How Is Neuropsychological Assessment Different From Cognitive Testing?

Corwin Boake, PhD, ABPP/CN
Division 40 representative to APA Council of Representatives
Neuropsychologist, TIRR/Memorial Hermann, Houston, TX
Clinical Associate Professor, Dept. of Physical Medicine & Rehabilitation, University of Texas-Houston Medical School
corwin.boake@uth.tmc.edu

Cady Block, PhD

Chair, Association of Neuropsychology Students in Training (http://www.div40-anst.com/)

Clinical neuropsychology postdoctoral fellow, TIRR/Memorial Hermann and Dept. of Physical Medicine & Rehabilitation, Baylor College of Medicine, Houston, TX

cady.block@bcm.edu

With an extensive educational, clinical, and research training background in brain-behavior relationships, neuropsychologists are uniquely qualified in the conceptualization and assessment of cognitive problems in persons with brain disorders. From this perspective, all cognitive abilities arise from neurocognitive functions and thus would appear to fall within the expertise of the neuropsychologist. However, most clinical cognitive testing is performed by professions other than neuropsychologists or even by psychologists in general. More cognitive assessments are performed by physicians, educators, and rehabilitation therapists than by neuropsychologists. Cognitive assessment for educational recommendations is a major contribution of psychologists to schools.  But since these professionals use some of the same tests as do neuropsychologists, is it accurate for evaluations by these other professionals to be represented as neuropsychological assessment? What differentiates neuropsychological assessment from the cognitive testing conducted by these other professions?

The distinction between neuropsychological assessment performed by a clinical neuropsychologist and brief cognitive assessment as performed by physicians is formally recognized in the current revision of the Diagnostic and Statistical Manual of Mental Disorders. DSM-5 states that determination of cognitive impairment, as needed for the diagnoses of Mild and Major Neurocognitive Disorder, should be “preferably documented by standardized neuropsychological testing” (p. 602).  According to DSM-5, a key advantage of neuropsychological assessment over other forms of cognitive testing is to provide “quantitative assessment of all relevant domains” (p. 610), a feature that is particularly useful for diagnosis and for detecting change.

Another area in which this distinction has been clearly made is in guidelines for management of sports concussion. A recent consensus statement (4th International Conference on Concussion in Sport, Zurich, November 2012; McCrory et al., 2013) states, “It is recognized, however, that abbreviated testing paradigms are designed for rapid concussion screening … and are not meant to replace comprehensive neuropsychological testing which should ideally be performed by trained neuropsychologists that are sensitive to subtle deficits that may exist beyond the acute episode; nor should they be used as a stand-alone tool for the ongoing management of sports concussions” (p. 90).

The distinction between neuropsychological assessment and cognitive evaluations by psychologists in other specialties is also clearly made in the documentation on user qualifications that accompany many neuropsychological tests.  For example, the manual for the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) states that while other professionals “may engage in some initial interpretation of performance on RBANS, the test results should ultimately be interpreted only by individuals with appropriate professional training in neuropsychological assessment for diagnostic purposes” (Randolph,  2012, p. 9). Furthermore, the manual for Advanced Clinical Solutions for WAIS-IV and WMS-IV states that, “When ACS is to be used for a neuropsychological assessment, the examiner should have appropriate training in neuropsychology and neuropsychological assessment” (Pearson, p. 8).  These test qualifications make clear that administering neuropsychological tests is not equivalent to neuropsychological assessment. Specialized interpretation competencies are necessarily part of practicing neuropsychology.

These interpretation competencies are clearly outlined in the description of the clinical neuropsychology specialty published by the American Psychological Association Commission for the Recognition of Specialties and Proficiencies in Professional Psychology (CRSPPP).  The CRSPPP description (http://www.apa.org/ed/graduate/specialize/neuro.aspx) states that core competencies in clinical neuropsychology include not only the use of specialized neuropsychological assessment techniques, but also “the ability to integrate neuropsychological test findings with neurologic and other medical data, psychosocial and other behavioral data, and knowledge in the neurosciences,” as well as “an appreciation of social, cultural and ethical issues.”  

For comparison, the CRSPPP description of the geropsychology specialty (http://www.apa.org/ed/graduate/specialize/gero.aspx) states that core competencies include “cognitive and functional performance testing, integration of interdisciplinary assessments (e.g., medical, neuropsychological, social service).” This description implies that cognitive testing, while listed as a competency of this specialty, is distinct from neuropsychological assessment.

Recognition of clinical neuropsychology as a professional psychology specialty, rather than as a proficiency, indicates that the specialty’s core competencies should be practiced by psychologists who have undergone the education and training required of that specialty.  The large and expanding knowledge base required of clinical neuropsychologists explains the need for specialized postdoctoral training for two years, as outlined by the Houston conference guidelines.  Relevant areas of knowledge include (but are not limited to) neuropsychological assessment, psychometrics, diagnostic statistics, neuroanatomy and neurophysiology, brain-behavior relationships, and brain imaging.

