Neuropsychology in South Africa: confronting the challenges of specialist practice in a culturally diverse developing country.

OBJECTIVE: This was an invited paper on the history and current status of neuropsychology in South Africa. METHOD: Information was gathered from literature searches, personal communication, and the authors' experiences while occupying relevant professional and academic positions for over 30 years. RESULTS: Since its origins in the 1950s, the development of neuropsychology in South Africa has faced numerous challenges, against a background of extreme sociocultural and socioeconomic disparity in the country that is on-going. The creation of the South African Clinical Neuropsychological Society in the 1980s, a credentialing and training body, gave impetus to the discipline. In the absence of a neuropsychology category within the South African professional framework, university instruction has been ad hoc with vastly different levels of competency depending on the institution involved. The small number of practitioners and/or academics involved in neuropsychology includes mainly masters, and some doctoral level psychologists registered in clinical, counseling or educational categories. A prime emphasis of neuropsychological research has been local norming of psychometric tests to facilitate valid assessment practices in the country. South Africa is on the cusp of achieving a hard-won neuropsychology professional register. It is anticipated that this development will provide impetus to the discipline by promoting training programs, the creation of neuropsychology posts, wider service delivery, and increased research funding. CONCLUSIONS: Despite significant challenges in a culturally diverse, developing country, neuropsychology has evolved sufficiently to warrant the creation of a separate category in the professional framework. This development will facilitate training, research, and services in the country.

Vulnerability in speed of visuomotor ability.

The aim of this report is to illustrate the utility of neurocognitive testing as an investigative method to establish the presence of persistent effects of concussive brain injury amongst players of a contact sport with high risk of such injury. The report reviews the outcomes of three previously published neuropsychological studies on South African Rugby Union (hereafter 'rugby') from school through to the national adult level. The diagnostic utility of differential effects per se, as well as differential practice effects on visuomotor function, as a means of distinguishing poorer neurocognitive outcome for rugby versus demographically equivalent noncontact sports players, is described. From various methodological angles, at each level of play, the reviewed studies attest to the presence of long-term vulnerability in visuomotor speed in association with participation in rugby, in turn implicating diffuse frontotemporal dysfunction due to repetitive concussive and subconcussive injury amongst rugby players. As visuomotor speed is a prime function called upon for optimal scholastic and occupational performance, the robustly demonstrated decrement is of immediate clinical importance. Of critical heuristic relevance, however, is evidence of residual brain dysfunction in association with rugby as early as school level, which may ultimately be the precursor of chronic traumatic encephalopathy.

Practice effects reveal visuomotor vulnerability in school and university rugby players.

This article reports on three pre- versus post-season prospective studies in which male university and high school contact sport players predominantly of Rugby Union (hereafter rugby) were compared with age, education, and IQ equivalent non-contact sport controls on the ImPACT (Immediate Postconcussion Assessment and Cognitive Testing) test. All analyses revealed a relative absence of practice effects on the Visual Motor Speed (VMS) composite for contact sport groups compared with controls. The VMS data for rugby players from each study were pooled and subjected to additional analysis (Rugby, n = 145; Controls, n = 106). Controls revealed significant improvement over the season (p < .001), whereas no learning effect was in evidence for rugby players whose performance remained the same (interaction effect, p = .028). It is apparent that practice effects have diagnostic potential in this context, implicating vulnerability on speeded visuomotor processing in association with participation in rugby. Pointers for further research and concussion management in the individual case are explored.

Computerized neuropsychological profiles of South African versus US athletes: a basis for commentary on cross-cultural norming issues in the sports concussion arena.

Computerized programs are widely used as part of the overall medical management of concussion in order to monitor recovery and facilitate safe return-to-play decisions. Typically, neurocognitive profiles of concussed athletes are compared with baseline and/or normative data in the absence of baseline scores. However, the cultural equivalence of performance on neuropsychological tests cannot be assumed and has not been sufficiently researched. The purpose of this study was to investigate the neuropsychological test profiles of the ImPACT (Immediate Postconcussion Assessment and Cognitive Testing) on age-matched South African (SA) rugby and US football players. Participants included 11 257 English-speaking, predominantly white male athletes from multiple SA and US schools and sports organizations in 3 age groups: 11 to 13 years (SA, n = 301; US, n = 775); 14 to 16 years (SA, n = 997; US, n = 4081); and 17 to 21 years (SA, n = 319; US, n = 4784). ImPACT neurocognitive composite scores (verbal and visual memory, visual motor speed, reaction time, impulse control) and the ImPACT total symptom score, derived from the initial baseline testing, were used for comparison purposes between the targeted groups. Independent t-test comparisons revealed overall equivalence between the SA and US athletes on the neurocognitive measures, but they also revealed consistently higher symptom scores for SA athletes in association with clinically relevant effect sizes. It was concluded that US neurocognitive normative data on the ImPACT test are appropriate for use on South African athletes whose first language is English, whereas culture-specific sensitivity for symptom reporting on this same population should be taken into consideration for management purposes. It is argued that neurocognitive equivalence is less likely to apply in educationally disadvantaged populations. The use of registered psychologists is deemed necessary to provide contextualized interpretations of computerized test scores, thereby protecting against misdiagnosis that may occur within the concussion management arena via actuarial approaches that fail to take sociocultural complexities into account.

The comparative incidence of reported concussions presenting for follow-up management in South African Rugby Union.

