1. LEARNING DISABILITIES AND NEUROPSYCHOLOGICAL ASSESSMENT Suzie Beart Clinical Psychologist South Community Learning Disabilities Team and Jonny Powls Clinical Psychologist South Community Learning Disabilities Team and the Brain Injury Rehabilitation Team

2.

Outline

Clinical neuropsychology: definition and purpose

Potential barriers to using psychometrics, and ways of overcoming these

Neuropsychological Framework

Dilemmas and debates

Report writing

References

3. Clinical Neuropsychology Definition:

Clinical neuropsychology is an applied science

concerned with the behavioural expression of brain

dysfunction

Lezak (2004)

4. Purposes of neuropsychological assessment(Lezak, 2004)

• Diagnosis of neurological conditions (e.g. dementia)

• Profiling strengths and weaknesses (e.g. for care management)

• Treatment Planning (e.g. what specialists are required: OT, S&L)

• Treatment Evaluation (e.g. neurosurgery / medication)

• Research (e.g. to relate brain to behaviour)

• Forensic e.g. (did brain dysfunction contribute to illegal behaviour)

5. People with Learning Disabilities:

Suffer the same neuropsychological conditions

Are subject to all Lezaks (2004) purposes

Have same rights of access to neuropsych assessment..

BPS Clinical Practice Guidelines:

It is also good practice to have a clear picture of any specificneuropsychological difficulties the patient may have as a result ofbrain injury or impairment

(Ball, Bush and Emerson, 2004)

6.

• Barriers to using Neuropsychological Assessment

• with people with Learning Disabilities

• and ways in which they might be overcome

7.

• Lack of referrals

• Diagnostic Overshadowing:

• when a person's presenting symptomsareput down to their learningdisability, rather than seeking another, potentially treatable cause.

• Behaviour that is different is less noticeable when person alreadybehaves differently

• Nature of living environment (e.g. staff changes)

• Overcoming this: -

• If behaviour changes (e.g. increase / decrease, new ones emerge)consider all possible causes e.g. environmental,social, neurological

• Read information about the persons history (when did changes occur)

• Educate other professionals/staff/family

8. Fear :History of misuse/dubious use of psychometrics

IQ used historically (and now) as a cut off for inclusion/exclusion to services

• Learning disability services

• Social security in USA (Folstein, 1989)

• Right to formal education in UK in the past

Consent to sexual relationships

Eugenics: feeble mindedness justified compulsory sterilization

60,000-70,000 people sterilized against their will in USA (blocked in 1930s)

60,000 people with physical and/or learning disabilities murdered in Nazi Germany in 1930s

IQ and death row in USA today

9.

Many of the rigid boxes ferried through clinics, wards and dayrooms by psychologists in the 1960s, 1970s and 1980s helped seal the futures of unsuspecting men and women (Noonan Walsh, 2005)

Gillman et al (2000) who has the power to name?

Are Intelligence Score Useful:

• General intelligence is as valid as the strength of soil concept is for plant growers. It is not wrong but archaic (Das 1989)

• IQ as a score is inherently meaningless and not infrequently misleading as well. IQ- whether concept, score or catchword - has outlived whatever usefulness it may once have had and should be discarded (Lezak 1995, 2004)

Fear :History of misuse/dubious use of psychometricsCONT. 10. Overcoming this fear:

Using supervision to discuss how to guard against misuse of psychometrics

Working in partnership with people with learning disabilities and their families

Guarding against over analysing tests - psychometrics do not contain more truth!

Person centred reports that answer a clear question

Remind trainees of the knowledge/skills they already have

11. Overcoming fear: supervision discussions

Formal psychometric assessments are tools - just another type of behavioural observation

Always assess around an aim or question

Observe, observe, observe

Listen, listen, listen

Discuss, discuss, discuss

Convergence and the quasi-judicial method

Feedback can be powerful. Try and make it useful.

Sometimes it helps to test - it doesnt always

12.

• • • Lack of confidence

• • • Neuropsychological assessment seen as being:

• • • the domain of qualifiedclinical neuropsychologists

• • • a science, requiring detailed knowledge of:

• • • • Psychometrics

• • • • Mathematics

• • • • Statistical analysis

• • • Overcoming this: -

• • • Neuropsychological assessment as:

• • • Structured observation

• • • Providing rich qualitative (as well as quantitative) information

• • • Additional source of information, to strengthen a formulation

13.

