Date: 11/17/2008
By BETSY TAYLOR
Associated Press Writer
ST. LOUIS (AP) _ Spc. Glenn Barker is trying to recover after suffering a traumatic brain injury while serving in Iraq, the death of his 15-year-old son earlier this year, and flood damage that left his home uninhabitable.
On Monday, the American Legion Heroes to Hometowns program and the Missouri Veterans Commission asked for the public’s help to raise $63,000 to help Barker. The money would be spent on home repairs not covered by insurance and the purchase of a used trailer he can live in temporarily and later use as a work space.
Barker, 41, lives outside the east-central Missouri town of Potosi. He deployed with the Arkansas National Guard to hunt down improvised explosive devices in Iraq, and said he lived through nine detonations while driving an armored vehicle looking for roadside bombs.
The worst explosion came in August of last year, he recalled, when he ran over homemade explosives buried in a road. He suffered back injuries, a perforated ear drum and a traumatic brain injury that wreaked havoc on his short-term memory.
“The left ear is pretty much done,” he said, gesturing to that side of his head.
He writes himself notes and uses information stored on his cell phone to help him remember.
In May, his 15-year-old son, Zachary, was a passenger on an all-terrain vehicle in rural eastern Missouri that crossed onto a roadway and into the path of an oncoming car, killing the boy.
Barker, who is divorced, was out of state receiving treatment for his injuries when Zachary was killed.
“I have one other son. I guess you could say he’s my crutch; he keeps me going,” he said. “We miss his brother dearly.”
Barker is also trying to restore the log home that he had built himself. The house was destroyed by mold when it flooded after pipes burst following a multi-day power outage in 2006.
Barker is now in a program at Fort Leonard Wood working to improve his memory, his balance, his back and his right hand, which he said sometimes shakes.
The one-time auto body shop owner didn’t know what his future occupation might be, saying it’s hard to finish any task with his memory problems.
Family members mention that many of his tools were stolen while the Purple Heart recipient was gone, and that he sometimes has slept in his truck in recent months. They offer him a place to stay, but say right now, he’s having a hard time settling in one place.
“I don’t have in my mind what I want to do. I’m just lost,” he said.
The Department of Defense tells injured soldiers what help is available to them, and they must give their permission for their information to be shared.
For the first half of 2008, the American Legion’s Heroes to Hometowns program has assisted 380 soldiers nationwide. Since June of last year, the Missouri effort has helped more than 20 soldiers.
Shirley Janes, who chairs the Missouri American Legion’s Heroes to Hometowns program, notes that there are multiple efforts to help soldiers in need as they return home — whether it’s trying to make sure they keep medical appointments, providing them gas cards or helping with housing.
“The bottom line is we will do whatever it takes, as long as it takes, to help these heroes transition back home,” she said.
Barker, who explained during the interview that he wouldn’t be able to retain the conversation for more than a few minutes, thought for a moment when asked if he has regrets.
“For what it cost me, yes. But regret for my country? No,” he said. “I don’t feel the Army owes me. I’m just asking for a little help.”
____
On the Net:
Home for Wounded Warrior: http://aidforourwoundedsoldiers.org/woundedmissourian.htm
Copyright 2008 The Associated Press.
General bucks culture of silence on mental health
Date: 11/8/2008
By PAULINE JELINEK
Associated Press Writer
WASHINGTON (AP) _ It takes a brave soldier to do what Army Maj. Gen. David Blackledge did in Iraq.
It takes as much bravery to do what he did when he got home.
Blackledge got psychiatric counseling to deal with wartime trauma, and now he is defying the military’s culture of silence on the subject of mental health problems and treatment.
“It’s part of our profession … nobody wants to admit that they’ve got a weakness in this area,” Blackledge said of mental health problems among troops returning from America’s two wars.
“I have dealt with it. I’m dealing with it now,” said Blackledge, who came home with post-traumatic stress. “We need to be able to talk about it.”
As the nation marks another Veterans Day, thousands of troops are returning from Iraq and Afghanistan with anxiety, depression and other emotional problems.
Up to 20 percent of the more than 1.7 million who’ve served in the wars are estimated to have symptoms. In a sign of how tough it may be to change attitudes, roughly half of those who need help aren’t seeking it, studies have found.
Despite efforts to reduce the stigma of getting treatment, officials say they fear generals and other senior leaders remain unwilling to go for help, much less talk about it, partly because they fear it will hurt chances for promotion.
That reluctance is also worrisome because it sends the wrong signal to younger officers and perpetuates the problem leaders are working to reverse.
“Stigma is a challenge,” Army Secretary Pete Geren said Friday at a Pentagon news conference on troop health care. “It’s a challenge in society in general. It’s certainly a challenge in the culture of the Army, where we have a premium on strength, physically, mentally, emotionally.”
Adm. Mike Mullen, chairman of the Joint Chiefs of Staff, asked leaders earlier this year to set an example for all soldiers, sailors, airmen and Marines: “You can’t expect a private or a specialist to be willing to seek counseling when his or her captain or colonel or general won’t do it.”
Brig. Gen. Loree Sutton, an Army psychiatrist heading the defense center for psychological health and traumatic brain injury, is developing a campaign in which people will tell their personal stories. Troops, their families and others also will share concerns and ideas through Web links and other programs. Blackledge volunteered to help, and next week he and his wife, Iwona, an Air Force nurse, will speak on the subject at a medical conference.
A two-star Army Reserve general, 54-year-old Blackledge commanded a civil affairs unit on two tours to Iraq, and now works in the Pentagon as Army assistant deputy chief of staff for mobilization and reserve issues.
His convoy was ambushed in February 2004, during his first deployment. In the event that he’s since relived in flashbacks and recurring nightmares, Blackledge’s interpreter was shot through the head, his vehicle rolled over several times and Blackledge crawled out of it with a crushed vertebrae and broken ribs. He found himself in the middle of a firefight, and he and other survivors took cover in a ditch.
He said he was visited by a psychiatrist within days after arriving at Walter Reed Army Medical Center in Washington. He had several sessions with the doctor over his 11 months of recovery and physical therapy for his injuries.
“He really helped me,” Blackledge said. And that’s his message to troops.
“I tell them that I’ve learned to deal with it,” he said. “It’s become part of who I am.”
