Sociocultural effects in neuropsychological assessment

Sentence Comprehension in Primary Progressive Aphasia: A Study of the Application of the Brazilian Version of the Test for the Reception of Grammar (TROG2-Br)

Sentence-comprehension deficits have been described in patients with primary progressive aphasia (PPA). However, most instruments to address this domain in more detail and in a clinical context have not been adapted and translated into several languages, posing limitations to clinical practice and cross-language research.

Objectives

The study aimed to (1) test the applicability of the Brazilian version of the Test for Reception of Grammar (TROG2-Br) to detect morphosyntactic deficits in patients with PPA; (2) investigate the association between performance in the test and sociodemographic and clinical variables (age, years of formal education, and disease duration); (3) characterize the performance of individuals presenting with the three more common variants of PPA (non-fluent, semantic, and logopenic) and mixed PPA (PPA-Mx) and analyze whether TROG-2 may assist in the distinction of these clinical profiles.

Methods

A total of 74 cognitively healthy participants and 34 individuals diagnosed with PPA were assessed with TROG2-Br. Overall scores (correct items, passed blocks), types, and categories of errors were analyzed.

Results

In controls, block scores were significantly correlated with years of formal education (Spearman's r = 0.33, p = 004) but not with age. In PPA, age, education, and disease duration were not significantly associated with performance in the test. Controls presented a significantly higher performance on TROG2-Br compared to PPA individuals and their errors pattern pointed to mild general cognitive processing difficulties (attention, working memory). PPA error types pointed to processing and morphosyntactic deficits in nonfluent or agrammatic PPA, (PPA-NF/A), logopenic PPA (PPA-L), and PPA-Mx. The semantic PPA (PPA-S) subgroup was qualitatively more similar to controls (processing difficulties and lower percentage of morphosyntactic errors). TROG2-Br presented good internal consistency and concurrent validity.

Discussion

Our results corroborate findings with TROG-2 in other populations. The performance of typical older adults with heterogeneous levels of education is discussed along with recommendations for clinical use of the test and future directions of research.

Updated demographically adjusted norms for the Brief Visuospatial Memory Test-revised and Hopkins Verbal Learning Test-revised in Spanish-speakers from the U.S.-Mexico border region: The NP-NUMBRS project

OBJECTIVE

We generated demographically adjusted norms for the Brief Visuospatial Memory Test-revised (BVMT-R) and the Hopkins Verbal Learning Test-revised (HVLT-R) for Spanish-speakers from the U.S.-Mexico border region as part of a larger normative project. Methods: Healthy native Spanish-speakers (n = 203; Age: 19-60 years; Education: 0-20 years, 59% women) living in Arizona (n = 63) and California (n = 140) completed the BVMT-R and the HVLT-R as part of the larger Neuropsychological Norms for the U.S.-Mexico Border Region in Spanish (NP-NUMBRS) project. Raw scores were converted to T-scores utilizing fractional polynomial equations, which considered linear and non-linear effects of demographic variables (age, education, sex). To demonstrate the benefit of employing our population-specific norms, we computed the proportion of our participants whose test performance fell below one standard deviation (T-score < 40) when applying published norms from non-Hispanic English-speakers, compared to the base rate derived from the new normative sample. Results: The resulting demographically adjusted T-scores showed the expected psychometric properties and corrected the misclassification in rates of impairment that were obtained when applying norms based on the English-speaking sample. Unexpectedly, participants in Arizona obtained slightly lower HVLT-R T-scores than those in California. This site effect was not explained by available sociodemographic or language factors. Supplementary formulas were computed adjusting for site in addition to demographics. Conclusions: These updated norms improve accuracy in identification of learning and memory impairment among Spanish-speaking adults living in the U.S.-Mexico border region. It will be important to generate additional data for elders, as the present norms are only applicable to adults age 60 and younger.

