Cross-cultural considerations for teleneuropsychology with Asian patients

Abstract

Objective:

Recent teleneuropsychology (TeleNP) models provide some degree of guidance in the application of telecommunication technologies toward the practice of neuropsychology. However, there remains a paucity of peer-reviewed data on TeleNP practices with culturally diverse patients, including Asian patients. This manuscript describes the challenges related to TeleNP practices with Asian patients and offers practical recommendations to complement existing TeleNP guidelines.

Method:

Based on extant literature on multicultural applications of neuropsychology, we

provide recommendations for TeleNP services with Asian patients that pertain to specific components of a TeleNP evaluation, such as a) pre-evaluation preparation, b) determining the appropriateness of the referral, c) determining language proficiency, d) working with interpreters, e) informed consent and confidentiality issues, f) conducting a culturally sensitive clinical interview, g) behavioral observations and communication, h) test selection, and i) interpreting data and writing reports.

Conclusions:

Our recommendations for TeleNP services with Asian patients highlight the need for flexibility to accommodate cultural differences and commitment to the complex nature of working with patients requiring interpretation services, while also recognizing the importance of preserving the validity of neuropsychological methods. Moving forward, it is imperative that the field of neuropsychology increases the training and accessibility of neuropsychologists who are knowledgeable in providing TeleNP services to Asian patients, and promotes research on the validation of TeleNP for Asian and other ethnic minority groups.

Keywords:

• Teleneuropsychology
• telehealth
• cross-cultural neuropsychology
• Asian patients

Medical and mental health care services delivered via telehealth have grown exponentially during the past 20 years and is transforming the delivery of health care for millions of individuals, particularly those living in underserved and distant rural locations (Brearly et al., 2017). A growing body of literature supports the viability of providing neuropsychological assessment through teleneuropsychology (TeleNP) (Cullum et al., 2014; Grosch et al., 2011; Harder et al., 2020; Parks et al., 2021). For example, TeleNP has demonstrated comparable effectiveness to face-to-face (FTF) assessments for diagnosing dementia in older adults (Cullum et al., 2006), and discriminating between cognitively impaired and non impaired older individuals (Wadsworth et al., 2018). Additionally, TeleNP has also been shown to increase service utilization among underserved populations (Caze et al., 2020), and patients and their family members have provided positive feedback about services delivered in this manner(Harrell et al., 2014; Parikh et al., 2013; Turner et al., 2012).

In response to logistical problems in providing FTF neuropsychological assessment during the COVID-19 pandemic, an advocacy group formed by the Inter Organizational Practice Committee (IOPC) developed comprehensive recommendations for TeleNP based on extant clinical and research to inform practitioners on the validity and effectiveness of the technique, as well as ethical, technical, and practical concerns, with the overall goal of ensuring the protection of both patients and neuropsychologists (IOPC, 2020). The proposed IOPC guidelines generally suggest that TeleNP is a feasible, cost-efficient, and readily available means for addressing the diagnostic and clinical needs for patients who are homebound, thereby allowing providers to reach a great number of individuals in a timely manner (Bilder et al., 2020; Postal et al., 2021). Other guidelines have also emphasized the importance of considering the competency of the provider, the best interest of the patient, and the balance of access to care with ethical, legal, logistical, and practical considerations with direct-to-home TeleNP models (Stolwyk et al., 2020).

TeleNP holds great potential for increasing access to culturally and linguistically competent services for Asian patients, many of whom lack accessibility to services from linguistically and culturally informed providers. With video technology, culturally competent neuropsychological assessments can theoretically be offered to Asian patients living in all 50 states. Another advantage of TeleNP with Asian patients is the potential to increase participation from collaterals and family members by including those who would otherwise be unable to join the patient for an in-person appointment due to geographic or scheduling conflicts. Currently, there is a paucity of studies investigating the validity of TeleNP with Asian patients, and no guidelines exist for conducting TeleNP assessments with Asian patients despite the need for increasing accessibility to TeleNP across diverse populations (Salinas et al., 2020).

