Integrative Care Models in Neuropsychology: A National Academy of Neuropsychology Education Paper.

Although collaborative, and more specifically, integrated models of care have existed for years, the 2010 Patient Protection and Affordable Care Act expanded their use, and Medicare has adopted a value-based payment system that further emphasizes service provision within the collaborative health care setting. Neuropsychology as a field is well-situated to work within the integrated health care setting, which presents both opportunities and challenges for clinical neuropsychologists. This education paper details how different neuropsychology clinical practice settings fit into an integrated care framework; discusses challenges to service delivery and fiscal viability in such settings and other health care related settings; and examines future directions for the role of neuropsychology within a dynamic health care system.

Cognitive Screening Tests Versus Comprehensive Neuropsychological Test Batteries: A National Academy of Neuropsychology Education Paper†.

The American Medical Association Current Procedural Panel developed a new billing code making behavioral health screening a reimbursable healthcare service. The use of computerized testing as a means for cognitive screening and brief cognitive testing is increasing at a rapid rate. The purpose of this education paper is to provide information to clinicians, healthcare administrators, and policy developers about the purpose, strengths, and limitations of cognitive screening tests versus comprehensive neuropsychological evaluations. Screening tests are generally brief and narrow in scope, they can be administered during a routine clinical visit, and they can be helpful for identifying individuals in need of more comprehensive assessment. Some screening tests can also be helpful for monitoring treatment outcomes. Comprehensive neuropsychological assessments are multidimensional in nature and used for purposes such as identifying primary and secondary diagnoses, determining the nature  and severity of a person's cognitive difficulties, determining functional limitations, and planning treatment and rehabilitation. Cognitive screening tests are expected to play an increasingly important role in identifying individuals with cognitive impairment and in determining which individuals should be referred for further neuropsychological assessment. However, limitations of existing cognitive screening tests are present and cognitive screening tests should not be used as a replacement for comprehensive neuropsychological testing.

Pain and mild traumatic brain injury: the implications of pain severity on emotional and cognitive functioning.

PRIMARY OBJECTIVE: The aim of this study was to examine the effect of high chronic pain on (a) neuropsychological test performance and (b) self-reported emotional complaints in persons suffering from Postconcussional Disorders (PCD) after a mild traumatic brain injury (TBI). RESEARCH DESIGN: A two-group comparative research design was employed. METHODS AND PROCEDURE: An outpatient sample of 66 patients with mild TBI and PCD using the Ruff Neurobehavioural Inventory (RNBI) and a neuropsychological test battery. MAIN OUTCOMES AND RESULTS: According to ANOVAs, no significant between-group differences were found on neuropsychological test performances; however, the high pain group had significantly more emotional residuals; particularly elevated on the RNBI were the Anger and Aggression, Anxiety, Depression and Paranoia and Suspicion sub-scales. Furthermore, an ANOVA found participants of the high pain group reporting significantly higher impairments on the RNBI Cognitive, Physical and Quality-of-Life composite scores and several RNBI sub-scales compared to their pre-morbid functioning. CONCLUSIONS: High chronic pain exacerbates the emotional aspect of PCD and, therefore, should be given special observance in treatment settings.

The Inter-Organizational Summit on Education and Training (ISET) 2010 survey on the influence of the Houston Conference training guidelines.

A conference specific to the education and training of clinical neuropsychology was held in 1997, which led to a report published in the Archives of Clinical Neuropsychology (Hannay, J., Bieliauskas, L., Crosson, B., Hammeke, T., Hamsher, K., & Koffler, S. (1998). Proceedings of the Houston Conference on Specialty Education and Training in Clinical Neuropsychology. Archives of Clinical Neuropsychology, 13, 157-250.). The guidelines produced by this conference have been referred to as the Houston Conference (HC) guidelines. Since that time, there has been considerable discussion, and some disagreement, about whether the HC guidelines produced a positive outcome in the training of neuropsychologists. To explore this question and determine how widely the HC guidelines were implemented, a meeting was held in 2006. Present and past leaders of the American Psychological Association Division 40 (Clinical Neuropsychology), the National Academy of Neuropsychology, and the Association of Postdoctoral Programs in Clinical Neuropsychology met to discuss the possible need for an Inter-Organizational Summit on Education and Training (ISET). A decision was reached to have the ISET Steering Committee conduct a survey of clinical neuropsychologists that could address the extent to which HC guidelines were present in the specialty and whether the influence of the HC guidelines was positive. An online survey was constructed, with data gathered in 2010. The current paper presents and discusses the ISET survey results. Specific findings need to be viewed cautiously due to the relatively low response rate. However, with some direct parallels to a larger recent survey of clinical neuropsychologists, the following general conclusions appear well founded: (a) the demographics of respondents in the ISET survey are comparable with a recent larger professional practice survey and thus may reasonably represent the specialty; (b) the HC guidelines appear to have been widely adopted by training programs, in that a large proportion of younger practitioners endorsed having had HC-adherent training; and (c) HC-adherent training is associated with a higher frequency endorsement of being well prepared to engage in key professional activities subsequent to the completion of training when compared with those not having HC-adherent training. Overall, the ISET Steering Committee has concluded that the HC guidelines have been widely adopted and that trainees associate participation in HC-adherent training as advantageous. A potential revision based on unfavorable outcomes is deemed unnecessary. Nonetheless, the ISET Steering Committee recognizes that training needs change as a function of the broadening of our field and the introduction of related new technologies, which may prompt updates. The ISET Steering Committee supports the idea that periodic review and updating of training models may be is prudent.

