Introduction
Neurological conditions have been on the rise in the United States and across the globe, prompting an increasing need for emerging trainees and professionals to provide competent neuropsychological care for patients (www.recruiter.com, n.d.; Janca et al., 2006; cited by Bazargan-Hejazi et al., 2020; Kennedy & Adolphs, 2012). In response, neuropsychology training programs implement specific competencies within their graduate programs, with one of those competencies being the Houston Conference Guidelines. However, following the COVID-19 pandemic, neuropsychology students reported a lack in training and clinical hours regarding general assessment and intervention skills (Towns et al., 2022; Thompson et al., 2023). Given the growing demand for neuropsychological services and the increased focus on competency-based education, it is essential to evaluate whether current training standards are effectively preparing students to meet the expectations of clinical practice. A common goal across programs is to ensure that students receive high-quality training, but the question remains: Is this goal being met from the students’ perspectives? This article reports on a national survey study designed to assess self-perceived competencies of graduate students in neuropsychology training programs. Specifically, the study evaluates how students perceive their competence across key coursework and clinical domains outlined in the Houston Conference Guidelines. By capturing student experiences from across APA-accredited programs in the United States, the study aims to identify strengths and gaps in current training practices, and to inform future curriculum and competency development.
Methods
Neuropsychology graduate students were recruited from doctoral training programs across the United States to assess their insight about their training experiences. Participants were recruited through their program’s neuropsychology emphasis area director(s) or program chair via email and were asked to disseminate the survey to their neuropsychology students. Programs were sought through internet search and included American Psychological Association Accredited graduate programs with a neuropsychology emphasis area or concentration. Participants were prompted with questions regarding coursework and clinical skills related to the Houston Conference Guidelines on a 7-point Likert scale including: “not at all competent”, “slightly incompetent”, “neither competent nor incompetent”, “slightly competent”, “very competent”, “course not offered”, or “haven’t had experience in this domain yet”. This study was submitted and approved by Spalding University’s Institutional Review Board.
Participants and Recruitment
After review of 52 responses, 40 participants were included in the final data analysis and 12 were removed due to lack of completion. The 40 participants were representatives of training programs from California (n = 4), Michigan (n = 7), Texas (n = 4), Illinois (n = 4), Kentucky (n = 12), Louisiana (n = 2), Maine (n = 2), Pennsylvania (n = 1), Utah (n = 3), and Washington (n = 4) with varying years of education (1st year, n = 4; 2nd year, n = 7; 3rd year, n = 9; 4th year, n = 12; 5th+ year, n = 8). Thirty participants were enrolled in a PhD program and ten were enrolled in a PsyD program. The participants were also representative across race/ethnicity (African American, n = 1; Asian, n = 4; Caucasian, n = 20; Hispanic/Latino, n = 2; Multi-Racial, n = 2; and Other, n = 1), gender (female, n = 29; male, n = 9; non-binary, n = 1; transgender, n = 1), and age (21-23, n = 1; 24-26, n = 14; 27-29, n = 19; 30-32, n = 4; 33-35, n = 1; 36-38, n = 1). Responses were collected from May to July of 2024, assessing for their perceived competency levels post-COVID-19 pandemic.
Neuropsychological Training Domains Addressed
Per the current Houston Conference Guidelines, there are vague areas of competencies intended to provide necessary skills for neuropsychologists across areas of psychology and neuropsychology coursework and application-based skills (Hannay et al., 1998). Coursework competency was assessed across both general psychology and neuropsychology courses. General psychology courses included “statistics, biological basis of behavior, lifespan development, history of psychology, cultural and individual differences and diversity, learning/cognition and perception, social psychology and personality,” (Hannay et al., 1998). Clinical psychology courses assessed were “psychopathology, psychometric theory, intervention/assessment techniques, intervention techniques, and professional ethics,” (Hannay et al., 1998). Neuropsychology courses included “functional neuroanatomy, neurological and related disorders, other disorders that impact the central nervous system functioning, neuroimaging techniques, psychopharmacology, and the neuropsychology of behavior,” (Hannay et al., 1998).
Clinical work was also assessed across both psychology and neuropsychology practices. General and neuropsychology assessment skills that were measured included: “information gathering, history taking, selection of tests and measures, administration of tests and measures, interpretation and diagnosis, treatment planning, report writing, provision of feedback, and recognition of multicultural issues,” (Hannay et al., 1998). Neuropsychology related treatment and intervention skills included “identification of intervention targets, specification of intervention needs, formulation and implementation of intervention plans, monitoring and adjusting the plan as needed, assessing outcomes, and recognition of multicultural issues,” (Hannay et al., 1998). General consultation skills were further assessed through domains of “effective communication, determination and classification of referral issues, education of referral sources regarding neuropsychological services, communication of results and recommendations, and providing education to patients and families regarding services and disorders,” (Hannay et al., 1998).