Determining a Short Form Montreal Cognitive Assessment (s-MoCA) Czech Version: Validity in Mild Cognitive Impairment Parkinson's Disease and Cross-Cultural Comparison

The Montreal Cognitive Assessment (MoCA) is one of the most common screening instruments for mild cognitive impairment. However, the standard MoCA is approximately two times longer to administer than the Mini-Mental State Examination. A total of 699 Czech and 175 American participants received the standard MoCA Czech and English versions and in the clinical part, a sample of 102 nondemented patients with Parkinson's disease (PD). We created a validated Czech short version (s-MoCA-CZ) from the original using item response theory. As expected, s-MoCA-CZ scores were highly correlated with the standard version (Pearson r = .94, p < .001). s-MoCA-CZ also had 80% classification accuracy in the differentiation of PD mild cognitive impairment from PD without impairment. The s-MoCA-CZ, a brief screening tool, is shorter to administer than the standard MoCA. It provides high-classification accuracy for PD mild cognitive impairment and is equivalent to that of the standard MoCA-CZ.

Generalizability of demographically corrected Zambian neuropsychological norms to South African women

Objective: Demographically corrected norms typically account for the effects of age, education, and in some cases, sex and other factors (e.g. race/ethnicity). However, generalizability of normative standards to different countries and ethnic groups is not universal. This study sought to determine whether demographically specific Zambian neuropsychological norms would generalize to a group of South African women.Method: 212 English-Xhosa bilingual, South African (SA) women were administered a comprehensive neuropsychological (NP) test battery in either English or Xhosa. We examined rates of "impairment" using Global Deficit Scores (GDS) based upon published, demographically corrected norms from a nearby African country (Zambia). Using multiple regression, we examined the extent to which Zambian norms "corrected" for the effects of age and education in this SA sample.Results: Compared to the normative standards from Zambia, the South African women performed somewhat worse than expected on a few test measures and better than expected on others, but their GDS and associated "impairment" rates were close to what was seen in Zambia. Demographically corrected Zambian norms adequately adjusted for the effects of age and years of education in this sample of SA women, with the exception that Zambian norms appeared to "under correct" for the positive effects of years of education on tests of information processing speed.Conclusions: Demographically corrected norms developed for Zambia may adequately adjust for the effects of age in SA women. Further research is needed to determine whether additional corrections for education are needed in SA, especially for tests of information processing speed.

Chicanas/os and Mental Health Services

This article reviews recent literature pertaining to Chicanas/os’ utilization of conventional mental health services, their counselor preferences, and the psychological testing and assessment of Chicanas/os. Chicanas/os likely underutilize mental health services, instead preferring family or nontraditional helpers for assistance. However, both Chicanas/os’ level of identification with their indigenous culture as well as their level of acculturation to the majority culture appear to affect their use of services and counselor preferences. Despite longstanding concerns ranging from language barriers to clinician bias in interpreting test results, the literature continues to lack validation studies that specifically support the use of many major psychological tests with Chicanas/os. Unfortunately, these instruments continue to be routinely used clinically to assess Chicana/o clientele, even though the literature cautions that these instruments may generate an inaccurate picture of Chicanas/os’ psychological functioning. Recommendations for counseling practice and future research concerning Chicanas/os are offered.

Culture as a variable in neuroscience and clinical neuropsychology: A comprehensive review

Culture is a dynamic system of bidirectional influences among individuals and their environment, including psychological and biological processes, which facilitate adaptation and social interaction. One of the main challenges in clinical neuropsychology involves cognitive, behavioral and functional assessment of people with different sociocultural backgrounds. In this review essay, examining culture from a historical perspective to ethical issues in cross-cultural research, including the latest significant and publications, the authors sought to explore the main features related to cultural variables in neuropsychological practice and to debate the challenges found regarding the operational methods currently in use. Literature findings suggest a more comprehensive approach in cognitive and behavioral neuroscience, including an interface between elementary disciplines and applied neuropsychology. Thus, as a basis for discussion on this issue, the authors analyzed key-topics related to the study of new trends in sociocultural neuroscience and the application of their concepts from a clinical perspective.

