The Neuropsychology of Asian Americans

Daryl E.M. Fujii

• Publisher: Psychology Press
• Year: 2011
• ISBN:
  9781136949449
• Edition: 1
• Topic: Psychology
• Subtopic: History & Theory in Psychology
• Index: Psychology

This volume is the first comprehensive resource to assist neuropsychologists to provide culturally competent services to Asian Americans. It highlights pertinent historical socio-cultural characteristics of the largest Asian American ethnic groups, which helps to conceptualize presentation, provide an optimal environment for test administration, interpret tests within a cultural context, and offer culturally sensitive feedback and recommendations. In addition, the volume gives a summary of the available neuropsychological literature for each Asian American ethnic group, recommendations for testing, and illustrative case samples.

The second purpose of the volume is to provide a glimpse of how neuropsychology is currently practiced in different Asian countries, by reviewing the neuropsychological literature and by listing the available resources. This information gives valuable insights to neuropsychologists working with Asian communities throughout the world.

Neuropsychology of Asian Americans is an essential resource for clinical neuropsychologists and school psychologists who perform neuropsychological services to Asians. It is also an important resource for academic neuropsychologists and students with Asians in their sample, as cultural variables may have moderating effects on data that information in this book helps to elucidate.

1 Introduction

Daryl Fujii

Introduction

Although relatively small in number compared to the total American population, Asians are the fastest-growing ethnic minority in the United States. According to the 2000 U.S. Census Bureau, there were 10,171,820 Asians living in the United States, which is about 3.6% of population. The figure rises to 11,859,446, or 4.2% of the total population, if persons of part-Asian ancestry are included. These numbers reflect a 48% to 72% increase for various subgroups from 1990 to 2000 in comparison to 13% of the general population (Barnes & Bennett, 2002). The growth in the Asian population will not only continue but exponentially increase, as by 2050 it is projected that the number of Asian Americans will increase 213% to 33.4 million, or 8% of U.S. population (U.S. Census Bureau, 2004).

Given the growing number of Asians, it is likely that a clinical neuropsychologist will at some point in time be referred a client of Asian heritage. An Asian client may pose a special challenge for Western neuropsychologists, as many are not familiar with Asian culture, and most standard tests and procedures may have questionable validity and reliability with this population (Fujii & Wong, 2005; Wong & Fujii, 2004). Salient issues in working with Asians include ethnic diversity, language barriers, acculturation, and different value systems and communication styles.

Asian Americans are a highly diverse group. The 2000 U.S. Census Bureau lists 24 different ethnicities under the Asian category. The 11 largest Asian ethnicities in the United States are as follows (Barnes & Bennett, 2002):

1. Chinese (2,422,970, 23.8%)
2. Filipinos (1,864,120, 18.3%)
3. Asian Indians (1,645,510, 16.2%)
4. Vietnamese (1,110,201, 10.9%)
5. Korean (1,072,682, 10.5%)
6. Japanese (795,051, 7.8%)
7. Cambodian (178,043, 1.8%)
8. Hmong (170,049, 1.7%)
9. Laotian (167,792, 1.6%)
10. 10. Pakistani (155,909, 1.5%)
11. Thai (110,851, 1.1%)

Not only are Asians ethnically diverse, but they are demographically diverse as well. For example, although known as the “model minority” due to high academic and occupational achievement, persons with a bachelor’s degree or higher range from a high of 63.9% for Asian Indians to 7.7% and 7.5% for Laotian and Hmong, respectively. Similarly, although the median family income of all Asians was $9,000 higher than the median for all American families ($59,300 vs. $50,000), median incomes of subgroups vary from a high of $70,849 for Japanese to a low of $32,384 for Hmong. These differences illustrate that “one size does not fit all” when understanding Asian ethnic groups, as characteristics of one ethnicity do not necessarily apply to another. This diversity increases the knowledge base required for working with Asian Americans, thereby making it more difficult to work with this population.

