Learning Disabilities and Neuropsychological Assessment


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Learning Disabilities and Neuropsychological Assessment

  1. 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. 2. <ul><li>Outline </li></ul><ul><li>Clinical neuropsychology: definition and purpose </li></ul><ul><li>Potential barriers to using psychometrics, and ways of overcoming these </li></ul><ul><li>Neuropsychological Framework </li></ul><ul><li>Dilemmas and debates </li></ul><ul><li>Report writing </li></ul><ul><li>References </li></ul>
  3. 3. Clinical Neuropsychology – Definition: <ul><li>“ Clinical neuropsychology is an applied science </li></ul><ul><li>concerned with the behavioural expression of brain </li></ul><ul><li>dysfunction ” </li></ul><ul><li>Lezak (2004) </li></ul>
  4. 4. Purposes of neuropsychological assessment (Lezak, 2004) <ul><ul><li>Diagnosis of neurological conditions (e.g. dementia) </li></ul></ul><ul><ul><li>Profiling strengths and weaknesses (e.g. for care management) </li></ul></ul><ul><ul><li>Treatment Planning (e.g. what specialists are required: OT, S&L) </li></ul></ul><ul><ul><li>Treatment Evaluation (e.g. neurosurgery / medication) </li></ul></ul><ul><ul><li>Research (e.g. to relate brain to behaviour) </li></ul></ul><ul><ul><li>Forensic e.g. (did brain dysfunction contribute to illegal behaviour) </li></ul></ul>
  5. 5. People with Learning Disabilities: <ul><li>Suffer the same neuropsychological conditions </li></ul><ul><li>Are subject to all Lezak’s (2004) purposes </li></ul><ul><li>Have same rights of access to neuropsych assessment.. </li></ul><ul><li>… BPS Clinical Practice Guidelines: </li></ul><ul><li>“ It is also good practice to have a clear picture of any specific neuropsychological difficulties the patient may have as a result of brain injury or impairment” </li></ul><ul><li>(Ball, Bush and Emerson, 2004) </li></ul>
  6. 6. <ul><ul><li>Barriers to using Neuropsychological Assessment </li></ul></ul><ul><ul><li>with people with Learning Disabilities… </li></ul></ul><ul><ul><li>… and ways in which they might be overcome </li></ul></ul>
  7. 7. <ul><ul><li>Lack of referrals </li></ul></ul><ul><ul><li>Diagnostic Overshadowing: </li></ul></ul><ul><ul><li>“ when a person's presenting symptoms are put down to their learning disability, rather than seeking another, potentially treatable cause.” </li></ul></ul><ul><ul><li>Behaviour that is ‘different’ is less noticeable when person already behaves ‘differently’ </li></ul></ul><ul><ul><li>Nature of living environment (e.g. staff changes) </li></ul></ul><ul><ul><li>Overcoming this: - </li></ul></ul><ul><ul><li>If behaviour changes (e.g. increase / decrease, new ones emerge) consider all possible causes e.g. environmental, social, neurological </li></ul></ul><ul><ul><li>Read information about the person’s history (when did changes occur) </li></ul></ul><ul><ul><li>Educate other professionals/staff/family </li></ul></ul>
  8. 8. Fear : History of misuse/dubious use of psychometrics <ul><li>IQ used historically (and now) as a cut off for inclusion/exclusion to services </li></ul><ul><ul><li>Learning disability services </li></ul></ul><ul><ul><li>Social security in USA (Folstein, 1989) </li></ul></ul><ul><ul><li>Right to formal education in UK in the past </li></ul></ul><ul><li>Consent to sexual relationships </li></ul><ul><li>Eugenics: ‘feeble mindedness’ justified compulsory sterilization </li></ul><ul><li>60,000-70,000 people sterilized against their will in USA (blocked in 1930s) </li></ul><ul><li>60,000 people with physical and/or learning disabilities murdered in Nazi Germany in 1930’s </li></ul><ul><li>IQ and death row in USA today </li></ul>
  9. 9. <ul><li>“ Many of the rigid boxes ferried through clinics, wards and dayrooms by psychologists in the 1960’s, 1970’s and 1980’s helped seal the futures of unsuspecting men and women” (Noonan Walsh, 2005) </li></ul><ul><li>Gillman et al (2000) who has the power to name? </li></ul><ul><li>Are Intelligence Score Useful: </li></ul><ul><ul><li>General intelligence is as valid as the ‘strength of soil’ concept is for plant growers. It is not wrong but archaic (Das 1989) </li></ul></ul><ul><ul><li>“ 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) </li></ul></ul>Fear : History of misuse/dubious use of psychometrics CONT.
