Psychometric Testing Meets the New Revised Mental Listings: The Attorney s Job Just Got Harder. Ronald Houston, Ph.D.

Transcription

1 Psychometric Testing Meets the New Revised Mental Listings: The Attorney s Job Just Got Harder F Ronald Houston, Ph.D.

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3 Psychometric Testing Meets the New Revised Mental Listings: The Attorney s Job Just Got Harder Section F Psychometric Testing Meets the New Revised Listings: The Attorney s Job Just Got Harder Ronald Houston, Ph.D Neurocognitive Disorder Subtypes All subtypes must meet the criteria for major or mild neurocognitive disorder Alzheimer s. Downward mental deterioration affecting language, memory, and executive functioning. Pre-senile dementia can start in a person s 40s more common in a person s 60s and older. Progressive ending in death 4 to 7 years after diagnosis. Frontotemporal Dementia. Progressive development of behavioral and personality change and/or language change due to atrophy or shrinking of the frontal and temporal lobes in the brain. Unlike in Alzheimer s cognitive decline may be less obvious and formal testing usually shows relatively few deficits in the early stage. More about executive functioning lack of planning and organization, distractibility, and poor judgment. Learning and memory are spared. Lewy Bodies. After Alzheimer s this is the second most common type of progressive dementia. Nerve cells in brain regions involved in thinking, memory, and movement get gummed up by proteins. Vascular. Cerebrovascular disease accounts for the cognitive deficits. Etiology can be large vessel stroke, microvascular disease etc. that result in lesions in the white matter, basal ganglia, and thalamus of the brain. See it on CT and MRI which is good evidence for disability cases. That is not enough, however, as you need neurocognitive testing to assess not only brain structure deficit but severity of functional impairments in attention, memory, executive function, and language. CT and MRI cannot give you this functional information even better than what we see from fmri or functional MRI. Traumatic Brain Injury. Post-concussive syndrome is no longer. It has been replaced by a new diagnostic category in the DSM 5; mild neurocognitive disorder due to traumatic brain injury. Has a new set and very strict criteria. (1) Forcible blow or impact to the head. (2) Loss of consciousness (3) Posttraumatic amnesia immediately following TBI person is confused, disoriented, and unable to recall events, their name, where they are, and what time it is. It is said to be resolved once continuous memory returns. (4) Disorientation and confusion. (5) Neurological signs and symptoms CT, MRI, seizure, hemiparesis, balance etc. (6) Neurocognitive disorder starts immediately after the TBI or recovery from being unconscious and persists past the acute post-injury phase. 135

4 Section F National Social Security Disability Law Conference Substance/Medication-Induced Major or Mild Neurocognitive Disorder. Organic based cognitive impairments because of substance abuse. Induced where neurocognitive impairments persist beyond the usual duration or intoxication and withdrawal. This is very complicated and your brief probably requires a medical expert opinion. Getting rid of Substance addiction disorders is not a good thing for the disability attorney. It now is so loose ALJs have more discretion and greater latitude with the concept contributory. Example is alcohol induced amnestic confabulatory or Korsakoff s. They present with severe problems learning new information with rapid forgetting. ALJ can say alcohol is contributory. But it is a thiamine deficiency due to chronic heavy alcohol abuse. However, stop drinking and take Thiamine in the early stages you get recovery. So no disability there. The person s confusion may take some time to subside, and even incomplete recovery of memory can take up to a year. So 3 or 6 month abstinence is irrelevant because alcohol use even with 3 or 6 month abstinence is still contributing. No disability there. But in the later stages, if damage to the brain is irreversible, individuals are likely to have lasting problems with memory and gait (for example, lack of muscle coordination and numbness or weakness in limbs). Here you have disability because there is a fixed cognitive impairment in the absence of alcohol that is not going to improve. Causation is irrelevant. That is why you need a medical expert or physician to give you an opinion. HIV Infection. Some people with HIV develop neurocognitive disorder. It shows with impaired executive function, slow, processing speed, problems on more demanding attention tasks and learning new information. Pathogenic process can affect any part of the brain. Prion Disease. This is so rare that is unlikely that any disability attorney will encounter it in their practice. Transmissible spongiform encephalopathies (TSEs), also known as prion diseases, are a group of progressive conditions (encephalopathies) that affect the brain and nervous system of many animals, including humans. TSE is transmitted by prions although some data suggests a spiroplasma infection. A prion is a type of protein that can trigger normal proteins in the brain to fold abnormally. Prion diseases can affect both humans and animals and are sometimes spread to humans by infected meat products. Mad Cow disease is the most famous to the public. Mental and physical deterioration because of changes in the brain. Imaging studies show tiny holes where the cortex looks like a sponge. Changes in memory and personality as well movement are chronic and progressively get worse. Creutzfeldt-Jakob disease (CJD), a fatal neurodegenerative disorder, is a classic example of prion disease in humans. Parkinson s Disease. Progressive nervous system disorder that affects movement. Actor Michael J. Fox. Boxer Muhammad Ali. Mild neurocognitive disorder develops in the early stages. Also, get apathy, depressed mood, anxious mood, hallucinations, delusions, and personality changes. Neuropsychological testing is very good at detecting Parkinson related cognitive deficits especially when controlling for the motor component. Since it is a movement disorder tests like Block Design that have a motor component will not say much about cognition. But Visual Puzzles which assesses the same nonverbal cognitive abilities without a motor component will tell a lot. 136

