Conducting a culturally informed neuropsychological evaluation

Conducting a culturally informed neuropsychological evaluation The numbers of culturally and linguistically diverse individuals in the U.S. who need neuropsychological services relative to the number of professionals who can provide these services has created a particular conundrum. This is in part because the American Psychological Association Ethics Code (2010) and Multicultural Guidelines for Assessment (2003) state that psychologists must practice within his or her boundary of competence, and that tests need to be appropriate (e.g., fair, developed, and validated) for the client. However, given current limits on the availability of culturally validated instruments as well as culturally competent providers, many of whom may potentially benefit from neuropsychological services are denied, which also pushes ethical boundaries (Brickman, Cabo, & Manly, 2006). Moreover, there are major gaps in the availability of cultural neuropsychology training programs in the U.S., and no firm training guidelines have been established to determine “Who is culturally competent?” Simply because a psychologist/neuropsychologist is a member of an identified minority group, or speaks the language of client does not certify his or her competency in providing culturally appropriate services; yet, it is not uncommon for referrals to be made with this implicit assumption. While the literature has expanded in addressing ethical, theoretical, and practical issues in cultural neuropsychology, there has not been a comprehensive integrated resource for conducting culturally informed assessments until now. In the book “Conducting a Culturally Informed Neuropsychological Evaluation”, Dr. Daryl Fujii provides a conceptual framework and practical elements that can guide clinicians and researchers working with culturally diverse clients. The book is organized into three distinct, yet complementary sections that serve as building blocks of training. Part I, “Foundations: Attitudes, Perspective and Conceptual Overview” places emphasis on the clinician's attitude and perspective using Bennett's developmental model of intercultural sensitivity (1993), which explains the process of intercultural understanding and defines it as continuum of different levels of personal development in the recognition and acceptance of cultural differences. Part II, “Preparation” provides organizing steps and principles to help the clinician prepare for the neuropsychological exam. Part III, “Evaluation and Report Writing” is a comprehensive review of the evaluation, report writing and feedback. Although it is generally accepted that culturally informed neuropsychological assessments are critical to improving outcomes, reducing healthcare gaps, and reducing diagnostic errors that often occur among ethnic/racial minorities, very few practitioners have the requisite training in how to write culturally informed reports and give feedback to culturally diverse clients. For educators who teach graduate level courses in multicultural psychology or cultural neuropsychology, the practical examples make this text an excellent resource for the curriculum. This book can be supplemented with other relevant neuropsychology literature, particularly literature that provides more statistical and technical detail of psychometric and test development theory. Students would also benefit from applying Bennett's developmental model of intercultural sensitivity (1993) to their personal experiences interacting with different cultures. Considering that understanding one's own intercultural sensitivity is critical to working with culturally diverse clients, more practical examples of how a clinician can identify stages of this model are needed. For example, a brief chapter exercise could include potential statements made by a neuropsychologist (e.g., “I don't understand what culture has to do with describing the cognitive impairments due to this brain injury.”) and relating it to Bennett's developmental stage (i.e., Minimization). Further, before clinician's can effectively work with clients, they must be able to engage introspectively and conduct a self-assessment. In theory, self-assessment helps clinicians and researchers to gauge the degree to which they are effectively addressing the needs and preferences of culturally and linguistically diverse groups, and determine individual strengths and areas for growth. And while Chapter 1 would benefit from providing direct examples of questions or tools to help guide the clinician's self-assessment, this is a minor shortcoming, and speaks more to the few validated self-assessment tools that are available rather than omissions from the author. Along these lines, more recent self-assessment instruments offer promise in light of the reported preliminary psychometric data (e.g., Cultural Competence Health Practitioner Assessment, CCHPA-67) (Harris-Haywood et al., 2014). Although this measure was designed for physicians, future versions of “Conducting a Culturally Informed Neuropsychological Evaluation” may address how current self-assessment measures could be useful to the neuropsychologist. In Part II, Fujii uses the example of Native Indian and Alaskan Native (NI/AN) cultures to provide a framework to the assessment process. Particularly helpful are the detailed questions proposed to help guide the literature review and conceptualization of the client's presenting problem. Questions at the macrosocietal (larger society) level include questions about important historical events, languages spoken, educational system, etc. Specific to the macrosocietal structures of NI/AN cultures, Fujii includes questions about values, beliefs and societal structures, medical conditions and beliefs about illness, and