Assessment in Neuropsychology (Critical Readers in Theory and Practice)
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Multiple cultural, institutional, and financial barriers may impede neuropsychological service utilization among ethnic minorities. The only comprehensive research of which we are aware that has examined US neuropsychologists' current practice with ethnic minorities was conducted by Echemendia, Harris, Congett, Diaz, and Puente Overall, the authors of the survey concluded that US neuropsychologists are not adequately prepared to provide services to Latinos, nor do they have the appropriate tools to do so Echemendia et al.
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No other studies have examined similar practice issues with other ethnic minority populations to our knowledge. In sum, neuropsychologists are faced with several disparities. Current health disparities and continued growth of ethnic minority populations suggest that neuropsychologists will be increasingly called to provide services to ethnically diverse clients.
Current diagnostic disparities due to a lack of appropriate training and instrumentation put ethnic minority clients at risk of not receiving appropriate diagnoses and the standard of care. Given these disparities, some of the most pressing challenges currently facing neuropsychologists in practice are discussed below.
Clinicians often lack in-depth training in assessment of ethnic minorities. The fact that the referenced chapter was written more than 9 years ago is a striking observation about the lack of progress in multicultural training within our field.
However, little detail was provided in the proceedings about the level of multicultural knowledge and skills required to function as a clinical neuropsychologist, or how this was to be achieved. However, it is unclear that neuropsychology training programs have taken the initiative to formally integrate multicultural issues to foster cultural competence into their curricula, didactics, or training. Ethnic minorities are sorely under-represented as professionals within the field of neuropsychology. Unfortunately, this gap in representation has widened since then. While membership in professional organizations is not a precise marker of ethnic minority presence in the field, it is consistent with anecdotal evidence and serves as an indicator of the status of the profession.
The lack of concerted, national leadership to cultivate ethnic minority neuropsychologists at early stages of professional development is a major barrier for the diversification of neuropsychology. As compared to other psychology specialty programs, such as counseling and school psychology, ethnic minorities are disproportionately underrepresented within neuropsychology training programs Rivera Mindt, Previous efforts have largely failed as they have been too few and too circumscribed.
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Few minority students are applying to graduate programs that offer specific training in neuropsychology. Even in clinical psychology graduate programs where the overall proportion of ethnic minority applicants is relatively high, fewer minorities apply to the neuropsychology track within those programs. Equally challenging, many programs do not have access to ethnically or linguistically diverse populations who can participate in research or provide trainees with clinical experience with ethnic minorities.
Domain D Guidelines and principles for accreditation of programs in professional psychology; APA, , p. Increasing ethnic minority faculty in neuropsychology training programs, and avoiding the common trend of ethnic minority faculty being more likely to occupy adjunct or instruction-only positions would be one way for neuropsychology programs to encourage diversification within the student body. The focused goals for this issue are to advocate for and demonstrate practical ways in which the field of clinical neuropsychology and individual practitioners can increase multicultural awareness and knowledge, increase multicultural education and training, increase multicultural research, and increase the provision of culturally competent neuropsychological services to ethnic minorities.
We will review some of the obstacles to obtaining these goals and suggest ways to overcome the barriers. Ethnic minorities are significantly under-represented in clinical research National Institute of Mental Health, , including neuropsychology. It is unclear if many of the neurocognitive models utilized in neuropsychology are valid in ethnic minority populations. While this work improves diagnostic accuracy and specificity for particular ethnic minority groups, there are also limits to this work.
This is problematic as US Latino subgroups tend to exhibit nonrandom, preferential geographical affinity i. As we discussed previously, the only comprehensive research of which we are aware that has specifically examined neuropsychological practice as it pertains to ethic minorities is Echemendia et al.
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While Echemendia and Harris ; Echemendia et al. Little exists in the way of formalized guidelines for neuropsychological practice with ethnically diverse clients. Determination of language proficiency is a complex issue in bilinguals as some bilinguals may be more proficient in their native language, as opposed to their second language, or vice versa. Balanced bilinguals i. The paucity of bilingual neuropsychologists and psychometrists has led many well-intentioned clinical neuropsychologists of varying levels of fluency to administer neuropsychological evaluations in languages other than English.circjewasoni.cf
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Echemendia et al. Eighty percent of these reported that the translators had no formal psychological or neuropsychological training. Further exacerbating this problem is the use of existing neuropsychological instruments in non-standardized applications. Examples include the reliance on nonverbal neuropsychological instruments and literal translations of English instruments for use with examinees with limited English proficiency.
Although it is often mistakenly assumed otherwise, multicultural assessment practices do not advocate deviations from standard procedures with ethnic minorities, and such use of tests is not empirically supported Cuellar, The potential for effective advocacy within neuropsychology comes from variations of our current practice and knowledge skill set. Small, yet consistent, changes in the way we conduct neuropsychological training, research, and practice will produce a significant shift in the provision of services to ethnic minority communities.
We propose the following specific recommendations as a call to action for all neuropsychologists to increase the provision of culturally competent neuropsychological services. These recommendations are based on our review of the literature and the field, as well as APA's Multicultural Guidelines The recommended actions are necessary, though not sufficient, first steps towards transforming the field of neuropsychology into one that is ready and able to effectively work with ethnically diverse populations.
