Neuropsychological Assessment

1. Neuropsychological Assessment William P. Wattles, Ph.D. Francis Marion University

2. Practicum Log • Supervision Hours (coaching, feedback sessions, etc.) (S), • Student-contact Hours (i.e. assessment, intervention) (ST), • Consultation Hours (i.e. direct contact with consultees, interviews, meetings) (C ) • Research Hours (projects, program evaluation, etc.) (R) • Administrative Hours (i.e. scheduling, record review, scoring, report writing) (A), • Other Hours (e.g. staff meetings, in-service, conferences) (O)

3. Neuropsychology • Nothing more than the study of human brain/behavior relationships.

4. Neuropsychology goals •  Diagnosis determine the nature of the underlying problem. • Understand the effects of any brain injury • measure change in functioning over time, such as to determine the consequences of treatment

5. Neurologist • A physician specializing in diseases and disorders of the brain, spinal cord, nerves, and muscles, including stroke, Parkinson's disease, epilepsy, Alzheimer's disease, and muscular dystrophy

6. Neuropsychologist • A psychologist with specialized training in the evaluation of cognitive functions. Neuropsychologists use a battery of standardized tests to assess specific cognitive functions and identify areas of cognitive impairment

9. Classically, brain/behavior relationships have been inferred from the study of individuals with head injuries, tumors, neurological disease, and other unpleasant brain pathologies.

10. Phineas Gage • Amazingly, he was talking and could walk. He lost a lot of blood, but after a bout with infection, he not only survived to the ghastly lesion, but recovered well, too.

11. Phineas Gage • He became extravagant and anti-social, a fullmouth and a liar with bad manners, and could no longer hold a job or plan his future.  "Gage was no longer Gage",

12. His skull was recovered and in 1994 researchers discovered that most of the damage was done to the ventromedial region of the frontal lobes on both sides The part of the frontal lobes responsible for speech and motor functions was apparently spared, so they concluded that the changes in social behavior observed in Phineas Gage were probably due to this lesion Phineas Gage

13. Phineas Gage • "Gage's story was the historical beginnings of the study of the biological basis of behavior

14. Methods of Neuropsych Assessment • Medical History • Clinical Interview • Behavioral Observations • Psychometric Tests

15. Major cognitive domains typically assessed include Attention Memory Intelligence Visual-Spatial-Perceptual functions Psychosensory and Motor abilities "Executive" or "Frontal Lobe" functions Personality or Emotional Functioning. Neuropsych assessment

16. Elaborated functions of logic, strategy, planning, problem solving reasoning. These capacities help us solve problems of all sizes in our lives. Executive Functioning

17. Executive Functioning • Executive Functioning difficulties relate to planning, organizing and strategizing behaviors.

18. Executive Functioning • Analyze the context and the expected objective in order to formulate hypotheses on the probable outcomes of a decision

19. Behavioral changes are assumed to be due to this brain tissue damage. • For instance, stroke damage to the back of brain results in visual difficulties even though eyes are intact.

20. CNS involvement • Behavioral manifestation of CNS deficits is highly heterogeneous. • Thus, a battery is often called for.

21. Organic Mental Disorders • Prior to DSM-IV we had a category called organic mental disorders for those with a physical or organic cause. • Suggest mind body separation • Most disorders involve a mix of biological and psychological factors

22. Cause Head injuries Diseases of the brain Endocrinological disorders Exposure to toxins Symptom Depression Anxiety Delusions Mental impairment aggressiveness Dysfunctions of the Brain

23. One Tequila Two Tequila Three Tequila Floor Substance Abuse

24. Goal of Neuropsychological assessment • Originally to Differentiate between organic and functional

25. Distinguishing Brain Damage • Lesion Detection • Localization • Lateralization

26. Neuropsychologist • A Neuropsychologist is a psychologist who specializes in studying brain behavior relationships.

27. Two approaches • Comprehensive Battery Approach • Qualitative hypothesis-testing approach

28. The first method is to use an assessment technique in which a fixed battery of tests is given and in which we only want to know what functions are impaired and what functions are not impaired. The most commonly used representative of this type of test is the Halstead - Reitan Neuropsychological Battery. Detect Impairment