how to maximize cooperation and facilitate communication. Specific examples are provided that are easily relatable for clinicians working with diverse populations in general. Of equal importance, in addition to garnering a better understanding of the cultural context, these questions also allow the clinician to capture the social determinants that drive health outcomes. Considerations of the social determinants that drive health outcomes are of increasing importance to healthcare (Marmot, Friel, Bell, Houweling, & Taylor, 2008). Factors such as socioeconomic status, education, the physical environment, employment, and social support networks, as well as access to healthcare are all key to outcomes. Understanding the social determinants of a client's culture provides a unique framework for interpreting neuropsychological test performance, which can also be utilized to inform targeted recommendations and future care. One of the more growing challenges in the practice of neuropsychology is proper assessment of clients with Limited English Proficiency (LEP). When clinicians are faced with an LEP client—as Fujii highlights—selection of the appropriate interpreter is critical for optimizing the clinician's chances for gathering a proper assessment. Specific recommendations for using interpreters, with emphasis on how to prepare and educate the interpreter, translate tests and post-interview debriefing are provided. Clinicians who find themselves struggling with the question of “Should I use an interpreter?” when referred LEP clients will particularly appreciate this chapter. In Chapter 8 (which begins Part III), Fujii synthesizes the elements mentioned in previous chapters to illustrate the process of conducting an evaluation. Chapter 9 reviews interpretation and case formulation that includes consideration of test validity, appropriate scoring, and interpreting the data within the client's culture. Finally, Chapter 10 concludes with report writing and feedback. Each chapter in Part III uses the example of one client (i.e., Mr. Kim), which allows the reader to almost “witness” each step of the evaluation process. Because the testing considerations, context, and test adaptation processes are described carefully in these chapters, the reader can compare the issues, methods, procedures, and problems facing researchers and practitioners attempting to conduct a culturally informed evaluations. In sum, this book has numerous strengths, the main strength being Fujii's remarkable ability to distill complex theoretical and practical elements into a single book. This is a book that easily maintains the reader's interest, and is not bogged down by technical detail. Second, practical examples and application are well integrated in this book, which also provide a quick “go to” resource for practitioners, researchers and educators. This book could easily be utilized in any graduate level course, practicum, or internship training experience. Students enrolled in multicultural psychology course and/or neuropsychological training programs should be required to read this book. Considering recent AACN Practicum Guidelines (see Nelson et al., 2015), elements of this book (especially Part III) could be used to determine how core competencies related to cultural assessment have been achieved in a training program. As a field, directing organizational change for a more diverse neuropsychology requires the development of a core set of values, guidelines, and educational resources (Romero et al., 2009). This book represents a major step towards this initiative and was an absolute pleasure to read. References American Psychological Association. ( 2010). Ethical principles of psychologists and code of conduct (2002, Amended June 1, 2010). Retrieved from http://www.apa.org/ethics/code/index.aspx American Psychological Association. ( 2003). APA guidelines on multicultural education, training, research, practice, and organizational changes for psychologists. American Psychologist , 58, 377– 402. CrossRef Search ADS PubMed  Bennett, M. ( 1993). Towards ethnorelativism: A developmental model of intercultural sensitivity. In Paige R. M. (Ed.), Education for the intercultural experience  (pp. 21– 71). Yarmouth, ME: Intercultural press. Brickman, A. M., Cabo, R., & Manly, J. J. ( 2006). Ethical issues in cross-cultural neuropsychology. Applied Neuropsychology , 13, 91– 100. Google Scholar CrossRef Search ADS PubMed  Harris-Haywood, S., Goode, T., Gao, Y., Smith, K., Bronheim, S., Flocke, S. A., et al.  . ( 2014). Psychometric evaluation of a cultural competency assessment instrument for health professionals. Med Care , 52, e7– e15. 10.1097/MLR.0b013e31824df149. Google Scholar CrossRef Search ADS PubMed  Marmot, M., Friel, S., Bell, R., Houweling, T. A., & Taylor, S., Commission on Social Determinants of Health. ( 2008). Closing the gap in a generation: health equity through action on the social determinants of health. Lancet , 372, 1661– 1669. Google Scholar CrossRef Search ADS PubMed  Nelson, A. P., Roper, B. L., Slomine, B. S., Morrison, C., Greher, M. R., Janusz, J., et al.  . ( 2015). Official position of the American Academy of Clinical Neuropsychology (AACN): Guidelines for practicum training in clinical neuropsychology. The Clinical Neuropsychologist , 29, 879– 904. doi:10.1080/13854046.2015.1117658. Google Scholar CrossRef Search ADS PubMed  Romero, H. R., Lageman, S. K., Kamath, V., Irani, F., Sim, A, & Suarez, P. ( 2009). Proceedings: Challenges in the neuropsychological assessment of ethnic minorities: A problem solving summit. The Clinical Neuropsychologist , 23, 761– 779. Google Scholar CrossRef Search ADS PubMed  © The Author 2017. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Archives of Clinical Neuropsychology Oxford University Press

