Cross Cultural Neuropsychology


This chapter focuses on the Diagnostic Interview. A lot of this is basic “good interviewing practice” even if someone is not from another culture. These are the major points to keep in mind from this chapter

from Cross Cultural Neuropsychological Assessment, Theory and Practice, Chapters 8-9 by Victor Nell

Major Points

  • Think of the diagnostic interview as a real-life drama. You as the interviewer set the scene, beside the sequence facilitate the dialogue flow and intervene to maintain communication and level of intensity. With clients unaccustomed to testing it is the neuropsychologist’s main objective to put them at ease. There are several ways to do this–
  • The most important element is natural, personal warmth. They may have traveled a long distance, or are worried about catching a bus home, and communication may not be optimal. Obviously being genuine and warm, explaining who you are, why the interview is necessary, why it takes so much time etc. will help set the scene to make things flow more smoothly.
  • Learn how to maintain eye contact with client not the translator in a circumstance where the translator is being used. If the translator interacts with the neuropsychologist in a language that the client doesn’t understand, the client soon feels that the neuropsychologist has no interest in them.
  • When you ask a question the comment should be translated to the family in their language. Then instead of speaking the translation back to you, the translator repeats the answer, but this time in English (so of course now you, the neuropsychologist, understands!) But now the client doesn’t feel marginalized. What should happen when it’s done right is that the client should be replying directly to your questions and maintaining eye contact with you even if they are answering in their own language. (On page 149 there is a nice example of how to do this).
  • Teach the translator to translate both the client’s and the neuropsychologist speech into first person rather than using the indirect/third person approach. Translation should occur completely (don’t abbreviate what client says) and frequently. In other words, after the client says a sentence or two it should be translated. There is a sort of funny story at the bottom of page 149 that is abridged here: A South African psychiatrist has a nurse translator. The psychiatrist asks the client, “Are you hearing voices?” An animated conversation ensues between the client and the nurse translator, and the client becomes very excited and animated. The psychiatrist sits there listening attentively and after about 10 minutes, the nurse turns to the psychiatrist and provides him with the translation: “He says, Yes, doctor!”
  • You often have to get collateral information from a caregiver and you need to do it without slighting the client. At the beginning of the interview explain that people very often see the same things in different ways and that you will be putting the same question first to the client and then to the caregivers, not in order to check up on them but to see how other people in their lives are feeling about the same thing. Moving back and forth between the client and the caregivers is an essential aspect of the diagnostic interview. A good principle to follow is that there are no secrets and that everything will be discussed openly in the presence of client and family members. One danger to avoid is that the pace of the interview needs to be swift to maintain the energy level in the room.
  • Be sure to go to the primary source of information about a client rather than some senior person. In the analogy of a school system, don’t go to the principal, rather go to the teacher who sees the kid six hours a day. With an adult, it’s important to visit the patient’s job setting when discrepancy occurs between client files and the test results. If a client file says the client has excellent job performance but the test results suggest something very different, it’s time to do a site visit.
  • Client will want to talk about what is most important to them, perhaps the accident or hospital treatment, which of course is important but the interviewer may fail to get vital information such as educational background, achievements of the client and their family, and employment history. Use a standardized intake form which helps you get through the interview.

Body of the history

Intellectual And Social Accomplishments

Dr. Nell’s research suggests that it’s essential to have information not only about the client but about their parents and the highest standard they have passed in their life/career rather than the total years of schooling. The career level and place of residence of the parents give an idea of the enrichment at home or in client’s general environment. In the case of a child who sustained a brain injury early in life, the family background is often the only way of determining pre-morbid ability.

School Record

Construct a year-by-year table tabling grades and grade averages. Teacher comments can be misleading since most teachers try to be positive about a child. Often the child and the mother can remember where the child was placed before the accident and can compare this to present achievements. Try to get information about any kinds of classes that were failed and when this happened in relationship to the accident. Be sure to ask about behavior complaints at school or level of arousal and disinhibition. Also keep in mind a few other things: Is there a difference in information processing? Did the child begin to forget their homework assignments or develop any other sort of memory problem? What is the child’s playground behavior like?

