Transcript using neuropsychological assessments to guide program

USING
NEUROPSYCHOLOGICAL
ASSESSMENTS TO GUIDE
PROGRAM SUPPORTS
Greg Thaler, Ph.D., Psychologist
Katherine Schoech, MA, LPC, Doctoral Candidate
Katie TenHulzen, MA, Registered Psychotherapist
Rocky Mountain Human Services
Denver, CO
PURPOSES OF NEUROPSYCHOLOGICAL
ASSESSMENT
• Identifies brain-behavior relationships, the reallife consequences of impaired brain functioning
• Compares and contrasts the functioning of the
left and right hemispheres of the brain across
multiple domains
• Lateralizes which hemisphere(s) and localizes
which lobe(s), i.e., prefrontal/frontal, temporal,
parietal, and/or occipital, are showing impaired
functioning
PURPOSES OF NEUROPSYCHOLOGICAL
ASSESSMENT
• Assesses adaptive abilities to determine
eligibility for I/DD services and/or to identify
goals for intervention
• Assesses academic abilities to identify learning
issues
• Includes projective and/or objective personality
testing
• May include Socio-Sexual Knowledge &
Attitudes Assessment Tool-Revised (SSKAAT-R)
PURPOSES OF NEUROPSYCHOLOGICAL
ASSESSMENT
• Each person with I/DD exhibits a
unique profile of neuropsychological
and personality strengths and
issues, which can be identified
through assessment and on behalf
of which supports can be
implemented
PURPOSES OF NEUROPSYCHOLOGICAL
ASSESSMENT
• Assessments celebrate each
person’s uniqueness, minimize the
negative impacts of unidentified
and un-remediated issues, e.g., on
self-esteem and mood stability, and
maximize personal empowerment
while minimizing confusion and
frustration
NEUROPSYCHOLOGICAL ASSESSMENT
BATTERY
• INTELLECTUAL ABILITIES
• Wechsler Adult Intelligence Scale-Third
Edition
• Wechsler Adult Intelligence Scale-Fourth
Edition
• Stanford-Binet Intelligence Scales-Fifth
Edition
• Leiter International Performance Scale
NEUROPSYCHOLOGICAL ASSESSMENT
BATTERY
• ATTENTION AND MEMORY
• Wechsler Memory Scale-Third Edition
• Wechsler Memory Scale-Fourth Edition
• Memory for Sentences from the StanfordBinet Intelligence Scale-Fourth Edition
• Tactual Performance Test
(tactile memory, perception, and problem
solving)
NEUROPSYCHOLOGICAL ASSESSMENT
BATTERY
• WORD FINDING/OBJECT NAMING
• Boston Naming Test-Second Edition
• LANGUAGE COMPREHENSION
• Peabody Picture Vocabulary Test-Third
Edition
• ACADEMIC ABILITIES
• Wide Range Achievement Test-Fourth Edition
NEUROPSYCHOLOGICAL ASSESSMENT
BATTERY
• MULTI-TASKING
• Trail Making Test
• EXECUTIVE FUNCTIONING AND CONCEPT
FORMATION
• Booklet Category Test
• Wisconsin Card Sort
• REITAN-INDIANA APHASIA SCREENING TEST
• FINGER TAPPING TEST (motor speed)
NEUROPSYCHOLOGICAL ASSESSMENT
BATTERY
• DEMENTIA RATING SCALE-SECOND EDITION
• VINELAND ADAPTIVE BEHAVIOR SCALES,
SECOND EDITION
• PROJECTIVE PERSONALITY FUNCTIONING
• Rorschach Psychodiagnostic Plates
• Thematic Apperception Test (TAT)
• OBJECTIVE PERSONALITY FUNCTIONING
• Minnesota Multiphasic Personality Inventory
EXECUTIVE FUNCTIONING AND
DYSFUNCTION
• Prefrontal cortex (PFC), located behind and
below the forehead in both hemispheres, is
specialized for the various Executive
Functions (EFs).
• Fundamental EFs of Response Initiation
(“start” and “speed up”) and Response
Inhibition (“stop” and “slow down”) provide
scaffolding for remaining EFs.
