Hispanic neuropsychologists in the United States: What do we know about them and how can the field address their needs?

1Introduction

Despite numerous calls throughout the years for an increase in ethnic, cultural, and racial diversity within the field of psychology, it remains an elusive reality for clinical neuropsychology practitioners in the United States (U.S.), especially for Hispanic professionals. Most recent data document a slow diversity growth rate, where Caucasian neuropsychologists continue to be the predominant group (84.5%), followed by Asian or Pacific Islanders (4.7) and Hispanics (4.5) (Sweet et al., 2021). This data is particularly concerning in view of the shifting demographic trends in the U.S. pointing to an increasingly diverse country, and thus, patient base. For example, 40% of the population self-identify as ethnic minorities, with Hispanics as one of the largest groups, accounting for 18% (U.S. Census Bureau, 2019). Numbers are projected to increase by the year 2060, where nearly one in three U.S. residents or 111 million people in the U.S. will be Hispanic (Hernández & Moreno-Fernández, 2018; U.S. Census Bureau, 2011).

Neuropsychology researchers and scholars have recently and urgently responded to the issues and implications spurred by these concerns, namely, an increasingly diverse population in the U.S., a country where the political environment and the neuropsychology profession are yet to be considered inclusive and culturally consonant with the shifting demographics. They have eloquently proposed transformative ways for neuropsychology to respond to the changing times by becoming more multicultural/multiracial/multilingual, antiracist, as well as culturally, socially and healthcare relevant (Byrd, 2021; Cory, 2021, Postal, 2021).

If clinical neuropsychology is to responsibly increase its cultural relevance and best meet the needs of a changing U. S. population with its shifting professional and patient base, it is important to understand current Hispanic neuropsychologists’ professional characteristics, practice trends, and experiences. For that reason, this study sought to: 1) determine the background and current work situation of Hispanic clinical neuropsychologists in the U.S. (e.g., professional training, assessment and diagnostic procedures used, rehabilitation techniques employed, populations targeted, teaching responsibilities, and research activities), and 2) examine issues related to perceived discrimination in the field of neuropsychology and what this means for our profession.

2Methods

3Results

4Discussion

Considerable decades-long efforts have been made to document the characteristics and professional practice of ethnically diverse neuropsychologists in the United States. In that direction, the present study can contribute by describing the current profile of Hispanic neuropsychologists in this country. Some of the changes that have occurred during the COVID-19 pandemic in neuropsychologists’ practice are depicted as well. In addition, timely information is presented regarding the participants’ experiences with discrimination in the workplace and the barriers confronted. Following is a discussion and interpretation of salient survey results, which included data from 107 clinical neuropsychologists residing in the United States.

Study results revealed that neuropsychologists in the United States are mostly women with an average age of 43 years who reside primarily in Florida, Texas, and California, the three states with the largest Hispanic population (Pew Research Center, 2019). They are predominantly U.S. born, belong to the main origin groups, namely Caribbean (Puerto Ricans, Cuban, Dominican) and Mexican (U. S. Department of Health and Human Services Office of Minority Health, 2019), and report that Spanish is the native language employed by their family of origin. Most consider themselves bilingual (English/Spanish) with an advanced to superior Spanish language level of proficiency. This is congruent with data provided in a report from Harvard’s University Cervantes Institute stating that 76% of Hispanics in the U.S. are Spanish-dominant or bilingual, and come from families where Spanish is spoken at home (Hernández-Nieto & Gutiérrez, 2017).

Like their non-Hispanic colleagues in the United States (Elbulok-Charcape et al., 2014; Sweet et al., 2021), Hispanic professionals are licensed, doctoral-level psychologists who have completed one to two years of post-doctoral residency/fellowship training in neuropsychology. Based on their mean age, they are early and mid-career neuropsychologists, who mostly work on a full-time basis in hospital and medical centers, followed by private practice.

It is important to note that similarities in professional training, experience level, work time and setting between Hispanic and non-Hispanic neuropsychologists in the U.S. end there. An income disparity with their non-Hispanic counterparts was evident.

When examining reported salary ranges and excluding the ones who earned less than US$50,000 (who can presumably be postdoctoral trainees) almost one fourth of the Hispanic respondents earned between US$101,000 to US$125,000 followed by roughly one fifth who earned US$76,000 to US$100,000. These reported earnings represent between US$6,300 to US$25,000 less than the calculated median income for similar experience level neuropsychologists (Sweet et al., 2021) in the geographic areas where most Hispanic neuropsychologists’ practice.