This paper addresses shortcomings in the literature by providing guidance for using TeleNP with Asian patients. First, we briefly describe the Asian U.S. population and available services. Next, general cross-cultural neuropsychological considerations for working with the Asian American population living in the United States (U.S.) and its application towards TeleNP are discussed. The strengths and weaknesses of delivering culturally competent services via TeleNP, along with the recommendations towards TeleNP services with Asian patients are provided. The paper concludes with a discussion of future directions for neuropsychology and TeleNP services for Asian patients.

Demographics of Asian Americans in the United States and available neuropsychological resources

Asian Americans are the fastest-growing major racial group in the U.S. with an estimated 23.2 million people accounting for about 7% of the U.S. population (Budiman & Ruiz, 2021). According to 2019 census data, which lists 20+ specific Asian ethnic groups, the largest Asian ethnicities in the U.S. in descending order are Chinese (23%), Asian Indians (20%), Filipinos (18%), Vietnamese (9%), Koreans (8%), and Japanese (6%). Not only are Asian Americans ethnically heterogeneous, they are also demographically diverse. For example, household income among Asian ethnic groups range from $44,000 (Burmese) to $119,000 (Asian Indian),percentages of the population that are foreign born range from 27% (Japanese) to 85% (Bhutanese), percentages with limited English proficiency range from 22% (Filipino) to 53% (Vietnamese), and percentages with at least a bachelor’s degree range from 15% (Bhutanese) to 75% (Asian Indian) (Budiman & Ruiz, 2021). In comparison to the Asian population, there are relatively few Asian neuropsychologists practicing in this country. Notably, only 4.7% of respondents from a recent salary survey of clinical neuropsychologists practicing in the U.S. identified themselves as Asian or Pacific Islander (Sweet et al., 2021). Problems with accessibility to services for many Asians are more pronounced than the ratios would suggest, as neuropsychologists speaking Asian languages are most prevalent in coastal states and large cities. Moreover, numbers of neuropsychologists vary by ethnicity. As an example, for the six largest Asian ethnic groups, the Asian Neuropsychological Association (ANA) membership lists the following numbers of foreign language speakers: Chinese (Cantonese and Mandarin), Asian Indian (Hindi, Gujarati, Punjabi, Tamil, Telegu, Kannada, Oriya, Urdu, Marathi), Vietnamese, Korean, Japanese, and Filipino (Tagalog).

Recommendations for TeleNP services with Asian patients

Telemedicine has a number of attractive qualities when applied towards minority populations, including increased access to care and flexibility (Hilty et al., 2007; Waller & Stotler, 2018). Studies have validated TeleNP service delivery to culturally diverse populations such as Indian Americans in rural regions (Wadsworth et al., 2016) and elderly Japanese patients (Iiboshi et al., 2020; Yoshida et al., 2020). However, there remains a paucity of peer-reviewed data on best TeleNP practices for culturally diverse populations. To provide direction for TeleNP to clinicians working with Asian patients, we developed preliminary guidance adapted from models for conducting culturally informed neuropsychological assessments (Fujii, 2017, 2018; Wong & Fujii, 2004). Issues include: a) pre-evaluation preparation, b) determining the appropriateness of the referral, c) determining language proficiency, d) working with interpreters, e) informed consent and confidentiality issues, f) conducting a culturally sensitive clinical interview, g) behavioral observations and communication, h) test selection, and i) interpreting data and writing reports. It should be emphasized that cultural issues vary by ethnicity as well as level of acculturation; thus, it is essential that cultural contexts are individualized for each patient.