  10. 10. Overcoming this fear: <ul><li>Using supervision to discuss how to guard against misuse of psychometrics </li></ul><ul><li>Working in partnership with people with learning disabilities and their families </li></ul><ul><li>Guarding against over analysing tests - psychometrics do not contain more truth! </li></ul><ul><li>Person centred reports that answer a clear question </li></ul><ul><li>Remind trainees of the knowledge/skills they already have </li></ul>
  11. 11. Overcoming fear: supervision discussions <ul><li>Formal psychometric assessments are tools - just another type of behavioural observation </li></ul><ul><li>Always assess around an aim or question </li></ul><ul><li>Observe, observe, observe </li></ul><ul><li>Listen, listen, listen </li></ul><ul><li>Discuss, discuss, discuss </li></ul><ul><li>Convergence and the quasi-judicial method </li></ul><ul><li>Feedback can be powerful. Try and make it useful. </li></ul><ul><li>Sometimes it helps to test - it doesn’t always </li></ul>
  12. 12. <ul><ul><ul><ul><li>Lack of confidence </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Neuropsychological assessment seen as being: </li></ul></ul></ul></ul><ul><ul><ul><ul><li>the domain of qualified clinical neuropsychologists </li></ul></ul></ul></ul><ul><ul><ul><ul><li>a ‘science’, requiring detailed knowledge of: </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Psychometrics </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Mathematics </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Statistical analysis </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><li>Overcoming this: - </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Neuropsychological assessment as: </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Structured observation </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Providing rich qualitative (as well as quantitative) information </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Additional source of information, to strengthen a formulation </li></ul></ul></ul></ul>
  13. 13. <ul><ul><ul><ul><li>Lack of suitable tests, and normative data </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Familiarity with test material </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Complex instructions </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Floor effects </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Overcoming this: - </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Give trainees a framework of neuropsychological theory </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Help trainees become familiar with the debates and dilemmas (e.g. around WAIS-III and other psychometrics) </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Pick tests carefully </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Be creative </li></ul></ul></ul></ul></ul>
  14. 14. <ul><ul><ul><ul><li>Limited literature </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Limited reference to neuropsychology and people with Learning Disabilities in Text books (e.g. Lezak) </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Overcoming this: - </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Provide a core of reading relevant to the department and supervisor. </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Short papers on use of WAIS-III with people with learning disabilities is a good starting point for discussion </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Use non normed tests (e.g. RBMT, SIB) </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Wider range of literature around people with Downs Syndrome and dementia </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Sohlberg and Mateer (2001): for a general understanding of neuropsychological models </li></ul></ul></ul></ul>
  15. 15. <ul><ul><ul><ul><li>More factors that influence performance </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Physical disabilities </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Communication difficulties </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Harder to screen for factors such as depression/anxiety </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Overcoming this: - </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Lezak’s guidelines re using psychometrics </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Pick Tests/ subtests carefully </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Be creative: </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>adapted HAD’s </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Enlarged Raven’s Progressive Matrices </li></ul></ul></ul></ul></ul>
