Neuropsychological Services Research Articles

Predictors of Heterogeneity in Cognitive Function: APOE-e4, Sex, Education, Depression, and Vascular Risk.

Mild cognitive impairment and dementia are clinically heterogeneous disorders influenced by diverse risk factors. Improved characterization of the effect of multiple risk factors influence on specific cognitive functions may improve understanding of mechanisms in early cognitive change and lead to more effective interventions. Structural equation modeling (SEM) simultaneously examined the effects of modifiable (education, depression, and metabolic/vascular risk) and nonmodifiable risk factors (age, sex, and apolipoprotein E-ɛ4 allele [APOE-e4] status) on specific cognitive domains in 461 cognitively normal older adults. The hypothesized model(s) provided an adequate fit for the data. Sex differences in cognition, depression, and vascular risk were found. On average, men were higher in vascular risk with generally lower cognitive performance than women; women were more likely to have depression. APOE-e4 associated with depression but not age, sex, or metabolic/vascular risk. Depression associated with lower executive attention, memory, and language performance, whereas metabolic/vascular risk associated with lower executive attention, memory, and working memory. Older age and lower education are associated with worse performance across the cognitive domains. The combined risk factors accounted for 16%-47% of the variance in the cognitive domains. Results highlight the combined effect of risk factors on cognitive function. Future research is needed to determine whether the multifactorial risk effects on cognition vary by sex. Precision medicine approaches that integrate neuropsychological services may improve diagnostic accuracy and earlier identification of those at risk of cognitive decline.

Familiarity with Neuropsychological Assessment among Israeli Physicians.

The current study examines whether Israeli physicians are familiar with neuropsychological assessment (NPA) in general and with referral to NPA in particular. In total, 274 physicians in relevant fields participated in an online survey that targeted levels of familiarity with NPA, beliefs about assessment needs, and actual referral practices. Israeli physicians see many patients with neuropsychological difficulties, but assess fewer patients for these difficulties by themselves. Approximately 80% of participants reported that they had heard of NPA before, but only 25% knew how to refer patients to NPA. Familiarity was greater among neurologists and neurosurgeons than among family doctors. Physicians had only general knowledge about NPA, with little practical understanding of how to refer patients to such a service. To increase referral rates and create consistent demand for effective neuropsychological services, neuropsychologists should engage in greater advocacy activity that will lead to clarification of referral procedures.

American Academy of Clinical Neuropsychology consensus conference statement on uniform labeling of performance test scores

Objectives: Descriptive labels of performance test scores are a critical component of communicating outcomes of neuropsychological and psychological evaluations. Yet, no universally accepted system exists for assigning qualitative descriptors to scores in specific ranges. In addition, the definition and use of the term “impairment” lacks specificity and consensus. Consequently, test score labels and the denotation of impairment are inconsistently applied by clinicians, creating confusion among consumers of neuropsychological services, including referral sources, trainees, colleagues, and the judicial system. To reduce this confusion, experts in clinical and forensic neuropsychological and psychological assessment convened in a consensus conference at the 2018 Annual Meeting of the American Academy of Clinical Neuropsychology (AACN). The goals of the consensus conference were to recommend (1) a system of qualitative labels to describe results from performance-based tests with normal and non-normal distributions and (2) a definition of impairment and its application in individual case determinations. Results: The goals of the consensus conference were met resulting in specific recommendations for the application of uniform labels for performance tests and for the definition of impairment, which are described in this paper. In addition, included in this consensus statement is a description of the conference process and the rationales for these recommendations. Conclusions/Importance: This consensus conference is the first formal attempt by the professional neuropsychological community to make recommendations for uniform performance test score labels and to advance a consistent definition of impairment. Using uniform descriptors and terms will reduce confusion and enhance report comprehensibility by the consumers of our reports as well as our trainees and colleagues.

Increasing research capacity in a clinical neuropsychology service

A service development initiative to increase research activity was implemented in a large clinical neuropsychology department. The number of research-active clinicians increased from 3 clinicians to 22. Reflections on facilitators and barriers to increasing research practice are presented.

Prognostic role of Mini-Mental State Pediatric Examination (MMSPE) on neuropsychological functioning.

