Cross-Cultural Neuropsychological Assessment Workshop

I. Introductions and backgrounds, nature of students' practices and interest in the topic.

II. Basic considerations.

1. What is culture?

According to Wikipedia (http://en.wikipedia.org/wiki/Culture), ""Culture (from the Latin cultura stemming from colere, meaning "to cultivate"), generally refers to patterns of human activity and the symbolic structures that give such activity significance... A common way of understanding culture sees it as consisting of four elements that are "passed on from generation to generation by learning alone": values; norms; institutions; artifacts.""

In psychology, we are usually more interested in values and norms than material parts of culture. What makes cross-cultural communication and interaction difficult is, of course, the fact that values and norms comprising a large part of one's cultural background are one's basic assumptions about the meaning of oneself, the world, and one's interactions with it. As such, they are usually unexamined and are, in fact, very difficult to understand, because they are the basic framework underlying our understanding. Unless we come in direct and explicit contact with a different set of assumptions, we tend to remain unaware of the majority of our own.

Hills, M. D. (2002) provided a detailed review of research on cultural values in psychology at http://www.wwu.edu/~culture To summarize: "cultural norms can take a variety of forms. Attitudes have long been studied by psychologists - especially social psychologists. However, as we became more psychometrically sophisticated, and able to measure attitudes accurately, we learned that attitudes are much more complex than we had realized. Social psychologists therefore started looking for more fundamental, slower changing concept, which might give more reliable behavioral prediction. One such concept is the values which a person holds. Values are seen as being relatively few in number. Perhaps the best-known student of values is Rokeach (1979), who suggests that there are at most 36 values held by human beings. Moreover they are considered to be widely, and perhaps universally held. On the other hand, Hofstede (1980, 2001), in a huge world-wide study, has been able to find no more than five which are universally held.

One theory of basic human values, which has been very influential is that of Kluckhohn and Strodtbeck (1961). Florence Kluckhohn and Fred Strodtbeck developed a theory, which put these principles into action. They started with three basic assumptions: (1) "There is a limited number of common human problems for which all peoples must at all times find some solution"; (2) "While there is variability in solutions of all the problems, it is neither limitless nor random but is definitely variable within a range of possible solutions"; (3) "All alternatives of all solutions are present in all societies at all times but are differentially preferred". They suggested that the solutions for these problems preferred by a given society reflects that society's values. Consequently, measurement of the preferred solutions would indicate the values espoused by that society. They suggested five basic types of problem to be solved by every society. They then spelled out the possible answers to each of the questions, arguing that the preferred answer in any society reflects the basic orientation of the society to that aspect of its environment.

Since then other theorists have also developed theories of universal values - notably Rokeach (1979), Hofstede (1980, 2001) and Schwartz (1992). However the theory developed by Kluckhohn Strodtbeck remains widely used and has sparked a good deal of research."

If we think of culture in those terms, we realize that culture is extremely difficult to delineate. Once we start examining norms and values, we find that they differ quite dramatically not only between different countries and religions, but also between numerous subcultures within one country and, to some degree, even between different families. Usually, we take basic cultural concordance for granted and know what kinds of differences to look out for if we are talking to people from similar backgrounds or cultures or subcultures we are intimately familiar with. Thus, all health professionals conduct cross-cultural assessment of one form or another every day as a regular part of their practice and their definition of cross-cultural largely depends on their familiarity and comfort with their client base, as well as their degree of self-awareness. These are the good news - we can use skills we already developed, and the bad news - we usually tend to assume too much.

2. What does "cross-cultural" mean in the context of your case?

The next logical question is, then, what does "cross-cultural" mean in the context of your case? The specific answer to this question will determine the type of assessment one can conduct, the type of consultation one needs, and the information one can gain from such consultation.

It is impossible to list all relevant factors. However, there are some that may serve as a shorthand description of client's cultural background. The major factors to consider include:

A. Country or area of origin;

B. In many cases religious background;

C. Linguistic background;

D. Subcultural groupings, including class issues, racial ethnic and tribal differences, etc;

E. Environmental differences such as wealth, educational background, rural or urban upbringing, etc.;

F. If you are working with an immigrant, generation of immigration and degree of acculturation.

NOTE: In many countries class, religion and ethnicity are understood differently. For example, class is associated with money in the United States and familial background in England; Jewish, Catholic or Protestant is a religion here and an ethnicity in Russia and Ireland, respectively.