The Inter-Organizational Summit on Education and Training (ISET) 2010 survey on the influence of the Houston conference training guidelines.

A conference specific to the education and training of clinical neuropsychology was held in 1997, which led to a report published in the Archives of Clinical Neuropsychology (Hannay, J., Bieliauskas, L., Crosson, B., Hammeke, T., Hamsher, K., & Koffler, S. (1998). Proceedings of the Houston Conference on Specialty Education and Training in Clinical Neuropsychology. Archives of Clinical Neuropsychology, 13, 157-250.). The guidelines produced by this conference have been referred to as the Houston Conference (HC) guidelines. Since that time, there has been considerable discussion, and some disagreement, about whether the HC guidelines produced a positive outcome in the training of neuropsychologists. To explore this question and determine how widely the HC guidelines were implemented, a meeting was held in 2006. Present and past leaders of the American Psychological Association Division 40 (Clinical Neuropsychology), the National Academy of Neuropsychology, and the Association of Postdoctoral Programs in Clinical Neuropsychology met to discuss the possible need for an Inter-Organizational Summit on Education and Training (ISET). A decision was reached to have the ISET Steering Committee conduct a survey of clinical neuropsychologists that could address the extent to which HC guidelines were present in the specialty and whether the influence of the HC guidelines was positive. An online survey was constructed, with data gathered in 2010. The current paper presents and discusses the ISET survey results. Specific findings need to be viewed cautiously due to the relatively low response rate. However, with some direct parallels to a larger recent survey of clinical neuropsychologists, the following general conclusions appear well founded: (a) the demographics of respondents in the ISET survey are comparable with a recent larger professional practice survey and thus may reasonably represent the specialty; (b) the HC guidelines appear to have been widely adopted by training programs, in that a large proportion of younger practitioners endorsed having had HC-adherent training; and (c) HC-adherent training is associated with a higher frequency endorsement of being well prepared to engage in key professional activities subsequent to the completion of training when compared with those not having HC-adherent training. Overall, the ISET Steering Committee has concluded that the HC guidelines have been widely adopted and that trainees associate participation in HC-adherent training as advantageous. A potential revision based on unfavorable outcomes is deemed unnecessary. Nonetheless, the ISET Steering Committee recognizes that training needs change as a function of the broadening of our field and the introduction of related new technologies, which may prompt updates. The ISET Steering Committee supports the idea that periodic review and updating of training models is prudent.

Computerized neuropsychological assessment devices: joint position paper of the American Academy of Clinical Neuropsychology and the National Academy of Neuropsychology.

This joint position paper of the American Academy of Clinical Neuropsychology and the National Academy of Neuropsychology sets forth our position on appropriate standards and conventions for computerized neuropsychological assessment devices (CNADs). In this paper, we first define CNADs and distinguish them from examiner-administered neuropsychological instruments. We then set forth position statements on eight key issues relevant to the development and use of CNADs in the healthcare setting. These statements address (a) device marketing and performance claims made by developers of CNADs; (b) issues involved in appropriate end-users for administration and interpretation of CNADs; (c) technical (hardware/software/firmware) issues; (d) privacy, data security, identity verification, and testing environment; (e) psychometric development issues, especially reliability, and validity; (f) cultural, experiential, and disability factors affecting examinee interaction with CNADs; (g) use of computerized testing and reporting services; and (h) the need for checks on response validity and effort in the CNAD environment. This paper is intended to provide guidance for test developers and users of CNADs that will promote accurate and appropriate use of computerized tests in a way that maximizes clinical utility and minimizes risks of misuse. The positions taken in this paper are put forth with an eye toward balancing the need to make validated CNADs accessible to otherwise underserved patients with the need to ensure that such tests are developed and utilized competently, appropriately, and with due concern for patient welfare and quality of care.

