When individuals migrate from one nation or culture to another, there is a high likelihood that cultural and ethnic identity will change. Ethnic identity is the “felt belongingness” to a specific group that can be approached, avoided, or achieved by an individual (Caltabiano, 1984). In its simplest form, ethnic identity is a multidimensional affiliative construct, whereby a person views himself or herself (and others) as belonging to a specific ethnic or cultural group (Phinney & Rotheram, 1987). As a result, immigrants may delineate boundaries between “self” and “others” or “us” and “them” altering the dynamic between examiner-patient dyads, particularly in cases of differing ethnic identities. In general, the development and subsequent shift in ethnic identification can occur as early as 4–8 years of age, necessitating careful consideration in clinical settings. Clinicians should first attempt to establish ethnic identity based on the patient’s viewpoint. For example, does a recent Korean immigrant self-identify as Korean, Korean-American, Asian, Asian-American, American, or another classification? Careful questioning is essential to establishing the patient’s preferences, as well as any shifts in his or her ethnic identification post-emigration, in order to facilitate a greater understanding of the individuals’ psychological needs.

Ethnic and cultural identity are strongly related to the theoretical construct of acculturation, the process in which an individual belonging to cultural minority changes their behaviors, beliefs, values, or customs after coming into continuous contact with a “majority” or mainstream culture (Berry, 1980; Berry, Trimble, & Olmedo, 1986; Marin, 1992). The process of acculturation in immigrant populations is generally a fluid process during which the person may identify exclusively with their “home” (native country) culture, “host” (new country) culture, or a combination of both. Sociological studies suggest that this long-term, dynamic process is shaped by each person’s unique immigrant experience and occurs at differing rates, even within the same families.

It has been widely suggested that the construct of acculturation is an important culture-specific moderator of neuropsychological test performance among non-native US populations (e.g., Arnold, Montgomery, Castaneda, & Longoria, 1994; Boone, Victor, Wen, Razani, & Ponton, 2007; Harris, Tulsky, & Schultheis, 2003; Kennepohl, Douglas, Nabors, & Hanks, 2004). In a recent study evaluating the relationship between acculturation and neuropsychological functioning in a clinical neurological sample, Boone et al. (2007) reported that acculturation is a significant predictor of neuropsychological test performance and is not attenuated by the presence of psychiatric or neurologic illness. Although these investigators did not find acculturation to be a significant performance moderator of nonverbal neuropsychological test measures, others suggest that acculturation accounts for diminished performance on nonverbal measures of tactile perception, problem solving, motor speeds, and executive functioning (e.g., Arnold et al., 1994; Coffey, Marmol, Schock, & Adams, 2005).

Given the potential impact of acculturation on neuropsychological test performance, it is necessary to gather information via real-world proxies of this construct. While much of this information can be gathered during the interview process, several self-report rating scales or “acculturation instruments” can be used to quantitatively assess the extent that individuals have adopted and assimilated in various aspects of the dominant (“host”) culture, as well as how much of the person’s nondominant (“home”) cultural traits have been retained (see Marin & Marin, 1992). Specifically, acculturation is most frequently measured by examining several proxy variables, including: (1) language preferences, (2) behavior, (3) knowledge, (4) cultural identity, and (5) values (Cortes, Rogler, & Malgady, 1994; Marin & Gamba, 1996). One such example is the Bidimensional Acculturation Scale (BAS; Marin & Gamba, 1996), a self-report inventory that assesses acculturation among Hispanics. This scale provides an acculturation score for two major cultural dimensions (Hispanic and non-Hispanic domains) which measures three language-related areas: (1) language use, (2) linguistic proficiency, and (3) electronic media. The BAS evaluates bidirectional changes in behavior that are central to the individual in both of these domains. Another instrument, the Short Acculturation Scale for Hispanics (SASH; Marin, Sabogal, Marin, Otero-Sabogal, & Perez-Stable, 1987), evaluates a broader range of acculturation-related constructs, including sociocultural relations. One advantage of the SASH is that its questions are presented in both English and Spanish, allowing for use with either bilingual or monolingual Spanish-speaking populations.

