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Addressing racial inequities in neuropsychological assessment requires international prescriptive standards, not demographically adjusted norms

Nature Reviews Neurology volume 18, page 377 (2022)Cite this article

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In their forward-looking Comment, Byrd and Rivera-Mindt address longstanding racial inequities in neuropsychological assessment (Byrd, D. A. & Rivera-Mindt, M. G. Neuropsychology’s race problem does not begin or end with demographically adjusted norms. Nat. Rev. Neurol. 18, 125–126; 2022)1. We agree with their premise that race serves as an imperfect proxy for a spectrum of shared exposures to the effects of systemic racism2. We agree that, because these exposures are linked to adverse neuropsychological outcomes, they should be measured and considered in neuropsychological assessment. Our concern is that the continued use of race-based adjustments risks propagation of entrenched scientific racism by justifying differential thresholds for disparate, ill-defined racial populations. Not only would the clinical application of demographically adjusted norms be tedious in regions (such as Africa and Asia) with a multiplicity of ethnoculturally and linguistically diverse populations, but also the rationale for such adjustments fundamentally begs an investigation of the socio-ethnocultural neutrality of existing neuropsychological tests.

Recent reports from multisite studies of neurodevelopmental outcomes in young children — including the INTERGROWTH-21st project (five countries)3, INTERBIO-21st study (six countries)4 and an NIH-funded observational study (four countries)5 — converge on two crucial findings. First, within-population variability is far greater than between-population variability when basic health and nutritional needs are met and when outcomes are measured on standardized, culturally unbiased tests3,5,6. Second, epidemiological differences between populations are largely environment-driven4. Although these studies probed outcomes in children below 3 years of age (which limits generalizability), the findings provide a basis upon which to argue against the rationale for demographic-specific norms.

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Author information

Authors and Affiliations

  1. MRC Lifecourse Epidemiology Centre, Faculty of Medicine, University of Southampton, Southampton, UK

    Michelle Fernandes

  2. Human Development and Health Academic Unit, Faculty of Medicine, University of Southampton, Southampton, UK

    Michelle Fernandes

  3. Nuffield Department of Women’s & Reproductive Health, University of Oxford, Oxford, UK

    Michelle Fernandes

  4. Department of Paediatrics, College of Medicine, University of Ibadan, Ibadan, Nigeria

    Adejumoke Idowu Ayede

  5. Department of Paediatrics and Neonatology, University College Hospital, Ibadan, Nigeria

    Adejumoke Idowu Ayede

  6. Newborn and Child Survival Research Consortium, Centre for African Newborn Health and Nutrition, University College Hospital, Ibadan, Nigeria

    Adejumoke Idowu Ayede

  7. Department of Psychiatry and Psychology, Mayo Clinic, Jacksonville, FL, USA

    Karen Blackmon

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  1. Michelle Fernandes
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  2. Adejumoke Idowu Ayede
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  3. Karen Blackmon
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Corresponding author

Correspondence to Michelle Fernandes.

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The authors declare no competing interests.

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Fernandes, M., Ayede, A.I. & Blackmon, K. Addressing racial inequities in neuropsychological assessment requires international prescriptive standards, not demographically adjusted norms. Nat Rev Neurol 18, 377 (2022). https://doi.org/10.1038/s41582-022-00652-7

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