Computerized neuropsychological assessment devices: joint position paper of the American Academy of Clinical Neuropsychology and the National Academy of Neuropsychology.

This joint position paper of the American Academy of Clinical Neuropsychology and the National Academy of Neuropsychology sets forth our position on appropriate standards and conventions for computerized neuropsychological assessment devices (CNADs). In this paper, we first define CNADs and distinguish them from examiner-administered neuropsychological instruments. We then set forth position statements on eight key issues relevant to the development and use of CNADs in the healthcare setting. These statements address (a) device marketing and performance claims made by developers of CNADs; (b) issues involved in appropriate end-users for administration and interpretation of CNADs; (c) technical (hardware/software/firmware) issues; (d) privacy, data security, identity verification, and testing environment; (e) psychometric development issues, especially reliability and validity; (f) cultural, experiential, and disability factors affecting examinee interaction with CNADs; (g) use of computerized testing and reporting services; and (h) the need for checks on response validity and effort in the CNAD environment. This paper is intended to provide guidance for test developers and users of CNADs that will promote accurate and appropriate use of computerized tests in a way that maximizes clinical utility and minimizes risks of misuse. The positions taken in this paper are put forth with an eye toward balancing the need to make validated CNADs accessible to otherwise underserved patients with the need to ensure that such tests are developed and utilized competently, appropriately, and with due concern for patient welfare and quality of care.

Comparison of subjective cognitive complaints with neuropsychological tests in individuals with mild vs more severe traumatic brain injuries.

PRIMARY OBJECTIVE: The aim of this study was to examine the complex inter-relationship between subjective reports of cognitive impairments and neuropsychological performances in compensation-seeking individuals with traumatic brain injury (TBI) of differing severities. Specifically, this study examined: (a) the participants' neuropsychological test scores and self-reported ratings according to TBI severity; (b) whether there was a predictive relationship between self-report and cognitive test scores; and (c) the influence of emotional functioning on self-reported cognitive functioning. RESEARCH DESIGN: A multi-group comparative research design was employed. METHODS AND PROCEDURE: An outpatient sample of 61 patients with TBIs using neuropsychological testing, RNBI (Ruff Neurobehavioral Inventory) and clinical interviews. MAIN OUTCOMES AND RESULTS: The mild TBI group exhibited greater attentional impairments, while the moderate-to-severe group exhibited greater memory and learning impairments on neuropsychological tests. The mild group reported more cognitive symptoms than their more severely damaged counterparts. The mild TBI participants reported significantly more symptoms of post-traumatic stress disorder (PTSD). CONCLUSIONS: Individuals with moderate-to-severe TBI were more accurate when reporting their memory and learning difficulties, whereas individuals with mild TBI were more accurate when reporting attentional difficulties. It is likely that the occurrence of PTSD worsens the outcome of a mild TBI. There likely is a cumulative effect between the PTSD symptoms and the emotional residuals in the mild TBI population.

Mild traumatic brain injury and neural recovery: rethinking the debate.

A debate exists concerning whether a mild traumatic brain injury (MTBI) can cause permanent brain-based residuals. This debate is examined by reviewing meta-analytic studies that found no significant effect sizes between large samples of patients with and without MTBI at three months post-accident. In contrast, research studies with MTBI patients have captured cognitive deficits corroborated by positive neuroimaging, which supports the viewpoint that brain-based postconcussive disorders likely exist in a small minority of individuals. Ongoing hurdles that likely contribute to this debate are identified. This includes the lack of agreed upon definitions; substantial differences exist between the ICD-10 definition for Postconcussion Syndrome and the DSM-IV-TR definition for Postconcussional Disorder. Confining the debate to brain-based versus psychologically-based viewpoints results in a false dichotomy. Instead, a more refined sub-classification of the postconcussive complex is proposed that captures different constellations across the physical, emotional, and cognitive symptoms complex. Moreover, this diagnostic framework attempts to expand discipline-based approaches with a patient-based understanding.

Re-examination of the Controversial Coexistence of Traumatic Brain Injury and Posttraumatic Stress Disorder: Misdiagnosis and Self-Report Measures.

