Editorial from the TCN department of culture and gender in neuropsychology: Updates, future directions, and next steps

The Clinical Neuropsychologist’s (TCN) Culture and Gender in Neuropsychology (CGN) Department is dedicated to advancing cutting edge and relevant science, editorial leadership, and open dialogue on issues related to diversity and inclusion (e.g., cultural, gender, etc.). Consistent with the aims set forth in our inaugural editorial (Rivera Mindt & Hilsabeck, 2018), the purpose of this editorial is to: (1) review TCN’s 2019 publications addressing cultural/linguistic and gender diversity, (2) summarize our activities over the past year, and (3) provide a “sneak peek” at upcoming TCN CGD projects.

Publications relevant to culture and gender in 2019

The review below shines a light on 2019 TCN publications that explicitly focused on issues relevant to dimensions of diversity and inclusion. There were 11 articles that fell into three general categories: (1) cultural/linguistic (see Table 1), (2) sex/gender (see Table 2), and (3) international perspectives (see Table 3). Four of these 11 articles are noted in the following tables twice as they provide information pertaining to multiple dimensions of diversity relevant to this review (i.e., Dassanayake & Ariyasinghe, 2019; Denckla et al., 2019; Kirsebom et al., 2019; Ryan et al., 2019).

Table 1. Neuropsychological studies of cultural/linguistic diversity published in 2019.

Author/s & Year	Title	Highlights
Fernandez (2019)	Modern neuropsychological tests for a diversity of cultural contexts	Overview: Issue 2 in 2019 was a special issue on modern neuropsychological assessment methods. In the final article of this special issue, the author highlighted important cultural considerations for globalization of modern neuropsychological tests.
		Methods/Results: Sample: Review of the 13 other articles in the special issue Results: Many people around the world do not have access to the internet, and computers, tablets, and wearable devices can be prohibitively expensive. Modern neuropsychological tests might not be appropriate in some countries because of high rates of illiteracy or low literacy, as well as inclusion of items that are not culturally appropriate or relevant.
		Take Home: Modern neuropsychological techniques should benefit all, both developed and underdeveloped countries, and take into consideration cost, educational opportunities (or lack thereof), and cultural factors.
Gasquoine et al. (2019)	Specificity rates for non-clinical, bilingual, Mexican Americans with California Verbal Learning Test-3, verbal fluency, and Rey 15-IR performance validity measures	Overview: This study examined failure rates of Mexican American adults on embedded performance validity (EPV) measures using valid/invalid performance cut scores developed for monolingual English-speaking adults.
		Methods/Results: Sample: N = 60 of Mexican American bilingual (English/Spanish) adults from the Texas-Mexico border region (M age = 34 yrs; 55% women; M education = 12 yrs; Born in U.S. [65%] vs. Mexico [35%], of which resided in U.S. M = 23 yrs]) Measures: CVLT-3, verbal fluency, the Rey 15-Item Test plus 15-IR Results: No significant differences were observed on failure rates with the different cut scores and language administered.
		Take Home: In this study, commonly used EPV measures demonstrated failure rates comparable to those recommended for monolingual English-speaking adults.
Ryan et al. (2019)	Normative performance of healthy older individuals on the Modified Mini-Mental State (3MS) examination according to ethno-racial group, gender, age, and education level	Overview: This study provides demographically-adjusted normative data (e.g., ethnoracial group, gender, age, and education) for the 3MS for community-dwelling older adults.
		Methods/Results: Sample: N = 19,000 older adults from Australia & the U.S. (Median age = 74 yrs; 56% women; M ed. = 12 yrs; 4.7% African-American; & 1.7% Latinx) Results: Significant effects of age, gender, education, and ethno-racial background were observed prior to applying the demographic adjustments.
		Take Home: Accounting for demographic characteristics, including ethno-racial background and gender, is important for improved understanding of 3MS test performance.

Notes. M = mean; U.S. = United States; CVLT-3 = California Verbal Learning Test-3; Rey 15-IR = Rey 15-item Test Plus Recognition.

Table 2. Neuropsychological studies relevant to sex/gender published in 2019.

