Neurobehavioral Clinic Lake Forest, CA DAVID LECHUGA

Neurobehavioral ClinicLake Forest, CA

DAVID LECHUGA

Rationale

• Meetings at UCLA (Cultural Neuropsychology Initiative:– http://www.semel.ucla.edu/cni

• Xavier Cagigas, Paola Suarez, Lisa Moran, David Lechuga:– Rachel Casas and Christine Salinas

• Pipeline issues:– Attracting those that will help meet the needs

http://www.semel.ucla.edu/cni

http://www.semel.ucla.edu/cni

Refinements to Houston Conference

• Evolved from public health concern:– Changing demographics of United States

• Concerns about level and commitment:– Cultural factors as they affect clinical and research

endeavors– Political and legislative influences

• Need to rethink and revise guiding document

From Houston to Austin

• Dovetailed with HNS Mission:– http://hnps.org/about/mission-statement/

• Consistent with efforts from other entities interested in cultural competency enhancement in neuropsychology– Guilds– Regulatory bodies

http://hnps.org/about/mission-statement/

http://hnps.org/about/mission-statement/

Today

• Presentations that provide context and background

• Brainstorming session – Translate into action steps

• Partnerships with other professional groups as part of Houston Conference refinement process

Goal

• Generally, to be part of the change process– Respond to the challenges encountered when

working with monolingual Spanish speakers, bilingual (English, Spanish)

– Elevate the narrative• Other demographic groups that require greater

sensitivity re: cultural factors

Bienvenidos!

• Fortunate to have representatives from various national and international groups

• Leaders of HNS• Students of HNS• Members and guests of HNS

HNS Board• Xavier Cagigas• Roy Aranda• Veronica Bordes Edgar• Katrina Esherick Belen• Delia Silva

• Gretchen Berrios-Siervo• Christina Salinas• Christina Eguizabal Love• Johanna Rengifo-Nevarez

Muchas Gracias

MONICA RIVERA MINDT, Ph.D., A.B.P.P.Fordham University/

Icahn School of Medicine at Mount Sinai

STANDARDS OF TRAINING: WHAT IS CURRENTLY RECOMMENDED IN THE

GUIDELINES & WHAT IS NEEDED?

Overview

• Experience with the Houston Guidelines• Current Guideline Recommendations• What is Needed for the Guidelines?• So What Now?

Experience with the Houston GuidelinesIn My Own Training & Training Others

Overview


Current Guideline Recommendations

0Series1

0

1

2

3

4

5

Demographic Factors Ethnic Lingusitc Multicultural Culture/Cultural Diverse/Diversity

Representation of ‘Cultural Competence’ Language #

of W

ords

Houston Guidelines: Total Words = 2,035; Total Culturally-Relevant Words = 11 (0.5%)

Current Guideline RecommendationsVV. Professional and scientific activity:The specialist whose professional activities involve diverse cultural, ethnic, and linguistic populations has the knowledge and skills to perform those activities competently and ethically.

VI. Knowledge base:1.General Psychology Core: 1G. Cultural & Indiv. Diff’s &Diversity 2. General Clinical Core: 03. Foundations for Study of Brain-Behavior Relationships: 04. Foundations for Practice of Clinical Neuropsychology: 0

VII. Skills:1. Assessment: Recognition of multicultural issues 2. Treatment & Intervention: Recognition of multicultural issues 3. Consultation: 04. Research: 05. Teaching & Supervision: 0

Training Level (Criteria Set By)

VIII. Doctoral (APA) Reviewed/Revised Core Competencies Exit Criteria Includes Cultural Competencies IX. Internship (APA) Reviewed/Revised Core Competencies Exit Criteria Includes Cultural Competencies X. Residency (NP)☐ Reviewed/Revised Core Competencies☐ Exit Criteria Includes Cultural Competencies

So Maybe It’s Not Quantity, But Quality?

}

Overview


What is Needed for the Guidelines?• Paradigm Shift in Neuropsychology

• Cultural Competence Framework for Neuropsychology

• Lifespan Model to Cultural CompetenceSource: Arial Narrow 8 pt.

Rivera Mindt et al., 2010

Paradigm Shift in Neuropsychology • Avoid the ‘ghetto-ization’ of multicultural issues• Develop & implement comprehensive multicultural NP

training standards• Empirical approach to cultural competence in NP via:

• Rigorous research with URMs • Application of evidence-based practice (EBP)• Training that integrates:

– Best research evidence + clinical expertise + patient values (Chelune, 2008; Sackett et al., 2000) Source: Arial Narrow 8 pt.

