Training in Neurorehabilitation Psychology: Defining Competencies, Requisite Skill Sets, and a Proposed Developmental Pathway

Psychologists have been applying neurorehabilitation models of care for many years. These practitioners come from different training backgrounds and use a variety of titles to refer to themselves despite considerable overlap in practice patterns, professional identification, and salary. Titles like 'neurorehabilitation psychologist' and 'rehabilitation neuropsychologist' are sometimes used by practitioners in the field to indicate their specialty area, but are not formally recognized by the American Psychological Association, the American Board of Professional Psychology, or by training councils in clinical neuropsychology (CN) or rehabilitation psychology (RP). Neither the CN or RP specialties alone fully address or define the competencies, skill sets, and clinical experiences required to provide high quality, comprehensive neurorehabilitation psychology services across settings. Therefore, irrespective of practice setting, we believe that both clinical neuropsychologists and rehabilitation psychologists should ideally have mastery of specific, overlapping competencies and a philosophical approach to care that we call neurorehabilitation psychology in this paper. Trainees and early career professionals who aspire to practice in this arena are often pressured to prioritize either CN or RP pathways over the other, with anxiety about perceived and real potential for falling short in their training goals. In the absence of an explicit training path or formal guidelines, these professionals emerge only after the opportunity, privilege, or frank luck of working with specific mentors or in exceptional patient care settings that lend themselves to obtaining integrated competencies in neurorehabilitation psychology. This paper reflects the efforts of 7 practitioners to preliminarily define the practice and philosophies of neurorehabilitation psychology, the skill sets and competencies deemed essential for best practice, and essential training pathway elements. We propose competencies designed to maximize the integrity of training and provide clear guideposts for professional development.

Survey of evaluation policies and procedures in clinical neuropsychology postdoctoral fellowship programs

OBJECTIVE

The objectives of this study were to examine current procedures that are used to evaluate competency development in clinical neuropsychology at the postdoctoral level and to investigate policies and procedures for the management of performance that is below expectations during the postdoctoral fellowship.

METHOD

Clinical neuropsychology fellowship program directors were invited via email with multiple reminders to participate in an online survey between 1/26/2023 and 3/31/2023.

RESULTS

Most programs administer a competency-based written evaluation of fellow performance (92%) and have a written policy for managing performance that is below expectations (86%). However, greater variability was reported regarding the use of other evaluation tools, including fellow self-assessments (46% of programs), program evaluations (57% of programs), supervisor evaluations (73% of programs), and exit interviews (82% of programs). Moreover, there was variability between programs with regard to the specific competencies that were measured and how performance that is below expectations is managed.

CONCLUSIONS

Competency-based evaluations and clear, written policies and procedures for management of performance that is below expectations are recommended. Such tools and policies provide clear expectations for fellowship outcomes, promote regular communication between fellows and supervisors, foster early identification of gaps in training, facilitate program quality improvement, and increase opportunities to support and intervene during the course of fellowship training.

Competencies unique to clinical neuropsychology: A consensus statement of educators, practitioners, and professional leaders in Australia

Objective: To delineate the unique role of clinical neuropsychologists in contemporary Australian clinical practice and present a comprehensive consensus-based set of clinical neuropsychology competencies to guide and standardize the training of clinical neuropsychologists. Method: Twenty-four national representatives of the clinical neuropsychology profession (71% female, M = 20.1, SD = 8.1 years clinical practice), including tertiary-level educators, senior practitioners and members of the executive committee of the peak national neuropsychology body, formed the Australian Neuropsychology Alliance of Training and Practice Leaders (ANATPL). Informed by a review of existing international competency frameworks and Australian Indigenous psychology education frameworks, a provisional set of competencies for clinical neuropsychology training and practice were developed, followed by 11 rounds of feedback and revisions. Results: The final set of clinical neuropsychology competencies achieved full consensus and falls into three broad categories: generic foundational (i.e. general professional psychology competencies applied to clinical neuropsychology); specific functional (i.e. specific to clinical neuropsychology areas of practice) competencies relevant to all career stages; and functional competencies relevant to advanced career stages. Competencies span a number of knowledge and skill-based domains including neuropsychological models and syndromes, neuropsychological assessment, neuropsychological intervention, consultation, teaching/supervision and management/administration. Conclusion: The competencies reflect recent advances in the field of clinical neuropsychology, including expanded intervention competencies, culturally-informed neuropsychological practice and use of emerging technologies. They will be available as a resource to guide curriculum development for clinical training, as well as providing a useful framework for professional practice and advocacy more broadly within the discipline of clinical neuropsychology.

