Minority and Cross-Cultural Aspects of Neuropsychological Assessment

Enduring and Emerging Trends

F. Richard Ferraro, F. Richard Ferraro

• Publisher: Psychology Press
• Year: 2015
• ISBN:
  9781317483632
• Edition: 2
• Topic: Psicologia
• Subtopic: Storia e teoria della psicologia

Minority and cross-cultural psychology is more relevant now than ever in our diverse world. Given the dramatic local and global changes occurring daily with regard to demographics, population changes, and immigration issues, minority and cross-cultural psychology is fast becoming a respected and critical area of scientific study. Pair that with the fact that people of all cultures and racial groups are living longer and experiencing age-related diseases and disorders, one can easily see the need for additional work on issues related to neuropsychological assessment.

This new edition brings to the forefront recent developments by seasoned experts in the field. They offer up their newest projects in minority and cross-cultural aspects of neuropsychological assessment and are joined by new, up-and-coming professionals across a wide array of disciplines including psychology, medicine, and neuropsychology. Like the first edition, this updated collection sheds light on the ever-growing need for adequate neuropsychological assessment to a wider subset of individuals, crossing many cultural and minority barriers in the process. Continuously pushing the boundaries of neuropsychological assessment, this collection is essential reading for cognitive and clinical psychologists, and neuropsychologists, and a model text for advanced courses dealing with minority and cross-cultural issues.

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Trends in the Neuropsychological Assessment of Culturally Diverse Populations

Torrii Yamada and Greg J. Lamberty

Introduction

In the first edition of this book (Ferraro, 2002), a chapter entitled “Traditions and Trends in Neuropsychological Assessment” served as the introduction to a volume that sought to provide insights into conducting neuropsychological assessments with individuals from a wide range of cultural and ethnic backgrounds. Up to that point, the neuropsychology literature was characterized by a number of articles examining specific groups and their performance on different measures. There were implicit and explicit acknowledgments that a “onesize-fits-all” view of assessment was untenable and possibly harmful. Thus, the importance of appreciating the unique qualities and needs of different groups was highlighted and synthesized into a 20-chapter volume. Clearly, no such effort could be described as definitive, as the idea for such a volume was relatively new for neuropsychology and the science behind it was still very much in its infancy. Nevertheless, the contributions from the first edition of “Minority and Cross-Cultural Aspects of Neuropsychological Assessment” provided a strong foundation for practicing neuropsychologists interested in appropriately broadening the scope of their understanding and practices for cultural competency.

New clinical disciplines typically spend a good deal of time debating the preferred way of doing things. In our previous chapter (Lamberty, 2002), different approaches to neuropsychological assessment were briefly reviewed. It is important to have an understanding of the history and evolution of a field so that practitioners can appreciate both the theoretical underpinnings and clinical exigencies that shape it. At some point, however, general agreement about how to practice is reached and other obstacles to high-quality practice can be tackled. How a field deals with developing quality measures for culturally different groups is one such major obstacle. It would seem to be the case that, in many fields, special circumstances and unique cases are relegated to a different priority status. In the early days of clinical neuropsychology, there was a focus on test and battery development that was based on modal cases seen in clinic practices. As measures improved and evolved, issues of how to handle exceptions became more pressing and are now a standard part of test development.

In this chapter we will discuss the further evolution of clinical neuropsychology as a data-based science that is grounded in careful clinical observation and various theories about cognitive functioning. The importance of the foundational work is not diminished but rather validated by the power of carefully collected clinical data. The implications for improving neuropsychological assessments for culturally diverse populations will be highlighted and suggestions for further advancement will be made.

Foundational Influences in Neuropsychological Practice

Curiosity about cognitive functioning likely dates back to the earliest humans, but the earnest development of ways to assess those functions can be traced to the late 19th century. Early neurologists and psychiatrists like Charcot, Jackson, Head, and Freud provided elegant descriptions of what they observed in the individuals that came to see them for all manner of clinical concerns. They painstakingly documented these observations for the clinical and scientific communities and developed theories about underlying pathology. Around the same time, pioneers in test methods like Galton and Binet began to develop discrete ability measures that quantified performance on tasks designed to assess various hypothesized mental abilities. The promise of these tests became quickly apparent and early psychometrists and mathematicians like Karl Pearson and Charles Spear-man facilitated their development and scientific relevance by developing statistical techniques that continue to undergird psychometrics (Finger, 1994; Lamberty & Nelson, 2012). Many in the psychology community touted the use of intelligence tests as means of classification and selection. Group intelligence test development efforts led by American academics like Terman, Goddard, and Yerkes were considered a great success, and they eventually led to the early versions of individual intelligence tests that remain in wide usage today (Boake, 2000).