5 Psychometric Testing Meets the New Revised Mental Listings: The Attorney s Job Just Got Harder Section F Huntington s Disease. This is a death sentence. It is hereditary. Nerve cells of the brain gradually breakdown over time and with this deterioration comes decline in physical movements, emotions, and cognitive abilities. Get behavioral disturbance as well including apathy, disinhibition, impulsivity, and poor insight. Motor disturbance including speech and gait to the point of becoming non-ambulatory. Due to Other Medical Conditions. This would include medical conditions such as epilepsy, multiple sclerosis, hepatic encephalopathy, endocrine disorders such as diabetes, infections, cancer treatment, tumors, and neurotoxins. Most Relevant Functional Abilities to Disability Determination Working Memory. Working memory is a foundational cornerstone of higher level cognition that includes memory and executive function. It is essentially a precursor to memory sometimes referred to as a buffer at the earliest stage of information processing. It has a limited capacity, sort of a temporary holding tank or waiting room where incoming information sits and gets immediately processed and manipulated before getting transferred to immediate and short-term memory for deeper processing and then eventually stored in long term memory for later retrieval. It is that first stop or receptacle box in the information processing system where incoming information gets registered and quickly processed to carry out complex cognitive tasks that require following instructions, learning new tasks, reasoning, and decision making. See slide presentation for real life examples of working memory on the job. Processing Speed. Rate that we can take in (1) information, (2) process that information, (3) reach a decision or judgement based on that information, and (4) then act based on the decision made Neurocognitive Disorder where there is acquired brain dysfunction whether it is TBI depending on the nature and extent of the head injury, cerebral vascular accident, epilepsy, or dementia good chance that the claimant will have some slowness in their information processing. White matter changes or lesions can impede transfer of information from axon brain nerve cells. Think of it as electrical wiring and circuits and poor connection (Internet) equals slowed processing. In the case of psychomotor slowing may be one of the first indicators of dementia Neurodevelopmental disorders as well. Research has shown that persons diagnosed with ADHD in addition to working memory deficits can have slowed processing speed. We also see slowing in severe stress related cases where (major depression), 2.06 (anxiety), and (PTSD) may be involved. Factors affecting processing speed: White matter changes. Neurotransmitters. Medications, especially anticonvulsants and atypical neuroleptics such as Zyprexa, Geodon, Seroquel. Sleep. 137

6 Section F National Social Security Disability Law Conference Medical Expert (ME) counter opinion that can offset your processing speed argument. Sleep makes it temporary. Slow processing speed is not an issue on tasks that are already automatic and well-practiced especially when it comes to simple routine repetitive work. See slide presentation for real life job-related disability examples. Executive Function. Higher level of complex brain function than working memory and processing speed. The process is organization, planning, and effective execution of that plan all controlled by the frontal lobes. Involved in inhibiting behavior, flexibly shifting attention, taking behavioral initiative, working memory, organization, planning, and self-monitoring one s behavior. See slide presentation for real life examples of executive dysfunction. Structure Dependence. This is a simple occupational concept but one that is hard to describe using the WAIS-IV subtests Block Design, Matric Reasoning, and Visual Puzzles. Note that each of these 3 subtests measures the same nonverbal reasoning, visual-spatial problemsolving ability. Block Design This is a timed construction task with a motor component where the claimant is given a stimulus picture of a geometric design pattern. They must look at that picture and use it as a model to guide their response as they motorically assemble the blocks in a way that recreates or looks just like the design in the picture. Matrix Reasoning This is not a speed timed test. It does not have a motor component. It involves only mental analysis of visual-spatial relationships and depends on attention, concentration, and persistence. The claimant is presented with an incomplete array of visual patterns or colored matrices with one missing piece in the array. For example, a square followed by a circle followed by a triangle, then a blank, then a circle followed by a triangle. The claimant must select the missing piece that completes the pattern from several different options presented below. In this case it would be a square to continue the established sequence of square circle triangle. Visual Puzzles. Like Matrix Reasoning this is not a speed timed test where the performance score is determined in part on how fast the task is done. It also is not a constructional task and does not have a motor component. It is mental analysis only. So, the claimant is presented with a completed geometric puzzle figure and must select three pieces from a group of pieces below that when mentally put together reconstruct the puzzle in the picture. It is the mental construction counterpart to Block-Design without the motorically assembling the solution. The performance expectation is that the claimant s performance should be relatively equivalent because each of the three subtests assesses the same nonverbal reasoning ability. This is not always the case. In cases of frontal lobe pathology claimants may do well on Block Design (e.g. Scaled Score = 10; Average) and Visual Puzzles (Scaled Score = 8; Average) but poorly on Matrix Reasoning (Scaled Score = 4; well below average -2 sd). The general rule of thumb is that a 3 point or more difference between subtest scaled scores is meaningful or significant. 138