Rivera Mindt et al., 2010

Cultural Competence Framework for NPACQUISITION

• Specific, culturally appropriate assessment, intervention, & communication skills

• Necessary to

effectively work with cultural minority groups

INDIVIDUALS & ORGANIAZATIONS

• Development of core cultural competencies

• Based on new theories, practices, policies

• Organizational structures that are more responsive to all groups.

KNOWLEDGE & UNDERSTANDING• Own world view

• Clients’ culture & world view impacts NP performance & intervention

• Understanding of sociopolitical influences

AWARENESS• Assumptions/

values/biases @ cultural minorities

• Impact provision of NP services

• Positive stance towards multiculturalism

+ +

D.W. Sue, 2001; Rivera Mindt et al., 2010

Lifespan Model to Cultural Competence

(Undergraduate)Doctoral Training

InternshipPostdoctoral Fellowship

• Didactics completed with a standard for mastery of cultural considerations in NP, based on the growing empirical literature

• Clinical Training in Culturally Diverse Settings

• Proficiency Exam Qs specific to Cultural NP

• Exit Criteria Includes Cultural Competencies

Early CareerMid- & Late Career

• Cohesive multicultural training curricula for those already in the profession (ABPP?)

• Specific task forces charged with providing coherent CC training for memberships

Fastenau et al., 2002; Rivera Mindt et al., 2010

The Nitty Gritty – Food for Thought• What is the minimum type of curricula, didactics and/or training

needed for cultural competence to be achieved?• What is the minimum level of bilingual proficiency needed?• How would this be evaluated?• Who would be appropriate to teach and/or supervise these

courses or students? Who would be available?• Are broad courses on cultural diversity sufficient?• Who would provide oversight? (Houston Guidelines have little

detail; APA has criteria for Psych but not NP)

Source: Arial Narrow 8 pt.

Overview


Moving Forward

Who is Responsible?


When Does This Happen?

How Does This Happen?

…………………………Let me give you a HINT.

Where Does this Happen?

Moving Forward• Here • Inter-Organizational Effort• NOW • Together

– We Are Responsible For Making this Happen

Icahn School of Medicine at Mount SinaiFordham University

Muchas Gracias, Thank you!

Christine M. Salinas, PsyD

NEUROPSYCHOLOGY IN A CHANGING US

CULTURE

The American Dream: Embracing Diversity

Houston Conference-2000

Location

Location

Location

“Call to Action”-2010

Location

Location

Location

Houston to Austin:2013-2015

Location

Location

Location

educationethnicity language race nationality

country culture acculturation immigration insurance

economics

literacypolitics

religion

Heterogeneity of Hispanics

Hispanic Subgroups by Region13

38

0.03

12

16.9

20

76.9

8.5

1.3 6.9

2.7 3.7

80.9

1.70.8 7

2.47.2

MexicoPR

Cuba

Central America64.17.3

7.9

9.3

5.85.6

South AmericaOther

South

NortheastMidwestWest

Language Use Among Hispanics• ~50% of the world are bilinguals • ~20% of US citizens are bilinguals• Spanish is 2nd most common language (38M) fejkj • 82% of Latino adults speak Spanish*

• 38% Spanish “dominant”• 38% bilingual• 24% English “dominant”

• Dialect differences • (“tutear”; grammar use; vocabulary)

• Cultural influences on L1 maintenance

Language Use Among Foreign Born Hispanics

IMPLICATIONS FOR NEUROPSYCHOLOGY & COMMUNITY

Changing US Culture

Neuropsychology Trends

19811983

19851987

19891991

19931995

19971999

20012003

20052007

20090

500

1000

1500

2000

2500

3000

3500

4000

4500

5000

# of Division 40 Members

Healthcare Disparities for Hispanics

TX, NJ:VA:

CA, NY, NM, NC, NV:

CO, WA, MA:FL, IL, GA, PA:

AZ:

Organization # Spanish Speaking NPs

NAN 96

HNS 157

AACN 25

= 1:81,000(std. NP:PX in the US)

Salinas, Bordes-Edgar, & Puente, In Press; Romero et al., 2009; Judd, 2010

Training Challenges: Hispanics

15.2

17.7

35.4

19.6

10.8

1.3

Satisfaction with Training Received to Work with Hispanics

N/A Dissatisfied Somewhat SatisfiedModerately Satisfied Extremely Satisfied Did not disclose

