Neuropsychology Review, Vol. 11, No. 3, September 2001 (c ?2001)
Neuropsychological Issues in the Assessment
of Refugees and Victims of Mass Violence
Cheryl S. Weinstein,1,4Robert Fucetola,2and Richard Mollica3
Brain injury, stressor severity, depression, premorbid vulnerabilities, and PTSD are frequently inter-
twined in trauma populations. This interaction is further complicated when the neuropsychologist
evaluates refugees from other cultures. In addition, the observed psychiatric symptoms reported in
currence of starvation, torture, beatings, imprisonment, and other head injury experiences in refugee
and POW populations to alert treators to the presence of chronic and persistent neuropsychiatric
morbidity, with implications for psychosocial adjustment. The concept of fixed neural loss may also
interact with environmental and emotional stresses, and a model of neuropsychological abnormalities
triggered by traumatic events and influenced by subsequent stress will also be considered. Neuropsy-
injury with tools that are relatively culture-fair.
KEY WORDS: neuropsychology refugees/victims; mass violence.
Victims of mass violence are at risk for a wide range
of psychiatric, neurobehavioral, and cognitive disorders,
including traumatic brain injury (Priebe and Esmaili,
1997; Wolfe and Charney, 1991). The neuropsychologist
is challenged to differentiate the significant overlap of
symptoms associated with traumatic brain injury (TBI),
depression, stress, and posttraumatic stress disorder
(PTSD). The common symptoms of TBI, including mem-
ory and attentional deficits (Gasquoine, 1997), and apa-
thy, labile affect, impaired social judgment, distractibil-
ity, and impulsivity (Dikmen et al., 1996) may easily be
labeled as PTSD, and it is possible that in a subgroup
of torture survivors, psychiatric symptoms are primar-
1Department of Psychiatry, Beth Israel-Deaconess Hospital, Harvard
Medical School, Boston, Massachusetts.
2Department of Neurology, Washington University School of Medicine,
St. Louis, Missouri.
3Harvard Refugee and Trauma Program, Harvard Medical School,
4To whom correspondence should be addressed at Department of
Psychiatry, Beth Israel-Deaconess Hospital—East Campus, Rabb
Building, 2nd Floor, Boston, Massachusetts 02115.
ily due to TBI alone, and are exacerbated by stressor
because treators are pulled to the war-related experiences
of the refugee. Unfortunately, failure to assess comorbid
cognitive impairment secondary to TBI may lead to failed
treatment interventions. Refugees from other cultures are
at particular risk for psychiatric or neurological misdiag-
22.4% of Asian American patients as compared to 12.7%
of Caucasians even though the available prevalence rates
in the general population indicate that psychosis appears
to be approximately the same in both groups (Sue and
Zane, 1994; Vega and Rumbaut, 1991).
In this paper we review current knowledge of neu-
rological, psychiatric and neuropsychological data on the
victims of mass violence from World War II, the Vietnam
War, Cambodia, and the Gulf War. Issues related to a
culture-fair assessment are presented as the refugee who
be from the nonmajority culture. A qualitative approach
is emphasized so the functions of each refugee/patient are
viewed as unique, and comparisons can be made between
functional cognitive domains to make treatment recom-
mendations (Kaplan, 1991; Christensen, 1998).
1040-7308/01/0900-0131$19.50/0C ?2001 Plenum Publishing Corporation
132Weinstein, Fucetola, and Mollica
THE PSYCHIATRIC SEQUELAE OF WAR
Repeated exposure to traumatic events is a major
contributor to psychiatric, neurobehavioral, and cognitive
disorders in the refugee population (Priebe and Esmaili,
1997; Wolfe and Charney, 1991). Refugees who survive
preimmigration trauma such as physical deprivation,
brainwashing, separation from family, and torture are
particularly vulnerable to posttraumatic stress disorder
(PTSD), cognitive difficulties, and poor functional out-
comes in the community (Sack et al., 1997; Sinnerbrink
et al., 1997).