The process of acculturation can be the source of significant psychological turmoil for many immigrants, termed “acculturative stress.” Berry (1980) proposes a model of acculturation which serves to explain the sources of stress based upon the individual’s degree of participation in home (e.g., cultural maintenance) and host (contact participation) culture. In this two-dimensional model, individuals who subscribe to neither their home nor host culture are described as undergoing “marginalization” and are therefore at considerable risk for psychological and emotional distress. Similarly, those who maintain contact with their native culture and forgo participation in majority culture are considered “separated” or “segregated” and are also at increased risk for economic stressors (e.g., difficulty finding suitable employment, adequate housing, or sufficient income) and coping difficulties. Even individuals who assimilate with the host culture often do so at the expense of the long-standing cultural identity and beliefs. As a result, assimilation can be associated with guilt and unstable support systems within one’s ethnic or cultural group. Optimized long-term outcomes (e.g., economic, social, psychological, and physical) are most often achieved with “integration,” whereas cultural attitudes and mores are accepted from both home and host cultures. Although the direct relationship between acculturative stress and neuropsychological test performance has yet to be clearly established, clinicians are encouraged to consider its role in cases where their patients report feelings of isolation or in those who lack a support system of culturally similar peers. The Social, Attitudinal, Familial, and Environmental Acculturation Stress Scale (SAFE; Mena, Padilla, & Maldonado, 1987) is a useful tool for evaluating an individual’s feelings of stress and perceived discrimination within Hispanic populations.

Stereotype threat is another powerful psychological process with the potential to limit the validity and reliability of neuropsychological assessment with minority populations. Most often studied in the context of racial and gender differences, stereotype threat is a situational feeling or awareness of alleged intellectual inferiority, thereby creating anxiety and fear of confirming the possibility (Aronson et al., 1999; Aronson, Steele, Salinas, & Lustina, 1998; Steele, 1997; Steele & Aronson, 1995). Such increased anxiety may interfere with, and decreases performance on, tasks to which the stereotype applies. In their seminal study, Steele and colleagues (1997) assessed the performance of well-educated African-American young adults on difficult verbal items from the Graduate Record Exam; half of the sample was told that the task measured intellectual ability, and the others were informed that it was a laboratory problem-solving task. African-American students performed below their Caucasian peers with matched SAT scores when told that their scores were being used to measure intellectual ability, while African-American students in the non-ability condition performed equally to Caucasian students. In these cases, the salience of racial stereotypes to African-Americans depressed their score on measures of cognitive functioning. Similar findings have been reported in a sample of West Indian immigrants, who are typically perceived as Black in the United States (Deaux et al., 2007). Interestingly, while first-generation immigrants do not exhibit a decrease in performance on testing conditions which activate stereotype threat, US-born second-generation immigrants exhibited stereotype threat effects and a concomitant decrease in performance. Although it is difficult to gauge a patient’s feelings of stereotype threat during the testing session, it is certainly a potential performance moderator that should be thoroughly guarded against, and its effects fully considered.

Beyond the impact of factors stemming from the patient’s worldview and immigrant experiences, several variables within the testing room must also be considered prior to testing and interpretation. In an effort to provide optimum care to nonnative US populations, neuropsychologists should strive to broaden their cultural competence through peer supervision, independent research, participation in continuing education, and/or journal clubs and by remaining abreast of current world events. Although a daunting and, at times, overwhelming prospect, the first step in raising a clinician’s own level of awareness can be achieved by obtaining a basic understanding about the culture and history of the country from which each patient originates. In doing so, themes salient to a patient’s degree of openness and willingness to provide an honest, complete history may emerge. For example, immigrants from countries recently engaged in warfare may hesitate to fully participate in the evaluation process due to concerns of retribution, stigmatism, and/or deportation.

The aforementioned research and study should, at a minimum, include a basic understanding of culturally based communication practices, interactional style, family structure, and taboos. Failure to consider the presence and impact of such social mores can lead to unintentional offenses which may interfere with fluid rapport. For example, in several cultures, being addressed by one’s given name, rather than his/her surname, is indicative of disrespect. The use of titles (e.g., Mr., Mrs., Miss, Ms.), last name (apellido), hyphenated surnames (apellidos in Hispanic culture, e.g., Señora Rodriguez-Rivera, indicating the patient’s mother’s last name, Rivera, and father’s last name, Rodriguez), and patronymics (e.g., Svetlana Grigorievna Lermontov, denoting that Svetlana is the daughter of Grigory) is unique to individual cultures and should be carefully studied and considered prior to assessment. Similarly, pronoun usage can be highly culture specific and reflective of status, rank, formality, and/or familiarity of a relationship; the pronoun “you” in Spanish can differ to indicate the informality of a relationship, “tú” [used with children, family, and friends by most groups], or great respect, rank, and courtesy, “usted” [used with older adults and with professionals, such as teachers].