III. Non-technical issues affecting cross-cultural assessment.

1. Cultural perception and description of mental and physical health ("headache", "stone in my stomach", "nervous breakdown", etc.. For instance, through interviews of 100 Chinese patients suffering from shenjing shuairuo (neurasthenia), Klienman (1986) concluded that 93 of them indeed might be suffering from depression. However, instead of spontaneously reporting dysphoria, ideas of insufficiency and the other core symptoms of depression, these "depressed" (or shenjing shuairuo ) patients spontaneously reported headaches (90%), sleep problems (87%), and dizziness (73%). On the other hand, over the past quarter of a century, the WHO has undertaken several major studies on the expression, course, and prognosis of schizophrenia in 17 different countries, including Colombia, the former Czechoslovakia, Denmark, England, India, Nigeria and the former Soviet Union, Thailand, and the United States. Using standardized instruments, researchers have identified a set of symptoms that were present across all cultures in the schizophrenic samples. These symptoms include lack of insight, auditory and verbal hallucinations, and ideas of reference.

2. Cultural perception of medical profession and one's expectations of interactions with them (e.g. degree of professional's authority vs. patient's choice and informed consent issues)

3. Culturally-specific manifestations of illnesses

4. Religious perceptions and proscriptions with regards to symptoms and treatments

5. Cultural framework for adaptation and treatment

6. The effect of structure and adaptational requirements of the culture of origin on adaptation

7. Stigma associated with various illnesses

8. Effects of linguistic differences on communication and understanding

9. Secondary gain issues

10. Subgroup issues in terms of pre-emigration trauma experiences. Relevant factors:

(A large body of research indicates significantly higher prevalence of depressive, anxiety, and post-traumatic symptoms in refugees. The prevalence, of course, depends on the extent and nature of traumatic events affecting the refugees. PTSD in refugees has been studied most actively. A good review article by Trang Thomas and Winnie Lau can be found at: http://www.humanrights.gov.au/human_rights/children_detention/psy_review.html To summarize: "The research in the psychological well-being of children and adolescent refugee and asylum seekers has identified key areas of consistency. This research clearly demonstrates that refugee children and adolescents are vulnerable to the effects of pre-migration, most notably exposure to trauma. It is also apparent that particular groups in this population constitute higher psychological risk than others, namely those with extended trauma experience, unaccompanied or separated children and adolescents and those still in the process of seeking asylum. Finally, it is apparent that certain risk and protective factors exist to temper or aggravate poor psychological health. Such factors include family cohesion, family support and parental psychological health; individual dispositional factors such as adaptability, temperament and positive esteem; and environmental factors such as peer and community support.

For an extreme example, in a study with 209 Cambodians aged between 13-25 resettled in the United States, Sack and colleagues (1994) found an 18% prevalence rate of PTSD and an 11% rate of depressive disorder in their participants. High rates of psychiatric disorder were also observed in participants' parents, with 53% of mothers reporting symptoms consistent with a PTSD diagnosis, and 23% with a diagnosis of depression. Amongst fathers of this sample, 29% indicated PTSD symptomology and 14% indicated depression.

Sinnerbrink and colleagues (1997) also examined the relationship between exposure to violence and mental health outcome in Khmer adolescents in the USA. A quarter of these subjects partially or fully met criteria for PTSD with the number of violent events experienced predicting PTSD and level of functioning. Not only was pre-migration exposure predictive of PTSD, the number of violent events exposed to across subjects' lifetime (i.e., time in Cambodia and US) also and more strongly predicted PTSD and level of functioning. This finding is noteworthy as it demonstrates the cumulative effect of trauma and its predisposing features to future distress and function (Sinnerbrink et al., 1997

Parental psychological well-being is a key factor in the mental health of child/adolescent refugee and asylum seekers (Papageorgiou et al., 2000; Sack et al., 1994). Research directed at parental and familial influences has demonstrated that disorders associated with child and adolescent refugee experiences cluster in families. Simultaneous presence of more than one disorder associated with PTSD is a common finding in the literature concerning the mental health of refugee children and adolescents. For example, Hubbard, and colleagues (1995) found that the existence of more than one disorder in their sample of 59 Cambodian adolescents and young adults exposed to trauma as children. Of the 24% of adolescents and young adults that were diagnosed with PTSD, 57% of these had at least one additional diagnosis, all being affective and anxiety related.")