The aim of this study was to evaluate the ability of the Mini-Mental State Pediatric Examinations (MMSPE) in the individuation of neuropsychological impairments. MMSPE was administered to 60 children attending a primary or lower secondary school suffering from neurological diseases, admitted to our neuropsychology services. All children performed both a MMSPE examination and a neuropsychological evaluation. Results of neuropsychological evaluation and MMSPE were dichotomized. Positive predictive value (PPV), negative predictive value (NPV), and accuracy were also calculated. The diagnostic performance of MMSPE showed a good overall accuracy (0.83, CI 95% 0.64-0.91), NPV (0.81, CI 95% 0.73-1.00), PPV (0.87, CI 95% 0.68-0.94), specificity (0.91, CI 95% 0.81-1.00), sensitivity (0.74, CI 95% 0.57-0.90), and odds ratio of 28.5 (CI 95% 6.6-123), p < 0.001. MMSPE has a good prognostic ability in predicting neuropsychological problems in the context of different neurological pediatric diseases. We suggest that this instrument could greatly improve pediatric clinical practice in identifying high-risk children.

Integrating Neuropsychology Services in a Multidisciplinary Concussion Clinic.

To describe the integration of neuropsychology services in a multidisciplinary concussion clinic and provide descriptive information on patients, services, and initial health status. A university-based outpatient sports medicine concussion clinic. A consecutive sample of 338 patients ages 8 to 84 years (median 23.5 years, 35% 13-18 years), 49.1% male, seen between 2014 and 2018. Patients' injuries included sports 42%, work 28.4%, and vehicular 12.1% and 48.5% were students. Descriptive statistics with group comparisons. 12-Item Short Form Health Survey (SF-12) T scores (mean = 50, SD = 10) referenced to US population. Half of the patients were seen within 24 days of their injury and showed reduced physical functioning (40.2) and average mental (emotional) functioning (48.8). Patients seen after 24 days showed even more reduced physical functioning (33.9) and reduced mental functioning (41.0), both P < .0001. Average treatment time was also longer, 88.1 (173.9) versus 186.8 (211.1) days, P < .0001. Two-thirds of patients were referred for cervical or vestibular physical therapy at their initial visit. Early referral for specialized care, including neuropsychology services, may be beneficial.

Tackling clinical neuropsychology’s ‘wicked’ problem: Evidencing the value of a multiagency approach to rehabilitation for people with ABI and complex social needs

People with ABI and complex social needs are not well served by current activity-based contracts. This vulnerable subgroup is at heightened risk of falling through the gaps and of suffering preventable harm. Key predictors include younger age and executive dysfunction. This paper describes a survey on clinical complexity that was conducted within a community neuropsychology service. The results informed the development ofa matched care model, as well as new tria,ging and data collection tools.

Thematic analysis of youth mental health providers' perceptions of neuropsychological assessment services.

A growing number of quantitative studies have investigated the utility of neuropsychological assessment in mental health settings. However, to the best of our knowledge, no previous study has qualitatively explored youth mental health providers' perceptions of neuropsychological assessment services. A more in-depth understanding of the perceived advantages and barriers associated with neuropsychological assessment in youth mental health settings is critical to better inform policy, practice and service uptake. Thus, the aim of this study was to qualitatively explore clinicians' views about neuropsychological assessments for youth with mental health concerns. A single open-ended qualitative question, included as part of an anonymous cross-sectional online survey, was completed by clinicians (N = 206) treating or assessing adolescents and young adults within Australian primary care mental health centres (headspace). Responses were analysed using an inductive approach to thematic analysis. Five main themes were identified. Clinicians (a) identified barriers to accessing neuropsychological assessments (53%), (b) indicated a range of mixed outcomes following neuropsychological assessment (39%), (c) highlighted a need for neuropsychological assessments (22%), (d) reported a lack of awareness about this resource (10%) and (e) described practice issues associated with neuropsychological services (4%). This study uncovered perceived factors contributing to reduced access to neuropsychological assessment in Australian youth mental health settings. Given potential adverse outcomes resulting from this clinical service gap, efforts should be made to address factors contributing to poorer access, thereby mitigating the impact of poor access on the management of mental illness in youth. Several strategies, including funding neuropsychological assessments, are discussed.

