Transcript Using a Neuropsychological Evaluation to Develop Effective

Using a Neuropsychological Evaluation
to Develop Effective Individualized
Strategies to Intervene
with Individuals with Traumatic or
Acquired Brain Injury
Amanda Messina, Psy.D., and
Mahin Para-Cremer, M.Ed.
Lakeview Specialty Hospital and Rehab
Lakeview’s Third Thursday at Three Speaker Series
February 2012
Presentation Goals
 A Neuropsychological Evaluation can provide
extensive information about how an individual’s
functioning has been impacted following a TBI/ABI.
 There are many different areas that are potentially
assessed during this evaluation process and the
resulting information can be very valuable in the
identification of effective strategies for intervention
and treatment.
 This presentation will review the components of
Neuropsychological Evaluation and identify the
process for developing effective individualized
intervention strategies based on the results from this
evaluation.
The Components of a
Neuropsychological Evaluation
Intake Interview
 Family History
 Social History
 Psychiatric Placement History
 Drug and Alcohol Use History
 Abuse History
 Medical History and current functioning
 Legal Issues
 Work History
 Risk Assessment
Mental Status
 Overall General Appearance
 Behavioral Observations
 Mood and Affect
 Insight and Judgment
 Hallucinations or delusions
 Psychomotor functioning
 Speech language functioning
 Orientation
Intellectual and Cognitive Ability
 VERBAL COMPREHENSION
 Verbal abstract reasoning
 Rote verbal memory
 Verbal comprehension
 WORKING MEMORY
 Gathering and retaining information, processing, and
applying to new situations
 PERCEPTUAL REASONING
 Processing visual information and applying to new
situations
 PROCESSING SPEED
 Rate of understanding information
Academic Ability
 Reading Ability
 Comprehension
 Word identification
 Writing
 Spelling
 Creating sentences
 Mathematics
 Applied Mathematics
 Abstract Mathematics
 Calculations
Attention/Executive Functioning
 Stopping
 Ability to process and move on from upsetting events
 Switching
 Transition from tasks
 Starting
 Generate new information
 Initiation
 Problem Solving Skills
 Maintaining
 Ability to stay on task
Memory / Learning
 Auditory
Storing and processing
information that you hear
 Visual
 Storing and processing
information that you see
 Immediate
 Processing and repeating
information back
 Short term
 Ability to report events
that occurred recently
(last 24 hours)
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 Long term
Ability to report events
that occurred prior to 24
hours ago
 Crystallized
 Ability to recall facts,
auditory or visual
 Recognition
 Ability to recognize
familiar information in a
novel setting

Visual/Motor Coordination
 Fine motor skills

Writing, picking up small objects
 Gross motor skills
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Skipping, jumping, kicking
 Perceptual copy skills

Ability to re-create an object you are currently
looking at
 Visual motor memory
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Ability to re-create an object from memory
Adaptive Functioning
 Communication
 Listening and Understanding
 Talking
 Reading and Writing
 Daily Living
 Caring for Self
 Caring for Home
 Living in the Community
 Social Skills and
Relationships
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Relating to others
Playing and Using Leisure
Time
Adapting
 Physical Activity
 Using Large Muscles
 Using Small Muscles
 Problem Behaviors/Example:
 Isolation from others
 Anxiety
 Impulsive
 Aggressive
 Sucks thumb
 Attention problems
 Runs away
 Stereotypy
 Chronic pain
 Defiance
Personality / Emotional Status
 Reality contact
 process real life events and interpret
accurately
 Coping Skills
 Ability to deal with emotional dis-regulation
 Self-Image
 Self-esteem, self-worth
 Depression/ Suicidal Ideation
 Perception
 How you view the world (positively /negatively)
Compiling Summary
 Gather information on Pre-Brain Injury
functioning, when possible
 Use a comprehensive person centered
approach to identify best individualized goals
 Identify strengths and deficits across all
testing areas
 Assess for emotional stressors versus
acquired brain damage when evaluating
functional skill areas
Diagnostic Summary
 Axis I: Psychological Diagnosis
 Axis II: Intellectual Disabilities
 Axis III: General Medical Conditions
 Axis IV: Life Stressors
 Axis V: GAF score
Case Studies
Case Study – 13 year old female
 Referred to Lakeview because of aggressive and violent
behaviors in the home & for additional testing to assess for her
cognitive, academic, neurological and emotional functioning.
 Prior diagnosis of Dandy-Walker Syndrome and has had a shunt
placed; precocious puberty, hyperinsulinemia syndrome, and
mood and learning disorders.
 Functioning intellectually in the low average range
 Difficulty with processing speed and discriminating details in the
environment
 Academically, functioning around the 5th grade level
 While no formal Learning Disorder can be diagnosed, she is
functioning approximately two grade levels behind due to her
information processing deficits.
Case Study – 13 year old female
 Specific domains of memory where she very quickly and accurately
remembers rote facts, such as birthdates, variety of facts and
calculations
 Memory for such things as reading comprehension and following
directions given verbally is below average
 Learns best through repetition – needs more repetitions than peers
 Difficulty with complexity and ambiguity and requires intense structure
to function
 Escalation occurs when faced with an unstructured situation and may
have difficulty remembering what took place
 Difficulty identifying own emotional states and may have some sensory
integration issues revolving around touch and temperature.
Case Study – 13 year old female
Axis I: Asperger’s Syndrome
Cognitive Disorder NOS with attention deficit
R/O Intermittent Explosive Disorder (by history)
Parent-Child relational problems
Axis II: Deferred
Axis III: Dandy-Walker Syndrome, precocious puberty,
hyperinsulinemia syndrome
Axis IV: adjusting to a residential facility, separation
from parents, parent and sibling discord, divorce,
poor peer relationships
Axis V:
GAF= 50
Case Study – 13 year old female
Needs:
 Intense structure, routines, and a strong support system
 Daily routine with Choices and Clear Expectations
 Pre-Teaching of Changes to Expectations or Schedule
 Review of Rules, Use of Social Stories to establish Rules
 Clear concrete reinforcers & consequences across
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settings
Establish daily routines for self care to establish
consistency and compliance
Provide Visual Cues: reminder for chores, schedules
and a visual set of directions given to her in the
classroom as well as the verbal instructions.
Teach Social Skills
Example Rules / Expectations
Green Behaviors –
I will earn my dollar and extra 30 minutes of
TV before bed when I:
Yellow Behaviors –
I will not earn my dollar but will still earn 30 minutes
of extra TV

