International perspectives on education, training, and practice in clinical neuropsychology: comparison across 14 countries around the world

Ethical issues in clinical neuropsychology: International diversity perspectives

OBJECTIVE

Much of the information about the ethical practice of clinical neuropsychology has focused on North America. Additionally, of the scholarly publications on the intersection of ethical issues and cultural diversity practices in neuropsychology, most have focused on North America. The extent to which practitioners in other parts of the world are aware of, and find useful, such information is largely unknown. Similarly, the extent to which North American neuropsychologists are familiar with ethical issues and challenges encountered around the world is unknown. The purpose of this article is to advance the discussion of ethical issues in clinical neuropsychology from an international diversity perspective.

METHOD

The article presents, via a panel interview format, the thoughts and experiences of a small sample of neuropsychologists who represent all continents except North America (and Antarctica).

RESULTS

Neuropsychologists across continents share an ethical commitment to providing services that are beneficial, and not harmful, to the recipients of the services. Professional competence is at the heart of such services.

CONCLUSIONS

Through continued and expanded dialogue about ethical issues with neuropsychology colleagues around the world, the potential exists for improvement in the provision of effective and compassionate care in our own towns.

Neuropsychology in Greece: Results from a survey of practicing professionals

Neuropsychology is a fast-growing specialty in Greece. This study surveyed the status of neuropsychologists in Greece investigating several aspects of the profession. An online-based questionnaire collected data from December 2019 to February 2020. A total of 133 participants specialized in neuropsychology were included in the final sample: 81% of the participants were women with a mean age of 35 years. In the total sample, 25.8% of the participants reported working in the hospital system, 18.5% in the university or college, and 17.7% in a private practice job. Greek professionals cited to engage actively in assessment (87.9%), in research (65.1%), in rehabilitation (47.7%), and teaching (30.2%). Professionals primarily declared to assess individuals with dementia (80.3%), depression (47.7%), and stroke (44.0%), and they reported neurologists, psychiatrists and psychologists as their leading sources of referrals. The top five perceived barriers to the field include the lack of recognized specialty (75.9%), the lack of clinical training opportunities (63.9%), the lack of strong professional associations (57.9%), the lack of access to neuropsychological instruments (57.9%) and the lack of willingness to collaborate between professionals (48.9%). The average monthly income of professionals represents a ratio of 0.76 in comparison to that of other scientists in the country and is the lowest reported among other countries. Despite the significant development of the profession, it is essential to create more clinical training opportunities, apply practices systematically to diverse populations, redefine the specialty of neuropsychology in the national health system of the country, and advocate for the profession.

The ambivalence toward neuropsychology in dementia research, diagnosis, and drug development: Myths and misconceptions

Clinical assessment remains the gold standard for diagnosing dementia, monitoring progression, and conducting clinical research. Biomarkers hold promise for targeted therapeutic approaches, selection of participants in clinical trials, and direct physiological efficacy readouts. However, the anchoring of biomarker research to clinical symptomatology is often based on short and insensitive cognitive screening. This gives the impression that cognitive symptoms occur relatively late and that their progression in the early stages of the disease is slow. A thorough cognitive assessment is a powerful tool and has a key role in the accurate and early diagnosis of dementia. It is very different from the cognitive testing usually seen in biomarker research and drug development. Yet the distinction between these approaches is unclear to many. This paper highlights the misconceptions around cognitive research in dementia and suggests a way forward to facilitate biomarker and drug development through the improved utility of cognitive assessment tools.

The profession of neuropsychologist in Canada: Findings of a national survey

The purpose of this study was to investigate the demographic characteristics, academic training and types of professional activities of clinical neuropsychologists in Canada.

282 participants completed an online-based survey.

Respondents were women for the most part and had a mean age of 43 years. They typically had doctoral-level training (85%) and about one-quarter had postdoctoral training (23%). Nearly half (47%) had a lifespan practice, over one-third (37%) had an adults-only practice, and about one-sixth (16%) had an exclusively pediatric practice. Most worked full-time (79%). Respondents were almost evenly split three ways between those who worked in the public sector, those who worked in the private sector, and those who worked in both. The most common professional activities related to assessment (95%), although clinical supervision (43%) and rehabilitation (42%) were also quite frequent, whereas research (27%) and teaching (18%) were less so. The most common reason for referral was to determine a diagnosis (79%). Pediatric neuropsychologists worked primarily with individuals with neurodevelopmental disorders and neuropsychologists working with adult populations worked primarily with individuals with emotional disorders, acquired neuropsychological disorders (traumatic brain injury, stroke/vascular), and neurocognitive disorders (dementia).