Development and testing of an intervention to increase staff knowledge and confidence in responding to health anxiety in the context of cognitive decline: a pilot study

BACKGROUND

Memory complaint in the absence of organic pathology is a common phenomenon accounting for up to one third of patients presenting to memory clinics. Health anxiety has been specifically linked to dementia worry and repeated presentations to the National Health Service (NHS). Providing reassurance that an individual does not have dementia appears ineffective in reducing presentations to primary and secondary care services.

AIMS

This study sought to evaluate and establish the effectiveness of a 1-hour pilot training workshop to enhance healthcare professionals' knowledge and confidence to those with health anxiety around cognitive decline.

METHOD

The one-session pilot training workshop was developed and informed by previous work and consultation with the 2Gether NHS Foundation Trust Memory Assessment Service staff. The training workshop was then evaluated by employing an idiosyncratic self-report questionnaire. Participants completed the questionnaire prior to and after the training workshop.

RESULTS

Pre- and post-training questionnaires revealed that the pilot training workshop was effective in increasing perceived knowledge and confidence in staff responding to patients presenting with health anxiety and co-occurring subjective memory complaints.

CONCLUSIONS

The findings suggest that healthcare professionals may benefit from training in identifying and addressing health-anxious individuals with subjective memory complaints. This may have implications in the provision of psychologically informed care offered in a memory assessment service. Recommendations are made for further enhancing the effectiveness of staff training and promoting alternative service treatment pathways.

Recent Advances in Neuropsychological Test Interpretation for Clinical Practice

Much attention in the field of clinical neuropsychology has focused on adapting to the modern healthcare environment by advancing telehealth and promoting technological innovation in assessment. Perhaps as important (but less discussed) are advances in the development and interpretation of normative neuropsychological test data. These techniques can yield improvement in diagnostic decision-making and treatment planning with little additional cost. Brooks and colleagues (Can Psychol 50: 196-209, 2009) eloquently summarized best practices in normative data creation and interpretation, providing a practical overview of norm development, measurement error, the base rates of low scores, and methods for assessing change. Since the publication of this seminal work, there have been several important advances in research on development and interpretation of normative neuropsychological test data, which may be less familiar to the practicing clinician. Specifically, we provide a review of the literature on regression-based normed scores, item response theory, multivariate base rates, summary/factor scores, cognitive intraindividual variability, and measuring change over time. For each topic, we include (1) an overview of the method, (2) a rapid review of the recent literature, (3) a relevant case example, and (4) a discussion of limitations and controversies. Our goal was to provide a primer for use of normative neuropsychological test data in neuropsychological practice.

Nonverbal memory tests revisited: Neuroanatomical correlates and differential influence of biasing cognitive functions

The detection of right temporal lobe dysfunction with nonverbal memory tests has remained difficult in the past. Reasons for this might be the potential influence of other biasing cognitive functions such as executive functions or the verbalisability of nonverbal material. The aim of this study was to investigate three classic nonverbal memory tests by identifying their neuroanatomical correlates with lesion-symptom mapping (LSM) and by probing their independence from verbal encoding abilities and executive functions. In a cohort of 119 patients with first-time cerebrovascular accident, memory performance was assessed in the Nonverbal Learning and Memory Test for Routes (NLMTR), the Rey Complex Figure Test (RCFT), and the Visual Design Learning Test (VDLT). Calculating multivariate LSM, we identified crucial brain structures for these three nonverbal memory tests. Behavioural analyses were performed to assess the impact of executive functions and verbal encoding abilities with regression analyses and likelihood-ratio tests. LSM revealed for the RCFT mainly right-hemispheric frontal, insular, subcortical, and white matter structures and for the NLMTR right-hemispheric temporal (hippocampus), insular, subcortical, and white matter structures. The VDLT did not reach significance in LSM analyses. Behavioural results showed that amongst the three nonverbal memory tests the impact of executive functions was most pronounced for RCFT, and the impact of verbal encoding abilities was most important in VDLT. Likelihood-ratio tests confirmed that only for NLMTR did the goodness of fit not significantly improve by adding executive functions or verbal encoding abilities. These results suggest that amongst the three nonverbal memory tests the NLMTR, as a spatial navigation test, could serve as the most suitable marker of right-hemispheric temporal lobe functioning, with the right hippocampus being involved only in this test. In addition, the behavioural results propose that only NLMTR seems mostly unaffected by executive functions and verbal encoding abilities.

