Faculty Bibliography

Practical experience is central to the education and training of neuropsychologists, beginning in graduate school and extending through postdoctoral fellowship. However, historically, little attention has been given to the structure and requirements of practicum training in clinical neuropsychology. A working group of senior-level neuropsychologists, as well as a current postdoctoral fellow, all from a diverse range of settings (The AACN Practicum Guidelines Workgroup), was formed to propose guidelines for practicum training in clinical neuropsychology. The Workgroup reviewed relevant literature and sought input from professional organizations involved in education and training in neuropsychology. The proposed guidelines provide a definition of practicum training in clinical neuropsychology, detail entry and exit criteria across competencies relevant to practicum training in clinical neuropsychology, and discuss the relationship between doctoral training programs and practicum training sites. The proposed guidelines also provide a methodology for competency-based evaluation of clinical neuropsychology practicum trainees and outline characteristics and features that are integral to an effective training environment. Although the guidelines discussed below may not be implemented in their entirety across all clinical neuropsychology practicum training sites, they are consistent with the latest developments in competency-based education.

OBJECTIVE: The Standardized Assessment of Concussion (SAC) is a standardized mental status screening instrument initially developed for assessment and tracking of concussion symptoms in athletes. The purpose of the current study was to validate the utility of the SAC as an embedded screening measure for insufficient effort in independent medical examinations (IME) and personal injury cases. METHOD: A known-groups design was used to examine the SAC's utility for the detection of insufficient effort in 75 de-identified private IME and civil litigation evaluations. Initial classifications of insufficient effort were made independently of SAC scores, on the basis of having two or more scores falling below established cut-offs on previously validated neuropsychological measures. RESULTS: Results suggest that the total score on the SAC significantly distinguishes effortful respondents from those exhibiting insufficient effort. Empirically derived cut-off scores yielded adequate sensitivity (.62-.95) and negative predictive power (.93-.97). CONCLUSIONS: While optimal cut-off scores depend upon intended use, our data suggest that the SAC is useful as a potential screener for insufficient effort, after which one can employ additional measures to rule out false-positives. Further research is required before cut-off scores can be recommended for clinical use.

The effect of transcranial direct current stimulation (tDCS) is cumulative. Treatment protocols typically require multiple consecutive sessions spanning weeks or months. However, traveling to clinic for a tDCS session can present an obstacle to subjects and their caregivers. With modified devices and headgear, tDCS treatment can be administered remotely under clinical supervision, potentially enhancing recruitment, throughput, and convenience. Here we propose standards and protocols for clinical trials utilizing remotely-supervised tDCS with the goal of providing safe, reproducible and well-tolerated stimulation therapy outside of the clinic. The recommendations include: (1) training of staff in tDCS treatment and supervision; (2) assessment of the user's capability to participate in tDCS remotely; (3) ongoing training procedures and materials including assessments of the user and/or caregiver; (4) simple and fail-safe electrode preparation techniques and tDCS headgear; (5) strict dose control for each session; (6) ongoing monitoring to quantify compliance (device preparation, electrode saturation/placement, stimulation protocol), with corresponding corrective steps as required; (7) monitoring for treatment-emergent adverse effects; (8) guidelines for discontinuation of a session and/or study participation including emergency failsafe procedures tailored to the treatment population's level of need. These guidelines are intended to provide a minimal level of methodological rigor for clinical trials seeking to apply tDCS outside a specialized treatment center. We outline indication-specific applications (Attention Deficit Hyperactivity Disorder, Depression, Multiple Sclerosis, Palliative Care) following these recommendations that support a standardized framework for evaluating the tolerability and reproducibility of remote-supervised tDCS that, once established, will allow for translation of tDCS clinical trials to a greater size and range of patient populations.

The International League Against Epilepsy (ILAE) Diagnostic Methods Commission charged the Neuropsychology Task Force with the job of developing a set of recommendations to address the following questions: (1) What is the role of a neuropsychological assessment? (2) Who should do a neuropsychological assessment? (3) When should people with epilepsy be referred for a neuropsychological assessment? and (4) What should be expected from a neuropsychological assessment? The recommendations have been broadly written for health care clinicians in established epilepsy settings as well as those setting up new services. They are based on a detailed survey of neuropsychological assessment practices across international epilepsy centers, and formal ranking of specific recommendations for advancing clinical epilepsy care generated by specialist epilepsy neuropsychologists from around the world. They also incorporate the latest research findings to establish minimum standards for training and practice, reflecting the many roles of neuropsychological assessment in the routine care of children and adults with epilepsy. The recommendations endorse routine screening of cognition, mood, and behavior in new-onset epilepsy, and describe the range of situations when more detailed, formal neuropsychological assessment is indicated. They identify a core set of cognitive and psychological domains that should be assessed to provide an objective account of an individual's cognitive, emotional, and psychosocial functioning, including factors likely contributing to deficits identified on qualitative and quantitative examination. The recommendations also endorse routine provision of feedback to patients, families, and clinicians about the implications of the assessment results, including specific clinical recommendations of what can be done to improve a patient's cognitive or psychosocial functioning and alleviate the distress of any difficulties identified. By canvassing the breadth and depth of scope of neuropsychological assessment, this report demonstrates the pivotal role played by this noninvasive and minimally resource intensive investigation in the care of people with epilepsy.

