Neurobehavioral Clinic Lake Forest, CA DAVID LECHUGA.

Neurobehavioral Clinic Lake Forest, CA DAVID LECHUGA

RationaleRationale Meetings at UCLA (Cultural Neuropsychology Initiative: Meetings at UCLA (Cultural Neuropsychology Initiative: – http://www.semel.ucla.edu/cni http://www.semel.ucla.edu/cni Xavier Cagigas, Paola Suarez, Lisa Moran, David Lechuga: Xavier Cagigas, Paola Suarez, Lisa Moran, David Lechuga: – Rachel Casas and Christine Salinas Pipeline issues: Pipeline issues: – Attracting those that will help meet the needs

Refinements to Houston Conference Evolved from public health concern: Evolved from public health concern: – Changing demographics of United States Concerns about level and commitment: 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 Need to rethink and revise guiding document

From Houston to Austin Dovetailed with HNS Mission: Dovetailed with HNS Mission: – http://hnps.org/about/mission-statement/ http://hnps.org/about/mission-statement/ Consistent with efforts from other entities interested in cultural competency enhancement in neuropsychology Consistent with efforts from other entities interested in cultural competency enhancement in neuropsychology – Guilds – Regulatory bodies

TodayToday Presentations that provide context and background Presentations that provide context and background Brainstorming session Brainstorming session – Translate into action steps Partnerships with other professional groups as part of Houston Conference refinement process Partnerships with other professional groups as part of Houston Conference refinement process

GoalGoal Generally, to be part of the change process 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 Other demographic groups that require greater sensitivity re: cultural factors

Bienvenidos!Bienvenidos! Fortunate to have representatives from various national and international groups Fortunate to have representatives from various national and international groups Leaders of HNS Leaders of HNS Students of HNS Students of HNS Members and guests of HNS Members and guests of HNS

HNS Board Xavier Cagigas Xavier Cagigas Roy Aranda Roy Aranda Veronica Bordes Edgar Veronica Bordes Edgar Katrina Esherick Belen Katrina Esherick Belen Delia Silva Delia Silva Gretchen Berrios-Siervo Gretchen Berrios-Siervo Christina Salinas Christina Salinas Christina Eguizabal Love Christina Eguizabal Love Johanna Rengifo-Nevarez 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?

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

Experience with the Houston Guidelines In My Own Training & Training Others

Current Guideline Recommendations 0 Representation of ‘Cultural Competence’ Language # of Words Houston Guidelines: Total Words = 2,035; Total Culturally-Relevant Words = 11 (0.5%)

Current Guideline Recommendations V V. 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: 0 3. Foundations for Study of Brain-Behavior Relationships: 0 4. Foundations for Practice of Clinical Neuropsychology: 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? }

What is Needed for the Guidelines? Paradigm Shift in Neuropsychology Paradigm Shift in Neuropsychology Cultural Competence Framework for Neuropsychology Cultural Competence Framework for Neuropsychology Lifespan Model to Cultural Competence Lifespan Model to Cultural Competence Source: Arial Narrow 8 pt. Rivera Mindt et al., 2010

Paradigm Shift in Neuropsychology Avoid the ‘ghetto-ization’ of multicultural issues 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 NP ACQUISITION Specific, culturally appropriate assessment, intervention, & communication skills Specific, culturally appropriate assessment, intervention, & communication skills Necessary to effectively work with cultural minority groups Necessary to effectively work with cultural minority groups INDIVIDUALS & ORGANIAZATIONS Development of core cultural competencies Development of core cultural competencies Based on new theories, practices, policies Based on new theories, practices, policies Organizational structures that are more responsive to all groups. Organizational structures that are more responsive to all groups. KNOWLEDGE & UNDERSTANDING Own world view Own world view Clients’ culture & world view impacts NP performance & intervention Clients’ culture & world view impacts NP performance & intervention Understanding of sociopolitical influences Understanding of sociopolitical influences AWARENESS Assumptions/va lues/biases @ cultural minorities Assumptions/va lues/biases @ cultural minorities Impact provision of NP services Impact provision of NP services Positive stance towards multiculturalism Positive stance towards multiculturalism + + D.W. Sue, 2001; Rivera Mindt et al., 2010