Occupational History

For adult clients, often school is far behind them. Therefore occupational history has precedence in answering what life was like before the accident. For working class individuals whose job descriptions may not have changed much, the key thing that may have changed is their actual job earnings. In clients who come from third world countries, keep in mind informal businesses are numerous from roadside talking to door to door trinket sales. These should be fully recorded. There may be a lack of formal income records, yet a person may have made a lot of money. There is a great story at the top of page 154 about this.

Main Complaints

Keep in mind that spontaneous complaints have greater diagnostic weight than those that are elicited by direct questioning. Using broad, open-ended questions first to the client and then to the caregiver is essential. Once the main complaint/spontaneous complaints are elicited, it’s important to move beyond this information and probe additional information you suspect may be present such as problems with arousal, alcohol, temper, self-monitoring, and memory. Again, don’t ask leading questions: (e.g., rather than “Do you find you sleep more now than you did before?”, say “Have you noticed any changes in your sleeping habits since the accident?”) In order to probe without leading, you have to begin with what your client has brought to your interview. In a situation where there is a head injury, be sure to pay attention to the key issues discussed in Chapter 7 about classic dimensions of concussion syndrome (e.g., changes in arousal, personality, thinking).

Physical Complaints

Although some neuropsychologists leave this out, it’s an important area to ask questions about. Often the client will talk about their weak arm or a leg that hurts, but it’s important to ask about things like chronic pain. Not only does this affect their performance potentially, but it’s a primary area that needs to be addressed in a therapeutic setting. Oddly enough, sometimes a neuropsychological evaluation is completed and the evaluator never reports whether the client can walk unaided, has full use of both hands, or can see well enough to what TV. Although you may not be able to do a full sensory motor exam, you can still ask questions about these issues, look at their handwriting, ask them about their ability to feel hot and cold temperatures, or watch our client walk around the consulting room etc.

Chapter 9

This is a wonderfully interesting chapter for any neuropsychologist, (but especially for the pediatric neuropsychologist!) There is a nice discussion about Vygotsky’s work, the Zone of Proximal Development (ZOPED) and its applicability to testing. This is defined as the distance between a child’s actual developmental level during independent problem solving and the child’s level of potential development revealed by problem-solving under adult guidance or when working with more competent members of the child’s own age group. A very interesting discussion ensues about the role of mediated learning in acquiring cognitive schemes. The chapter goes into a discussion about psychometric testing and it’s classic “arms length procedure” where it standardized instruments are always read in a very specific way, nothing can be explained only repeated, and pat answers to client questions such as, “Whatever you think is best,” are given. Needless to say, clients from different cultures or different socioeconomic status may be put off by this type of formality. He discusses what South African psychologists contributed to the testing profession in that subject should have ample opportunity to learn to do the task involved in the test by preliminary exercises. He seems to say that this idea of practice and feedback came from Biesheuvel’s work in South Africa on the 1950s South African General Adaptability Battery (this was new and interesting!). The idea to take away is that guided learning experiences do indeed produce significant performance increase and that the distance between actual performance and performance after triggering in the zone of proximal development, might be a more reliable guide to an individual’s capacity to benefit from training rather than a simple performance measure that is applied indiscriminately to test-wise clients and those from socially and culturally different backgrounds.

A couple of other things to note: in Appendix 3 of this book, there is an interesting section on something he calls “Educating the Executive”. There are some informal activities he suggests to work on with a client from a different culture before beginning testing in order to establish if your client can do things such as identifying numbers, and has the visual acuity needed for the test you plan to administer. It’s rather interesting and is on page 232-234.

