Competencies unique to clinical neuropsychology: A consensus statement of educators, practitioners, and professional leaders in Australia

Abstract

Objective: To delineate the unique role of clinical neuropsychologists in contemporary Australian clinical practice and present a comprehensive consensus-based set of clinical neuropsychology competencies to guide and standardize the training of clinical neuropsychologists. Method: Twenty-four national representatives of the clinical neuropsychology profession (71% female, M = 20.1, SD = 8.1 years clinical practice), including tertiary-level educators, senior practitioners and members of the executive committee of the peak national neuropsychology body, formed the Australian Neuropsychology Alliance of Training and Practice Leaders (ANATPL). Informed by a review of existing international competency frameworks and Australian Indigenous psychology education frameworks, a provisional set of competencies for clinical neuropsychology training and practice were developed, followed by 11 rounds of feedback and revisions. Results: The final set of clinical neuropsychology competencies achieved full consensus and falls into three broad categories: generic foundational (i.e. general professional psychology competencies applied to clinical neuropsychology); specific functional (i.e. specific to clinical neuropsychology areas of practice) competencies relevant to all career stages; and functional competencies relevant to advanced career stages. Competencies span a number of knowledge and skill-based domains including neuropsychological models and syndromes, neuropsychological assessment, neuropsychological intervention, consultation, teaching/supervision and management/administration. Conclusion: The competencies reflect recent advances in the field of clinical neuropsychology, including expanded intervention competencies, culturally-informed neuropsychological practice and use of emerging technologies. They will be available as a resource to guide curriculum development for clinical training, as well as providing a useful framework for professional practice and advocacy more broadly within the discipline of clinical neuropsychology.

Keywords:

• Clinical neuropsychology
• competencies
• neuropsychological assessment
• neuropsychological intervention
• clinical training

In recent years in Australia, the regulatory authorities that govern the training and registration of psychologists have progressively moved toward the delineation and assessment of defined competencies to determine whether a trainee practitioner has attained a threshold of proficiency that makes them eligible for registration (Australian Psychology Accreditation Council, 2019). Within this framework, leaders across individual areas of advanced practice within the field of psychology are increasingly under pressure to define the competencies unique to their discipline. It is therefore timely, within the Australian context, to clearly delineate the competencies that are unique to clinical neuropsychology. These competencies are often referred to as “functional” competencies (i.e. competencies specific to different areas of psychology practice), which are built upon “foundational” competencies (i.e. general competencies that should be acquired by all professional psychologists and applied across areas of practice; Gates & Sendiack, 2017).

Clinical neuropsychology is an internationally recognized area of practice within professional psychology that focuses on the assessment, diagnosis, formulation, management, and treatment of cognitive, emotional, and behavioral consequences of brain impairment (Lezak et al., 2012). In Australia, clinical neuropsychology is regulated by the Psychology Board of Australia (PsyBA), an arm of the Australian Health Practitioners Regulation Agency (AHPRA). Clinical neuropsychologists are registered as general psychologists and also hold practice endorsement in the area of clinical neuropsychology (PsyBA, 2013). The Australian Psychology Accreditation Council (APAC) is responsible for the development of standards and assessment of training quality of professional psychology training programs. To receive practice endorsement in clinical neuropsychology, in addition to completing undergraduate and fourth year psychology training (APAC Level 1 and 2), trainees must successfully complete both generalist psychology training (APAC Level 3) and advanced clinical neuropsychology training (APAC Level 4) within an APAC-accredited Masters level or Doctoral level postgraduate program (APAC, 2019). Upon completion of this training, individuals must then successfully complete a PsyBA-regulated registrar training program in clinical neuropsychology before being eligible for an area of practice endorsement in clinical neuropsychology (PsyBA, 2013). In precisely delineating and regulating the pathway to achieving area of practice endorsement in clinical neuropsychology, AHPRA has aligned Australian psychological practice with international standards by classifying clinical neuropsychology as a designated or “endorsed” area of clinical practice. In other words, it is recognized that clinical neuropsychology is an area of psychological practice that has unique skills and knowledge which warrant recognition as a specific clinical discipline.

Despite this recognition by AHPRA, several threats exist to the profession of clinical neuropsychology in Australia. First, funding for training programs for areas of practice endorsement, including clinical neuropsychology, is inadequate. Traditionally, psychology training in Australia has been largely publicly funded by the federal government. Unlike undergraduate psychology training, for decades the cost of providing postgraduate psychology training has been greater than the amount provided for this training by successive governments. This mismatch occurs because high quality advanced training is necessarily teaching intensive and requires a substantial number of hours of student placements (at least 1000). These placement opportunities are limited in number due to the reduced availability of PsyBA-accredited supervisors (senior practitioners). Consequently, training providers are unable to “scale up” intake numbers to make training a cost-effective proposition. Rather, publicly funded universities have continued to offer this training at a loss, in recognition of the important role professional psychologists with advanced training and competencies play in society, and because advanced psychology training as a professional pathway remains extremely popular with students and encourages their enrollment at the undergraduate level.