Mood changes, anxiety disorders, alcohol use, con-
fusion, detachment, and apprehension are commonly ob-
served among refugees (Sutker et al., 1990a,b,c). When
profile patterns of World War II and Korean POWs were
compared to those of nontraumatized combat survivors,
negative ruminations, heightened anxiety, anger, suspi-
ciousness, low self-esteem, and less-adaptive personality
structures were reported in POWs (Sutker et al., 1989).
Effects of cumulative trauma manifested in symp-
toms such as somatic complaints, attentional difficulties,
anxiety, and depression appear to be dose-dependent
(Mollica et al., 1997). Postimmigration stressors such as
adapting to living in a new land, racial discrimination,
loneliness, and barriers to employment compound poten-
et al., 1997; Shiang et al., 1998). In particular, older,
stigma associated with mental illness often pushes family
members to “hide” the problems of the impaired fam-
ily member (Shiang et al., 1998). Gorst-Unsworth and
Goldenberg (1998) recently studied refugees from Iraq
and reported that the greatest emotional burden to this
refugee population was not the original trauma but the
psychological “trauma” that occurred as they resettled in
a new environment. In sum, psychiatric comorbidity is
1996), and psychiatric disorders, including PTSD and de-
pression, have substantial functional consequences influ-
encing resiliency in the community.
ACQUIRED BRAIN DAMAGE IN POWs
AND VICTIMS OF MASS VIOLENCE
promise, and reduced resiliency in civilians with brain
damage is not a new concept (Eitenger, 1964) (Goldfeld
et al., 1988). What is surprising, however, is that old data
on neurological compromise in victims of mass violence
has been overlooked. The neurological status of civilians
imprisoned in concentration camps was studied exten-
sively after World War II. Gronvik and Lonnum (1962,
pp. 51–54) demonstrated “remarkable parallelism” be-
cerebral organic changes. Thygesen et al. (1970) studied
100 concentration camp survivors living in Denmark and
demonstrated significant neurological and psychiatric
morbidity, with “blows and kicks to the head” being the
most commonly reported torture.
and Israeli concentration camp trauma survivors. Out-
ground, occupational distribution, “hereditary tainting”
premorbid personality traits, alcohol addiction, and previ-
ous mental disorders. In addition, length of captivity, loss
including head injuries, and number of illnesses during
internment in concentration camps were noted. Overall,
negative outcome in both Norwegian and Israeli concen-
tration camp survivors who did not respond to treatment
was correlated primarily with considerable mechanical or
toxic trauma (or both) to the brain (e.g., infectious dis-
eases, malnutrition and the consequent famine, edemas,
tentional impairment, fatigue, loss of initiative, headache,
ness, and feelings of unworthiness (Eitenger and Strom,
1973; Thygessen et al., 1970).
When Eitenger and Strom (1973) evaluated 1,000
Nazi concentration camp survivors who were repatriated
weight loss of greater than 30%. Neurological exams,
EEG, spinal fluid analysis, and pneumoencephalograms
showed more than 50% of the subjects exhibited soft
or hard neurological signs, including a remarkable 75%
showing cerebral atrophy.
In the 1980s, the biological basis for war- and non–
war-related PTSD symptoms again received attention.
of torture when he documented cerebral changes on CT
scans of five prisoners of war. Hougen et al. (1988) com-
and reported a strong association between torture and
neuropsychiatric symptoms. Trauma-induced weight loss
Neuropsychology and Assessment of Refugees and Mass Violence Victims133
attention, memory, abstraction, and organization as well
as a high prevalence of PTSD (Sutker et al., 1990b). The
was also reported to lead to a mild “Korsakoff’s-type”
In contrast, other researchers have reported that mal-
nutrition and starvation were not the primary cause of
cognitive impairment. Instead, malnutrition was associ-
ated with stress severity, and stress was a critical vari-
able leading to cognitive deficits (Sulway et al., 1996).
An association between prolonged stress and cognitive
dysfunction (particularly memory impairment) was ob-
served by Bremner et al. (1993), who noted smaller right-
hippocampal volume in patients with combat-related
PTSD (Bremner et al., 1995a) (Bremner et al., 1995b).
These findings were consistent with formulations that
stress-induced alterations in brain regions subserving
memory might lead to many of the symptoms of PTSD
of (1) the sensitivity of hippocampal neurons to hypoxia
injury associated with brain injury (Oppenheimer, 1968).
Most recently Mollica et al. (1998) looked at the as-
sociation of traumatic brain injury with the psychiatric
symptoms of depression and posttraumatic stress disor-
der. A total of 967 Cambodian refugees were sampled in
the refugee camp known as Site Two. Strikingly, 15,000
trauma events were reported, with TBI being most com-
mon in highly educated refugees and individuals with the
ily injury were relatively less common at low levels of
cumulative trauma than were material deprivation, coer-
cion, and warlike conditions. At higher levels of cumula-
tive trauma, however, the frequency of brain and bodily
injury rose, whereas the proportional frequency of mate-
rial deprivation declined. Of all trauma categories, trau-
matic brain injury revealed the strongest association with
symptoms of depression, with a weaker association with
PTSD. Overall, these findings overlap with the European
concentration camp studies in which a greater degree of
education was not a protective factor against the psychi-
atric effects of high levels of cumulative trauma associ-
ated with brain injury events. The persistence of psychi-
atric symptoms almost 10 years past the initial trauma of
the Pol Pot era is also consistent with what is known to
occur to affected head-injured individuals in mainstream
BIOLOGICAL VULNERABILITIES TO PTSD
Biological vulnerabilities have been minimally ad-
dressed in the POW and refugee population. Eitenger
(1964, p. 189) observed World War II concentration camp
survivors and reported that
the average mentally well-equipped are capable of both
sonality a number of mental stress situations without this
affecting to any great extent their mental health, on the
condition that their personal and environmental anchor-
age has been kept intact, and that these stress situations
do not persist for too long a time.
When addressing biological vulnerabilities to PTSD,
“brain reserve” (Satz, 1997) merits consideration. One
performances would be more likely to have PTSD if ex-
posed to prolonged stress. Premorbid vulnerability to the
stressors of war and imprisonment was studied in combat
veterans (Gurvits et al., 1993). When 27 medication-free,
outpatient Vietnam veterans who met DSM-III-R crite-
ria for PTSD were compared to Vietnam veterans with-
out PTSD exposed to the same “trauma,” significant cor-
relations were observed between the PTSD group and
(1) several neuropsychological test scores (e.g., complex
(e.g., bedwetting in childhood; Gurvits et al., 1993).
Vasterling et al. (1997) suggested that Gulf War
Veterans with higher intellectual resources, particularly
verbal skills, might be more resistant to psychopathol-
bat intelligence were more likely to develop PTSD symp-
toms as assessed by the Clinician-Administered PTSD
Scale even after adjustment for the extent of combat ex-
posure (Macklin et al., 1998).
Cassiday and Lyons (1992) provided further support
for the vulnerability model in a case report of the PTSD
symptoms in a World War II veteran, following a cere-
bral vascular accident. Although these data on biologi-
cal vulnerabilities to PTSD are compelling, comparisons
of refugees and POW victims to combat veterans with
short exposure to violence is flawed because of the pre-
cultural issues merit consideration. For example, Mollica
et al. (1998) reported that the most educated Cambodian
refugees were more likely to be targets of torture, in an
effort to destroy a culture. Thus, it is not clear that higher
intellect or brain reserve inoculates against trauma symp-
toms in the Indochinese population.
134Weinstein, Fucetola, and Mollica
Van der Kolk et al. (1985) were the first researchers
whose work primarily focused on PTSD. Hyperarousal,
constriction, and compulsive reexperiencing of PTSD
symptoms for war-related and non–war-related trauma
were reported. It was speculated that depletion of nora-
directly affect the symptoms of PTSD were associated
with inescapable stress (Krystal et al., 1995). Moreover,
neurobiologic response to trauma might enhance the en-
coding of traumatic memories (van der Kolk et al., 1985).
The locus ceruleus activation by electrical stimulation
of adrenergic receptor antagonists is thought to enhance
memory retrieval (Devauges and Sara, 1990). The mem-
ory enhancing effects of increased noradrenergic activity
are also mediated by beta noradrenergic receptors within
the amygdaloid complex (McGaugh, 1989).
As noted above, stress-induced alterations in brain
regions and systems involved in memory (Bremner et al.,
1993) and sleep (Friedman, 1989) are also reported. The
latter symptoms, however, contribute to a diagnostic
dilemma, because such symptoms tend to be related to
depressed affect rather than stress-induced brain system
stress or glucocorticoid exposure (“neuroendangerment”)
may not only atrophy hippocampal neurons but will also
compromise the ability of these neurons to survive neuro-
logic disease (Sapolsky 1994/1998, 1995).
ATTENTION AND MEMORY FUNCTIONS
et al., 1985) also implicate dysfunction in an inhibitory
gating mechanism in the frontal–subcortical system
et al. (1998) studied Gulf War Veterans with and with-
out PTSD who were young, healthy and exposed to trau-
matic events for a circumscribed period of time. Gulf War
Veterans diagnosed with PTSD showed relative deficien-
cies on tasks of attention rather than memory. Deficits
in sustained attention, mental manipulation, initial acqui-
sition of information, and retroactive interference were
reported. A pattern emerged of errors of commission and
intrusion, with a tendency toward response disinhibition
and intrusions on cognitive tasks that correlated positi-
vely with reexperiencing symptoms and negatively with
Accumulated research further suggests problems in
trauma populations in the initial encoding of information.
1991; Wagaenaar and Groeneweg, 1990). Attention may
also be directed to emotionally salient information and
away from neutral stimuli (Vasterling et al., 2001). If en-
coding of traumatic memories is compromised and there
tients may have reduced capacities to inhibit unwanted or
situation-inappropriate information. The individual with
PTSD may be “pulled” to trauma-related thoughts and
have difficulty focusing attention. Thus, intrusion of un-
wanted thoughts may further increase if the refugee or
trauma-exposed individual does not have a familiar rou-
tine or faces continued stresses.
In contrast to PTSD populations exposed to shorter
periods of severe stressors, declarative memory problems
have been documented in groups that survived the pro-
longed stressors of nutritional deprivation and physical
torture, such as concentration camp survivors and POWs
(Thygesen et al., 1970). Current research indicates that
declarative memory for material unrelated to trauma ap-
to trauma is enhanced. Again, however, the source of the
depressed affect or concurrent medical conditions. To an-
swer this question, future studies must determine whether
groups without other potential medical causes of memory
impairment (Krystal et al., 1995).
CONTROVERSY IN SYMPTOMS OF PERSIAN
GULF WAR VETERANS
A review of the literature related to Persian Gulf War
Unexplained Illnesses (GWUI) provides an interesting
of stress and violence. Veterans of the Gulf War deployed
to different areas of the Persian Gulf have reported ad-
verse heterogeneous health symptoms, including fatigue,
trointestinal complaints, sleep disruption, forgetfulness,
of self-reported symptoms of deployed and nondeployed
military personnel in the Gulf War further revealed an in-
creased prevalence of medical and psychiatric symptoms
in deployed versus nondeployed veterans (Iowa Persian
Gulf Group, 1997).
War Veterans, however, remains unclear, and like the
refugees of mass violence the presence of cognitive dys-
function versus psychological stresses continue to be
Neuropsychology and Assessment of Refugees and Mass Violence Victims 135
debated. The NIH Technology Assessment Workshop
(NIH Technology Assessment Workshop Panel, 1994) as
well as follow-up studies did not provide support for a
(2000) questioned if nontoxic related interactions might
explain the symptoms of deployed veterans in the Iowa
study. This included increased smoking, alcohol intake,
and sexual discomfort, which were all suggested by the
study. Another complicating factor is that medical symp-
toms of Gulf War veterans appear to be remitting, making
it difficult to identify what initially caused a medical ill-
ness (Axelrod and Milner, 2000).
Haley et al. (1997) attempted to clarify the etiology
of diverse behavioral symptoms in GWUI by factorial
analyses. Two hundred and forty-nine of the 606 Gulf
War veterans of the Twenty-Fourth Reserve Naval Mo-
bile Construction Battalion were studied by measuring
anatomical characteristics of symptoms, wartime expo-
sures, and personality variables. Of the 249 participants,
30% reported no serious health problems and 70% re-
ported serious health problems that they attributed to the
war. Based on responses, six syndrome factors were iden-
tified: (1) impaired cognition including problems with
sion, daytime sleepiness, and headaches; (2) confusion–
ataxia, including problems with thinking, balance, and
vertigo; (3) arthromyo-neuropathy; (4) phobia–ataxia;
clustering the veterans’ symptoms, a spectrum of neuro-
logic injury involving central, peripheral, and autonomic
nervous systems were identified. Of the veterans stud-
ied, 48.4% were found to have symptoms consistent with
the syndromes above. Moreover, the latter group differed
from patients diagnosed with PTSD, depression, somato-
form disorder, and malingering behavior. This led them
to conclude that psychological makeup might be influ-
enced by an overriding medical condition (Hom et al.,
nonrandom survey questions, which led to factor analy-
ses and cluster of factors based on nonrandom symptoms.
chological performance, medical findings, and subjective
to have been exposed to toxins; veterans with little like-
lihood of exposure; and a control group that were in the
service during the Gulf War. Axelrod and Milner (2000)
the negligible-to-modest neuropsychological findings
in the literature on Gulf War veterans should not inval-
idate the health research.
More recent studies on Gulf War veterans have
focussed on the symptomatology in deployed versus
nondeployed veterans (Palumbo et al., 2001). Deployed
veterans who reported a high number of health symptoms
were compared to veterans who reported relatively few
Differences were seen in dorsolateral prefrontal cortex
with the low symptom group showing increased activa-
tion in the right frontal region. Thus, it was questioned if
altered neurobiological functioning might be the basis for
the symptoms reported by some Gulf War veterans.
Because stress has continuously been raised as the
contributing factors to GWUI, another group of researc-
erans versus nondeployed veterans in Germany (Lindem
to diagnose PTSD, and these symptoms did relate to neu-
ropsychological performance in deployed veterans. After
controlling for age, education, disability status, depres-
sion, and the information subtest of the WAIS-III, it was
concluded that stress did not fully explain the lowered
scores of Gulf War veterans, and factors such as exposure
At the current time, however, the possible role of neuro-
toxin exposure remains unclear, and additional nontoxic
tims of mass violence is as follows: If depression and
does PTSD/depression versus brain injury drive behav-
ioral and cognitive symptoms? A complicating diagnostic
factor is the difficulty documenting the etiology of cog-
nitive and behavioral changes in refugees (see Table I).
For example, head-injured soldiers from the Vietnam and
the Middle East wars had access to field stabilization and
from developing countries may not have corroborat-
ing data about the length of unconsciousness and the type
of brain injury. The length and severity of the stressor,
also be unclear. Overall, if a refugee’s depression is re-
the likelihood of co-morbid cognitive change increases
(Dikmen et al., 1986, 1996; Schacter, 1995; Sapolsky,
appears to be related to the stresses of wartime exposure,
136 Weinstein, Fucetola, and Mollica
Table I. Clarification of Diagnostic Issues
Review patient records
Obtain detailed medical and psychological history
Seek corroborating data about type of injury/length of LOC
Identify complicating medical contributors to behavior (alcohol and
smoking leading to asthma and sexual dysfunction; Bieliauskas
and Turner, 2000)
Complete neurobehavioral symptom checklist
Interview family with focus on current and premorbid personality and
Document family reports of intellectual changes
Assess arousal problems (e.g., hypoarousal, reduced alcohol tolerance,
and noise intolerance; Nell, 2000)
Assess reports of personality change (e.g., increased aggressiveness,
irritability, apathy, changes in tact and social appropriateness,
decreased personal hygiene, fear, and risk taking; Nell, 2000)
Establish baseline of cognitive functions with culture-fair measures
Evaluate inconsistencies in current performance (e.g., loss of set,
perseverative behavior, intrusions, impaired handwriting, and
Delineate types of cognitive impairment that are less likely to be
observed in primary depression (e.g., severe visual–spatial
deficits, failure to learn with drilling, and language impairment
that represents a change; Veiel, 1997; King and Caine, 1996;
the trauma of exile, and significant cultural change, the
likehood of significant cognitive changes decreases.
Specifically, depression may lead to “complaints of cog-
nitive impairment” as well as a bias for recall of neg-
ative, especially self-referential, information (MacLeod
and Mathews, 1988).
Although research (Veiel, 1997) indicates little or no
difference in attention and concentration when controls
are compared to depressed subjects, there is support for
global-diffuse impairment of brain functions, with par-
ticular involvement of the frontal lobe. This includes de-
(3) scanning and visuomotor tracking, and (4) executive
functions in general. In addition, neuroimaging studies in
subjects with clinical (functional) acute depression
(Mayberg, 1997; Drevets, 1998; Doughterty and Rauch,
distributed network of limbic cortical pathways. Mayberg
population is transient in fluoxetine treatment responders,
and recovery is dependent on both the inhibition of over-
active paralimbic regions and the normalization of hypo-
functioning dorsal neocortical sites. Strikingly, improved
cognitive performance points primarily to normalization
of dorsal prefrontal hypometabolism.
Because there may be uncertainty about the degree
of cognitive impairment associated with depression, de-
lineation of potential contributing factors to depression
and description of behavioral changes is in order. This in-
cludes the influence of comorbid medical illness, age of
erogeneity can “lead to marked variation among persons
suffering the same categorically defined disorder” (King
and Caine, 1996, p. 213).
MODELS FOR THE NEUROPSYCHOLOGIST
TO UNDERSTAND AND DESCRIBE
Nell (2000) proposes a behavioral model to under-
stand victims of violence/brain injury. He writes that pa-
tients coming to the neuropsychologist’s attention in an
acute medical setting are more likely to have discrete fo-
cal injuries, with detailed neuroradiological assessments
and clear documentation of length of unconsciousness.
The neuropsychologist, however, in private practice, re-
habililtation settings, or in developing countries may see
victims of violence that are exposed to falls, multiple as-
saults, or torture such as being submerged in a barrel in
likely “to give rise to marvelously bizarre syndromes as
unilateral neglect, pure alexia, or mistaking one’s wife for
a hat” (Nell, 2000, p. 104). According to Nell, such pa-
tients are more likely to have diffuse dysfunction, and the
neuropsychologist’s task is to describe relevant biologi-
cal and behavioral functions rather than localize deficits.
The neuropsychologist provides more valuable data by
systematically observing and describing behavior, based
on descriptions of real-life behavior, and on tests that are
simulations of real life (Matarazzo, 1990). Our role now
is (Nell, 2000, p. 108)
to describe and understand the behavioral consequences
symptom in the medical diagnostic system.
Screening is useful as a “frontline” measure to begin
describing a patient’s behavior. The question answered
by screening will seldom be “Does this individual have
brain impairment?” but rather “Does the documented (re-
ported) brain impairment in this indivdiual affect his or
her thinking and behavior?” (Nell, 2000, p. 109). This is
Neuropsychology and Assessment of Refugees and Mass Violence Victims137
Development Course sponsored by the Harvard Program
in Refugee Trauma (Croatia, January 1997). Overall, they
endorsed the Neuropsychological Symptom Checklist
(1996) as the most helpful screening tool because it posed
questions that the mental health worker did not think to
ask or did not have the time to ask. In addition, screening
served as a guide to treators regarding the most appro-
priate treatment interventions (e.g., appropriate referral
If there are indications of neuropsychiatric difficul-
ties based on (1) a symptom checklist, (2) clinical in-
terview, and (3) family reports of cognitive or personal-
ity problems, the neuropsychologist now addresses if the
problems are longstanding versus new. Reports of cogni-
tive decline are important, because PTSD-related symp-
tom severity does not lower intelligence (Macklin et al.,
1998). Identifying personality change likewise is essen-
athy) in head-injured patients is a major contributing fac-
tor in social integration difficulties (Dikmen et al., 1996;
McGuire et al., 1998). Although it has been reported that
premorbid personality variables influence PTSD outcome
in Vietnam veterans (Kulka et al., 1990), this was not
supported by Eitenger’s research on concentration camp
survivors (Eitenger, 1964). He (Eitenger, 1964, p. 188)
found that premorbid personality was of
mere subordinate significance in the degree of trauma
severity for Norwegian concentration camp survivors ex-
posed to the most severe trauma, and that the degree
and duration of trauma were decisive for the tragic final
Thus concerns about intellectual and personality changes
merit investigation when screening victims of violence.