7 Psychometric Testing Meets the New Revised Mental Listings: The Attorney s Job Just Got Harder Section F What you have here is a case of structure dependence. The reason the claimant did well on Block Design is that they had the benefit of external structure which is the stimulus picture containing the solution. All they must do is use the picture as a pattern or reference to guide the correctness of their responses. Visual Puzzles also presents the solution already so half the battle is done. Matrix Reasoning in contrast offers no such structure or salient external cue to facilitate a correct response. The solution is not provided andmust be generated mentally with no obvious available clues. Why this is occupationally important is that it suggests a structure dependence where if there is enough external structure the claimant can compensate for their executive deficit and perform adequately but in the absence of such structure their performance declines. This would could prove helpful in determining what type of employment is suitable and the need for structured sheltered employment with higher levels of supervision. Note the reverse can be true where the claimant does well on Matrix Reasoning and poorly on Block Design. This is also indicative of frontal lobe dysfunction. It means they have the knowledge in their head and now what to do but cannot translate this knowledge into effective action. So it its no the knowing how but executing on their knowledge. Statistical Interpretative Tools 139

8 Section F National Social Security Disability Law Conference Standard Score Scaled Scores % Tile Rank Standard Deviation Classification 150 > 99.9 Very Superior 149 > 99.9 Very Superior Very Superior Very Superior Very Superior Very Superior Very Superior Very Superior Very Superior Very Superior Very Superior Very Superior Very Superior Very Superior Very Superior Very Superior Very Superior Very Superior Very Superior Very Superior 140

9 Psychometric Testing Meets the New Revised Mental Listings: The Attorney s Job Just Got Harder Section F Very Superior Superior Superior Superior Superior Superior Superior Superior Superior Superior Superior High Average High Average High Average High Average High Average High Average High Average High Average High Average High Average Average 141

10 Section F National Social Security Disability Law Conference Average Average Average Average Average Average Average Average Average Average Average Average Average Average Average Average Average Average Average Low Average Low Average Low Average 142

11 Psychometric Testing Meets the New Revised Mental Listings: The Attorney s Job Just Got Harder Section F Low Average Low Average Low Average Low Average Low Average Low Average Borderline 79 8 Borderline Borderline 77 6 Borderline 76 5 Borderline Borderline 74 4 Borderline Borderline 72 3 Borderline 71 3 Borderline Borderline 69 2 Extremely Low Extremely Low 67 1 Extremely Low 66 1 Extremely Low Extremely Low 143

12 Section F National Social Security Disability Law Conference 64 1 Extremely Low Extremely Low 62 1 Extremely Low Extremely Low Extremely Low Extremely Low Extremely Low Extremely Low Extremely Low Extremely Low Extremely Low Extremely Low Extremely Low 51 <0.1 Extremely Low 50 <0.1 Extremely Low MENTAL RFC GRID Mental RFC Processing Speed Working Memory (Attention) Memory Executive Functions Understand and remember simple instructions. Digit Span (Forward) Arithmetic All WSM-IV Subtests Block Design Matrix Reasoning Visual Puzzles 144

13 Psychometric Testing Meets the New Revised Mental Listings: The Attorney s Job Just Got Harder Section F Carry out simple instructions. Symbol Search Coding Trail Making Part-A Digit Span (Forward) Arithmetic All WSM-IV Subtests Block Design Matrix Reasoning Visual Puzzles The ability to make judgments on simple workrelated decisions. Digit Span (Forward) Arithmetic All WSM-IV Subtests Block Design Matrix Reasoning Visual Puzzles Understand and remember complex instructions. Trail Making Part B Digit Span (Backward) Digit Span (Sequencing) Arithmetic All WSM-IV Subtests Block Design Matrix Reasoning Visual Puzzles Carry out complex instructions. Symbol Search Coding Trail Making Part B Digit Span (Backward) Digit Span (Sequencing) Arithmetic All WSM-IV Subtests Block Design Matrix Reasoning Visual Puzzles The ability to make judgments on complex workrelated decisions. Trail Making Part B Digit Span (Sequencing) Arithmetic All WSM-IV Subtests Block Design Matrix Reasoning Visual Puzzles Interact appropriately with the public. Trail Making Part-B Digit Span (Forward, Backward, Sequencing) Arithmetic Trail Making Part B All WSM-IV Subtests Block Design Matrix Reasoning Visual Puzzles 145

14 Section F National Social Security Disability Law Conference Interact appropriately with supervisor(s). Trail Making Part B Digit Span (Forward, Backward, Sequencing) Arithmetic Trail Making Part B All WSM-IV Subtests Block Design Matrix Reasoning Visual Puzzles Interact appropriately with co-workers. Trail Making Part B Digit Span (Forward, Backward, Sequencing) Arithmetic Trail Making Part B All WSM-IV Subtests Block Design Matrix Reasoning Visual Puzzles Respond appropriately to usual work situations and to changes in a routine work setting. Trail Making Part B Digit Span (Forward, Backward, Sequencing) Arithmetic Trail Making Part B All WSM-IV Subtests Block Design Matrix Reasoning Visual Puzzles An entire 1-hour seminar can be spent teaching the value of this grid and how to apply it in a hearing! 146

15 Psychometric Testing Meets the New Revised Mental Listings: The Attorney s Job Just Got Harder Section F Psychometric Testing Meets the New Revised Listings The Attorney s Job Just Got Harder Ronald Houston, Ph.D. 147

16 Section F National Social Security Disability Law Conference Psychometric Tes<ng Meets the New Revised Lis<ngs The AAorney s Job Just Got Harder NOSSCR DISABILITY LAW CONFERENCE Phoenix, AZ September 13-16, 2017 Course ObjecLves 1. Understand how much more difficult it is to get a favorable decision with revised mental impairment lis<ngs: Neurocogni<ve Disorders Intellectual Disorders Neurodevelopmental Disorders Course ObjecLves Learn how to overcome difficul<es to increase chances of favorable decision. Learn how to use WAIS-IV and WMS-IV to screen winning from losing cases. Learn the increasing need to submit a detailed hearing brief. much more difficult it is to get a favorable decision understand how U much more difficult it is to get a 148