A. Discrimination;

B. Persecution;

C. Physical/sexual violence;

D. Poverty;

E. Lack of or specifics of medical care;

F. Separation from family;

G. Lack of community support;

H. Toxic exposure.

11. Immigration as traumatic experience (caveat - not necessarily, most immigrants are mentally healthy and many better off than they were before; the same applies to refugees, even from the most horrible situations - human psyche is amazingly resilient and, if you look at statistics, you will see that the majority of people surviving wars, interment, torture and starvation remain clinically healthy). Relevant factors:

(A British survey of refugee mental health issues A SHATTERED WORLD: THE MENTAL HEALTH NEEDS OF REFUGEES AND NEWLY ARRIVED COMMUNITIES by the MIGRANT & REFUGEE COMMUNITIES FORUM & CVS CONSULTANTS can be found at: http://www.harpweb.org.uk/downloads/pdf/rep1(ref).pdf

They found that most common mental health issues in British refugees include: (1) Marital problems; (2) Trauma responses; (3) Depression; (4) Bereavement; (5) Suicides; (6) Psychosomatic problems; (7) Memory problems (diagnostic difficulty here - organic vs. functional); (8) Anger; and (9) Substance abuse.

A. Circumstances (planned vs. escape, transition camps, boat crossings);

B. Environmental issues (education, money, previous knowledge of the language improving one's chances);

C. The degree of cultural, racial and religious differences with the host population;

D. Expectations;

E. Familial issues;

F. Age at immigration;

G. Generational issues;

H. Degree of acculturation and self- image;

I. Language and accent;

J. The basic sense of insecurity and impermanence;

K. Poverty, exploitation, housing and health problems.

IV. Technical issues in cross-cultural assessment.

Before talking about technical issues in assessment, we need to discuss what it is we are actually attempting to assess.

WHAT IS INTELLIGENCE?

The technical difficulties in cross-cultural assessment can be beautifully illustrated by the perennial debate about the meaning of intelligence. Leaving political issues aside, we have a very fundamental problem on our hands. As professionals, we know that estimating intelligence is of great practical importance in our work: it tells us what level of care or resources are needed for the person to function in social work, which interventions are likely to work in psychotherapy, how to explain relevant issues to obtain informed consent in medicine, whether there is an active dementing process present or the person functions at their baseline in neurology, whether the person has a learning disability in education, etc..

However, if you look at the literature on intelligence, you quickly begin to realize that, while we all have a vaguely similar idea of what the word means, we have no decent operational definition of the concept or way of measuring it. Existing tests of intelligence measure certain cognitive processes, but there is no agreement in the field as to what combination of these processes constitutes intelligence. Standard tests, such as WAIS-III, are supposed to measure "g" - a general intelligence factor presumed to underlie one's ability to think. It turns out, it only measures it in the context specific to one's educational background (i.e. it measures one's ability to benefit from standard education) - which only works for as long as the person we are testing received that education and will function within that society.

It turns out that even processes Western cultures tend to think of as basic, such as abstract categorization, are a product of the cultural and educational environment. One of the most stunning examples of cultural and educational mediation of categorization, abstraction. generalization and reasoning styles was provided by Luria's "Uzbek study". For example, when presented with a picture of a hammer, a saw, a log and an axe and asked which of these does not belong, Uzbek people with no education tended to inflexibly group them by experience of a practical situation, such as building a hut (i.e. they all belong together and abstract categorization was seen as irrelevant even when suggested) and people with more education tended to use both concrete (situational) and abstract (e.g. "tools") classifications, flexibly depending on the demands of the situation. Bad news for cross-cultural assessment, since it means that the commonly used measures of intelligence have to be developed and normed within the educational context of a given culture or subculture.

An additional problem with intelligence testing is that our ability to solve problems turns out to be heavily context-dependent. A number of studies, such as that of Brazilian street children running successful street businesses but unable to do simple math (Carraher, Carraher, and Schliemann (1985)), or Berkeley housewives, able to do complex math for comparison shopping, but unable to solve isomorphic problems in a "classroom" form (Lave (1988)) showed it quite convincingly.

Fortunately, these are caveats to be kept in mind rather than insurmountable obstacles. In a moment, we will talk about ways of taking these caveats into account.

Accumulating body of research indicates that there does appear to exist a relatively cross-culturally stable concept of intelligence. Sternberg (1997) proposed an interesting theory of successful intelligence defined in terms of one's adaptive ability. This theory of successful intelligence has 4 key elements:

1. Intelligence is defined in terms of the ability to achieve success in life in terms of one's personal standards, within one's sociocultural context.

2. One's ability to achieve success depends on one's capitalizing on one's strengths and correcting or compensating for one's weaknesses.

3. Success is attained through a balance of analytical, creative, and practical abilities (cross-cultural factor analyses seem to support this structure).

Operational definitions of components of intelligence in Sternberg, Grigorenko, Ferrari, Clinkenbeard, 1999 are presented since it helps to compare tests one administers to those used to operationalize the theory:

1. Analytical-Verbal: Figuring out meanings of neologisms (artificial words) from natural contexts. Students see a novel word embedded in a paragraph, and have to infer its meaning from the context.