The result of the long-term discrepancy between the cost and income of advanced psychology training is that some training providers have chosen to discontinue training programs. This decision has particularly affected training programs in areas of practice endorsement outside of clinical psychology, such as clinical neuropsychology, which now has only five training providers nationally within Australia compared with eight programs 10 years ago. The recent suspension of the second oldest clinical neuropsychology program in the country and the ongoing threat of closure to other longstanding programs represent a significant risk to the profession in Australia. Additionally, funding and workforce pressures in Australia make generic psychology training an attractive option for training providers and health services, as it is cheaper and quicker to achieve than advanced training. However, losing neuropsychology training options could lead to clinical neuropsychologist roles being re-defined for psychologists or other allied health professionals without specific neuropsychology training due to workforce shortages. A further consequence of this trend would be losing the community benefit of neuropsychological expertise and seeing Australian health services fall behind in relation to international comparators for neuropsychological services (Ponsford, 2017).

Detailing the competencies that are unique to clinical neuropsychology can highlight to program funders, health services, accreditors, registration bodies and other professionals the “value-add” of clinical neuropsychologists and how we differ from other professional psychologists. It is therefore timely to review and expand upon the competencies that are specific to the profession of clinical neuropsychology and with a contemporary expert consensus perspective, identify the distinctive and complex skill set neuropsychologists provide, particularly within Australian settings. The Level 4 competencies for clinical neuropsychology outlined by APAC are very broadly defined and are focused on the competencies that postgraduate training programs must assess. Outlining unique neuropsychology competencies in more detail, as well as incorporating competencies acquired by the time of area of practice endorsement (i.e. including the registrar program period of supervised practice and professional development) has several benefits. Not only does it give a more comprehensive picture of the unique contribution clinical neuropsychologists bring to the workforce, but it can also provide greater clarity to universities when designing, evaluating, and benchmarking course content.

The development of a framework of competencies to inform training needs in Australia is mirrored in the international context, with a framework of core competencies for training in clinical neuropsychology recently being developed in the USA (Smith & CNS, 2019; https://minnesotaconference.org/) and Europe (Kosmidis et al., 2022). However, these frameworks do not reflect all aspects of contemporary practice in clinical neuropsychology in Australia, which is characterized by three emerging trends: (1) growing awareness and understanding of the need for culturally safe practice with Australian Aboriginal and Torres Strait Islander peoples; (2) emerging technologies that are particularly important for the accessibility of neuropsychological services in our geographically spread population; and (3) the increased importance of the role of neuropsychologists in intervention delivery.

To ensure widespread representation from the profession of clinical neuropsychology within Australia, national leaders in the areas of training, practice and the broader profession were invited to participate in a consensus-building exercise, and the Australian Neuropsychology Alliance of Training and Practice Leaders (ANATPL) was formed. The ANATPL comprises (1) tertiary-level educators in clinical neuropsychology, representing all Australian postgraduate training programs; (2) senior clinical neuropsychology practitioners from all states and territories in Australia, except for the Northern Territory; and (3) members of the national committee of the Australian Psychological Society—College of Clinical Neuropsychologists (CCN), which is the representative body for clinical neuropsychologists in Australia. The primary aim of ANATPL was to develop a comprehensive list of competencies unique to clinical neuropsychologists. The group used the international context to inform their initial framework (Hannay et al., 1998; Hessen et al., 2018; Smith & CNS, 2019) but were committed to making this specific to the contemporary Australian context. In this paper, we present these consensus-based clinical neuropsychology competencies with the aim of defining the unique competencies that are needed for a psychologist to attain sufficient knowledge and skills to practice competently in clinical neuropsychology.

Development process

ANATPL comprises 24 clinical neuropsychologists (listed in supplemental material), 71% of whom are female. The workgroup’s years of practice in the field of clinical neuropsychology range from 9 to 40 years (M = 20.1, SD = 8.1) with a range of 7 to 34 years of training postgraduate clinical neuropsychology students (M = 16.7, SD = 7.2). It includes all course directors and several staff members from the five active and one suspended neuropsychology programs in Australia: La Trobe University (suspended), Macquarie University, Monash University, The University of Melbourne, University of Queensland, and University of Western Australia. It also includes industry representation in the form of senior clinical neuropsychologists, neuropsychology departmental heads, managers and directors from all states and territories of Australia, except for the Northern Territory, which has very limited clinical neuropsychology representation. The national Chair and Past-Chair of the CCN are also members of ANATPL.

Key international and Australian papers outlining existing competency frameworks were reviewed to guide the identification of clinical neuropsychology competencies in the Australian context. These included Bardenhagen (2006), Rey-Casserly et al. (2012), Nelson et al. (2015), Hessen et al. (2018), Smith & CNS (2019), Heffelfinger et al. (2022), and Gonsalvez et al. (2021). The Clinical Neuropsychology Synarchy (CNS) entry-level competencies (Smith & CNS, 2019) were adopted as the primary starting point, given that they are recent, comprehensive, neuropsychology-specific and consensus-based.

