Summaries: the best scientific articles for clinical neuropsychology and rehabilitation neuropsychology summarized

What is the purpose of a feedback model?

Medical staff often fear conversations about a patient's effort due to the potential or interpersonal conflict with the patients. Even so, doctors have an obligation to provide an explanation about the assessment results. Therefore the potential harm to both patient and society when malingering, poor effort or exaggeration take place outweigh the experienced discomfort by the doctor in a feedback session. This feedback model described in this article is useful for patients in a clinical setting, when providing feedback regarding test performance, effort testing, response bias and exaggeration of symptoms.

How does exaggeration differ from malingering?

Exaggeration is not the same as malingering, although malingering always includes exaggeration. Exaggeration refers to one specific symptom that can occur independent of effort test failure and independent of malingering per se.

How does the symptom validity feedback model work?

The symptom validity feedback model can be divided into three phases.

Phase 1: Developing an effective working relationship and obtaining informed consent

In the first phase trust must be established so patients will more easily accept feedback about uncomfortable topics. When the patient provides questionable information, the model advises to challenge the information in a non-judgmental, respectful manner. However, patients should know the examiner will not blindly believe everything that the patient says and they should be made aware of the consequences of symptom exaggeration or poor effort on tests. Informed consent must be obtained from the patient. Patients should not be told which tests will be used to assess effort and honesty.

Phase 2: Completion of the evaluation

If test results show evidence of suboptimal effort, the examiner should decide whether it is useful to continue with the evaluation and how willing the patient is to acknowledge the poor effort. Patients are more likely to admit they are not fully invested than that they are faking or lying, and are more willing to admit that when disapproving terms are being avoided. If a patient does not want to acknowledge suboptimal effort, the topic can be discussed again later in another session. By holding the feedback session on another day the examiner has time to integrate the information and find the best approach.

Phase 3: The feedback session

The feedback session can be started by asking how the patient thinks he performed on the tests. This encourages patients’ values and decreases their anxiety for the results. When discussing the results, the examiner should start with the good test scores. When discussing the lower scores, the examiner should point out that the conclusions are based on objective data, not on a subjective impression. Elaborate the fact that in order to perform this poor on a test, while you know they have no neurological condition, there must be a non-neurological explanation for the results. Inform them the scores can be improved if the non-neurological factors are addressed (a form of good news), for example with psychotherapy. If a patient does not follow through with these recommendations, this is clinically informative. Keep basing your findings on data and facts, try to avoid an accusative tone and consist with the approach of building an effective working relationship. After the feedback has been provided, debrief the patients by asking how they feel about the information they received. Document the feedback session, including the patient’s responses and reactions

How does one use terms like malingering and exaggeration?

It is very important to carefully explain the meaning of the terms to prevent misinterpretation. For instance, it is useful to inform the patients that there are many factors that can cause an exaggerated presentation and that the term does not necessarily equate to willful deceit (although this may very well be the case). When using the term malingering, use the evidence which provides a high degree of diagnostic confidence. It is not useful to solely use the term malingering. Clinical services are encouraged to provide the patient’s motives for malingering and to suggest relevant treatment options.

How does one handle aggressive, defensive or resistant reactions and complaints?

Factors which affect how patients respond are their personality traits, expectations, and perception of the stakes of the evaluation. The sensitivity and empathy level of the examiner also influences the patient’s response. By anticipating and preparing for resistant reactions, for instance by planning ahead, not giving in to intimidation, and remaining open to explanations, neuropsychologists can improve the chances for a reasoned and tempered reaction.

Should patients be allowed access to their mental health file?

Opinions about providing a copy of the neuropsychological assessment report differ. Although the law typically grants patients access to their medical and mental health files, neuropsychologists have the right to withhold reports. This is permitted when providing a copy of the report would cause significant harm to the patient. This has to be determined for each case individually.

How to deal with the official complaint of a patient?

