Clinical Neuropsychology in North America: What the First Twenty Five Years Might Tell Us About the Future of the Specialty and Its Implication for the Development of Neuropsychology in Spain Congreso de Asociaciones de Neuropsicologia Espanolas Universidad de Granada Junio 10, 2005

Antonio E. Puente Department of Psychology University of North Carolina a Wilmington Wilmington, North Carolina USA

Outline Focus: Education, Personnel/Organization, Activities Focus: Education, Personnel/Organization, Activities Introduction Introduction Brief Overview of Twenty Five Years Brief Overview of Twenty Five Years Current Panorama Current Panorama Challenges, Pitfalls and Opportunities Challenges, Pitfalls and Opportunities

Introduction Personal Background Personal Background Education and Training Education and Training Scientific, Professional & Pedagogical Activities Scientific, Professional & Pedagogical Activities Research; Cultural Neuropsychology, Coronary Artery Bypass, Roger W. Sperry Research; Cultural Neuropsychology, Coronary Artery Bypass, Roger W. Sperry Professional; Assessment & Rehabilitation Professional; Assessment & Rehabilitation Pedagogical; Classroom, Clinic & Laboratory Pedagogical; Classroom, Clinic & Laboratory Organizational; APA, NAN, & AMA/Medicare Organizational; APA, NAN, & AMA/Medicare

Background: Initial History of Academic Psychology in the USA Science Science Psychological Review (1894; purchased) Psychological Review (1894; purchased) First Laboratory (1885; Harvard) First Laboratory (1885; Harvard) Later- Hopkins, Penn, Iowa, Wisconsin, etc. Later- Hopkins, Penn, Iowa, Wisconsin, etc. Pedagogy Pedagogy First Undergraduate Course (1840; Marshall) First Undergraduate Course (1840; Marshall) First Graduate Course (1847; Yale) First Graduate Course (1847; Yale) First PhD Granted (1861; Yale) First PhD Granted (1861; Yale) First Textbook(1890; James) First Textbook(1890; James)

The Beginning of APA Model Model American Physiological Society American Physiological Society Preliminary Meeting Preliminary Meeting Worcester, Mass (Clark; July 8, 1892) Worcester, Mass (Clark; July 8, 1892) 26; 2 Jews, 1 Catholic Priest, Psychiatrists… 26; 2 Jews, 1 Catholic Priest, Psychiatrists… First Official Meeting First Official Meeting Philadelphia, PA (Penn; December, 1892) Philadelphia, PA (Penn; December, 1892) 18 attended and presented; Hall elected 18 attended and presented; Hall elected

The Beginning of Clinical Psychology WWII and the VA System ( ) WWII and the VA System ( ) Licensing Laws ( ) Licensing Laws ( ) Third Party Reimbursement ( ) Third Party Reimbursement ( ) Medicare Program (1990-present) Medicare Program (1990-present) Specialities in Psychology (2000-present) Specialities in Psychology (2000-present)

APA Membership YearDoctorateMastersBachelors

APA Membership by Division Approximately 150,000 members Approximately 150,000 members Approximately 55 different divisions Approximately 55 different divisions Top three divisions are: Top three divisions are: Clinical Psychology Clinical Psychology Clinical Neuropsychology Clinical Neuropsychology Independent Practice Independent Practice

APA Membership Health Provider 70% Health Provider 70% Clinical = 50% Clinical = 50% Research20% Research20% Other11% Other11%

History: Education Bachelors (4 years) Bachelors (4 years) Generic Introduction/Liberal Arts Generic Introduction/Liberal Arts Masters (2 years) Masters (2 years) Stepping-Stone Stepping-Stone Psychological Assistant/Associate Psychological Assistant/Associate Doctorate (4-7 years) Doctorate (4-7 years) PhD Vs PsyD PhD Vs PsyD Requirement to be Called and to Practice as a Psychologist Requirement to be Called and to Practice as a Psychologist Clinical Vs Other Clinical Vs Other Post-Doctorate (1-2 years) Post-Doctorate (1-2 years) Clinical Neuropsychology as a Specialty Clinical Neuropsychology as a Specialty Continuing Education Continuing Education Half-Life of Doctorate Education = 8 years Half-Life of Doctorate Education = 8 years

History: Clinical Activities in Neuropsychology Assessment Assessment Fixed (Halstead-Reitan Vs. Luria-Nebraska) Vs. Flexible (Boston) Fixed (Halstead-Reitan Vs. Luria-Nebraska) Vs. Flexible (Boston) Clinical (e.g., Dementia, Stroke, Head Inj.) Clinical (e.g., Dementia, Stroke, Head Inj.) Educational (e.g., Learning Disability) Educational (e.g., Learning Disability) Rehabilitation Rehabilitation Cognitive Rehabilitation Cognitive Rehabilitation Forensic Forensic Disability (Social Security; Pension) Disability (Social Security; Pension) Workers Compensation Workers Compensation Personal Injury Personal Injury Death Penalty Death Penalty