Pre-evaluation preparation

Preparation for an assessment with a patient from a culturally diverse background should begin prior to the assessment, as this information is crucial for developing a cultural context for understanding the patient and for guiding the examination process. The ECLECTIC Framework (Fujii, 2018) identifies cultural facets that are pertinent to neuropsychological assessment which include: 1) Education and literacy, 2) Culture and acculturation, 3) Language issues, 4) Economics, 5) Communication style, 6) comfort with the Testing situation, 7) conceptualization of Intelligence, and 8) Context of immigration (ECLECTIC framework; Fujii, 2017, 2018). An in-depth discussion of each facet of the ECLECTIC framework and its impact on the assessment process is beyond the scope of this manuscript. However, a few examples will be described to illustrate cultural considerations for TeleNP. Computer use requires a degree of reading skills to navigate websites and screens even when using a mouse. Thus, illiterate and persons with low levels of education may be less familiar with using technology. Websites or software may not be available for many languages as there are costs associated with technical development; thus persons from low resource countries who do not speak English may lack basic computer skills. Although widely accessible, there are minimal costs associated with using computers and surfing the Internet, and TeleNP may not be feasible for patients from low resource countries or who currently live in poverty, due to a lack of available equipment. Relatedly, some may have inferior equipment or services resulting in suboptimal connectivity (Bilder et al., 2020). For instance, cultural characteristics needed for TeleNP would suggest that service delivery in this modality may be inappropriate for Bhutanese Americans. Bhutan’s literacy rate is 66.6% (World Population Review, 2021). It is a low resource country (ranked 167 of 228 countries), with comparatively low internet availability (ranked 160 of 228 countries) (Central Intelligence Agency, 2021). In the early 1990s, the Lhotshampas, southern Nepali-speaking Bhutanese, were evicted from the country and placed in seven refugee camps around the country. The U.S. began accepting Bhutanese in 2008 (Wikipedia, 2021). Given the recency and reasons for immigration, it is not surprising that Bhutanese have low levels of English proficiency (36%) and household median income ($25,000) (Budiman, 2021). Given these characteristics, it is highly likely that Bhutanese may face technological challenges adapting to the Internet and use of technology, and furthermore be at an increased risk for discomfort and anxiety in the TeleNP setting.

Determining the appropriateness of the referral

It is the neuropsychologist’s professional and ethical responsibility to weigh benefits and risks, determine if the referral question can be answered through TeleNP and, if so, what model of TeleNP would be the most appropriate for the evaluation (e.g., in-clinic TeleNP, home TeleNP, hybrid models; IOPC, 2020). Part of this decision entails that the clinician determines whether the patient has access to adequate equipment (e.g., Internet, computer/laptop access) and knowledge of how to receive services via telecommunications. Given that racial/ethnic minorities are more likely to have the lowest SES (Eberly et al., 2020), some Asian patients may have limited access to technology and/or reduced understanding of how to navigate telehealth tools, especially if instructions are provided in the patient’s non-native language. Furthermore, it is recommended that the clinician consults with the referral source or meets with the patient prior to the first meeting to ascertain relevant diversity characteristics and cultural background of the patient, including ethnic origin, native language, language proficiency, and level of acculturation (Lau, 2014). The degree to which these cultural factors are salient for a patient, as well as the clinician’s knowledge and competency in working with patients of a certain cultural background will influence the clinician’s decision to provide services to the patient.

If a clinician decides to refer the patient elsewhere, a more suitable neuropsychologist (e.g., one who is competent to interact in the patient’s primary language) can be found by utilizing member directories associated with professional associations including the National Academy of Neuropsychology, International Neuropsychological Society, American Academy of Clinical Neuropsychology, and ANA. For example, a directory of Asian neuropsychologists listed by their ethnicity, languages spoken, areas of expertise, state licensures, and contact information is accessible on the ANA’s website (https://the-ana.org/membership/members-directory/). Unfortunately, as mentioned previously, neuropsychologists with expertise in every Asian language might not be available and there is limited availability of neuropsychologists in certain geographical regions, such as rural areas. When a neuropsychologist that speaks a similar language/dialect as the patient is not available, clinicians may choose to provide TeleNP services via an interpreter.