Accelerated long-term forgetting of recall and recognition memory in people with epilepsy

PURPOSE

Persons with epilepsy (PWE) report memory deficits as one of the most distressing aspects of their disorder. Recently, a long-term memory deficit known as Accelerated Long-Term Forgetting (ALF) has been described in PWE. ALF is characterized by the initial retention of learned information, followed by an accelerated rate of memory decay. However, the rate of ALF varies widely across literature and it is unclear how it impacts different memory retrieval types. The current study aimed to capture the time course of ALF on both free recall and recognition memory using a movie-based task in PWE.

METHODS

A sample of 30 PWE and 30 healthy comparison (HC) subjects watched a nature documentary and were tested on their recall and recognition of the film's content immediately after viewing and at delays of 24 hours, 48 hours, and 72 hours. Participants also rated the confidence they had in their recognition memory trial responses.

RESULTS

For recall, PWE exhibit ALF at 72 hours (β = -19.840, SE = 3.743, z(226) = -5.301, p < 0.001). For recognition, PWE had decreased performance compared to controls at the 24-hour (β = -10.165, SE = 4.174, z(224) = -3.166, p = 0.004), 48-hour (β = -8.113, SE = 3.701, z(224) = -2.195, p = 0.044), and 72-hour (β = -10.794, SE = 3.017, z(224) = -3.295, p = 0.003) delays. The PWE group showed positive correlations (tau = 0.165, p < 0.001) between confidence ratings and accuracy, with higher confidence reflecting successful recognition. PWE were 49% less likely to answer either retrieval type correctly at 72 hours (OR 0.51, 95% CI [0.35, 0.74], p < 0.001). Left hemispheric seizure onset decreased the odds of successful retrieval by 88% (OR 0.12, 95% CI [0.01, 0.42], p = 0.019).

CONCLUSIONS

These findings provide evidence of ALF in PWE, with a differential impact on recall and recognition memory. This further supports the call to include ALF assessments in standard memory evaluations in PWE. Additionally, identifying the neural correlates of ALF in the future will be important in developing targeted therapies to alleviate the burden of memory impairment for PWE.

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.

Individuals with Wiedemann-Steiner syndrome show nonverbal reasoning and visuospatial defects with relative verbal skill sparing

OBJECTIVES

Wiedemann-Steiner syndrome (WSS) is a rare Mendelian disorder of the epigenetic machinery caused by heterozygous pathogenic variants in KMT2A. Currently, the specific neurocognitive profile of this syndrome remains unknown. This case series provides insight into the cognitive phenotype of WSS.

METHODS

This study involves a retrospective medical chart review of 10 pediatric patients, each with a molecularly confirmed diagnosis of WSS who underwent clinical neuropsychological evaluation at an academic medical center.

RESULTS

The majority of patients performed in the below average to very low ranges in Nonverbal Reasoning, Visual/Spatial Perception, Visuoconstruction, Visual Memory, Attention, Working Memory and Math Computation skills. In contrast, over half the sample performed within normal limits on Receptive Vocabulary, Verbal Memory, and Word Reading. Wilcoxon signed rank test showed weaker Nonverbal versus Verbal Reasoning skills (p = .005). Most caregivers reported deficits in executive functioning, most notably in emotion regulation.

CONCLUSIONS

Nonverbal reasoning/memory, visuospatial/construction, attention, working memory, executive functioning, and math computation skills are areas of weakness among those with WSS. These findings overlap with research on Kabuki syndrome, which is caused by variants in KMT2D, and suggest disruption in the neurogenesis of the hippocampal formation may drive shared pathogenesis of the two syndromes.