The distinction between neuropsychological assessment and cognitive testing is commonly accepted and is consistent with the CRSPPP description.  It follows that training of psychologists in other specialties, which may include exposure to neuropsychology, is not adequate preparation for practicing neuropsychological assessment.  Yet this does not mean that practitioners in other psychological specialties should amend cognitive assessment from their scope of practice.  Practitioners in other specialties can continue to describe their assessments as cognitive assessment or cognitive evaluation (among many possible labels) while maintaining the existing scope of specialty practice. Cognitive assessment is one of the tools that may be shared among psychological specialties but it is not equivalent to neuropsychological assessment.

REFERENCES:

American Psychiatric Association. (2013). Diagnostic and statistical manual for mental disorders, fifth revision. Washington, DC: American Psychiatric Publishing

Houston conference on specialty education and training in clinical neuropsychology. (1997). http://www.div40.org/pub/Houston_conference.pdf

McCrory, P., Meeuwisse, W.H., Aubry, M. ... (2013). Consensus statement on concussion in sport: The 4^th International Conference on Concussion in Sport, Zurich, November 2012. Journal of Sports Medicine, 23, 89-117. http://bjsm.bmj.com/content/47/5/250.full

Advanced Clinical Solutions for WAIS-IV and WMS-IV, Administration and scoring manual. (2009). San Antonio: NCS Pearson.  

Randolph, C. (2012). Repeatable Battery for the Assessment of Neuropsychological Status Update (p. 9). Bloomington, MN: NCS Pearson – PsychCorp.

2015 APA Convention

Looking for a cornucopia of excitement, knowledge, and networking? Look no further than the 2015 APA Convention!

 

Workshops, Symposia, Posters, SCN Events, ANST Events, Networking

 

Soundy tasty?

We welcome your proposals for symposia, posters, and individual papers! The theme of Division 40’s 2015 Convention Program is “Integrated Healthcare.” We especially welcome submissions centered around this theme, but please know that all submissions are welcome. Please note that the deadline for individual submissions is December 1, 2014 at 5pm (EST).

 

Click here for detailed descriptions of the proposal guidelines, submission procedures, and a subject index for the convention program. All proposals must be submitted to the APA submission portal, which may be accessed here. 

 

For more information or questions/concerns, please contact:
 

Shawn McClintock, 2015 Convention Program Chair: shawn.mcclintock@duke.edu
 

Dawn Schiehser, 2015 Convention Program Co-Chair: dschiehser@ucsd.edu

 

Click here for a PDF of this information.

 

 

Job Posting: Pediatric Neuropsychologist in Southeastern Massachusetts

See the PDF for this job posting at Pediatric Neuropsychologist in Southeastern Massachusetts

Job Posting: Chicago – Faculty Pediatric Neuropsychologist

The Northwestern University Feinberg School of Medicine and the Ann & Robert H. Lurie Children’s Hospital of Chicago are seeking a clinical pediatric neuropsychologist to join a multidisciplinary child psychiatry department in a nationally ranked freestanding children’s hospital located on the medical school campus.  Duties are primarily: 1) neuropsychological evaluation of infants, children, and adolescents; 2) Consultation to parents, schools and medical/surgical staff; 3) teaching in multidisciplinary child health and mental health training programs. Instructor or Assistant Professor position is full-time continuing appointment faculty, requiring experience and excellence in teaching and an interest in an academic environment. Experience with patients post-concussion is a plus. Research is encouraged. A PhD in clinical psychology from an APA-approved program and an APA-approved predoctoral internship are required, at least one of which has a focus on clinical child or pediatric psychology, and postdoctoral fellowship in pediatric neuropsychology are required.

Rank and salary commensurate with qualifications and experience. Research pilot funding is available.  Start date immediate after licensure in Illinois.  Applications will be evaluated as received.

To assure full consideration, applications must be received by November 30, 2014, but position is open until filled. Send CV with a letter describing clinical and academic interests and names of three professional references to: John Lavigne, PhD, Chief Psychologist, Lurie Children’s Department of Psychiatry, 225 E. Chicago Ave. Box 10, Chicago IL, 60611-2605

Email: jlavigne@luriechildrens.org

Northwestern University and Lurie Children’s Hospital are Equal Opportunity, Affirmative Action Employers of all protected classes, including veterans and individuals with disabilities. Women and minorities are encouraged to apply. Hiring is contingent upon eligibility to work in the United States and licensure in Illinois.

APA Convention 2015

Join SCN/Division 40 and be part of the APA 2015 Convention

Confirmed Invited Speakers

It's not too early to start planning for APA 2015! Whether you're a seasoned professional, early career psychologist, or trainee, the Society for Clinical Neuropsychology is designing programming with YOU in mind. Speakers already confirmed:

Donald Stuss, PhD, ABPP-CN
Ontario Brain Institute

Kathleen Welsh-Bohmer, PhD
Duke University School of Medicine

George Prigatano, PhD, ABPP-CN
Barrow Neurological Institute

Morris Moscovitch, PhD
University of Toronto

Angela Troyer, PhD
Baycrest Health Sciences

August 6-9, 2015 -- Toronto, ON
www.div40.org | www.facebook.com/division40

Society for Clinical Neuropsychology (APA Division 40) Early Career Award

The Society for Clinical Neuropsychology (APA Division 40) is accepting applications for the Robert A. and Phyllis Levitt Early Career Award in Neuropsychology. Eligible candidates are APA member psychologists not more than ten years postdoctoral degree, who have made a distinguished contribution to neuropsychology in research, scholarship, and/or clinical work. 