17 Psychometric Testing Meets the New Revised Mental Listings: The Attorney s Job Just Got Harder Section F Revision of Listed Impairments Sec<on , 12.05, much more difficult it is Revision of the LisLngs Revised <tles of exis<ng lis<ngs to correspond to DSM-5. New lis<ngs criteria with and some recategorized listed impairments Anxiety-related to Trauma and stressor related disorders. ADHD no longer Organic mental disorders but Neurodevelopmental disorders. Paragraph A criteria in each lis<ng based on diagnos<c features for corresponding DSM-5 categories of mental disorders. much more difficult it is to Major Challenge PRT DefiniLons Revised lis<ngs went into effect January DSM-5 revision went into effect January 1, S<ll have medical records prior to 2015 based on DSM-IV criteria. Trea<ng sources and diagnos<cians s<ll using DSM-IV criteria. ALJs are now focused much more on whether A Lis<ng requirements are met if not the case goes no further. The revised A Lis<ng requirements are much more detailed and specific with lower probability of being documented in the record (12.02 and A Criteria are good examples). much more difficult it is to 149

18 Section F National Social Security Disability Law Conference Other Major Challenge The Claimant The slide that follows is one that all of you can relate to the challenge of the claimant and how important psychometric tes<ng can be to establishing a medically determinable impairment and func<onal limita<ons due to that impairment. much more difficult it is to How do you know a claimant is genuine? Some are obvious whereas others it can be very difficult to tell! Organic Mental Disorders Psychological or behavioral abnormali<es associated with a dysfunc<on of the brain as evidenced by at least one of the following: Disorienta<on to <me and place. Memory impairment. Perceptual or thinking disturbances. Change in personality. 150

19 Psychometric Testing Meets the New Revised Mental Listings: The Attorney s Job Just Got Harder Section F Organic Mental Disorders Emo<onal lability and impairment in impulse control. Loss of measured intellectual ability of at least 15 IQ points from premorbid levels or overall impairment index clearly within the severely impaired range on neuropsychological tes<ng, e.g., the Luria-Nebraska, Halstead-Reitan, etc NeurocogniLve Disorders Medical documenta<on of a significant cogni<ve decline from a prior level of func<oning in one or more of the cogni<ve areas: Complex aaen<on. Execu<ve func<on. Learning and memory. Language. Perceptual-motor. Social cogni<on. Major NeurocogniLve Disorder Evidence of significant cogni<ve decline from premorbid level. Substan<al impairment in cogni<ve performance on standardized objec<ve neuropsychological tes<ng. In the absence than subs<tute with another quan<fied clinical assessment. 151

20 Section F National Social Security Disability Law Conference Major NeurocogniLve Disorder Major Cogni<ve deficits interfere with independence in everyday ac<vi<es. DSM-5 states at a minimum require assistance with complex instrumental ac<vi<es of daily living such as paying bills or managing medica<ons. (p.602). (Marked Limita<on B Criteria) Mild NeurocogniLve Disorder Mild Evidence of modest decline from premorbid level. Modest impairment in cogni<ve performance on standardized neuropsychological tes<ng. In the absence than subs<tute with another quan<fied clinical assessment. Mild NeurocogniLve Disorder Cogni<ve deficits do not interfere with independence in everyday ac<vi<es. DSM-5 states complex instrumental ac<vi<es of daily living such as paying bills or managing medica<ons are preserved but greater effort, compensatory strategies or accommoda<on may be required. (P.605) (Moderate Limita<on B Criteria). 152

21 Psychometric Testing Meets the New Revised Mental Listings: The Attorney s Job Just Got Harder Section F Types of Impairment (See Handout) Alzheimer s disease. Frontotemporal lobar degenera<on. Lewy body disease. Vascular disease. Trauma<c brain injury. Substance/medica<on- induced. HIV infec<on Types of Impairment Prion s disease. Parkinson s disease. Hun<ngton s disease. Due to another medical condi<on. Due to mul<ple e<ologies Types of Impairment Major Revision Gone is AAen<on-deficit Hyperac<vity Disorder Gone is Borderline Intellectual Func<oning. ADHD is now Neurodevelopmental Disorder. Borderline Intellectual Func<oning is now Neurodevelopmental Disorder. 153

22 Section F National Social Security Disability Law Conference versus ADHD is an organic mental disorder so why is it no longer considered under 12.02? Borderline Intellectual Func<oning is an organic mental disorder that is congenital so why is it no longer considered under 12.02? Neurodevelopmental Disorders Mental disorders that have an onset during the developmental period of childhood or adolescence. This is true even if they do not get diagnosed un<l adulthood which is olen the case in ADHD and Borderline IQ Neurodevelopmental Disorders The dis<nc<on SSA makes between and mental impairments is not solely the onset during the developmental period. The other intended dis<nc<on between and is that of knowing vs. not knowing the cause of a child s mental impairment. 154

