‘‘Understanding how our brains work: The new ‘PIE Neuropsychology Offer’ to homeless young people’…
23.06.2022: As I write this week’s PIE blog, as the Lead for Psychologically Informed Environments (PIE) at the national youth homeless charity — Centrepoint, I have had another busy couple of weeks. I firstly had the pleasure of visiting our new Independent Living Scheme’s (ILS) first project; Reuben House, which is an exciting and innovative development to support homeless young people, aged 18–25 years, to access their first home. I have previously written a PIE blog about this scheme, so please see here for further details: https://medium.com/@drhelenmiles/a-psychologically-informed-environment-pie-approach-to-living-independently-778c378f4578. You can also read further details about Reuben House’s official opening by our patron HRH Prince of Wales this week here: https://www.royal.uk/news-and-activity/2023-06-13/the-prince-of-wales-attends-opening-of-centrepoints-reuben-house and here: https://www.bbc.co.uk/news/uk-65880099.
In addition, this week I have been speaking to potential funders about our new PIE Team offer within our Education, Employment and Training (EET) team(s) at Centrepoint: CP Works, involving the work of our Educational Psychologist: Dr Marc Pescod (c.f. PIE Blog here: https://medium.com/@drhelenmiles/enabling-and-empowering-homeless-young-people-with-disabilities-a-psychologically-informed-3e2170d00896). Just like the Centrepoint ILS, this is an innovative approach to supporting homeless young people, in this case with the aim of improving their access to EET by exploring the barriers to EET further, and then providing psychologically informed support / inventions to increase our EET rates on departure. In other words, ensuring that young people that move on from Centrepoint not only have a ‘home’ but also a ‘job’, because we know that this will reduce their risk of further homelessness in the future. We hope that any psychologically informed intervention(s) that are found to ‘work’ in this population, can then be amplified more widely across the youth homeless sector in order to #EndYouthHomelessness in the future.
As part of increasing homeless young people’s access to EET, it is important that we understand whether there are any specific learning needs or neurodiversity issues (e.g. Attention Deficit & Hyperactivity Disorder: ADHD and Autism Spectrum Disorders: ASD) that might need further specialised support. Consequently, we are excited in the PIE team to be expanding PIE further in Centrepoint to include some direct delivery to homeless young people through our new ‘PIE Neuropsychology Offer’. This will provide homeless young people and the staff that support them access to advice and consultancy around these issues, as well as the provision of specialist neuropsychological assessments when appropriate, with the aim to provide individualised support plans to enable them to be better able to access EET opportunities in the future. I am therefore delighted to hand over the rest of this PIE blog to Dr Marc Pescod to explain in more detail about the offer, why this is so important in this population and how internal Centrepoint staff blog readers can access this in the future…
‘It is probably best to start by going through some terms which might be used throughout this PIE blog, firstly “neuropsychology or neuropsychological”. I am aware that the word neuropsychological might be unfamiliar and come across as being inaccessible and scientific. To put it plainly, a neuropsychology assessment looks at brain functioning and how the brain works, and covers areas highlighted in the blog picture above (as well as others). The neuro part relates to the neurons in the brain and psychological relates to the psychological theories associated with it.
You might also have heard of the term “neuro-diversity”, which refers to diagnosable conditions such as Autism Spectrum Disorder (ASD), Attention Deficit Hyperactivity Disorder (ADHD), Dyspraxia and Dyslexia, as well as many more. Neurodiversity just means that some individuals have a different neurological ‘make up’ from others who are described as ‘neuro-typical’, which impacts the way they perceive the world and function within it. For internal Centrepoint staff reading this blog who would like to learn more about this and how to work with ‘neurodiverse’ individuals, please do sign up to our PIE Module Training on ‘Understanding Neurodiversity’ via Learning Point.