  16. 16. <ul><ul><ul><ul><li>Time: May take several sessions </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Overcoming this: - </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Use shorter tests </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Select appropriate subtests </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Talk through discrepancies between the course and clinical expectations to avoid potential clashes </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Hope the trainee’s course is understanding </li></ul></ul></ul></ul>
  17. 17. <ul><ul><ul><ul><li>Gaining consent </li></ul></ul></ul></ul><ul><ul><ul><ul><li>More difficult to ensure person understands: </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>What testing will involve </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Possible implications of testing (e.g. eligibility to services) </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><li>Overcoming this: - </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Always ensure that: </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Reason for referral is clear (e.g. parenting) </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>All testing is in the best interest of the person </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><li>Make testing as unthreatening as possible </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Make it clear that the testing can be stopped at any point (and regularly remind) </li></ul></ul></ul></ul>
  18. 18. Neuropsychological framework <ul><li>Intelligence </li></ul><ul><li>Perception </li></ul><ul><li>Attention </li></ul><ul><li>Memory </li></ul><ul><li>Language </li></ul><ul><li>Executive functioning </li></ul>
  19. 19. Executive functioning <ul><li>Sohlberg & Mateer (2001) </li></ul><ul><ul><li>Initiating (Starting behaviour) </li></ul></ul><ul><ul><li>Response inhibition (stopping behaviour) </li></ul></ul><ul><ul><li>Task persistence (maintaining behaviour) </li></ul></ul><ul><ul><li>Organisation of thoughts and behaviour </li></ul></ul><ul><ul><li>Generative thinking (being creative and flexible) </li></ul></ul><ul><ul><li>Awareness (monitoring & modifying ones own behaviour) </li></ul></ul>
  20. 20. <ul><li>Multi-step tasks will test the above </li></ul><ul><li>Use a task that doesn’t de-motivate or frustrate e.g. make toast and jam </li></ul><ul><li>This allows good opportunity to look at planning, starting, stopping and self monitoring </li></ul><ul><li>Can use the same model when observing tests e.g. block design </li></ul>Executive functioning: an example
  21. 21. Memory: an example <ul><li>If a carer says someone has memory problems, the trainee might ask: </li></ul><ul><li>What type of memory: </li></ul><ul><ul><li>autobiographical memory </li></ul></ul><ul><ul><li>memory for something just told </li></ul></ul><ul><ul><li>prospective memory </li></ul></ul><ul><li>Could this memory problem actually be difficulties in: </li></ul><ul><ul><li>Concentrating </li></ul></ul><ul><ul><li>Language that is too complex </li></ul></ul><ul><ul><li>Motivation </li></ul></ul><ul><ul><li>Problems hearing </li></ul></ul>
  22. 22. Debates and dilemmas: <ul><li>Should you ever deviate from standardised text in manuals? </li></ul><ul><li>To standardise assessments the standardised instructions should be followed </li></ul><ul><li>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. </li></ul><ul><li>Example : WAIS-III-(Vocabulary subtest) “Tell me what bed means?” in my experience is usually met with a puzzled look </li></ul><ul><li>The Speed and Capacity of Language-Processing test (SCOLP) </li></ul><ul><li>“ Don’t worry if there are some pairs where you don’t recognise either of the items. Nobody is expected to know them all. I don’t mind admitting there are some I didn’t know myself..” </li></ul>
  23. 23. Debates and dilemmas CONT. <ul><li>Instructions that are more complex than the item (Whittaker,2005) </li></ul><ul><li>Arithmetic subtest on WAIS-III? </li></ul><ul><li>The reverse rule (Leyin,2006) </li></ul><ul><li>Mild, moderate, severe and profound (Leyin, 2008) </li></ul><ul><li>Ravens matrices (Gunn & Jarrold, 2004) </li></ul><ul><li>Using non-normed tests (Martin et al, 2001; McKenzie et al, 2002) </li></ul>
  24. 24. <ul><li>Would you deviate from the standardised text? </li></ul><ul><li>Why or why not? </li></ul>Debates and dilemmas CONT.