EXECUTIVE FUNCTIONING AND
DYSFUNCTION
•
•
•
•
Maintaining and shifting attention/focus
Verbal and Visual Working Memory
Multi-Tasking
Learning style/preference, i.e., verbal, visual,
or tactile
• Self-Talk and other coping skills such as
planning ahead, self-monitoring/insight,
reasoning, judgment, and problem solving
EXECUTIVE FUNCTIONING AND
DYSFUNCTION
• Self-Management of mood, thinking,
and behavior
• Learning of concepts
• Learning from consequences and
feedback
• Maintaining motivation and persistence
to achieve short-term and long-term
goals
EXECUTIVE FUNCTIONING AND
DYSFUNCTION
• Regardless of IQ, the vast majority of
persons with I/DD demonstrate at least
moderate to generally severe Executive
Dysfunction (EDF)
• Neuropsychological insults such as TBI,
alcoholism, catatonia, neuroleptic
malignant syndrome, cerebral palsy, and
dementia may result in increased EDF
EXECUTIVE FUNCTIONING AND
DYSFUNCTION
• Dually diagnosed mental health disorders
such as ADHD, PTSD, Bipolar Disorder, and
Schizophrenia are, in reality, brain disorders
that directly and adversely impact the
various EFs in their own right
• In PTSD, the chronic overproduction of the
stress hormone cortisol directly impairs PFC
EFs
EXECUTIVE FUNCTIONING AND
DYSFUNCTION
• ADHD and OCD are both fundamentally
EF disorders, as they involve impaired
response initiation and response
inhibition
• Genetic disorders such as Down
Syndrome, Fragile X syndrome, and
Autism Spectrum Disorder also produce
EDF
EXECUTIVE FUNCTIONING AND
DYSFUNCTION
• Any condition or medication that affects the
brain can impact executive functioning, e.g.,
• Untreated sleep apnea. EF may improve
when sleep apnea is treated.
• Psychoactive medications, particularly at
higher doses, e.g., Neurontin, which may
slow down information processing speed,
e.g., on Boston Naming Test retrieval speed
WORKING MEMORY
• Working Memory is a core deficit in many
persons with I/DD
• In Verbal Working Memory, verbal
information is stored on-line and in real-time
in the left Prefrontal Cortex (PFC)
• In Visual Working Memory, visual
information is similarly stored in the right
PFC
WORKING MEMORY
• Working memory allows you to mentally
add up the prices of three items and
figure out how much change you will
receive from a $20.00 bill.
• Working memory allows you to mentally
visualize the steps in tying a tie
• Working memory allows you to mentally
keep a five-sentence speech in-mind
WORKING MEMORY
• Working Memory has a storage capacity of 7
+/- 2, i.e., 5-9, pieces of information
• The less the capacity, the less information the
person can keep in-mind and on-line to guide
behavior, e.g., planning ahead becomes
difficult
• The greater Working Memory is impaired,
the more the person depends upon step-bystep external supports and structure
SKETCH OF ANDREW
• 35-year-old man with ADHD, Hoarding
Disorder, Autism Spectrum Disorder
• ADHD and Hoarding indicate significant EDF
• Working Memory has a “filter” that allows
you to ignore distractions so you can focus
your attention on the relevant stimulus
• Andrew’s “filter” is broken. He can’t ignore
the actions of fellow passengers on the bus.