The other word you might have heard of before, and will be discussed more in this PIE blog, is “cognition”. Essentially ‘cognition’ is a catch all term that describes the different ways our brain processes information to help us to interact with everything around us, and includes areas such as attention, memory, perception, reasoning and language abilities. Therefore, a ‘cognitive’ or ‘neuropsychological’ assessment will look look at these areas of brain functioning, and importantly, how well it does this including areas of individualised strengths and difficulties. This can then lead to recommendations for how to capitalise on the person’s strengths, as well as compensate for any difficulties.
So, let us take our brain for a spin! Take a moment to grab a pencil or pen and a piece of paper. Now, have a look around the room where you are reading this PIE blog and pick something to draw. Take a few moments to draw that object. Once you have completed your brilliantly brief masterpiece, take another few moments to reflect on what your brain needed to do in order to do that drawing activity…
Firstly, your brain needed to remain attentive. It needed to consider all the different elements of the object, focusing on it in such detail that allows you to understand and copy it on the paper. Secondly, you also needed to block out any distractions round you (perhaps not always successfully), stopping you from being distracted by your phone, other people nearby or perhaps even a pigeon outside. Next, your brain also used your ‘Working Memory’ in that it needed to keep certain bits of information about the object in your mind long enough for you to draw it on the paper. You then need to completely forget that bit of information in order for your brain to look back at the object to identify and remember the next component of the object. In addition, your brain needed to look at the object itself (i.e. ‘perception’) and consider lengths, shapes, angles, and colours in order to accurately draw the image on the paper. It also needed to think about how big the object is in comparison to other objects around it to give the right size perspective.
Moreover, you might have also used some of your reasoning skills to develop a strategy of how to approach this task. For example, you might have used a grid method and/or broken the object down into several shapes to make it easier to draw. Some of these strategies might have been taught to you in an art class at school (drawing on your long-term memory) or self-taught. Perhaps now in hindsight, you might have approached the task differently if asked to do it again. Alternatively, you might have made the decision to take just two seconds to draw something vaguely similar to the cup of coffee or tea you are currently drinking, which you do not want to get cold doing some weird drawing exercise (and I do not blame you!). All of this is ‘cognition’ — any process whereby your brain does… well anything! If you have difficulties in one or more of these areas, it will hinder you in being able to draw something, have a conversation, utilise maps or public transport, problem-solve and generally manage day to day in life, education or in the workplace; all of which are generally set up for ‘neuro-typical’ individuals (i.e. those without such difficulties).
So why is it important that we understand ‘cognition’ in homeless young people? Psychological research has shown that homeless young people are more likely to fail at school (Sullivan-Walker et al., 2017) and achieve less than their housed peers (Buckner, 2008). They will often be slower at learning numeracy and reading skills (Masten, Burt, & Coatsworth, 2015) and will score low in tests (Obradović, Long, Cutuli, Chan, Hinz, Heistad & Masten, 2009). While this is likely to be due to issues occurring within their home or living environment, it is also possible that they have specific cognitive challenges, which hinder their ability to access education. Moreover, homeless young people with these difficulties can lack the home support network (i.e. engaged parents) that is often essential to advocate for them within the education system, resulting in them not being able to access the specific assessments and support required to understand and manage any special educational needs.
Other research into cognition and homelessness specifically looking at Executive Functioning (EF) in particular (i.e. memory, attention, verbal abilities and higher-order thinking), has highlighted that EF in homeless young people is also lower than that of their housed counterparts (Fry, Langley, & Shelton, 2017, 2019). This EF deficit can not only impact on EET but also their wider presentation, including underpinning some challenging behaviours (see video here for more details: https://youtu.be/yoy1aDqMmbk).
There is also anecdotal evidence that because the homeless young people we support at Centrepoint may have a history of disrupted education or multiple education providers before coming to us, so that any issues with cognition or neurodiversity may not have been identified. Instead, the individual has just ‘dropped’ out of education, negatively influencing their future life chances. Consequently, we believe that it is important that we establish which of the homeless young people we support may have some additional needs that are barriers to them engaging in EET, and offer individualised support plans to empower them to access EET opportunities in the future. This is rationale at the heart of our new ‘PIE Neuropsychological Offer’.
