Table 3: Neurodevelopmental domains: criteria for severe impairment

Size: px

Start display at page:

Download "Table 3: Neurodevelopmental domains: criteria for severe impairment"

Theresa Williams
5 years ago
Views:

1 Table 3: Neurdevelpmental dmains: criteria fr severe impairment 1. Brain Structure / neurlgy Definitin Direct/indirect assessment Cnsideratins Brain structure and neurlgy includes: Abnrmal ccipitfrntal head circumference Structural brain abnrmalities Seizure disrder nt due t knwn pstnatal causes Significant neurlgical diagnses therwise unexplained Severe impairment is present when ne r mre f the fllwing are identified: Occipitfrntal head circumference is <3 rd PC r 2 SD Fr premature infants OFC shuld be crrected fr gestatinal age until 2 years f age Structural brain abnrmalities knwn t be assciated with prenatal alchl expsure are shwn n brain imaging i Examples include: Reductin in verall brain size Crpus callsum (agenesis, hypplasia) Cerebral crtex (reduced gyrificatin r anterir cingulated crtex surface area) Reductin in vlume in specific areas: cerebellum, hippcampus, basal ganglia caudate Seizure disrder in which ther aetilgies have been excluded. Significant neurlgical diagnses therwise unexplained are identified e.g. cerebral palsy, visual impairment, sensrineural hearing lss when ther aetilgies have been excluded Micrcephaly There are many ther causes f micrcephaly which shuld be excluded, including familial micrcephaly, chrmsmal abnrmalities, intrauterine infectin r expsure t teratgens ther than alchl. These causative factrs may be identified in additin t PAE. When pssible, parental head circumference shuld be measured. Investigate as clinically indicated. Guide t the Diagnsis f FASD Table 3 Neurdevelpmental dmains: criteria fr severe impairment pages 22-32

2 In sme circumstances a child may have reliable past dcumentatin f an OFC <3 rd percentile, but at the time f assessment the OFC is >3 rd percentile. In this situatin, clinical judgement shuld be used t judge whether this discrepancy reflects persistent micrcephaly r may reflect measurement errr. Neurimaging Brain imaging such as MRI is nt required fr a diagnsis f FASD, but is recmmended when clinically indicated e.g. by the presence f micrcephaly r macrcephaly that is nt familial; lcalising neurlgical signs; fcal seizure disrder; r signs f neurdegenerative disrder. 2. Mtr Skills Definitin Mtr skills include fine mtr skills (manual dexterity, precisin), grss mtr skills (balance, strength, c-rdinatin, ball skills and agility), graphmtr skills (handwriting) and visu-mtr integratin (VMI). (44, 45) Indirect assessment Severe impairment in mtr skills is present when n a validated test f mtr skills: a cmpsite scre is belw the clinical cut-ff; r 1 r mre majr subdmain scres (grss mtr skills; fine mtr skills; graphmtr skills; and visu-mtr integratin) is/are belw the clinical cut-ff (e.g. grss mtr and fine mtr skills can be scred separately using the BOT-2). (39) Examples f standardised tests: Bruininks-Oseretsky Test f Mtr Prficiency (BOT-2); (40) (grss mtr and fine mtr); 4y-6y. Berry-Buktenica Develpment Test f Visual-Mtr Integratin (VMI); (32) (visual mtr integratin); 2y - adult. BOT-2 (40) (grss mtr and fine mtr); 6y- 21y. Mvement Assessment Battery fr Children 2 nd Ed (Mvement-ABC 2) (45) 3y- 16y 11m Clinical assessment may prvide supprting evidence f severe impairment: e.g. reprt f prblems with balance, crdinatin. Guide t the Diagnsis f FASD Table 3 Neurdevelpmental dmains: criteria fr severe impairment pages 22-32

