Editorial from the TCN department of culture and gender in neuropsychology: Moving the field toward broader representation in neuropsychological studies

The Culture and Gender in Neuropsychology (CGN) Department at The Clinical Neuropsychologist (TCN) continued its efforts to advance the science and practice of diversity and inclusion in 2021 through provision of a special issue (detailed below) and virtual workshop at the annual meeting of the American Academy of Clinical Neuropsychology (Rivera Mindt et al., 2021). In this end-of-year editorial, we summarize 2021 publications in TCN that addressed various forms of diversity (cultural, linguistic, and gender).

Publications relevant to culture and gender in 2021

One of the main products of TCN’s CGD in 2021 was completion of a special Issue on white privilege in neuropsychology and norms for Spanish-speakers in the United States-Mexico border region (see Rivera Mindt et al., 2021a). The commentary by Cory (2021), along with comments by Byrd (2021), Cagigas (2021), and Postal (2021), highlighted the potential for professional complacency that comes from white privilege, and offered suggestions on how neuropsychology can take action. The rest of that special issue consists of a series of articles focused on the development of neuropsychological test norms on a comprehensive battery of tests for Spanish-speakers living in the United States (U.S.)-Mexico border region, i.e., the Neuropsychological Norms for the U.S.-Mexico Border Region in Spanish (NP-NUMBRS) project (see Table 1). The articles include an introduction to the NP-NUMBRS project (Marquine et al., 2021), a review of the literature on neuropsychological normative data available for Spanish-speakers in the U.S. (Morlet-Pareders et al., 2021a, 2021b), a detailed description of the sample characteristics and methodology of the NP-NUMBRS project (Cherner, Marquine et al., 2021), several manuscripts describing the development of normative data and the results for specific tests in the NP-NUMBRS battery (Marquine et al., 2021; Rivera Mindt et al., 2021; Suarez et al., 2021a; Gooding et al., 2021; Marquine et al., 2021; Morlett Paredes et al., 2021; Diaz-Santos et al., 2021; Heaton et al., 2021and Scott et al., 2021), the application of the NP-NUMBRS data to a sample of Spanish-speakers with HIV (Kamalyan et al., 2021), the influence of English fluency on the data derived from the NP-NUMBRS project (Suárez et al., 2021), and a discussion of the overall findings, limitations and future directions of the NP-NUMBRS project (Rivera Mindt et al., 2021b, 2021c, 2021d). Overall, these articles underscore the importance of utilizing culturally and linguistically relevant norms to improve diagnostic accuracy among Spanish-speakers in the U.S.

Table 1. Manuscripts included in the special issue on the neuropsychological norms for the United States (U.S.)-Mexico border region in Spanish (NP-NUMBRS) Project.

