Exam 1

Posterior Tertiary Skills

Abstraction, reasoning, analysis/synthesis Some prefrontal involvement (e.g., abstract reasoning) Arithmetic: 3+ aspects - Number concepts (L>R) Spatial processing (R>L) Calculation (L>R)

Mental Activity

Activity Rate Attention Awareness Consciousness

Language: Aphasia and Dysphasia

Aphasia - absence of language Problems with langauge that is acquired - you could comprehend before you and now you can't Dysphasia - problems with language Long-standing, genetic-based problem, never could use language Types of Aphasia Disorders of comprehension Poor auditory comprehension Poor visual comprehension Disorders of production Poor articulation Word-finding deficit (anomia) Unintended words or phrases (paraphasia) {Semantic - say unintended words Phonetic - substitute meaning} Loss of grammar and syntax Inability to repeat aurally presented material Low verbal fluency Inability to write (agraphia) Loss of tone in voice (aprosidia)

Behavior Observations (What to look for)

Appearance Orientation Cooperation Arousal/alertness/activity level/vigilance Sensorimotor Language Speech Affect Thought processes Social skills Etc..

Halstead-Reitan Adult Battery

Appropriate for ages 15+ Category Test (similar to WCST but don't know the categories will change) Finger Oscillation (or Grip Strength) Speech Sounds Perception Test Seashore Rhythm Test Tactual Performance Test Sensory-perceptual exam (basic sensory, tactile) Aphasia Screening Test Trail Making Test: A&B

Conduct Disorder

Behavioral disorder, not NDD but could be some brain-based contributions Problems with literature is they don't control for: don't stick to strict DSM dx (don't have good operational definition), don't focus on studying kids (just adolescents), don't control for comorbid ADHD or TBI Stimulation seeking or risk seeking - prone to head injuries (can cause EF problems) Studies have found EEG abnormalities in frontal region and low levels of arousal (skin conductance test, sweat, heart rate, cortisol, etc.) Comorbid SLDs - engagement in school, suspensions? NP deficits: verbal/linguistic deficits (issues with expression and comprehension which can cause family frustration & create behavioral problems), EF, risk factors Need for early treatment (language/communication, problem-solving)

H-R: Interpretation: Multiple Inferential Approach

Better than any one of the approach above in isolation More sensitive and specific Takes a pretty skilled examiner to do this well - need lots of training Pretty subjective in how you integrate across all four

Luria-Nebraska: Interpretation

Caveats: scales are heterogenous; can't interpret one solely You can't interpret just one by itself You have to look at patterns of performance First level: yes/no; success rate (not replicated) Pick their best score (closest to normal) at the scale level And then look at how many impaired relative to their best performance 2+ below - suspected brain damage 1 - normal variation Second level: patient descritpion including qualitative Third Level: Determine causation What is the etiology of this Fourth level: integration and conclusions Instructor opinion (Kibby) These conclusions are just based off of a screener where scales have only a few items scored 0-2. You are giving a full diagnostic battery using a screener - it is not good and is overly ambitious

H-R: Interpretation: Rules Approach

Combined Approach Same 4 but rubric based (objective); scoring 0-4 on 37 aspects (0 is average and categorically worse as you increase in numbers) More objective

Halstead-Reitan: General Neuropsychological Deficit Scale

Complete battery (42 scores) Uses: yes/no, severity of damage, lateralization, and localization Computerized scoring Problems: lat/loc (not great at this); psychiatric (not good specificity); time (takes a lot)

Too Long Note Card on Memory

Complex entity - multiple components & theories Learning/encoding, long term memory/storage, retrieval Two long-term storage systems: explicit and implicit Explicit/declarative (multiple theories; conscious) - Semantic - facts you no longer remember where you learned them (acquired knowledge) - semantic networks activated (nodes for recalling) Episodic - autobiographical/new material (e.g. studying info for a test) Declarative: ability to learn purposefully and remember information (volitional or intentional process) Episodic stages - sensory register, short term memory, long term memory - the more you think about these episodes and link with meaning and prior knowledge, they start to become part of the semantic networks Sensory register Components: iconic/visual/sensory (200ms), ionic/echoic/auditory (2 seconds) Focused attention STM/Primary memory (lots of models) Immediate memory - span, short term memory (30 sec) - modality specific - right hemisphere - visual, left -verbal Working memory - do something with that information/mental manipulation - easiest working memory task digit span backward - sequencing is a tad harder - working memory is limited by your span length, and how well you manipulate Baddeley's model- Phonological Loop builds on Verbal short term memory, Visual Spatial Sketchpad, Central Executive, Episodic Buffer - takes new image you're holding from STM and integrates it with experience with similar things from your past to create a coherent trace Rehearsal (passive) & mnemonics/encoding (active) strategies for short term memory Brain areas (verbal [Phonetic (sounds) vs semantic (meaning)], visual [2 streams? Visual and spatial are separate], Central Executive - all networks always include a frontal component) Long term memory/Secondary memory Definition - store information over time and retrieve it Consolidation - encoding into long term memory Brain areas (Papez circuit includes hippocampus) Encoding vs storage sites (stored where processed - e.g., visual info stored where visual is processed); hippo's role - binds all together from all different areas; more times recalled, network connecting the pieces are solidified and you won't use the hippocampus as much - modality - left hippocampal damage (verbal) & right (visual) but are strongly connected so relative difference, not absolute Recent (learned just prior to injury) vs remote memories (learned further in the past - usually year or two more) Amnesia: abnormal forgetting (declarative) - disorder of declarative LTM Anterograde (problems forming new memories/consolidation) vs retrograde deficits (recent)- can have brain damage to both (common with severe TBI) Brain areas: hippocampus/Papez (anterograde), subcortical - hypothalamus/thalamus (diancephalon) or White Matter damage Recall vs recognition Active retrieval (active search process) vs stimulus triggers the memory/familiarity Teasing apart memory deficits (on neuropsych testing) Focused attention/encoding - Retrieval problem - Memory loss/consolidation problem All poor then its focused/short term memory, just problems on retrieval and consolidation, then its consolidation problems, if do ok on long term memory recognition but not recall, its retrieval problem Simplistic... Explicit long term memory Declarative: modality-specific - how much do you know? Brain (stored where processed) - left verbal, right visual for consolidation but they talk - hippocampus is affected by CO2 poisoning because high O2 load (and any other O2 deprivation) and you could have bilateral damage Source memory (who, where?, temporal memory/when) Brain region - frontally based Prospective memory -sensitive to brain damage (I need to do something later and then actually do it) Brain region - frontal functioning - can be affected by a variety of things such as frontal or stress, fatigue, etc. Non-declarative/implicit memory - not trying to learn on purpose, learning by doing Primary subsystems Priming/perceptual learning - subcortial structures (thalamus) Procedural/skill learning - cerebellum (making skills automatic) - then cerebellum isn't important anymore once its automatic (Classical conditioning) - cerebellum important for classical conditioning too All three: less conscious role Brain areas - above Intact in amnesia

Depression: Effects of Testing

Deficits: Attention - which affects working memory and encoding into long term memory & processing speed Can generally cause slowing which affects processing speed (psychomotor slowing) Motivation - effortful tasks/processing (normally occurs with severe depression - moderate may not be enough) - effortful processing is involved in executive functioning: problem solving, planning, higher reasoning, or on novel tasks Memory problems - problems with attention > effortful encoding > leads to problems with recall but not recognition Moderate severity and worse - you will begin seeing effects on testing and a dose response relationship (worse depression will lead to worse symptoms) Positive (mood) material - more difficulty encoding stimuli that is positive rather than neutral or negative Comorbid anxiety: encoding/retrieval may be even more effected Prospective memory - incredibly sensitive to internalizing problems, stress & fatigue Role of comorbid brain damage and age: TBI - minor (mild/mod) vs severe & depression Common in minor head injury to develop depression due to insight into functioning Severe TBI - much less likely to develop depression due to lack of insight

Factors Affecting Test Performance: Malingering

Definition - intentionally worsening performance (suboptimal ability, exaggeration) Things to look for: Consistency: deficits, pattern (do we expect this?), hx consistent with problems having?, behavior observations, testing (repeat testing to see consistency) Motivation/effort (usually less of a problem than malingering); tests of suboptimal effort - TOMM, ACS (WAIS-IV) includes social function and others Secondary gain possibility? - law suit? Extra help, get out of things? B.O.'s: questions (defensive? Exaggerated? Vague?), during testing, DS (forward should be pretty easy unless NDD - shouldn't be affected by acquired injury), recognition Hebben Table (in the text) - for neuropsych peoples Determining impairment - be mindful of premorbid functioning Education-norms Ethnocultural factors Personality Negative - feeling negative about things may play role of suboptimal effort and could also play a role in healing (less likely to have full recovery) Social support Changed by injury/disease (frontal/temporal - both affect motivation/effort and emotional regulation)

