The rapid expansion of global neuropsychology has led to an increasing need for translating, adapting, and norming tests across several languages and cultures (Kosmidis et al., Reference Kosmidis, Bozikas and Vlahou2012; Messinis et al., Reference Messinis, Malegiannaki, Christodoulou, Panagiotopoulos and Papathanasopoulos2011). Research consistently demonstrates that tests and normative data originally designed for middle-class Western populations can lead to misclassifications when used with ethnic minorities or non-Western populations (Daugherty et al., Reference Daugherty, Puente, Fasfous, Hidalgo-Ruzzante and Pérez-Garcia2017; Heaton et al., Reference Heaton, Taylor, Manly, Tulsky, Saklofske, Chlune, Heaton, Ivnik, Bornstein, Prifitera and Ledbetter2003). Misclassifications often arise from cultural and linguistic differences, varying levels and quality of education, the use of non-representative data, culturally biased test content, and differences in test-taking attitudes (Rivera Mindt et al., Reference Rivera Mindt, Marquine, Aghvinian, Paredes, Kamalyan, Suárez and Cherner2020; Shuttleworth-Edwards, Reference Shuttleworth-Edwards2016). These issues affect a range of neuropsychological tests, including those for general intelligence, verbal and visual memory (Walker et al., Reference Walker, Batchelor and Shores2009), language assessments (Patricacou et al., Reference Patricacou, Psallida, Pring and Dipper2007), non-verbal visuo-constructional tests (Nielsen & Jørgensen, Reference Nielsen and Jørgensen2013; Rosselli & Ardila, Reference Rosselli and Ardila2003), and executive functioning measures (Agranovich et al., Reference Agranovich, Panter, Puente and Touradji2011; Messinis et al., Reference Messinis, Malegiannaki, Christodoulou, Panagiotopoulos and Papathanasopoulos2011).
Efforts to tackle these challenges have involved creating culturally relevant test content and normative data for various cultural and ethnic groups globally, including minority groups in the United States (Norman et al., Reference Norman, Moore, Taylor, Franklin, Cysique, Ake, Lazarretto, Vaida and Heaton2011; Rivera Mindt et al., Reference Rivera Mindt, Marquine, Aghvinian, Paredes, Kamalyan, Suárez and Cherner2020) and both majority and minority groups in Europe (33; Nielsen et al., Reference Nielsen, Segers, Vanderaspoilden, Beinhoff, Minthon, Pissiota, Bekkhus-Wetterberg, Bjørkløf, Tsolaki, Gkioka and Waldemar2019). These initiatives have generally enhanced diagnostic accuracy. Nevertheless, the development of culturally appropriate neuropsychological tests and normative data remains an ongoing and iterative process, particularly when assessing ethnic minority and immigrant populations with limited education. Surprisingly, explicit guidelines for translating and adapting neuropsychological tests for cross-cultural use are currently lacking.
The field of test translations and adaptations has grown significantly, and there is a noticeable increase in the development of guidelines to improve these processes (Hernández et al., Reference Hernández, Hidalgo, Hambleton and Gómez-Benito2020). Professional organizations such as the American Educational Research Association (AERA), the American Psychological Association (APA), and the National Council on Measurement in Education (NCME) have joint efforts to sponsor the Standards for Educational and Psychological Testing (AERA, APA, & NCME, 2014) and issued guidance and standards related to testing, with a focus on fairness. This guideline approaches fairness in testing from different perspectives, including equitable treatment during testing, the absence of measurement bias, accessibility to the concepts being measured, and the validity of test scores for their intended purposes. While the specifics of their guidelines and recommendations may differ, their overarching goal is to promote fair and valid educational and psychological assessment practices.
One standard currently employed for such processes is the Guidelines for Translating and Adapting Tests developed by the International Test Commission (ITC). The ITC comprises 20 members representing national psychological associations, 65 affiliates, and over 700 individual members from 63 countries globally. The ITC’s primary goal is to promote collaboration and information exchange among its members, dealing with psychological test development, distribution, and utilization issues. In 2005, the ITC introduced the Guidelines for Translating and Adapting Tests, which underwent a Second Edition revision in 2017. These guidelines offer a comprehensive framework to ensure the quality and validity of psychological tests when translated and adapted for use in diverse linguistic and cultural contexts. While the second edition of the ITC guidelines (International Test Commission, 2017) has made significant strides by offering practical suggestions, these recommendations are not specifically tailored to the theoretical underpinnings of cognitive processes related to neuropsychological assessment. Consequently, their applicability in this context is limited.
In response to these limitations, the Cultural Neuropsychology Special Interest Group of the International Neuropsychological Society formed a working group aimed at furthering the application of the ITC Guidelines for neuropsychology. This group has crafted a set of recommendations specifically designed to steer the translation and adaptation of neuropsychological tests. Authors from over ten different nations worldwide contributed to these guidelines. The process involved conducting a comprehensive review of literature and research experiences pertaining to the translation, adaptation, and development of neuropsychological tests.
