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Neuropsychology in South Africa

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 Applied Neuropsychology: Adult

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Neuropsychology in South Africa

Sharon Truter, Menachem Mazabow, Alejandra Morlett Paredes, Diego

Rivera & Juan Carlos Arango-Lasprilla

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APPLIED NEUROPSYCHOLOGY: ADULT
http://dx.doi.org/10.1080/23279095.2017.1301453

Neuropsychology in South Africa

Sharon Trutera, Menachem Mazabowb, Alejandra Morlett Paredesc, Diego Riverad and Juan Carlos Arango-
Lasprillad,e
a
Rhodes University, Psychology Department, South Africa; bSouth African Clinical Neuropsychological Association, Johannesburg, South Africa;
c
Virginia Commonwealth University, Psychology, Richmond, Virginia, USA; dBioCruces Health Research Institute, Cruces University Hospital,
Barakaldo, Spain; eIKERBASQUE, Basque Foundation for Science, Bilbao, Spain

ABSTRACT KEYWORDS
This survey forms part of an international research study conducted in 39 countries and is the first to Evaluation;
describe the characteristics of individuals engaged in the practice of neuropsychology in South neuropsychologist; practice;
Africa (SA). The purpose was to analyze the characteristics of individuals working in the profession of rehabilitation; South Africa;
training
neuropsychology in order to understand their background, professional training, current work
situation, assessment and diagnostic procedures, rehabilitation techniques, teaching responsibilities,
and research activities. Ninety-five professionals working in neuropsychology completed an online
survey between July and November 2015. The majority of participants were female and the mean
age was 46.97 years. The majority of professions working in neuropsychology have a background in
psychology, with additional specialized training and supervised clinical practice. Over half work in
private practice and are on average satisfied with their work. Participants identified as clinicians
primarily work with TBI and ADHD individuals. The main limitation for the use of neuropsychological
instruments is the lack of normative data in SA and the main barrier to the field is the lack of
academic training programs. There is a need to improve graduate curriculums, enhance existing
clinical training, develop professional certification programs, validate existing neuropsychological
tests, and create new, culturally relevant instruments.

Introduction registration, recognition, and differentiation of

South Africa enjoys a rich diversity of cultures and
languages, presenting unique challenges to psychologi-
cal assessment efforts. This is especially so in the
historical context of the imbalances associated with
Apartheid, including differential access to resources
such as quality of education. Although attempts to
overcome the imbalance in quality of education have
been instituted since the advent of democracy in 1994,
this process has been hindered by ongoing obstacles,
including faulty infrastructure and under-resourced
schooling facilities, which continue to represent
impediments to individual neuropsychological
practitioners and to researchers who are attempting to
derive useful and practical assessment data.
This historical legacy, with its ongoing, contempor-
ary consequences, provides a salient example of the
specific challenges facing the neuropsychologist in
South Africa in 2017, and which is compounded by
the continuing dearth of neuropsychological services/
skills accessible to large portions of the country.
These challenges are coupled with regulatory/statutory
inhibitions, which have restricted the formal
neuropsychological practitioners.
Origins of neuropsychology in South Africa
Neuropsychology as a discipline in South Africa is of
relatively recent advent, and its history has been
elaborated recently by Watts (2008) and, more recently
by Shuttleworth-Edwards (2016) and Watts and
Shuttleworth-Edwards (2016). The latter trace the
origins of neuropsychology in South Africa to the
requirements of the South African Air Force, during
World War II, to establish reliable and valid means of
selection of pilots along cognitive lines. This require-
ment led to the institution of the Aptitude Tests Section
(ATS) responsible for development and implementation
of research involving pilot stress and flight accidents.
Following World War II, the ATS was superseded by
the NIPR (National Institute for Personnel Research),
and in 1953 the Division of Neuropsychology (DoN)
was established as a branch of the NIPR. The research
interests of the DoN (until its closure, together with
the NIPR, in the 1990s) included the EEG, epilepsy,