29. Advantages Easier to use for research Better norms Easier to learn Disadvantages Time consuming Can overlook reasons Difficult to tailor to client Advantages of Battery Approach

30. The second method is to assess a hierarchical arrangement of items within each subtest so that if a function is impaired, the level at which it is impaired can be determined. The most common representative of this type of test is the Luria - Nebraska. Assess level of impairment

31. Advantages Tailor to individual Emphasizes process Time efficient More depth Disadvantages Focuses on weaknesses More difficult to research Requires extensive experience Advantages of Qualitative approach

32. Specificity means when we measure "A" with our test, we know that the test does not measure "B", "C," or "D." If we wish to measure a thing "A" then the test has to be able to measure "A" even when very little of "A" is present; this is sensitivity. Specificity & Sensitivity

33. Specificity- the ability to rule out those without the condition Sensitivity the ability to provide a definitive diagnosis Specificity and Sensitivity

34. Visuoconstructive Abilities Mental Activity (Attention and speed of information processing) Memory and Learning Verbal Functions and Academic skills Motor Performance Executive Functions Emotional Status Screening Battery

35. Interviewing for Brain Impairment • The strongest tool for a clinician is still a clear, thorough and well-informed history.

36. Bender Gestalt • Developed 1938 • Narrow focus resulting in low sensitivity and high number of false negatives (misses)

37. The Bender test is a brief, non-verbal assessment consisting of nine stimulus cards, each showing a figure.The client is asked to reproduce the figures. The task requires visual association, motor coordination,and the ability to integrate perceptual and motor skills to achieve accurate reproductions Bender Gestalt

38. The results of the Bender Gestalt alone are rarely sufficient to make a differential diagnosis between neuropsychological impairment and emotional disturbance. Bender Gestalt

39. RBANS • Repeatable Battery for Assessment of Neuropsychological Status (1998) • Focuses on Verbal skills, attention, visual memory, and visuoconstruction. • 11 subtests • 5 indices

40. RBANS • Broad band (Assesses multiple domains) • Brief (under 30 mins) • Portable • alternate forms • moderate difficulty

41. RBANS • Standard scores with mean of 100 and standard deviation of 15. • Thus, 70 represents the 2nd percentile.

42. Utility of the RBANS in detecting cognitive impairment associated with Alzheimer’s disease: Sensitivity, specificity, and positive and negative predictive powers • Duff, et al 2009 • Each patient with AD was matched to a comparison patient on variables shown to affect cognitive functioning (i.e., age, education, and gender) (In matching patients, age was considered first, followed by education, followed by gender

43.  Results suggest that RBANS scores yield excellent estimates of diagnostic accuracy and that the RBANS is a useful screening tool in detection of cognitive deficits associated with AD.

45. Training • Neuropsychologists have extensive training in the anatomy, physiology, and pathology of the nervous system.

46. Changes is Neuropsych Assessment • Emphasis more on application than measurement. • Employability • Treatability • Need for support

47. Impairment vs. Disability • Impairment reflects normative comparisons and test data. • Disabilty considers context including circumstances, environment, interests.

48. Identifies the vocational and everyday impact of cognitive disability, and the real life obstacles related to work, school, and daily living. Through functional assessment individuals gain a better understanding of strengths and needs, and the effect these have on career choice Functional assessment

49. Ability to effectively regulate and direct self-behavior. Most often involves frontal lobe damage. Volition Planning Purposive action Effective performance Executive Functions

50. Most frequently associated with left hemisphere brain damage Aphasia Speech production. Six Major Functions Spontaneous speech Speech repetition Speech comprehension Naming Reading Writing Verbal Functions