The workgroup met monthly from March 2021 to November 2022 to review these papers, discuss competencies relevant to the Australian context, delineate foundational and functional competencies, draft the proposed competencies, and seek consensus on these and all revisions made. It was agreed that the division into foundational and functional competencies, similar to Levels 3 and 4 of the APAC accreditation standards for postgraduate psychology programs, was a useful framework for defining competency types. It was also agreed not to include all foundational competencies (i.e. relevant to all professional psychologists) but rather focus on the application of foundational competencies to clinical neuropsychology practice. To guide the incorporation of neuropsychological competencies as they relate to Aboriginal and Torres Strait Islander health, the workgroup consulted with the CCN’s Decolonizing Neuropsychology sub-committee and adhered to the recommended Curriculum Framework produced by the Australian Indigenous Psychology Education Project (AIPEP; Dudgeon et al., 2016).

The process behind the development of the current competency framework can be summarized in the following steps:

1. Expert group formed

2. Review of existing competency frameworks relevant to clinical neuropsychology training and practice worldwide

3. Detailed review of CNS entry-level competencies (Smith & CNS, 2019) as a starting point for this contemporary Australian version

4. Formulation of revised competencies for clinical neuropsychology training and practice in Australia

5. Consultation with colleagues who have expertise in working with Aboriginal Australians and existing Indigenous psychology education frameworks to inform cultural competencies

6. Eleven rounds of feedback and revisions

7. Informed consensus-based decision achieved on final set of competencies.

Competencies for clinical neuropsychology training and practice in Australia

The competency document included (i) a preamble and (ii) a set of tables (Tables 1–9) outlining the various competency types. Both are presented below.

Table 1. Foundational competencies as applied to clinical neuropsychology.

Foundational competency type	Competencies encompassed by domain
	The clinical neuropsychologist:
Scientific Knowledge and Methods	Demonstrates knowledge of the clinical and cognitive neurosciences, including neuroanatomy, neurophysiology, and neuropathology. Understands brain functioning across the lifespan, including neurodevelopment and age-related changes. Maintains currency with key scientific developments in fields related to clinical neuropsychology practice. Demonstrates and applies knowledge of scientific and scholarly developments in clinical neuropsychology.
Evidence-Based Practice	Understands key signs and symptoms of disease processes relevant to practice and how patient characteristics (e.g. demographic factors, comorbidities) affect their expression. Understands patterns of incidence, prevalence (i.e. base-rates), and natural course of conditions of interest in neuropsychology. Understands scientific principles of assessment strategy, including test selection, use of appropriate normative standards, psychometric and operating characteristics, and test limitations. Understands clinical reasoning and evidence-based decision-making strategies and their applications in improving the accuracy of differential diagnosis of neuropsychological conditions, and in the selection and delivery of intervention strategies. Understands evaluation of quality of methods and patient-relevance of intervention research. Is cognisant of potential sources of bias/error in clinical judgements (e.g. overconfidence, “clinician’s illusion,” confirmation bias, illusory correlation, availability heuristic) and applies relevant de-biasing techniques to address these limitations (e.g. active consideration of alternatives, referencing quality evidence, semi-structured interviewing techniques). Knows the scientific basis for diagnostic conclusions across a range of neuropsychological disorders. Incorporates and uses outcome research in neuropsychology in guiding assessments and formulating interventions, integrating patient and contextual factors. Applies key components of evidence-based practice (i.e. best evidence guided by the “levels-of-evidence” hierarchy, clinical expertise, and patient characteristics/culture/values) in selecting appropriate neuropsychological assessment and intervention approaches and informing clinical understanding. Applies information technology and literature search/review strategies to assess and consider the best current evidence to guide practice in clinical neuropsychology.
Individual and Cultural Identity and Diversity	Integrates knowledge of diversity issues in neuropsychological assessment, research, treatment, and consultation (e.g. health disparities, language differences, educational level, cultural context, literacy, gender and sexuality, individual differences). Understands and appreciates how culture, language, gender, sexuality, disability, other demographic/socioeconomic factors, and the societal context affect the process and outcomes of neuropsychological assessments and the application of normative data and interpretations in specific populations. Seeks information from the client about their cultural identity, beliefs, and practices and how these may shape their conceptualisation of brain functioning and disorders. Understands the history and colonisation of Aboriginal and Torres Strait Islander peoples, is aware of associated trauma and post-traumatic stressors, and how these impact presentation for neuropsychological services.
Ethical, Legal Standards and Policy	Applies ethical concepts across a range of settings; demonstrates awareness of legal issues relevant to the professional activities of clinical neuropsychologists across settings, including healthcare, research, school, military/veteran, industry, and forensic (e.g. criminal, personal injury, disability determination, fitness for duty, etc.). Understands specific ethical and legal issues relevant to neuropsychologists’ activities across settings, including informed consent, third-party assessments and requests for information, use of technicians/psychometrists, third-party observers, use of technology (including telehealth), disclosure of neuropsychological test data, and test security.
Professional Identity	Demonstrates professional identity as a clinical neuropsychologist; understands the unique contributions of neuropsychology to different educational, healthcare, and forensic/legal contexts. Demonstrates awareness of clinical neuropsychologists’ roles, and how these vary across settings (e.g. practice, research, training, etc.) and assessment/intervention contexts.
Reflective Practice/Self-Assessment/Self-Care	Engages in reflective self-assessment regarding the dynamic knowledge/relevant evidence base and skill sets necessary for practice in clinical neuropsychology across settings to improve skill level over time; understands limits of competence in particular populations or settings and seeks to lessen their impact through continuing education, peer supervision/consultation, or additional training as needed.
Relationships	Maintains effective and productive relationships with patients/clients, families, caregivers, colleagues, team members, trainees/students, and communities across complex interprofessional settings. Communicates clearly and effectively through both oral and written means, integrating and explaining neuropsychological concepts and interpretations in a manner best suited to the audience and setting (e.g. other professionals, patients/clients, families, caregivers).
Interdisciplinary Systems	Demonstrates knowledge of key issues and concepts in related disciplines (e.g. medical and allied health specialties such as neurology, psychiatry, rehabilitation; other areas of practice endorsement in psychology; education) and the ability to communicate and interact knowledgeably with professionals across these disciplines. Understands the roles of other professionals in client care and support and integrates the perspectives of related disciplines into their case conceptualisations. Makes appropriate referrals to other health professionals as part of treatment planning. Works as a member of interprofessional teams and collaborates with other professionals to contribute neuropsychological information to overall team diagnostic formulation, planning, and intervention.