Determining language proficiency

A general cross-cultural neuropsychological consideration when working with ethnic minority patients is determining language proficiency to decide if interpretation services are needed. Clinicians should avoid making any assumptions about the patient’s language capabilities since not all Asian patients require language assistance, particularly those who are born and educated in the U.S. However, some patients who seem to have proficient conversational fluency may not possess higher-level verbal skills required for some neuropsychological tests. Factors related to bilingualism should also be considered, as patients with experiences of learning a second language may vary in their language proficiencies and comfort in use of English as their second language. While the final determination may not be made until the start of the assessment procedures, clinicians can rely on information from referral sources or demographic questionnaires to gather clues as to whether the evaluation should be conducted in a language other than English (Fujii, 2018). Furthermore, existing instruments are available to assess bilingualism and English proficiency for a more formal assessment, such as the Language Experience and Proficiency Questionnaire (Marian et al., 2007), the Language History Questionnaire (Li et al., 2006; 2014), and Language Background Questionnaire (Anderson et al., 2018). It is recommended that patients be contacted ahead of time to complete a preferred language questionnaire to determine whether acquiring interpreter services is necessary.

Working with interpreters

For monolingual patients or those with limited English proficiency, the utilization of interpretation services is necessary to avoid communication errors and increase comprehension. If TeleNP service requires an interpreter from a third-party organization, it is recommended that the interpreter use a HIPAA-complaint telehealth platform that is compliant with both state and federal regulations. An obvious challenge to working with an interpreter from a third-party organization include issues with the connection/bandwidth that could impede the evaluation. It is highly recommended that clinicians ensure that the interpretation service strictly adheres to the technical specifications proposed by the IOPC (e.g., bandwidth assessment, managing internet connectivity, equipment needed for telecommunication). Overall, the interpreter should be comfortable and proficient with video-based technology to ensure efficiency of services.

Following a general cross-cultural neuropsychological consideration when working with ethnic minority patients, clinicians should adhere to professional guidelines related to utilization of the use of interpreters in neuropsychological services. For example, Judd et al. (2009) recommended the use of interpreters who are trained and certified, adhere to professional ethics guidelines, and include their qualifications and document their involvement in the final assessment report. When interpretation services are indicated, Fujii (2018) suggested meeting with interpreters prior to the evaluation to discuss the overall goals of the evaluation, preparing materials and strategies for the evaluation, and introducing all parties involved in the process. Given the small size of some Asian communities, a pre-assessment teleconference enables clinicians to investigate whether the patient and interpreter are familiar with one another in some capacity to prevent breach of the American Psychological Association’s ethics code of dual relationships (Fujii, 2011).

A pre-assessment videoconference with the interpreter is also recommended to review the logistical details of the telehealth platform and testing procedures of the TeleNP appointment. Details such as how and when the interpreter is integrated onto the video appointment should be discussed. Additionally, presentation of appropriate test stimuli via “shared screen” for familiarization prior to test administration is recommended (e.g., presenting the verbal word list learning task to reduce the likelihood of translation mistakes during the TeleNP appointment). When possible, a pre-assessment training with the patient is recommended to enhance comfort with testing; a similar training procedure has been successfully adapted in TeleNP services with Parkinson’s disease patients seen for pre-deep brain stimulation candidacy at Emory University (Hewitt & Loring, 2020). Specifically, a pre-assessment training session was scheduled with a patient to ensure that the patient has sufficient infrastructure for TeleNP services, as well as assisting the patient with navigating the TeleNP platform to ensure a successful evaluation (Hewitt & Loring, 2020).

Another general cross-cultural neuropsychological consideration when working with ethnic minority clients includes examination of the pertinent dialects spoken in the patient’s native country. Specifically, many Asian countries have more than one national language that can constitute variations in dialect, word usage, and/or colloquialisms. For example, the Philippines contain over 100 different languages and dialects. Therefore, even when the interpreter and patient are speaking the same language, certain Asian dialects or cultural expressions can influence how questions and responses are phrased and interpreted. In such situations, clinicians should discuss with interpreters to ask patients to incorporate examples and definitions of terms when conversing to reduce the likelihood of miscommunication.

Informed consent and confidentiality issues

When working with Asian patients in TeleNP, clinicians should be prepared to provide an explanation about informed consent and confidentiality not only with the patient, but also with their family members if there is evidence of interdependence in health care decision-making. This is particularly important as many Asian patients live in multigenerational households and share the same living spaces (Cohn & Passel, 2018), making it difficult to obtain privacy. During the consent process, clinicians should explain the purpose, procedures, and implications of the assessment, as well as inquire about the patient’s understanding and goals for the assessment (Lau, 2014).