Application requirements:  A letter of nomination and one supporting letter (from a nationally-known neuropsychologist who is familiar with the candidate’s work and its impact on the field) should be included.  The nominee should also send a (1) a CV, (2) three supporting documents that provide evidence of national/international recognition (e.g., major publications, research grants, assessment, clinical, or teaching techniques, treatment protocols), and (3) a 500-word statement describing professional accomplishments, personal long-term goals, and future challenges and directions in the field of neuropsychology that they wish to address.  

Application procedure:  All materials provided by applicant are to be submitted electronically to Michael Basso, Chair, SCN Awards Committee, at michael-basso@utulsa.edu. Please submit all application materials in a single .pdf file. The letter of nomination and supporting letters may be included in the application file, or e-mailed directly to Dr. Basso. 

Application deadline:  October 25, 2014

Award:  The awardee will receive $1,000 and may be invited to give an address at the 2015 APA Convention in Toronto.

 

Apportionment Ballots

Neil Pliskin, PhD 

Neil Pliskin, PhD

President, Society for Clinical Neuropsychology

In a few weeks you will receive an apportionment ballot from APA. This is the method that determines division and state representation on APA’s Council of Representatives. You will be provided with 10 votes for allocation, and I strongly encourage you to allocate ALL of your votes for SCN/Division 40 (or at least 6/10) so that clinical neuropsychology can maintain its strong representation in the APA Council.

Although various issues confront our field as a whole, we know that reimbursement for assessment and treatment services is one area that we can all agree demands more attention from APA, along with other issues related to specialty practice.  Apportionment of ballots is the way that we get neuropsychology’s voice at the table.  Representation by APA on national healthcare issues is one of the biggest ways we have of influencing the process, and the number of representatives to council we have is essential to effective influence.  Our council members have been doing an excellent job representing our interests, but there is indeed strength in numbers, and SCN is well-positioned to gain a better foothold within APA. I strongly urge you to allocate your votes for SCN/Division 40 to maintain and hopefully increase our representation within APA. Remember, every vote counts!

Nominations for Fellows

Nomination to become an APA Fellow is an honor that recognizes evidence of unusual and outstanding contribution to or performance in the field of psychology that has had impact beyond a local, state, or regional level (i.e., national or international impact). Election as a Fellow is an honor not only for the individual but for the Division as well, and we welcome the nomination of outstanding division members for this distinction who have made substantial contributions to the field of neuropsychology.

Criteria: Evidence of unusual and outstanding contributions in the field of neuropsychology may be demonstrated in diverse ways reflecting the diversity of career and practice roles performed by neuropsychologists. Supporting letters and the candidate’s self-statement should clearly and specifically identify the candidates’ unusual and outstanding qualifications that have advanced the field, and should not be summary statements about the candidate’s general competency. Examples of contributions in Clinical Neuropsychology of interest to the Committee include, but are not limited to, the following:

• Supporting specialty recognition through board certification in Neuropsychology (e.g., ABPP/ABCN)
• A record of scientific and/or clinical accomplishments published in respected peer reviewed journals
• Authorship or editorship of a major psychology textbook(s)
• Federal grant support
• Senior level lectureships/invited presentations
• Journal editorial or reviewer responsibilities
• Elected and volunteer positions in professional or academic organizations
• Evidence of outstanding teaching and/or innovation in clinical neuropsychology
• History of mentorship of students and early career colleagues
• Development of innovative therapeutic applications
• Other evidence of outstanding contributions that have a national or international impact

Nominations of Initial Fellows: The nomination procedure for an SCN member applying for Fellowship is outlined on the division website listed at the end of this notice. Application requires the completion of a "Uniform Fellow Blank," which is available on the SCN website.  A minimum of three endorsement letters are required, preferably from current APA Fellows who can address the nominee’s accomplishments in the area of neuropsychology.  Other requisite supporting materials include a current vita, a listing of the nominee's publications with "R" for refereed indicated, and the nominee's self-statement setting forth the accomplishments that warrant Fellow status in SCN. SCN strongly encourages women and minority members to apply for Fellowship.  

Nominations of Current Fellows: APA Members who are already Fellows in other Divisions may also become Fellows in SCN/Division 40. The same nomination materials as are required for initial fellow appointments must be submitted. Nominees should demonstrate their specific accomplishments in the area of neuropsychology.

Submission of Materials: All nomination materials should be completed and submitted to the Division's Fellowship Committee Chair listed below (not APA Central Office) by December 1, preferably as electronic pdf or Word files. Those nominees supported by the SCN Fellows Committee will be forwarded to the APA Fellows Committee for consideration. Successful nominations are announced in August the following year after the APA annual meeting. Nomination materials can be obtained from the APA website listed below.