He still has bad dreams about once a week but no longer wakes from them in a sweat, and they are no longer as unsettling.
On his second tour to Iraq, Blackledge traveled to neighboring Jordan to work with local officials on Iraq border issues, and he was in an Amman hotel in November 2005 when suicide bombers attacked, killing some 60 and wounding hundreds.
Blackledge got a whiplash injury that took months to heal. The experience, including a harrowing escape from the chaotic scene, rekindled his post-traumatic stress symptoms, though they weren’t as strong as those he’d suffered after the 2004 ambush.
Officials across the service branches have taken steps over the last year to make getting help easier and more discreet, such as embedding mental health teams into units.
They see signs that stigma has been slowly easing. But it’s likely a change that will take generations.
Last year, 29 percent of troops with symptoms said they feared seeking help would hurt their careers, down from 34 percent the previous year, according to an Army survey. Nearly half feared they’d be seen as weak, down from 53 percent.
The majority of troops who get help are able to get better and to remain on the job.
___
Associated Press writer Lolita Baldor contributed to this report.
___
On the Net:
Information on veterans health care: www.warriorcare.mil
Copyright 2008 The Associated Press.
By PAULINE JELINEK
Associated Press Writer
WASHINGTON (AP) _ It takes a brave soldier to do what Army Maj. Gen. David Blackledge did in Iraq.
It takes as much bravery to do what he did when he got home.
Blackledge got psychiatric counseling to deal with wartime trauma, and now he is defying the military’s culture of silence on the subject of mental health problems and treatment.
“It’s part of our profession … nobody wants to admit that they’ve got a weakness in this area,” Blackledge said of mental health problems among troops returning from America’s two wars.
“I have dealt with it. I’m dealing with it now,” said Blackledge, who came home with post-traumatic stress. “We need to be able to talk about it.”
As the nation marks another Veterans Day, thousands of troops are returning from Iraq and Afghanistan with anxiety, depression and other emotional problems.
Up to 20 percent of the more than 1.7 million who’ve served in the wars are estimated to have symptoms. In a sign of how tough it may be to change attitudes, roughly half of those who need help aren’t seeking it, studies have found.
Despite efforts to reduce the stigma of getting treatment, officials say they fear generals and other senior leaders remain unwilling to go for help, much less talk about it, partly because they fear it will hurt chances for promotion.
That reluctance is also worrisome because it sends the wrong signal to younger officers and perpetuates the problem leaders are working to reverse.
“Stigma is a challenge,” Army Secretary Pete Geren said Friday at a Pentagon news conference on troop health care. “It’s a challenge in society in general. It’s certainly a challenge in the culture of the Army, where we have a premium on strength, physically, mentally, emotionally.”
Adm. Mike Mullen, chairman of the Joint Chiefs of Staff, asked leaders earlier this year to set an example for all soldiers, sailors, airmen and Marines: “You can’t expect a private or a specialist to be willing to seek counseling when his or her captain or colonel or general won’t do it.”
Brig. Gen. Loree Sutton, an Army psychiatrist heading the defense center for psychological health and traumatic brain injury, is developing a campaign in which people will tell their personal stories. Troops, their families and others also will share concerns and ideas through Web links and other programs. Blackledge volunteered to help, and next week he and his wife, Iwona, an Air Force nurse, will speak on the subject at a medical conference.
A two-star Army Reserve general, 54-year-old Blackledge commanded a civil affairs unit on two tours to Iraq, and now works in the Pentagon as Army assistant deputy chief of staff for mobilization and reserve issues.
His convoy was ambushed in February 2004, during his first deployment. In the event that he’s since relived in flashbacks and recurring nightmares, Blackledge’s interpreter was shot through the head, his vehicle rolled over several times and Blackledge crawled out of it with a crushed vertebrae and broken ribs. He found himself in the middle of a firefight, and he and other survivors took cover in a ditch.
He said he was visited by a psychiatrist within days after arriving at Walter Reed Army Medical Center in Washington. He had several sessions with the doctor over his 11 months of recovery and physical therapy for his injuries.
“He really helped me,” Blackledge said. And that’s his message to troops.
“I tell them that I’ve learned to deal with it,” he said. “It’s become part of who I am.”
He still has bad dreams about once a week but no longer wakes from them in a sweat, and they are no longer as unsettling.
On his second tour to Iraq, Blackledge traveled to neighboring Jordan to work with local officials on Iraq border issues, and he was in an Amman hotel in November 2005 when suicide bombers attacked, killing some 60 and wounding hundreds.
Blackledge got a whiplash injury that took months to heal. The experience, including a harrowing escape from the chaotic scene, rekindled his post-traumatic stress symptoms, though they weren’t as strong as those he’d suffered after the 2004 ambush.
Officials across the service branches have taken steps over the last year to make getting help easier and more discreet, such as embedding mental health teams into units.
They see signs that stigma has been slowly easing. But it’s likely a change that will take generations.
Last year, 29 percent of troops with symptoms said they feared seeking help would hurt their careers, down from 34 percent the previous year, according to an Army survey. Nearly half feared they’d be seen as weak, down from 53 percent.
The majority of troops who get help are able to get better and to remain on the job.
___
Associated Press writer Lolita Baldor contributed to this report.
___
On the Net:
Information on veterans health care: www.warriorcare.mil
Copyright 2008 The Associated Press.
Brain Injury Association Urges Support for Wounded Warriors Act
From the Brain Injury Association of Wisconsin:
Dear Friends:For those not in Wisconsin, your Senators and Congressmen can be found at http://www.senate.gov/ and http://www.house.gov/
Take Action!
Urge Your Senator to Cosponsor The Caring for Wounded Warriors Act of 2008
BIAA (Brain Injury Association of America) has endorsed The Caring for Wounded Warriors Act of 2008 (S. 2921), legislation introduced on Monday, April 28 by Senator Hillary Rodham Clinton which would increase support for family caregivers of servicemembers with TBI. Several recommendations made by BIAA during the legislative drafting process were incorporated into the bill.
BIAA encourages you to urge your Senator to sign on as a cosponsor of this important legislation.
The bill would require two pilot programs to be implemented through the Department of Veterans Affairs, improving the resources available to those caring for returning service members with TBI.
