Performance-based alternatives to race-norms in neuropsychological assessment.

Groupings of neurologically intact African Americans have mean scores below those for Caucasian Americans on a wide range of neuropsychological tests. This provided the impetus for the creation of race-norms that reduce false positive African American misclassifications (i.e., neurologically intact individuals misdiagnosed with neurocognitive impairment). Race-norming of neuropsychological tests has proved controversial as evidenced by a recent widely publicized lawsuit filed by African American ex-football players against the National Football League (NFL) 2014 concussion settlement that prompted the NFL to halt the use of race-norms and to review past claims for evidence of racial bias. Here it is argued that there is a viable alternative to the use of race-norms in neuropsychological assessment whereby false positives are reduced through the use of obtained postinjury hold measures to estimate preexisting skill levels with standard norms. These performance-based estimates: (a) can be used with all race/ethnic minorities; (b) are applicable to all neuropsychological tests; (c) are more accurate than using the mean of published norms for members of any race/ethnic grouping who possess "true" preexisting neuropsychological skill levels at either end of the normal curve; (d) promote fairness in testing as individuals of differing race/ethnic groupings but otherwise similar demographic profiles, test scores, and estimated preexisting skill levels have the same assessed level of neurocognitive impairment; and (e) the implied causation of lower preexisting estimates in a racially diverse patient is not race per se but behavioral correlates of race like quality of education and acculturation that have demonstrated effects on test scores.

Specificity rates for non-clinical, bilingual, Mexican Americans on three popular performance validity measures.

OBJECTIVE: To measure specificity as failure rates for non-clinical, bilingual, Mexican Americans on three popular performance validity measures: (a) the language format Reliable Digit Span; (b) visual-perceptual format Test of Memory Malingering; and (c) visual-perceptual format Dot Counting, using optimal/suboptimal effort cut scores developed for monolingual, English-speakers. METHODS: Participants were 61 consecutive referrals, aged between 18 and 65 years, with <16 years of education who were subjectively bilingual (confirmed via formal assessment) and chose the language of assessment, Spanish or English, for the performance validity tests. RESULTS: Failure rates were 38% for Reliable Digit Span, 3% for the Test of Memory Malingering, and 7% for Dot Counting. For Reliable Digit Span, the failure rates for Spanish (46%) and English (31%) languages of administration did not differ significantly. CONCLUSIONS: Optimal/suboptimal effort cut scores derived for monolingual English-speakers can be used with Spanish/English bilinguals when using the visual-perceptual format Test of Memory Malingering and Dot Counting. The high failure rate for Reliable Digit Span suggests it should not be used as a performance validity measure with Spanish/English bilinguals, irrespective of the language of test administration, Spanish or English.

Belief Reasoning and Emotion Understanding in Balanced Bilingual and Language-Dominant Mexican American Young Children.

Belief reasoning and emotion understanding were measured among 102 Mexican American bilingual children ranging from 4 to 7 years old. All children were tested in English and Spanish after ensuring minimum comprehension in each language. Belief reasoning was assessed using 2 false and 1 true belief tasks. Emotion understanding was measured using subtests from the Test for Emotion Comprehension. The influence of family background variables of yearly income, parental education level, and number of siblings on combined Spanish and English vocabulary, belief reasoning, and emotion understanding was assessed by regression analyses. Age and emotion understanding predicted belief reasoning. Vocabulary and belief reasoning predicted emotion understanding. When the sample was divided into language-dominant and balanced bilingual groups on the basis of language proficiency difference scores, there were no significant differences on belief reasoning or emotion understanding. Language groups were demographically similar with regard to child age, parental educational level, and family income. Results suggest Mexican American language-dominant and balanced bilinguals develop belief reasoning and emotion understanding similarly.

Age of dementia diagnosis in community dwelling bilingual and monolingual Hispanic Americans.

Bilingualism has been reported to delay the age of retrospective report of first symptom in dementia. This study determined if the age of clinically diagnosed Alzheimer's disease and vascular dementia occurred later for bilingual than monolingual, immigrant and U.S. born, Hispanic Americans. It involved a secondary analysis of the subset of 81 bi/monolingual dementia cases identified at yearly follow-up (1998 through 2008) using neuropsychological test results and objective diagnostic criteria from the Sacramento Area Latino Study on Aging that involved a random sampling of community dwelling Hispanic Americans (N = 1789). Age of dementia diagnosis was analyzed in a 2 × 2 (bi/monolingualism × immigrant/U.S. born) ANOVA that space revealed both main effects and the interaction were non-significant. Mean age of dementia diagnosis was descriptively (but not significantly) higher in the monolingual (M = 81.10 years) than the bilingual (M = 79.31) group. Overall, bilingual dementia cases were significantly better educated than monolinguals, but U.S. born bilinguals and monolinguals did not differ significantly in education. Delays in dementia symptomatology pertaining to bilingualism are less likely to be found in studies: (a) that use age of clinical diagnosis vs. retrospective report of first dementia symptom as the dependent variable; and (b) involve clinical cases derived from community samples rather than referrals to specialist memory clinics.

Cognitive impairment in common, noncentral nervous system medical conditions of adults and the elderly.

Common, noncentral nervous system medical conditions linked with cognitive impairment in adults and the elderly include: acute respiratory distress syndrome; cancer; chronic kidney disease; chronic obstructive pulmonary disease; coronary heart disease; hypertension; obesity (bariatric surgical candidates); obstructive sleep apnea; and type 2 diabetes. Cross-condition comparison of the nature and frequency of cognitive impairment is difficult as these conditions often coexist, and there exists no consensus as to the definition of cognitive impairment, nor the optimal number and type of neuropsychological tests required for evaluation. There is as yet no clear evidence for condition-specific profiles of cognitive impairment. Rather, a generalized profile consisting of subclinical levels of impairment in attention, processing speed, executive, and memory functions from bilateral frontal-subcortical ischemia fits across all conditions. This profile: occurs only in subgroups of patients; is inconsistently related to measures of illness severity; is unrelated to patient self-report or level of functional independence; is exacerbated by very high levels of emotional distress; and is reversible in some cases but can also progress to frank neurological disease (dementia) in others, especially the elderly, when multiple conditions coexist, and/or when medical condition severity progresses.

Race-norming of neuropsychological tests.

Recent studies in the United States indicate that some neurologically intact minority groupings perform well below White Americans on neuropsychological tests. This has sparked the production of race-norms, especially for African Americans, that seek to reduce false positive rates (i.e., neurologically intact individuals misdiagnosed with cognitive impairment) in neuropsychological assessments. There are problems with this enterprise including: possible justification for inferior/superior treatment of different racial groupings; unknown effects on false negative rates (i.e., cognitive deficit misdiagnosed as normal); the overlooking of factors possibly responsible for group racial differences (e.g., acculturation); non-scientific and non-operational definitions of race/ethnic groupings; and an impossibly large number of potential race/ethnic groupings for which to generate race-norms. An alternative approach is to use a single set of combined race/ethnic norms and estimate preexisting neuropsychological skill levels by using individual comparison standards. This alternative has been poorly researched, a situation that needs correcting.