Lifespan Model to Cultural Competence (Undergraduate) Doctoral Training Internship Postdoctoral 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 Career Mid- & Late Career Early Career Mid- & Late Career Cohesive multicultural training curricula for those already in the profession (ABPP?) Specific task forces charged with providing coherent CC training for memberships 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 type of curricula, didactics and/or training needed for cultural competence to be achieved? What is the minimum level of bilingual proficiency needed? What is the minimum level of bilingual proficiency needed? How would this be evaluated? How would this be evaluated? Who would be appropriate to teach and/or supervise these courses or students? Who would be available? Who would be appropriate to teach and/or supervise these courses or students? Who would be available? Are broad courses on cultural diversity sufficient? Are broad courses on cultural diversity sufficient? Who would provide oversight? (Houston Guidelines have little detail; APA has criteria for Psych but not NP) Who would provide oversight? (Houston Guidelines have little detail; APA has criteria for Psych but not NP) Source: Arial Narrow 8 pt.

Moving Forward Who is Responsible? Who is Responsible? Source: Arial Narrow 8 pt. When Does This Happen? How Does This Happen? …………………………Let me give you a HINT. Where Does this Happen?

Moving Forward Here Here Inter-Organizational Effort Inter-Organizational Effort NOW NOW Together Together – We Are Responsible For Making this Happen

Icahn School of Medicine at Mount Sinai Fordham University Muchas Gracias, Thank you! 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

education ethnicity language race nationality country culture acculturation immigration insurance economics literacy politics religion Heterogeneity of Hispanics

Hispanic Subgroups by Region Mexico PR Cuba Central America South America Other South Northeast Midwest West

Language Use Among Hispanics ~50% of the world are bilinguals ~50% of the world are bilinguals ~20% of US citizens are bilinguals ~20% of US citizens are bilinguals Spanish is 2 nd most common language (38M) fejkj Spanish is 2 nd most common language (38M) fejkj 82% of Latino adults speak Spanish* 38% Spanish “dominant” 38% bilingual 24% English “dominant” Dialect differences Dialect differences (“tutear”; grammar use; vocabulary) (“tutear”; grammar use; vocabulary) Cultural influences on L1 maintenance Cultural influences on L1 maintenance

Language Use Among Foreign Born Hispanics

IMPLICATIONS FOR NEUROPSYCHOLOGY & COMMUNITY Changing US Culture

Neuropsychology Trends

Healthcare Disparities for Hispanics TX, NJ: VA: CA, NY, NM, NC, NV: CO, WA, MA: FL, IL, GA, PA: AZ: Organization# Spanish Speaking NPs NAN96 HNS157 AACN25 = 1:81,000 (std. NP:PX in the US) Salinas, Bordes-Edgar, & Puente, In Press; Romero et al., 2009; Judd, 2010

Training Challenges: Hispanics Echemendia et al, 1997; Renteria et al, 2010

Challenges in Practice ~15% of 3500 tests are in Spanish ~15% of 3500 tests are in Spanish Only 5 meet Standards for Educational & Psychological tests Only 5 meet Standards for Educational & Psychological tests Use and selection of appropriate interpreters 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 Clinicians are NOT using normative data when available – Only 1/3 of time Supervision of bilingual and diverse psychometrists and trainees 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) 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! 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 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 1,834 abstracts reviewed – 10 articles identified for inclusion in review (<1% over 5 yrs): Peer reviewed Peer reviewed Direct examinations of culture/ethnicity on test performance Direct examinations of culture/ethnicity on test performance Use of at least 1 standardized or experimental neuropsychological test Use of at least 1 standardized or experimental neuropsychological test No parsimonious link between ethnicity and test performance; several complex factors at play No parsimonious link between ethnicity and test performance; several complex factors at play Byrd, Arentoft Scheiner, Westerveld & Baron, 2008 Byrd, Arentoft Scheiner, Westerveld & Baron, 2008

