Clinical Neuropsychology in North America: What the First Twenty Five Years Might Tell Us About the Future of the Specialty and Its Implication for the.

Clinical Neuropsychology in Clinical Neuropsychology in North America:North America:

What the First Twenty Five Years Might Tell What the First Twenty Five Years Might Tell Us About the Future of the SpecialtyUs About the Future of the Specialty

and Its Implication for the Development of and Its Implication for the Development of Neuropsychology in SpainNeuropsychology in Spain

Congreso de Asociaciones de Congreso de Asociaciones de Neuropsicologia EspanolasNeuropsicologia Espanolas

Universidad de GranadaUniversidad de GranadaJunio 10, 2005Junio 10, 2005

Antonio E. PuenteAntonio E. Puente

Department of PsychologyDepartment of PsychologyUniversity of North Carolina a WilmingtonUniversity of North Carolina a Wilmington

Wilmington, North Carolina 28403 USAWilmington, North Carolina 28403 USAwww.uncw.eduwww.uncw.edu/people/puente/people/puente

www.clinicalneuropsychology.uswww.clinicalneuropsychology.uspuente@[email protected]

OutlineOutline

Focus: Education, Focus: Education, Personnel/Organization, ActivitiesPersonnel/Organization, Activities

IntroductionIntroduction Brief Overview of Twenty Five YearsBrief Overview of Twenty Five Years Current PanoramaCurrent Panorama Challenges, Pitfalls and OpportunitiesChallenges, Pitfalls and Opportunities

IntroductionIntroduction

Personal BackgroundPersonal Background Education and TrainingEducation and Training Scientific, Professional & Pedagogical Scientific, Professional & Pedagogical

ActivitiesActivities Research; Cultural Neuropsychology, Coronary Research; Cultural Neuropsychology, Coronary

Artery Bypass, Roger W. SperryArtery Bypass, Roger W. Sperry Professional; Assessment & RehabilitationProfessional; Assessment & Rehabilitation Pedagogical; Classroom, Clinic & LaboratoryPedagogical; Classroom, Clinic & Laboratory Organizational; APA, NAN, & AMA/MedicareOrganizational; APA, NAN, & AMA/Medicare

Background: Initial History of Background: Initial History of Academic Psychology in the Academic Psychology in the

USAUSA ScienceScience

Psychological Review (1894; purchased)Psychological Review (1894; purchased) First Laboratory (1885; Harvard)First Laboratory (1885; Harvard) Later- Hopkins, Penn, Iowa, Wisconsin, etc.Later- Hopkins, Penn, Iowa, Wisconsin, etc.

PedagogyPedagogy First Undergraduate Course (1840; Marshall)First Undergraduate Course (1840; Marshall) First Graduate CourseFirst Graduate Course (1847; Yale) (1847; Yale) First PhD Granted (1861; Yale)First PhD Granted (1861; Yale) First TextbookFirst Textbook (1890; James)(1890; James)

The Beginning of APAThe Beginning of APA

ModelModel American Physiological SocietyAmerican Physiological Society

Preliminary MeetingPreliminary Meeting Worcester, Mass (Clark; July 8, 1892)Worcester, Mass (Clark; July 8, 1892) 26; 2 Jews, 1 Catholic Priest, 26; 2 Jews, 1 Catholic Priest,

Psychiatrists…Psychiatrists… First Official MeetingFirst Official Meeting

Philadelphia, PA (Penn; December, 1892)Philadelphia, PA (Penn; December, 1892) 18 attended and presented; Hall elected18 attended and presented; Hall elected

The “Beginning” of The “Beginning” of Clinical PsychologyClinical Psychology

WWII and the VA System (1945-1960)WWII and the VA System (1945-1960) Licensing Laws (1960-1980)Licensing Laws (1960-1980) Third Party Reimbursement (1970-Third Party Reimbursement (1970-

1990)1990) Medicare Program (1990-present)Medicare Program (1990-present) Specialities in Psychology (2000-Specialities in Psychology (2000-

present)present)

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 55 different divisionsApproximately 55 different divisions Top three divisions are:Top three divisions are:

Clinical Psychology Clinical Psychology Clinical NeuropsychologyClinical Neuropsychology Independent PracticeIndependent Practice

APA Membership APA Membership

Health Provider Health Provider 70%70% Clinical = 50%Clinical = 50%

ResearchResearch 20%20% OtherOther 11%11%

History: EducationHistory: Education

Bachelors (4 years)Bachelors (4 years) Generic Introduction/Liberal ArtsGeneric Introduction/Liberal Arts

Masters (2 years)Masters (2 years) Stepping-StoneStepping-Stone Psychological Assistant/AssociatePsychological Assistant/Associate

Doctorate (4-7 years)Doctorate (4-7 years) PhD Vs PsyDPhD Vs PsyD Requirement to be Called and to Practice as a PsychologistRequirement to be Called and to Practice as a Psychologist Clinical Vs OtherClinical Vs Other

