The Challenges and Status of

Neuropsychological Assessment of
Spanish Speakers
ANTONIO E. PUENTE
PUENTE@UNCW.EDU
WITH ASSISTANCE OF ROGER W. SPERRY NEUROPSYCHOLOGY LAB

UNIVERSITY OF NORTH CAROLINA WILMINGTON

1er CONGRESO
IBEROAMERICANO DE
NEUROPSICOLOGÍA
4 de Junio de 2016 Bilbao, España
Alexander Luria
Roger W. Sperry
 Defining Culture &
Appreciating the Universal and
the Indigenous
 Dictates the way in which a group of individuals live
 Sharing beliefs and practices to physically and socially survive

 Allows for an individual to identify with a particular group

 Sharing common ideas, purposes, and social norms, such as religion,
economics and politics

 Dictate what is important for survival and what is crucial in the

development and use of specific cognitive and behavior skills.
 Criterion

 Is there a “g”? What is universal?

 Is what is universal what is biological?
(95%)
 What is culture? What is indegenous
 is culture what the brain learns to adapts
to? (5%)
 “Cross Cultural” in PsycINFO
Hits per Decade (Bullock, 2013)

 1932-1940 - 57
 1941-1950 - 92
 1951-1960 - 257
 1961-1970 - 1,100
 1971-1980 - 3,024
 1981-1990 - 6,303
 1991-2000 - 12,449
 2001-2010 - 23,107
 “International” in PsycINFO
Hits per Decade (Bullock,2013)
 1900-1910 - 244
 1911-1920 - 120
 1921-1930 - 630
 1931-1940 - 703
 1941-1950 - 1,168
 1951-1960 - 1,803
 1961-1970 - 16,637
 1971-1980 - 65,608
 1981-1990 - 92,954
 1991-2000 - 111,685
 2001-2010 - 206,319
 Literature X region
(Bullock, 2013)

 Articles from 40 top psychology

producing countries, (Scopus 2003)
 North America 47%
 Europe/Middle East 39%
 Asia/Oceania 10%
 Globalization of the
Science of Psychology
 Psychological testing
 Beyond the cross cultural
 Comparison to the standard
 Understanding indigenous

 For clinical assessment of migrants/immigrants

 Accurate assessment of how a person fits in
 Understanding of what they are capable of
“A test that is fair does not
unduly advantage or
disadvantage certain
examinees because of
individual characteristics
that are irrelevant to the
construct being measured.”
(AERA, et al., 2014)
Neuropsychological Function: From Global to
Local (Luria Redux)

Motor,
language,
social cognition,
executive function
3.Pre-motor areas, frontal lobes

Perception, visuospatial,
memory
2. Parietal, occipital, temporal lobes

Attention, orientation, effort

1. Brainstem
 Spanish-speakers and
Intelligence Testing:
Wechsler’s Adult Intelligence
Scales
 The Wechsler Adult Intelligence Scales
 Most widely used intelligence test (now and ever)
 High validity and reliability
 User friendly administration and scoring guidelines
 Excellent psychometric properties
 WAIS-IV (2008)
 Most current version
 WAIS-III (1997) (Spanish versions)
 Mexico (2003)
 Puerto Rico (2008)
 Spain (2001)
 Literature on the Spanish Versions
of the WAIS-III
 WAIS-III has been used in the U.S and in Spanish-
speaking countries
 Limited literature
 A total of 7 studies
 4: Mexican version
 3: Spaniard version
 1: Puerto Rican version (non-peer reviewed)
 Results
 Overestimated IQs
 Large Confidence Intervals
 Technical problems
 Non-representative sample
Example: WAIS-III in Capital Cases
Atkins v Virginia – execution of the intellectually
disabled, a violation of the Eighth Amendment

Variable Mexican Norms English Norms

Full Scale IQ 79 66

Confidence Intervals 65 – 105 63 – 71

Intellectual Disability NO YES

Death Penalty YES NO

INITIAL STUDY ON THE SPANISH WAIS
 A Qualitative Study
 Standardization sample
 Structure
 Concept of Items
 Ordering of Items
 Response options
 Hypothetical profile of 45-year-old
 Results
 On the surface, they appear to be similar, but
the qualitative analysis suggested unusually
small to large differences.
 Purpose of Present study
 To further examine equivalence across
the Mexican, Puerto Rican, and Spaniard
versions of the WAIS-III against each
other and against the English version of
the WAIS-III.
 Phase I: Qualitative analysis
 Phase 2:Quantitative analysis

