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As the elder population in the US is increasingly becoming more demographically diverse, it is crucial that practitioners and researchers recognize the impact of these demographic changes on the needs of this population. Population estimates predict that by 2050 the proportion of non-Hispanic Whites over the age of 65 will be 42% minority (Vincent & Velkoff, 2010), a large percentage will be Latino. In 30 years, the number of Latinos over the age of 50 is predicted to increase three-fold (Yamada, Valle, Barrio & Jeste, 2006). By mid-century, the proportion of Latino elderly is expected to increase from 5% to 14% (Hobbs, 2001). A significant segment of this growing elder Latino population will be 75 years old and older. These "old-old" will probably be first-generation immigrants who are primarily monolingual Spanish speakers who adhere to traditions, outlooks and practices of their culture of origin (Yamada, Valle, Barrio & Jeste, 2006). Therefore, clinicians and researchers will see a growing segment of elders entering the healthcare system who fall on an "acculturation continuum" ranging from highly acculturated to low acculturation (Stauble, 1980). Healthcare professionals will face clients who may feel uncomfortable using English or hold on to the values and traditions of their home country. The fluid nature of the process of acculturation is beginning to gain the notice of researchers and clinicians.
Theories of Acculturation: Gordon's Stages of Assimilation
The process of acculturation is a controversial and a misunderstood concept that attempts to explain how people from one culture "take in" the culture of another. Anthropologists in the early 20th century began to study how colonized cultures transform after the arrival of the colonizers (Acevedo-Garcia, 2004). Much of the early sociological research focused on assimilation, which is a process of incorporation of immigrant cultural groups into the host culture (Bean & Stevens, 2003). Assimilation was seen as unidirectional, in which the person changes his/her original beliefs and values into those that are more in line with those of the dominant society (Aponte & Barnes, 1995). Gordon's 1964 landmark book Assimilation in American Life introduced assimilation as a linear process of sociocultural change experienced by the immigrant group. Gordon's structural theory predicts that the longer the immigrants live in the host society, the greater the probability that they will exhibit similarities with the majority group than immigrants who have spent less time in the host society. Gordon's straight-line model of assimilation was used to describe the experience of European immigrants to the United States during the turn of the previous century and was the dominant theory used until the 1980's when a more dynamic theory of acculturation was developed (Schildkraut, 2007).
Gordon improved upon Park's previous work (1950) Race Relations Cycle which conceptualized assimilation as a linear process of contact or migration, which leads towards competition for resources and the conflict it creates. Accommodation is achieved via social and personal interactions and finally assimilation is achieved when cultural/ethnic distinctions are gone. Assimilation as the end stage is complete and irreversible (Alba & Nee, 1997).
In Gordon's influential theory, he included several stages that increase in interactional intensity in which a minority group has to pass through in order to become assimilated to the host country (Marger, 2008).((CREATE TABLE OF STAGES)) In the acculturation or cultural assimilation stage, the minority group's adoption of the host society's cultural patterns such as language, dress, political beliefs is inevitable. It is possible, Gordon argued, that an immigrant group remains in this initial stage indefinitely and used Eastern European Jews and African-Americans as examples of groups that adhere to the dominant culture's values and behaviors but remain segregated due to discrimination from the majority culture or due to geographic isolation (Gordon, 1950; Alba & Nee, 1997; Marger, 2008). The second and equally important stage-structural assimilation-occurs when there are larger scale social interactions of the immigrant group with the host culture. These social contacts may occur on two different levels and in tandem. Primary relationships include friendships with members of the dominant group; living in a neighborhood that is not an ethnic or cultural enclave; having intermarriages with members of the dominant group (Bean & Stevens, 2003; Alba & Nee, 1997). Further assimilation is achieved as members of the minority intermarry into the dominant group and aligning their values and beliefs to the majority, thus relinquishing ethnic identity and leading to the disappearance of prejudice and discrimination (Marger, 2008; Alba & Nee, 1997). Holding public office, attending college, holding managerial or executive positions indicate a more formal social interaction by the minority group. According to Gordon (1950) these non-affective interactions are secondary relationships and indicate that the immigrant group has eliminated their status as a minority and has become part of the larger mainstream group. Gordon further states that once the structural assimilation has occurred, the other levels of assimilation will follow and that these shifts will be irreversible and permanent (pp 80).