CONTACT Juan Carlos Arango-Lasprilla jcalasprilla@gmail.com Plaza de Cruces s/n 48903, Barakaldo. Bizkaia, Spain.
© 2017 Taylor & Francis Group, LLC
2 S. TRUTER ET AL.
Alzheimer’s disease, the effects of underground mining
conditions, and the impact of kwashiorkor (a syndrome
caused by severe protein deficiency) on cerebral
development and cognitive functioning.
Academic roots
Watts (2008) points out that, although during the 1950s
some universities maintained neuropsychology labora-
tories, teaching in the field was initially subsumed by
the domain of Physiological Psychology, and it was only
after the 1970s that neuropsychology emerged as an area
of study in its own right. By the 1980s and 1990s,
neuropsychology as a discipline was being taught at
different universities, including: the University of
Natal’s Medical School in Durban, the University of
Cape Town, the University of Zululand, the University
of Durban-Westville, Rhodes University in
Grahamstown, the University of South Africa (UNISA)
in Pretoria, the University of Natal’s Pietermaritzburg
campus, and the University of the Witwatersrand
(Watts & Shuttleworth-Edwards, 2016).
Registration in neuropsychology
The psychology registration/licensing with the Pro-
fessional Board for Psychology of the Health Professions
Council of South Africa (HPCSA, 2011) is based on
formal academic education and practical training, with
five categories of such registration currently recognized:
Clinical, Counselling, Educational, Industrial, and
Research. In 2011, the HPCSA promulgated, in the
Government Gazette, the Scope of Practice of a new
category, Neuropsychology, and in 2013 the HPCSA’s
Professional Board of Psychology announced the recog-
nition of neuropsychology as a separate registration
category, pending attention to outstanding legislative
issues (Sodi, 2013, 2014). Amendments to the regula-
tions were drafted and approved in principle, thereafter.
Unfortunately, the process of finalizing and imple-
menting the specific registration of neuropsychologists
in South Africa has been slow (having, in fact, been
a subject of negotiation with the HPCSA and its
predecessor since 1985), and this process has been
characterized by lengthy periods of inactivity and delay.
In 2016, a Task Team under the Professional Board of
Psychology, attempted again to finalize the procedures
intended to populate the initial register of neuropsy-
chology, and to elaborate the nature of the core training
curriculum. The outcome is pending.
In the interim, clinical practice in the field of
neuropsychology remains an activity that falls within
the scope of practice of the “conventional” categories
of registration (Clinical, Counselling and Educational),
with many practitioners undergoing formal, albeit
incidental, training (in the process of their standard
Master’s degree training), or informal postgraduate
training, and with some practitioners having undergone
formal postdoctoral neuropsychological training at
international institutions.
Organisations and conferences
Watts (2008) and Lucas (2013) have traced the organi-
zational history of neuropsychology in South Africa to
its origin in the South African Society for Brain and
Behaviour Studies, which was formed at the landmark
First South African Neuropsychology Conference in
Durban in 1981. The South African Clinical Neuro-
psychological Society (SACNA) was established soon
afterwards, in 1985, during the Third National
Neuropsychology Conference, and that organization
has remained active over the past 32 years.
The aim of SACNA, as a peer credentialed associ-
ation of psychologists, has been to promote the interest
of neuropsychology in South Africa, while enhancing its
professional development and maintaining standards in
neuropsychological practice and training, including
through training workshops and CPD/CEU activities
(activities for continued professional development),
and via its peer credentialing procedure. Biennial
national conferences in neuropsychology have been
addressed by a number of key figures, such as George
Prigatano, Kevin Walsh, Muriel Lezak, Barbara Wilson,
Donald Stuss, and Thomas McAllister, amongst others.
Furthermore, in 1999 SACNA co-hosted, together
with the International Neuropsychological Society
(INS), its first international neuropsychology confer-
ence. This was held in Durban under the organisation
of Prof. S. Tollman and Dr. A. Watts (the latter having
been SACNA President at the time, and having later, in
2015, been appointed INS President). In 2017, nearly
two decades later, the INS Mid-Year Meeting is due to
be held in Cape Town, in collaboration with the Psycho-
logical Society of South Africa (PsySSA) and SACNA.
In addition to SACNA, the Division of Neuropsy-
chology was formed (within PsySSA) in 2001, the aim
of which was to stimulate interest in neuropsychology
and to foster an awareness of the specialist knowledge
and skills required of the field. Finally, although not a
professional organization, the current burgeoning inter-
est in the field is reflected in the launch of a web-based
organization, NeuropsychologySA, in 2012, aiming to
serve as a hub of information pertaining to South
African neuropsychology for the benefit of psycholo-
gists and psychology students.

Neuropsychological testing in South Africa
The marked diversity and stark contrasts in levels of
socioeconomic development and in access to resources
that persist in present day South Africa (Nell, 2000),
present a challenge to local neuropsychologists
concerned with utilizing assessment tools in a manner
that may be applied fairly to all levels of population,
while remaining relevant to clinical demands.
The first neuropsychological test battery imported
into South Africa was the Halstead-Reitan Battery in
1969, which, although developed in the United States,
spurred researchers to compile South African norms
for children aged 9–14 years (Painter & Murdoch,
1977; Reitan, 1985).
Also in 1969, the NIPR completed an adaptation and
standardization of the Wechsler-Bellevue Scales for
South Africa, and the adapted test was termed the South
African Wechsler Adult Intelligence Scale (SA-WAIS).
However, the Wechsler-Bellevue Scales themselves were
outdated by the time the SA-WAIS was released,
prompting justified cautions about its psychometric
properties and its ongoing use (Nell, 1994).
In 1997, in an effort to find a solution to the above
problem, the Human Sciences Research Council (HSRC)
contracted with the Psychological Corporation to adapt
and standardize the Wechsler Adult Intelligence Scale
III (WAIS-III) for different population groups in South
Africa (Claassen, 2000). However, criticisms have been
levelled against this project, relating to the manner of
standardization and its practical suitability (Foxcroft &
Aston, 2006; Shuttleworth-Edwards, 2016).
Various studies have since been undertaken to collect
norms for smaller, more specific cultural groups
(Shuttleworth-Edwards, 2016; Shuttleworth-Edwards,
De Kock, & Radloff, 2014), and to emphasize the vari-
able “Quality of education” as a key element mediating
differential responses to neuropsychological instru-
ments (following from an appreciation of the historical
inequities previously noted). A brief overview of the
research aimed at developing local norms for neuropsy-
chological tests is provided by Lucas (2013).
In spite of the thriving and developing nature of the
profession, there is a dearth of survey data providing
information regarding the state of neuropsychology as
a profession in South Africa, including the sociodemo-
graphic characteristics of practitioners, their pro-
fessional activities and settings, their education and
training, the relevant fees and salary ranges, and related
ethical beliefs. The intention of this study was to canvas
a group of professionals identifying as psychologists
practicing in the field of neuropsychology, and to can-
vas descriptive aspects, such as background professional
APPLIED NEUROPSYCHOLOGY: ADULT 3
training, current working situation, assessment and
diagnostic procedures used, rehabilitation techniques
employed, population targeted, teaching responsibil-
ities, and research activities.
Method
Participants
Participants in the present study are those who self-
identified as psychologists working in the field of
neuropsychology in South Africa, and who completed
the survey. Data were included for analysis if parti-
cipants: (1) reported having at least a Master’s degree;
(2) reported currently living in South Africa; (3) con-
sidered themselves to be psychologists with expertise
in neuropsychology and/or performing at least some
of the activities related to neuropsychology (i.e., assess-
ment, diagnosis, treatment, teaching or research) over
the past year; and (4) completed at least the sociodemo-
graphic questions located at the beginning of the survey.
A total of 138 individuals completed the survey
initially. Of these, 11 reported they did not have a
bachelor’s degree and a master’s degree, six were not
residing in South Africa, 18 did not consider themselves
to have expertise in neuropsychology and/or were not
performing at least some of the activities related to
neuropsychology, and eight failed to complete the
demographic questions, resulting in a final sample of
95 individuals who met all inclusion criteria for analysis.
The majority of participants were female (84.2%,
n ¼ 80) and the mean age was 46.97 years (range
25–73 years). Most participants had a Master’s degree
(n ¼ 67, 70.5%), followed by a doctorate (24.2%, n ¼ 23)
and a post doctorate degree (5.3%, n ¼ 5). Participants’
average number of years of experience in neuropsychol-
ogy was 10.85 (range 1–35) and the majority of their
neuropsychological work is reported to take place in
private practice (56.2%, n ¼ 50), with 10.1% (n ¼ 9)
practicing at a college or university.
Measures
The survey was composed of 67 questions which covered
seven areas of interest: (1) professional training, (2)
current work situation, (3) evaluation and diagnosis, (4)
rehabilitation, (5) teaching, (6) research, and (7) ethics
in the workplace. Questions in the survey aimed to
address each of these areas, as well as to canvas demo-
graphic information. Subsequently, the survey was sent
to a group of experts in neuropsychology in South Africa
to ensure that the questions were suitably adapted to its
cultural and linguistic context. The questions were entered
4 S. TRUTER ET AL.

