clinical neuropsychology: a window to understanding brain and behavior relationships flagler college...
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Clinical Neuropsychology:Clinical Neuropsychology:A Window to Understanding Brain and Behavior A Window to Understanding Brain and Behavior
RelationshipsRelationships
Flagler CollegeFlagler CollegeMarch 9, 2004March 9, 2004
Antonio E. PuenteAntonio E. PuenteDepartment of PsychologyDepartment of Psychology
University of North Carolina at WilmingtonUniversity of North Carolina at WilmingtonWilmington, North Carolina 28403Wilmington, North Carolina 28403
www.uncw.edu/people/puentewww.uncw.edu/people/puentewww.clinicalneuropsychology.uswww.clinicalneuropsychology.us
puente@uncw.edupuente@uncw.edu
What is Psychology?What is Psychology?
The Story of PsycheThe Story of Psyche The Definition of SkinnerThe Definition of Skinner The Organization of PsychologyThe Organization of Psychology
PersonnelPersonnel Ph.D., Psy.D.Ph.D., Psy.D.
Professional ActivityProfessional Activity Academic Academic Applied (clinical, school, counseling, health, Applied (clinical, school, counseling, health,
industrial, nr)industrial, nr) OrganizationsOrganizations
American Psychological AssociationAmerican Psychological Association Others (e.g., APS, FPA, SEPA)Others (e.g., APS, FPA, SEPA)
APA MembershipAPA MembershipYear Doctorate Masters Bachelors
1970 1505 457 2975 218319077 14602
1980 1921 1333 4096 5812 15440 26653
1990 1566 2245 3377 7353 15336 38616
2000 1405 2905 3552 10913 17402 56600
APA Membership by DivisionAPA Membership by Division
Approximately 150,000 membersApproximately 150,000 members Approximately 50 different divisionsApproximately 50 different divisions Top three divisions are:Top three divisions are:
Clinical Psychology Clinical Psychology Clinical NeuropsychologyClinical Neuropsychology Independent PracticeIndependent Practice
What is Clinical What is Clinical Neuropsychology?Neuropsychology?
Study and practrice of the Study and practrice of the relationship between brain (nervous relationship between brain (nervous system?) and behavior, especially in system?) and behavior, especially in neurological patientsneurological patients
Approximately 4-5,000 (out of Approximately 4-5,000 (out of 150,000)150,000)
Doctorate with post-doctorate Doctorate with post-doctorate training is minimum requirementtraining is minimum requirement
OutlineOutline
IntroductionIntroduction Brief Overview of Twenty Five YearsBrief Overview of Twenty Five Years Current StatusCurrent Status Projections for the FutureProjections for the Future
History: OrganizationalHistory: Organizational
American Psychological Association (American Psychological Association (APAAPA))Division of Clinical Neuropsychology (Division of Clinical Neuropsychology (4040))
National Academy of Neuropsychology (National Academy of Neuropsychology (NANNAN)) International Neuropsychological Society (International Neuropsychological Society (INSINS)) 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, Sub-specialty Groups (e.g., Forensics, Sports,
Pediatrics, Hispanic)Pediatrics, Hispanic)
History: InformationalHistory: Informational
PublicationsPublications Books (Goldstein, 1974)Books (Goldstein, 1974) Journals (ACN, JCEN, TCN, Neuropsychology, NR)Journals (ACN, JCEN, TCN, Neuropsychology, NR) OnlineOnline
TrendsTrends Assessment (1970s-…)Assessment (1970s-…) Rehabilitation (1990s-…)Rehabilitation (1990s-…) Forensic (1995-…)Forensic (1995-…) Other Sub-specialties (2000-…)Other Sub-specialties (2000-…)
History: PersonnelHistory: Personnel
Overall TrendsOverall Trends Growth Patterns Growth Patterns
Founding of NAN and Division 40 - Founding of NAN and Division 40 - 19801980 Demographic PatternsDemographic Patterns
Primarily Male to now Primarily Male to now Mostly MaleMostly Male Primarily Academic to Primarily Academic to Primarily ClinicalPrimarily Clinical