Towards a Multidirectional Understanding: Berry's Acculturation Theory
The unidirectional model of assimilation came under intense scrutiny during the turbulent societal and intellectual eras of the 1960s and 1970s (Aponte & Barnes, 1995). One of the major criticisms of the accepted model is that the assimilation model assumed that the minority group will have to change almost completely in order to become part of the culture, leaving the majority culture unchanged (Alba & Nee, 2005). Another criticism is that the unidirectional model was more concerned with changes within a group when encountering a new culture instead of the changes that occur in the individual level. Berry's multidimentional model was influenced by Graves' (1967) notion of "psychological acculturation" which concerns the psychological changes that occurs with an individual when he/she is in direct contact with a new culture.
Current research uses the concept of acculturation as a multidirectional process of cultural and psychological change (Berry, 2005; Berry, Phinney, Sam & Vedder, 2006). Acculturation is the result of contact between the members of two or more societies. This is a dynamic experience that is shared by both the individual and the group and depending on the situation, a person may adopt different aspects of the dominant culture (Aponte & Barnes, 1995; Berry, 2005). Acculturation differs from assimilation in that assimilation is a transitory phase, whereas acculturation is a process over time (Berry, 2005). Berry defines acculturation as a process in which there are behavioral and psychological changes that occur interpersonally as a result of contact with a new culture (Berry, 1995). In this model, acculturation occurs in four modes: integration, assimilation, separation, and marginalization. During the acculturation process, individuals could experience these modes simultaneously. Individuals experiencing integration maintain their cultures and are able to accept and adapt to the host's cultures. Berry characterizes this as "multiculturalism". When an individual fully adapts to the host culture at the expense of their indigenous culture, a "melting pot" or assimilation has occurred. Conversely, separation occurs when individuals segregate themselves from the host culture and main society. They mainly prefer to socialize with persons from their own culture. Marginalization is when individuals exclude themselves or do not show interest in engaging in either the home or host cultures (Ryder, Allen & Palhus, 2000; Berry, 2005). Berry (2006) notes that not only is acculturation is a cultural process but it can also occur in different dimensions such as the physical, biological, political, economical, and/or social levels.
If acculturation is a multidirectional process in which change happens at a personal and societal level simultaneously, how is it operationally defined in research? The experiential nature of these acculturation variables challenges researchers to operationally define and measure acculturation. Researchers have used a variety of methods to measure acculturation.
Variables such as language use, residency, immigration status, socioeconomic status and social support have been used as indicators that determine one's level of acculturation (Acevedo-Garcia, 2004) and are on a continuum. Neuropsychological researchers regularly report demographic variables such as age, education and gender in their studies, but rarely report results that incorporate acculturation variables such as language use, time of residency or results from acculturation assessments (O'Bryant, O'Jile & McCaffrey, 2004).
Artiola i Fortuny, Heaton & Hermosillo (1998) attempted to define acculturation by measuring the length of stay in the US, level of education and bilingualism. Arnold, Montgomery, Cantañeda, & Longoria (1994) used a self-report scale, such as the ARSMA-II (Cuéllar, Arnold, & Maldonado, 1995) that quantified acculturation. While some researchers (Gasquoine, 2001) recommend using the length of residence in the U.S. as a measure of acculturation, others have suggested that language use is a better indicator (Manly et al., 1998).
A long held assumption in the field of neuropsychology is that brain functioning is largely unaffected by language, culture, age and other sociocultural variables (Ardila, Roselli & Puente, 1994). Cross-cultural psychologists have long argued that ignoring language and culture variables in assessment and treatment reduces ecological validity (Olmedo, 1979). Clinicians who are faced with an increasingly diverse aged population are faced with few resources that address sociocultural variables. Recent studies have suggested that neuropsychological training programs are ill prepared to face cross-cultural challenges in the assessment and interpretation of test results of diverse populations (Echemendia & Harris, 2004; Brickman, Cabo & Manly, 2006).