The neuropsychological applications of the ITC Guidelines for Test Translation and Adaptation are presented by Judd et al. (Reference Judd, Colon, Dutt, Evans, Hammond, Hendriks, Kgolo, Marquine, Mbakile-Mahlanza, Nielsen, Nguyen, Rampa, Serrano, Staios, Zapparoli and Zhou2024) and summarized in the subsequent sections of this publication. For clarity, test translation is a simplified language transfer that maintains accuracy, serving as one component of the broader adaptation process. In contrast, test adaptation encompasses evaluating a test’s ability to measure the same concept in a different context effectively. This process involves selecting skilled translators, establishing translation criteria, making necessary accommodations, modifying the test format, ensuring equivalence, and conducting essential validity studies for a comprehensive assessment. The 18 ITC Guidelines are categorized into six sections: Pre-condition, Test Development, Confirmation, Administration, Scoring and Interpretation, and Documentation. The first three guidelines in the Pre-condition section emphasize the importance of making well-informed decisions before embarking on the translation or adaptation process. The Test Development section comprises five guidelines that discuss specific test adaptation procedures. Four guidelines in the Confirmation section address the systematic gathering of empirical evidence for assessing a test’s equivalence, reliability, and validity across various linguistic and cultural contexts. The last three sections each contain two guidelines, encompassing the categories of Administration, Score Scales and Interpretation, and Documentation. A summary of each guideline is presented in Table 1.
Table 1. Summary of the International Test Commission Guidelines and its applications for neuropsychology
Pre-condition (PC) guidelines
PC-1 (guideline 1): obtain permission from the intellectual property rights owner
When choosing tests to adapt that were originally created by an individual or corporation, it is important to take intellectual property and copyright laws into account. Intellectual property comprises two main subdivisions: (i) industrial property, which encompasses patents safeguarding inventions, industrial designs, trademarks, and commercial names, and (ii) copyright, which pertains to artistic and technology-based creations. Test adapters should recognize copyright law and agreements for the original test. Before starting a test adaptation, one should have a signed agreement from the intellectual property owner (i.e., the author or the publisher). The agreement should specify the modifications in the adapted test that will be acceptable regarding the original test’s characteristics and should clarify who would own the intellectual property rights in the adapted version. Seeking permission to undertake test adaptation is common practice for several measures under copyright from major publishers (e.g., the Wechsler scales). Contacting the original test developers is advised to avoid intellectual property and copyright breaches and to gain clarity around these procedures.
PC-2 (guideline 2): evaluate the overlap between the test construct and item content
Adapting and developing neuropsychological tests demand meticulous attention to cultural factors and the concept’s equivalence when modifying tests for a specific population. For instance, one must consider how intelligence is conceptualized within the target population. In neuropsychology, intelligence is a frequently measured trait, yet a consensus on its definition remains elusive. An illustrative example comes from Kenya, where intelligence is delineated in the DhoLuo language using four distinct terms: rieko (knowledge and skills), luoro (respect), winjo (comprehension of real-life problem-solving), and paro (initiative), which deviate from the Western understanding (Grigorenko et al., Reference Grigorenko, Geissler, Prince, Okatcha, Nokes, Kenny, Bundy and Sternberg2001).
Test adapters and developers should explore how culture influences other constructs, such as working memory and executive functioning, without assuming universality. Verifying that the construct measured by the test is part of the target population’s vocabulary and examining the item-content equivalence of the test items are necessary initial steps. Test adapters and developers should know the target population’s culture and intended uses of the test to establish construct equivalence early in the adaptation process. Establishing construct equivalence requires experts in more than just both languages, and considerations for diagnostic validity and adaptive behavior should also be considered.
To achieve effective translation or adaptation of neuropsychological tests, involving language and cultural experts knowledgeable about the target population, including academics, professionals, and local informants, is recommended. Merely having experts present, however, does not guarantee the quality of the final product. Hence, efforts should focus on providing specific recommendations tailored to neuropsychological test translation or adaptation processes. For example, during translation, emphasis should be placed on achieving linguistic equivalence, while adaptation necessitates consideration of cultural equivalence, ultimately aiming for psychometric equivalence as the final result. These concepts are crucial to incorporate into the translation or adaption process to ensure the validity and reliability of the test across different cultural and linguistic contexts.
PC-3 (guideline 3): minimize the influence of cultural and linguistic differences irrelevant to intended test uses in target populations
To mitigate the impact of cultural and linguistic differences that are irrelevant to the test’s intended purpose on the results in the target populations, a comprehensive approach that involves reviewing, surveying, piloting, and debriefing test-takers, administrators, and focus groups is recommended. Multiple-choice and Likert scale response formats may be unfamiliar or ill-aligned with cultural norms in some cultures. For example, Chinese culture values moderation and may prefer neutral responses on Likert scales, even for positive emotions. Chinese and Japanese individuals tend to choose midpoints when acknowledging positive emotions, differing from European Americans (Wang et al., Reference Wang, Hempton, Dugan and Komives2008). Cultural variations also impact the value placed on speed in neuropsychological tests, willingness to guess, acceptance of synonyms and paraphrases, and knowledge of cardinal directions (Ardila, Reference Ardila2005).