Why Biological Psychiatry Hasn't Delivered Yet - and Why Neurology Knows

It is increasingly recognized that neuroscience has not delivered the revolutionary clinical possibilities for psychiatry that had been promised. Explanations differ, however: some proponents emphasize the divide between biopsychosocial psychiatry and mechanistic neurology. Others rely on further basic experimental neuroscience as only the most elementary level of explanation will allow us to fully understand and treat mental disorders. From a clinical-neuropsychological perspective, I shall argue that both views are mistaken. Diagnosis and treatment of neurological diseases demands a biopsychosocial perspective similar to psychiatry. Acknowledging this might help to bring both disciplines together and improve clinical outcome.

Montreal Cognitive Assessment as Screening Measure for Mild and Major Neurocognitive Disorder in a Chilean Population

Background

The Montreal Cognitive Assessment (MoCA) is a sensitive screening instrument for mild neurocognitive disorder (mild NCD). However, cut-off scores and accuracy indices should be established using representative samples of the population. In this context, the aim of this study was to update the normative values, and diagnostic efficiency statistics of the MoCA to detect mild NCD in the Chilean population.

Methods

This study included 226 participants from the north, center, and south of the country, classified into 3 groups: healthy elderly (HE; n = 113), mild NCD (n = 65), and major neurocognitive disorder (major NCD; n = 48).

Results

The optimal cut-off score to discriminate mild NCD from HE participants was 20 points with a sensitivity of 82.8% and a specificity of 84.1%. The observed balance between sensitivity and specificity shows a good test performance either to confirm or discard a diagnosis. The cut-off between mild NCD and major NCD from HE participants was 19 points with 85.6% of sensitivity and 90.3% of specificity.

Conclusion

Overall diagnostic accuracy can be considered as outstanding (AUC ≥0.904) when discriminating HE from both mild NCD and major NCD. These results showed that the MoCA is a suitable tool to identify mild NCD and major NCD.

The Factor Structure of Cognitive Functioning in Cognitively Healthy Participants: a Meta-Analysis and Meta-Analysis of Individual Participant Data

Many neuropsychologists are of the opinion that the multitude of cognitive tests may be grouped into a much smaller number of cognitive domains. However, there is little consensus on how many domains exist, what these domains are, nor on which cognitive tests belong to which domain. This incertitude can be solved by factor analysis, provided that the analysis includes a broad range of cognitive tests that have been administered to a very large number of people. In this article, two such factor analyses were performed, each combining multiple studies. However, because it was not possible to obtain complete multivariate data on more than the most common test variables in the field, not all possible domains were examined here. The first analysis was a factor meta-analysis of correlation matrices combining data of 60,398 healthy participants from 52 studies. Several models from the literature were fitted, of which a version based on the Cattell-Horn-Carroll (CHC) model was found to describe the correlations better than the others. The second analysis was a factor analysis of the Advanced Neuropsychological Diagnostics Infrastructure (ANDI) database, combining scores of 11,881 participants from 54 Dutch and Belgian studies not included in the first meta-analysis. Again, the model fit was better for the CHC model than for other models. Therefore, we conclude that the CHC model best characterizes both cognitive domains and which test belongs to each domain. Therefore, although originally developed in the intelligence literature, the CHC model deserves more attention in 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.

Education and Training in Clinical Neuropsychology: Recent Developments and Documents From the Clinical Neuropsychology Synarchy

The Clinical Neuropsychology Synarchy (CNS) interfaces with the American Psychological Association and affiliated organizations to address issues and advances in specialty training. The past several years have seen the development and dissemination of several initiatives pertinent to specialty training. Among these initiatives was the creation of a taxonomy for education and training in clinical neuropsychology. In additional there has been a movement towards competency-based education that has become codified in the APA’s new Standards for Accreditation. Calls for competency-based education have also influenced the expectations of the APA’s Committee on Recognition of Specialties and Proficiencies in Professional Psychology. As the convener of national clinical neuropsychology organizations the CNS has overseen the development of relevant documents for our specialty. This paper presents three documents critical to training in our field that were developed through the CNS and approved by its member organizations. The first is the Taxonomy for Education and Training in Clinical Neuropsychology. The second is Entry Level Competencies for Clinical Neuropsychology and the third is a distillation of the entry-level competency document for the purpose of identifying competencies to be addressed at the post-doctoral residency level.

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.

