Two Lenses, One Setting: Similarities and Differences in the Practice of Neuropsychology in Pediatric and Adult Acute Rehabilitation Settings

Commentary

In general, neuropsychologists operate as integration specialists, tasked with the evaluation of cognitive, emotional, and behavioral functioning in the context of known or suspected central nervous system conditions and other relevant developmental, biopsychosocial, and functional processes. This emphasis on integration comes into even sharper relief when examined in the IPR setting, where care is inherently interdisciplinary, patients are medically complex, and the stakes are high with respect to striking the right balance between safety and independence. As such, the rehabilitation neuropsychologist—whose role we seek to illuminate in this paper—takes on a variety of roles as an IPR team member: clinical evaluator, interventionist, consultant, subject matter expert, etc.

Still, within this shared foundation, developmental context emerged as a central theme and differentiator. Within the practice of rehabilitation neuropsychology with a primarily pediatric IPR population, care is often both habilitative and rehabilitative, meaning that intervention focuses on new skill development concurrent to the reacquisition of prior repertoires (Kaufman et al., 2017). This orientation aligns with decades of research demonstrating that pediatric brain injury outcomes are influenced by a variety of factors, including injury characteristics, developmental stage, and social-contextual factors (Johnson et al., 2009). A pediatric clinician must therefore situate the results of their inpatient evaluation within the broader systems relevant to their patient, including those related to family, education, and community.

In contrast, the adult IPR setting places greater emphasis on autonomy, capacity, and independence. In the adult IPR setting, neuropsychological assessment often addresses urgent questions, like determining readiness for discharge, evaluating decision-making capacity, and planning for supervision in the home environment. This difference is rooted in the assumption that the adult participating in IPR was fully independent immediately prior to their admission, as opposed to practice in a pediatric setting where ongoing guardianship and parental support post-discharge is the norm.

Given these considerations, providers practicing with adults in this setting must be especially savvy to medicolegal risk, ensuring that their approach to clinical practice is grounded in solid and internally consistent ethical and legal frameworks. One instance where this comes up often is assessment of capacity to make informed healthcare decisions. Sensitivity is required here to the implications for restricting someone’s own bodily autonomy, while at the same time ensuring that individuals are not putting themselves in harm’s way while in a state of reduced capacity. To this point, Appelbaum and Grisso (1995) identified specific behavioral anchors of capacity (i.e., understanding the dilemma, weighing options, appreciating potential consequences, demonstrating consistency of choice). Inpatient referrals related to the assessment of capacity exemplify many of the types of roles common to the practice of rehabilitation neuropsychology (e.g., clinical evaluator, consultant, subject matter expert).

Beyond informing specific inpatient treatment recommendations, the rehabilitation neuropsychologist in an IPR setting is often tasked with generating recommendations for post-discharge planning and outpatient follow-up. Across the lifespan, rehabilitation neuropsychologists in IPR settings are often tasked with identifying post-discharge supervision needs related to neurobehavioral and neurocognitive dysfunction (Boake, 1996); however, the focus varies between adult and pediatric settings. Considerations around readiness to return to work (Sherer et al., 2002), driving (Cullen et al., 2014), or other complex activities immediately post-discharge are more characteristic of adult settings. In adult rehabilitation, post-discharge planning frequently centers on connecting patients with disability resources, as indicated, in addition to outlining the steps necessary for a safe, sustainable, and gradual return-to-work and independent living. In pediatric settings, post-discharge recommendations often prioritize educational reintegration, since a return-to-school as soon as it is safe to do so represents both a developmental imperative and a significant indicator of post-injury recovery (Stubberud et al., 2022). Therefore, pediatric providers often focus on school readiness, appropriate academic accommodations, communication with educational personnel, and strategies to support re-entry into age-salient activities.

Referral questions are also often posed—both in pediatric and adult IPR settings—about how best to implement various aspects of rehabilitation therapy, in consideration of neurobehavioral, neurocognitive, and emotional challenges. With respect to intervention, specific therapies implemented in the IPR setting often incorporate aspects of traditional cognitive rehabilitation (Kersey et al., 2021; for an IPR case example, please see Skidmore et al., 2011), in addition to evidence-based psychotherapy (Li et al., 2017), and transdiagnostic principles of behavior change (Block et al., 2022; Burren & Dickson, 2025). With respect to cognitive rehabilitation, evidence continues to support the use of both restorative (e.g., restoring the body’s ability to function independently) and compensatory strategies (e.g., “workarounds” used to mitigate the impact of disability on meaningful outcomes; Barman et al., 2016), with a combination of the two often utilized concurrent to one another in the IPR setting.

