Pre-appointment online assessment of patient complexity: Towards a personalized model of neuropsychological assessment.

Recent events such as the global pandemic of COVID-19 have challenged neuropsychologists to scale up their capacity to conduct portions of their assessment remotely. While more complex patients will likely continue to require on-site, office-based interaction and assessment, the current emergency-based expansion of online and telehealth evaluation practices may ultimately lay the groundwork for more routine, online assessment of patients with less complex presentations in the future. To this end, the current study evaluated a pre-appointment, online methodology for differentiating referred pediatric patients based upon the scope and severity of their caregiver-reported adaptive, academic, attentional, behavioral, and emotional impairment. Prior to on-site assessment, parents/caregivers of 2197 children (Mean age = 10.0y, range = 4-19y, 62% male) completed an online developmental history form screening for symptoms of adaptive, attentional, learning, affective, and behavioral impairment; 71% of those children eventually underwent assessment. Using latent class analysis, the data supported a reproducible 4-class model consisting of groups of children at increased risk for: 1) severe multi-domain dysfunction; the "High Complexity" group, 30%, 2) behavioral-affective (but not academic) dysregulation; the "Behavioral Focus" group, 13%, 3) academic (but not behavioral-affective) problems; the "Academic and Inattention" group, 37%, and 4) patients with minimal clinical complexity; the "Low Complexity" group, 20%. Comparison of pre-visit classification with day-of-assessment standardized test scores supported the validity of patient subtypes. Moving forward, pre-appointment clarification of patient complexity may support efficient patient triage with regard to assessment modality (e.g., on-site or online) and length of appointment (e.g., comprehensive or targeted).

Technology meets tradition: a hybrid model for implementing digital tools in neuropsychology.

The COVID-19 pandemic has significantly impacted the provision of mental health care services and the ability to provide neuropsychological evaluations. The inability to conduct traditional evaluations has left neuropsychologists with the unprecedented task of determining how to modify existing paradigms while balancing the need to provide services and adhere to safety parameters. The COVID-19 literature suggests clinicians are modifying their evaluations based on the following models: (1) continuing to administer in-person evaluations; (2) discontinuing all evaluations due to issues related to standardization, test security, and patient-specific characteristics; (3) conducting virtual evaluations; and/or (4) adopting a hybrid model incorporating both traditional and technology-based modalities. Given the challenges with models 1-3, along with the modifications in telehealth guidelines and insurance reimbursement rates, neuropsychologists are more poised than ever to solidify the implementation of a hybrid model that lasts beyond COVID-19. We introduce the term Hybrid Neuropsychology, a model for the future of neuropsychological evaluations that includes three Action Items: (1) building a technology-based practice; (2) integrating data science; and (3) engaging with innovators in other fields. Hybrid Neuropsychology will enable clinicians to effectively modernize their practice, improve health care equity, and ensure neuropsychology secures its place in a technology-based world.

Why are neuropsychologists so reluctant to embrace modern assessment techniques?

OBJECTIVE: Computerized tests and use of the internet offer many opportunities for improvement of neuropsychological assessment over traditional paper-and-pencil tests. Nevertheless, many clinical neuropsychologists are conservative in their choice of tests when assessing patients; the majority still seems to prefer using well-established paper-and-pencil tests. METHOD: This deliberately one-sided opinion paper discusses several reasons that may explain the reluctance to embrace modern techniques. These reasons are of a psychometric, technical, theoretical, and strategic nature. CONCLUSIONS: A range of issues regarding each of these reasons need to be solved before digital assessment techniques can fulfill their promises. In the meantime, it seems wise to be cautious, and to be critical in adopting the digital assessment techniques.

Conducting neuropsychological assessment with transgender individuals.

