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Development of Culturally Appropriate Neuropsychological Tests for the Greek Population

Final Report Summary - DECANT (Development of Culturally Appropriate Neuropsychological Tests for the Greek Population)

The DECANT research project concerns the development of culturally appropriate neuropsychological tests for the Greek population. As most neuropsychological tests used in Greece have been originally designed for white occidental Europeans and people residing in North America, we aimed to adapt these tests or to create new ones that take into account the Greek language and cultural particularities. Further, the approach developed could be extended to neighbouring countries, and this project could serve as a template for designing culturally sensitive neuropsychological tests in countries outside North America and Western Europe.

As originally proposed, the selection of tests to be created or adapted and normed was made with the goal of covering all major areas assessed in a thorough neuropsychological assessment, including measures of psychosocial functioning, intelligence, academic achievement, and advanced cognitive abilities (i. e., language, memory, executive abilities, spatial and visual perceptual skills, and motor abilities). We have achieved our stated goal. In detail, the progress made in each domain is as follows.

For the assessment of psychosocial functioning, we validated Greek versions of a depression and an anxiety inventory and established their psychometric properties (reliability and validity) in the Greek population. More specifically, our findings suggested a higher cut off score on the Beck Depression Inventory-II than the American scores (17, instead of 13), and a very high internal consistency of the items in a group of patients currently in a depressive episode (Cronbach's alpha = .85). Our patients'responses led to the emergence of two factors that explained 43 % of the total variance in scores: somatic/affective symptoms (e. g., sadness, crying, changes in sleep and appetite, fatigue) and cognitive symptoms (e. g., pessimism, guilt, sense of being punished or unworthy). We found that Greeks tend to express their depression primarily via somatic and affective rather than cognitive symptoms. The Beck Anxiety Inventory also showed good internal reliability in a group of university students on the first (Cronbach's alpha = .92) and second administration (alpha = .94). The correlation coefficient of repeated measurements was also very high (r =.82, p <. 001).

For the assessment of intelligence, we spent several months generating and reconsidering the particular items (given the importance of achieving varied levels of abstraction), examined samples produced by several artists and finally chose an artist who has now completed the process of drawing the test stimuli. Pilot testing is in progress. In the meantime, we have contributed (both scientifically and procedurally) to the efforts of colleagues (not in our research group) who are responsible for the adaptation and standardisation of a Greek version of widely used American intelligence tests (namely, the Wechsler Adult Intelligence Scale-IV, the Wechsler Abbreviated Scale of Intelligence and the General Ability Measure for Adults).

Academic achievement measures in Greek are lacking, with the exception of a recent study by another group developing a Greek version of the Wechsler Quicktest. Therefore, we focused on a test of reading comprehension, as we already have two vocabulary tests created by members of our own group. Regarding language, we were involved in the adaptation (headed by another neuropsychologist in the group) of the Boston Diagnostic Aphasia Examination-Short Form (BDAE-SF) to the Greek language and culture, a study that also included a small sample of neurological patients. The reading comprehension test mentioned above also falls into the present category. In the domain of verbal memory, we created three versions of a Greek word list learning test, which have been administered to healthy adults to assess the equivalence of the three tests to each other. We have collected normative data from 313 healthy adults for version A and have also administered this version to a sample of psychiatric and neurological patients for the purpose of determining its diagnostic validity. In the domain of non-verbal memory, we have collected normative data for three versions of a complex figure test for use in cases in which follow-up testing is necessary. Given our recent observation that abstraction ability hinders at least some healthy individuals in the process of reproducing a complex visual stimulus, we have begun to collect data from an existing picture, faces and location recognition memory test, as well as a test of spatial memory based on location.

With respect to executive abilities, the data collection process for the investigation of those components of the Wisconsin Card Sorting Test (WCST), which may account for the relatively poor performance found in an earlier normative study conducted by our lab has been completed. Our preliminary findings suggest that the component of this test, which may account for low performance among healthy Greek adults relates to the vagueness of its instructions, requiring examinees to develop a strategy to test hypotheses in their search of the most productive response approach. We additionally initiated two separate investigations to evaluate the cultural appropriateness of tests of executive functioning, particularly for elderly individuals with a low education level who are, presumably, not "test-wise. " In the first study, we explored the role of executive functioning in prospective memory, and, specifically, medication adherence in a sample of neurologically healthy elderly Greek women. For the purpose of this study, we designed a series of tests that have ecological validity and have included pre-existing tests in order to assess the convergent validity of our new measures. Given the importance of identifying tests for use with non test-wise elderly individuals with a low level of education, we are also examining the usefulness of another series of tests, primarily of executive functioning, in a separate large sample of individuals over 60 years of age (part of an ongoing epidemiological study in Greece in which the lab is involved, headed by researchers at Columbia University in the USA). These include a modified version of the Wisconsin Card Sorting Test, which removes the ambiguity that made it difficult for our normative sample and a series of simple Luria-type tasks sensitive to perseveration, and which have face validity. So far, we have observed a very strong education effect on comprehension of the test's instructions, making the modified card sorting task of limited value in assessing the elderly population in Greece. Our additional new measures were well accepted by the participants.

Although we did not incorporate attention and working memory in our proposal, we were involved in the creation of normative data for a series of new and existing tests of attention and working memory by members of the lab. For the assessment of spatial and visual perceptual skills, we have collected data on a series of measures assessing visuospatial perceptual abilities from healthy adults. We found relatively lower scores in the Greek samples as compared with published norms from other countries on some tests, but not others, pertaining to whether the tests require a certain level of abstraction in order to reach the correct response or simply straightforward perceptual skills. Additional exploration is underway in order to determine whether there is an age effect favoring younger vs. older adults, given the almost universal exposure of younger generations to symbolic visual information through school, the media and the internet. Finally, with respect to the assessment of motor abilities, we have included a series of motor programming and sequencing tests in our battery (described above) for the elderly.

Based on our analyses of the components of existing tests which make them of questionable utility in Greece, we developed a complete battery of tests appropriate for the Greek culture. This battery includes all major domains of cognitive functioning: verbal and visual memory, executive functioning, verbal skills, visuospatial perception, attention and working memory. After a pilot study of the initial battery of tests on a healthy sample of 114 adults, we modified several tests and administered the revised battery to a sample of 350 healthy Greek adults, as well as to neurological and psychiatric patients.

Our main goal in the present project was to explore, through experimentation, components of various tests that make them unsuitable for Greeks and to tailor newly developed tests to populations with special characteristics, such as the elderly, who often have limited schooling and may be non test-wise, yet who are frequently in need of an assessment of their cognitive abilities. We also tested culturally appropriate measures on populations of clinical significance (e. g., women with postpartum depression), and continue the data collection process for our newly developed battery from psychiatric and neurological patient populations.

We expect that our work will provide Greek clinicians with scientifically solid tools that will advance the practice of neuropsychology significantly. In addition, our findings have broader societal implications, as a similar process can be followed by neighboring countries, which are also in the process of developing neuropsychological assessment tools for their own populations, as well as by countries in which English is the dominant language, yet include many cultural minority groups.