How To Test For Neurocognitive Impairment

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Aerospace Medical Association Meeting: Pay Attention! ADHD in Civil Aviation (May 16, 2013)

Neuropsychological Evaluation of ADHD: Recent FAA Revisions

Kevin O’Brien, Ph.D., ABPP-Cn

Arizona Neuropsychology, P.C. 9832 N. Hayden Road, Suite 106 Scottsdale, AZ 85258 (480) 945-3475 www.azn.us

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Disclosure Information

84th Annual AsMA Scientific Meeting

Kevin P. O’Brien, Ph.D.

I have no financial relationships to disclose.

I will not discuss off-label use and/or

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SPECIFICATIONS FOR NEUROPSYCHOLOGICAL EVALUATIONS: Revised January 2013

 Protocols for P & P’s, SSRI, Alcohol &

Substance Abuse/Dependence, Potential Neurocognitive Impairment and ADHD/ADD were reviewed and revised by The FAA

Neuropsychology Working Group:

 Robert Elliott, Ph.D., ABPP-CN, SP  _{Gary Kay, Ph.D.}

 Jeffrey Moore, Ph.D.

 Randy Georgemiller, Ph.D., ABPP-CP  Carlos Porges, Ph.D., ABPP-RP, and  Dan DaSilva, Ph.D.

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What is Role of Neuropsychologist?

1) Consultative (work with AME/FAA)

2) Augments, does not replace, medical

decision-making

3) Provides objective data regarding

neurocognitive functioning

4) Required by FAA in cases where history

of ADHD or ADD and/or psychostimulant medication use are an issue

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“Testing” means different things in

Medicine and Neuropsychology

 Physicians order a test or tests to assess a specific

function or blood level (e.g., thyroid series, glucose tolerance, cholesterol, creatinine)

 A neuropsychological examination includes tests but

does not rely on any single test. There is no one neuropsychological test that is a marker for any neurological/psychological/psychiatric condition.

 Neuropsychological evaluation relies on:

 _{Pattern of test performance}

 _{How a test score fits with other similar test results, history,}

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ADHD: Three Types per DSM-IV*



1. Inattentive



2. Hyperactive-Impulsive



3. Combined

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ADHD: Common Themes



1. Individuals with a DSM-IV diagnosis

of ADHD who are enrolled in an

aviation school and want to fly



2. Bright individuals who took meds

for “ADHD” as a child for lackluster

(or not) academic performance



3. General aviation pilots who were

Rx’d psychostimulants for focus

issues, daytime fatigue or sleepiness,

etc.

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ADHD: Diagnostic Pitfalls



1. Many with DSM-IV diagnoses had

evals that were based on cursory

work-up that did not include interview of

parents or teachers.



2. Many given DSM-IV diagnoses to

justify Tx with a psychostimulant.



3. Many with “true” history of ADHD

are fit to fly.



4. Psychostimulants are currently not

allowed by FAA (despite demonstrated

effectiveness in Air Force sorties).

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CFR’s / FAR’s*



§67.107, 207 & 307-Mental:

(c) No other personality disorder,

neurosis, or other mental

condition that the Federal Air

Surgeon, based on the case history

and appropriate, qualified medical

judgment relating to the condition

involved

finds-CFR: Code of Federal Regulations FAR: Federal Aviation Regulations

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CFR’s / FAR’s*



§67.107, 207 & 307-Mental:

(c)(1) Makes the person unable to safely perform the duties or exercise the

privileges of the airman certificate applied for or held; or

(c)(2) May reasonably be expected, for the maximum duration of the airman

medical certificate applied for or held, to make the person unable to perform those duties or exercise those

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CFR’s / FAR’s*



§67.109, 209 & 309-Neurologic:

(b) No other seizure disorder,

disturbance of consciousness, or

neurologic condition that the

Federal Air Surgeon, based on the

case history and appropriate,

qualified medical judgment relating

to the condition involved

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finds-CFR’s / FAR’s*



§67.109, 209 & 309-Neurologic:

(b)(1) Makes the person unable to safely perform the duties or exercise the

privileges of the airman certificate applied for or held; or

(b)(2) May reasonably be expected, for the maximum duration of the airman

medical certificate applied for or held, to make the person unable to perform those duties or exercise those

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SPECIFICATIONS FOR NEUROPSYCHOLOGICAL

EVALUATIONS FOR ADHD OR ADD (January 2013)



Who may perform:

 Clinical psychologist who is

“board-certified” (ABPP or ABPN) or:

 “Board eligible” in clinical

neuropsychology (has training and background to qualify for application to either Board)

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SPECIFICATIONS FOR NEUROPSYCHOLOGICAL EVALUATIONS FOR ADHD OR ADD (January 2013):



Core Test Battery:

 WAIS-IV – Overall intellectual abilities  Trail Making A – Sustained attention  Trail Making B – Alternating attention  Category Test OR Wisconsin Card

Sorting Test AND Stroop Test –

Executive functioning

 PASAT – Speed of mental processing &

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

Core Test Battery (continued):

 TOVA-8 or CPT-II or IVA – Continuous

performance tests that require visual and/or auditory vigilance

 WMS-IV subtests, Rey AVLT, CVLT-II –

Verbal memory

 WMS-IV subtests, BVMT-R or Rey

Complex Figure – Visual memory

 BNT, COWAT and Semantic Fluency -

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SPECIFICATIONS FOR NEUROPSYCHOLOGICAL

EVALUATIONS FOR ADHD OR ADD (January 2013):



Core Test Battery (continued):

 Finger Tapping Test – Manual motor

speed

 Grooved Pegboard or Purdue

Pegboard – Visual motor (“eye-hand

coordination”)

 MMPI-2 (and others if needed) –

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

Core Test Battery (continued):

 Additional Testing if problems are

noted on tests of reading or math

 Additional Testing if any other areas

of concern are identified by the neuropsychologist

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Q: Is additional testing in the

future required?

A

: If eligible for unrestricted medical

certification, no additional testing would be required. However, pilots

found eligible for Special Issuance will be required to undergo periodic

re-evaluations. The letter authorizing special issuance will outline required testing (and scope).

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How to Find a Neuropsychologist

http://www.theabcn.org/  Directory of members  Listed by state http://www.cogscreen.com/*  Providers:

 _{Listed alphabetically OR by State}

* List includes both

neuropsychologists and

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SUPPLEMENTAL SLIDES:

DSM-IV Criteria for ADHD: Inattentive

Criterion A (1): six (or more) of the

following symptoms of inattention:

 a) Often fails to give close attention to details  _{b) Difficulty sustaining attention in tasks or play}  c) Often does not seem to listen

 _{d) Often does not follow thru/fails to finish}  _{e) Often has difficulty organizing tasks/activity}

 f) Often avoids/dislikes tasks involving sustained mental

exertion

 _{g) Often loses things necessary for tasks etc}  h) Often easily distracted by extraneous stimuli  _{i) Often forgetful in daily activities}

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SUPPLEMENTAL SLIDES:

DSM-IV Criteria for ADHD: Impulsive-Hyperactive

Criterion A (1): six (or more) of the

following symptoms of hyperactivity-impulsivity:

 a) _{Often fidgets with hand or feet or squirms}

 _{b) Often leaves seat in classroom or other situation}

 c) Often runs about or climbs excessively or (in adults)

subjective feelings of restlessness

 d) Often has difficulty playing in activities quietly  e) Often “on the go”/acts as if “driven by a motor”  _{f) Often talks excessively}

 _{g) Often blurts out answers/responds before Q’s}

completed

h) Often has difficulty awaiting turn

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SUPPLEMENTAL SLIDES:

DSM-IV Criteria for ADHD: Inattentive

Criterion B:

Some hyperactive-impulsive or

inattentive symptoms that caused impairment were present before age 7 years.

Criterion C:

Some impairment from the symptoms is present in two or more settings (e.g., school, work, home).

Criterion D:

There must be clear evidence of clinically significant impairment in social, academic, or occupational functioning.

Criterion E:

The symptoms do not occur exclusively during the course of another mental disorder.