Current Practices in Cross-Cultural Neuropsychology: A Survey of Providers' Use of Appropriate Normative Data and Views on a Web-based Approach to the Collection and Dissemination of Normative Data for Spanish-speaking Populations

Abstract Objective As the U.S. Spanish-speaking population grows, neuropsychologists provide assessment services to an increasingly diverse group of individuals. In response to the need for a centralized resource, NeuroShare, a no-cost website that collects and organizes cross-cultural neuropsychological normative data was created. The purpose of this study was to gather information on the current practices of cross-cultural neuropsychology, the utility of NeuroShare, and potential improvements that could be made to the platform. Participants and Method An anonymous survey was distributed to neuropsychologists and trainees through national and regional professional listservs. Participants’ demographics, clinical experience, and current practices (e.g. use of language specific normative data, assessment of acculturation/bilingualism) when providing neuropsychological services to Spanish-speaking populations were collected. The survey examined feedback on the NeuroShare database. Results 60 participants completed the survey, and they were primarily White/ Caucasian (62%), along with Hispanic/ Latino (36%), Black/African American (1%), and biracial/multiracial (1%). About 66% reported that they often search for Spanish language normative data depending on the patient’s demographics. 70% of respondents reported administering tests developed primarily for English-speaking populations, that are then adapted, when testing Spanish-speaking individuals. Some recommendations for improving Neuroshare included the incorporation of pediatric normative data and a normative data calculator tool. Conclusions This study highlights the needs and benefits of a comprehensive, easy to use system in collecting and organizing normative information for diverse populations. NeuroShare serves as a tool to facilitate the practice of cross-cultural neuropsychology, as well as a catalyst to improve neuropsychological services through the provision of improved access to appropriate normative measures for use with diverse populations.

Cognitive Test Differences Between our Bronx English and Spanish Speaking Patients: Lessons Learned Through the Expansion of Neuropsychological Services

Abstract Objective To demonstrate the differences between the English-speaking and Spanish-speaking patients evaluated at a Memory Disorders Clinic. Participants and Method Through a foundation grant to reduce barriers to appropriate neurological care, we established a bilingual/bicultural neuropsychology post-doctoral fellowship. In the initial 2 years, 405 new patients were seen at our multidisciplinary memory disorders clinics for neuropsychological and neurological evaluations. These patients were 63% female (n = 256), and had a mean age of 73.09 (SD = 10.63, range 52-98). Fifty-eight percent of our population identified as Hispanic/Latino (primarily Puerto Rican and Dominican) and 42% were evaluated in Spanish. Results Patients evaluated in Spanish had less education (p &amp;lt; .001) and were younger (p = .03) than those evaluated in English (including our Hispanic/Latino English speaking patients). Individuals evaluated in Spanish performed worse on a mental status exam (Blessed) than those evaluated in English (p = .001) even after controlling for age and education (p = .048). However, those evaluated in Spanish were more likely to do better on memory tasks than those evaluated in English, compared to their respective normative peers. Higher levels of anxiety and depression were evident in Hispanics/Latinos compared to non-Hispanics with highest levels in Hispanics evaluated in English. Conclusions Through a grant to expand services to the previously underserved Spanish-only speaking population of the Bronx, we were able to validate the need for appropriate language and cultural resources in our robust medical community. We demonstrated that our Spanish speaking population is diverse and requires different resources from their English-speaking counterparts. Our data supports the establishment of additional studies (including improved cultural and language specific normative data) and further education of providers working with our diverse populations.