21.5

41.8

37.349.4

40.5

9.5

Type of Training Received to work with Hispanics

None Graduate School Internship/PostDocCE Peer Consultation Self-Taught

Echemendia et al, 1997; Renteria et al, 2010

Feel Prepared

Yes No

Challenges in Practice• ~15% of 3500 tests are in Spanish• Only 5 meet Standards for Educational & Psychological tests• Use and selection of appropriate interpreters

– 25% still use family members• Verbatim translations are used greater than adaptations

– Up to 1/3 of time• Clinicians are NOT using normative data when available

– Only 1/3 of time• Supervision of bilingual and diverse psychometrists and trainees• Minorities are judged as cognitively impaired more often • Rec’s may based on myths, not evidence (e.g., English only ST)

(Renteria et al, 2010; Ojeda & Puente, 2010; Echemendia & Harris, 2004; Manly et al, 1998)

Challenges in Practice • Assessment is more complex & time consuming

• Minorities may be vulnerable to comorbidities

• Serving the underserved: innovate or perish!– Volume was on avg 2.5x colleagues– department collected 10% for all charges 2011-2015

• Bilingual colleagues have seen 2.6x clinical volume than co-workers– 51% Medicaid– Medicaid & ethnic minority pxs were 7x higher than co-workers

Challenges in CN Research • 1,834 abstracts reviewed

– 10 articles identified for inclusion in review (<1% over 5 yrs):• Peer reviewed• Direct examinations of culture/ethnicity on test performance • Use of at least 1 standardized or experimental neuropsychological test• No parsimonious link between ethnicity and test performance; several

complex factors at play

Byrd, Arentoft Scheiner, Westerveld & Baron, 2008

Challenges in CN Research

• >600 abstracts reviewed (PubMed):• Epilepsy+

language/memory/cognition/behavior/QOL/NP/fMRI• 15 articles identified for inclusion in manuscript review:

– Peer reviewed – Use of at least one standardized or experimental neuropsychological test– Sample size greater than 5

• Keywords: culture, Hispanic, Spanish

Challenges in CN: Latin AmericaLack of academic training programs 46.9%

Lack of clinical training opportunities 45.4%

Lack of willingness to collaborate between professionals 35.9%

Lack of access to neuropsychological instruments 35.0%

Lack of professional leaders in the field 30.9%

Lack of access to literature/ libraries 11.3%

There are no barriers 8.3%

Lack of access to technology/ computers 3.7%

Lack of access to the internet 1.2%

Lack normative data for my country 62%Not adapted to my culture 56%Too costly/ expensive 49%

Aimed at individuals with high levels of education 25%

Are often not applicable because my patients cannot read or 23%Not translated to my language 19%

Do not have good psychometric properties 15%Take a long time to administer 13%

There are no problems with the instruments that I use 8%

Too complicated to administer and/ or score 5%Other 3%

Arango et al, 2015

Xavier E. Cagigas, Ph.D.UCLA Cultural Neuropsychology

Initiative

CNP 365: New Mandates

Cultural Neuropsychology:The New Norm

N

Title VIFederal Civil Right Act of 1964

• Prohibits discrimination on the basis of race, color, or national origin

• National origin includes language and so prohibits discrimination against persons who are limited English proficient (LEP)

Executive Order 13166

• Requires recipients of federal financial assistance to take reasonable steps to ensure that LEP persons have meaningful access to federally funded programs and services

Rehabilitation Act of 1973 - Section 508 Plain Writing Act of 2010

• Requires federal agencies to use plain writing for all public communication, especially public communication about benefits and services…in any language used to communicate with individuals with LEP.

Patient Protection andAffordable Care Act – Section 1557

• Prohibits discrimination on the ground of race, color, national origin, sex, age, or disability under any health program or activity that is administered by an Executive agency or any entity established under Title I of the Affordable Care Act or its amendments.

