How to Become (and Remain) an Aerospace Neuropsychologist who Performs Assessments for the FAA Ray King, Psy.D, J.D. FAA Office of Aerospace Medicine Washington, DC
The Tasks Neuropsychological assessments are outlined in Specification Sheets ( Spec Sheets ): PSYCHIATRIC AND NEUROPSYCHOLOGICAL EVALUATIONS FOR SUBSTANCE ABUSE/DEPENDENCE NEUROPSYCHOLOGICAL EVALUATIONS FOR ADHD OR ADD NEUROPSYCHOLOGICAL EVALUATIONS FOR POTENTIAL NEUROCOGNITIVE IMPAIRMENT NEUROPSYCHOLOGICAL EVALUATIONS FOR TREATMENT WITH SSRI MEDICATIONS HUMAN IMMUNODEFICIENCY VIRUS (HIV) neuropsychological assessment 2
The Batteries The Spec Sheets outline the batteries. Most include CogScreen CogScreen currently recommended but not required for ADD/ADHD CogScreen preferred for HIV 3
Other Components of a Neuropsychological Assessement Review of all available records, including academic records, records of prior psychiatric hospitalizations, and records of periods of observation or treatment (e.g., psychiatrist, psychologist, or pediatric neuropsychiatrist treatment notes). Records must be in sufficient detail to permit a clear evaluation of the nature and extent of any previous mental disorders Thorough clinical interview to include a detailed history regarding: psychosocial or developmental problems; academic and employment performance; legal issues; substance use/abuse (including treatment and quality of recovery); aviation background and experience; medical conditions, and all medication use; and behavioral observations during the interview and testing Mental status examination Interpretation of a full battery of neuropsychological and psychological tests including but not limited to the core test battery (specified in each Spec Sheet) An integrated summary of findings with an explicit diagnostic statement, and the neuropsychologist's opinion(s) and recommendation(s) regarding clinically or aeromedically significant findings and the potential impact on aviation safety consistent with the Federal Aviation Regulations 4
Remember to Include: Copies of all computer score reports (e.g., CogScreen-AE score report, Pearson MMPI-2 Extended Score Report, TOVA, CPT-II or IVA+ Report) An appended score summary sheet that includes all scores for all tests administered. When available, pilot norms must be used. If pilot norms are not available for a particular test, then the normative comparison group (e.g., general population, age/education-corrected) must be specified. Also, when available, percentile scores must be included 5
Final Points REPEAT: ALWAYS INDICATE THE NORMS YOU ARE USING FOR COMPARISON Do not repeat administration of the same version of Cogscreen The key summary statement we are looking for is whether there are or are not aeromedically significant cognitive deficiencies Be sure to send the raw data (so get the signed released up front). The FAA doesn t want to send a report to a consultant and then have him/her need to chase down the raw data 6
Final Points Gary Kay: Recommendations should be strictly limited to the neuropsychologist's area of expertise (unless you are a check airman, do not comment on their piloting performance). Bob Elliott: Comment on the neurocognitive implications impacting functional skills and perhaps leave the commentary about the aeromedical safety to an FAA consultant NP. 7
Who may perform a neuropsychological evaluation? Neuropsychological evaluations must be conducted by a licensed clinical psychologist who is either board certified or board eligible in clinical neuropsychology. Board eligible means that the clinical neuropsychologist has the education, training, and clinical practice experience that would qualify him or her to sit for board certification with the American Board of Clinical Neuropsychology, the American Board of Professional Neuropsychology, and/or the American Board of Pediatric Neuropsychology. (From the Spec Sheets) 8
A Change Being Considered would qualify him or her to sit for board certification as evidenced by documentation from one of the boards verifying that the neuropsychologist has applied for board certification, has had his or her credentials reviewed, and has been determined by the board to be eligible to continue in the certification process. 9