Longitudinal predictors of caregiver burden in amyotrophic lateral sclerosis: a population-based cohort of patient-caregiver dyads

OBJECTIVE

Caregiver burden is a recognised consequence of caring for a patient with neurodegeneration. Amyotrophic lateral sclerosis (ALS) differs from other neurodegenerations by its rapid progression and impairment of motor, cognitive, and behavioural function, which contribute to caregiver burden. However, longitudinal factors that determine the extent of caregiver burden, and in particular the impact of psychological distress among caregivers, have not been fully established.

METHODS

Patients with ALS (n = 85) and their primary caregivers (n = 85) completed three serial evaluations. Caregiver burden was measured using the Zarit Burden Interview (ZBI). Anxiety and depression were evaluated using the Hospital Anxiety and Depression Scale (HADS). The Edinburgh Cognitive-Behavioural ALS Screen (ECAS) was used to determine cognitive function in patients. The ALS Functional Rating Scale (ALSFRS-R) measured disease progression.

RESULTS

Using the ZBI, caregivers were categorised as high or low burden. In the low burden group, anxiety scores from the HADS predicted caregiver burden (r = 0.410, F = 3.73, p = 0.033), whereas the depression sub-score from the HADS was predictive of caregiver burden in the high burden group (r = 0.501, F = 5.87, p = 0.006) for cross-sectional analyses. Longitudinally, an elevated score on the HADS at Time 1 was the largest predictor of caregiver burden across serial assessments.

CONCLUSION

In a patient cohort with relatively preserved cognitive function (65%), anxiety and depression at Time 1, as measured by the HADS, were the best predictors of caregiver burden at Time 3. This observation provides a mechanism by which caregiver burden can be identified by health-care professionals and a stepped care programme of intervention initiated.

The practice of clinical neuropsychology in Australia

OBJECTIVE

This paper describes the development and practice of clinical neuropsychology in Australia.

METHOD

Clinical Neuropsychology has shown rapid growth in Australia over the past three decades. Comprehensive and specialized training programs are producing high quality graduates who are employed in a broad range of settings or private practice.

RESULTS

Australia now has a substantial number of clinical neuropsychologists with specialist training. Whilst the majority of Australian clinical neuropsychologists still undertake assessment predominantly, there are growing opportunities for clinical neuropsychologists in rehabilitation and in a broad range of research contexts. Cultural issues relating to the assessment of Indigenous Australians and immigrants from many countries present significant challenges. Some major contributions have been made in the realms of test development and validation across various age groups. Australian clinical neuropsychologists are also contributing significantly to research in the fields of traumatic brain injury, aging and dementias, epilepsy, memory assessment, rehabilitation, substance abuse, and other psychiatric disorders.

CONCLUSION

Expansion of roles of clinical neuropsychologists, in domains such as rehabilitation and research is seen as essential to underpin continuing growth of employment opportunities for the profession.

Neuropsychology in Finland - over 30 years of systematically trained clinical practice

OBJECTIVE

The aim of this invited paper for a special issue of international practice in The Clinical Neuropsychologist is to provide information on training models, clinical practice, and professional issues within neuropsychology in Finland.

METHOD

Relevant information was gathered via literature searches, a survey by the Neuropsychology Working Group of the Finnish Psychological Association, archives of the Finnish Neuropsychological Society, and personal communication with professionals in Finland.

RESULTS

The roots of Finnish neuropsychology are linked to the early German tradition of experimental psychology. Since the 1970s, it has been strongly influenced by both the psychometric approach in the U.S. and the qualitative approach by Luria. Systematic specialization training program began in Finland in 1983. It was first organized by the Finnish Neuropsychological Society and since 1997 by Finnish universities. At present, around 260 neuropsychologists have completed this training. According to the survey by the Finnish Psychological Association in 2014, 67% of Finnish neuropsychologists work in the public sector, 36% in the private sector, and 28% reported that they had private practice. Work includes assessments for 90% of the respondents, rehabilitation for 74%, and many are involved in teaching and research. Of the respondents, 20% worked both with adults and children, 44% with adults only and 36% with children only. Within test development, pediatric neuropsychology is an especially prominent field.

CONCLUSIONS

A unique blend of approaches and a solid systematic training tradition has led to a strong position of neuropsychologists as distinguished experts in the Finnish health care system.