23 Psychometric Testing Meets the New Revised Mental Listings: The Attorney s Job Just Got Harder Section F Neurodevelopmental Disorders SSA states if the mental impairment has a known organic cause it gets evaluated under Neurocogni<ve Lis<ng. If the cause is not known it gets evaluated under lis<ng Another way is neurodevelopmental versus acquired brain dysfunc<on Neurodevelopmental Disorders What are Neurodevelopmental Disorders? Impairment of the growth and development of the brain or central nervous system. Results is a disorder of brain func<on that affects emo<on, learning ability, self-control and memory which unfolds over the course of a person s development Neurodevelopmental Disorders Examples ADHD. Learning disabili<es. Borderline intellectual func<oning. ToureAe s. Language (Speech Ar<cula<on, Expressive/ Recep<ve) 155

24 Section F National Social Security Disability Law Conference Neurodevelopmental Disorders Note Two neurodevelopmental disorders not included under are Intellectual Disabili<es (12.05 Intellectual disorders). Au<sm Spectrum Disorders (12.10 Au<sm spectrum disorders Intellectual Disorder Why is Borderline IQ a Neurodevelopmental disorder and not a Intellectual disorder? Like mental retarda<on it is characterized by significantly sub-average intellect. Like mental retarda<on it is manifest before age 22. Key dis<nc<on is significant deficits in adap<ve func<oning. Revision Equals Less Favorable Sec<on 2 Psychometric Tes<ng 156

25 Psychometric Testing Meets the New Revised Mental Listings: The Attorney s Job Just Got Harder Section F Key WAIS-IV Indexes WAIS-IV Summary Indexes Verbal Comprehension (VCI) Perceptual Reasoning (PRI) Working Memory (WMI) Processing Speed (PSI) Full Scale General Ability Key WAIS-IV Indexes Job Relevant WAIS-IV Indexes WAIS-IV Indexes (Forget Verbal Comprehension Index- VCI) Working Memory Index (WMI) Processing Speed Index (PSI) Perceptual Reasoning Index (PRI) These Indexes assess aaen<on, memory, and execu<ve func<on cri<cal to & as well as B Criteria. Key WAIS-IV Subtests Job Relevant WAIS-IV Subtests Working Memory Index (WMI) - AAen<on Digit Span & Arithme<c Processing Speed Index (PSI) Processing Speed Symbol Search Coding Perceptual Reasoning Index (PRI) Execu<ve Func<ons Block Design Matrix Reasoning Visual Puzzles 157

26 Section F National Social Security Disability Law Conference Key WAIS-IV Indexes DDS Psychological CE WAIS-IV Working Memory Index (WMI). Processing Speed Index (PSI). Perceptual Reasoning Index (PRI). These Indexes assess simple and complex aaen<on, processing speed, memory, and execu<ve func<on cri<cal to & as well as B Criteria. Key WMS-IV Indexes Brief Cogni<ve Status Exam (BCSE) Evaluates basic cogni<ve func<ons through tasks that assess orienta<on to <me, incidental recall, mental control, planning/visual perceptual processing, inhibitory control, and verbal produc<vity. Key WMS-IV Indexes WSM-IV Summary Indexes Immediate Memory (LMVR). Delayed Memory (LMVR). Auditory Memory (LM). Visual Memory (VM). 158

27 Psychometric Testing Meets the New Revised Mental Listings: The Attorney s Job Just Got Harder Section F Key WAIS-IV Indexes DDS Psychological CE WMS-IV Immediate Memory Delayed Memory Auditory Memory Visual Memory Establish CogniLve Decline Premorbid Es<ma<on Compare WAIS-IV and WMS-IV Indexes and subtests with WAIS-IV Vocabulary Subtest Block Design Subtest If there is a -1 standard devia<on either between the Indexes (15 points) or Scaled Score subtests (3 points). AeenLon Ability to resist distrac<on, alloca<ng and divide aaen<on, simultaneous informa<on processing, and mental flexibility. More than just arousal and sustaining focus. 159

28 Section F National Social Security Disability Law Conference AeenLon Only way you can establish this is through objec<ve neurocogni<ve tes<ng. Pa<ent self-report or that of others according to the DSM is no longer enough. Usually cannot determine based on simple mental status exam because it is a screener. AeenLon Working Memory Index 85 Mild to Moderate; -1 sd; 16 th percen<le Marked; -2 sd; 2 nd percen<le. 55 Extreme; -3 sd; 0.1. percen<le. (See Sta's'cal Tools Handout) AeenLon Working Memory Subtests Digit Span (WMI) Digit Span Forward - Simple AAen<on Digit Span Backward Complex AAen<on Sequencing Complex AAen<on Arithme<c (WMI) Complex AAen<on Symbol Search & Coding (PSI) Complex AAen<on 160

29 Psychometric Testing Meets the New Revised Mental Listings: The Attorney s Job Just Got Harder Section F AeenLon Working Memory Strong rela<onship between working memory and a person s ability to resist distrac<ons and irrelevant informa<on. AeenLon Working Memory Cocktail Party Effect Focus on one voice and not be distracted by surrounding noise depends on working memory. Reference - Conway, A.R., Cowan N., and Bun<ng, M.F. (2001) The cocktail party phenomenon revisited: the importance of working memory capacity. Psychonomic Bulle<n & Review 8: AeenLon Working Memory Being off-task and daydreaming correlate with working memory deficit. Reference - Kane, M. J. Brown, L. H. McVay, J. C. Silvia, P. J. Myin-Germeys, I., and Kwapil, T. R. (2007) For whom the mind wanders, and when: an experiencesampling study of working memory and execu<ve control in daily life. Psychological Science 18:

