The Nightmare, oil on canvas by John Henry Fuseli
Clinical neuropsychology is a sub-field of psychology
concerned with the applied science of brain-behaviour relationships.
Clinical neuropsychologists use this knowledge in the assessment,
diagnosis, treatment, and or rehabilitation of patients across the
lifespan with neurological, medical, neurodevelopmental and psychiatric
conditions, as well as other cognitive and learning disorders. The branch of neuropsychology associated with children and young people is pediatric neuropsychology.
Clinical neuropsychology is a specialized form of clinical psychology. Strict rules are in place to maintain evidence as a focal point of treatment and research within clinical neuropsychology. The assessment and rehabilitation of neuropsychopathologies is the focus for a clinical neuropsychologist.
A clinical neuropsychologist must be able to determine whether a
symptom(s) may be caused by an injury to the head through interviewing a
patient in order to determine what actions should be taken to best help
the patient. Another duty of a clinical neuropsychologist is to find cerebral abnormalities and possible correlations. Evidence based practice in both research and treatment is paramount to appropriate clinical neuropsychological practice.
Assessment is primarily by way of neuropsychological tests, but also includes patient history, qualitative observation and may draw on findings from neuroimaging and other diagnostic medical procedures. Clinical neuropsychology requires an in-depth knowledge of: neuroanatomy, neurobiology, psychopharmacology and neuropathology.
History
During
the late 1800s, brain–behavior relationships were interpreted by
European physicians who observed and identified behavioural syndromes
that were related with focal brain dysfunction.
Clinical neuropsychology is a fairly new practice in comparison
to other specialty fields in psychology with history going back to the
1960s.: The specialty focus of clinical neuropsychology evolved slowly into a more defined whole as interest grew.
Threads from neurology, clinical psychology, psychiatry, cognitive
psychology, and psychometrics all have been woven together to create the
intricate tapestry of clinical neuropsychology, a practice which is
very much so still evolving. The history of clinical neuropsychology is long and complicated due to its ties to so many older practices.
Researchers like Thomas Willis (1621–1675) who has been credited with
creating neurology, John Hughlings Jackson (1835–1911) who theorized
that cognitive processes occurred in specific parts of the brain, Paul
Broca (1824–1880) and Karl Wernicke (1848–1905) who studied the human
brain in relation to psychopathology, Jean Martin Charcot (1825–1893)
who apprenticed Sigmund Freud (1856–1939) who created the psychoanalytic
theory all contributed to clinical medicine which later contributed to
clinical neuropsychology.
The field of psychometrics contributed to clinical neuropsychology
through individuals such as Francis Galton (1822–1911) who collected
quantitative data on physical and sensory characteristics, Karl Pearson
(1857–1936) who established the statistics which psychology now relies
on, Wilhelm Wundt (1832–1920) who created the first psychology lab, his
student Charles Spearman (1863–1945) who furthered statistics through
discoveries like factor analysis, Alfred Binet (1857–1911) and his
apprentice Theodore Simon (1872–1961) who together made the Binet-Simon
scale of intellectual development, and Jean Piaget (1896–1980) who
studied child development.
Studies in intelligence testing made by Lewis Terman (1877–1956) who
updated the Binet-Simon scale to the Stanford-Binet intelligence scale,
Henry Goddard (1866–1957) who developed different classification scales,
and Robert Yerkes (1876–1956) who was in charge of the Army Alpha and
Beta tests also all contributed to where clinical neuropsychology is
today.
Clinical neuropsychology focuses on the brain and goes back to the beginning of the 20th century.
As a clinician a clinical neuropsychologist offers their services by
addressing three steps; assessment, diagnosis, and treatment. The term clinical neuropsychologist was first made by Sir William Osler on April 16, 1913.
