Neuropsychological assessment of traumatic brain injury: Current ethical challenges and recommendations for future practice.

Numerous ethical challenges may arise over the course of neuropsychological assessment. This paper highlights the ethical considerations associated with neuropsychological assessment of individuals with traumatic brain injury. Issues regarding professional competency, providing and obtaining informed consent, neuropsychological test selection and administration, effectively communicating assessment results, and working as part of a multidisciplinary team are discussed with practical recommendations. Ultimately, a comprehensive understanding of these issues as well as an integration of resources to guide clinical practice will contribute to ethical decision-making and strong professional practice.

Regulación en la práctica de la neuropsicología clínica en México / Regulation in the practice of clinical neuropsychology in Mexico

En México, no existe una adecuada regulación legal de la práctica profesional de la neuropsicología, a pesar de que existen pautas a nivel internacional donde se estipula que el profesional debe tener una formación teórica-práctica sobre neurociencias, psicología clínica y psicometría, además de destreza en habilidades clínicas y formulación de programas de intervención sólidamente fundamentados en estudios empíricos. Por lo tanto, es necesario que los profesionistas estén capacitados para desarrollar su labor, pues de lo contrario estaría atentando contra derechos fundamentales del ser humano. Por lo que las autoridades en materia de salud mental, al tener facultades suficientes para actualizar y legalizar en relación con la práctica clínica, deberán implementar medidas más específicas y rígidas en cuanto a los requisitos que deben reunir los profesionales en materia de neuropsicología. Finalmente, se debe impulsar el consenso entre las asociaciones, universidades y profesionales del campo, para establecer vías de comunicación que tenga como objetivo la regulación y reconocimiento de la profesionalización en neuropsicología clínica.

In Mexico, there is a lack of legal regulation of the professional practice of neuropsychology, even though there are international guidelines on the practice of neuropsychology which stipulate to have theoretical-practical training in neuroscience, clinical psychology and psychometrics, as well as skills in clinical and formulation of intervention programs solidly based on empirical studies. Therefore, it is a necessity that the professionals are properly trained, because otherwise it would be attacking the fundamental rights of the human being. Thus, the mental health authorities should update and legalize in relation to clinical practice more specific measures on the requirements to practice clinical neuropsychology. Finally, consensus among associations, universities, and professionals in the field should be encouraged to establish a communication that aims to regulate and recognize the practice in clinical neuropsychology.

Perception of ethical misconduct by neuropsychology professionals in Spain.

OBJECTIVE: To examine the prevalence of perceived ethical misconduct in clinical practice, teaching, and research in the field of neuropsychology in Spain. METHOD: Two hundred and fifteen self-identified mental health professionals who engage in neuropsychology practice in Spain completed an online survey from July to December of 2013. In the ethics section of the survey, participants were asked to identify if neuropsychologists they know who work in their country engaged in specific kinds of ethical misconduct. RESULTS: 41% reported receiving formal training in professional ethics. The clinical findings are as follows. The highest rate of perceived misconduct was found in the area of professional training and expertise, with an average of 40.7%, followed by research/publications (25.6%), clinical care (23.9%), and professional relationships (8.8%). Specifically, regarding training, over half of respondents (56.7%) know professionals who claim themselves to be neuropsychologists, even though they lack proper training or expertise and 46.0% know professionals in the field who do not have adequate training for experience to be working in the field. Regarding research/publications, 41.9% of respondents know professionals who appear as authors on publications where they have not made a significant contribution. Regarding clinical care, over one third of respondents endorse knowing professionals who (1) provide results of neuropsychological evaluations in such a way that patients or other professionals are not likely to understand (37.2%) and (2) do not have the skills or training to work with patients who are culturally different from them (34.9%). CONCLUSIONS: Less than half of survey respondents reported receiving ethics training. It is possible that introducing more or improved ethics courses into pre-graduate and/or graduate school curriculums, and/or requiring continuing ethics education certification may reduce perceived ethical misconduct among neuropsychological professionals in Spain.