The coexistence of traumatic brain injury (TBI) and posttraumatic stress disorder (PTSD) remains a controversial issue in the literature. To address this controversy, we focused primarily on the civilian-related literature of TBI and PTSD. Some investigators have argued that individuals who had been rendered unconscious or suffered amnesia due to a TBI are unable to develop PTSD because they would be unable to consciously experience the symptoms of fear, helplessness, and horror associated with the development of PTSD. Other investigators have reported that individuals who sustain TBI, regardless of its severity, can develop PTSD even in the context of prolonged unconsciousness. A careful review of the methodologies employed in these studies reveals that investigators who relied on clinical interviews of TBI patients to diagnose PTSD found little or no evidence of PTSD. In contrast, investigators who relied on PTSD questionnaires to diagnose PTSD found considerable evidence of PTSD. Further analysis revealed that many of the TBI patients who were initially diagnosed with PTSD according to self-report questionnaires did not meet the diagnostic criteria for PTSD upon completion of a clinical interview. In particular, patients with severe TBI were often misdiagnosed with PTSD. A number of investigators found that many of the severe TBI patients failed to follow the questionnaire instructions and erroneously endorsed PTSD symptoms because of their cognitive difficulties. Because PTSD questionnaires are not designed to discriminate between PTSD and TBI symptoms or determine whether a patient's responses are accurate or exaggerated, studies that rely on self-report questionnaires to evaluate PTSD in TBI patients are at risk of misdiagnosing PTSD. Further research should evaluate the degree to which misdiagnosis of PTSD occurs in individuals who have sustained mild TBI.

Secretive recording of neuropsychological testing and interviewing: official position of the National Academy of Neuropsychology.

Neuropsychologists are occasionally asked to have neuropsychological testing observed via the presence of a third party, through one-way mirrors, or with audio or video monitoring or recording devices. The primary reasons for not allowing observation are its effect on the validity of the examination results and the security of copyrighted test materials. To overcome the problem of observer effects on the examinee's performance, some individuals have suggested that examinations be monitored or recorded without the examinee's awareness (i.e., secretly). However, secretive recording of neuropsychological interviews and testing is deceptive, which is inconsistent with ethical principles. In addition, such recording may affect the behavior of the examiner. For these reasons, neuropsychologists do not, and should not, encourage, condone, or engage in secret recording of neuropsychological interviews or testing.

Recommendations for diagnosing a mild traumatic brain injury: a National Academy of Neuropsychology education paper.

A special interest group of the American Congress of Rehabilitation Medicine [ACRM; Mild Traumatic Brain Injury Committee. (1993). Definition of mild traumatic brain injury. Journal of Head Trauma Rehabilitation, 8 (3), 86-87.] was the first organized interdisciplinary group to advocate four specific criteria for the diagnosis of a mild traumatic brain injury (TBI). More recently, the World Health Organization (WHO) Collaborative Center Task Force on Mild Traumatic Brain Injury [Carroll, L. J., Cassidy, J. D., Holm, L., Kraus, J., & Coronado, V. G. (2004). Methodological issues and research recommendations for mild traumatic brain injury: the WHO Collaborating Centre Task Force on Mild Traumatic Brain Injury. Journal of Rehabilitation Medicine, (Suppl. 43), 113-125.] conducted a comprehensive review of the definitions utilized in evidence-based studies with mild TBI patients. Based on this review, the WHO task force maintained the same four criteria but offered two modifications. The similarities and differences between these two definitions are discussed. The authors of the ACRM and the WHO definitions do not provide guidelines or specific recommendations for diagnosing the four criteria. Thus, we provide recommendations for assessing loss of consciousness, retrograde and post-traumatic amnesia, disorientation and confusion as well as clarification of the neurologic signs that can be indicative of a diagnosis of mild TBI. Finally, confounding factors mentioned in both definitions that should exclude a mild TBI diagnosis are summarized.

Neuropsychological consequences of boxing and recommendations to improve safety: a National Academy of Neuropsychology education paper.

Boxing has held appeal for many athletes and audiences for centuries, and injuries have been part of boxing since its inception. Although permanent and irreversible neurologic dysfunction does not occur in the majority of participants, an association has been reported between the number of bouts fought and the development of neurologic, psychiatric, or histopathological signs and symptoms of encephalopathy in boxers. The purpose of this paper is to (i) provide clinical neuropsychologists, other health-care professionals, and the general public with information about the potential neuropsychological consequences of boxing, and (ii) provide recommendations to improve safety standards for those who participate in the sport.

Geriatric neuropsychology: implications for front line clinicians.