SKETCH OF ANDREW
• Andrew can’t inhibit talking out loud, e.g.,
when he feels frustrated
• He can’t inhibit intrusive thoughts about past
injustices, increasing his agitation
• His cursing on the bus makes others feel
threatened and causes conflicts
• He came into conflict with several
passengers, who punched him in the head
• A female passenger pulled a knife on him
SKETCH OF ANDREW
• SUPPORTS
• Consult with prescriber re. ADHD medication
• Andrew will review a written step-by-step selfmanagement plan before boarding the bus, i.e., to
take calming breaths, to keep his self-talk covert, to
use headphones to gate out distractions, to use his
coping skills to de-escalate his frustration, to inhibit
negative interactions, to exit the bus if he is not
able to use his coping skills effectively, to self-praise
for having used his coping skills
SKETCH OF ANDREW
• Andrew will practice covert self-talk and
ignoring provocative comments in therapy
• Host Home Provider (HHP) will observe
Andrew on bus to give him feedback
• Andrew will text/call HHP upon boarding bus
and when his coping skills are not working, to
receive support
• Specialized “curb to curb” transit to increase
structure and safety
PROGRAM SUPPORT PRINCIPLES
•The greater the EDF, the
more the person
benefits from external
supports and structure,
regardless of IQ
PROGRAM SUPPORT PRINCIPLES
• A person with a TBI, ADHD, and
PTSD with an IQ of 70 makes 140
errors (65+ reflects severely
impaired EF) on the Booklet
Category Test (BCT). He/she may
require as much support as a person
with an IQ of 55 who makes only 70
errors on the BCT.
PROGRAM SUPPORT PRINCIPLES
• At all points, don’t give
any more or any less
support than the person
needs to be successful.
Unneeded supports can be
hard to fade.
PROGRAM SUPPORT PRINCIPLES
• At all points, our goals are to
minimize confusion, frustration,
errors, and inappropriate
participation and to maximize
appropriate participation, success,
and personal empowerment, i.e.,
Bandura’s Self-Efficacy (“I can do
this!” and “I did it!”).
PROGRAM SUPPORT PRINCIPLES
• At all points, our on-going goal is to
promote as much self-management
as possible. Self-management is an
EF. “Compliance” is not an EF.
Solving a problem for someone or
giving unneeded prompts to get
quick results does not promote selfmanagement.
PROGRAM SUPPORT PRINCIPLES
• The “errorless
discrimination/learning”
of Terrace and Skinner
inspires us to use a stepby-step task analysis when
teaching a skill.
PROGRAM SUPPORT PRINCIPLES
• Like a sculptor shapes marble into a
masterpiece step-by-step, the Method
of Successive Approximations, or
Shaping, involves reinforcing each of a
series of behaviors that more closely
approximate the goal. Shaping can be
done in a forward or a backward
direction.
PROGRAM SUPPORT PRINCIPLES
• In Forward Chaining, the person learns a
given behavior using a step-by-step task
analysis from beginning to end.
• In Backward Chaining, the person begins
with the final step and learns step-bystep toward the first step.
PROGRAM SUPPORT PRINCIPLES
• These step-by-step approaches minimize the
negative impact of the person’s working
memory impairments, i.e., the person may
be able to keep only a single step in-mind at a
time.
• In Chaining, the completion of one step not
only reinforces that step but cues the next
step.
PROGRAM SUPPORT PRINCIPLES
• The person’s working memory capacity
determines the size of a given step and the
number of steps in a task analysis .
• One person may need a 10-step task analysis
to learn (720) 218-7272. Another person may
need 3 steps, i.e., 720, 218, and 7272. A third
person may be able to store the 10 numbers
as a single piece of information in one step.
PROGRAM SUPPORT PRINCIPLES
• The Booklet Category Test is the best single
predictor of the person’s learning and
support needs. Learning its concepts involves
working memory, multi-tasking, mental
flexibility, maintaining concentration and
motivation toward a goal, reasoning,
planning, self-monitoring, learning from
feedback, a learning curve, and short-term
retention of what was learned.
PROGRAM SUPPORT PRINCIPLES
• The relative strength or inefficiency of each
of these EFs can be separately evaluated and
then used to inform program supports.
• For example, a person who does well on
verbal concept formation on Similarities and
verbal reasoning on Comprehension would
be encouraged to use these strengths in selftalk to guide solving both verbal and visual
learning problems.
PROGRAM SUPPORT PRINCIPLES
• A person with visual working
memory impairments would
benefit from using her strength in
verbal working memory to talk
herself through a visual learning
situation, i.e., turn a visual into a
verbal learning situation.
PROGRAM SUPPORT PRINCIPLES
• Persons with PFC impairment benefit
from recognition cues when they can
not recall information without cues.
• A person recalls 0/8, 6/8, 6/8, and 5/8
word pairs on four presentations. This
person would benefit most from a single
repetition by self or others.