History: Information in Neuropsychology Publications Publications Books (Goldstein, 1974) Books (Goldstein, 1974) Journals (IJCN; 1978) Journals (IJCN; 1978) Online ( 2002) Online ( 2002) Trends Trends Assessment (HRNB & LNNB; 1970s) Assessment (HRNB & LNNB; 1970s) Rehabilitation (CR; 1980s) Rehabilitation (CR; 1980s) Forensic (1990s) Forensic (1990s)

History: Personnel in Neuropsychology Overall Trends/Zeitgeist Overall Trends/Zeitgeist Growth Patterns Growth Patterns Demographic Patterns Demographic Patterns Academic Vs. Clinical Academic Vs. Clinical Individuals Individuals Reitan Reitan Golden Golden Kaplan Kaplan

History: Organizations in Neuropsychology American Psychological Association (1892) American Psychological Association (1892) Division of Clinical Neuropsychology (1980;40) Division of Clinical Neuropsychology (1980;40) National Academy of Neuropsychology(1975) National Academy of Neuropsychology(1975) International Neuropsychological Society (72) International Neuropsychological Society (72) Other issues/groups; Other issues/groups; APAs First Specialty (1996) APAs First Specialty (1996) Board Certification (e.g., ABPN; 1885) Board Certification (e.g., ABPN; 1885) Licensure (e.g., Louisiana; 2000) Licensure (e.g., Louisiana; 2000) Specialty Groups (e.g., Pediatrics; 2005) Specialty Groups (e.g., Pediatrics; 2005)

What is Clinical Neuropsychology? Study and practrice of the relationship between brain and behavior, especially but exclusively neurological patients Study and practrice of the relationship between brain and behavior, especially but exclusively neurological patients Approximately 4-5,000 (out of 150,000) Approximately 4-5,000 (out of 150,000) Doctorate with post-doctorate training as minimum requirement Doctorate with post-doctorate training as minimum requirement Difficulties in agreement of definition Difficulties in agreement of definition

Surveying the Specialty Brief History of Surveys Brief History of Surveys Hartlage Hartlage DeLuca & Putnam DeLuca & Putnam Current Survey Methodology Current Survey Methodology Sweet & Peck Sweet & Peck Division 40 and NAN Division 40 and NAN

Latest Survey of Clinical Neuropsychology National Academy of Neuropsychology National Academy of Neuropsychology Division of Clinical Neuropsychology of the APA Division of Clinical Neuropsychology of the APA Surveyors: Jerry Sweet & Ted Peck Surveyors: Jerry Sweet & Ted Peck Date: Date:

Survey Return Rates Actual Return Rate 1569 returns 1569 returns 5791 mailed 5791 mailed 1569/5791 = 27.1% Adjusted Return Rate Or returns, 1406 U.S., Doctoral, Licensed, Clinicians Or returns, 1406 U.S., Doctoral, Licensed, Clinicians Of mailed, 1590 excluded (duplicates, unintended, undelivered) Of mailed, 1590 excluded (duplicates, unintended, undelivered) 1406/4201 = 33.5%

Organizational Membership (All Doctoral Licensed Clinicians) Percent

Type of Doctoral Degree (All Doctoral Licensed Clinicians) Percent

Field of Doctoral Degree (All Doctoral Licensed Clinicians) Percent

Board Certification Status (Doctoral Licensed Clinicians) Percent

Gender (All Doctoral Licensed Clinicians vs. Younger Samples) Age: Males = 48.6 (n=866) Females = 45.5 (n=524) Years Since Licensed: Males = 14.6 (n=855); Females = 10.1 (n=508) Among licensed <10 years: (n=525) Males = 48.6% Females = 51.4% Among licensed <5 years: (n=216) Males = 36.6% Females = 63.4% Percent

Work Status (All Doctoral Licensed Clinicians) Percent

Work Setting (All Doctoral Licensed Clinicians) Percent

Gender Within Work Setting (Doctoral Licensed Clinicians) Percent

Weekly Professional Activities by Organization Percent

Weekly Professional Activities by Organization Percent

Incomes by Organization (Doctoral Licensed Clinicians Working Full Time or Full Time+) $

Income by Work Setting (Doctoral Licensed Clinicians Working Full Time or Full Time+)

Income by Years of Licensure Stratification - Mean (Median)Starting Salaries - Mean (Median)

Percentages of Reimbursement Sources (For All Doctoral Licensed Clinicians)

HOURS/Week Clinical Activity

Time-Related Case Activities (All Doctoral Licensed Clinicians) Hours billed: Private=11.1 (SD=5.0); Institution=8.2 (SD=3.3) * Only scoring is not significant between groups; covarying amount of forensic practice did not eradicate group differences Minutes

Evaluation Time by Evaluation Goal (Except forensic, those using assistants test more hours (e.g., for determination of diagnosis, 6.6 hrs vs. 5.8 hrs, p=.017.) However, hours billed are similar.