Overview
Authors (Year)	Title	Highlights
Overview: This manuscript provides an overview of the conceptual framework and rationale that guided the development of the NP-NUMBRS project.
Marquine et al. (2021)	Introduction to the Neuropsychological Norms for the U.S.-Mexico Border Region in Spanish (NP-NUMBRS) Project	Take Home: The NP-NUMBRS project aimed to provide a tool to best identify underlying brain dysfunction via neuropsychological tests, and characterize cognitive strengths and weaknesses among Spanish-speakers in the U.S., which represent a sizable proportion of the U.S. population that has been underrepresented in neuropsychological research.
Overview: This study identified published neuropsychological normative data for Spanish-speakers in the U.S. to date.
Morlett Paredes et al. (2021)	The state of neuropsychological test norms for Spanish-speaking adults in the United States	Methods/Results: Methods: Systematic literature review Results: 18 sources of normative data were identified; 4 of these provided normative data separately in Spanish-speakers on comprehensive test batteries. Take Home: There is an urgent need for co-normed batteries of neuropsychological tests among large, diverse, and well-characterized groups of Spanish-speaking adults living in the U.S.
Overview: This manuscript details the methodology and sample characteristics of the NP-NUMBRS project
Cherner, Marquine et al. (2021)	Neuropsychological Norms for the U.S.-Mexico Border Region in Spanish (NP-NUMBRS) Project: Methodology and sample characteristics	Methods/Results: Sample: 254 healthy native Spanish-speakers (age: 19-60 years; years of education: 0-20; 59% women) living in the U.S.-Mexico border regions of Arizona and California. Measures: Comprehensive neuropsychological test battery; standardized culturally-appropriate approach for determining years of education; measures of educational, social and linguistic background. Statistical approach: Fractional polynomial equations were used to model linear and non-linear effects of demographic factors (age, education, gender) on test performances. Rates of “impairment” (T-scores < 40) were calculated by applying the newly developed norms and available norms for non-Hispanic English-speakers on comparable tests. Take Home: The NP-NUMBRS project co-normed a comprehensive neuropsychological test battery via robust statistical methods in a well-characterized group of Spanish-speakers in the U.S.-Mexico border region.
Overview: These studies provide normative data on specific cognitive tests
Marquine et al. (2021)	Demographically-adjusted norms for selected tests of verbal fluency: Results from the Neuropsychological Norms for the US-Mexico Border Region in Spanish (NP-NUMBRS) project	Measures: Tests of letter (PMR) and semantic/category fluency (Animal Naming) Results: There were positive small effects of age and medium effects of education on verbal fluency raw scores. Published norms for non-Hispanic Whites overestimated rates of impairment, while published norms for non-Hispanic Blacks/African Americans underestimated impairment.
Rivera Mindt et al. (2021)	Demographically-adjusted norms for the processing speed subtests of the WAIS-III in a Spanish-speaking adult population: Results from the Neuropsychological Norms for the U.S.-Mexico Border Region in Spanish (NP-NUMBRS) project	Measures: WAIS-III Digit Symbol Coding and Symbol Search subtests Results: Older age and lower education were related to lower raw scores on both tests. Published norms for English-speaking non-Hispanic Whites slightly overestimated impairment rates on both tests, while norms for English-speaking non-Hispanic Black/African Americans yielded impairment rates within expectation.
Suarez et al. (2021)	Demographically adjusted norms for the Trail Making Test in native Spanish speakers: Results from the neuropsychological norms for the US-Mexico border region in Spanish (NP-NUMBRS) project	Measures: Trail Making Test (TMT): Parts A and B Results: Older age and lower education were associated with worse TMT raw scores. Published norms for English-speaking non-Hispanic Whites overestimated impairment on the TMT, while norms for non-Hispanic Blacks/African Americans yielded generally expected rates of impairment.
Gooding et al. (2021)	Demographically-adjusted norms for the Paced Auditory Serial Addition test and Letter Number Sequencing test in Spanish-speaking adults: Results from the Neuropsychological Norms for the U.S.-Mexico Border Region in Spanish (NP-NUMBRS) Project	Measures: Paced Auditory Serial Addition Test (PASAT) and Wechsler Adult Intelligence Scale Letter Number Sequencing (LNS) subtest Results: Lower education was associated with lower raw scores on both tests. Older age was associated with lower raw scores on LNS, and women obtained lower raw scores than men on PASAT. Published norms for English-speaking non-Hispanic Whites substantially overestimated impairment on both tests, while norms for non-Hispanic Blacks/African Americans resulted in generally expected impairment rates.
Marquine et al. (2021)	Demographically adjusted normative data for the Wisconsin Card Sorting Test-64 item: Results from the Neuropsychological Norms for the U.S.–Mexico Border Region in Spanish (NP-NUMBRS) project	Measures: Wisconsin Card Sorting Test (WCST)-64 item Results: Older age and lower education were associated with worse raw scores on most WCST-64 measures, with stronger education effects among women than men. Norms developed for non-Hispanic Whites overestimated rates of impairment, while norms developed for non-Hispanic Blacks/African Americans resulted in generally expected rates of impairment.
