26-Diversity.Rmd

# Cultural and Individual Diversity {#diversity}

Like [ethics](#ethics), considerations of cultural and individual diversity are relevant to all of our domains as psychologists, including (but not limited to) research, teaching, assessment, intervention, and supervision.\index{diversity}
As a result, we have discussed important considerations about diversity throughout the book, including the chapters on [validity](#validity), [evidence-based assessment](#evidence-based), and [test bias](#bias).\index{diversity}
At the same time, given the importance of cultural and individual diversity, we also provide this section, which is devoted more fully to these issues within the assessment context.\index{diversity}
Diverse samples provide stronger tests of theories and better generalizability of findings ([external validity](#externalValidity)).\index{diversity}
On the assessment side, we need measures that provide us with the best information, and that are [reliable](#reliability) and [valid](#validity) for all people we use them with.\index{diversity}\index{reliability}\index{validity}
Diversity is a broad concept, and it spans many dimensions of differences among people.\index{diversity}

## Terminology {#terminology-diversity}

### Diversity, Equity, and Inclusion (DEI) {#dei}

#### Diversity {#deiDiversity}

*Diversity* refers to all aspects of differences between people.\index{diversity}
Diversity is a characteristic of a group, not a characteristic of an individual.\index{diversity}
Thus, a person is not diverse.\index{diversity}
There are many aspects of human difference, including but not limited to race, ethnicity, creed, color, sex, gender, gender identity, sexual orientation, socioeconomic status, language, culture, national origin, religion/spirituality, age, (dis)ability, military/veteran status, personality, political perspective, and associational preferences.\index{diversity}

Having a diverse group (e.g., of participants, clients, patients, etc.) is insufficient.\index{diversity}
It is also important to make sure that we take steps for all groups to feel included ([inclusion](#inclusion)) and to thrive ([equity](#equity)).\index{diversity}\index{inclusion}\index{equity}

#### Equity {#equity}

*Equity* refers to [fair](#fairness) and just practices and policies that ensure everyone can thrive.\index{equity}\index{fairness}
Equity is different from equality.\index{equity}\index{equality}
*Equality* involves treating everyone equally (i.e., treating everyone the same).\index{equality}
However, due to structural inequities—historic and current (e.g., structural racism and patriarchy)—some people are disadvantaged and marginalized more so than others.
Structural racism refers to "the normalization and legitimization of an array of dynamics—historical, cultural, institutional, and interpersonal—that routinely advantage non-Latinx White persons while producing cumulative and chronic adverse outcomes for Black and other people with minoritized identities in housing, education, employment, health care, criminal justice, and psychology." [@Byrd2021, p. 279].
Patriarchal societies reflect society's long history of wage gaps, gender discrimination, violence against women, etc.
Treating people equally (equality) does not allow everyone to thrive given these different experiences and unequal access to opportunities.\index{equality}
Thus, equity seeks to help everyone thrive, including those who are marginalized with fewer access to opportunities.\index{equity}

#### Inclusion {#inclusion}

*Inclusion* refers to providing a community where all members are and feel respected, have a sense of belonging, and are able to participate and achieve their potential.\index{inclusion}

### Aspects of Difference {#aspectsOfDifference}

There are many aspects of difference.\index{diversity}
However, identifying labels to capture these differences can be challenging.
"Asian" is an overly broad term.\index{diversity}
There are more than 4 billion people from Asian countries, and considerable heterogeneity.\index{diversity}
"Hispanic" is based on language (i.e., a person from a Spanish speaking country), whereas "Latino/a/x" and "African American" are based on geography (i.e., a person from a Latin American country).\index{diversity}
Traditional classifications of race/ethnicity by the National Institutes of Health miss groups that may be important to distinguish, including Arab, Middle Eastern, or North African (AMENA) populations.\index{diversity}

Labels by the 2020 U.S. Census attempt to be more precise than traditional classifications of race and ethnicity by the National Institutes of Health.\index{diversity}
For the classification of "Hispanic, Latino, or Spanish origin" in the 2020 U.S. Census, see Figure \@ref(fig:census-hispanic).\index{diversity}
Notice how the question distinguishes between identities of people from (or whose ancestors were from) various countries, including Mexico, Puerto Rico, Cuba, etc.\index{diversity}