OBJECTIVE: The objective of this study was to compare the seasonal concussion incidence for school, university, club and provincial level Rugby Union players in South Africa. DESIGN: The study presents a retrospective statistical analysis of the number of reported concussions documented annually for groups of Rugby Union players as a proportion of those who received preseason neurocognitive assessment. SETTING: Between 2002 and 2006, concussion management programs using computerized neuropsychological assessment were implemented for clinical and research purposes by psychologists in selected South African institutions involved in Rugby Union from school through to the professional level. PARTICIPANTS: The incidence figures were based on 175 concussive episodes reported for 165 athletes who were referred for neurocognitive assessment from a population of 1366 athletes who received preseason baseline testing. INTERVENTIONS: Concussion management routines varied according to the protocols adopted by the different psychologists and rugby organizations. MAIN OUTCOME MEASUREMENTS: It was expected that the incidence of concussion would vary significantly due to level of play and different management protocols. RESULT: There was wide disparity in the manner in which concussion follow-up was managed by the various organizations. Within broadly comparable cohorts, tighter control was associated with a relatively higher concussion incidence for athletes per rugby playing season, with average institutional figures ranging from 4% to 14% at school level and 3% to 23% at adult level. CONCLUSIONS: This analysis suggests that concussion goes unrecognized and therefore incorrectly managed in a number of instances. Recommendations for optimal identification of concussed athletes for follow-up management are presented.

Central or peripheral? A positional stance in reaction to the Prague statement on the role of neuropsychological assessment in sports concussion management.

The objective of this paper is to clarify the role of neuropsychological assessment in sports concussion management in response to the Prague summary statement of the most recent international conference on concussion (McCrory, P., Johnston, K., Meeuwisse, W., Aubry, M., Cantu, R., Dvorak, J., et al. (2005). In the Prague statement it is proposed that there should be a new categorization of concussion ('simple' versus 'complex') to inform management of the injury, including the suggestion that neuropsychological assessment is not indicated for 'simple' concussion. However, from a neuropsychological perspective the Prague position is conceptually problematic. The present paper proposes on theoretical and empirical grounds, that neurocognitive evaluation is warranted for any concussive injury to increase diagnostic sensitivity and provide prognostic indications. Further, three levels of neurocognitive assessment and their professionally legitimate implementation (that are poorly defined in the Prague paper) are delineated. Recommendations are provided for consideration at the next international concussion meeting, with emphasis on giving due weight to the neuropsychological position.

Neurocognitive vulnerability amongst university rugby players versus noncontact sport controls.

University rugby players were compared with IQ-equivalent noncontact sports controls on memory and attentional tasks at the pre- and postseason intervals. Results revealed significant lowering for rugby players relative to controls at the postseason interval for attentional tasks with a speeded visuomotor component (ImPACT Visual Motor Speed; Trail Making Test, TMT, A and B). There was a practice effect for controls only between the pre- and postseason intervals for attentional tasks that commonly reveal improvements after a long retest interval (TMT A and B; Digits Backwards). Medium to large effect sizes implicate clinically relevant cognitive vulnerability for university-level rugby players in association with years of exposure to repetitive concussive injury.

Cross-cultural effects on IQ test performance: a review and preliminary normative indications on WAIS-III test performance.

This article presents a review of cross-cultural influences on Wechsler IQ tests, together with a preliminary investigation into WAIS-III test performance (English administration) for a southern African sample (age range 19-30) stratified for white English first language and black African first language, level and quality of education. ('African language' is the term used to denote the indigenous languages of black populations in southern Africa). A two-way ANOVA revealed highly significant effects for both level and quality of education within the black African first language group. Scores for the white English and black African first language groups with advantaged education were comparable with the US standardization, whereas scores for black African first language participants with disadvantaged education were significantly lower than this. Thus indications from this research are that normative studies should take account of the influential variable of quality of education, in addition to level of education. Alternatively faulty conclusions may be drawn about the effects of ethnicity, with the potential for neuropsychological misdiagnosis.

A cross-cultural study with culture fair normative indications on WAIS-III Digit Symbol-Incidental Learning.

The WAIS-III Digit Symbol-Incidental Learning optional procedure, including Pairing and Free Recall, was administered to a southern African sample (N=68, age range 19-30), which was stratified for ethnicity in association with language of origin (white English first language versus black African first language), educational level (Grade 12 and Graduate), and quality of education (advantaged and disadvantaged). ('African language' is the term used to denote the indigenous languages of black populations in southern Africa). Results yielded no significant differences for ethnicity/language of origin, level or quality of education, indicating that Digit Symbol-Incidental Learning may be a relatively culture independent task with utility as a neuropsychological screening instrument. Broad normative guidelines are provided for diagnostic purposes, and comparisons are made with available norms.

Fine tuning of the digit symbol paired associate recall test for practitioner purposes in clinical and research settings.

Guidelines are presented to facilitate the use of the WAIS Digit Symbol measure of paired associate recall as a neuropsychological instrument. Currently three formal variants of the test exist with accompanying normative data (the original WAIS-R-NI form; a WAIS-R Short Form; a longer WAIS-III form), providing a potential source of confusion which may limit its application. To circumvent this, the present article critically evaluates: (i) variations in test forms and their advantages; (ii) available norms in terms of age and education, with pointers for more differentiated guidelines in this regard; and (iii) the desirability of incorporating a delayed recall variant of the test. Finally, a synopsis of data is presented that supports the screening potential of Digit Symbol paired associate recall in cases of mild neurocognitive dysfunction. For the purposes of this paper, the term WAIS is used with broad reference to all variations of the original Wechsler Adult Intelligence Scale (1955) upon which they were based, including the WAIS-R (1981) and WAIS-III (1997) updated editions, and the South African WAIS (1969). The terms South African WAIS (South African Wechsler Adult Intelligence Scale), WAIS-R (Wechsler Adult Intelligence Scale - Revised), and WAIS-III (Wechsler Adult Intelligence Scale-III), refer to these specific versions of the test.