Following Directions
Talking back / arguing more than 3 times

Following my Schedule
Yelling in the house / Stomping feet

Staying safe and calm
Threat to hurt myself or others
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Taking my Medications
Not following my schedule

Following the rules
Not following my diet
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Doing my Chores
Not following directions

Taking care of myself
Not doing chores

Following menu choices
Not washing my hands after toileting
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Sharing TV and Computer time
Not telling the truth
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Telling the truth
Calling people hurtful names
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No calling hurtful names
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No Yellow or Red Behaviors
Example Rules / Expectations
Red Behaviors –
I will not earn my dollar or my 30
minutes of extra TV time
Level Blue = 7 days of green in a row
earns a trip to the Dollar Store
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Destroying ANY property
Bed time at 9:00 if I am on Green /
Yellow
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Aggression towards other
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Doing a Supervised Activity
without permission
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Throwing things
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Hurting Animals
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Hurting myself / Self injurious
Behaviors
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Continuing to argue, threaten,
yell, after 2 yellows in a row
Red Restrictions = 24 hours from the
start of the Red Behaviors
Chores:
Every morning:
Make my Bed
Unload the dishwasher
When clothes are clean:
Put clothes away
Every Saturday:
Clean Bathroom
SODAS Problem Solving Sheet
Situation: What is the problem?
S
O
D
Options: What could you do that would solve the problem?
Option 1:
Option 2:
Option 3:
Option 4:
Disadvantages: What are the disadvantages (bad things about) of these options?
Option 1:
Option 2:
Option 3:
Option 4:
Advantages: What are the advantages (good things about) these options?
A
Option 1:
Option 2:
Option 3:
Solutions: What is the best solution? Which option has the least disadvantages and the most advantages?
S
Option 4:
Example Social Story
 I have lost weight! This makes me feel happy
and look healthy.
 When I lose weight, some of my clothes might
not fit right. When my clothes don’t fit, I need
new clothes.
 New clothes that fit well make me feel better
about how I look.
 They are also more comfortable!
 I get new clothes from the store. I’ll go to the
store with a staff member.
Case Study – 10 year old male
 Ten months post a traumatic brain injury.
 Referred because of aggressive behavior in both the home and
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school environment
Pre-injury diagnoses of Bipolar Disorder, Asperger’s Syndrome,
and ADHD.
Severe deficits in executive functioning and memory, especially
in the areas of initiating activities and focusing on anything for
an extended period of time, even things that previously
interested him.
Perseverates on things and often needs assistance with
transitions.
Difficulty with short term memory storage and appears to have
difficulty retaining any new information, either auditory or visual.
While he appears to have retained old information that he
learned before the injury, this is severely affecting his ability to
learn any new information.
Case Study – 10 year old male
 Aware he is having difficulties that he did not have prior to injury
causing increased stress, anxiety, and depressive symptoms.
Reports that he remembers being able to do things very well,
such as play video games, and now he is unable to do many of
the things he once enjoyed.
 Experiences seizures that are variable in intensity and
frequency and often appear to happen when he is unoccupied
or transitioning between activities such as finishing breakfast
and waiting for class to start.
 Records indicate that there was some abnormal brain activity on
a weekend study, but there was no pattern
 Because of his high level of anxiety as well as his tendency to
not talk about it with others, he may be experiencing some
pseudo-seizures along with brain activity seizures from the TBI
Case Study – 10 year old male
Axis I: Cognitive Disorder NOS with attention, memory,
and learning difficulties
R/O Intermittent Explosive Disorder (by history)
R/O Dementia due to Head Trauma
Generalized Anxiety Disorder
Axis II: No Diagnosis
Axis III: Seizure disorder (by chart report)
Traumatic brain injury
Axis IV: brain injury, difficulties in the home and school
environment, adjustment to residential treatment
setting
Axis V:
GAF: 45
Case Study – 10 year old male
Needs:
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High levels of structure and support – Clear expectations / rules
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Frequent cueing for daily activities, such as chores, school work,
and transitions through use of schedule and established routines
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Pre-teaching upcoming events / transitions;
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Small class setting / avoid crowds or over-stimulation