Conducting a culturally informed neuropsychological evaluation

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Oxford University Press
Copyright
© The Author 2017. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.
ISSN
0887-6177
eISSN
1873-5843
D.O.I.
10.1093/arclin/acx057
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Abstract

The numbers of culturally and linguistically diverse individuals in the U.S. who need neuropsychological services relative to the number of professionals who can provide these services has created a particular conundrum. This is in part because the American Psychological Association Ethics Code (2010) and Multicultural Guidelines for Assessment (2003) state that psychologists must practice within his or her boundary of competence, and that tests need to be appropriate (e.g., fair, developed, and validated) for the client. However, given current limits on the availability of culturally validated instruments as well as culturally competent providers, many of whom may potentially benefit from neuropsychological services are denied, which also pushes ethical boundaries (Brickman, Cabo, & Manly, 2006). Moreover, there are major gaps in the availability of cultural neuropsychology training programs in the U.S., and no firm training guidelines have been established to determine “Who is culturally competent?” Simply because a psychologist/neuropsychologist is a member of an identified minority group, or speaks the language of client does not certify his or her competency in providing culturally appropriate services; yet, it is not uncommon for referrals to be made with this implicit assumption. While the literature has expanded in addressing ethical, theoretical, and practical issues in cultural neuropsychology, there has not been a comprehensive integrated resource for conducting culturally informed assessments until now. In the book “Conducting a Culturally Informed Neuropsychological Evaluation”, Dr. Daryl Fujii provides a conceptual framework and practical elements that can guide clinicians and researchers working with culturally diverse clients. The book is organized into three distinct, yet complementary sections that serve as building blocks of training. Part I, “Foundations: Attitudes, Perspective and Conceptual Overview” places emphasis on the clinician's attitude and perspective using Bennett's developmental model of intercultural sensitivity (1993), which explains the process of intercultural understanding and defines it as continuum of different levels of personal development in the recognition and acceptance of cultural differences. Part II, “Preparation” provides organizing steps and principles to help the clinician prepare for the neuropsychological exam. Part III, “Evaluation and Report Writing” is a comprehensive review of the evaluation, report writing and feedback. Although it is generally accepted that culturally informed neuropsychological assessments are critical to improving outcomes, reducing healthcare gaps, and reducing diagnostic errors that often occur among ethnic/racial minorities, very few practitioners have the requisite training in how to write culturally informed reports and give feedback to culturally diverse clients. For educators who teach graduate level courses in multicultural psychology or cultural neuropsychology, the practical examples make this text an excellent resource for the curriculum. This book can be supplemented with other relevant neuropsychology literature, particularly literature that provides more statistical and technical detail of psychometric and test development theory. Students would also benefit from applying Bennett's developmental model of intercultural sensitivity (1993) to their personal experiences interacting with different cultures. Considering that understanding one's own intercultural sensitivity is critical to working with culturally diverse clients, more practical examples of how a clinician can identify stages of this model are needed. For example, a brief chapter exercise could include potential statements made by a neuropsychologist (e.g., “I don't understand what culture has to do with describing the cognitive impairments due to this brain injury.”) and relating it to Bennett's developmental stage (i.e., Minimization). Further, before clinician's can effectively work with clients, they must be able to engage introspectively and conduct a self-assessment. In theory, self-assessment helps clinicians and researchers to gauge the degree to which they are effectively addressing the needs and preferences of culturally and linguistically diverse groups, and determine individual strengths and areas for growth. And while Chapter 1 would benefit from providing direct examples of questions or tools to help guide the clinician's self-assessment, this is a minor shortcoming, and speaks more to the few validated self-assessment tools that are available rather than omissions from the author. Along these lines, more recent self-assessment instruments offer promise in light of the reported preliminary psychometric data (e.g., Cultural Competence Health Practitioner Assessment, CCHPA-67) (Harris-Haywood et al., 2014). Although this measure was designed for physicians, future versions of “Conducting a Culturally Informed Neuropsychological Evaluation” may address how current self-assessment measures could be useful to the neuropsychologist. In Part II, Fujii uses the example of Native Indian and Alaskan Native (NI/AN) cultures to provide a framework to the assessment process. Particularly helpful are the detailed questions proposed to help guide the literature review and conceptualization of the client's presenting problem. Questions at the macrosocietal (larger society) level include questions about important historical events, languages spoken, educational system, etc. Specific to the macrosocietal structures of NI/AN cultures, Fujii includes questions about values, beliefs and