Testing Spanish Speaking Individuals: Challenges, Practices and Ethical Concerns Antonio E. Puente, Ph.D. (with assistance of Carlos Ojeda) University of North Carolina Wilmington American Psychological Association 08.06.11, Washington, DC

Expected Growth Hispanics in the U.S. Source: U.S. Census Bureau, 2008 2

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Percentages of Hispanics in the U.S. Source: US Census, 2008

Psychology and Hispanics A total of 1,199,239 citations for PSYCHOLOGY A total of 11,019 citations using either the word HISPANIC OR SPANISH Approximately .01% (source: PsycBooks & PsycInfo, 07.11)

Psychological Testing & Hispanics CATEGORY TOTAL # SPANISH HISPANIC PSYCHOLOGICAL ASSESSMENT 13,674 203 87 TESTING 34,221 862 242 TOTALS 47,895 1065 329 (combined=.03%)

Neuropsychological Assessment & Hispanics CATEGORY TOTAL # SPANISH HISPANIC PSYCHOLOGICAL ASSESSMENT 14,566 227 106 TESTING 1,992 12 TOTALS 16,558 238 118 (combined=.02%)

Clinical and Neuropsychological Test Usage Camara, Nathan, and Puente (2000) surveyed test usage. Five most frequently used tests were: MMPI (I&II), WAIS R, WMS-R, WISC-R-III, TMT. None of them were in Spanish. Consistent in other studies like Rabin et al (2005).

Standards for Psychological and Educational Testing Validity = Fairness. Validity is defined: “the degree to which evidence and theory support the interpretations of tests scores entailed by proposed uses of tests” (AERA, 1999; p.9). Fundamental question of validity: Are psychological tests available unfair?

Standards for Educational and Psychological Testing Testing standards have been developed by a joint committee for the last 50 years. The Joint Committee was formed to oversee the accuracy with Standardized testing in the U.S.

Chapter 9: Testing Individuals of Diverse Linguistic Backgrounds It is important to consider language background when developing, selecting, administering, and interpreting test performances (AERA, 1999; p. 91).

Chapter 9: Testing Individuals of Diverse Linguistic Backgrounds According to the Standards, tests for Spanish speakers individuals should meet the following criteria: Test in Spanish Hispanic norms (US) Non-US Hispanic norms Instructions and manuals in Spanish

Neuropsychological Testing Spanish Speakers Approximately 83% of neuropsychologists felt inadequately prepared to work with Hispanic individuals (Echemendia et al., 1997). Salazar, Perez-Garcia, Puente (2007) listed 60 Spanish test. Hispanic Neuropsychological Society includes over 170 tests (in progress). Judd et al (2009) published recommendations when evaluating Hispanics. (NAN)

Questions? What tests are available in Spanish to assess Spanish speakers? (Phase 1) What tests in Spanish are neuropsychologists who are members of the HNS using to evaluate Spanish speakers? (Phase 2) Do these tests meet the testing standards criteria ? (Phase 3)

Method: Phase 1 Obtained UNCW IRB Approval. Developed comprehensive list of Spanish tests by reviewing the following: Prior literature ( Camara et al., 2000; Salazar et al. 2007; etc.) Buros Mental Measurement Yearbook (Website & Online Database). Hispanic Neuropsychological Society Test Database Psych Info & World Cat. Spanish Test Publishers (TEA & Manual Moderno)

Method: Phase 1 After searches, tests in the list were recorded and organized in alphabetical order. Acronym and test edition was included next to Spanish test if available.

Method: Phase 2 After completing the list of tests, an online survey was conducted to assess usage. Created using Survey Monkey IRB approval and HNS BoD approval were obtained.

Method: Phase 2 Pilot testing was conducted. Data collection started December 15th 2009 and ended on March 4th 2010. A total of three reminders were sent.

Method: Phase 2 Included electronic informed consent & nine demographic questions. Participants endorsed whether they did or did not use the test listed. Survey was sent to participants’ e-mails and only one response was allowed for each e-mail address registered.

Method: Phase 2 56 participants out of 83 HNS members (67%) participated in the study. Participants received contact emails for faculty supervisor and student investigator if they had questions and concerns. Participation was voluntary and their responses were confidential.

Method: Phase 3 Survey were results were matched to the criteria of the Standards. One point was given if the following criteria were met. Test in Spanish? Hispanic Norms (U.S.)? Non U.S. Hispanic Norms? Test Manual in Spanish (including instructions)? Each test was rated using a rating scale of: 0(not at all) to 4(all)

Results: Phase 1 Found 555 tests in Spanish out of a total of approximately 3,500 tests. These are both psychological and neuropsychological tests.

