forensic neuropsychological evaluations: issues and controversies

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Forensic Neuropsychological Evaluations: Issues and Controversies L. Randolph Waid, Ph.D. Clinical Psychologist/Neuropsychologist Clinical Associate Professor in Psychiatry and Neurology Medical University of South Carolina, Charleston, SC

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Forensic Neuropsychological Evaluations: Issues and Controversies. L. Randolph Waid, Ph.D. Clinical Psychologist/Neuropsychologist Clinical Associate Professor in Psychiatry and Neurology Medical University of South Carolina, Charleston, SC. - PowerPoint PPT Presentation

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Page 1: Forensic Neuropsychological Evaluations: Issues and Controversies

Forensic Neuropsychological Evaluations: Issues and Controversies

L. Randolph Waid, Ph.D.Clinical Psychologist/Neuropsychologist

Clinical Associate Professor in Psychiatry and NeurologyMedical University of South Carolina, Charleston, SC

Page 2: Forensic Neuropsychological Evaluations: Issues and Controversies

I. Evaluation of Testing Effort/Malingering

Malingering: The diagnostic and Statistics Manual of Mental Disorders, Fourth Edition (1994) defines malingering as, “…the intentional production of false or grossly exaggerated physical or psychological symptoms, motivated by external incentives such as avoiding military duty, avoiding work, obtaining financial compensation, evading criminal prosecution, or obtaining drugs.” p. 683

Malingering can occur in one of three patterns in neuropsychological settings:

(A) false or exaggerated reporting of symptoms(B) intentionally poor performance on

neuropsychological tests(C) a combination of symptom exaggeration and intentional performance deficit

Page 3: Forensic Neuropsychological Evaluations: Issues and Controversies

Significant increase in research on developing specialized procedures to detect malingering include:

(A) Stand alone tests/symptom validity tests

(B) Patterns of malingering on standard clinical tests

(C) Fabrication and exaggeration of symptoms on psychological measures/validity scales

Page 4: Forensic Neuropsychological Evaluations: Issues and Controversies

Properties of a good stand alone test (Hartman, 2003)

• Measure willingness to exert basic effort and are insensitive to the cognitive dysfunction being assessed (sensitivity and specificity).

• Appear to the patient to be a realistic measure of the cognitive modality under study (face validity).

• Measure abilities that are likely to be exaggerated by patients claiming brain damage.

• Have a strong normative basis underlying test results to satisfy scientific and Daubert concerns.

• Are based on validation studies that include normals, patient populations and individuals who are suspected and/or verified malingerers in actual forensic or disability assessment conditions.

• Should be difficult to fake or coach.• Should be relatively easy to administer.• Are supported by continuing research.

Page 5: Forensic Neuropsychological Evaluations: Issues and Controversies

Stand Alone Tests/Symptom Validity Test

• Test of Memory Malingering (TOMM)• Word Memory Test• Validity Indicator Profile• Structured Interview of Reported Symptoms-II (SIRS-II)

Page 6: Forensic Neuropsychological Evaluations: Issues and Controversies

Formulas using Existing Tests

• Digit Span Test (Reliable Digit Span)• Measures on Recognition Memory (CVLT-II)• Measures of Problem Solving Ability

Page 7: Forensic Neuropsychological Evaluations: Issues and Controversies

Detection of Symptom ExaggerationMinnesota Multiphasic Personality Inventory-II•F family of scales

F, Fb, F (p)•FBS scale

Page 8: Forensic Neuropsychological Evaluations: Issues and Controversies

Detection of Cognitive Malingering (Slick et al 1999)

• A multi-dimensional approach• Malingering vs. Less than optimal testing effort• Consideration of evidence from neuropsychological testing

and self report

Page 9: Forensic Neuropsychological Evaluations: Issues and Controversies

Detection of Cognitive Malingering

• Evidence from Neuropsychological Testing includes:(A) Definite negative response bias(B) Probable response bias

Page 10: Forensic Neuropsychological Evaluations: Issues and Controversies

Detection of Cognitive Malingering

• Evidence from Neuropsychological Testing also includes:(A) Discrepancies between test data and patterns of brain functioning(B) Discrepancies between test data and observed behavior(C) Discrepancies between test data and reliable collateral reports(D) Discrepancies between test data and documented background history