Challenges in CN Research >600 abstracts reviewed (PubMed): >600 abstracts reviewed (PubMed): Epilepsy+ language/memory/cognition/behavior/QOL/NP/fMRI Epilepsy+ language/memory/cognition/behavior/QOL/NP/fMRI 15 articles identified for inclusion in manuscript review: 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 Keywords: culture, Hispanic, Spanish

Challenges in CN: Latin America Lack of academic training programs46.9% Lack of clinical training opportunities45.4% Lack of willingness to collaborate between professionals35.9% Lack of access to neuropsychological instruments35.0% Lack of professional leaders in the field30.9% Lack of access to literature/ libraries11.3% There are no barriers8.3% Lack of access to technology/ computers3.7% Lack of access to the internet1.2% Lack normative data for my country62% Not adapted to my culture56% Too costly/ expensive49% Aimed at individuals with high levels of education25% Are often not applicable because my patients cannot read or23% Not translated to my language19% Do not have good psychometric properties15% Take a long time to administer13% There are no problems with the instruments that I use8% Too complicated to administer and/ or score5% Other3% Arango et al, 2015

Xavier E. Cagigas, Ph.D. UCLA Cultural Neuropsychology Initiative CNP 365: New Mandates

Cultural Neuropsychology: The New Norm N

Title VI Federal Civil Right Act of 1964 Prohibits discrimination on the basis of race, color, or national origin 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) 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 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. 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 and Affordable 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. 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: 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 Timeline: End of Fiscal Year 2016

HHS/NIH LAP for LEP Recipients must consider: 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 Elements 1.Assessment of Needs and Capacity 2.Oral Language Assistance Services 3.Translation of Written Materials 4.Policies and Procedures 5.Notification of the Availability of Free Language Assistance 6.Staff Training on the Provision of Language Assistance 7.Assessment of the Accessibility and Quality of Services 8.Stakeholder Consultation 9.Digital Information 10.Grant Assurance and Compliance

NIH Cultural Framework for Health Provides a tool for researchers and program evaluators to use in project design. 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 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. 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. 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. 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 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.

ContinuedContinued 12.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 NIH EDI 365 Pledge  CNP Houston to Austin Pledge Revisit Houston Guidelines in light of CLAS 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…? 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, PhD Cultural 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.” “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.” Source: Arial Narrow 8 pt.

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. 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. Source: Arial Narrow 8 pt.

Equality vs. Equity Equality vs. Equity Equality: Equality: – Ad-hoc translations – Use of interpreters – Ask bilingual students to provide care for patients without proper supervision

Equity vs. Equality Equity: Equity: Norms Norms Guidelines for practicing with underrepresented groups Guidelines for practicing with underrepresented groups Assessment tools for non-English speakers Assessment tools for non-English speakers Programs to serve the underrepresented Programs to serve the underrepresented Some of us in this room; culture relevant assessments Some of us in this room; culture relevant assessments

Socially Responsible Neuropsychology 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. 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. Source: Arial Narrow 8 pt.

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 Source: Arial Narrow 8 pt.

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 Source: Arial Narrow 8 pt.

Case Sample #3 Demographics: Pt. was a 73-year old, Spanish- dominant female of Puerto Rican-descent with 12 years of education 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. 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. Source: Arial Narrow 8 pt.

Case Sample #4 Demographics: Pt. was a 54-year old, Spanish- dominant male of Mexican-descent with some college education 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. 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. Source: Arial Narrow 8 pt.

Socially Responsible Neuropsychology 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. 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. Source: Arial Narrow 8 pt.