into an online survey platform (www.surveymonkey. the majority (63.2%, n ¼ 60) reported not having an
com). Five psychologists with expertise in neuropsychol- official certification to act as a neuropsychologist because
ogy completed the survey in order to ensure accuracy, no official certification exists in this country. However, if
validity and proper operation of the online survey prior such certification were to exist, all who answered this
to distribution. The questions were developed in English. question (100.0%, n ¼ 68) reported that they would be
willing to obtain it. Moreover, the majority (93.6%,
n ¼ 88) reported a belief that professionals practicing
Procedure as clinical neuropsychologists should have a degree in
This survey forms part of an international research study Psychology. The most frequently identified barriers to
conducted in more than 30 different countries worldwide. the development of neuropsychology in South Africa
Published articles analysing the characteristics of the were considered to be a lack of academic training
profession of neuropsychology include those of Latin programs (74.7%, n ¼ 71), a lack of clinical training
America (Mexico, Argentina, Colombia; Arango-Lasprilla opportunities (64.2%, n ¼ 61), and a lack of willingness
et al., 2015; Arango-Lasprilla, Stevens, Morlett-Paredes, to collaborate between professionals (34.7%, n ¼ 33).
Ardila, & Rivera, 2016; Fernandez, Ferreres, Morlett- Please see Table 1 for additional barriers.
Paredes, Rivera, & Arango-Lasprilla, 2016; Fonseca-
Aguilar et al., 2015; Panyavin, Fonseca-Aguilar, et al., Current work situation
2015; Panyavin, Goldberg-Looney, et al., 2015), Spain
(Olabarrieta-Landa et al., 2016), and Scandinavian coun- According to the 82 respondents answering this
tries (Egeland et al., 2016). Currently under analysis are question, of the 95 who met inclusion criteria, the
those of the United States, Canada, Italy, and Portugal. average length of time working in the field of
Upon ethics approval, recruitment of participants
was conducted via email inviting neuropsychology Table 1. Professional training of participants in South Africa.
professionals across several professional organizations Percentage
Frequency (%)
in South Africa to participate. The email included the
Assessment of training received (n ¼ 94)
details of the study, the hyperlink to the online survey, Excellent 14 14.9
and a request for their assistance in recruiting other Very good 32 34.0
Good 30 31.9
neuropsychology professionals as participants. Data col- Fair 13 13.8
lection was conducted from July 7 to November 3, 2015. Poor 3 3.2
No training received 2 2.1
Clinical supervision received during training (n ¼ 94)
Excellent 16 17.0
Statistical analysis Very good 22 23.4
Good 20 21.3
Following the conclusion of data collection, the final Fair 14 14.9
database was downloaded from the online survey Poor 3 3.2
No supervision received 19 20.2
platform (www.surveymonkey.com) and analyses were Neuropsychology Qualifications (n ¼ 95)
conducted using SPSS 22.0 (IBM Corp., Armonk, NY). Have not obtained official certification; 60 63.2
none exists
Have not obtained official certification; 12 12.6
certification exists
Results Have obtained official certification 13 13.7
Have not obtained official certification; 10 10.5
Professional training unaware if any exists
Opinion as to what degree is required to practice as a clinical
neuropsychologist (n ¼ 94)
Table 1 summarizes participant responses related to Psychology degree needed 88 93.6
issues of professional training. Briefly, the majority Psychology degree not needed 6 6.4
(76.8%, n ¼ 73) of participants reported having received Barriers for the development of neuropsychology in South Africa*
Lack of academic training programs 71 74.7
training in neuropsychology through continuing Lack of clinical training opportunities 61 64.2
education as independent professionals. Around one Lack of willingness to collaborate between 33 34.7
professionals
third (34.0%, n ¼ 32) characterized this training as “very Lack of access to neuropsychological 31 32.6
good”, and 23.4% (n ¼ 22) characterized the quality of instruments
Lack of professional leaders in the field 26 27.4
clinical supervision they received during training as Lack of other professional resources 16 16.8
“very good”. However, it is important to note that out Lack of access to literature/ libraries 10 10.5
Lack of access to the internet 3 3.2
of 94 participants, 19 (20.2%) reported not having Lack of access to technology/ computers 3 3.2
received any clinical supervision during their training Note. *Multiple response options available, responses do not add up to
in neuropsychology. With regard to their qualifications, 100%. Percentages are calculated out of total n ¼ 95.
 APPLIED NEUROPSYCHOLOGY: ADULT 5