Page 11: Forensic Neuropsychological Evaluations: Issues and Controversies

Detection of Cognitive Malingering

• Evidence from self report includes:(A) Self report history discrepant with documented history(B) Self reported symptoms discrepant with known patterns of brain functioning(C) Self reported symptoms discrepant with behavioral observations(D) Self reported symptoms discrepant with information obtained from collateral informants(E) Also includes evidence of exaggerated or fabricated psychological dysfunction on well validated validity scales (e.g. MMPI-2)

Page 12: Forensic Neuropsychological Evaluations: Issues and Controversies

Definite Malingering

• Presence of a substantial external incentive (Criterion A).• Definite negative response bias (Criterion B).• Behaviors meeting necessary criteria from group B are not

fully accounted for by psychiatric, neurological, or developmental factors (Criterion D).

Page 13: Forensic Neuropsychological Evaluations: Issues and Controversies

II. Estimating Pre-morbid Intelligence

• Obtainment of previous educational records including standardized Educational test scores/military records, etc.

• Level of educational/occupational attainment• Current test results• The problem of above and below average intelligence

Page 14: Forensic Neuropsychological Evaluations: Issues and Controversies

Estimating Premorbid Intelligence

• Four general methods used to estimate premorbid IQ(A) The best performance method(B) Subject’s performance on intelligence subtests that are thought to be relatively insensitive to the effects of brain damage (e.g. vocabulary, information)(C) Tests of overlearned skills such as reading which are highly correlated with intelligence (e.g. NART, WRAT-4, WTAR)(D) Actuarial methods that use demographic data such as age, sex, race, education, and occupation to estimate premorbid IG (e.g. Barona Index)(E) WAIS-IV Advanced Clinical Solutions

Page 15: Forensic Neuropsychological Evaluations: Issues and Controversies

Mild Traumatic Brain Injury

• Accounts for 72% of all traumatic brain injury• The issues of the incidence, cause, and persistence of

deficits following MTBI remains controversial• Iraq war veterans and sports psychology/NFL• Recent research-Simple blood test to identify mild

brain trauma• New research on higher resolution imaging

Page 16: Forensic Neuropsychological Evaluations: Issues and Controversies

Mild Traumatic Brain Injury

• Diagnosing(A) Direct observation(B) Retrospective determination

Page 17: Forensic Neuropsychological Evaluations: Issues and Controversies

Mild Traumatic Brain Injury

• Definition (ACRM 1993)1. Any period of loss of consciousness2. Any loss of memory for events immediately before or after the accident3. Ant alteration of mental state at the time of the accident (e.g. feeling dazed, disoriented, or confused)4. Focal neurological deficit(s) that may or may not be transient5. Exclusion Criteria6. Compared to DSM-IV diagnosis

Page 18: Forensic Neuropsychological Evaluations: Issues and Controversies

Acute Symptoms of MTBI

• Nausea• Vomiting• Blurred vision• Somnolence

Page 19: Forensic Neuropsychological Evaluations: Issues and Controversies

Symptoms of Post-Concussive Syndrome (PCS)

• Headaches• Fatigue• Insomnia• Irritability• Emotional lability• Anxiety

Is a concussion the same as a Post-Concussive Disorder

• Depression• Photosensitivity• Dizziness• Attentional Problems• Memory Deficits• Intolerance to alcohol

Page 20: Forensic Neuropsychological Evaluations: Issues and Controversies

Can We Rely on Objective Evidence?

• Neuroimaging – CT and MRI Scans

Diffuse axonal injuries possibly associated with MTBI are typically not visible on static neuroimaging.

• PET and SPECT Scans• EEG/Brain Mapping and Computerized EEGs

Page 21: Forensic Neuropsychological Evaluations: Issues and Controversies

Mild Traumatic Brain Injury

Post-concussion Disorder refers to somatic, cognitive and emotional residuals that should be classified as follows:•Acute: lasting up to one month post-injury•Sub-acute: lasting greater than one month and less than 12 months•Chronic: duration greater than one year

Page 22: Forensic Neuropsychological Evaluations: Issues and Controversies

Cultural/Language Differences

• The Hispanic brain damaged worker• How to evaluate

1. Review the physics of the accident; the acute neurological sequelae; neuroradiographic studies; and emergent medical records most important.

• Neuropsychological testing is a sampling of behaviors but lacks validity due to language/cultural differences.

• Use of translator and Spanish version of tests• The value of a neuropsychological evaluation