Clinical Neuropsychology:Clinical Neuropsychology:A Window to Understanding Brain and Behavior A Window to Understanding Brain and Behavior

RelationshipsRelationships

Sandhills Regional Psychology Sandhills Regional Psychology ConferenceConference

UNCWUNCWMarch 20, 2004March 20, 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., Ed.DPh.D., Psy.D., Ed.D

Professional ActivityProfessional Activity Academic Academic Applied Applied

(nr, clinical, school, counseling, health, industrial, forensic)(nr, clinical, school, counseling, health, industrial, forensic) OrganizationsOrganizations

American Psychological AssociationAmerican Psychological Association Others (e.g., APS, NCPA, SEPA)Others (e.g., APS, NCPA, 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 53 different divisionsApproximately 53 different divisions Top three divisions (#s) are:Top three divisions (#s) 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 NeuropsychologyNational Academy of Neuropsychology Division of Clinical Neuropsychology of the Division of Clinical Neuropsychology of the

APAAPA Primary Surveyors: Jerry Sweet & Ted PeckPrimary Surveyors: 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.)(in %)(in %)

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 Diagnosis/DeficitsDetermination of Diagnosis/Deficits Treatment PlanningTreatment Planning Documentation of Baseline FunctioningDocumentation of Baseline Functioning Educational Evaluation/IEPEducational Evaluation/IEP Forensic Activities Forensic Activities (civil; criminal; disability/workers (civil; criminal; disability/workers

comp)comp) 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 & Applications (AEP)Applications (AEP)

ApplicationsApplications Diagnoses and Rehabilitation of Brain Diagnoses and Rehabilitation of Brain

Injury and DiseaseInjury and Disease Death PenaltyDeath Penalty

ResearchResearch Coronary Artery Bypass SurgeryCoronary Artery Bypass Surgery Cultural NeuropsychologyCultural Neuropsychology Roger Sperry/ConsciousnessRoger Sperry/Consciousness

Immediate Predictions for the Immediate Predictions for the Practice of NeuropsychologyPractice of Neuropsychology

Income

Professional Activities

Recognition

Paradigms

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

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, Unpredictable, ExcitingVibrant, Unpredictable, Exciting

Defining the Defining the Future…Future…

Paradigm = Change