Cultural Diversity

A Special Issue of applied Neuropsychology

Ruben J. Echemendia, Ruben J. Echemendia

• Publisher: Psychology Press
• Year: 2015
• ISBN:
  9781135066482
• Edition: 1
• Topic: Psychologie
• Subtopic: Geschichte & Theorie in der Psychologie

Cultural Diversity studies the relationship between culture and neuropsychology. Its goal is to examine salient aspects of this relationship and assist in bringing the issue of culture and cultural diversity to the forefront of neuropsychological discussions. The articles help further the understanding that ethnic and cultural variables are important not only in research design but also in clinical practice. In addition they urge clinicians to make cultural variables an integral component of any neuropsychological assessment and examine clinical data in the context of the patient's ethnic and cultural backround.

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ARTICLES

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Neuropsychological Test Use With Hispanic/Latino¹ Populations in the United States: Part II of a National Survey

Reben J. Echemendia

Psychological and Neurobehavioral Associates, State College, Pennsylvania

Josette G. Harris

Departments of Psychiatry and Neurology University of Colorado School of Medicine

A national survey was conducted with the aim of characterizing the status of neuropsychological practice with Hispanic¹ individuals in the United States. In an earlier article (Echemendia, Harris, Congett, Diaz, & Puente, 1997), survey findings were presented concerning the characteristics of neuropsychologists who work with Hispanic populations, specific graduate and postgraduate preparation to provide services to culturally diverse groups, and predictors of self-rated competence to work with Hispanic people. In this article, additional results from the survey are presented. Specifically, these results concern reported use of standardized and nonstandardized measures to assess Hispanic people, with particular emphasis on assessment practices with monolingual versus bilingual patients and the use of norms for clinical interpretation.

To present these findings in the proper context, it is important first to address briefly some of the pertinent issues with regard to neuropsychological assessment of culturally or linguistically diverse people. Although the need to consider and address cultural variables is clearly outlined in ethical standards and practice guidelines (American Psychological Association [APA], 1990, 2002), various issues may interfere with the clinician’s full consideration of such variables in the assessment of neurobehavioral functions. For example, neuropsychologists may be poorly informed regarding the extent to which cultural factors are relevant or may exert an influence on neuropsychological test scores. This may be as much a function of relatively limited published research in the area of cultural neuropsychology as it is the application of untested assumptions of “general” neurobehavioral principles to culturally and linguistically diverse people. Although some of these assumptions may yet prove to be valid, many remain untested. Specific aspects of culture, such as experience living in the United States, country of education, and preferred language, are increasingly being identified as potent variables that affect neuropsychological performance (Harris, Tulsky, & Schultheis, 2003).

With regard to language, little systematic attention has been given to the assessment of language proficiency or competence and the implications for neuropsychological assessment. Standard measures that have been available for some time are not widely used among neuropsychologists and are better known among psychoeducational providers for use in the identification of school-age English Language Learners and Limited English Proficiency students (Language Assessment Scale, 1990, 1994; Stanford English Language Proficiency Test, 1990; Woodcock-Muñoz Language Survey, Woodcock & Muñoz-Sandoval, 1993; Idea Proficiency Test). The focus of these measures tends to be on the measurement of comprehension, vocabulary, syntax, and other fundamental language skills important to educational testing and educational services planning and intervention. Neuropsychologists may base their decisions regarding the appropriateness of using English language verbal measures on the examinee’s ability to participate in casual conversation with the examiner, but examinees may at times overstate their mastery of English in an effort to gain acceptance by peers and others in the community, including professionals with whom they interact. Examiners may rely on an arbitrary standard for administering a test in English, such as the length of time an individual has resided in the United States. The latter variable, in particular, may correlate with language proficiency, but second language learning is very complex, and a multitude of factors influence patterns of use, proficiency, and perceived competence (Ardila, 1998; Harris, Echemendia, Ardila, & Rosselli, 2001).

Finally, these survey results must be presented in the context of the current state of affairs regarding the underrepresentation of culturally diverse providers in all specialties of psychology. Perhaps clinicians approach the assessment of culturally diverse people with the realization that their resources, knowledge base, and experiences are limited, but nevertheless, they feel compelled, because of a lack of available providers (e.g., Hispanic, Spanish-speaking neuropsychologists) and pressure from referral sources, to meet the needs of these people. With the continued growth of the linguistic and cultural diversity of the U.S. population, such demands, which outstrip resources, are likely to continue to rise. Thus, it becomes imperative to identify the current practices in the provision of neuropsychological services to various subgroups and people living within the larger U.S. population, to understand the strengths and weaknesses of those approaches, and to ultimately develop more effective tools and methodologies for meeting the challenges that our societal diversity presents.

Method

The methods used in this study have been described in detail elsewhere (Echemendia et al., 1997). A comprehensive survey concerning professional training and clinical practices with Hispanic, Spanish-speaking patients was mailed to a national sample of neuropsychologists. A total of 911 surveys were returned. The sample was deemed to be representative of U.S. neuropsychologists on the basis of a variety of demographic and practice factors (Echemendia et al., 1997). The survey was divided into two components. The first component addressed the cultural background and training of neuropsychologists; their ability to speak, read, and write in Spanish; their experiences working with Latinos, Spanish-speaking populations; and their self-perceived competence to work with these populations. The second portion of the survey, which is the focus of this article, examined the instruments and norms used by U.S. neuropsychologists when working with Spanish-speaking populations. Only those neuropsychologists who reported experience working with Hispanics completed this portion of the survey.