2. Analytical-Quantitative: Number series. Students have to say what number should come next in a series of numbers.

3. Analytical-Figural: Matrices. Students see a figural matrix with the lower right entry missing. They have to say which of the options fits into the missing space.

4. Practical-Verbal: Everyday reasoning. Students are presented with a set of everyday problems in the life of an adolescent and have to select the option that best solves each problem.

5. Practical-Quantitative: Everyday math. Students are presented with scenarios requiring the use of math in everyday life (e.g., buying tickets for a ballgame), and have to solve math problems based on the scenarios.

6. Practical-Figural: Route planning. Students are presented with a map of an area (e.g., an entertainment park) and have to answer questions about navigating effectively through the area depicted by the map.

7. Creative-Verbal: Novel analogies. Students are presented with verbal analogies preceded by counterfactual premises (e.g., money falls off trees). They have to solve the analogies as though the counterfactual premises were true.

8. Creative-Quantitative: Novel number operations. Students are presented with rules for novel number operations, for example, "flix," which involves numerical manipulations that differ as a function of whether the first of two operands is greater than, equal to, or less than the second. Participants have to use the novel number operations to solve presented math problems.

9. Creative-Figural: In each item, participants are first presented with a figural series that involves one or more transformations; they then have to apply the rule of the series to a new figure with a different appearance, and complete the new series.

The analytical essay required students to comment on the use of security guards in schools; the creative essay required students to design an ideal school; and the practical essay required students to state a problem they are facing in their life and to describe three practical solutions to it.

4. Balancing of abilities is achieved in order to adapt to, shape, and select environments.

More details regarding the theory can be found in Sternberg (1985, 1997, 1999). An online summary can be found at http://www.ac.wwu.edu/%7Eculture/Sternberg.html A concrete example of the application of more fundamental parameters of Sternberg's theory to neuropsychological assessment can be seen in Nell (2000).

WHAT IS PERSONALITY?

Disputes about which structure was best continued for decades, but toward the end of the last century it became clear to most personality psychologists that most traits could be described in terms of five factors or dimensions. The organization of many specific traits in terms of the five factors of Neuroticism (N), Extraversion (E), Openness to Experience (O), Agreeableness (A), and Conscientiousness (C) is known as the Five-Factor Model (FFM; McCrae and John, 1992). Individuals who are high in Neuroticism are likely to be anxious, easily depressed, and irritable, whereas those who are low in Neuroticism are calm, even-tempered, and emotionally stable. Extraverts are lively, cheerful, and sociable; introverts are sober and taciturn. Open men and women are curious, original, and artistic; closed people are conventional and down-to-earth. Agreeableness is characterized by trust, compassion, and modesty; Conscientiousness is seen in organization, punctuality, and purposefulness.

Originally, the five factor model was discovered through analyses of English-language trait names. A wide variety of measures of the five factor model have now been developed, of which the most widely used is the Revised NEO Personality Inventory (NEO-PI-R; Costa and McCrae, 1992). The NEO-PI-R assesses 30 specific traits, six for each of the five factors, and has been shown to be a reliable and valid measure for the assessment of normal personality traits.

The five factor model was discovered by American researchers in American samples using instruments based on English-language trait terms, but there has been considerable research on its cross-cultural applicability. Lexical studies, which examine personality factors in trait adjectives from different languages, have had somewhat mixed results. Extraversion, Agreeableness, and Conscientiousness factors almost always appear, but Neuroticism and Openness to experience sometimes do not (Saucier and Goldberg, 2001). More definitive results come from studies of the NEO-PI-R. That instrument has been translated into more than 40 languages or dialects, and studies of its factor structure have been conducted in more than 30 cultures (McCrae and Allik, 2002). In every case studied so far, a reasonable approximation to the intended structure has been found when adequate samples and appropriate statistical methods have been used.

Another source of information about relative universality of certain personality traits comes from biological psychology. This summary comes from the Wikipedia, references to specific studies can be found at: http://en.wikipedia.org/wiki/Extraversion#_note-1: For example, the relative importance of nature versus environment in determining the level of extraversion is controversial and the focus of many studies. Twin studies find a genetic component of .39 to .58. In terms of the environmental component, the shared family environment appears to be far less important than individual environmental factors (not shared by siblings). Eysenck proposed that extroversion was caused by variability in arousal; "introverts are characterized by higher levels of activity than extroverts and so are chronically more cortically aroused than extroverts". Because extroverts are less aroused internally, they require more external stimulation than introverts. This theory may be backed up by evidence that the brains of extroverts are more responsive to dopamine than those of introverts. Other evidence of this "stimulation" hypothesis is that introverts salivate more than extraverts in response to a drop of lemon juice. One study found that introverts have more blood flow in the frontal lobes of their brain and the anterior or frontal thalamus, which are areas dealing with internal processing, such as planning and problem solving. Extraverts have more blood flow in the anterior cingulate gyrus, temporal and posterior thalamus, which are involved in sensory and emotional experience. This study and other research indicates that introversion-extroversion is related to individual differences in brain function.