Trastorno específico del lenguaje: subtipos de una patología compleja / Specific language impairment: subtypes of a complex disorder

Existen distintas propuestas sobre marcadores psicolingüísticos y sobre taxonomías del trastorno específico del lenguaje (TEL). Este trabajo presenta los resultados obtenidos en 8 tareas psicolingüísticas por 2 grupos de niños: 31 niños con TEL (GTEL) y 31 niños igualados en edad cronológica (GC). Las tareas han sido elaboradas ad hoc para valorar los marcadores psicolingüísticos en las 4 áreas clásicas: fonología, morfosintaxis, semántica y pragmática. En primer lugar, se comprueba que los niños del GTEL rinden significativamente peor que los niños del GC en las 8 tareas. En segundo lugar, un análisis de conglomerados K-medias clasifica a los 31 sujetos del grupo TEL en 4 conglomerados. En tercer lugar, un análisis discriminante comprueba si la clasificación clínica hecha a priori se mantiene tras los resultados del estudio. Se presenta el perfil de los conglomerados y se discuten sus características respecto a los subtipos de la taxonomía clínica de Rapin y Allen. Finalmente, se analizan las similitudes y diferencias entre ambas tipologías. Los resultados obtenidos ayudan a esclarecer los marcadores psicolingüísticos del TEL en niños de habla española y refuerzan la utilidad clínica de su clasificación en subtipos y la vigencia de la taxonomía de Rapin y Allen (AU)

There are various proposals for psycholinguistic markers and for taxonomies of specific language impairment (SLI). This study presents the results obtained in eight psycholinguistic tasks by two groups of Spanish-speaking children: 31 children with SLI (SLI) and 31 children matched for chronological age (CA). The tasks were developed ad hoc to assess psycholinguistic markers in the four traditional areas: phonology, morphosyntax, semantics and pragmatics. Firstly, we found that SLI group scored significantly worse than CA group in the eight tasks. Secondly, a K-Means cluster analysis distinguished five clusters within the 31 subject of SLI group. Thirdly, a discriminant analysis checks whether an a priori clinical classification is maintained after the study results. We present the profile of these clusters and discuss their features regarding Rapin & Allen taxonomy clinical subtypes. Finally, the similarities and differences between the two classifications are analyzed. The results obtained in this work help shed light on the psycholinguistic markers of the Spanish-SLI and reinforce the clinical utility of its classification into subtypes and the validity of the Rapin & Allen taxonomy (AU)

Utilidad clínica y propiedades psicométricas del inventario de síntomas prefrontales (ISP) en el daño cerebral adquirido y las demencias degenerativas / Clinical utility and psychometric properties of Prefrontal Symptoms Inventory (PSI) in acquired brain injury and degenerative dementias

Introducción. Las alteraciones cognitivas, emocionales y comportamentales secundarias al daño cerebral adquirido y las demencias degenerativas pueden valorarse cuantitativa y cualitativamente mediante la administración de autoinformes que interroguen –a pacientes e informadores fiables– sobre las dificultades de los pacientes en la vida cotidiana. Sujetos y métodos. Se administró el inventario de síntomas prefrontales (ISP) y el cuestionario de fallos de memoria en la vida cotidiana modificado (MFE-30) a 174 participantes emparejados: 87 pacientes con daño cerebral o demencias degenerativas y sus 87 informadores fiables. Se exploró, junto con la bondad psicométrica de las pruebas, la utilidad clínica de la aplicación de estos cuestionarios a pacientes e informadores para obtener un índice de discrepancia de las puntuaciones como medida de la anosognosia. Resultados. Los resultados muestran cómo aplicar el ISP-20 (20 ítems) o el ISP (46 ítems), sean o no administrados conjuntamente con el MFE-30 (30 ítems), resulta un procedimiento muy útil para la valoración de la sintomatología en los individuos con daño cerebral adquirido o demencias degenerativas, al proporcionar una gran cantidad de información sobre las dificultades de los pacientes en la vida cotidiana. Conclusiones. Se recomienda, junto con la obligada evaluación neuropsicológica, la cumplimentación de cuestionarios o inventarios de síntomas como los propuestos, dado que presentan ventajas desde el punto de vista clínico, además de resultar eficaces, efectivos y eficientes en términos económicos (AU)

