Controlling Cultural and Educational Variables in Neuropsychological Evaluations

According to Ardila (1995) and Greenfield (1997), tests are not cultural or educationally isolated. Some tests, more than others, have attempted to be less affected by education and culture (Jensen, 1980; Greenfield, 1997). However, it must be understood that even before the actual testing, these variables begin to affect our understanding of the patient. As a consequence we begin by addressing the review of records, then the interview, and finally the actual testing.

1. Records

Every neuropsychological evaluation begins with a review of existing records. These records might include school, prison, service, and vocational ones. By design, individuals with limited educational background and different cultural heritage pose significant difficulties for a number of reasons, including existence of such records, obtaining them, appreciating the American equivalence, and so on. For example, recently the senior author was asked to complete an evaluation of an Arabic woman. Because premorbid intelligence is an important factor to be addressed and because educational attainment is often considered a good measure of premorbid intelligence, review of school records is a must. However, in some Arabic cultures, especially the more traditional ones, formal education for women is not considered appropriate for middle and upper classes. However, it is important to note that formal education in some Arabic countries does not equate with intellectual abilities. In fact, in some cases, education is considered for those not intelligent enough to be able to marry early and adequately.

When records are available, it is important to realize that things are not equivalent simply because face validity appears evident. For example, a college education in non-North American countries usually equals to a Master's degree in the United States. Hence, some understanding of the culture of origin and the educational system is in order. Otherwise, mistakes will be made in estimating premorbid functioning.

2. Interview

For starters, let us begin by addressing the issue of interpreters. In order of preference, we propose, that all things being equal (and they are not often the case), that the evaluation be done by a culturally similar individual (Spanish patient and Spanish evaluator) in the native tongue of the patient. Next best would be a translator. However, unusual care must be taken in that two common errors are often made. One is that the translator, though qualified, could be literal and miss the cognitive equivalence of the intended question. A second issue is that it is often easier to use available family members. Such individuals are apt to provide their own interpretation as they are not entirely objective. Finally, one could conceivably argue that it would be better to attempt a neuropsychological evaluation without any understanding of the culture or language of the person rather than not do an evaluation at all. In this case, extreme caution should be taken and any final report should address explicitly these concerns. What it comes down to is the clinician weighing Type 1 versus Type II errors. Is it better to have some flawed data than none?

As Velasquez et al. (1997) have suggested, however, a lack of understanding of language and culture will invariably produce errors in the interview process. These errors could include specific terms or concepts, cognitive equivalence issues, and subtle meanings only deciphered with a fluid understanding of the language and culture. If at all possible, the major cultural issue should be understood. Among other variables, Greenfield (1997) has suggested that the following variables should be considered in an interview.

1. The value and significance of specific cultural concepts. For example, educational systems in Spanish cultures may reflect more social ability than formal education.

2. Modes of knowledge. Mode of knowledge is the collective form of knowing. It is common for a head of a family to speak on behalf of the rest of the family. Hence, better information might be ascertained not from the patient but from the head of the family.

3. Modes of communication. It is important to note the role and strategies of communicating. Sometimes apparently important and straightforward questions can be construed as an invasion of privacy, eventually affecting the success of the later testing.

In addition to these considerations, the following information should be obtained, as it may help in appreciating the role of acculturation and education in neuropsychological functioning.

1. Prior testing history. Considering that individuals with either cultural or educational differences are often not exposed to standardized testing, it would be valuable to determine prior knowledge with these modes of understanding.

2. Level of education. Clearly, educational attainment affects neuropsychological functioning. It is imperative that the level and type of education be obtained and understood. However, as Loewenstein, Arguelles, Arguelles, & Linn-Fuentes (1994) have argued, care must be taken not to translate equally the number of years of schooling.

3. Acculturation. Though sometimes understood in general counseling and some testing situations, this is rarely appreciated by neuropsychologists. Whereas one might be able to use acculturation measures (see Magana et al., 1996), number of years in U.S. culture, knowledge of English, employment records, and language spoken at home are some of the variables that could be easily obtained in an interview.

The aforementioned information provides the clinician with a working hypothesis of neuropsychological impairment. This hypothesis helps the clinician identify the types of tests that are necessary and most appropriate. For example, if a person does not speak English (e.g., Vietnamese), the use of some portions of the Halstead-Reitan Neuropsychological Battery (e.g., Speech-sounds Perception Test) would be totally inappropriate, because some items are nothing more than tests for phonetic understanding.

3. Neuropsychological Testing

The lengthiest portion of any neuropsychological evaluation is the testing. Indeed, it is common clinical knowledge that neuropsychological evaluations take twice as long as standard clinical ones, in large part because of the extensive set of labor-intensive tests. In this section we address the different concerns as well as tests that could be used with culturally dissimilar patients. We begin with specific suggestions for the selection of appropriate neuropsychological tests:

1. Address the variables that need to be measured, then select the tests that measure that variable. Sometimes the abilities that need to be measured do not have a cultural equivalence (Helms, 1992). For example, time is often an important variable in determining intelligence in North American cultures. If intelligence is the issue, time might not be that valuable a measure in certain ethnic groups.