A more controversial associated outcome of the early psychological testing movement involved the field of eugenics, a term coined by Francis Galton. In essence, eugenics advocated the propagation of more “pure” races in humans, similar to animal husbandry or selective breeding practiced in animal species. One means of identifying desirable traits and individuals was psychological tests. It is beyond the scope of this chapter to address this issue except to note that the misuse of tests is often based on misunderstanding of the limits of such technology. Objections to the use of psychological tests have been around nearly as long as the tests themselves. For instance, Stephen J. Gould was very critical of the entire psychological testing enterprise in his popular book The Mismeasure of Man (Gould, 1981). A second edition was published in 1996, partly as a critique of Herrnstein and Murray’s controversial The Bell Curve (Herrnstein & Murray, 1994), which many criticized as an overreaching treatise on the social predictive power of IQ and standardized cognitive tests. Despite these criticisms, or perhaps because of them, development of modern psychological and neuropsychological test measures proceeded with a more empirical and less culturally biased approach.

In neuropsychological assessment, questions about spared and impaired functioning dictated the nature of tests that would come into regular use. Similar to the clinical and psychometric early influences noted above, a qualitative and quantitative dichotomy is represented in the differences between the Boston Process Approach (BPA; Milberg, Hebben, & Kaplan, 2009) and the Halstead Reitan Battery (HRB; Reitan & Wolfson, 2009). The BPA emphasizes the careful description of intra-test behaviors and elements of performance, while the HRB stresses the importance of quantifying performances on a standardized battery of tests. Numerous other approaches to neuropsychological assessment rest at different points on the quantitative/qualitative continuum. For example, Benton’s “hypothesis testing” model (Tranel, 2009) is known for applying a rigorous psychometric approach to assessing a range of higher cortical functions that were observed to be disrupted in neurologically impaired patients. Indeed, most extant approaches in neuropsychological assessment have incorporated both psychometric and observational methods to elucidate their models (Grant & Adams, 2009).

The neuropsychology literature of the recent past has included debates and discussions about methods and theoretical approaches to assessment. Perusal of popular texts in clinical neuropsychology provides an overview of this history (Grant & Adams, 2009; Lezak et al., 2012; Morgan & Ricker, 2009), but the emerging reality is that there has been a steady trend away from “fixed” and toward “flexible” battery approaches in neuropsychological assessments over the past 25 years (Sweet & Moberg, 1990; Sweet, Moberg, & Suchy, 2000; Sweet, Moberg, & Westergaard, 1996; Sweet et al., 2011). While the use of different batteries or test selection methods is likely driven by a number of factors, there is ample research literature and normative data to support the use of today’s most commonly used measures. The availability of rigorously standardized tests has slowly made arguments about testing philosophy or approach less relevant. A clear standard in neuropsychological assessment is that measures are carefully normed and supported by peer-reviewed literature (AACN, 2007; Lezak et al., 2012).

Contemporary Neuropsychological Assessment Strategies

As noted, most neuropsychologists use a “flexible” battery approach to neuro-psychological evaluation (Sweet et al., 2011). Proponents of the HRB and the Luria Nebraska Neuropsychological Battery (LNNB; Golden, Purisch, & Hammeke, 1985) have argued that the lack of ability to standardize such ad hoc batteries makes them less adequate as comprehensive assessments. In contrast, the primary advantage of batteries like the HRB and LNNB was that all measures were administered as a battery, thus allowing the validation of the entire battery (Reitan & Wolfson, 2009). While this argument held some sway in the early days of clinical neuropsychology, it has eventually became apparent that the batteries did not comprehensively assess cognition, and the original intent of the measures (determining the presence or absence of “brain damage”) was no longer a primary goal of the neuropsychological assessment.

The value of co-norming measures has not been lost on the neuropsychological and assessment communities, but in the time between the heyday of the HRB and the present, the assumption was that the costs and logistical challenges for such efforts were simply prohibitive. In fact, the most-wide ranging of such co-norming efforts has been undertaken for recent versions of the Wechsler Adult Intelligence Scale (WAIS-IV; Wechsler, 2008), Wechsler Memory Scale (WMS-IV; 2009), and the Wechsler Test of Adult Reading (WTAR; Holdnack, 2001) by Pearson, a company with considerable resources and profit motivation. While these efforts provide solid and comparable data for specific measures, the re-norming and marketing of the tests on varied schedules makes it difficult to both update assessment tools and utilize the norms provided. Further, the impracticality of administering comprehensive measures and lengthy batteries continues to be the most obvious functional limitation of this approach.

The term “flexible” battery is used to convey the fact that a given practitioner uses a number of different measures to assess cognition. It should be obvious that one practicing neuropsychologist’s approach can be quite different from that of another neuropsychologist. Consequently, the ability to know what neuro-psychologists do within their assessments is hard to discern except to note that a common aim among practitioners is to answer a particular referral question. It is tempting to conclude that there are good reasons as to why the “flexible” battery approach is the most commonly used among practitioners presently (e.g., Sweet et al., 2011). Unfortunately, it is not always clear whether this is truly the case from one neuropsychologist to the next. Ordering tests from an al a carte menu of well-normed measures is convenient, but it might also engender a lack of appreciation for a more unified understanding of cognitive functioning. Although this is probably more troubling to neuropsychologists than it is to their patients or referral sources, a conceptually coherent set of assumptions should underlie any assessment, no matter how brief or extensive it may be. Mentors of today’s aspiring neuropsychologists need to be mindful of the fact that neuropsychology is not simply an enterprise of test-giving and data collection.

