Neuropsychological assessment of children and adults with traumatic brain injury - SIRA
The party initiating the assessment should inform all other parties and provide information about the assessment and the nominated psychologist by completing the NAN form. Any dispute regarding the psychologist nominated to conduct an assessment must be raised with the party initiating the assessment within 10 working days after advice has been provided and the following process applied. A number of issues should be considered when determining whether a neuropsychological assessment is required, including but not limited to the following:.
The timing and number of assessments should be guided by injury severity and clinical need. The timing of assessments for clinical purposes will vary depending on clinical indicators. It is important that medico-legal assessments do not take place at the same time as clinical reviews unless the assessment report can be shared by all parties including the treating team. A medico-legal assessment coinciding with clinical reviews at critical times during treatment and recovery can interfere with the rehabilitation process. Communication and collaboration between the parties will ensure multiple assessments are not required.
Neuropsychological assessments are sometimes repeated to measure the change attributable to spontaneous recovery, treatment effects or deterioration in brain function. However, neuropsychological tests are unlike other medical tests such as blood tests or MRI brain scans.
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Such medical tests can be done at repeated intervals without one assessment influencing the other. In contrast, one occasion of neuropsychological testing can have a significant impact on the results of the subsequent occasion of testing. To reduce these effects and maximise reliability, the assessments need to be carefully timed and only tests with known errors of measurement should be used.
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Interpretation of test scores on a second occasion of testing presents considerable challenges. The complexity of interpretation is exponentially compounded the more times a person undergoes assessment on a particular test. For this reason the number of occasions of testing should be kept to a minimum. A minimum period of 12—24 months between assessments is recommended. Before arranging a medico-legal assessment every effort should be made to acquire the required information in what is available or could be obtained through liaison with the assessing psychologist.
In order to provide an informed and valid interpretation, it is imperative that the psychologist is provided with the names of the tests used and the raw scores obtained on previous assessment for comparison with current test scores. This will allow for appropriate statistical analysis of the change in results and for the selection of tests to be included to minimise practice effects.
Cognitive fatigue commonly occurs following TBI and may result in impaired concentration and sub-optimal performance on neuropsychological testing. The impact of fatigue on test performance should be taken into account.
When fatigue is an obvious problem appropriate rest breaks should be provided. For people with moderate to extremely severe TBI, rest breaks during a single session may be appropriate, or testing over several days may be required. All parties have responsibility to communicate and share information before and after a neuropsychological assessment as outlined in the roles and responsibilities section. A series of fact sheets, available in Part Three of the Guidelines, provide information about neuropsychological assessment for individuals undergoing assessment, their families, significant others and other parties with an interest in the information provided in reports.
To ensure that effective communication and sharing of information occurs for each neuropsychological assessment, the party arranging the assessment should facilitate the following:. Adherence with the Guidelines by all parties will ensure that neuropsychological assessment reports will meet clinical, CTP claims management and LTCSA planning needs as well as providing important information to the injured person, their family and service providers involved in treatment, rehabilitation and care.
This includes satisfying the need for information in the early recovery period that provides:. Neuropsychological assessment reports may be used up to and during the process of settling a CTP claim. Reports prepared according to the Guidelines should include test raw scores and sources of normative data such that a qualified psychologist with access to the manuals and reference material would be able to provide an independent interpretation.
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There are significant differences in the assessment of neuropsychological function in children and adults, and in the assessment of mild or moderate-severe TBI. This section recommends tests that are sensitive and useful for the neuropsychological assessment of all TBI.
The selection of specific tests and normative data recommended in the Guidelines are examples of appropriate measures. These can be supplemented or substituted with other tests at the discretion of the psychologist depending on the circumstances of each case. The assessment of TBI and classification of the severity of an injury is reflected both by the depth of disturbance in consciousness coma , as well as the duration of post-traumatic amnesia PTA.
Clinical assessment is used to determine the duration of PTA of children under seven years and may also be used to determine the duration of PTA for older children and adults with TBI. Due care is required when interpreting PTA test scores as failure on PTA scales can occur for reasons other than amnesia. Operational criteria for clinical identification include:. These manifestations of mild TBI must not be due to drugs, alcohol, medications, caused by other injuries or treatment for other injuries eg systemic injuries, facial injuries or intubation , caused by other problems eg psychological trauma, language barrier or coexisting medical conditions or caused by penetrating craniocerebral injury.
Axons are stretched or twisted without being sheared or torn, and most axons recover over time Iverson, Cellular and vascular mechanisms such as ionic shifts, abnormal energy metabolism, diminished cerebral blood flow and impaired neurotransmission have been implicated in the acute cognitive and behavioural symptoms reported following a mild TBI Barkhoudarian et al.
It is important to differentiate between individuals with uncomplicated mild TBI and those with a complicated mild TBI. A complicated mild TBI has been defined as meeting diagnostic criteria for mild TBI, with a trauma related abnormality — eg contusion that does not require surgery, present on the day-of-injury brain CT scan Carroll et al, In individuals with mild complicated TBI neuropsychological performance in the early days and weeks after injury may be poorer, and longer-term cognitive outcome may be worse Iverson, than for individuals with uncomplicated mild TBI.
Primary TBI refers to a form of brain damage that results from mechanical forces producing tissue deformation at the moment of injury. These deformations may directly damage the blood vessels, axons, neurons and glia in a focal, multi-focal or diffuse pattern of involvement. Secondary TBI occurs as a complication of the different types of primary brain damage Blumbergs, Children with a TBI present with different patterns than adults. The typical patterns of impairment are described for each group. Children with mild TBI and their families often describe cognitive, emotional and somatic symptoms in the first few months following an uncomplicated mild TBI.