Table 2. Neuropsychological models and syndromes competencies.

Functional competency type	Competencies encompassed by domain
Knowledge-based competencies	The clinical neuropsychologist has knowledge of: Theories and models of cognition, emotion, and behaviour, including information processing theories, cognitive/affective neuroscience, neurodevelopment, social neuroscience, cultural neuroscience, and behavioural neurology. Diagnostic features and neuropathology of conditions affecting the brain (including, but not limited to stroke, traumatic brain injury, dementia, neurodevelopmental disorders, multiple sclerosis, epilepsy, psychiatric disorders), including their staging/course over time. Patterns of cognitive, emotional, and behavioural impairments associated with neurological and related diseases and conditions that affect brain structure and functioning. Patterns of cognitive, emotional, and behavioural impairments associated with psychiatric disorders and alcohol/substance use disorders. Effects of common systemic medical illnesses on brain functioning and behaviour. Medications used for common medical diseases and psychiatric disorders and their effects on brain functioning and behaviour. Functional neuroanatomy, neurochemistry, neuropsychopharmacology, neuroendocrinology, and related areas relevant to practice. Neurosurgical procedures and the role of neuropsychology practice within neurosurgical interventions (e.g. assessing suitability, “live” and post-surgical outcomes). Neurodiagnostic techniques relevant to practice, including neuroimaging, neurological examination.
Applied competencies	The clinical neuropsychologist is able to:Integrate knowledge of neuropsychological models and syndromes to form a comprehensive neuropsychological formulation for individual cases.

Table 3. Neuropsychological assessment competencies.

Domain	Competencies encompassed by domain
Knowledge-based competencies	The clinical neuropsychologist has knowledge of: Theories and evidence-based methods of measurement and psychometrics relevant to cognitive abilities (including attention, memory, executive functions, verbal and visuospatial abilities), social and emotional functioning, and brain–behaviour relationships, including test development, reliability, reliable change, and validity approaches (e.g. construct, content, criterion, ecological). Methods for measuring cognitive change, including decline from estimated premorbid abilities, and repeated/longitudinal assessment. Potential influences of motivational factors and assessment context on test performance. Potential functional implications of neuropsychological impairments as they relate to everyday ability, independence in activities of daily living, quality of life, and capacity to participate in education/ work/ social relationships/ leisure activities. Theory, legislation, and ethical & professional responsibilities pertaining to assessment of decision-making capacity, fitness to perform duties/activities/life roles across the lifespan, and medicolegal and forensic issues. The history of testing and assessment, to appreciate its role in today’s societal and cultural context and its relationship to the health and wellbeing of marginalised groups, including Aboriginal and Torres Strait Islander peoples and others who have experienced disadvantage due to their culture, gender, sexuality, socioeconomic circumstances, educational level, health literacy, or disability.
Applied competencies	The clinical neuropsychologist is able to: Analyse and clarify referral questions and legal requests based on the context, professional roles, and patient/client presentation. Gather information key to addressing the referral question, including client and collateral interview(s), targeted behavioural observations, and review of records. Appropriately select and critically appraise tests, measures, and other information sources consistent with best evidence, theoretical and legal frameworks, and specific context of assessment, including assessment of performance and symptom validity, if relevant. Generate and test hypotheses about diagnoses and biological, psychological, and social factors underlying the patient’s presenting features. Appropriately administer and score tests and measures, in keeping with best practice guidelines. Evaluate suitability for inclusion of technologies within neuropsychological assessment (e.g. telehealth, computerised scoring) and demonstrate proficiency using such technologies. Identify factors potentially affecting test performance (e.g. fatigue, motivation, anxiety, distracting environment, technological competence, assessment modality), and when possible, manage these to optimise performance. Interpret assessment results in the context of population norms and the range of typical performance, as well as estimated premorbid abilities where relevant, with formation of an integrated biopsychosocial formulation that draws from all relevant information sources (e.g. interview, test results, behavioural observations, medical history/health records). Provide recommendations for management that are appropriate to the assessment context and biopsychosocial formulation and consistent with evidence-based practices. Appropriately conduct assessments evaluating decision-making capacity and fitness to perform duties/activities/life roles in various clinical populations. Demonstrate written communication skills in producing neuropsychological assessment reports that answer the referral question and are appropriate for the audience. Provide feedback, as appropriate to the assessment context and modality, to patients, families, caregivers, and/or treating team in a sensitive manner adapting to the needs of the specific audience. Appropriately address issues related to specific populations (e.g. those with cultural or linguistic differences, physical or mental disability, requiring use of interpreters, low educational level) by referring on to other providers with specialised competence when needed, or seeking cultural consultation regarding the assessment process, such as selecting, adapting, and interpreting tests. Consider and acknowledge in oral/written communications all relevant limitations of neuropsychological assessments, particularly those with specific populations (e.g. very young children, cultural appropriateness of tests, language difficulties, severe disability).