1) Validity of the assessment techniques in general:

A. Interview - validity would depend on your familiarity with the culture in question and can be increased by using an informant (beware of you do not know what you do not know phenomenon);

B. Pathognomonic signs-based assessment tends to be largely valid, with validity decreasing with the increase in function complexity (e.g. frontal release signs - good cross-cultural validity, span of apprehension - not as good);

C. Process approach and ipsative comparisons are difficult to execute, but often the only option;

D. Norm-based, actuarial approach is largely invalid unless there is normative database for your client's group or research indicating that current norms apply.

2) Specifics of techniques would depend on the purpose of the assessment and specifics of your case.

A. Purpose of assessment - for example, if you are testing someone who immigrated as an adult to determine placement and need for accommodations in college, achievement testing is appropriate, even though normative database is not - you would use grade, rather than age scores (WAIS-III Vocabulary, Comprehension and Information subtests would be valid to determine one's cultural and linguistic knowledge base, but still not valid for determining one's intellectual potential);

B. In general, educational environment is most relevant for the validity of intelligence and educational testing (someone who immigrated at the age of 2 to be and went to school here, even if they are bilingual, can be tested reasonably safely with WAIS), [however, very little or no education would affect all tests and even standardized interview techniques, since a person not exposed to formal education may not understand the techniques of test-taking, such as concentrating on the task (rather than chatting to examiner), working fast, ruling out incorrect answers, coming up with the correct (rather than nice or melodious, for example) answer, etc., even if these things are explicitly stated, they are unlikely to be semiautomatic, as in people with more educational exposure, and less educated people will spend a considerable time during testing learning how to test, rather than responding to actual test items, making interpretation of test scores quite difficult];

C. Cultural background, on the other hand, is much more relevant for personality and emotional functioning testing. Empirically developed measures, such as MMPI and Rorschach, cannot be used with populations they have not been validated on since you do not know how they work. Face-valid, symptom-based measures, on the other hand, can be used if you are reasonably familiar with the culture (BAI, BDI, SCL-90, etc.). Vegetative and physical symptoms, since they are less culture-dependent, tend to be more reliable.

3) If you work with a specific population, you can sometimes find appropriate instruments, but beware of culture vs. language distinction and people "translating" norms. (e.g. Russian battery from Moscow and Leningrad Universities, University of Hong Kong - beware of using with patients from mainland China, lots of Spanish measures - have to know exactly if and were they were normed). The Handbook of Normative Data for Neuropsychological Assessment [by M. Mitrushina, K. B. Boone, J. Razani and L. F. D'Elia, Oxford University Press, 2005] contains a number of culture and language-specific normative data sets.

4) If no appropriate measures exist, we have to do our best, and then it is a question of adaptation of testing techniques. The basic idea is to understand, as much as possible, why the client did what they did on the test and whether it is a reflection of underlying pathology or an artifact of cultural differences (see Appendix 2 for a list of commonly used instruments).

5) Some general principles of adaptation of neuropsychological measures include:

A. Make sure the task is understood. Explain, demonstrate, teach, and have a sample item for each task (Nell [2000] recommends teaching followed by practice and speeded practice trials for all tasks for "non-test-wise" subjects);

B. Have several similar tasks that are slightly different in terms of contributing processes and test your hypotheses as to which underlying process is impaired by analyzing the pattern of performance;

C. Always test limits;

D. Look for extremes of performance;

E. Example - adaptation of WAIS-III and WAISR-NI (Appendix 3).

6) In terms of personality and emotional functioning, detailed interview and mental status exam are invaluable (see Appendix 1). Projective measures, such as TAT and Projective Drawings, can also be used for the members of your own culture, since their interpretation is largely subjective anyway.

