Performance-based alternatives to race-norms in neuropsychological assessment

Groupings of neurologically intact African Americans have mean scores below those for Caucasian Americans on a wide range of neuropsychological tests. This provided the impetus for the creation of race-norms that reduce false positive African American misclassifications (i.e., neurologically intact individuals misdiagnosed with neurocognitive impairment). Race-norming of neuropsychological tests has proved controversial as evidenced by a recent widely publicized lawsuit filed by African American ex-football players against the National Football League (NFL) 2014 concussion settlement that prompted the NFL to halt the use of race-norms and to review past claims for evidence of racial bias. Here it is argued that there is a viable alternative to the use of race-norms in neuropsychological assessment whereby false positives are reduced through the use of obtained postinjury hold measures to estimate preexisting skill levels with standard norms. These performance-based estimates: (a) can be used with all race/ethnic minorities; (b) are applicable to all neuropsychological tests; (c) are more accurate than using the mean of published norms for members of any race/ethnic grouping who possess "true" preexisting neuropsychological skill levels at either end of the normal curve; (d) promote fairness in testing as individuals of differing race/ethnic groupings but otherwise similar demographic profiles, test scores, and estimated preexisting skill levels have the same assessed level of neurocognitive impairment; and (e) the implied causation of lower preexisting estimates in a racially diverse patient is not race per se but behavioral correlates of race like quality of education and acculturation that have demonstrated effects on test scores.