The cross-cultural utility of foreign- and locally-derived normative data for three WHO-endorsed neuropsychological tests for South African adolescents

Interpretation of neuropsychological tests may be hampered by confounding sociodemographic factors and by using inappropriate normative data. We investigated these factors in three tests endorsed by the World Health Organization: the Grooved Pegboard Test (GPT), the Children's Color Trails Test (CCTT), and the WHO/UCLA version of the Auditory Verbal Learning Test (AVLT). In a sample of 12-15-year-old, Afrikaans- and English-speaking adolescents from the Cape Town region of South Africa, analyses of covariance (ANCOVAs) demonstrated that quality of education was the sociodemographic factor with the biggest influence on test performance, and that age also significantly influenced GPT and CCTT performance. Based on those findings, we provide appropriately stratified normative data for the age group in question. Comparisons between diagnostic interpretations made using foreign normative data versus those using the current local data demonstrate that it is imperative to use appropriately stratified normative data to guard against misinterpreting performance.

Brief assessment of cognition in schizophrenia: normative data in an English-speaking ethnic Chinese sample

There is a dearth of non-Western normative data for neuropsychological batteries designed to measure cognitive deficits in schizophrenia. Here, we provide normative data for English-speaking ethnic Chinese on the widely used Brief Assessment of Cognition in Schizophrenia acquired from 595 healthy community participants between ages 14 and 55. Means and standard deviations of subtests and composite scores were stratified by age group and sex. We also explored linear regression approaches to generate continuous norms adjusted for age, sex, and education. Notable differences in subtest performances were found against a Western comparison sample. Normative data established in the current sample are essential for clinical and research purposes as it serves as a reference source of cognition for ethnic Chinese.

Intellectual function in Mexican children living in a mining area and environmentally exposed to manganese

BACKGROUND

Excessive exposure to manganese (Mn), an essential trace element, has been shown to be neurotoxic, especially when inhaled. Few studies have examined potential effects of Mn on cognitive functions of environmentally exposed children.

OBJECTIVE

This study was intended to estimate environmental exposure to Mn resulting from mining and processing and to explore its association with intellectual function of school-age children.

METHODS

Children between 7 and 11 years of age from the Molango mining district in central Mexico (n = 79) and communities with similar socioeconomic conditions that were outside the mining district (n = 93) participated in the cross-sectional evaluation. The revised version of the Wechsler Intelligence Scale for Children adapted for the Mexican population was applied. Concentrations of Mn in blood (MnB) and hair (MnH) were used as biomarkers of exposure.

RESULTS

Exposed children had significantly higher median values for MnH (12.6 μg/g) and MnB (9.5 μg/L) than did nonexposed children (0.6 μg/g and 8.0 μg/L, respectively). MnH was inversely associated with Verbal IQ [β = -0.29; 95% confidence interval (CI), -0.51 to -0.08], Performance IQ (β = -0.08; 95% CI, -0.32 to 0.16), and Total Scale IQ (β = -0.20; 95% CI, -0.42 to 0.02). MnB was inversely but nonsignificantly associated with Total and Verbal IQ score. Age and sex significantly modified associations of MnH, with the strongest inverse associations in young girls and little evidence of associations in boys at any age. Associations with MnB did not appear to be modified by sex but appeared to be limited to younger study participants.

CONCLUSIONS

The findings from this study suggest that airborne Mn environmental exposure is inversely associated with intellectual function in young school-age children.

Mayo older americans normative studies: factor analysis of an expanded neuropsychological battery

The Mayo Cognitive Factor Scores were derived from a "core battery" consisting of the WAIS-R, WMS-R, and Auditory Verbal Learning Test. The present study sought to clarify the factor structure of an expanded neuropsychological battery in normal elderly controls. Confirmatory factor analysis was performed on the WAIS-III, WRAT-3 Reading, Boston Naming Test, Controlled Oral Word Association Test, Category Fluency, Rey-Osterreith Complex Figure, Visual Form Discrimination, and Trail Making Test A & B. A base four-factor model consistent with the WAIS-III factor structure was utilized. Only one novel five-factor model differentiating processing and motor speed tests improved upon this base model. Other models did not, including a factor for executive function, division of construction/visuospatial ability, or "hold"/"no hold" language abilities.