7) Working with an interpreter:

A. If you can - don't. You never know what you are missing.

B. Try to avoid using family members because of family dynamics, concealment or exaggeration of pathology, embarrassments, cultural stigma, etc.;

C. Random bilingual speakers have the same problems of embarrassment and cultural stigma plus the issue of confidentiality (they don't have to keep it and clients know it and may clam up);

D. Interpreter's job is making sense of what people try to convey. You want them to translate errors, word salad, etc. - to do exactly the opposite of what the essence of their job is. This is difficult and requires specialized training and experience. Use a certified mental health interpreter whenever possible;

E. Things to look out for (from Dr. Evelyn Lee):

(1) Omissions (You ask the client how they feel, they speak for half an hour and the interpreter says: "She has a headache" - she probably explained why and how and who caused it.);

(2) Bad paraphrasing (Client: "My left leg hurts, so I have to rely on the right one, and it starts hurting after a while as well", interpreter: "Both his legs hurt" - accurate, but less helpful.);

(3) Lack of translatable concept (e.g. Trying WAIS proverbs through the interpreter);

(4) Inaccurate translation of concepts or words (Clinician: "Do you hear voices?"; interpreter: "Do you hear noises ["voice" and "noise" are the same word in Chinese]?"; client: "I hear noises all the time. I live on a busy street.";

(5) Distortion of meaning due to lack of understanding by the interpreter (Clinician: "Are you allergic to any medication?"; interpreter: "Does Western drug make you vomit?");

(6) Adding information (to make the patient look better, to explain something they think you do not understand, to help you out if they happen to know the family, etc.);

(7) Omitting cultural meaning of the information (Client: "I took the whole bottle of po chia pills last night" [it's a Chinese medicine, one is actually supposed to do that]; clinician: "Where you trying to kill yourself last night"?);

F. So, make sure you have at least an hour before testing to go over the procedure, what you want them to pay attention to (paraphasias, etc.), review the instruments and pre-translate whatever necessary;

G. Make sure you have half an hour afterwards for debriefing;

H. Make sure you explain the procedure, interpreter's role, and your (and, hopefully, their) commitment to confidentiality and address the client directly, looking at them (rather than the interpreter);

I. Try to avoid jargon, to be as concrete and specific as possible and to ask each question twice in different forms (e.g. rather than asking "Do you feel depressed?" ask "Did you feel sad most of the day yesterday? Did you feel happy at any time last week?", etc.)

J. Sign language interpreters usually need a break after two hours - if you need more time book two.

V. Common pitfalls and biases in cross-cultural assessment.

"A great many people think they are thinking when they are really rearranging their prejudices." - William James

"From their experience or from the recorded experience of others, men learn only what their passions and their metaphysical prejudices allow them to learn." - Aldous Huxley

(Quotes come from an article Lloyd I. Cripe, Ph.D. in Brain Injury Professional called "A Professional Awakening: Discovering the Biased Beliefs of Clinical Neuropsychologists")

Spot the underlying biased assumption:

AMCD Multicultural Counseling Competencies Guidelines: "Culturally skilled counselors possess knowledge about their social impact upon others. They are knowledgeable about communication style differences, how their style may clash with or foster the counseling process with persons of color or others different from themselves." - assumes that the counselor is white.

1) In assessment specifically, under- and over-diagnosing.

2) Missing factors not encountered in the USA.

3) Assuming that the meaning of a concept is the same in two cultures.

4) Assuming that the methods of treatment are the same.

5) Assuming that goals of treatment are the same.

6) Assuming that the meaning of symptoms is the same across cultures.

7) Diagnosing culture-specific conditions.

8) Approaching a client as a victim.

9) Using lists of "cultural specifics", which, however well-meaning, as most generalizations tend to lead to misunderstandings and embarrassment in each particular case. They are attempting to keep the impossible balance between providing information specific enough to be useful and general enough to be applicable to a whole culture.

VI. Additional information and resources.

1) APA guidelines on multiculturalism have excellent collection of references. They can be found at: http://www.apa.org/pi/multiculturalguidelines/references.html

2) An extensive collection of references on cross-cultural issues for mental health professionals: http://culturedmed.sunyit.edu/bib/mental/index.html

3) A good website with useful links to other sources of information and further references at UCSF: http://medicine.ucsf.edu/resources/guidelines/culture.html

4) Books specific to neuropsychology:

Minority and Cross-Cultural Aspects of Neuropsychological Assessment By F. Richard Ferraro, Published 2002, Taylor and Francis, ISBN 9026518307

I highly recommend Cross-Cultural Neuropsychological Assessment: Theory and Practice, By Victor Nell, Published 1999, Lawrence Erlbaum Associates, ISBN 0805833560

Handbook of Cross-Cultural Neuropsychology, By Tony L. Strickland, Cecil R. Reynolds, Elaine Fletcher-Janzen, Published 2000, Springer Psychology, ISBN 0306463237

Appendix 1: Possible Interview and Mental Status Exam Outline.