Language barriers are another issue. It is estimated that 69% of the Asian Americans are foreign born. Asian Indians, Vietnamese, Koreans, and Thais are the subgroups with the highest percentage of foreign-born persons, ranging from 75% to 78% (Reeves & Bennett, 2004). By contrast, the Asian ethnic group with the lowest percentage of foreign born is the Japanese, at 39% (Reeves & Bennett, 2004). An implication of this demographic is that a large number of Asian Americans are not proficient in English. Data from the 2000 U.S. Census Bureau indicate that 79% of Asian households speak a language other than English at home, with percentages ranging from 47% for Japanese households to over 90% for Cambodians, Laotians, and Vietnamese, and 96% for Hmong (Reeves & Bennett, 2004). Forty percent of Asians are reported to speak English less than “very well,” with the highest percentage being the Vietnamese, 62%. The Japanese were the only subgroup with over 50% of the households speaking only English at home (Reeves & Bennett, 2004).

An issue related to immigration is acculturation. In addition to language spoken at home and whether one was foreign born, years living in the United States is another contributor to level of acculturation. Data from the 2000 census indicate varying patterns of immigration for each Asian subgroup. For example, the numbers of Asian Indian immigrants have steadily increased over the past decades, with 18.2% immigrating before 1980, 27.8% immigrating in the 1980s, and 54% during the 1990s. Immigration patterns for Filipinos have been relatively steady across the three decades, with 31.3%, 33%, and 35.6% immigrating to the United States before 1980, during the 1980s, and the 1990s, respectively. By contrast, immigration patterns of Southeast Asians, including Cambodians, Hmong, and Laotians, resemble a bell-shaped curve, with significantly large numbers of persons immigrating in the 1980s, and much fewer immigrating before 1980 and after 1989 (Reeves & Bennett, 2004). The different patterns in longitudinal immigration would suggest different levels of acculturation both between and within specific Asian ethnicities.

Acculturation issues are particularly salient in Asian populations. Unlike many Western societies, which are heavily influenced by Judeo-Christian religions and beliefs, Asian values are influenced by Eastern religions such as Buddhism and Hinduism, which emphasize selflessness and a harmony with nature and others. The different foundational influence is a double-edged sword, as it affects both a foreign-born individual’s adjustment to Western society and a neuropsychologist’s ability to understand behaviors and develop rapport, the latter essential for data gathering. In addition, typical Asian behaviors associated with illness, such as routinely agreeing with authority figures, including health care professionals, to show respect even if one disagrees, and a tendency to somaticize emotional problems, may confuse Western clinicians who may be unfamiliar with these behaviors (Wong & Fujii, 2004).

Despite the growing numbers of Asian Americans, there are very few Asian neuropsychologists practicing in America. Preliminary data indicate the numbers of Asian American neuropsychologists in comparison to the total number of neuropsychologists are lower than the percentage of the population in America. A rough estimate of Asian American neuropsychologists based upon identifying Asian surnames on the International Neuropsychological Society’s (INS) membership directory for U.S. citizens resulted in roughly 115 names, or about 3% of the total number of American neuropsychologists (n = 3855). Numbers are very similar (3.1%) when Canadian neuropsychologists are included (130/4211). These percentages are about 20% or 28.5% lower than the percentage of Asians or part-Asians in America, respectively.

Not only are there too few neuropsychologists, but the ethnic distribution of neuropsychologists does not coincide with that of Asian Americans. As mentioned previously, the largest Asian ethnicities in descending order are Chinese, Filipinos, Asian Indians, Vietnamese, Koreans, and Japanese. By contrast, the Asian ethnicities with the most neuropsychologists in order are Chinese, Asian Indian, Korean, and Japanese. Thus, among the Asian ethnic groups with the highest populations, both Filipinos and Vietnamese have very few practicing neuropsychologists.

Using a similar methodology with the American Academy of Clinical Neuropsychology (AACN) directory, 11 board-certified Asian neuropsychologists were identified: Japanese, 4; Chinese, 3; Korean, 2; and Asian Indians, 2; which is roughly 1.7% of all neuropsychologists certified by the American Board of Professional Psychology (ABPP). Again, the ethnic distribution does not coincide with the ethnic distribution of Asian Americans. Another interesting statistic is the distribution across states: Hawaii, 3; California, 3; Ohio, 2; New York, 2; and Washington, DC, 2. These numbers indicate that board-certified Asian neuropsychologists are primarily located on the coasts and in Hawaii, leaving 46 states without an ABPP-credentialed Asian neuropsychologist.

