Clinical Neuropsychology

1. Clinical Neuropsychology Topic 6

2. Definition • The study of the relation between brain function & behavior. • Deals with the understanding, assessment, & treatment of behaviors directly related to the functioning of the brain

3. Neuropsychological Assessment • A non-invasive method of describing brain functioning based on a patient’s performance on standardized test s that have been shown to be accurate and sensitive indicators of brain behavior relationships.

4. Roles of Neuropsychologists • Helps neurologists or other physicians to establish or rule out a particular diagnosis • Make predictions regarding the prognosis for recovery • Intervention & rehabilitation

5. Cont’d • Evaluate patients with mental disorders to help predict the course of illness as well as to help tailor treatment strategies to patient’s strengths & weaknesses.

6. History of Neuropsychology • Theories of Brain functioning • Edwin Smith Surgical Papyrus – a document thought to date between 3000 & 1700 BC, discusses localization of function in the brain

7. Cont’d • Pythagoras – human reasoning occurs in the brain • Galen ( 2nd cent BC) – mind was located in the brain

8. Cont’d • 19th Cent – damage to specific cortical areas was related to impaired function of certain adaptive behaviors • Franz Gall – phrenology; certain individual differences in intelligence & personality could be measured by noting the bumps & indentations of the skull.

9. Cont’d • Paul Broca (1861) – found the location of motor speech; localization of function – maps of the brain that located each major function • Pierre Flourens & Karl Lashley – concept of equipotetiality – although there is certainly localization of brain function, the cortex really functions as a whole rather than isolated units

10. Cont’d • Jackson & Luria – functional model; areas of the brain interact with each other to produce a behavior; behavior is a result of several functions or systems of the brain areas, rather than the result of unitary or discrete areas.

11. Cont’d • Neuropsychological Assessment • Psychological tests were oriented to simple assessment of the presence & absence of brain damage • Ward Halstead – observed people with brain damage in natural settings, & identify specific characteristics of the behavior

12. Cont’d • Halstead-Reitan Neuropsychological Battery • Luria-Nebraskan Neuropsychological Battery ( 1980) • Flexible battery approach to assessment

13. Review of the Brain Structure & Functions • Left Hemisphere – controls the right side of the body; language functions; logical inference; detail analysis • Right hemisphere – controls the left side of the body; visual-spatial skills, creativity, musical activities, perception of direction

14. Cont’d • Frontal lobes – executive functions; emotional modulation • Temporal lobes – linguistic expression; reception, & analysis, auditory processing of tones, sounds, rhythms & meanings that are nonlanguage in nature

15. Cont’d • Parietal lobes – tactile & kinesthetic perception, understanding, spatial perception, some language understanding & processing • Occipital lobes – visual processing, visually mediated memory • Cerebellum – motor coordination, control of equilibrium & muscle tone

16. Cause of Brain Damage • Trauma • Concussions – momentary disruptions of brain functioning • Contusions – severe outcome, may be followed by coma & deliriums • Lacerations – serious forms of damage

17. Cont’d • Cerebrovascular accidents ( stroke ) • Occulusions – aphasia, apraxia, agnosia • Cerebral hemorrhage – death, paralysis, speech problems, memory & judgment difficulties

18. Cont’d • Tumors – headaches, vision problems, problems in judgment, poor memory, affect problems, or motor coordination • Degenerative disease – severe disturbance in many behavioral areas i.e motor, speech, language, memory, & judgment difficulties

19. Cont’d • Nutritional deficiences – neurological & psychological disorders i.e. Korsakoff’s psychosis • Toxic disorders – brain damage, delirium • Chronic alcohol abuse – deficits in memory formation, emotional regulation, & sensory integration

20. Consequences & Symptoms of Neurological Damage • Impaired orientation • Impaired memory • Impaired intellectual functions • Impaired judgment • Shallow & labile affect • Loss of emotional & mental resilience • Frontal lobe syndrome

21. Methods of NA • Major approaches • Standard battery approach or Fixed battery approach • Flexible approach or hypothesis-testing approach

22. Testing Areas of Cognitive Functioning • Intellectual functioning – WAIS III • Abstract Reasoning & Memory – WAIS III, WMS • Visual-perceptual Processing – Rey-Osterrieth Complex Figure Test, Block design of WAIS III • Language Functioning – Luria Nebraska

23. Test batteries • The Halstead-Reitan Battery – category test, seashore rhythm test, finger oscillation test, speech-sounds, trail-making test, strength of grip test, sensory-perceptual examination, finger localization test, fingertip-writing perception test, tactile form recognition test, aphasia screening test

24. Cont’d • Luria-Nebraska Battery – motor functions, rhythm functions, tactile functions, visual functions, receptive speech, expressive speech, writing functions, reading skills, arithmetic skills, memory, intellectual processes

25. Intervention & rehabilitation • Thorough assessment of the patient’s strengths & weaknesses is conducted • Development of the rehabilitation program given the patient’s condition

26. Training • In addition to training in general clinical psychology, it involves specialized training in theoretical, empirical, and practical aspects of the brain-behavior relationship.