There may also be intracultural variability in familiarity with test materials and techniques due to education policies, language policies, and writing systems. Test item content should have similar difficulty and familiarity relative to the culture and across all subcultures of anticipated application. Consulting the full range of intended test users early and addressing these differences through piloting is necessary. At this stage, assessing the feasibility, planning strategies, and establishing project objectives becomes pivotal. Early in the project, it is essential to determine whether the most feasible strategy is to translate and make slight adaptations to a test, perform a full translation with adaptation, create a test in the target language following the model test’s paradigm, or construct a new test in the target language with a new design, as outlined in the Test Adaptation Typology provided in Table 2. To systematize the adaptation process, it is important to apply adaptation frameworks that are construct-driven, language-driven, culture-driven, theory-driven, and familiarity/recognizability-driven (Malda et al., Reference Malda, van de Vijver, Srinivasan, Transler, Sukumar and Rao2008).
Table 2. Test adaptation typology
Note. The test adaptation typology is conceptualized as a continuum rather than discrete categories.
Test development (TD) guidelines
TD-1 (guideline 4): consider linguistic, psychological, and cultural differences by consulting with content experts
Many widespread languages may have different versions or dialects in different communities and parts of the world, such as English, Spanish, French, Arabic, Chinese, Swahili, and Quechua (Harris, Reference Harris2022). Test developers should be conscious of whether they are developing localized or language-wide versions of their tests. To ensure that test materials are relevant and appropriate for the target population, the project team should include members with cultural, content, and testing expertise in the target language/population. The definition of an “expert” should include not only knowledge of (1) the languages involved, (2) the cultures, (3) the content of the test, and (4) general principles of testing but also (5) knowledge of the constructs of the test and their measurement. For example, take the item, “How are these two things alike, Orange-Banana?” A translator who is an expert in the content of the test and in Spanish localization would know to translate “banana” as “guineo” for the Caribbean but as “banano” for other parts of Latin America. But if “orange” had been translated” as “anaranjado” (the color orange rather than the fruit orange), this would back-translate fine and could appear correct to a content expert. But a construct expert would recognize that this item misses the intended construct (the similarity of being fruit. It would be like asking, “How are these two things alike? Blue-Banana”).
As demonstrated in the example, relying solely on individuals well-versed in testing fundamentals would fall short. The process should also require a deep understanding of test constructs. Collaboration with professionals possessing expertise in neuropsychological testing and a strong grasp of the language and culture, such as speech-language pathologists, for assessments related to language functions and aphasia tests can be highly beneficial. The translation and localization process should involve a multidisciplinary team with language and neuropsychological testing expertise to ensure the highest quality and validity of the adapted test materials.
TD-2 (guideline 5): maximize test adaptation suitability for target populations through appropriate translation designs and procedures
Neuropsychological assessments often rely on language-related processes to gauge various language skills, memory, and executive functions. When translating these assessments, prioritizing maintaining the core concepts rather than merely preserving semantic similarity is recommended for a successful adaptation. In some cases, the semantic content becomes irrelevant to the evaluation, a concept that may be unfamiliar to professional translators. For instance, assessments designed for aphasia and language-specific evaluations cannot be directly translated but require adaptation to linguistic features of the target language (Ivanova & Hallowell, Reference Ivanova and Hallowell2013). Established guidelines exist for such cases, as illustrated by the phonemic discrimination subtest in the Bilingual Aphasia Test (Paradis & Libben, Reference Paradis and Libben1987). This subtest involves selecting the correct image from a set of options and necessitates careful selection of words with initial consonantal sound differences. A pure semantic translation would undermine the subtest’s purpose.
Tasks involving verbal working memory and mental calculations are often used when evaluating attentional functioning. Cross-cultural and cross-linguistic studies reveal the influence of factors like word length, speech rates, and literacy on performance in verbal working memory tasks (Chan & Elliott, Reference Chan and Elliott2011; Chincotta & Underwood, Reference Chincotta and Underwood1996; Rosselli & Ardila, Reference Rosselli and Ardila2003). As such, adapting digit and mental math tasks to different languages requires considering both digit universality and phonemic, visual, and cultural distinctions. Adapting verbal memory tasks across languages is challenging due to stimuli familiarity and word frequency variations (Nell, Reference Nell2000). Several strategies have been proposed for adapting neuropsychological assessments for culturally diverse groups, including substituting culturally appropriate items and ensuring ecological relevance. The goal is to have materials and tasks that are understandable in the target culture, cover an appropriate psychometric range, evaluate the intended cognitive concepts, and maintain clinical relevance (Vlahou et al., Reference Vlahou, Kosmidis, Dardagani, Tsotsi, Giannakou, Giazkoulidou, Zervoudakis and Pontikakis2013). Factors like word length, material, and task familiarity are essential considerations in this process (Messinis et al., Reference Messinis, Nasios, Mougias, Politis, Zampakis, Tsiamaki, Malefaki, Gourzis and Papathanasopoulos2016).
Once these goals of the adaptation have been clearly identified, appropriate translation designs and procedures can be selected. The ITC Guidelines recommend using multiple designs, discussing the advantages and disadvantages of double translation and reconciliation, translation from more than one language, back translation, simultaneous development of multiple language versions, and designing a source version that minimizes translation problems. Hambleton and Zenisky (Reference Hambleton, Zenisky, Matsumoto and van de Vijver2010) list 25 empirically validated features recommended for translated tests. Back translation, although still used for some very technical and literal translation, is now considered obsolete for most test translation purposes, in large part because back translation is errorful and favors semantic equivalence over cultural, functional, linguistic, construct, and psychometric equivalence (Colina et al., Reference Colina, Marrone, Ingram and Sánchez2017; DuBay et al., Reference DuBay, Sideris and Rouch2022).
TD-3 (guideline 6): provide evidence that the test instructions and item content have similar meanings for intended populations
Developing culturally-congruent test instructions is a key priority during the translation and adaptation process. A simple translation of instructions may not suffice for equivalence in measurement and construct. Consider the example of the clock drawing test, where the phrase “10 after 11” in one setting might be expressed as “10 past 11” in another, as in Botswana. While this difference may seem subtle, it could lead some test-takers to misinterpret it as “10 minutes to 11” rather than the intended “10 after 11.” In another example, nine of the twelve naming items on the Addenbrooke’s Cognitive Examination (Bak & Mioshi, Reference Bak and Mioshi2007) from the United Kingdom were found to be insufficiently familiar with the Arabic translation for Saudi Arabia (Al Salman, Reference Al Salman2013). Test instructions and other item content should be pilot-tested and refined with the adaptation team until a consensus is reached.
To enhance the validity and cultural appropriateness of neuropsychological tests, stimuli, and test instructions, it is recommended that test developers involve individuals native to the local culture and proficient in the language of the test being translated and adapted, as well as bilingual individuals, to solicit feedback and insights into test equivalence. Customizing test administrations that align instructions with cultural and linguistic preferences also enhances acceptability and validity for diverse populations. Conducting interviews with participants and test administrators following the test administration will offer valuable qualitative insights into any potential discrepancies between intended and perceived meanings, thereby enhancing the overall validity of the assessments.
TD-4 (guideline 7): provide evidence that the item formats, rating scales, scoring categories, test conventions, and modes of administration, and other procedures are suitable for intended populations
This guideline emphasizes the necessity of familiarity with test items and administration methods to ensure unbiased testing results; however, in neuropsychological assessment, ensuring test suitability for all intended populations encompasses more than mere familiarity. Establishing semantic equivalence may not suffice in some instances. For example, Franzen et al., (Reference Franzen, van den Berg, Kalkisim, van de Wiel, Harkes, van Bruchem-Visser, de Jong, Jiskoot and Papma2019) found systematic performance variations among culturally diverse individuals in the Netherlands on the Visual Association Test (Lindeboom & Schmand, Reference Lindeboom and Schmand2003), noting that memory performance differed depending on whether participants were presented with black-and-white line drawings or pictures. Differences in neuropsychological performance can stem from the individual’s approach influenced by cultural strategies. Given the significance of speed and reaction time in numerous neuropsychological assessments, wherein cultures prioritize performance speed differently (e.g., Ardila, Reference Ardila2005), additional attention might be necessary in crafting test instructions. Similarly, thoroughly assessing the scoring criteria during the adaptation phase is necessary. In the evaluation of the suitability of the Clock Drawing Test for Bengali-speaking individuals in India, researchers observed that low-educated, healthy participants frequently combined English and Bengali when marking numbers on the clock face, prompting the implementation of an alternative scoring system (Crombie et al., Reference Crombie, Dutt, Dey, Nandi and Evans2023).
In practical application, closely monitoring how test adaptation procedures may impact construct measurement is recommended. Key considerations include whether the adapted test maintains functional suitability and ensuring that alterations to test items and administration tools align with the original purpose of assessing the operational definition of the construct. Additionally, test developers should examine whether response categories accurately reflect the intended constructs, particularly regarding Likert scales, to ensure that high scores consistently represent the same values across diverse populations. Qualitative approaches like error analyses and feedback surveys can provide holistic insights during the piloting phase. Practice items play a crucial role in familiarizing test-takers with unfamiliar tasks without inducing practice effects, especially pertinent for domains like executive functions. Clear instructions for testers are imperative to gauge test-takers’ understanding. Lastly, it is prudent to consider amending scoring criteria to optimize test validity in new linguistic or cultural contexts, drawing upon data from validity studies and replication efforts for informed decisions.
TD-5 (guideline 8): collecting pilot data
Before initiating the extensive data collection and test adaptation phases, it is advisable to employ pilot qualitative and quantitative procedures that include item analysis, reliability assessment, and small-scale validity studies. Qualitative piloting involves assessing comprehension, item suitability, and method appropriateness by engaging with test-takers and administrators to gain insights into potential validity and reliability issues. Following this, quantitative piloting delves deeper into evaluating method and item suitability, collecting extensive qualitative data on errors, the test-taking experience, and overall reception. The pilot sample should closely resemble the target standardization/normative population and the intended test users, such as individuals with dementia. Initial qualitative piloting may require adjustments to test instructions or items, while further quantitative piloting helps identify and adapt problematic items and procedures. Examples of detailed piloting techniques can be found in the Canadian Indigenous Cognitive Assessment development project (Jacklin et al., Reference Jacklin, Pitawanakwat, Blind, O’Connell, Walker, Lemieux, Warry and Phinney2020) and the procedures demonstrated by Franzen et al. (Reference Franzen, van den Berg, Bossenbroek, Kranenburg, Scheffers, van Hout, van de Wiel, Goudsmit, van Bruchem-Visser, van Hemmen, Jiskoot and Papma2022).