D40 Fellows url: http://www.div40.org/Committee_Activities_Pages/fellows.htm

APA Fellow Forms url: http://www.apa.org/membership/fellows/index.aspx

A John McSweeny, JD, PhD

Department of Psychology MS#948
The University of Toledo
2801 W. Bancroft Street
Toledo, OH 43606-3390
Email: john.mcsweeny@utoledo.edu

 

 

From the President's Corner



Neil Pliskin, PhD

Neil Pliskin, PhD
President, Society for Clinical Neuropsychology

As everyone knows or has experienced by now, healthcare delivery in the United States is undergoing a major transformation.  The passing of the Affordable Care Act has led to the formation of Accountable Care Organizations (ACOs) in many states.  One of the main ways the Affordable Care Act seeks to reduce health care costs is by encouraging doctors, hospitals and other health care providers to form networks which coordinate patient care and become eligible for bonuses when they deliver that care more efficiently.

This emphasis on coordinated or INTEGRATED CARE is already occurring in many medical centers, and it is changing the way that medicine (and neuropsychology) is being practiced.  While many of us “seasoned veterans” (#neuropsychologydinosaurs) are still working in our comfortable “silos” of clinical practice, it is highly likely that more of us will be practicing differently in a few years, and certainly the upcoming generation of neuropsychologists needs to understand and be prepared for changes in neuropsychology practice models.  Indeed, neuropsychologists working in institutions, medical centers and VAs will be increasingly “embedded” in multispecialty clinics with approaches to assessment shifting to shorter batteries, shorter reports and fast feedback.  The shifts in practice models is already occurring in some settings, with neuropsychologists working in primary care clinics, and specialty clinics (memory, geriatrics, pediatrics, diabetes, epilepsy) to name a few.

The most recent membership data about our Division indicate that we have 4754 members, of which 80% are licensed, 70% provide clinical services and 43% are in independent practice, so this topic is highly relevant to a majority of our Division members.  Therefore, I would like to learn more from members who are already involved in providing neuropsychology services in the context of integrated settings, and I would like to share this information over the course of the year with our early career psychologists and students who will be facing these challenges in their future.

Within the next several months, you will receive a survey inquiring about your experience with different models of integrated care in neuropsychology.  Please take the time to respond to the survey and share with our membership your experiences, and I will be sure to include updated information in the coming months through our blogs, newsletters and NeuroBlasts.  Additionally, a portion of SCN’s program at the upcoming 2015 APA convention in Toronto (August 6-9) will be devoted to presentations on Models of Integrated Care in Neuropsychology.  Please save the date and plan on attending the convention.

SCN colleagues, the era of integrated care creates new opportunities for providing services and for demonstrating our value in the world of healthcare. If you have comments, thoughts, suggestions or experiences you wish to share, I would welcome hearing from you during this year; please feel free to contact me (npliskin@uic.edu).

NeuroBlog: The Value of Student Involvement in Neuropsychology Governance

Cady Block, ANST Chair

 

Cady Block

When I was first asked to write a piece for our NeuroBlog, I immediately knew I wanted to write about a topic that I am very passionate about: student involvement in neuropsychology governance. My own journey into student governance has been a very rewarding one. When I began my doctoral work at UAB in 2008, another student and myself saw the need for representation of student interests in neuropsychology within our program. With some research and a little bit of luck, we found out that APA has a Division representing neuropsychology, and that this Division not only has a trainee organization (the Association of Neuropsychology Students in Training, or ANST) but that it sponsors a network of chapters. We began our own UAB chapter and it is still successful and thriving today.

I then became interested in issues impacting all trainees and wanted to become more involved in governance at the national level. I was elected as the national ANST Communications Officer, which was followed by being elected the national Chair for ANST. I find that both of these positions offered the opportunity to connect and network with other individuals who are passionate about improving the profession for current and our future colleagues, and to effect change at the national level. Student leadership has been a valuable experience for me, and I hope to share my excitement and passion with other trainees and create opportunities for others to become more involved. I know such an experience can seem very daunting to trainees, but I would encourage them by saying that becoming involved is actually easier than one might think and the rewards in return are countless! The Society for Clinical Neuropsychology and ANST have long fostered such an opportunity through our network of chapters housed at various doctoral programs throughout the country. Chapters are led by active, energetic trainees and offer an excellent entry into student leadership and can often open the door for later involvement to neuropsychology governance. In fact, one of our original two student founders of ANST – Michael Cole – is currently the head of the SCN Publications and Communications Committee! Our current SCN Communications Liaison and former ANST Chair, Erica Kalkut, also began as a chapter representative at her doctoral program.

I could continue on about the many, many benefits of becoming involved in student leadership and neuropsychology governance. However, I felt that the best people to speak to this are some of our wonderful chapter representatives. I offer my thanks and appreciation to each of them for their willingness to contribute to this NeuroBlog piece. I also offer my gratitude to the excellent people in SCN who make these experiences available to trainees. I hope you enjoy this piece!

Jesse Passler, University of Alabama at Birmingham         

 

Jesse Passler
 

It was very important to me to become involved with the ANST chapter at University of Alabama at Birmingham (UAB) as soon as possible. The importance of being a part of ANST leadership to me cannot be overstated. It has proven to be an excellent way to become integrated into the neuropsychology community at UAB as well as across the country. I have also found the support and knowledge of fellow ANST chapters (as well as ANST’s wonderful leadership!) to be such an appreciated resource in my professional development.

