Unmasking Cultural and Racial Bias in Neuropsychological Assessment
by Thảo-Châu Trịnh, Psy.D. and Rebecca MurrayMetzger, Psy.D.
Neuropsychological assessments play a crucial role in understanding brain function and diagnosing cognitive disorders. However, the presence of cultural and racial biases in these assessments call into question their validity and fairness, particularly for individuals who come from diverse backgrounds. As we strive for more inclusive and accurate evaluations for all people, it’s important to address these biases and explore their impact on assessment outcomes.
Understanding Neuropsychological Assessment
Neuropsychological and psychoeducational assessments involve an array of tests designed to measure various cognitive functions. These include memory, attention, language, and problem-solving abilities. Clinicians, educational psychologists and researchers use these evaluations to diagnose neurological disorders, track cognitive changes over time, and inform treatment plans and interventions.
Comprehensive assessments like those at Mind Matters also include measures of social-emotional functioning. These may include direct tests, as well as questionnaires and standardized interviews designed to better understand a person’s personality, perspective, social skills and internal emotional experiences. We often look at behavior as an extension of the person’s social emotional experience.
Bias in Assessment Tools
The many forms of bias embedded in the test materials themselves presents one of the biggest challenges in neuropsychological assessment. Many tools were developed and normed on predominantly White, Western populations. This can lead to misdiagnosis and misunderstanding when applied to individuals from diverse cultural backgrounds. Some examples of the various forms of bias include:
Language Bias:
Language-based tests may be disadvantageous toward individuals who speak English as a second language or have different language patterns. A bilingual learner may know fewer words in English than their English-only counterparts, even though they often know more words combined across their two languages. Additionally, someone learning English as a second language may not yet be familiar with various idioms and ironic statements, even though they are fully capable of grasping metaphors and recognizing sarcasm in their own language.
Cultural Bias:
While humans share many common experiences and expressions across cultures, important differences exist that affect how we interpret test results. For example, while direct eye contact may be valued in one culture, it may be considered rude in another. Thus, requiring eye contact in order to “perform well” on a test can disadvantage some people. Additionally, family experiences and household routines can vary across cultures, limiting some children’s familiarity with names of objects that are common in many households.
Socioeconomic Factors and Bias:
Socioeconomic status often intersects with cultural and racial backgrounds. Individuals from marginalized communities might have limited access to quality education, healthcare, and other resources that influence cognitive development. These disparities can result in lower test scores, which could be misattributed solely to cognitive deficits rather than systemic inequalities. For example, differences in early academic skills exist for children who attended preschool versus those who did not have access to early learning opportunities. These children may look less capable on academic measures, when actually their scores just reflect this as an early “opportunity gap.”
Racial Bias in Interpretation:
Even when assessment tools attempt to address cultural diversity through more fair test construction, biases can still seep into the interpretation process. Clinicians and researchers might unconsciously stereotype or assume certain beliefs about different racial or cultural groups when analyzing results. This can lead to overdiagnosis or underdiagnosis of cognitive disorders and further worsen the gap in health disparities. For example, African Americans are more than twice as likely to be diagnosed with schizophrenia-spectrum diagnoses than White Americans, even when they present with very similar symptoms. When compared to White youth, Black and Hispanic youth are much more likely to be diagnosed with a disruptive behavior disorder (Oppositional Defiant Disorder, Conduct Disorder) than ADHD, even when symptoms of ADHD are clearly present.
The Historical Relevance of Larry P. and What It Means for Children and Education
Historically, the State of California’s educational code required school districts to use IQ scores to assess students for special education services. As a result, despite making up a small minority (<10%) of the student population, Black students represented 65% of students in special education. However, in 1971, a group of African American parents (together with the Bay Area chapter of the Association of Black Psychologists) filed a lawsuit against the San Francisco Unified School District over concerns that Black children were disproportionately classified as “educable mentally retarded.” The case centered around a child known as Larry P. who the school district placed in an ERM classroom. (Later, it became apparent that he was actually dyslexic).