neuropsychology was 10.9 years (SD ¼ 9.9), and 86 part- Table 3. Type of assessment battery, and instruments used by
icipants reported working an average of 24.8 hours (SD the participants in South Africa.
¼ 20.1) per week. The reported average monthly income Percentage
Frequency (%)
from neuropsychological related work was USD
Type of battery used (n ¼ 68*)
$1,439.35 (this amount is based on the exchange rate Flexible batteries 37 54.4
at the time of data collection, 1:0.075). Finally, regarding Personalized/flexible batteries 25 36.8
Standardized batteries 8.8
satisfaction with their income, which was measured 20 most used instruments**
using a scale from 1 to 10 (with 1 being “dissatisfied” WAIS (Wechsler Adult Intelligence Scale) 61 81.3
RAVLT (Rey Auditory Verbal Learning Test) 58 77.3
and 10 “satisfied”), of 95 participants 79.8% (n ¼ 84) Bender (Bender Visual Motor Gestalt Test) 46 61.3
reported an average satisfaction of 5.7; and in relation ROCFT (Rey–Osterrieth Complex Figure Task) 44 58.7
to satisfaction with their work in the field of neuropsy- Finger Tapping (Finger Tapping/Finger 43 57.3
Oscillation Test)
chology, 85.6% (n ¼ 89) of participants reported an TMT A&B (Trail Making Test A&B) 43 57.3
average satisfaction of 6.6. WMS (Wechsler Memory Scale) 42 56.0
COWAT (Controlled Oral Word Association 40 53.3
As summarized in Table 2, 54.4% (n ¼ 49) of parti- Test/FAS)
cipants were employed full time and 34.4% (n ¼ 31) Stroop Test (Stroop Neuropsychological 39 52.0
Screening Test)
part-time. The most frequently reported work setting Clock Drawing Test 37 49.3
was private practice (52.6%, n ¼ 50), followed by college WISC (Wechsler Intelligence Scale for Children) 37 49.3
SDMT (Symbol Digit Modalities Test) 35 46.7
or university (9.5%, n ¼ 9), and other (8.4%, n ¼ 8). MMSE (Mini-Mental State Examination) 29 38.7
D-KEFS (Delis–Kaplan Executive Function 28 37.3
System)
NEPSY (A Developmental Neuropsychological 22 29.3
Evaluation Assessment)
WCST (Wisconsin Card Sorting Test) 18 24.0
75 of 89 (66.8%) participants reported having TOMM (Test of Memory Malingering) 17 22.7
performed neuropsychological assessments over the BNT (Boston Naming test) 16 21.3
WIPPSI (Wechsler Preschool and Primary 15 20.0
past year. Of these, 64.7% (n ¼ 66) conducted neuropsy- Scale of Intelligence)
chological assessments on an average of 8.9 patients per Other 14 18.7
month, requiring, on average, 10.5 hours (SD ¼ 6.4; Notes. *89 of 95 participants reported having conducted neuropsychological
evaluations within the past year.
range: 2–48) to evaluate, score, interpret the results, **Multiple response options available, responses do not add up to 100%.
and write the report. Percentages are calculated out of total n ¼ 75.
As summarized in Table 3, around half (54.4%,
n ¼ 37) of respondents use flexible batteries (i.e.,
commonly used neuropsychological instruments for
tailored to the needs of an individual case, rather than
neuropsychological assessment and diagnosis, Table 3
being uniform across patients), with an additional
presents those 20 that were most commonly used, with
36.8% (n ¼ 25) using personalized/flexible batteries
the most frequent being the Wechsler Adult Intelligence
(i.e., variable but routine groupings of tests selected
Scale (81.3%, n ¼ 61), the Rey Auditory Verbal Learning
for various types of diagnoses, such as head injury,
Test (77.3%, n ¼ 58), and the Bender Visual-Motor
alcoholism, dementia, etc.). Only 6 participants (8.8%)
Gestalt Test (61.3%, n ¼ 46).
used fixed batteries (e.g., Halstead-Reitan, Luria-
The most common procedures reported for scoring
Nebraska, Benton, or other routine groupings of tests
neuropsychological tests was the use of normative data
that remain uniform across patients). From a list of 60
from another country (66.3%, n ¼ 52) and from their
own country/region (66.1%, n ¼ 52). The most reported
Table 2. Current work situation of participants in South Africa. methods for obtaining neuropsychological instruments
Frequency Percentage (%)
included purchasing them from the publisher (70.7%, n
Work status (n ¼ 90) ¼ 53), borrowing them from colleagues (38.7%, n ¼ 29),
Full time 49 54.4
Part time 31 34.4 and making photocopies or reproducing them (36.0%,
Unemployed 8 8.9 n ¼ 27). The problems with neuropsychological instru-
Retired 2 2.2
Setting of neuropsychology practice (n ¼ 89) ments most commonly identified included a lack of
Private practice 50 52.6 local normative data (77.3%, n ¼ 58), and the absence
College or university 9 9.5
Other 8 8.4 of measures adapted to their culture (72.0%, n ¼ 54).
Non-profit rehabilitation facility 6 6.3 Please see Table 4 for more detailed information.
Hospital system 6 6.3
School system 5 5.3
The reported patient populations that most
Private clinic 4 4.2 frequently underwent neuropsychological evaluations
Profit rehabilitation facility 1 1.1 were individuals with ADHD (54.2%), Traumatic Brain
6 S. TRUTER ET AL.