  25. 25. Writing up <ul><li>Put the person at centre of the report (e.g. encourage trainees to write the first paragraph about the client as a person) </li></ul><ul><li>Be clear about the question that you are trying to answer </li></ul><ul><li>Draw out strengths (e.g. persistence, patience, ability to reflect) </li></ul><ul><li>Think about language </li></ul><ul><li>No empty phrases- “tests indicate sequencing problems” (e.g. may need prompting to complete a task) </li></ul><ul><li>Don’t avoid the difficult bits. Don’t surround them with positives in the hope the client won’t notice. </li></ul><ul><li>Read through with the client first. </li></ul>
  26. 26. Writing up CONT. <ul><li>Try to relate results to the questions, and everyday life </li></ul><ul><ul><li>NOT “Bob’s verbal memory was in impaired range, or ‘block design had scaled score of 5.” </li></ul></ul><ul><ul><li>Bob learns best from visual prompts (picture reminders of what he has to do) </li></ul></ul><ul><ul><li>Bob often needs quite a bit of time to complete a new task, but approaches new tasks systematically, and is persistent. </li></ul></ul><ul><ul><li>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) </li></ul></ul>
  27. 27. References <ul><li>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. </li></ul><ul><li>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 </li></ul><ul><li>Linley, P. A., & Harrington, S. (2006). Playing to your strengths. The Psychologist, 19, 2, 86-89 </li></ul><ul><li>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 </li></ul><ul><li>Anderson M (1986) Understanding the Cognitive Deficit in Mental Retardation. Journal of Child Psychology and Psychiatry, 27, 3, 297-306 </li></ul><ul><li>Ball T; Bush A & Emerson E (2004) Challenging Behaviours: Psychological interventions for severely challenging behaviours shown by people with learning disabilities. BPS </li></ul><ul><li>Bonis J & Jones A (2003) Do Cognitive Assessments lead to change for people with Intellectual Disabilities. Clinical Psychology Forum, BPS </li></ul><ul><li>Bowley C & Kerr M (2000) Epilepsy and Intellectual Disability. Journal of Intellectual Disability Research, 44, 5, 529-543 </li></ul>
  28. 28. <ul><li>British Medical Association and the Law Society (1995) Assessment of Mental Capacity: Guidance for Doctors and Lawyers. British Medical Association </li></ul><ul><li>CAF (2000) Contact a Family Directory of Specific Conditions and Rare Synchromes in Children. Contact a Family, Tottenham Court, London </li></ul><ul><li>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 </li></ul><ul><li>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 </li></ul><ul><li>Robertson C; Murphy D (2000) Brain Imaging and Behaviour. In Bouras, N. (Ed) Psychiatry and Behavioural Disorders in Developmental Disability and Mental Retardation. Cambridge University Press </li></ul><ul><li>Vakil E; Shelef-Reshef E & Levy Shiff R (1997) Procedural and Declarative Memory Processes: Individuals with and without Mental Retardation. American Journal of Mental Retardation, 102,2,147-160 </li></ul><ul><li>Whitmann T L (1990) Self Regulation and Mental Retardation. American Journal of Mental Retardation, 94,4,347-362 </li></ul><ul><li>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 </li></ul>
  29. 29. <ul><li>Kaufman A.S & Lichtenberger E.O (1999) Essentials of WAIS III Assessment. Wiley, New York </li></ul><ul><li>Lezak M D (1995) Neuropsychological Assessment, 3rd Edition. Oxford University Press </li></ul><ul><li>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 </li></ul><ul><li>Mayes A (1992) Memory Assessment in Clinical Practice and Research. In Crawford J R et al A Handbook of Neuropsychology Assessment. Lawrence Earlbaum Associates </li></ul><ul><li>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. </li></ul><ul><li>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; </li></ul><ul><li>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. </li></ul><ul><li>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. </li></ul><ul><li>Hoyes J S; Hale D B & Gouvier W (1998) Malingering Detection in a Mentally Retarded Forensic Population. Applied Neuropsychology Vol 5 (1) p33-36 </li></ul>