Instead, past evidence suggests that neuropsychologists' efforts to change their attitudes and biases will go far to thwart such attitudes from negatively impacting their relationships with clients, students, and research participants APA, As neuropsychologists strive to become culturally competent, we must understand the sociocultural context that our clients, students, and research participants come from. Experiences with prejudice, racism, and the realities of being a member of a stigmatized group can all have a substantive impact on both utilization of neuropsychological services and actual test performance e.
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By incorporating knowledge of other cultures and minority identity development, as well as specific sociocultural information from those we work with, neuropsychologists will improve the standard of care and elevate the standard of practice for all clients APA, In this section we provide three overarching recommendations aimed at increasing cultural competence of neuropsychologists and neuropsychology organizations, developing and implementing standards for multicultural neuropsychology, and mending the broken pipeline in neuropsychology. All of these recommendations are grounded in the following principle:.
Despite the pioneering work of Vygotsky, Luria, and others, the field of neuropsychology has been historically reticent to move away from a purely biologically deterministic perspective towards one that also incorporates cultural, historical, and sociopolitical factors APA, Consequently, neuropsychological education and training curricula reflect this reticence if not outright rejection , and as a result fail to achieve the standards set forth in APA Multicultural Guideline 3 Rivera Mindt, The cost of this reticence is manifest in our utter lack of preparation and competency for providing appropriate services to a full one-third of our US population.
Such collateral damage is simply unacceptable. Below we provide our recommendations for moving the field forward through education and training. Doctoral, internship, postdoctoral fellowship and continuing education programs are primary targets for the development of cultural competence in neuropsychology.
Each level of the neuropsychologist's training should be completed with a standard for mastery of cultural considerations in the administration and interpretation of neuropsychological measures based on the growing empirical literature. Additional mechanisms to ensure competency include: proficiency exam questions specific to culture and neuropsychology, and provision of clinical opportunities in diverse settings. For a more detailed discussion of efforts to enhance multicultural neuropsychology training, see Fastenau, Evans, Johnson, and Bond Ways to implement EBP are discussed in another article in this issue Chelune, Readers are encouraged to apply the principles of EBP to work with ethnically diverse populations.
It is important to note that efforts to increase cultural competence through multicultural and diversity training result in increasing students' self-awareness and therapeutic competence APA, , which Echemendia et al. Moreover, culture-centered education and training has been shown to provide benefits at the individual i. However, comprehensive multicultural training standards in neuropsychology are sorely lacking.
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The Houston Guidelines are among the most influential training guidelines in the field, outlining training standards and minimum competencies. Since the Houston Guidelines are to be updated in the near future, this is an ideal opportunity to expand the guiding principles for neuropsychology training programs with respect to training in multicultural neuropsychology.
We recommend that the future delegates take up this topic with full comprehension of how current research, practice, and ethical multicultural concerns can be integrated into neuropsychological training at graduate and postdoctoral levels. Close attention must also be paid to developing cohesive multicultural training curricula for neuropsychologists already in the profession.
Instead of ad hoc culture-related presentations, symposia, or workshops, organizations are encouraged to put together specific task forces charged with working with program committee members to provide coherent and useful cultural competency training for its membership. Individuals who have had success with specific aspects of training in multicultural neuropsychology, and those that may be able to provide specific examples and templates that will help programs implement these standards, would be ideal candidates for this task force.
The ultimate goal for this task force would be to help neuropsychology training programs live up to the commitment of Domain D of the Guidelines and principles for accreditation of programs in professional psychology APA, The following recommendations are geared towards increasing empirical and practice research to develop evidence-based practice and better target-improved service utilization by ethnic minorities.
Our second recommendation is to increase research dedicated to examining the psychometric integrity of neuropsychological measures in ethnic minority cohorts. In spite of the overwhelming evidence of the impact of culture on neuropsychological test performance, the discipline has lagged in the demonstration of sound psychometric properties of neuropsychological instruments. We cannot assume that neuropsychological instruments test the same or different constructs in different cultural groups or that these measures are equally reliable, sensitive, or specific.
Rigorous empirical investigation into the reliability, as well as construct and diagnostic validity of neuropsychological instruments across different ethnic and linguistic groups is paramount to moving the field forward. Editors of major neuropsychological journals can consider invited issues in which such research is welcomed and encouraged. Consideration of base rates of conditions and symptoms, e.
The use of base rates is especially relevant in practice with ethnic minority populations given the demonstrated health disparities that impact the relative prevalence of neurocognitive conditions in these groups. Not only can base rate information assist in diagnostic accuracy, it can lessen the chance of obtaining false-positive errors. The more accurate base rate estimates are for ethnic minorities, the less likely the chance of erroneous findings.
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Our third recommendation aimed at fostering evidence-based practice is the development of norms for those groups for whom high-quality comprehensive norms do not yet exist, including English-speaking Latinos, bilinguals, Asian Americans, Native Hawaiians and Pacific Islanders, and American Indians and Alaska Natives. Such norms must include information on the geographic region from which the sample is drawn and sociocultural characterization acculturation, quality of education, country of origin, etc. While improved norms are important, we clearly recognize and have discussed the limitations of ethnic-specific norms.
Our fourth and final recommendation is for an increase in research to better understand the effects of education, language, and other sociocultural factors on neuropsychological test performance. This issue is critical for informing evidence-based practice. The field must move away from handling such variables as either invisible or as posthoc issues to be controlled for—this impedes our progress as a field.