Table 4. Scoring procedures used, method of obtaining instru- Table 5. Groups of patients assessed and frequency of evalu-
ments, and problems with instruments identified by participants ation of various cognitive domains by South African participants.
in South Africa. Percentage (%)
Percentage Groups of patients assessed*
Frequency (%) ADHD 54.2
Scoring procedures utilized (n ¼ 75*) Traumatic brain injury 53.1
Use of normative data from another country 52 66.3 Learning disabilities 45.8
Use of normative data from own country 52 65.1 Depression 45.6
Custom procedures through clinical practice 19 24.1 Dementia 34.0
Use of raw scores without normative group 3 4.8 Stroke 32.7
comparison Pain 31.9
Other 4 4.8 Stroke/vascular 30.8
Method of obtaining neuropsychological instruments* AIDS 29.4
Purchasing from publisher 53 70.7 Anxiety disorders 28.8
Borrowing from colleagues 29 38.7 Mental retardation 20.8
Making photocopies or reproducing instruments 27 36.0 Substance abuse 17.4
Downloading from the internet 12 16.0 Personality disorders 16.7
Borrowing from libraries or laboratories 15 20.0 Schizophrenia 11.4
Other 3 4.0 CNS tumor 11.1
Requesting from author 3 4.0 Bipolar disorders 10.6
Main problems with neuropsychological instruments* Pervasive Developmental Disorder 6.3
Lack normative data for my country 58 77.3 Toxic/metabolic 4.5
Not adapted to my culture 54 72.0 Movement disorders 4.4
Too costly/expensive 50 66.7 Multiple sclerosis 2.3
Not translated to my language 38 50.7 Other 0.0
Aimed at individuals with high levels 33 44.0 Cognitive domains assessed*
of education Attention 77.3
Are often not applicable because my 26 34.7 Executive functions 74.2
patients cannot read or Verbal memory 60.9
Take a long time to administer 13 17.3 Visuospatial skills 42.6
Do not have good psychometric properties 7 9.3 Nonverbal memory 50.8
Too complicated to administer and/ or score 1 1.3 Construction 66.2
Language 52.4
Note. *Multiple response options available, responses do not add up to Intelligence 57.1
100%. Percentages are calculated out of total n ¼ 75. Motor skills 63.6
Auditory perception 69.2
Achievement 46.2
Injury (53.1%), and individuals with learning disabilities Tactile perception 6.9
(45.8%). Individuals with dementia, depression and Note. *Multiple response options available, responses do not add up to
stroke were also among the more frequently tested 100%. Percentages are calculated out of total n ¼ 75.
(see Table 5 for a complete list of the types of disorders
most frequently evaluated). Table 5 also presents the
neuropsychological domains that are more frequently
addressed in a neuropsychological evaluation.
Additional sources of information typically used for Table 6. Referral sources of patients attending neuropsychol-
evaluation and diagnosis include medical or psychiatric ogy services and sources.
history (86.7%; n ¼ 65), developmental history (85.3%: Frequency Percentage (%)
n ¼ 64) and current social support (82.7%: n ¼ 62). Referral sources*
Law (attorney) 44 58.7
The three primary reasons for consultation were for- Psychology 36 48.0
ensic consultation (57.3%, n ¼ 43), determination of Psychiatry 34 45.3
School system 29 38.7
diagnosis (46.7%: n ¼ 35), and education planning Neurology 27 36.0
(26.7%, n ¼ 20). Table 6 lists all the referral sources Family (general medicine) 22 29.3
Pediatrics 21 28.0
received by neuropsychologists, of which the most fre- Neurosurgery 19 25.3
quently endorsed were legal (58.7%, n ¼ 44), psycho- Self-referral 18 24.0
logical (48.0%, n ¼ 36), and psychiatric (45.3%, n ¼ 34). Insurance company 13 17.3
Rehabilitation (rehab. nurse, counselor, 12 16.0
or other rehabilitation specialty)
Physiatry 10 13.3
Rehabilitation Alcohol/drug facilities 8 10.7
Geriatrics 8 10.7
Only 25.6% (n ¼ 21) of the participants reported work- Friends 7 9.3
Occupational Medicine 6 8.0
ing in neuropsychological rehabilitation during the past Orthopedics 6 8.0
year. Within this sub-group, services were provided, on Internal medicine 4 5.3
Other 2 2.7
average, to 8.5 patients per month (SD ¼ 11.8, Range: Cardiology 0 0.0
1–50), with an average of 11.2 hours (SD ¼ 12.42, Note. *Response options available, responses do not add up to 100%.
Ranges: 1–50) per week devoted to therapy. Table 7 Percentages are calculated out of total n ¼ 75.
 APPLIED NEUROPSYCHOLOGY: ADULT 7

provides details about the diagnostic groups and areas of Table 8. Types of treatment provided and technological tools
neuropsychological treatment. The majority of rehabili- used in rehabilitation by participants in South Africa.
tation services were provided to people with traumatic Frequency Percentage (%)