However, the most important experience I’ve garnered from the opportunity to serve in student governance is that of being continually humbled by the amazing people around me. I have always had aspirations to serve as a leader, both professionally and in the community. Stated simply, serving in a leadership role requires honesty, openness, and the challenge to adequately represent a group as a whole as opposed to any special or specific expertise. In this way, I have been honored to work alongside my fellow UAB ANST members in trying to ensure both an excellent professional and personal experience. I highly encourage this opportunity to other students; I hope that you’ll find, as I have, that better than growing personally or (in some small way) helping others to grow, is growing together.      

Dede Ukueberuwa, Pennsylvania State University

 

Dede Ukueberuwa

The key to getting involved in student leadership is being proactive, and the effort can lead to incredibly rewarding experiences for students. In addition to having an impact on the goals of the organization by sharing their expertise, students benefit from leadership opportunities when they are able to learn new skills and further develop their career interests. Joining a committee for a professional organization is a great way to meet and learn from clinical neuropsychologists at every career level and from different settings. However, many students may feel hesitant to pursue leadership positions. My first experience with leadership in graduate school was on the organizing committee for a student-run neuroscience interest group at Penn State, where I felt comfortable sharing ideas among peers. I also started a chapter of ANST at Penn State in order to foster a sense of community among students with a specialization in clinical neuropsychology and to provide a resource for professional development. I’ve also joined a committee for a national neuropsychological organization. Although I felt hesitant when first exploring leadership roles, I found that with each new role, I was more confident and able to be proactive in pursuing additional opportunities.

Once interested in gaining leadership experience, many students may feel uncertain about how to get started. Talking to an advisor or another faculty member in their program is a great first step. An advisor may be involved in professional organizations or know about committees that welcome student members. Talking to an advisor may also help students to assess their strengths and to build confidence in their ability to be a leader. Through the process of searching for opportunities, students learn about the work of different organizations, which then helps to further define their own interests – are they drawn to public education about clinical neuropsychology, advocating for legislature that promotes our mission, or reviewing research projects for publication or awards? Once students start to get involved, they will likely feel more comfortable sharing their skills and ideas, develop a sense of identity as a clinical neuropsychologist in training, and continue growth as a leader in the field.

Nick Bott, Palo Alto University

 

Nick Bott

Woody Allen has opined that 80% of success is showing up, and this resonates with my experience in becoming involved in leadership and governance of my program's ANST chapter. The current ANST leadership was transitioning out, and in speaking with one of the chapter reps at the end of a meeting, she asked me about ideas for how to strengthen the resources and opportunities that the chapter offers to students. Sharing some of my ideas turned into a conversation about becoming more involved in leadership and eventually led to my taking a leadership role as the ANST co-chapter rep for our program. 

Having served as co-chapter rep for two years now, I am so happy that I showed up. My time helping to lead our chapter has convinced me of the importance of leadership and governance as an integral part of graduate school education. Graduate work encompasses three spheres: clinical education, research, and involvement in the field of the profession. Often, one or two of these becomes the focus of a graduate student, to the exclusion of the other. And sadly, it is often involvement in the field that is first to go. But involvement in the field is incredibly important. Knowledge of the structures that govern and support the field, and the networks of professionals that provide leadership for these structures is an education in itself, and extremely valuable for your own professional development in the expansion of your professional network and your understanding of the issues that are facing our field. And the field shrinks incredibly once you start engaging in a professional leadership capacity. You also realize that the volunteerism of students and professionals is critical to supporting so many budding neuropsychologists, as well as supporting the profession as a whole. Without serving in a leadership capacity, you are much less likely to be exposed to this critical area within our field. So my recommendation: show up and see what happens!

Clinical Neuropsychology and Sports Concussion: Have We Come Full Circle?

William B. Barr, PhD, ABPP

William B. Barr, PhD, ABPP
Associate Professor of Neurology & Psychiatry,
NYU School of Medicine

This year marks the 20^th anniversary of the “modern era” in the study of concussion in sports, which began in 1994 following the retirements of Merrill Hoge and Al Toon and the National Football League’s (NFL) formation of its first Mild Traumatic Brain Injury Committee. Since that time, we have witnessed a marked shift from what was a pervasive attitude of denying or minimizing the effects of head injury in sport to one where stories of the current “concussion epidemic” or the controversy about long-term consequences of head injury in retired athletes appear in our newspapers on a daily basis. Over the same time period, the field of neuropsychology has received an unprecedented degree of public attention resulting from the fact that many in our field, including members of the Society of Clinical Neuropsychology (SCN), have provided important contributions to the scientific study of sports concussion and development of methods for its assessment. My goal in this SCN NeuroBlog is to provide a brief review and critique of neuropsychology’s role in the clinical management of sports concussion with suggestions on how we can maintain our position as leaders with regard to this highly publicized injury.

At the beginning of concussion’s modern era, it was not uncommon to hear statements from other health professionals that we were in the infancy in the study of the head injury and without any available scientific information to guide clinical management. Any practicing neuropsychologist at that time knew that this was not the case. We were well aware that Dorothy Gronwall and her colleagues in New Zealand had published a number of groundbreaking studies during the 1970’s, using neuropsychological methods for tracking information-processing capacity following minor head injury.  During the 1980’s, Jeffrey Barth, Sureyya Dikmen, and Harvey Levin and colleagues had all conducted a number of important investigations in the United States using neuropsychological test batteries to characterize outcomes in mild head injured subjects. The results of those studies demonstrated that recovery from milder forms of head injury was characterized by a complex interaction of cognitive, somatic, and emotional factors with the expression of symptoms influenced significantly by a range of psychosocial factors.