OBJECTIVE: The purpose of this paper is to provide an overview of helpful clinical practices when working with transgender adult individuals. METHOD: While the number of openly transgender individuals appears to be growing with society's increased acceptance and awareness, many neuropsychologists have had few opportunities to gain experience with this patient population. In this article, we review the existing literature as it relates to clinical neuropsychological practice. RESULTS: We describe important terminology, ideals for creating an environment of respect, and how existing clinical guidelines for transgender individuals may apply to neuropsychology. In addition, we review the primary steps in the assessment process and provide a set of principles and recommendations for conducting neuropsychological assessments with transgender patients. CONCLUSIONS: There is a paucity of guidance in the field for working with transgender individuals. This article represents a step forward in the dialog and we look forward to future research that develops appropriate normative information, increases understanding of psychosocial factors, and better appreciates the range of hormonal influences for transgender individuals.

Communication is key: the utility of a revised neuropsychological report format.

OBJECTIVE: The neuropsychological report is a critical tool for communicating evaluation results to multiple audiences who have varying knowledge about neuropsychology and often have limited ability to review long, complex reports. Considerable time is spent writing these reports and challenges persist related to readability, length/complexity, and billable clinical time (which may be capped by third-party payors or families' ability to pay). METHODS: This quality improvement effort systematically evaluated the redesign of pediatric neuropsychological reports in an outpatient clinic serving primarily medical populations. RESULTS: Revised reports were shorter, with improved readability, structure, and effectiveness in communicating results and recommendations. Improved clinical efficiency was also observed. CONCLUSIONS: We suggest that adaptation to efficient, readable, and effective reports is possible within the practice of neuropsychology. Findings encourage replication in other settings. Through collaboration with key stakeholders, providers can identify their populations' and audience's unique needs and set report targets accordingly. To encourage that practice, we summarize our general process, provide a set of guidelines that can be adapted across multiple settings, and include an appended sample report.

Toward generally accepted forensic assessment practices among clinical neuropsychologists: a survey of professional practice and common test use.

OBJECTIVE: This study investigated professional practice and common test use among clinical neuropsychologists engaging in forensic assessment. METHOD: Doctorate-level psychologists active in the practice of neuropsychology and on the INS and NAN membership listings (n = 502) were surveyed about their demographics, professional practice, and common test use. Participants who reported engaging in forensic practice (n = 255) were further surveyed about their forensic practice. RESULTS: Forensic participants were more likely to be male and Caucasian, and reported higher ages, more years of professional experience, and a higher prevalence of board certification. While characteristics of their professional and forensic practice varied, forensic participants reported spending most of their professional time conducting neuropsychological assessments with adult clients in a private or group practice setting, focusing on civil referrals and civil legal questions involving older adult issues, developmental issues, head injury, and psychiatric issues. Common test use across neuropsychological assessment domains is presented for board-certified forensic participants (n = 77). An examination of these results reveals that the current pattern of test use is similar to the results of a more general survey of neuropsychological test use. CONCLUSIONS: The findings provide insight into the practice of forensic neuropsychological assessment, and further establish the admissibility of neuropsychological evidence in the United States legal system. Results will be useful for clinical neuropsychologists, field leaders, and legal professionals hoping to gain insight into the role of clinical neuropsychology in civil and criminal legal decision-making.

Neuropsychological Assessment: Past and Future.

Neuropsychological assessment tools are the staple of our field. The development of standardized metrics sensitive to brain-behavior relationships has shaped the neuropsychological questions we can ask, our understanding of discrete brain functions, and has informed the detection and treatment of neurological disorders. We identify key turning points and innovations in neuropsychological assessment over the past 40-50 years that highlight how the tools used in common practice today came to be. Also selected for emphasis are several exciting lines of research and novel approaches that are underway to further probe and characterize brain functions to enhance diagnostic and treatment outcomes. We provide a brief historical review of different clinical neuropsychological assessment approaches (Lurian, Flexible and Fixed Batteries, Boston Process Approach) and critical developments that have influenced their interpretation (normative standards, cultural considerations, longitudinal change, common metric batteries, and translational assessment constructs). Lastly, we discuss growing trends in assessment including technological advances, efforts to integrate neuropsychology across disciplines (e.g., primary care), and changes in neuropsychological assessment infrastructure. Neuropsychological assessment has undergone massive growth in the past several decades. Nonetheless, there remain many unanswered questions and future challenges to better support measurement tools and translate assessment findings into meaningful recommendations and treatments. As technology and our understanding of brain function advance, efforts to support infrastructure for both traditional and novel assessment approaches and integration of complementary brain assessment tools from other disciplines will be integral to inform brain health treatments and promote the growth of our field. (JINS, 2017, 23, 778-790).