A patient’s communication style is also largely governed by cultural practices and expectations. For example, individuals from Latino culture may often engage in plática or platicar (loosely translated as “small talk” in Spanish) upon introduction with a health-care provider (Ríos & Fernández Torres, 2004). In such scenarios, patients may initially discuss themes unrelated to their illness, such as the weather or traffic. Although many Western or European countries value communication efficiency, many areas in Latin America or Mexico would consider it rude or offensive to begin an interaction without such preliminaries. According to Davila and colleagues (2011), plática was shown to be instrumental when establishing empathetic relationships and facilitating cooperation in a focus group designed to evaluate the health behaviors of Spanish-speaking Hispanics. Anecdotal evidence further suggests that beginning clinical interviews with similar, non-health-related themes is useful for establishing rapport and a therapeutic alliance (M. Rodriguez-Rivera, personal communication).

Knowledge and awareness of cultural taboos are often important and necessary considerations in the assessment of culturally and ethnically diverse immigrant patients. Beyond the need to demonstrate respect of the patients’ belief systems, understanding cultural taboos is also instrumental in gathering and contextualizing the historical information provided by the patient (and his or her family) during the clinical interview. Specifically, direct discussion of death, dying, or accidents can be considered “bad luck” in many Asian cultures (Wong, Strickland, Fletcher-Janzen, Ardila, & Reynolds, 2000). In such cases, an Asian patient’s reluctance to discuss the history of present illness or his/her vague responses to health-based questions should not be potentially misinterpreted as the result of memory difficulties, emotional disturbance, or psychological resistance. To this end, a review of available medical records and/or a discussion with a family member, community elder, or patient representative may be a particularly important source of medically relevant information (e.g., seizure semiology and postictal sequelae) and seizure-related risk factors (e.g., traumatic brain injury and central nervous system infection). Similarly, non-verbal behaviors which a European-American clinician may view as his/her own expressions of keen interest, warmth, and sincerity (e.g., direct eye contact, body contact, hand shaking) can be construed as inappropriate by culturally dissimilar patients. For example, individuals from China may consider extended direct eye contact from a male examiner to be rude or sexual in nature towards females (Ivey & Ivey, 2003).

Family structure and hierarchy varies considerably across cultures and can reflect societies which are matriarchal, patriarchal, individualistic, or collectivistic. For example, Hispanic populations are largely collectivistic, valuing group needs and goals above one’s own (Marin & Marin, 1991a, 1991b). Familismo, or the care and concern for a multigenerational, extended family network is frequently noted, whereas family members often take a high degree of responsibility in the day-to-day care and long-term planning of individuals with epilepsy. Neuropsychologists should be particularly mindful of the potential consequences of collectivistic culture or familismo during the clinical interview, as patients may rely heavily on family members for assistance and can often rely on them as behavioral and attitudinal referents (Marin & Marin, 1991a, 1991b). Accordingly, clinicians should take care as to not misinterpret diminished independence as reduced adaptive functioning or health-related decline. Moreover, family members, including those outside the “nuclear family,” should be involved in the assessment process (where possible and with the patient’s consent) and may be excellent collateral sources of information.

In large part because of its changing cultural landscape, America is also experiencing a collective shift away from the previously held assumption of English as the nation’s primary “mother tongue.” According to a recent US Census Bureau report, the number of people aged five and older who primarily speak a language other than English at home has doubled from 1980 to 2007 (US Bureau of the Census, 2007 American Community Survey). In that time frame, the percentage of non-English speakers has reportedly risen by 140 %; a dramatic increase compared to an overall population growth of 34 %. Spanish-speakers represent the largest numeric increase (23.4 million more speakers in 2007, as compared to 1980), whereas the Vietnamese-speaking population accounts for the largest percentage increase (an approximate 511 % rise in the same time frame).

While compelling, these statistics do not fully capture the degree of English-language proficiency or bilingualism in non-native US populations. Notably, it is relatively rare to encounter patients who are capable of functioning equally well in either language in each domain or activity (ambilingualism; Halliday, McKintosh, & Strevens, 1970) or who use both languages equivalent to monoglot speakers in their respective languages (balanced bilinguals). Rather, it is much more common for non-native English-speaking, particularly newly arrived immigrants, to demonstrate either monolingualism for their primary language (L1) or functional bilingualism. To this end, ascertaining an individual’s degree of bilingualism is a critical aspect of the clinical interview of non-native English-speaking populations undergoing assessment in an epilepsy setting. Such information has important implications for the patient’s obtained neuropsychological profile, and, by extension, the lateralizing value of the data and post-operative outcome. Direct questioning of the patient is necessary to establish the following information: (1) age of primary and secondary language acquisition, (2) setting in which secondary language was learned, (3) language spoken at home and in social settings, (4) primary language of education, (5) primary language spoken at current job, (6) language-related media preferences (e.g., television, radio, newspaper), (7) frequency that primary and/or secondary languages were spoken in recent months, (8) and patient’s subjective sense of impairment in primary vs. secondary language (e.g., word-finding difficulties are more prominent in French (L1) than English (secondary language; L2). Only after obtaining such information can neuropsychologists plan an appropriate assessment strategy, including performing the evaluation in the patient’s native language, in English only, or obtaining language-related measures in both languages. Should the latter option be selected, it is important to evaluate the patient’s comparative level of abilities across languages by assessing functioning in all aspects of this construct, including word reading, reading comprehension, verbal fluency, confrontation naming.