Institutional SettingsInstitutional Settings AcademicAcademic Departments of Psychology Departments of Psychology Medical SchoolMedical School Neuropsychology Services Neuropsychology Services Community/Rehabilitation HospitalCommunity/Rehabilitation Hospital Services Services Private PracticePrivate Practice
History: Clinical ActivitiesHistory: Clinical Activities
AssessmentAssessment 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)
RehabilitationRehabilitation Cognitive RehabilitationCognitive Rehabilitation Medical Compliance and beyond (H & B CPT Codes)Medical Compliance and beyond (H & B CPT Codes)
ForensicForensic Social Security DisabilitySocial Security Disability Worker’s CompensationWorker’s Compensation Personal InjuryPersonal Injury Death PenaltyDeath Penalty
Current Status: Review of the Current Status: Review of the SurveysSurveys
Brief History of SurveysBrief History of Surveys Hartlage; othersHartlage; others DeLuca & PutnamDeLuca & Putnam
Current Survey MethodologyCurrent Survey Methodology Sweet & Peck (and others; 2002)Sweet & Peck (and others; 2002) Knauss, Schatz, & Puente (2004)Knauss, Schatz, & Puente (2004)
Survey of Clinical Survey of Clinical NeuropsychologyNeuropsychology
National Academy of National Academy of NeuropsychologyNeuropsychology
Division of Clinical Neuropsychology Division of Clinical Neuropsychology of the APAof the APA
Surveyors: Jerry Sweet & Ted PeckSurveyors: Jerry Sweet & Ted Peck Date: 2001-2002Date: 2001-2002
Survey Return RatesSurvey Return Rates
ActualActual Return Rate Return Rate 1569 returns1569 returns 5791 mailed5791 mailed
1569/5791 = 1569/5791 = 27.127.1%%
AdjustedAdjusted Return Rate Return Rate Or returns, 1406 Or returns, 1406
U.S., Doctoral, U.S., Doctoral, Licensed, CliniciansLicensed, Clinicians
Of mailed, 1590 Of mailed, 1590 excluded excluded (duplicates, (duplicates, unintended, unintended, undelivered)undelivered)
1406/4201 = 1406/4201 = 33.533.5%%
Organizational Organizational MembershipMembership
(All Doctoral Licensed Clinicians)(All Doctoral Licensed Clinicians)
05
101520253035404550
NAN only(n=156)
D40 only(n=276)
Both(n=670)
Unknown(n=304)
Percent
Gender Gender (All Doctoral Licensed Clinicians vs. (All Doctoral Licensed Clinicians vs.
Younger Samples)Younger Samples)62.3
37.7
0
10
20
30
40
50
60
70
Male (n=871) Female (n=528)
Age: Age: Males = 48.6 Males = 48.6 (n=866)(n=866)
Females = 45.5 Females = 45.5 (n=524)(n=524)
Years Since Licensed: Years Since Licensed: Males = 14.6 Males = 14.6 (n=855);(n=855); Females = 10.1 Females = 10.1 (n=508)(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 DegreeType of Doctoral Degree (All Doctoral Licensed Clinicians)(All Doctoral Licensed Clinicians)
0
10
20
30
40
50
60
70
80
90
PhD (n=1225) PsyD (n=143) EdD (n=24)
Percent
Field of Doctoral DegreeField of Doctoral Degree(All Doctoral Licensed Clinicians)(All Doctoral Licensed Clinicians)
0
10
20
30
40
50
60
70
Clinical Couns. Neuro. School Ed. Psy. Comb.
Percent
Work StatusWork Status(All Doctoral Licensed Clinicians)(All Doctoral Licensed Clinicians)
0
10
20
30
40
50
60
70
80
Full Time Part Time Full + Part NotWorking
Percent
Work SettingWork Setting(All Doctoral Licensed Clinicians)(All Doctoral Licensed Clinicians)
0
5
10
15
20
25
30
35
40
PrivatePractice
Institution Comb. Other
Percent
Gender Within Work Gender Within Work SettingSetting
(Doctoral Licensed Clinicians)(Doctoral Licensed Clinicians)
0
10
20
30
40
50
60
70
Private Institution Comb. Other
Male Female
Percent
Board Certification StatusBoard Certification Status(Doctoral Licensed Clinicians)(Doctoral Licensed Clinicians)
0
10
20
30
40
50
60
70
80
Board Certified(n=271)
Not Board Certified(n=1053)
Percent
Weekly Professional Activities Weekly Professional Activities by Organizationby Organization
01020304050607080
Clinical Pract.
