Objectives A Consumer's Guide to Neuropsychological Evaluation - PDF document

Objectives A Consumer's Guide to Neuropsychological Evaluation  Understand what is neuropsychological assessment. Who it is for and how used? Richard A. Lanham, Jr., Ph.D.  Know the elements of a good evaluation Asst. Prof. of Psychiatry & Behavioral Sciences  Problems typically seen Johns Hopkins University School of Medicine  Case review  Q & A www.LanhamNeuro.com 2 What is Neuropsychology?  The study of brain-behavior relationships  Not a set of tests or techniques  A way of thinking about cognitive abilities, academic achievement, and behavior – often expressed as test scores The Object of Investigation PARENT’S BRAIN (ADOLESCENT’S PERSPECTIVE) 5 1

“ Each child’s brain is as similar and/or unique as their face.” Martha Denkla, M.D. 8 10/1/2018 Therefore….. Child Development accurate assessment of a child’s functioning should be comprehensive. An evaluation = snapshot in a child’s developmental timeline Broad Scope Appropriate in Depth (Sampling) 9 DEVELOPMENT: PIAGET’S DEVELOPMENT: CELLULAR Stage 1: Sensorimotor (Birth to 18-24 months) • Experiences world through senses and actions Stage 2: Preoperational (2 – 6 years) • Represents things with words and images Stage 3: Concrete Operational (7 – 11 years) • Thinks logically about concrete events; grasps concrete analogies & performs arthmetical operations Stage 4: Formal Operational (12+ years) • Reason Abstractly 2

DEVELOPMENT: COGNITIVE Cited in Fischer, K. W. (2008). 13 10/1/2018 Factors That Can Influence School Performance Intellectual Disability  Specific Learning Disabilities  WHO IS IT FOR  Reading, Writing, Math (3 Rs)  Receptive – Expressive Language  Sensory-Motor Functioning Emotional/Behavioral Disturbances   Mood and Anxiety Disorders  Oppositional Defiant and Conduct Disorders  Executive Dysfunction  Attention Deficit/Hyperactivity Disorder (ADHD) 16 Developmental Model Developmental Model Factors That Can Influence Heredity Gender School Performance Co-morbid Core Symptoms Cognitive Resources Socio-economic  Disorders Person  e.g., poverty Sensory Impairments  Age  Vision  Hearing Environment Brain Injury  Pervasive Developmental Disorders  Family Social School/Work  Autistic Spectrum Disorders  Asperger’s Disorder Therapeutic Legal 17 18 3

MAXIMIZATION Need for Comprehensive Evaluation PROCEDURE  Given the complexity of the situation, a comprehensive evaluation will increase the Neuropsychological Evaluations likelihood of accurately identifying the are conducted in a manner to core problems to be addressed in school obtain “Best Performances” and possibly for treatment.  Evaluation is the most important part of intervention. 20 INFLUENCES ON GOOD ADMINISTRATION TESTING* 1. Follow standardized procedures, unless the child’s limitations would interfere with a  Testing environment valid administration, then carefully adjust.  Examiner-examinee rapport 2. Minimize environmental factors extraneous  Oral presentation style and rate to brain-behavior relationship under study  Similarity or familiarity between the personal 3. Make sure examinee is alert and sufficiently characteristics of examiner and examinee aroused  Supportive or encouraging gestures and 4. Record all responses and response times comments 5. Provide sufficient help and encouragement  Test-taking anxiety (just the patient?) to ensure task is being attempted * Anastasi (1988) PRINCIPLES OF NSY EVALUATION Tests are multifactorial. Elements of a Good Evaluation Different individuals may obtain the same score for very different reasons. This applies equally in cases of success as well as failure. 25 4