(ref:census-hispanicCaption) Question Asking About One's Hispanic Origin in the 2020 U.S. Census. (Figure reprinted from the American Community Survey (2020): [https://censusreporter.org/topics/race-hispanic/](https://censusreporter.org/topics/race-hispanic/) [archived at https://perma.cc/LRW6-4JAJ])

```{r census-hispanic, out.width = "100%", fig.align = "center", fig.cap = "(ref:census-hispanicCaption)", fig.scap = "Question Asking About One's Hispanic Origin in the 2020 U.S. Census.", echo = FALSE}
knitr::include_graphics("./Images/census-hispanic.png")
```

For the classification of "Race" in the 2020 U.S. Census, see Figure \@ref(fig:census-race).\index{diversity}
Notice how the question distinguishes between identities of people from (or whose ancestors were from) various countries, including India, China, Philippines, etc.\index{diversity}

(ref:census-raceCaption) Question Asking About One's Race in the 2020 U.S. Census. (Figure reprinted from the American Community Survey (2020): [https://censusreporter.org/topics/race-hispanic/](https://censusreporter.org/topics/race-hispanic/) [archived at https://perma.cc/LRW6-4JAJ])

```{r census-race, out.width = "100%", fig.align = "center", fig.cap = "(ref:census-raceCaption)", fig.scap = "Question Asking About One's Race in the 2020 U.S. Census.", echo = FALSE}
knitr::include_graphics("./Images/census-race.png")
```

Society treats people differently based on factors that they are born into and are outside of their control, including their race and their family's socioeconomic status.\index{diversity}
Socioeconomic status refers to the social standing or class of an individual, and it is often assessed as a combination of education, income, occupation, access to resources, privilege, power, and control [@Suzuki2013].\index{diversity}
There is also growing attention to neighborhood- and community-level factors associated with deprivation.\index{diversity}

There are also many other important aspects of difference to assess when thinking about individual differences in behavior.\index{diversity}
For instance, one important aspect of difference is family structure.\index{diversity}
Family structure includes lots of components, such as whether the parent is a single parent or whether there are two parents, whether the parents are working parents or whether the family has a stay-at-home parent, and whether there are other family members (e.g., grandparents) in the household.\index{diversity}

Another important aspect of diversity includes one's sex, gender identity, and gender expression.\index{diversity}
Sex is the person's gender that was assigned at birth, and includes male, female, and intersex.\index{diversity}
Gender identity is how one self-identifies in terms of their gender.\index{diversity}
Gender identity is a spectrum in terms of the degree to which a person identifies as a female/woman/girl, a male/man/boy, or other genders, in terms of personality, likes/dislikes, jobs/hobbies, and roles and expectations.\index{diversity}
The person's gender identity may be non-binary or genderqueer if they do not identify as a man or woman (e.g., genderfluid).\index{diversity}
When the person's sex assigned at birth and their gender identity are aligned, the person is cis-gender.\index{diversity}
When the person's sex assigned at birth and their gender identity are not aligned, the person is transgender.\index{diversity}
Gender expression deals with how the person's gender is expressed to others, including their appearance.\index{diversity}

Another dimension of diversity is whether someone is from a rural versus urban area.\index{diversity}
People from rural areas may have less access to resources.\index{diversity}
Another aspect of diversity is refugee or immigrant status.\index{diversity}
Refugee and immigrant groups may have less access to resources and may have language barriers, in addition to difficulty finding work, and fear of deportation.\index{diversity}

It is also important to consider diversity in terms of sexual orientation and sexual behaviors.\index{diversity}
There is a distinction between one's sexual orientation (e.g., lesbian, gay, bisexual, heterosexual, pansexual, asexual)—that is, who one is sexually or romantically attracted to—versus whom one has sex with (i.e., sexual behavior).\index{diversity}
There are also differences in terms of the degree of people's sexual risk taking and sexual aggression.\index{diversity}

Ability and disability are other important facets of diversity, including learning disabilities.\index{diversity}
Additionally, there are important brain-related differences that lead people to interact and experience the world in different ways, as reflected in the term, neurodiversity.\index{diversity}
Neurodiversity can include differences related to autism and other conditions such as attention-deficit hyperactivity disorder.\index{diversity}