In cases where clinicians opt to use test measures which were translated from English (source text) into another language (target text), careful attention must be paid to the specific translation practices and procedures. The process of translatorship is a socially defined role, involving at least two languages and two cultural traditions, each of which is being governed by its own set of culture-bound standards of behavior (e.g., “norms”) (Toury, 1980, as cited in Bender, García, & Barr, 2010). Inasmuch, translators can choose to subscribe to the norms of either the source or the target culture, thereby indicating the overall sociocultural relevance of the translation for the target audience. If the source culture is selected, as in the case of most neuropsychological test measures and practices, cultural and linguistic incompatibilities may occur, thus favoring adequacy of the source text. However, if the translator follows the target text, he/she will deviate from the source and will consequentially foster target-culture acceptability.

When selecting translated test materials, clinicians should attempt to evaluate the balance between acceptability and adequacy. For example, concern has been raised regarding linguistic equivalence of the phrase “no ifs, ands, or buts,” across multiple languages. When translated from English into another language, this Folstein Mini-Mental Status Exam (Folstein, Folstein, & McHugh, 1975) item must possess an equivalent number of function words, a comparable mixture of vowels and consonants (e.g., the word “gymnasium” in English is “гимнастический зал” in Russian, pronounced “geem-nas-ti-che-skii-zall,” a much longer, consonant-dense word which is more difficult to pronounce than the English version) and a similar idiomatic meaning in order to evaluate the underlying abilities in the same manner the original does. Although several alternative Spanish-language phrases have been suggested, including “No hay pero que valga” (There is nothing that is not of worth; as cited in Valle, 1990), “Si no bajo, entonces me subo” (If I do not go down then I will go up; as cited in Valle, 1990), and “Él quiere irse a casa” (He wants to go home; Teng et al., 1994), they lack comparable frequency and pragmatic ease.

To obviate similar problems, a French translation of the CERAD (Consortium to Establish a Registry for Alzheimer’s Disease) battery substituted “no ifs, ands, or buts” with the phrase, “pas de si ni de mais” (literally translated as “neither yes, nor but” or, more loosely as “no ifs or buts”), as this phrase preserves the overall meaning and the grammatical categories of its constituents, and it also serves to evaluate the same cognitive and articulatory functions as Geschwind’s original phrase (e.g., articulatory agility, comprehension, and presence of paraphasias in repetition; Demers et al., 1994).

Neuropsychological test translation is further complicated by transliterated words (e.g., “laundromat” or “launderette” are referred to as “washatería” by Mexican populations residing in Texas or “el londri” for Hispanic individuals residing in Los Angeles; Pontón & Ardila, 1999) or those that are region- or country-specific (e.g., the word “bus” is most commonly referred to as “autobús” in Spain, “camión” in Mexico, and “guagua” in Cuba, Canarias, and Antillas). When translating the Boston Naming Test (CERAD version) into French, test translators acknowledged differences in intracultural salience of a picture of a canoe to French-speaking Canadians, as compared to the French population residing in France (Demers et al., 1994). To this ENP, test makers should consult multiple translators from a variety of communities speaking derivatives of the same official language (e.g., French text translated by professionals in French-speaking Canada, Haiti, France, Belgium, and the Republic of the Congo) to resolve such sociocultural disparities (American Psychiatric Association, 2000). Information detailing translation procedures, including those used to minimize region-specific dialectical differences and colloquialisms, should be provided in the test manual. Prior to using such test measures, neuropsychologists should critically evaluate these processes in relation to the needs and abilities of their individual patients.

The following subsection will provide brief descriptions of measures of mental status and general intellectual functioning appropriate for culturally and linguistically diverse epilepsy patients. Of note, many of the tests described herein are appropriate for Hispanic populations, as multiple instruments have been developed or translated for use with Spanish-speakers.

