Civil Capacities in Clinical Neuropsychology (Capacities) is a multiauthored text in four parts suitable for early-career forensic psychiatrists and for those who are preparing for recertification. Part I has two chapters that discuss civil capacities from a clinical and legal standpoint. All the essential definitions, legal and clinical, that one must understand in the text that follows are provided. Part II is composed of six chapters focusing on specific capacity assessments such as financial, testamentary, health care decision-making, driving capacities, and independent living and adult guardianship. Part III has five chapters starting with a proposed evaluative framework for capacity assessments, research trends with respect to specific instruments, forensic report writing, ethics, and other sources of data of use in conducting such evaluations as the history and cognitive screening, the clinical interview, and the risk assessment. In Part IV a chapter walks us through the legal steps that are often necessary to bring these concerns before a legal decision maker. The final chapter deals with future research. This book is not just about testing, it is about assessment and the role testing can play.
The chapters in Part II are as much a step-by-step guide to conducting the specific assessments as they are a review of the literature on specific tests. For example, I have been interested in the question of driving capacity for some years. As noted in the excellent chapter by Drs. Penny L.Wolfe and Jessica A. Clarke, the laws governing assessment and reporting requirements vary widely from state to state. Some states have laws similar to mandated reporting statutes. In other states, reporting would constitute a violation of confidentiality. Reading this chapter, I discovered where one can go to find out the law in one's own state (p 122) and where one can find training programs for individuals recovering from an injury or dealing with disability or for older drivers (p 124). The chapter lists not only the neuropsychological domains where impairment is associated with poor driving, it also lists general medical and neurological conditions that are relevant to an assessment of driver safety, placing the neuropsychological testing in the context of a multidisciplinary approach that includes vehicle testing on and off the road.
After a detailed review of the evidence of what kinds of tests are helpful in assessing driving capacity, at the end of the chapter are two case examples that help the reader appreciate how all these factors might work in an assessment. The authors are well aware of the limited use testing can play in some cases, because driving performance often relies on overlearned procedural memory rather than cognitive/perceptual processing, potentially rendering results of testing less important than an in-vehicle evaluation in considering an individual's ability to drive defensively on the road. In this light, the authors raise the question of whether ethics require that before such assessments the person be informed that decisions will be made about his capacity to drive a car based on the results of the testing.
Given the impact of the decisions to be made from the results, the authors emphasize the ethics of telling test subjects about the uses to which the results of the tests they are about to take will be put.
The one concern I have regarding the various capacity assessments is that insufficient attention is paid to the impact of pain and fatigue and sleep deprivation on both functioning and test performance.
The literature on the impact of chronic pain on executive functioning is extensive but is given short shrift in this text (mentioned on page 149 in relation to the assessment of an individual's capacity to care for himself independently). As Moriarty et al.1 demonstrated in a review in 2011, the literature on the effects of pain on neurocognitive functioning is better developed and more extensively studied than one might think in reading this otherwise excellent book. Their review may be a good place to start for those interested in learning more.
The literature on the neurocognitive consequences of sleep deprivation in general was reviewed in 2005 by Dumer and Dingas.2 Since 2005, the literature has developed further but this review may offer a good starting point.
A look at the literature on the effects of pain and sleep deprivation and fatigue on test and decision-making, task performance, cognitive functioning makes it obvious that inquiry into these matters should be part of the assessment, even as the individual subject prepares to work on tests that place heavy demands on sustained attention and require considerable effort and focus. My hope is that in future editions, these concerns will be addressed further.
Footnotes
Disclosures of financial or other potential conflicts of interest: None.
- © 2016 American Academy of Psychiatry and the Law