Acculturation Self-Reports in Neuropsychological Studies
Two well known studies examined the relationship of acculturation, using self-report scales, to performance on neuropsychological tests. Arnold et al. (1994) studied the performance of college students on selected tests from the Halsted-Reitan Battery (HRB) and measured their level of acculturation using the Acculturation Rating Scale for Mexican Americans (ARSMA-II). The ARSMA-II (Cuéllar, et al., 1995) is a 30 item self-report scale that measures several dimensions of acculturation: language use and preference, ethnic identity and classification, cultural behaviors and ethnic interaction. There are five acculturation levels ranging from Level I (Very Mexican Oriented) to Level V (Very Assimilated; Anglicized).
Using scores from the ARSMA, Arnold et al. (1994), classified the subjects, all of Mexican origin (n=150), into three acculturated groups: Mexican identified, Mexican Americans, and Anglo identified. The authors found that after controlling for age, education level and gender, the subjects who were on the Very Assimilated end of the scale scored significantly higher on several tests of the HRB than the bicultural Mexican Americans. The Anglo identified subjects also scored higher on the conditions of the Tactual Performance Test, which measures dexterity and spatial memory as well as scoring fewer errors than Mexican Americans on the Category test, which measures abstract concept formation and mental efficiency (Lezak, 1995). The bicultural Mexican American group scored higher than the others (Anglo and Mexican Identified) on the Seashore Rhythm Test (SRT). The SRT measures non-verbal auditory discrimination, and is particularly sensitive to the subject's ability to attend and concentrate (Lezak, 1995).
Arnold et al. (1994) suggested that differences in culturally based problem solving and expectations of the testing situation may account for the differences between the more Anglicized subjects and the Mexican Americans in tests that involved motor speed and abstraction. The authors also suggested that the higher scores found with the bicultural Mexican Americans, auditory attention tasks, such as the SRT, may be due to their bilingualism.
Several years after Arnold et al. (1994), Manly et al. (1998) used a similar model to test their hypothesis on the effects of acculturation in test performance with African Americans. Manly et al. (1998) studied the performance of normal African American subjects on several neuropsychological tests and used scores from the African American Acculturation Scale (Landrine & Klonoff, 1996). The African American Acculturation Scale (AAAS) is a 33 item scale that measures acculturation using 10 scales. The AAAS scales are on a unidimensional continuum such that low scores on the scales indicate a higher acculturation level (Landrine & Klonoff, 1996). The subjects in the Manly et al. (1998) study were assessed using a variety of neuropsychological tests encompassing 9 domains: abstraction, verbal skills, visuospatial ability, information processing speed, attention-working memory, memory, learning, sensory ability and motor skills. The authors found that even after controlling for age, gender and education, African Americans (N=170) who scored higher on "traditional African American" practices, scored lower than other participants on neuropsychological measures of verbal abilities, such as those found in the WAIS-R Information subtest and the Boston Naming Test. The authors suggested that a good performance on the Information subtest depended on whether the subject had opportunities to be exposed to general mainstream knowledge through cultural and educational experiences. Exposure to the mainstream culture can also explain the lower scores on the Boston Naming Test (BNT). The authors proposed that the lower acculturated African Americans had little to no exposure to some of the objects that the BNT is based upon; therefore, it would have been difficult for subjects to recall items that have no cultural context.
The Role of Language
According to the US Census Bureau (2005), almost a quarter of households in the United States speak a language other than English; of those households, 61% speak Spanish. In a recent survey by the Pew Hispanic Center (2007), 44% of Latino adults, both foreign and native born, describe themselves as "bilingual". These data suggest that neuropsychological tests that were traditionally normed on white, monolingual subjects may not reflect the realities of the changing demographics.