Clinicians can ensure the patient’s understanding of the evaluation process by asking them to repeat back what they understand and check for nonverbal cues (e.g., head nodding) to indicate that they are actively listening. Culturally diverse groups may display greater hesitancy in disclosing personal information (e.g., medical history, family history) due to concerns regarding how providers may use the private information. Therefore, discussions about the principle of confidentiality, the role of the neuropsychologist, and involvement of family should precede the assessment. In addition, clinicians should clearly communicate that any modifications to standard test administrations and involvement of interpreters or family members in nonstandard ways may influence confidence in diagnostic conclusions (IOPC, 2020).

Examining the patient’s social support network to identify trusted family members to assist with the technical aspects of the TeleNP evaluation is recommended. Clinicians may consider asking family members to assist with technological proficiency of the evaluation (i.e., set-up and education of technological features) where appropriate. For instance, the level of comfortability with technology use often varies by generational cohorts, as adolescents and young-to-middle-aged adults may feel more at ease navigating telehealth platforms relative to their older adult counterparts. This phenomenon becomes especially difficult when considering underrepresented minority, low SES, and limited English proficiency populations, as these individuals may have limited access to technology and reduced understanding of how to navigate telehealth tools. To ensure that TeleNP evaluations are conducted successfully, clinicians should allow adequate time in the interview/meeting to review the roles and expectations of any arrangement for family members who will provide assistance with technology, as well as allot extra time for interaction with interpretation services for the set-up, interview, and testing.

Conducting a culturally sensitive clinical interview

A general cross-cultural neuropsychological consideration when working with ethnic minority patients include incorporating the knowledge about the patient’s culture to help interpret presentations of the patient and family members, establish rapport, formulate culturally appropriate questions, and gather information about relevant contextual elements. This culturally sensitive approach to a clinical interview in traditional FTF neuropsychological assessment is applicable in TeleNP settings. The presence of family members, when appropriate, can help clinicians build trust and rapport with the patient, which may increase the willingness of the patient and family in sharing useful personal information. To further improve rapport, clinician should consider allowing more time for the patient to talk about their family, experiences in their country of origin, and daily lives (Fujii, 2011; Lau, 2014).

Clinicians should consider inquiring both the patient and family members about social history via the ECLECTIC framework in order to assess for levels of acculturation, values placed on family interdependence in health care decision-making, and available resources in the family and the larger community. Detailed collateral accounts can also provide valuable information about the presence or severity of any neurocognitive deficits and impairments in daily functioning. Although clinicians typically estimate premorbid abilities with reading tests, educational level, and/or occupational history, this data might not be valid for patients from immigrant populations. Information that can help estimate premorbid functioning for such patients include the native country the patient was born and raised, date and reason for immigrating, occupation and educational level in the native country, academic achievement in the native country, parent’s occupation and educational attainment, and the patient’s education and occupation after immigration (Wong & Fujii, 2004).

Test selection

With regard to appropriate tests for TeleNP, multiple guidelines for test selection have been proposed (e.g., Bilder et al., 2020; Grosch et al., 2011; Marra et al., 2020). For example, a recent systematic review of 19 studies by Marra et al. (2020) indicated that cognitive screeners (Mini-Mental State Examination [MMSE] and Montreal Cognitive Assessment), Category Fluency test, Digit Span, Hopkins Verbal Learning Test-Revised (HVLT-R), and Clock Drawing tests are all measures with moderate to strong support for TeleNP validity. More recently, Parks et al. (2021) compared in-home testing with FTF neuropsychological testing and demonstrated that a cognitive battery consisting of tests such as the Digit Span, HVLT-R, and Clock Drawing tests is a valid and clinically useful approach. Another study comparing in-home versus FTF testing have indicated that in-home administration of the Symbol Digit Modalities Test and California Verbal Learning Test-II are also valid and reliable measures for assessing processing speed and verbal memory, respectively (Barcellos et al., 2020).