Armed with the findings from studies listed above, clinical neuropsychologists were well prepared in the 1980’s and 1990’s to conduct a comprehensive assessment of symptoms in patients they encountered following what was eventually termed as mild traumatic brain injury (MTBI). Many at that time continued to use the Halstead-Reitan Neuropsychological Test Battery for evaluation of these patients. However, an increasing number of practitioners began to use a more flexible approach to neuropsychological assessment, with test batteries comprised of measures of intelligence, attention, executive functions, and memory. It is important to note that, most clinicians were also including measures of symptom reporting in their test batteries, using standardized measures such as the Minnesota Multiphasic Personality Inventory (MMPI) and its descendants.  While the clinical batteries often took numerous (3-6) hours to complete, they provided the most effective means known at that time for evaluating symptoms in patients with MTBI.

Neuropsychology’s approach to head injury received a substantial boost in the late 1980’s following research performed by Barth, Macciocchi and colleagues at the University of Virginia, who developed the methodology for obtaining empirical data on concussion through controlled prospective studies of athletes following head injury. Their model of data collection, now known as the Sports Laboratory Assessment Model (SLAM) consisted of obtaining preseason neuropsychological test data to serve as a baseline in athletes at risk for sustaining a concussion during competition and repeating the same tests in injured athletes and matched controls on a serial basis to measure the effects of the injury and its pattern of recovery. Among the major findings from early studies using the SLAM methodology were that neuropsychological tests were established as being sensitive to the effects of concussion and that those effects were observed to clear rather rapidly, within a period of 5 to 10 days, in the vast majority of cases.

Given the fact that results from standard imaging and electrophysiological studies were usually negative in athletes following concussion, the hope in the beginning of the modern era of sports concussion management was that neuropsychological testing would provide most effective means for assessing symptoms during recovery. The SLAM methodology was promptly adapted for clinical use by a number of neuropsychologists working primarily with collegiate and professional football teams. Brief test batteries were assembled and administered to entire teams through large-scale baseline testing programs. The length of the test batteries was kept to less than 30 minutes, understanding the need to limit the time burden for the athletes and the assessment team. The test batteries were limited in contents to measures of attention, processing speed, and memory, while also including a brief measure of post-concussion symptoms. The belief was that, due to athletes’ reputed tendency to minimize symptoms, information from the neurocognitive tests administered serially following injury would provide the most accurate means for tracking the effects of the injury and marking the time course of its recovery.

The baseline testing programs in sports began with the use of paper-pencil tests that were readily available to all licensed neuropsychologists. However, those tests were soon replaced by computerized test batteries developed specifically for assessment of concussion symptoms in athletes, which were promoted and sold via a large-scale marketing campaign to physicians, certified athletic trainers, and other clinicians in addition to neuropsychologists. The computerized tests were claimed by their developers to provide an advantage over the paper-pencil tests by providing a more sensitive, reliable, and efficient means of assessing concussion symptoms. Through substantial media exposure, the brand names of computerized tests became synonymous with baseline testing in sports, with the science and methodology of clinical neuropsychology relegated to a less prominent role.

While sportscasters, the media, and the public at large were emphasizing the use of baseline testing in sports, there was a controversy developing within the field of neuropsychology regarding its ultimate benefits. Some investigators began to question the increasing use of this methodology, given the lack of empirical support, particularly from investigative teams that were independent of the test developers. This was followed by studies, emerging over time, demonstrating that information from neuropsychological tests added little to the assessment of acute post-concussion symptoms compared to what was obtained through a more brief form of sideline testing using a combination of symptom questionnaires, balance measures, and a brief screen of cognitive functioning.

Results from other investigations began to show that many of the tests used for serial testing in athletes demonstrated unacceptably low levels oftest-retest reliability in addition to disappointing levels of sensitivity/specificity for detecting the effects of concussion. The validity of the baseline test performance came into question when measures were administered on a group basis, as suggested by the manufacturers. Athletes began to realize the benefits of underperforming on baseline testing so that the effects of concussion would be obscured on repeat testing following injury, affecting the validity of a growing number of baseline assessments. Further complications began to emerge from the fact that practitioners without adequate training in psychometrics and brain-behavior relations were often the ones obtaining the test results following injury, causing them in many cases to make serious interpretive errors. Based on these findings and trends, an international panel of experts on concussion in sports concluded in statements published in 2012 that, “there is insufficient evidence to recommend the widespread routine use of baseline neuropsychological testing.”

Turning to what we have learned over the past 20 years, there has been a convergence of information obtained through studies of animal models and humans indicating that the acute physiological effects and symptoms associated with concussion resolve within 7-10 days in the vast majority (80%-95%) of injured athletes, upholding the findings originally reported much earlier by University of Virginia group. While cognitive deficits are known to be present during the acute time period, neuropsychological testing does not appear to be the optimal choice for assessment at that time, since symptoms can be monitored effectively through briefer sideline test procedures using the Sports Concussion Assessment Tool (SCAT-3).