Respondents were asked to report the tests they use and then to indicate whether they use each test with monolinguals (Spanish only) or bilinguals. They also were asked to indicate the version of the test that they use: (a) published English language test, (b) nonpublished personal verbatim translation of an English test, (c) nonpublished Spanish culturally adapted translation (not a verbatim translation) of a published English test, or (d) published Spanish language test. The respondents were asked to indicate whether they use published norms from an English-speaking sample, published norms from a Spanish-speaking sample, or clinical judgment to interpret the test results. A list of the most commonly used tests in neuropsychology was provided, with columns for these variables as well as space for respondents to include any test used that was not listed.

Results

A total of 475 (52%) neuropsychologists completed the second portion of the survey. Table 1 presents the 10 most frequently reported tests used with bilingual and monolingual Hispanics. As can be seen, the Wechsler Adult Intelligence Scale (WAIS) is the most widely used test within each group. Please note that the “combined” category is not a simple addition of the monolingual and bilingual categories. This category indicates that the neuropsychologist used the test with both monolingual and bilingual groups. Some neuropsychologists use tests with only monolinguals, others with only bilinguals, and some use the combination. Similarly, some neuropsychologists may practice with only bilinguals, whereas others may practice exclusively with monolinguals.

Table 1 reveals remarkable consistency among the tests used with the different language groups. The WAIS, Trail Making Test (Trails), Wechsler Memory Scale, Wisconsin Card Sorting Test (WCST), Rey Complex Figure Test, California Verbal Learning Test (CVLT), and Boston Naming Test (BNT) were common to all three groups. The combined group also made use of the Ravens Progressive Matrices and the Symbol Digit Modalities Test. Those neuropsychologists working with monolinguals also reported using the Reitan–Klove Sensory Perceptual Exam (S/P) and the Mini Mental Status Examination (MMSE). Neuropsychologists working with bilinguals reported using the Halstead–Reitan Battery (HRB) and the Stroop Color–Word test, among the most frequently used tests.

Table 1. Comparison of Tests With the Highest Frequency of Endorsement Across Groups

Test Name (Frequency)
Combined^a	Monolingual	Bilingual
WAIS (461)	WAIS (110)	WAIS (283)
Trails (366)	Trails (57)	WMS (195)
WMS (302)	WMS (55)	Trails (180)
WCST (269)	CVLT (46)	CVLT (171)
RCFT (258)	S/P (43)	WCST (149)
CVLT (253)	MMSE (41)	Log. Mem (141)
S/P (228)	Log. Mem (38)	BNT (135)
BNT (215)	WCST (38)	HRB (126)
Ravens (212)	BNT (35)	RCFT (120)
SDMT (159)	RCFT (35)	Stroop (119)

Note: WAIS = Wechsler Adult Intelligence Scale; Trails = Trail Making Test; WMS = Wechsler Memory Scale; WCST = Wisconsin Card Sorting Test; CVLT = California Verbal Learning Test; RCFT = Rey Complex Figure Test; S/P = Reitan-Klove Sensory Perceptual Exam; MMSE = Mini Mental Status Examination; Log. Mem = Logical Memory (WMS); BNT = Boston Naming Test; HRB = Halstead-Reitan Battery; Ravens = Ravens Progressive Matrices; SDMT = Symbol Digit Modalities Test.

^aThe combined group is not a total of the monolingual and bilingual groups.

This pattern of test use with Hispanic, Spanish-speakers is quite consistent with that used in the general population (Butler, Retzlaff, & Vanderploeg, 1991; Table 2). The only tests endorsed more frequently with the general population were the Token Test, the Controlled Oral Word Association Test, and the Finger Tapping Test. The Token Test was the 11th most frequently used test among both monolinguals and bilinguals in our survey.

Table 2. Neuropsychological Test Usage in the General Population—Tests With the Highest Use Endorsement

Test	Endorsement
WAIS–R	86
Wisconsin Card Sorting	73
Boston Naming Test	63
Rey-Osterrieth Complex Figure	60
Trail Making Test	59
Wechsler Memory Scale	49
Token Test	49
Controlled Oral Word Association	48
Rey Auditory Verbal Learning	46
Finger Tapping	46
Ravens Progressive Matrices	45
Stroop Color–Word Test	45

Note: WAIS–R = Wechsler Adult Intelligence Scale-Revised. From “Neuropsychological Test Usage,” by M. Butler, P. Retzlaff, and R. Vanderploeg, 1991, Professional Psychology: Research and Practice, 22, p. 511–512. Copyright © 1991 by the American Psychological Association. Adapted with permission.

We examined whether test selection varied as a function of the neuropsychologist’s self-perceived level of competence to work with Hispanics. Neuropsychologists were asked to rate their competence to work with Latinos on a 7-point Likert scale ranging from 1 (not at all competent) to 4 (somewhat competent) to 7 (extremely competent). Echemendia et al. (1997) reported that 22% of the sample felt not all competent to work with Hispanics, and 1.4% felt extremely competent. Approximately 82% of the sample fell in the marginally to somewhat competent range (scale points 2 through 4). Table 3 lists the five tests with the highest frequency of use, with monolinguals and bilinguals as a functi...