NIH LAP: Language Access Plan

• Scope:– Programs or activities involving the general public

as part of ongoing NIH operations– Programs or activities directly administered by

NIH for program beneficiaries and participants• Timeline: End of Fiscal Year 2016

HHS/NIH LAP for LEP

• Recipients must consider:– The number or proportion of LEP persons in the

eligible service area– The frequency with which LEP persons come into

contact with programs– The importance of services provided by the program– Resources available

NIH LAP 10 Elements1. Assessment of Needs and Capacity2. Oral Language Assistance Services3. Translation of Written Materials4. Policies and Procedures5. Notification of the Availability of Free Language Assistance6. Staff Training on the Provision of Language Assistance7. Assessment of the Accessibility and Quality of Services8. Stakeholder Consultation9. Digital Information10. Grant Assurance and Compliance

NIH Cultural Framework for Health• Provides a tool for researchers and program evaluators to use in project design.• Identifies why culture is fundamental for understanding human behavior and the

impact of cultural ways of life on mental and physical health and well-being.• Identifies the major scientific challenges with the current use of the concept of

culture for health behavior research.• Presents methods and tools to discover the salient cultural processes involved

with health behaviors, and how the processes and behaviors influence health and well-being.

• Provides a processual framework that guides researchers through six steps that more effectively distinguish cultural processes relevant in any given study context, and how they likely influence health outcomes.

National CLAS Standards

• Intended to advance health equity, improve quality, and help eliminate health care disparities by providing a blueprint for individuals and health and health care organizations to implement Culturally and Linguistically Appropriate Services

Principal Standard

1. Provide effective, equitable, understandable, and respectful quality care and services that are responsive to diverse cultural health beliefs and practices, preferred languages, health literacy, and other communication needs.

Governance, Leadership & Workforce:2. Advance and sustain organizational governance and leadership

that promotes CLAS and health equity through policy, practices, and allocated resources.

3. Recruit, promote, and support a culturally and linguistically diverse governance, leadership, and workforce that are responsive to the population in the service area.

4. Educate and train governance, leadership, and workforce in culturally and linguistically appropriate policies and practices on an ongoing basis.

Communication & Language Assistance:5. Offer language assistance to individuals who have limited English

proficiency and/or other communication needs, at no cost to them, to facilitate timely access to all health care and services.

6. Inform all individuals of the availability of language assistance services clearly and in their preferred language, verbally and in writing.

7. Ensure the competence of individuals providing language assistance, recognizing that the use of untrained individuals and/or minors as interpreters should be avoided.

8. Provide easy-to-understand print and multimedia materials and signage in the languages commonly used by the populations in the service area.

Engagement, Continuous Improvement, & Accountability:9. Establish culturally and linguistically appropriate goals, policies,

and management accountability, and infuse them throughout the organization's planning and operations.

10. Conduct ongoing assessments of the organization's CLAS-related activities and integrate CLAS-related measures into measurement and continuous quality improvement activities.

11. Collect and maintain accurate and reliable demographic data to monitor and evaluate the impact of CLAS on health equity and outcomes and to inform service delivery.

Continued12. Conduct regular assessments of community health assets and needs and

use the results to plan and implement services that respond to the cultural and linguistic diversity of populations in the service area.

13. Partner with the community to design, implement, and evaluate policies, practices, and services to ensure cultural and linguistic appropriateness.

14. Create conflict and grievance resolution processes that are culturally and linguistically appropriate to identify, prevent, and resolve conflicts or complaints.

15. Communicate the organization's progress in implementing and sustaining CLAS to all stakeholders, constituents, and the general public.

The so what, now what test…

• NIH EDI 365 Pledge CNP Houston to Austin Pledge

• Revisit Houston Guidelines in light of CLAS• Do we need a CNP sub-specialty or are we

committed to raising the bar together as a community of practice in neuropsychology…?

¡Gracias!

TONY PUENTE

Paola Suarez, PhDCultural Neuropsychology Initiative,

Postdoctoral Fellow

“REAL LIFE EXAMPLES:” SOCIALLY RESPONSIBLE NEUROPSYCHOLOGICAL

PRACTICE

Social Responsibility

• “Ethical framework which suggests that an entity, be it an organization or individual, has an obligation to act for the benefit of society at large.”


Socially Responsible Neuropsychology

• Practicing socially responsible neuropsychology (SRN) challenges our field to engage in individual and organizational practices that benefit all patients in an equitable manner regardless of their race, ethnicity, sex, language, or sexual orientation.


