II 8 Visual Reproduction I 10 Visual Reproduction II 10 128 Copyright 2013. All rights reserved. 64

Moderate TBI and Memory On WMS-IV, all index scores are in the average range. Delayed memory is a strength relative to Immediate Memory (contrast scaled score = 14). Scores on memory indexes are average relative to general ability. Note relative weakness for VPA I and VPA II and relative strength for LM II. 129 Copyright 2013. All rights reserved. Ability Memory Analysis Predicted Difference Method: GAI = 106 Index Predicted WMS-IV Index Score Actual WMS IV Index Score Diff. Critical Value Sign. Diff. Y / N Base Rate AMI 103 105-2 9.35 N -- VMI 104 96 8 8.95 N -- VWMI 104 100 4 10.61 N -- IMI 104 96 8 9.78 N -- DMI 103 107-4 9.57 N -- 130 Copyright 2013. All rights reserved. 65

Moderate TBI Is this profile atypical for Blake s education level? Is there evidence for loss of cognitive functioning. Use Demographically Adjusted Norms 131 Copyright 2013. All rights reserved. Demographically Adjusted Norms Enable clinician to refine hypothesis about the degree to which a specific score is unexpected when compared to individuals of similar background characteristics (e.g., education level). Norms approximate the unique demographic subgroup of an individual. 132 Copyright 2013. All rights reserved. 66

Demographically Adjusted Norms Available for WAIS-IV and WMS-IV subtest and index scores. Education-only adjusted t-scores. Full Demographically adjusted t-scores. 133 Copyright 2013. All rights reserved. Use of Demographically Adjusted Norms Meant to minimize the impact of psychosocial variables on the diagnosis of cognitive impairment, such as estimating the degree of cognitive impairment after a brain injury or insult.... most appropriately applied in the context of a neuro-diagnostic assessment. 134 Copyright 2013. All rights reserved. 67

WAIS-IV IV DAN WAIS-IV Education Adjusted Composite Score Summary Composite Age Adjusted Composite Score Percentile Rank T Score Education Adjusted Percentile Rank VCI 114 82 55 69.1 Qualitative Description Above Average PRI 98 45 44 27.4 Low Average WMI 100 50 45 30.9 Average PSI 102 55 48 42.1 Average FSIQ 105 63 48 42.1 Average GAI 106 66 49 46.0 Average 135 Copyright 2013. All rights reserved. WAIS-IV IV DAN WAIS IV Education Adjusted Subtest Score Summary Age Adjusted Education Adjusted Subtest Scaled Score Percentile Rank T Score Percentile Rank Qualitative Description Similarities 13 84 57 75.8 Above Average Vocabulary 13 84 55 69.1 Above Average Information 12 75 52 57.9 Average Block Design 10 50 47 38.2 Average Matrix Reasoning 9 37 43 24.2 Low Average Visual Puzzles 10 50 49 46.0 Average Digit Span 10 50 47 38.2 Average Arithmetic 10 50 46 34.5 Average Symbol Search 11 63 50 50.0 Average Coding 10 50 47 38.2 Average 136 Copyright 2013. All rights reserved. 68

WMS-IV DAN WMS-IV Education Adjusted Index Score Summary Index Age Adjusted Index Score Percentile Rank T Score Education Adjusted Percentile Rank Qualitative Description AMI 105 63 52 57.9 Average VMI 96 39 45 30.9 Average VWMI 100 50 47 38.2 Average IMI 96 39 44 27.4 Low Average DMI 107 68 52 57.9 Average 137 Copyright 2013. All rights reserved. WMS-IV DAN WMS IV Education Adjusted Subtest Score Summary Age Adjusted Education Adjusted Subtest Scaled Score PR T Score PR Qualitative Description Logical Memory I 13 84 58 78.8 Above Average Logical Memory II 16 98 69 97.1 Above Average Verbal Paired Associates I 7 16 38 11.5 Mild Impairment Verbal Paired Associates II 8 25 41 18.4 Low Average Designs I 8 25 41 18.4 Low Average Designs II 10 50 49 46.0 Average Visual Reproduction I 10 50 48 42.1 Average Visual Reproduction II 10 50 48 42.1 Average Spatial Addition 12 75 54 65.5 Average Symbol Span 8 25 42 21.2 Low Average 138 Copyright 2013. All rights reserved. 69

What do we know about Moderate to Severe TBI and WAIS-IV/WMS IV/WMS-IV/ACSIV/ACS Executive Functioning D-KEFS Trail Making Test Trail Making Letter and Number Sequencing 6.5 Number-Letter Switching Time 7.1 Number-Letter Switching Errors 11.0 Also see Yochim, B., Baldo, J., Nelson, A., & Delis, D. (Jul 2007). D-KEFS trail making test performance in patients with lateral prefrontal cortex lesions. Journal of the International Neuropsychological Society, 13(4), 704-709. 139 Copyright 2013. All rights reserved. Trail Making D-KEFS Trail Making - Blake Visual Scanning SS = 10 Number Sequencing SS = 7 Letter Sequencing SS = 8 Number-Letter Switching SS = 6 Number-Letter Switching Errors SS = 10 Motor Planning SS = 9 140 Copyright 2013. All rights reserved. 70