A Landmark Case
In the landmark case of Larry P. v. Riles (1979), the judge ruled that IQ tests were “racially and culturally biased” and “discriminatory,” and did not accurately measure a child’s intellectual ability. The judge ordered that school districts could not use IQ tests to identify African American students as falling in the ERM category unless the court specifically approved the test. Though the ruling only applied to the original category (“educable mentally retarded”) and its current equivalent (Intellectual Disability), school districts across the state interpreted the ruling as banning IQ tests for the purposes of considering any special education placement for Black/African American students. For a time period, some school districts extended the ruling to other students of color as well.
Mixed Outcomes
While the court meant to reduce discriminatory practices, recent studies indicate that Black and minority students still disproportionately represent students placed in special education (though now under the category of “Emotional Disturbance” based on behavior). Additionally, partially due to the lack of IQ data, some Black and minority students with learning disabilities such as dyslexia are miscategorized and thus not receiving appropriate interventions at school.
Persisting Problems
The implication of this ruling was well-intentioned, aiming to reduce disparities in the educational system. However, it limits school districts as to which assessments they can use to explore the question of a learning disability. This puts parents of Black children in a difficult position. As a result, some parents of multi-racial children deny their Black identity in order to be able to seek assessments and appropriate services for their child. Also, this ruling does not consider how IQ tests (and our understanding of how to interpret these tests) have evolved to reduce racial and cultural biases. Thus, an ongoing conversation ensues among members of the California Association of School Psychologists asking for clarity about this ruling. Specifically, they propose using IQ tests in situations when it could be helpful to the child (such as identifying a learning disability).
Reducing Bias for Fairer Assessments:
Given the scope of the problem, addressing the various forms of bias in assessment may seem insurmountable. However, with a multi-pronged approach, we can mitigate some or most of these factors:
Cultural Awareness Training:
Clinicians and researchers must actively seek training to raise awareness about biases and learn how to approach assessments with sensitivity and understanding.
Diverse Norming Samples:
Assessment tools should be normed on diverse populations that consider ethnicity, race, gender identity, language, and socioeconomic status. Comparing individual performance to similar peers leads to more accurate interpretations of cognitive function across different groups. Clinicians need to choose appropriate assessment tools for the individual based on these normative samples.
Flexible Assessment Methods:
Using flexible assessment methods that consider an individual’s cultural and linguistic background can help reduce bias. For example, with most tests, clinicians stop administering when a child answers more than a certain number of questions incorrectly. However, a clinician may suspect cultural bias or language learning issues at play. At these times, they “test the limits” of that client’s ability by continuing to ask questions beyond that stop point. Offering this information alongside their official score provides a more nuanced picture of the child. Tests must be administered in the language they are normed for. However, bilingual assessors can greet bilingual children and provide general instructions in their preferred language before beginning the test. Offering alternatives to traditional tests, like performance-based assessments, can provide a more comprehensive understanding of cognitive abilities.
Contextualized Interpretation:
Clinicians should take into account an individual’s cultural history and socioeconomic context when interpreting assessment results. Hold in mind the premise that we must “ask and not assume.” This helps clinicians explore the various cultural, familial and socio-economic factors that may impact a person’s testing results. This can help us more accurately reflect an individual’s strengths and weaknesses in the assessment.
Conclusion
Cultural and racial bias in neuropsychological assessment is an important issue that demands attention from clinicians, researchers, and policymakers. Recognizing the presence of bias and actively working to reduce its impact increases equity and improves treatment outcomes. Selecting assessment tools sensitive to cultural and racial diversity presents a key step in this endeavor.
Get a Neurodiversity Affirming Evaluation for Your Child in Berkeley or San Francisco, CA
Psychoeducational and Neuropsychological tests are administered by a dedicated Licensed Psychologist (or Licensed Educational Psychologist). The analysis you receive from Mind Matters helps you tailor their accommodations and interventions to your child’s needs. This test can pave the path to success for your child. Follow these steps to get started:
- Reach out to our intake coordinator to ask questions and find the best evaluator for your child.
- Schedule your child’s evaluation at our Berkeley office or our San Francisco office.
- Understand your child better, and learn how to help them thrive.
Other Services We Offer in the San Francisco Bay Area
In addition to psychoeducational and neuropsychological evaluations, we provide neurodevelopmental screenings. Both of these services include autism testing, dyslexia testing and ADHD testing. We attend school meetings for our clients too. If you aren’t sure what you’re looking for, we offer parent guidance sessions to help you decide on next steps. If you want to know how we can help support you and your neurodivergent child reach out to us.