PROGRAM SUPPORT PRINCIPLES
• A person who shows a very gradual
learning curve of 0/12, 1/12, 2/12, and
3/12 words benefits from continued
repetition
• A person who shows no learning curve
of 0/8, 0/8, 0/8, and 0/8 word pairs
will benefit from recognition cues
PROGRAM SUPPORT PRINCIPLES
• A person who recalls 12% of several-sentence
conversations, 38% of word pairs, and 75% of a
word list will do best when we speak to her in as
few words as possible.
• We all do the best we can with the resources
we’ve got. Our job is to support our persons to
learn as effortlessly as possible by maximizing
their use of their strengths and minimizing the
negative impact of their issues.
PROGRAM SUPPORT PRINCIPLES
•Our persons support
us in teaching us how
to support them as
effectively as
possible.
SKETCH OF BILLY
• 37 years old
• “Energizer Bunny on speed” before he
developed Catatonia in March of 2013
• Special Olympics gold medalist
• Autism Spectrum Disorder and OCD
• 2006 episodes of excessive fatigue, social
withdrawal, and prolonged giggling thought
to be Bipolar Disorder may have been
Catatonia
SKETCH OF BILLY
• 2007 persistent lower back spasm may have
been Catatonia
•
2006 Baseline 2013 2014 2015
• Trails A
33’
61’ 143’ 55’
• Trails B
65’
246’ 590’ 531’
• L N Seq.
• Spatial Span
SS = 8
SS = 2
1
2
1
2
1
1
SKETCH OF BILLY
•
•
•
•
• PROGRAM SUPPORTS
Reduce need to multi-task verbal and visual
information
Give single-step verbal instructions or singlestep visual demonstrations but not both
simultaneously
Speak to Billy in 7-word sentences
Give him verbal recognition cues, i.e., choices
SKETCH OF BILLY
• Historically, Billy worked 30-40 hours/week,
with irregular visits by his job coach
• Since his Catatonia, Billy works two, 3-hour
shifts/week with his job coach present
• Support by his 17-year employer has been
crucial
• Billy continues his very slow and uneven
recovery on GABA and Ambien, i.e., more
alert, energetic, interactive on a “good day”
SKETCH OF BORIS
• 31 years old. Born in Russia. His speech
is hard to understand because of tongue
thrusting.
• ADHD with inattention, hyperactivity,
impulsivity. Alcohol Use Disorder.
• Getting drunk several times/week in
2008 living in own apartment. Assault
and battery toward girlfriend. Needed
more structure. Moved into host home.
SKETCH OF BORIS
• Eloped from another host home in 2013 to
get drunk with buddy, who choked him
• Eloped in middle of night from host home in
2014. Highly intoxicated, broke into auto
body garage and smashed car through door.
Jailed. Needed more structure. Placed into
group home with awake staff. Completed
diversion program successfully.
SKETCH OF BORIS
•
•
•
•
•
•
•
Pleaded guilty to making racial slurs in 2015
2008
2015
Logical Memory I
41%
9%
Logical Memory II
24%
14%
Log Mem II Recognition 80%
60%
Letter-Number Seq
SS = 2
SS = 5
Spatial Span
SS = 1
SS = 5
SKETCH OF BORIS
• His abilities to multi-task verbal and
visual information have improved on his
ADHD medication, but his memory for
conversations has declined significantly,
contributing to his interpersonal
conflicts.
• Consult with Psychiatrist
• Impaired cause-and-effect reasoning
SKETCH OF BORIS
•
•
•
•
•
•
•
•
Booklet Category Test: 109 errors/208 cards
Subtest I : 1 error
Subtest II : 1 error
Subtest III: 31 errors
Subtest IV: 28 errors
Subtest V : 19 errors
Subtest VI: 20 errors
Subtest VII: 9 errors
SKETCH OF BORIS
• Severely impaired Executive Functioning
• Showed learning curve, but did not make
further progress on learning concept with
continued feedback
• Only modest retention of what he learned
• Understands conversations and instructions
like a person who is 8 years, 4 months, old
SKETCH OF BORIS
• His 2015 Rorschach results almost identical to
his 2008 results. He impulsively rushed
through the “inkblots”, just like in real-life.