Equality vs. Equity• Equality:

– Ad-hoc translations– Use of interpreters– Ask bilingual students to provide

care for patients without proper supervision

Equity vs. Equality• Equity:

• Norms• Guidelines for practicing with

underrepresented groups• Assessment tools for non-English

speakers• Programs to serve the

underrepresented• Some of us in this room; culture

relevant assessments


• However, as a field, we continue to fall short in judiciously providing equitable care for all patients, in part, due to insufficient emphasis on the development of competencies relevant to working with culturally and linguistically diverse patients through the course of neuropsychological training.


Case Sample #1 Demographics: 63-year old right-handed married “Spanish-

American” man with 15 years of formal schooling (education Mexico)

Reason for referral: Pt. was referred for neuropsychological evaluation by the epilepsy team for localization of epileptogenic foci since an evaluation conducted outside did not provide any significant clinical information


Case Sample #2 Demographics: Pt was a 55-year old, bilingual (Spanish-

dominant) female of Central-American descent with 12 years of education (completed in Spanish)

Reason for referral: Pt. was referred for neuropsychological evaluation by the cardiac transplant team given a previous diagnosis of dementia, which was questioned by the Spanish-speaking cardiologist at the time of his evaluation


Case Sample #3

• Demographics: Pt. was a 73-year old , Spanish-dominant female of Puerto Rican-descent with 12 years of education

• Reason for referral: Pt. was referred for an assessment by a Spanish-speaking neurologist who questioned an AD diagnosis given to the patient 3-years prior.


Case Sample #4

• Demographics: Pt. was a 54-year old , Spanish-dominant male of Mexican-descent with some college education

• Reason for referral: Pt. was referred for a language evaluation by the cardiology team to better characterize his aphasia (approximately 1 year post-stroke) in order aid in treatment planning.



• These real life examples were selected to illustrate how and why we need to intervene as a discipline in a culturally and linguistically responsive manner, and not just delegate the care of LEP or culturally diverse populations to minority professionals or those with an expressed interest in issues of diversity.


ConclusionEquality

• Individual• Patients are most vulnerable• Trainees are vulnerable• No specific guidelines• Left to individual interpretation• No accountability

Equity•Competencies are acquired at the individual level•Patients are served adequately• Burdensome for a few•Trainees are still vulnerable

SRN•Collective•Culture at the core of competencies•Equitable care for ALL patients• Broader impact on the Health Care System• Social Justice

THANK YOU

JENNIFERMANLY

RACHEL CASAS

Xavier E. Cagigas, Ph.D.UCLA Cultural Neuropsychology Initiative

CNI: A CNP Training Model

A Point of Departure…

• "Of all the forms of inequality, injustice in health is the most shocking and inhuman.”

• “Justice too long delayed is justice denied…”

– Martin Luther King, Jr.

Olvera Street, Los Angeles (November, 2015)

Moving Beyond Bystander Status Quo

The Bed of Procrustes

The WEIRD problemBehavioral Science Citations

USNon-US70% 30%

96% of behavioral clinical samples come from countries with only 12% of the world’s population

“W E I R D” Populations

• W estern• E ducated• I ndustrialized• R ich• D emocratic

• R ace• E thnicity• A nd• L anguage

The First Cultural Neuropsychologist…We all need Heroes!

The Cultural Neuropsychology Initiative (CNI)

• A clinical service to provide Spanish and bilingual neurocognitive and psychodiagnostic assessments

• A training program to help develop the next generation of culturally and linguistically competent clinical neuropsychologists

• A new base for clinical and translational research with an explicit multicultural focus on brain health

CNI Culture and Neurocognition Assessment Service (CANAS)

• Presurgical epilepsy evaluations (e.g., Wada)• Organ transplants (e.g., heart, liver, kidney, lung)• Deep Brain Stimulation (DBS) for Parkinson’s disease• Brain tumor resection (e.g., electrocorticography)• Differential Diagnosis (e.g., dementia, neurological)• First-response psychodiagnostic assessment• Bilingual educational assessments

Philosophy for leveraging the pipeline• Direct clinical service for patients• Multiplicative impact of students• Multi-level students learning alongside attending doctors• Feedback to structural components of health system• Community engagement within own institution and

beyond our borders• Disruptive Innovation…

CNI as Transformative Nexus

CNI Modus Operandi• Building resilience in providers is as important as cultural and

linguistic competence• Bilingual supervision in an open and inclusive case conference

environment• Multidisciplinary input and convergence of ideas to

triangulate best practice• Patient-centered clinical pathway• Reconfiguration and/or allocation of resources

Psychiatry 463: CNS Syllabus(10 week Quarter)