Cultural and Linguistic Competency Training from a Socially Responsible Neuropsychology Model: Perspectives from Trainees

Abstract Objective The Cultural Neuropsychology Program (CNP) is the sole bilingual clinical training program specifically focused on culturally and linguistically competent neuropsychological services to the Latino/a population in the UCLA Health System. Following the Socially Responsible Neuropsychology Model (SRN; Suarez et al., 2016), trainees learn the best practices in providing equitable clinical care to all patients irrespective of their background. The current paper discusses various trainees’ professional development in the process of becoming culturally and linguistically competent clinical neuropsychologists. Method The use of case studies illustrates the competency paradigm shift trainees encounter when systematically integrating the SRN model with their clinical training. Three components of the model are emphasized: (1) integration of Etic and Emic approaches during the clinical intake, (2) merging psychometric properties with qualitative processes to compensate for the cultural-linguistic limitations of mainstream gold-standard neuropsychological tools, and (3) becoming an advocate through this social justice framework. Outcomes All trainees were previously exposed to the foundational - and typically required - knowledge-based competency model of understanding and appreciating cultural-individual differences and diversity in neuropsychology. Attaining cultural and linguistic competency through the SRN model, however, requires a salient paradigm shift in all skill-based competencies that trainees may not have been prepared for through their previous education. Discussion By presenting trainees’ perspectives regarding their professional development, the importance of the explicit and systematic integration of fundamental brain-behavior relationships with the SRN model early in graduate training is highlighted. In so doing, this approach can ultimately augment the number of culturally- and linguistically-competent neuropsychologists needed to reduce health disparities. References Suárez, P., Casas, R., Lechuga, D., Cagigas, X. Socially Responsible Neuropsychology in Action: Another Opportunity for California to Lead the Way. Feature in The California Psychologist. Fall of 2016.

The False Hope of Becoming a Neuropsychologist. A Call for Action!

Abstract The Problem According to the Census Bureau, the number of immigrants living in the US will increase to 69 million by 2060. Unfortunately, the number of international neuropsychologists who practice in the U.S. is behind in terms of this expected shift in the population. This is not due to a lack of interest - as many international students are accepted into neuropsychology doctoral programs each year. However, the acquisition of appropriate postdoctoral training proves to be a significant challenge. In general, the required two-year postdoctoral positions in neuropsychology are competitive, as they should be; however, international students are at a remarkable disadvantage. They cannot stay in the U.S. without a sponsor for a visa after a year of graduating, thus placing them in a disadvantaged state to secure a neuropsychology postdoctoral position. The Impact Given the projected population changes, neuropsychological assessments will have to be adjusted, new norms will need to be collected, and providers who speak non-English languages will be in higher demand. International neuropsychologists contribute to the field of neuropsychology through the addition of cultural competence, the enrichment in our understanding of cognition across racial and ethnic groups, and the development and selection of tests from a different perspective. In addition, they strengthen research pursuits, increase access to high-quality healthcare service to minorities, and provide quality service to non-English speaking patients. Finally, they can disseminate quality neuropsychological services throughout the world. Call for Action We encourage all neuropsychologists to create an action plan to support international students. There are many ways in which this could be accomplished: advocate to your human resource department to sponsor international students, educate yourself on the barriers and the process of sponsoring a work/training visa, and assist international students in strengthening their training experience with research, authorship, and collaboration.

B-79 Trauma through the Neuropsychologist's Eyes: A Systematic Review of Standardized Test Results after Trauma

Abstract Objective Approximately 90% of adults in the United States have been exposed to trauma (Kilpatrick et al. 2013). Among clients seen for neuropsychological services, trauma may be an etiological or co-occurring factor, especially with traumatic brain injury. Understanding neuropsychological impact is essential to trauma-informed assessment, diagnosis, and rehabilitation. Prior reviews were limited to between-group statistical differences rather than clinically significant results. In accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses, this review evaluated studies of standardized neuropsychological test scores among adults with trauma histories and psychopathology. Data Selection Terms for “neuropsychology” and “trauma” were searched within peer-reviewed empirical studies from PsycINFO, MedLine with Full Text, and Published International Literature on Traumatic Stress from 1/2013-8/2018. 2350 initial records were ultimately reduced to 21 articles, after removing duplicates and ineligible articles (e.g., no standardized neuropsychological tests or scores, baseline treatment assessments, studies where age groups were not stratified, non-clinical samples). Extracted data included demographic, neuropsychological, and clinical characteristics, and potential study biases. Data Synthesis Studies assessed combat trauma (n = 8), developmental trauma (n = 2), intimate partner violence and sexual assault (n = 2), accidental trauma (n = 2), refugee trauma (n = 1), and unspecified trauma (n = 6) in the context of various psychiatric conditions. Performance across neuropsychological domains ranged from low to high average, with one borderline verbal memory score. Conclusions Lack of clinically observable neuropsychological impairment suggests cognitive challenges are state-based, driven by intra-individual variability and the psychophysiological traumatic stress response. Client-centered rehabilitation emphasizing self-regulation is recommended. Future research can expand on assessment comprehensiveness and ecological validity.