The first pilot program, which would provide for training, certification, and compensation for family caregiver personal attendants for veterans and members of the Armed Forces with TBI, is very similar to a provision in last year’s Heroes At Home Act of 2007, which BIAA also strongly endorsed.
The second pilot program would leverage existing partnerships between Veterans Affairs facilities and the nation’s premier universities, training graduate students to provide respite care for families caring for wounded warriors suffering from TBI.
To urge your Senator to become a cosponsor of S. 2921, click on the ‘Take Action’ link in the upper right corner of this email.
The Brain Injury Association of Wisconsin and the Brain Injury Association of America support this legislation.
If you have trouble with the “Take Action” button at the top, please let BIAW know. To “Take Action” visit www.biausa.org. Click on Policy & Legislation, then Legislative Action Center, and then Take Action.
Sincerely yours,
Pat David
Brain Injury Association of WI
Brain Injury Association to Hold Caregivers’ Conference
Caregivers’ Conference
The National Brain Injury Caregivers’ conference will be held in Dallas, TX on June 6-8, 2008 at the Westin Dallas Fort Worth Airport Hotel. The conference provides, caregivers of a person with a brain injury, support and guidance.
The conference will feature numerous medical professionals, over 25 experts and Lee Woodruff, special guest and best selling author. Lee Woodruff is the wife of Bob Woodruff, who suffered a brain injury in the Iraq War. His story is well chronicled, see for example: http://abcnews.go.com/WNT/Story?id=2904214
The conference is presented by The Brain Injury Association of America (BIAA). BIAA was founded in 1980, as an organization that supports individuals that are affected or individuals that have someone close that has been affected by a traumatic brain injury, by providing information and education.
Other speakers:
For further information:
http://biausa.org/livingwithbi.htm
The National Brain Injury Caregivers’ conference will be held in Dallas, TX on June 6-8, 2008 at the Westin Dallas Fort Worth Airport Hotel. The conference provides, caregivers of a person with a brain injury, support and guidance.
The conference will feature numerous medical professionals, over 25 experts and Lee Woodruff, special guest and best selling author. Lee Woodruff is the wife of Bob Woodruff, who suffered a brain injury in the Iraq War. His story is well chronicled, see for example: http://abcnews.go.com/WNT/Story?id=2904214
The conference is presented by The Brain Injury Association of America (BIAA). BIAA was founded in 1980, as an organization that supports individuals that are affected or individuals that have someone close that has been affected by a traumatic brain injury, by providing information and education.
Other speakers:
Joseph C. Richert
Chair, Brain Injury Association of America
President & CEO, Special Tree Rehabilitation System
Gregory J. O’Shanick, MD
President/Medical Director, Center for Neurorehabilitation and
National Medical Director, Brain Injury Association of America
Thomas Kay, PhD
Director Neuropsychology, Carmel and Associatates
Sarah Wade
Spouse of Injured Veteran
John Corrigan, PhD
Director, Ohio Valley Center for Brain Injury Prevention and Rehabilitation
Michael Howard, PhD
Clinical and Rehabilitation Psychologist, Lecturer
Biomed General Corporation
Janet Tyler, PhD
Director, Kansas TBI Project
Julie Peterson-Shea
Parent of child with brain injury
Lisa Silver
Transition Assistance Advisor, West Virginia National Guard
Peggy Keener
Parent of Person with Brain Injury
Faye Eichholzer
Spouse of Person with Brain Injury
Cheryl Amoruso
Sibling of Person with Brain Injury
Richard P. Bonfiglio, MD
Medical Director, HealthSouth Harmarville
Mike Davis, CBIS-CE
Neurological Case Management Associates
James Mikula, PhD
Neuropsychologist, Private Practice
Carolyn Rocchio
Caregiver of Person with brain injury
Laura Schiebelhut
Director of Public Policy, Brain Injury Association of America
Tim Feeney PhD
Executive Director, School and Community Support Services
Planning for the Transition from School Services to Adulthood
Linda Wilkerson, MSEd
President, Minds Matter LLC
Janet Tyler, PhD
Director, Kansas TBI Project
Visual Changes after Brain Injury
William Padula, OD
Director, Padula Institute of Vision Rehabilitation
Vocational Options After Brain Injury
Brandy Reid
Team Leader/Vocational Evaluator, Pate Rehab Dallas, TX
Kellie Manderfeld
Clinical Manager, Pate Rehab Dallas TX
Bill Ditto
Director, New Jersey Division of Disability Services
Tina Trudel, PhD
President/COO, Lakeview Healthcare Systems, Inc.
Susan H. Connors
President & CEO, Brain Injury Association of America
For further information:
http://biausa.org/livingwithbi.htm
TBI Act Signed into Law
From the Brain Injury Association:
Brain Injury Association of America
Policy Corner E-Newsletter – May 2, 2008
A weekly update on federal policy activity related to traumatic brain injury
__________________________________________________________________
Dear Advocates:
This week marked a major legislative victory for the brain injury community, as President Bush officially signed into law legislation reauthorizing the TBI Act (S. 793) on Monday, April 28! Congratulations to all BIAA state affiliates, advocates, and national stakeholders who helped make TBI Act reauthorization a reality. To view a copy of BIAA’s official press release applauding this major accomplishment, please visit our website at http://www.biausa.org/policyissues.htm.
In other exciting news, BIAA proudly endorsed The Caring for Wounded Warriors Act of 2008 (S. 2921), legislation introduced on Monday, April 28 by Senator Hillary Rodham Clinton which would increase support for family caregivers of servicemembers with TBI. Several recommendations made by BIAA during the legislative drafting process were incorporated into the bill. A copy of BIAA’s Letter of Endorsement for S. 2921 will be available shortly on our website at http://www.biausa.org/policyissues.htm.
Also this week, a report was released by the Department of Veterans Affairs Inspector General which found that the VA is not providing the necessary standard of support and long-term follow-up assistance needed by veterans with TBI and their families.
In addition, after the House of Representatives passed by a veto-proof margin last week important legislation which would place a moratorium until March 2009 on several harmful Medicaid regulations (H.R. 5613), the fate of the bill was left up to the Senate. Earlier this week, Senate Majority Leader Harry Reid (D-NV) attempted to bring the bill up on the Unanimous Consent Calendar, but this attempt was blocked by Senator Coburn (R-OK). Now there is an effort to get the bill included in the FY 2008 Supplemental Appropriations bill. BIAA continues to strongly endorse H.R. 5613 and supports efforts to include the bill in the FY 2008 Supplemental Appropriations bill.