At time of study, Canadian neuropsychologists seemed to enjoy a fairly balanced situation: Their level of training and the ratio of neuropsychologists per population were both high. However, these varied widely across Canada. This suggests that the profession and public interest would stand to gain from seeing training standardized to some extent nationwide.

Normative Data for Adult Mandarin-Speaking Populations: A Systematic Review of Performance-Based Neuropsychological Instruments

OBJECTIVES

Normative data are essential for neuropsychological evaluations, but they are scarce for Mandarin-speaking populations, despite Mandarin being the language with the most native speakers. Several normative data studies have been reported in recent years for Mandarin speakers, who reside in different countries/regions (e.g., mainland China, Taiwan, and Singapore, etc.). This review aims to serve as a reference guide to appropriate norms when working with a Mandarin-speaking patient and to guide future endeavors in test validation and development in areas where studies to date fall short.

METHOD

We conducted a systematic review utilizing the PsycInfo, PubMed, and China Knowledge Resource Integrated databases as well as additional literature search through citations. We performed evaluations of the existing norms based on their test selection, cognitive domains covered, sample size, language, regions of participant recruitment, stratification by age/gender/education levels, and reporting of other psychometric properties. We focused on articles that included performance-based tests for adults but excluded those with purely clinical norms or from commercial publishers.

RESULTS

We reviewed 1155 articles found through literature search and identified 43 articles reporting normative data for this population that met our inclusion criteria. Sixty-five distinctive tests and 127 versions were covered. The results are presented within two detailed tables organized by articles and tests, respectively.

CONCLUSIONS

We discussed the strengths and limitations of these normative reports. Practitioners are recommended to utilize normative data that most closely approximate a test-taker's cultural and demographic backgrounds. Limitations of the current review are also discussed.

Social cognition in neuropsychology: A nationwide survey revealing current representations and practices

As a key domain of cognition, social cognition abilities are altered in a wide range of clinical groups. Accordingly, many clinical tests and theories of social cognition have been developed these last decades. Contrasting this abundant development from a research perspective, recent evidence suggests that social cognition remains rarely addressed from a clinial perspective. The aim of the present research was to characterize the current practices, representations, and needs linked to social cognition from the perspective of professional neuropsychologists and graduate students. A nationwide survey allowed us to determine the classical field conception of social cognition and its associated symptoms or notions. It also allowed us to quantify practice activities and the use of the different clinical tools available. This study revealed that neuropsychologists lack confidence regarding social cognition assessment and its rehabilitation, and that students are in demand for more knowledge and training. Suggestions of change in practices and dissemination of knowledge are discussed. Considering the importance of social cognition, an extension of initial and continuous training alongside an enrichment of interactions between researchers and clinicians were key recommendations to formulate, as well as the need for a consensual lexicon of current concepts.

Status of Clinical Neuropsychology Training in Finland

This paper provides information on different training models within clinical neuropsychology in Finland. Systematic specialization training program began in Finland in 1983. It was first organized mainly by the Finnish Neuropsychological Society and since 1997 by the Finnish universities. At present, close to 400 clinical neuropsychologists have completed the training. The number of professionals still does not cover the needs of the country (population 5.5 million, area 338,440 km2), and geographical disparities are a constant concern. The training models in Finland have changed over the years and will continue to evolve. Specialization training can be organized by national societies or by universities. It can lead to an academic degree or a diploma. It can be linked to doctoral studies or form a parallel track. Financial model can involve student fees or be governed by ministries (such as the Ministry of Education or Ministry of Health). This paper describes and compares different strategies in education that have impact on the output of professionals. One model does not fit all, or even one country at all times. The strategies of the stakeholder ministries can change over time. The experiences from Finland can be useful for other countries that are developing their models. The estimated need of practitioners and the educational resources including the available financial models for training differ between countries. The guiding principles in specialist training should focus on the advanced competencies expected from the neuropsychologist when entering the profession.

Global Perspectives on Brief Cognitive Assessments for Dementia Diagnosis

BACKGROUND

Timely diagnosis of dementia is a global healthcare priority, particularly in low to middle income countries where rapid increases in older adult populations are expected.

OBJECTIVE

To investigate global perspectives on the role of brief cognitive assessments (BCAs) in dementia diagnosis, strengths and limitations of existing measures, and future directions and needs.

METHODS

This is a qualitative study of 18 dementia experts from different areas of the world. Participants were selected using purposeful sampling based on the following criteria: 1) practicing in countries with projected growth of older adult population of over 100%by 2050; 2) expertise in dementia diagnosis and treatment; 3) involvement in clinical practice and training; and 4) recognition as a national dementia expert based on leadership positions within healthcare system, research, and/or policy work. Participants were individually interviewed in their language of choice over secure videoconference sessions. Interviews were analyzed by a multidisciplinary team using theme identification approach.