Children: Pseudoseizures

Definition: conversion disorder (faking for gain), or true seizures that don't pick up on EEG Focus on conversion disorder for these notes (psychiatric origin) Distinguishing features: fecal incontinence typically doesn't occur here (urinary might), same with self-injury (hard falls to the ground), true seizure: no awareness or memory (not a focal seizure)

Psychiatric Factors: Dementia

Delusions (paranoid especially or persecution) Alzheimer's & Parkinson's - visual hallucinations (or auditory in Alzheimer's) Frontotemporal dementia will have hallucinations & delusions but also personality changes Dementia vs psychiatric - with basal ganglia involvement - vegetative signs of depression may present (Parkinson's disease or Huntington's disease) - doesn't mean they are depressed - dysphoria present? This could help determine

H-R Ability to Answer Referral Questions

Determine diagnoses Depends on diagnosis Brain injury vs. Not - Yes! Other things - not so great, not a lot of support Cognitive strengths and weaknesses Not the best for that Not made to differentiate between different types of functioning Describe and monitor changes in functioning Yes and no Depends on what you are monitoring Why is this person acting so odd Not so much Etiology - bio or something else? Not great for localization to a particular area or to a particular cause Prognosis/potential - no Treatment planning recommendations - no Competency decisions - no Guidelines for caregivers/treatment team - no Placement decisions - for some of the questions (if severely impaired) Discharge planning - no

H-R: Interpretation: Pragmatic Approach

Flexible approach Use whatever you need (those in the battery and other materials that you want to bring in) The other approaches require a fixed battery Goal is to look at st/wk with whatever aspects you are looking at Problems H-R wasn't developed for this purpose, it was supposed to be a y/n question (brain damage or not) Lot of subjective judgments that come into place - particularly because you aren't using the set battery (you are choosing what you want to use) Have to have REALLY good training for this one because it isn't how the battery was supposed to be used Not a lot of empirical support for this particular method

Luria-Nebraska: Norms

Form I - 50 medical patients were the "norm" or "average" Mean age - 42 Huge age breakdown - so would overestimate or underestimate if you were far from age 42 Bad education breakdown Form II - actual average population BUT all of the rest of the norm problems were maintained Child Norms Description One normative sample consisting of children ages 8-12 years Same 11 clinical scales irrespective of development Norm development (above) Purpose Supposed to be a screening measure of neurological functioning which you can then build on BUT he's still trying to say yes/no, loc, and lat Almost like he's trying to deflect criticism Reliability Isn't great Just a few items per scale with scores of 0-2 Need a lot more items Validity Factor scores vs. Clinical scores Discriminate He says he has 80% accuracy for determining yes/no - but does he? Not so much Internal and external Internal is not great because the reliability is poor Not supported by factor scores

ADHD

Frontal circuits (60% of those with ADHD have some form of frontal problem): dorsal lateral (cog, EFs like problem solving and planning), orbital frontal (emotional behavioral regulation) delay aversion (Orbital frontal circuit) Other potential contributions - cerebellum, right parietal (mild left neglect & selective attention also contributes to focused attention), cerebral volume/working memory reduced in ADHD (at least 3% smaller vs controls) - might affect processing speed, and reticular activating system (arousal level control)

Boston Process Approach Overview

Fully flexible, process/qualitative approach Forerunners - cognitivists, theory-driven Goodglass Butters Cermak Qualitative as important as scores How they approached the task is just as important as the standard score Also important in the diagnostic considerations Werner --> Kaplan WAIS/WISC NI: based off process approach Clock drawing Kaplan's whole book on interpretation Based on how the patient/client draws a clock Kaplan-Baycrest Neurocognitive Assessment

Luria-Nebraska: Golden

Golden's goals (3) and methods - used face validity to determine the scales - which items discriminate patients from controls End result vs. Luria (~10% NP) - Golden used a set battery (Luria never did that), Golden's scales were broad and not measuring one thing (Luria's goal would be to determine why impairment so those wouldn't have helped) Luria was fond of hypothesis testing where as Golden wasn't. Luria-Nebraska - tried to be complex but no one else uses it because its not great.

Luria-Nebraska: Child Battery Development

He took the adult battery, gave it to children ages 5-12 years Found that kids ages 8+ could do most of the tasks even if they weren't very good at Kids that were 13+ could do just as well as adult controls Tells us this battery is not very sensitive bc full matured brains were the same as developing brains on tasks Took the tough items out and left the rest in + added a few more easier items to round it up Then he normed it Red flags One norm for 8-12 because all of these kids were able to perform the same on the measures

Forms of Attention

Hierarchy (modality effects) Automatic (subcortical/thalamus) to registration (iconic, echoic; cortex) - helps filter sensory stimuli Voluntary (cortex) - engaging in further processing - now will last longer in registration Focus (vs internal and some external distractors) - how well can you voluntarily focus your attention when you have things internally going on and sometimes external things? Encode (span - overlaps with immediate memory) - focus on span - how much can you hold while encoding Selective (vs non targets within task) - how well can you attend despite external distractors and non targets within task External distractors, not part of the task - could be argued for focused or selective Sustained vigilance (tonic) -maintaining attention over time (best 20 min or more) Shift/alternating (phasic; AKA shift of executive functioning)- Divided (most difficult; mass action) - builds on shift and focus - how well you can attend to two things at once? - easier when one is auditory and one is visual but not when you have the stimuli on the same modality (frontal areas connected with posterior areas and intertwined)

Appropriate Training for Neuropsychologists

Houston Guidelines Knowledge base in generic psychology, generic clinical, foundations for the study of brain-behavior relationships, foundations for the practice of clinical neuropsychology Skills in assessment, treatment and interventions, consultation, research, teaching, and supervision Doctoral education Internal training in APA or CPA accredited program (50%)

Awareness

How aware/insightful are you of your deficits Correlated to consiousness but comes from different brain areas Anosognosia - no awareness (right inferior parietal lesion, unilateral neglect) Anodosdiaphoria - aware of problems but are indifferent to them (left inferior parietal lesion Frontal damage - lack of insight

Psychiatric Factors: Schizo

How much is neurological factors versus stress/situational factors because there is strong connection to genetic links Neurological contributors: size (ventricle size differences even in young adulthood), frontal lobes and limbic areas differentially affected by schizophrenia Positive symptoms (neurotransmitter function) - early symptoms in childhood - auditory hallucinations/delusions and progress to keeping train of thought or visual hallucinations - not yet showing structural changes Negative symptoms (structural) - frontal/limbic structural damage - symptoms correspond with amount of damage as disease progresses

H-R: Interpretation: Patterns of Performance

Idiographic approach Patterns of relative strengths and weaknesses compared to mean level of functionin Are areas of weakness brain based? Problems: Other things affect test performance - environmental opportunity, rapport, motivation that day, mood, sociocultural factors (can't ASSume it is brain based)

H-R Child Batteries

Immediate Battery (ages 9-14) Same measures as adult, but with new norms and easier Young Child (ages 5-8) Category Test, TPT, sensory-perceptual, finger tapping, grip strength, aphasia screening Marching, color-form, progressive figures, Target Test, Drawing Shapes, Knox Cube

Factors Affecting Test Performance: Pain & Fatigue

Injury, medical conditions, elderly Cognitions; Tests to assess pain throughout measures given Variable (within and across pts; interview) Subjective within and across Pain meds (using? Effectiveness? Side effects?) Acute (reschedule) vs. Chronic (testing) Breaks, may need to be quite frequent Test ordering Neurological patients, medical patients - tend to get fatigue quicker (lesions, injury, stroke, etc) or medical patients can have more fatigue (high blood pressure, diabetes, etc.) affects attention, thus any measure attention affects - effortful cognitive processing and advanced cognitive measures Testing - similar to what you would do for attention - frequent breaks, (fatigue likert scale),

Anxiety

Moderate to severe performance anxiety or anxiety over litigation Severe anxiety: attention (focused/sustained) which causes memory encoding and retrieval problems and slowed processing speed - biggest difference with depression = psychomotor symptoms is only in depression Psych symptoms and brain damage ¼ of patients with dementia have depression TBI acquired (symptom timing) Frontal lobe dysfunction - confusion, behavior & cognitive changes (too little inhibition or too much) Temporal lobe dysfunction - erratic, personality, psychosis, memory changes Right hemisphere dysfunction: schizophrenia

Factors Affecting Test Performance: Litigation

Motivation? Who is the client? Practice effects Premorbid functioning

Bipolar Disorder

NP deficits: attention, processing speed, spatial processing (including spatial learning), EF Verbal functioning often intact Neuroimaging - prefrontal (orbital frontal - emotional behavioral regulation issues), limbic, subcortical (thalamus - central relay system)