2. Select measures that have been adequately translated. By this we mean that the cognitive equivalence and not the literal one is being measured. This should include an understanding of the underlying factors that the test measures and a point-to-point correspondence with the translation. For example, the recall of digits is an integral part of several tests of attention, memory, and intelligence. However, if the issue is memory, then the number "eight" is a monosyllabic memory, whereas "ocho" (Spanish for eight) is two syllables. This becomes even more complex when going between American and Asian cultures and languages.

3. Use tests that have appropriate norms. For example, a recent study by Camara, Nathan, and Puente (in press) revealed that the most common test used by neuropsychologists is the MMPI. The MMPI has been translated into various languages but no formal norms are available in most instances for groups other than the mainstream United States population.

4. Use tests that have specific instructions and protocols. It is our contention that greater errors are made when the degrees of freedom are larger in circumstances where culture and language become intervening variables.

5. Select tests that reflect the language ability and culture of the patient. Tests such as the Mini-Mental Status Exam (MMSE) is relatively easy and brief. However, even with such a test, education can have significant effects. Berto-lucci, Brucki, Campacci, and Juliano (1994) have reported that in illiterate patients, a cutoff of 13 should be used to detect pathology. Of particular concern is the use of intellectual tests, especially in educational settings. Since the likelihood of a false-positive is greater with ethnic minorities, care must be taken not to make educational placement decisions in specific programs (e.g., brain-injury programs) using these tests alone (Puente & Salazar, 1998). Another example comes from the work of Loewenstein and Rubert (1992), who discovered that differences between elderly Hispanic and white European-American individuals on dementia screening was due to performance on tests involving fluency with the letters F, A, and S. These letters occur with greater frequency in the English than in the Spanish language.

6. Be careful not to assume that nonverbal tests mean nonculturally biased tests. As Mahurin et al. (1992) have found, some nonverbal tests yield differences in different cultural groups. If possible, use nonverbal tests that appear to be culture-free. Cuevas and Osterich (1990) reported that the original booklet version of the Category test appears to have cultural equivalence, especially for men.

7. If available, use ecologically valid, tests of function, especially of activities of daily living. One example of this is the Direct Assessment of Continual Status by Loewenstein et al. (1989). Of course, one must be also concerned about the lack of reliability that such tests often provide.

4. Interpretation of Neuropsychological Test Results

Once the testing is complete, then comes the most difficult part of an evaluation— the integration of record, clinical, and testing information. This task is difficult in and of itself without adding cultural and educational confounds. Considering that it is almost impossible to find a perfect evaluation situation (i.e., similar culture and language between tester and patient, adequate tests, and norms, etc.), it is imperative to be extremely careful with the integration of a variety of data to address the presence and impact of a brain injury. We offer several suggestions in attempting this difficult task;

1. Interpret the results in a biopsychosocial context. Whenever possible, understand the biological, psychological, and social context of the patient, including, but not limited to, language and culture.

2. Appreciate what the criterion variable is. This is a difficult issue. If the question is whether a patient is brain-injured, extremely careful attention must be paid to all the issues addressed in this chapter. If the question is whether the patient has the capacity to adapt to the culture where the patient is residing, then it might be reasonable not to accommodate accordingly In other words, the question might be more of acculturation than brain function. Of course, it could very well be that both questions bear being asked, and the evaluation strategies might actually be mutually exclusive. Here is where clinical acumen, including understanding of the referral question, would be valuable.

3. Use a variety of sources of information. Traditionally, neuropsychologists rely heavily on test results, interview, and, typically, existing records. Such sources of information, while valuable, may be insufficient. The clinician might consider alternative strategies, including collateral interviews, thorough histories, assessment of social abilities, and so on. Although immigrants often score poorer on standardized neuropsychological tests, sometimes they are successful in adapting to the immeasurable demands placed on them by a foreign culture and language.

4. Avoid stereotypical interpretations. Although it is imperative to guide interpretation with existing literature, as Velasquez et al. (1997) has underscored, most of that literature does not exist for culturally dissimilar patients. Although intuition would suggest something to be true (e.g., whenever possible, use nonverbal tests), existing studies sometimes provide differing conclusions. An interesting example comes from the study by Karno and Jenkins (1993) that reports that schizophrenia has a better prognosis in less developed countries than in more developed ones.

5. If follow-up with the patient is possible, explain the results in a manner that could be understood by the patient and their family. Avoidance of technical and medical terms and explaining the results in practical, day-to-day, colloquial language will increase an understanding of the situation. One must realize that these individuals may not only have educational and cultural differences, but these are superimposed on neuropsychological deficits. The combination makes for a unique and challenging task of information dissemination.

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