If a patient feels like filing a complaint after following all the steps of the feedback model, there isn’t much more to be done for a neuropsychologist. It is advisable to save a copy of the complaint in writing, because they might contain inaccurate information or inflammatory language that can be used in the neuropsychologist’s defense. Complaints are most likely to occur when the access to external gain is blocked for the patient by the neuropsychologist’s report. It can be useful to routinely collect patient satisfaction surveys, because it is likely these data will show that the vast majority of patients are satisfied with the provided service. There are two important issues that psychologists can use in their defense:

1. The patient provided informed consent for the evaluation and was aware of the possible consequences.
2. The conclusions in the report are primarily based on objective, empirically derived data.

In any case, the neuropsychologist should provide the members of the investigating body with a copy of the American Academy of Clinical Neuropsychology’s position paper handling ethical complaints during adversarial proceedings. This paper specifically focuses on the possible self-interested motives of those who file the complaints.

Aphasia refers to an impairment of language, affecting both the production or comprehension of speech and the ability to read or write.

Assessment of aphasia

Assessment of aphasia can serve several purposes:

1. To determine the underlying language disorder using a hypothesis-testing manner. 
2. To identify the functions in which any residual skills are observed, because these functions possess the highest probability of progression.
3. To determine a baseline for which the impact of severe aphasia on the different functioning levels of the ICF and on the quality of life is assessed.
4. To screen for the presence of non-linguistic disorders. Many persons with severe aphasia have comorbid non-linguistic disorders.
5. To look for prognostic factors. Next to the nature, localisation, and size of the injury, there are other factors important for predicting the outcome of recovery, such as whether executive functions are intact or not.  

According to the authors of this article, traditional assessment in persons with severe aphasia consists of a couple of important disadvantages: (1) is is frustrating for both parties; (2) it often is little informative, and; (3) it is not adapted to frequently occurring comorbid disorders. Traditional assessment almost always focuses on detecting disorders within a strongly controlled, non-interactive setting. Yet, we know from clinical practice that persons with severe aphasia often function better in a natural context. In sum, traditional assessment instruments yield problems regarding frustration, sensitivity, and validity. To overcome these issues, dynamic assessment is proposed. With dynamic assessment, the examiner is no longer an observer, but instead incorporates the role of supportive communication partner. In this article, the concept of dynamic assessment is illustrated using the workbook GLOBAMIX.

A static assessment instrument is characterised by a strict protocol regarding the administration and scoring rules. The examiner should play a neutral role. As the word already implies, a static assessment aims at assessing the static performance of the present functioning of an individual. 

In contrast, a dynamic assessment instrument is characterised by an interactive approach of assessment with an individual and experimental nature. The examiner is no longer an observer. Instead, the examiner changes to being an active participant. Active efforts are conducted to determine the effect of factors such as strategies, task adaptions, context factors, and contextual support on the outcomes. The learning potential of the participant and his or her maximum level of performance are under study. Dynamic assessment is in particular suitable for complex groups including people with severe and multiple disorders. 

GLOBAMIX is developed for the dynamic assessment of persons with both fluent and non-fluent aphasia. The ultimate goal is to identify residual skills and to explore perspectives for the treatment and guidance. Both linguistic and non-linguistic skills are assessed, as both play a role in the functional communication and the possibility of compensation (strategies and aids). In addition, some supportive and contextual factors are identified. It is important to know that GLOBAMIX is not a test, but a toolbox with material for holistic, dynamic assessment. It is not a replacement of existing assessment instruments, but an addition to yet existing material. GLOBAMIX is developed from the following four basic principles: 

1. Primum non nocere: first and foremost, do not harm. People with severe aphasia are very limited in their interactions and therefore need an examiner that is supportive and collects information with minimal frustration. 
2. Acknowledge competence and reveal competence. 
3. A bio psychological vision on assessment, aiming for a more holistic approach than is offered by the ICF.
4. It is both based on scientific evidence (evidence-based practice) and clinical experience (practice-based evidence).

Recommendations

Finally, some recommendations on how to implement the principles of dynamic assessment in assessment for persons with severe aphasia:

• Spread the tasks over several sessions.
• Provide enough practice items. 
• Provide enough difficulty levels.
• Look for discrepancies in functioning of the individual.
• Stop the task if there is too much frustration.
• Take input disorders into account.
• Support language comprehension by giving instructions.
• Ask as little as possible for verbal responses.
• Determine the most adequate yes/no response.
• Use labelled yes/no questions.
• Provide a pointing stick.
• Use manipulable stimuli.
• Provide cues for incomplete, wrong, or absent responses.
• Evaluate the effectiveness of given cues.
• Determine the learning potential of the individual.
• Conduct an elaborate qualitative analysis.

