Diversity and Cultural Considerations in Neuropsychology
Providing culturally sensitive clinical services is an ethical responsibility for all practicing neuropsychologists. Approximately 50 million Hispanics, 39 million African-Americans, and 15 million Asian-Americans live in the U.S. Minority populations are rapidly growing as demonstrated by a 40% increase in Hispanic and Asian populations, and a 13% increase in the African-American population since 2000 (U.S. Census Bureau, 2011). However, there is currently a substantial lack of qualified professionals in our field to meet the needs of individuals with diverse cultural backgrounds (e.g., individuals speaking a language(s) other than English with different cultural customs and/or acculturation concerns).
Conducting Neuropsychological Evaluations with Linguistically Diverse Populations
There are several issues to consider when conducting neuropsychological assessment with linguistically diverse populations. The first step as a graduate student is to obtain adequate clinical supervision by a neuropsychologist who has experience with the targeted population. This ensures that services are provided with a culturally sensitive approach. Although on-site supervision is not always possible, other options such as consulting with a neuropsychologist with expertise in cross-cultural assessments can be done via teleconference in conjunction with their on-site supervisor. The second step involves deciding with your supervisor which approach is the most appropriate for your evaluation. For example, you must decide whether you will be employing the use of an interpreter if you do not speak the patient’s native language or if you will be providing clinical services as a native speaker of that language. Both an interpreter and/or graduate student need to be fluent in the patient’s native language, and need training and familiarity with research regarding cultural issues inherent to neuropsychological assessment. Thirdly, you must be familiar with the population your clients belong to. For example, the Hispanic population is rather heterogeneous in nature. Therefore, being familiar with subtle linguistic nuances and cultural traditions are paramount for a proper intake assessment and in choosing norms that best suit your patient. Regarding the latter, having knowledge of the norms for the particular measure you are using is important, such as the size and demographics of the sample (i.e., whether it was normed with native Mexicans, Mexican-Americans, or individuals from other Spanish-speaking countries). Test selection may be guided by proper translation that meets International Test Commission guidelines including translation into the desired language, review by a bilingual expert panel, and finally, translating the instrument back to English (back-translation) to identify any problem words or phrases. Furthermore, you must consider the level of acculturation of your patient, including the preference of their native language versus English and their integration into the current culture versus their native culture. Other important factors include the impact of bilingualism, socioeconomic status, and educational level on an individual’s performance on neuropsychological measures.
Issues with Providing Cross-Cultural Neuropsychology Services
The steps above reflect an ideal situation in which a) you recognize the need to conduct a culturally sensitive evaluation; b) you are able to obtain adequate clinical supervision in conjunction with your on-site supervisor; and c) you have tests available that have adequate norms for the populations you want to work with that are reliable and valid. However, the current state of neuropsychology indicates a strong need for not only individuals trained to provide such services, but also for culturally sensitive neuropsychological measures and assessments of which there is a substantial inequality compared to tests for English speakers. The use of interpreters and native-speaking psychometrists/graduate students requires adequate clinical supervision and heavily depends on the resources available for an evaluation. Minority trainee students may find themselves in uncomfortable positions when asked to provide literal translation of tests that does not meet ITC standards. However, this provides an opportunity for students to inform their supervisors of these standards and why a literal translation is not linguistically equivalent or an applicable use of norms. Overall, competence in conducting neuropsychological evaluations with diverse populations involves a complex process that requires extensive clinical training and familiarity with appropriate measures and associated research.
Resources for Graduate Students Pursuing Training in Cross-Cultural Neuropsychology:
Below is a compilation of various organizations that provide resources for trainees interested in this area:
- Hispanic Neuropsychological Society
- Society for Clinical Neuropsychology (SCN) PIAC Ethnic Minority Affairs (EMA) Subcommittee
- The National Academy of Neuropsychology (NAN) Culture and Diversity Committee
- AACN Multicultural References.
- American Educational Research Association, American Psychological Association, & National Council on Measurement in Education. (1999). Standards for educational and psychological testing. Washington, DC: American Educational Research Association.
- American Psychological Association. (2002). Guidelines on multicultural education, training, research, practice, and organizational change for psychologists. http://www.apa.org/pi/oema/resources/policy/multicultural-guidelines.aspx.
- Antonio E. Puente, Ph.D.: website with multiple resources listed.
- Artiola i Fortuny, L. & Mullaney, H. A. (1998). Assessing patients whose language you do not know: can the absurd be ethical? The Clinical Neuropsychologist, 11(3), 113-126.
- Boone, K. B., Victor, T. L., When, J., Razani, J., & Ponton, M. O. (2007). The association between neuropsychological scores and ethnicity, language, and acculturation variables in a large patient population. Archives of Clinical Neuropsychology 22, 355– 365.
- Brickman, A., Cabo, R., & Manly, J. (2006). Ethical issues in cross-cultural neuropsychology. Applied Neuropsychology, 13(2), 91-100.
- International Test Commission.
- Mindt, M. R., Arentoft, A., Germano, K.K., D’Aquila, E., Scheiner, D., Pizzirusso, M., Sandoval, T.C., & Gollan, T.H. (2008).Neuropsychological, cognitive and theoretical considerations for evaluation of bilingual individuals. Neuropsychol Rev., 18 (3): 255-268.
- Mindt, M. R., Byrd, D. Saez, P., & Manly, J. (2010). Increasing culturally competent neuropsychological services for ethnic minorities: A call to action. Clin Neuropsychol, 24 (3): 429-453.
- Perez-Arce, P. (1999). The influence of culture on cognition. Archives of Clin Neuropsychol, 14 (7): 581-592.
- Puente, A. E., Zink, D. N., Hernandez, M., Jackman Venanzi, T, & Ardila, A. (2013). Bilingualism and its impact on psychological assessment. In L. Benuto (Ed.), Guide to psychological assessment with Hispanics (pp. 15–31). New York, NY: Springer.
- Robbins, R. N., Schuler, M., Ferrett, H. L., & Strutt, A. M. (2013). Operationalizing a standard and ethical approach to neuropsychological assessment across diverse cultures. In F.R. Ferraro (Ed.), Minority and Cross-Cultural Aspects of Neuropsychological Assessment. Swets & Zeitlinger. (In Review).
- U.S. Census Bureau (March, 2011). Overview of Race and Hispanic Origin: 2010. Retrieved from http://www.census.gov/prod/cen2010/briefs/c2010br-02.pdf
- Wong, T. M. (2006). Ethical Controversies in Neuropsychological Test Selection, Administration, and Interpretation. Applied Neuropsychology,13(2), 68-76.
This ANST Chapter Rep Corner on Diversity and Cultural Considerations in Neuropsychology was created in collaboration with Octavio A. Santos, ANST Liaison Officer, and Christine M. Salinas, Psy.D., Member-at-Large for the Hispanic Neuropsychological Society.