NR Times reports from the side-lines of an Irwin Mitchell event which explores the case for tele-neuropsychology.
COVID-19 has presented major challenges to those delivering neuropsychological assessments.
Perhaps in the early days of the pandemic, deferring assessments may have been an initial consideration. But as it became clear that the crisis would be around for months, rather than weeks, other solutions were quickly sought.
Such assessments are crucial in ensuring the seriously injured are given a level playing field in their journey to secure compensation and support for care.
Speaking at the virtual event, Matt Brown, partner in the serious injury team at Irwin Mitchell’s Manchester office, introduces the topic, asking delegates: “Just how important is it that the neuropsychological expert meets the client in person to conduct the testing? Does it matter that the expert is not in the room?”
Also, he continues, “how will clients take to the new method of testing?”
Neuropsychological opinions can be pivotal to the outcome of cases, with huge implications in terms of claims for loss of earnings, requirement for care and support; and the question over whether an individual has the ability to manage their own finances.
In a criminal case, the results may help determine the connection between a brain injury and a criminal act, and the potential need for rehabilitation.
At the beginning of the first COVID-19 lockdown, three options in relation to assessing and reporting psychoneurological impact in legal cases were set out in an article by Dr Freedman:
1. Delay all reports and testing until the situation changed
2. Complete reports based on interviews and medical records (with no testing)
3. Report based on video interviews with remote psychological tests, and review medical records
Dr Nick Priestley, consultant neuropsychologist, advocates option three – but should this continue post-pandemic?
Speaking at the Irwin Mitchell event, he says: “It’s not a question of whether I think it should continue. It will continue as it is a modality of assessment which is valid and revealing with many advantages and very few disadvantages.
“This has been around for almost two decades in some shape or form, and when looking at the evidence there are two very good international peer-reviewed journals that deal with tele assessments in medicine and other clinical fields (The Journal of telemedicine and telecare, the Journal of Cyberpsychology, Behaviour and Social Networking).
“These have been publishing important articles for quite a long time, but in terms of the research – while this has been going on for 10 to 15 years previously, it has accelerated and it has certainly started to come together.”
In the webinar, Dr Nick Priestley answers questions posed by Brian Cummins, barrister from Old Square Chambers in London.
Brian Cummins (BC): When it comes to the devices used to carry out these assessments, what is the best methodology?
Dr Nick Priestley (NP): “There are a number of markers that should be observed and both Pearson’s assessment and that of other authorities – not least the division of British Neuropsychology. [It] has set out certain criteria that must be observed, for example mobile phones are not acceptable to use. There has to be a check on the image size of the respondent’s equipment, there has to be 25cm screen measured diagonally in order that test materials don’t become distorted or fall below a certain proportion.
“This screen size restriction relates to testing as some of the visually presented materials cannot validly be used if they are presented below a certain size or proportion. There has been a great deal of research on the validity of verbal tests, however less objective research on visually presented measures and so, for instance, the Wechsler Memory Scale Four, the sub tests have not been fully validated for tele-neuropsychological use, although they are supported in certain circumstances.
“In terms of software, clinicians need to give very careful thought to the platform they sign up for, but it’s important that the platform used is a professional subscription. When it comes to encryption, in some circumstances, it is an important feature. However when visual materials are presented and copies are made, it’s extremely important that those are destroyed in camera view by the client.
“The recording of an assessment is set out in the consent form and pre-examination interview, but it is unacceptable to record an interview or take copies of the standardised tests.”
BC: While easily managed through physical assessments, are there any rules or restrictions on who can be in the room while a tele-assessment is being conducted?
NP: “In the pre-assessment, it is often the case that a third party is present to help set things up and get things working. However, when the main assessment is in progress, it’s very important there is no one else in the room, which is explained and made clear during the preparation stages. Having a third party in the room during the assessment itself invalidates and complicates the examination.”
BC: Is the ability of a claimant to receive the email and dealt with those instructions, set up the equipment and participate in that pre-assessment, part of the assessment itself?
NP: “It certainly provides valuable information. There are also instances where an individual who may respond in a disorganised or frontal way. Even at that stage, you are gaining pointers, even minor fragments of clinical information, before you get onto the pre-assessment. These are things I would investigate in the assessment and examination in particular detail.
“Neuropsychologists are behavioural scientists, experts in brain behaviour relationships, and a medico-legal report that relies entirely on neuropsychological testing is a weak report as no single test score should ever be used to make a clinical decision.
“Even under the best possible testing circumstances, it contributes to a decision, but the tests used are more proxies to describe underlying abilities, states and functions, and there is no test in any discipline that is capable of explaining with 100 per cent accuracy any underlying trait or peculiarity.
“The emphasis must be on the basis of all evidence and assessment, not just neuropsychological testing but also behavioural analysis.”
BC: Is this virtual method of assessment suitable for all of your clients and if not, when would it not be suitable?
NP: “No, it isn’t suitable for all. For example, those that have complex mental health problems, have language or communication difficulties, or have complex neuro developmental conditions are not suitable for tele-neuropsychological assessment.”
BC: Is it your view that, in the cases for which this is suitable, video is just as effective as face to face or is it still limited? In other words, can you still build up that rapport – what do you do if a client starts crying, for example?
NP: “This is a particularly interesting area, and I think it has been an urban myth that has been developed that somehow tele or remote assessments cannot generate empathy. When you look at the evidence, there is virtually none to suggest that remote assessments are in some way cold or heartless, or that you cannot generate empathy.
“The authorities for this go back a long time. A paper by Kirkwood in 2000 found no significant difference at all when objective measurement was made between face to face and virtual assessment of ‘customer satisfaction’.
“In another paper in 2010, even the clients that initially said they were ‘not keen’ and would prefer face to face, showed an equivalent outcome and did not complain about the modality of the service delivery. In fact, it was just the opposite and they were quite surprised, given their initial scepticism, that it worked just as well.”
BC: How is visual stimuli to be presented in the context of a tele-assessment?
NP: “The logistics of sending things through the post raises so many complications and is something I personally don’t do at all.
“Holding things up to a camera in order that the client can see it, screen sharing techniques and screen mirroring are all approved of by Pearson. and all observe any copyright issues as they are not being reproduced.”
BC: Due to the pandemic and people being stuck at home, could the subjects be displaying signs such as apathy or disinhibition as a matter of the pandemic rather than a result of any illness or injury?
NP: “I think certainly as far as issues of mood are concerned that is likely to be the case. However I don’t think there is any evidence to suggest that lockdown, or more repressive social circumstances, provoke disinhibition or perseveration. Issues to do with empathy and social judgement are still going to be evident within a family setting.”
BC: Are there any disadvantages to doing the assessment within the family setting of the home?
NP: “Yes, and I have found that there’s a very obvious one in that all individuals who have sustained a brain injury all suffer from fatigue problems of some kind or another, so fatigue ability is a ubiquitous problem.
“If you are seeing someone in their own home, the burden of travel to a city centre or unknown location has been removed, and in their own home, behaviours often become less guarded with the number of signs and signals both during the interview phase of the assessment and also during the testing phase become more apparent if you are observant enough.
“It is important to remember that behaviour is environment-specific. When an individual is in your consulting room and everything is ordered, secure and disciplined, it doesn’t easily lead itself as an environment to allowing the individual to show themselves in their least favourable form. There is a degree of constraint on their behaviour in a consulting room that is not going to be there when you are a guest in their home.”
Watch the event in full, including a Q&A session with Dr Nick Priestley, below: