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A Pilot Study of the Sensitivity and Specificity Analysis of the Standard-Spanish

Version of the Culture-Fair Assessment of Neurocognitive Abilities and the
Examen Cognoscitivo Min...

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APPLIED NEUROPSYCHOLOGY, 19: 53–60, 2012
Copyright # Taylor & Francis Group, LLC
ISSN: 0908-4282 print=1532-4826 online
DOI: 10.1080/09084282.2011.643938

A Pilot Study of the Sensitivity and Specificity Analysis of the

Standard-Spanish Version of the Culture-Fair Assessment
of Neurocognitive Abilities and the Examen Cognoscitivo
Mini-Mental in the Dominican Republic
Genomary Krigbaum
Clinical Psychology, Argosy University, Phoenix, Arizona

Kiran Amin and Thomas B. Virden

Clinical Psychology, Midwestern University, Phoenix, Arizona

Louise Baca
Clinical Psychology, Argosy University, Phoenix, Arizona

Alejandro Uribe
Psychiatry, Hospital Salvador B. Gautier, Santo Domingo, Dominican Republic

This pilot study purports to address the need for culturally validated, evidence-based
assessments and to serve as a springboard for future culturally sensitive research. This
study was conducted in the Dominican Republic. It entailed counterbalanced adminis-
tration of a standard Spanish translation of the Culture-Fair Assessment of Neurocog-
nitive Abilities (S-S CANA) and the standard Spanish translation of the Mini-Mental
State Examination (Examen Cognoscitivo Mini-Mental; ECM-M). The sample was
composed of 30 Spanish-speaking Dominican adults who met the inclusion criteria for
the normative and clinical groups. In an effort to initiate the validation process for the
S-S CANA, as well as norm it to the given population, the efficacy of the S-S CANA
in determining neuropathology was then compared to that of the ECM-M. Analyses
of variance and covariance and t-tests were conducted, and a receiver-operating
characteristic curve was computed. Results indicated significantly greater sensitivity
and specificity of the S-S CANA relative to the ECM-M.

Key words: assessment, cross-cultural=minority, dementia, mild cognitive impairment, norms=

normative studies, test construction

Disclosure: The authors wish it to be known that the Culture-Fair Assessment of Neurocognitive Abilities is codeveloped by and is the partial
property of the second author, Dr. Kiran Amin. The copyright for the Standard-Spanish CANA (SS-CANA), [Evaluación Transcultural de
Habilidades Neurocognitivas, S-S CANA], is currently held by the first author Genomary Krigbaum. At present, no income has been generated
from the sale of this test. No sources of financial support have been provided for this study.
Address correspondence to Thomas B. Virden, Clinical Psychology, Midwestern University, 19555 N. 59th Avenue, Phoenix, AZ 85308. E-mail:
tvirde@midwestern.edu
54 KRIGBAUM ET AL.
INTRODUCTION
This pilot study was developed from the need for cultu-
rally sensitive neurocognitive screening tools to address
the neuropathology of Hispanic populations in the
United States. Hispanics are one of the fastest-growing
groups in the United States. As of 2006, the U.S. Census
Bureau estimated that the total population of the United
States is 299,398,485 with 44,252,278 being Hispanic. It
is estimated that by the year 2050, 1 in 4 Americans will
be Hispanic and at least 50% will be Spanish speaking
and foreign born (U.S. Bureau of the Census, 1999).
Moreover, 1 in 10 residents older than 5 years of age
speaks Spanish at home, and approximately 48% are
not fluent in English (U.S. Census Bureau, 2005).
In light of this statistic, neuropsychologists will be
increasingly interacting with this population in research
and clinical settings. There is a vital need for culturally
sensitive screening tools to assess the neurocognitive
demands of this population (Ponton, Gonzalez,
Hernandez, Herrera, & Higareda, 2000). Consequently,
culturally competent neuropsychological screenings in
this population require the utilization of instruments
normed and validated on Hispanics. Furthermore, it is
necessary to take into consideration the cultural and edu-
cational factors that can potentially confound the evalu-
ation process and results. Much of the testing limitations
that we are confronted with are based on inferring
psychological phenomena as it is manifested in the main-
stream culture. Thus, we are faced with inaccurate
results that affect Hispanics’ access to services. When
considering a referral question, it is crucial to consider
the relevance of culture before considering a diagnosis
(Acevedo-Polakovich et al., 2007).
When working with Hispanics in assessing neural defi-
ciencies, it is necessary to account for the functional
equivalence of the assessments, attempting to narrow
down the constructs that are specifically efficient in
screening this population. Although it may not be poss-
ible to account for every cultural idiosyncrasy among
Hispanics, it is possible to account for and assess com-
monalities, as it is noted in the literature that cultural
and linguistic experiences correlate with neuropsycholo-
gical test performance (Brickman, Cabo, & Manly,
2006). Therefore, refining neuropsychological assessment
in a culturally sensitive context will increase the diagnos-
tic accuracy of the instruments and fairness in the
provision of services. With this in mind, and as the
opportunity presented to work with a group of native
Hispanics who reside in Latin America, this study was
performed in the Dominican Republic.
Due to the steady growth of the Hispanic population,
and the cognizance that there is a great need for neuro-
logical evidence-based screening tools culturally
validated in Spanish, the Culture-Fair Assessment of
Neurocognitive Abilities (CANA; Amin, Dill, & Thomas,
2003) was translated into standard Spanish and back-
translated into American English. Petrella (n.d.) and
Vogelmann (n.d.) stated that standard Spanish could be
defined as Spanish free of regionalisms; the words can
be found in the dictionary and are unanimously relevant
to the cultural values of Hispanic individuals. Thus, this
definition of standard Spanish was used in translating
the CANA’s stimulus booklet, the answer form (Amin
et al., p. 42), the clinical information and demographic
data sheet (Amin et al., p. 40), and the consent form.
The first author and a certified translator performed both
translations.
Although The Mini-Mental State Examination
(MMSE) has been normed and validated in Spanish,
the CANA surpasses the MMSE’s cross-cultural aspects,
and it was specifically developed for use with patients
from varying cultural backgrounds (Amin et al., 2003;
Jablonski, 2007). The CANA is ‘‘applicable to cultures
in which the concepts of geometric shapes, elephants,
flowers, rocks, water, trees, hands, boats, drums, hair,
clouds, rivers, numbers, animals, and mazes have
meaning’’ (Amin et al., p. 1). It is also useful as a brief
(wide-spectrum) screening tool of first-line care when
neurocognitive deficiencies are suspected (Amin et al.).
Moreover, considering the increase in the elderly
Hispanic population, there is a potential concomitant
increase in neurological disorders associated with aging
among this group, and an increase in the prevalence of
dementia as well as cognitive impairment conditions is
likely to follow. These demographic changes call atten-
tion to the need for appropriate neuropsychological
screening tools that help identify cognitive impairments
and dementia in Hispanics (e.g., Mungas, Reed,
Marshall, & González, 2000).
In contrast, there are no specific brief neurocognitive
screening tools of wide spectrum normed and validated
in Spanish. At present, the MMSE is an established
screening tool in Spanish that measures orientation,
registration, attention=calculation, recall, and language.
However, it lacks some cross-cultural aspects and does
not appear effective in controlling variables such as level
of formal education or cultural values. Often, Spanish
translations are literal renditions of English analogues
and do not necessarily take into account education
levels and cultural values, which may account for differ-
ences in performance scores between the Spanish- and
English-speaking populations (Mungas et al., 2000;
Simpao, Espino, Palmer, Lichtenstein, & Hazuda,
2005). Consequently, cognitive deficiencies could be
overdiagnosed in Hispanics and those individuals who
do not speak English or have limited educational levels.
One pitfall addressed in the available literature con-
cerns where and with which population the test is
normed. Furthermore, it is suggested that even though

some neurocognitive screening tools are available in
Spanish, there are scarce data regarding the differential
performance of these tests in equivalent English and
Spanish samples by analyzing test bias (Mungas et al.,
2000; Simpao et al., 2005). This poses a difficulty in
separating face and construct validity from legitimate
variance in cognitive functioning. This is a phenomena
not adequately accounted for in the MMSE with respect
to the Spanish version. For instance, aside from the
insufficiently addressed diversity variables mentioned
above, it needs more validation of external variables to
include cultural, education, and language variance
(e.g., Mathuranath et al., 2007; Mungas et al.; O’Keeffe,
Mulkerrin, Nayeem, Varughese, & Pillay, 2005; Peña-
Casanova, Monllau, & Gramunt-Fombuena, 2007).
Conversely, the CANA addresses these variables by
first screening the examinees’ alertness and capacity to
communicate through the Alertness and Communi-
cation Subscale, and it has the advantage in that the con-
struct validity accounts for culturally relevant items that
seem to have some similarity among varying cultures
(Amin et al., 2003). These salient cultural variables are
intrinsic to the diagnostic and differentiating process
between clinical and nonclinical populations in cross-
cultural assessment (Brickman et al., 2006). With the
available neurocognitive research with Hispanic popula-
tions taken into account, it is relevant to note Simpao
et al. (2005) found that Mexican Americans scored lower
on the MMSE than their American counterparts. Their
findings substantiate that—aside from age, education,
and socioeconomic status (SES)—contextual factors
such as living context (neighborhood) influence the
scores in neurocognitive screening tools like the MMSE.
Thus, examinees will tend to score lower than the cutoff
points and present a clinical profile (Mungas et al., 2000;
Peña-Casanova et al., 2007; Reyes-Ortiz et al., 2005;
Tombaugh, McDowell, Kristjansson, & Hubley, 1996).
Although the MMSE is useful in equally diagnosing
dementia as well as Alzheimer’s disease in English- and
Spanish-speaking populations, it does not sufficiently
account for a broad range of neurocognitive deficiencies
and the evaluation of executive functions (Amin et al.,
2003; Borson, Scanlan, Watanabe, Tu, & Lessig, 2005;
Mathuranath et al., 2007; Mungas et al., 2000; Peña-
Casanova et al., 2007; Van Gorp et al., 1999). In addition,
the MMSE is not useful in distinguishing between poten-
tially reversible or acute cognitive decline caused by
delirium and chronic impairment due to dementia
(O’Keeffe et al., 2005). Rather, in its initial administra-
tions, the MMSE was used to screen overall neurocogni-
tive decline (Folstein et al., 1998). On the other hand, the
CANA attends to different cognitive domains, such as:
Language; Immediate Verbal Recall; Immediate Visual
Recall; Orientation; Attention; Visuospatial; Verbal
SPANISH CANA IN THE DOMINICAN REPUBLIC 55
Reasoning; Visual Reasoning; Delayed Verbal Recall;
and Delayed Visual Recall. Additionally, the CANA
Test allows the clinician to obtain more general measures
of verbally processed information with the Verbal
Quotient (VQ) and nonverbally processed information
with the Performance Quotient (PQ). The Problem
Solving Quotient (PSQ) allows an interpretative view of
the ability to perform inductive reasoning, sequencing,
synthesis, and analysis tasks. Finally, the overall
cognitive functioning is measured with the Total Cogni-
tive Quotient (TCQ). (Amin et al., 2003, p. 1)
Furthermore, it has been argued that when instru-
ments are translated literally and without taking into
consideration cultural values=meanings, it poses diffi-
culties in accurately assessing for cognitive impairment
in the given culture. In many respects, because of the
dearth of culturally sensitive assessments, it is necessary
to resort to screening tools that have been validated in
English and then translated into Spanish. Subsequently,
these assessments have been normed in English and the
translations normed in mostly bilingual individuals
(English=Spanish speakers) in the United States.
This poses a cultural limitation, because the indivi-
duals may have been confounded by variables of assimi-
lation into the American culture as the host culture. It
is imperative to consider whether the measures lack
construct, metric, and functional equivalence (a
cultural-convergent validity) and have low sensitivity in
Spanish-speaking populations. The construct equivalence
examines whether the translated test measures the same
constructs as the original one; the metric equivalence
addresses whether the scores in the original test mean
the same as the translated one; and functional equival-
ence refers to what extent the attitudes, behaviors, beliefs,
and skills measured are cross-culturally valuable. It is
suggested that the failure to take into consideration the
mentioned equivalences would considerably affect the
convergent and discriminant validity of the translated
test. Not considering them poses the ethical dilemma of
clients being misdiagnosed, being recommended for
services not needed, or having needed services withheld
(Acevedo-Polakovich et al., 2007; Cofresı́ & Gorman,
2004; Echemendia & Harris, 2004; Fernandez,
Boccaccini, & Noland, 2007; Mathuranath et al., 2007;
Mungas et al., 2000; Reyes de Beaman et al., 2004;
Simpao et al., 2005; Trochim, 2006).
For this reason, there is a need for wide-spectrum neu-
rocognitive screening tools in Spanish with a strong sen-
sitivity and specificity that are able to discriminate
between those who are cognitively impaired from those
who are not. Such tests must take into account the cul-
tural operational definition of what it purports to mea-
sure. This will ensure that the normative sample is not
merely an inferential representative of the population
in question (Acevedo-Polakovich et al., 2007; Brickman
56 KRIGBAUM ET AL.
et al., 2006; Echemendia & Harris, 2004). Therefore, the
translation of the CANA into standard Spanish in this
pilot study should serve as a springboard to address
the need for a culturally sensitive neurocognitive screen-
ing tool validated in indigenous Hispanics (in this case,
Dominicans). This preliminary research aims to be more
than simply culturally sensitive research but aims to open
a door and address the need for culturally sensitive
assessments that are normed and acculturated to
Spanish-speaking populations. Hence, it is hypothesized
that: (1) The area under the receiver-operating character-
istic (ROC) curve between the CANA and MMSE
standard-Spanish versions will yield a significant differ-
ence; and (2) the translation of the CANA or the Evalua-
ción Transcultural de Habilidades Neurocognitivas,
standard-Spanish CANA (S-S CANA) will show better
sensitivity and specificity than the standard-Spanish
MMSE or Examen Cognoscitivo Mini-Mental (ECM-
M) through the computation of an ROC analysis.
METHOD
Participants and Selection Procedure
The scope of this research was limited to 30 Spanish-
speaking individuals in the Dominican Republic. The
various diagnoses for the clinical sample were obtained
from the participants’ medical charts. The normative
group included individuals without any history of cogni-
tive impairment, neurological disorder, legal blindness,
deafness, a preexisting brain injury that resulted in loss
of consciousness, a preexisting psychiatric disorder, or
excessive alcohol use. The clinical group included indivi-
duals with a history of cognitive deficiency (such as trau-
matic brain injury, cognitive deficiency secondary to
stroke, frontal-lateral syndrome, subcortical atrophy,
thrombosis) who were not legally blind. Because disorders
such as attention-deficit hyperactivity disorder (ADHD)
and learning disabilities are not documented consistently
in the Dominican Republic, the presence of these disor-
ders was not used as exclusionary subject variables.
All participants were Dominicans who were racially
classified as mulatto (a multiracial blend of White, Black,
and indigenous peoples). As this is the most prevalent
racial group in the Dominican Republic and Latin
America (Menendez-Alarcon, 2002), such a result is
unsurprising. The normative sample (n ¼ 15) consisted
of 4 females and 11 males who were 26 to 81 years of
age (M ¼ 27.33, SD ¼ 7.56), whereas the clinical sample
(n ¼ 15) included 7 females and 8 males aged 18 to 39
years (M ¼ 50.93, SD ¼ 18.07). The mean level of edu-
cation among the clinical patients and normative sample
was 8.13 (SD ¼ 4.56) and 13.13 (SD ¼ 2.16) years,
respectively. Similarly, 13 participants in the clinical
sample (86.67%) reported low SES, 1 (6.67%) reported
middle SES, and 1 (6.67%) reported high SES. The
normative sample included 14 (93.33%) participants
who reported middle SES and 1 (6.67%) who reported
low SES. The participants in the normative group were
recruited via a convenience and snowball sampling by
inviting individuals from the community who met the
criteria to participate. In the clinical group, the
participants were recruited via a convenience sampling
from the neurology department of the Hospital Salvador
B. Gautier, in Santo Domingo, Dominican Republic.
This was accomplished through medical referrals from
the neurology unit or Dr. Alejandro Uribe (chief of psy-
chiatry) and in compliance with hospital guidelines.
None of the invitees declined participation. The Hospital
Salvador B. Gautier is a training facility that serves
individuals from different social statuses and with a wide
range of pathologies.
Instruments
The neurocognitive screening tools used were the
ECM-M and the S-S CANA. The ECM-M is a neuro-
cognitive screening tool used to assess mental status. It
has 30 stimulus items that tests five areas of cognitive
function, such as orientation, registration, attention
calculation, recall, and language. The maximum raw
score is 30 points with a cutoff of 23 for impairment.
The ECM-M test takes approximately 10 to 15 minutes
to administer (Ediciones TEA, 2002). Ediciones TEA
(2005) distributes the ECM-M. This is the copyrighted
version used in Spain, Latin America, and the
Caribbean. It is adapted from the Folstein, Folstein,
and McHugh (1975) original English version. The
ECM-M has been revalidated twice; both times yielded
equally significant results (Ediciones TEA, 2002). It is
documented that it has a strong construct and content
validity, as well as a sensitivity of 89.8% and a specificity
of 75.1% (Lobo et al., 1999).
The English version of the CANA was developed by
Amin et al. (2003), and it consists of 50 items and ‘‘10
quantitative domain-specific subscales, which are:
Language; Immediate Verbal Recall; Immediate Visual
Recall; Orientation; Attention; Visuospatial; Verbal
Reasoning; Visual Reasoning; Delayed Verbal Recall;
and Delayed Visual Recall’’ (p. 1). The maximum raw
score is 70 with a cutoff T-score of 38, while a T-score
equal to or greater than 45 is considered to be within
normal limits. The CANA can be administered in
approximately 20 to 30 minutes, including scoring time.
It is distributed by the authors and has recently been used
in the United States (Amin et al.). The norming and
validation process of the test showed good construct
and content validity, yielding a sensitivity of 94.2% and
a specificity of 91.4% (Amin et al.).

The English versions of the CANA’s stimulus book-
let, answer form, clinical information and demographic
data sheet, and a consent form were translated into stan-
dard Spanish by the researcher and a certified translator.
The process consisted of a translation from English to
Spanish, followed by a back translation by another
certified translator. Inconsistencies were retranslated
until a successful transfer of meaning was achieved in
an attempt to maintain the construct, metric, and func-
tional equivalence of the English CANA. The materials
utilized included the translation of the consent form, the
S-S CANA’s clinical information and demographic data
sheet, the stimulus booklet, and the answer form. TEA’s
copyrighted version of the ECM-M was also used, in
addition to a stopwatch, pens, pencils, and writing paper
as needed.
Testing Procedure
The participants were given an explanation of the pur-
pose of the research and testing protocol. In addition,
each participant was asked to sign a consent form
addressing the confidentiality and privacy practices to
conduct the research in Spanish. None of the individuals
invited to participate refused to do so or were excluded
due to misreporting. Afterward, the first author, a clini-
cal psychology doctoral student with a master’s degree in
clinical psychology, completed the S-S CANA’s clinical
information and demographic data sheet to administer
both screening tools. The first author is fluent in both
Spanish and English and administered the S-S CANA
and the ECM-M in accordance with their respective
manuals. Both test administrations lasted less than 90
minutes. Test administrators were not blind to condition.
Tests were conducted in private rooms with at least
one table and two chairs. However, when testing the
clinical sample, four of the participants were inpatients,
and the test was conducted in their rooms, by their bed-
side with hospital-food rolling tables. In all cases, the
administration was performed with minimal interrup-
tions from outside noises such as phones, cars, and
people talking. No significant disruptions to the parti-
cipants occurred during testing. In addition, the concepts
of familism and simpatia were taken into consideration in
the test administration (Cofresı́ & Gorman, 2004). It is
customary to be personable and to allow the participant
to comment on the weather, their family, and so forth
between administration of the tests and subtests
(Acevedo-Polakovich et al., 2007).
Research Design
The tests were administered in a counterbalanced design,
and the researcher was not blind to the participants’
normative or clinical group membership. The first
SPANISH CANA IN THE DOMINICAN REPUBLIC 57
participant in the normative sample was administered
the ECM-M, then the S-S CANA. Subsequently, a coun-
terbalanced order followed. The first participant of the
clinical sample was initially administered the S-S CANA,
then the ECM-M; afterward, each participant was admi-
nistered the tests in a counterbalanced order as well. Test
directions were precisely followed from their respective
instruction manuals (Amin et al., 2003; Ediciones
TEA, 2002).
Statistical Analyses
Analyses of variance (ANOVAs), t-test for independent
samples, and analyses of covariance (ANCOVAs) were
conducted with the Statistical Package for the Social
Sciences. The ROC analysis was conducted with
ROCKIT software (Kurt Rossmann Laboratories for
Radiologic Image Research, 2007). All participants from
the normative and clinical sample failed to understand
instructions of Item 41 from the nonverbal reasoning sub-
scale of the S-S Cana; none of the participants answered
correctly. As such, two analyses were run: one with the
test results as originally administered and another exclud-
ing Item 41. The presented results are based on the analy-
ses conducted without Item 41. It may be interesting to
note, however, that the results did not differ notably from
the analyses that included the item.
RESULTS
Order of Test Administration
The ANOVA indicated that order of test administration
did not affect test performance. Participants who
received the ECM-M first tended to be slightly older than
those who received the S-S CANA first, F(1, 28) ¼ 4.037,
p ¼ .054 (ECM-M first, Mage ¼ 45.47 years; S-S CANA
first, Mage ¼ 32.80).
Receiver Operating Characteristic Curve
The ROC was analyzed with the program ROCKIT
(Kurt Rossmann Laboratories for Radiologic Image
Research, 2007). The area under the curve (AUC) was
found to be .9111 for the ECM-M, and the AUC for
the S-S CANA was .9800. The difference between these
AUCs yielded a significant difference (p < .0448) in the
expected direction. It is interesting to note that the
inclusion of the problematic Item 41 yielded a similarly
significant effect (p < .0478). The optimum specificities
and sensitivities for the ECM-M were 93.33% and
80.00%, respectively, for a raw score of 25 (T ¼ 32), and
were 93.33% and 100%, respectively, for the S-S CANA,
with a raw score of 49 (T ¼ 23) for the current sample.
58 KRIGBAUM ET AL.