Neuropsychological Examination

Appendix 2: Instruments Commonly Used in Assessment of non-English Speaking Clients

Words of caution: In many listed tests only non-verbal subtests are commonly used. Normative data from the American samples cannot be utilized, only qualitative and functional analyses of the test results are possible unless normative data exists for the Client's group. Compiled from: Elliott et al., 1987, Mental Health Assessment of Deaf Clients: a practical manual; Sattler, 1992, Assessment of Children; Lezak, 1995, Neuropsychological Assessment.)

Nonverbal Cognitive Skills

Wechsler scales

KABC-II: Kaufman Assessment Battery for Children, Second Edition

Leiter International Performance Scales

Hiskey Nebraska Test of Learning Aptitude

Raven Progressive Matrices

Columbia Mental Maturity Scale

Healy Picture Completion Test

Chicago Nonverbal Examination

Bayley Scales of Development

Blind Learning Aptitude Test

Goodenough-Harris Drawing Test

Pictorial Test of Intelligence

System of Multicultural Pluralistic Assessment

Social-Emotional and Behavioral Measures

Goodenough-Harris Drawing Test

Walker Problem Behavior Checklist

Vineland Social Maturity Scale

Rorschach

Thematic Appeception Test

California Achievement Test

Projective Drawings

Behavioral Assessment System for Children=II

Language and Communication Skills

Peabody Picture Vocabulary Test

Expressive One-Word Picture Vocabulary Test

Sequenced Inventory of Communication Development

Assessment of Children's Language Comprehension

Boehm Test of Basic Concepts

Detroit Test of Learning Aptitude

Illinois Test of Psycholinguistic Abilities

Developmental Sentence Analysis (Laura Lee)

Picture Story Language Test

Test of Written English

Boston Naming Test

Auditory Skills

Templin Sound Discrimination Test

Detroit Test of Learning Aptitude

Illinois Test of Psycholinguistic Abilities

Visual/Spatial Skills

Bender Visual Motor Gestalt Test

Beery VMI

Benton Revised Visual Retention Test

Slingerland Screening Test for Developmental Language Disability

Detroit Test of Learning Aptitude

Illinois Test of Psycholinguistic Abilities

Motor-Free Visual Perception Test

Jordan Left-Right Reversal Test

Visual-Aural Digit Span Test

Rey-Osterrieth Complex Figure Test

Hooper Visual Organization Test

Knox Cubes

Motor Skills

Lincoln Oseretsky Motor Development Scale

Ayres So. California Motor tests

Purdue Pegboard

Purdue Perceptual-Motor Survey

Sequin Form Board

Tactile and kinesthetic perception tasks

Neuropsychological Batteries and Additional Tests

World Health Organization Neurobehavioral Core Test Battery

Luria-Nebraska Battery

Halstead-Reitan Battery

Wechsler Memory Scales

Cognistat

RBANS

Wisconsin Card-Sorting Test

Cancellation Tasks

Stroop Test

Appendix 3: WAIS-III and WAIS-R NI example

Picture Completion

(For WAIS-R NI omit time limits and discontinuation rules, score for 20" and overtime, as well as scatter. For naïve subjects, always be explicit about time limits. Nell also suggests doing all initial practice items with explicit teaching when necessary and speeded practice for naïve subjects for all subtests. If you feel standard administration is useful [e.g. you are testing someone who partially conforms to the normative database], after it has been accomplished, you can see if performance improves with training. Go to the first erroneous answer, ask the client for his reasoning and walk the client through the solution. Be careful to elicit Client's spontaneous level of understanding, starting with minimal explanation and gradually becoming more explicit. If it is a visual attention item, like nose on the face, encouraging attending is usually enough. If not, you may try asking the client to list the features face is supposed to have and, failing that, to scan systematically by quadrants. This will tell you if they are failing to access exemplars or to scan carefully. If it is a logic item, walk them through the logic. For example, if on the missing door handle item the client gives a wrong answer [e.g. "the person opening the door"], you can say: "You are absolutely right, there is no person. But tell me, what is most important about the door?" If the client does not come up with an answer: "What is the door supposed to do?" "That's right, it should open and close. Keeping that in mind, can you see what important part is missing?" If the client does not come up with an answer: "Even if somebody tried to open the door - they would not be able to because there is no door handle. So, you can see that there are a lot of things missing, like a person, the rest of the room, and the door handle, but the door handle is most important, because without it the door will not work. Does it make sense to you?")