Morlett Paredes et al. (2021)	Demographically adjusted normative data for the Halstead category test in a Spanish-speaking adult population: Results from the Neuropsychological Norms for the U.S.-Mexico Border Region in Spanish (NP-NUMBRS)	Measures: Halstead Category Test Results: Older age, lower education and female gender were significantly associated with increased number of errors. Norms for English-speaking non-Hispanic Whites and Blacks overestimated rates of impairment, except in participants with higher than a high school education where rates of impairment using non-Hispanic Black norms were within expectation.
Díaz-Santos et al. (2021)	Updated demographically adjusted norms for the Brief Visuospatial Memory Test-revised and Hopkins Verbal Learning Test-revised in Spanish-speakers from the U.S.-Mexico border region: The NP-NUMBRS project	Measures: Brief Visuospatial Memory Test-Revised (BVMT-R) and Hopkins Verbal Learning Test-Revised (HVLT-R) Results: Less years of education were associated with lower raw scores in BVMT-R and HVLT-R measures, and older age was associated with worse BVMT-R raw scores, with this latter association being evident only among women on some HVLT-R measures. Norms for non-Hispanic Whites overestimated impairment, while norms for non-Hispanic Blacks/African Americans generally resulted in expected rates of impairment. Participants in Arizona obtained slightly lower T-scores than those in California, and thus site was added to T-scores formulas.
Heaton et al. (2021)	Demographically-adjusted norms for the Grooved Pegboard and Finger Tapping tests in Spanish-speaking adults: Results from the Neuropsychological Norms for the U.S.-Mexico Border Region in Spanish (NP-NUMBRS) Project	Measures: Grooved Pegboard Test and Finger Tapping Test Results: Lower education was associated with worse performance on both tests. Associations of age and gender differed by measure. Norms for English-speaking non-Hispanic Whites and Blacks generally underestimated impairment rates.
Scott et al. (2021)	Demographically-adjusted norms for the WAIS-R Block Design and Arithmetic subtests: Results from the Neuropsychological Norms for the US-Mexico Border Region in Spanish (NP-NUMBRS) project	Measures: WAIS-R Block Design and Arithmetic subtests Results: Higher education and male gender were associated with higher raw scores on both tests. Norms for English-speakers underestimated impairment.
Overview: This study examined the rate, pattern, and correlates of HIV-associated neurocognitive impairment in native Spanish-speakers living in the US near the Mexican border.
Kamalyan et al. (2021)	Neurocognitive impairment in Spanish-speaking Latinos living with HIV in the US: Application of the neuropsychological norms for the US–Mexico border region in Spanish (NP-NUMBRS)	Methods/Results: Sample: N = 407 Spanish-speakers (153 persons living with HIV [PLWH] and 254 participants from the NP-NUMBRS project) Measures: A neuropsychological test battery including tests in the NP-NUMBRS project Results: Utilizing NP-NUMBRS normative data, global neurocognitive impairment was significantly higher among PLWH (39%) than healthy controls (17%). Applying norms developed for English-speaking non-Hispanic Whites and Blacks to the current sample of PLWH resulted in overestimation (63%) and underestimation (18%) of impairment, respectively. More years of antiretroviral exposure were significantly associated with decreased rates of neurocognitive impairment among PLWH without a history of substance use disorder. Take Home: Findings support the validity of the normative data developed via the NP-NUMBRS project.
Overview: This study evaluated the influence of English-fluency on normative data derived from the NP-NUMBRS project.
Suárez et al. (2021)	Native Spanish-speaker’s test performance and the effects of Spanish-English bilingualism: results from the neuropsychological norms for the U.S.-Mexico Border Region in Spanish (NP-NUMBRS) project	Methods/Results: Sample: N = 170 participants from the NP-NUMBRS project Measures: Letter fluency was assessed in English (F-A-S) and Spanish (P-M-R). Degree of bilingualism was calculated as the ratio of words produced in English over total words in both languages. Results: Higher bilingualism was associated with higher raw scores on all tests, but only associated with higher demographically adjusted T-scores on a limited number of tests (i.e., WAIS-III Digit Symbol, Symbol Search, Letter-Number Sequencing and Trails B). Take Home: Normative adjustments provided by the NP-NUMBRS project appear generally applicable to Spanish speakers with various degrees of bilingualism.
Overview: This manuscript summarizes findings and discusses strengths and limitations of the NP-NUMBRS project, and offers directions for future research.
Rivera Mindt, Marquine et al., (2021)	The Neuropsychological Norms for the U.S.-Mexico Border Region in Spanish (NP-NUMBRS) Project: Overview and considerations for life span research and evidence-based practice	Results: Higher age and lower education were associated with worse raw scores on most tests, with effects of gender being less common. Applying norms developed for other cultural groups resulted in misestimation of neurocognitive impairment. Take Home: The application of population-specific normative adjustments to neuropsychological data for Spanish-speakers is likely to improve diagnostic accuracy in this group. Future studies might include U.S.-dwelling Spanish-speakers from other regions and ages; include additional cognitive domains (language, visuospatial); examine how sociocultural factors impacting test performance; investigate these norms’ diagnostic and ecological validity; and develop norms for neurocognitive change across time.