• His many “mask” responses indicate that he
does not see himself realistically and does
not take personal responsibility for his
actions, projecting a false front to the world.
• Narcissistic Personality traits
SKETCH OF BORIS
•
•
•
•
•
•
•
• SUPPORTS:
ADHD is an Executive Function disorder
His severely impaired Executive Functioning:
Emotional self-regulation
Impulse control and Conflict resolution
Insight and personal responsibility
Cause-and-effect reasoning, learning from
consequences
SKETCH OF BORIS
• His significant Executive Dysfunction resulted
in a Support Intensity rating of 5/6, reflecting
his need for a high degree of support and
structure by others, e.g., no alone time in the
community
• Recently snuck a bottle of beer into the home
of the staff person he was visiting; his visiting
her has been suspended
SKETCH OF BORIS
• Self-Management program at work, home, day
program
• Behavioral Consultation
• Psychotherapy
• Medications
• Self-confrontation to minimize defensiveness
• Forecasting to minimize conflicts with others
• Accepting consequences non-defensively and
learning from them
SKETCH OF BORIS
• Teach through behavioral rehearsal how to
redirect himself away from conflicts when he
can’t use his coping skills to resolve a conflict
• Give him a situation-appropriate time to use
his coping skills before giving first a General
Reminder and then, if needed, a Specific
Reminder
• Increase his empathy toward others
SKETCH OF GARY
• 28 years old
• As a youngster, indoctrinated with racial
prejudice and physically abused by
stepfather, toward whom he became
aggressive, and was removed from his home
• Assaulted by minority students in high school
• Concussion playing football
• Assaulted at group home by minority client
SKETCH OF GARY
• Conflicts with minority job coaches, coworkers
• Inked arms with Nazi swaztikas. Watched
video of Columbine shootings, triggering
thoughts of killing. On bus, threatened to kill
minority students at his former high school.
• Pulled knife on his host home provider
• Lost job, lost alone time in community
SKETCH OF GARY
• 130 errors/208 cards on Booklet Category
Test. Very slow learning curve. Only 40%
delayed retention. “Practice, Practice,
Practice”
• 52% immediate recall of conversations. 30
minutes later, recalled 16% of story he had
heard once but 36% of story he had heard
twice. “Repetition, Repetition, Repetition”
SKETCH OF GARY
• Recalled 38% of word pairs 30 minutes later
with no cues. 96% recognition with cues.
• Impaired memory for faces and for what is
happening in social situations
• Impaired multi-tasking of verbal and visual
information. Give single-step instructions or
single-step visual demonstrations but not
both together.
SKETCH OF GARY
• Repeated one 12-word sentence but spaced
out the next
• Understands words at 9 year, 3 month, level
• Named 67% of objects within 2 seconds
• “Father” card on Rorschach: “Monster with
big feet”
• “I recall pieces of physical abuse by my
stepfather.”
SKETCH OF GARY
• “A volcano. That’s its red on top. It’s all
black. It has lava inside. It explodes.”
• Did not respond to other emotional
areas on the “inkblots”. Did not know
what to say.
• Deals with feelings by not dealing with
them, lest he lose control and explode.
• “Lost little boy” story on TAT card
SKETCH OF GARY
• Blank Card 16 on TAT: “Two girls. They went
to the same school together. They graduated
together. They went to college together. They
are still best friends.”
• Issues with insecurity. Now in respite.
• Had on-going issues with impulse control,
i.e., “going off”, stealing, runs out of chewing
tobacco, and his mood gets irritable
SKETCH OF GARY
• SUPPORTS
• “Gary and the Volcano” self-management
program to self-monitor thoughts, feelings
• Speak to Gary in 11-word sentences using
vocabulary he understands
• Give Gary time to recall. Provide recognition
cue in form of 2 choices when needed, e.g.,
“Do you feel sad or mad?”
SKETCH OF GARY
• 1:1 job coaching at volunteer jobs for past 1.5
years to increase his coping skills, i.e., to
inhibit racist, homicidal thoughts around
minority co-workers, supervisors
• Current suspension from violent videos.