How do we do this? What exactly are neuropsychological assessment(s) and why would we use them? These assessments have been developed by psychologists to explore the way an individual’s brain functions in order to help us better understand why there might be barriers in completing certain activities or challenges in managing some areas of everyday life. The tests can help explore if there is a cognitive difficulty, which might be why someone is struggling to write essays for the college course, or it might support us to identify a neurodiversity issue. They give us a useful insight into some of the difficulties which an individual is experiencing (i.e. what is the reason for a particular presentation or issue), and consequently lead to suggestions of different coping strategies that will best support them moving forward.
Neuropsychological assessments consist of a variety of different tasks, including puzzles, pictures, questions and other activities that are normally different from everyday tasks but are each designed to look at specific cognitive skills (e.g. learning, memory, attention, speed of processing, perception etc.). All of us have both strengths and difficulties (i.e. no one brain is the same as another!), so we might find some tasks easier than others might but taken together a neuropsychological assessment can enable us to understand an individual’s unique cognitive functioning abilities. Some tests are standardised to the wider or ‘normative’ population, which means psychologists can compare the results to other people of the same age and educational background. For example, I am sure most of us have found ourselves at some point or another completing an online IQ test (and then asking our friends / family to do the same to see if we get a higher score than them!). This is a type of standardised cognitive assessment that looks at a wide variety of cognitive functioning to produce a score for our general intelligence (although arguably far less reliable or accurate than a formal assessment!).
Other tests are more closely focused on ‘learning potential’, and look specifically at how the young person can engage in learning or employment by utilising specific aides or resources and/or more effective compensatory strategies. Finally, some neuropsychological assessments are utilised to explore ‘neurodiversity’, and can identify traits of ASD, ADHD or other learning needs (e.g. Dyslexia), which can lead to a formal diagnosis as well as specific support recommendations in education (e.g. extra time in exams) or daily life (e.g. behaviour support plans).
Ultimately, neuropsychological assessments are a really useful way to find out more about an individual’s cognitive functioning and will benefit those who are experiencing challenges in their daily lives but do not understand why. These difficulties might look like issues in their ability (or lack of) to understand information presented to them, or they might be struggling to access education or employment due to some unknown barrier, and/or perhaps they are experiencing difficulties socialising and engaging with others.
It is also worth highlighting that there may be some homeless young people we support who have experienced these difficulties all their lives and have previously had a neuropsychological assessment to investigate these issues. It is therefore always worth asking a young person you are supporting about this. Perhaps we might not need to undertake a new assessment but rather need to gain access to this prior assessment information (not always readily provided to support staff as it may have been undertaken many years ago) so we can understand, explain and support the young person to manage their difficulties. Supporting key-workers to access and ‘translate’ any previous assessments will also be part of this new PIE offer.
Lastly, it is important to highlight that neuropsychological assessments can be difficult activities to undertake and the young person may refuse to engage especially with an ‘unknown’ psychologist. They are also not often described as ‘fun’ (although they can be described as ‘interesting’ to participants), and will inevitably involve the young person experiencing some challenge and failure. As a result, we will work hard to make the experience as pleasant as possible, using all our PIE skills to engage with the young person and ensure they give their informed consent to the process as well as making sure that any neuropsychological assessment provides positive outcomes and recommendations that outweigh any ‘cost’ to them.
As a result, we have carefully considered the new ‘PIE Neuropsychology Offer’ to ensure that it is psychologically informed. Below is a visual for Centrepoint staff reading this blog, which outlines the pathway to accessing the offer, as well as what the process involves and what happened afterwards. It is split into four sections: (1) Identification of Needs, (2) Referral Process, (3) Assessment Process, and (4) Post-assessment Feedback/Processes, each of which is outlined further.