In addition to this special issue, there were nine articles focused on cultural/linguistic diversity in 2021 (see Table 2). The majority (i.e., eight) were psychometric and/or normative studies involving a variety of international samples (Anni et al., 2021; Dassanayake et al., 2021; Fazio et al., 2021; Goudsmit et al., 2021; Havlik et al., 2021; Muller et al., 2021; Ryan et al., 2021), and one was a systematic literature review of the effects of acculturation on neuropsychological test performance (Wen Tan et al., 2021).

Table 2. Neuropsychological studies of cultural/linguistic diversity published in 2021.

Authors & Year	Title	Highlights
Anni, Käärik, and Mõttus (2021)	WAIS-III measurement invariance: Data from Estonian standardization	Overview: This study investigated the measurement invariance of the WAIS-III across age, sex and education in an Estonian sample Methods: Sample: 770 participants from the Estonian WAIS-III standardization sample, stratified by age (16-29, 30-54, 55-89 years), sex (56% female), and education (less than 9 years, 10-12, and 13-20 years) Measure: WAIS-III Results: The structure model was partially invariant across age and sex, but not education. Take Home: While the WAIS-III functions similarly across Estonians of different ages and sex, it might measure different constructs across education groups.
Chovaz, Ashton Rennison, and Chorostecki (2021)	The validity of the test of memory malingering (TOMM) with deaf individuals	Overview: The purpose of the study was to explore whether the standard TOMM cut-off scores would be appropriate for use with deaf individuals whose first language is ASL. Methods/Results: Sample: 30 culturally Deaf, community-dwelling adults from Canada (M age = 46 years, range 21-64 years; 63% women; 18 attended School for the Deaf, 16 had university or Master’s degrees; none reported litigation or secondary gain issues Measures: WASI-II, MMSE, TOMM Results: All but one participant scored > = 45 on Trial 1 of the TOMM and all > =45 on Trial 2 and the Retention Trial Take Home: The TOMM can be used without modifications with Deaf individuals who use ASL.
Dassanayake, Hewawasam, Baminiwatta, and Ariyasinghe (2021)	Regression-based, demographically adjusted norms for Victoria Stroop Test, Digit Span, and Verbal Fluency for Sri Lankan adults	Overview: This study provides sex-, age-, and education-adjusted norms for three attention/executive functioning measures for Sri Lankan adults. Methods/Results: Sample: 606 community-dwelling adults in Sri Lanka; age range = 19-83 years (M age = 49.7 years), 55% women, education range = 1-23 years (M education = 12.9 years) Measures: Victoria Stroop Test (VST), Digit Span, and Verbal Fluency Results: Younger age and higher education were associated with better performance on all measures, while female sex was associated with better performance on some VST and Verbal Fluency measures. Take Home: Regression-based demographic adjusted norms (sex, age, and education) are provided for the VST, Digit Span, and Verbal Fluency for Sri Lankan adults. An excel worksheet with embedded regression equations is available to calculate standardized scores.
Fazio, Soósová, Bak, Růžička, & Bezdicek, 2021	A normative study of the Czech Edinburgh Cognitive and Behavioural ALS Screen (ECAS): a brief report	Overview: This study provides internal consistency and normative values for the Czech version of the ECAS. Methods: Sample: 102 healthy participants recruited from the community; age range 20-90 years (M age = 54.92 years), 53% female, and education range 9-19 years (M education = 14.52 years) Measure: ECAS Results: Internal consistency was acceptable (α = 0.69), and age and education correlated significantly with ECAS total and subscale scores. Take Home: The ECAS is valid for use as a screening tool for patients with ALS. Normative data stratified by age (≤ 60 and > 60 years) and education (< 14 and ≥ 14 years) are provided.
