"People like numbers": a descriptive study of cognitive assessment methods in clinical practice for Aboriginal Australians in the Northern Territory.

0.86 MB·English

by  Dingwall, Kylie M

Dingwalletal.BMCPsychiatry2013,13:42
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RESEARCH ARTICLE Open Access
“ ”
People like numbers : a descriptive study of
cognitive assessment methods in clinical practice
for Aboriginal Australians in the Northern
Territory
Kylie M Dingwall1,3*, Jennifer Pinkerton1 and Melissa A Lindeman2
Abstract
Background: Achieving culturally fair assessments ofcognitivefunctioning for Aboriginal people is difficult due to
a scarcity of appropriately validated toolsfor usewiththis group. As a result, some Aboriginal people with cognitive
impairments may lack fair and equitable access to services.The objective of this study was to examine current
clinical practice in the Northern Territory regardingcognitiveassessment for Aboriginal people thereby providing
some guidance for clinicians new to this practice setting.
Method: Qualitative enquiry was used to describe practice context, reasons for assessment, and current practices in
assessing cognition for Aboriginal Australians. Semi-structured interviews were conducted with 22 clinicians
working withAboriginal clients incentral and northern Australia. Results pertaining to assessment methods are
reported.
Results: A range of standardised testswere utilised with littleconsistency across clinical practice. Nevertheless, it
was recognised that such testsbear severe limitations, requiring some modification and significant caution intheir
interpretation.Clinicians reliedheavily oninformal assessment or observations, contextualinformationand clinical
judgement.
Conclusions: Cognitivetests developed specifically for Aboriginal people are urgently needed. Inthe absence of
appropriate, validated tests, clinicians have relied onand modified a range ofstandardised and informal
assessments, whilst recognising thesevere limitations of these. Past clinical training has not prepared clinicians
adequately for assessing Aboriginal clients, and experience and clinical judgment were considered crucial for fair
interpretation of test scores. Interpretation guidelines mayassist inexperienced cliniciansto consider whether they
are achieving fair assessments of cognition for Aboriginal clients.
Keywords: Cognition, Assessment, Cross-cultural, Testing, Indigenous, Aboriginal
Background Subtle cognitive impairment can be difficult to detect
AboriginalAustraliansintheNorthernTerritory(NT)are throughclinicalinterviewornormalconversation,andthe
oftenexposedtoanumberofcognitiveriskfactorsinclud- ability of clinicians to accurately estimate cognitive
ingpoornutrition,infections,headinjury,violence,paren- functioning without the use of standardised tests can be
tal and personal substance abuse, and complex trauma poor[3].However,existingcognitivetestscanrelyheavily
associated with disadvantaged social circumstances [1,2]. on the use of the English language, require written
responsesandresemblemainstreameducationalprocesses
*Correspondence:[email protected] [4]. Poor English literacy, a lack of formal education, as
1MenziesSchoolofHealthResearch,InstituteofAdvancedStudies,Charles wellas differingconceptsofnumbers,timeandspacecan
DarwinUniversity,Darwin,NT,Australia
3MenziesSchoolofHealthResearch,POBox4066,AliceSprings0870, meanthat Aboriginal people mayhavelimited experience
Australia with the knowledge base from which such tests are
Fulllistofauthorinformationisavailableattheendofthearticle
©2013Dingwalletal.;licenseeBioMedCentralLtd.ThisisanOpenAccessarticledistributedunderthetermsoftheCreative
CommonsAttributionLicense(http://creativecommons.org/licenses/by/2.0),whichpermitsunrestricteduse,distribution,and
reproductioninanymedium,providedtheoriginalworkisproperlycited.
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derived [5-11]. Furthermore, test interpretation often one physician (N = 22). Clinicians had a range of experi-
relies upon inappropriate normative data, typically drawn ence working with Aboriginal Australians, from few to
from non-Indigenous samples [12]. Consequently, for over 20 years experience. A participant reference group
Aboriginal people cognitive dysfunction often remains consistingofsome participants, andanadditional OTand
undetected,misdiagnosedandultimately,untreated. Aboriginal researcher was established, meeting at three
Inability to identify cognitive impairment reliably for timepoints,toguidetheresearchprocess.Theprojectwas
Aboriginal people may place them at further disad- also reviewed by a Menzies School of Health Research
vantage. For example, cognitiveimpairment mayreduce (Menzies) Indigenous Reference Group for advice and
an individual’s insight into their own behaviours and guidance. Ethical approval was granted by the Human
their desire or ability to seek or respond to available Research Ethics Committee for the NT Department of
treatment [13,14]. Furthermore, when in contact with Health and Menzies (including an Aboriginal sub-
the criminal justice system, being both Aboriginal and committee) and the Central Australian Human Research
having a cognitive disability may be a “dual disadvantage” EthicsCommittee.
[15;p.iii].Suchindividualsmaybelesslikelytoknowtheir Written informed consent was obtained prior to
rightswhenquestionedbypolice,lessabletoassistintheir conducting 18 individual or small group (2–3 people)
defence,beatriskofvictimisationincustody,andatriskof semi-structured interviews with participants either in
reoffending [15]. Aboriginal people may therefore experi- person or over the telephone. The interviews took 45–
ence detention as a result of inadequate assessment, treat- 60 minutes and consisted of the same stem questions
mentandservices[16]. used for all participants. Questions enquired about the
Whiletheinadequacyofmainstreamserviceprovision practice context, reasons for assessment, current assess-
and cognitive assessment for Aboriginal Australians has ment methods, outcomes of assessments, and strategies
been recognised for a number of years, little practical for managing identified impairments. Rich data were
development has occurred [17]. An extensive review of collected,butduetopublicationconstraints,onlyselected
theliteraturecritiquingthecognitivetestscurrentlyand themesas theyrelatetoassessmentmethodsarereported
previously used with Aboriginal Australians, found very here. Additional data will be published in subsequent
few tools that were appropriately developed or valida- papers. Interviews were audio-recorded and transcribed
ted for this group [4]. Regardless, anecdotal evidence verbatim. Transcripts were critically analysed using
suggests that alternate tests are being utilised in differ- thematic analysis assisted through NVivo software[18].
ent ways within clinical practice. However, there is no Common themes were generated by organising inter-
documentary evidence detailing what is being used and view data into a system of coded patterns, concepts and
how. categories. Themes were identified by author one, inde-
Clinicians new to the field of Aboriginal health and pendentlycross-checkedwithco-authorsthendiscussed
those wanting to perform evidence based practice there- until consensus was reached. During the data collection
forehavelittleguidancewhenitcomestoassessingcogni- and analysis phase, emerging themes were presented on
tionappropriatelyforAboriginalclients.Asaresult,some two occasions to the participant reference group for
Aboriginalpeoplewithcognitiveimpairmentmaylackfair verification and discussion. Pseudonyms are used to
and equitable access to services. This project aimed to presentresults.
addressthisknowledgegapbydrawingontheexpertiseof
clinicians in the field. In doing so, it sought to bring an
Results
expanded evidence base to the conduct of cognitive
assessments in practice and to identify how assessments Reasonforandimportanceofassessment
are beingconducted toachieve culturallyfair measures of Most practitioners agreed that a good clinical justification
functioning. foracognitiveassessmentisneededasassessmentcanhave
importantandlong-termconsequences.
Methods
“Onceit’swritten inafile,it’sthereforever.”(Victoria)
This study sought to describe current clinical practice in
assessingcognition for AboriginalAustraliansusingquali-
tative enquiry. Purposive sampling with snowballing was “Youneed toreallysitdownwith thereferrerand say
usedtorecruitparticipants.Participantswereprofessionals ‘whydoyou want thisdone?’‘What purpose isitgoing
who had conducted cognitive assessments for Aboriginal tobe putto?’”(Chantelle)
people, including 11 general psychologists (including one
Aboriginal psychologist), three school psychologists, one Clinicianswouldgenerallyconductcognitiveassessments
provisional psychologist, three occupational therapists for either therapeutic or bureaucratic reasons, sometimes
(OTs), one speech pathologist, two aged care nurses, and both.
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“The...testing sideofthingsprovidesinformationfor qualify for additional support; service access/gate keeping
fundingpurposes[and]itprovidesinformationfor reasons,toidentifywhethertheclientcanaccessaspecific
developingeducationaladjustment plansfor students.” service, and as support for funding bids in a particular
(Sarah) sector or region. Bureaucratic reasons generally required
an assessment via standardised assessments, with more
Therapeuticreasonsgenerallyrevolvedaroundinforming importanceplacedonthetestscore.
the intervention. This included identifying the impact of
impairment on daily functioning, identifying strengths “Peoplelikenumbers.”(Scott)
to work with, tailoring treatment to the capabilities of
the client, assessing how well an individual might cope “Someofthebureaucracy isorganisedinthat
in a specific program (i.e. program fit), developing edu- direction,theywant assessments.”(Martin)
cationalsupportinterventions,andprovidingsupportto
others(e.g.family,teachers)inassistingtheclient. The reason for the assessment was considered in
selecting the assessment tool. Emphasis was placed on
“Ithink youhave todosome sortofassessment tailoring the assessment to the individual according to
because youneed to.Asintobe abletooffer services suspected reasons for impairment, language ability,
and support. And alsototryand support orassist education,age,acculturationorotherfactors.
teachersingaining thebestfrom thekids.”(Sarah)
“Yeah,youusedifferentmethodsfordifferent people
“Assessment istodetermine eligibility fortheprogram, really.”(Michelle)
and iftheyarenot suitableforagroup program,then
whatinterventionswouldbe suitable.”(Hayley) Assessmentmethods
A range of mainstream standardised assessments were
Working from a strengths approach, rather than a discussed and clinicians stressed the importance of
deficitsapproach featured strongly. tailoring anassessmenttoindividualclients.
“If[thechild]looksdullbutthey’renot dull,you want “I'd...be loathe topickacouple [oftests]out just
tobe abletopickitup...Inmy viewthepower of[the becauseIwouldn’twantpeopletosay‘justdothis
tests]isn’ttosaythiskid’sdull, it’stosayhe’sbright sub-test andgo’.Itdependsreallytoo,someIndigenous
here and he’sbright there,[and]togettheteachers peoplereallyhavequite aWesternlife,they’vegot
and the adultstobe more optimistic about thechild.” post-gradeducation,they’vegot vocabulary,language
(Martin) ...Whatwe wouldbe wanting todoismatch ittothe
person.”(Felicity)
Another important therapeutic reason for conducting a
structured assessment included teasing out the issues Even experienced clinicians, working with Aboriginal
basedonassessmentnotassumptions,therebyminimising people for over 15 years, did not consider themselves
reliance on subjective opinion which itself may contain experts, and stressed that there are no hard and fast
culturalbias. rules.
“Getting anideaof...[whether]there aredeficits, “[I’m]experiencedbut alwayslearning. Imean, Ijust
[and] wherethedeficits[lie]and [do]theymatch up thinkthereissomuchmore tounderstand andknow
with thetypicaldeficitsof[someonewith]alcohol about assessingcognitionwith Indigenouskids.”
injuryor isthere adifferent...patternthere...that (Sarah)
we’dbebetteroffto...address?...Rather thanjust a
blanket[assumption that] ‘thispersonisIndigenous, It was considered necessary however to ‘know’ the test
theyliveintheriver,theymustbe alcohol’.No, pull wellinordertobeabletointerpretitappropriately.
backand assess.”(Julie) Table 1 presents a list of assessments used by different
professions in different contexts. The assessments used
Bureaucratic reasons included legal/court requirements, mostoften arediscussed below.
to assess culpability, fitness to stand trial or victims’
compensation claims; employment reasons, to identify Kimberleyindigenouscognitiveassessment(KICA)
those who should be on pensions; adult guardianship The KICA [9,19,20] is a dementia screen that assesses
assessments, to identify those who require guardianship orientation, free and cued recall, language, verbal fluency,
orders; resource allocation issues, to identify those who copying sequence pattern and ideational praxis and was
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Table1Assessmentusereportedbydisciplineandcontext
General Research School Prison Aged&disability Hospital
Assessmenttool Psych Psych Psych Psych Nurses OT Speechpath Dr Total
KimberlyIndigenousCognitiveAssessment(KICA) 2 1 2 3 1 1 10
Matrices
RavensProgressiveMatrices 1 3 4 8
KaufmanBriefIntelligenceTest(KBIT) 3 2 5
NaglieriNonverbalAbilityTest(NNAT) 1 3 4
TestofNon-verbalIntelligence(TONI) 1 1
WechslerScales
WAIS/WISC 3 1 2 6
WechslerNonVerbal 2 2
WechslerMemory 2 1 3
AdaptiveBehaviourScales
AdaptiveBehaviourAssessmentSystem 2 1 3
VinelandAdaptiveBehaviourScales 1 1 1 3
BRIEF 1 1
AchenbachBehaviourChecklist 1 1
Bender-GestaltII 3 3
Mini.MentalStateExamination 2 1 3
Addenbrooke’sCognitiveExamination 1 1 2
Genograms 2 2
ReyComplexFigureTest 1 1 2
RowlandUniversalDementiaAssess.Scale(RUDAS) 2 2
SchonellReadingTest 1 1 2
ActivitiesofDailyLiving(ADLs) 1 1
FunctionalCommunicationAssessment 1 1
FunctionalImpairmentMeasure(FIM) 1 1
BostonNamingTest 1 1
ComprehensiveAphasiaTest 1 1
JuniorA&B 1 1
L'hermitteSignoret 1 1
Otis-LennonSchoolAbilityTest 1 1
PeabodyPictureVocab.Test 1 1
QuickNeurologicalScreeningTest 1 1
StanfordBinetIV 1 1
WesternAphasiaBattery 1 1
WestmeadPTA 1 1
WHIPPSI 1 1
PorteusMaze 1 1
NotePsychpsychologist,OTOccupationaltherapist,SpeechPathSpeechpathologist,DrMedicaldoctor.
recognised as one of few cognitive assessments appro- ithadnotbeennormedforthoseunder45yearsanddoes
priate and developed for Aboriginal people. As a result, it not necessarily test the right functions for intellectual
was sometimes utilised for purposes other than assessing disabilityorsubstancemisuseinjury,forexample.
dementia. This was recognised as a significant problem
for some clinicians. It was considered inappropriate for “AndIknowpartsof itwillfitintoboth needsbutit’s
younger people or non-dementia related referrals because not appropriate touse atoolfordementiaforassessing
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whether someoneisintoxicated andcanmake safe ones...Wechsler scales,that’swhatIknowbest.I’ve
decisions.”(Natasha) used them for solong andIcanmodify[them].Iknow,
lookingatthenumbers,Iknowwhatitmeans.”
However other clinicians were not so strict, and (Sampson)
suggested the KICA was useful as a “loose guideline” or
an “ice breaker” among younger or non-dementing “...attheendoftheday,our systemsfunction onthe
clients and qualitative information could be gleaned, to score oftheWAIS;even thoughyou wanttorecordit
informtheoverallclinicalimpression. responsibly interms ofculturalbias.”(Felicity)
“If someonefailstheKICAandthey'retooyoung... it Psychologists who utilised these scales used predomin-
givesyouaguide astowhat[other test]touse,[and] antly performance or non-verbal subtests of the general
you lookathowtheyfailedit.”(Felicity) intelligence scales (i.e. Wechsler Adult Intelligence Scale
(WAIS) & Wechsler Intelligence Scale for Children
While there were mixed opinions about the KICA, (WISC)), or the Wechsler Memory Scale (WMS) that
mostwere positive,ifusedforitsintended purpose. typically assesses functions such as perceptual reasoning
and problem solving, processing speed and memory.
“Itreally isagood assessmentfordementia screening. Interestingly only the school psychologists utilised the
Itisawonderfulassessment.Itisjustthatitsusehas Wechsler Non-Verbal (WNV), but it was perceived by
been exploited alittle bit.It’sseenasthe answerto Belinda as a very “peculiar” test (due to some of the
everything.”(Victoria) pictures) witha sense of “unevenness” toit. The full scale
IQ score of the WAIS was generally not considered valid
ParticularlylikedwastheKICAguideforinvolvingfamily and selection and interpretation of subtests relied heavily
and collecting contextual information. The training, the upon experience and clinical judgement. For example, an
guidelinesforassessingpeoplewithlowvisionanditbeing individual’s level of English, education and acculturation
freely available were also rated positively. However, the were considered when selecting Wechsler scales, often
comprehensivenessofthecontextualcomponentpresented conceptualised as a difference between ‘remote’ and
some issues regarding the time taken to complete and ‘urban’ based clients. One well regardedpsychologist who
inabilitytoholdtheclients’attentionforprolongedperiods. had been assessing Aboriginal people for over 20 years
used specific subtests, albeit with certain caveats. For
“Ireallylikedoing itbutit’ssotimeconsuming.” example, the coding subtest is timed and “Aboriginal
(Victoria) people don’t really get into being timed, so you’ve got to
becarefulhowyouinterprettheresults”(Martin).
There was however, a general acknowledgement that
all assessments have their limitations, even Aboriginal “IntheWAISI’dusetheblocks,I’dusethecodingI’d
specific ones, reflecting the fact that the assessment usethedigit spanandImightusecomprehension if
process itself isbased ondifferentcultural concepts. their Englishisgoodenough...I’dusememoryfor
designs...nowthat’smeanttobe sensitive toalcohol
“Timedresponse doesn’tworkand‘look atthese impairment...Memoryfordesigns,tensecond
picturesand lateronI’mgoing toask you’and then,‘so exposure isuseful,you cancarrythecardsinyour
rememberwhatthosepictureswere?’But[theclient] pocket,that’sanotherreasonwhy it’susefuland it’s
will talkabout lotsofother thingsand...itjust not traumaticforthem...Iusethedigit span
doesn’t...work andit’snot acognitionthing...Ijust verbal...with Aboriginalpeople...buttheydon’t
don’tthinktesting inthat mannerworks,or[even] usuallylikeit verymuch.Theother oneIuseoutof
wantingaresponseinthatmanner,theysortof seem theWechsler iscalled...visualmemoryspan...where
tothinkthat you’re abitcrazy.”(Lisa) you have acardwith dotsonit andyoutouch the
dotsinacertainsequence andthey’vegottotouch the
Wechslerscales dotsinthe same sequence,sothere’snolanguage,once
The Wechsler intelligence scales were used exclusively by you’vegotthetrick across. Soyou dothemforward
psychologistsastheywerefamiliarwiththem,mainstream and then yougetthem todoitinreverse andthey
systems relied upon them and there was a perceived oftendothereversebetterthan [theydo]thefirst.”
relativelackofalternatives. (Martin)
“Well,we’re stuckwith the sub-sectionsoftheWAIS, Many agreed that there is cultural bias in many of the
and soforth, andyou’vegottochoose theright Wechsler scales particularly due to language and
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educationdifferences and most agreed thattheWAISfull “IliketheTONIand theRey[ComplexFigureTest].
scaleIQscoreisinvalid. I’vejustgrownveryfond ofthem.”(Kirsty)
“Soyoumightknowthatno,theydon’thave an This psychologist reported “on average, those who did
intellectualdisabilityeventhough [the score] saidthey the WAIS and then theTONI would score 10–15 points
do,butthey[actually]don’t.Butwhatistrue about it lowerontheWAISthan theTONI”.
isthat theywill operate atthatlevelwithinthat The NNAT was used predominately by the school
Westerneducation system”(Belinda) psychologists,giventhatitisatestfor children.
“Ethically theWAISisinappropriate touseinan Observation,informal,orfunctionalassessments
Indigenous environment.”(Kirsty) Almost all clinicians would supplement their standardised
assessments with qualitative or informal observations and
Matrices(includingKBIT,Raven’s,TONI,NNAT) tasks during the clinical interview. They might ask clients
to complete certain tasks along with monitoring specific
“When Iwentbackandlooked attheirWAIS scores, behavioursorpresentingstate.
their best subtestswerethematrices.”(Kirsty)
“Inthecourseof providing therapy,Iwouldinformally
Many psychologists (including an Aboriginal psycholo- be assessing these sortsofcognitive functions. Just asa
gist) found the matrices components of tests such as the matterofcourse,thatwouldbeinformal.”(Neil)
Kaufman Brief Intelligence Test (KBIT), the Raven’s
Matrices, theTest of Non-verbalIntelligence (TONI) and “Howalert arethey...have theybeen upall night,or
the Naglieri Non-verbalAbility Test(NNAT) tobeuseful aretheystoned? ...andusuallytoget abitofanidea
and completed well, even enjoyed by Aboriginal people. of memory,Ialwaysgive themmyname and askthem
Thesetestsmeasurereasoningabilityandwerethoughtto againlater.Isay‘I’mgoing toask youthat later’.”
beintuitive,quickandeasytoadministerandrequirelittle (Martin)
relianceonlanguage.
Other things observed or assessed informally included
“IwouldusetheRavens;that wouldbemy weaponof speech patterns, perception (e.g. hearing, vision), social
firstchoiceinallthis...It’squiteintuitiveinmany interactions, memory for biographical data, identifying
ways...SoIhave adegree ofconfidencethat itis and remembering objects, money management, attention
probablyrelativelyculturallyunbiased.SoyeahIhave anddistractibility,alertnessoractivitiesofdailyliving.For
adegree of faithinthat. Andothershave alsosaid example, some allied health professionals would ask a
similar.”(Scott) client to make a cup of tea and observe for sequencing,
identifying what items are required etc. Some would
TheKBITwasseenbysomeasthemostengagingasthey observe the client ordering off a takeaway menu asking
included pictures of people etc., rather than using purely questions for example, ‘How much money would you
geometricpatterns,butwereagainusedwithcaution. give?’ and ‘Would you get any change back?’ They might
also ask clients to name objects in the room, identify an
“That’swhyIliketheKBIT,becauseitisrelatively object’s use, and ask them to recall those objects later.
quick,youget reallyquite animpressively reliable Some psychologists would use playing cards and ask
score,eventhough youwould stillmake allowances– clients to sort the cards into suits or sum the values of
you wouldn’ttaketheliteralscore... you wouldn’tpay twocards.
attention tothat,butyou’dpayattentionrelative to
thoseother little tests,because almostcertainly it’llbe “Imightputout anace and atenand say‘Howmuch
anunderestimateoftheperson’srealability becauseof isthat?’...Iaskthem whattheyplay andhowthey
acculturation.”(Martin) play it...And alotofthem arequitegood atit.Butif
theydon’tknowanythingabout cardsthen thatmeans
“TheTONIwasveryboring intheway itwas nothing,butiftheysaytheyplay,andtheycan’tdo
presented;and veryrepetitive justinitsformatting.” thissimple arithmetic,you’vegottosay,‘What’sgoing
(Sarah) onhere?’”(Martin)
The TONI was used least out of the matrices tests, but “Specificlanguage useisquite interesting, andif
highlyregardedbyonepsychologistwhowasverypracticed informationisrepetitive and thingslikethat.With
initsuse. skillsand watchingpeople operatethroughanormal
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dailyenvironmentit's quite enlightening towatchthe “Iwouldnever,ever doone.Never,ever,ever.I
standardproceduralskills,butit'salsoveryusefulto normallydothree.”(Belinda)
see whenthey'reinterrupted. Sohowsomeoneresponds
toanunexpectedcircumstance,forcing themofftheir Conductingtheassessment
standardbehaviouralscript,and they... improvise a Buildingrapport
response...lookingathoweffectivethat response is, Cliniciansstressedtheimportanceofengagingthe client,
[and] howlong ittakesthem toactually develop an and building rapport was usually the clinicians’ first
alternativeresponse. Thatinformationcanbe really priority.
insightful.”(David)
“Thefirst stepisdevelopingrapport andoften the
Generally clinicians reported it was essential to use Indigenous workerwill meetthem first and thenthey’ll
more than one assessment and more than one form of have tovouchforus.Sothere’snowayknownwecan
data collection and cultural factors impact all of these just sitthemdownand say,‘Okay,nowwe’redoing the
(see Figure1). assessment.’”(Chantelle)
Figure1Schematicofassessmentprocesswithexamples.
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Rapport-building might include conducting the assess- exist. The interpreter did not appear to have the same
ment in a comfortable setting for the client, which may depth of understanding of the language leaving the
beawayfrom theoffice orcommonly,outdoors. clinician uncertain about the level of reliance to place on
It’s about making the individual feel comfortable and interpreters(referencegroupmeetingdiscussion).
there is also often a degree of personal disclosure on the
clinician’s part in order to find some kind of connection Modificationoradaption
with theperson. When asked if they conducted the assessment in the
standardised way orwith someflexibility,most clinicians
“Ohyeah,there’sthatlevelofpersonaldisclosure,I’ll reported that they would pretty much “stick to the
talkabout myfamilybackground and whatmy script”. However, there were moments of flexibility
connectionsare,I’lltalkabout football,I’lltalkabout around that in terms of introducing what was going to
fishingorwhatever isgoing tostart aconnection occur, starting with the easier (lower age) items to give
between us.”(Scott) clients a chance to practice the task, or using language
aswellasgestureininstructions.
“If you appealtothe sense of humour,that’svery
good.”(Sampson) “Itrytodo[thetests]asstandardised aspossible,but
put them inanaccessibleway.SoItendtointroduce
It often takes a lot of time to build rapport, with some whatitisthatI’mdoing,whyI’mdoing itthatway,
clinicians reporting the importance of returning many [explain]that‘Wewillbeproceeding throughthingsin
timesuntilaleveloftrustisbuilt. a sequentialway,one aftertheother,wewouldbe
going fromonething,Imightbe askingaquestion orI
“Mostpeople wouldgotwice; wegotentimesortwenty mightbe asking youtodrawsomething’and soon.
timesorwhatever.Andyou justkeep going untilyou Andthen I’llsay‘Now wecometothispart’.SoI’lltry
sort offeelthatyou knowthem more and theytrust tooutlineit,butthat’stheonly wayIreallychangeit.
you more and they’lltalktoyoumore andthey’llgive IfIneed tosimplifythelanguage,then Iwillorthe
you more information.”(Lisa) interpreter mightneed todowhateverneedstobe
done.”(Neil)
Aboriginalliaisonorinterpreterservices
Clinicians advocated for the use of Aboriginal Liaison Whilst assessments would generally be delivered
Officers (ALOs) and interpreters in conducting according to the standardised instructions, modifications
assessments. This was generally seen by all as good to wording or particular item content were sometimes
practice. made in order to make the test material morerelevant or
localised to the immediate context. For example, items
“We... alwayshave anALOwith us.Iwon’tdo[the requiring memory for addresses were changed to reflect
assessment] without anALOpresent...Andpeople, Northern Territory addresses, naming the prime minister
even iftheyspeak goodEnglish,willsaythingsto of Australia rather than the president of the country
Aboriginalpeople that theywon’t saytous.”(Victoria) wherethetestwasdeveloped.
ALO’s tended tobeused toassist withrapportand cul- “Thisother one,with thepictures,whichonehasa
tural understanding (and many organisations employ nauticalconnection, sowe’ve saidwhichonehasa
ALOsforthis purpose),whereasinterpretershavea more connectiontothe sea.Thepiano accordion isonethat
specific role with translation of language, and need to be we wanttochange,becauseitisnot acommonlyused
engaged through an interpreter service or found privately thinghere,and theharp. ...if someone says it’sa
through local contacts. The use of interpreters was musicalinstrument,then tickitoff.”(Julie)
acknowledged as difficult and not always possible given
the setting, timeframes and availability of appropriate Interpretingandcontextualisingfindings
people. Time was spent coaching the interpreter in terms Something that was stressed throughout the interviews
of what to say and what not to say when conducting an was the importance of contextual information and
assessment.A further issue reported arose whenaninter- clinician experience in conducting an assessment and
preter was not able to translate words such as ‘left’ and interpretingtheresults.