THE NEUROPSYCHOLOGICAL ASSESSMENT
In contrast to screening, the neuropsychological as-
(a) basic mental processes (e.g., problem solving, atten-
tion, memory, and the planning and regulation of intel-
lectual activity); (b) the ways in which behavior has or
has not been disrupted; and (c) the potential contribu-
tions of PTSD, TBI, depression, and neurodevelopmen-
tal vulnerabilities in the etiology or maintenance of the
patient’s symptoms in daily living (Wolfe and Charney,
1991). Specifically, Nell writes that a description of be-
havior addresses the following influences on a patient’s
personality: (1) inhibition of impulse-governed behav-
ior; (2) the maintenance of social appropriateness by the
correct perception of social cues; (3) adequate conversa-
tional pragmatics; and (4) satisfactory intimate relation-
ships with both family of origin (parents and siblings)
and the marital family (children and spouse; Nell, 2000,
Interpretation follows in which apparently disparate
For example, if a 40-year-old Indochinese refugee who
was a former high school teacher in his homeland reports
memory changes following repeated blows to the head in
a prisoner of war camp, there is more support for brain in-
jury: (1) if he does not recall four common items from his
culture that are drilled repetitively, even when provided
with cues (in his native language); and (2) if he persever-
and word generation. One may begin to understand why
States) where new learning and flexibility is needed. The
neuropsychologist may now reassure the family that the
damage most probably is not progressive and needless
hopitalizations or overmedication may be avoided. Ap-
propriate work recommendations can now be made, be-
cause the loss of the ability to work is “shameful” in the
In contrast, if an Indochinese patient with memory
complaints and comorbid PTSD symptoms is markedly
depressed but has good new learning when drilled repeti-
vely shows no signs of perseverative behavior, disinhi-
bition, or arousal problems and copies visual–spatial
for “what is driving” cognitive complaints. Treatment ef-
forts may now focus on “keeping the patient in the here
and now,” a supportive work program, and treatments for
PTSD (e.g., EMDR).
Issues to consider in the neuropsychological eval-
uation are presented in Tables II and III. When selecting
miliar items from the patient’s environment is important.
Notably, even if the refugee is evaluated in their native
language, cultural influences may render the measure as
and language development.” One must also consider the
nature of the experience of the patient from the nonmajor-
style neuropsychological evaluation. Specifically, are the
patient’s values about resistance or deference to author-
138 Weinstein, Fucetola, and Mollica
Refugee’s proficiency with English
Amount of formal schooling (Manly et al., 1998)
Vocational background in native country
Degree of acculturation
Variations within culture (urban versus agrarian background)
Identification of general themes within culture (e.g., increased
collectivism in Vietnamese and Cambodian culture)
Recognition that there is no “homogenized” cultural response
Determining in the North American Practice, if the patient is from an
assimilated culture, an assimilating culture, or “cultures apart”
(Adams, 2000, p. 22)
Refugee’s response to authority and familiarity with prototypic
american evaluation (i.e., extra points for working rapidly;
understanding what is a “good” response [right–wrong response
versus creative response])
Cultural familiarity of the testing environment and the ability to feel
comfortable with an interpreter
Use of trained interpreter who can “write patient responses verbatim,
discern subtle alternations in language, and communicate/translate
back myriad of observations” (Perez-Arce and Puente, 1998,
Preparation given patient prior to the evaluation about testing process
(Shepherd and Leatham, 1999)
points from working rapidly, or working independently
without support from the examiner. In sum, the goal of
a “culture-fair” and ecologically valid assesment is to
ropsychological deficiencies” (Perez-Arce and Puente,
1998, p. 291).
Example of “Culture-Fair” Battery for the Vietnamese
Fuld Object Memory Evaluation (Fuld, 1982)
Three Words–Three Shapes Test (Khmer/Vietnamese/Cantonese
translations; Mesulam, 1985)
Stick Copy and Memory/ Boston Spatial Quantitative Battery
(Goodglass and Kaplan, 1983)
Rey–Osterrieth Complex Figure Test (Osterrieth, 1944; Rey, 1941)
Draw-A-Bicycle (Familiar Environmental Item; Lezak, 1995)
Test of Non-Verbal Intelligence (Brown et al., 1990).