• • • Lack of suitable tests, and normative data

• • • • Familiarity with test material

• • • • Complex instructions

• • • • Floor effects

• • • • Overcoming this: -

• • • • Give trainees a framework of neuropsychological theory

• • • • Help trainees become familiar with the debates and dilemmas(e.g. around WAIS-III and other psychometrics)

• • • • Pick tests carefully

• • • • Be creative

14.

• • • Limited literature

• • • Limited reference to neuropsychology and people with LearningDisabilities in Text books (e.g. Lezak)

• • • Overcoming this: -

• • • Provide a core of reading relevant to the department and supervisor.

• • • Short papers on use of WAIS-III with people with learning disabilities is agood starting point for discussion

• • • Use non normed tests (e.g. RBMT, SIB)

• • • Wider range of literature around people with Downs Syndrome anddementia

• • • Sohlberg and Mateer (2001): for a general understanding ofneuropsychological models

15.

• • • More factors that influence performance

• • • Physical disabilities

• • • Communication difficulties

• • • Harder to screen for factorssuch as depression/anxiety

• • • Overcoming this: -

• • • Lezaks guidelines re using psychometrics

• • • Pick Tests/ subtests carefully

• • • Be creative:

• • • • adapted HADs

• • • • Enlarged Ravens Progressive Matrices

16.

• • • Time:May take several sessions

• • • Overcoming this: -

• • • Use shorter tests

• • • Select appropriate subtests

• • • Talk through discrepancies between the course and clinicalexpectations to avoid potential clashes

• • • Hope the trainees course is understanding

17.

• • • Gaining consent

• • • More difficult to ensure person understands:

• • • • What testing will involve

• • • • Possible implications of testing (e.g. eligibility to services)

• • • Overcoming this: -

• • • Always ensure that:

• • • • Reason for referral is clear (e.g. parenting)

• • • • All testing is in the best interest of the person

• • • Make testing as unthreatening as possible

• • • Make it clear that the testing can be stopped at any point (and regularly remind)

18. Neuropsychological framework

Intelligence

Perception

Attention

Memory

Language

Executive functioning

19. Executive functioning

Sohlberg & Mateer (2001)

• Initiating (Starting behaviour)

• Response inhibition (stopping behaviour)

• Task persistence (maintaining behaviour)

• Organisation of thoughts and behaviour

• Generative thinking (being creative and flexible)

• Awareness (monitoring & modifying ones own behaviour)

20.

Multi-step tasks will test the above

Use a task that doesnt de-motivate or frustrate e.g. make toast and jam

This allows good opportunity to look at planning, starting, stopping and self monitoring

Can use the same model when observing tests e.g. block design

Executive functioning: an example 21. Memory: an example

If a carer says someone has memory problems, the trainee might ask:

What type of memory:

• autobiographical memory

• memory for something just told

• prospective memory

Could this memory problem actually be difficulties in:

• Concentrating

• Language that is too complex

• Motivation

• Problems hearing

22. Debates and dilemmas:

Should you ever deviate from standardised text in manuals?

To standardise assessments the standardised instructions should be followed

90% of psychologists working in learning disabilities say they do not always read instructions word for word (e.g. re-word / add when using WAIS-III.

Example : WAIS-III-(Vocabulary subtest) Tell me whatbedmeans? in my experience is usually met with a puzzled look

The Speed and Capacity of Language-Processing test (SCOLP)

Dont worry if there are some pairs where you dont recognise either of the items. Nobody is expected to know them all.I dont mind admitting there are some I didnt know myself..

23. Debates and dilemmas CONT.

Instructions that are more complex than the item (Whittaker,2005)

Arithmetic subtest on WAIS-III?

The reverse rule (Leyin,2006)

Mild, moderate, severe and profound (Leyin, 2008)

Ravens matrices (Gunn & Jarrold, 2004)

Using non-normed tests (Martin et al, 2001; McKenzie et al, 2002)

24.

Would you deviate from the standardised text?

Why or why not?

Debates and dilemmas CONT. 25. Writing up

Put the person at centre of the report (e.g. encourage trainees to write the first paragraph about the client as a person)

Be clear about the question that you are trying to answer

Draw out strengths (e.g. persistence, patience, ability to reflect)

Think about language

No empty phrases- tests indicate sequencing problems (e.g. may need prompting to complete a task)

Dont avoid the difficult bits. Dont surround them with positives in the hope the client wont notice.

Read through with the client first.

