Many years ago I was administering a confrontation naming test to a Hmong woman for qualitative purposes. When we got to the picture of a chair the interpreter said to me, in an aside, that there was no word for “chair” in Hmong because back home in their mountain villages in Laos they had no chairs. Without chairs how do you sit at desks, read, write, draw, use computers, and take tests? Many of us have had such epiphanies that helped us to realize just how profound cultural differences can be. While no one book can allow us to understand such differences fully, the current volume goes a long way in helping neuropsychologists feel much less helpless than I felt that day.
I prefer to think that all reasonably competent neuropsychologists, when faced with the evaluation of a client with a rare diagnosis that they have never seen before, for example, moyamoya disease, would take a half-hour to research that condition in preparation for the evaluation. Certainly, this would also be a reasonable type of preparation when seeing an immigrant client from a country or culture that the clinician has not previously encountered. In my experience, however, too few clinicians make this same kind of routine effort with respect to culture that they would make with respect to diagnosis. A common excuse is that they don't know where to look. When it comes to U.S. neuropsychologists seeing Asian clients that excuse is now obsolete. The Neuropsychology of Asian-Americans is the place to look.
The first two-thirds of this book consists of chapters covering each of the major Asian immigrant populations in the United States. Organized alphabetically, these are: Cambodians, Chinese, Filipinos, Hmong, Asian Indians, Japanese, Koreans, Laotians, Thais, and Vietnamese. The editor has wisely seen to it that each chapter has a similar organization: a brief history of the country, including the history of migration to the United States; characteristics of the immigrant population in the United States; testing considerations such as educational background, language considerations, mental health issues, health issues, cultural factors, family structure, religious values, illness beliefs, and traditional healing; recommendations for neuropsychological evaluation for children and adults; pertinent research, tests, and norms, when available; and an illustrative case example.
“Asia” for the purposes of this book, stretches from India eastward, not including the former Soviet Union, and extends into the Pacific as far as the Philippines. Since the focus is on the major immigrant populations in the United States, some major countries with relatively few immigrants in the United States are appropriately left out, such as Myanmar, Sri Lanka, Bangladesh, and Indonesia.
The illustrative cases often focus appropriately on the clinical history and cultural factors in the encounter, with less emphasis on testing, especially for those groups that often have low education and few validated tests available. The cases are presented openly, warts and all. They analyze the clinician's errors as well as culturally sensitive practices. At the same time, some errors or weak practices go past without comment and I found myself cringing at times. For example, in the Filipino chapter, there was an example of using a family friend as interpreter. While this reflects the realities of clinical practice and of making compromised clinical decisions in the interest of the client and according to the needs of the circumstances, a discussion of the dangers of such a practice should have been included. There are also useful examples of neuropsychologists who find themselves in over their heads and have to figure out how to cope.
While the chapter for a prospective client may take only a half hour to read, the clinician should not wait until 30 min before the appointment to pull this book off the shelf. The pertinent chapter should be consulted well in advance of any appointment so as to help determine if the clinician is prepared for this particular client, to find consultation or referral, if needed, to seek particular tests and norms when called for, and perhaps to read secondary literature, as needed.
The final third of the book reviews the state of neuropsychology as a science and a profession in 8 Asian countries: China, India, Japan, Korea, Malaysia, the Philippines, Singapore, and Thailand. This section is particularly interesting with respect to the history of our field as these chapters demonstrate how cultural values, epidemiology, as well as educational, health care, and political systems all influence the development of neuropsychology in a given country.
This book covers a vast geographic region encompassing over half the world's population. There are many cultural and epidemiological differences between Asian societies and those of the West that are of considerable theoretical interest in neuropsychology. Reading lateralization is less pronounced in Chinese brains than in Western brains. “Dyslexia” is largely a matter of impaired naming speed and morphological and orthographic awareness in China rather than impaired phonemic awareness as in the West. In bilingual dyslexics, instruction in the transparent orthography of Filipino facilitates literacy development in English. Rates of Alzheimer's disease versus vascular dementia vary greatly. Southern China has high levels of nasopharyngeal carcinoma apparently for dietary reasons. Many of these differences are mentioned and referenced in this volume, although this is not the place to find thorough theoretical reviews or even a systematic catalog of such differences.
Most readers are unlikely to read the book straight through. They are more likely to read the chapters that apply to the populations they see and keep it on hand as a reference for the occasion when they see someone from a group they have not yet read about. The entire book is nevertheless a rewarding read for those who are interested in cross-cultural issues generally. The astonishing range of languages, levels and types of education, cultural practices and influences, and histories represented in this book is a useful antidote to Asian stereotyping. From traditional Hmong who may treat the disorder of a wandering soul with shamanism and animal sacrifice, to highly educated Chinese and Japanese who may outperform Westerners on some neuropsychological tests, to Filipinos who have much in common culturally with Latin Americans due to their historic colonization by Spain, the reader will get a nuanced picture of major Asian groups in the United States. The history of migration given in each chapter is especially valuable for understanding the selection processes that account for which portions of the different Asian populations came to the United States, when, and under what circumstances. For example, war refugees have very different circumstances from those who come seeking secondary education.
Writing can suffer at times among authors for whom English is a second language. Happily, that is not the case with this book. The writing is uniformly clear and straightforward, another indication of excellent editing. Unfortunately, the index is brief and much less useful than it could be.
There are a few things that the clinician should not expect to find in this book. It is not a complete guide to cross-cultural assessment. It does not give detailed guidance in interpreter use. It does not itself contain tests or norms for these populations, although these are referenced. And knowledge about a population, while necessary, is not sufficient for cultural competence and cannot substitute for supervised clinical experience in the development of cultural competence. Although the Civil Rights Act of 1964 requires U.S. neuropsychologists not to discriminate on the basis of national origin, including language spoken (Department of Health and Human Services, 2002), as a profession and as a science we are not consistently prepared with the cultural competence required to meet this equity requirement. This book contributes significantly to the needed knowledge base, although no book can supply the skills of cultural competence.
The Neuropsychology of Asian-Americans is a very practical book. It provides a concise guide to the clinician that is well-written and well-organized. Hopefully, it may serve as a model for future work concerning other immigrant populations. Among U.S. neuropsychologists, there is a need for similar guides that detail the cultural, linguistic, educational, and epidemiological variance in Latin American immigrants that impacts our practice. Similar guides for African, Middle Eastern, and European immigrants would, likewise, be helpful. For practitioners in Europe and Australia, distinct guides will be necessary since the patterns of migration to those regions are different. Such guides might take a Web-based form to accommodate changes in immigration more flexibly, but would nevertheless do well to follow the model of this book. Ironically, neuropsychology in most Asian countries is at a point where the focus is on clearly characterizing their dominant population group, and it will be some years before they will be able to turn their attention to their own, internal immigrant groups. India, for example, has a population of over one billion people speaking more than 1600 dialects, and they are educating fewer than 20 neuropsychologists per year; a neuropsychological guide to immigrant populations will be a low priority for them.
Western neuropsychology has developed around a myopic set of beliefs, practices, tests, philosophies, and interventions that we deem best for those we typically serve. We seldom have the need or the opportunity to question the validity of such beliefs. Yet, as globalization increases, many of us are being asked to serve clients who force us to do just that. Cross-cultural test application is the true test of construct validity (Manly, Reference Manly2011). If we in the West truly want to understand the neuropsychological functioning of the human brain, we must become more aware of that other half of humanity that is addressed in this book.