However, as most neuropsychologists know, there are those individuals, including athletes, who continue to report symptoms well beyond the window of typical recovery from concussion. These individuals, exhibiting symptoms of what we term as post-concussion syndrome (PCS), create clinical conundrums for most clinicians involved in concussion management. I argue that this is the group on whom neuropsychologists should be focusing attention.  As a result of neuropsychologists’ unique combination of training and use of empirically advanced assessment techniques, we are the group of professionals who can provide the most valuable input for diagnosis and management for of individuals with PCS.

Investigators focusing on the search for the elusive biomarker of concussion often ignore the fact that the diagnosis of concussion and subsequent PCS is based primarily on a subject’s subjective account of his or her symptoms. We are well aware that the reporting of those symptoms can be affected substantially by a number of “non-injury” factors. To begin with, research has shown that those with PCS commonly experience co-morbid conditions such as mood disorder, chronic pain, attention deficit hyperactivity disorder (ADHD), or the effects of somatization, all of which can result symptoms overlapping with those commonly reported in PCS. We are also aware that a number of “normal” psychological factors secondary to misattribution of symptoms, including “expectation as etiology”, the “diagnosis threat”, and the “good old days” phenomenon can influence symptom expression in that group. We are likely to be seeing an increase in the frequency of these misattribution phenomena as a result of increased availability of information related to concussion available through the popular media and Internet. Using our strengths in clinical assessment, neuropsychologists are in an excellent position to serve as those members of the treatment team who are in the best position to identify and treat the co-morbid conditions and other important “non-injury” factors that can influence the reporting of PCS symptoms in athletes and other groups.

My belief is that the optimal time for a referral to clinical neuropsychologists in a sports concussion setting is not immediately following the injury, but when the athlete is continuing to report symptoms for a period of 14-days or more. At that relatively early time point, he or she will have passed through the typical period of symptom recovery but will have not yet reached the critical juncture when PCS symptoms have become chronic and possibly intractable in nature. A comprehensive neuropsychological evaluation using tests of cognitive functioning, self-report, and performance validity performed at that time will provide the clinician with valuable diagnostic data and information to guide recommendations for subsequent intervention. As demonstrated in clinical studies, early identification and treatment of the co-morbid conditions and psychological factors provides the most effective means known for preventing the development of long-term PCS symptoms.

In conclusion, while we can admire our field’s initial attempt to offer neuropsychological testing as the primary tool for tracking the acute symptoms of concussion in athletes, it is time to admit that these watered-down test batteries did not end up being as useful as we had hoped.  My opinion is that clinical neuropsychologists can now play a more important and useful role in the management of sports concussion by going back to where we were 20 years ago by providing evaluations of athletes using more comprehensive test batteries prior to development of chronic PCS symptoms. I am not suggesting that we return to the use of 3-6 hour test batteries with all of these athletes. We can clearly benefit from advances in test development and clinical studies of concussion to narrow our test batteries down to less than two hours, including the use of a comprehensive symptom measure such as the MMPI-2-RF. In the end, returning to the  “psychology” in neuropsychology will enable us to provide a unique perspective to the modern treatment team that has evolved for assessment and treatment of sports concussion and help many of our athletes obtain the services they need to reach a full and successful recovery.

Telepsychology Update

C. Munro Cullum, PhD, ABPP

C. Munro Cullum, PhD, ABPP

Professor of Psychiatry and Neurology & Neurotherapeutics

The University of Texas Southwestern Medical Center

Dallas, TX

This is an adapted version of an article by Dr. Cullum that appeared in the Texas Psychologist, Fall 2013.

 

Telemedicine or telehealth technology is spreading rapidly and promises to become increasingly prominent in the future of healthcare worldwide.  Telehealth programs are growing rapidly in the U.S., particularly since the technology has become more available and less expensive.  At least four professional journals now focus on telehealth and telemedicine, and the literature has seen a tremendous increase in “tele-“ based publications in the last decade.  Programs in telestroke, teleradiology, teledermatology, and telerehabilition are among the most commoly reported, although telepsychiatry, telepsychology, and telemental health references have seen a three- to four-fold increase in the past decade, now with over 200 such references in the PubMed database.  The VA system has made wide use of telehealth services through its various outreach clinics, and Medicare’s announcement in 2012 that tele-based services (albeit with some restrictions) will be covered has also helped to increase awareness and availability of distance-based healthcare services.  Numerous companies now offer practitioners assistance with information, technology setup and monitoring of telehealth-based services.

The evidence base supporting the provision of mental health services using electronic means continues to grow (e.g. see Myers and Turvey, 2013, for a comprehensive review).  For example, there is now good support for many of our standard psychological services (particularly therapies) being provided via video teleconference.  Provider- and patient-satisfaction ratings with telemental health have consistently been high, suggesting good receptivity and acceptability.  Although it may take some getting used to seeing your patient or doctor over a monitor rather than in person, adaptation is usually realized quickly, and a majority of patients and providers find it to be an “acceptable” means of service provision in many cases.  Most individuals prefer in-person interactions even if they have to travel a few hours, but distance and time are often cited as determining factors for consumers in terms of selecting telehealth-based services.  Data regarding outcome efficacy in various telemental health interventions is somewhat more limited, although research suggests similar results when compared to tradition in-person therapeutic interactions for most studies.  Most of the literature in this area has been conducted in adult and underserved populations, however, with less known about efficacy of telemental health interventions in children.