As a final note, BIAA is waiting to see if Congress will be able to establish a budget this year before sending out its Legislative Action Alert on FY 2009 TBI Appropriations. There is speculation that Congress may indeed be able to achieve a budget agreement in the upcoming next few weeks, and BIAA’s Appropriations Action Alert will be sent out shortly thereafter.
*Distributed by Laura Schiebelhut, BIAA Public Affairs Manager, on behalf of the Brain Injury Association of America; 703-761-0750 ext. 637; lschiebelhut@biausa.org
The Policy Corner is made possible by the Adam Williams Initiative, Centre for Neuro Skills, and Lakeview Healthcare Systems, Inc. The Brain Injury Association of America gratefully acknowledges their support for legislative action.
__________________________________________________________________
President Bush Signs TBI Act Reauthorization Bill Into Law
This week marked a major legislative victory for the brain injury community, as President Bush officially signed into law legislation reauthorizing the TBI Act (S. 793) on Monday, April 28! Congratulations to all BIAA state affiliates, advocates, and national stakeholders who helped make TBI Act reauthorization a reality.
BIAA issued a press release applauding this major accomplishment, noting that achieving successful reauthorization of the TBI Act has been BIAA’s biggest federal legislative priority this year.
BIAA President and CEO Susan Connors said, “TBI is recognized as a signature injury of the conflicts in Iraq and Afghanistan. The programs authorized by the TBI Act play a critical role in improving the nation’s ability to meet the needs of individuals with brain injury, military and civilian alike.”
This major policy accomplishment simply would not have been possible without the tremendous efforts of BIAA state affiliates, advocates, and collaboration among national stakeholders, as well as the leadership of numerous Members of Congress and the dedicated efforts of their staff members.
In particular, BIAA expresses profound appreciation for the leadership efforts of Senator Edward Kennedy, Senator Orrin Hatch, Representative Bill Pascrell, Representative Todd Platts, Representative John Dingell, and Representative Frank Pallone, all of whom played critical roles in ensuring the progress of this bill.
To view a copy of BIAA’s press release, please visit our website at http://www.biausa.org/policyissues.htm.
BIAA Strongly Endorses The Caring for Wounded Warriors Act of 2008
In other exciting news, BIAA proudly endorsed The Caring for Wounded Warriors Act of 2008 (S. 2921), legislation introduced on Monday, April 28 by Senator Hillary Rodham Clinton which would increase support for family caregivers of servicemembers with TBI. Several recommendations made by BIAA during the legislative drafting process were incorporated into the bill.
The bill would require two pilot programs to be implemented through the Department of Veterans Affairs, improving the resources available to those caring for returning servicemembers with TBI.
The first pilot program, which would provide for training, certification and compensation for family caregiver personal attendants for veterans and members of the Armed Forces with TBI, is very similar to a provision in last year’s Heroes At Home Act of 2007 (S. 1065/H.R. 3051), which BIAA also strongly endorsed.
The second pilot program would leverage existing partnerships between Veterans Affairs facilities and the nation’s premier universities, training graduate students to provide respite care for families caring for wounded warriors suffering from TBI.
Note: The legislation specifies that the curricula for the TBI Family Caregiver Personal Care Attendant Training and Certification Program “shall incorporate applicable standards and protocols utilized by certification programs of national brain injury care specialist organizations.” The legislation further specifies that the VA should also use such applicable standards and protocols in providing training for graduate student respite care providers.
A copy of BIAA’s Letter of Endorsement for S. 2921 will be available shortly on our website at http://www.biausa.org/policyissues.htm.
VA Inspector General Releases Report Criticizing TBI Care for Veterans
Also this week, a report was released by the Department of Veterans Affairs Inspector General which found that the VA is not providing the necessary standard of support and long-term follow-up assistance needed by veterans with TBI and their families.
The report, which was conducted at Senate Veterans Affairs Committee Chairman Daniel Akaka’s (D-HI) request, found specifically; “While case management has improved, long-term case management is not uniformly provided for these patients, and significant needs remain unmet.”
A copy of the report can be found at http://www.va.gov/oig/54/reports/VAOIG-08-01023-119.pdf.
TBI Act Reauthorization
From the Brain Injury Association of Wisconsin
But how come the tail of the brain injury animal, war injuries, gets all of the research and attention? There are a million Subtle Brain Injuries© a year in the U.S. and perhaps, a few thousand in Iraq. What about all the civilians who have brain injuries? Isn’t it time we did some major research on those most likely to be disabled by brain injuries, those over 40 – especially women over 40, those with prior head injuries and those with co-morbid issues such as other neurologic or emotional disorders?
A Subtle Brain Injury is a complicated synergistic maze. Limiting our research to young jocks and war casualties is not going to enlighten us as to why some people have apparent full recoveries and others never get better. It is not an accident that there is consistently 10-15% of those with concussions who wind up with persistant post concussion syndrome. Let us start screaming louder so that the real pathology in those cases is understood, and treated.
- TBI Act Reauthorization Update: Last week the US Congress passed legislation to reauthorize the Traumatic Brain Injury Act! The bill appears ready to be sent on to President Bush for his signature. In addition to authorizing ongoing CDC, NIH and HRSA TBI programs, the bill also authorizes a new study by the CDC and NIH in collaboration with the Dept. of Defense and the Dept. of Veterans Affairs to identify the incidence of brain injury among our veterans, especially veterans of Iraq and Afghanistan. Again, THANK YOU to all who took time to share their opinions with Congress regarding this legislation during the past year.
But how come the tail of the brain injury animal, war injuries, gets all of the research and attention? There are a million Subtle Brain Injuries© a year in the U.S. and perhaps, a few thousand in Iraq. What about all the civilians who have brain injuries? Isn’t it time we did some major research on those most likely to be disabled by brain injuries, those over 40 – especially women over 40, those with prior head injuries and those with co-morbid issues such as other neurologic or emotional disorders?