• Introduction: Historical Antecedents & Sociocultural Theory• The Cultural Neuroscience Paradigm• Literacy, Quality of Education & Demographically Adjusted Norms • Ethnographic Considerations & the Influence of Technology• Bilingualism as a unique Cultural Practice• A Developmental Perspective to CNP• Acculturation, Stereotype Threat, & other Factors• Ethno-neuropsychopharmacology & Pharmacogenomics• Interpreters and Translations: Limitations in Equivalence & Equity• Ethical Considerations in CNP

Cultural “considerations” reframed… More than half of the world population, and by some estimates up to two thirds, is multilingual

Globalization is making self-identification with a single race/ethnicity more untenable

Documented Health Disparities exist across all levels of assessment, intervention, and outcome

Increased utilization of services by underrepresented groups (or not…)

Historical lack of participation and/or inclusion in research studies

Investigators are not in the habit of reporting cultural demographic information in the studies they do publish; poor evidence-base

Limited instrumentation; poor diagnostic specificity (and at times sensitivity) in assessment measures, and poorer clinical outcomes as a result

The “Ouch!” Factor & Minority Tax

Cultural Humility

Humble reflection on how “one’s knowledge is always partial, incomplete, and inevitably biased”

(Wear, 2008)

Cultural Humility: 3 principles• Lifelong learning and critical self-reflection

(process-oriented)

• Recognize and challenge power imbalances and affirm contributions (Patient-focused)

• Institutional accountability & respectful partnerships for advocacy(CBPR)

» (Tervalon & Murray-Garcia, 1998)

Competence vs HumilityCultural Competence Cultural Humility

Goals • To build an understanding of minority cultures to better and more appropriately provide services

• To encourage personal reflection and growth around culture in order to increase awareness of service providers

Values • Knowledge• Training

• Introspection• Co-learning

Shortcomings

• Enforces the idea that there can be 'competence' in a culture other than one's own.

• Supports the myth that cultures are monolithic. • Based upon academic knowledge rather than lived experience.• Believes professionals can be "certified" in culture.

• Challenging for professionals to grasp the idea of learning with and from clients.

• No end result, which those in academia and medical fields can struggle with.

Strengths • Allows for people to strive to obtain a goal. • Promotes skill building.

• Encourages lifelong learning with no end goal but rather an appreciation of the journey of growth and understanding.

• Puts professionals and clients in a mutually beneficial relationship and attempts to diminish damaging power dynamics.

The so what, now what test…

• Use CNI Training Model to Develop:– CNP Faculty Training Consortium– CNP Training Fellowships– CNP

¡Gracias!

CULTURALLY AND LINGUISTICALLY DIVERSE TRAINING:

STUDENTS’ PERSPECTIVEChristina E Love, MS Octavio A. Santos,

MSPsyD Candidate PhD Candidate

Stats

“Ethnic minorities in particular are horrendously underrepresented in NP” (Monitor, 2015)

11%

89%

2014 ANST Survey (n=188)

Hispanic/Latino (n=20)

Non-Hispanic/Latino (n=167)

88%

6%

5%

1%

ANST survey

Caucasians (n=166)

Asians (n=12)

African-Americans (n=9)

American-Indian/Alaska na-tive (n=1)

13%

87%

1993 Survey (Monitor, 2004)

Hispanic/Latino

Non-Hispanic/Latino

Octavio Christina

• B.S. from Colombia: Tests normed in Spain/U.S.

• Bilingual psychometrician: On-site translations & lack of norms

• PhD – No Spanish-speaking faculty/NPs,

lack of appropriate tests– Misperceived as an “expert”

• 2nd generation immigrant to the US, Colombia

• B.A. Psychology – Shadowed and worked with bilingual NP

• Florida Institute of Technology – M.S. 2013 – PsyD

Our Training Journey: Background & Issues

Ethical dilemmas in Training

• NPs responsible for ensuring they are trained in cross-cultural and/or cross-language work

• Currently no consensus on who is qualified to provide supervision for cross-cultural NP training

• Referral question?

• Language(s) of evaluation?

• Interpreter available?

• What do I know about this culture?

• Anyone more appropriate to refer to?

• Do I have the clinical skills for these questions?

• Cultural consultation available?

• Should I take the case?

Started questioning myself & others…

Burden or Asset?