Factors Affecting Test Performance: Variability

Neurological dx (frontal, limbic motivation too), NDD - SD tends to be bigger (more variable performance) Testing: behavioral observations, different days (similar measures both days to obtain range of ability), hx (how representative is testing in daily life), patterns (similar measures, start/end of day); disclaimer (if not sure how much SD is playing a role in pattern of performance, bad day? Then add a disclaimer in report) - could be due to SD rather than suboptimal effort

H-R: Interpretation: Level of Performance

Norms (2 SD cut-off) All or nothing decision Yes/no Set up to minimize false positives Problems Risk for false negatives Will miss more mild or subtle problems Less sensitivity because of specificity Standard deviations are bigger than the adult battery

Factors Affecting Test Performance: Ethnocultural

Norms (US vs Foreign) Bilingual - 9 or 10 years old - can be behind/slower before 9 and better at both languages than others after 9 For ethnocultural groups be cautious when interpreting 'weakness' - within a SD can be mild differences in performance so don't overinterpret into concerns Norms include? SES, Cultural factors - how much do these fit with your client, cognitive measures are greatly affected by education Use tests with less cultural bias when available Check to see if there are appropriate norms for test using

Receptive Language

Oral: You've heard someone say something Heschel's Processing, tonal registration What sounds am I hearing Speech range of tones Heschel's If registered, sends to secondary auditory region on the left (Area 41) Wernicke's area Contains images of words (lexicon) What words are you familiar with Gateway into comprehension of speech

Rivermead

Overview Not a complete battery Has various, separate tests Memory, Post-concussion symptoms (PCS), Perception Goal: ecological validity How might these scores give us a better idea of functioning in real life Better guide recommendations Wanted these items to be more face valid in this sense Pros It could have more ecological validity than standard measures Though not well tested at this point Cons Questionable whether these measures are as good as theory-driven, traditional measures May not be as good in terms of test quality Tests are easy so the norms don't tend to be quite as good for sensitivity in detecting deficits Relatedly, can miss subtle deficits

Fixed Battery Approach (Quantitative)

Overview Test Batteries (HRB, published, own) Length/approach varies across sites For one diagnosis or another Halsteid-Reitan Battery Published CANAB NEPSY Pros/Strengths Tends to be pretty comprehensive, at least for the problem area Not likely to miss anything related to that problem If you have a large test battery with a variety of measures - not likely to miss any problems Good for strengths and weaknesses Good for recommendations Good for research Less likely to miss anything Cons/Weaknesses Time - takes a lot of it Insurance will only pay up to a certain amount of time - so likely will be hard for reimbursement purposes Problem-focused approach likely to miss something, not get strengths - but more time efficient! Theoretical Approach Fits Localization (unless HR as fixed) Cognitive (unless HR as fixed) Ability to address common referral questions depends on battery's ability

NEPSY

Overview (fixed, fixed flexible, flexible) Comprehensive Tries to get at all domains of cognition and motor Ages 3-12 (first edition); now 3-16 5 core domains (core and supplemental measures of each) Attention/EF Language Learning and Memory Visual-spatial Sensory and Motor Supplemental measures (several) Each subtest normed Qualitative Ways to code them Pros/Strengths Comprehensive impression Flexibility All normed on the same group Fairly good for ages 5/6 and up Cons/Weaknesses Doesn't have a great floor (especially for children 3-4) Some scores only get down to an 85

Factors Affecting Test Performance: Psychiatric

Overview (organic vs reactionary) - bipolar/schizophrenia (very neuro based) & unipolar depression could be reactionary or organic/genetic - look for family hx and own hx False positives for brain damage or not (acquired) Assess for psychiatric dx/problems - want to know mood during measures (so give a measure of psych issues each testing session) Meds levels (correct, stable) and side effects? (attention level?) - defer testing until stable? Or use frequent psychiatric measures to identify what role mood plays in performance Cognitions affected go beyond psych dx? Acquired on top of premorbid neurodevelopmental or psych condition - be mindful of fxn prior to injury (could have also had a neurodevelopmental disorder) More to come

Luria-Nebraska: Battery

Overview: adult, kid 1.5-2.5 hours for adult - that's pretty short to look at all functioning 1.5-3 hours for child (ages 8-12) Goal: Brain damage or not, localization, and lateralization - Do it all! Form I - adults 269 items Performance is rated on a 0-2 scales 0 = average 1 = 1 SD below 2 = 2 SDs below Every item is scored separately All ages have the same norms 11 scales Sum of the item performances Cluster together into 5 summary scales 8 localization scales - injury locale Factor analysis - 28 factors but he didn't do anything with that knowledge Form II - Exactly the same as Form I, just re-normed it and added a delayed memory tasks 66 items you watched for while they did these tests so you could score qualitatively for your behavioral observations 10 qualitative categories

Constructional Apraxia and The Brain

Parietal - problems with reproducing the design because I didn't process the design well to begin with; problems with perception Frontal - perception is intact but planning and execution is poor (give VMI to break down) L Parietal - hard time getting details, no neglect, overall concept is intact but misses details (e.g., missing spokes or pedals of the bike) R Parietal - gestalt is poor, pieces of the bike aren't fully together, left neglect is common Variable functioning - puzzles vs. drawing Tests of this often measure more than just motor

Components of Sound-Based Language

Phonemes - individual sound units whose concatentation, in particular order, produces below Morphemes - smallest meaninful unties of a word, whose combination creates a word Syntax - admissible combinations of words in phrases and sentences (called grammar in popular usage) Lexicon - collection of all words in a given language, each lexical entry includes all information with morphological or syntactic ramifications bu does not include onceptual knowledge Semantics - meaning of words Prosody - vocal intonation that can modify literal meaning Discourse - linking of sentences such that they constitute a narrative (conversation or reading)

Schizophrenia Affects on Testing

Positive signs by age 12 (early onset schizophrenia) IQ, motor slowing, processing speed, learning/memory, reasoning, executive functioning Verbal short term memory & long term memory most prominent: language, working memory 80% Childhood vs adult onset - greater cognitive impairment, socioemotional, overall severity, resistant to treatment in childhood Structural findings Progressive ventricle enlarged; decrease total brain volume, thalamus alterations, medial temporal volume decrease, older usually reduction in frontal too Most takes place in teens; peak young adult Functional MRI & PET - decreased frontal metabolism

Constructional Praxis/Apraxia

Praxis - execution of reproduction of complex designs Apraxia - deficit Not true apraxia as true apraxia is much more general problem with purposefully executing complex motor acts (CP is more specific) Involves parietal, frontal, left and right hemisphere

Personality/Emotional Functioning and The Brain

Prefrontal damage - overactivity vs. underactivity Inhibition - acting out, emotion regulation, irritability and impulsivity Initiation - motivation to itneract, flact, anhedonia, lack of movement, resembles depression Orbitofrontal limbic cricuit - change in sex drive Anterior/Medial temporal Lobe - Religiousity Overly philosophical Schizophrenia, delusions, hallucinations (auditory) Paranoia, persecution Brain damage in general: Fatigue, irritability, reduced frustration tolerance, less cognitive or physical energy, mild apathy, greater emotional lability Individual differences dependent on premorbid functioning, location and severity, and situation factors post-injury (e.g., supportive vs. chaotic/negative environment)

Three Levels of Mental Operations: Motor

Primary - movement execution Doing a simple movement Final common pathway telling the motor to move Secondary - Sequences of movement Instructs the sequences for the primary to follow through on premotor area anterior to the primary motor Tertiary - executive functioning Internal motivations relative to external demands Do I want to move, how should I move Boss of secondary

Three Levels of Mental Operations: Sensory

Primary - registration and location Visual - where is the visual stimulus (occipital lobe) Auditory - where is the auditory stimuli Occiptal, temporal - locaiton specific in the brain Secondary - perception What is this thing? I know I have a series of dots in my periphery - NOW I know it is a square And location - how are these things related to each other Relative locations Uses more brain areas for each function Tertiary - global - cognition Lot of cross talk amongst regions in the brain Reasoning through the situation to come to a conclusion

Apraxia: Ideomotor

Problems in the limbs (hands, feet) Command - can't do it on command by self Imitation - can't follow someone else doing it Etiology - copmplex motor sequencing due to pre-motor deficits contralteral to the affected hand/food AND/OR angular gyrus damage in the left anterior parietal region

Luria-Nebraska: Pros and Cons

Pros Brief and covering a lot during that time All items are standardized on one sample Some very loyal followers Cons Sensitivity Not great for mild problems Psychometrics Normative samples are all regional (maybe a better job on the 3rd version) Not good replicability Not good for localization Not good for aphasia (most instructions are all oral) Poor reflection of __________.