Results: Phase II Demographics Gender Male 22 40.7% Female 32 59.3% Race/Ethnicity Caucasian/White 14 25.0% Hispanic/Latino 42 75.0% Degree Ph.D. 34 61.8% Psy.D. 14 25.5% Other 7 12.7% Board Certified No 46 82.1% Yes 10 17.9% Use Technicians/Translators Certified Translators 6 10.9% Uncertified Technicians 6 10.9% Uncertified Translators 1 1.8% None of the Above 44 80.0%

Results: Phase II Demographics Primary Work Setting Hospital 15 27.3% Outpatient Clinic 9 16.4% Private Practice 23 41.8% University 8 14.5% Level Spanish Proficiency No Proficiency 2 3.6% Limited Proficiency 1 1.8% Some Proficiency 4 7.1% Extensive Proficiency 49 87.5% Cultural Context Knowledge Limited Knowledge 1 1.8% Some Knowledge 8 14.3% Extensive Knowledge 47 83.9% Spanish Speaking Clients Less than 25% 15 26.8% More than 25% 15 26.8% More than 50% 10 17.9% More than 75% 8 14.3% 100% 8 14.3%

Results: Phase 2 Test Results A total of 56 (67%) HNS members participated. Participants reported using 216 (39%) tests. Approximately 25 tests that were used for most of the participants. There were 69 tests used by only one participant .

Results: Frequency & Test Rank Rank Order Test Name n % 1 Trail Making Test 35 76.1% 2 Beck Depression Inventory (BDI-II) 33 71.7% 3 Boston Naming Test 29 63.0% 4 Test of Memory Malingering (TOMM) 28 60.9% 5 Beck Anxiety Inventory (BAI) 27 58.7% 6 Inventario Multifásico de Personalidad de Minnesota-2 (MMPI 2) 26 56.5% Stroop Test de Colores y Palabras 7 Bateria III Woodcock Muñoz (BATERIA III) 24 52.2% 8 Vineland Adaptive Behavior Scales 23 50.0% 9 Color Trails Test (CLT) 22 47.8%

Results: Frequency & Test Rank Rank Order Test Name n % 9 Escala de Inteligencia de Wechsler para Adultos III (EIWA III) 22 47.8% Raven Matrices Progresivas (RAVEN) 10 Escala Wechsler de Inteligencia para Niños IV (WISC IV). 21 45.7% Evaluación Neuropsicológica Breve en Español (NEUROPSI) 11 Wechsler Adult Intelligence Scale Third Edition (WAIS III) 20 43.5% 12 Wechsler Memory Scale 3rd Edition (WMS III) 19 41.3% 13 California Verbal Learning Test (CVLT) 18 39.1%

Results: Frequency & Test Rank Rank Order Test Name n % 13 Examen Cognoscitivo Mini-Mental (MMSE) 18 39.1% Test de Copia de una Figura Compleja de Rey 14 Escala de Inteligencia Wechsler para Adultos (EIWA) 17 37.0% 15 Test de Vocabulario en Imagenes Peabody 16 34.8% Test de Clasificación de Tarjetas de Wisconsin (WCST) Bateria Woodcock Muñoz 32.6% Adaptive Behavior Assessment System (ABAS-II) 30.4% Prueba Beery Buktenica del Desarrollo de la Integración Visomotriz (VMI)

Results: Phase 3 Of the top 25 most frequently used tests, almost none meet the criteria of the Standards for testing Spanish speakers.

Results 3: Table of top 25 tests X criteria Test Name Number of Times Test Selected Test in Spanish Hispanic Norms (U.S.) Hispanic Norms (Non-U.S.) Test Manual Spanish Total 1) Trail MakingTest 35 0 (No) 2) Beck Depression Inventory II (BDI-II) 33 1 (Yes) 1 (Yes) (MX) (SP) 1(Yes) 3 3) Boston Naming Test 29 2 4) Test of Memory Malingering (TOMM) 28 0 )No) 5) Beck Anxiety Inventory (BAI) 27

Results 3: Table of top 25 tests X criteria Test Name Number of Times Test Selected Test Name in Spanish Hispanic Norms (U.S.) Hispanic Norms (Non-U.S.) Test Manual Spanish TOTAL 6) Inventario Multifásico de Personalid. de Minnesota-2 (MMPI 2) 26 1 (Yes) 4 7 ) Stroop Test de Colores y Palabras 0 (No) 3 8)Bateria III Woodcock Muñoz (Bateria III) 24 1 ( Yes) 9) Vineland Adaptive Behavior Scales 23 Color Trails Test (CLT) 22