Author/s & Year	Title	Highlights
Dassanayake and Ariyasinghe (2019)	Sex-, age-, and education-adjusted norms for Cambridge Neuropsychological Test Automated Battery (CANTAB) in literate Sri Lankan adults	Overview: This study provides age-, sex-, and education-adjusted norms for the CANTAB for Sri Lankan adults.
		Methods/Results: Sample: N = 311 community-dwelling adults in Sri Lanka (Age Range = 20–64 yrs; 50% women; Education Range = 2-20 yrs) Measures: CANTAB Results: There were significant and robust effects of age education across the CANTAB subtests. In contrast, smaller effects for gender were observed on processing speed and visuospatial subtests only.
		Take Home: This study provides regression-based demographic adjusted norms (age, education, and sex) for the CANTAB, and a link to electronically generate the norms is provided in the article.
Denckla et al. (2019)	Generalizability of demographically corrected Zambian neuropsychological norms to South African women.	Overview: The purpose of this study was to evaluate whether demographically corrected norms developed in Zambia would generalize to woman in South Africa (SA).
		Methods/Results: Sample: N = 212 Black, SA women with major medical, neurological or psychiatric conditions that would affect test performance (Age Range = 18–54 yrs; at least 5^th grade education) Measures: 17 test covering seven cognitive domains Results: The Zambia norms placed 17.9% of the sample below 1 SD from the mean on the Global Deficit Score. However, four of seven domains, verbal fluency (27.4%), working memory (24.2%), information processing speed (22.2%), and executive function (18.4%), classified a significantly larger proportion below expected levels.
		Take Home: The Zambia demographically corrected norms adequately corrected for age in the SA sample but did not adequately correct for the effects of education in this sample.
Kirsebom et al. (2019)	Demographically adjusted CERAD wordlist test norms in a Norwegian sample from 40 to 80 years.	Overview: The purpose of this study was to investigate the effects of age, gender, and education on performance on the wordlist memory test (WLT) of The Consortium to Establish a Registry for Alzheimer’s Disease (CERAD) in Norwegian adults aged 40-80 years.
		Methods/Results: Sample: N = 227 healthy adults and 168 persons diagnosed with mild cognitive impairment (MCI) Measures: CERAD WLT Results: Younger age, higher education, and female gender predicted better performance on the CERAD WLT; regression-based norms derived from heathy controls showed no effect of age, gender, or years of education when applied to the MCI group, indicating adequate adjustment of demographic factors in an independent sample.
		Take Home: This study provides demographic-adjusted (age, gender, and education) regression-based norms for the CERAD WLT for use with Norwegian adults aged 40-80 years. A free web-based norms calculator is included in the article.
Merritt et al. (2019)	A systematic review of sex differences in concussion outcome: What do we know?	Overview: This systematic review examined sex differences in outcomes in adults with concussion or mild traumatic brain injury (mTBI), updating previous critical reviews.
		Methods/Results: This review included adult human studies related to concussion, psychiatric, neuropsychological, and neuroimaging evaluations. Despite the robust concussion literature, there was a relative paucity of research addressing sex differences following concussion. The prevalence of concussion was generally higher in females than males.
		Take Home: Given the increased prevalence of concussion and potential higher symptom reporting among women, ongoing research is necessary to better understand the role of biological sex on outcome following concussion.
Ryan et al. (2019)	Normative performance of healthy older individuals on the Modified Mini-Mental State (3MS) examination according to ethno-racial group, gender, age, and education level	Please see Table 1 above for details as ethno-racial background was a key variable.

Table 3. International studies in neuropsychology published in 2019.