Anne-Lise Christensen Pros and Cons

Pros (6) Pretty quick to give - hour or two, only test where you think there are problems, not the whole thing Based off of Luria's test but with flexibility - not made up on the fly If you are a good neurologist - you can get at some localization if you have okay norms Because it is short and easy - you can give this battery to individuals with dementia, schizophrenia, etc. Inexpensive Some frontal tasks still used today Cons (9+) Not great measures for attention or memory Not good for attention control or mental tracking either Most tasks are simple - so subtle problems won't be missed (need moderate to severe brain damage) Isn't good for mild or diffuse problems Diffuse - the whole goal of the battery was to use fine-tuned So how do you address more global problems No norms - have to have a really good, internalized sense of this Usually need supplemental measures if you want to get at higher order memory, EF, IQ, subtle language measures, etc. Very subjective Need A LOT of training in order to be good at it Does not have good psychometric properties because it does not have normative data

Apraxia

Purposeful execution of complex motor tasks Mild - learning new complex voluntary tasks is difficult, old skills intact Severe - new AND past learning are poor

Halstead-Reitan: Impairment Index

Rated from 0-1, presense/absence of brain damage (1) - have to fail 50% of the test to indicate brain damage Actuarial approach - plug formula into a computer Average impairment ratings typically come from 7 scores on 5 tests: Category Test (categorical test, problem solving); Finger Oscillation (finger tapping test, motor); Seashore Rhythm (right temporal - are these two sounds the same or not); Speech Sounds Perception (left temporal - matching sound to a word); Tactual Performance Test (frontal functioning, problem solving, spatial, sensory, motor; gets at Total Time, Memory, and Localization) Other measures added might include Trail making test, aphasia screening, sensory perceptual exam, grip strength, WAIS/WISC, WMS/CMS, MMPI

Sensation

Registration of the senses Early location - where am I being stimulated? Brain areas - occipital, temporal, and parietal

Factors Affecting Test Performance: Attention/Memory

Testing that tests attention and memory Don't take this into account necessarily What about other measures? Forget what they are doing during the testing? STM Forget what they are supposed to do - remind periodically every few or several items Tell me what you are supposed to be doing WM/Attention Take lots of works Put the more effortful tasks first Then order by attention demands

Problems with Neuropsychological Testing

Tests measure more than 1 thing (hard to differentiate problems) Developed to detect dysfunction Psychometrics *developed before there was more understanding of why we need good psychometrics Norms - who is included in the samples? Ecological validity Need extensive training to do well

Luria-Nebraska: Theoretical Approach and Common Referral Question Ability

Theoretical approach Holism and localization - would probably say both Tested it using empiricism for the items but then used face validity to plug them into cognitivism approach Ability to address common referral questions? Determine diagnoses - not very reliable outside of his camp of followers Cognitive st/wk - same answer as preceding Describe & monitor changes in functioning - not well supported since it is a screener, but Golden would probably say yes Person acting odd? He would say yes Etiology? He would say yes Prognosis/potential? He would say yes Not so much/with my measures + other measures Treatment planning recs Competency decisions Guidelines for caregivers Placement decisions Discharge planning

H-R Approach Cons

Time, efficiency; meant to be used as battery NOTE: But it is time efficient if your question is just yes/no Some very easy or difficult Some times you have to have very global difficulties in order to tank a test Ecological validity has yet to be established for many of these measures How well can you interpret beyond "you have brain damage" Kids and elderly individuals do not have great norms memory, EF - not the best measures Lateralization and localization Full battery tries to get at it but it doesn't do a great job (ties into other cons) So. Many. Norms.

Depression: Case Example

Unipolar Depression CA = 22 WISC-IV: VCI = 100 (intact working with info already know, no novelty or EF), PRI = 89 (mild dip because timed), WMI = 85 (all subtests mildly reduced), PSI = 80s (both subtests affected - speed + attention affected) WJ -III: LW is automatic (not affected 100), Reading, writing and math fluency (timed so affected = 80), story recall (long passage with details and memory - mildly affected = 85) understanding directions (effortful = 85), calculation and spelling isn't affected (rote learning = 100), applied problems (only affected if severe = 100), passage comp and writing samples (spared unless severe depression = 95) Composites - probably low 90s, oral language (bigger dip because of effort and memory), written expression might have a slight dip due to fluency Visual- Spatial fxn - Bender gestalt or VMI- 100 and Rey O - 100 (both tests spared in depression) - RayO Delay recall score might be poorer but recognition is spared WMS: visual reproduction = 85 (similar to ReyO), logical = 85 (remembering details of story is hard), Paired Associates = 100 (you always give them a cue so this isn't as affected), LNS = 80 (affected because of WM) WMS delayed: visual = 90 (norms are more forgiving here), logical = 90, PA = 100 - recognition should all be fine CVLT (z scores): Trial 1 = -1, Trial 5 = -0.5 (do learn over trials but slower), List B = -1, ShortDelayFreeRec = -0.5, SDCueR = 0, LongDFR = -1, LDCR = 0, Recognition = 0 Psychosensory = okay Psychomotor = tapping slow, strength ok Grooved pegboard = 80 (slow) BDI = moderate (on higher side) depression Executive Fxn: Trails A: 88 (sensitive to processing speed & attention to detail) Trails B: 78 (extra effort - WM & shift required) WSCT perseverative errors - 100, Categories ach = 95, Failure to MMS = 80 (attention issues) Stroop color & word = 85 (timed measure), interference = 90 (takes more effort because novel rather than inhibition issues)

H-R: Interpretation: Neuropsychological Deficit Scale

Uses level of performance, pathgnomic signs, and laterality Uses cut-off scores for motor, sensory-perception, attention/concentration, memory, visual-spatial, reasoning, and articulation Normed by age Attention/concentration and memory are a little more difficult to look at Uses information to interpret or frame the results of cognitive, academic, and personality measures Put them in perspective relative to the brain functioning Problems Still pretty subjective, primarily in the last step for interpretation of all other testing results So you need a lot of training Brain development is such a two-way street - genes and environment Brain formation is between ages 5-24 depending on the particular area So using a one-way interpretation may not allow for the other directionality e.g., academic affecting attention/concentration Does not count for the interaction for brain development which is not as helpful for children who are still developing with interactions between genes and environment Measures are not developed for good sensitivity and specificity (more global) and you are trying to tease that out using this approach - using them not well for what they are used for

Children: Personality Disorders

Vague symptoms (headaches, fuzzy thinking, mental slowing, blackouts, memory loss, word retrieval problems) Possible etiologies: MS, stress, vascular Dementia, psychiatric problems Ways to determine etiology: Signs inconsistent with brain damage Signs of a neurological disorder - lateralized deficits (sensorimotor on right, not left - more likely neurologic); should only get lateralization effects below eyes - above eyes- maybe not neurologically based Signs of neurosis/hysteria - variable symptoms tend to be psychiatric (change with suggestion definitely) - MS variable symptoms across day or parts of the day but not within that time

Factors Affecting Test Performance: Sensory-Motor

Vision (elderly, TBI; screen; glasses; testing) Hearing (elderly; stigma- resistant to hearing testing or telling you that they cant hear you well; screen; hearing aids; testing) One-sided effects (CNS damage, PNS damage; screen (if had neurologic insult); testing) - suppressions tests, could have homomous heminopsia - colored snow (form is hard to make out) SS/Motor (Central nervous system, peripheral nervous system, Neurodevelopmental disorders, elderly; screen; testing) - suppressions testing (CNS) and unilateral testing (PNS) - motor - any manipulation tasks can be affected - arthritis in elderly Implications (what measures, domain affected; document) - qualitatively describe performance rather than using norms if severely deviated from norms - consider role of adaptations in interpretation and document any adaptations and potential effects of interpretation