Table 4. Neuropsychological intervention competencies.

Domain	Competency encompassed by domain
Knowledge-based competencies	The clinical neuropsychologist has knowledge of: Evidence-based intervention techniques and practices to address cognitive, emotional, and behavioural consequences of conditions affecting the brain, with consideration of both the quality of the evidence and whether there is evidence for meaningful impact on everyday activities, participation in life roles, and quality of life in the relevant clinical population. Theoretical and procedural bases of intervention methods appropriate to address disorders of attention, processing speed, learning and memory, executive skills, problem solving, language, perceptual and visuospatial skills, social cognition, psychological/emotional adjustment, and behaviours of concern. How complex neurobehavioural disorders (e.g. anosognosia, neuropsychiatric conditions) factors can affect the applicability of interventions. Sociocultural considerations when planning and using interventions; referring on to other providers with specialised competence if appropriate; and/or seeking cultural consultation as required. How to promote cognitive health with patients through activities such as physical exercise, cognitive stimulation, stress management, and healthy lifestyle (e.g. sleep, nutrition) practices. Empirically supported interventions provided by other psychologists and other mental and behavioural health professionals.
Applied competencies	The clinical neuropsychologist is able to: Identify targets of interventions and client goals and preferences. Employ neuropsychological assessment and provision of feedback for therapeutic benefit. Provide psychoeducation and information about neuropsychological disorders to aid the patient and family’s understanding of their presenting concerns and how to manage them. Identify potential barriers to intervention and adapt interventions to minimise such barriers. Develop a comprehensive biopsychosocial case formulation, including the cultural context, which usefully guides the intervention. Develop and implement treatment plans for neuropsychological problems based on the case formulation and client goals. Implement evidence-based cognitive interventions for neuropsychological disorders across the lifespan. Deliver evidence-based psychological therapies (e.g. for depression, anxiety) appropriately adapted for people with neuropsychological impairment. Provide behavioural interventions (e.g. positive behaviour support) for behaviours of concern in people with neuropsychological disorders. Consider suitability and provide adequate training and support for use of technologies within neuropsychological interventions (e.g. assistive technologies, telehealth). Independently evaluate the effectiveness of interventions employing appropriate outcome measures that are meaningful in everyday life, relevant to the patient’s goals, reliable and valid. Demonstrate an awareness of ethical and legal ramifications of neuropsychological intervention strategies.

Table 5. Consultation competencies.

Functional competency type	Competencies encompassed by domain
Knowledge-based competencies	The clinical neuropsychologist has knowledge of: Professional roles and expectations of a consulting clinical neuropsychologist specific to each setting. Relevant literature on the roles of neuropsychologists in consultation settings. Contextually appropriate and culturally sensitive methods of consultation. How to communicate effectively (both verbally and non-verbally) about neuropsychological issues with culturally diverse groups, including Aboriginal and Torres Strait Islander peoples, clients, and organisations.
Applied competencies	The clinical neuropsychologist is able to: Determine and clarify referral issues and/or legal requests. Educate referral sources regarding the utility and relevance of neuropsychological services. Effectively communicate neuropsychological case formulations that emphasise the value-add of neuropsychological services. Communicate findings from consultation activities effectively and efficiently. Provide effective assessment feedback and articulate appropriate recommendations in language appropriate for the audience. Provide effective consultation services within common settings and contexts in clinical neuropsychology practice. Communicate scientific findings within clinical neuropsychology in a manner that is relevant to the consultation setting and cultural context and accessible to the recipient. Provide consultation in clinical research regarding brain–behaviour relationships and appropriate neurobehavioural assessment strategies and tools.

Table 6. Research and evaluation competencies.

Functional competency type	Competencies encompassed by domain
Knowledge-based competencies	The clinical neuropsychologist has knowledge of: The scientific method in generating reliable and valid neuropsychological knowledge and evaluating findings related to neuropsychological techniques, brain–behaviour relationships, assessment strategies, and effective interventions. Research design, methodology and analysis relevant to clinical neuropsychological science and practice. Tools and methods for critically appraising neuropsychology research The wide array of factors that mediate and modulate behaviour and their implications for neuropsychological and related research. The conduct of research in an ethical and responsible manner, adhering to established national and institutional guidelines.
Applied competencies	The clinical neuropsychologist is able to: Select research topics and perform literature reviews effectively. Critically appraise research and the extent to which there is scientific consensus on particular topics to guide evidence-based practice. Demonstrate skills in conceptualising, implementing, and interpreting research design and statistical analysis. Perform research activities, monitoring of progress, and evaluation of outcomes accurately and effectively. Communicate research findings effectively. Apply research methods in evaluating the effectiveness of professional activities in clinical neuropsychology, including program evaluation and other methods for assessing outcomes of their practice.