(Note: only 2 of 4 phases in this study are reported here)

 Phase 1:
Qualitative Comparison
 Phase 1: Method
 Teaching Items
 Item number
 Item content
 Range of Subtest Scores
 Range of IQ & Index Scores
 Confidence Intervals
 4 Indices
 3 IQs
 Phase 1: Results
 Average Confidence Interval Ranges:

Version VIQ PIQ FSIQ VCI POI WMI PSI

English 9.6 14 8 11.2 14 14 17.8

Mexican 26.2 48.8 37.4 41 20.4 50 8.4

Puerto Rican 9.6 12.4 8 11.2 14 15 19

Spaniard 10 12 16 8 8 8.4 8
 Phase 1: Discussion
 Superficially the same, however:
 Categorization of standardization variables
 Test structure
 Concept of items
 Order of items
 Response types and scoring differences
 Teaching Items
 Range of scores
 Confidence Intervals
 Overestimated IQ scores
 Phase 2:
Quantitative Analysis
 Phase 2: Introduction

 Determine extent to which the

Spanish versions overestimate IQ
and Index scores relative to the
English version
 Determine whether scores
differences are statistically
significant.
 Phase 2: Method
 Instruments
 Four administration and scoring manuals
 48 De-identified test profiles
N Males Females Mage Medu

North Carolina 12 5 7 44.83 12.92

Mexico 12 5 7 38.00 15.33

Puerto Rico 10 5 5 45.40 15.30

Spain 14 7 5 22.50 9.86

 English Version

Mexican
Spaniard
Version
Puerto Rican Version
Version

1 profile = 4 profiles

12 profiles = 48 profiles

Therefore, 48 profiles from all four versions will yield 192

profiles
 Phase 2: Results Summary
 Overestimation of IQ and Index Scores
Total Point Overestimation
Mean English
Variable
Score
Mexican Puerto Rican Spaniard

Full Scale IQ 88.60 3.30 14.28 4.70

Verbal IQ 89.46 3.69 15.00 2.83

Performance IQ 89.40 7.20 10.89 (-0.21)

Verbal Comprehension Index 90.65 9.75 13.81 2.37

Perceptual Organization Index 92.23 6.23 10.54 (-1.98)

Working Memory Index 86.58 12.52 15.42 3.43

Processing Speed Index 88.15 13.10 7.27 3.50

 WAIS III SPANISH ADAPTATION
 Overestimation of IQ and Index Scores
Mean Total Point Overestimation
Variable English
Puerto Spaniar
Score Mexican
Rican d
Full Scale IQ 88.60 3.30 14.28 4.70

Verbal IQ 89.46 3.69 15.00 2.83

Performance IQ 89.40 7.20 10.89 (-0.21)

Verbal Comprehension
90.65 9.75 13.81 2.37
Index
Perceptual Organization
92.23 6.23 10.54 (-1.98)
Index
Working Memory Index 86.58 12.52 15.42 3.43

Processing Speed Index 88.15 13.10 7.27 3.50

 Phase 2: Discussion
 General Patterns
 Sum of Scales Scores are different
 IQs are different

 English version overall yields the lowest scores

 Puerto Rican overall yields the highest scores
 General Discussion of WAIS Study
 Phase 1:
 Tests are qualitatively different.
 Phase 2:
 Tests are quantitatively different.
 Phase 3:
 Subtests within tests are qualitatively and
quantitatively different.

 Phase 4:
 Scores vary depending on the version being
administered.
 Overall Summary
 IQ Assessment
 IQ Testing
 Adaptive Deficits
 State Vs. Clinical Standards Interpretation
 WAIS
 Gold Standard for IQ Testing
 Limitations & Challenges
 Conclusion
 Best Vs. Perfect Research & Practices
 Globalization of Professional
Neuropsychology
 PERSPECTIVES:
 One world/One health?
 ASSESSMENT:
 Standards for testing
 DIAGNOSTIC:
 Unified diagnostic system
 Globalization of Healthcare
& Neuropsychology

• Expansion of psychology’s self-perception

• Past – prevalence of U.S. and English language in

psychology

• Present – expanding beyond the U.S.;

internationalization as well as local contexts

(Bullock, 2012; Goodheart, 2013)

 Globalization of Healthcare &
Neuropsychology (cont.)