Color Trails 1 and 2 (D’Elia et al., 1996)
Digit Span ( WAIS-III)
Spatial Span subtest from the Wechsler Adult Intelligence
Scale—Revised—as a neuropsychological instrument (Kaplan
et al., 1991)
Luria Motor Tests (hand sequencing, reciprocal motor programs,
multiple loops, and recurrent series writing; Luria, 1973)
Grooved Pegboard Test (Klove, 1964)
Oral Word Generation By Category (animals/fruits and
vegetables/articles of clothing)
WHAT MEASURES ARE APPROPRIATE
WHEN EVALUATING INDIVIDUALS
FROM THE NONMAJORITY CULTURE?
The question of separate measures and norms for
each culture is raised as neuropychologists evaluate non-
majority patient populations. Adams (2000, p. 18) argues,
however, against a “separate but equal” strategy of
taking all the apparent linguistic content out of existing
neuropsychological measures; making brief screening
versions of established tests; eliminating or minimi-
to make this parameter non-contributory; and collecting
new norms to provide equivalency.
Nell supports the latter ideas and further recommends
that neuropsychologists follow the “underlying principles
of guided learning and extended practice when assessing
the non-test-wise-client” (Nell, 2000, p. 173). This means
talking the patient through the initial stage of the task and
making sure that the concept of time limits is understood.
ing between three and five reversal items at the beginning
Design, Arithmetic, Matrix Reasoning, Information, and
If neurocognitive impairment is identified as that
which interferes with daily living (work, school, social
relationships), treatment modifications are needed, and
this has major public health implications. One obvious
modification is the level of environmental support. Re-
search indicates that concentration camp survivors with
brain injuries who went to Israel and lived on a kibbutz
centration camp survivors who returned to a competitive
work environment (Eitenger, 1964). Eitenger (1964,
pp. 96–97) wrote that
registered so early by the person himself as they would
have been by a free market worker (Norwegians), who
knew that his own and his family’s existence depended
on his tireless competitive capacity and the ability to
Strikingly, most refugees adapt, and need only min-
imal interventions. Eitenger (1964, p. 189) studied World
Neuropsychology and Assessment of Refugees and Mass Violence Victims 139
War II holocaust survivors and reported that the
average mentally well-equipped are capable of both en-
during, working in spite of, and integrating in their per-
sonality a number of mental stress situations without this
affecting to any great extent their mental health, on the
condition that their personal and environmental anchor-
age has been kept intact, and that these stress situations
do not persist for too long a time.
He goes on to state that when the survivor cannot adapt,
organic factors must be carefully assessed. By identifying
high risk refugees and by providing rehabilitation pro-
grams targeted to specific refugee populations, we may
influence outcome in refugee readjustment in the after-
math of war. By documenting neurocognitive strengths
and weaknesses and the conditions under which the pa-
tient recoups, prognosis may improve as treators connect
with the refugee at his or her cognitive level.
The neuropsychologist is challenged when evaluat-
toms reported in this population may not be the primary
features of PTSD and depression but may be symptoms
frequently intertwined in trauma populations, because
there is an increased incidence of starvation, torture, beat-
lead to chronic and persistent neuropsychiatric morbidity
with implications for psychosocial adjustment. In addi-
tion, the concept of fixed neural loss may interact with
environmental and emotional stresses, and a model of
neuropsychological abnormalities triggered by traumatic
events and influenced by subsequent stress merits
Neuropsychologists working with refugees must as-
sess neurocognitive functions in an environment that is
sensitive to cultural issues because patients most likely
are from a nonmajority culture. Such evaluation can be
completed by utilizing culture-fair measures in a testing
environment that is sensitive to cultural issues and that
versus neuropsychological deficiencies” (Perez-Arce and
Puente, 1998). By identifying what may drive neuropsy-
chiatric behavior (TBI, stress, depression, cultural adjust-
seeing victims of violence through a single lens (e.g.,
stress), we may influence outcome in refugee readjust-
ment in the aftermath of war.
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