A Subtle Brain Injury is a complicated synergistic maze. Limiting our research to young jocks and war casualties is not going to enlighten us as to why some people have apparent full recoveries and others never get better. It is not an accident that there is consistently 10-15% of those with concussions who wind up with persistant post concussion syndrome. Let us start screaming louder so that the real pathology in those cases is understood, and treated.
Consistent Best Effort
This week I have been discussing the basic principles of neuropsychological assessment, and its two foundational assumptions: the ability to reconstruct pre-morbid IQ and the need for “consistent best effort”. Yesterday’s blog dealt with the pre-morbid IQ. Today, we will discuss the issue of “consistent best effort.”
The number side of the neuropsychological assessment is based upon the theory that a neuropsychologist can make certain conclussions about pathology based upon an examination of the pattern of test scores. The process of doing this is called “discrepancy analysis”, meaning that if there is a discrepancy in certain areas, this points to pathology. Two other terms are important: “relative weakness” and “intraindividual comparison”. If while doing the intraindividual comparision (mean comparing the patient, only to his or her own scores versus the population as a whole) a “relative weakness” shows up, then that means something.
In a perfect world, it is a beautiful theory. You chart the scores, the “relative weakness” jumps out at the neuropsychologist, you look to the part of the brain that controls that area of function, and thus, make a diagnosis. The fundamental problem is that you must be able to presume that the test subject was making the same effort during the test where he or she did poorly, as across the entire battery of tests. But can we make that assumption?
I like to quote from depositions I have done to make these type of points, and I will do that again. My apologies to my son for my references to his middle school running career.
12 Q (By Mr. Johnson) Do you still have your Exhibit Number 1
13 before you?
14 A I do.
15 Q Page 6?
16 A Yes.
17 Q Now, as I understand what you’re saying in the first
18 paragraph of Page 6, what you’re saying is that because you
19 cannot be sure that the patient did not give optimum effort,
20 that you can’t reach conclusions based on the data in those
21 testing — in that testing; is that correct?
22 A I can make certain conclusions, but not on her current
23 status, on that date. That’s what I’m — all I’m trying to say
24 is this set of data had serious reservations because of lack of
25 effort.
54
1 Q Now, there are any number of things — strike that. Let’s
2 talk about the continuum of effort when you’re giving someone a
3 test; all right? I’ll give you an example.
4 My son, who is a 13 year old, goes out and runs a six-
5 minute mile, and he gave better effort than anyone else in the
6 class if you judge it just based on his performance, because he
7 won the race; okay?
8 A Got you.
9 Q Now, would that be considered best effort?
10 A It was certainly a sufficient effort to be recorded, yes.
11 Q Two months later in a track meet in his conference meet,
12 he’s able to run a five-minute, six-second mile without
13 significant change in this training status. In comparison to
14 the gym class — in comparison to the conference meet time of
15 five minutes and six seconds, did he give best effort in gym
16 class?
17 A There are other variables that have to be considered, and
18 I’d have to know other things. I’m not really following you.
19 Q Okay. Tell me what the variables would be.
20 A Like the environmental conditions, the contingencies if he
21 won or if he didn’t win, the particular mood or attitude that he
22 had on that day, how his physical health was, if he had a cold,
23 if he had some sort of limitation.
24 Q Now, we always have all of those limitations anytime we
25 give someone any type of test; is that correct?
55
1 A Exactly right.
2 Q If we were going to pick an example of when we might get
3 the highest percentage of people giving maximal effort or
4 optimal effort, is there a better example than the law school
5 admission test?
6 A Well, I’ve never seen the law school admission test, but if
7 it’s like the test that I took to get to graduate school, then
8 one certainly has to do well, as best as they can, yes.
9 Q And can we — if there ever — can we ever presume a higher
10 likelihood of maximum effort in an academic test than we would
11 in something like a law school or a medical college admissions?
12 A Well, I agree. I mean, one can’t do better than one can
13 do.
14 Q But what’s unique about the law school and the medical
15 school admission test, is people’s whole lives revolve around
16 how they do on this test; correct?
17 A Well, that’s probably their interpretation, but it’s not
18 real. They probably think —
19 Q And that thinking that would convince them at least
20 relative to other variables to give it their best shot?
21 A I would think so, yes.
22 Q Despite that, sometimes people who are testing in high-
23 pressure situations like a law school admissions test or a
24 medical college entrance exam, do not wind up at their optimum
25 performance level; correct?
56
1 A I presume that’s correct.
2 Q And what explanations for that would do?
3 A Again, we just went through some of them. They have a
4 cold, they’re worried about money, they have stress at home,
5 they have stress on the job, I mean, there are all kinds of
6 events that could influence particular effort on a particular
7 day.
8 Q Or actually the stress of the test itself?
9 A Well, yes, of course. There’s some people who don’t do
10 well on tests.
11 Q And there are some people who do worse the more the
12 pressure is?
13 A Right. It’s not really the pressure; it’s how the patient
14 manages the pressure that’s the issue.
Now as we consider this long introduction in the context of the search for “relative weaknesses”, what does that mean? What if our test subject was only using the gym class effort level, versus the conference meet effort level? Can we make statistical comparisons then? Or should we compare that performance to how people do in gym class, and not comparing how they do in more stimulating environments?
Neuropsychology is a science, right? They should have control out all of these variables, right? Guess again, not because they don’t want to, but because they are dealing with human beings, and in brain injury evaluations, human beings who prevented from doing what they are presumed to do, based upon the precise disability for which we are evaluating them: brain damage.
Next: The Scope of the Problem for Brain Injured Person in Giving Consistent Best Effort.
The number side of the neuropsychological assessment is based upon the theory that a neuropsychologist can make certain conclussions about pathology based upon an examination of the pattern of test scores. The process of doing this is called “discrepancy analysis”, meaning that if there is a discrepancy in certain areas, this points to pathology. Two other terms are important: “relative weakness” and “intraindividual comparison”. If while doing the intraindividual comparision (mean comparing the patient, only to his or her own scores versus the population as a whole) a “relative weakness” shows up, then that means something.
In a perfect world, it is a beautiful theory. You chart the scores, the “relative weakness” jumps out at the neuropsychologist, you look to the part of the brain that controls that area of function, and thus, make a diagnosis. The fundamental problem is that you must be able to presume that the test subject was making the same effort during the test where he or she did poorly, as across the entire battery of tests. But can we make that assumption?