ADHD Case

WISC-IV Sim 8 BD 8 DS 7 PC 10 V 10 CD 7 LNS 8 MR 9 Info 11 Pic Com 10 Arith 8 Canc 7 SIm - higher level of abstract verbal reasoning (frontal lobe) Verbal working memory - DS Forward is sometimes affected due to focused attention piece because it seems so easy and they zone in and out LNS - seems a bit more challenging so they do a little bit better Arith - same as LNS Vocab, Comp, Info - literal langauge is ifne BD - mild right parietal or right frontal problems which affects output of constructional praxis PS - neurodevelopmental disorders in general for SS and CD MR and Pic Completion - not a lot of right frontal or frontal contribution Cancellation - selective attention WJ-III Basic R 101 Read Comp 90 Calc 90 App Prob 87 Basic Wr 88 Writ Exp 89 Dips due to not looking at the signs Some issues with not paying attention to everything reading App Problsm - extraneous information, WM and figuring out all of the details to come up with the right operation Editing - not paying attention to detail well EF NEPSY Arrows - 80 Right frontal affected in ADHD Hooper VOT - 97 This kid is having more problem with output, so most of these scores will be okay TVPS Discrim - 100 Cue them to look at all of the answer choices before they respond TVPS Form Constancy - 99 TVPS Visual Closure - 90 More sensitive to spatial perception CMS Immediate or STM Dots - 85 (spatial input and output) Faces - 100 (very few spatial demands, just attention) Stories - 95 (same) WP - 105 (same as long as attending) Delayed recall - similar to immediate (as long as attending) CVLT Trail 1 = -1 (so many items and might have occasional little attention lapses) Trial 5 - 0 List B - -1.5 SDFR - -0.5 SDCR - 0 LDFR and LDCR - 0 Recognition hits - 0 Rey - O Copy - 85 (similar to ASD, decrased praxis and planning) Immediate R - reduced encoding Delayed recall - 80 Recog - 100 (mild praxis and planning, so usually do fine with retrieval) Psychomotor and psychosensory WNL Trails A - 89; Trails B - 77 A processing speed B for shift or working memory problems TPT Total - 88 (PS and planning) Memory - 100 Localization - 90 Language BNT - 109 COWAT - 85 (fluency, affected verbally and nonverbally) SEntence REp - 95 (as long as attending) Token test - 90 (inhibition) WCST (shift) Total categories - 85 (failure to maintain set, change set for a brain fart and forget how they are supposed to be sorting) Perseveration Responses - 85 Stroop - color and word (88); Interference (85) Processing speed, cognitive interference TOVA Omissions - 85 (usually isnt sensitive enough in adults but is fine to pick up in kids) Commissions - 82 (If HI or Combined Types) RT - 89 (processing speed) RT Variability - 77 (inattention) Grooved pegboard - 95 Might get mild problems depending on the kiddo DTVMI - 85 (praxis and planning)

Anne-Lise Christensen

Wanted to take Luria's approach and bring it into the United States Made his most common tests into a battery Was flexible with the battery Some tasks still used Frontal patients - connect cursive letters m and n Go No-Go - If I do one thing you go and if I do another thing you don't go Conflict tests - if I tap once, you tap twice. If I tap twice, you tap once

Expressive Language

Wernicke's area Broca's area Include secondary motor sequences for speech Stores motor programs for speaking words Complex sequences you will be seeing Primary motor facial area to activate in a parituclar order Cranial nerves in the face Speaking

Interview/Record Review information for a NP Evaluation

Why is it important? - puts testing in context Record review - what records do you need? Previous testing: psych, cog, sensory/motor, SLP, OT, PT (motor), medical records (neurology notes, EEG, ERP, imaging, radiology) - head injury (ER note, admission note, discharge note), doctors notes (if chronic hx), school records (all the way through to get a trajectory), criminal records, psychiatric records, police records if accident, Need for multiple informants Components of an interview Background/confidentiality Demographic data and orientation check Presenting problem Medical hx and current status Psychiatric hx Educational hx - kids every year - adults, at least high school (grades by subject) - see D2L for studying reference Birth/dev. Hx - pregnacy/prenatal, birth/perinatal, early development - see D2L for studying reference - can use these to help with contributing factors to problems - TBI doesn't happen in a vacuum - ease of conception, miscarriages?, exposure to toxins, what did you take if you were sick, especially post implantation (1st trimester - pervasive all or nothing - problems may be linked with ID), (2nd trimester - migration, insults lead to more subtle problems ADHD/LD), (3rd trimester -differentiation, insults lead to minimal effects in learning or something) - significant traumatic events or stressors can affect the baby Examples: SLD - reading - migration errors - extra bumps or missing pieces (more severe problems reading) Birth: type of birth, breach presentation association with ADHD, stressors during pregnancy (heart rate, oxygen, etc), born blue or purple lips is concerning Early development: infections, blow to head, high fevers (104 or more) - how long lasted and how managed? Vocational hx for adults (pre/post injury) Family background Social hx, environmental/situational factors Premorbid hx of functioning vs post for each area above Current situation - living factors & what supports they have in environment? Legal hx - any criminal activity to determine premorbid functioning? Or records from car accident

Reading - Brain Process

Written word Visual - Area 17 for primary visual area Right hemisphere - left visual space and vice versa Secondary, beginning perception -18 and 19 Recognizes that this is a word Fusiform gyrus Visual lexicon - recognizing words that you have learned Within visual stream If the word is there Semantic networks for that word, one ofr each word Hearing - Wernicke's Reading - Occipital-temporal Read the word If the word is not there Area 39 - angular gyrus (left - angular) - inferior parietal area on the left Sound-letter mashing Sounding out words that you do not recognize immediately Left parian sylvian fisure for further processing Segement and blend words Sends the word to Wernick's area Wernicke's sends to the semantic network Read the word and now have the word in your brain

Halstead-Reitan: General Uses of the Battery

Yes/No questions Severity Lateralization Localization

H-R: Interpretation: Pathognomnic Signs

any substantial neurologic signs (hemiplegia (unilateral paralysis) on sensory motor worse in right or left; aphasia - receptive or expressive language problems or articulation - make sure this is age appropriate or not - 9 and younger; problems with vision besides acuity - homonymous hemianopsia: loss of half the visual field on the same side in both eyes) Problems There is a range of dominance with handedness Norms are strictly left vs. Right handed but you don't know the percentage Will affect how well this generalizes to other people Miss more subtle sensory-motor problems

Relationship between neurological and psychiatric

brain basis: bidirectional; MS, dementia do neurological symptoms go above and beyond psychiatric alone? Look at time course when making conclusions because problems adjusting can be caused by neurological problems but problems adjusting can also cause neuro problems to worsen as well MS can look psychiatric (screen anyway with variable presentation onset 30s-40s) Early vascular dementia can look psychiatric too (around 50s)

Flexible vs. Fixed

Fixed (15%) Fully flexible (15%) Tests are designed based on the client presentation and presenting concerns Fixed flexible (typical; 70%) Core and then add in in a flexible fashion By diagnosis By presenting problem Standard core Core add to How you decide to add to it will progress through your evaluation Core based on Referral question Diagnosis Everybody Age # in it varies

H-R Child Interpretation Approaches

Level of Performance Pathognomonic Signs Patterns of Performance Comparison of R vs. L Sides Multiple Inferential Approach Rules Approach Neuropsychological Deficit Scale Biobehavioral Approach Pragmatic Approach

Holism vs. Localization (Definition, Goals, and Problems)

1. Localization: neuropsychological functions are subserved by separate, distinct parts of the brain Goal: localize function Problems: individual, different, networks No absolute because the brain does not work in that absolute of a fashion 2. Holism: brain works together to produce fx (NO localization; mass action, equipotential) Location no matter - size of damage loss Goal: presence or absence of dysfunction Network to the extreme - all the brain works together to execute the functions that you have 3. We want something in the middle

Consciousness

Level that a person is receptive to their environment or to their stimulation Coma - Stupor - Somnolence - Drowsiness - Disoriented - Fully-alert Effects - metabolism, circadian rhythm, fatigue level Reticular activating system in the brain stem - most related to consiousness and arousal as an index of severity

Boston Process Approach: HL & EC

Localizaiton > Holism Cognitivism - theory dirven Ability to address common referral questions depends on the measures tha tyou use, can likely answer answer a lot of them!

More Language Stuff

Look at copied pictures in notes

Luria-Nebraska: Third Edition

(ages 5-adult) - attempted to address criticisms Description Start; ended with 27 scales and 1000 items Still takes under 2.5 hours End product is not validated Administration: pick and choose You need to use the whole test to answer yes/no Qualitative scales were kept Goals: Underlying problems Impairment in daily life - how affecting functioning - no ecological validity data to support Diagnosis Problems Norms - lack sensitivity Number of items on scales Psychometrics Little outside research support

Common Referral Questions

1. Determine Diagnosis [DSM-5, tough differentials, medical diagnoses] 2. Cognitive strengths and weaknesses (current functioning in areas, cognitive, sensory, motor, etc.) 3. Describe and monitor changes in functioning (TBI, dementia, NDDs, epilepsy surgery, recovery period, trajectory of healing, rate of decline, changes in manifestation over time) 4. Why is this person acting so odd? 5. Is there a biological etiology or something else? (localized to a particular cause or area) 6. Prognosis/potential 7. Treatment planning recommendations 8. Competency decisions 9. Guidelines for caregivers or treatment teams 10. Placement decisions (adult vs. child) 11. Discharge planning (placement, services)

Empiricism vs. Cognitivism

1. Empiricism: sensitivity to damage primary; test content & meaning are secondary (strengths/weaknesses) Is this brain damage or not? Patients or not patients? Not theoretically based (e.g., MMPI) - psychiatric patients vs. Not psychiatric patients (which discriminate) Better at identifying brain damage 2. Cognitivism: test constructed to measure certain skills; determining damage is secondary Better at identifying strengths and weaknesses than brain damage

Common uses of neuropsych assessments

1. Identifying and describing changes in functioning 2. Determining biological correlates 3. Determining potential etiologies 4. Assessing changes over time 5. Offering treatment guidelines to a patient's team 6. Determining competency