Table 7. Advocacy competencies.

Domain	Competency encompassed by domain
Knowledge-based competencies	The clinical neuropsychologist has knowledge of: Regulatory and policy initiatives that can affect provision of neuropsychology services and access to care. Knowledge of past and contemporary cultural and social issues that can affect provision of neuropsychology services and access to care.
Applied competencies	The clinical neuropsychologist is able to: Apply scientific knowledge and skills in neuropsychology to advocate for the needs of individuals/groups across systems and to advocate for equity and access to quality care; particularly for people who are marginalised or disadvantaged due to their culture, gender, sexuality, socioeconomic circumstances, geographic location, educational level, health literacy, or disability. Effectively communicate to relevant decision makers how neuropsychological services can help mitigate the personal, societal, and financial costs associated with brain impairment. Educate our colleagues, community stakeholders, policymakers and the public about the nature and value of neuropsychology in healthcare. Collaborate with psychologists and other professionals to advocate for the profession and the specialty of neuropsychology.

Table 8. Teaching and supervision competencies.

Functional competency type	Competencies encompassed by domain
Knowledge-based competencies	The clinical neuropsychologist has knowledge of: Supervision theories, methods, and practices in professional psychology and clinical neuropsychology. Developmental stages in training that may impact the acquisition of clinical neuropsychology knowledge and skills. Ethical issues and regulatory standards relevant to teaching and supervision.
Applied competencies	The clinical neuropsychologist is able to: Provide effective teaching activities, presenting materials in an organised manner that is appropriate to the needs of the audience. Provide effective training to psychology trainees in the foundations of assessment, psychometric theory, and the administration and scoring procedures for tests and measures employed in clinical neuropsychology practice. Provide effective training in developing and asserting professional identity and role as a clinical neuropsychologist. Provide effective training in neuropsychological interviewing, test interpretation, case conceptualisation, and the development of recommendations. Provide effective training in treatment planning and delivery, including the provision of feedback. Demonstrate sensitivity to individual and cultural differences in supervisory contexts.

Table 9. Management and administration competencies.

Functional competency type	Competency
Knowledge-based competencies	The clinical neuropsychologist has knowledge of: Common administrative and business practices needed to address prevalent assessment and consultation issues in neuropsychology practice (e.g. referral patterns, billing, documentation). Governance structures of the organisation where neuropsychological practice occurs, including delegations, clinical governance (including protocols, procedures, and guidelines), corporate governance (including line reporting, management), risk reporting and governance, governance of student placements, and research governance processes. Methods and procedures for outcome assessment, program evaluation, and research in neuropsychology. Administrative structures of practice settings relevant to neuropsychology.
Applied competencies	The clinical neuropsychologist will be able to: Function effectively within administrative and governance systems, educating others about the role of neuropsychology and supporting structures with the goal of improving access to needed services. Implement administrative structures and business case proposals to address needs in public and private neuropsychology practice settings (e.g. quality improvement, access to care, funding). If relevant, train and supervise technicians/assistants and monitor their skills following regulatory, ethical, and legal standards. Awareness of activity data recording and reporting and advocating for systems that enable visibility of clinical neuropsychology activity within this.

Preamble

This document lists competencies necessary for professional practice as a clinical neuropsychologist in Australia. Broadly, clinical competencies in psychology can be divided into foundational and functional competencies. Foundational competencies are general competencies that are necessary across specializations or areas of practice endorsement in professional psychology (e.g. understanding ethical and professional boundaries); and functional competencies are specific to the different areas of clinical neuropsychology practice (e.g. assessment, intervention). “Generic” foundational competencies that apply across areas of practice are not covered in this document, though it should be noted that they apply to clinical neuropsychologists just as they do to other psychologists (as outlined in APAC’s Level 1–3 competencies for all psychologists; APAC, 2019). However, we will cover foundational competencies that are specifically applied to clinical neuropsychology, as explained further below. The competencies covered fall into three broad categories: (1) foundational competencies as applied to clinical neuropsychology; (2) functional competencies unique to clinical neuropsychologists at all career stages; and (3) functional competencies for clinical neuropsychologists at advanced career stages.

Foundational competencies as applied to clinical neuropsychology

These are common across the functional competency domains (i.e. relevant for assessment, diagnosis, intervention, etc.) for clinical neuropsychologists at all career stages. Clinical neuropsychology registrars are expected to have acquired these competencies by the completion of the registrar program, at which point they are recognized as having an area of practice endorsement in clinical neuropsychology. It is expected that their skill level and fluency would gradually improve with experience, from novice through to advanced levels.