Author/s & Year	Title	Highlights
Dassanayake and Ariyasinghe (2019)	Sex-, age-, and education-adjusted norms for Cambridge Neuropsychological Test Automated Battery (CANTAB) in literate Sri Lankan adults	Please see Table 2 above for details as gender was a key study variable.
Denckla et al. (2019)	Generalizability of demographically corrected Zambian neuropsychological norms to South African women	Please see Table 2 above for details as gender was a key study variable.
Kirsebom et al. (2019)	Demographically adjusted CERAD wordlist test norms in a Norwegian sample from 40 to 80 years	Please see Table 2 above for details as gender was a key study variable.
Lo et al. (2019)	Auditory memory span in Mandarin-speaking preschoolers with congenital hearing loss: Impact of task structure	Overview: This study examined whether children with and without hearing loss, who were all developing spoken language at comparable levels, would demonstrate differences on an auditory working memory span task if speech production was excluded from the task requirement.
		Methods/Results: Sample: N = 63 Mandarin-speaking preschoolers (52% with hearing loss vs. 48% without; 40% girls) Measures: A listen-and-point Digit Span (LPDS) task, the WISC-IV Verbal Digit Span and Matrix Reasoning subtests, and a language assessment Results: There were no differences between the two groups on the LPDS task.
		Take Home: Children with hearing loss were able to perform comparably to hearing children on an auditory working memory task when speech processes were not required.
Nyamayaro et al. (2019)	Assessment of neurocognitive deficits in people living with HIV in Sub Saharan Africa: A systematic review	Overview: This systematic review focused on how neurocognitive impairment (NCI) is assessed in HIV-infected adults in Sub-Saharan Africa (SSA).
		Methods/Results: Sample: N = 23 articles that reported using a comprehensive neuropsychological battery (i.e., at least one test across six cognitive domains) to assess NCI in HIV-infected adults in SSA. Results: Studies from seven out of 46 countries in SSA were included; sample sizes ranged from 60 to 266; the most commonly used tests were Color Trails and WAIS-III Digit Symbol; some tests have been translated into languages commonly used in SSA; some verbal learning tests were adapted to contain culturally relevant words; test administration was almost always conducted by non-neuropsychologists
		Take Home: While tests utilized to detect NCI in HIV-infected adults in SSA are similar to tests used around the world, the process of adaptation often is not clear, and local norms are lacking.
Raudeberg et al. (2019)	Norms matter: U.S. normative data under-estimate cognitive deficits in Norwegians with schizophrenia spectrum disorders	Overview: This study investigated how different normative data impact the accuracy of identifying cognitive impairment in persons with schizophrenia spectrum disorders (SSD).
		Methods/Results: Sample: N = 315 adults with SSD residing at a psychiatric inpatient hospital in Norway (Age Range = 18 - 38 yrs; 38% women; Education Range = 9 - 18 yrs) Measures: Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) Results: Significant differences between the Norwegian and U.S. normative scores were observed on the RBANS Total Scale Index and numerous domains, with higher scores resulting from U.S. normative data.
		Take Home: Utilizing U.S. normative data with Norwegian adults with SSD increases the risk of misclassification of impairment on the RBANS.
Shanhu et al. (2019)	Effects of age and education on clock-drawing performance by elderly adults in China	Overview: This study examined the effects of gender, age, and education on the Clock Drawing Test (CDT) scores.
		Methods/Results: Sample: N = 885 older community-dwelling adults in southeastern China (M age = 75 yrs; 50% women; % school completed = 25% primary, 53% high school, and 22% university; specific language/s used in study [e.g., Mandarin, Cantonese] = not reported) Measures: CDT and Mini-Mental State Examination (MMSE) Results: There were significant effects of age and education, but not gender on the CDT.
		Take Home: This study provides demographically-adjusted normative data (e.g., age, education) for the CDT for use with older adults residing in China to enhance the use and diagnostic accuracy of the CDT as a screening tool.

* Note. CERAD = The Consortium to Establish a Registry for Alzheimer’s Disease; WISC-IV = Wechsler Intelligence Scale for Children-IV; U.S. = United States; M = mean.

The results of the current review merit comment on a few key findings. First, it is notable that the majority (6 of 11) of TCN’s 2019 publications focused on providing normative data for various populations. While these newly published normative data undoubtedly represent critical contributions to the advancement of neuropsychological science, it is also imperative to remember that such studies do not actually advance our understanding of the effects of biological sex, gender, or the myriad sociocultural factors that may be contributing to brain function and neuropsychological test performance. In fact, only one of the three cultural/linguistic publications and one of the five sex/gender publications were empirical studies investigating these fundamental questions. Thus, it is clear that additional research is needed to go beyond just providing demographic adjustments to better help us understand the underlying mechanisms affecting brain function and neuropsychological test performance among different populations.

Second, as Fernandez (2019) cogently argues, as our field becomes more globalized and increasingly incorporates electronic and digital technologies into our assessment methods, it is essential that researchers and clinicians alike consider the implications of this evolution for individuals in low resource settings and those with limited literacy. For instance, access and utilization of the internet, computers, tablets, and wearable devices may not be feasible or sustainable in many settings. Further, the dearth of culturally relevant neuropsychological instruments remains an urgent problem for our field. The increasing globalization of our field, the digitizing of our neuropsychological techniques, and the need for culturally relevant instruments (through validation of existing measures or new measures) represent burgeoning areas for future research.