Steps for NP Evaluation

1. Intake/Referral question review 2. Interview/gathering information/behavior obs 3. Test Selection/Administration 4. Conceptualization 5. Report Writing - quality/recommendations 6. Feedback/Consultation - client, consultation with referral source 7. Recording Keeping (HIPAA)

H-R: Interpretation: Biobehavioral Approach

4 factors differentiating child NP assessments from others' Assesses four types of variables: symptoms, test data, environment, and bio/genetic Consider how the 4 above interact to impact daily life and performance on tests St/wk on testing and how they influence sx presentation and daily life problems (ecological validity) Interpretation: scores affected by brain integrity and environmental contributions Biological imposes limits on behavior and cognitive gains/fx (one-way direction again) Problems The one-way reaction rather than bio-environment interaction BUT you do have a window that is set by your genes and your environment determines where you fall in that window (so, some truth) Biology imposes thresholds Doesn't give enough credit to clinical psychologists without the neuro speciality

ASD Level II Case

8-0 WISC-IV Sim 4 BD 5 DS 7 PC 7 Voc 4 Cd 4 LNS 5 MR 7 Comp 3 SS 5 Info 6 Pic Comp 8 Arith 3 Canc 7 VC = 64; PR = 82; WM = 80; PS = 71 Missed these notes because my computer kept kicking me off WJ-III Basic R 93 Read Comp 70 Cal 82 App Prob 70 Bas W 83 Writ Exp 65 Hyperlexia - can read well for basic reading and spelling Reading comprehension - level of oral langauge Cal - higher level math will take even more of a dive in middle school and high school App - language and gestalt Basic writing - spelling is relatively presevered Editing - have to have good syntax knowledge Sequencing Written expression - figure out what the sentence is saying and the best way to finish it - not so good, might even get like a 55 on that one related to the same problems EF NEPSY - 80 Dose-response, frontal problems Hooper VOT - 85 Greater affects related to spatial processing TVPS Discrim - 100 (preserved if they understand what they need to do) TVPS Form Constancy - 89 Highest levels where you need more of gestalt and visual-spatial abilities TVPS Visual Closure - 75 Gestalt required most Children's Memory Scale (CMS) - dose response Immediate/STM Dots - 80 Faces - 60 Stories - 75 (literal language) WP - 85 Delayed recall - similar to initial encoding Dots - 70; Faces - 55; Stories - 60; WP - 80 Retrieval hippocampul areas starting to kick in CVLT (z scores) Trial 1 - -2 (linguistic demands) Trial 5 - -1 (can learn but still don't move up to normal range) List B - 3 (frontal proactive interference affects) SDFR (free recall) - -2 (retroactive interference) SDCR (cued) - -1.5 (some improvement with cues) LDFR & LDCR - -2, -1.5 Recognition hits - -1 Rey-O Copy - 68 *decreased praxis and planning, dose response) ImmR - reduced encoding as before Delayed recall - 58 Recognition - 80 (not having to retrieve it) Psychomotor exam Psychosensory exam Sensitive to tactile/touch so won't like it Trails A - 73; Trails B - 58 TPT Total time - 67 Frontal - need planning Spatial ?? Memory - 80 Localization - 65 Planning and spatial Dose response for everything on this second slide Language (strcutural langauge largely spared) Boston Naming Test - Word Retrieval - 85 Control Oral Word Association Test - 70 Rapidly accessing and retrieving information Frontal and language contributions Sentence Repetition - 80 Token test - 73 Sentence level comprehension Structural langauge demands WCST Perseverations (shift) - 63 Total Categories achieved - 75 Affected by the number of perseverations Stroop Color and Word - 75 Interference - 88 TOVA - sustained attention Omissions - 90 Commissions - 100 RT - 77 RT Variability - 70 (brief lapses of attention) Grooved Pegboard - 78; DTVMI - 72 (praxis and planning) BRIEF Reduced cognitive and emotional regulation

Factors Affecting Test Performance: Severe Impairment

Can use tests for lower age groups Can use dementia tests (IQ tests specific for those with dementia) Mental status exams with norms Aphasia screening test (not good for most language impairment) but this would be good for severely impaired patients (global aphasias)

Luria-Nebraska: 11 Clinical Scales

none are homogenous all of the way through Motor - both fine and gross Rhythm Tactile Visual - identification, perception, spatial perception and rotation (where) Receptive Expressive Writing Reading Arithmetic Memory IQ

Child Psychiatric

Brain damage and psychiatric functioning - dose-response just like adults Rutter study: Kids with a known psychiatric dx of some kind: No hx of neurologic damage (no brain damage) - 6-7% would look impaired (brain damage); 12% of the medical disorder population; 34% neurological history Risk factors of the study: epilepsy or widespread damage was a big contributor of the 34% Soft signs: more common in: young boys, or younger kids in general, in those with Lower IQ, those with LD, those with psychiatric dxs, emotional immaturity, inattention & impulsivity Symptoms: facial abnormality, dysdiado kinesis (making hands do different things at once), graph (sensory testing), unusual movements (tongue protrusions, overflow with movements, excessive movements, etc. - more that you have, more likely neuro over and beyond psychiatric (remember these are very subjective so read literature and think of developmental effects) Brain dysfunction in psychological disorders Kids hospitalized for psych reasons: 60% do poorly on neuropsych testing without neurologic insults; (25% have clear brain damage) Associated with problems with IQ, academic performance, psych history When rule out neuro basis: same except IQ (neuropsych testing is correlated with academic and psych history) NP impairment was associated with degree of ventricle size & CT density (fuzzy areas on CT) Another study NP & Behavior problems in young boys Regardless of IQ, SES, & specific history of brain insult - NP testing is correlated with amount of behavior problems Contributing factors: NDD, environment, test behavior Neuropsych tests index of increased psych risk? NP better predictor of academic achievement than IQ alone, sex, age, & severity of behavioral problems in hospitalized patients What about in controls? IQ & SES can predict academic achievement

Factors Affecting Test Performance: Biological Sex

Brains: asymmetry (males tend to have more asymmetry), size (taller people may have bigger brains) Hormones (development, current function) - testosterone contributes increased lateralization and females have more connectivity, cognitive function is influenced by hormones Lateral insult effects (e.g., language vs visual-spatial) - more pronounced effects in men because of the likelihood of more lateralization Cognitive Debated; small effect size; often no need different norms Men vs women - men (spatially) & women: (linguistically) & perceptual motor tasks (visual motor integration) Math - variability across tasks - spatial/applied component types = men & calculation = women (grade school) because of its linguistic components Emotional - differences are more significant here rather than cognitive differences - use gender norms

Conduct Disorder Case

CA = 8-0 WISC-IV Sim 7 BD 9 DS 10 PCon 8 Vocab 6 CD 8 LNS 9 MR 9 Comp 4 SS 9 Info 7 PicComp 10 Arith 4 Canc 10 Langauge performance due to verbal weaknesses and poor social functioning just because they want to shock you Arithmetic - academic and high linguistic demands Not a lot of spatial problems Picture concepts - little dip because most people verbally mediate this task and verbal functioning is lower Processing speed - general brain integrity might result in a tiny dip WJ-III Basic R 95 ReadComp 83 Cal 88 AppProb 79 BasicWr 89 WritExp 80 Will be related to verbal demands and whether or not education is valued at home EF NEPSY arrows - 95 Hooper VOT - 100 TVPS Discrim - 100 TVPS Form Constancy - 99 TVPS Visual Closure - 98 CMS Immediate/STM Dots - 95 Faces - 95 Stories - 85 (linguistic) WP - 95 Delayed - similar to initial encoding CVLT - linguistic demands, not as much frontal contribution All -1 to -1.5 Rey-O Copy - 98 Immed, Delayed, Recog - ok, 95, 99 Psychomotor and psychoensory WNL Trails A and B - 95, 93 TPT Langauge BNT - 85 WCST Stroope Some langauge TOVA Omissions - 98 Commissions - 80 (behavioral regulation) RT - 95 RT variability - 97 Grooved Pegboard - 99 DTVMI -0 97 Poor moeiotnal and behavioral regulation on the BRIEF