3 Abnrmal tne, reflexes, strength, sft neurlgical signs (46) and ther findings n the neurlgical examinatin may be cnsidered in cmbinatin with direct assessment f mtr skills using a standardised assessment tl. Clinical evidence f impairment in speech articulatin r ral-mtr functin may be cnsidered in cmbinatin with direct assessment f mtr skills. Cnsideratins Fr mtr skills, significant functinal impairment may be evident in learning and play when mtr skill levels are at 1 standard deviatin belw the mean ( 16 th centile). If this is dcumented during assessment it is imprtant t ensure adequate therapeutic supprts are in place, even if criteria fr severe impairment ( 2SD r <3 rd PC) are nt met. As therapeutic appraches differ significantly fr different cmpnents f the mtr dmain (e.g. grss mtr versus fine mtr) it is preferential t use a mtr assessment (e.g. BOT-2) (39) which prvides separate cmpsite scres fr grss and fine mtr functin t infrm therapy. An verall mtr cmpsite scre may hide an individual s relative strengths and weaknesses. Musculskeletal based structural defects may als need t be cnsidered fr their impact n the mtr dmain e.g. lack f cmplete extensin f ne r mre digits, decreased supinatin/prnatin at the elbws, ther jint cntractures including inability t cmpletely extend and/r cntract at the hips, knees, and ankles. (47) 3. Cgnitin Definitin Cgnitin includes IQ, verbal and nn-verbal reasning skills, prcessing speed, and wrking memry. Severe impairment is present when standardised tests f cgnitin r intelligence shw: a cmpsite scre belw the clinical cut-ff - e.g. full scale IQ <70; r a majr subdmain scre belw the clinical cut-ff e.g. fr the WISC (34) this includes Verbal Cmprehensin, Visual Spatial, Fluid Reasning, and Prcessing Speed r there is a significant discrepancy amng majr subdmain scres. Examples f standardised tests: < 6 years Wechsler Preschl and Primary Scale f Intelligence (WPPSI-IV) (34); 2y 6m - 7y 7m Guide t the Diagnsis f FASD Table 3 Neurdevelpmental dmains: criteria fr severe impairment pages 22-32

4 Cnsideratins Stanfrd-Binet Intelligence Scales (SB-5); (48) 2y - 85 y Differential Abilities Scales (DAS-II) (49); 2y 6m - 17y 11m Wechsler Nn-Verbal Scale f Ability-II (WNV-II); (50) up t 21 y > 6 years Wechsler Intelligence Scales fr Children (WISC-V ANZ)(35); 6y - 16y 11m Stanfrd-Binet Intelligence Scales (SB-5); (48); up t 85 y Wechsler Adult Intelligence Scale (WAIS-IV) (35); y Differential Abilities Scales (DAS-II); (49); up t 17 y Universal Nnverbal Intelligence Test (nn-verbal test) (37); 5-21y 11m Wechsler Nn-Verbal Scale f Ability (WNV); (50) 4-21y Naglieri Nnverbal Ability Test - Secnd Editin (NNAT-2) (51) 4-18 y Individuals wh fulfil criteria fr an Intellectual Disability, by definitin, typically will have impairment in 3 dmains f neurdevelpment as defined fr FASD criteria (e.g. Cgnitin, Adaptive behaviur, Language, Mtr skills). If wrking memry alne is severely impaired (belw the clinical cut-ff), this shuld be cnsidered evidence f impairment in the Executive functining dmain rather than in the Cgnitin dmain. A test that is independent f language and culture may be apprpriate fr certain ppulatins (see Cultural and Linguistic Cnsideratins, Sectin B). 4. Language Definitin Language includes expressive and receptive language skills. Severe impairment is present when: a cmpsite scre assessing cre language, receptive language, and/r expressive language is belw the clinical cut-ff; r there is a significant discrepancy between receptive and expressive cmpsite scres; r there are 2 r mre scres belw the clinical cut-ff n subtests assessing higher-level language skills (i.e. the integrative aspects f language such as narrative and cmplex cmprehensin abilities) Examples f standardised tests: Clinical evaluatin f language fundamentals (CELF-4);(52) 5y - 21y 11m Pre-Schl Language Scales, 5 th Ed (PLS-5); (53) birth - 7y 11m Guide t the Diagnsis f FASD Table 3 Neurdevelpmental dmains: criteria fr severe impairment pages 22-32