Results 3: Table of top 25 tests X criteria Test Name Number of Times Test Selected Test Name in Spanish Hispanic Norms (U.S.) Hispanic Norms (Non-U.S.) Test Manual Spanish TOTAL 11) Escala de Inteligencia Wechsler para Adultos III (EIWA III) 22 1 (Yes) 4 12) Raven Matrices Progresivas (RAVEN) 0 (No) 3 13) Escala Wechsler de Inteligencia para Niños IV (WISC IV) 21 14) Evaluación Breve Neuropsicologica (NEUROPSI) 15) Wechsler Adult Inteligence Scale Third Edition (WAIS III) 20

Results 3: Table of top 25 tests X criteria Test Name Number of Times Test Selected Test Name in Spanish Hispanic Norms (U.S.) Hispanic Norms (Non-U.S.) Test Manual Spanish TOTAL 16) Wechsler Memory Scale 3rd Edition (WMS III). 19 1 (Yes) 1 (No) 3 17) California Verbal Learning Test (CVLT) 18 0 (No) 1 18) Examen Cognoscitivo Mini-Mental (MMSE) 4 19) Test de Copia de una Figura Compleja de Rey 20) Escala de Inteligencia Wechsler para Adultos (EIWA) 17

Results 3: Table of top 25 tests X criteria Test Name Number of Times Test Selected Test Name in Spanish Hispanic Norms (U.S.) Hispanic Norms (Non-U.S.) Test Manual Spanish TOTAL 21) Test de Vocabulario en Imagenes Peabody 16 1 (Yes) 4 22) Test de Clasificacion de Tarjetas de Wisconsin (WCST) 1(Yes) 0 (No) 0(No) 1 23)Bateria Woodcock Muñoz 15 3 24) Adaptive Behavior Assessment System (ABAS-II) 14 25)Prueba Beery Buktenica del Desarrollo de la Integracion Visomotriz (VMI)

Overall Study Summary Few tests available in Spanish (555 out of 3,500) Fewer tests being used (216). Approximately 25-40 tests that are used frequently, a few are infrequently used and most tests are never used. Most of the tests available do not meet the criteria of the testing Standards.

Discussion: Phase 1 The number of Spanish tests found in our list exceeds previous reports from Camera et al. (2000); Salazar et al. (2007); Lazarus and Puente (2009); HNS (in press); & Renteria (2010). However, the number of tests represent only 16% of the 3,500 tests in Buros.

Discussion: Phase 2 Participants use 216 (39%) of 555 tests. Only TMT is consistent with the top five most frequently used tests. (Camara et al., 2000; Rabin et al. 2005; Lazarus & Puente, 2009). Differences in tests usage might be due to differences in availability of tests (ENG >SPA).

Discussion: Phase 3 Most, if not all, of the tests met criteria of the Standards. Lack of norms were common. Test manual in Spanish for 17 out of 25 tests….etc. If the Standards are not followed, such assessments are considered potentially invalid and their use potentially unethical (Vilar-Lopez & Puente, 2010).

Ethical Concerns Translators Translations Norms Expertise

Translators Typical “Qualified” Problems Family Non-psychological staff member “Qualified” Certified translators and psychological knowledge Problems Significant error (both false positives and negatives)

Translation Problems Customized Translations Official Translations Linguistic equivalence Cultural equivalence Customized Translations Translate as you go Official Translations Approaches Back translation Translation check by experts The case of the Spanish WAIS III

Norms Sample Statistical Manipulation Case of the Spanish WAIS III Samples of convenience Rural Vs. City dwellers (community?) Country of Origin Parental Origin & Educational Attainment Language spoken at home/school Socio-economic status Statistical Manipulation Community Vs. Statistical Goals Case of the Spanish WAIS III

Expertise Personnel Linguistic Cultural Country of Origin Using neuropsychology as an example, 01% Linguistic Literal Vs. Cognitive Equivalence Cultural Bi-cultural? Country of Origin Bure, et al (unpublished)

Conclusion There are increasing and large number of Spanish speakers There are relatively few tests. Of those few tests, very few are being regularly used. Those being used do not appear to meet the Standards criteria. Serious ethical challenges face as demographics, science and practice do not match