In this context, a comprehensive approach involving both qualitative and quantitative piloting is proposed. Piloting should involve individuals representing the intended test populations across various relevant dimensions, including age, education, cultural background, language proficiency, cognitive abilities, and so forth. Additionally, test administrators involved in piloting should mirror the intended demographic in terms of language proficiency, educational background, and testing experience.
Qualitative piloting should involve exploring the comprehension of standardized instructions and test materials, along with incorporating open-ended observation and reporting of testing experiences and challenges from test-takers and administrators through interviews, surveys, focus groups, and/or other appropriate techniques. This can allow for iterative adaptations and targeted repiloting of problematic procedures and materials. For example, during the adaptation of the Addenbrooke’s Cognitive Examination III for the Bengali-speaking population in Kolkata, India, it was observed that phonemic verbal fluency instructions were poorly understood. Adding any vowel form - aa, i, u, e, OI, O, OU - and others to the phoneme “Pa” made the instruction clear to both healthy participants and patients with dementia and optimized test performance (Dutt et al., Reference Dutt, Nandi, Venkatesh, Rao, Bhargava, Goplakrishnan, Bose, Ghosh and Evans2024).
Quantitative piloting can be done when iterative qualitative piloting and adaptations have clarified common misunderstandings. This piloting evaluates the psychometric characteristics, including item analysis, reliability, and validity of the scores obtained from the adapted test. Based on the results, necessary revisions should be made to the final version of the test. The pilot sample size must be adequate to conduct the necessary statistical analysis for the study.
Confirmation (C) guidelines
C-1 (guideline 9): select a sample relevant to the intended use of the test and sufficient size for analysis
A successful adaptation process for neuropsychological tests for a particular language or culture should involve a strategic plan to recruit participants for validation studies who are representative of the population with whom the test is intended to be used. It is essential that test adapters consider the elements that characterize the target population and could impact both test performance and language. Ensuring the presence of these characteristics in the validation sample is of particular significance, especially considering the cultural diversity within a language group and the influence of sociocultural factors on test performance.
Factors such as bilingualism/multilingualism, socioeconomic status, sex, ethnicity, nationality, quantity or quality of education, and familiarity with tests should be examined in relation to neuropsychological test performance. Examiner-related factors, such as stereotype threat and examiner bias, can also impact test performance and should be considered in developing studies to validate neuropsychological tests empirically (Thames et al., Reference Thames, Hinkin, Byrd, Bilder, Duff, Mindt, Arentoft and Streiff2013). To reduce the likelihood of stereotype threat impacting test performance, strategies during the test adaption process can involve developing test items that represent diverse contexts, cultures, and identities. Before finalizing test items, pilot them with a diverse sample of individuals to assess whether any items evoke stereotype threat or exhibit biases. Furthermore, validity studies should be implemented to assess whether the test effectively predicts performance outcomes without being confounded by stereotype threat effects. Collecting data from large samples may not always be feasible, particularly in resource-limited settings where skilled examiners must individually administer tests. As such, analyses should be limited to those appropriate for the sample size that can be obtained, and the limitations of using small samples must be documented.
C-2 (guideline 10): provide relevant statistical evidence about the construct equivalence, method equivalence, and item equivalence
A main concern when translating or adapting a test to a new language and/or cultural group is to ensure the test’s validity for its intended purpose. For instance, verifying if the same factor structure is essential when translating or adapting the Wechsler Adult Intelligence Scale (WAIS) – Fourth Edition (IV). This ensures that the test battery assesses identical constructs across various languages and cultural groups and validates the appropriateness of computing and reporting the four index scores. Thus, Cockcroft et al. (Reference Cockcroft, Alloway, Copello and Milligan2015) compared a multilingual, low socioeconomic group of black South African students with a predominantly white, British, monolingual, higher socioeconomic group and found that subtest scores loaded differently for the two groups. Exploratory factor analysis showed that a four-factor structure was most suitable for the South African data, albeit with Arithmetic loading more on the verbal comprehension factor than the working memory factor. Still, a three-factor structure better suited the British data, although interestingly, the same four-factor structure present in the United States standardization sample was also evident in the sample used for the United Kingdom WAIS-III standardization. Another recent example is the work of Staios et al. (Reference Staios, Kosmides, Nielsen, Kokkinis, Stogoannidou, March and Stolwyk2023), who conducted a confirmatory factor analysis of normative data from an elderly sample of Greek Australians on the Greek adaptation of the WAIS-IV and showed a good fit for the same four-factor solution as the original version.
Test validity can be examined by examining convergent and discriminant validity, and item equivalence can be assessed to ensure that all items are useful in the new language and/or cultural group. For example, a naming test may introduce method bias as some cultures may be less familiar with line-drawing representations of objects (e.g., Reis et al., Reference Reis, Faísca, Ingvar and Petersson2006). Therefore, it is important to assess item equivalence between the original and new language and/or cultural group for all items, assessing both adopted words and object exemplars and, if necessary, replacing items. A broad construct measured by the original test may be equivalent in the new language and/or cultural group. Still, some or all the items in the test may not be equivalent in both the original and target languages. The relevance is especially notable in neuropsychological tests where items are arranged by increasing difficulty and discontinuation rules are in effect. Differential item functioning analysis should be carried out to examine whether items function differently in different samples.