5 5. Academic Achievement Cnsideratins Definitin Indirect assessment Cnsideratins This dmain shuld be assessed as if it is a single entity.. It is inapprpriate t use scres n verbal IQ sub-tests as a measure f bth language and cgnitin. When pssible, testing shuld be dne in the individual s first language. Specific tests may be available e.g. fr sme Indigenus languages. Clinical judgment regarding severity f impairment is required if: testing is nt standardised testing is nt in an individual s first language direct assessment is nt pssible. Prblems with phnlgical awareness may impact n language and if present may cntribute t impairment in this dmain. Academic achievement includes skills in reading, mathematics, and/r literacy (including written expressin and spelling). Severe impairment is present when standardised measures f reading, mathematics, and/r literacy shw: a cmpsite scre belw the clinical cut-ff; r a significant discrepancy between cgnitin and either reading, mathematics, and/r written expressin. Examples f standardised tests: Wechsler Individual Achievement Test (WIAT II) (54) 4y- adult Wdcck Jhnsn Achievement Test (WJAT-III) (55) 4y- adult The fllwing infrmatin can be used as supprting evidence fr severe impairment: The Natinal Assessment Prgram Literacy and Numeracy (NAPLAN) test results (54) Schl semester reprts with achievement levels The clinical team must determine whether the individual has had adequate access t and attendance at schl r alternative instructin and/r remedial interventin befre a deficit can be recrded. Cnsideratin must als be given t the individual s educatinal placement i.e. mainstream versus educatinal supprt class and pprtunity e.g. remte lcatin, multi-lingual Guide t the Diagnsis f FASD Table 3 Neurdevelpmental dmains: criteria fr severe impairment pages 22-32

6 setting, new immigrant. Even if the Full Scale IQ is belw 70 (indicating impairment f Cgnitin), impairment can als be given in the dmain f Academic Achievement as cgnitive and academic skills d nt necessarily directly crrelate (e.g sme individuals with mild intellectual disability perfrm in the lw average range academically). Bth dmains shuld be tested and cnsidered separately. If an individual has a Specific Learning Disrder accrding t DSM-5 (30) they fulfil criteria fr severe impairment in academic achievement, prviding testing shws evidence f impairment at clinical cut-ff f at r belw 2SD. Prblems with phnlgical awareness may impact n academic achievement and if present may cntribute t impairment in this dmain. 6. Memry Definitin Memry includes verall memry, verbal memry, and visual memry Cnsideratins Severe impairment in memry is present when: a cmpsite scre fr verall memry and/r verbal memry, and/r visual memry scre is belw the clinical cut-ff;=r there is a significant discrepancy between verbal and nnverbal memry Examples f standardised tests: Develpmental Neurpsychlgical Assessment (NEPSY-II) (55), Memry and Learning sub-tests; 3-16 years Wide Range Assessment f Memry and Learning, 2 nd Editin (WRAML-II); (56) 5-90 years Children s Memry Scale (CMS), (57) 5-16 years A deficit in wrking memry shuld be cnsidered in the Executive Functin, including impulse cntrl and hyperactivity rather than Memry dmain. 7. Attentin Definitin Attentin has several cmpnents: i) selective attentin (i.e. fcusing n a particular stimuli) ii) divided attentin (i.e. attending t 2 r mre stimuli at the same time) iii) alternating attentin (i.e. switching fcus frm ne stimuli t anther) Guide t the Diagnsis f FASD Table 3 Neurdevelpmental dmains: criteria fr severe impairment pages 22-32