‘right’,advisingtheclinicianthatthewordsdidnotexistin
their language. As the clinician’s previous experience of “It’sjustreally,really important totryandgatheras
this language did not concur, another speaker of the muchinformationasyoucanandtoreally-be
language was consulted, confirming that the words did prepared tojustworkwith thecomplexity of it andnot
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sort ofjumptowhatwouldbe arathersimplistic sort problems, transient delirium or psychosis, medication or
of interpretationof it,becausethere are somany intoxication. Most would also take note of qualitative
factorswhichcaninfluencethese scoresand soIguess information during the testing process such as whether
there’saresponsibility onthepartofthepractitioner they were engaged, motivated, tired, distracted, hungry
tomake surethat theyreallyare aswellversed as oractuallyunderstoodwhat wasbeingasked etc.:
theycanbeinthethingsthat actually impactonthese
scores.”(Belinda) “It'sabouthavingafairassessment.Say withblock
designit'stimed,and we'llsay‘In45secondsthey
“You’vereallygottohave awide sourceof information werehalfwaythrough,theywere keentoworkfor
before [you] lookatyour interpretation.Because ...if another threeminutesandfinishthedesign’.Soyou
you’regettingalowscore you’vegottosay,‘Okay,why can't score it asafinisheddesignbutit's differentfrom
amIgettingalowscore here?’and then lookat all the someonewhodidn'ttryandthen 45secondsareup.”
other factors”.(Sarah) (Felicity)
The key was identifying discrepancies and trying to “Eventhefactthat sometimestheydon’tunderstand
account for them. For example, most would always do whatyou’ve asked themtodoispartofthe
more than one assessment and look at the patterning of assessment.”(Kirsty)
results. It wasn’t about the test score, but why they got
that score and whether it fit the clinical profile expected The context in which the assessment was conducted is
for that person given their individual circumstances, also important to consider and might impact (negatively
history,languageability, literacyoreducationlevel. orpositively)upon theresults.
“If you’relooking at,let’ssay,Korsakoff Syndrome... “Ithinkthewholetesting situation isproblematic,in
Weknowwhatthat means,andthat meansthatthe that it’sunfamiliar,and often itisout ofcountryand
workingmemoryshouldremainrelatively intact, somebody who’snot knowninthe service,allthat sort
where alltheother numbersdrop. Soif you’relooking of meta-cognitiveunderstanding.”(Neil)
at somethinglikeWernicke-Korsakoff’sand youfind
that,okaytheworking memory ishigh,butyou’vegot “Have you everbeentoemergency in[thehospital]?
twoother onesthat are alsohigh,you startthinking, It'snot relaxing, they're obviouslynot well.Having
‘No.There’ssomethingelse atworkhere’.”(Sampson) said that,ifthey’vebeeninforeighthours,for some
peoplethey’vehad afeed,they’vehad a sleep,so
Clinicians would also look for concordance between they're reallywell.Theyarebetterthantheyhave
different sources of information. In their interpretation been.”(Felicity)
they would assess how well the scores reflected their
clinical impression of the person based on informal or Discussion
observational data collection during the interview, as The results of this study highlighted a relative lack of
well as information from other sources such as talking consistency and guidance around appropriate cognitive
with familyorteachers,orreviewing medicalhistory. testing methods for use with Aboriginal Australians in
clinical practice. Practitioners often developed informal
“Butthat’swhere you’vegottotriangulatebygettinga methods for assessing cognition or relied on mainstream
bithere and abitthere and abitthere and standardised tests which they adapted or with which they
comparing themand having alook...Soit’sthe sortof werehighlyfamiliarinordertobeabletoassessthevalid-
gestaltthat youarelooking at,thispersonand the ity of the results. Some reported becoming “fond of” or
historyandyoupull it alltogether ...”(Martin) developing a “love affair” with particular tests suggesting
familiarity with the assessment was essential to be able to
“Iwouldhavetosaythemosteffectivemethod of interpret mainstream tests in a culturally fair manner.
assessingcognitionisacombination of interviewand Nevertheless, the importance of tailoring assessments to
observations. Thetoolsthat exist atthemomentjust the individual was emphasised. Test selection, delivery
don'tweighupenough comparedtothat. If you were and interpretation therefore relied heavily on experience
tojustrunwith atool Ithink you'dbequite deceived.” and clinical judgement, leaving inexperienced clinicians
(David) with little guidance or confidence. While it appeared that
clinicaltrainingdidnotequipemergingclinicianswiththe
Clinicians would examinewhethertherewas a medical appropriateskillsandknowledgetoassesscognitionconfi-
reason for the result, for example hearing or vision dently for Aboriginal clients, the Australian Psychological
Dingwalletal.BMCPsychiatry2013,13:42 Page10of13
http://www.biomedcentral.com/1471-244X/13/42
Society(APS) Guidelines forthe provisionofPsychological might be useful, what could prove even more useful is
ServicesforandtheConductofPsychologicalresearchwith guidance around achieving a fair interpretation of the
Aboriginal and Torres Strait Islander People in Australia results.
werelargelyreflectedthroughclinicians’narratives[21].