• Psychology’s growth in global perspectives

yet relevant to localized & practical needs

• Focus on understanding and balancing the

universal to explain human behavior and
function while preserving a local and even
personal socio-historial context
 Culture-Specific Disorders in ICD-10

Disorder Culture
1. Amok Malaysian
2. Dhat Indian
3. Koro Indonesia, Thailand
4. Latah Southeast Asia
5. Ataque de Nervios Latin American Caribbean
6. Pa-leng (Frigophobia) China, Southeast Asia
7. Piblokto Inughuit societies living in Arctic Circles
8. Susto, Espanto Latin American
9. Taijin Kyofusho Japanese
10. Ufufuyane, Saka Kenya, Southern Africa
11. Uqamairineq Inuit
12. Windigo Algonquian peoples in Atlantic coast and Great Lakes
region in US and Canada
 Hispanics in the U.S.
 Any individual with Spanish-
speaking background
 Central and South America,
Mexico, and Spain
Share of the Total Change of
the U.S. Population between
2000 and 2012

6%
 53 million individuals
16%
Hispanic
White
 11 million undocumented Hispanic Black
immigrants 55% Asian
15%
Other

 Hispanics are the largest minority 8%

group
 17% of the US population

Source: Pew Research Center, 2009; U.S. Census Bureau, 2014

Neuropsychological Assessment of Hispanics

 Difficult task because of the linguistic and cultural diversity of

this population

 Over 20 Spanish-speaking nations represented in the U.S.

 Get categorized together because they have the Spanish
language in common

 Each Spanish-speaking country have their own distinctions

regarding customs, words, and expressions
 Existing Issues in the
Assessment of Hispanics
 Language
 Frequency of words cannot be assumed the same
 10 major Spanish dialects
 Some words don’t exist or have different meanings

 “Bus”
 U.S = South America (most)
 Uruguay and Chile: microbus, or micro.
 Cuba =“guaga”
 Chile, Ecuador, and Peru “guaga” = baby; not bus

Source: Puente & Puente, 1999; Ojeda, 2010

 Heterogeneity of Hispanics and
the Impact on Performance
 Development of cognitive abilities
 Maya indigenous and individuals from Mexico City were given the
NEUROPSI
 Indigenous outperformed on visuospatial tasks
 Individuals from Mexico City outperformed on delayed verbal memory

 Development of specific words

 “Bus”
 U.S = South America (most)
 Cuba =“guagua”
 Chile, Ecuador, and Peru “guagua” = baby; not bus
 Some words do not exist or have different meanings

Sources: Ostroski-Solis, Ramirez, Lozano, Picasso, & Velez, 2004; Puente & Puente, 1999; Puente,
Ojeda, Zink &, Portillo Reyes, 2015
 Standards for Educational
and Psychological Testing (2014)
 Standards revised every 15 years over the last 50
 Provide criteria for the development and evaluation of
tests and testing practices
 Sponsored by:
 American Educational Research Association
 National Council on Measurement in Education
 American Psychological Association

(Note: Puente only clinician and only Spanish-speaker on the Committee

for the Revision of the Standards of Educational and Psychological Tests)

Source: AERA, 1999

 Psychological Tests in Spanish
Puente, Ojeda & Zink (2015)

1. Developed a list of available tests

• 3,500 psychological tests in print in the U.S.
 555 (16%) are in Spanish.
 25 – 50 (4%) are used the most
2. Compared tests to Standards using the following criteria:
1. Test name in Spanish,
2. Hispanic norms (U.S.),
3. Non U.S Hispanic norms, and
4. Test manual in Spanish.
3. Evaluation of the most commonly used tests by using the Standards
• Only 6/25 tests meet all four criteria
• Most did not meet the criteria for the Standards
 Missing norms
 Those with norms, may not be accurate
 Existing Issues in the Assessment of
Hispanics
 Numerous variables that affect performance on assessment
 Test Translations
 Item and back translations do not ensure item equivalence
 Different words to convey the same meaning/idea
 Culture dictates what is culturally relevant

 Are there improvements?