30 Section F National Social Security Disability Law Conference AeenLon Working Memory It is a pre-fontal lobe ability. Working memory is a big deficit ADHD - neurodevelopmental disorder where frontal lobes are late to mature. Frontal lobes are affected by the organic brain disorders just covered under AeenLon Working Memory AAorneys need real life job relevant examples for their cases: Understanding wriaen material in work documents. Listening and then communica<ng informa<on effec<vely on the job. AeenLon Working Memory Controlling and opera<ng work equipment e.g. gauges, dials, switches. Monitor self as one is performing and taking correc<ve ac<on. Trouble shoo<ng and deciding what to do. 162

31 Psychometric Testing Meets the New Revised Mental Listings: The Attorney s Job Just Got Harder Section F AeenLon Working Memory Classic is the frequent problem of not remembering what to do next, which disrupts their ability to complete the task as planned or on <me. Employee hears instruc<ons or told to do something and forget the details as soon as they get to another room. Complex AeenLon Working Memory So you can see WAIS-IV Working Memory Index is very relevant to occupa<onal disability as it pertains to PRT B Criteria: Understanding, remembering, or applying informa<on. Concentra<on, persistence, and pace. Adapt or manage oneself. Note- Argue that a Marked WMI (70 or -2 sd) translates to Marked on each of the above B Criteria. Simple and Complex AeenLon What about social interac<ons and working memory? View working memory as a cogni<ve deficit not a social deficit. What about talking to others and not communica<ng informa<on properly? Distracted and not paying full aaen<on to our supervisor or co-worker so as not to full understand leading to annoying ques<ons, interrup<ons for clarifica<on, mistakes, and employer frustra<on. Case where the claimant is nice and affable but socially a problem on the job because of working memory. 163

32 Section F National Social Security Disability Law Conference Simple and Complex AeenLon Trail Making Tests Condi<on 1 Visual Scanning Condi<on 2 Number Sequencing Condi<on 3 LeAer Sequencing Condi<on 4 Number/LeAer Sequencing AeenLon Trail Making Test Condi<on 4 Number/LeAer Sequencing Most challenging and cogni<vely demanding. Analog for mul<tasking. Visual scanning, number sequencing, and leaer sequencing of preceding Condi<ons 1 through 3. Addi<on of switching cogni<ve sets back and forth between number and leaer sequences. Mental RFC Marked AAen<on Limita<ons WAIS-IV WMI & Trail Making Test Can do Understand and remember simple instruc<ons. Carry out simple instruc<ons. The ability to make judgments on simple work-related decisions. Cannot do Understand and remember complex instruc<ons. Carry out complex instruc<ons. 164

33 Psychometric Testing Meets the New Revised Mental Listings: The Attorney s Job Just Got Harder Section F Processing Speed Speed the person takes in, processes, and effec<vely executes the informa<on they processed. Very important with great job relevance. One variable that can eliminate even simple rou<ne work like selling <ckets at a movie theater, even housekeeping. Processing Speed WAIS-IV Processing Speed Subtests Symbol Search Coding These two subtests make up the Processing Speed Index (PSI). PSI = 70-2sd, Extremely Low, Marked deficit. Scaled Score Symbol Search or Coding = 4, -2 sd, well below average, Marked deficit. Get this from DDS CE Psychological. Processing Speed Real Life on the Job Examples Ways that processing speed can be involved in a child s (or anyone s) daily Trouble with simple on the job decision making. Copying words or sentences correctly on job paperwork. Manipula<ng numbers and doing simple arithme<c opera<ons. Recognizing simple visual paaerns on jobs where verbal demands are minimized. Reading even simple instruc<ons. Be limited in ability to understand manage verbal and/or visual concepts in a <mely way. Carry out even simple tasks under a <me demand. 165

34 Section F National Social Security Disability Law Conference Processing Speed B Criteria PSI Understanding, Remembering and Applying Informa<on Processing speed even more than working memory has disability implica<ons. Understanding, remembering, and applying informa<on. If PSI is -1 sd looking at Mild to Moderate. -2 sd PSI looking at Marked. Processing Speed B Criteria - PSI What does speed have to do with understanding, remembering, and applying informa<on? Slow in processing informa<on not going to get all the informa<on needed to understand. Same holds for memory if one is slow in processing and not able to get all the informa<on than memory is going to be affected as well, especially in <me demand situa<ons. Applying informa<on in an effec<ve <mely manner is limited. Processing Speed B Criteria - PSI So what this means is the Processing Speed Index is reflects more than just speed. Speed is the primary func<onal construct Memory is a secondary func<onal construct. Execu<ve func<on is a secondary func<onal construct. PSI Index encompasses all three abili<es. 166