Autism Level 1 Case

CA = 8-0 WISC-IV Similarities 9 Block Design 7 DS 10 PC 9 Vocab 10 Coding 7 LNS 8 MR 8 Comp 7 SS 8 Info 11 Pic Com 10 Arith 7 Canc 9 Some mild difficulties in LNS > DS because it is letters Arith - higher WM load Comp - social reasoning component, but not too low because of practical knowledge BD - constructional praxis and gestalt PC - don't have to get to the bigger picture until the end MR - gestalt at the end but a little earlier than PC PS - frontal WJ-III Basic R 101 Reading Comp 90 Calc 99 App Pro 88 Bas W 98 WrEx 90 Working memory demands on Reading Comp Calc - no problems because younger and don't struggle with higher order functioning - more problems will pop up in HS Applied Problems - gestalt, central coherence, figuring out what to do (EF) TOWL - 80 Pragmatics coming into play NEPSY Arrows - 90 Measures sensitive to right pre-frontal functioning relating to frontal eye fields Bilateral but mostly right EF might bring this score down just slightly Hooper VOT - 92 Puzzle pieces on a page in a little box and you put them together in your mind and say what the object is More challenging items - problems with gestalt TVPS Discrim - 100 Form discrimination TVPS Form Constancy - 99 See same shape getting a little smaller, bigger, or turned Not a lot of spatial processing or gestalt happening so doesn't present a lot of problems TVPS Visual Closure - 85 Connect the dots in your mind Picture in your mind if you connected the dots, what would this shape be - select the correct shape at the bottom Takes a good gestalt because there are some tricky foils in there Children's Memory Scale (CMS) Immediate/STM Dots - 85 You have a small grid with 6-8 boxes that have circles inside Turn the page and they put chips in the boxes that had the circles Three trials to do this Measures of spatial memory - gestalt problems might result in a mild dip Faces - 75 Differential affect for ASD Most substantial lower score here Stories - 95 Language - some retrieval weaknesses might pop up WP - 105 Retrieval minimized by the cues that you are giving them Delayed recall - similar to initial encoding CVLT (z scores) Trial 1 - 0 (do fine, literal language spared) Trial 5 - 0 (still doing fine) List B - -0.5 (some due to frontal functioning) SDFR (free recall) - 0 (tends to be okay, might get as low as .5) SDCR (cued) - 0 LDFR & LDCR - 0 (usually fine) Recognition hits - 0 Semantic clustering (-1) Ser Rey-O Copy - 80 (decreased praxis and planning) ImmR - similar to copy (reduced encoding) or a little lower Delayed recall - 70 Recognition - 90 (not having to retrieve it) Psychomotor exam Psychosensory exam Sensitive to tactile/touch so won't like it Trails A - 89; Trails B - 74 (Shift component) TPT Total time - 80 Frontal - need planning Spatial ?? Memory - 100 Localization - 80 Planning and spatial Language (strcutural langauge largely spared) Boston Naming Test - Word Retrieval - 105 Control Oral Word Association Test - 85 Rapidly accessing and retrieving information Sentence Repetition - 99 Token test - 95 Sentence level comprehension Categories - would likely do great (what items go in the categories) More laterally temporally driven rather than medial WCST Perseverations (shift) - 78 Total Categories achieved - 85 Affected by the number of perseverations Stroop Color and Word - 90 Interference - 97 TOVA - sustained attention Omissions - 95 Commissions - 100 RT - 89 RT Variability - 86 (brief lapses of attention) Grooved Pegboard - 90; DTVMI - 85 Laksdfj BRIEF Reduced cognitive and emotional regulation

Autism

Developmental opposed to acquired and affected by environment but also genetic contributions Strongest biological/genetic basis out of NDDs - leading to brain abnormalities (more symptoms, likely more abnormalities) Soft signs - 25% seizures - signs of minimal brain dysfunction (called this before) - seizures don't cause autism - later development in adolescence typically Neuroimaging: abnormalities in frontal, limbic system (amygdala & hippocampus), cerebellum (implicated in all NDDs), basal ganglia EEG: 40-50% abnormalities (more slow wave Beta activity and bilateral - engaging with environment) ERP: laterality for both auditory processing worse than visual - especially in higher level processing Neuropsych testing: Problems with Language, sequential processing, motor imitation (dose response relationship and mostly secondary motor areas - sequencing), IQ, and processing speed Language deficits: prosody, pragmatics, struct (OK phonics) Executive deficits (common in all NDDs): shift, all; (behavior inhibition is okay) Visual-spatial (gestalt isn't as good because stuck in details): problems with memory recall and complex memory, differential problems processing and remembering faces due to "social" nature of stimuli Achievement: reading comp, writing (both due to language impairment usually), math reasoning (also could be due to language with word problems, but also spatial relationships - geometry due to problems with getting gestalt) - basic reading and spelling usually spared.

Anxiety Effects on Testing

Effects on testing (inverted U) Attention, processing speed: not as bad as depression though Secondary manifestation (reaction to neurological problem) or direct result of neurological problem? Inhibit new learning? - due to inattention and processing well Panic disorder: right hippocampus and hormones OCD: basal ganglia, orbital frontal cortex, anterior cingulate, thalamus PTSD: HPA & limbic damage (cortical), frontal lobes Reciprocal hippocampus (decreased ability to handle stress and then stress yields further decrease) Problems with Attention, constructional praxis, executive functioning, proactive interference, could have problems with allocentric space too

Halstead-Reitan Background

Empirically driven (similar to the MMPI; NOT cog) Original conception was holism, later edition more localized

Neuropsych test perofmrance (Austin notes)

Endogenous (brain damage) vs reactive (psychological) Axis I symptoms: anxiety/depression - effects: attention (focused/sustained), processing speed, working memory - these can be due to anxiety/depression/stress/mood rather than neurological (typically dose response relationship - especially depression) mild anxiety won't affect testing or would improve performance (severe anxiety can affect testing) Lateralization (neurological contributing factor), # of soft signs (more signs = more likely its neurologic), consistent pattern on testing that fits with a neurologic etiology, history (consistency also should fit for neurologic) Signs of neurological etiology (not all psych) Neurologic conditions more likely to develop following something physical - injury, illness, O2 deprivation, etc. Psychiatric factors from emotional/situational stress

Executive Functioning vs. Intelligence/Cognition

Executive deficits and functioning Regulation Cognitive Behavioral Emotional regulation Executive vs. Cognitive OR Frontal vs. Posterior EF - whether, how, when Will they do the task How - problem-solving, planning When - can they prioritize it - planning - temporal aspect of planning IQ - how much, what How much knowledge to they have What do they know Extent of knowledge, memory Frontal (EF) vs. Posterior (IQ) Role of posterior vs. Frontal deficits play in daily life Q tests: overview, problems Not great for looking at progress, gains, improvements in functioning (rehabilitation centers) Not sensitive to therapy or new learning More dependent on posterior brain regions that frontal - you are their frontal lobe on IQ measures - so much more a measure of cognitive and posterior

Test Selection Consideration Factors

Factors to consider when selecting tests? Client characteristics - norms should be appropriate Good measures & good norms Ethnocultural considerations Which ones have you seen

Conceptualization during an NP Eval

Integration of data (4 pillars, premorbid, ethnocultural) Qualitative? Importance of good norms Determining weaknesses/impairment (1SD, 2+) Is this typical variability? Idiographic (1+ SD in pattern) - if saying due to a lesion, may want it to be 1 SD lower than their own typical mean and variability - but if not tied to a lesion, you can just report the regular relative S/W OR decline from prior testing Comparing 2+ tests directly (familywise error) - more direct comparisons you make, more likely from chance (familywise error) Compare to IQ (how much affected by dx?) - dx can impact IQ Caveats? Signs: One mechanism to assess for impairment Common signs of moderate + damage Perseveration/reduced mental flexibility Concreteness/poor adaptability - 1 pt answers rather than 2 in IQ (mostly temporal/frontal damage) Catastrophic reactions - frontal/temporal/parietal lesions - can go with size of lesion One-sided deficits - hemiplasia or homomonous heminopsia Need more than a few soft signs (Lezak table of list) Common interpretation errors: Overgeneralizing - pattern of performance = dx - too strong of a generalization in either direction False negative - absence of low scores doesn't mean they don't have problems, you may not have measured the problem or above average people might now be average but that still indicates problems Confirmatory bias - clinic for a certain disorder - many people are diagnosed! Hmm? Over/under-interpretation - specific cog ability or measuring deficits Underutilization of base rates Caveats (patterns, premorbid, individual differences)

Perception

Integration of sensory registration into a meaningful gestalt by way of active processing and filtering Dorsal stream - Egocentric space - where is it in relation to me Reach Frontal eye fields Ventral - Form Recognition - that's a circle, that's a square Agnosia - lack of recognition despite intact sensory functioning Prosopagnosia - problem recognizing faces Familiar vs unfamiliar Right (gestalt of the face - problem with familiar) vs left contributions (missing details of the face - may have problems with happy/sad rather than who they are and with unfamiliar faces) Along ventral stream - complicated on bottom of brain - vision though: (apperceptive, associative, anomia) Calcurn fissure - bilateral is how primary vision works - specialization in perception (visual info is sent along ventral stream to get to perception integrated across hemispheres) Apperceptive agnosia - no form at all, no early perception (visual discrimination would be affected) Associative agnosia - more downstream additional processing, have early processing but secondary processing is an issue (can distinguish between visual items/visual discrimination but can't recognize it with meaning - a ball, block, what the thing is) - middle of the stream Anomia - can't label it - linking to semantic meaning