Adherence to Validity Testing Recommendations in Neuropsychological Assessment: A Survey of INS and NAN Members.

OBJECTIVE: The National Academy of Neuropsychology (NAN) has published recommendations for best validity testing practices, as has the American Academy of Clinical Neuropsychologists (AACN) in their review of critical issues in the field. However, surveys show not all neuropsychologists follow these recommendations consistently. Examiner characteristics (e.g., training history) and current practice characteristics (e.g., type of practice setting) may affect systematic adherence to these recommendations. Further, previous surveys focused on distinct countries or continents rather than an international sample. This study sought to provide better understanding of examiner factors that contribute to recommendation adherence and identify opportunities for improving validity testing training and practice. METHOD: A sample of 654 NAN and International Neuropsychological Society (INS) neuropsychologists responded to online survey questions about their demographic, training, and practice characteristics, as well as validity testing practices. RESULTS: Findings indicate that neuropsychologists from other countries generally adhere to NAN and AACN recommendations as closely as United States neuropsychologists. Across all neuropsychologists, those who work with pediatric and geriatric populations do not follow recommendations as consistently as those who work with adults, despite research supporting that recommendations should be followed with all patients. Neuropsychologists who have been practicing longer were also less likely to adhere to recommendations, suggesting that continuing education would be beneficial even for more experienced neuropsychologists. CONCLUSIONS: Results highlight the need for continued training on the importance of validity testing practices across different countries and all assessment settings, and identify groups of neuropsychologists to whom training could be targeted to maximize effectiveness.

2015 American Academy of Clinical Neuropsychology (AACN) student affairs committee survey of neuropsychology trainees.

OBJECTIVE: Surveys of practicing neuropsychologists have been conducted for years; however, there have been no comprehensive surveys of neuropsychology trainees, which may result in important issues being overlooked by the profession. This survey assessed trainees' experiences in areas such as student debt, professional development, and training satisfaction. METHOD: Survey items were written by a task force of the AACN Student Affairs Committee (SAC), and neuropsychology trainees were recruited via neuropsychology-focused listservs. In total, 344 trainees completed the survey (75% female) and included participants from every region of the US and Canada. RESULTS: Based on the survey questions, nearly half of all trainees (47%) indicated financial factors were the greatest limitation in their training. Student debt had a bimodal distribution; 32.7% had minimal debt, but 45% had debt >$100,000. In contrast, expected starting salaries were modest, but consistent with findings ($80-100,000). While almost all trainees intended to pursue board certification (97% through ABPP), many were 'not at all' or only 'somewhat' familiar with the process. CONCLUSIONS: Results indicated additional critical concerns beyond those related to debt and lack of familiarity with board certification procedures. The results will inform SAC conference programming and the profession on the current 'state of the trainees' in neuropsychology.

Official Position of the American Academy of Clinical Neuropsychology Social Security Administration Policy on Validity Testing: Guidance and Recommendations for Change.