Third, Merritt et al. (2019) systematic review is particularly notable as this review indicates that concussion prevalence appears higher in women than men. However, the role of biological sex in this association remains poorly understood as this continues to be an under-researched area. Thus, this work highlights the critical need for future research to investigate the role of biological sex, and we would argue gender diversity as well, on brain health outcomes and neuropsychological test performance in concussion and traumatic brain injury research and beyond.

Fourth and finally, the Lo et al. (2019) study merits consideration for multiple reasons. This study represents a vital contribution to the developmental neuropsychological literature as it sheds light on an important research topic. Specifically, the investigators found that among Mandarin-speaking preschoolers residing in China, those with hearing loss were able to perform comparably to hearing children on an auditory working memory task when speech processes were not required. This is an important finding on its own. However, this study is also noteworthy for two additional reasons. It is the only study in TCN’s 2019 slate of diversity-related papers that: (1) includes a pediatric sample, and (2) addresses a key dimension of diversity that often goes understudied, sensory loss (in this case, hearing loss). Regarding the former issue, Byrd et al. (2008) noted the profound paucity of cultural neuropsychological research within pediatric and adolescent populations over 10 years ago and the need for research in this area continues. Moreover, the effects of intersectionality (e.g., different abilities, LGBT) and consideration of multiple dimensions of diversity merit further research and attention.

TCN CGN department activities in 2019

Following our inaugural editorial, we were contacted by the publisher of Science Editor who requested a webinar and case report describing the strategic efforts of TCN to improve diversity and inclusion in several aspects of the journal (Rivera Mindt et al., 2018). Specifically, the article highlights TCN’s efforts to solicit submissions that address issues of culture, gender, and diversity, improve scientific reporting practices with respect to gender and culture, increase representation of women and underrepresented minorities on the Editorial Board, and creation of the CGN Department. Over the past year, these efforts have been appreciated and recognized by several other journal publishers.

Upcoming TCN CGN department projects

We are encouraged by the number of publications in 2019 focused on issues related to culture and gender diversity and inclusion. To keep the momentum going, we have solicited a commentary on white privilege and have asked a few individuals to comment, and a special issue on cultural neuropsychology is in the planning stages. In addition, a special issue dedicated to the Neuropsychological Norms for the US-Mexico Border Region in Spanish (NP-NUMBRS) Project will be published in early 2021. This collection of papers will provide normative data for a comprehensive, co-normed neuropsychological test battery for native Spanish-speaking community-dwelling adults from the U.S. (California/Arizona)-Mexico borderland region (N = 254; ages 19-60 years). Many of these papers are already available online.

There are two additional upcoming projects that are worth mentioning. First, TCN’s CGN Department will be convening a workshop at the American Academy of Clinical Neuropsychology’s (AACN) annual meeting in June 2021 in Portland, OR (Rivera Mindt et al., 2021). The workshop will include an active discussion about two “hot topics” in culture and gender diversity in neuropsychology, including the use of normative data in culturally/linguistically diverse populations and neuropsychological assessment of transgender individuals. Second, we will be surveying TCN editorial board members and individuals completing ad hoc reviews for TCN within the past year in an effort to understand demographic characteristics, including gender, ethnocultural background, and primary language, as well as competing demands for completing reviews and ways to improve the editorial review process. It is anticipated that information gleaned from this survey will inform future decisions about selection of and support for editorial board members and reviewers.

In closing, we continue to be excited about and inspired by ongoing efforts of TCN and other neuropsychological organizations and journals to promote the science of diversity and inclusion. We encourage the readers of TCN to reach out to us with feedback and/or ideas for future projects. Together, we can move forward science and practice on this important topic.

Robin C. Hilsabeck, PhD, ABPP Associate Professor of Neurology, Dell Medical School at University of Texas-Austin Director, Comprehensive Memory Center, Mulva Clinic for the Neurosciences, Austin, TX, USA [email protected] Monica Rivera-Mindt, PhD, ABPP Professor of Psychology & Latin American Latino Studies Institute Fordham University, Department of Neurology, Icahn School of Medicine at Mount Sinai, New York City, NY, USA [email protected]