RESULTS

Four domains with subthemes emerged illustrating participants' perspectives: 1) strengths of BCAs; 2) limitations of BCAs; 3) needs related to the use of BCAs; and 4) characteristics of an ideal BCA. While most experts agreed that BCAs were important and useful for dementia diagnosis, the themes emphasized the need for development and validation of novel measures that are sensitive, psychometrically sound, and culturally appropriate.

CONCLUSION

BCAs are important for guiding diagnosis and care for dementia patients. Findings provide a roadmap for novel BCA development to assist in diagnostic decision making for clinicians serving a rapidly growing and diverse dementia population.

Clinical Neuropsychology as a Specialist Profession in European Health Care: Developing a Benchmark for Training Standards and Competencies Using the Europsy Model?

The prevalence and negative impact of brain disorders are increasing. Clinical Neuropsychology is a specialty dedicated to understanding brain-behavior relationships, applying such knowledge to the assessment of cognitive, affective, and behavioral functioning associated with brain disorders, and designing and implementing effective treatments. The need for services goes beyond neurological diseases and has increased in areas of neurodevelopmental and psychiatric conditions, among others. In Europe, a great deal of variability exists in the education and training of Clinical Neuropsychologists. Training models include master’s programs, continuing education courses, doctoral programs, and/or post-doctoral specialization depending on the country, with no common framework of requirements, although patients’ needs demand equal competencies across Europe. In the past 5 years, the Standing Committee on Clinical Neuropsychology of the European Federation of Psychologists’ Association has conducted a series of surveys and interviews with experts in the field representing 30 European countries. The information, along with information from the existing literature, is used in presenting an overview of current and relevant topics related to policy and guidelines in the training and competencies in Clinical Neuropsychology. An option for the way forward is the EuroPsy Specialist Certificate, which is currently offered in Work and Organizational Psychology, and in psychotherapy. It builds upon the basic certificate and complements national standards without overriding them. General principles can be found that can set the basis for a common, solid, and comprehensive specialty education/training, sharpening the Neuropsychologists’ competencies across Europe. The requirements in Clinical Neuropsychology should be comparable to those for the existing specialty areas in the EuroPsy model. Despite the perceived challenges, developing a specialist certificate appears a step forward for the development of Clinical Neuropsychology. Recommendations are proposed toward a shared framework of competencies by the means of a common level of education/training for the professionals in Europe. Benchmarking training standards and competencies across Europe has the potential of providing protection against unqualified and ethically questionable practice, creating transparency, raising the general European standard, and promoting mobility of both Clinical Neuropsychologists and patients in Europe, for the benefit of the professional field and the population.

Clinical Neuropsychology: Status in Western Countries and Potential in Lithuania

We present an overview of the development of clinical neuropsychology, the current status of the specialty of clinical neuropsychology in Western countries, and the possibilities of developing this specialty in Lithuania. The main duties of a clinical neuropsychologist are to perform neuropsychological assessments and clinical interventions. Clinical neuropsychologists working within health care are professionals who offer services to patients across the lifespan with cognitive and behavioral/emotional symptoms related to neurological, developmental, and psychiatric disorders. Specialists of clinical neuropsychology are needed in neurology and psychiatry clinics, in centers of mental health and rehabilitation, and institutions of psychological assessment and education of children. The specialization models of clinical neuropsychology in Europe and North America are similar in their content and requirements for courses and practice. Nevertheless, specialist education in most of European countries is related to clinical training and not an academic degree, as it is in the USA and Canada. The duration of specialist education in clinical neuropsychology in Europe varies, but this education can only be started after acquiring a Master’s degree in most of the European countries. The regulation of the specialty of clinical neuropsychology in Europe also varies. In some countries, this specialty is fully legally regulated, and in some countries not regulated at all. For specialization in clinical neuropsychology, the license of a psychologist, enabling an individual to work in the health care system of the country, is required in most Western countries. Taking into consideration the Scandinavian experience, it can be expected that the planning of specialization studies in Lithuania would be easier if the licensing of psychologists would be regulated. Today, traditional specializations of psychology in Lithuania may be obtained through Master’s degree studies, i.e., a specialized Master’s diploma compensates a license and any need of further specialization. This Lithuanian tradition is not in accord with the EuroPsy politics of obtaining a diploma: a Master’s diploma is acquired within 6 years of studies, and, after these studies, specialization is continued for a few more years (participation in specialized courses, performance of supervised practice). The model of specialization in clinical neuropsychology in Lithuania should be developed in accordance with international standards of neuropsychology, which are in constant development. In Western countries, the knowledge and skills of clinical and health psychology are considered to be an important part of the specialist education in clinical neuropsychology. Therefore, two years of Master’s studies in clinical neuropsychology would not be sufficient when preparing competent clinical neuropsychologists, unless it is combined with a supervised neuropsychological practice of a defined duration. A doctoral degree is required for neuropsychological practice in the USA, but it is usually not required in Europe. In Lithuania, such a tradition for other specializations of psychology does not exist either, which suggests that a doctoral degree should not be necessary for the specialty of clinical neuropsychology as well. Nevertheless, like in Western countries, supervised clinical neuropsychological practice should be a necessary part of the specialists’ education in clinical neuropsychology.