I like to quote from depositions I have done to make these type of points, and I will do that again. My apologies to my son for my references to his middle school running career.
12 Q (By Mr. Johnson) Do you still have your Exhibit Number 1
13 before you?
14 A I do.
15 Q Page 6?
16 A Yes.
17 Q Now, as I understand what you’re saying in the first
18 paragraph of Page 6, what you’re saying is that because you
19 cannot be sure that the patient did not give optimum effort,
20 that you can’t reach conclusions based on the data in those
21 testing — in that testing; is that correct?
22 A I can make certain conclusions, but not on her current
23 status, on that date. That’s what I’m — all I’m trying to say
24 is this set of data had serious reservations because of lack of
25 effort.
54
1 Q Now, there are any number of things — strike that. Let’s
2 talk about the continuum of effort when you’re giving someone a
3 test; all right? I’ll give you an example.
4 My son, who is a 13 year old, goes out and runs a six-
5 minute mile, and he gave better effort than anyone else in the
6 class if you judge it just based on his performance, because he
7 won the race; okay?
8 A Got you.
9 Q Now, would that be considered best effort?
10 A It was certainly a sufficient effort to be recorded, yes.
11 Q Two months later in a track meet in his conference meet,
12 he’s able to run a five-minute, six-second mile without
13 significant change in this training status. In comparison to
14 the gym class — in comparison to the conference meet time of
15 five minutes and six seconds, did he give best effort in gym
16 class?
17 A There are other variables that have to be considered, and
18 I’d have to know other things. I’m not really following you.
19 Q Okay. Tell me what the variables would be.
20 A Like the environmental conditions, the contingencies if he
21 won or if he didn’t win, the particular mood or attitude that he
22 had on that day, how his physical health was, if he had a cold,
23 if he had some sort of limitation.
24 Q Now, we always have all of those limitations anytime we
25 give someone any type of test; is that correct?
55
1 A Exactly right.
2 Q If we were going to pick an example of when we might get
3 the highest percentage of people giving maximal effort or
4 optimal effort, is there a better example than the law school
5 admission test?
6 A Well, I’ve never seen the law school admission test, but if
7 it’s like the test that I took to get to graduate school, then
8 one certainly has to do well, as best as they can, yes.
9 Q And can we — if there ever — can we ever presume a higher
10 likelihood of maximum effort in an academic test than we would
11 in something like a law school or a medical college admissions?
12 A Well, I agree. I mean, one can’t do better than one can
13 do.
14 Q But what’s unique about the law school and the medical
15 school admission test, is people’s whole lives revolve around
16 how they do on this test; correct?
17 A Well, that’s probably their interpretation, but it’s not
18 real. They probably think —
19 Q And that thinking that would convince them at least
20 relative to other variables to give it their best shot?
21 A I would think so, yes.
22 Q Despite that, sometimes people who are testing in high-
23 pressure situations like a law school admissions test or a
24 medical college entrance exam, do not wind up at their optimum
25 performance level; correct?
56
1 A I presume that’s correct.
2 Q And what explanations for that would do?
3 A Again, we just went through some of them. They have a
4 cold, they’re worried about money, they have stress at home,
5 they have stress on the job, I mean, there are all kinds of
6 events that could influence particular effort on a particular
7 day.
8 Q Or actually the stress of the test itself?
9 A Well, yes, of course. There’s some people who don’t do
10 well on tests.
11 Q And there are some people who do worse the more the
12 pressure is?
13 A Right. It’s not really the pressure; it’s how the patient
14 manages the pressure that’s the issue.
Now as we consider this long introduction in the context of the search for “relative weaknesses”, what does that mean? What if our test subject was only using the gym class effort level, versus the conference meet effort level? Can we make statistical comparisons then? Or should we compare that performance to how people do in gym class, and not comparing how they do in more stimulating environments?
Neuropsychology is a science, right? They should have control out all of these variables, right? Guess again, not because they don’t want to, but because they are dealing with human beings, and in brain injury evaluations, human beings who prevented from doing what they are presumed to do, based upon the precise disability for which we are evaluating them: brain damage.
Next: The Scope of the Problem for Brain Injured Person in Giving Consistent Best Effort.
Best Performance Method in Neuropsychological Assessment
There are two fundamental premises upon which the statistical application of the science of neuropsychology is based: The first is that a determination can be made of what a given individual’s premorbid abilities were. The second is that an individual is giving consistent best effort throughout the test battery. Neither assumption works perfectly, but the extent to which these two assumptions work well enough, will determine whether legitimate statistical based diagnostic conclusions can be incorporated into the assessment. In today’s blog, we will discuss the Premorbid Ability assumption. In tomorrow’s, the consistent best effort issue.
Premorbid ability. By premorbid ability, we mean a given individuals abilities prior to the onset of the accident or disease process. If no assumptions can be made about premorbid ability, no diagnosis about “cause” can be made by a neuropsychologist. All they are capable of saying is that a given individual has certain weaknesses and disabilities, but no definitive diagnosis can be made. Thus, some method of assessing premorbid ability is essential.
Most neuropsychologists don’t look at enough information in determining pre-morbid IQ. They base far too much of their assessment with respect to pre-morbid ability on the test battery itself. In our earlier example of the person with the IQ of 135 post the accident, that is less of a problem. Clearly a person who has a post-morbid IQ of 135, was very superior before the onset. But most cases are not so clear cut. A previously brilliant person may not continue to have a very superior IQ after the accident. If certain deficits bring the person down into an IQ range of 110 or so, we would likely need to look for other evidence to determine IQ.
One way is by looking at the areas where they still have strengths. If their average scores are in the 130 or above area, and there are a few scores in areas we might suspect would be effected by the injury, then it might be easy to say this person was very superior before. But again, that is the easy pattern to spot. Most profiles are not that obvious.
Another method is to look at certain subtest scores, where it is believed that a given ability is unlikely to be substantially effected by the given injury. Reading scores are often thought to be an ability that is rarely changed significantly by a mild or moderate injury. Thus, a neuropsychologist might say that a person with a “very superior” reading score and a much lower current IQ, had pathological deficits, based on the retained ability to read at a high level.
All of these methods work far better with someone with a very high IQ. When you are dealing with people in the average range, IQ’s of 90-110, it becomes much more difficult to make such assumptions about premorbid IQ from subtest scores.