TABLE 1 independent variable and age and educational level as

Age and Subtest Means of S-S CANA Scales and ECM-M covariates. All the subtests of the S-S CANA as well
Variables Samples M (SD) t as the ECM-M total scores still indicated significantly
higher scores in the clinical sample relative to the
Age Normative 27.33 (7.56) 4.67


Clinical 50.93 (18.07)
normative sample (Table 2).
PSQ Normative 18.13 (2.80) 5.77


Clinical 9.20 (5.31)
VQ Normative 37.00 (4.42) 6.00

DISCUSSION
Clinical 21.47 (9.00)
PQ Normative 22.13 (3.07) 5.84


Clinical 12.67 (5.47)
The AUC between the S-S CANA and the ECM-M
TCQ Normative 58.33 (3.48) 6.54

yielded a significant difference in the expected direction.
Clinical 33.67 (14.18) Thus, the S-S CANA shows a better sensitivity and
ECM-M Normative 28.53 (1.96) 4.47

specificity and outperformed the ECM-M as a strong,
Clinical 20.13 (7.01) culturally sensitive, neurocognitive screening tool. The
The CANA scales are PSQ ¼ Problem-Solving Quotient; VQ ¼ analyses between both groups indicated that the norma-
Verbal Quotient; PQ ¼ Performance Quotient; TCQ ¼ Total Cognitive tive and clinical samples were unequal with regard to age.
Quotient; ECM-M ¼ Examen Cognoscitivo Mini-Mental. Indeed, it is documented that most cases of cognitive



p  .001. deficiencies occur in older individuals (Mathuranath
et al., 2007; Mungas et al., 2000; O’Keeffe et al., 2005;
Clinical Versus Normative Samples Peña-Casanova et al., 2007; Simpao et al., 2005). Age
and education were used as covariates to account for
All the S-S CANA subtests and the ECM-M demon- their potentially confounding effects in the normative
strated significantly higher scores in the clinical sample and clinical samples, as well as with the SS-CANA and
relative to the normative sample (Table 1). The clinical the ECM-M. The results did not support either age or
sample also appeared significantly older relative to the education as a confounding variable and confirmed that
normative sample, posing a potentially confounding that the S-S CANA is a strong predictor of neurocogni-
variable. tive deficiencies relative to the ECM-M. This is parti-
cularly relevant considering the marked difference in
Analysis of Covariance level of education between the clinical and normative
samples. However, this result may best be interpreted
ANCOVAs were conducted in an attempt to control for
with a degree of caution given the small sample size.
the possible confound of age and level of education.
The implications of these results indicate that S-S
Assumptions of normality, linearity, homogeneity of
CANA efficiently discriminates for neurocognitive defi-
variance, and homogeneity of regression slopes were
ciencies and that the translation has sufficient cultural
met. The analyses were performed on the subtests of
relevance, while retaining the neurological characteris-
the S-S CANA as well as the ECM-M total scores,
tics of the English version of the CANA’s constructs.
with normative or clinical sample membership as the
Therefore, the S-S CANA is a promising culturally
sensitive neurocognitive screening tool that adds to the
TABLE 2 limited body of information with respect to this popu-
ANCOVA Analyses Results Comparing Normative Versus Clinical lation, and it will facilitate working with first-generation
Groups Using Age and Level of Education as Covariates
Hispanics or those for whom Spanish is the first lan-
Variables Samples M (SD) F guage. These findings imply that the cultural experience
of the participants was psychometrically taken into
PSQ Normative 18.13 (2.80) 12.975


Clinical 9.20 (5.31) account. This preserves the validity, reliability, sensi-
VQ Normative 37.00 (4.42) 17.926

tivity, and specificity of the S-S CANA in identifying
Clinical 21.47 (9.00) and classifying neurocognitive dysfunction and increases
PQ Normative 22.13 (3.07) 9.769
its utility potential (e.g., Brickman et al., 2006). The sig-
Clinical 12.67 (5.47)
nificant difference between the S-S CANA and the
TCQ Normative 58.33 (3.48) 17.730


Clinical 33.67 (14.18) ECM-M provides evidence that when clinicians refine
ECM-M Normative 28.55 (1.96) 10.970
the neurocognitive measures in the contexts of cultural
Clinical 20.13 (7.01) and linguistic diversity, it will improve the accuracy of
the assessments and diagnostic potential (Brickman
The CANA scales are PSQ ¼ Problem-Solving Quotient; VQ ¼
Verbal Quotient; PQ ¼ Performance Quotient; TCQ ¼ Total Cognitive et al.). It can be argued that multiculturally trained
Quotient; ECM-M ¼ Examen Cognoscitivo Mini-Mental. clinicians have an understanding of test-taking differ-


p  .01.