Evolution of a Data-Based Science

Under the best circumstances the measures neuropsychologists employ are reliable, valid and can be flexibly used with a wide range of individuals. However, for many years, issues relevant to race, ethnicity, socioeconomic status, culture, language, and other demographic factors have provided cause for reflection on how to best serve the needs of diverse patients. Challenges involving limited resources, restricted access to clinical samples, and a basic lack of experience or understanding of the impact of cultural factors have made the development of quality measures difficult.

In an era of “big data” the ability to bring data and clinical practice together is becoming a reality. Efforts of corporate players can provide a framework for test development, data collection, and marketing. Eventually, a more substantial contribution to the improvement of measures will come from collection of data in the clinical settings where it is most commonly utilized. Some examples of this development process are illustrative, particularly where developing measures for specific populations are concerned. The concept of “local norms” has been in existence for many years and the notion that clinics and practices should gather data on cases relevant to them has always been recommended. Consistent with this practice is the idea that sometimes test measures, as published, do not always “work” for the patients seen in a particular kind of practice or locale. The theory behind a test seems solid and the initial data collected in a clinical study or standardization trial seems adequate, but the test simply does not fit with other findings in a typical assessment.

An example of this process is apparent in the updating both the WAIS and the WMS over the past couple of iterations of those measures. In updating the WAIS-III to the WAIS-IV and the WMS-III to the WMS-IV, both “batteries” included new subtests in the third editions, which were subsequently removed from the fourth editions of the measures. The authors and developers noted several reasons for updating the measures. Among the reasons were clinical practice patterns, reported difficulty of administration, reducing the emphasis on motor demands, length of testing required, and errors in the reported factor structure (Wechsler, 2008, 2009). In other words, a combination of marketing and scientific factors were responsible for changes and updates in these widely used measures of cognitive ability.

Relying on test publishers to direct the future of neuropsychological measures does not seem like an ideal approach. While there are many quality tests produced by test publishers, there are also many widely used non-proprietary measures that can benefit from the sharing and combining of clinical data sets. Most neuropsychologists would likely agree that open source assessment resources are a desirable and possibly even preferable model. Several examples in this realm are also notable. For instance, the NIH toolbox has been developed for the purpose of “meeting the need for a standard set of measures that can be used as a ‘common currency’ across diverse study designs and settings” (http://www.nihtoolbox.org). The advantage of multiple studies and sites using the same measures is obvious. Tests can be standardized quickly and accurately, and data for widely disparate demographic groups can be conglomerated with ease and efficiency. In addition to brief and deficient measures developed for clinical studies, data from other studies’ sources can similarly be combined. The National Institute on Neurological Disorders and Stroke (NINDS) has developed a general common data elements (CDE) project (http://www.commondataelements.ninds.nih.gov) that is intended to assist those conducting clinical research. Such data often include commonly utilized measures in clinical practice (Wilde et al., 2010) that are familiar to both researchers and clinicians. The stated end goal in such projects is to identify common measures and variables and to encourage researchers to use such measures, which improves communication and presumably the quality of measures that are used. In the first edition of this volume, we discussed differences between academic and clinical practitioners and how they pursue knowledge differently. Ten years later this gap is closing rapidly and the goals of researchers and clinicians are more consistent with one another. Evidence-based practice is a reality and research data will ultimately be the primary determinant of what we know clinically and how we will be required to practice.

Finally, the field of health informatics is likely to play a significant role in the development of neuropsychological practice and research. Bilder (2011) has suggested that the creation of “collaborative neuropsychological knowledge bases” can be achieved by formally defining neuropsychological concepts in “cognitive ontologies,” which can facilitate assessment methods and ultimately refine tests and constructs. These new concepts can be challenging and somewhat disorienting, though ultimately the goal of informatics is to find the most efficient way to utilize the staggering amount of health and biomedical information that is routinely collected. The advantage of such methods, particularly where under-served and underrepresented groups are concerned, is that a far greater amount of timely and accurate information can be collected and applied to improve the reliability and validity of measures used for culturally diverse populations.

Cross-Cultural Considerations

In the recent past, practicing neuropsychologists have convened to discuss increasing concerns regarding culturally competent neuropsychological practices with ethnic populations. In 2008, a summit was convened to explore potential ways to advocate for innovative scientific approaches to further advance ...

Table of contents

• Cover
• Title
• Copyright
• CONTENTS
• Contributors
• Series Editor Foreword
• Preface
• 1 Trends in the Neuropsychological Assessment of Culturally Diverse Populations
• 2 Cultural Competence Guidelines for Neuropsychology Trainees and Professionals: Working With Ethnically Diverse Individuals
• 3 Multiracial Considerations in Neuropsychology
• 4 Cross-Cultural Issues in the Neuropsychological Assessment of Dementia
• South Africans
• American Indians/Alaska Natives
• Old Order Anabaptists
• Asians/Pacific Islanders
• Hispanics/Latinos
• Brazilians/Portuguese
• Children With Learning Disabilities, Adolescents, and the Elderly
• Emerging Issues
• Index