Navigating Neuropsychological Assessments in Culturally Diverse Populations: Reflections from the PIE Team at Centrepoint…

28.11.2024: For regular previous readers of the PIE blog, you may be aware there hasn’t been any posts for many months now! This of course isn’t because PIE has stopped in Centrepoint, it is just in my role as Head of Psychologically Informed Environments (PIE) within the national youth homeless charity, we have just been through an extremely busy period and sadly writing a blog has slipped off my to do list this year with the priority being embedding PIE across the organisation, recruiting and inducting an expanded team, and ensuring that our new direct PIE offer to young people (e.g. neuropsychological assessment, psychological intervention) in conjunction with the wider therapeutic services team is up and running. However, the PIE blog is back! Moving forward, rather than a regular weekly blog, which still remains unrealistic (!), there will be ad hoc blogs with different features, and as per a PIE, more co-production with other voices from across the organisation.

I am therefore delighted to restart the PIE blog, with a piece written by Hará Sakellariadi, who is an Assistant Psychologist within the Lambeth Emotional Well-being Service (LEWS) — see details of this service here: ‘Time to let LEWS’: Introducing the new PIE informed Lambeth Emotional Wellbeing Service in National Mental Health Awareness Week’… | by Dr Helen Miles | Medium. As part of our work in the PIE team this year, we have been developing a neuropsychological assessment offer (see details here: ‘‘Understanding how our brains work: The new ‘PIE Neuropsychology Offer’ to homeless young people’… | by Dr Helen Miles | Medium, but also beginning our own journey around issues of race and culture. Combining these two themes has been critical in order to appropriately develop our PIE offer in this area, given the disproportionately high numbers of homeless young people from racialised minority backgrounds within Centrepoint, and the wider youth homeless population. It is this combined subject that Hara will be writing about in this PIE blog, so over to Hará…

‘I am an Assistant Psychologist in the Lambeth Emotional Wellbeing Service (LEWS) and was previously a Support and Progression Officer at Centrepoint. During the implementation of the new pathway, I had the opportunity to observe and score some neuropsychological assessments. Drawing on this experience, I collaborated with my colleague, Dr. Leah Francis, to develop a Continuing Professional Development (CPD) session for the PIE team focused on the testing experiences of individuals from the global majority and those for whom English is a second language. This blog reflects on our team’s key insights and discussions around these topics.

The Psychologically Informed Environments (PIE) team has recently launched new neuropsychology pathway at the start of 2024. As we reflected on how to best develop this pathway to be shaped around the needs of young people (YP) in Centrepoint we quickly became aware of a challenge around neuropsychology assessment; that the majority of neuropsychology tests were normed on and developed for White westernised populations whilst we, in a youth homelessness service are predominantly working with clients from ethnically, culturally, and linguistically diverse backgrounds.

As a team we have therefore taken time to reflect on these challenges. 64% of YP in CentrePoint are ethnically diverse, 19% are asylum seekers, 8% refugees, 4% hold an indefinite leave to remain, 2% hold discretionary leave, and 1% are citizens of other EEA countries, (2023–2024 data) many of these YP have English as a second/additional language. During our PIE staff training, we regularly highlight the importance of being informed by the evidence base and therefore, as part of our reflections on this work, we reviewed the research literature in this area. Whilst we found very little relevant to this issue, one exception was a helpful paper titled ‘an exploration of the perspectives of neuropsychologists working with clients from ethnically, culturally, and linguistically diverse backgrounds’ (Barber, 2020). This paper uses a cohort of clinical psychologists working in neuropsychology to investigate how they work, and what was helpful to guide our thinking as the pathway has developed.

This reflective blog will focus on our learning on this topic and our thoughts / key reflections on how it might apply to some of the young people at Centrepoint.

1. Neuropsychology tests, instruments, and norms

The majority of neuropsychological tests have been normed on Western, industrialized, rich societies. However, tests are highly influenced by cultural, ethnic, and linguistic factors. This means that bias might arise when the said tests are used on diverse populations. This can lead to misinterpretation of results, misdiagnosis or underdiagnoses, and result in ineffective interventions. The tests therefore risk becoming less applicable or even inaccurate when used on individuals from diverse backgrounds. This is reflected in Barber’s research (2020) where psychologists reported it was important that we are “Being cautious about the interpretation of the findings given the lack of validity and reliability of tests for people of multi-cultural backgrounds” (p.74).

Barber (2020) also reported as a result a trend by psychologists to remove or give less importance to certain items that are more linked to the clients’ cultural, linguistic, and ethnic background: “We remove certain test items we deem to be most damaging to test validity; we accept that tests within the language domain will have very limited validity indeed”(p.72) However, although this might create test results that are more ‘culture fair’, it creates a level of discrimination in other ways, since it reduces the amount of testing that an individual from a diverse background is subjected to, which in turn might influence the validity of their tests results.