Introduction. The cognitive, emotional and behavioural alterations secondary to acquired brain injury and degenerative dementias can be quantitatively and quantitatively appraised by administering self-reports that ask both patients and reliable informants about the difficulties patients have in their everyday life. Subjects and methods. The Prefrontal Symptoms Inventory (PSI) and the Modified Memory Failures in Everyday Life Questionnaire (MFE-30) were administered to 174 paired participants: 87 patients with brain damage or degenerative dementias and their 87 reliable informants. In addition to the psychometric goodness of the tests, the study also explored the clinical usefulness of applying these questionnaires to patients and their informants in order to obtain a rate of discrepancy in the scores as a measure of anosognosia. Results. The results show how applying the PSI-20 (20 items) or the PSI (46 items), whether administered together with the MFE-30 (30 items) or not, is a very useful procedure for assessing the symptoms in individuals with acquired brain injury or degenerative dementias, since it yields a great deal of information about patients’ difficulties in their daily life. Conclusions. We recommend that, in addition to the compulsory neuropsychological assessment, questionnaires or inventories of symptoms like those proposed here should be carried out, due to the fact that they offer a number of advantages from the clinical point of view, as well as being efficacious and effective in economic terms (AU)

Perception of Ethical Misconduct by Neuropsychology Professionals in Latin America.

To date, extremely limited research has focused on the ethical aspects of clinical neuropsychology practice in Latin America. The current study aimed to identify the frequency of perceived ethical misconduct in a sample of 465 self-identified neuropsychology professionals from Latin America in order to better guide policies for training and begin to establish standards for practitioners in the region. Frequencies of neuropsychologists who knew another professional engaging in ethical misconduct ranged from 1.1% to 60.4% in the areas of research, clinical care, training, and professional relationships. The most frequently reported perceived misconduct was in the domain of professional training and expertise, with nearly two thirds of participants knowing other professionals who do not possess adequate training to be working as neuropsychologists. The least frequently reported perceived misconduct was in the domain of professional relationships. Nearly one third of participants indicated that they had never received formal training in professional ethics.

Estado epiléptico eléctrico durante el sueño: estudio retrospectivo multicéntrico de 29 casos / Electrical status epilepticus during sleep: a retrospective multi-centre study of 29 cases

Introducción. El estado epiléptico eléctrico durante el sueño (ESES) es un síndrome epiléptico caracterizado por la presencia de descargas epilépticas tipo punta-onda lenta de manera muy persistente durante el sueño no REM. En la actualidad, el manejo de esta patología es heterogéneo y no hay estudios controlados con los tratamientos utilizados, ni se ha comprobado si éstos mejoran la evolución cognitiva de los pacientes. Pacientes y métodos. Se revisan los pacientes diagnosticados de ESES durante 15 años en cuatro centros hospitalarios, se recoge la presentación clínica, el manejo terapéutico y la evolución clínica, y se compara con la bibliografía. Resultados. Se seleccionaron 29 pacientes con ESES, 20 de ellos idiopático y 26 de ellos generalizado. Los fármacos con los que se consiguió mayor control de la actividad eléctrica fueron los corticoides/hormona adrenocorticotropa (ACTH), el clobazam y el levetiracetam. La mediana de duración del ESES en los casos primarios fue de seis meses, y en los secundarios, el doble. El 45% de los pacientes mantuvo un cociente intelectual normal y un 40% presentó en la evolución discapacidad cognitiva de diferente grado. Conclusiones. El pronóstico neuropsicológico evolutivo suele ser desfavorable y la evolución cognitiva parece estar en relación con la duración del ESES y el área donde esté concentrada la actividad epiléptica, lo que sugiere que el mal pronóstico, si se trata precozmente, se puede evitar. Los antiepilépticos más frecuentemente utilizados son el ácido valproico, la etosuximida y el levetiracetam, y en nuestra muestra también se utilizaron con frecuencia el clobazam y la lamotrigina. Los fármacos más eficaces para el control del ESES fueron los corticoides/ACTH, el clobazam y el levetiracetam (AU)