27. Cont’d • Education, training, and supervision in Clinical Neuropsychology is available primarily at the postdoctoral level, although preparation begins at the doctoral level.

28. Be knowledgeable Houston Conference Guidelines Provides an integrated model of professional education and training in Clinical Neuropsychology: • General Knowledge Base and Skills • Doctoral, Internship and Postdoctoral Training Guidelines • Continuing Education • Professional and Scientific Activity • Subspecialties

29. DEFINITION OF A CLINICAL NEUROPSYCHOLOGIST (1989) • A professional psychologist who applies principles of assessment and intervention based upon the scientific study of human behavior as it relates to normal and abnormal functioning of the central nervous system. The Clinical Neuropsychologist is a doctoral-level psychology provider of diagnostic and intervention services who has demonstrated competence in the application of such principles for human welfare following:

30. Cont’d • A. Successful completion of systematic didactic and experiential training in neuropsychology and neuroscience at a regionally accredited university.

31. Cont’d • B. Two or more years of appropriate supervised training applying neuropsychological services in a clinical setting.  • C. Licensing and certification to provide psychological services to the public by the laws of the state or province in which he or she practices.  

32. D. Review by one's peers as a test of these competencies. *Attainment of the ABCN/ABPP Diplomate in Clinical Neuropsychology is the clearest evidence of competence as a Clinical Neuropsychologist, assuring that all of these criteria have been met.

33. PRELIMINARY STEP UNDERGRADUATE TRAINING • UNDERGRADUATE FOCUS: • Psychology coursework and/or major (esp. abnormal, developmental, statistics). • Biology or behavioral medicine coursework (provides a strong foundation for graduate neuropsychology coursework) • Research Assistanceship and/or involvement

34. SELECTING A GRADUATE PROGRAM Graduate Schools: University or Professional? • University programs are highly competitive (low selection ratio). Your application will be helped by excellent grades, GRE scores and some previous research experience—preferably, a published paper, if only as a co-author.

35. Cont’d • Professional schools are easier to get into, but they are very expensive. You will have to take out enormous student loans, or you might try to work while studying—perhaps even studying part-time. Also, many professional schools offer primarily the Psy.D. degree, reserving the Ph.D. (if they offer it at all) for a few, select students.

36. Neuropsychology Track? • Specialization in NP can begin at the doctoral level. • Often, Clinical Neuropsychology is offered as a distinct track in clinical psychology programs, designed to follow APA Div40/Houston Conference guidelines.

37. Cont’d • Recognized tracks make it easier to specialize (existing, easily accessible NP faculty, research labs, clinics, on/off campus practical sites, core coursework curriculum…). • No Track? That’s OK. • Important to be proactive • Seek out didactics, research and clinical training opportunities in the community to be competitive.

38. Predoctoral NP Specialty Preparation • Core Coursework in NP • In addition to the basic Clinical Psychology curriculum, competitive students have completed doctoral level coursework in: • Neuropsychology Assessment • Clinical Neuropsychology • Behavioral and Clinical neurosciences • Behavioral (Clinical) Neurology (coursework generally includes exposure to functional neuroanatomy, neuropathology, psychopharmacology, neuroimaging, relevant test construction/research, neuropsychology assessment, case conceptualization…)

39. Predoctoral Clinical Experience Practical Placement • Hospital (acute inpt, rehab, outpt services) • Mental Health Clinics (LD, ADHD, TBI, CVA, MDC) • Private Practice Goal: • Exposure to a wide range of diagnoses, tests, clinical settings, age range, conceptualization style… • Experience conducting interviews, administering comprehensive test batteries, staffing cases, writing reports and working within a multidisciplinary treatment team.

40. Research • Many internship sites place a strong emphasis on research and scholarly interest and “product” (even if you intend to practice as a clinician). • National conference attendance and association membership • Journal club participation • Poster presentations • Book chapters • Peer reviewed publications • Grants • Tendency to prefer applicants who have successfully proposed or defended their dissertation prior to the start of internship.

41. Houston Conference guidelines for postdoctoral training • Goal is to complete the education and training necessary for independent practice of clinical neuropsychology (CN) • Residency is a REQUIRED component in specialty education in CN • The equivalent of 2 years of full-time education and training • Residency MUST occur on at least a half-time basis • ENTRY criteria: • 1. Entrance SHOULD be based upon completion an APA/CPA- accredited doctoral program. • 2. Residents WILL have successfully completed an APA/CPA- accredited internship which includes SOME training in CN.