Forensic Issues in Child Neuropsychology

1. Forensic Issues inChild Neuropsychology H. Gerry Taylor, PhD, ABPP/CN Department of Pediatrics Rainbow Babies and Children’s Hospital and Case Western Reserve University School of Medicine

2. Outline of Presentation • Summarize approach to forensic evaluation of children. • Review relevant knowledge base on effects of childhood brain insult. • Illustrate with case examples. • Discuss issues involved in giving expert opinion.

3. Similarities Specify problems, contributing factors, treatment Determine cognitive strengths and weaknesses Determine if brain insult likely present Differences Defend methods & conclusions Make judgments regarding cause and future Limited relationship with client Records and judgments subject to scrutiny How Forensic Neuropsychological Assessments Differ from Standard Clinical Assessments

4. Forensic Neuropsychology Specializes in providing and communicating neuropsychological assessment and research information for application to legal questions, and as means for assisting triers of fact (i.e., judge, jury, hearing officer). Dennis, 1989; Giuliano et al., 1997

5. What’s Required • Knowledge of assessment methods and comprehensive approach • Knowledge of disorder in question • Circumspection in drawing conclusions • Willingness to deal with attorneys and defend judgments

6. Goals in Pediatric Neuropsychological Assessment of Personal Injury Cases • Identify impairment • Determine likely cause • Determine prognosis and needs Dennis, 1989; Donders, 2005; Wills & Sweet, 2006

7. Examples of Forensic Cases • Lead exposure • Brain injury due to accidents or medical treatment • Failure to identify/treat disease Note that other potentially relevant areas of forensic psychology not covered (e.g., educational entitlement, competency, child custody).

8. Procedures for Forensic Assessments:Establishing an Agreement with Attorney • Information on case and appropriateness • Potential conflicts of interest. • Procedures, fees, understanding regarding patient feedback, assessment procedures • Credentials: CV • Letter of agreement from attorney • Records review (medical, school, depositions)

9. Contents of Assessment • Parent interview • Child testing and behavior ratings using well-accepted methods (see list of tests) • Child interview and child status exam • Attorney feedback • Written report to attorney

10. Case Formulation: Determining if Brain Injury is Cause of Neuropsychological Impairment • Evidence for insult and credibility of symptoms: Is brain injury likely to have occurred and how severe was it? • Proportionality: Correspondence between severity of injury and degree of impairment?

11. Consistency of findings within test battery and with “real world” deficits: What is the underlying impairment and how is it manifest in everyday functioning? • Preexisting risk factors and base rates: Is there a family history of similar problems or a previous history of brain insult, and what is the likelihood of condition if not for injury?

12. Postinjury events: Could the impairment be due to other disease or injury occurring after the event, or present psychological factors unrelated to event? • Nature of relationship between insult and impairment: Is insult a direct or proximal cause (need to be only one) or only distal or indirect influence? Arkes, 1989; Binder, 1997; Hartman, 1999; Lewin, 1998

13. Written Report • Outline—see handout • Conclusions about nature of patient’s problems • Conclusions about causation and prognosis—see handouts • Recommendations—both short- and long-term intervention and monitoring; reasonable benefit

14. Issues Related to Interpretation of Findings • Little research on some conditions, age-related effects, and long-term outcomes • Limited validity of measures of injury severity • Effects of sensory-motor deficits, general inattentiveness, meds, environmental factors

15. Other Issues Arising in Forensic Cases • What tests to give • What to include in report • Third party observers (see attached policy) • Detecting lack of effort, malingering • Opinions about children not seen and evaluations of others • Release of records, test security Brown et al., 1993; Esssig et al., 2001; Ivnik et al., 2000; Kay, 1999; Larrabee, 2000; Lees-Haley et al., 2005; Melton et al., 1999; Meyer et al., 2001; Otto & Heliburn, 2002; Weiner, 1999

16. Conceptual Framework and Knowledge Base for Child Assessments

17. Model for Pediatric Neuropsychological Assessment Child Traits Cognition Behavior Achievement Biological Factors Manifest Disability Environmental Factors

18. Consequences of Childhood Brain Insults • Common deficits: perceptual-motor skills, attention and executive functions, new memory & learning, processing speed, abstract reasoning, IQ • Common strengths: skills acquired through practice and repetition, performance on concrete tasks

19. Disease specific features or “modal profiles” (see appended listing) • Variable strengths and weaknesses, subject to moderating influences Bellinger, 1995; Dennis, 2000; Yeates et al., 2000