OBJECTIVE: This study investigated the classification accuracy of the Minnesota Multiphasic Personality Inventory-2-Restructured Form validity scales in a sample of disability claimants and civil forensic litigants. METHOD: A criterion-groups design was used, classifying examinees as "Failed Slick Criteria" through low performance on at least two performance validity indices (stand-alone or embedded) and "Passed Slick Criteria." The stand-alone measures included the Test of Memory Malingering and the Dot Counting Test. The embedded indices were extracted from the Wechsler Adult Intelligence Scales Digit Span and Vocabulary subtests, the California Verbal Learning Test-II, and the Wisconsin Card Sorting Test. RESULTS: Among groups classified by primary complaints at the time of evaluation, those alleging neurological conditions were more frequently classified as Failed Slick Criteria than those alleging psychiatric or medical conditions. Among those with neurological or psychiatric complaints, the F-r, FBS-r, and RBS scales differentiated between those who Passed Slick Criteria from those who Failed Slick Criteria. The Fs scale was also significantly higher in the Failed Slick Criteria compared to Passed Slick Criteria examinees within the psychiatric complaints group. CONCLUSIONS: Results indicated that interpretation of scale scores should take into account the examinees' presenting illness. While this study has limitations, it highlights the possibility of different cutoffs depending on the presenting complaints and the need for further studies to cross-validate the results.

OBJECTIVE: For patients with medically intractable focal epilepsy, the benefit of epilepsy surgery must be weighed against the risk of cognitive decline. Clinical factors such as age and presurgical cognitive level partially predict cognitive outcome; yet, little is known about the role of cross-hemispheric white matter pathways in supporting postsurgical recovery of cognitive function. The purpose of this study is to determine whether the presurgical corpus callosum (CC) midsagittal area is associated with pre- to postsurgical change following epilepsy surgery. METHODS: In this observational study, we retrospectively identified 24 adult patients from an epilepsy resection series who completed preoperative high-resolution T1 -weighted magnetic resonance imaging (MRI) scans, as well as pre- and postsurgical neuropsychological testing. The total area and seven subregional areas of the CC were measured on the midsagittal MRI slice using an automated method. Standardized indices of auditory-verbal working memory and delayed memory were used to probe cognitive change from pre- to postsurgery. CC total and subregional areas were regressed on memory-change scores, after controlling for overall brain volume, age, presurgical memory scores, and duration of epilepsy. RESULTS: Patients had significantly reduced CC area relative to healthy controls. We found a positive relationship between CC area and change in working memory, but not delayed memory; specifically, the larger the CC, the greater the postsurgical improvement in working memory (beta = 0.523; p = 0.009). Effects were strongest in posterior CC subregions. There was no relationship between CC area and presurgical memory scores. SIGNIFICANCE: Findings indicate that larger CC area, measured presurgically, is related to improvement in working memory abilities following epilepsy surgery. This suggests that transcallosal pathways may play an important, yet little understood, role in postsurgical recovery of cognitive functions.

Focal cortical dysplasia (FCD) is a malformation of cortical development that is associated with high rates of cognitive morbidity. However, the degree to which specific irregularities of dysplastic tissue directly impact cognition remains unknown. This study investigates the relationship between blurring of the cortical gray and white matter boundary on magnetic resonance imaging (MRI) and global cognitive abilities in FCD. Gray-white blurring (GWB) is quantified by sampling the non-normalized T1 image intensity contrast above and below the gray and white matter interface along the cortical mantle. Spherical averaging is used to compare resulting GWB for patients with histopathologically verified FCD with matched controls. Whole-brain correlational analyses are used to investigate the relationship between blurring and general cognitive abilities, controlling for epilepsy duration. Results show that cognitive performance is reduced in patients with FCD relative to controls. Patients show increased GWB in bilateral temporal, parietal, and frontal regions. Furthermore, increased GWB in these regions is linearly related to decreased cognition and mediates group differences in cognitive performance. These findings demonstrate that GWB is a marker of reduced cognitive efficiency in FCD that can potentially be used to probe general and domain-specific cognitive functions in other neurological disorders.

Recent acceleration in development of computerized neuropsychological tests and test batteries has led to gains in sophistication, intuitiveness, and capability with concomitant opportunities for greater adoption among practitioners. Advantages attributed to computerized methods (e. g., standardization, large-scale screening, measurement of performance attributes inaccessible by traditional means) enhance prospects for growth. Despite technological improvement and potential benefit to neuropsychological assessment, the regularity with which neuropsychologists utilize computer-based methods remains unsettled. As part of a 10-year follow-up study of neuropsychological test usage practices, we surveyed neuropsychologists' utilization of computerized instruments and investigated practice-related factors that influence computerized test adoption. Respondents were 512 doctorate-level psychologists residing in the United States and Canada (26% usable response rate; 54% female) affiliated with the National Academy of Neuropsychology or the International Neuropsychological Society. Of the 693 distinct instruments reported by respondents, only 6% (n = 40) were computerized, and the average respondent reported rarely using computerized tests. We present the top-ranked computerized instruments and results of correlational analyses, which indicate that fewer years practicing and the youth of respondents associates with increased likelihood of computerized test utilization, along with increased utilization of neuropsychological tests with alternative or parallel forms. Implications for existing and emerging technologies in research and clinical settings are considered.