Working with Gary to self-inhibit his
homicidal thoughts from being triggered.
• His internet use is monitored
SKETCH OF GARY
• Working with Gary on increasing his
community alone time, i.e., walking to stores,
riding specialized transit, then riding bus
increasingly independently
• Gary has successfully self-inhibited any
temptation to steal during weekly therapy
practice in which he is left alone with money
• Working with DVR to re-enter work force
SKETCH OF LEONARD
• 65-year-old man living in a host home
• Asked to keep in-mind, “The little child
would not stop crying,” he said “stop crying.”
• Severely impaired verbal working memory
• Able to keep in-mind a two-step visual
demonstration inconsistently
• Severely impaired visual working memory
• Understands vocabulary at 7-year level
SKETCH OF LEONARD
• Immediately recalled just 10% of a severalsentence conversation, directly contributing
to his misinterpretation of social situations
• He frequently comes into conflict with other
• He loses his cool when teased by others
• Repeating the story didn’t help immediately,
but his recall 30 minutes later was a little bit
better
SKETCH OF LEONARD
• Did not learn any of 8 word pairs after 4 tries
• Learned 2/12 words after 4 presentations
• Even with “repetition, repetition, repetition”,
he will show a very slow learning curve, e.g.,
Leonard has told himself “Keep it cool” for
years, and he still gets upset when teased
• Recalled just 10% of characters’ actions on
the four Family Pictures cards
SKETCH OF LEONARD
• His impaired ability to keep in-mind what is
happening also directly contributes to his
misinterpretation of social situations and to
his behavioral issues in such situations
• His default strategy is to tease or talk about
sports
• Reacted with “wow!” and “damn!” when
confronted by the colored Rorschach blots
SKETCH OF LEONARD
• Because he did not know what to do with the
colored areas on the inkblots, he will have
trouble recognizing and coping with his
feelings in real-life
• On card where most people see “butterfly”,
he saw a “mean husky with teeth” and a
“mean, dangerous eagle flying”. He reacts
angrily when he feels threatened, e.g., by
others’ teasing
SKETCH OF LEONARD
• On TAT’s blank Card 16, when he felt
overwhelmed and could not tell a story, he
talked about watching the Pro Bowl
yesterday. Talking sports is his “go-to”
strategy.
• Because of his working memory
impairments, he does not have much of an
imagination or mental life, living in the “here
and now”. Highly concrete thought process.
SKETCH OF LEONARD
•
•
•
•
• SUPPORTS
Speak to Leonard at a slower pace in one, 5word sentence at a time using words he can
understand
Check for comprehension
Single-idea sentences and single-step
instructions
Single-step visual demonstrations
SKETCH OF LEONARD
• Because he did not benefit much at all from
continued repetition, give him recognition
cues in the form of 2 choices when he can’t
recall, e.g., “Do you see Dr. Thaler on Monday
or Wednesday?”
• Forecast by walking him through a social
situation step-by-step, i.e., task analysis
• Draws a blank when asked, “What were/are
you thinking?”
SKETCH OF LEONARD
• Able to answer, “Good choice or bad choice?”
• His feeling words are limited to “sad”, “mad”,
“bad”, and “not good.” His coping skills are
limited to concrete strategies such as leaving
a frustrating situation before he “goes off”
because of his severely impaired executive
functioning
• Work with Leonard on making emotional
faces in the mirror so he can learn what they
SKETCH OF LEONARD
• look and feel like and to label each feeling.
• Have him watch others make a given face and
learn to imitate it and label the feeling.
• Can pick from among several pictured
emotional faces when he does not know how
he is feeling.
• These interventions will increase his Theory
of Mind.
SKETCH OF LEONARD
• Redirect Leonard to take calming breaths
before entering a social situation
• Give him a situation-specific amount of time
to redirect himself to calm down and to selfpraise. Give a General Reminder, e.g., “What
should you do?” before giving a Specific
Reminder, e.g., “Leonard, keep it cool.”
• Don’t give Leonard any more or any less
support than he needs.
Sketch of Sarah
Trauma background:
Saw mother neglect her sick father.