35 Psychometric Testing Meets the New Revised Mental Listings: The Attorney s Job Just Got Harder Section F Processing Speed B Criteria - PSI Concentra<on, Persistence, and Pace. Working memory is more concentra<on driven than processing speed. So may get a None or Mild limita<on. Slow speed directly affects persistence in that the reason a person may be slow on a test is they have a hard <me sustaining focus needed to complete the task. -1 sd is Mild to Moderate. -2 sd is Marked. Slow speed is directly related to pace and doing the task according to the <me demand. -1 sd is Mild to Moderate -2 sd is Marked Processing Speed B Criteria PSI Interact with Others What does processing speed have to do with social interac<on on the job? Keep up with the content and pace of job relevant conversa<ons with supervisors and co-workers. At most even if PSI is at the Marked level only going to have a Moderate limita<on presuming the claimant has social skills to interact appropriately and handle cri<cism. Processing Speed B Criteria PSI Adapt or Manage Oneself Slow to process means slow to adapt to change especially unexpected. Manage oneself and processing speed are weakly related. Can manage personal hygiene, set goals, and make plans independent of others irrespec<ve of mental processing speed. So even if there is a Marked PSI and Marked adapt limita<on there is not going to be much for managing oneself so at most the overall ra<ng is going to be Moderate, presuming that there is not a deficit in this area due to something else. 167

36 Section F National Social Security Disability Law Conference ExecuLve FuncLon Frontal Lobe ADHD kids frontal lobe development is 3-5 years behind non ADHD kids. ADHD disorder of self-regula<on and execu<ve dysfunc<on due to immature frontal lobes. Neurodevelopmental disorder. Catch up by age 25. Residual impairment due to all those years of impulsivity, learning difficul<es, poor judgement and decision making. ExecuLve FuncLon Frontal Lobe Execu<ve Func<on is the Chief Execu<ve Officer (CEO) that regulates or governs our Emo<ons, cogni<ons, and behaviors. Conductor of the orchestra. ExecuLve FuncLon Example of Everyday Execu<ve Func<on (Courtesy of WebMD) For example, seeing a piece of chocolate cake on a dessert cart at a restaurant may be temp<ng. That's where execu<ve func<on can step in. The organiza<onal part reminds you that the slice is likely to have hundreds of calories. Regula<on tells you that ea<ng the cake conflicts with goals you may have, like ea<ng less sugar or losing weight. 168

37 Psychometric Testing Meets the New Revised Mental Listings: The Attorney s Job Just Got Harder Section F ExecuLve DysfuncLon & Occupa<onal Deficits Poor <me management. Limited aaen<on. Trouble switching focus. Faulty planning and organiza<on. Reduced ability to mul<task. Remembering details. Say or doing the wrong things. Not good at using past experience as a guide to behavior. ExecuLve DysfuncLon & WAIS IV Subtests Execu<ve Dysfunc<on Perceptual Reasoning Index (PRI) -1 sd Mild to Moderate. -2 sd Marked. Perceptual Reasoning Subtests -1 sd Mild to Moderate. -2 sd Marked. Visual Puzzles. Matrix Reasoning. Block Design. ExecuLve DysfuncLon & Structure Dependence This is a cri<cal slide. See Page 5 of the handout. Highly, highly, highly occupa<onally relevant. 169

38 Section F National Social Security Disability Law Conference ExecuLve DysfuncLon & B Criteria Block Design, Matrix Reasoning, and/or Visual Puzzles Understanding, remembering, and applying informa<on any one or all three can be limited. -1 sd Mild to Moderate limita<on. -2sd Marked limita<on. Concentra<on, Persistence, or Pace any one or all three can be limited. -1 sd Mild to Moderate limita<on. -2sd Marked limita<on. ExecuLve DysfuncLon & B Criteria Block Design, Matrix Reasoning, and/or Visual Puzzles It s a mistake to think of execu<ve dysfunc<on solely in terms of cogni<ve theory and non-social features. There are social features to execu<ve func<ons. Interac<ng with Others. Establish execu<ve dysfunc<on on these tests extrapolates to social impairments in the form of disinhibi<on, impulsivity, and behaving appropriately with others in terms of saying or doing things. -1 sd Mild to Moderate limita<on. -2sd Marked limita<on. ExecuLve DysfuncLon & B Criteria Block Design, Matrix Reasoning, and/or Visual Puzzles Adapt or Manage Oneself. This is what defines execu<ve func<on and deficits means deficit in adapta<on and self management. -1 sd Mild to Moderate limita<on. -2sd Marked limita<on. One of the big symptoms if you may is the inability to selfmonitor and take ini<a<ve. 170

39 Psychometric Testing Meets the New Revised Mental Listings: The Attorney s Job Just Got Harder Section F ExecuLve DysfuncLon Other Listed Impairments Au<sm Spectrum Disorder Block Design, Matrix Reasoning, and/or Visual Puzzles Au<sm is all about frontal lobe execu<ve dysfunc<on. -1 sd Mild to Moderate limita<on. -2sd Marked limita<on. The non-social features of au<sm including a restricted repertoire of repe<<ve and obsessive behaviors, rigidity and persevera<on are going to impact all B Criteria including understanding, remembering, applying informa<on interac<ng with others, concentra<on, persistence, or pace, and adapt and manage oneself. So Your Job Just got Harder How so? The A Lis<ng requirements are more difficult to sa<sfy because they are more detailed and specific with the 2017 revised PRT. As a result, they are not going to be well documented if at all in the medical record unless you have psychometric tes<ng even a CE with just the WAIS-IV and WSM-IV. You will need to educate the ALJ and even many medical experts transla<ng processing speed, working memory, memory, and execu<ve func<ons into every day prac<cal job relevant deficits and how they apply to the new B criteria. So Your Job Just got Harder No Go B Criteria The B Criteria defini<ons are such that they are almost impossible to meet. Seldom are you going to get a case where there are two Marked limita<ons in any area. Moderate yes Marked no. Mild TBI or post-concussive cases are now almost virtually unwinnable in terms of the B Criteria and even the C Criteria and that is with psychometric tes<ng. 171