In neuropsychology, language is a primary "tool of assessment" (Artiola i Fortuny & Mullaney, 1998) that is used in measuring performance. There has been a growing interest in language use, specifically bilingualism, in neuropsychological assessment. According to Schultz (1991), acquiring a second language is essential in the acculturation process in that as the acquisition and use of a new language increases, proficiency in the native language decreases (Artiola i Fortuny, Heaton, & Hermosillo, 1998; Miranda & Umhoefer, 1998). Bilingualism, as seen by some researchers, is characterized as a "deficit" supported by comparing test scores with monolingual speakers (Anastasi & Cordova, 1953; Gasquione, Croyle, Cavasos-Gonzalez, & Sandoval, 2007). Current research suggests that although there are processing differences between monolinguals and bilinguals, there is a prophylactic effect of bilingualism on cognitive decline (Gollan, Fennema-Notestine, Montoya & Jernigan, 2007; Bialystok, Craik, Klein, & Viswanathan, 2004).
Much of the research regarding the influence of bilingualism in neuropsychological testing has been with Latinos in the US (Gasquoine, 2001). Language use is seen as a proxy for acculturation by some researchers as it is less subjective and easier to measure. (Gasquoine, 1999; Miranda & Umhoefer, 1998; Noels, Pon, & Clement, 1996). Neuropsychological research on bilingualism has focused primarily on localization, impairment, and effects on memory tests (Roselli et al., 2000; Vaid & Genesee, 1980). A few studies have focused on the acculturation aspects of bilingualism in neuropsychological research. In a study of verbal fluency in Spanish-English bilinguals, Roselli et al. (2000) found that bilinguals' performance was practically the same as the monolingual speakers in all areas of verbal fluency with the exception of semantic fluency. Boone, Victor, Wen, Razani & Pontón (2007) found that patients who spoke English as a second language (ESL) had significantly lower scores in Digit Span, Boston Naming Test and the FAS test (Verbal fluency). Interestingly, the ESL group had higher scores in the Rey-Osterreith (copy) test than other groups. Furthermore, Boone et al. (2007) also found that verbal fluency scores (FAS) are positively correlated to the number of years living in the US. In a study of bilingual effects on the Boston Naming Test (BNT), Kohnert, Hernandez, and Bates (1998) found that subjects performed better with picture naming in English than in Spanish. The authors also found there is much more item variability of the BNT stimulus in Spanish than in English. This suggests that a direct translation of the items may result in inaccurate results. Furthermore, the authors suggest that a "dual-language approach" in assessment and interpretation is warranted with bilingual speakers (Marrero, Golden, & Espe-Pfeifer, 2002).
Artiola i Fortuny et al. (1998) conducted a complex study that compared the outcomes in selected neuropsychological assessments of monolingual Spanish speakers from Spain and bilingual (Spanish/English) speakers from the US-Mexico border region. The authors measured the level of bilingualism using a 15 item questionnaire and an assessment of "oral fluency" in Spanish by an "educated native speaker of Spanish". It is not clear how the raters were chosen. The authors used modified assessments to measure abilities in several areas such as memory, attention/concentration and verbal learning. The authors found that bilingual speakers in the Borderland areas performed better than monolingual Spanish speakers on verbal learning recall tasks. The authors also found that the length of stay in the US was positively correlated to better performance on executive functioning tasks such as the Wisconsin Card Sorting Test. According to the authors, these results may be due to the interaction between education and length of stay in the US. The authors implied that race/ethnicity is not a factor in differences but, those socioeconomic factors such as poverty; access to health care; education and time in the US are the variables that are likely to influence outcomes in neuropsychological testing.
Although most studies on the effect of bilingualism in neuropsychological testing have been on Spanish/English speakers, one study by Manly et al. (1998) focused on neuropsychological test scores of Black English speakers. In this study, the authors used "Black English" as an indicator of acculturation and found that scores in Trails B test, the Information subtest of the WAIS-R, and with story learning were lower in those subjects who were frequent users of Black English. These results suggest that lack of exposure to tasks such as the Trails test or information presented in the WAIS-R was not part of the cultural experience for some African-Americans.