More comprehensive assessments of intellectual functioning are often warranted when performing neuropsychological evaluations with epilepsy patients. Notably, such measures can be used to more accurately assess premorbid intelligence, identify areas of strengths and weaknesses, track performance from a neurocognitive baseline, and as a prognostic indicator of postsurgical outcomes.

The Escala de Inteligencia de Wechsler para Adultos (EIWA; Wechsler, Green, & Martinez, 1968) is an adaptation of the original version of the Wechsler Adult Intelligence Scale (WAIS) which was normed on 616 Puerto Ricans, ranging in age from 16 to 54 years. Although the development of the original EIWA represented an important first step in the assessment of Spanish-speaking persons, it has been widely criticized for having questionable psychometric properties and a restricted standardization sample (e.g., Lopez & Taussig, 1991; Melendez, 1994). Of note, significant performance disparities emerged among bilingual individuals (Spanish/English) administered both the WAIS and the EIWA (Melendez, 1994). Perhaps most strikingly, cognitive functioning in non-English-speaking Hispanics was shown to be underestimated by the WAIS-R but overestimated using the EIWA, whereas WAIS-R subtests indicated cognitive impairment in neurologically healthy Spanish speakers, and the EIWA subtests suggested less cognitive impairment in participants with Alzheimer’s disease (Lopez & Taussig, 1991). Attempts were made to develop a “short form” of the EIWA, similar to the English-language Wechsler Abbreviated Intelligence Scale (WASI), by using derivations of 2–5 of the existing subtests; however, many of these combinations lacked the ability to calculate verbal and performance IQs (Demsky, Gass, Edwards, & Golden, 1998). Moreover, none of the brief forms with strong reliabilities and validities (0.95–0.98) included Object Assembly, Digit Span, and Digit Symbol Coding; the latter two subtests are known to be potential areas of weakness in epilepsy patients.

More recently, several revisions and updates of the EIWA have been published to address many of the aforementioned concerns. The Escala de Inteligencia de Wechsler para Adultos—Tercera edición (EIWA-III; Wechsler, 2004, 2008) was published with specific considerations and modifications appropriate for Puerto Ricans. Developed in collaboration with the Ponce School of Medicine in Puerto Rico, the EIWA-III possesses improved psychometric properties, extended “floors” for lower functioning patients, and a reduced administration time. A version of the WAIS-III has also been developed for individuals from Spain (TEA Ediciones, 2001); this version of the EIWA-III was normed on 1,369 subjects representative of the adult population of Spain in the late 1990s.

The goals of evaluations aimed solely at characterizing seizure focus have considerable overlap with those conducted in preoperative contexts, as test data are interpreted to assess functional brain status in populations with epilepsy and, by extension, lateralize a resectable region of cortex responsible for seizure onset (Loring, 1997). Inasmuch, neuropsychologists administer domain-specific tests with relevance to hemispheric lateralization and functional postoperative outcome (e.g., language, visuospatial processing new learning, and delayed recall) (Jones-Gotman, 1991). Briefly, it is believed that when the left hemisphere is dominant, left-sided seizure focus is identified by a relatively consistent material-specific deficit in verbal abilities (e.g., naming, verbal fluency) and verbal declarative memory (Jones-Gotman, 1991). Right-sided lesions (again, in patients with left hemisphere dominance) typically correlate with poor visuospatial skills (e.g., visuospatial construction, visual abstract reasoning) and nonverbal memory deficits. At times, a clear pattern of material-specific deficits in language or memory-related abilities emerge during preoperative assessments, thereby suggesting the side of epileptogenesis (Buelow & McNelis, 2002; Loring & Meador, 2001; Milner, 1975).

While there is a considerable, albeit inconsistent, body of literature evaluating the predictive power of material-specific patterns of neuropsychological deficit in lateralizing seizure focus in English speakers, comparably few investigations have studied the efficacy of neuropsychologically predicted lateralization in non-US-born, non-native English-speaking individuals with epilepsy. Yet, it is well known that a variety of methodological and ecological factors place ethnic minorities at an inherent disadvantage on testing, when compared to monolingual Anglo-Americans, resulting in considerable performance disparities (Ardila et al., 1994; Rosselli, Ardila, & Rosas, 1990). Clinically, consistently low scores, which may or may not reflect the patient’s true level of cognitive functioning, can result in an overestimation of cognitive impairment in non-native English-speaking minorities. Therefore, the risk of misdiagnosis is great. The subsequent subheadings will introduce three linguistically appropriate test batteries (e.g., NeSBHIS, RBANS-SRE, and the CCNB) and several domain-specific measures with the potential to yield the breadth and quality of neuropsychological test data necessary for the diagnostic decision-making and treatment planning of epilepsy patients.