While clinical neuropsychology was not a focus until the 20th century
evidence of brain and behavior treatment and studies are seen as far
back as the neolithic area when trephination, a crude surgery in which a
piece of the skull is removed, has been observed in skulls. As a profession, clinical neuropsychology is a subspecialty beneath clinical psychology. During World War I (1914–1918) the early term shell shock was first observed in soldiers who survived the war. This was the beginning of efforts to understand traumatic events and how they affected people. During the Great Depression (1929–1941) further stressors caused shell shock like symptoms to emerge.
In World War II (1939–1945) the term shell shock was changed to battle
fatigue and clinical neuropsychology became even more involved with
attempting to solve the puzzle of peoples' continued signs of trauma and
distress.
The Veterans Administration or VA was created in 1930 which increased
the call for clinical neuropsychologists and by extension the need for
training. The Korean (1950–1953) and Vietnam Wars (1960–1973) further solidified the need for treatment by trained clinical neuropsychologists.
In 1985 the term post-traumatic stress disorder or PTSD was coined and
the understanding that traumatic events of all kinds could cause PTSD
started to evolve.
The relationship between human behavior and the brain is the focus of clinical neuropsychology as defined by Meir in 1974. There are two subdivisions of clinical neuropsychology which draw much focus; organic and environmental natures.
Ralph M. Reitan, Arthur L. Benton, and A.R. Luria are all past
neuropsychologists whom believed and studied the organic nature of
clinical neuropsychology.
On the other side, environmental nature of clinical neuropsychology did
not appear until more recently and is characterized by treatments such
as behavior therapy.
The relationship between physical brain abnormalities and the
presentation of psychopathology is not completely understood, but this
is one of the questions which clinical neuropsychologists hope to answer
in time. In 1861 the debate over human potentiality versus localization began. The two sides argued over how human behavior presented in the brain.
Paul Broca postulated that cognitive problems could be caused by
physical damage to specific parts of the brain based on a case study of
his in which he found a lesion on the brain of a deceased patient who
had presented the symptom of being unable to speak, that portion of the
brain is now known as Broca's Area.
In 1874 Carl Wernicke also made a similar observation in a case study
involving a patient with a brain lesion whom was unable to comprehend
speech, the part of the brain with the lesion is now deemed Wernicke's
Area. Both Broca and Wernicke believed and studied the theory of localization.
On the other hand, equal potentiality theorists believed that brain
function was not based on a single piece of the brain but rather on the
brain as a whole.
Marie J.P Flourens conducted animal studies in which he found that the
amount of brain tissue damaged directly affected the amount that
behavior ability was altered or damaged. Kurt Goldstein observed the same idea as Flourens except in veterans who had fought in World War I. In the end, despite all of the disagreement, neither theory completely explains the human brains complexity. Thomas Hughlings Jackson created a theory which was thought to be a possible solution.
Jackson believed that both potentiality and localization were in part
correct and that behavior was made by multiple parts of the brain
working collectively to cause behaviors, and Luria (1966–1973) furthered
Jackson's theory.
The job
When considering where a clinical neuropsychologist works, hospitals are a common place for practitioners to end up.
There are three main variations in which a clinical neuropsychologist
may work at a hospital; as an employee, consultant, or independent
practitioner.
As a clinical neuropsychologist working as an employee of a hospital
the individual may receive a salary, benefits, and sign a contract for
employment. In the case of an employee of a hospital the hospital is in charge of legal and financial responsibilities.
The second option of working as a consultant implies that the clinical
neuropsychologist is part of a private practice or is a member of a
physicians group.
In this scenario, the clinical neuropsychologist may work in the
hospital like the employee of the hospital but all financial and legal
responsibilities go through the group which the clinical
neuropsychologist is a part of.
The third option is an independent practitioner whom works alone and
may even have their office outside of the hospital or rent a room in the
hospital.
In the third case, the clinical neuropsychologist is completely on
their own and in charge of their own financial and legal
responsibilities.
Assessment
Assessments
are used in clinical neuropsychology to find brain psychopathologies of
the cognitive, behavioral, and emotional variety.