Saw her father die of heart attack.
Physically abused by mother. Social services placed her with her
grandparents.
Saw her grandmother die in front of her.
Grandfather neglected her and couldn’t care for her.
Placed back with mother and mother’s boyfriend.
Sexually assaulted twice by mother’s boyfriend which resulted in pregnancy both
times.
First child died in childbirth, born in toilet.
Second child – parental rights terminated due to Sarah not being able to care for
child.
Homeless for a year. Protective order against mother and eventually mother’s
parental rights taken away.
Placed in foster care and then into ID/DD Services.
Multiple sexual assaults by a Paratransit driver.
Sketch of Sarah
Neuropsychological Testing Results and Support Recommendations
WAIS - III Full Scale IQ: 67 (age 20 - 2005)
FSIQ score of 53 in 1999 on WISC - III.
Reasoning for score differences: Persons tend to score somewhat lower on WISC – III than on WAIS III. Most likely some factor such as poor rapport, or stress due to homelessness and/or sexual abuse,
lowered her 1999 score.
Nine point difference between Verbal IQ and Performance IQ – possible ADHD.
Inefficiencies in short-term verbal memory and concentration - when asked to rearrange sequences of
numbers and letters in numerical and alphabetical order, she could only keep in-mind long enough to
rearrange a single number and single letter.
Sarah demonstrated inconsistent abilities in common-sense verbal reasoning and in logical reasoning.
Sarah demonstrated a strength in attention to small visual detail involving the identification of the
missing part in each of a series of pictures. However, in logical reasoning involving rearranging a series
of picture cards to tell a story that made sense, she demonstrated inefficiencies.
Supports: Sarah thinks and learns in a concrete and literal manner. She will do best when
we demonstrate new tasks one step at a time.
Sketch of Sarah
a
Supports: Train providers to be aware that, at times, Sarah will have a keen, perceptive
understanding of a complex social situation, while, at other times, she will misread cues in
relatively straightforward situation and make inappropriate choices.
Develop a systematic problem-solving/decision making plan
1. “Sizes up” a situation
2. Identify possible courses of action
3. Review the pros and cons for each choice
4. Self-monitor whether an appropriate choice was made
5. Praise herself for having made an appropriate choice
6. Plans how to handle the situation appropriately the next time incorrect decision is made.
Wechsler Memory Scale III – Sarah’s overall immediate and delayed memory were significantly better
than her working memory by a 25 - point difference.
An Auditory Immediate Memory subtest involved recalling two, three-sentence stories. On the first
story, she immediately recalled 20 % of its details and 43 % of the major themes. She recalled 16 % of
the second story’s details and 50 % of its major themes. Thirty minutes later, her delayed recall
increased to 24% of the first story’s details and 57% of its major themes and 20 % of the second story’s
details and 63 % of its major themes.
Sarah was able to recognize 60 % of both stories’ details when given recognition cues.
Supports: Provide cues in which all she has to do is to recognize the correct answer. Provide
comprehension checks in the form of choices, e.g., “Did I ask you to clean your room or to
take out the trash?”
Sketch of Sarah
Sarah was asked to recall a list of 12 words presented four times. She recalled 1, 2, 4, and 6
after the first through fourth presentations. She was then given a new list of 12 words and
recalled 4 of them. She then was asked to recall the words from the original list and could
only recall 3 of them, indicating Retroactive Interference, in that the presence of new
information in-mind reduced her recall of older information.
Supports Discuss one topic at a time and provide repetition of important
information and have her rehearse important information by simply
repeating the information to herself.
A Visual Immediate memory subtest involved Sarah viewing four complex family pictures for
ten seconds each and then being asked to recall each story’s characters, their locations, and
their activities. Sarah recalled 88% of the characters, 19 % of their locations, and 81% of their
activities. Thirty minutes later, her delayed recall of the family pictures was the same for
characters and their locations, but she only recalled 63% of their activities.
events
Supports: Do not rush to judgement that Sarah is intentionally lying about what
she saw or did, she may not be able to keep in-mind a complex sequence of
long enough to make sense of the interaction and may create details
(confabulation) to fill in the gaps in her memory. Take the time to allow her to
feel safe and probe the series of events step-by-step.