brain injury (81.0%, n ¼ 17) and stroke (57.1%, n ¼ 12). Types of treatment provided*
Individual 15 78.9
In addition, the most common areas of functioning Both 3 15.8
addressed in neuropsychological treatment or rehabili- Group 1 .3
Technological tools used in rehabilitation**
tation were emotional/behavioral adjustment and iPads/ tablets 11 52.4
wellbeing (85.7%, n ¼ 18), attention/concentration, Personal computers (PC, Mac, etc.) 9 42.9
Mobile phones/ smartphones 9 42.9
executive functions and memory (71.4%, n ¼ 15 each). Other 4 19.0
As can be seen in Table 8, the most common type of Neuromodulation (TMS, tDCS) 3 14.3
treatment provided was individual therapy (78.9%, Neurofeedback 2 9.5
Virtual Reality 0 0.0
n ¼ 15), and the technological tools used most com- Notes. *Multiple response options available, responses do not add up to
monly during rehabilitation included iPads or tablets 100%.
(52.4%, n ¼ 11), personal computers and mobile phones **Multiple response options available, responses do not add up to 100%.
Percentages are calculated out of total n ¼ 21.
or smartphones (42.9%, n ¼ 9 each). Please see Table 8
for the list of technological tools utilized by respondents.
neuropsychology, with 31.6% (n ¼ 25) of these report-
ing moderate satisfaction with their role as professors/
Teaching instructors in the area of neuropsychology (average of
In the past year, 25 of 79 (31.6%) participants reported 6.4, using a scale of 1–10, where 1 is “not at all satisfied,”
having engaged in teaching activities related to and 10 “completely satisfied”). As can be seen in
Table 9, the majority (56.0%, n ¼ 14) taught at public
Table 7. Diagnostic groups for neuropsychological institutions, with most involved in teaching and
rehabilitation treatment and areas in which participants in South directing theses or dissertations with topics in
Africa perform neuropsychological rehabilitation treatment. neuropsychology at Master’s degree level (64.0%, n ¼ 16
Frequency Percentage (%)
and 56.0%, n ¼ 14, respectively).
Diagnostic groups*
Traumatic brain injury 17 81.0
Stroke/vascular 12 57.1
Seizure disorders 9 42.9 Research
ADHD 8 38.1
Depression 6 28.6 Of the 79 individuals who responded to the question on
Pain 6 28.6 research, 25.3% (n ¼ 20) indicated having conducted
Dementia 5 23.8
Multiple sclerosis 5 23.8 research in the area of neuropsychology in the last year.
Learning disabilities 5 23.8 Of the 17 who responded to the following questions
Substance abuse 5 23.8
Anxiety disorders 5 23.8 70.6% (n ¼ 12) of the institutions in which these
AIDS 5 23.8 researchers work had an ethics committee, 76.5%
Bipolar disorders 4 19.0
CNS tumor 4 19.0
(n ¼ 13) always sought ethics approval prior to starting
Movement disorders 3 14.3
Personality disorders 3 14.3
Pervasive Developmental Disorder 2 9.5
Mental retardation 1 4.8 Table 9. Teaching by participants in South Africa.
Toxic/metabolic 1 4.8
Frequency Percentage (%)
Other 1 4.8
Schizophrenia 0 0.0 Institution where teaching occurs*
Areas of neuropsychological rehabilitation treatment Public institution 14 56.0
Emotional/ behavioral adjustment and 18 85.7 Both 6 24.0
well-being Private institution 5 20.0
Attention/Concentration 15 71.4 Level at which teaching occurs*
Executive functioning 15 71.4 Master 16 64.0
Memory 15 71.4 Undergraduate 7 28.0
Awareness of disability/disease 14 66.7 Specialization 5 20.0
Family functioning 14 66.7 Doctorate 3 12.0
Autonomy and independence 11 52.4 Level at which thesis or dissertations were supervised*
Returning to work 10 47.6 Master 14 56.0
Visual-perceptual and constructional 8 38.1 Doctorate 5 20.0
abilities Undergraduate 4 16.0
Communication/Speech & language 7 33.3 Specialization 3 12.0
Sexual adjustment problems 5 23.8 Note. *Multiple response options available, responses do not add up to
Motor skills/strength 3 14.3 100%. Percentages are calculated out of total n ¼ 25 (those who
Note. *Multiple response options available, responses do not add up to reported having engaged in teaching related to neuropsychology within
100%. Percentages are calculated out of total n ¼ 21. the past year).
8 S. TRUTER ET AL.
a research project, and 94.1% (n ¼ 16) obtained
informed consent from their participants.
Regarding research training, 64.7% (n ¼ 11) reported
receiving training in neuropsychological research
during their clinical education or training, the majority
of participants (52.9%, n ¼ 9) reported having received
grant funding for research, yet 64.7% (n ¼ 11) reported
not having sufficient resources and material to conduct
neuropsychological research.
Regarding the use of statistical software and statisti-
cal analysis, 56.3% of participants reported a medium
level of proficiency in Excel and 50.0% in SPSS. In
addition, 100% of participants indicated having no
knowledge in the statistical software Epi info, Stata
and R, respectively. Finally, 68.9% (n ¼ 11) of the 16
participants who answered this question reported
conducting their own statistical analysis when perform-
ing research, while 31.3% (n ¼ 5) did not perform their
own statistical analyses.
Discussion
This study is the first to describe the characteristics of
individuals engaged in the practice of neuropsychology
in South Africa. In the following sections the main
findings of the study are discussed.
Professional training
The majority of participants in South Africa reported
having received training in neuropsychology during
their post-graduate studies. These results are similar to
those reported in Latin America (Arango-Lasprilla
et al., 2016), Spain (Olabarrieta-Landa et al., 2016)
and the U.S. (Sweet, Benson, Nelson, & Moberg,
2015). Although the educational systems and training
in the field of neuropsychology vary from country to
country, these results indicate that the respondents from
the differing countries are nevertheless in agreement
that additional training should be located at postgradu-
ate level.
In South Africa 20.2% of participants indicated that
they did not receive clinical supervision during their
training in neuropsychology. This is likely facilitated
by the absence of mechanisms requiring supervision
as a prerequisite for practice. As previously discussed,
the HPCSA permits practice in the field of neuro-
psychology with no additional training or supervision
required beyond that accumulated in the course of their
registration as a psychologist in the other registration
categories (Clinical; Counselling; Educational). This
unsatisfactory situation will likely be addressed in
the near future, as the new specialized category of
neuropsychology registration is formalized. Training
and supervision was rated as “very good” by less than
50% of professionals in South Africa. These results
coincide with those reported by neuropsychologists in
Latin America (Arango-Lasprilla et al., 2016), and in
Spain (Olabarrieta-Landa et al., 2016). This relatively
low satisfaction rate in South Africa may be explained
by the currently limited available formal training
opportunities, given the absence of official registration
mechanisms. In that regard, it is noted that the majority
of the training in neuropsychology completed by parti-
cipants from South Africa was attained via Continuing
Education activities, as independent professionals.
These findings underline the necessity for South African
neuropsychologists to work toward developing formal
academic training programs and to increase the
available clinical training opportunities.
Although in the United States the majority of neu-
ropsychologists reported having obtained official certifi-
cation to work as neuropsychologists in their country
(Sweet et al., 2015), in South Africa the majority of
participants reported having no official certification to
practice as neuropsychologists because no such formal
certification exists as yet. These results are similar to
those of countries such as Spain (Olabarrieta-Landa
et al., 2016) and Latin American (Arango-Lasprilla
et al., 2016), in which official certification also does
not exist. The situation in South Africa is, however,
different from that of Spain and Latin America in that
an official registration category is due to be activated
and populated, once the outstanding additional
legislative requirements have been addressed.
Current work situation
The majority of neuropsychologists in the United States
(96.8%), work full-time in activities related to neuropsy-
chology (Sweet et al., 2015) as compared to only half
of those in South Africa (54.4%), Spain (51.4%;
Olabarrieta-Landa et al., 2016) and Latin America
(43.1%; Arango-Lasprilla et al., 2016). The general work-
setting for neuropsychological practice in South Africa is
similar to that of Latin America (Arango-Lasprilla et al.,
2016), which is private practice, while for Spain a hospital
setting is more prevalent (Olabarrieta-Landa et al., 2016).
This distribution of work settings, favouring private
practice, is, however, not an accurate representation of
the distribution of the broader population’s needs in
South Africa, but is instead a reflection of the concen-
tration of income sources in the private sector. Unfortu-
nately, few positions are available for specialists within
hospital, clinic, school and rehabilitation settings in South
Africa, and the high costs of these services ensures that