Post-Doctorate (1-2 years)Post-Doctorate (1-2 years) Clinical Neuropsychology as a SpecialtyClinical Neuropsychology as a Specialty

Continuing EducationContinuing Education Half-Life of Doctorate Education = 8 yearsHalf-Life of Doctorate Education = 8 years

History: Clinical Activities in History: Clinical Activities in NeuropsychologyNeuropsychology

AssessmentAssessment Fixed (Halstead-Reitan Vs. Luria-Nebraska) Vs. Flexible Fixed (Halstead-Reitan Vs. Luria-Nebraska) Vs. Flexible

(Boston)(Boston) Clinical (e.g., Dementia, Stroke, Head Inj.)Clinical (e.g., Dementia, Stroke, Head Inj.) Educational (e.g., Learning Disability)Educational (e.g., Learning Disability)

RehabilitationRehabilitation Cognitive RehabilitationCognitive Rehabilitation

ForensicForensic Disability (Social Security; Pension)Disability (Social Security; Pension) Worker’s CompensationWorker’s Compensation Personal InjuryPersonal Injury Death PenaltyDeath Penalty

History: Information in History: Information in NeuropsychologyNeuropsychology

PublicationsPublications Books (Goldstein, 1974)Books (Goldstein, 1974) Journals (IJCN; 1978)Journals (IJCN; 1978) Online (Online (www.npsych.orgwww.npsych.org; 2002); 2002)

Trends Trends Assessment (HRNB & LNNB; 1970s)Assessment (HRNB & LNNB; 1970s) Rehabilitation (CR; 1980s)Rehabilitation (CR; 1980s) Forensic (1990s)Forensic (1990s)

History: Personnel in History: Personnel in NeuropsychologyNeuropsychology

Overall Trends/ZeitgeistOverall Trends/Zeitgeist Growth PatternsGrowth Patterns Demographic PatternsDemographic Patterns Academic Vs. ClinicalAcademic Vs. Clinical

IndividualsIndividuals ReitanReitan GoldenGolden KaplanKaplan

History: Organizations in History: Organizations in NeuropsychologyNeuropsychology

American Psychological Association (1892)American Psychological Association (1892) Division of Clinical Neuropsychology (1980;40)Division of Clinical Neuropsychology (1980;40) National Academy of Neuropsychology(1975)National Academy of Neuropsychology(1975) International Neuropsychological Society (’72)International Neuropsychological Society (’72) Other issues/groups;Other issues/groups;

APA’s First Specialty (1996)APA’s First Specialty (1996) Board Certification (e.g., ABPN; 1885)Board Certification (e.g., ABPN; 1885) Licensure (e.g., Louisiana; 2000)Licensure (e.g., Louisiana; 2000) Specialty Groups (e.g., Pediatrics; 2005)Specialty Groups (e.g., Pediatrics; 2005)

What is Clinical What is Clinical Neuropsychology?Neuropsychology?

Study and practrice of the relationship Study and practrice of the relationship between brain and behavior, especially between brain and behavior, especially but exclusively neurological patientsbut exclusively neurological patients

Approximately 4-5,000 (out of 150,000)Approximately 4-5,000 (out of 150,000) Doctorate with post-doctorate training Doctorate with post-doctorate training

as minimum requirementas minimum requirement Difficulties in agreement of definitionDifficulties in agreement of definition

Surveying the SpecialtySurveying the Specialty

Brief History of SurveysBrief History of Surveys HartlageHartlage DeLuca & PutnamDeLuca & Putnam

Current Survey MethodologyCurrent Survey Methodology Sweet & PeckSweet & Peck Division 40 and NANDivision 40 and NAN

Latest Survey of Clinical Latest 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

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

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

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

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

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

Incomes by OrganizationIncomes by Organization(Doctoral Licensed Clinicians Working (Doctoral Licensed Clinicians Working

Full Time or Full Time+)Full Time or Full Time+)

78,228

99,296 107,856 108,794 103,336

0

20,000

40,000

60,000

80,000

100,000

120,000

NAN n=125

D40n=223

Bothn=581

Unkn.n=259

Overalln=1188

Mean Median

$

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

Income by Years of Income by Years of LicensureLicensure

0 Yrs $44,763 (47K)

1-5 73,567 (63K)

6-10 93,172 (77K)

11-15 109,457 (88K)

16-20 118,776 (93K)

21-25 126,979 (102K)

26-30 152,359 (120K)

0 Yrs $44,763

1 66,810 (56K)

2 61,512 (61K)

3 69,061 (60K)

4 94,800

4 (minus outlier)

78,641 (70K)

5 73,596 (65K)

Stratification - Mean (Median) ‘Starting’ Salaries - Mean (Median)

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

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

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

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.