Introduction. Electrical status epilepticus during sleep (ESES) is an epileptic syndrome characterised by the presence of very persistent slow spike-wave-type epileptic discharges during non-REM sleep. The management of this pathology, today, is heterogeneous and no controlled studies have been conducted with the treatments employed; similarly, whether or not they improve patients’ cognitive development or not has still to be determined. atients and methods. A review was carried out of the patients diagnosed with ESES at four hospitals over a period of 15 years; data concerning their clinical presentation, therapeutic management and clinical course were collected and compared with the literature. Results. Altogether 29 patients with ESES were detected, 20 of them idiopathic and 26 generalised. The drugs with which the greatest control of the electrical activity was achieved were corticoids/adrenocorticotropic hormone (ACTH), clobazam and levetiracetam. In the primary cases ESES lasted an average of six months and the duration was twice that time in the secondary cases. Findings showed that the intelligence quotient remained normal in 45% of patients and 40% presented differing degrees of cognitive disability in the course of the pathology. Conclusions. The developmental neuropsychological prognosis is usually unfavourable and the cognitive development seems to be related with the duration of ESES and the area where the epileptic activity is concentrated, which suggests that the poor prognosis can be avoided if treatment is established at an early stage. The antiepileptic drugs that are most commonly used are valproic acid, ethosuximide and levetiracetam, and in our milieu clobazam and lamotrigine were commonly employed. The most effective drugs for controlling ESES were corticoids/ACTH, clobazam and levetiracetam (AU)

Examining and reporting the status of statistical assumptions in neuropsychological research: a misbegotten ethical obligation?

The ethical responsibilities within clinical practice are ubiquitous. Yet, several aspects comprising the clinical neuropsychologist's role, although carrying equal ethical 'weight, ' may be relegated to a lesser value and are considered irregularly. This paper is of the position that statistical assumptions are arbitrarily and unpredictably reported in research. However, violating statistical assumptions can often yield untenable results, rendering the inferences based on the primary analysis equally precarious. Just as clinicians are enjoined by their respective professional organizations to abide scrupulously by ethical principles in clinical practice, neuropsychologists should be equally careful over such important matters in research. Consistent examination (and rectification when needed) and reporting of the status of statistical assumptions will help to not only broaden and maintain the ambitions of sound ethical practice but, ultimately ensure optimal patient care.

Atención sostenida visual y funciones ejecutivas en niños con dislexia de desarrollo / Visual sustained attention and executive functions in children with developmental dislexia

Introducción: Alteraciones atencionales y ejecutivas han sido descritas en la dislexia, aunque los resultados sean contradictorias. Objetivo: Comparar el desempeño de niños con dislexia pero sin dificultades en pruebas de atención y funciones ejecutivas. Método: Participaron 50 alumnos escolares divididos en: 25 con dislexia y 25 sin dificultades de aprendizaje. Fueron utilizados los instrumentos: Trail Making Test, Tests de Cancelamiento, Stroop Color Word Test y Tower of Lon-don. Las puntuaciones fueron comparadas entre los grupos. Resultados: El grupo con dislexia ha presentado peores desempeños en los tests, con excepción de la Torre de Londres. Conclusión: Los resultados sugieren que los disléxicos pueden presentar alteraciones en la atención sostenida visual y en algunos aspectos de las funciones ejecutivas: flexibilidad e inhibición cognitiva, pero no en la planificación. Las alteraciones en los componentes ejecutivos pueden juntarse al déficit central en el procesamiento fonológico en la dislexia (AU)