The income inequality found is extremely concerning and requires further in-depth exploration. Pay should be commensurate with experience level and ultimately income should be determined by several variables, ethnicity not being one of them. It can be argued that culturally and linguistically diverse neuropsychologists provide services to a wider range of patients and thus, ought to receive pay that does justice to their unique set of professional skills. Bonuses and pay equity would be an incentive to promote a much-needed increase in participation and representation of Hispanic neuropsychologists in the field, issue that will be addressed in more detail in the last section of this discussion.

A vast majority of neuropsychologists in the U.S. see Spanish speaking patients in their practice and many expressed that their cultural origin or descent increased their referrals for Hispanic patients. A similar proportion felt competent providing services to Spanish speaking individuals, including intake interviews and neuropsychological evaluations.

Most of them conducted neuropsychological evaluations, identifying prevalent conditions, such as dementias, traumatic brain injuries and cerebrovascular accidents, as well as ADHD, epilepsy, and mood disorders. However, of the neuropsychological evaluations performed, just a fourth of the participants indicated conducting them exclusively in Spanish. This was surprising as it represents a small amount considering not only their access to Spanish language instruments but their reported proficiency in providing neuropsychological evaluations to Spanish speaking patients. A possible explanation for this inconsistency is that although most Hispanics in the United States are reportedly bilingual (Hernández-Nieto & Gutiérrez, 2017), the determination of the language of evaluation is dependent on many factors, including the patient’s language abilities, preference, and proficiency. According to Judd and colleagues (2009), language of evaluation procedures should depend upon the situation and context for which these results are going to be used for. Ultimately, it is the neuropsychologist’s best and informed clinical judgment what matters most in determining which should be the language of evaluation.

In the case of bilingual patients, what are the steps to ensure the level of bilingualism to conclude which would be the best language to be used for evaluation? At this point, there is no universal procedure on how to best evaluate the level of proficiency in bilingual Hispanic patients. In fact, most Hispanic neuropsychologists reported relying on information obtained during intakes and self-reports of the patient, and not using language proficiency tests or instruments to determine language competence. It has been suggested that Hispanic individuals may have stronger skills in English for informal conversational purposes, but not for formal evaluations (Salinas et al., 2016). The opposite may also be true. It is known that bilingualism has different proficiency levels which may have a broader impact on test performance. For example, Harris and colleagues (1995) found that unbalanced bilinguals presented less efficiency in learning and retention of words when compared to balanced bilinguals. Therefore, the development of uniform guidelines to confirm the language for the neuropsychological evaluation with bilingual examinees is crucial, as arbitrary standards elevate the risk of a mismatch between the patient, the instruments, and the clinician. Salinas and colleagues (2016) recommendation of using both interview questions and standardized instruments to determine proficiency is strongly endorsed.

As well as language proficiency, another essential area to be considered when working with a Hispanic patient is acculturation. According to the guidelines published in Professional Considerations for Improving the Neuropsychological Evaluation of Hispanics, neuropsychologists are required to evaluate the level of acculturation, particularly in first- and second-generation immigrants (Judd et al., 2009). However, those guidelines are being followed by 6 out of 10 Hispanic neuropsychologists surveyed in this study. It is possible that one of the reasons why almost 40% of Hispanic neuropsychologists in the study did not evaluate acculturation in bilingual patients can be related to the specifics of the demographics they see (perhaps, third generation immigrants). However, we agree that, in addition to the evaluation of language proficiency, acculturation measure guidelines should be emphasized as a fundamental step in the evaluation of Spanish-speaking patients. Additional as well as updated research on the relation between acculturation levels and test performance may be needed to assist in creating more awareness of this essential aspect. Clearly, this recommendation is tied with the need to develop multicultural competency as part of the training in neuropsychology.

The use of normative data in Hispanic neuropsychology has been an important topic for decades. Despite increased availability of updated normative data for some neuropsychological tests across Hispanic groups and improvements in recent years of including demographic adjustments (such as ethnic backgrounds and/or language) for norm comparisons, most neuropsychologists in this study reported that lack of normative data for specific Hispanic subgroups is still the main barrier to neuropsychological testing of Spanish-speaking individuals from different backgrounds. In fact, many of the tests used in clinical practice do not have norms for such a culturally diverse population (Morlett-Paredes et al., 2021). All of the normative data studies that are available for Hispanics in the U.S., unfortunately, have many methodological issues. Therefore, clinicians should use caution when interpreting test scores based on these studies.