It might appear therefore that psychologists are stuck between Scylla and Charybdis (as the culture of Greek myths would say, or more generally stuck between a rock and a hard place), but not all is lost and like Odysseus our team has been looking for innovative ways around these challenges. For example, we have been looking into non-verbal tests, such as the Leiter-3 which has been developed to decrease biases created by verbal communication. These tests allow communication through gestures and test clients through game like tasks. The Leiter-3 is therefore very useful for nonverbal, or non-English speaking individuals. It is however important to remember that cultural differences are not only found in language, and can affect tests in many different ways including non-verbal communication (such as the Greeks moving their heads up and down to say no).

2. Cross-cultural challenges

Differences in norms, values, beliefs, and cultures are highly likely to influence performance on cognitive testing. Differences in education systems in particular can have a major impact on an individuals’ performance on these tests. For instance, a person who has grown up in the UK is likely to be used to sit tests such as SATs, GCSEs, and A-levels and will understand well how such tests might be scored. This is likely to make it easier for them to sit through neuropsychological testing in comparison to someone that has not experienced sitting tests in their previous education and is therefore likely to not understand the purpose of the process. We can imagine that in this instance the requests to complete certain tasks might appear bizarre and could create additional anxiety, which will in turn influence the outcome or results of the tests undertaken.

Cultural differences might also influence an individuals’ interaction with the educational system. For example, Childs & Wooten (2022) found that teachers showed biases around student’s race, ethnicity, and immigration status. Casteel (1998) found that teachers initiated most student contact with White American students and interacted with them more positively compared to African American students. These experiences are exclusionary and likely to trigger feelings of rejections on racialized minority students, who might respond with disengagement from the school environment. Furthermore, when reflecting on anxieties related to test performance it is important to reflect on the education system culture. For example, the use of corporal punishment is still in use in a third of the world’s countries (Gershoff, 2017), again this is something that may affect anxieties surrounding performance and what ‘testing’ means for an individual.

Within our team we reflected on the paramount importance of doing our best to engage with the homeless young person with cultural humility. Our aim is to do our best to understand and be curious about every individual young person’s background, how they relate to their own culture, and how that fits with the UK culture that they are now living in. Furthermore, we reflected on the need for our team to continue to look critically at our own biases and how they might be affecting our view of the young person we are assessing.

We have also noted the importance of having diversity among the professionals in the team administering neuropsychological testing. Professionals from diverse cultural backgrounds bring unique perspectives and understanding to the table, contributing to more accurate and sensitive assessments. They can also help bridge cultural and linguistic gaps, fostering a more comfortable and understanding atmosphere during the testing / assessment process. In fact, we often experience requests from the homeless young people we support to work with a psychologist who also has experiences of being racialized. Whilst we accept that it is not always possible to have a professional of the same cultural background working with every young person we support due to the range of different cultures we support and the issue of team resources as well as the lack of diversity of the clinical psychology profession generally (HCPC, 2023)), the presence of diversity in a team can serve as a model for cross-cultural sensitivity in clinical practice. Psychologists from different backgrounds can influence and inspire their peers and contribute to a more inclusive environment, where clients from diverse backgrounds can feel more understood and comfortable. However, the onus is on all of us, regardless of their cultural background to approach these areas sensitively and with a cultural humility towards those who are different to ourselves (Samuel & Simonds, 2023).

3. Lack of training

A further challenge in this area is the lack of sufficient training for professionals administering neuropsychological assessments regarding ‘how’ to effectively test culturally and linguistically diverse clients. In Barber’s (2020) research, psychologists reported having to use other methods in order to familiarise themselves with themes of culture in neuropsychology. In particular, psychologists highlighted using more generic cultural continuing professional development (CPD) training to reflect on these issues (which may not specifically cover the issues of neuropsychological assessments), using supervision or more senior colleagues, or looking in written resources for advice and guidance. Although these are all valid and valuable ways to gain insight into how to tackle these challenges as a psychologist, they also appear to be compensatory strategies for a lack of more formal professional development either during or post clinical training courses.

While cultural competence is a recognized aspect of professional competency, the level of training provided varies across training institutions and programs. This can lead to inconsistent practices and potentially impact the quality of care delivered to diverse populations. Many psychologists’ may not have the necessary skills or knowledge to appropriately assess and interpret the results of clients from diverse backgrounds, particularly those different from their own. Therefore, it is crucial to develop and embed a more standardized, comprehensive clinical psychology / neuropsychology training program that emphasizes the importance of cultural and linguistic competence to enhance psychology professionals’ ability to effectively serve diverse communities. Beyond this, we believe psychologists should also consider engaging in ongoing cultural competence training as understanding is a ‘journey’ not a ‘destination’ (i.e. cultural humility) This can help them keep up-to-date with the latest research on cultural and linguistic influences on cognitive testing and ensure that their practice remains sensitive to difference, inclusive and effective. This is a topic of particular relevance for our team because of the diversity of the cohort that we work with. We therefore remain reflective and open to further education on these topics.