Goudsmit et al. (2021)	Dementia detection with a combination of informant-based and performance-based measures in low-educated and illiterate elderly migrants	Overview: The goal of the study was to investigate the diagnostic accuracy of the IQCODE and RUDAS compared to a clinical diagnosis made by a geriatrician. Methods/Results: Sample: 109 non-Western immigrant older adults evaluated for cognitive concerns (27 cognitively intact, 33 MCI, and 49 dementia) and 20 community controls; most participants were from Turkey or Morocco; 40-55% of participants across groups were illiterate Measures: IQCODE, RUDAS Results: IQCODE scores did not correlate with demographic variables, including literacy, education, or ethnicity; median RUDAS scores differed significantly by ethnic group but not by literacy status; diagnostic accuracy of IQCODE was slightly better than RUDAS and the combination was slightly better than IQCODE alone Take Home: An informant-based measure, IQCODE, showed good diagnostic accuracy for discriminating among cognitively intact vs. MCI. vs. dementia in non-Western older adults who were illiterate or had low levels of education; the addition of a cognitive performance-based measure, RUDAS, improved diagnostic accuracy slightly
Havlik, et al. (2021)	The normative data study of the Czech MATRICS consensus cognitive battery	Overview: This study provides normative data for the MATRICS consensus cognitive battery (MCCB) for use with individuals from the Czech Republic. Methods: Sample: 573 healthy adults recruited from the community; age range 17-62 years (M age = 31.2 years), 56% female, and education range 9-19 years (M education = 15.6 years) Measure: MCCB Results: Age, sex, and education were significantly associated with MCCB scores, with younger age, female sex, and higher education associated with better performance in some but not all cognitive domains. Take Home: Normative data stratified by age, sex, and education as well as regression-based normative data are provided for the MCCB for use with the Czech population.
Muller, et al. (2021)	Nonverbal fluency assessed by the five-point test in epilepsy patients with unilateral mesial temporal sclerosis—a Brazilian study	Overview: This study examined performance on nonverbal and verbal fluency measures in a Brazilian sample of epilepsy patients with unilateral mesial temporal sclerosis. Methods/Results: Sample: 180 epilepsy patients with unilateral mesial temporal sclerosis (79 right, 101 left epiloptogenic focus) and 150 healthy controls; age range 18-65 yrs; 48-53% women. Measures: Five-point test (nonverbal fluency); COWAT (FAS) & Animal naming (verbal fluency) Results: Patients performed lower than controls on nonverbal fluency. Within the patient group, there were no differences on nonverbal fluency by lateralization focus, but verbal fluency was lower among patients with left compared to right focus. Take Home: The temporal lobe appears to be involved in nonverbal fluency tasks.
Ryan et al. (2021)	Normative performance of older individuals on the Hopkins Verbal Learning Test-Revised (HVLT-R) according to ethno-racial group, gender, age and education level	Overview: This study provides demographically-corrected normative data for the HVLT-R in community-dwelling older adults from Australia and the United States (U.S.) Methods/Results: Sample: 16,251 white Australian and 2,290 U.S. participants (1,082 white, 894 African-American, and 314 Hispanic/Latino, 56 of whom were Spanish-speaking); age range 65-98 years; 55-68% women Measure: HVLT-R Results: Ethno-racial group, gender, age, and education were significant independent predictors of HVLT-R Total, Delayed Recall, percent retention, and recognition discrimination index; there also were significant between-country differences; most consistent finding was that women outperformed men in total and delayed recall tasks across all ethno-racial groups Take Home: Demographic corrections are useful for interpreting HVLT-R performance, and stratification by country and ethno-racial groups in addition to age, gender, and education levels are needed for some scores.
Wen Tan, Burgess, and Green (2021)	The effects of acculturation on neuropsychological test performance: A systematic literature review	Overview: This study synthesized quantitative studies investigating the association of acculturation and neuropsychological test performance Methods/Results: Methods: Systematic literature review including studies that used a validated acculturative scale and routinely used neuropsychological test(s), and that used statistical methods which considered potential confounding variables. Results: Twenty-one studies were included. The majority were conducted in the U.S., and scales of acculturation were mostly unidimensional. Seven studies did not find a significant association between acculturation and neuropsychological test performance. Take Home: While acculturation might influence performance on some cognitive tests, this association is less notable in delayed memory tests.