Clinical neuropsychology practice and training in Canada

OBJECTIVE

This invited paper provides information about professional neuropsychology issues in Canada and is part of a special issue addressing international perspectives on education, training, and practice in clinical neuropsychology.

METHOD

Information was gathered from literature searches and personal communication with other neuropsychologists in Canada.

RESULTS

Canada has a rich neuropsychological history. Neuropsychologists typically have doctoral-level education including relevant coursework and supervised practical experience. Licensure requirements vary across the 10 provinces and there are regional differences in salary. While training at the graduate and internship level mirrors that of our American colleagues, completion of a two-year postdoctoral fellowship in neuropsychology is not required to obtain employment in many settings and there are few postdoctoral training programs in this country. The majority of neuropsychologists are employed in institutional settings (e.g. hospitals, universities, rehabilitation facilities), with a growing number entering private practice or other settings. There are challenges in providing neuropsychological services to the diverse Canadian population and a need for assessment measures and normative data in multiple languages.

CONCLUSIONS

Canadian neuropsychologists face important challenges in defining ourselves as distinct from other professions and other psychologists, in maintaining funding for high-quality training and research, in establishing neuropsychology-specific training and practice standards at the provincial or national level, and ensuring the clinical care that we provide is efficient and effective in meeting the needs of our patient populations and consumers, both within and outside of the publically funded health care system.

Clinical neuropsychology in Israel: history, training, practice and future challenges

OBJECTIVE

This is an invited paper for a special issue on international perspectives on training and practice in clinical neuropsychology. We provide a review of the status of clinical neuropsychology in Israel, including the history of neuropsychological, educational, and accreditation requirements to become a clinical neuropsychologist and to practice clinical neuropsychology.

METHOD

The information is based primarily on the personal knowledge of the authors who have been practicing clinical neuropsychology for over three decades and hold various administrative and academic positions in this field. Second, we conducted three ad hoc surveys among clinical and rehabilitation psychologists; heads of academic programs for rehabilitation and neuropsychology; and heads of accredited service providers. Third, we present a literature review of publications by clinical neuropsychologists in Israel.

RESULTS

Most of the clinical neuropsychologists are graduates of either rehabilitation or clinical training programs. The vast majority of neuropsychologists are affiliated with rehabilitation psychology. The training programs (2-3 years of graduate school) provide solid therapeutic and diagnostic skills to the students. Seventy-five percent of the participants in this survey are employed at least part-time by public or state-funded institutions. Israeli neuropsychologists are heavily involved in case management, including vocational counseling, and rehabilitation psychotherapy. Conclusions and future goals: Although clinical neuropsychologists in Israel are well educated and valued by all health professionals, there are still several challenges that must be addressed in order to further advance the field and the profession. These included the need for Hebrew-language standardized and normalized neuropsychological tests and the application of evidence-based interventions in neuropsychological rehabilitation.

Kurt Goldstein's test battery

Kurt Goldstein was a founder of clinical neuropsychology. This thesis is illustrated with a description of Goldstein's test battery that he used as a screening instrument in a special clinic for soldiers in World War I. Parts of the battery were also used for neuropsychological rehabilitation. Goldstein's early work in Germany focused on both neuropsychological assessment and rehabilitation. He was interested in how individuals go about compensating for their deficits, The notion of ecological validity (Lebenswahr vs Lebensfremd), only becoming widely popular in the nineteen-eighties, played an important role in Goldstein's selection of test procedures.

A 54-point verbal-performance IQ discrepancy on the WISC-R: cognitive functioning of a child from an alternative school

Marked WISC-R verbal-performance discrepancy commonly leads to the assumption that such children have brain pathology or cognitive disorders. Children without brain dysfunction may also exhibit wide discrepancy, but a discrepancy score of 30 is assumed to occur in only 2% of the population. The actual investigation presents an 11-year-old child showing a 54-point discrepancy between the two scales of the WISC-R. Results of wide ranging testing and other considerations strongly suggested that this child didn't manifest any kind of brain dysfunction. It was concluded that the particular academic environment of the child, an alternative school, exerted a very strong influence on her results on the WISC-R. This conclusion is furthermore supported by the results of a follow-up evaluation, done 1 year after the child has been transferred to a traditional school, which revealed a WISC-R verbal-performance discrepancy of only 12 points.