neuropsychologists will remain concentrated predomi-
nantly in private practice.
The reported average income per month in South
Africa was similar to that identified in Spain
(Olabarrieta-Landa et al., 2016) and Latin America
(Arango-Lasprilla et al., 2016). This is in contrast to neu-
ropsychologists working in the U.S. whose monthly
income was almost double (Sweet et al., 2015). This could
be accounted for in part by the finding that the majority
of U.S. neuropsychologists work full-time, in contrast
with those in South Africa, Spain, and Latin America,
whose neuropsychological-based earnings derive largely
from part-time activities. Despite these differences in
average income between neuropsychologists in South
Africa, Spain, and Latin American, on the one hand, in
comparison with those in the United States, on the other
hand, it is interesting to note that the reported levels of
satisfaction with their respective incomes were very
similar: All reported largely average-to-medium satisfac-
tion with their income and work.
Evaluation
It is notable that only two-thirds of the respondents in
South Africa reported having performed neuropsycho-
logical assessments over the previous year. This is to
be compared with the findings from Latin America
(Arango-Lasprilla et al., 2016) and Spain (Olabarrieta-
Landa et al., 2016), in which a more substantial majority
was active in the previous year (88.9% and 88.5%
respectively). Approximately half the respondents in
South Africa reported using flexible batteries. This is
similar to the findings for neuropsychology in the
United States, where the use of flexible batteries has
grown from 1989 until 2015 (Sweet et al., 2015).
The most commonly used test in South Africa, as
indicated in the survey, is the WAIS, whereas in Latin
America and Spain neuropsychologists most commonly
used the Stroop Test. The popularity of the WAIS in
South Africa is enhanced by the availability of South
African norms for both the 3rd and 4th Revisions,
although the composite nature of these norms has been
criticized (Shuttleworth-Edwards, 2016). One of the less
commonly used tests in South Africa is the NEPSY-II,
whose utility will likely be increased by the recent trans-
lation into six South African languages (Afrikaans,
Xhosa, Zulu, Sepedi, Setswana, & Sesotho). Similarly,
local norms have been collected for the ROCFT, TMT
A & B, parts of the WMS, the Stroop test, the Clock
Drawing test, the WISC, WCST and the TOMM, adding
to their utility and probably their popularity. Further-
more, the RAVLT has been formally and informally
translated into several South African languages,
APPLIED NEUROPSYCHOLOGY: ADULT 9
although there remains a lack of appropriate local
norms for both the original English and the translated
versions.
The majority of respondents in South Africa reported
utilising an average of 10.5 hours to complete an evalu-
ation from administration to report writing. This is
rather longer than the time reported by professionals
in Latin America (8.4 hours; Arango-Lasprilla et al.,
2016), Spain (6.7 hours; Olabarrieta-Landa et al., 2016)
and the United States (6.1 hours; Block, Santos, Flores,
Rivera, & Arango-Lasprilla, 2017). It is possible that
more time is needed because professionals in South
Africa must often account for cultural diversity when
scoring and interpreting test results. They typically rely
largely on norms from other countries, using local
norms where these are available, whereas the reverse is
true in Latin America and Spain, where local normative
data is used predominantly and with reliance on nonlo-
cal norms only when local norms are not available.
Nevertheless, it is of interest that more than three quar-
ters of respondents in South Africa identified a lack of
such local normative data/adapted instruments as a limi-
tation, and that this finding is similar to that of Latin
American (Arango-Lasprilla et al., 2016) and Spanish
(Olabarrieta-Landa et al., 2016) neuropsychologists.
The most frequently evaluated diagnosis in South
Africa was Attention Deficit/Hyperactivity Disorder
(ADHD), similar to Latin American findings (Arango-
Lasprilla et al., 2016). Traumatic Brain Injury (TBI)
was the second most assessed group, endorsed by more
than half of participants from South Africa, similar to
the findings in Spain (Olabarrieta-Landa et al., 2016),
whereas this was the most frequently evaluated diag-
nosis for neuropsychologists in the United States (Block
et al., 2017). Just over half of evaluations in South Africa
were conducted for forensic purposes, referred by the
legal profession, while neurology was the primary
referral source for patients attending neuropsychologi-
cal services in Latin America (Arango-Lasprilla et al.,
2016), Spain (Olabarrieta-Landa et al., 2016) and the
United States (Block et al., 2017). It is noted that foren-
sic evaluations are traditionally a source of more stable
income for many South African professionals, lending
to its popularity. Attention was the most assessed
cognitive domain by participants, followed by executive
functions, which is similar to the findings in Latin
America (Arango-Lasprilla et al., 2016) and Spain
(Olabarrieta-Landa et al., 2016), but is different from
that reported in the United States, in which memory
was the most evaluated domain, followed by attention
and concentration (Block et al., 2017).
The majority of professionals in South Africa prefer
to purchase neuropsychological instruments directly
10 S. TRUTER ET AL.
from the publisher, similar to professionals in Latin
America (Arango-Lasprilla et al., 2016) and Spain
(Olabarrieta-Landa et al., 2016). However, a number
of neuropsychologists from South Africa also report
borrowing from colleagues, while others in Spain, Latin
America, and South Africa report making photocopies/
reproducing the instruments as their preferred method
for obtaining neuropsychological tests. In South Africa,
the prohibitive exchange-rate and import-fees would
contribute to this tendency.
Rehabilitation
Of some concern is the finding that only 25.6% of
participants in South Africa reported working in
neuropsychological rehabilitation during the past year.
Within this subgroup services were provided, on
average, to 8.5 patients per month per participant. This
is significantly lower than the rates identified in Spain
and in Latin America: In Spain, 58.7% of the sample
reported having worked in neuropsychological
rehabilitation during the past year, each helping, on
average, 19.4 patients per month. In Latin America,
61.0% of the sample provided rehabilitation services to
12.6 patients per month per participant, on average.
This dearth of rehabilitation workers in South Africa,
despite the dire need for this level of care, is in part a
consequence of the failure thus far to institute and
implement a workable category of registration and to
provide standardized, specialized training in rehabili-
tation. It is due, too, to the difficulties that many South
African practitioners experience in seeking remuneration
within the medical insurance systems, which do not
make adequate provision for such specialized treatment,
or for the necessary duration of treatment required. It
is notable that such payment difficulties are relatively
less apparent in the medicolegal industry (although not
consistently so), and assessment, as well as rehabilitation,
of traumatic brain injury within that context is a far more
popular area of neuropsychological activity currently.
The majority of the survey participants who perform
rehabilitation services in South Africa indicated that
they provide “individual therapy”. This is similar to
the case in Latin America (Arango-Lasprilla et al.,
2016) and the United States (Block et al., 2017),
although it differs in Spain (Olabarrieta-Landa et al.,
2016), where the majority provides mixed therapy
(combining individual and group therapy). Just over
half of the South African participants who are engaged
in rehabilitation work indicated that they use iPads/
tablets for rehabilitation purposes, followed by the use
of personal computers. This differs from the findings
in Spain (Olabarrieta-Landa et al., 2016), Latin America
(Arango-Lasprilla et al., 2016), and the United States
(Block et al., 2017), where the use of personal computers
(PC, Mac, etc.) is the technological tool most used
during rehabilitation, followed by iPads/ tablets.
Teaching
Unlike in Latin America where teaching in neuropsy-
chology takes place mostly at an undergraduate level
(Arango-Lasprilla et al., 2016), teaching in neuropsy-
chology in South Africa takes place mostly at a post-
graduate level. South Africa is thus more in keeping
with Spain, where teaching also takes place mostly at
a postgraduate level (Olabarrieta-Landa et al., 2016).
In South Africa, preliminary training programs have
recently been initiated at a postgraduate level at some
universities, but in the absence of the formal implemen-
tation of the registration category, these programs have
been seriously restricted in terms of their outcome, or,
in at least one case, forced to disband. Nevertheless,
throughout the country, modules in neuropsychology
continue to be presented within the broader context
of standard (generic) degree curricula. There are,
however, no standard guidelines relating to the content
of those courses or to the qualifications required by the
lecturers. The 25 participants in the survey who claimed
that they have been involved in the teaching of neurop-
sychology are likely to be involved primarily in one of
these teaching initiatives.
In contrast to the findings from Latin American and
Spanish respondents, in which satisfaction with their
role as professors/instructors in the area of neuropsy-
chology is rated as medium to high (Arango-Lasprilla
et al., 2016; Olabarrieta-Landa et al., 2016), South
African professionals reported a lower satisfaction with
their roles. This may be due to the lower level of
remuneration in comparison with the case for private
practice, along with frustration that successful students
cannot as yet register as licensed neuropsychologists.
Research
In South Africa, only 25.3% of participants reported
having conducted research in the area of neuropsychol-
ogy during the past year. This low level of participation
is likely due to the lack of incentives for private
practitioners to carry out research activities, which are
time- consuming and generally not remunerated (while
some research grants are available, these are rare and
are typically directed at students and/or academics at
universities). This is different from the case for pro-
fessionals in Latin America and Spain, where the
majority of respondents conduct their own research