Vocabulary

(For WAIS-R NI offer multiple choice, omit discontinuation and score for scatter. For teaching purposes, go over synonym [repair=fix], attribute-based [tirade=angry verbal outburst], function-based [bed=furniture you sleep on], category-based [ditto] and descriptive [assemble=put things together] definitions, explain the expected level of specificity. For example, just saying that bed is a piece of furniture is not specific enough, saying that it is made of wood with four vertical legs and a horizontal part, etc. is too specific. Remember that for uneducated subjects, even native speakers, it's likely to be invalid as an intelligence marker anyway.)

Digit Symbol - Coding

(For WAIS-R NI allow continuation until 90s, unless have not completed the 3 rd row - in that case finish 3 rd row; score at 30" intervals for pattern. For teaching have a speeded practice trial in addition to practice.)

Similarities

(For WAIS-R NI omit discontinuation and score for scatter. For teaching explain categorization and level of specificity - i.e. that one needs to find a description both items fit which distinguishes them from most other things. Remember that for uneducated subjects, even native speakers, it's likely to be invalid as an intelligence marker anyway.)

Block Design

(For WAIS-R NI record the sequence and pattern of performance. For teaching Nell suggests an extra practice item where diagonals cross the block lines, making parsing non-obvious. If teaching by example does not work, you can revert to the graduate explicit teaching described above, including teaching structure [all squares with 2 or 3 blocks to a side], parsing techniques [e.g. imagine two lines splitting it in four - and show with your fingers], and systematic problem-solving [e.g. rotate each block through all four possibilities until it looks right].)

Arithmetic

(For WAIS-R NI do pen-and-paper trial, omit discontinuation and score for scatter. You can do explicit training, which is standard algebra. Remember that for uneducated subjects, even native speakers, it's likely to be invalid as an intelligence marker anyway.)

Matrix Reasoning

(In addition to standard training, training in dealing with multiple choice format is needed for uneducated subjects - i.e. explaining how to eliminate wrong choices based on any variable and then select the correct choice from remaining items based on remaining variable[s] and that guessing once some choices are eliminated is a fruitful strategy.)

Matrix Reasoning subtest pattern analysis:

SA. Same + 1 variable

SB. 1 variable

1. Same

2. Same + 1 variable

3. Same + 1 variable

4. Same + 1 variable

5. 1 variable

6. Pattern completion

7. Pattern completion + 2 variables

8. Pattern completion + 2 variables

9. Pattern completion + 2 variables

10. 2 variables

11. 2 variables

12. 2 variables

13. Rotation

14. 2 variables

15. Rotation + 1 variable

16. 2 variables

17. 2 variables

18. Rotation + 1 variable

19. Rotation + irrelevancy

20. 2 variables + irrelevancy

21. Subtraction

22. Addition + Rotation+ irrelevancy

23. 2 variables + 2 irrelevancy

24. 1 variable + 2 differences

25. Figure-ground switch + subtraction

26. No idea. Submissions welcome.

Digit Span

(For WAIS-R NI omit discontinuation and score for error types: omission, addition, perseveration, substitution, and sequence. For teaching for backwards trial, can explain that rehearsal is necessary. There are several different methods used to perform on this test, depending on the individual: selecting items and ranking them by iteration is a verbal solution, visualizing a line - a visual one, and associating numbers with fingers - a sensory-motor one.

Information

(For WAIS-R NI omit discontinuation, do multiple choice and score for scatter. Remember that for uneducated subjects, even native speakers, it's likely to be invalid as an intelligence marker anyway.)

Picture Arrangement

(For WAIS-R NI omit discontinuation, ask the person to verbalize the stories and score for scatter. Additional training may involve instruction to verbalize to himself and see how things follow from each other, scanning and seeing how differences between similar pictures fit into the story. This one has more to do with cultural exposure than education.)

Comprehension

(For WAIS-R NI omit discontinuation and score for scatter. For uneducated subjects can explain problems in detail [e.g. what parole system consists of] and encourage them to explain things "in their own words", since formulation of a response is often problematic. Remember that for uneducated subjects, even native speakers, it's likely to be invalid as an intelligence marker anyway.)

Symbol Search

(For training can also do speeded practice and explain that they can stop searching once one match is found.)

Letter-Number Sequencing

(Before trying, check if alphabet recital and counting speed are within expectations. For teaching, can explain that rehearsal is necessary. There are several different methods used to perform on this test, depending on the individual: selecting items and ranking them by iteration is a verbal solution, visualizing a line - a visual one, and associating numbers with fingers - a sensory-motor one. Remember that for uneducated subjects, even native speakers, it's likely to be invalid as an intelligence marker anyway.)

Object Assembly

(For WAIS-R NI omit discontinuation, record sequence and timing of junctures, solution strategy, whether they recognized the object, and score for times at which each junction is made. For teaching, explain using of internal detail, outline, and systematic rotation.)