societal structures, medical conditions and beliefs about illness, and how to maximize cooperation and facilitate communication. Specific examples are provided that are easily relatable for clinicians working with diverse populations in general. Of equal importance, in addition to garnering a better understanding of the cultural context, these questions also allow the clinician to capture the social determinants that drive health outcomes. Considerations of the social determinants that drive health outcomes are of increasing importance to healthcare (Marmot, Friel, Bell, Houweling, & Taylor, 2008). Factors such as socioeconomic status, education, the physical environment, employment, and social support networks, as well as access to healthcare are all key to outcomes. Understanding the social determinants of a client's culture provides a unique framework for interpreting neuropsychological test performance, which can also be utilized to inform targeted recommendations and future care. One of the more growing challenges in the practice of neuropsychology is proper assessment of clients with Limited English Proficiency (LEP). When clinicians are faced with an LEP client—as Fujii highlights—selection of the appropriate interpreter is critical for optimizing the clinician's chances for gathering a proper assessment. Specific recommendations for using interpreters, with emphasis on how to prepare and educate the interpreter, translate tests and post-interview debriefing are provided. Clinicians who find themselves struggling with the question of “Should I use an interpreter?” when referred LEP clients will particularly appreciate this chapter. In Chapter 8 (which begins Part III), Fujii synthesizes the elements mentioned in previous chapters to illustrate the process of conducting an evaluation. Chapter 9 reviews interpretation and case formulation that includes consideration of test validity, appropriate scoring, and interpreting the data within the client's culture. Finally, Chapter 10 concludes with report writing and feedback. Each chapter in Part III uses the example of one client (i.e., Mr. Kim), which allows the reader to almost “witness” each step of the evaluation process. Because the testing considerations, context, and test adaptation processes are described carefully in these chapters, the reader can compare the issues, methods, procedures, and problems facing researchers and practitioners attempting to conduct a culturally informed evaluations. In sum, this book has numerous strengths, the main strength being Fujii's remarkable ability to distill complex theoretical and practical elements into a single book. This is a book that easily maintains the reader's interest, and is not bogged down by technical detail. Second, practical examples and application are well integrated in this book, which also provide a quick “go to” resource for practitioners, researchers and educators. This book could easily be utilized in any graduate level course, practicum, or internship training experience. Students enrolled in multicultural psychology course and/or neuropsychological training programs should be required to read this book. Considering recent AACN Practicum Guidelines (see Nelson et al., 2015), elements of this book (especially Part III) could be used to determine how core competencies related to cultural assessment have been achieved in a training program. As a field, directing organizational change for a more diverse neuropsychology requires the development of a core set of values, guidelines, and educational resources (Romero et al., 2009). This book represents a major step towards this initiative and was an absolute pleasure to read. References American Psychological Association. ( 2010). Ethical principles of psychologists and code of conduct (2002, Amended June 1, 2010). Retrieved from http://www.apa.org/ethics/code/index.aspx American Psychological Association. ( 2003). APA guidelines on multicultural education, training, research, practice, and organizational changes for psychologists. American Psychologist , 58, 377– 402. CrossRef Search ADS PubMed  Bennett, M. ( 1993). Towards ethnorelativism: A developmental model of intercultural sensitivity. In Paige R. M. (Ed.), Education for the intercultural experience  (pp. 21– 71). Yarmouth, ME: Intercultural press. Brickman, A. M., Cabo, R., & Manly, J. J. ( 2006). Ethical issues in cross-cultural neuropsychology. Applied Neuropsychology , 13, 91– 100. Google Scholar CrossRef Search ADS PubMed  Harris-Haywood, S., Goode, T., Gao, Y., Smith, K., Bronheim, S., Flocke, S. A., et al.  . ( 2014). Psychometric evaluation of a cultural competency assessment instrument for health professionals. Med Care , 52, e7– e15. 10.1097/MLR.0b013e31824df149. Google Scholar CrossRef Search ADS PubMed  Marmot, M., Friel, S., Bell, R., Houweling, T. A., & Taylor, S., Commission on Social Determinants of Health. ( 2008). Closing the gap in a generation: health equity through action on the social determinants of health. Lancet , 372, 1661– 1669. Google Scholar CrossRef Search ADS PubMed  Nelson, A. P., Roper, B. L., Slomine, B. S., Morrison, C., Greher, M. R., Janusz, J., et al.  . ( 2015). Official position of the American Academy of Clinical Neuropsychology (AACN): Guidelines for practicum training in clinical neuropsychology. The Clinical Neuropsychologist , 29, 879– 904. doi:10.1080/13854046.2015.1117658. Google Scholar CrossRef Search ADS PubMed  Romero, H. R., Lageman, S. K., Kamath, V., Irani, F., Sim, A, & Suarez, P. ( 2009). Proceedings: Challenges in the neuropsychological assessment of ethnic minorities: A problem solving summit. The Clinical Neuropsychologist , 23, 761– 779. Google Scholar CrossRef Search ADS PubMed  © The Author 2017. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.

Journal

Archives of Clinical NeuropsychologyOxford University Press

Published: Mar 1, 2018

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