7 iv) sustained attentin (i.e. attending fr a lng perid f time and resistance t distractins). Attentin deficits usually manifest as prblems with cncentratin, task fcus and wrk rganisatin. In many definitins and theries f brain functin, attentin verlaps with sme f the executive functins. In rder t distinguish these dmains fr diagnstic purpses in FASD, attentin has been defined separately. Deficits in inhibitin, impulse cntrl r hyperactivity shuld be cnsidered in the dmain f Executive functin, Impulse cntrl and Hyperactivity rather than Attentin. Indirect assessment Severe impairment in attentin is present n direct assessment when tw r mre subtest scres are belw the clinical cut-ff n cntinuus perfrmance tests r ther neurpsychlgical measures f selective, divided, alternating r sustained attentin. Examples f standardised tests: Cnner s Cntinuus Perfrmance Test: 3 rd Ed (58); y Test f Everyday Attentin fr Children (Tea-CH) (59); 6-16 y Delis-Kaplan Executive Functin System (DKEFS) (60) i.e. Trail Making Test, Clur/Wrd Interference; 8-89 y Develpmental Neurpsychlgical Assessment (NEPSY-II)(55), Attentin subtests; 3-16 y Children s Clur Trails Test (61) ; 8-16 y Adult Clur Trails Test; (62) y Severe impairment in attentin by indirect assessment is present when tw r mre assessments prvide cnverging evidence f impairment e.g.: clinical interview by different prfessinals scres at r belw the clinical cut-ff n standardised bserver rating scales e.g. Cnnrs 3 (parent, teacher r self-reprt) (58) file review direct clinical bservatin during neurdevelpmental testing Examples f standardised rating scales: Cnners 3 rd Editin (Cnners 3) (58); 6-18y Guide t the Diagnsis f FASD Table 3 Neurdevelpmental dmains: criteria fr severe impairment pages 22-32

8 8. Executive Functin, including impulse cntrl and hyperactivity Cnners Adult ADHD Rating Scales (CAARS) (63); y Achenbach schl-age scales - Child Behaviur Check List (CBCL), Teacher Reprt Frm (TRF), Yuth-Self Reprt (YSR) (64); 6-18y Cnners Cmprehensive Behaviur Rating Scales (CBRS) (65); 6-17y 11m Cnsideratins A diagnsis f Attentin Deficit Hyperactivity Disrder (ADHD) based n DSM-5 criteria (30) either inattentive r cmbined presentatin - fulfils criteria fr severe impairment in the dmain f Attentin. Valid direct r indirect assessment methds and cut-ffs shuld be used t make this diagnsis. ADHD hyperactive-impulsive presentatin cntributes t impairment in the Executive functin, including impulse cntrl and hyperactivity dmain. Definitin Direct tests f attentin which are part f testing in ther dmains (e.g. WISC, memry testing) can be used as evidence f impairment. When indirect and direct tests f attentin d nt cncur, clinical judgment is required t determine whether severe impairment exists. Cnsideratin that indirect assessment may better reflect attentin deficits in real life situatins (e.g. at wrk r in schl) may be pertinent. Executive functin refers t a set f higher-level skills invlved in rganising and cntrlling ne s wn thughts and behaviurs in rder t fulfil a gal with maximum efficiency. Fr the purpses f FASD diagnstic criteria, the dmain f Executive Functin includes impulse cntrl and inhibitin respnse, hyperactivity, wrking memry, planning and prblem slving, shifting and cgnitive flexibility. While in many definitins and theries f brain functin attentin verlaps with sme f the executive functins, they have been defined separately fr diagnstic purpses in FASD. Impulse cntrl deficits are characterised by actins withut frethught, which ften have ptential fr harm t self r thers. Hyperactivity is characterised by inapprpriate and excessive levels f mtr activity r speech. Severe impairment in executive functin and/r impulse cntrl by direct assessment is present when at least tw r mre subtest scres belw the clinical cut-ff are btained n neurpsychlgical measures f executive functin (which ften assess impulse cntrl). Examples f standardised assessment tls: Guide t the Diagnsis f FASD Table 3 Neurdevelpmental dmains: criteria fr severe impairment pages 22-32