Attention

Interrelated processes, correlated set of skills Receptivity and responsivity to internal and external stimuli when fully alert Automatic - rapid orientation to auditory, pain, etc. (bottom-up; baseball thrown at you) Voluntary - choosing to orient your attention or focus Tonic - sustained over time Phasic - shifting attention in a flexible manner Responsivity - sensory, semantic stimulation (more meaningful stimuli) Limited capacity - span, two attention-demanding tasks (dual) Sensitive to arousal, mood, PS, lesion/insult, pain, and fatigue

Boston Process Approach: Weaknesses

Is rather subjective Challenging to norm qualitative information/data Reliability is not that great (unless well trained) Validity is not that great (unless well trained) Some measures do not have great norms Not much information on reliability and validity Takes a LOT of exposure to patients and clients - need to have an internalized sense of norms for the qualitative work Easy to potentially miss things Short and in/out Based just on interview Limited information on strengths Tremendous amount of training Signs of pathology (e.g., articulation) Not great for research Hard to do systmatically and with a client-centered approach Really have to keep up with the literature to keep with new presentations, literature, and diagnoses

Child: Role of Brain Development

Kids/teens brain still developing Young kids weeks/months can make a huge difference due to rapid changes in development Good norms (fine-tuned to development) Take into account in acquired insult - manifest differently Timing of insult/type of insult - interactionary Severe TBI/global: young kid worse verbal & sensorimotor than older kid: worse outcome Focal: some plasticity, bilateral < unilateral - kids heal more than adults when it is a smaller lesion and when it is unilateral (small lesion on one part of the brain) <1 year (anywhere): FSIQ: poor outcome Brain Development Using Luria Perspective: 1 degree to 2 degree to 3 degree Before birth, 1 degree (primary) well developed, early childhood 2 (secondary) well developed, 3 degree (tertiary) posterior areas, anterior - young adulthood (all the way to young 30s before fully mature Gray & white matter Gray: peak at 6-7 then pruning into young adulthood (giving efficiency because of pruning) Development in this order: Dorsal parietal (egocentric space) & sensory motor, then lateral, caudal, & rostral White matter: linear increase into young adulthood Ability development mirrors brain development (reciprocal though) Motor Development 3 months - reach, 4 months- head/neck, 11 months - pincer, 12 months - walk, 2 stairs, 3 trike, 5-6 bike, 5 most Sensory development Birth: taste, survival odors, phonemes, basic SS (pressure, pain, fair temp), fuzzy vision 2ish years: good visual acuity; basic sentences 4ish years: advanced auditory/localization perception (visual takes longer to develop) Language development Pre-birth through 5 years Lateralization by 5 years Left lesion pre-5 (right temporal will kick in but at a cost to right temporal functions; post 5 years (less plastic the temporal areas become) Visual-spatial development Most perception by 10ish unless PF comp Early lesion - will improve but doesn't reach normal Right damage - left does not take over well Left damage - right help left function but at a cost to its own Memory Development Long term memory - recognition easiest so develops first - 4 months old, Recall with cues 1 yr; adolescence Procedural: plateau middle childhood - follows cerebellum Short term memory 2 yrs - 2 digits, 5 yrs - 4 digits, 9 yrs - 6, adults 7 - 4 chunks All milestones with median values but lots of individual differences Role of prematurity Correct for this for first 2 years Premies increased risk for developmental diagnosis, academic problems, inattention, language, respiratory issues, cerebral palsy, retinopathy < 3.5ish lbs > 3.5ish lbs Role of environment More varied/stimulating environment, better outcome Problems with lesion studies: adults Lateral, localization effects differ in kids Confounding factors affecting scores Won't know effect until brain regions & network matures Diff sources same test profile Individual differences with same lesion - interaction lesion, genes, development, environment Predictions Be careful (see top bullet) Resulting behavioral change across development Effects vary with age at insult Need careful premorbid & environmental review

Brain Dysfunction in Psych Disorders

Relationship between brain damage/neuro and psychopathology Camps: Brain damage leads to both cognitive and emotional dysfunction/deficits Psych symptoms secondary/reaction (coping issue or poor family, etc.) Psych due to interaction of bio, learned/environment & maturation NP deficits put one at risk for poor adjustment/coping & poor academics; how this manifests depends on environment Internalizing vs externalizing symptoms Some say brain damage more tied to internal symptoms long term On NP testing internalizing only (mild effects on neuropsych testing), externalizing only (moderate effects), both problems (most severe effects) Is there a neurodevelopmental origin to psych disorders? Organic vs functional controversy - same findings apply from adults to kids (schizophrenia, bipolar, chronic dep are strong neurologic/genetic/endogenous) and can be made worse from environmental contributions Now look at continuous perspective - how much of it is genetic versus environment? How do these things interact? Relative contributions Frontal lobes Development of psychopathology: frontal symptom risk factors Comorbidity: internalizing & ASD or LD, externalizing & ADHD - probably due to certain frontal networks at play (more inhibited vs less inhibited) Left vs right hemispheres L: more reactive emotionally in young kids (R dampens the reactivity of the L later in development 8-10 yrs old normal development) L lesions - dysphoric depression & catastrophic reactions to symptoms R lesions - euphoria or indifferent - R dysfunction: general depression (dysphoria and anhedonia)

Mental Operations: Size/Location/Qualitative

Role of lesion size and location Primary area - lesion location matters A LOT Secondary - size is more important than location Tertiary - he believed it was all size Qualitative All of Luria's measures to look at mental operations were qualitative Wide range of qualitative tasks Patient-specific: If the patient has a problem, he would develop tests Difficult to learn; takes much skills and practice No psychometrics

Posterior Networks

Sensation and Perception

Factors Affecting Test Performance

Sensory-Motor Severe Impairment Ethnocultural Biological Sex Psychiatric Malingering Attention/Memory Pain, Fatigue Variability Litigation

H-R: Interpretation: Comparison of R vs. L Sides

Sensory-Motor Approach Getting at laterality of brain functioning Most focused on sensory-motor but not always limited to this Is the lesion coming from this side or the left side (more specific that pathognomic signs)

D'Amato's 8 Domains of Functioning

Sensory/Perception Motor IQ/Cognitive Attention/Learning/Processing Communication/Language Academics/Occupational Personality/Behavior Environmental/Situational

Boston Process Approach: Strengths

Shorter approach Watching all qualitative and quantitative Really adaptable to the patient and to the referral question Helpful if you have a good knowledge of what the deficits should look like on during testing Skilled users can localize lesions with this approach Can get a pretty good description of the problem using the qual/quant information Better education parent, client, teachers Make good recommendations

Unipolar Depression

Soft signs - more likely to have unipolar depression compared to those without soft signs Neurologic diagnoses - high risk for internalizing problems Right hemisphere dysfunction - motor speed, processing speed, and attention Symptoms improve with medication Common neuropsych deficts - attention, processing speed, effortful tasks Often takes more depression in kids/teens than adults Hypothalamus Pituitary Adrenal axis - especially with chronic stress sensitizes HPA axis to future stressors Neuroimaging in chronic depression - reduction in bilateral amygdala volume (emotional negative reactivity), frontal atypicality and white matter reductions EEG in teens: increased variance right hemisphere (paranoid increase variability in left hemisphere; control)

Apraxia: Facial

Speech - affects sequencing of all Apraxia - acquired speech Dyspraxia - never learned to talk Dysarhria - ability to make specific sounds related to primary motor of the tongue, cheecks, and/or lips Cerebeller damage

Activity Rate

Speed of performing mental and motor activities Mental - processing speed Motor - motor speed Also referred to as reaction or response time Mass action - damage in a secondary or tertiary area will affect processing speed White matter damage affects processing speed as well

H-R Approach Strengths

Standard battery is fixed and reliable Good specificity rate 70-80% accuracy for brain damage vs. No brain damage Very accturial approach - do not need as many behavioral observations You can have a technician give it for you Valid for brain damage vs. Not Even mild and diffuse cases (TBI, carbon monoxide poisoning) Norms - all measures are normed on the same individuals Good yes/no (all) & severity of damage (Average Impairment rating)

Children: Memory Complaints

most common overlapping symptom between neuro and psychiatric Fugue state (substance induced or extreme stress induced usually); PTSD Retrograde amnesia (recent info affected - no recollection of brain injury and a little before the injury (could go back 2 years if severe) - neurological); Post Traumatic Amnesia (PTA) /anterograde - problems forming continuous memories - forget new info Depression: attention/encoding/Working Memory Signs of neurologic problems: Retrograde: recent memory effected (not remote memory) Anterograde: Episodic memory effected (not semantic/skill) Inconsistent pattern or erratic symptoms (not usually neurological)