Another method is to assume IQ based on a assessment of that person’s educational level. So a person with a college degree would be assumed to have a higher IQ than someone without. The obvious flaw in such logic, that some brilliant people don’t go to college, isn’t even the most significant problem. The significant problem is that it groups all college graduates together. Ask anyone who went to college. Not all of their classmates were of equal intelligence and ability.
Another method, one I believe to be considerably better than the first two, is called the ‘best performance method.” The best performance method is based upon the assumption that a person’s highest areas of achievement are the best indicators of premorbid ability. If these areas of highest achievement are in contrast to significantly lower subtests scores that may point to pathology.
Of course, there is considerable disagreement as to how to apply the “best performance method.” Many neuropsychologists dismiss it as they interpret this method as applying only to the best performance on individual tests, within the full battery of tests. That would mean if the person got 99% in arithmetic or vocabulary, that would mean that such person is in the 99%. It is easy to poke holes in a restricted use of the “best performance method” because we all have normal variances in what we are good at.
However, another interpretation of the best performance method is that it makes a full assessment – not just of the scores on the given battery of tests – but also the person’s real world performances or achievements. For example, if a person has graduated from medical school, one assumes that they are very near the top of the pre-morbid ability level. Likewise, if they have risen to the top of any profession, they would be assumed to be near the top.
In my opinion, the overall preferred method, which of course is harder to reduce to statistical probabilities, is to use of the real world “best performance method”. Such method considersall factors, school records, work performance records, areas of retained strength on the test. If someone got a math score of 700 and a verbal score of 700 on the SAT when applying to college, they clearly were way above average at that time. If they went on to graduate from a competitive law school or medical school, we must almost assume that they were at the superior or likely very superior level.
If the scores were good, but not great, if they graduated from college with more than a B average and went on to have a successful career, we can’t assume they were only average. Whether they are high average or superior is open to interpretation but that is what professionals are supposed to do: make subjective interpretations of complex multi-faceted variables, to reach conclusions.
Who a person was before injury is far more complex than how well they do now on a reading score. Only if neuropsychologists look at not the basic outline of a person’s premorbid life, but level of achievement within that life, will neuropsychology be able to identify the true areas of acquired deficits and disability.
Tomorrow the concept of “consistent best effort.”
Premorbid ability. By premorbid ability, we mean a given individuals abilities prior to the onset of the accident or disease process. If no assumptions can be made about premorbid ability, no diagnosis about “cause” can be made by a neuropsychologist. All they are capable of saying is that a given individual has certain weaknesses and disabilities, but no definitive diagnosis can be made. Thus, some method of assessing premorbid ability is essential.
Most neuropsychologists don’t look at enough information in determining pre-morbid IQ. They base far too much of their assessment with respect to pre-morbid ability on the test battery itself. In our earlier example of the person with the IQ of 135 post the accident, that is less of a problem. Clearly a person who has a post-morbid IQ of 135, was very superior before the onset. But most cases are not so clear cut. A previously brilliant person may not continue to have a very superior IQ after the accident. If certain deficits bring the person down into an IQ range of 110 or so, we would likely need to look for other evidence to determine IQ.
One way is by looking at the areas where they still have strengths. If their average scores are in the 130 or above area, and there are a few scores in areas we might suspect would be effected by the injury, then it might be easy to say this person was very superior before. But again, that is the easy pattern to spot. Most profiles are not that obvious.
Another method is to look at certain subtest scores, where it is believed that a given ability is unlikely to be substantially effected by the given injury. Reading scores are often thought to be an ability that is rarely changed significantly by a mild or moderate injury. Thus, a neuropsychologist might say that a person with a “very superior” reading score and a much lower current IQ, had pathological deficits, based on the retained ability to read at a high level.
All of these methods work far better with someone with a very high IQ. When you are dealing with people in the average range, IQ’s of 90-110, it becomes much more difficult to make such assumptions about premorbid IQ from subtest scores.
Another method is to assume IQ based on a assessment of that person’s educational level. So a person with a college degree would be assumed to have a higher IQ than someone without. The obvious flaw in such logic, that some brilliant people don’t go to college, isn’t even the most significant problem. The significant problem is that it groups all college graduates together. Ask anyone who went to college. Not all of their classmates were of equal intelligence and ability.
Another method, one I believe to be considerably better than the first two, is called the ‘best performance method.” The best performance method is based upon the assumption that a person’s highest areas of achievement are the best indicators of premorbid ability. If these areas of highest achievement are in contrast to significantly lower subtests scores that may point to pathology.
Of course, there is considerable disagreement as to how to apply the “best performance method.” Many neuropsychologists dismiss it as they interpret this method as applying only to the best performance on individual tests, within the full battery of tests. That would mean if the person got 99% in arithmetic or vocabulary, that would mean that such person is in the 99%. It is easy to poke holes in a restricted use of the “best performance method” because we all have normal variances in what we are good at.
However, another interpretation of the best performance method is that it makes a full assessment – not just of the scores on the given battery of tests – but also the person’s real world performances or achievements. For example, if a person has graduated from medical school, one assumes that they are very near the top of the pre-morbid ability level. Likewise, if they have risen to the top of any profession, they would be assumed to be near the top.
In my opinion, the overall preferred method, which of course is harder to reduce to statistical probabilities, is to use of the real world “best performance method”. Such method considersall factors, school records, work performance records, areas of retained strength on the test. If someone got a math score of 700 and a verbal score of 700 on the SAT when applying to college, they clearly were way above average at that time. If they went on to graduate from a competitive law school or medical school, we must almost assume that they were at the superior or likely very superior level.
If the scores were good, but not great, if they graduated from college with more than a B average and went on to have a successful career, we can’t assume they were only average. Whether they are high average or superior is open to interpretation but that is what professionals are supposed to do: make subjective interpretations of complex multi-faceted variables, to reach conclusions.
Who a person was before injury is far more complex than how well they do now on a reading score. Only if neuropsychologists look at not the basic outline of a person’s premorbid life, but level of achievement within that life, will neuropsychology be able to identify the true areas of acquired deficits and disability.
Tomorrow the concept of “consistent best effort.”