Regarding the use of interpreters, none of the responders employed them for their work in English, but a few required those services for Spanish language evaluations. Again, this might be the representation of those who indicated to be from a Hispanic heritage but spoke Spanish at a beginner’s level. Historically, there have been many controversies with the use of interpreters (Ardila et al., 2002; Echemendia et al., 1997, Ponton & Ardila, 1999; Puente et al., 1997), practice that should be avoided whenever practically possible (Judd et al., 2009). The documented effects of the use of interpreters include a negative impact on test scores, mostly on verbal subtests from the Wechsler Scales in a small sample of Spanish speakers (Casas et al., 2012). Nonetheless, it is a reality that there is a huge disproportion between Spanish speakers in the community and available neuropsychologists who can competently perform evaluations in that language. Interpreter skills and training with neuropsychological tests, test demands, culture-specific language, and specific language-related instructions will be required to reduce the concerns with interpreter use.

The challenges confronted in the times of the COVID-19 pandemic motivated many Hispanic neuropsychologists to adapt their practice to use telehealth, and more of them considered the continued use of teleneuropsychology in the future. Although teleneuropsychology had been in practice for some years before COVID-19 (Cullum et al., 2014), the pandemic moved Hispanic practitioners in the field to embrace its widespread implementation. Arias and colleagues (2020) described the employment of systematic teleneuropsychology models of neuropsychological assessment and care developed by cross-cultural neuropsychologists in five U.S. academic institutions that serve monolingual and bilingual Spanish-speaking adults. It is hoped that the implementation of teleneuropsychology evidence-based models may facilitate treatment availability and reduce access-to-service barriers that have historically afflicted underserved Spanish-speaking patients, such as the need to travel long distances to obtain neuropsychological evaluation services from a “language-congruent” specialist. Despite the potential assistance afforded by teleneuropsychology practice, it remains important to consider ways to overcome the possible obstacles to its use with Hispanic patients, some of whom may lack required equipment, physical space, and specialized computer knowledge (Arias et al., 2020).

Concerning rehabilitation services, it was observed that one in four Hispanic neuropsychologists in the U.S. provided them. That proportion is below the 41 percent reported in a study with U.S. neuropsychologists of all ethnicities (Block et al., 2017), and suggest an underrepresentation of Hispanic neuropsychologists in that service provision area. It is possible that the limited access that Hispanic patients have to rehabilitation services (Flores et al., 2020), as well as underutilization of services associated with restrictive costs, poor access to health insurance, diminished referrals by physicians (Rivera Mindt et al., 2010) may explain these results. It is also possible that the restricted number of treatment interventions available in Spanish which in turn may be associated with limited perceived competency in performing rehabilitation activities in that language (as reported by almost half of the participants in the study) contribute to the reduced participation in the provision of rehabilitation activities by neuropsychologists in the study.

Hispanic neuropsychologists were also found to be underrepresented in academic activities such as teaching and training. Thirty-five percent of respondents had teaching duties at an educational institution, which contrasts with the 75 percent documented for all neuropsychologists in the U.S. (Sweet et al., 2021). This gap reflects the general situation in the U.S. where only 5 percent of all university and psychology professors are Hispanic (Davis & Fry, 2019; Bichsel et al., 2019). The low number of Hispanic educators can be decisive for future representation of Hispanics in the field. Several investigations suggest that the presence of ethnically diverse professors contributes to culturally diverse students continuing doctoral studies (Rabin et al., 2017; Cole & Barber, 2003).

With regards to other non-clinical activities, half of the participating Hispanic neuropsychologists reported that research was one of the professional areas in which they worked. A similar proportion had conducted research with Hispanic populations in the U.S. This data is consistent with Sweet and colleagues (2021) assertion that research participation is a less frequent professional activity among their clinical neuropsychology respondents, with 53 to 32 percent of them involved in non-funded and funded research, respectively. This is an important issue because scientific and professional progress in the field depends on research (Arango-Lasprilla et al., 2017). Thus, it is essential to increase multicultural neuropsychological research. Based on the American Psychological Association Multicultural Guideline #4 (APA; American Psychological Association, 2003), the research emphasis should be on instruments, norms, psychometric properties of instruments, validity of diagnoses and evidence-based practices for Hispanic populations (Elbulok-Charcape et al., 2014).

In the area of training of young researchers, recommendations have been issued over a decade ago [e.g., Rivera Mindt and colleagues (2010)]. However, there is a need for actionable recommendations that specify specific stakeholder actors and a timeline for implementation. For instance, neuropsychology programs should be held accountable for the institutional support they provide to ethnically diverse students at all levels of education. Metrics should be developed alongside recommendations to be able to assess the extent to which the recommendation has been taken into account. For instance, how much reach do outreach services have and how many diverse candidates are mentored. Although financial support is of course an important facilitator, the metrics should measure the impact of that spending. Over a decade ago, recommendations were made for neuropsychology programs to develop culturally competent neuropsychology models of training and purposefully recruit and retain diverse faculty. Unfortunately, it is not clear what progress has been made in this area and best practices leading to expected outcomes should be widely disseminated in order to move from recommended improvements to concrete, actionable, steps with meaningful success indicators.