C-3 (guideline 11): provide evidence supporting the norms, reliability, and validity of adapted version
To ensure the usefulness of neuropsychological tests, the quality of the normative data utilized for interpreting test performance plays a pivotal role. Test developers must assess the adapted test’s reliability in its intended context, including internal consistency, test-retest, inter-rater, and parallel-version reliability. When adapting a test, assess the suitability of the original norms or consider collecting new normative data. Avoid assuming that a national identity always provides the ideal basis for norms, as cultural diversity can influence norm applicability (Guàrdia-Olmos et al., Reference Guàrdia-Olmos, Peró-Cebollero, Rivera and Arango-Lasprilla2015). For example, cultural heterogeneity may challenge the generalizability of the norms developed within a specific cultural context (e.g., Bengali-speaking population residing in Kolkata, in Eastern India) compared to another context (e.g., Malayalam speaking population residing in Bangalore, in Southern India) within the same country (Das et al., Reference Das, Banerjee, Mukherjee, Bose, Hazra, Dutt, Das, Chaudhuri and Raut2006; Mathuranath et al., Reference Mathuranath, George, Cherian, Alexander, Sarma and Sarma2003). Factors such as acculturation often significantly influence test outcomes (Tan et al., Reference Tan, Burgess and Green2021), leading to the non-uniform application of norms within a language or cultural group across different levels of acculturation and generations of immigrants. This includes international migration and migration within a country, particularly rural-to-urban movement. Ideally, acculturation should be assessed in diverse normative samples, covering individuals from various cultural backgrounds who have immigrated.
C-4 (guideline 12): use an appropriate equating design and data analysis procedures when linking scores between language versions
Complex cultural factors affecting neuropsychological test performance make it challenging to compare scores across different test versions (Casaletto & Heaton, Reference Casaletto and Heaton2017), as the primary purpose of these tests is not to compare scores across language populations directly but to serve similar functions in each population. The adaptation process should focus on whether the test measures a similar construct across language groups and whether the scores derived from a given population have strong psychometric properties. It is important to exercise caution when interpreting scores derived from different cultural or language groups. Neuropsychological scores are closely tied to the normative sample from which they were developed. Tests may function well clinically within a population when referencing appropriate population norms. Test adaptors should select the appropriate equating design and data analysis procedures if they wish to equate data and comparisons across populations.
Administration (A) guidelines
A-1 (guideline 13): prepare administration materials and instructions to minimize any culture- and language-related influences on test administration
The nature and purpose of neuropsychological testing may be a foreign concept for test-takers without prior assessment exposure, which can lead to misunderstanding and potentially inaccurate results. Such misunderstanding may be mistaken for cognitive impairment, test anxiety, poor test effort, malingering, or other concerns. To minimize these effects, neuropsychologists must take into consideration the sociocultural, demographic, and functional context of the intended population in both the research aspects of the test (e.g., construction, validation, and standardization) and their clinical applicability (e.g., providing clear and culturally appropriate test description, explanations to clients/patients to obtain their consent for testing, and administration procedures). Thus, the true scope of the guideline presented here must encompass the adaptation of instructions specific to a given test and the entire testing context. Practical considerations are presented in Table 3.
Table 3. Administration guidelines: practical considerations
A-2 (guideline 14): specify testing conditions to be followed in all populations of interest
In the context of neuropsychological testing, it is essential to strike a delicate balance between adhering to standardized procedures and adapting tests to suit various clinical settings and populations. Consideration of factors includes distinctions such as inpatient versus outpatient settings, teleneuropsychology, and the needs of individuals with disabilities or specific cultural requirements. When adjusting tests for environments divergent from their original validation context, it is essential to consider the test-specific components and the aspects of the testing environment that could impact results or the construct being measured. These adaptations require detailed documentation of changes made to the test structure, materials, and administration. In inpatient settings, where testing conditions can be constrained by patient posture, limited space, potential distractions, and frequent interruptions, adaptations may need to alter test length, timing, practice items, or instruction to accommodate these challenges. When outpatient tests are used in inpatient settings without formal adaptations, administrators should consider the impact of the hospital environment on patient stress levels, privacy, and performance. For teleneuropsychology, where assessments are conducted remotely, additional considerations include potential equipment failures, display and audio issues, and internet connectivity problems. The test administrator should also be aware of distractions, interruptions, and privacy concerns in the test-taker’s home environment. Ensuring the security of test materials and addressing issues related to cultural and technological familiarity is crucial. Lastly, it is imperative to adapt tests for individuals with specific needs, such as those with hearing, visual, or motor impairments and those with lower levels of formal education. These adaptations may involve modifying tasks to accommodate verbal or visual mediation, adjusting practice item allowances, and offering appropriate feedback.