Input EXECUTIVE SKILL MODEL “Executive Control” Developmental Issues Processing, Attention, Working Memory  Self Monitor Metacognitive:  Sustain Problem Solving  Plan Language Skills Visuospatial Skills  Organize  Working Memory  Initiate Verbal Memory Nonverbal Memory  Emotional Control Behavioral/Emotional  Shift Executive Functions, Reasoning, Abstract Thinking, Regulation  Inhibit Conceptualizing, Problem Solving, Etc. Output 22 ELEMENTS OF NEUROPSYCH EVAL ELEMENTS OF NEUROPSYCH EVAL Multiple sources of information  General Intelligence  Clinical interviews of parent(s) and child  Attention/Concentration/Orientation  Historical Review  Executive Functions  Developmental  Initiating, sustaining, inhibiting  Educational  Mental flexibility, set-shifting  Medical  Concept formation, problem solving  Psychiatric  Family  Receptive & Expressive Language  Input of Educators  Visual-Spatial & Visual-Motor Integration 28 ELEMENTS OF NEUROPSYCH EVAL ELEMENTS OF NEUROPSYCH EVAL Five Pillars for Reading Success:  Motor Functioning  Phonemic Awareness – manipulation of spoken syllables in  Sensory/Perceptual Functioning words  Phonics – letter-sound correspondence  Learning & Memory  Fluency – reading speed and accuracy  Psychological/Emotional Functioning  Vocabulary – lexicon of known words  Comprehension Skills – deriving meaning from print  Social Functioning  Academic Achievement Mathematics:  Fluency  Numerical Operations  Quantitative Reasoning 31 5

ELEMENTS OF NEUROPSYCH EVAL ELEMENTS OF NEUROPSYCH EVAL Additionally, the evaluation should “Threats to test validity” assess the child’s mood, interpersonal functioning, effort and other behaviors/factors and their potential impact on current test performance. The Neuropsychological Evaluation should answer both the questions posed by the referring source as well as those relevant but unasked questions. Social Inability  Frequent problem area for individuals with AD/HD and LDs, other Neurodevelopmental conditions, and traumatically acquired brain dysfunction that has direct, significant impact on functioning. 36 37 10/1/2018 10/1/2018 6

PROBLEMS ENCOUNTERED Social Inability  Appropriate normative data Given the tremendous amount of “data” needing  Appropriate level of difficulty to be processed and responded to in “real  Established reliability & validity time,” social skill difficulties would be  Adequate coverage of relevant cognitive predicted, if not expected, and can be domains understood in terms of weaknesses in  Multiple measures of domains attention, process speed, inhibition, and  Scoring executive functions.  Interpretation 38 10/1/2018 “ IF YOUR CRITERION FOR A DIAGNOSIS OF READING “WHAT DOES YOUR DISORDER IS A SPECIFIC SCORE MEAN REALLY ON A READING TEST… MEAN?” “… THEN SMALL CHILDREN, PETS, AND HOUSEHOLD APPLIANCES ARE ALL LIKELY TO BE LABELED READING DISORDERED” 43 7

TYPICAL QUESTIONS ASSESSMENT IS 1) What are the areas of weakness? “A BODY-CONTACT Strengths? 2) How impacted is this student? SPORT ” 3) Is the student progressing or declining? - WALSH, 1992 4) Does the student qualify for services? “WHY TEST?” “WHY TEST?” Test Score = a standardized method of Ideally, the benefit is that the score can summarizing (usually) observed behavior. provide objective, reliable, replicable data in a form that can aid interpretation and permit  Examiner evaluates each behavior sample, fitting it to meaningful comparison across patients and a predetermined scale (often Pass/Fail, 1/0) across areas of function within a patient.  Test with more than one item typically render summary scores (frequently a simple summation) 8

“HOW IMPAIRED IS THIS STUDENT?” “What does this score mean?” Test scores in and of themselves have little meaning in isolation. To derive meaning, some comparison is made. “Daddy, I got a 30 on the Math test!” “HOW IMPAIRED IS THIS PERSON?” “HOW IMPAIRED IS THIS Typical Rule of thumb: 2 SD deviation PERSON?” from premorbid functional level represents Norm-referenced significant impairment.  Grade Equivalents  Too Stringent  Percentile Ranks  Will miss too many students  Standard Scores (T score, z score ) Criterion- referenced “Clinical neuropsychology is not about test  “Mastery Level” (% correct) data and the application of statistical rules  Cut-off score alone but about a much underused process called…..Thinking. Learning Disability: Prevalence  A child with reading disabilities is 2x as likely as a member of the general population to meet diagnostic criteria for ADHD (15% vs. 7%).  Individual diagnosed with ADHD more likely than an individual in the general population to have a reading disability (36% vs. 17%).  Despite co-occurrence, studies suggest reading disabilities and ADHD are distinct and separable disorders. 54 55 9