Results
General Psychology and Neuropsychology Coursework Competency
Regarding general psychology and clinical courses, the majority of participants felt “very competent” in biological basis of behavior (55%), learning/cognition and perception (52.5%), psychopathology (55%), and intervention/assessment techniques (75%). Of note, most students reported feeling “slightly competent” with social psychology (55%) and psychometric theory (57.5%).
In terms of neuropsychology related coursework, most participants only felt “slightly competent” in areas of functional neuroanatomy (60%), neurological and related disorders (57.5%), and other disorders that impact the central nervous system functioning (62.5%).
General Psychology and Neuropsychological Assessment Competency
Outside of coursework, general psychology and neuropsychology related clinical skills were also assessed. For assessment skills, the majority reported feeling “very competent” with information gathering skills (55%). Within administration of testing measures, 75.5% reported “very competent” for general measures and 65% reported that for neuropsychology specific measures. Across other general assessment skills, 57.5% of participants reported feeling “very competent” with history taking. With regards to other areas of neuropsychology specific skills, 52.5% of students reported feeling “very competent” with specialized assessment measures.
Additional results revealed students reported feeling “slightly competent” with general and neuropsychology specific interpretation and diagnosis (75% for general; 72.5% for neuropsychology specific) and treatment planning (60% for general; 52.5% for neuropsychology specific). The majority of participants reported feeling “slightly competent” with selection of tests (57.5%), report writing (57.5%), administration of feedback (52.5%) and recognition of multicultural issues (52.5%).
Neuropsychology Intervention and Treatment-Related Competency
For neuropsychology intervention and treatment skills, there was variability across domains that did not lend to majority responses in any one area of perceived competency.
Neuropsychology and Consultation-Related Practice Competency
Other areas of neuropsychology practice where participants felt “very competent” include specialized assessment and “slightly competent” for professional ethics (57.5%) and practical implications of related conditions (55%).
General consultation skills related to providing effective communication revealed 65% of students noted feeling “very competent” in this area. Other related skills that were reported “slightly competent” include determining and classification of referral issues (62.5%) as well as providing education to patients and families regarding services and disorders (57.5%).
Conclusions
The purpose of this article is to provide neuropsychology training directors and professors with insight into the effectiveness of graduate level education by measuring self-perceived competency related to the Houston Conference Guidelines. Overall, the majority of participants, over 50%, reported feeling either “slightly competent” or “very competent” across general and neuropsychology related coursework and clinical skills. These results suggest that students, although not endorsing full competence, are still self-reporting slight expertise within various aspects of training. Coursework associated with feeling “slightly competent” included social psychology, psychometric theory, functional neuroanatomy, neurological and related disorders and other disorders that impact the central nervous system. In terms of clinical skills within psychology, neuropsychology, and consultation work, students reported feeling “slightly competent” with interpretation and diagnosis, treatment planning, selection of testing measures, report writing, administering feedback, and recognition of multicultural issues. Other domains of slight competence include professional ethics, practical implications of related conditions, determining and classification of referral issues, and providing education to patients and families regarding services and disorders. These results suggest that there are a wide range of domains that programs report a lack of full perceived competence, thus leading to areas of growth for training programs. These results also suggest variability in students’ perception of their competency across neuropsychology graduate training, showing that there are differences between and within.
Neuropsychology Coursework
Given results, there appears a need for increased focus within neuropsychology training programs on functional neuroanatomy, neurological and related disorders, and disorders that impact the central nervous system. This is especially important as these are tenets of the services neuropsychologists provide. With that said, programs can emphasize a bottom-up approach through initial focus on core neurological structures and their functions with utilization of visual/interactive tools such as 3D brain applications and/or virtual neurological atlases. After foundational skills are established, a push for application appears warranted. Programs can reinforce foundational knowledge with clinical examples through case studies, neurological grand rounds, practicing lesion localization, etc. To take this competence one step further, linking function to dysfunction will assist in integrating theoretical knowledge into clinical insight, which can produce increased competence in students.
Neuropsychological Assessment
The vast majority of students included in this study endorse competence in specialized neuropsychological assessment measures, general consultation, and information gathering. The current training standards appear adequate. The education provided for neuropsychology students helps build confidence in both technical tools and clinical thinking. Programs should continue starting with assessment foundations to allow students to understand what and why specific assessments are utilized. Additionally, teaching normative foundations and what constitutes impairments is an important competency benchmark. Students continue to need hands-on repetition for fluency through mock assessments, rotation of roles (administrator, examinee, observer), and scaffolding of interpretation skills.