Teach. Research($)
Res. (No $)
Non-ClinAdmin.
NAN D40 Both Unknown
Percent
Weekly Professional Activities Weekly Professional Activities by Organizationby Organization
01020304050607080
Supervision Forensic
NAN D40 Both Unknown
Percent
Percentages of Percentages of Reimbursement SourcesReimbursement Sources
(For All Doctoral Licensed Clinicians)(For All Doctoral Licensed Clinicians)
0
5
10
15
20
25
30
Managed Care
Medi- care
IndemnityInsur
Self Pay
CHAMPUS Public Aid
Indigent Forensic
Correlates of IncomeCorrelates of Income
Years licensed .27**Years licensed .27** Work Setting Work Setting -.25-.25**** % Forensic .24**% Forensic .24** Gender Gender -.21-.21**** % Self Pay .19**% Self Pay .19** Age .18**Age .18**
Hrs Hrs billed/Eval .13**billed/Eval .13**
% Public Aid % Public Aid -.12-.12**** % Medicare % Medicare -.09-.09** % Man. Care % Man. Care -.09-.09** % Indemnity .07% Indemnity .07 % Indigent % Indigent -.04-.04
*=.05 **=.01 *=.05 **=.01 Negative correlations in red.Negative correlations in red.““Work Setting” above limited to Private and InstitutionWork Setting” above limited to Private and Institution
All All nns between 775 and 1185s between 775 and 1185
Income by Work SettingIncome by Work Setting(Doctoral Licensed Clinicians Working Full (Doctoral Licensed Clinicians Working Full
Time or Full Time+)Time or Full Time+)127318
105000
7646370000
105149
87750
$0
$20,000
$40,000
$60,000
$80,000
$100,000
$120,000
$140,000
Private (n=424)
Institution(n=378)
Comb. (n=358)
Mean Median
HOURS/Week Clinical ActivityHOURS/Week Clinical Activity
3.32.1
13.73.7
2.12.5
4.90.6
2.22.1
0 5 10 15
DX Interv Nbeh Ex Npsy Test Psy TestF/ Up Ass. TX (BD) TX (No BD) CogRehTx plan Superv
Evaluation Time by Evaluation Evaluation Time by Evaluation GoalGoal
6.3
4.4
4.2
4.8
9.3
0 2 4 6 8 10
Determ DX (n=1022) (1-16)
TX Plan (n=914) (.5-12)
Pre/ Post (n=566) (1-10)
Baseline (n=784) (1-10)
Forensic (n=790) (1-20)
(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 ActivitiesTime-Related Case Activities(All Doctoral Licensed Clinicians)(All Doctoral Licensed Clinicians)
319
260
050
100150200250300350
IntakeInterview
Rec Rev
Test Admin
Scoring *
Interp/ Rep
Feedback
Cons Ref So
Private Institution
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 AssistantsUse of Testing Assistants(All Doctoral Licensed Clinicians)(All Doctoral Licensed Clinicians)
51.2 48.8
0
10
20
30
40
50
60
Yes (n=692)
No (n=660)
Percent
Use Of Testing Assistants By Use Of Testing Assistants By Work SettingWork Setting
72
48
46
51
39
0 20 40 60 80
Private Practice
Institution
Combination
Other
Total
Percent Using Assistants(n=1349)
Knaus, Schatz & Puente Knaus, Schatz & Puente (2004)(2004)
(Demographics: in %)(Demographics: in %)GenderGender MaleMale 49.249.2 FemaleFemale 50.850.8
Highest Degree EarnedHighest Degree Earned Ph.D.Ph.D. 80.080.0 Psy.D. Psy.D. 17.817.8 Ed.D.Ed.D. 1.81.8 M.D./Ph.D.M.D./Ph.D. 11
Board CertifiedBoard Certified YesYes 29.129.1 NoNo 70.970.9
Demographics (cont.)Demographics (cont.)