Regarding the latter of these approaches, implementation and generalization of compensatory strategies can be challenging, as both require an acknowledgement (or, acceptance) of impairment and a willingness to be flexible, as a means of engaging in meaningful and enjoyable activities. As such, acceptance-and-commitment therapy (ACT; Hayes et al., 1999), which simultaneously emphasizes nonjudgmental acceptance of the present moment, principles of graded exposure, and values-based behavioral activation, as a means of achieving a state of psychological flexibility (Kashdan, 2010), can be a particularly useful therapeutic approach for both adult and pediatric specialists. Unlike traditional cognitive behavioral therapy, which emphasizes cognitive restricting, the focus of ACT on experiential acceptance provides a framework within which clinicians can “roll with resistance,” by targeting behavior change even when thoughts (including those rooted in neurocognitive dysfunction) may themselves function as barriers.

Our group also explored the topic of theoretical orientation during this conversation, raising specific points about the theory-rich nature of rehabilitation psychology (Dembo et al., 1975), which is rooted firmly in a set of foundational principles (Wright, 1972). To this point, both pediatric and adult providers framed rehabilitation as a theoretical orientation (or lens) by which rehabilitation neuropsychologists approach their work. Ways that this theoretical orientation tend to emerge in both adult and pediatric practice include: conceptualization of disability as a dynamic state caused by the person-environment interaction (rather than something inherent to an individual; Dunn, 2015), a fundamental appreciation of disability as an aspect of human diversity, an obligation to identify the strengths of all individuals regardless of disability severity, and a commitment to centering the voices of people with lived experience in programmatic decision making (i.e., “nothing about us without us;” Andrews et al., 2019).

Members of our group also shared that, at professional meetings, other psychologists have casually referred to clinical neuropsychology as the “what?” and rehabilitation psychology as the “what’s next?” This, taken alongside the other points raised above, underscores why the services provided by psychologists practicing in this blended specialty can be thought of as a gestalt—or, a whole greater than the simple sum of its parts. At the same time, our discussion acknowledged that it can be difficult for trainees to articulate their interest and background in this blended specialty within traditional training pathways without appearing scattered or distracted. Ongoing visibility and recognition efforts (e.g., Stucky et al., 2024; Watson et al., 2023) represent important steps in addressing these developmental pathway constraints. Similarly, the increasing number of opportunities for targeted mentorship and networking (e.g., ANST Rehabilitation Focus Group; Pediatric Rehabilitation Neuropsychology Consortium) offer more avenues for trainees interested in learning about various routes within this blended specialty. Situating this blended identity within the broader context of certification by the American Board of Professional Psychology (ABPP) may also clarify how rehabilitation‑oriented neuropsychologists can articulate a coherent professional trajectory that both honors the distinct competencies of each specialty and aligns with ABPP’s larger mission to recognize and advance specialist-level practice across diverse clinical settings.

Finally, we considered the future of clinical neuropsychology, emphasizing how the integration of traditional clinical psychology with the theory-rich aspects of rehabilitation psychology may help to “future proof” the profession. That is, advances in machine learning and generative artificial intelligence have the potential to reshape aspects of neuropsychological practice (Bilder & Reise, 2019). Our group highlighted how—even in the current era of near-constant innovation—relational, contextualized, and functionally oriented competencies will likely remain central to high-quality clinical care. While this point applies to the practice of rehabilitation neuropsychology within the IPR setting, it also has more general implications for clinical practice across settings and populations. Put more simply, while there are a number of frameworks that emphasize a biopsychosocial approach in neuropsychology, neuropsychologists who embrace the humanistic and collaborative principles that define the emerging field of rehabilitation neuropsychology (whether they identify as such or not) will likely be well equipped to adapt to changes in day-to-day practice driven by rapid technological progress.