Physical evidence is not always readily visible so clinical
neuropsychologists must rely on assessments to tell them the extent of
the damage.
The cognitive strengths and weaknesses of the patient are assessed to
help narrow down the possible causes of the brain pathology.
A clinical neuropsychologist is expected to help educate the patient on
what is happening to them so that the patient can understand how to
work with their own cognitive deficits and strengths.
An assessment should accomplish many goals such as; gage consequences
of impairments to quality of life, compile symptoms and the change in
symptoms over time, and assess cognitive strengths and weaknesses.
Accumulation of the knowledge earned from the assessment is then
dedicated to developing a treatment plan based on the patient's
individual needs. An assessment can also help the clinical neuropsychologist gage the impact of medications and neurosurgery on a patient.
Behavioral neurology and neuropsychology tools can be standardized or
psychometric tests and observational data collected on the patient to
help build an understanding of the patient and what is happening with
them.
There are essential prerequisites which must be present in a patient in
order for the assessment to be effective; concentration, comprehension,
and motivation and effort.
Lezak lists six primary reasons neuropsychological assessments are carried out: diagnosis, patient care and its planning, treatment planning, treatment evaluation, research and forensic neuropsychology.
To conduct a comprehensive assessment will typically take several hours
and may need to be conducted over more than a single visit. Even the
use of a screening battery covering several cognitive domains may take
1.5–2 hours. At the commencement of the assessment it is important to
establish a good rapport with the patient and ensure they understand the
nature and aims of the assessment.
Neuropsychological assessment can be carried out from two basic
perspectives, depending on the purpose of assessment. These methods are
normative or individual. Normative assessment, involves the comparison of the patient’s performance against a representative population. This method may be appropriate in investigation of an adult onset brain insult such as traumatic brain injury or stroke.
Individual assessment may involve serial assessment, to establish
whether declines beyond those which are expected to occur with normal aging, as with dementia or another neurodegenerative condition.
Assessment can be further subdivided into sub-sections:
History taking
Neuropsychological
assessments usually commence with a clinical interview as a means of
collecting a history, which is relevant to the interpretation of any
later neuropsychological tests. In addition, this interview provides
qualitative information about the patient’s ability to act in a socially
apt manner, organise and communicate information effectively and
provide an indication as to the patient’s mood, insight and motivation.
It is only within the context of a patient’s history that an accurate
interpretation of their test data and thus a diagnosis can be made.
The clinical interview should take place in a quiet area free from
distractions. Important elements of a history include demographic
information, description of presenting problem, medical history
(including any childhood or developmental problems, psychiatric and psychological history), educational and occupational history (and if any legal history and military history.)
Selection of neuropsychological tests
It
is not uncommon for patients to be anxious about being tested;
explaining that tests are designed so that they will challenge everyone
and that no one is expected to answer all questions correctly may be
helpful.
An important consideration of any neuropsychological assessment is a
basic coverage of all major cognitive functions. The most efficient way
to achieve this is the administration of a battery of tests covering: attention, visual perception and reasoning, learning and memory, verbal function, construction, concept formation, executive function,
motor abilities and emotional status. Beyond this basic battery,
choices of neuropsychological tests to be administered are mainly made
on the basis of which cognitive functions need to be evaluated in order
to fulfill the assessment objectives.
Report writing
Following
a neuropsychological assessment it is important to complete a
comprehensive report based on the assessment conducted. The report is
for other clinicians, as well as the patient and their family so it is
important to avoid jargon or the use of language which has different
clinical and lay meanings (e.g. intellectually disabled as the correct clinical term for an IQ below 70, but offensive in lay language).
The report should cover background to the referral, relevant history,
reasons for assessment, neuropsychologists observations of patient’s
behaviour, test administered and results for cognitive domains tested,
any additional findings (e.g. questionnaires for mood) and finish the
report with a summary and recommendations. In the summary it is
important to comment on what the profile of results indicates regarding
the referral question. The recommendations section contains practical
information to assist the patient and family, or improve the management
of the patient’s condition.