The remainder of the chapter goes into a couple of extended practice tasks to familiarize an individual from another culture about how to complete a task that they may not be particularly familiar with. Something called the Hick Box Reaction Time Test is described and a set of steps is offered to teach the task in a way to bring the client into the ZOPED. Next, he presents a practice task similar to the Rey Complex Figure. It’s an informal test and the picture is on page 168. Basically you have the client do this task and then afterward you discuss any discrepancies in their drawing from the copy. Essentially they learn how to construct a novel complex figure, you go over there are errors, how their drawing was different from the picture etc., and then provide other examples if necessary. At this point you give them the real ROCF and tell them not to rush but make a copy that looks exactly like the one you’ve given them. This assesses whether they can learn, benefit from this approach and he argues it may be a more beneficial or practical way to gain insight into their skills.

Cross Cultural Neuropsychology

(Nancy Viscovich)

A Core Test Battery

from Cross Cultural Neuropsychological Assessment, Theory and Practice, Ch. 10 by Victor Nell

“Test norming is a market-driven enterprise, and because the Wechsler tests have meticulous norms for North American and most Western countries, they provide a useful comparative platform for standardization in the developing countries.”

The World Health Organization Neurobehavioral Core Test Battery authors have urged that its 7 tests be included “as standard marker tests within larger batteries to allow cross-cultural comparisons between studies and countries.”

Included: 11/14 WAIS-III subtests 12/17 WMS-III 6 WHO-NCTB tests


With more reversal items (until 2 correct responses are reached – basal), the WAIS-R maximum age of 74 increased to age 89 in WAIS-III. This leads to greater clinical utility in the diagnosis of mild to moderate mental retardation, and therefore of both traumatic and degenerative brain damage. WAIS –III has become more client friendly in non-Western settings – by using the reversal items, the patient can ease into the test in a non-threatening way (teach test demands, prepare for more difficult items later, etc.). So, while catering to the need to lower the test’s floor level, it caters to culturally different clients.

Some restructuring of what constitute the Index scores has led to more cultural fairness (e.g., Verbal Comprehension Index being excluded from the core test battery, since tests that carry heavy cultural baggage cannot be adapted by translation).

In the WMS-III, The Family Pictures subtest has not been taken up in the core test battery because the activities shown in the color pictures of these White middle class Americans will be incomprehensible to clients unfamiliar with daily life in the U.S.

How to prepare non-test-wise clients in the testing procedures

  • Extended Practice: It exists to level the playing field by helping the non-test-wise client to a point of familiarity with the test apparatus and the task demands that is equivalent to that taken for granted by the test author.

The emphasis on practice is on familiarization with the test materials or apparatus, and the test demands with regard to speed, accuracy, self-correction, and so on (task acquisition). It’s like active coaching. Extended practice is recommended for all clients who are not fully test-wise (e.g., individuals include victims of a failed educational school system).

  • Unpacking Hidden Meanings: This includes eye contact, saying things like “OK, let’s try another.” The test wise individual may pick up on these clues and self-correct. The non-test-wise client may not appear to be putting forth more effort because they are not picking up on these clues and self-correcting. You don’t want to attribute this behavior with low motivation, but lack of familiarity to hidden meanings. So prepare the client ahead of time and explain how you will respond and what is expected of them after they respond (e.g., cannot say right or wrong, will wait until time is up if no answer is given yet, etc.). Time limits can also be not understood. Explicit instructions about the kind of timing required is thus needed (for time limits of bonus time, need explanation).
  • Computer-Administered Tests: In non-Western cultures, computerized test administration may not be feasible because of poor reading skills, little familiarity of computers – can be intimidating to semiliterate, rural testees. Using two-button response boxes (with examiner being the one who controls the keyboard) may help with this (color coded for yes/no responses, for example).