While the previously mentioned reviews and recent studies acknowledge the underrepresentation of ethnic minorities as well as small fraction of tests that are validated for TeleNP services, some have also recommended that future protocols include both validated measures as well as additional measures specific to the patient population and referral question (Marra et al., 2020). In this context, clinicians can consider the following tests that have been validated with different cultures for adaptation to TeleNP services. The Consortium to Establish a Registry for Alzheimer’s disease (CERAD; Morris et al., 1989) was developed as a measure for assessing and tracking the progression of dementia, consisting of subtests such as Animal Fluency, Boston Naming Test (15-item short form), MMSE, Constructional Praxis and Recall, and World List Memory. As discussed in Fujii (2018), the CERAD has been translated and evaluated in a number of countries in Asia, including Korea (J. H. Lee et al., 2002), China-Hong Kong (Liu et al., 2011), India (Chandra et al., 1998), and Japan (Larson et al., 1998).

Clinicians can also consider subtests from the Neurobehavioral Core Test Battery (NCTB; Anger et al., 1993), such as the Digit Span and Benton Visual Retention (Recognition Form), for inclusion into a TeleNP test battery. The NCTB was originally developed by the World Health Organization (WHO) to identify the impact of chemical exposures on cognitive across different countries worldwide, including Asian countries such as China (Zhou et al., 2002), Japan (Yokoyama et al., 1998), Korea (Shin et al., 2007), and Singapore (Chia et al., 1997). Subtests from a second WHO international study among HIV patients in Thailand (Maj et al., 1994), such as the Auditory Verbal Learning Test (15-item similar to the Rey Auditory Verbal Learning Test), Picture Memory and Interference, and Verbal Fluency (animals and first names) can also be adapted for TeleNP services. Furthermore, the Bilingual Verbal Abilities Test (Munoz-Sandoval et al., 1998) was developed to assess language skills of individuals with aphasia and other language impairment and has been translated into Asian languages such as Cantonese, Hindi, Japanese, Korean, Mandarin, Tagalog, Tamil, Tulu, and Vietnamese. Test manuals for selected languages, along with stimulus books, are available for download at the publisher’s website. For a collateral measure in dementia evaluations, clinicians are encouraged to consider the Informant Questionnaire of Cognitive Decline in the Elderly (IQCODE; Jorm, 2004). As discussed by Fujii (2018), the IQCODE has been translated and evaluated in multiple Asian countries, such as China (Fuh et al., 1995), Japan (Yamada et al., 2002), Korea (Lee et al., 2005), and Thailand (Siri et al., 2006).

Behavioral observations and communication

Logistics of TeleNP, including small screens, a limited view of the patient and examiner, and intermittent connectivity interruptions, can negatively impact the obtainment of data from verbal and nonverbal forms of communication. This can be especially challenging for working with Asian patients due to indirect communication styles, stoicism, reticence to disclose personal information, and deference to authority. Asian cultures emphasize allegiance to the group, so indirect communication styles are often employed to avoid offending others during conversation. Nonverbal communications, such as facial expressions and body language, are important for determining mood and emotional responses in a patient with poor English proficiency. Furthermore, meaning of gestures may differ across cultures. For example, nodding for many Asian cultures means “I am listening to you” versus indicating agreement, and direct eye contact can be perceived as rude and invasive versus being honest (Fujii, 2011; Lau, 2014). These challenges to communication may be exacerbated by a deference to authority that is common in many Asian cultures. Thus, an Asian patient may be reticent to inform the examiner of difficulties encountered in communication due to suboptimal telehealth connections.

To improve telecommunication with TeleNP services, clinicians should consider cultural influences in nonverbal communication, such as facial expressions, eye contact, and body language, to avoid misinterpretations of their observations. For example, clinicians should look directly at the webcam rather than into the screen or the eyes of the patient throughout the evaluation to give the impression of direct eye contact. To prevent possible misunderstanding of disrespect, clinicians can explain to the patients that they may be taking notes during the assessment procedures to avoid the perception that the clinician is occupied with other matters not related to the evaluation. Clinicians should routinely check in with Asian patients to ensure optimal comfort and communication, and encourage patients to frequently ask questions and to provide immediate feedback of any technological difficulties throughout the TeleNP appointment. For patients requiring interpretation services, interpreters can serve the role of cultural guides and can be relied upon to provide information in a post-evaluation debriefing meeting to discuss relevant cultural issues that were observed (Fujii, 2011).