Employment SettingsEmployment Settings Private PracticePrivate Practice 58.54 58.54 Medical/HospitalMedical/Hospital 45.1245.12 College/UniversityCollege/University 15.85 15.85 RehabilitationRehabilitation 15.85 15.85 OtherOther 10.06 10.06 Psychiatric FacilityPsychiatric Facility 3.69 3.69
Work StatusWork Status Full-timeFull-time 39.9439.94 Part-timePart-time 27.7427.74 Full w/ Part-timeFull w/ Part-time 17.9917.99 Two Part-timeTwo Part-time 9.45 9.45
Professional ActivitiesProfessional Activities
Report WritingReport Writing 95.9495.94 Neuropsychological AssessmentNeuropsychological Assessment 94.7294.72 Personal History of PatientPersonal History of Patient 93.9493.94 Diagnostic Interview (no formal testing)Diagnostic Interview (no formal testing) 92.6792.67 Psychological AssessmentPsychological Assessment 88.5188.51 Follow-up Assessment (w/ patient or family)Follow-up Assessment (w/ patient or family) 85.3685.36 Neurobehavioral ExaminationNeurobehavioral Examination 83.5283.52 Treatment Planning w/ other Healthcare ProvidersTreatment Planning w/ other Healthcare Providers82.6182.61 Psychotherapy with PatientPsychotherapy with Patient 75.3975.39 Clinical Supervision of students (or Post-Docs)Clinical Supervision of students (or Post-Docs) 75.0075.00 Clinical ResearchClinical Research 61.3461.34 Cognitive RehabilitationCognitive Rehabilitation 51.6751.67 Reviews for Insurance OrganizationsReviews for Insurance Organizations 50.7750.77 OtherOther 19.1219.12
Referral SourcesReferral Sources(in order of prevalence)(in order of prevalence)
NeurologyNeurology Other Medical SpecialistsOther Medical Specialists Physiatry Physiatry General MedicineGeneral Medicine OtherOther PsychiatryPsychiatry Pediatric MedicinePediatric Medicine Other Mental Health SpecialistsOther Mental Health Specialists Forensic/LawForensic/Law NeurosurgeryNeurosurgery
Professional ActivityProfessional Activity(in order of prevalence)(in order of prevalence)
Determination of DiagnosisDetermination of Diagnosis Determination of Effects of DeficitsDetermination of Effects of Deficits Treatment PlanningTreatment Planning Documentation of Baseline FunctioningDocumentation of Baseline Functioning Educational Evaluation/IEPEducational Evaluation/IEP Forensic ActivitiesForensic Activities (civil & criminal) (civil & criminal) Disability/Workers CompensationDisability/Workers Compensation Monitoring Cognitive RecoveryMonitoring Cognitive Recovery Pre/Post Medical ProcedurePre/Post Medical Procedure Independent Medical ExaminationsIndependent Medical Examinations
Overall SummaryOverall Summary
PersonnelPersonnel Clinical ActivitiesClinical Activities Income/ReimbursementIncome/Reimbursement
Examples of Research & Examples of Research & ApplicationsApplications
ResearchResearch Coronary Artery Bypass SurgeryCoronary Artery Bypass Surgery Cultural NeuropsychologyCultural Neuropsychology
ApplicationsApplications Diagnoses and Rehabilitation of Brain Diagnoses and Rehabilitation of Brain
Injury and DiseaseInjury and Disease Death PenaltyDeath Penalty
Immediate Predictions for the Immediate Predictions for the Practice of NeuropsychologyPractice 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 TrendsPotential Overall Trendsfor Clinical Neuropsychologyfor Clinical Neuropsychology
Catching up to PsychiatryCatching up to Psychiatry Leaving PsychiatryLeaving Psychiatry Joining MedicineJoining Medicine Leaving MedicineLeaving Medicine
SportsSports GovernmentalGovernmental IndustrialIndustrial LegalLegal
Future Problems Future Problems
Empirical Data Base
Limited Understanding of Culture
Personnel Issues
Value to Society (face Vs. criterion validity)
SummarySummary
Continued GrowthContinued Growth Especially in the Professional Especially in the Professional
DomainsDomains Expansion Beyond Mental Health, to Expansion Beyond Mental Health, to
Health, to Other AreasHealth, to Other Areas Vibrant and Unpredictable yet Vibrant and Unpredictable yet
ExcitingExciting
Defining the Defining the Future…Future…
Paradigm = Change
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