(1) Identification of Needs: This stage will be about identifying more information about the needs of the homeless young person before completing (if applicable) a formal neuropsychological assessment. Those staff working with the homeless young person may have concerns that they are struggling with something by observing them and/or they may be told by the homeless young person themselves that they find something difficult. Therefore, staff are encouraged to approach a member of the PIE team, either within a team Reflective Practice session or directly via email, to explore if there are useful coping strategies or tips that they can utilise to support this individual or provide directly to the homeless young person to empower them to manage their difficulties. If such recommendations are helpful, then it may be that there is no need for a formal neuropsychological assessment. However, if this is not sufficient, then it might be helpful to refer to the next stage in the pathway.
(2) Referral Process: Referrals will be made via our electronic records system (In-Form) by staff directly working with the homeless young person (and there will be an information guide to support this process). This referral allows the PIE team to get as much information as possible. However, it is also likely that we will reach out to discuss the referral directly with the staff member to gain additional information in order to determine whether a formal neuropsychological assessment is required and help us to identify the most appropriate method of assessment if needed including arrangements for the actual process (e.g. when, where etc.).
(3) Assessment Process: The actual neuropsychological assessment will vary from one individual to another, as different tests will be used for different issues, although there are some elements that are similar regardless. For example, there will be conversations with key individuals (e.g. Key-worker, CP Works staff and the homeless young person themselves) to get a better understanding of the issues as well as other relevant observations etc. There will be some form of assessment or ‘test’, wherein the psychologist and the homeless young person meet to undertake. This may be in the presence of another trusted person (e.g. the Key-worker) if the young person would find that helpful and reduce some of their anxiety. The neuropsychological assessment will vary in time taken and content, depending on the identified needs, but will be undertaken with plenty of breaks and only after the young person is comfortable with the process and in a suitable location free from distractions. The purpose of this stage is to get a solid understanding of the homeless young person’s needs, which will inform us of what support might need to be put in place in the future.
(4) Post-assessment Feedback/Processes: The final stage will be sharing the outcome(s) of the neuropsychological assessment. We will do this in three different ways. Firstly, conversation with the homeless young person and any relevant party (e.g. staff working with the young person). This meeting is an opportunity to share the findings, and explore what this means for them in practical terms. This can also be a space for staff and the young person to feed back their thoughts on the process and outcomes, as well as consider possible support strategies suggested from the assessment results that are realistic and have the highest likelihood of success, in order to develop a support ‘plan’ for the future. This plan will include suggestions for strategies for the homeless young person themselves to implement as well as for those staff working with them.
Secondly, the provision of a psychological report for professionals detailing all the neuropsychological assessment results and linked recommendations for future actions / support requirements. Thirdly, a summary report of key highlights, aiming to be more accessible, which can be shared with the homeless young person who has completed the assessment. Importantly, once the psychological report is completed, that is not the end of the PIE Team involvement. We will also arrange to meet with the homeless young person and any staff working with them approximately 6 weeks after the initial assessment feedback meeting. This further meeting will be to check the impact of the support offered so far, consider if any additional input is required and amend the plan for support moving forward if necessary.
In summary, we are very excited in the PIE Team to begin to roll this new neuropsychology offer out across Centrepoint over the coming weeks and months, with more specific details to follow to staff in due course. This offer is also available in our new LEWS service (c.f. see PIE blog here: https://medium.com/@drhelenmiles/time-to-let-lews-introducing-the-new-pie-informed-lambeth-emotional-wellbeing-service-in-8ee75b82f24c). We very much hope that this offer can provide vital and timely help to homeless young people who are struggling to access EET opportunities, or may need evidence of a diagnosis to inform their future housing needs and/or suitability to access further specialist statutory services. For Centrepoint staff reading this blog, if you have any questions on the new ‘PIE Neuropsychology Offer’ or you have a homeless young person you are supporting that you think might benefit from this offer, then please do not hesitate to get in touch with the PIE team to discuss further.’