NEUROPSI ATTENTION AND MEMORY: a neuropsychological test battery in Spanish with norms by age and educational level

Health care professionals are now faced with a growing number of patients from different ethnic groups, and from different socioeconomical backgrounds. In the field of neuropsychology there is an increasing need of reliable and culturally fair assessment measures. Spanish is the official language in more than 20 countries and the second most spoken language in the world. The purpose of this research was to develop and standardize the neuropsychological battery NEUROPSI ATTENTION AND MEMORY, designed to assess orientation, attention and concentration, executive functions, working memory and immediate and delayed verbal and visual memory. The developmental sequences of attention and memory as well as the educational effects were analyzed in a sample of 521 monolingual Spanish Speaking subjects, aged 6 to 85 years. Educational level ranged from 0 to 22 years of education. The consideration of the developmental sequence, and the effects of education, can improve the sensitivity and specificity of neuropsychological measures.

Symbol vs. digit substitution task performance in diverse cultural and linguistic groups

In spite of limited empirical data to guide their use, nonverbal neuropsychological measures are frequently utilized in the assessment of non-native English speakers in an effort to minimize cultural and linguistic factors that may influence performance. In this study, three groups of participants from different cultural and linguistic backgrounds were compared on two brief, nonverbal substitution tasks sensitive to cerebral dysfunction: WAIS-R Digit Symbol and the Symbol Digit Modalities Test. Within each group, participants exhibited a similar pattern of performance, earning higher scores on Digit Symbol. However, when dominant Spanish speakers were further subdivided into higher and lower education groups, less educated Spanish speakers achieved lower scores compared to all other groups on both tasks, and failed to show the performance advantage for Digit Symbol. In spite of differences in the respective countries of educational experience, the more highly educated dominant Spanish speakers performed as well as monolingual nonHispanic and Hispanic bilingual participants on both tasks. Years of formal education appears to be the most relevant variable in explaining performance differences across cultural and linguistic groups on these tasks.

What can be localized in the brain? Toward a "factor" theory on brain organization of cognition

A theoretical integration attempt among the lesional (neuropsychological), physiological (functional), and psychometric models of cognition is presented in this article. Recent neuroimaging techniques particularly fMRI have shown that there are some brain functions (i.e., simple) that can be localized into single brain areas whereas there are others (i.e., complex) that cannot. Clinical neuropsychology has been able to propose some "cognitive factors" based on empirical observations in patients with brain lesions. Factor analysis in psychometry may provide an additional tool to extract some constitutive elements of psychological functions (factors). "Factors" in factor analysis, however, may have different levels of specificity. Some times they refer to functional systems (complex cognition); in other occasions to elements of cognition ("cognitive factors"). It is emphasized that the very same brain areas (and cognitive factors) may be potentially involved in different types of cognition. It is proposed that complex cognition depends on specific patterns of activation of different brain areas and specific circuitries ("modules"), each one making its own contribution to the whole system (functional system). Impairment in a specific cognitive factor, on the other hand, may result in diverse types of impairments. At the moment, it seems feasible to suppose some cognitive factors responsible for normal neuropsychological performance. Theoretically, the impairment in any of these factors could be responsible for some specific neuropsychological syndromes.

Demographically corrected norms for the Brief Visuospatial Memory Test-revised and Hopkins Verbal Learning Test-revised in monolingual Spanish speakers from the U.S.-Mexico border region

The large number of primary Spanish speakers both in the United States and the world makes it imperative that appropriate neuropsychological assessment instruments be available to serve the needs of these populations. In this article we describe the norming process for Spanish speakers from the U.S.-Mexico border region on the Brief Visuospatial Memory Test-revised and the Hopkins Verbal Learning Test-revised. We computed the rates of impairment that would be obtained by applying the original published norms for these tests to raw scores from the normative sample, and found substantial overestimates compared to expected rates. As expected, these overestimates were most salient at the lowest levels of education, given the under-representation of poorly educated subjects in the original normative samples. Results suggest that demographically corrected norms derived from healthy Spanish-speaking adults with a broad range of education, are less likely to result in diagnostic errors. At minimum, demographic corrections for the tests in question should include the influence of literacy or education, in addition to the traditional adjustments for age. Because the age range of our sample was limited, the norms presented should not be applied to elderly populations.