Sarah’s delayed verbal memory was significantly better than her delayed visual memory.
Sketch of Sarah
SB IV – Memory for Sentences – Sarah was asked to repeat word-for-word increasingly longer and
more complex sentences. Her first error was on a 4-word sentence, and the next error was on a 7word sentence. She was able to repeat three, 8-word sentences before missing up to 11-word
sentences.
Support: Her ability to keep in-mind others’ conversations and instructions needs to be
limited to sentences no longer than 8 words.
Peabody Picture Vocabulary Test (III) – Sarah was asked to listen to a series of vocabulary words and
then identify the corresponding picture from among 4 choices. She received a standard score of 75.
Support: Use language consistent with a 10 year, 4 month, level of
understanding. Provide her the “gist” of the conversation rather than the details.
Booklet Category Test: Measures executive functioning; sensitive to the general effects of brain
damage and impairments in prefrontal lobe functioning. This complex measure of concept formation
involves problem-solving, working memory, short-term memory, multi-tasking, mental flexibility,
sustained attention and motivation, and learning from feedback. Sarah committed 131 errors out of
208 cards. She easily exceeded the 65+ error criterion for severely impaired executive functioning.
Sketch of Sarah
Trail Making Test: A measure of executive functioning involving working memory and multi-tasking.
On Trails A, Sarah was asked to connect numbers 1-25 in order as quickly as possible using a pencil.
She connected the numbers without error, but her completion time was 1 minute, 47 seconds. The
average person takes less than 27 seconds to complete. On Trails B, Sarah was asked to alternate
between numbers in their numerical order and letters in alphabetical order, i.e., 1-A-2-B-3-C, etc.,
using a pencil. Her completion time was 4 minutes, 25 seconds. The average person takes less than 66
seconds.
Executive Function Supports: Sarah will have difficulty keeping track of two conversations
simultaneously, therefore, in group situations, speak to Sarah one at a time rather than
engage in simultaneous conversations with her.
Sarah will have difficulty keeping verbal and visual details in-mind at the same
time. She will most likely pay attention to what she sees (visual information) because it is
more salient to her than verbal information.
Introduce new tasks by either verbally walking her through the steps or provide
visual demonstration, but not both simultaneously.
a
Sketch of Sarah
Diagnostic Impressions from Neuropsychological Testing:
PTSD
ADHD
Cognitive Disorder NOS (Neurocognitive Disorder)
Mathematics Disorder
Impulse Control Disorder
Mild Intellectual Disability
Histrionic Personality traits
Implications for Therapy
Identify sexual arousal levels: Utilizing concrete terms of high, medium, and low and what that
means to her.
Traumatic Event Timeline: Using social stories and anniversary dates.
Relationships: Identify the differences between healthy relationships and abusive relationships.
Self-Soothing Skills: Deep breathing, guided imagery, muscle relaxation exercises, Emotional
Freedom Tapping, Butterfly Bilateral Stimulation Tapping, Peaceful place – using 5 senses.
Therapeutic Part Work: Utilizing her good parts, e.g., Caring and Responsible, to overcome the
trouble maker parts, e.g., Nasty, Stealing, and Sneaky.
Sketch of Sarah
Eye Movement Desensitization and Reprocessing (EMDR)
Adapting the protocol to work on one stage at a time for each traumatic event:
Memory only (Taking a ride along)
Level of disturbance using a drawing of a faces instead of likert scale
Body sensations
Emotions – each one separately
Negative cognition
Putting it all together
Positive cognition
Current Status:
Sarah is no longer on Lorazepam and has decreased her Paxil to 20 mgs.
She can identify the difference between healthy and unhealthy relationships and makes
appropriate decisions when developing friendships.
She now has 3 hours of alone time at home.
Sarah is participating in co-ed group activities at day program at least one time a month with no
problems.
Sarah can process traumatic events using the complete EMDR protocol without adaptations.
ACKNOWLEDGEMENTS
We express our heartfelt appreciation
to our clients, from whom we have
learned so much over the years.
• Greg Thaler may be reached at
[email protected]