Application of telehealth technology to the provision of mental health services requires a number of adaptations and special considerations (e.g. see Grosch et al., 2011).  In terms of informed consent, clients must be made aware of the special circumstances that exist or may arise in the remote provision of clinical services.  This includes the fact that their confidential information (visual and verbal) is being shared across a distance via electronic transmission. This raises the possibility of inadvertent compromise of confidentiality in various ways, and implications for HIPAA also must be considered.  For example, there is ongoing debate about the level of security offered by various popular internet-based videoconference applications (i.e., which ones are truly HIPAA compliant?).  This merits careful exploration before services are offered, and clients must be informed of the additional potential risks of loss of confidentiality when using electronic transmission of information.  Other questions that arise include:  Is the transmission of data (i.e., the entire interaction during the session) fully encrypted?  Is it in fact HIPAA compliant just because the vendor indicates so?  Are there appropriate safeguards in place, such as firewalls, etc.?  Who might have access to the information? Are third-parties involved in the process (e.g. IT personnel), and if so, what is their role and access to data?  Depending upon the far-end set-up, what is the possibility of a third-party wandering into the area where the client is being seen?  What is the likelihood of interruptions in that setting? If any data are being stored as part of the process, this must be disclosed and appropriately safeguarded.  

The provision of mental health services using distance technology also requires that the provider be competent in this mode of intervention. Continuing education to support training in this specialized application of services is encouraged, even as preliminary guidelines are developed by the American Psychological Association and American Telemedicine Association (e.g. see their respective websites for information).  Practical issues must also be addressed, including preparedness for potential emergencies during distance-based interactions.  Appropriate review of procedures with clients should be conducted, in addition to consideration being given to staff availability at the far end, appropriate training in emergency situations, and IT personnel availability in the event of equipment failure should be considered.

From a diagnostic interviewing standpoint, psychological interviews appear as valid when conducted via videoteleconference as in-person, although less information exists with respect to the validity of psychological or neuropsychological assessments administered in this fashion.  Preliminary studies of videoteleconference-based neuropsychological assessment have been promising in terms of patient satisfaction (e.g. see Parikh et al., 2013) as well as validity of the measures that have been studied to date, although many tests have not been studied in this environment.  Our research group has demonstrated the comparability of video teleconference-based and traditional in-person administration of neuropsychological tests using a brief battery of generally language-based instruments that are commonly used in dementia evaluations (Cullum et al., 2006). This has included tests of attention, naming, verbal fluency, verbal memory, and visuoconstructional ability that required little to no modification of standard test instructions.  We have also experimented with other tasks that require the use of manipulable test materials, but such tasks require the availability of equipment for the remote client as well as alteration in instructions and in some cases, administration procedures.  Our results are also limited to tests studied to date, although a list of many tests used under video teleconference conditions can be found in Cullum and Grosch (2013). If significant modifications to procedures are required for the administration of some tests, for example, this must be noted, and the potential impact upon traditional scoring and interpretation must be understood.  As such, more research needs to be done to ensure the validity of our procedures administered remotely, as some tests may require modified instructions, procedures, and/or norms, and these factors must be considered by clinicians conducting this work.

As noted above, Medicare and some insurance companies have approved reimbursement for telemedicine-based mental health services, although it is incumbent upon clinicians to verify local provider procedures along these lines, as many payors are yet to get on board with reimbursement despite good headway being made by the American Telemedicine Association.  A related issue in the provision of distance-based services is that of licensure, since many states require that the provider be licensed not only in her or his own state, but also in the state where the client is located.  

As telehealth technology continues its rapid growth, opportunities for psychologists’ services will expand.  Familiarity and training with these technologies, including advantages, limitations, and evidence-based support for various procedures and services, will become increasingly important for psychologists.  Fortunately, many of our services are amenable to the telehealth environment, and with appropriate education and experience, we should be in a good position to help drive and participate in the provision of behavioral health and mental health services using telehealth technologies within our changing healthcare environment.

References

Cullum, C.M. & Grosch, M.G. (2013). Teleneuropsychology. In K. Myers & C. Turvey (Eds.), Telemental health: Clinical, technical and administrative foundations for evidence-based practice. Elsevier (pp 275-294).

Grosch, M.C., Gottlieb, M.C., & Cullum, C.M. (2011). Initial practice recommendations for teleneuropsychology. The Clinical Neuropsycholgist, 25, 1119-1133. 

Myers, K., & Turvey, C.L. (2013).  Telemental Health: Clinical, technical and administrative foundations for evidence-based practice.  Elsevier. 

Parikh, M., Grosch, M.C., Graham, L.L., Hynan, L.S., Weiner, M.F., & Cullum, C.M. (2013). Consumer acceptability of brief videoconference-based neuropsychological assessment in older individuals with and without cognitive impairment.  The Clinical Neuropsychologist, 27,5, 808-817.