Functional competencies unique to clinical neuropsychologists at all career stages

Entry-level clinical neuropsychology registrars are expected to have acquired these competencies, and it is expected that their skill level and fluency would improve with experience, from novice through to advanced. These are divided into six functional domains, with both knowledge-based and applied (skill-based) competencies listed for each domain:

• Neuropsychological models and syndromes

• Neuropsychological assessment—This includes file review, clinical interview with patients and informants, behavioral observation, administration, scoring and interpretation of tests of cognition, emotion and behavior, neuropsychological formulation, and communication of findings, including feedback on assessment results

• Neuropsychological intervention—This is defined as an intervention that targets the cognitive, emotional, and/or behavioral consequences of conditions affecting the brain, and includes both brief and extensive intervention approaches

• Consultation—to individuals, organizations, and communities

• Research/evaluation—including reviewing, appraising, and conducting research relevant to clinical neuropsychology

• Advocacy—on behalf of our patients/clients, organizations, our profession, and disadvantaged communities

Functional competencies for clinical neuropsychologists at advanced career stages

These competencies are expected to be acquired by neuropsychologists at more advanced career stages. These are divided into two further domains:

• Teaching/supervision—these apply to those who teach and/or supervise

• Management/administration—these apply to those in management and/or administration roles

Differences from the existing clinical neuropsychology Synarchy (CNS) competencies

The entry-level clinical neuropsychology competencies developed by the Clinical Neuropsychology Synarchy (Smith & CNS 2019) were taken as the starting point for the Australian competencies. Comparable to those reported in this paper, the CNS framework describes competencies across two broad categories: (1) foundational competencies; and (2) functional competencies pertaining to specific areas of clinical neuropsychology practice, with both knowledge-based and applied skill-based competencies across seven domains: (i) neuropsychological assessment, (ii) neuropsychological intervention, (iii) consultation, (iv) research/evaluation, (v) advocacy, (vi) teaching/supervision, and (vii) management/administration.

The current Australian competencies were revised to incorporate advancements in the field of clinical neuropsychology across these categories and domains. Key differences from the CNS competencies included recognizing the emergence of a range of technologies that can be utilized within neuropsychological practice. The need to define clinical competencies more clearly for these technologies, including skill proficiency and ethical/legal considerations, was acknowledged. Additionally, in consultation with key stakeholders, ANATPL included knowledge-based and applied skill-based competencies related to individual and cultural identity and diversity across all domains to better reflect the Australian context. Our approach included developing specific competencies related to Aboriginal and Torres Strait Islander peoples and highlighting the importance of how cultural issues might impact presentation and engagement with neuropsychological services as well as all aspects of the assessment and treatment process. We also re-classified teaching/supervision and/or management/administration competencies as more relevant for practitioners in advanced career stages.

Another key difference from the CNS competencies was the inclusion of an eighth domain: Neuropsychological models and syndromes, which was placed in the “functional competencies at all career stages” category. This domain covers theories and models of cognition, emotion, and behavior from a neurodevelopmental perspective. It includes some competencies previously included by CNS under specific areas of practice, which ANATPL moved as we considered that these competencies extended beyond the skill requirements for assessment or intervention, and rather were required across all areas of practice. Other knowledge-based competencies added within this section include (i) diagnostic features and neuropathology of conditions affecting the brain, including their staging/course over time; (ii) functional in addition to structural neuroanatomy; (iii) patterns of cognitive, emotional, and behavioral impairments associated with alcohol/substance use disorders; (iv) types of neurodiagnostic techniques; and (v) neurosurgical interventions. Additionally, a new applied competency was added to recognize the need for neuropsychologists to integrate their knowledge of models and syndromes to develop comprehensive neuropsychological formulations.

Several changes were also made to specific functional competency domains that were outlined in the original CNS document (Smith & CNS, 2019). In the neuropsychological assessment domain, competencies were added and extended to acknowledge changes in the field, several of which reflect the wider range of reasons for, and outcomes of, neuropsychological assessment beyond diagnosis. These include: (i) an increased emphasis on everyday practical implications given the importance of intervention, rehabilitation, and informing prognosis, (ii) increased emphasis on decision-making capacity and fitness to perform key life roles; and (iii) the recognition that competencies related to theoretical knowledge also extend to an understanding of current legislation as well as ethical and professional responsibilities. Additionally, applied neuropsychological assessment competencies were extended to acknowledge the importance of (i) generating and testing hypotheses regarding diagnoses and biological, psychological and social factors underlying the patient/client’s presenting features; (ii) identifying factors that affect test performance; (iii) critically appraising tests/measures and all assessment sources; (iv) considering symptom and performance validity; (v) interpreting results in the context of population norms, premorbid abilities and cultural issues, and (vi) writing reports that answer the referral question and are tailored to the audience. The importance of a biopsychosocial framework that considers cultural issues and draws from a wide range of sources was also highlighted.

Intervention competencies were significantly expanded to reflect the increased role of clinical neuropsychologists in this practice area (Wong et al., under review). Knowledge-based competencies for neuropsychological intervention were revised to consider emotional factors and quality of life in the relevant clinical population and expand upon intervention domains relating to processing speed, visuospatial skills, social cognition, and behaviors of concern. For applied competencies, we included additional focus on (i) patient/client goals and preferences; (ii) psychoeducation; (iii) linking comprehensive biopsychosocial case formulation with treatment goals, including consideration of the cultural context; (iv) cognitive-based interventions; (v) working across the lifespan; vi) the delivery of evidence-based psychological therapies that are suitably adapted for neuropsychological impairments; and vii) the need for outcome measures to be meaningful and relevant to the patient’s goals, as well as reliable and valid.