Age is another important dimension of diversity.\index{diversity}
Consider the issue of [heterotypic continuity](#heterotypicContinuity).\index{diversity}\index{heterotypic continuity}
For example, externalizing problems look different at different ages and should be assessed in different ways with different measures at different ages [@Chen2015; @Miller2009; @Moffitt1993; @Patterson1993; @Petersen2015; @Petersen2022; @Wakschlag2010].\index{diversity}

Another important aspect of diversity is culture, which includes belief systems, value orientations, psychological processes, worldview, learned and transmitted beliefs, and practices [@Suzuki2013].\index{diversity}\index{culture}
A person's culture has many facets, including but not limited to experiences related to geographic boundaries, language, religious belief, social class, gender, sexual orientation, and ability status [@Suzuki2013].\index{diversity}\index{culture}
However, culture and one's related identities are dynamic and changing [@Suzuki2013], which makes them challenging to assess.\index{diversity}\index{culture}
Culture tends to be ignored in psychological research relative to other facets of diversity, but culture is arguably the most important in terms of influencing behavior.\index{diversity}\index{culture}
Additional dimensions of difference include religion and spirituality.\index{diversity}

Another aspect of diversity is intersectionality, the intersecting of multiple identities.\index{diversity}
Intersectionality deals with how the combination of various identities can combine to influence behavior and [bias](#bias).\index{diversity}

There are many other important aspects of difference, too.\index{diversity}
This was not an exhaustive list!\index{diversity}

## Assessing Cultural and Individual Diversity: Multicultural Assessment Frameworks {#multiculturalFrameworks}

A review of frameworks for multicultural assessment is provided by @Edwards2017a.\index{multicultural assessment}

### The ADDRESSING Model {#addressing}

The *ADDRESSING* model [@Hays2016] provides a framework to consider some of the commonly examined differences between people within a clinical context.\index{multicultural assessment}\index{diversity!ADDRESSING acronym}
ADDRESSING is an acronym that stands for:\index{multicultural assessment}\index{diversity!ADDRESSING acronym}

- **A**ge and generational differences\index{multicultural assessment}\index{diversity!ADDRESSING acronym}
- **D**evelopmental or other <br/>\index{multicultural assessment}\index{diversity!ADDRESSING acronym}
  **D**isability\index{multicultural assessment}\index{diversity!ADDRESSING acronym}
- **R**eligion and spiritual orientation\index{multicultural assessment}\index{diversity!ADDRESSING acronym}
- **E**thnic and racial identity\index{multicultural assessment}\index{diversity!ADDRESSING acronym}
- **S**ocioeconomic status\index{multicultural assessment}\index{diversity!ADDRESSING acronym}
- **S**exual orientation\index{multicultural assessment}\index{diversity!ADDRESSING acronym}
- **I**ndigenous heritage\index{multicultural assessment}\index{diversity!ADDRESSING acronym}
- **N**ational origin\index{multicultural assessment}\index{diversity!ADDRESSING acronym}
- **G**ender\index{multicultural assessment}\index{diversity!ADDRESSING acronym}

These are important aspects of differences between people that can be helpful to understand when working with a client and how they self-identify.\index{multicultural assessment}\index{diversity!ADDRESSING acronym}
For instance, the therapist could ask the client how they self-identify in each of these domains and how their identity is meaningful to them.\index{multicultural assessment}\index{diversity!ADDRESSING acronym}
In addition to the aspects of diversity identified in ADDRESSING, there are other aspects of diversity and difference that may be worth considering, including but not limited to personality, culture, and political beliefs.\index{multicultural assessment}\index{diversity!ADDRESSING acronym}

### DSM-5 Cultural Formulation Interview {#dsm5CulturalFormulationInterview}

The [Diagnostic and Statistical Manual of Mental Disorders](#dsm) (DSM) provides a framework for clinicians to organize cultural information about a client using the Cultural Formulation Interview [@LewisFernandez2014].\index{multicultural assessment}\index{Diagnostic and Statistical Manual of Mental Disorders}
The Cultural Formulation Interview is a [semi-structured interview](#semiStructuredInterview) and is available here:\index{multicultural assessment}\index{Diagnostic and Statistical Manual of Mental Disorders}\index{interview!semi-structured} https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/APA_DSM5_Cultural-Formulation-Interview.pdf (archived at https://perma.cc/3EWR-LGEN)