Numbers are even smaller for neuropsychologists reporting proficiency in Asian languages. The following are the number of neuropsychologists speaking Asian languages listed on the National Academy of Neuropsychology (NAN) directory: Chinese, 4 (Chinese, Cantonese, Mandarin unique clinicians combined); Vietnamese, 4; Asian Indian, 3 (Gurajati, Hindi, Urdu unique clinicians combined); Filipino, 3; Japanese, 2; Korean, 1; and Malay, 1. Although numbers are small, the distribution of speakers is generally consistent with the Asian population broken down by ethnic groups. The following is the distribution of clinicians across the states (including Canada): Washington, 5; California, 4; Utah, 2; Oregon, 1; Texas, 1; Ohio, 1; Indiana, 1; Virginia, 1; Massachusetts, 1; and Alberta, 1. These numbers indicate a strong West Coast bias followed by the Midwest and East Coast.

It should be emphasized that the methodology for procuring these data is crude. First, the population estimates are based upon 2000 census data, while the clinician numbers are based upon 2008 data. Differences in data sources would suggest that population numbers underestimate the actual numbers of Asian Americans. Similarly, our number likely underestimated the numbers for both Asian neuropsychologists and neuropsychologists proficient in Asian languages. Our data do not account for Asians who have non-Asian surnames due to marriage or adoption, those who do not belong to one of the major neuropsychological associations, or those who did not list their foreign language ability. Also, some Asian surnames are identical to Western names, for example, Lee, Young, Alvarez, and Martinez; thus, some clinicians may have been mistaken for European or Hispanic and not included as Asian. Given this caveat, it should be mentioned that the author did experience significant difficulty in finding potential contributors to this book for many of the ethnic subgroups, particularly the ones with few numbers as reported by this methodology, thereby lending credence to these results.

The relatively small numbers of Asian neuropsychologists, particularly for many of the specific ethnicities, such as Filipino and Vietnamese, are alarming for Asian clients seeking neuropsychological services, as it is assumed that a neuropsychologist who shares the same ethnic background and speaks the same language as the client would be more likely to produce a culturally informed evaluation due to familiarity with the culture, ability to develop rapport, and better communication. It should also be emphasized that just because a neuropsychologist is of a related Asian heritage as a client (e.g., Chinese clinician, Hmong client), this does not guarantee culturally informed services, as there is much diversity within specific Asian ethnicities, and an Asian clinician may be just as naïve about a specific culture than a non-Asian one. In any case, an implication of the shortage of Asian neuropsychologists is that non-Asian neuropsychologists will have ample opportunity to provide services to Asian clients.

In summary, Asians are the fastest-growing ethnic minority in the United States. Asians are diverse with the U.S. Census, listing 24 distinct ethnicities in the Asian category. There are few Asian neuropsychologists who can provide services to this population, particularly in ethnic subgroups such as Filipinos, Vietnamese, Cambodian, Laotians, Hmong, and Thai. Thus, many Asian clients in need of neuropsychological services would likely have to seek services from a non-Asian clinician or Asian clinician who may not be entirely familiar with the client’s culture. Asian clients can pose special challenges to neuropsychologists due to issues of ethnic diversity, language barriers, acculturation, and differences in values and communication style. Given the number of pertinent issues that require attention for a clinician to perform a culturally informed evaluation, a neuropsychologist, particularly non-Asian, may be reluctant to work with an Asian client.

Purpose of this book

The purpose of this book is twofold. The first purpose, associated with the section on neuropsychology of Asian Americans, is to provide clinical neuropsychologists with a knowledge base of the demographic, cultural, and neuropsychological literatures, and practical recommendations for working with the major Asian ethnic groups to facilitate culturally informed neuropsychological evaluations. The overall goal is to increase the resource pool of neuropsychologists who are competent in delivering services to Asian Americans.