Interpreting data and writing reports

All assessment data (e.g., patient history, test results, collateral reports, and behavioral observations) should be integrated and interpreted within the context of the TeleNP procedures and the patient’s cultural characteristics. For example, results on verbal tests used in the U.S. are likely a low estimate of actual abilities if the patient is not proficient in English. In this case, the clinician must rely more heavily on consistencies in the patient’s overall presentation rather than focus on “deficits” in performance on select tests. However, even if the patient speaks fluently and is highly acculturated, the clinician should remain cautious in assuming that the predictive validity of test results is the same as for non-Asian patients (Wong & Fujii, 2004). Additionally, clinicians are encouraged to apply conservative interpretations of test results and widen the confidence intervals of interpretation where appropriate.

When test results are deemed to have poor validity, the clinician may need to emphasize functional abilities described by collateral sources in the interpretation of assessment data. Clinicians should clearly document all non standardized assessment procedures, rationale for the modifications, as well as limitations of test interpretations in the neuropsychological report. This includes a statement outlining the use of remote audiovisual presentation of test instructions and test stimuli, as well as remote behavioral observations via audiovisual technologies (IOPC, 2020). When writing diagnostic considerations, the clinician must evaluate the role of relevant cultural factors in the patient’s presenting concerns. This will help conceptualize implications of findings for the patient and family, as well as inform culturally sensitive treatment recommendations.

Future directions

Due to limited ethnically and linguistically congruent neuropsychologists, there is significant disparity in the utilization of neuropsychological and TeleNP services among Asian American population. Therefore, it is imperative that the field of neuropsychology continues to promote the training of clinicians who possess both foundational knowledge and skills of technological approaches, as well as ongoing cultural competency in their clinical practice before starting work with culturally diverse patients in TeleNP. For example, there needs to be a cadre of bilingual Asian-American neuropsychologists who are knowledgeable and trained in providing TeleNP services large enough to adequately service each Asian population. To accomplish this, the discipline needs to recruit trainees of Asian descent to develop a pipeline of providers in different Asian subgroups. While challenges have been documented in the successful retention and training of ethnic minority students (Byrd et al., 2010),developments such as the American Academy of Clinical Neuropsychology Relevance 2050 Initiative Student Pipeline Subcommittee are emphasizing the facilitation of neuropsychology training and professional development for trainees of diverse backgrounds. Additionally, the ANA offers educational webinars, mentorship opportunities, and peer support systems to increase opportunities for multicultural training, mentorship from neuropsychologists with diverse backgrounds, and social support for trainees of Asian descent.

To further address these issues, practice models where academic and clinical neuropsychology programs collaborate with Asian American neuropsychologists from around the country is worthwhile to consider. Although specifics of these relationships can take many forms, in one such model a neuropsychological service with a residency program could contract with a bilingual Asian neuropsychologist to provide services to local Asian patients. The Asian neuropsychologist could then provide supervision and mentor trainees in working with these patients. Training programs with these partnerships would benefit by increasing their ability to service ethnic minority populations, attract clinicians interested in cross-cultural neuropsychology, and research in healthcare disparities.

Asian neuropsychologists could be enticed to develop aforementioned partnerships through adjunct faculty positions, training and experience in TeleNP, reimbursement, honoraria, or opportunities for collaborating in research. Particularly, more research on the validation of TeleNP services, particularly for Asians and other ethnic minority groups is needed. Although there is a growing number of studies establishing TeleNP as a viable option of service delivery, there are no extant studies evaluating the use with ethnic minority samples or with use of interpreters. Also, more translated, normed, and validated tests for Asian populations need to be developed, particularly tests that can be administered via videoconferencing. While this model of service delivery can increase access to neuropsychological services for Asian patients, feasibility may rest upon continued support and advocacy by psychological organizations by way of legislation to loosen or change specific state licensure laws and reimbursement rates.

Disclosure statement

No potential conflict of interest was reported by the authors.