### Multicultural Assessment Procedure {#multiculturalAssessmentProcedure}

The Multicultural Assessment Procedure was developed by @Ridley1998.
The framework includes four phases:\index{multicultural assessment}

1. Gather clinical data, including cultural data, through history taking and multiple methods for the purpose of formulating a case conceptualization\index{multicultural assessment}\index{case conceptualization}\index{methods!multiple}
2. Interpret clinical and cultural data to formulate a hypothesis, while keeping in mind to:\index{multicultural assessment}
    - differentiate the cultural data as being either idiosyncratic (i.e., unique to the individual client and would not necessarily be expected of other members of the client's culture) or culture-specific\index{multicultural assessment}
    - consider [base rates](#baseRate)\index{multicultural assessment}
    - differentiate dispositional from environmental stressors\index{multicultural assessment}
    - differentiate clinically significant data from data that are not clinically significant\index{multicultural assessment}
3. Incorporate cultural data with other clinical information to test the hypotheses by ruling out medical explanations and using appropriate assessments and testing\index{multicultural assessment}
4. Arrive at a sound assessment decision (case conceptualization)\index{multicultural assessment}\index{case conceptualization}

The procedure also includes [debiasing](#bias) strategies to minimize the likelihood of clinical judgment errors.\index{multicultural assessment}
@Ridley2001 expanded on this framework in consideration of [ethical issues](#ethics) in multicultural assessment.\index{multicultural assessment}\index{ethics}

### Multicultural Assessment–Intervention Process {#multiculturalAssessmentInterventionProcess}

The Multicultural Assessment–Intervention Process was developed by @Dana1998.
The process provides a flowchart for clinicians to conduct assessment by asking relevant questions about cultural orientation, type of assessment instrument (e.g., etic or emic), cultural formulation for diagnosis, and intervention approach (e.g., universal, culture-general, culture-specific, identity-specific, etc.).\index{multicultural assessment}
*Etic* assessments are culture-general, whereas *emic* assessments are culture-specific.\index{multicultural assessment}\index{multicultural assessment!etic}\index{multicultural assessment!emic}

## Assessments with Ethnic, Linguistic, and Culturally Diverse Populations {#guidelinesForAssessmentWithDiversePopulations}

### Methodological and Conceptual Challenges in Research {#researchChallengesDiversePopulations}

Methodological and conceptual challenges for conducting research with ethnic minorities are described by @Okazaki1995.\index{diversity!assessment of minority populations}
Guidelines for conducting research with diverse groups are described by @Burlew2019.\index{diversity!assessment of minority populations}

#### Use of Terms: Race, Ethnicity, Culture {#raceEthnicityCulture}

Use of terminology with respect to race, ethnicity, and culture is a key challenge in assessment of diverse samples.\index{diversity!assessment of minority populations}\index{culture}
Many people refer to race, ethnicity, and culture interchangeably, which reflects conceptual confusion.\index{diversity!assessment of minority populations}\index{culture}
There is no definition of race, ethnicity, and culture that is universally agreed on [@Okazaki1995].\index{diversity!assessment of minority populations}\index{culture}
As described by @Okazaki1995, "the use of the term 'race' appears to imply biological factors, as races are typically defined by observable physiognomic features such as skin color, hair type and color, eye color, stature, facial features, and so forth" (p. 367).\index{diversity!assessment of minority populations}
By contrast, ethnicity (ethnic status) has been defined as "an easily identifiable characteristic that implies a common cultural history with others possessing the same characteristic" [@Eaton1980, p. 160].\index{diversity!assessment of minority populations}
Ethnic identifiers for evaluating whether people share a "common cultural history" include racial, national, tribal, religious, linguistic, or cultural origin or background.\index{diversity!assessment of minority populations}
Thus, race and ethnicity, though conceptually distinct, are related as race can be an ethnic identifier.\index{diversity!assessment of minority populations}