 Recent studies have demonstrated issues regarding availability of
measures of Hispanics
 Measures are not meeting criteria for testing individuals of diverse
backgrounds

Source: Puente, Ojeda, Zink &, Portillo Reyes, 2015; Zink & Puente, 2011
Comparison of Spanish Batteries
Comprehensiveness
Name Domain Length Computerized U.S. Hispanic norms Age Total score
BR 1 1 1 3
BNE 1 1 1 3
BNS 1 NA 1 NA 2
Bat III 1 1 1 1 4
CANS-MCI 1 1
CERAD 0
CANTAB 1 1 1 1 4
COGNI 1 1 1 3
CNS VS 1 1 1 1 4
DW 1 1
LDNA 1 1 1 3
MNB 1 1 1 3
NEURO II 1 1 2
NEURO S 1 NA 1 2
NeSBHIS 1 1 NA 1 1 4
SENAS 1 NA 1 2
 Results
 Limited information
 Research
 Clinical vs. research
 Commercialized
 Many batteries have been developed for Spaniards
 Non-representative normative data
 Only four had norms from U.S.
 Questionable construct validity
 Spanish & English Summary of
Neuropsychological Domains
Empirical Quasi-empirical Clinical Theoretical

Empirical Quasi-empirical Clinical Theoretical

Domain English Spanish CNT HNDNA NA TCN DSM ICD Luria Sperry

Domain Achievement English Spanish X CNT HNDNA X NA TCN DSM ICD Luria Sperry
Adaptive func. X X
Achievement X X
Attention 13/15 14/16 X X X X X X X
Adaptive func. X X
Auditory percep X
Attention 13/15 14/16 X X X X X X X
Calculation X X
Auditory percep X
Exec. function 13/15 15/16 X X X X X X X X
Calculation X X
Language 8/15 7/16 X X X X X X X X
Exec. function 13/15 15/16 X X X X X X X X
Memory 14/15 15/16 X X X X X X X X
Language 8/15 7/16 X X X X X X X X
Motor 7/15 6/16 X X X X X X X X
Memory 14/15 15/16 X X X X X X X X
Orientation 5/15 5/16 X X X X
Motor 7/15 6/16 X X X X X X X X
Perception 3/15 3/16 X X X X X X X X
Orientation 5/15 5/16 X X X X
Reading X
Perception 3/15 3/16 X X X X X X X X
Response bias X X
Reading X
Sensation 3/15 3/16 X X X
Response bias X X
Social cognition 2/15 3/16 X X X
Sensation 3/15 3/16 X X X
Visuospatial 12/15 8/16 X X X
Social cognition 2/15 3/16 X X X
Writing X X
Visuospatial 12/15 8/16 X X X

Writing X X
Domain Frequency
Sources
Domain Original 39 Unique 31 Included in INCog
Memory 37 30 X
Executive functions 36 29 X
Attention 34 28 X
Language 23 21 X
Visuospatial 23 19 X
Motor 21 17 X
Orientation 14 13 X
Perception 14 12 X
Sensation 9 7
Social cognition 8 6 X
Achievement 2 2
Adaptive function 2 2
Calculation 2 2
Effort 2 2 X
Writing 2 2
Auditory perception 1 1
Reading 1 1
 Practical Concerns:
Norms & Culture
 “Instrumentsmust be normed for the
individual’s sociocultural background
and native language.” DSM-5 .

 Accuracy of assessment requires that

those conducting the assessment “[u]se
appropriate norms.” AAIDD (11th ed.) .
 Practical Concerns:
Specific Issues with the Assessment of
Hispanics

 Bilingual vs. Bicultural

 Between Hispanic Subgroup Variability
 Translators & Translations
 Accommodation VS. Modification
 Splitting NP from Function
 Splitting Function from Value
 Future Directions
 New Norms
 Neuronormas, first normative multicenter study in Latin
America
 Deusto series of articles
 Electronic/digital norms
 Static
 Living

 Development of New Measures

 EMBRACED
 New Horizons

 New Value
 Social Justice Neuropsychology
 “Cultural” Neuropsychology =
our entry to “g”
Maybe not…
 Resources
 American Psychological Association
 Ethical Standards for Psychologists
 Standards for Educational and Psychological Tests &
Assessments
 Guidelines on Multicultural Education, Training,
Research, Practice, and Organizational Change for
Psychologists
 National Academy of Neuropsychology
 Hispanic Neuropsychological Society
 Available book chapters & articles
 www.antonioepuente.com
 www.alfredoardila.wordpress.com