Attention and memory evaluation across the life span: heterogeneous effects of age and education

The developmental sequences of attention and memory were studied by utilizing normative data derived from the neuropsychological battery named NEUROPSI ATTENTION AND MEMORY. A sample of 521 Spanish-speaking individuals, aged 6 to 85 years, participated in this study. In the adult sample, educational level ranged from 0 to 22 years of education. Data from subtests measuring orientation, attention and concentration, executive functions, working memory, immediate and delayed verbal memory, and immediate and delayed visual memory were included. The factor structure of the analyzed battery is presented. The effects of age and education on this structure were analyzed. Results suggested that although attention and memory are related, their developmental sequences are separated from one another. During childhood, the development of selective and sustained attention, attentional-working memory, and executive functions showed a fast improvement in performance. Development of verbal memory and place and person orientation showed a slower increment in scores. In the adult sample it was found that factors related to memory are sensitive to age, whereas those related to attention and executive functions are sensitive to education. The consideration of both the developmental sequence, as well as differential effects of education, can improve the sensitivity and specificity of neuropsychological measures, allowing early diagnosis of cognitive dysfunction and implementation of adequate rehabilitation programs.

[Influence of education on the neuropsychological assessment of the elderly: application and analysis of the results from the Mattis Dementia Rating Scale (MDRS)]

OBJECTIVE

To assess the influence of low education and illiteracy on the evaluation of dementia by the Mattis Dementia Rating Scale (MDRS).

METHOD

We applied the MDRS to 62 normal elderly subjects (64-77 years), divided into five groups according to schooling, i.e., 15-16 years, 11-12 years, 8-9 years, 4 years, and illiterate. The MDRS covers the study of five subscales and the sum of their scores may represent the degree of cognitive impairment.

RESULTS

A significant difference (p < 0.05) in performance on this scale was observed among the subgroups in relation to education on 12 items, 5 subscales (illiterates < all other groups and 15-16 years > 4 and 8 years of schooling, p < or = 0.001) and the total MDRS score (illiterates < all others and 4 and 8 years < 15-16 years, p < 0.001). No significant correlations where found for age and, regarding gender, the differences were significant in only one item.

CONCLUSION

Education interfered with individual performance on the MDRS. Illiteracy is a determinant factor of lower MDRS scores that could generate diagnostic errors.

Performance of a Brazilian population sample in the Boston Diagnostic Aphasia Examination: a pilot study

Brazilian researchers and health professionals often face the challenge of having to use tests developed in foreign languages and standardized for populations of other countries, especially in the fields of Neuropsychology and Neurolinguistics. This fact promotes a feeling that some scoring systems may be inadequate for our sociocultural reality. In the present study, we describe the performance of a Brazilian population sample submitted to a translated and adapted version of the Boston Diagnostic Aphasia Examination (BDAE). Sixty normal volunteers (21 men and 39 women), all Portuguese native speakers, ranging in age from 15 to 78 years (average 43.7) and with an educational level of 2 to 16 years (average 9.9), were tested using a translated and adapted Portuguese version of the BDAE. Cut-off scores are suggested for our population and the performance of the Brazilian sample is compared to that of American and Colombian samples, with the results being closely similar in all tasks. We also performed a correlation analysis between age, gender and educational level and the influence of these variables on the performance of the subjects. We found no statistically significant differences between genders. Educational level correlated positively with performance, especially in the subtests involving reading and writing. There was a negative correlation between age and performance in two subtests (Visual Confrontation Naming and Sentences to Dictation), but a coexisting effect of educational level could not be ruled out.

