Clinical Neuropsychology: A Window to Understanding Brain and Behavior Relationships Flagler College March 9, 2004 Antonio E. Puente Department of Psychology University of North Carolina at Wilmington Wilmington, North Carolina

What is Psychology? The Story of Psyche The Story of Psyche The Definition of Skinner The Definition of Skinner The Organization of Psychology The Organization of Psychology Personnel Personnel Ph.D., Psy.D. Ph.D., Psy.D. Professional Activity Professional Activity Academic Academic Applied (clinical, school, counseling, health, industrial, nr) Applied (clinical, school, counseling, health, industrial, nr) Organizations Organizations American Psychological Association American Psychological Association Others (e.g., APS, FPA, SEPA) Others (e.g., APS, FPA, SEPA)

APA Membership YearDoctorateMastersBachelors

APA Membership by Division Approximately 150,000 members Approximately 150,000 members Approximately 50 different divisions Approximately 50 different divisions Top three divisions are: Top three divisions are: Clinical Psychology Clinical Psychology Clinical Neuropsychology Clinical Neuropsychology Independent Practice Independent Practice

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

Outline Introduction Introduction Brief Overview of Twenty Five Years Brief Overview of Twenty Five Years Current Status Current Status Projections for the Future Projections for the Future

History: Organizational American Psychological Association (APA) American Psychological Association (APA) Division of Clinical Neuropsychology (40) National Academy of Neuropsychology (NAN) National Academy of Neuropsychology (NAN) International Neuropsychological Society (INS) International Neuropsychological Society (INS) Other issues/groups; Other issues/groups; APA’s First Specialty (1996) APA’s First Specialty (1996) Board Certification (e.g., ABPN vs ABCN) Board Certification (e.g., ABPN vs ABCN) Licensure (e.g., Louisiana) Licensure (e.g., Louisiana) Sub-specialty Groups (e.g., Forensics, Sports, Pediatrics, Hispanic) Sub-specialty Groups (e.g., Forensics, Sports, Pediatrics, Hispanic)

History: Informational Publications Publications Books (Goldstein, 1974) Books (Goldstein, 1974) Journals (ACN, JCEN, TCN, Neuropsychology, NR) Journals (ACN, JCEN, TCN, Neuropsychology, NR) Online Online Trends Trends Assessment (1970s-…) Assessment (1970s-…) Rehabilitation (1990s-…) Rehabilitation (1990s-…) Forensic (1995-…) Forensic (1995-…) Other Sub-specialties (2000-…) Other Sub-specialties (2000-…)

History: Personnel Overall Trends Overall Trends Growth Patterns Growth Patterns Founding of NAN and Division Founding of NAN and Division Demographic Patterns Demographic Patterns Primarily Male to now Mostly Male Primarily Male to now Mostly Male Primarily Academic to Primarily Clinical Primarily Academic to Primarily Clinical Institutional Settings Institutional Settings Academic Departments of Psychology Academic Departments of Psychology Medical School Neuropsychology Services Medical School Neuropsychology Services Community/Rehabilitation Hospital Services Community/Rehabilitation Hospital Services Private Practice Private Practice

History: Clinical Activities Assessment Assessment Individual Tests (Wecshler Intellingence Scales) Individual Tests (Wecshler Intellingence Scales) Fixed Battery (Halstead-Reitan Vs. Luria-Nebraska) Fixed Battery (Halstead-Reitan Vs. Luria-Nebraska) Flexible Approach (Boston) Flexible Approach (Boston) Rehabilitation Rehabilitation Cognitive Rehabilitation Cognitive Rehabilitation Medical Compliance and beyond (H & B CPT Codes) Medical Compliance and beyond (H & B CPT Codes) Forensic Forensic Social Security Disability Social Security Disability Worker’s Compensation Worker’s Compensation Personal Injury Personal Injury Death Penalty Death Penalty

Current Status: Review of the Surveys Brief History of Surveys Brief History of Surveys Hartlage; others Hartlage; others DeLuca & Putnam DeLuca & Putnam Current Survey Methodology Current Survey Methodology Sweet & Peck (and others; 2002) Sweet & Peck (and others; 2002) Knauss, Schatz, & Puente (2004) Knauss, Schatz, & Puente (2004)

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

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

Type of Doctoral Degree (All Doctoral Licensed Clinicians) Percent

Field of Doctoral Degree (All Doctoral Licensed Clinicians) Percent

Work Status (All Doctoral Licensed Clinicians) Percent

Work Setting (All Doctoral Licensed Clinicians) Percent

Gender Within Work Setting (Doctoral Licensed Clinicians) Percent

Board Certification Status (Doctoral Licensed Clinicians) Percent

Weekly Professional Activities by Organization Percent

Weekly Professional Activities by Organization Percent

Percentages of Reimbursement Sources (For All Doctoral Licensed Clinicians)