4. Interpreters

Linguistic differences and language barriers present another significant challenge in neuropsychological assessments and testing situations. Many tests are language-dependent, requiring clients to understand and respond in the language the test is administered. For clients who are not proficient in English, their test scores may not accurately reflect their cognitive abilities but rather their language skills and understanding. This can lead to a skewed perception of the client’s cognitive capabilities, which can impact subsequent treatment plans and care pathways.

Our experience so far has highlighted that when using interpreters to overcome linguistic challenges there are a few things to keep in mind. Interpreters may not be familiar with the specific jargon and intricate nuances related to neuropsychological testing, leading to inaccurate translations and miscommunication. Furthermore, the presence of an interpreter can affect the dynamics of the testing process, potentially influencing the individual’s responses or the way they understand and respond to the test. Despite these challenges, interpreters play a crucial role, and their involvement should be carefully managed, with efforts made to ensure they are adequately briefed beforehand and preferably trained, to maintain the integrity of the testing process.

Interpreters might also be used by a psychologist during the clinical interview in order to gather information around the client’s culture. However, we have also reflected that psychologists must remain mindful that individual values and norms might differ between individuals of the same culture, and therefore we must not uncritically base our understanding of the individual’s culture on what the interpreter reports.

So what is needed? — An integrative approach

Barber (2020) concludes that an integrative approach is essential when working with clines from ethnically, culturally, and linguistically diverse backgrounds. This will support the psychologist to combine different aspects of the assessments (quantitative and qualitative data — such as behavioural observations, other records and referral information, clinical interviews and feedback from other informants in the individuals’ system were possible). All these different aspects of the neuropsychological assessment are required to truly understand the presenting issues and develop appropriate formulations and provide diagnoses if applicable. Consequently, neuropsychological assessments should arguably be seen as more than just the ‘test’; good practice even if an individual being tested is from a white western culture, essential if they are from a racialised minority background.

The challenge of conducting neuropsychology testing on diverse populations is multi-faceted and complex. As we continue the neuropsychology assessment pathway in Centrepoint, in order to truly provide the best service for the homeless young people we support, we remain strongly committed to taking the time to reflect on these issues, and to find innovative and sensitive ways to address them. We are guided by our PIE Team commitment to practising cultural humility and our dedication to understanding each individual’s unique background and experiences. By fostering diversity within our team, undertaking ongoing CPD on the issues of race and culture, and by critically examining our own conscious and unconscious biases, we aim to ensure that our neuropsychological testing process is as fair and effective as possible. We acknowledge that this is a journey that will require continuous learning and adaptation, as well as evaluation. However, we believe that with careful consideration and a commitment to cultural sensitivity, we can start to navigate these challenges and provide the best possible service to the homeless young people we support in Centrepoint.

Finally, we also happily welcome thoughts, feedback and perspectives on this issue as well as the neuropsychology pathway offer, from readers of this blog, whether fellow psychologists working in this area, other colleagues within the sector and Centrepoint, as well as the homeless young people supported by this offer…’

References

· Baber, Z. 2020. An Exploration of the Perspectives of Neuropsychologists Working With Clients From Ethnically, Culturally and Linguistically Diverse Backgrounds. Prof Doc Thesis University of East London School of Psychology https://doi.org/10.15123/uel.88861

· Casteel, C. A. (1998). Teacher–Student Interactions and Race in Integrated Classrooms. The Journal of Educational Research, 92(2), 115–120. https://doi.org/10.1080/00220679809597583

· Childs, T. M., & Wooten, N. R. (2022). Teacher bias matters: an integrative review of correlates, mechanisms, and consequences. Race Ethnicity and Education, 26(3), 368–397. https://doi.org/10.1080/13613324.2022.2122425

· Gershoff, E. T. (2017). School corporal punishment in global perspective: prevalence, outcomes, and efforts at intervention. Psychology, Health & Medicine, 22(sup1), 224–239. https://doi.org/10.1080/13548506.2016.1271955

· Health and Care Professions Council (2023). Diversity Data: practitioner psychologist — July 2023. Retrieved November 15, 2024, from Diversity data: practitioner psychologists — July 2023 |

· Samuel, N. & Simonds, L. (2023). Cultivating Cultural Humility in Clinical Psychology Training: Bridging the ‘Competency’/‘Humility’ Gap. [Manuscript in preparation]. University of Surrey.