Conclusion

To conclude, assessment of persons with severe aphasia is challenging. We know from experience that elaborate dynamic assessment according to the above described principles can offer an important contribution to identify the residual skills and learning potential of the individual. This information is important for the treatment and guidance of both the person and his or her environment. Next to theoretical insight, the authors hope to provide practical material to the field by means of GLOBAMIX. Deficits are diagnostic and positive performance is prognostic. 

What is aphasia?

Aphasia is a language disorder resulting from brain damage. Aphasia can occur simultaneously with dysarthria. Dysarthria is an articulatory disorder resulting from paralysis and / or verbal apraxia (a disorder in programming articulatory movements). This distinction cannot always be made clear in clinical practice. The following classical aphasia types that have clinical value can be distinguished: Broca's aphasia, Wernicke's aphasia, amnestic aphasia, global aphasia, conduction aphasia and sensory aphasia.

Which disorders related to the basic linguistic components can be distinguished?

Language has three basic linguistic components that can be individually or simultaneously impaired:

• Semantics (meaning). A semantic disorder is manifested in semantic paraphasia and misunderstanding of content words.

• Phonology (sound). A phonological disorder is mainly expressive and is characterized by phonemic paraphasia. The input route can also be disturbed, for example if 'leg' is understood as 'boat'.

• Syntax (sentence formation). In a syntactic disorder, someone speaks and writes in a telegram style and there are problems understanding complex sentence constructions, such as passive and compound sentences.

How is the presence of aphasia diagnosed?

A speech therapist uses certain measuring instruments to determine the presence, nature and severity of aphasia and to investigate the characteristics of the aphasia. The diagnosis focuses on the demonstration of disorders in the various language modalities and in the basic linguistic components and is important for cognitive-linguistic therapy.

Which test instruments are regularly used when investigating a language disorder as a result of brain damage?

• On the basis of 'Analysis Spontaneous Language', insight can be obtained into functional verbal communication and the spontaneous language can be assessed objectively. This can provide leads for follow-up research and setting up a therapy.

• The 'Boston Appointment Task' is used to diagnose word-finding disorders, to determine the course of aphasia and / or to evaluate the effect of therapy.

• The 'Semantic Association Test' serves to diagnose verbal and / or visual semantic disorders as a possible cause of a word-finding disorder. This can help set up follow-up treatment.

• The 'Token Test' distinguishes persons with brain injuries with aphasia from persons with brain injuries without aphasia.

What does the treatment of a person with aphasia look like?

The treatment of a patient with aphasia focuses on different levels, namely the function level, activity level and participation level. Treatment takes into account the patient's environmental and personal factors.

• At the function level, therapy focuses on restoring the language functions.

• At the activity level, the therapy focuses on the individual skills and competences of the patient in order to maintain oneself in social situations.

• At the participation level, it is about the actual implementation of communicative activities during the fulfilment of a social role.

How effective is aphasia therapy?

When looking at the effectiveness of aphasia therapy, the focus is on the content of the therapy, the intensity of the therapy and the timing. Research shows that early use of intensive cognitive-linguistic therapy in patients with aphasia as a result of brain injuries does not affect the quality of verbal communication. It also appears that semantic and phonological therapy can have a therapy-specific effect on verbal communication. Finally, there are no indications that cognitive-linguistic therapy can facilitate the generation of words according to a given concept (important for the word discovery). 

What is recommended when a person develops aphasia as a result of brain injury?

When a person develops aphasia as a result of a brain injury, it is not necessary to immediately apply an intensive cognitive-linguistic therapy aimed at the word discovery. It is better to wait for the spontaneous recovery and to investigate the more stabilised aphasia well. Then a therapy can be applied that is more tailored to the patient. In the acute phase, attention can first be paid to counselling and optimising communication between the patient and his or her loved ones.