Correlates of Income Years licensed.27** Years licensed.27** Work Setting -.25** Work Setting -.25** % Forensic.24** % Forensic.24** Gender -.21** Gender -.21** % Self Pay.19** % Self Pay.19** Age.18** Age.18** Hrs billed/Eval.13** Hrs billed/Eval.13** % Public Aid -.12** % Public Aid -.12** % Medicare -.09* % Medicare -.09* % Man. Care -.09* % Man. Care -.09* % Indemnity.07 % Indemnity.07 % Indigent -.04 % Indigent -.04 *=.05 **=.01 Negative correlations in red. “Work Setting” above limited to Private and Institution All ns between 775 and 1185

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

HOURS/Week Clinical Activity

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.

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

Use of Testing Assistants (All Doctoral Licensed Clinicians) Percent

Use Of Testing Assistants By Work Setting Percent Using Assistants (n=1349)

Knaus, Schatz & Puente (2004) (Demographics: in %) Gender Male 49.2 Male 49.2 Female50.8 Female50.8 Highest Degree Earned Ph.D Ph.D Psy.D Psy.D Ed.D.1.8 Ed.D.1.8 M.D./Ph.D.1 M.D./Ph.D.1 Board Certified Yes29.1 Yes29.1 No70.9 No70.9

Demographics (cont.) Employment Settings Private Practice58.54 Private Practice58.54 Medical/Hospital45.12 Medical/Hospital45.12 College/University15.85 College/University15.85 Rehabilitation15.85 Rehabilitation15.85 Other10.06 Other10.06 Psychiatric Facility 3.69 Psychiatric Facility 3.69 Work Status Full-time39.94 Full-time39.94 Part-time27.74 Part-time27.74 Full w/ Part-time17.99 Full w/ Part-time17.99 Two Part-time 9.45 Two Part-time 9.45

Professional Activities Report Writing95.94 Report Writing95.94 Neuropsychological Assessment94.72 Neuropsychological Assessment94.72 Personal History of Patient93.94 Personal History of Patient93.94 Diagnostic Interview (no formal testing)92.67 Diagnostic Interview (no formal testing)92.67 Psychological Assessment88.51 Psychological Assessment88.51 Follow-up Assessment (w/ patient or family)85.36 Follow-up Assessment (w/ patient or family)85.36 Neurobehavioral Examination83.52 Neurobehavioral Examination83.52 Treatment Planning w/ other Healthcare Providers82.61 Treatment Planning w/ other Healthcare Providers82.61 Psychotherapy with Patient75.39 Psychotherapy with Patient75.39 Clinical Supervision of students (or Post-Docs)75.00 Clinical Supervision of students (or Post-Docs)75.00 Clinical Research61.34 Clinical Research61.34 Cognitive Rehabilitation51.67 Cognitive Rehabilitation51.67 Reviews for Insurance Organizations50.77 Reviews for Insurance Organizations50.77 Other19.12 Other19.12

Referral Sources (in order of prevalence) Neurology Neurology Other Medical Specialists Other Medical Specialists Physiatry Physiatry General Medicine General Medicine Other Other Psychiatry Psychiatry Pediatric Medicine Pediatric Medicine Other Mental Health Specialists Other Mental Health Specialists Forensic/Law Forensic/Law Neurosurgery Neurosurgery

Professional Activity (in order of prevalence) Determination of Diagnosis Determination of Diagnosis Determination of Effects of Deficits Determination of Effects of Deficits Treatment Planning Treatment Planning Documentation of Baseline Functioning Documentation of Baseline Functioning Educational Evaluation/IEP Educational Evaluation/IEP Forensic Activities (civil & criminal) Forensic Activities (civil & criminal) Disability/Workers Compensation Disability/Workers Compensation Monitoring Cognitive Recovery Monitoring Cognitive Recovery Pre/Post Medical Procedure Pre/Post Medical Procedure Independent Medical Examinations Independent Medical Examinations

Overall Summary Personnel Personnel Clinical Activities Clinical Activities Income/Reimbursement Income/Reimbursement

Examples of Research & Applications Research Research Coronary Artery Bypass Surgery Coronary Artery Bypass Surgery Cultural Neuropsychology Cultural Neuropsychology Applications Applications Diagnoses and Rehabilitation of Brain Injury and Disease Diagnoses and Rehabilitation of Brain Injury and Disease Death Penalty Death Penalty

Immediate Predictions for the Practice of Neuropsychology Income (depends on activity; if clinical) Professional Activities Recognition – Mental vs. Physical Health Paradigms – Industrial vs. Boutique – Health vs. Non-Health

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

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

Summary Continued Growth Continued Growth Especially in the Professional Domains 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

Defining the Future… Paradigm = Change