A-06 The Culturally Expressive and Responsive (CER) Supervision Model in Neuropsychology

Abstract Objective The competency-based movement within neuropsychology training programs has done much to create uniform standards of training and identify the “readiness” of trainees to progress to the next level. However, there is little research regarding best practices for development of a supervisory style. The successful progression from trainee to independent practitioner requires a training model that evolves, allowing for independence and collegiality, which includes knowledge expansion, changes in professional relationships and successful institutional navigation. Culture mediates interactions in the patient-doctor relationship, case conceptualization, and also within and between institutional frameworks; therefore, a supervision model should include a multicultural perspective at its core. Data Selection: An otherwise unrestricted multi-database search for “Neuropsychology Supervision” within the title of peer-reviewed journals yielded six results with publication years spanning 1999-2017. Only three specifically address models of supervision and only one is US-based (Stucky et al., 2010). Given then demographic shift estimated for 2050 (Passel &amp; Cohn, 2008), there is a call to action to increase culturally competent neuropsychological services, including training and strengthening the student pipeline (Mindt Rivera et al., 2010). Data Synthesis: The proposed Model for Neuropsychology Supervision (Stucky et al., 2010) recommends supervision to be individually tailored, with both process-based and developmental approaches. Conclusions There is a strong need for clear supervision models designed specifically for neuropsychology that integrate culture at all levels of training. Authors propose the Culturally Expressive and Responsive (CER) Supervision Model in Neuropsychology. This is a framework for both trainees and professionals that provides a developmental approach integrating culture and the competency-based standards.

Neuropsychology in France

The purpose of this study was to investigate sociodemographic characteristics, clinical and academic training, and the types of activities engaged in by practicing psychologists specialized in neuropsychology in France. A total of 804 French psychologists specializing in neuropsychology participated in an online-based survey: 90.2% of the participants were women, with a mean age of 32 (range 22–60). In the total sample, 54.2% of the participants worked in the hospital system, 38.2% in the private sector, and 24.9% had a private practice job; and 97.3% engage in evaluation, 74% in rehabilitation, 22.1% in research, and 35.8% in teaching. Clinicians primarily work with individuals with stroke/vascular (56.7%), dementia (53.3%), depression (36.7%), and learning disabilities (34.5%). The top perceived barriers to the field include: lack of willingness to collaborate between professionals (43.7%), lack of professional leaders in the field (40.7%), and lack of clinical training opportunities (24.9%). A total of 68.9% of the clinicians indicate that normative data for their countries do not exist. It is essential for psychologists specialized in neuropsychology in France to establish better-defined guidelines for academic and clinical education, since there is no legal protection of the specialty and given that needs for neuropsychological services are increasing.

Signs and symptoms method in neuropsychology: A preliminary investigation of a standardized clinical interview for assessment of cognitive decline in dementia

Psychologists usually perform a preliminary assessment of the person’s cognitive status through a brief interview conducted before the formal testing. However, this exam has not yet been standardized with ad hoc recommendations in psychology literature. In this work, a standard observational NeuroPsychological Examination (NPE) designed for psychologists was proposed, and its clinical effectiveness evaluated. The NPE was administered to patients referred to a neuropsychological service in a memory clinic over a 2-year period. The NPEs of the patients with Alzheimer dementia (AD), vascular dementia (VaD), and healthy controls (HC) were retrospectively retrieved. Comparisons among the three groups were conducted. Abnormalities/signs identified during the NPE in the AD and VaD groups are more numerous compared to those reported in the HC group. About 80% of HCs show none or only one abnormal sign. Vice versa, 87.5% of both AD and VaD patients show three or more abnormalities. Accordingly, the NPE has 0.88 (95%CI = 0.81–0.95) sensitivity and 0.95 (95%CI = 0.88–1.02) specificity for detecting cognitive decline when a cut-point of three or more signs is applied. Some significant differences also emerge on the number of pathological signs between AD and VaD patients. NPE is a promising tool with demonstrated diagnostic utility in dementia patients.