9 Indirect assessment Cnsideratins Develpmental Neurpsychlgical Assessment (NEPSY-II) (55) Executive Functining sub-tests frm 3-16 y Delis-Kaplan Executive Functin System (DKEFS) (60) frm 8-89 y Rey-Osterrieth Cmplex Figure (ROCF) (66) Severe impairment in executive functin and/r impulse cntrl by indirect assessment is present when a clinical assessment prvides cnverging evidence f impairment frm multiple surces, including scres at r belw the clinical cut-ff n standardised rating scales and supprting evidence frm clinical interview, file review and direct clinical bservatin during neurdevelpmental testing. Examples f standardised rating scales: Behavir Rating Inventry f Executive Functin (BRIEF-II) (67); 5 18y Cmprehensive Executive Functin Inventry (CEFI) (68); 5-18y Frntal Systems Behaviur Scale (FrsBe) (69);18-95 y Hyperactivity is measured n rating scales which als measure attentin prblems, as listed fr indirect assessment in the Attentin dmain (e.g. Cnners 3) (58). A diagnsis f Attentin Deficit Hyperactivity Disrder (ADHD) either cmbined r hyperactiveimpulsive presentatin - based n DSM-5 criteria (30), des nt fulfil criteria fr severe impairment in the dmain f Executive functin, including impulse Cntrl and hyperactivity Dmain. Additinal evidence is required frm ther indirect and direct assessments t fulfil criteria fr severe impairment. Assessment may shw a discrepancy between direct and indirect tests in this dmain due t the varying cnceptualisatins f executive functin and related tests. In the situatin where indirect tests shw impaired scres but direct tests scres are nrmal, significant weight shuld be given t the indirect assessments, as they are a mre valid measure f functinal brain impairment in this dmain. Hence, if tw r mre standardised rating scales (e.g. bserver and self-reprt r tw bservers) are belw clinical cut-ff, then the Executive Functin, Impulse Cntrl and Hyperactivity dmain is cnsidered severely impaired. Guide t the Diagnsis f FASD Table 3 Neurdevelpmental dmains: criteria fr severe impairment pages 22-32

10 9. Affect Regulatin Definitin Affect regulatin includes md and anxiety disrders. 10. Adaptive Behaviur, Scial Skills, r Scial Cmmunicatin Indirect assessment Cnsideratins Definitin Nt pssible Severe impairment in affect regulatin by indirect assessment is present when an individual meets the DSM-5 (30) criteria fr: Majr Depressive Disrder (with recurrent episdes) Persistent Depressive Disrder Disruptive Md Dysregulatin Disrder (DMDD) Separatin Anxiety Disrder Selective Mutism, Scial Anxiety Disrder, Panic Disrder, Agraphbia, r Generalised Anxiety Disrder. Clinicians shuld frmally ascertain that the individual meets criteria rather than assign a diagnsis n the basis f clinical impressin r data frm rating scales alne. Standardised rating scales which may assist diagnsis include: Spence Children s Anxiety Scales (SCAS); (70) 8-15y Behaviur Assessment System fr Children-III (71); 2-21y Beck Yuth Inventries, 2nd Editin (BYI-II) (72) Children s Depressin Inventry 2 (CDI-2), (73)7 17y Multidimensinal Anxiety Scale fr Children 2nd Editin (MASC 2) (74) Care shuld be taken t dcument lngstanding dysregulatin rather than a shrt-term respnse t unfavurable life events r envirnmental cnditins (e.g. multiple fster placements). Fr the purpse f FASD diagnses, children wh meet criteria A t F fr the Disruptive Md Dysregulatin Disrder may be cnsidered t have impairment in this dmain. This diagnsis cannt be frmally made until children are >6 and <18 years f age and the nset f symptms must ccur befre the age f 10 years. Adaptive behaviur is defined as the life skills which enable an individual t live independently in a safe and scially respnsible manner, and hw well they cpe with everyday tasks. These include: (30) Cnceptual skills - language, reading, writing, math, reasning, knwledge, and memry Guide t the Diagnsis f FASD Table 3 Neurdevelpmental dmains: criteria fr severe impairment pages 22-32