Notes: WAIS-III = Wechsler Adult Intelligence Scale-Third Edition; ASL = American Sign Language; M = Mean; WASI-II = Wechsler Abbreviated Scale of Intelligence - Second Edition; MMSE = Mini Mental State Examination; IQCODE = Informant Questionnaire for Cognitive Decline in the Elderly; RUDAS = Rowland Universal Dementia Assessment Scale; ALS = amyotrophic lateral sclerosis; COWAT = Controlled Oral Word Association Test.

Articles specifically addressing issues related to sex and gender were limited to one case study by Scharaga et al. (2021), which presented the case of an 85-year-old transgender individual who has been diagnosed with dementia due to Alzheimer disease. The authors evaluated whether applying normative data for men or women resulted in significantly different standard scores. They found that scores did not differ by more than one or two standard score points and did not result in different interpretations of performance in any cognitive domain. The authors acknowledged that the level of impairment exhibited by their patient was significant, and differences may be present when individuals are less impaired. They provide recommendations about information to be elicited during clinical interviews with transgender individuals, such as the timeline of the gender transition and use of cross-sex hormones, and list several resources that may be helpful for neuropsychologists when serving the transgender population.

In closing, we implore the readers of TCN and the field of neuropsychology more broadly to continue to investigate how cultural, linguistic, and gender diversities affect brain functioning and performance on neuropsychological tests and to consider publishing your work in TCN. Please see our ongoing call for papers here: Welcoming Research on Culture and Gender Diversity.

Robin C. Hilsabeck, PhD, ABPP
TCN Culture and Gender Department Co-editor
Associate Professor of Neurology, The University of Texas at Austin Dell Medical School
Director, Comprehensive Memory Center, Mulva Clinic for the Neurosciences,
Austin, TX, USA
[email protected]
Twitter: @DrRCHilsabeck
María J. Marquine, PhD
TCN Culture and Gender Department Co-editor
Associate Professor
Departments of Medicine and Psychiatry
University of California San Diego
[email protected]
Twitter: @Marquine_Maria

Disclosure statement

No potential conflict of interest was reported by the authors.

Funding

The author(s) reported there is no funding associated with the work featured in this article.