Taking Action!• Purchased 1st Spanish battery & supervised by English-speaking

faculty & HNS consultants

• Initiated communications between HNS members & NP practicum supervisors

• Hosted 1st Div 40 EMA/ANST Cross-cultural NP Webinar

• Represented fellow trainees at APA/APAGS, AACN, NAN & HNS

Taking Action!

• Referral for middle-aged Mexican-American woman– Rule outs: Memory problems vs. depression

• Provided case consultation and joint supervision in test-selection, interpretation of results, and dx

– Loaned test-materials

• Practice issues, when to say “no”

• Sustainability of consultation model

• Advanced NP Epilepsy Practicum

• 2+ years clinical and research

• Know your population (CF)

• Test-selection (norms)– Translated vs. adapted

• Not just learning the tests in other language– Cross-cultural NP literature

• Language dominance

• Mentoring

Taking Action!

56%22%

11%

11%

Hispanics seen at FH by Nationality

Puerto Rico (n=5)Colombia (n=2)Mexico (n=1)Cuba (n=1)

Octavio (2015) Christina (2014)

Internship Applications

29%

71%

Spanish-Speaking NP

Yes (n=5)No (n=12)

19%

81%

Spanish-Speaking NP

Yes (n=4)No (n=17)

Aspirational Training Goals• Be skilled at:

– Assessing literature, researching/taking client’s cultural, language, acculturation & migration history

– Interpreting/translating or working with an interpreter if needed

– Establishing rapport across cultures

– Understanding neuroepidemiology & public health relevant to immigrant populations

– Communicating findings/recommendations to clients, families & other professionals

Aspirational Training Goals• Know/follow professional ethics, laws and guidelines concerning cross-cultural

clinical work

• Consider diversity variables in interviewing, testing & planning interventions

• Evaluate test translation/adaptation according to ITC guidelines

• Be aware of personal cultural perspectives/background & linguistic limitations

• Educate others in cultural sensitivity/competency

Imagine…

Modeling Global

PerspectivesCreating a

Collaborative LearningCommunity

Engaging students in class/case discussions

Using hypothesis-testing approach

Preparing trainees to work responsively

Testing carried out in accordance with APA, ITC, HHS, Judd et al. (2009) and related

guidelines/literature

¡Gracias Totales!

HNS BOD&

Drs. Christine Salinas, Tedd Judd, Orlando Sanchez, Melissa Castro, Shelley Peery, Paola Suarez, Antonio Puente, Pedro Saez, Juan Arango,

April Thames, Jakeel Quiroz, Franchesca Arias, Michelle Madore, David Mirich & many others who have been part of our training journey

Brainstorm 101• Ground Rules

– One Conversation at a time– Go for Quantity– Headline! (1 idea per Post-it)– Build on the Ideas of Others– Encourage wild ideas– Be visual– Stay on Topic– Defer Judgment-NO Blocking

• “How might we develop a culturally competent neuropsychologist at the entry level?”

CNP Ethics & EthosCourtesy of Monica Rivera-Mindt

Ethics & Ethos• Under the provision of APA’s Ethical Principles of

Psychologists and Code of Conduct , it is clear that neuropsychologists, similar to all psychologists, have an ethical mandate to provide culturally competent neuropsychological services to ethnic minority clients.

– APA’s Ethical Principles of Psychologists and Code of Conduct (EPPCC; 2002)

Ethics & Ethos• Ethical Standard 2.01 (Boundaries of Competence) states that:

– “cultural expertise or competence at the individual level is essential for the clinician who is working with cross-cultural populations.”

• APA Ethical Standard 9.02b states:– “Psychologists use assessment instruments whose validity and

reliability have been established for use with members of the population tested.”

– EPPCC, 2002

Ethics & Ethos• Charge of APA - New Ethical Subsections:

– Assessment Standards, Standard 9.0– 9.02 - Emphasizes that psychologists:

• If validity & reliability not yet established -describe strengths/weaknesses of results & interpretation

• Use assessment methods APPROPRIATE for a patient’s language preference and competence (unless the use of another language is relevant to the assessment)

Ethics & Ethos• Standard 9.06 (Interpreting Assessment Results) of the code states that:– when psychologists interpret assessment results,

they should:• “…take into account the various test factors, test-taking

abilities, and other characteristics of the person being assessed, such as situation, personal, linguistic, and cultural differences, that might affect psychologists’ judgments or reduce the accuracy of their interpretations.”

Documents

Neurobehavioral Clinic Lake Forest, CA DAVID LECHUGA