26. Writing up CONT.

Try to relate results to the questions, and everyday life

• NOT Bobs verbal memory was in impaired range, or block design had scaled score of 5.

• Bob learns best from visual prompts (picture reminders of what he has to do)

• Bob often needs quite a bit of time to complete a new task, but approaches new tasks systematically, and is persistent.

• To support Bob in his aim to be a good father it would help If new information was given in picture form (e.g. how to make up a bottle)

27. References

De Wall, C. N. (in press). Alone but Feeling No Pain: Effects of Social Exclusion on Physical Pain Tolerance and Pain Threshold, Affective Forecasting, and Interpersonal Empathy.Journal of Personality and Social Psychology.

Baumeister, R. F., Gailliot, M. De Wall, C. N., & Oaten, M. (year).Self-Regulation and Personality: How Interventions Increase Regulatory Success, and How Depletion Moderates the Effects of Traits on Behaviour

Linley, P. A., & Harrington, S. (2006).Playing to your strengths. The Psychologist, 19, 2, 86-89

Davies, K., Lewis, J., Byatt, J., Purvis, E., & Cole, B. (2004).An evaluation of the literacy demands of general offending behaviour programmes.Home Office, 1-4

Anderson M (1986) Understanding the Cognitive Deficit in Mental Retardation. Journal of Child Psychology and Psychiatry, 27, 3, 297-306

Ball T; Bush A & Emerson E (2004) Challenging Behaviours:Psychological interventions for severely challenging behaviours shown by people with learning disabilities. BPS

Bonis J & Jones A (2003) Do Cognitive Assessments lead to change for people with Intellectual Disabilities.Clinical Psychology Forum,BPS

Bowley C & Kerr M (2000) Epilepsy and Intellectual Disability.Journal of Intellectual Disability Research, 44, 5, 529-543

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British Medical Association and the Law Society (1995) Assessment of Mental Capacity: Guidance for Doctors and Lawyers. British Medical Association

CAF (2000) Contact a Family Directory of Specific Conditions and Rare Synchromes in Children. Contact a Family, Tottenham Court, London

Murphy L (2000) Neuropsychology. In Patel N; Bennett E; Dennis M; Dosanjh N; Mahtoni A; Miller A & Madirshaw Z. Clinical Psychology, Race and Culture: A Training Manual. British Psychological Society Books, Leicester

Pennington B & Bennetto L (1998) Toward a Neuropsychology of Mental Retardation. In Bura, K. et al Handbook of Mental Retardation and Development. Cambridge University Press

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Whitmann T L (1990) Self Regulation and Mental Retardation. American Journal of Mental Retardation, 94,4,347-362

Critchley H D; Simmons A; Daly E M; Russell A; van Amelsvoort T; Robertson D M; Glover A & Murphy D G M (2000)Prefrontal and Medial Temporal Correlates of Repetitive Violence to Self and Others.Society of Biological Psychiatry

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Kaufman A.S & Lichtenberger E.O (1999) Essentials of WAIS III Assessment. Wiley, New York

Lezak M D (1995) Neuropsychological Assessment, 3rd Edition. Oxford University Press

Matthews C G (1974) Application of Test Methods in Mentally Retarded Subjects.In Reitan, R M et al Neuropsychology:Current Status and Applications. Winston Publications

Mayes A (1992) Memory Assessment in Clinical Practice and Research.In Crawford J R et al A Handbook of Neuropsychology Assessment. Lawrence Earlbaum Associates

Crayton, L., Oliver, C., Holland, A. J., Bradbury, J., & Hall, S. (1998). The neuropsychological assessment of age related cognitive deficits in adults with Down's syndrome. Journal of Applied Research in Intellectual Disabilities, 11, 255-272.

Kalsy,S., McQuillan, S., Adams, D. et al. (2005). A Proactive Psychological Strategy for Determining the Presence of Dementia in Adults with Down Syndrome: Preliminary Description of Service Use and Evaluation. Journal of Policy and Practice in Intellectual Disabilities, 2, 75-169;

Oliver, C., Crayton, L., Holland, A., Hall, S., & Bradbury, J. (1998). A four year prospective study of age-related cognitive change in adults with Down's syndrome. Psychol.Med., 28, 1365-1377.

Oliver, C. (1999). Perspectives on Assessment and Evaluation. In M.P.Janicki & A. Dalton (Eds.), Dementia, Aging and Intellectual Disabilities (pp. 123-140). New York: Brunner/Mazel.

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