ConclusionConclusionEquality Individual Individual Patients are Patients are most vulnerable most vulnerable Trainees are Trainees are vulnerable vulnerable No specific guidelines No specific guidelines Left to individual Left to individual interpretation interpretation No accountability No accountability Equity Competencies are Competencies are acquired at the acquired at the individual level individual level Patients are served Patients are served adequately adequately Burdensome for a Burdensome for a few few Trainees are still Trainees are still vulnerable vulnerable SRN Collective Collective Culture at the core of Culture at the core of competencies competencies Equitable care for ALL Equitable care for ALL patients patients Broader impact on Broader impact on the Health Care the Health Care System System Social Justice Social Justice

THANK YOU

JENNIFER MANLY

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.” "Of all the forms of inequality, injustice in health is the most shocking and inhuman.” “Justice too long delayed is justice denied…” “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 problem 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 W estern E ducated E ducated I ndustrialized I ndustrialized R ich R ich D emocratic 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 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 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 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) Presurgical epilepsy evaluations (e.g., Wada) Organ transplants (e.g., heart, liver, kidney, lung) Organ transplants (e.g., heart, liver, kidney, lung) Deep Brain Stimulation (DBS) for Parkinson’s disease Deep Brain Stimulation (DBS) for Parkinson’s disease Brain tumor resection (e.g., electrocorticography) Brain tumor resection (e.g., electrocorticography) Differential Diagnosis (e.g., dementia, neurological) Differential Diagnosis (e.g., dementia, neurological) First-response psychodiagnostic assessment First-response psychodiagnostic assessment Bilingual educational assessments Bilingual educational assessments

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

CNI as Transformative Nexus

CNI Modus Operandi Building resilience in providers is as important as cultural and linguistic competence Building resilience in providers is as important as cultural and linguistic competence Bilingual supervision in an open and inclusive case conference environment Bilingual supervision in an open and inclusive case conference environment Multidisciplinary input and convergence of ideas to triangulate best practice Multidisciplinary input and convergence of ideas to triangulate best practice Patient-centered clinical pathway Patient-centered clinical pathway Reconfiguration and/or allocation of resources Reconfiguration and/or allocation of resources

Psychiatry 463: CNS Syllabus (10 week Quarter) Introduction: Historical Antecedents & Sociocultural Theory Introduction: Historical Antecedents & Sociocultural Theory The Cultural Neuroscience Paradigm The Cultural Neuroscience Paradigm Literacy, Quality of Education & Demographically Adjusted Norms Literacy, Quality of Education & Demographically Adjusted Norms Ethnographic Considerations & the Influence of Technology Ethnographic Considerations & the Influence of Technology Bilingualism as a unique Cultural Practice Bilingualism as a unique Cultural Practice A Developmental Perspective to CNP A Developmental Perspective to CNP Acculturation, Stereotype Threat, & other Factors Acculturation, Stereotype Threat, & other Factors Ethno-neuropsychopharmacology & Pharmacogenomics Ethno-neuropsychopharmacology & Pharmacogenomics Interpreters and Translations: Limitations in Equivalence & Equity Interpreters and Translations: Limitations in Equivalence & Equity Ethical Considerations in CNP Ethical Considerations in CNP

Cultural “considerations” reframed… More than half of the world population, and by some estimates up to two thirds, is multilingual 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 Globalization is making self-identification with a single race/ethnicity more untenable Documented Health Disparities exist across all levels of assessment, intervention, and outcome Documented Health Disparities exist across all levels of assessment, intervention, and outcome Increased utilization of services by underrepresented groups (or not…) Increased utilization of services by underrepresented groups (or not…) Historical lack of participation and/or inclusion in research studies 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 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 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) Lifelong learning and critical self-reflection (process-oriented) Recognize and challenge power imbalances and affirm contributions (Patient-focused) Recognize and challenge power imbalances and affirm contributions (Patient-focused) Institutional accountability & respectful partnerships for advocacy (CBPR) Institutional accountability & respectful partnerships for advocacy (CBPR) » ( Tervalon & Murray-Garcia, 1998)

Competence vs Humility

The so what, now what test… Use CNI Training Model to Develop: Use CNI Training Model to Develop: – CNP Faculty Training Consortium – CNP Training Fellowships – CNP

¡Gracias!

