Interpreting neuropsychological test results in the context of linguistic and cultural diversity has long been a major challenge for clinical neuropsychologists. According to the Pew Research Center1, only 47% of the U.S. population will be non-Hispanic whites in 2050, with Latinos/Hispanics being the second largest group (29%). By then, the nation’s foreign-born population is projected to grow by 129% (81 million people). To avoid over-pathologizing normal inter-group differences, it is imperative that the field of neuropsychology adapt to the changing demographics. For example, cognitively healthy Spanish-speaking individuals are found to perform more poorly on many neuropsychological measures relative to English-Speaking controls.
When assessing non-Western-born and/or non-English-speaking individuals, culturally competent neuropsychologists should exercise caution with verbally-based tests, as they would undoubtedly underestimate the individual’s actual abilities3. Contrary to some beliefs, nonverbal tests are not free of culture and educational attainment. It is important to consider how similar the individual one is assessing to the normative sample on which the tests were developed.
The acquisition of nonverbal skills is immensely dependent on culture. Exposure to and use of pictorial materials strongly influence performance levels on tasks of visuospatial skills. Most European children start to perceive two-dimensional pictures as three-dimensional around 12 years old, whereas Bantu/Guinean children and illiterate adults responded to the pictures as flat4. When elderly Chinese participants were compared to their Finnish counterparts, the Chinese participants performed more poorly in copying designs but better in recalling words5. Aruaco Amerindians of Colombia evidenced weaker performances on tests that required them to copy figures and draw a map when compared to a Colombian sample in Canada6. Fast performance is also a skill highly valued by Americans but not as much by other cultures. Russians were found to perform more slowly on timed tasks compared to Americans7.
It is essential to understand various biases that exist within our test instruments. Language, culture, acculturation, quality of education, and location of residence (e.g., urban vs. rural) are some of the factors that need to be considered when interpreting results. Using primarily nonverbal tests is not enough. It may mean that one needs to apply culture-specific norms (such as norms provided with the Neuropsychological Screening Battery for Hispanics or NeSBHIS8), if they exist, when examining the scores. This would address group differences in test performance but not the inherent biases within the tests. Developing tests that are less culturally specific would be an important step moving into the future.
The impact of culture and education on non-verbal neuropsychological measurements: A critical review (2003)
Clinical neuropsychology has frequently considered visuospatial and non-verbal tests to be culturally and educationally fair or at least fairer than verbal tests. This paper reviews the cross-cultural differences in performance on visuoperceptual and visuoconstructional ability tasks and analyzes the impact of education and culture on non-verbal neuropsychological measurements. This paper compares: (1) non-verbal test performance among groups with different educational levels, and the same cultural background (inter-education intra-culture comparison); (2) the test performance among groups with the same educational level and different cultural backgrounds (intra-education inter-culture comparisons). Several studies have demonstrated a strong association between educational level and performance on common non-verbal neuropsychological tests. When neuropsychological test performance in different cultural groups is compared, significant differences are evident. Performance on non-verbal tests such as copying figures, drawing maps or listening to tones can be significantly influence by the individual’s culture. Arguments against the use of some current neuropsychological non-verbal instruments, procedures, and norms in the assessment of diverse educational and cultural groups are discussed and possible solutions to this problem are presented.
Citation: Rosselli, M., & Ardila, A. (2003). The impact of culture and education on non-verbal neuropsychological measurements: A critical review. Brain and cognition, 52(3), 326-333
1. Passel, J. S., & Cohn, D. (2008). US population projections: 2005-2050. Pew Research Center. Link: http://www.pewhispanic.org/2008/02/11/us-population-projections-2005-2050/
2. Jacobs, D. M., Sano, M., Albert, S., Schofield, P., Dooneief, G., & Stern, Y. (1997). Cross-cultural neuropsychological assessment: A comparison of randomly selected, demographically matched cohorts of English-and Spanish-speaking older adults. Journal of Clinical and Experimental Neuropsychology, 19(3), 331-339. Link: http://www.tandfonline.com/doi/abs/10.1080/01688639708403862
3. Brickman, A. M., Cabo, R., & Manly, J. J. (2006). Ethical issues in cross-cultural neuropsychology. Applied Neuropsychology, 13(2), 91-100. Link: http://www.tandfonline.com/doi/pdf/10.1207/s15324826an1302_4
4. Hudson, W. (1960). Pictorial depth perception in sub-cultural groups in Africa. The Journal of Social Psychology, 52(2), 183-208. Link: http://www.tandfonline.com/doi/abs/10.1080/00224545.1960.9922077?journalCode=vsoc20
5. Salmon, D. P., Riekkinen, P. J., Katzman, R., Zhang, M., Jin, H., & Yu, E. (1989). Cross-cultural studies of dementia: a comparison of Mini-Mental State Examination performance in Finland and China. Archives of Neurology, 46(7), 769-772. Link: http://jamanetwork.com/journals/jamaneurology/article-abstract/589141\
6. Ardila, A., Rosselli, M., & Rosas, P. (1989). Neuropsychological assessment in illiterates: Visuospatial and memory abilities. Brain and cognition, 11(2), 147-166. Link: http://s3.amazonaws.com/academia.edu.documents/46563366/Neuropsychological_assessment_in_illiter20160617-14360-1d1ns2u.pdf AWSAccessKeyId=AKIAIWOWYYGZ2Y53UL3A&Expires=1492208677&Signature=HcFkTTKXpEPZZykKqW6coqGGQtA%3D&response-content-disposition=inline%3B%20filename%3DNeuropsychological_assessment_in_illiter.pdf
7. Agranovich, A. V., & Puente, A. E. (2007). Do Russian and American normal adults perform similarly on neuropsychological tests?: Preliminary findings on the relationship between culture and test performance. Archives of Clinical Neuropsychology, 22(3), 273-282. Link: http://www.sciencedirect.com/science/article/pii/S0887617707000091
8. Pontón, M. O., Satz, P., Herrera, L., Ortiz, F., Urrutia, C. P., Young, R., ... & Namerow, N. (1996). Normative data stratified by age and education for the Neuropsychological Screening Battery for Hispanics (NeSBHIS): Initial report. Journal of the International Neuropsychological Society, 2(02), 96-104. Link: https://www.cambridge.org/core/journals/journal-of-the-international-neuropsychological-society/article/normative-data-stratified-by-age-and-education-for-the-neuropsychological-screening-battery-for-hispanics-nesbhis-initial-report/5D64C0E3A2227B97AF41418800BF682DAdditional Resources
- Webinar: Cross-cultural neuropsychology: Training and practice considerations. Part of the webinar series by the SCN Ethnic Minority Affairs, in collaboration with ANST. Link:https://www.youtube.com/watch?v=9dWSvu2Rhic
- Professional Organization: American Academy of Clinical Neuropsychology (AACN)’s 2050 Relevance Initiative, whose goals are “to support new assessment methods, training models, mid career supervision models, and clinical strategies that every Academy member can access in order to begin to substantially increase the percentage of patients we, and the generation of neuropsychologists who follow us, are able to competently serve.” Link: https://theaacn.org/relevance-2050-initiative/#gsc.tab=0
- Professional Organization: National Academy of Neuropsychology (NAN)’s Bulletin, Volume 31, Issue 1. Diversity issues: student perspective, research highlight, and professional issues. Link: http://www.nanonline.org/docs/ResearchandPublications/NANBulletin/Spring%202017%20Bulletin_Reduced.pdf