40 Section F National Social Security Disability Law Conference So Your Job Just got Harder Winds of Change Have Shiled With the demand for greater scru<ny and defini<onal change find that claimants are not as impaired or disabled as they present. Revised defini<ons in the DSM-5 and the PRT by extension now say selfreported TBI, PTSD, or any other mental symptoms is not sufficient and cannot be taken at face value. Objec<vely impairments are realis<cally going to mainly Moderate not Marked in most disability cases. Here s why! So Your Job Just got Harder This is an example of a high percentage of disability claimants. Clearly impaired in terms of execu<ve func<on self-monitoring and appropriateness of his behavior in the immediate situa<on. But he also demonstrates some impressive adaptability. Moral of the story most claimants have some areas of strengths and are Moderately limited but occupa<onally disabled. 172

41 Psychometric Testing Meets the New Revised Mental Listings: The Attorney s Job Just Got Harder Section F So Your Job Just got Harder Say Yes to the C Criteria Marginal Adjustment With the revisions get more Moderate limita<ons. So more olen than not it becomes a maaer of the C Criteria where the concept of marginal adjustment is easier to objec<fy. Great for which has C Criteria. Not so great for which does not have C Criteria. This means ADHD, learning disabili<es are gong to be very tough cases to win. So Your Job Just got Harder Say Yes to the C Criteria To win you need to work harder and apply the concepts of this seminar to real work abili<es using standard devia<on sta<s<cal tools in this handout and translate processing speed, working memory, memory, and execu<ve deficits into actual behavioral liabili<es in an occupa<onal sewng. Dr. Houston s Grid Rules See Handout It is a resource grid in an effort to give you a summary that maps B Criteria and Mental RFC Variables in rela<on to processing speed, working memory, memory, execu<ve func<on and WAIS-IV and WMS-IV tests most relevant to occupa<onal disability 173

42 Section F National Social Security Disability Law Conference Case Example 1 CE Psych WSM-IV Verbal Comprehension Index = 85-1 sd Low Average Perceptual Reasoning Index = 84-1 sd Low Average Working Memory Index = sd Borderline Processing Speed Index = sd Borderline Full Scale IQ (FSIQ) = sd Borderline Referral Several head injuries Case Example 1 CE Psych WAIS-IV Subtests Similari<es = 9 Average Vocabulary = 7-1 sd Below Average Informa<on = sd Below Average Block Design = 9 Average Matrix Reasoning = 7-1 sd Below Average Digit Span = sd Below Average Arithme<c = sd Below Average Symbol Search = 7-1 sd Below Average Coding = 4-2 sd Well Below Average Immediate Memory Delayed Memory Auditory Memory Visual Memory Case Example 1 CE Psych WMS-IV Indexes = sd Extremely Low = sd Extremely Low = sd Borderline = 45 <.01 sd Extremely Low Subtests Logical Memory I = sd Below Average Logical Memory II = 7-1 sd Below Average Verbal Paired Associates I = 4-2 sd Well Below Average Verbal Paired Associates II = sd Below Average Visual Reproduc<on I = 1 <.01 sd Well Below Average Visual Reproduc<on II = 2 <.01 sd Well Below Average 174

43 Psychometric Testing Meets the New Revised Mental Listings: The Attorney s Job Just Got Harder Section F Case Example 1 CE Psych Formula<on Granted disability benefits based on Borderline Intellectual Func<oning and Personality Disorder. Mood Disorder, NOS. Learning Disorders, NOS. Evalua<on done at the <me of the old 12.02, 12.04, and Lis<ngs. Based on the CE diagnosis and new Lis<ngs this would be a 12.11, 12.04, and I was not the ME on this case. If it were me it would just a no because of performance validity issues on WMS-IV Visual Reproduc<on. Case Example 1 CE Psych Formula<on I was not the ME on this case. If it were me it would be just a no because of performance validity issues on WMS-IV Visual Reproduc<on I and II. No one who is func<oning in life is going to have a Visual Memory Index of 45. See the sta<s<cal handout and the lowest score is 50. CE examiner also noted less than full effort on memory tes<ng. Also lets assume this were a valid case of mul<ple TBIs and under Neurocogni<ve disorder I would have to establish cogni<ve decline from es<mated premorbid ability. Case Example 1 CE Psych Formula<on Also lets assume this were a valid case of mul<ple TBIs and under Neurocogni<ve disorder I had to establish cogni<ve decline from previous premorbid level. Look at WAIS Vocabulary (9) and/or Block Design (9) scores which are both Average. That is your premorbid es<mate by which to compare performance on other measures. For example the Working Memory Index (71) which is almost -2 standard devia<ons below average so one would say that cogni<ve decline can be established. 175

44 Section F National Social Security Disability Law Conference CONTACT INFORMATION Name: Ronald P. Houston, Ph.D. Firm: Psychological Ins<tute Educa<onal Services (PIES) Address: P.O. Box North Gateway Drive Suite 235 Providence, UT Phone: (435) Fax: (435) ronald@pies.ins<tute Website: PIES website under construc<on. 176