Score scales and interpretation (SSI) guidelines
SSI-1 (guideline 15): interpret group score differences with reference to all relevant available information
Understanding and accounting for cultural factors is essential for accurately interpreting neuropsychological test performance. For example, educational systems can significantly differ between countries and cultures. Factors such as the importance placed on teaching syntax rules, geographic regions (urban vs. rural), gender roles, generational differences, and variations in educational facilities (private vs. public schools) can all impact an individual’s test performance. Secondly, levels and types of literacy and writing systems should be considered, as they influence an individual’s familiarity with test materials and strategies. Additionally, attitudes, motivations, expectations, and strategies related to testing and attitudes toward timed tests and test procedures can significantly affect test outcomes. Immigration patterns and policies between countries, such as refugees or selection criteria based on skills, language, ethnicity, and age, can impact acculturation patterns and the representativeness of norms from one’s home country. The level of acculturation in immigrant groups is a crucial factor to consider, as it influences how individuals navigate and respond to neuropsychological assessments. The phenomenon of stereotype threat in marginalized groups, which can lead to underperformance due to the fear of conforming to negative stereotypes, should also be considered. Moreover, other social determinants of health or non-medical factors that affect disease, treatment, and outcomes may play a significant role in test performance.
SSI-2 (guideline 16): only compare scores across populations when scale invariance has been established
Interpreting neuropsychological test results requires careful consideration of the available normative data, especially when assessing individuals from diverse cultural or linguistic backgrounds. Directly comparing raw scores among individuals with varying demographic characteristics, including cultural and language factors, may not yield valid results. Take, for example, the WAIS test, which maintains a common reporting scale but utilizes different raw scores depending on the country-specific or cultural normative data applied. Even within the same language versions of the test, differences in normative data can lead to varying scaled scores, profiles, and diagnostic classifications across countries, as seen in the disparities between American, Canadian, Colombian, Mexican, and Spanish WAIS-IV norms (Duggan et al., Reference Duggan, Awakon, Loaiza and Garcia-Barrera2019).
Due to the lack of content equivalence, substantial sample sizes across multiple populations, and research necessary for scalar or full score equivalence, direct score comparisons across populations should generally be avoided in neuropsychological testing. The limitation extends to comparing an individual’s performance to a population they do not belong to, emphasizing the importance of considering the available validity evidence when interpreting test results. It is particularly challenging for multicultural and multilingual individuals, including older migrants, as neither the normative data from their country of origin nor the new country may accurately represent this population (Dutt et al., Reference Dutt, Evans and Fernandez2022; Plitas et al., Reference Plitas, Tucker, Kritikos, Walters and Bardenhagen2009; Staios et al., Reference Staios, Kosmides, Nielsen, Kokkinis, Stogoannidou, March and Stolwyk2023).
These concerns might not be relevant in criterion-based testing scenarios, where the assessment focuses on specific competencies or adaptive behaviors. In such cases, using scores and norms from a population that does not perfectly match the individual being evaluated could be deemed acceptable. For instance, in evaluations of driving safety or worker qualifications, it may be permissible to employ norms that do not precisely align with the individual’s demographic background. However, even in these situations, it is prudent to proceed with caution. Considering alternative, context-specific assessments like on-road driving tests can ensure a more accurate evaluation of the individual’s capabilities.
Documentation (Doc) guidelines
Doc-1 (guideline 17): provide technical documentation of changes, including evidence of equivalence, when a test is adapted to a different population
A comprehensive technical document and test manual are essential in neuropsychological test adaptation. This document should offer detailed insights into the adaptation process, providing evidence of the adapted test’s reliability and validity within its intended new context. It should encompass a description of the normative data collection process, use of interpreters, characteristics of the normative sample, and the metrics used for test performance evaluation, such as scaled scores or T scores. Recommendations include presenting this technical documentation as a manual accompanying the test or a technical paper in a journal article. The document should address crucial aspects, including the adapted test’s purpose in the new context, the relevance of the construct measured, the process of item translation or adaptation, ensuring familiarity of test formats for the target population, addressing factors influencing test performance, evidence from initial piloting, interpreter qualifications and roles, and thorough reliability and validity assessments. Additionally, it should detail the normative sample and data collection processes, offering demographic characteristics and outlining applicability limitations. The choice of metrics, analysis of normative data, rationale for norm provision, and user-friendly presentation of normative data should also be included. It is important to note that the specific content may vary depending on the test being adapted, and these guidelines offer a comprehensive framework for ensuring the integrity of the adaptation process.
Doc-2 (guideline 18): provide documentation to support good practice in the use of an adapted test in the target population
A user manual is essential for all neuropsychological tests to ensure proper administration, scoring, and interpretation of the test results. It can serve as a vital resource, elucidating the rationale behind the test’s original and new language or cultural group adaptation, substantiating the test’s reliability and validity, furnishing precise administration and scoring instructions, and offering guidance on score interpretation. The user manual should encompass several key elements, including an explanation of the original test’s purpose and relevance in the new linguistic or cultural context, a concise overview of the adaptation process, and compelling evidence supporting the test’s reliability and validity within the new context. It should also delve into detailed instructions for test administration, accounting for any context-specific nuances or differences from the original test, elucidate the scoring process, and provide insight into score interpretation tailored to the new language or cultural group. Additionally, the manual should delineate whether the adapted version allows for direct population comparisons with the original test, specifying the basis for such a determination.