and have received training in neuropsychology
research. The majority of professionals in South
Africa reported conducting their own statistical
analysis when performing research. This concurs
with the finding that just over half of the participants
that reported a medium level of proficiency in Excel
and SPSS, which is similar to the case for neuropsy-
chologists in Latin America.
Limitations
The results of this study should be interpreted in light of
some significant limitations: First, the survey was admi-
nistered using an Internet platform where evident
intrinsic bias is prevalent; only those professionals with
access to the Internet and a willingness to answer the
survey are represented in the sample. Second, the ques-
tions included in the survey are limited and many
potentially instructive areas were not explored, such as
the particular nature of the reports used in neuropsy-
chology, level of participation in multi-disciplinary
teams, etc. Finally, as in any survey, the analyses were
based on self-reporting, and it is not possible to verify
these responses. However, regardless of these important
and obvious limitations, the current survey permits a
broad, albeit preliminary, understanding of the current
condition of neuropsychology as a profession in South
Africa, as a means of raising questions and setting goals
for further formal needs analyses.
Implications
These survey results underline the need for formal
professional training programs, which have been lim-
ited thus far as a result of the slow progress towards
establishing neuropsychology as a formal inde-
pendent registration category. These results also
highlight the needs for continuing efforts to compile
local normative data, and to adapt test instruments to
the local context. Also apparent from these results is
the need for greater focus on rehabilitation efforts,
which constitute only a minor portion of general neu-
ropsychological activity currently, and the require-
ment for the allocation of greater resources towards
neuropsychological rehabilitation and research.
Conclusion
This survey is the first of its kind in South Africa,
describing the characteristics of local psychologists
involved in neuropsychological practice. Three quarters
of the respondents reported receiving neuropsychologi-
cal training, but of these, 20% had received no clinical
supervision during that training, which is a function of
APPLIED NEUROPSYCHOLOGY: ADULT 11
the lack of formal registration in the field, as discussed
above. Indeed, the most frequently identified barrier to
the development of neuropsychology in South Africa
was regarded by nearly 75% of the respondents as the
lack of formal academic training programs. Of further
interest is that only one quarter of respondents reported
working in rehabilitation settings, with the majority of
these activities pertaining to traumatic brain injury and
stroke rehabilitation. Just under one third of subjects
were involved in teaching of neuropsychology, and only
one quarter had conducted research in the past year.
At the level of individual practitioners, it is clear from
attendance figures at conferences and workshops, and
from the progressively increasing membership base of
organizations such as SACNA, and from the results of
the current survey, that neuropsychology represents a
field of increasingly intense interest and practice in
South Africa. This has remained the case, despite the
unique and serious challenges facing local practitioners
in terms of practice and training, many of which are
reflected in the current survey responses previously
reviewed. It is hoped that the ongoing efforts of various
organizations and individuals—in particular, to establish
and implement a specialist category of registration, to
facilitate ongoing training and conferences, and to com-
pile relevant local norms and develop appropriate tests—
will continue to bear fruit in the next few years.
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