The issue of medical experts examining claimants and reporting to the courts during the Covid-19 crisis is a difficult one. Here Consultant Neuropsychologist Daniel Friedland provides some guidance.
The landscape has changed for all of us
We are all facing unprecedented times in both our professional and personal lives due to COVID-19. COVID-19 has already impacted on expert neuropsychological assessments for the Courts as we have been unable to conduct face-to-face neuropsychological assessments since the lockdown began. Tele-neuropsychology has become an area of significant interest in the last 6 weeks amongst the international neuropsychological community. This relates to neuropsychological services administered via web-based video conferencing, and includes both neuropsychological assessments and treatment. Tele-neuropsychology is not a new modality but it is not practised on a wide basis.
Neuropsychology assessments typically involve a review of records, interviews, and neuropsychological testing. Neuropsychological testing involves the assessment of various cognitive domains including processing speed, memory, and executive functioning by the administration of standardised tests.
The Division of Neuropsychology in the UK has provided interim guidelines on the use of tele-neuropsychology to support colleagues and services in the context of the global Covid-19 pandemic (1). These guidelines are designed to assist clinicians in making decisions about the strengths and weaknesses of adopting a tele-neuropsychology approach to their work. These guidelines do not specifically refer to medico-legal work but web-based video conferencing, which is central in tele-neuropsychology, is a key element of medico-legal work at present.
There are probably three main options for expert neuropsychologists at the moment. Firstly, to interview Claimants via video conferencing and also conduct neuropsychological testing via video conferencing, and provide expert reports based on these interviews, neuropsychological testing, and medical records. Secondly, to interview Claimants via video conferencing and provide expert reports based on these interviews and medical records. Thirdly, to delay expert neuropsychology assessments until face-to-face assessments can resume.
Option 1: to interview Claimants via video conferencing and also conduct neuropsychological testing via video conferencing and provide expert reports based on these interviews, neuropsychological testing, and medical records.
The challenge with this option is that neuropsychological testing is not traditionally conducted via video conferencing. There has been some promising research into the reliability of some neuropsychological tests typically administered face-to-face being used in tele-neuropsychology. However, administering neuropsychological tests via video conferencing in the medico-legal context would be an entirely new approach with no research to date on this methodology. Some expert neuropsychologists may still choose to conduct neuropsychological testing via video conferencing but the strengths and weaknesses of this approach would need to be outlined clearly.
Another important issue to consider relates to performance validity testing. This testing is considered to be an essential part of any expert neuropsychological assessment. The challenge is that there is no research looking at the reliability and validity of performance validity testing involving the most commonly used performance validity tests via video conferencing.
It is important to note that computerised neuropsychological testing which can be done remotely is available. The ImPACT neurocognitive test battery developed in the U.S. is a computer-based program for assessing neurocognitive function and concussion symptoms and is the most widely used computerized testing program in the sports setting (2). Our TBI service has developed computerised testing for traumatic brain injury which can also be done remotely (3). CNS Vital Signs, developed in the U.S., has been used to measure subtle neurocognitive changes or deficits in most neuropsychiatric conditions, stroke, and traumatic brain injury. This assessment has the benefit of having inbuilt validity measures (4). The challenge is that these computerised assessments have not been traditionally used in the medico-legal context.
Option 2: to interview Claimants via video conferencing and provide expert reports based on these interviews and medical records.
The advantage of this approach is that preliminary reports could be provided with a focus on neurorehabilitation requirements and any concerns about capacity issues. This assessment would probably need to be followed up by a further clinical interview and neuropsychological testing. The challenge in this situation is that subtle neurobehavioural mannerisms may be missed by not seeing the Claimant face-to-face. Colleagues have reported that unstable internets connections can make the interview challenging. It may also be difficult to know whether the Claimant is on their own or not.
Option 3: delay expert neuropsychology assessments until face-to-face assessments can resume.
The advantage of this approach is that the challenges inherent in video conferencing interviews and neuropsychological testing is avoided. However, it is far from clear when face-to-face expert neuropsychological assessments can resume. If there are delays for a further 3 to 6 months, or even longer, Claimants may not be able to receive valuable neurorehabilitation. Even when face-to-face assessments can resume Claimants may be reluctant to travel to clinics for assessments due to concerns about being exposed to COVID-19. There is a further issue in that there will be Claimants who would probably need to be shielded over a much longer period from exposure to COVID-19 due to their age/and or underlying health conditions. In this situation it may not be practical from a legal perspective to wait for a further 12 to 18 months for an expert neuropsychological report.
This is a very challenging time for everyone. There are no easy answers with how best to proceed with expert neuropsychological assessments at the present time. Option two: to interview Claimants via video conferencing and provide expert reports based on these interviews and medical records is certainly a practical way of dealing with the current restrictions on face-to-face expert assessments. If expert face-to-face assessments are not permitted for the next 12 to 18 months, expert neuropsychologists will need to look at conducting flexible neuropsychological testing via video conferencing or administering computerised batteries remotely. The key will be outlining the strengths and weaknesses of the approach that has been adopted in each case.
Mr Daniel Friedland is a Consultant Neuropsychologist and has been working in neurorehabilitation for the last 20 years. He is part of the Imperial Multi-Disciplinary Traumatic Brain Injury Clinic, St Mary’s Hospital, London. He conducts expert neuropsychology assessments and is a member of four different medico-legal supervision groups, and has been discussing these issues within these groups since COVID-19 has been spreading across the globe. Email: firstname.lastname@example.org
(1) Division of Neuropsychology Professional Standards Unit Guidelines to colleagues on the use of Tele-neuropsychology, April 2020
(2) Lempke, L. B., Howell, D. R., Eckner, J. T., & Lynall, R. C. (2020). Examination of Reaction Time Deficits Following Concussion: A Systematic Review and Meta-analysis. Sports Medicine.
(3) Jenkins, P., Fleminger, J., De-Simoni, S., Jolly, A., Gorgoraptis, N., Hampshire, A., & Sharp, D. (2015). Home computerised cognitive testing for TBI is feasible and popular Journal of Neurology, Neurosurgery & Psychiatry, 86, 11.)
(4) Comparing patients with mild traumatic brain injury to trauma controls on CNS VITAL SIGNS; American Congress of Rehabilitation Medicine 2012; Shawnda C. Lanting, Grant L. Iverson, and Rael T. Lange.