5Perceived discrimination

Hispanics represent 18 percent of the population (Lin et al., 2018, p.19) and 4.5 percent of the neuropsychologists in the United States (Sweet et al, 2021). As a heterogeneous group of people living in a primarily white dominant society, they have historically been subjected to discriminatory practices at cultural, institutional, and interpersonal levels (Buraschi & Aguilar-Idáñez, 2017; Byrd, 2021; Cagigas, 2021; Cory, 2021; Postal, 2021). This study’s participants were not the exception. The experiences shared by them regarding discrimination in the workplace are hereby documented. They provide us with the opportunity to reflect on ways to address a pervasive situation that detracts from the equality and justice that should be prevalent socially and in the field of neuropsychology.

The results of this survey revealed three findings regarding perceived discrimination that warrant a closer discussion. Hispanic neuropsychologists expressed that: (1) they experienced discrimination; (2) they had fewer professional opportunities than their Caucasian colleagues; and (3) there were barriers to the development of Hispanic neuropsychology, both intrinsic to the field and to the general socioeconomic situation predominant in the U.S. Each of these three concerns will be discussed next and in more detail.

In this study participants were asked directly if they had experienced discrimination during their training or in their workplace. Almost six out of 10 of the participating Hispanic neuropsychologists reported experiencing discrimination. The sources of discrimination were predominantly identified as coming from superiors or supervisors, followed by patients and colleagues. This finding is consistent with Roman (2017) who points out that in neuropsychology there are clear disparities in how Hispanic professionals are treated. This situation is explained by the low ethnoracial and cultural diversity in neuropsychology, including the limited presence of Hispanics in the field (Matthews, 1992; Sweet et al., 2021). For example, Sweet and colleagues (2021) found that close to 13 percent of neuropsychologists identified themselves as non-white, including 4.5 percent who identify as Hispanic. Moreover, within neuropsychology, the low representation and opportunities for Hispanics is evident, observed in the limited availability of instruments in Spanish, the lack of normative data and the scarcity of research with Hispanic participants (Morlett-Paredes et al., 2021; Morlett-Paredes & Arango-Lasprilla, 2017). The racial imbalance in neuropsychology represents a great obstacle for Hispanics (Byrd et al, 2010; Cory, 2021). For this reason, the field of neuropsychology has the challenge and the opportunity of overcoming the interpersonal, structural, and cultural manifestations of discrimination in the U.S.

Our survey also showed that almost all Hispanic neuropsychologists acknowledged that being bilingual had expanded their prospects in the field. Nonetheless, almost half of them perceived they had fewer professional opportunities than their Caucasian colleagues. This finding is not surprising as neuropsychology in the U.S. has been historically based on a Caucasian, educational, scientific, and social framework that does not facilitate the entry of culturally and linguistically diverse professionals to the field. Furthermore, the fact that neuropsychology is such a competitive field could put those with better competence in English at an advantage (Elbulok-Charcape et al., 2014).

Most neuropsychologists in the study identified the lack of adequate neuropsychological tests with norms for Hispanics and instruments in Spanish as one of the main barriers to the development of Hispanic neuropsychology in the U.S. It is notable that for the most part test producers are in the U.S. and their priority is research and publication of tests in English, resulting in limited availability of instruments in Spanish (Elbulok-Charcape et al., 2014). This barrier reflects the “chronic disconnect”, as Cory (2021) aptly labels it, between neuropsychology and the increased cultural, linguistic, and ethnoracial diversity within the population of the United States.

The paucity of instruments in Spanish and test norms for Hispanics in the U.S. affects both neuropsychologists and patients. It also underlines the need for both Caucasian and Hispanic neuropsychologists in the U.S. to be more dynamic in the development of adequately normed instruments in Spanish. Ultimately, the development of tests in Spanish is an academic, clinical, and economically viable agenda because Spanish-speakers in the world are close to 600 million people, of which 57 million live in the U.S. (Instituto Cervantes, 2019). As Echemendia & Harris (2004) pointed out, neuropsychologists in the U.S. must prepare to provide services to the Spanish-speaking population, which may reach nearly 98,000,000 people in 2050, according to estimates from the U.S. Census Bureau (2019).