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Engage in memory strategies to help him remember everyday
activities and events;
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Use of a journal / small notebook to write down things that he
wants to remember as they happen
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Use of a calendar to record upcoming events and appointments.
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Frequent praise, frequent review of strengths to increase selfesteem
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Group engagement and social skills training – increasing
recognition of similarities to same age peers
Case Study – 10 year old male
Morning Schedule
Afternoon Schedule
Home from School / Day Activities
Wake up
Snack
Get Dressed
Choose Independent Activity
Eat Breakfast / Take Meds
Brush Teeth
Do Chores
Supervised Activity with Mom
Go to Softball Game
Leave for school
OR
OR
Choose Independent Activity
Choose independent activity
Social Skills Task Analysis
Following Instructions
1. Look at the person
2. Nod or say “okay”.
3. Do what you’ve been asked right away.
Greeting Others
1. Look at the person.
2. Use a pleasant voice.
3. Say “Hi” or “Hello”.
Listening
1. Look at the person.
2. Stay still and quiet.
3. Think about what is being said.
4. Nod or say “okay”.
Accepting “No”
1. Look at the person.
2. Nod or say “Okay”.
3. Stay calm.
4. If you disagree, ask later.
Making a Request
1. Look at the person.
2. Use a nice voice.
3. Say please and tell what you want.
4. Say “Thank you”.
5. Or accept “No”.
Accepting Help/Consequences
1. Look at the person.
2. Nod or say “Okay”.
3. Don’t argue.
Case Study – 15 year old male
 Extensive history of severe problem behavior
 Multiple psychiatric hospitalizations and residential treatment
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placements
Born prematurely and tested positive for cocaine and alcohol upon
delivery
Adopted at age 2
Prior Diagnoses: Mood Disorder, NOS; Attention Deficit Hyperactivity
Disorder; Oppositional Defiant Disorder traits; Conduct Disorder traits;
Eating Disorder, by history; Mild Mental Retardation
Overall range of cognitive skills is significantly below average
Relative strength in verbal abilities – verbal concept formation & verbal
reasoning skills
Significant weakness in the area of working memory, deficit in retaining
information in short term memory, performing some operation or
manipulation with that information and verbalizing a result
Cognitive skills with academic performance suggest Mild MR
Case Study – 15 year old male
 Visual spatial and visual recognition skills adequate to above average
 Below normal limits in processing speed
 Working memory functions are severely compromised impacting
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attention, learning and retaining new information
Memory for verbal information somewhat impaired, visual memory well
within normal limits
Executive functioning appears intact, however shows significant
information processing deficits
Able to engage in cognitive shifting and problem solving
Abstract reasoning abilities are compromised resulting in difficulties
analyzing information and solving complex problems
Lacks inhibition – exhibits impulse control problems
Emotionally much younger than chronological age: struggles with the
ability to think abstractly, gain control, and form adaptive relationships
Case Study – 15 year old male
Axis I: Pervasive Developmental Disorder, NOS with
deficits in attention and impulsivity
Mood Disorder, NOS with mixed emotional
features
Reactive Attachment disorder
Eating Disorder, NOS (by history)
Axis II: Mild Mental Retardation
Axis III: Born prematurely and exposure to alcohol and
cocaine in utero (by report)
Axis IV: Out of home placement, separation from family,
behavioral disturbances, social deficits
Axis V: GAF = 30
Case Study – 15 year old male
 Needs:
 Approach in a calm and simplistic manner
 Use short, concise sentences
 Focus only on current issues
 Frequent repetition of directives and choices with visual
aids
 Provide single step directions
 Provide visual aids with verbal directions
 Frequent reminders of rules and expectations that are
consistent across all settings
 Use redirection in a crisis reminding him of his goals and
transfer focus to something else
 Provide 2-3 choices
Case Study – 15 year old male
 Schedule book with pictures of him completing each
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task
Routine tasks in picture order – numbered
Breaks and choice activities scheduled
Reinforcement need: activity based on an intermittent
schedule – Catch him being ‘good’
Problem solving using SOS
Very clear, simple rules – Level system
Repetition to develop crystalized memories
SOS Problem Solving Sheet
Situation: What is the problem?
S
Options: What could you do that would solve the problem?
O
Option 1:
Option 2:
Solutions: What is the best solution?
S
Option 3:
Please Contact Us with Questions
Amanda Messina, Psy.D.
Mahin Para-Cremer, M.Ed.
Director of Child & Youth Services Associate Director of Development/
Behavior Analyst
Lakeview Specialty Hospital
Lakeview Specialty Hospital
& Rehab
& Rehab
800-611-2063 x 524
800-611-2063 x 394
[email protected]
[email protected]