Conclusion
Establishing a set of specific neuropsychological test translation, adaptation, and development guidelines is critical to ensure that such processes produce reliable and valid psychometric measures. The neuropsychological adaptation of the ITC guidelines can function as a practical guide to translate and adapt tests for use with a broad range of target populations. Following a systematic approach based on test adaptation guidelines is essential for several reasons. First, it helps assess the suitability of a test within a specific cultural context, even within individual nations. Additionally, it aids in preventing biases related to the test’s construct, methods, and sampling. Adhering to a standardized adaptation process can significantly reduce the potential for these biases. A systematic and standardized adaptation process is necessary for developing robust and culturally sensitive assessment tools. A visual depiction of how this process may look is presented in Figure 1.
Figure1. Example of a systematic approach based on test adaptation guidelines. Adapting a neuropsychological test involves several phases, starting with obtaining permission from the copyright holder and conducting an expert review. This is followed by translating or adapting the test, conducting a pilot study, performing item analysis, assessing reliability, collecting normative data, and producing an administrative manual. An example of this process can be seen here in the neuropsychological adaptation of the International Test Commission Guidelines. This example illustrates how the relevant guidelines can be applied throughout the different phases of the adaptation process. Here, Dutt et al. (Reference Dutt, Nandi, Venkatesh, Rao, Bhargava, Goplakrishnan, Bose, Ghosh and Evans2022) utilized a systematic approach for adapting the naming test from the Addenbrooke’s Cognitive Examination III for the Bengali-speaking population in Kolkata, India. This figure is adapted from Dutt et al. (Reference Dutt, Nandi, Venkatesh, Rao, Bhargava, Goplakrishnan, Bose, Ghosh and Evans2024).
Although the suggested recommendations are intended for future test translation and adaptation procedures, neuropsychologists often rely on non-verbal tests (such as WAIS-IV Matrix and Block Design, Dot Counting) in their current practices with culturally diverse patients. While test translations may be available, securing these translations from the original authors may also be difficult. Other challenges may include dilemmas when working with interpreters unwilling to engage in on-spot translations. Typically, neuropsychologists face challenges accessing sufficient translations. Current practitioners are directed to the proposed systematic approach outlined in Figure 1. For example, during Phase 2, the question arises if a test needs to be translated or culturally adapted. If the translation test materials and stimuli are indicated, a recommended approach is for the practitioner to consult and collaborate with organizations such as the International Neuropsychological Society’s Cultural Neuropsychology Special Interests Group throughout the translation process. Other strategies for leveraging currently available international data to estimate premorbid functioning may be helpful in providing further clinical context, and additional resources for working with culturally diverse individuals are available elsewhere (see Fujii, Reference Fujii2017).
Navigating the evolving landscape of cognitive assessment and cross-cultural neuropsychology involves acknowledging the iterative nature of the test adaptation process. Continuous refinement is vital to promoting systematic and accountable adaptation practices to progress the field. It is recommended that translators, adaptors, developers, reviewers, and editors actively employ these guidelines. Additionally, journal editors and grant review agencies are encouraged to consider including a self-accountability component in submission requirements for authors adapting tests, as detailed in Table 4. Practitioners, researchers, and authors are encouraged to demonstrate their commitment to these guidelines. This enhances the rigor of the adaptation process and ensures transparency and accountability, ultimately improving the reliability and validity of adapted tests.
Table 4. Neuropsychological application of International Test Commission Guidelines: criteria for evaluative checklist
Future iterations of the neuropsychology adaptation of the ITC guidelines can focus on ethical implications and the impact of technology on test development adaptation. Ethical considerations extend beyond scientific and clinical domains and include fairness, cultural sensitivity, and the avoidance of biases when creating or adapting tests. Addressing cultural biases is crucial to avoid unjust outcomes and disparities. Transparency in test development and adaptation is essential for trust, and ethical test development requires a commitment to rigor, inclusivity, and continuous assessment. The impact of technology on neuropsychological test development and adaptation shows promise for revolutionizing various aspects of test creation. Computerized and digital assessments offer advantages like increased standardization, real-time data collection, and adaptive testing. Teleneuropsychology and remote assessments provide accessibility to individuals with geographical or physical limitations. Ethical considerations, such as data privacy, algorithmic biases, and maintaining the human element in assessment, remain critical as technology evolves. Researchers, practitioners, and policymakers must adapt to navigate the ethical, practical, and scientific implications to harness the full benefits of these technological advancements.
Acknowledgments
We gratefully acknowledge the thoughtful comments of Elaine Ballard, Jamie Berry, Kate Cockcroft, Andy Dawes, Sanne Franzen, Kristin Jacklin, Michel Paradis, Porrselvi A.P., Parisuth Sumranasub, and Sharon Truter, that have been helpful to our process.
Funding statement
The authors of this paper are members of the Cultural Neuropsychology Special Interest Group (CN-SIG), Assessment Workgroup of the International Neuropsychological Society (INS). We would like to express our appreciation for the inspiration and support provided by the many neuropsychologists and allied professionals working to translate, adapt, and develop neuropsychological tests, assessments, and other tools to serve unreached populations; the CN-SIG as a whole; INS administration, and especially the ITC for their pioneering work in developing and updating the ITC Guidelines for Translating and Adapting Tests, and for providing feedback on the current document. The views expressed in this paper are those of the authors and may not necessarily represent the views of the INS.
Competing interests
None.
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