The lack of mentors and leaders who can bridge the gaps within the neuropsychology field so that more Hispanics can enter the specialty in the U.S. was an additional barrier posed by many of the neuropsychologists in the study. The underrepresentation of Hispanics in the field highlights the need for organizations such as the Hispanic Neuropsychological Society to continue their efforts in promoting collaboration with other professional and educational organizations to draw more Hispanics into the field (Cory, 2018).

Neuropsychology organizations in the U.S. have the challenge to initiate immediate lines of action to promote cultural diversity among professionals in the field. As was mentioned previously, it is important to reduce the ethnoracial issues faced by Hispanic neuropsychologists and patients in the U.S. Along the same lines, Sweet and colleagues (2015) proposed establishing initiatives to educate neuropsychologists in the U.S. about ethnoracial diversity. Rabin and colleagues (2017) recommended increasing the recruitment and presence of culturally diverse professionals in faculty positions and providing doctoral students with financial support, mentoring programs, and clinical experiences with diverse groups.

6Limitations of the study

Several limitations should be contemplated when interpreting the study’s results. Ones are inherent to the survey research, and others to the prevailing social circumstances at the time of data collection. First, while all participants self-identified as Hispanic they also indicated their specific cultural origin. Relevant data could have been obtained if item response analyses by cultural group were performed. We recommend that future studies incorporate analyses that permit Hispanic intergroup comparisons.

Second, although important information regarding perceived discrimination was gained, due to constraints imposed by survey length, questions in that direction were few. Future studies could benefit from a more profound inquiry of discriminatory experiences, perhaps using a mixed methods design, to clarify and qualify them.

Regarding social context, the study was carried out during the early stages (summer of 2020) of the COVID-19 global pandemic. Therefore, the possibility that the pandemic had an impact on the Hispanic neuropsychologists’ responses cannot be excluded. Apart from content related to teleneuropsychology, which was directly related to the impact of the pandemic in clinical practice, it is unknown to what extent other responses may have been influenced. However, reported annual income, which included a year period, appeared unaffected by the pandemic as it most likely represented income from the previous pre-COVID year. We agree with Sweet and colleagues (2021, p. 76) assertion that responses to questions about income and professional practices could be impacted if participants were surveyed in 2021, “as the pandemic continues to ravage health and economies around the world.”

7Conclusions

Our findings confirm that Hispanic neuropsychologists in the United States are culturally diverse, present with varied levels of bilingualism, have been faced with discrimination during training and in their workplace, and compare favorably with non-Hispanic neuropsychologists in terms of education and clinical training (Sweet et al., 2021). It is important to highlight that our findings also document that systemic racism persists within the field of neuropsychology. This situation is clearly manifested by the study’s participants, many of whom had been subjected to discriminatory practices, had fewer professional opportunities, and received salaries beneath those of their non-Hispanic counterparts. The racial disparities extended to inadequate availability of neuropsychological instruments in Spanish for the increasing Hispanic population in the U.S. Lack of ethnic diversity continues to represent one of the major challenges within the specialty, evidenced by data published in the most recent survey from Sweet and colleagues (2021), where they report that less than 16 percent of neuropsychologists in the U.S. are non-Caucasian.

During the past 30 years, concerns about ethnic/racial disparities have consistently been voiced in multiple neuropsychology publications. The field of neuropsychology has been slow in responding to this situation and we believe changes are overdue regarding transformations that reflect the changing demographics in U.S. society. Attention to these matters is not only a social justice priority but is urgent to avoid the risk of neuropsychology becoming an irrelevant discipline (Andoh, 2021; Cagigas, 2021; Postal, 2021).

Importantly, the APA Council of Representatives adopted a resolution on October 29, 2021 regarding the Role of Psychology and APA in Dismantling Systemic Racism Against People of Color in U.S. (https://www.apa.org/about/policy/dismantling-systemic-racism). It espouses psychology’s role in helping to expose, understand, and ultimately dismantle racism that operates across all levels and sectors of society. Breaking with systemic racism in neuropsychology is a priority that requires a profound examination of institutional structures that may contribute to dismantling white privilege (Cagigas, 2021). The APA Resolution is a laudable example of action which should be implemented by neuropsychological institutions, societies, and organizations as an important first step. In order to eradicate discrimination and differential treatment, neuropsychology as a field must admit this problem. Transforming neuropsychology into a diverse and inclusive field requires intentional, strategic, and systematic interventions in education, academia, training, professional organizations and in research. Leaders in the field must take a stand on this issue and carry out actions to foster the inclusion of ethnically and racially diverse people in neuropsychology.

Conflict of interest

The authors declare that there is no conflict of interest.