Neuropsychological Interpretation and Diagnoses
In large, this domain is the most robust area of perceived low competence across neuropsychology graduate training students. How is this improved? It is important to train neuropsychology students that interpretation is not just about test scores, but patterns, context, and storytelling. Students should be asked, “What brain systems underlie this performance?” and “Could this be explained by mood, culture, language, effort, education, etc.?” Focus on training students to look across scores rather than in isolation. Coursework should include intra-individual patterns and case-based learning. Additionally, diagnostic thinking is a higher-order skill that comes with time, which can be accelerated through studying differential diagnoses, formulation practice, testing hypotheses, and creating decision trees or flowcharts (e.g., what paths lead to a diagnosis of MCI versus Dementia).
Also, within this domain, students note some competence in neuropsychology ethics and multicultural issues. As the field grows, it is important to train students to stop thinking of multicultural factors as an “add-on” and instead an integration from the outset of case conceptualization. Teaching culture through real-world scenarios using cross-cultural case studies, comparative norm examples, and mock interviews with diverse patients is especially crucial. Furthermore, training programs should help students understand that culturally responsive assessments lead to increased validity. Cultural responsiveness is not simply race/ethnicity, but rather the intersectionality of language, education, immigration history, socioeconomic status, religion, gender identity, ability/disability status, etc. This study provides insight into the need to teach ethical test selection and encourage students to have lifelong cultural humility. Within neuropsychology, cultural competence is not a destination, but a practice of skills. Modeling self-reflection, cultural assessment tools, and culturally appropriate norming practices should be an integral part of neuropsychology training programs.
Limitations and Future Directions
There are several important limitations to note in this study. First, the survey assessed participants’ perceived competency solely based on the Houston Conference Guidelines. While these guidelines are widely recognized, they are not universally adopted or required across graduate neuropsychology training programs. Some may incorporate alternative frameworks, which could result in lower self-reported competency related to the Houston Guidelines, despite students feeling more competent with other training models. Therefore, focusing on Houston Conference Guidelines may limit the scope of the assessment and fail to fully capture the breadth and variation of training experiences across programs.
Another limitation is the survey’s format of evaluating competency through a Likert scale format. The validity of participant responses may not be an accurate reflection of their true competency level due to the lack of specificity that was provided in the Houston Conference Guidelines to aid in descriptors for the study. Additionally, reliance on a self-report measure introduces the potential for response biases, including hesitancy to endorse lower levels of perceived competency due to concerns about self-presentation or perceived professional adequacy.
Furthermore, this study did not include participants in internship or postdoctoral fellowship training. While the focus was on graduate-level trainees, these later stages are critical for professional development and provide necessary experiences for a career in neuropsychology. As such, important periods of skill acquisition and competency development may have been excluded, overlooking valuable insights into self-perceived competency during advanced training phases.
Future research should also consider assessing a broader range of training models beyond the Houston Conference Guidelines to better capture the diversity of competencies emphasized across programs. Given that many programs follow alternative frameworks, such as American Psychological Association Committee of Accreditation competencies and the Clinical Neuropsychology Synarchy, limiting assessment to a single model may restrict the scope of findings.
References
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Hannay, H. J., Bieliauskas, L. A., Crosson, B., Hammeke, T., Hamsher, K. D., & Koffler, S.P. (1998). The Houston conference on specialty education and training in clinical neuropsychology-policy statement. Archives of Clinical Neuropsychology, 13(2).
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Towns, S. J., Breting, L. M. G., Butts, A. M., Brett, B. L., Leaffer, E. B., & Whiteside, D. M. (2022). Neuropsychology trainee concerns during the COVID-19 pandemic: A 2021 follow-up survey. Clinical Neuropsychologist, 36(1), 85–104. https://doi.org/10.1080/13854046.2021.1975826
www.recruiter.com. (n.d.). Career Outlook and job vacancies for neuropsychologists and clinical neuropsychologists.
Cassandra Lewandowski, MA
Correspondence: Clewandowski@spalding.edu
Hannah K. Richardson, PsyD
Correspondence: Hrichardson@aptivahealth.com
Brandon Dennis, PsyD, ABPP
Board Certified in Clinical Neuropsychology
Correspondence: Brandon.Dennis@nortonhealthcare.org
Kristen Mulcahy, MA
Correspondence: Kmulcahy@spalding.edu