A recent issue of JHTR focused on the topic of forensic neuropsychology. Although we, as practicing neuropsychologists, all welcomed the deserved attention to this complex subject matter, we want to express some concerns about aspects of the contribution by Dr Ruff, titled "Best Practice Guidelines for Forensic Neuropsychological Examinations of Patients With Traumatic Brain Injury."1 In the spirit of full disclosure, we would like to state that each of us is directly involved on a part-time basis with evaluations requested directly from attorneys, including those who represent the defense in civil litigation. We all also provide evaluations at the request of physicians, and some of us provide direct clinical service to persons with traumatic brain injury as the majority of our professional work. All of us have made contributions to the peer-reviewed neuropsychological literature, and some of us have written previously about issues of bias and ethics in the context of forensic neuropsychological assessment. In addition, some of us have been editors for peer-reviewed journals or textbooks related to the practice of clinical neuropsychology. For all these reasons, we believe that we can provide an informed and reasoned critique of the above-mentioned article.

The inclusion of the words "Best Practice Guidelines" in the title of the article was at least presumptuous and at worst misleading. Although Dr Ruff briefly acknowledges the existence of practice guidelines by major professional organization such as the American Academy of Clinical Neuropsychology and the National Academy of Neuropsychology, he then suggests a need for additional guidelines without sufficient distinction between his own biases and what constitutes evidence-based empirical facts or peer-reviewed consensus statements. Scientific venues, such as peer-reviewed professional journals, typically reserve phrases like "best practices" and "guidelines" for the representative views of a group of recognized experts in the field, not the views of a single individual. This was clearly not the case with Dr Ruff's article, which is particularly concerning in light of the fact that JHTR is the official journal of the Brain Injury Association of America. It should have been made much more explicit that these were merely the author's personal views and preferences and not an official statement or document that is unequivocally endorsed by any professional organization nor the position of the editors of JHTR.

There are several aspects of Dr Ruff's proposed guidelines that can be debated on the ground of insufficient evidence or lack of foundation. For example, statements indicating that the phenomenon of poor outcomes after mild traumatic brain injury is "without dispute" are overly broad in the absence of clear reference to the likelihood of such poor outcomes in the absence of any premorbid (eg, prior psychiatric history) or postmorbid (eg, financial compensation-seeking) risk factors or neurological complications (eg, positive neuroimaging findings that would suggest a complicated mild injury). Statements that dismiss multiple methodologically sound, peer-reviewed meta-analytic studies are particularly concerning. Although Dr Ruff presents his guidelines as starting points for discussion in the field of forensic neuropsychology, statements such as these, especially when published under the rubric of "Best Practice Guidelines" in a well-respected journal, are fertile grounds for misrepresentation of our best current knowledge in the field of mild traumatic brain injury, which is more adequately summarized elsewhere.2-4

There are other aspects of Dr Ruff's guidelines that give us grave concern, including the apparent ease with which he seems to embrace the "more probably than not" threshold of 50.1% legal certainty as a basis for neuropsychological testimony and repeatedly emphasizing the importance of "clinical judgment." His position allows for too much latitude in expressing opinions that are not consistent with the large relevant peer-reviewed literature and, therefore, has a high likelihood of encouraging the very kinds of bias that Dr Ruff bemoans earlier in his article. Although reasonable practitioners do not necessarily demand 95% to 99% certainty in all of the diagnostic decisions expressed in a forensic context, they do typically hold themselves to a higher professional standard than the equivalent of a flip of the coin, when asked the common question regarding a "reasonable degree of scientific [or neuropsychological] certainty."

We have no personal animosity toward Dr Ruff, and in fact, several of us have worked with him in a collaborative and constructive manner in other venues. However, the editors of JHTR should have seen to it that his "Practice Guidelines" were published as one man's opinion, with due caution against the very likely perception by the public as representing the views of a clinical specialty. We are concerned that this article was allowed to have the appearance of being sufficiently empirically founded and representative of a consensus in the professional community of clinical neuropsychology, which is clearly not the case.

Jacobus Donders, PhD, ABPP

Psychology Service, Mary Free Bed Rehabilitation Hospital, Grand Rapids, Michigan

Robin Hanks, PhD, ABPP

Department of Physical Medicine and Rehabilitation Wayne State University School of Medicine, Detroit, Michigan

Joel Morgan, PhD, ABPP

Independent Practice, Madison, New Jersey

Joseph Ricker, PhD, ABPP

Department of Physical Medicine & Rehabilitation, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania

Jerry Sweet, PhD, ABPP

Department of Psychiatry, University of Chicago Pritzker School of Medicine, Chicago, Illinois

REFERENCES