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.

Modern neuropsychological tests for a diversity of cultural contexts

OBJECTIVE

The appropriateness of the current neuropsychological tests for the assessment of different populations has been questioned. In this issue several articles have proposed the modernization of neuropsychological testing by incorporating modern technological devices such as computers, mobile phones, or tablets. This is a commentary on the articles contained in the special issue about the inclusion of modern assessment methods that can be properly used around the world and not only in technologically/economically advanced countries.

METHODS

The author of this article reviewed the articles included in the special issue with the goal of commenting on whether the new approaches proposed would have global relevance and applicability.

RESULTS

The use of biomedical databases and modern technological devices such as computers, wearables and tablets might not be available in many countries, thus leading to a situation in which modern neuropsychological tests might be available only in some world regions. In addition, because in many countries there are large percentages of population with low education these modern neuropsychological tests might not be appropriate for them. Finally, tests developed with culturally specific stimuli will not be applicable in some cultures.

CONCLUSION

This article provides an overview of several issues that should be considered to make neuropsychological tests both modern and accessible around the world, more specifically the cross-cultural appropriateness and accessibility for low educated individuals and availability in low/middle income regions.

Training models and status of clinical neuropsychologists in Europe: Results of a survey on 30 countries

OBJECTIVE

The aims of the study were to analyze the current European situation of specialist education and training within clinical neuropsychology, and the legal and professional status of clinical neuropsychologists in different European countries.

METHOD

An online survey was prepared in 2016 by a Task Force established by the European Federation of Psychological Associations, and representatives of 30 countries gave their responses. Response rate was 76%.

RESULTS

Only three countries were reported to regulate the title of clinical neuropsychologist as well as the education and practice of clinical neuropsychologists by law. The most common university degree required to practice clinical neuropsychology was the master's degree; a doctoral degree was required in two countries. The length of the specialist education after the master's degree varied between 12 and 60 months. In one third of the countries, no commonly agreed upon model for specialist education existed. A more systematic training model and a longer duration of training were associated with independence in the work of clinical neuropsychologists.

CONCLUSIONS

As legal regulation is mostly absent and training models differ, those actively practicing clinical neuropsychology in Europe have a very heterogeneous educational background and skill level. There is a need for a European standardization of specialist training in clinical neuropsychology. Guiding principles for establishing the common core requirements are presented.

Core competencies in clinical neuropsychology training across the world

OBJECTIVE

This work aimed to review main competency requirements from training models in countries with well-established specialties in clinical neuropsychology and to extract core competencies that likely will apply to clinical neuropsychologists regardless of regional and cultural context.

METHOD

We reviewed standards for post-graduate training in clinical neuropsychology from countries in Europe, Australia, and North America based on existing literature, presentations at international conferences, and from description of the training models from national psychological or neuropsychological associations.

RESULTS

Despite differences, the reviewed models share similar core competencies considered necessary for a specialty in clinical neuropsychology: (1) In-depth knowledge of general psychology including clinical psychology (post-graduate level), ethical, and legal standards. (2) Expert knowledge about clinically relevant brain-behavioral relationships. (3) Comprehensive knowledge about, and skills in, related clinical disciplines. (4) In-depth knowledge about and skills in neuropsychological assessment, including decision-making and diagnostic competency according to current classification of diseases. (5) Competencies in the area of diversity and culture in relation to clinical neuropsychology. (6) Communication competency of neuropsychological findings and test results to relevant and diverse audiences. (7) Knowledge about and skills in psychological and neuropsychological intervention, including treatment and rehabilitation.

CONCLUSIONS

All the models have undergone years of development in accordance with requirements of national health care systems in different parts of the world. Despite differences, the common core competency requirements across different regions of the world suggest generalizability of these competencies. We hope this summary can be useful as countries with less established neuropsychology training programs develop their models.