Understanding Neuropsychological Statistics in Diagnosing Brain Injury
Yesterday’s blog threw out a few numbers to illustrate some basic starting principles about neuropsychology. As an aid to our further discussion of this neuropsychology, today I will give some basic numerical principles to help in further understanding the numeric part of neuropsychological assessment.
First, neuropsych scores are typical given in one of three scoring methods: Standard score, percentile score and T scores. T scores are a little bit too complicated to try to explain to a laymen, so I will limit this discussion to standard scores and convert them to percentile scores.
Most people are somewhat familiar to standard scores, because IQ’s are given in them. Yesterday I used the example of our successful professional who had a post accident IQ of 135. An IQ of 100 is perfectly in the middle. Something below 70 is evidence of significant impairment. Each time you move down the standard score grid by 10 points, it represents a significant drop.
Here are the basic categories of Standard scores, with their percentile equivalents.
Very superior — 130 and above — 98% and above
Superior __ 120 to 129 — 92% to 97%
High Average — 110 to 119 — 76% to 91%
Average — 90 to 109 — 25% to 75%
Low Average — 80 to 89 — 8% to 24%
Borderline — 70 to 79 — 3% to 7%
Impaired — below 70 — 2% and below
T scores use the same basic concept, and again using 10 points as the break point, but with a T score, the mid point is 50. Some neuropsychologists may disagree as to the exact point that separates these categories, but this is certainly representative of the concept.
The second term to understand in terms of understanding the statistical analysis done by a neuropsychologist is the concept of “deviations”. While I am incapable of synthesizing the dozens of different explanations of this concept into one cohesive definition, in essence, when you move from one category like very superior, to superior, you have moved one deviation. When you move from very superior to high average, that would be two deviations. Movements of two deviations are deemed to be significant.
Yesterday’s example of an IQ score of 135, which was very superior, to an average processing speed score of 100, is a movement of three standard deviations. That could be quite significant, but of course is only one factor to be looked at in doing a full blown “assessment.”
Tomorrow: assessing premorbid IQ and other ability levels.
First, neuropsych scores are typical given in one of three scoring methods: Standard score, percentile score and T scores. T scores are a little bit too complicated to try to explain to a laymen, so I will limit this discussion to standard scores and convert them to percentile scores.
Most people are somewhat familiar to standard scores, because IQ’s are given in them. Yesterday I used the example of our successful professional who had a post accident IQ of 135. An IQ of 100 is perfectly in the middle. Something below 70 is evidence of significant impairment. Each time you move down the standard score grid by 10 points, it represents a significant drop.
Here are the basic categories of Standard scores, with their percentile equivalents.
Very superior — 130 and above — 98% and above
Superior __ 120 to 129 — 92% to 97%
High Average — 110 to 119 — 76% to 91%
Average — 90 to 109 — 25% to 75%
Low Average — 80 to 89 — 8% to 24%
Borderline — 70 to 79 — 3% to 7%
Impaired — below 70 — 2% and below
T scores use the same basic concept, and again using 10 points as the break point, but with a T score, the mid point is 50. Some neuropsychologists may disagree as to the exact point that separates these categories, but this is certainly representative of the concept.
The second term to understand in terms of understanding the statistical analysis done by a neuropsychologist is the concept of “deviations”. While I am incapable of synthesizing the dozens of different explanations of this concept into one cohesive definition, in essence, when you move from one category like very superior, to superior, you have moved one deviation. When you move from very superior to high average, that would be two deviations. Movements of two deviations are deemed to be significant.
Yesterday’s example of an IQ score of 135, which was very superior, to an average processing speed score of 100, is a movement of three standard deviations. That could be quite significant, but of course is only one factor to be looked at in doing a full blown “assessment.”
Tomorrow: assessing premorbid IQ and other ability levels.
Advances in Neuroimaging – Value in Diagnosis of Brain Injury
Last week’s blogs covered a series of articles about the advances in neuroimaging to assist in the diagnosis of subtle brain injury (otherwise called Mild Traumatic Brain Injury or concussion.) The key to looking back at those blogs, is the word “assist.” Imaging studies can only tell us what the structures of the brain look like. They cannot tell us how they got that way. They tell us very little about the function of the brain (although that may change dramatically with the continued development of fMRI.)
The first time a client of mine got an abnormal 3T MRI, I was so ecstatic, I thought my job had completely changed. It didn’t. The words “clinical correlation required” became an integral part of each case and frankly, it is a good thing it did. “Clinical correlation required” in essence means that did this person suffer a change in the way his brain was functioning, at a point in time consistent with the pathology that is being seen on the scan.
That is what being a brain injury lawyer is all about. Taking the technical findings of various subspecialist in the field of brain injury and putting them in front of a jury in a way that the jury can clearly see that the traumatic event, resulted in a change in this person, which is clearly related (correlated) to the brain damage that could be suffered in the accident. Without the real world picture of how this human being has been changed, with the line of demarcation of the accident, one can simply not make a diagnosis of brain injury.
I have been saying that same thing since I first wrote a web page on brain injury in 1996. Here is the words and the graphics I said at that time:
The first time a client of mine got an abnormal 3T MRI, I was so ecstatic, I thought my job had completely changed. It didn’t. The words “clinical correlation required” became an integral part of each case and frankly, it is a good thing it did. “Clinical correlation required” in essence means that did this person suffer a change in the way his brain was functioning, at a point in time consistent with the pathology that is being seen on the scan.
That is what being a brain injury lawyer is all about. Taking the technical findings of various subspecialist in the field of brain injury and putting them in front of a jury in a way that the jury can clearly see that the traumatic event, resulted in a change in this person, which is clearly related (correlated) to the brain damage that could be suffered in the accident. Without the real world picture of how this human being has been changed, with the line of demarcation of the accident, one can simply not make a diagnosis of brain injury.
I have been saying that same thing since I first wrote a web page on brain injury in 1996. Here is the words and the graphics I said at that time:
They are:
1. Sufficient Biomechanical Force;
2. One of the Four Acute Symptoms of the Rehab Congress’s definition, i.e.:
a) any period of loss of consciousness,
b) a change in mental state as a result of the accident,
c) amnesia, or
d) focal neurological deficits;
3. Neuropsychological Deficits; and
4. A Changed Person.
Click here for those words I first wrote in 1996.