Author's Response

I have been asked by the editors to respond to the letter authored by Donders, Hanks, Morgan, Ricker, and Sweet. The 5 authors questioned whether a single author could write "Best Practice Guidelines." In response, let me provide the following explanation as to the context for my writing this article. First, I did not volunteer to write this article, but rather I was invited by the issue editor to write an article on "Best Practice Guidelines" by integrating all of the experts who contributed articles to the March-April 2009 issue of JHTR. For a more in-depth explanation, see issue editor Dr Erin Bigler's letter.

Second, Part I of my article is titled "Proactive maintenance of ethical standards," which relies on well-accepted theories of the dialectical approach, countertransference, and cognitive dissonance. Part II summarized the salient viewpoints from the preceding 4 articles that were written by over 10 independent authors. In Part III, I assembled various guidelines that directly rely on my colleagues' contributions in this issue. Although the readers are provided with an understanding that these guidelines are a collective product, I take responsibility for synthesizing and adding my own perspectives.

Third, while Donders et al cast aspersions regarding my intentions, I must point out that at no time did I state that my article was a position statement or a consensus paper. Indeed, as the chair of the National Academy of Neuropsychology (NAN) Policy and Planning committee, I am well acquainted with the process that is involved in completing a position paper. I specifically stated that these guidelines are "intended as a starting point that will facilitate a further refinement based on a dialectical process with colleagues who may disagree with various guidelines" (p136). However, given the strong reaction by Donders et al, I would-in hindsight-emphasize this point more by changing the title to "Suggestions for best practice guidelines...."

Let me respond to the second major critique. Donders et al accused me of avoiding "evidence-based facts"!! In large part, they support this critique with the following statement I made: "The phenomenon of poor outcome following a mild TBI does exist without dispute even if the exact percentage is unknown" (guideline 11, pp 137-138). I firmly stand by this conclusion. The reasons are many. (1) I used the word "phenomenon" since it describes the existence of a poor outcome, and this statement does not imply that all poor outcomes are permanent or due to brain damage. (2) Every trained clinician understands that the phenomenon of a poor outcome is most often influenced-as Donders et al state-by the following: "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)." Accusing me of not understanding this point is unnecessarily vitriolic, especially in light of the fact that I spelled this out in subsequent guidelines 12 to 14 (p. 138). Indeed, I have published articles that conclude that a majority of patients with mild TBI have a favorable recovery, but that there is a "miserable minority" comprising individuals who have poor outcomes caused by neuropathology, psychopathology, physical injuries, secondary gain, or any combination thereof.1,2 (3) Conversely, it is inappropriate for Donders et al to imply that there are evidence-based facts that prove that all patients with mild TBI make a full and complete recovery.

We owe it to our patients to avoid unnecessary conflicts. Donders et al offer the opinion that there are evidence-based facts that support the conclusion that mild TBIs do not cause permanent brain damage. However, to support this erroneous conclusion, they simply relabel those mild TBI patients who have documented brain damage, objectified by positive neuroimaging, as no longer being "true" mild TBI patients. In other words, this logic posits that no mild TBI patients have brain damage by calling those mild TBI patients with positive neuroimaging results "complicated." I wholeheartedly disagree that these "complicated" mild TBI patients are no longer mild TBI patients. However, if Donders et al agree that some "complicated" mild TBI patients have poor outcomes, then, we can reach agreement. That is, if some "complicated" mild TBI patients indeed have poor outcomes, then, the phenomenon of poor outcome following a mild TBI does exist without dispute.

In the research context, it can be helpful to divide mild TBI (or any other population) into "complicated" versus "nocomplicated" on the basis of positive versus negative neuroimaging results. However, in the clinical setting, this division is of limited help for the following reasons: (1) Neuroimaging is not available in a large segment of the mild TBI population. Therefore, how can a neuropsychologist consistently rely on neuroimaging to determine if the patient has a "complicated" or a "noncomplicated" mild TBI? (2) Neuroimaging is not considered to be conclusive for diagnosing brain damage. (3) Mild TBI should be diagnosed according to accepted published definitions. All of the published definitions of mild TBI rely on the loss of consciousness, posttraumatic amnesia, and neurological signs-and none require neuroimaging as diagnostic criteria.3,4 (4) Clinical neuropsychologists are able to diagnose brain damage even in the absence of neuroimaging data. This includes various etiologies such as Alzheimer disease, learning disabilities, mental retardation, autistic disorders, and yes, mild TBI. (5) To date, there exists no consensus as to what neuroimaging techniques should be relied upon for clinically defining what is in fact a "complicated" mild TBI. For example, some patients have negative CT findings but positive MRI results. Some mild TBI patients have negative MRI findings but positive functional neuroimaging results. For all of these reasons, it is premature to clinically rely upon the separation of "complicated" versus "noncomplicated" in a dogmatic manner.

JHTR is the official journal of the Brain Injury Association of America. I take strong issue with the insinuation by Donders et al that I am potentially harming the reputation of either the journal or the Brain Injury Association of America by offering my best understanding of the evidence-based facts.

Ronald Ruff, PhD, ABPP

Department of Psychiatry, University of California, San Francisco.

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