11 Scial skills - empathy, scial judgment, interpersnal cmmunicatin skills, the ability t make and retain friendships Practical skills - self-management in areas such as persnal care and daily living skills, jb respnsibilities, mney management, recreatin, and rganising schl and wrk tasks. Scial cmmunicatin is a critical cmpnent f adaptive functin but can be assessed separately. Indirect assessment Severe impairment in scial cmmunicatin by direct assessment is present when a cmpsite scre measuring scial language, scial cmmunicatin skills r pragmatic language skills is belw the clinical cut-ff. Examples f standardised assessment tls fr individuals >6 years f age: The Scial Language Develpment Test Elementary (SLDT-E) (75); 6y - 11y11m The Scial Language Develpment Test Adlescent (SLDT-A) (76); 12y - 17y11m Severe impairment in adaptive behaviur, scial skills r scial cmmunicatin by indirect assessment is present when, accrding t a standardised interview r rating scale cmpleted by a key infrmant a: Cmpsite scre is belw the clinical cut-ff r a majr subdmain scre is belw the clinical cut-ff Fr children and mst adlescents, standardised bserver rating scales fr adaptive functin (typically fr caregiver and/r teacher) shuld be used, althugh this may nt be pssible e.g. fr a child in detentin. Examples include: Vineland Adaptive Behaviur Scales, 2 nd Ed (32) (VABS-II); birth - 90 y Adaptive Behaviur Assessment System (ABAS-III); (77) birth - 89y Behaviur Assessment System fr Children 3 (BASC-3) (77); 2-21 y Pragmatic Language Observatin Scale (PLOS) (78); 8 17y 11m Children s Cmmunicatin Checklist, 2 nd Editin (79); child and adult versins available. Clinical Evaluatin f Language Fundamentals (CELF-4 Australian) (52) Pragmatics Prfile; 5-21y 11m Guide t the Diagnsis f FASD Table 3 Neurdevelpmental dmains: criteria fr severe impairment pages 22-32

12 Observatin by a speech pathlgist f the individual interacting with their peers in institutinal, schl r family settings may als prvide supprting evidence f impairment. Special cnsideratins Severe impairment in scial skills and scial cmmunicatin is present when n frmal testing an individual meets the DSM-5 (30) criteria fr: Autism Spectrum Disrder Scial (Pragmatic) Cmmunicatin Disrder When individuals individual meet DSM-5 criteria fr Cnduct Disrder and/r severe Oppsitinal Defiant Disrder, this prvides supprting evidence fr impairment in the Adaptive behaviur, Scial skills r Scial cmmunicatin dmain hwever the individual still needs t meet ther criteria demnstrating severe impairments in multiple aspects f scial, practical and cnceptual functin (e.g. n Vineland Rating Scales). In sme lder adlescents and adults, indirect assessment can be cmplicated and additinal cnsideratins apply (see belw). Older adlescents and adults Fr lder adlescents r adults, a standardised, indirect rating scale fr adaptive behaviur is preferred wherever pssible and may be required fr eligibility fr sme services and financial supprt. Alternative assessment methds may be required fr peple living alne r in an institutinal setting wh have nt had a cnsistent caregiver r partner within the last tw years wh can act as an infrmant. Fr example, assessment f adaptive functin may invlve structured interview, bservatin f self-care and living skills, r use f histrical recrds. Severe impairment is based n clinical judgement that deficits are sufficiently severe t fall belw clinical cut-ff. This might include: Dcumented inability t functin in key aspects n independent living (e.g. inability t manage mney, maintain a husehld f reasnably safety and cleanliness, btain/maintain a jb, uphld persnal hygiene, exhibit scialisatin/cping strategies, care fr children). Guide t the Diagnsis f FASD Table 3 Neurdevelpmental dmains: criteria fr severe impairment pages 22-32

13 Dcumented difficulty in scial cmpetence (e.g. being financially victimised r unintentinally invlved in criminal behaviur due t scial gullibility; chrnic inability t participate successfully in grup treatments and/r grup hme placements). Fr scial cmmunicatin assessment, a direct, age-apprpriate measure shuld be used with the client, in cmbinatin with reprts and histrical infrmatin. Cultural and linguistic cnsideratins shuld be applied if relevant, and testing and interpretatin altered accrdingly. (see Cultural and Linguistic Cnsideratins in Sectin B). Guide t the Diagnsis f FASD Table 3 Neurdevelpmental dmains: criteria fr severe impairment pages 22-32

Neurodevelopmental areas of assessment: criteria for severe impairment

Neurodevelopmental areas of assessment: criteria for severe impairment 1. Brain structure Brain structure and neurology includes: abnormal occipitofrontal head circumference structural brain abnormalities