Competency domains related to Consultation, Research/Evaluation and Advocacy were reworded to emphasize the need for neuropsychologists to “add value” to various services and consider cultural issues, such as cultural safety. Furthermore, an increased emphasis on critical appraisal of the research literature to guide evidence-based practice was incorporated, as well as the addition of competencies related to program evaluation and the need for formal self-evaluation. Finally, it was recognized that advocacy for the neuropsychology role is becoming increasingly important at all career stages and that advocacy also needs to include the education of colleagues, community stakeholders, policymakers, and the public. For this reason, the advocacy-related competencies were retained in the “all career stages” category. Whilst a competency directly related to mentorship was not included in our guidelines, ANATPL acknowledges the important role of culturally responsive mentorship by more experienced neuropsychologists in facilitating the development of clinical neuropsychologists at all levels of training to positively impact future generations of psychologists (Calamia et al., 2022; Ellison & Johnelle Sparks, 2022).

Conclusions and future directions

This set of clinical neuropsychology competencies for training and practice in the Australian context achieved full consensus amongst our expert working group of experienced educators, practitioners, managers, and professional leaders. This work reflects unique competencies of clinical neuropsychologists across various settings and career stages in the current Australian context, highlighting how clinical neuropsychologists can add value to health services and clinics. In particular, these competencies reflect the important role of the clinical neuropsychologist in (i) culturally informed biopsychosocial case formulation as well as diagnostic assessment for people with neuropsychological disorders, (ii) providing expert opinion on an individual’s decision-making capacity and ability to perform key life roles, and (iii) delivering a range of cognitive, psychological and behavioral interventions for people with conditions affecting the brain.

In comparison to the international CNS competency framework (Smith & CNS, 2019), we have included several new competencies that reflect the contemporary Australian context, including emerging technologies such as telehealth and recognition of the importance of considering cultural issues, particularly regarding work with First Nations people. These new competencies represent the first attempt to acknowledge and characterize these important skills for clinical neuropsychologists in Australia. However, more work on cultural competencies is needed to identify what best practice should look like both in clinical neuropsychology and across the profession of psychology. Authentic and comprehensive engagement with Indigenous psychologists, community members and Indigenous people with neuropsychological conditions will be necessary to achieve this. This process of engagement could also provide a framework for other countries where colonization has affected engagement with neuropsychological services for First Nations people.

We anticipate several important uses for this set of clinical neuropsychology competencies. Firstly, they will be available as a resource to guide and standardize curriculum development for the training of clinical neuropsychologists across Australia and potentially internationally. Our competency framework can serve as a useful platform for clinical neuropsychology training program educators to guide which knowledge and skills need to be taught and assessed, as well as potentially informing future updates to APAC guidelines describing Level 4 competencies for clinical neuropsychology training programs. Secondly, these competencies may be used by various stakeholders to clearly articulate how clinical neuropsychologists are unique from other areas of practice endorsement. For example, they could assist health service managers in arguing how the addition of clinical neuropsychology may “value-add” and address current gaps within current health service provision. They could also potentially be used to guide future assessments and examinations that may be incorporated to demonstrate eligibility for an area of practice endorsement (e.g. for those trained overseas) or to guide requirements and structured group supervision programs for graduates completing their registrar program (Langborne et al., 2022). Self-auditing or reflective practice tools could also be developed based on these competencies, building on the audit tool recently developed by King et al. (2022). Finally, they may be a valuable step in highlighting the need for dedicated postgraduate clinical neuropsychology training programs and ensuring the viability of the Australian clinical neuropsychology field into the future.

To meaningfully guide training programs and assessment methods in this way, the next step will be to create a framework of recommendations for how to evaluate competency development, acquisition, and proficiency in each area. Our working group is currently developing this, focusing primarily on a recommended framework of competency evaluation for clinical placements completed during postgraduate training and for the registrar program, to be used by placement coordinators and supervisors of trainees and registrars. This competency evaluation framework will build on similar work conducted in America for clinical neuropsychology (Heffelfinger et al., 2022) and in Australia for clinical psychology (Gonsalvez et al., 2013, 2015). Further work will also be needed to develop, refine and evaluate more detailed evidence-based competency frameworks for specific areas of practice, such as neuropsychological assessment (Carrier et al., 2022), feedback (Wong et al., 2023), report-writing, and specific intervention types (Wong et al., 2019, 2020).

This paper highlights the distinctive knowledge and skills clinical neuropsychology can offer to the psychology workforce and health services more broadly. Ensuring that the unique competencies offered by clinical neuropsychologists to multidisciplinary teams are clearly defined can inform workforce planning for adequate health service delivery. A contemporary structured competency framework will result in a more coherent alignment of training pathways and workforce requirements in the Australian context. Such an approach will improve the standard of care for Australians with conditions affecting the brain.

Acknowledgments

Thank you to ANATPL members Kelly Allott, Rowena Beecham, Stephen Bowden, Heather Francis, Brian Long, Alexia Pavlis, and Clare Ramsden for their review and input to this paper.

Disclosure statement

The authors report there are no competing interests to declare.

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Funding

The author(s) reported there is no funding associated with the work featured in this article.