- 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.
- Clinical neuropsychology: definition and purpose
- Potential barriers to using psychometrics, and ways of
overcoming these
- Neuropsychological Framework
3. Clinical Neuropsychology Definition:
- Clinical neuropsychology is an applied science
- concerned with the behavioural expression of brain
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.
-
- 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)
-
- 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
- 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.
-
-
-
- Neuropsychological assessment seen as being:
-
-
-
- the domain of qualifiedclinical neuropsychologists
-
-
-
- a science, requiring detailed knowledge of:
-
-
-
- Neuropsychological assessment as:
-
-
-
- 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
-
-
-
-
- Give trainees a framework of neuropsychological theory
-
-
-
-
- Help trainees become familiar with the debates and
dilemmas(e.g. around WAIS-III and other psychometrics)
14.
-
-
-
- Limited reference to neuropsychology and people with
LearningDisabilities in Text books (e.g. Lezak)
-
-
-
- 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
-
-
-
- Communication difficulties
-
-
-
- Harder to screen for factorssuch as depression/anxiety
-
-
-
- Lezaks guidelines re using psychometrics
-
-
-
- Pick Tests/ subtests carefully
-
-
-
-
- Enlarged Ravens Progressive Matrices
16.
-
-
-
- Time:May take several sessions
-
-
-
- Select appropriate subtests
-
-
-
- Talk through discrepancies between the course and
clinicalexpectations to avoid potential clashes
-
-
-
- Hope the trainees course is understanding
17.
-
-
-
- More difficult to ensure person understands:
-
-
-
-
- What testing will involve
-
-
-
-
- Possible implications of testing (e.g. eligibility to
services)
-
-
-
-
- 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
19. Executive functioning
-
- 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:
-
- memory for something just told
- Could this memory problem actually be difficulties in:
-
- Language that is too complex
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?
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)
- 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
28.
- 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
- 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
- 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
- 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
29.
- 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.
- Hoyes J S; Hale D B & Gouvier W (1998) Malingering
Detection in a Mentally Retarded Forensic Population.Applied
Neuropsychology Vol 5 (1) p33-36