What do Kids with Acquired Brain Injury Want? Mapping Neuropsychological Rehabilitation Goals to the International Classification of Functioning, Disability and Health.

To increase understanding of the community neuropsychological rehabilitation goals of young people with acquired brain injuries (ABIs). Three hundred twenty-six neuropsychological rehabilitation goals were extracted from the clinical records of 98 young people with ABIs. The participants were 59% male, 2-19 years old, and 64% had a traumatic brain injury. Goals were coded using the International Classification of Functioning, Disability and Health: Children and Youth Version (ICF-CY). Descriptive statistical analysis was performed to assess the distribution of goals across the ICF-CY. Chi-squared and Cramer's V were used to identify demographic and injury-related associations of goal type. The distribution of goals was 52% activities and participation (AP), 28% body functions (BF), 20% environmental factors (EF), and &lt;1% body structures (BS). The number of EF goals increased with age at assessment (V = .14). Non-traumatic causes of ABIs were associated with more EF goals (V = .12). There was no association between sex or time post-injury and the distribution of goals across the ICF-CY. Young people with ABIs have a wide range of community neuropsychological rehabilitation goals that require an individualized, context-sensitive, and interdisciplinary approach. Community neuropsychological rehabilitation services may wish to ensure they are resourced to focus intervention on AP, with increasing consideration for EF as a young person progresses through adolescence. The findings of this research support models of community neuropsychological rehabilitation that enable wellness by combining direct rehabilitative interventions with attention to social context and systemic working across agencies. (JINS, 2019, 25, 403-412).

Why Sex Matters: A Cognitive Study of People With Multiple Sclerosis.

Cognitive dysfunction affects 40% to 70% of people with multiple sclerosis (MS). Sex may influence a person's cognition. Although a few studies have reported greater cognitive deficits in men than women, it is unclear whether specific cognitive domains are more vulnerable than others to the effects of sex or whether cognition is influenced by neurologic or psychiatric variables. A chart review was undertaken of 408 people with MS referred to neuropsychological services. Demographic and MS-related variables were extracted from the patients' records. We used the Minimal Assessment of Cognitive Functioning in Multiple Sclerosis for the neuropsychological assessment. Raw test scores were converted to z scores using Canadian regression-based normative means. A general linear model was conducted on the adjusted scores, controlling for age; years of education; disease course; illness duration; and disability, anxiety, and depression scores. Men were more likely than women to have primary progressive MS (χ=6.415, P=0.011). There were no other sex differences with respect to demographic, neurologic, or psychiatric data. Women performed significantly better than men on the California Verbal Learning Test-Second Edition Total Learning index (F=7.846, P=0.006). An analysis of a large, consecutive sample of people with MS demonstrated that sex, independent of demographic, neurologic, or psychiatric factors, is an important determinant in cognitive impairment, with men being more impaired than women on tests of verbal learning and memory.

All change: a stroke inpatient service’s experience of a new clinical neuropsychology delivery model

Adults presenting to stroke services are frequently faced with the challenge of adjusting to a different life following a stroke. Difficulties often include cognitive impairments, such as memory deficits, attention...

Cognitive Rehabilitation Improves Performance of Individuals with Mild to Moderate Traumatic Brain Injury: A Review of Comprehensive Neuropsychological Services as a Model Approach

Traumatic Brain Injuries (TBI) can result in physical, cognitive and emotional symptoms and the constellation of sequelae that can linger for years and is termed post-concussion syndrome (PCS). For these ailments, therapy is available to help individuals recover; however, it is controversial whether cognitive rehabilitation can improve or forestall lost or damaged abilities. It is important to clarify this because insurances companies can be reluctant to pay for this treatment.