Factor structure of nonverbal cognition

In order to define the factor structure of nonverbal cognitive processes, 156 twenty to sixty year-old participants were selected in Medellin (Colombia). A neuropsychological test battery for assessing different nonverbal cognitive domains (attention, memory, visuoperceptual and visuoconstructive abilities. executive functions, praxis abilities, and written calculation abilities) was administered. Initially, independent factor analyses were carried out for each domain. Three attention factors (Sustained Attention, Divided Attention, and Processing Speed, 73.1% of the variance); two memory factors (Categorical and Non-Categorical Memory, 59.7% of the variance): two visuoperceptual and visuoconstructive factors (Sequential and Simultaneous, 54.0% of the variance); and two executive function factors (Categorization and Trial Error, 82.0% of the variance) were found. Further, several sequential factor analyses using Varimax orthogonal rotations for noncorrelated variables were performed. The 32 test variables were included, but progressively some variables were removed. This procedure finally selected 13 variables corresponding to five factors accounting for 72.6% of variance. Factor I was an Executive Function factor (30% of variance). Factor 2 corresponded to a Sequential Constructional factor (14.7%). Factor 3 represented a Processing Speed factor and accounted for 10.6% of the variance. Factor 4 was Visuoperceptual factor (9.5% of the variance). Finally, Factor 5 (7.8% of the variance) was a Nonverbal Memory factor. It was concluded that several, different cognitive dimensions are included in nonverbal cognition.

Sensitivity and specificity of the Mini-Mental State Examination in a Spanish-speaking population

The Mini-Mental State Examination (MMSE; Folstein, Folstein, & McHugh, 1975) was given to a total of 430 normal participants divided into 3 age ranges (16-50, 51-65, and 66-89) and 4 educational ranges (0, 1-4, 5-9, and > or = 10 years). The educational level effect was notoriously stronger than the age effect. Normal illiterate participants obtained scores that would correspond to severe cognitive alterations (M = 17.67); low education participants (1-4 years) would be classified with moderate cognitive alterations (M = 20.61). Sensitivity and specificity of the MMSE were established. Low sensitivity and specificity were found for both the participants with 0 and 1 to 4 years of schooling, 50% and 72.73%, respectively. In participants with more than 5 years of schooling, the specificity (86.36%) and sensitivity (86.36%) indexes were higher. We concluded that the MMSE is an instrument with little diagnostic utility among participants with a low level of education.

Toward a model of neuropsychological activity

The main purpose of this research was to establish the intercorrelations existing among different psychological and neuropsychological test scores in a normal and homogeneous population. A second purpose was to attempt further step in the component analysis of cognitive activity measured by means of neuropsychological tests. A comprehensive neuropsychological test battery was assembled and individually administered to a 300-subject sample, aged 17-25 year-old. All of them were right-handed male university students. The battery included some basic neuropsychological tests directed to assess language, calculation abilities, spatial cognition, praxic abilities, memory, perceptual abilities, and executive functions. In addition, the Wechsler Adult Intelligence Scale was administered. Forty-one different scores were calculated. Correlations among the different test scores were analyzed. It was found that some of the tests presented a quite complex intecorrelation system, whereas other tests presented few or no significant correlations. Mathematical ability tests and orthography knowledge represented the best predictors of Full Scale IQ. A factor analysis with varimax rotation disclosed five factors (verbal, visuoperceptual, executive function, fine movements, and memory) accounting for 63.6% of the total variance. Implications of these results for a neuropsychological model about brain organization of cognition were analyzed.

A Note of Caution: Normative Neuropsychological Test Performance: Effects of Age, Education, Gender and Ethnicity: A Comment on Saykin et al. (1995)

Recently Saykin et at. (1995), departing from their results in a sample of normal individuals, concluded that, "Demographic factors infrequently account for more than 10% of the variance for many neuropsychological teat scores" (p. 79). In this short article it is pointed out that their results have to be interpreted with extreme caution, because the education and age ranges they used are not valid to analyze the education and age effects on neuropsychological test performance. Educational effect does not represent a linear effect; rather, it represents a kind of negatively accelerated curve, and age effect becomes evident only in a population older than the sample they have selected.