Use of Testing Assistants (All Doctoral Licensed Clinicians) Percent

Codes & Values for Professional Services: What is Neuropsychology Worth? CPT: Background CPT: Background American Medical Association Developed by Surgeons (& Physicians) in 1966 for Billing Purposes 7,500 Discrete Codes US Federal Insurance Program; Medicare AMA Under License with CMS CMS Now Provides Active Input into CPT Benchmark from Which All Third Party Uses

Applications for Neuropsychology Total Possible Codes = 7,500 Total Possible Codes = 7,500 Possible Codes for Psychology = Approximately 40 to 60 Possible Codes for Psychology = Approximately 40 to 60 Three Paradigms Three Paradigms Psychiatry/Mental Health Psychiatry/Mental Health Neurology Neurology Medicine Medicine Sections = Five Separate Sections Sections = Five Separate Sections Psychiatry Psychiatry Biofeedback Biofeedback Central Nervous Assessment Central Nervous Assessment Physical Medicine & Rehabilitation Physical Medicine & Rehabilitation Health & Behavior Assessment & Management Health & Behavior Assessment & Management

CPT Code for ActivitiesFrequencyPercent Intake Interview Other (16 codes) Clinical interview/history Other (20 codes) Test administration Other (12 codes) CPT Codes Used For Neuropsych Assessment Activities (Doctoral Level Clinicians)

CPT: The Future of the Profession Typical Code = X 2 Typical Code = X 2 Values of a CPT Code Values of a CPT Code.5 X Conversion Codes (US Congress sets).5 X Conversion Codes (US Congress sets) Psychotherapy as a Benchmark Psychotherapy as a Benchmark Approximately $100/hour Approximately $100/hour Estimated Goals Estimated Goals Current Timetable Current Timetable Major Paradigm Shift Major Paradigm Shift

Time for the Future Is Our History the Best Predictor for Our Future? Is Our History the Best Predictor for Our Future? What are APA Members Worried About? What are APA Members Worried About? My Own Personal Glimpse Into What Awaits Clinical Neuropsychology My Own Personal Glimpse Into What Awaits Clinical Neuropsychology

Initial Results of APA Policy & Planning Survey: A View of Psychology Procedure Procedure Five Year Review of Status of APA & Psychology Five Year Review of Status of APA & Psychology Random Survey of APA Membership, Staff, & Governance Random Survey of APA Membership, Staff, & Governance Results Results Public Image of Psychology Public Image of Psychology Protecting & Expanding Sources of Income Protecting & Expanding Sources of Income Membership Concerns Membership Concerns

What Trends Are Developing in Neuropsychology: Broad Analysis Organizational Organizational Informational Informational Professional (versus Clinical) Professional (versus Clinical) Financial Financial Public Policy Public Policy

Projected Specific Trends Income (depends on activity; if clinical) Steadier (if economy does not further erode) Probable incremental declines, up to 10-20% Final stabilization by 2005 Recognition Physician Level Mental vs. Physical Health Paradigms Industrial vs. Boutique Health vs. Non-Health What Hot: Cultural/Ecological, fMRI, Forensics

Potential Overall Trends Catching up to Psychiatry Catching up to Psychiatry Leaving Psychiatry Leaving Psychiatry Joining Medicine Joining Medicine Leaving Medicine Leaving Medicine Legal Legal Sports Sports Governmental Governmental Industrial Industrial

Anticipated Problems Empirical Data Base Limited Understanding of Culture Continued Professional Infighting Personnel Issues Value to Society (face Vs. criterion validity)

Some Personal Hopes for Neuropsychology in Spain (Inclusive) Organization (Inclusive) Organization Conference Conference Publication Opportunities Publication Opportunities Collaboration (e.g., ALAN, NAN, 40, INS) Collaboration (e.g., ALAN, NAN, 40, INS) (Practical) Research (Practical) Research Translation & Standardization of Exisiting Instruments Translation & Standardization of Exisiting Instruments Development of New Instruments Development of New Instruments Development of Appropriate Normative Samples Development of Appropriate Normative Samples (Robust) Practice (Robust) Practice Government & Institution Based Government & Institution Based Private Practice Private Practice (Engaging) Public Policy (Engaging) Public Policy Interface with Colegio de Psicologos Interface with Colegio de Psicologos

Summary for Neuropsychology Continued Growth, Especially in the Professional Domains Continued Growth, Especially in the Professional Domains Expansion Beyond Mental Health, to Health, to Other Areas Expansion Beyond Mental Health, to Health, to Other Areas Vibrant and Unpredictable yet Exciting Vibrant and Unpredictable yet Exciting

El Futuro… Nuevo Paradigmo = Cambio Mucho Cambio