Who Reads These Reports? Airmen neuropsychological reports are read by clinical psychologists, other neuropsychologists, and certification physicians of various specialties (in the medical certification division at CAMI, in one of the 9 Regional Flight Surgeon offices, and/or in Medical Appeals Branch, FAA Headquarters) and/or by one of the FAA psychiatrists. HIMS Substance Abuse reports for Class 1 Medical Certificates are read by the FAA psychiatrists 10
Neuropsychologists are not the Final Authority The final authority? The Federal Air Surgeon. Also: We don t know up front when we will need to send to send your work products to a consultant, thus you need to secure permission to release the raw data Airman needs to agree UP FRONT that both the report and the raw data can be sent to the FAA and potentially to our designated neuropsychology consultant(s) 11
Repeat: Raw Data Get Release UP FRONT! We need to have the right to share the data with our consultants without further permission About 10% of cases get referred to a neuropsychology consultant The data and clinical findings will be carefully safeguarded in accordance with the APA Ethical Principles of Psychologists and Code of Conduct (2002) as well as applicable federal law If the neuropsychologist feels they cannot share the data, they should not be doing this work 12
Quality Control Due to the needs of public safety and the rights of the airmen whose careers are on the line, much consideration is given to arriving at the correct disposition (aeromedically returned to flying or not) Pilots don t want to spend a lot of money and sit out from work for months and months only to learn that they need to do additional assessment due to errors make by a neuropsychologist 13
Topic for Group Discussion: Prototype of Proposed FAA QA Program: (I will quickly walk you through this chart) PI Number Case Type (HIMS, SSRI, etc.) Assessment Neuropsych Rec Reviewing Consultant Rec Second Consultant Rec Pending? (will f/u) X = pending Final Disposition Agree/Disagree Error/Issue (if any) - Considering 100% review first year (resources allowing) The FAA Goals: - The right tests (combined with history, MSE, etc.) - Comparison to the correct norms - The correct interpretation (that flows from the above) 14
Wait a Minute, What? First look: HIMS agreement rate (disposition recommended by assessing neuropsychologist and neuropsych consultant) is approximately 56% Concurrence not as high (18% first ½ CY2017) for other types of consults (SSRI, ADHD, cognitive impairment) Only the cases that are the most complex are sent to a consultant neuropsychologist. So there is a base rate issue. Most reports (90 %) are fine and not sent to a consultant Sometimes the issue may be that more time is needed for an airman to regain baseline function 15
Neuropsychological Assessment is Different with Airmen The FAA is cautious due to our safety mission. Airmen, even when impaired, are going to look relatively healthy compared to the population neuropsychologists typically assess (HINT: pay particular attention to the Norms lecture) 16
What Can Spoil an Assessment? According to the FAA Chief Psychiatrist, Dr. Charles Chesanow: Demonstrating advocacy due to counter-transference and/or aligning with the patient in an effort (either conscious or unconscious) to rebel against governmental authority ( stick it to the man ). 17
What Else Can Spoil an Assessment? According to Dr. Gary Kay Minimizing, or explaining away impairment by reporting that overall the airman s abilities are quite strong and he/she can compensate for the deficit found on testing If you find an impairment: Determine if the deficit is aeromedically significant, Determine if the deficiency is confirmed by other measures. 18
A Final Thought from Dr. Giovanetti Common reasons she sees to explain away high LRPV s: Is the math score the real reason the LRPV is high? Is the airman simply sacrificing speed for accuracy, or is there something more? 19
Future Plans Errors made by neuropsychologists will be closely tracked Feedback will initially be offered using the Kitten Hands approach (Allow me to explain) Failure to remediate errors will result in feedback that is a bit less gentle: Continued failure to modify practice after repeated feedback or gross errors will result in no more referrals being made to you 20
Future Plans (continued) How often should you attend recurrent training? New or returning, tell us what you need! A guideline for reports, with a model? Coaching on first case (we don t accept drafts ) What else? Talk to us! 21
Questions? 22