Introdution: Alterations in attention and executive functions have been described in dyslexia despite the conflicting results. Objective: To compare the performance of children with dyslexia and without difficulties in tests of attention and executive functions. Methods: Participated 50 students divided into: 25 with dyslexia and 25 without learning difficulties. The instruments were used: Trail Making Test, Tests of Cancellation, Stroop Color Word Test and Tower of London. The scores of the tests were compared between groups. Results: The group with dyslexia showed poorer performance with the tests, except the Tower of London. Conclusion: The results suggest that dyslexics may show changes in visual sustained attention and some aspects of executive functions: flexibility and cognitive inhibition, but not in planning. Changes in components executives can monitor the core deficit in phonological processing in dyslexia (AU)

Initial practice recommendations for teleneuropsychology.

Telemedicine refers to the use of electronic communications to deliver health-related services from a distance, and is particularly useful in bringing specialty services to remote and/or underserved areas. Despite the increasing use of videoconference technology in psychology, there are very few guidelines to direct practitioners as to the ethical practice and utilization of telemedicine, and even fewer resources for practitioners of telecognitive assessment or teleneuropsychology. This paper seeks to outline several practical and ethical considerations that are relevant to the practice of telecognitive assessment and to assist practitioners in providing safe, ethical, and competent care to their patients by proposing some initial practice recommendations.

Third party observation during neuropsychological evaluation: an update on the literature, practical advice for practitioners, and future directions.

A clash between neuropsychology and the law may exist when a demand is made for third party observation during forensic neuropsychological evaluation. Third party observation includes any person or observational process present during a neuropsychological evaluation aside from the psychologist and the examinee, including electronic devices (e.g., video and audio recordings). The goal of this paper includes succinctly providing to practitioners the scientific, ethical, and pragmatic (i.e., test security and coaching) reasons to not allow third party observation. Practitioners at the individual level need to be aware of the reasoning and be willing and able to advocate protecting the boundaries of neuropsychological practice and test security. We present practitioners with options when confronted with a request, provide a list of resources to educate the legal system and submit with motions, provide responses for some of the more common myths/reasoning used to support a request for a TPO, and encourage more global solutions such as state-by-state legislation.

Determining whether or when to adopt new versions of psychological and neuropsychological tests: ethical and professional considerations.

Test selection has significant implications for inferences that can be drawn from test data. Some tests undergo revisions, typically to improve their psychometric properties, normative data, relevance of stimuli, and ease of administration. Although revisions of psychological and neuropsychological tests are published periodically, little information is available regarding whether or when clinicians should transition to the most recent versions of the tests. The 2002 APA Ethics Code (Standard 9.08b) requires that psychologists not base their assessment or intervention decisions or recommendations "on tests and measures that are obsolete and not useful for the current purpose." However, there is no consensus regarding when tests should no longer be considered acceptable, and there may be sound reasons for delaying or foregoing the purchase and use of new versions of assessment measures. Determining whether or when to transition to a new version of a test can be particularly difficult for clinicians in psychological specialties because it can take years after publication of a revised test for research with special patient populations to be performed and published. As a result, different clinicians may adopt newer versions of tests at different times or elect not to use the newest version, depending on the specific patient population and referral questions. Decisions regarding transitioning to new test revisions should be based on the scientific merits of the tests, not on an arbitrarily defined time frame. Clinicians ultimately must use their judgment regarding which test version is best for a given patient at a given point in time.

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.

Best practice guidelines for forensic neuropsychological examinations of patients with traumatic brain injury.