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

Codes & Values forCodes & Values forProfessional Services:Professional Services:

What is Neuropsychology What is Neuropsychology Worth?Worth? CPT: BackgroundCPT: Background

American Medical Association Developed by Surgeons (& Physicians) in 1966

for Billing Purposes 7,500 Discrete Codes

US Federal Insurance Program; Medicare AMA Under License with CMS CMS Now Provides Active Input into CPT Benchmark from Which All Third Party Uses

Applications for Applications for NeuropsychologyNeuropsychology

Total Possible Codes = 7,500Total Possible Codes = 7,500 Possible Codes for Psychology = Approximately Possible Codes for Psychology = Approximately

40 to 6040 to 60 Three ParadigmsThree Paradigms

Psychiatry/Mental HealthPsychiatry/Mental Health NeurologyNeurology MedicineMedicine

Sections = Five Separate SectionsSections = Five Separate Sections PsychiatryPsychiatry BiofeedbackBiofeedback Central Nervous AssessmentCentral Nervous Assessment Physical Medicine & RehabilitationPhysical Medicine & Rehabilitation Health & Behavior Assessment & ManagementHealth & Behavior Assessment & Management

CPT Code for Activities Frequency Percent

Intake Interview 90801 96117 96115 Other (16 codes)

2311064021

16.57.62.91.5

Clinical interview/history 90801 96117 96115 Other (20 codes)

 2501805934

 17.912.94.22.4

Test administration 96117 96100 96115 Other (12 codes)

 498379

21

 35.72.70.61.5

CPT Codes Used For Neuropsych Assessment Activities(Doctoral Level Clinicians)

CPT: The Future of the CPT: The Future of the ProfessionProfession

Typical Code = X 2Typical Code = X 2 Values of a CPT CodeValues of a CPT Code

.5 X Conversion Codes (US Congress sets).5 X Conversion Codes (US Congress sets) Psychotherapy as a BenchmarkPsychotherapy as a Benchmark

Approximately $100/hourApproximately $100/hour Estimated GoalsEstimated Goals Current TimetableCurrent Timetable Major Paradigm ShiftMajor Paradigm Shift

Time for the FutureTime for the Future

Is Our History the Best Predictor for Is Our History the Best Predictor for Our Future?Our Future?

What are APA Members Worried What are APA Members Worried About?About?

My Own Personal Glimpse Into What My Own Personal Glimpse Into What Awaits Clinical NeuropsychologyAwaits Clinical Neuropsychology

Initial Results of APA Policy Initial Results of APA Policy & Planning Survey: & Planning Survey:

A View of PsychologyA View of Psychology ProcedureProcedure

Five Year Review of Status of APA & PsychologyFive Year Review of Status of APA & Psychology Random Survey of APA Membership, Staff, & Random Survey of APA Membership, Staff, &

GovernanceGovernance ResultsResults

Public Image of PsychologyPublic Image of Psychology Protecting & Expanding Sources of IncomeProtecting & Expanding Sources of Income Membership ConcernsMembership Concerns

What Trends Are Developing in What Trends Are Developing in Neuropsychology: Broad Neuropsychology: Broad

AnalysisAnalysis OrganizationalOrganizational InformationalInformational Professional (versus Clinical)Professional (versus Clinical) FinancialFinancial Public PolicyPublic Policy

Projected Specific TrendsProjected Specific Trends

Income (depends on activity; if clinical) Steadier (if economy does not further erode) Probable incremental declines, up to 10-20% “Final” stabilization by 2005

Recognition Physician Level Mental vs. Physical Health

Paradigms Industrial vs. Boutique Health vs. Non-Health What’ Hot: Cultural/Ecological, fMRI, Forensics

Potential Overall TrendsPotential Overall Trends

Catching up to PsychiatryCatching up to Psychiatry Leaving PsychiatryLeaving Psychiatry Joining MedicineJoining Medicine Leaving MedicineLeaving Medicine

LegalLegal SportsSports GovernmentalGovernmental IndustrialIndustrial

Anticipated ProblemsAnticipated Problems

Empirical Data Base Limited Understanding of Culture Continued Professional Infighting Personnel Issues Value to Society (face Vs. criterion

validity)

Some Personal Hopes for Some Personal Hopes for Neuropsychology in SpainNeuropsychology in Spain

(Inclusive) Organization(Inclusive) Organization ConferenceConference Publication OpportunitiesPublication Opportunities Collaboration (e.g., ALAN, NAN, 40, INS)Collaboration (e.g., ALAN, NAN, 40, INS)

(Practical) Research(Practical) Research Translation & Standardization of Exisiting InstrumentsTranslation & Standardization of Exisiting Instruments Development of New InstrumentsDevelopment of New Instruments Development of Appropriate Normative SamplesDevelopment of Appropriate Normative Samples

(Robust) Practice(Robust) Practice Government & Institution BasedGovernment & Institution Based Private PracticePrivate Practice

(Engaging) Public Policy(Engaging) Public Policy Interface with Colegio de PsicologosInterface with Colegio de Psicologos

Summary for Summary for NeuropsychologyNeuropsychology

Continued Growth, Especially in the Continued Growth, Especially in the Professional DomainsProfessional Domains

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

El Futuro…El Futuro…

Nuevo Paradigmo =

Cambio

Mucho Cambio