Health and Psychology

I testified in a hearing this past week about an individual I had evaluated.  The person had been evaluated on multiple occasions by multiple people.  I was seated across a table from another evaluator that had also evaluated the same person.  We were in front of a judge because we disagreed about diagnosis.  We weren't far apart diagnostically.  We were literally one check off box apart.  Other evaluators weren't even on the same page, making things even less clear.

It was nice meeting the other evaluator face-to-face.  I still can't understand how he was able to check off the box he checked off.  But I had a better idea that he wasn't malicious or unnecessarily rigid.  And he did have some ideas he was absolutely wrong about which didn't come up adequately in court so I'm going to address them here.  He likely wouldn't have been wrong had there been an adequate history, but none of us had that due to the circumstances of the case.

WHY TEST SCORES CAN VARY:

In this case, psychological, language and academic test scores were compared on a single individual over his lifespan starting at age 5 and continuing being tested at school every 1 to 3 years until he left high school. He was then evaluated by four different psychologists or neuropsychologists, none of whom were privy to the other's reports. Scores varied from not testible and highly impaired, to well over average to almost superior on similar measures.

There are a couple of ideas that psychological test publishers have.  First, the person being evaluated should be reasonably able to be compared to the standardization sample on which the test is based.  There are clinical samples used for tests as well, but if the person being evaluated is highly unusual, then the comparison is phenomenological not a standard assessment.

The more unusual the individual is the more different they will be on testing than expected.  This client is highly unusual.  So much so that I suggested to his attorney that he be present in court so the judge in the case could see him.  I think the difficulty the client has is obvious.  I also don't think it's adequately conveyed in any report, even mine.  He has limited speech.  The opposing expert asserts he had a conversation with the client.  The last 3 neuropsychologists have not been able to do that.  It changes a diagnosis if he is able to converse or not.  His family only provides information if asked direct and specific questions, so information is not readily forthcoming. They have always been this way, and that contribues to the difficulty in this case.  The judge could also see the interaction with the client and his family and could gauge for himself about the family dynamics and the issue about the client being able to converse.

When money, benefits, services, or other tangible advantages are a potential oucome of an assessment and there is unusual behavior or test scores then malingering or motivational difficulties must be evaluated.  In cases where there is some more objective measure, such as a video tape showing the person doing something they should not be able to do, or a CT scan or MRI scan showing some anomoly or something completely normal those should be given a great deal of weight in thinking about what is going on.

The opposing expert could not come up with any reason why test scores should vary to this degree apart from motivational issues.  It's a polite way of saying he didnt think the client did his best.  If he were to use less polite terms he'd say he thought the client was faking it.  He went on to say he knew of no psychological, medical, or neuropsychological condition that could account for such variance.

Here was my opposing argument:

The client has a history of seizures that are documented.  Subclinical seizures can produce this variance. The list of medical conditions that can present with this type of testing pattern is quite long:  diabetes mellitus, diabetes insipidus, hypoglycemia, labile hypertension, hypothyroidism, hyperthyroidism, adrenal cortical insufficiency, addison's disease, hormone secreting tumors, multiple sclerosis, parathyroid disorders, partial agenesis of the corpous callosum, atypical frontal lobe disorders, sleep apnea, atypical cardiac conditions causing anxiety-usually tachycardia or bradycardia, asthma, side-effects of herbs, side effects of vitamins, side-effects of prescribed medications.  

Before motivational or psychological causes can be asserted, medical conditions need to be ruled out.  

This case hasn't been ruled on and won't be for several months yet.  I wish I had evaluated this person earlier, so does the opposing expert, then we wouldn't be trying to figure out if this adult qualifies for services he obviously would have qualified for as a child.  

So here's what would have kept this from ending up in court:

• Get services when needed for a child and don't wait to see if the child "gets better"
• Keep records of all professionals that have seen the child and have records
• Keep a list of all diagnoses, treatments, and procedures
• Keep discharge diagnoses from all hospitalizations
• Understand what services are available from schools and what rights you are signing away for your child 
• If you are being asked to sign a waiver on behalf of a child have someone else read it and explain it to you before you sign it