p  .001. ences, how the cultural experience correlates with test

performance, and the manifestation of psychological
phenomena among these populations. It is therefore pre-
sumed that competent administration of the S-S CANA
will enhance the diagnostic accuracy of the evaluation
for first-generation Hispanics or for those for whom
Spanish is the first language (Brickman et al.; Cofresı́
& Gorman, 2004).
Some of the limitations of the present study include
the relatively small sample size, the limited subject pool,
and the exclusion of Item 41. Given that the sample size
was relatively modest in comparison with the original
study with the English version of the CANA, the results
were expected to reveal minimal significance in the
expected direction while utilizing the parametric tests
presented herein. In addition, the clinical group consisted
of considerably more low SES participants than did the
normative group. Further research involving equally dis-
tributed SES groups should be directed at examining any
potential effects that SES may have exerted on the
present results. It is also important to note that the test
administrators were not blind to condition. As the
administrators were aware of the participants’ clinical
or nonclinical status, it is indeed possible for researcher
bias to influence the present results. It thus is recom-
mended that future research be conducted with test
administrators who are blind to condition.
The pool of participants was limited to Dominicans.
Although this population shares some commonalities
with first-generation Hispanics in the United States, this
sample is not a comprehensive representation of the
omnibus umbrella of the Hispanic culture. Nonetheless,
it appears to shed some light on cultural commonalities
such as test-taking behaviors, concept-processing styles,
and the Spanish language when working with Hispanics.
However, it may not be applicable to Hispanics who are
experiencing a process of assimilation into a different
culture. It is therefore recommended to screen for the
acculturation level and, when appropriate, administer
both versions of the CANA (English and Spanish) with
analogous validated neurocognitive assessment in
English or Spanish depending on their first language
(within appropriate intervals of time). In doing so, the
clinician will be able to assess more accurately the level
of cognitive dysfunction of the individual and thus
decrease the chances and repercussions of a misdiag-
nosed neurocognitive deficiency.
As noted in the Methods section, the S-S CANA was
administered in its entirety. The participants, however,
failed to understand the instructions of Item 41 and did
not answer correctly. Statistical analyses were performed
with the item included and excluded, and they yielded
similar results. Although it did not pose a notable differ-
ence, it would be relevant to further explore the implica-
tions of this item with respect to the original study of the
English version of the CANA.
SPANISH CANA IN THE DOMINICAN REPUBLIC 59
At present, the S-S CANA is best administered with
the omission of Item 41. This is supported by the fact
that similar results were achieved with the inclusion as
well as the omission of this item. In the future, directions
for the S-S CANA research should include a rephrasing
and retranslation, or reconceptualization, of Item 41.
Item 41 specifically asked that the patient identify
pictures in order from sunrise to sunset. Given that many
patients complained that they did not understand
the demands of the question, reconceptualizing this
item may be a feasible option, because the concept of
sequence presented in this item is foreign to many Hispa-
nics’ learning experiences. Cofresı́ and Gorman (2004)
point out that construct validity is relevant only if the
construct measure exists in that given culture. Moreover,
Brickman et al. (2006) as well as Marton, Wen, and
Nagle (1996) noted that learning styles and cultural
experiences are strong correlates with comprehension,
learning, and psychological test performance.
Additionally, the S-S CANA may be tested as a pre-
dictor of lesion location in comparison to the ECM-M.
Future research would further strengthen the validity
and reliability of the S-S CANA if the test administrator
is kept unaware of the condition of the participants and
the sample size is increased. An increased sample size
should increase the diversity of age, SES, level of edu-
cation, and the variety of neurological conditions (from
mild to severe) in the clinical population.
In sum, this pilot study reveals that the S-S CANA is a
feasible, effective neurocognitive screening tool when
working with Spanish-speaking individuals. It has
demonstrated psychometrically significant sensitivity
and specificity with a Spanish-speaking population of
normative and clinical samples, which appear to be
greater than that of the ECM-M. Its discriminative value
closes the gap for clinicians having to resort to measures
validated in an English-speaking population in the
United States. This pilot study opens the door for con-
sidering the S-S CANA as a viable Spanish neurocogni-
tive screening tool that will lessen the chances of
individuals being misdiagnosed, given recommendations
for services not needed, or deprived of needed services.
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