As indicated by the APS guidelines, clinicians placed Testselection
importance on having a sound understanding of the The range of assessments appropriate for Aboriginal
test, including its limits, and often noted caveats on test clients is highly limited, bordering on negligent [4]. How-
interpretation [21]. They also reflected the importance ever, the use of standardised tests is often required for
of i) having a good understanding of the reason for the both bureaucratic and therapeutic reasons. A previous
assessment, ii) collecting detailed biographical and study observed poor concordance between counsellors’
contextual information, and iii) combining test results clinical impression of cognitive functioning and neuro-
with other forms of assessment, information and/or psychologicaltestresults,despiteimpressionsbeingbased
indicators of daily functioning. Implicit in clinician on information sources including detailed history,
responses is an underlying distinction between ‘testing’ clinical interview, medical examination and substance
and ‘assessment’ that has been recognised previously misuse history [3]. In this study, minimising reliance
[17,22]. In 1995, Davidson [17] proposed a multi-axial on assumptions, or purely clinical judgement, was
model of cognitive assessment for Aboriginal Australians, considered important for achieving a reliable assessment.
promoting assessment of cognitive functioning through Assessments utilised most often included the KICA,
examining individual functioning in particular contexts Wechslerscales,MatricestestssuchastheK-BIT,Raven’s
using measures of competence in performance of every- Progressive Matrices, the TONI, and the NNAT in
day life tasks; cognitive assessment through the use of conjunction with observation, informal assessment and
appropriate neuropsychological and cognitive tasks; and functionalassessments.
developing contextual scales including complexity of the Cliniciansoperatedonahypothesis-testingbasis,founded
cognitive functions involved, the familiarity and perceived on a thorough history and clinical impression. The
difficulty of the task, and levels of acculturation. The functions expected to be impaired (or preserved) given the
results of this study suggest that clinicians may ultimately history (e.g. alcohol misuse), or the suspected profile of
bealigningwiththistypeofmodel(seeFigure1). impairment (e.g. Wernicke-Korsakoff Syndrome) were
Evidently,issuessuchaslanguage,acculturation,literacy important considerations in choosing an assessment, to
andeducationlevelwereconsideredtoimpacttheassess- ensure the relevant functions were covered. The level of
mentprocesswithtimeand relationshipalsoidentifiedas acculturation, literacy, education and English language use
importantfactors[11].Issuesincludedadifferentconcept were also important considerations, with non-verbal
of time between Aboriginal and non-Aboriginal people assessments relied upon heavily for individuals where
thathasbeendescribedpreviously[10,23],andtheimpact English is a second language. Regardless, the concepts
that difference has on timed tasks, the amount of time upon which tests are based are often unfamiliar to
takentodeveloprapportandtrustbetweenthepractitioner individualsfromnon-westernculturesandconsequently
andAboriginalclient,theabilityofatestorpractitioner this must be considered in interpreting any results, and
to hold a client’s attention and engage them long importantly,indesigningmoreappropriatetests.
enough to complete a thorough assessment, and time
constraints regarding different bureaucratic or practice Testinterpretation
settings. Taking sufficient time to develop rapport, trust Gathering contextual information, informal assessments,
and engagement emerged as an important theme in indicatorsofdailyfunctioningandtriangulatingthesewas
working with Aboriginal clients, reflecting previous seen as vitally important in interpreting any test. The im-
findingsin this setting[2].Sheldon [2]providesdetailed pact of issues including the clinician/client relationship,
descriptions of appropriate and useful behaviours for language difficulties, whether the client’s basic needs
engagement and, as in our study, techniques such as are met, prolonged chronic trauma, poverty, and mistrust
finding a comfortable place to sit, identifying common of mainstream systems are important considerations,
connections, humour, and being vouched for proved particularly for Aboriginal clients. For mostclinicians this
useful. relies heavily on extensive experience in Aboriginal
While tests themselves are just one component of an settings and clinical judgement. It was therefore
assessmentthatmaybemoreorlessvalidforAboriginal considered valuable to put some structure around the
people, having a valid and fair interpretation of the test questions experienced clinicians ask in considering the
was considered vitally important. Caveats were almost validity of an Aboriginal assessment. Table 2 presents an
always placed on test scores and their interpretations. ‘Interpretation Guide’ that was developed from clinician
While some guidance for clinicians on test selection responses and subsequently refined by the participant