CULTURALLY AND LINGUISTICALLY DIVERSE TRAINING: STUDENTS’ PERSPECTIVE Christina E Love, MS Octavio A. Santos, MS PsyD CandidatePhD Candidate

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

OctavioChristina B.S. from Colombia: Tests normed in Spain/U.S. B.S. from Colombia: Tests normed in Spain/U.S. Bilingual psychometrician: On-site translations & lack of norms Bilingual psychometrician: On-site translations & lack of norms PhD PhD – No Spanish-speaking faculty/NPs, lack of appropriate tests – Misperceived as an “expert” 2 nd generation immigrant to the US, Colombia 2 nd generation immigrant to the US, Colombia B.A. Psychology B.A. Psychology – Shadowed and worked with bilingual NP Florida Institute of Technology 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 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 Currently no consensus on who is qualified to provide supervision for cross-cultural NP training

Referral question? Referral question? Language(s) of evaluation? Language(s) of evaluation? Interpreter available? Interpreter available? What do I know about this culture? What do I know about this culture? Anyone more appropriate to refer to? Anyone more appropriate to refer to? Do I have the clinical skills for these questions? Do I have the clinical skills for these questions? Cultural consultation available? Cultural consultation available? Should I take the case? Should I take the case? Started questioning myself & others…

Burden or Asset?

Taking Action! Purchased 1 st Spanish battery & supervised by English-speaking faculty & HNS consultants Purchased 1 st Spanish battery & supervised by English-speaking faculty & HNS consultants Initiated communications between HNS members & NP practicum supervisors Initiated communications between HNS members & NP practicum supervisors Hosted 1 st Div 40 EMA/ANST Cross-cultural NP Webinar Hosted 1 st Div 40 EMA/ANST Cross-cultural NP Webinar Represented fellow trainees at APA/APAGS, AACN, NAN & HNS Represented fellow trainees at APA/APAGS, AACN, NAN & HNS

Taking Action! Referral for middle-aged Mexican-American woman 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 Provided case consultation and joint supervision in test- selection, interpretation of results, and dx – Loaned test-materials Practice issues, when to say “no” Practice issues, when to say “no” Sustainability of consultation model Sustainability of consultation model

Advanced NP Epilepsy Practicum Advanced NP Epilepsy Practicum 2+ years clinical and research 2+ years clinical and research Know your population (CF) Know your population (CF) Test-selection (norms) Test-selection (norms) – Translated vs. adapted Not just learning the tests in other language Not just learning the tests in other language – Cross-cultural NP literature Language dominance Language dominance Mentoring Mentoring Taking Action!

Octavio (2015) Christina (2014) Internship Applications

Aspirational Training Goals Be skilled at: 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 Know/follow professional ethics, laws and guidelines concerning cross-cultural clinical work Consider diversity variables in interviewing, testing & planning interventions Consider diversity variables in interviewing, testing & planning interventions Evaluate test translation/adaptation according to ITC guidelines Evaluate test translation/adaptation according to ITC guidelines Be aware of personal cultural perspectives/background & linguistic limitations Be aware of personal cultural perspectives/background & linguistic limitations Educate others in cultural sensitivity/competency Educate others in cultural sensitivity/competency

Imagine…Imagine… Modeling Global Perspectives Creating a Collaborative Learning Community 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 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?” “How might we develop a culturally competent neuropsychologist at the entry level?”

CNP Ethics & Ethos Courtesy 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. 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: 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: 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: 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 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) 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: 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.” “…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.”

Neurobehavioral Clinic Lake Forest, CA DAVID LECHUGA.

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Neurobehavioral Clinic Lake Forest, CA DAVID LECHUGA.

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