Forensic examiners generally agree that their contributions to the forensic process have to be based on scientific principles, high ethical values, and sound clinical skills and judgment. In part I, the challenges of maintaining high ethical standards as a scientist-practitioner are addressed. In part II, the scientific strengths and weaknesses of our neuropsychological assessments are explored within the context of the 4 articles published in this issue. Specifically, Wood points out that while most traumatic brain injuries (TBIs) compromise the prefrontal cortex (PFC), traditional neuropsychological examinations do not fully capture to what extent PFC damage disrupts cognitive, emotional, and social regulation. New advances in clinical neuroscience are presented to facilitate a more detailed understanding of PFC functioning. Schwarz et al examine how clinical neuropsychology services can adequately handle forensic consultations. Frederick and Bowden, meanwhile, identify the persistent weaknesses of various Symptom Validity Tests in reliably classifying poor effort and malingering. Bailey et al conclude that the findings from sport concussion studies cannot be generalized to clinical populations, who, as a rule, have more premorbid and comorbid vulnerabilities. Finally, part III provides guidelines based on the introductory article by Bigler and Brooks, as well as a synopsis of the main conclusions offered by the contributors in this journal issue. Guidelines for both the diagnosis of mild TBI and the diagnosis of postconcussional disorder are included.

Brain imaging and brain privacy: a realistic concern?

Functional neuroimaging has been used to study a wide array of psychological traits, including aspects of personality and intelligence. Progress in identifying the neural correlates of individual differences in such traits, for the sake of basic science, has moved us closer to the applied science goal of measuring them and thereby raised ethical concerns about privacy. How realistic are such concerns given the current state of the art? In this article, we describe the statistical basis of the measurement of psychological traits using functional neuroimaging and examine the degree to which current functional neuroimaging protocols could be used for this purpose. By analyzing the published data from 16 studies, we demonstrate that the use of imaging to gather information about an individual's psychological traits is already possible, but to an extremely limited extent.

The provision of neuropsychological services in rural/regional settings: professional and ethical issues.

Despite rapid growth of the discipline of clinical neuropsychology during recent times, there is limited information regarding the identification and management of professional and ethical issues associated with the practice of neuropsychology within rural settings. The aim of this article is to outline the characteristics unique to practicing neuropsychology in rural communities and to describe the potential professional and ethical dilemmas that might arise. Issues are illustrated using examples from neuropsychological practice in a rural/regional setting in Victoria, Australia. Relative to urban regions, there is an inequality in the distribution of psychologists, including neuropsychologists, in rural areas. The unique characteristics of rural and regional communities that impact on neuropsychological practice are: 1) limited resources in expertise, technology, and community services, 2) greater travel distances and costs, 3) professional isolation, and 4) beliefs about psychological services. These characteristics lower the threshold for particular ethical issues. The ethical issues that require anticipation and careful management include: 1) professional competence, 2) multiple relationships, and 3) confidentiality. Through increased awareness and management of rural-specific professional and ethical issues, rural neuropsychologists can experience their work as rewarding and enjoyable. Specific guidelines for identifying, managing, and resolving ethically and professionally challenging situations that may arise during rural practice are provided.

Ethical considerations in geriatric neuropsychology.

The practice of geriatric neuropsychology demands specialized training and experience that enables the practitioner to appreciate the unique challenges and opportunities that are encountered when working with older adults. In addition to maintaining advanced knowledge regarding medical and psychological conditions, assessment issues, and treatment needs specific to older persons, clinicians working with older adults must be prepared to recognize and confront ethical dilemmas that arise. For example, ethical challenges related to professional competence, informed consent, assessment, and privacy and confidentiality may be prominent when working with older persons. Maintaining an emphasis on "positive ethics" and utilizing an ethical decision-making model will promote the practitioner's ability to avoid, identify, and resolve ethical challenges. The present article reviews (1) the concept of positive ethics, (2) a comprehensive ethical decision-making model, and (3) ethical issues that are commonly encountered by geriatric neuropsychologists. A case vignette is presented to illustrate the application of the aforementioned tools to promote ethical practice.