A Core Neuropsychological Test Battery

Adults With Less Than 12 Years of Education:

  • Visuo-motor Abilities: Grooved Pegboard, Santa Ana Pegboard (WHO), Pursuit Aiming
  • Processing Speed: Simple Reaction time (problem for individuals in which deliberation is more important than speed & slower for individuals who are not test-wise).
    • Reaction times in South America & South Africa are substantially slower than in Europe. In this light, extended practice is required. To emphasize reaction time or need to work quickly, use a scenario that best fits that culture (e.g., street fight, confrontation with poisonous snake, etc). — reframing
    • Digits symbol or coding is a good diagnostic and predictive test because it parallels with everyday work place tasks – visual scanning, fine motor control, and incidental learning. It’s well suited for non-test-wise clients, even semiliterate individuals because the task is not to write #s, but to write novel symbols. For extended practice, make an additional copy of the test blank, using the last 3 rows: 2 for practice and the third for speeded practice.
    • Target detection tests- symbol detection better for non-test-wise clients because possible limited experience with letters and #s. No comments on adjusting – poorly standardized (per book).
  • Perceptual Organization
    • Picture Completion – non-test-wise client, missing part principle may not be immediately obvious. A common error is to name a missing part that is external to the given frame. Practice is thus essential in order to familiarize both adult and child with requirement that the missing part must be a significant element of the whole. Extended practice on tasks like Block Design are needed for semiliterates or those in more impoverished environments since they may have limited exposure to tasks tapping into these construction areas (e.g., Legos).
    • In Block Design it is important to provide additional practice items for the non-test-wise client for the embedded figures (the ones where the colors flow and each block is not easily defined to one particular quadrant). The current practice items are for non-embedded figures. So for non-test-wise client give Items 1-4 no matter what age and then give the example provided on page 187 of this book.
    • For object assembly you provide practice items for those unfamiliar with jigsaw puzzles. This is one of the better tests for non-test-wise clients.
    • Matrix Reasoning is well-suited to the instructional needs of non-test-wise clients.
  • Working Memory
    • Arithmetic subtest is good to be in core because everyday math is used by even those who are not well educated. It has 4 reversal items which provides excellent extended practice gradient for non-test-wise clients.
    • Digits forward is often easily grasped by even semiliterates. For digits backwards, however, extended practice is essential. The task should be explained with particular care, first asking the client to reverse the digits 1,2 and then 1, 2, 3. If difficulties emerge at this level, according to Lezak, it is helpful to point at an imaginary 1-2-3 series in the air in front of you, and then , pointing to the imaginary 3 on the right saying “Now you say 3 – (point to 3) –2 (point to 2) –1.” It can also be written down. Keep practicing until the client grasps the reversal principle. If giving spatial span, it should be done right after digit span so the client understands the concept.
  • Auditory Memory (Immediate and Delayed)
    • Verbal Paired Associates – provide extended practice. First give pair that is associated. Then give a pair that is not. For Logical Memory, outside of North America, it is important to avoid confounding narrative memory with the acquisition of what for the client is likely to be meaningless information or not “encoding” a concept that is meaningless to them.
    • Benton Visual Retention Test has high novelty for non-test-wise clients, and that additional practice is essential.
  • Visuomotor Abilities
    • Animal Pegs has been used for children from non-Western cultures (age 8+, from the WPPSI-R). It is more readily understood than grooved pegboard (no particular reasons noted in the book – my guess, familiarity with animals. It has good practice items.
  • Working Memory
    • Serial 7s: usually given to clients with 12 or more years of education. It can be used with semiliterates with caution. Begin with serial 3 for those with less education, explaining what has to be done and coaching them over 5 trials or until the task is performed fluently. If it seems too easy, switch to serial 7s.
  • Misc.
    • Trailmaking test cannot be given to those with less than 12 years of education even if they have good language skills and can say the alphabet.
    • Austin Maze Test – For non-test-wise clients with 12 or more years of education, this is a useful method for the examination of orderly learning with effective error utilization – the information yielded is comparable to the WCST.
  • Language
    • COWAT: letter fluency for those with 12 or more years of education.
    • Animal fluency for illiterate or semiliterate clients. Interpret with caution unless local norms are used.
    • Telephone #s to dictation: 7 digit #s are standard worldwide – can be routinely added to battery.
    • Token test – can use objects to help clarify instructions of what to do (see page 201). Just really provides extra practice to help them understand the directions.