What do we know about Moderate to Severe TBI and WAIS-IV/WMS IV/WMS-IV/ACSIV/ACS Executive Functioning D-KEFS Verbal Fluency Letter Fluency 7.6 Category Fluency 6.7 Category Switching Total Correct 7.0 Category Switching Total Accuracy 8.1 141 Copyright 2013. All rights reserved. Verbal Fluency D-KEFS Verbal Fluency - Blake Letter Fluency SS = 11 Category Fluency SS = 9 Category Switching SS = 8 Category Switching Accuracy SS = 8 Set Loss Error SS = 10 Repetitions SS = 9 142 Copyright 2013. All rights reserved. 71

Moderate TBI Executive Functioning Are there deficits in executive functioning? Trail Making: low-average scores for number sequencing and switching. Cannot determine if the problem is executive functioning or slow processing speed. Verbal Fluency: scores in the average range. 143 Copyright 2013. All rights reserved. Moderate TBI Social Perception Is there a deficit in social perception? Social Perception has 3 tasks: Affect Naming (Happy, Sad, Angry, Surprise, Disgust, Fear, and Neutral) Prosody Face Matching (includes Sarcasm) Prosody Pairs Matching 144 Copyright 2013. All rights reserved. 72

What do we know about Moderate to Severe TBI and WAIS-IV/WMS IV/WMS-IV/ACSIV/ACS Holdnack & Drozdick (2009). Social Perception Deficits after Moderate to Severe Traumatic Brain Injury. www.psychcorp.com 145 Copyright 2013. All rights reserved. Moderate TBI Social Perception Is there a deficit in social perception? Scores range from low average to average with 3 of 4 scores at 1sd below mean. Compared to intellectual functioning, social perception scores were low average. Observationally, he made errors mostly on incongruent items, particularly sarcasm. 146 Copyright 2013. All rights reserved. 73

Symptom Exaggeration? What if the test results were exaggerated in order to gain an advantage in the law suit? Use ACS effort assessment to help determine if suboptimal effort issues should be considered. 147 Copyright 2013. All rights reserved. Suboptimal Effort Criteria for definite malingering, neurocognitive deficit: Presence of substantial external incentive, Definitive negative response bias, and The response bias is not accounted for by psychiatric, neurological, or developmental factors (Slick, Sherman, and Iverson, 1999). 148 Copyright 2013. All rights reserved. 74

Assessing Suboptimal Effort ACS Word Choice WAIS IV Reliable Digit Span WMS IV Logical Memory Delayed Recognition Verbal Paired Associates Delayed Recognition Visual Reproduction Delayed Recognition [Available for ages 16 69] 149 Copyright 2013. All rights reserved. Word Choice 1. Examinee sees and hears 50 words in succession. 2. Examinee identifies each word as either man-made or natural. 3. Examinee sees card with 50 pairs of words and selects word that was previously presented from each pair. 150 Copyright 2013. All rights reserved. 75

Suboptimal Effort Use at least 3 indicators. Require at least 2 indicators at or below cut off when using low cut offs (e.g. 10%). See Effort Assessment Score Report Blake Sample 23. 151 Copyright 2013. All rights reserved. Moderate TBI - Conclusions Is this protocol indicative of suboptimal effort? No Overall conclusions Blake suffered a moderate/severe TBI as documented by medical records. Relative to his verbal comprehension abilities, he demonstrated a weakness on measures of perceptual reasoning, working memory, and processing speed. 152 Copyright 2013. All rights reserved. 76

Moderate TBI - Conclusions Overall conclusions His memory abilities are average compared to his general ability. Interpretation of Blake s performance on the Auditory Memory index should account for the variability of the subtest scores. 153 Copyright 2013. All rights reserved. AMI Score Variability The clinical relevance of the score variability on the AMI should be addressed in terms of Blake s premorbid abilities, demands in his current environment, other co occurring physical factors (e.g., recent onset of auditory acuity difficulties or physical impairments), or emotional status (e.g., depression, anxiety). 154 Copyright 2013. All rights reserved. 77

Moderate TBI Conclusions Overall conclusions Acquired brain injury as a result of a MVA. Demonstrated weaknesses in switching mental set (executive function) and in social perception. These characteristics are consistent with known effects of brain injury. Frontal lobe damage can impair cognitive flexibility. Injury to anterior temporal region can produce deficits in affect labeling, recognition of emotion, theory of mind. 155 Copyright 2013. All rights reserved. Recommendations It may be necessary to give Blake very specific routines for work completion. For example, he should be told where to put materials, what to do if he does not understand the assignment, and what to do with the assignment once complete. Blake should be set well-defined time limits for task completion, so that tasks are completed in a timely manner. Blake should be allowed to monitor his own progress with a timing device. 156 Copyright 2013. All rights reserved. 78

Recommendations Blake should be taught to use a problem-solving approach to behavioral situations. Steps should involve Blake determining the best possible option for his behavior, choosing a problemsolving strategy, and evaluating the outcome. Concrete examples should be used to teach the approach (e.g., What should you do if you are trying to concentrate on your work and another person begins talking to you? ). 157 Copyright 2013. All rights reserved. For More Information... www.acsw4w4.com www.psychcorp.com Comments or Questions gloria.maccow@pearson.com 158 Copyright 2013. All rights reserved. 79

Customer Service 1-800-627-72717271 Questions or Comments gloria.maccow@pearson.com 80