A second, but related purpose, associated with the second part of this book, is to educate researchers and clinicians on neuropsychological practices and scientific literature in several Asian countries. For clinicians, these chapters may identify neuropsychological resources that would be useful for evaluating or treating a person from that Asian country. This information could also assist clinicians performing court evaluations in meeting Daubert level standards of evidence by incorporating tests used by clinicians, or citing rationales for test selection based upon neuropsychological practices in an Asian person’s native country. Another area of interest for clinicians would be learning about professional issues such as educational and training procedures and requirements, licensure, and professional organizations in different Asian countries.

For researchers, a peek into the neuropsychological literature can hopefully lead to a cross-fertilization of research ideas, or cross-cultural validation or refutation of neuropsychological findings or assumptions based upon Western research. This exposure to new ideas can hopefully inspire new directions for research or developing new technologies.

The remainder of the chapter will describe a framework for clinicians on how to use the information in this book to perform culturally informed neuropsychological evaluations with Asians.

How to use information from the book

Each Asian American chapter is organized similarly, covering topics such as immigration history, reason for immigration, educational system in home country, educational achievement and occupational attainment in America, cultural values, family structure, attitudes toward illness, neuropsychological testing, recommendations for testing, and an illustrative case sample. Information from these chapters should be used in the following manner:

1. Provide a knowledge base for understanding and developing rapport with persons from a specific Asian ethnic group
2. Assist in determining testing strategy or test selection
3. Assist in test interpretation
4. Assist in making recommendations

Due to lack of norms and shared clinical issues for several Asian American ethnicities (Cambodian, Hmong, Laotian), recommendations for these groups are very similar. Although repetitive, the same recommendations are repeated in these chapters for easy reference.

Provide a knowledge base

Before selecting a test strategy, clinicians require a knowledge base for understanding a person with a different cultural background. In many ways, this lack of understanding would be like trying to watch a 3D movie without the special glasses. Perceptions are blurry and it is difficult to appreciate the movie. However, once the glasses are worn, it is amazing how crystal clear the images become. Knowledge from each chapter can assist the clinicians in the following ways:

1. Provide a conceptual framework for understanding a person who was born and raised in another country. Some important factors include primary reasons for immigration, immigration patterns, acculturation, values, belief system, and general experiences in the country of origin and America that may shape values and behaviors.
2. Provide a context for evaluation. For example, many Asians do not typically see psychologists or mental health professionals unless a condition is serious due to shame, stigma, or attribution to karma, the latter because the person cannot do anything about his fate, which is deserved.
3. Help to understand the dynamics of the clinician-client relationship as perceived by the Asian client. For example, an Asian client may perceive the psychologist as an authority figure who is all-knowing or someone who is respected and with whom you should not disagree.
4. Help provide a strategy for interviewing the client and developing rapport. Many Asians may have trust issues and can be passive in providing information. Thus, encouraging clients to talk about their country, experience with immigration, or their name, or allowing family to participate in the interview process may be useful.
5. Provide guidance for working with interpreters. With a general knowledge base, clinicians can better inform interpreters of goals, clarify uncertainties, and map out strategies for i...

Table of contents

• Cover Page
• Title Page
• Copyright Page
• Series Preface
• Acknowledgments
• Contributors
• 1. Introduction
• 2. Neuropsychology of Cambodian Americans
• 3. Neuropsychology of Chinese Americans
• 4. Neuropsychological Assessments and Filipino Americans: Cultural Implications for Practice
• 5. Neuropsychology of Hmong Americans
• 6. Neuropsychology of Asian Indians
• 7. Neuropsychology of Japanese Americans
• 8. Neuropsychological Assessment of Korean Americans
• 9. Neuropsychology of Laotian Americans
• 10. Neuropsychology of Thai Americans
• 11. Neuropsychology of Vietnamese Americans
• 12. Neuropsychology In China
• 13. Neuropsychology In India
• 14. Neuropsychology In Japan
• 15. Neuropsychology In Korea
• 16. Neuropsychology In Malaysia
• 17. Neuropsychology In the Philippines
• 18. Neuropsychology In Singapore
• 19. Neuropsychology In Thailand