UNLABELLED: The milestone publication by Slick, Sherman, and Iverson (1999) of criteria for determining malingered neurocognitive dysfunction led to extensive research on validity testing. Position statements by the National Academy of Neuropsychology and the American Academy of Clinical Neuropsychology (AACN) recommended routine validity testing in neuropsychological evaluations. Despite this widespread scientific and professional support, the Social Security Administration (SSA) continued to discourage validity testing, a stance that led to a congressional initiative for SSA to reevaluate their position. In response, SSA commissioned the Institute of Medicine (IOM) to evaluate the science concerning the validation of psychological testing. The IOM concluded that validity assessment was necessary in psychological and neuropsychological examinations (IOM, 2015 ). OBJECTIVE: The AACN sought to provide independent expert guidance and recommendations concerning the use of validity testing in disability determinations. METHOD: A panel of contributors to the science of validity testing and its application to the disability process was charged with describing why the disability process for SSA needs improvement, and indicating the necessity for validity testing in disability exams. RESULTS: This work showed how the determination of malingering is a probability proposition, described how different types of validity tests are appropriate, provided evidence concerning non-credible findings in children and low-functioning individuals, and discussed the appropriate evaluation of pain disorders typically seen outside of mental consultations. CONCLUSIONS: A scientific plan for validity assessment that additionally protects test security is needed in disability determinations and in research on classification accuracy of disability decisions.

Implications of RDoC for the research and practice of psychotherapy.

The field of psychotherapy is at an important juncture. Recent changes in the field include (a) the skeptical reception of the fifth edition of the Diagnostic and Statistical Manual and (b) NIMH's prioritization of an alternative classification system to guide translational and intervention research. Moreover, (c) the field continues to be held accountable to governmental agencies and third-party payers to demonstrate its empirical basis. Thus, psychological research as it relates to the practice of psychotherapy is at a crossroads. In this article, we provide a brief overview of several generations of psychotherapy outcome research, including the consequences that followed in the 1980s as psychotherapy research moved toward randomized controlled trials for clinical disorders. We delineate the inherent strengths and limitations of this movement and address how the NIMH has recently responded with the Research Domain Criteria (RDoC). We then address philosophical and practical implications of the emphasis on a neuroscientific conceptualization of psychological problems. Finally, we discuss opportunities for a next generation of convergent science that incorporates, rather than replaces, psychosocial variables across stages of translational research and treatment development.

Who should conduct and interpret the neuropsychological assessment in sports-related concussion?

OBJECTIVE: This paper seeks to (i) describe the education and training of clinical neuropsychologists, (ii) discuss the significant differences between test administration and clinical assessment, (iii) outline the complex factors involved in psychometric test theory and test interpretation, and (iv) provide a framework for the role of clinical neuropsychologists in the interpretation and administration of neuropsychological instruments within the sports context. DESIGN: Review of pertinent professional practice, empirical and theoretical literature. INTERVENTION: Pubmed, Medline and Psych Info databases were reviewed. In total, 35 articles and 2 books were reviewed. RESULTS: The decision to return an athlete to play following sports-related brain injury is complex and requires the analysis of several sources of data. The decision is determined by a team physician; ideally within the context of a multidisciplinary team that employs comprehensive concussion surveillance and management, including baseline and post-injury neuropsychological assessment. Neuropsychologists possess the training and skill sets necessary to provide unique expertise in the assessment of cognitive functioning and post-injury neurocognitive and psychological assessment. CONCLUSIONS: Baseline neuropsychological testing is a technical procedure that can be conducted by technicians under the supervision/guidance of a neuropsychologist. Post-injury assessment requires advanced neuropsychological expertise that is best provided by a clinical neuropsychologist. Significant international differences exist with respect to the training and availability of clinical neuropsychologists, which require modification of these views on a country by country basis.

Neuropsychological assessment of HIV-infected populations in international settings.

Resource-limited regions of the world represent the areas most affected by the global HIV epidemic. Currently, there are insufficient data on the neurocognitive effects of HIV in these areas and neuropsychological studies that have been carried out thus far are marked by inconsistent methods, test batteries, and rating systems for levels of cognitive impairment. These differences in methods, along with genetic variability of both virus and host, differences in co-infections and other co-morbidities, differences in language and culture, and infrastructural deficiencies in many international settings create challenges to the assessment of neurocognitive functioning and interpretation of neuropsychological data. Identifying neurocognitive impairment directly attributable to HIV, exploring relationships between HIV-associated neurocognitive impairment, disease variables, and everyday functioning, evaluating differences in HIV-1 subtype associated neuropathology, and determining implications for treatment remain complicated and challenging goals. Endeavors to establish a more standardized approach to neurocognitive assessments across international studies in addition to accumulating appropriate normative data that will allow more accurate rating of neuropsychological test performance will be crucial to future efforts attempting to achieve these goals.

