Really Practical Neuropsychology

1. Really Practical Neuropsychology Kris Fernando Malcolm Stewart John R Smith Presentation to New Zealand College of Clinical Psychologists March 2011

2. Structure • Different types and levels of assessment • Barriers to Neuropsychological Assessment • Different levels of assessment • Ecological validity • Neuropsychology and vocational functioning • Recommended practice • Group exercise

3. Approach to Neuropsychological Assessment Quantitative Approach • Fixed battery of tests • Standardised administration and scoring Flexible Battery Approach • Flexible battery of tests • Qualitative and quantitative data • Testing of limits • Specific hypotheses formed and tested Qualitative Approach • Hypothesis testing approach • Unique assessment for each individual • Focus on qualitative information • Alternative – Battery approach

4. Barriers to Neuropsychological Assessment • Time • Resources • Clinical psychologists for whom neuropsychology is not their specialty • Lack of provision of appropriate supervision • A lack of understanding as to the value of neuropsychological assessment – what does it add relative to the resources required.

5. Screening Assessments Late Effects Assessment Team Three-step approach • Obtain information and ascertain whether there is a need for cognitive screening. BASC-2, BRIEF, and school report. Clinical interview with child and parents • Cognitive Screen – WISC-IV, CVLT-C, RCFT • Further neuropsychological assessment with a clinical psychologist specialised in neuropsychology

6. ACC Concussion Clinic Former system • Medical and neuropsychological screen a requirement • Often occurred within 2-4 weeks following mild traumatic brain injury • Limitations – how valid were results for functioning in 3-6 months etc • Deficits – created concern for some clients • Rehabilitation provided

7. Concussion Services Model • Referral from Registered Medical Professional no early than 10 days post-injury • Triage – OT/Nurse etc – some input from ClinPsychs in some clinics • Short-term OT/PT/SLT/RN intervention depending on what is required • Neuropsychological assessment (screen) if deemed necessary – allocation of five hours – short report only required • Medical assessment if deemed necessary • Short-term psychological intervention if required • Referral out of concussion services if problems more complex. • Full neuropsychological assessment and/or Psychological Services may be indicated.

8. ACC Concussion Services Cont … Neuropsychological Screen • Accident history/presenting problems • Personal Background and current history • Educational and occupational history • Medical history • Prior history of psychological problems • Forensic history • Quantitative Information • Estimated pre-accident level of cognitive, emotional and cognitive functioning • Attention, immediate and working memory, learning and memory abilities, executive functioning • Formulation/summary/recommendations

9. High Case Loads – CMHC’S CAMHS • Consistent and identifiable relationships between clinical conditions and cognitive functioning e.g. TBI, epilepsy, learning disorders, intellectual disability, depression, chronic pain, alcohol/drug abuse • Assessment is the start not the end of the process – contributes to an understanding of the client’s needs, to treatment planning and improved quality of life • Reporting with a high workload – what are the implications of the assessment for the adult’s/child’s functioning and treatment?

10. Ecological Validity Definition • The degree to which basic abilities assessed in controlled clinical settings apply to real-world performance • Inferences need to be made – how an individual’s pattern of strengths and deficits predict his/her ability to carry out everyday activities in the real world • Person’s ability to live independently, employment prospects and rehabilitation and need for environmental support

11. Ecological Validity Cont … Methods of identifying real world functioning • Direct observation • Self-report • Proxy/caregiver reports • Clinicians ratings • All have strengths and limitations • Limited face validity of traditional neuropsychological tests for determining competence with specific everyday activities. • Absence of established understanding as to specific abilities required by specific daily functions and how they relate to neuropsych tests – considerable clinical judgement is still required.

12. Ecological Validity Cont …. • In general, neuropsychological measures do measure abilities required for everyday functioning • Predictive of • Academic success • Current and future employment status • Performance of tasks required for everyday living • Medication management • Driving • Independent living • Reported correlations between test scores and functional outcomes generally do not exceed 40% of explained variance • Need to consider demographics, health status, level of experience with the activities in question and emotional/behavioural and environmental factors

13. Ecological Validity Cont … • Neuropsychological indices best for making global predictions such as employment status are summary scores • Complex tests better predictors of functioning in complex everyday lives • Most promising predictors of everyday functioning – executive functioning and learning and memory

14. Factors to be considered in Neuropsych Assessment • Clinic setting • Demands of home and work environments vary widely – types and degrees of impairment that can impact on performance of daily activities will vary with the situation • An individual who shows no impairment in routine aspects of everyday functioning – may be unable to respond in less common, high demand or emergency type situations which could put the individual or others at risk. How can this be assessed? • Important to consider an individual’s previous experience with a particular task or activities – will influence the degree to which an acquired cognitive deficit affects success in future task performance • Compensation for deficits possible but depends on individual’s strengths and environmental demands.

15. Instruments – Ecological Validity • Tests emphasising ecological validity – increased interest • More closely resemble tasks undertaken in everyday life to better predict real world functioning • Assess functional capacity – ability to perform tasks under optimal circumstances • RBMT-3 – TEA – BADS • Survey of 750 members of major NP societies • No clear consensus regarding which ecologically standardised measures most useful for predicting everyday functioning • Most common standardised measure used by <10% of respondents

16. Why such little use of newer EV Measures? • Assumption that traditional tests are ecologically valid • Tendency to stay with measures on which one received graduate training • Belief that traditional tests measure specific constructs even through application of labels to cognitive domains not necessarily reflective of unambiguous empirical findings • Belief that tests based on verisimilitude encroach on OT practice • Mimicking everyday tasks in the clinic does not necessarily mean findings will relate to how clients function in the real world

17. Vocational Functioning • Common question • Is this person able to maintain employment and perform work functions? • Research – neuropsychological predictions of employment status and job performance quite good but non-specific – TBI, Schizophrenia, MS • Research – supports a relationship between neuropsych test results and global vocational outcomes –dichotomous variables – more recent emphasis on quality and stability of employment

18. Vocational Functioning Cont … • Need to consider the differing cognitive demands of specific occupational when basing predictions of vocational functioning on an individual’s pattern of neuropsych strengths and difficulties • Always will be a role of substantial clinical judgement – more research needed in determining accuracy of such decisions and the client, job and environmental factors that contribute to success or failure. • Further research required to guide decisions regarding specific requirements of specific occupations; Many types of abilities required for most jobs and variable patterns of deficits may significantly interfere. • Need to be very careful in stating no likelihood of returning to work – self-fulfilling

19. Model of Employment Outcomes

20. Recommended Practice • Traditional neuropsychological tests are useful in terms of assessing individual’s capacity and are generally predictive of everyday functioning • A focus on memory and executive functioning using such measures • Information gleaned from well-developed ecologically oriented measures such as the BRIEF, RBMT-3 & Tinker Toy Test • Merging of traditional approaches with more ecologically valid measures • Assessing environmental, emotional, motivational and psychosocial factors in the context of a clinical interview • Collateral information – multidisciplinary approach

21. References Grant, I., & Adams, K. M. (2009). Neuropsychological Assessment of Neuropsychiatric and Neuromedical Disorders. (3rd ed.). Oxford: Oxford University Press. Marcotte, T. D., & Grant, I. (2010). Neuropsychology of Everyday Functioning. New York: Guilford Press. Reed, J., & Warner-Rogers, J. (2008). Child Neuropsychology. Concepts, Theory and Practice. Sussex: Wiley Blackwell

22. Group Exercise