Educational requirements of different countries
The
educational requirements for becoming a clinical neuropsychologist
differ between countries. In some countries it may be necessary to
complete a clinical psychology
degree, before specialising with further studies in clinical
neuropsychology. While some countries offer clinical neuropsychology
courses to students who have completed 4 years of psychology studies. All clinical neuropsychologists require a postgraduate qualification, whether it be a Masters or Doctorate (Ph.D, Psy.D. or D.Psych).
Australia
To become a clinical neuropsychologist in Australia requires the completion of a 3-year Australian Psychology Accreditation Council (APAC) approved undergraduate degree in psychology, a 1-year psychology honours, followed by a 2-year Masters or 3-year Doctorate of Psychology
(D.Psych) in clinical neuropsychology. These courses involve coursework
(lectures, tutorials, practicals etc.), supervised practice placements
and the completion of a research thesis.
Masters and D.Psych courses involve the same amount of coursework units,
but differ in the amount of supervised placements undertaken and length
of research thesis. Masters courses require a minimum of 1,000 hours
(125 days) and D.Psych courses require a minimum of 1,500 hours (200
days), it is mandatory that these placements expose students to acute
neurology/neurosurgery, rehabilitation, psychiatric, geriatric and
paediatric populations.
Canada
To become
a clinical neuropsychologist in Canada requires the completion of a
4-year honours degree in psychology and a 4-year doctoral degree in
clinical neuropsychology. Often a 2-year master's degree is required
before commencing the doctoral degree. The doctoral degree involves
coursework and practical experience (practicum and internship).
Practicum is between 600 and 1,000 hours of practical application of
skills acquired in the program. At least 300 hours must be supervised,
face-to-face client contact. The practicum is intended to prepare
students for the internship/residency. Internships/residencies are a
year long experience in which the student functions as a
neuropsychologist, under supervision. Currently, there are 3
CPA-accredited Clinical Neuropsychology internships/residencies in
Canada,
although other unaccredited ones exist. Prior to commencing the
internship students must have completed all doctoral coursework,
received approval for their thesis proposal (if not completed the
thesis) and the 600 hours of practicum.
United Kingdom
To become a clinical neuropsychologist in the UK, requires prior qualification as a clinical or educational psychologist as recognised by the Health Professions Council,
followed by further postgraduate study in clinical neuropsychology. In
its entirety, education to become a clinical neuropsychologist in the UK
consists of the completion of a 3-year British Psychological Society accredited undergraduate degree in psychology, 3-year Doctorate in clinical (usually D.Clin.Psy.) or educational psychology (D.Ed.Psy.), followed by a 1-year Masters (MSc) or 9-month Postgraduate Diploma (PgDip) in Clinical Neuropsychology.
The British Psychological Division of Counselling Psychology are also
currently offering training to its members in order to ensure that they
can apply to be registered Neuropsychologists also.
United States
In
order to become a clinical neuropsychologist in the US and be compliant
with Houston Conference Guidelines, the completion of a 4-year undergraduate degree in psychology and a 4 to 5-year doctoral degree (Psy.D. or Ph.D.)
must be completed. After the completion of the doctoral coursework,
training and dissertation, students must complete a 1-year internship,
followed by an additional 2 years of supervised residency. The doctoral
degree, internship and residency must all be undertaken at American Psychological Association approved institutions.
After the completion of all training, students must apply to become
licensed in their state to practice psychology. The American Board of
Clinical Neuropsychology, The American Board of Professional
Neuropsychology, and The American Board of Pediatric Neuropsychology all
award board certification to neuropsychologists that demonstrate
competency in specific areas of neuropsychology, by reviewing the
neuropsychologist's training, experience, submitted case samples, and
successfully completing both written and oral examinations. Although
these requirements are standard according to Houston Conference
Guidelines, even these guidelines have stated that the completion of all
of these requirements is still aspirational, and other ways of
achieving clinical neuropsychologist status are possible.