Professional considerations for improving the neuropsychological evaluation of Hispanics: a National Academy of Neuropsychology education paper.

In a national survey, 82% of U.S. neuropsychologists who offered services to Hispanics self-reported inadequate preparation to work with this population (Echemendia, Harris, Congett, Diaz, & Puente, 1997). The purpose of this paper is to improve the quality and accessibility of neuropsychological services for Hispanic people living in the United States by giving guidance for service delivery, training, and organizational policy. General guidance towards this end comes from professional ethics for psychologists and interpreters/translators, federal civil rights law, the International Test Commission, and the Office of Minority Health of the U.S. Department of Health and Human Services, among others. This guidance is specifically applied here to cover professional cultural and linguistic competence of neuropsychologists, psychometrists, interpreters, translators, and consultants; languages of evaluation; use of interpreters; evaluation of acculturation; test translation, adaptation, and interpretation; application of test norms; intervention issues; reimbursement; and organizational issues.

Forensic neuropsychological evaluations in an academic medical center.

Within the expanding field of clinical neuropsychology, the subspecialty of forensic neuropsychology has developed. Currently, there is considerable diversity within the discipline as to how practitioners approach test selection, reports, and number of hours billed. How individuals handle these issues is subject to debate, but what is clear is that there are no specific guidelines as to how to conduct these evaluations. The current study provides an introduction to the issues faced by clinical neuropsychologists completing forensic evaluations. In addition, the authors present how the relevant issues are addressed in one neuropsychology service housed within a university-affiliated academic medical center.

Methodological challenges in causal research on racial and ethnic patterns of cognitive trajectories: measurement, selection, and bias.

Research focused on understanding how and why cognitive trajectories differ across racial and ethnic groups can be compromised by several possible methodological challenges. These difficulties are especially relevant in research on racial and ethnic disparities and neuropsychological outcomes because of the particular influence of selection and measurement in these contexts. In this article, we review the counterfactual framework for thinking about causal effects versus statistical associations. We emphasize that causal inferences are key to predicting the likely consequences of possible interventions, for example in clinical settings. We summarize a number of common biases that can obscure causal relationships, including confounding, measurement ceilings/floors, baseline adjustment bias, practice or retest effects, differential measurement error, conditioning on common effects in direct and indirect effects decompositions, and differential survival. For each, we describe how to recognize when such biases may be relevant and some possible analytic or design approaches to remediating these biases.

American Academy of Clinical Neuropsychology (AACN) practice guidelines for neuropsychological assessment and consultation.

This document is the first set of practice guidelines to be formally reviewed and endorsed by the AACN Board of Directors and published in the official journal of AACN. They have been formulated with the assumption that guidelines and standards for neuropsychological assessment and consultation are essential to professional development. As such, they are intended to facilitate the continued systematic growth of the profession of clinical neuropsychology, and to help assure a high level of professional practice. These guidelines are offered to serve members of AACN, as well as the field of clinical neuropsychology as a whole.

Through the looking glass: Where is the thought? A reply to Rodriguez-Menendez.

In reply to my presidential address, Rodriguez-Menendez questions my comments about poorer performance on the national licensing exam by graduates of Psy.D. programs and professional schools than by Boulder-model Ph.D. programs. He goes on to confirm that their scores are indeed significantly lower, but suggests this is not important. Apart from this apparent confirmation, the remainder of his assertions that Psy.D. programs indeed provide good scientific training appear to be contraindicated by both the model and the performance of graduates of those programs. Finally, the need for standards is again asserted, with a reiteration of the need to ask who benefits from attacks on upholding standards: the patient and profession or the one who is doing the attacking.