Unilateral brain lesions and performance on Russell's version of the Wechsler Memory Scale in an African American population

Studies of patients with unilateral lesions report hemisphere-specific and locus-specific impairments on Russell's (1975) Revision of the Wechsler Memory Scale (RWMS). In the current investigation "race-homogeneous" and "race-comparative" paradigms provide the context in which the generalizability of RWMS findings are examined in a population of African Americans with unilateral lesions. The performances of brain-damaged patients were impaired relative to normal controls on five of the six RWMS measures. However, patients with left and right hemisphere damage in our sample did not differ systematically on RWMS subtests. Likewise, among patients with lesions confined to one of the quadrants in the brain, there were no quadrant group differences in performance on RWMS subtests. But, right posteriors were impaired relative to controls on immediate and delayed VR subtests. The relative merits of the race-comparative and race-homogeneous paradigms are considered in the context of these findings.

Spontaneous language production and aging: sex and educational effects

Sex and educational level effects on spontaneous language production at different ages were analyzed in a 180-normal subject sample taken from the general population. Subjects were divided into groups according to three variables: (1) age (16-30, 31-50, and 51-65 years), (2) educational level (3-7, 8-12 and more than 12 years of formal educational), and (3) sex (males and females) with 10 subjects in each cell. The oral description of the Plate #1 ("The Cookie Theft") from the Boston Diagnostic Aphasia Examination (Goodglass & Kaplan, 1972) was selected. Number of nouns, verbs, adjectives and grammatical connectors were scored for each subject's picture description. It was concluded that: (1) the ratio among different phrase elements was very uniform across age, educational level and sex groups; (2) the total number of words used to describe the "The Cookie Theft" picture significantly increased with the subject's educational level; (3) the amount of spontaneous language in general decreased with age; however, a significant interaction-effect between age and sex was observed. A steady and pronounced spontaneous language decrease across age-groups was observed in males. However, only mild differences across age-groups were observed in female subjects. It was hypothetized that language changes during aging are strongly sex-dependent: while in men spontaneous language rapidly decreases with aging, in women spontaneous language production remains quite well-preserved.

Directions of research in cross-cultural neuropsychology

Comparable cognitive disturbances associated with brain pathology have similar manifestations across members of the human species. However, cognitive abilities measured by neuropsychological tests represent, at least in their contents, culturally learned abilities. Performance is under the influence of a vast array of moderating variables, including: culture, ecological demands, primary language, and educational level. Test scores are associated therefore, not only with the subject's learning opportunities, but also with those variables which a culture dictates are worthy of cognitive amplification. Different cultural environmental contexts will result in the development of different patterns of abilities. The evaluation of an alien cultural group using our current neuropsychological instruments, procedures and norms, results in conceptual errors in assessment. Cross-cultural neuropsychology is in need of addressing several key focal points of neglected research: (1) the normalization of current basic neuropsychological instruments, in different cultural contexts, (2) the development of new neuropsychological instruments, appropriate for different cultural contexts, (3) the analysis of educational factors and subcultural variations in relation to test performance, (4) the analysis of cognitive disturbances in cases of brain pathology in different cultural and educational contexts, (5) the search for commonality in neuropsychological performance among existing human groups, and (6) the analysis of the origins of cognitive activity.

Normative data on the Boston Diagnostic Aphasia Examination in a Spanish-speaking population

Normative data of the Boston Diagnostic Aphasia Examination (Goodglass & Kaplan, 1972) in a Spanish-speaking population is presented. This test was given to 180 neurologically normal adults grouped according to three variables: sex, age, and educational level. The statistically significant differences found are presented. Few differences appeared between sexes, but there were marked differences among the different age groups and in particular among educational levels. A correction to the scoring is proposed for each of the subtests according the patient's educational level.

Neuropsychological assessment in illiterates. II. Language and praxic abilities

A basic neuropsychological examination of language and praxic abilities was administered to extreme educational groups (100 illiterates and 100 professionals). Subjects were matched according to sex and age (16-25, 26-35, 36-45, 46-55, and 56-65). The following tasks were included: language comprehension, phonological discrimination, naming (objects, figures, and body parts), repetition of words, verbal fluency, calculation, buccofacial and ideomotor praxis, finger alternating movements, meaningless movements, cancellation task, coordinated movements with both hands, and motor impersistence tasks. All the differences between the two educational groups were statistically significant. Two of the eight language tests (phonological discrimination and naming figures) and three of the seven praxic tests (buccofacial praxis, coordinated movements, and cancellation task) showed differences between age groups with a better performance in the younger groups. Calculation tasks and ideomotor praxis showed differences between sexes with a better performance in males. Influence of educational factors in performing routine neuropsychological tests is analyzed.