20. Relevance of Impairment Rates: Research Examples • Severe TBI: higher rates of special education (50% vs. 10%) and behavior problems (36% vs. 10%). • Meningitis: higher rates of perceptual motor deficits (21% vs. 3%), and grade repetition (23% vs. 9%). • <750g Birth Weight: higher rates of specific learning disabilities (40% vs. 20%), ADHD (26% vs. 5%). Schwartz et al., 2003; Taylor et al., 1995, 1997, 1998, 2004

21. Conclusions from Research on Outcomes of Childhood Brain Insults • Early neurological insults usually diffuse rather than focal. • Lateralization of function less specific for focal lesions. • Disease/injury severity predicts outcome.

22. Injury variables are more closely associated with some outcomes than others. • Effects of injury may be moderated by environmental factors. Bates & Roe, 2001; Bellinger, 1995; Dennis, 2000, Taylor & Alden, 1997; Taylor et al., 1998, 1999, 2002, 2004; Yeates et al., 1997

23. Conclusions from Research on Age Related Influences on Outcomes • Skills develop following insults but deficits persist (cognitive functioning, learning and behavior all affected). • Evidence for both improvement in early developing skills and increasing deficits at later ages, but pattern varies with type of skill. • Effects on development may vary with environmental factors.

24. Moderating Influences on Developmental Change After Childhood Brain Insults • Poorer cognitive recovery in younger children with diffuse insults. • Either “catch-up” growth or increasing deficits can be observed over time depending on environmental factors. Kolb & Gibb, 2001; Taylor & Alden, 1997; Taylor et al., 2000; Taylor et al., 2004

25. Prognosis After Childhood Brain Insults • May be more difficult to predict in very young children, except in cases of severe impairment • Likely depends on subsequent experiences. • Children with premorbid learning and behavior problems may be at higher risk. • Neuropsychological deficits related to school-age learning and behavior problems. Donders, 2005; Schwartz et al., 2003; Litt et al., 2004

26. Adult Outcomes • Deficits remain in adulthood. • Outcomes worse for children with education problems during school-age years. • Negative effects on employment and behavior. • Low IQ and physical handicaps predict difficulties in independent functioning. Baydar et al., 1993; Brooks-Gunn et al., 1993; Hack et al., 2002; Haupt et al., 1994; Kerns et al., 1997; Klapper L& Birch, 1966; Schwartz et al., 2003; Taylor et al., 2000; Stancin et al., 2002; Klebanov et al., 1994; Klonoff et al., 1993; Richardson & Koller, 1996

27. Adverse Effects on Families • Increased parent psychological distress (TBI) • Increase family burden and stress due to child’s problem and impact on rest of family (TBI, Low Birth Weight) • Adverse family effects associated with more negative behavioral outcomes Burgess et al., 1999; Taylor et al., 1995; Taylor et al., 2001; Wade et al., 1998, 2002

28. Providing Expert Witness Testimony:Guidelines and Ethical Considerations • Be frank; know facts and competence. • Be ready to discuss logic of testing and interpretations in layman’s terms and based on research findings. • Avoid speculations; be careful not to over-generalize; focus on individual. • Ask for repetition and clarification; avoid tacit agreement with presuppositions embedded in questions.

29. Criticisms of Method Skeptics • Assessment not standardized. • Experience not associated with judgmental accuracy. • Clinical inferences subject to bias. • Lack of information on base rates. • Limitations in predicting real-world competence. Giuliano et al., 1997; Heilbrun, 1992; Ziskin, 1995

30. In Response, Emphasize that Assessment More than Individual Test Findings • Assessment based on multiple methods. • Unique information yielded by different methods (type of test, source of information), and each method has strengths and limitations. Meyer et al., 2001

31. Use Strategies to Reduce Bias • Be frank about basis of judgments. • Consider alternative explanations and multiple influences on outcomes. • Consider source of information in weighing findings and drawing conclusions (objective vs. subjective). • Rely on relevant research literature. Borum et al., 1993; Garb, 1998; Martelli et al., 1999; Sweet, 1999

32. Impact of Forensic Work • Nerve-wracking but rewarding—encourage critical thinking and familiarity with research. • Exposes “weakest links” in assessment (e.g., not exact science, multiple causality). • Also showcases strengths (objective, hypothesis-driven, evidence-based). • Emphasizes scientific methods, stimulates pursuit of further knowledge.