These symptoms can include concentration problems, forgetfulness, fatigue and headache. These post-concussive symptoms can occur in the absence of demonstrable evidence of brain injury although CT scans are not always sensitive to identifying pathology.
The Neuropsychology of Everyday Life: Issues in Development and Rehabilitation
The majority of children who sustain a mild TBI have excellent outcomes with no long-term impairment Anderson et al. There is also an increase in the possibility of poor outcome following mild TBI when two or more risk factors are present, acting to compound the effect of any one factor on recovery and outcome.
For instance, children with premorbid learning or behavioural disturbance are at greater risk of poorer outcomes than children with an unremarkable premorbid history Dennis, et al. Children who sustain a complicated mild TBI, where there is evidence of cerebral pathology have poorer cognitive outcomes compared to those who sustain an uncomplicated mild TBI Yeates et al.
There is an increase in the risk of poorer outcomes when two or more risk factors are present. The research has consistently demonstrated that a moderate to extremely severe traumatic brain injury has neurobehavioural consequences that may be long-term and in the majority of cases, permanent Catroppa et al, There is typically a dose-response relationship between injury severity and neuropsychological outcomes, with the most severe injuries resulting in the poorest outcomes.
Age at injury is known to contribute to outcome. Younger children are most vulnerable to poorer outcomes. Emerging and developing skills are the most vulnerable to impairment following a brain insult, whereas established skills are less likely to be disrupted. Nevertheless, the relationship between age at injury and outcomes is not necessarily linear. The effects of a moderate to extremely severe TBI early in life may also disrupt future acquisition of cognitive skills that occur later in development eg high level planning.
The Neuropsychology of Everyday Life: Assessment and Basic Competencies
Deficits may therefore not become apparent until later in development when those skills are expected to emerge. Whilst the cognitive and behavioural sequelae of adult TBI is most often stabilised by two years post-injury, the full effects of a TBI acquired during childhood are often not established until early adulthood. Child, family and environmental factors are increasingly being recognised as important contributors to outcome. Children and families with premorbid vulnerabilities eg pre-injury attention difficulties, psychiatric disturbance, low socioeconomic status are known to have poorer cognitive, behavioural and functional outcomes.
The relationship between family functioning and severity of injury is known to be bidirectional Taylor et al. During childhood and adolescence, the young person has the opportunity to benefit and perhaps improve their prognostic outcomes with appropriate therapy and education supports.
For this reason, it is recommended that medico-legal neuropsychological assessments for those who have sustained a moderate to extremely severe TBI, take place in late adolescence or early adulthood when their cognitive abilities are likely to have stabilised. In some cases, the prognosis for individuals with extremely severe TBI can be determined earlier. Cognitive deficits in working memory, attention, information processing and memory have been reported immediately after a mild TBI.
In general, most individuals recover from these deficits within 1—3 months Ponsford et al, ; Frencham, Fox and Maybery, Impairments in perceptual reasoning and verbal comprehension indexed scores of the Wechsler scales and motor skills have not been reported either acutely or in the longer term. Gross memory problems have not been found after the acute phase Frencham et al, A number of individuals report cognitive, physical and emotional symptoms immediately after and in the months following a mild TBI.
Factors such as pre and post injury psychiatric disorder, post-traumatic stress, pain and being female are associated with PCS-like symptoms Meares et al, ; Meares et al, ; Meares et al, ; Ponsford et al.
A significant range of psychiatric disorders occur following mild TBI Bryant et al, and those such as depression may also influence symptom reporting Lange et al, Personality traits and individual's perceptions of their symptoms may also impact on recovery Garden et al, ; Hou et al, Following moderate to extremely severe TBI, a range of deficits or changes may occur in cognitive functioning. The degree of cognitive impairment is related to the severity of the injury, with more diffuse and persistent deficits occurring as the length of coma increases Dikmen et al. Such deficits may be detected at one, 12 and 24 months post injury Dikmen et al.
The most persistent of these deficits may be in memory, attention, executive function and speed of information processing Millis et al, ; Rohling et al. All sources relevant to formulating the neuropsychological opinion should be documented.
This may include ambulance and hospital records, discharge summaries, nursing records if relevant, radiological reports or the reports of any other relevant investigations. Reports of subsequent investigation or intervention by any health professional, including neurologists, rehabilitation medicine specialists, psychiatrists, or other psychologists may also be included. In general, reports of injuries other than TBI, and subsequent treatment are not relevant to the neuropsychological presentation. However, these should be included if they contain information that is used in forming the psychologist's opinion.
For example, other significant injuries which may suggest high energy at impact including facial fractures Hohlrieder et al, or medical procedures that could confound an accurate diagnosis. When the psychologist preparing the report refers to results for tests they have not conducted, they should identify the psychologist who conducted the testing, and state their qualification.
Any other person who was involved in the assessment apart from the psychologist eg interpreter, student, psychometrician should be named and their role and qualifications described in the report. There are usually at least two sources of information describing the injury. For children, a parent or caregiver will be the most likely provider of this information. If the history is given by someone other than the individual, this should be stated clearly. Another source is the record of the event from ambulance or hospital records, including the following information:. The injured person may be able to provide a description of the event; however the reliability of this will depend on their age, the length of their retrograde and post-traumatic amnesia, developmental level and cognitive abilities.
It should be stated clearly whether the history is provided by someone other than the individual being assessed and include their relationship. The location of the assessment should be identified. Where relevant, the following aspects of the presentation should be addressed, giving due consideration to cultural factors:. Significant information about the injured person's history is important to determine pre-injury level of functioning.
Any issues that may have given rise to a neuropsychological problem need to be included in the report by including relevant information on:. Children and adolescents — growth and development history including:. Like this document?
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