Detection of brain damage: neuropsychological assessment in a Spanish speaking population

We developed a neuropsychological battery for assessment of cognitive processes that was standardized in 150 neurologically intact subjects from different socioeducational levels in Mexico City (Ostrosky et al., 1985, 1986). The present study was designed to explore the capacity of this neuropsychological battery to discriminate a brain-injured population from a normal one. Thirty-four patients attending the neurological service of two hospitals institutions in Mexico City were studied. The reasons for going to the hospital included both neurological and neuropsychological symptoms. The group was divided into two subgroups: twenty-four patients who showed brain damage confirmed by brain scans, and ten patients with a normal brain scan. A control group of 19 normal subjects was also studied and paired with the other groups by sex, age and sociocultural level. The results show that the neuropsychological battery was able to recognize 83.3% of the patients with scanographically confirmed brain damage: the total percentage of successful diagnosis was 88.2% and there were no false positives. These results indicate that neuropsychological assessment is a powerful diagnostic procedure that also evaluates the patient's cognitive-behavioral activity and can help to predict the possibilities for rehabilitation and return to work.

Neuropsychological assessment in illiterates: visuospatial and memory abilities

A basic neuropsychological battery of visuospatial and memory abilities was administered to extreme educational groups (illiterates and professionals). Subjects were matched according to sex and age. The following visuospatial tasks were included: figure copy (cube, house, and Rey-Osterrieth complex figure), telling time, recognition of superimposed figures, recognition of a map, and drawing of the plan of the room. The following memory tasks were used: basic information, digit retention (forward and backward), memory curve, delayed verbal recall, sentence repetition, logical memory, delayed logical memory, immediate recall of the Rey-Osterrieth complex figure, immediate reproduction of a cube, visuospatial memory, and sequential memory. In visuospatial tasks all differences between the two groups were statistically significant. Five of the seven visuospatial tasks (all but telling time and recognition of superimposed figures) showed differences between age groups with a better performance found in the younger groups and four of the tasks (cube, house, Rey-Osterrith complex figure copying, and telling time) were significant between sexes with a better performance in men. In memory tasks, with the exception of the immediate memory of sentences, all tasks showed statistically significant differences between educational groups. Eight of the 13 memory tasks (digits forward and backward, delayed memory of words, immediate and delayed logical memory, Rey-Osterrieth immediate memory, cube immediate memory, and sequential memory) showed significant differences for age while 4 of the tasks (digits backward, memory curve, Rey-Osterrieth immediate memory, and cube immediate memory) were significant for sex. Results are analyzed with regard to current theories in cognitive psychology and anthropology. Emphasis is placed on the finding that cognitive skills usually examined by neuropsychological tests represent learned and highly trained abilities.

Effects of cultural background and education on handedness

A 5-item handedness questionnaire was given to 317 subjects in four different groups: (1) 51 Tucano (Amazonian jungle) adolescents (36 male, 15 female); (2) 66 Spanish-speaking adolescents (43 male, 23 female) with similar age and educational background to the Tucano group; (3) 100 urban subjects (50 male, 50 female) with a low educational level; and (4) 100 urban subjects (50 male, 50 female) with a high level of education. Hand preference scores were not affected by sex or educational level. The incidence of left-handedness was lower in the Tucano group than in the other groups, despite the fact that the Tucano culture is a highly permissive one. The two rural groups showed less extreme hand preferences than the urban groups, and the Tucano in particular were less likely to indicate extreme hand preferences on any of the items. These results indicate significant effects of culture and environment on declared hand preference, and may be pertinent to recent discussions of cerebral organization in illiterates.