Consistent with the aging population, neuropsychologists are being asked with increased frequency to evaluate older adults. These assessments are often complicated by medical and psychiatric co-morbidities, polypharmacy, and complex psychosocial and legal issues that are frequently encountered in this population. The aim of this review article is to address the challenges neuropsychologists and other frontline clinicians often confront when evaluating older individuals. Specifically, we review psychiatric and medical co-morbidities, testing accommodations, diagnostic versus descriptive testing approaches, normative issues, polypharmacy, and reimbursement rates. Finally, future implications are discussed for advancing the neuropsychologist's role in evaluating and treating older individuals.

A biopsychosocial perspective of aggression in the context of traumatic brain injury.

PRIMARY OBJECTIVE: The aim of this study was to explore the factors associated with aggression in the traumatic brain injury population. The focus of the study was to evaluate the (a) frequency and severity of aggressive behaviours in outpatients with traumatic brain injury (TBI), (b) ecological validity of the Ruff Neurobehavioral Inventory (RNBI) Anger scale, and (c) comorbid and pre-morbid factors associated with aggression in patients with TBIs. RESEARCH DESIGN: A multi-group comparative research design was employed. METHODS AND PROCEDURE: An outpatient sample of 67 patients with TBIs using the RNBI and clinical interviews. MAIN OUTCOMES AND RESULTS: Based on clinical ratings, 25% endorsed no aggression, 38% reported mild aggression and 37% reported moderate-to-severe aggression, which was validated with the RNBI Anger post-morbid scale. A MANOVA found that none of the pre-morbid RNBI scales were significantly elevated across the anger groups; however, pre-post-morbid differences between the groups were found. A principle component analysis showed three main domains: 'physical, cognitive and emotional' that related to elevated post-morbid anger. CONCLUSIONS: A biopsychosocial model of post-morbid aggression is proposed to advance both the diagnosis and treatment of patients with TBIs who experience elevated anger.

Learning disabilities: the need for neuropsychological evaluation.

A learning disability (LD) is a neurobiological disorder that presents as a serious difficulty with reading, arithmetic, and/or written expression that is unexpected, given the individual's intellectual ability. A learning disability is not an emotional disorder nor is it caused by an emotional disorder. If inadequately or improperly evaluated, a learning disability has the potential to impact an individual's functioning adversely and produce functional impairment in multiple life domains. When a learning disability is suspected, an evaluation of neuropsychological abilities is necessary to determine the source of the difficulty as well as the areas of neurocognitive strength that can serve as a foundation for compensatory strategies and treatment options.

Neuropsychological evaluation in the diagnosis and management of sports-related concussion.

A mild traumatic brain injury in sports is typically referred to as a concussion. This is a common injury in amateur and professional athletics, particularly in contact sports. This injury can be very distressing for the athlete, his or her family, coaches, and school personnel. Fortunately, most athletes recover quickly and fully from this injury. However, some athletes have a slow recovery, and there are reasons to be particularly concerned about re-injury during the acute recovery period. Moreover, some athletes who have experienced multiple concussions are at risk for long-term adverse effects. Neuropsychologists are uniquely qualified to assess the neurocognitive and psychological effects of concussion. The National Academy of Neuropsychology recommends neuropsychological evaluation for the diagnosis, treatment, and management of sports-related concussion at all levels of play.

Differential impairment of patients with right versus left hemisphere lesions on the Ruff-light Trail Learning Test.

The Ruff-Light Trail Learning Test (RULIT) was developed as a neuropsychological measure of visuospatial learning and memory. RULIT scores of patients with right hemisphere and left hemisphere damage, as well as matched controls were compared. Right hemisphere lesion patients scored significantly lower on RULIT measures than did left hemisphere lesion patients and controls. The performance of left hemisphere lesion patients and controls did not differ significantly on RULIT measures. Adequate clinical hit rates, sensitivity and specificity in identifying right hemisphere damaged patients were demonstrated.

The importance of neuropsychological assessment for the evaluation of childhood learning disorders NAN Policy and Planning Committee.

When children experience learning difficulties, an appropriate evaluation of abilities and skills can provide the foundation for an accurate diagnosis and useful recommendations. When comprehensive information about a child's brain-related strengths and weaknesses is necessary to understand potential sources of the problem and implications for functioning, a neuropsychological evaluation is most often the best choice. This paper was written to help parents, educators, health care providers, and third-party payors to understand the nature of neuropsychological assessment and to choose the type of evaluation that will furnish relevant information for the child's educational planning.