1. 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 28403 www.uncw.edu/people/puente www.clinicalneuropsychology.us puente@uncw.edu

2. 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)

3. APA Membership YearDoctorateMastersBachelors 19701505 4572975 2183 19077 14602 19801921 13334096 581215440 26653 19901566 22453377 735315336 38616 20001405 29053552 1091317402 56600

4. 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

5. 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

6. 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

7. 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)

8. 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-…)

9. History: Personnel Overall Trends Overall Trends Growth Patterns Growth Patterns Founding of NAN and Division 40 - 1980 Founding of NAN and Division 40 - 1980 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

10. 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

11. 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)

12. 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: 2001-2002 Date: 2001-2002

13. 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%

14. Organizational Membership (All Doctoral Licensed Clinicians) Percent

15. 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

16. Type of Doctoral Degree (All Doctoral Licensed Clinicians) Percent

17. Field of Doctoral Degree (All Doctoral Licensed Clinicians) Percent

18. Work Status (All Doctoral Licensed Clinicians) Percent

19. Work Setting (All Doctoral Licensed Clinicians) Percent

20. Gender Within Work Setting (Doctoral Licensed Clinicians) Percent

21. Board Certification Status (Doctoral Licensed Clinicians) Percent

22. Weekly Professional Activities by Organization Percent

23. Weekly Professional Activities by Organization Percent

24. Percentages of Reimbursement Sources (For All Doctoral Licensed Clinicians)

25. 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

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

27. HOURS/Week Clinical Activity

28. 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.

29. 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

30. Use of Testing Assistants (All Doctoral Licensed Clinicians) Percent

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

32. Knaus, Schatz & Puente (2004) (Demographics: in %) Gender Male 49.2 Male 49.2 Female50.8 Female50.8 Highest Degree Earned Ph.D. 80.0 Ph.D. 80.0 Psy.D. 17.8 Psy.D. 17.8 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

33. 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

34. 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

35. 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

36. 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

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

38. 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

39. 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

40. 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

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

42. 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

43. Defining the Future… Paradigm = Change