Researchers have argued that race designations are arbitrary [@Helms2005], that race is a social, cultural, and/or political construct rather than a biological construct [@Sternberg2005; @Yudell2016], that race has no genetic basis [@Yudell2016], that within-race differences are greater than between-race differences [@Zuckerman1990], and that racial categories lack conceptual meaning [@Helms2005].\index{diversity!assessment of minority populations}
According to the American Anthropological Association [-@AAA1998, p. 712], "physical variations in the human species have no meaning except the social ones that humans put on them".\index{diversity!assessment of minority populations}
However, even though race does not appear to have a genetic or biological basis and therefore appears to be a social construct rather than a biological construct, racism as a social problem is real and is a major issue [@Smedley2005].\index{diversity!assessment of minority populations}
People are born into different social reactions based on their race.\index{diversity!assessment of minority populations}
Thus, race is important to consider from a perspective of racialized experiences and discrimination even if the racial categories do not represent underlying biological differences.\index{diversity!assessment of minority populations}

In terms of determining what to assess and analyze, it is important for the researcher to determine whether they are interested in evaluating race as a biological variable, ethnicity as a demographic variable, or an aspect of cultural experience as a psychological variable [@Okazaki1995].\index{diversity!assessment of minority populations}
Researchers often use race and/or ethnicity as proxy variables for psychological variables such as cultural values, self-concept, minority status, etc.\index{diversity!assessment of minority populations}
However, race and ethnicity are distal to the variables that may be of most psychological interest.\index{diversity!assessment of minority populations}
Some people identify their primary culture as being different from their self-identified ethnicity.\index{diversity!assessment of minority populations}
It is thus important to assess the psychological processes of interest, rather than merely relying on racial or ethnic categories as proxies.\index{diversity!assessment of minority populations}

Culture refers to a psychological variable: i.e., the social context.\index{diversity!assessment of minority populations}\index{culture}
Researchers often group people together based on race or ethnicity with the implicit assumption that they share some cultural experience.\index{diversity!assessment of minority populations}\index{culture}
According to Okazaki and Sue [-@Okazaki1995], assumptions underlying the use of race or ethnicity in a study should be made explicit.\index{diversity!assessment of minority populations}
Research should directly assess the underlying psychological variables associated with culture, such as different spiritual practices, that are hypothesized to produce the racial/ethnic/cultural differences.\index{diversity!assessment of minority populations}\index{culture}
That is, it is generally best not to rely solely on race or ethnicity, which are imprecise, to classify people unless the goal is to classify people based on racialized reactions and experiences.\index{diversity!assessment of minority populations}
Thus, the researcher can classify people according to race/ethnicity, but can also examine the more proximal cultural variables that are thought to drive group-related differences.\index{diversity!assessment of minority populations}\index{culture}

#### Whether to Examine Individual Differences or Group Characteristics {#individualDifferencesOrGroupCharacteristics}

One question the researcher should consider is whether they are interested in understanding individual differences or group characteristics.\index{diversity!assessment of minority populations}
Both can be valuable and important questions to examine.\index{diversity!assessment of minority populations}
However, researchers should not under-estimate within-group heterogeneity [@Okazaki1995].\index{diversity!assessment of minority populations}
The greater the within-group heterogeneity, the less accurate predictions tend to be.\index{diversity!assessment of minority populations}
Moreover, inferences at the group-level cannot necessarily be applied to the individual level; the confounding of an individual with the individual's culture leads to stereotyping [@Okazaki1995], which should be avoided.\index{diversity!assessment of minority populations}\index{culture}

#### Selecting Participants {#selectingParticipants-diversity}

One question is which groups to include in the research design and in what proportion.\index{diversity!assessment of minority populations}
For group-related comparisons, the researcher would need a large enough sample size for every group examined to have adequate power to identify group-related differences.\index{diversity!assessment of minority populations}
If the researcher is interested in studying a particular group, a question is whether to use a comparison group.\index{diversity!assessment of minority populations}
A comparison group can provide a basis of comparison to better interpret the findings in the group of interest.\index{diversity!assessment of minority populations}
However, inclusion of a comparison group can add time, cost, and as a result may lead to achieving a smaller sample in the group of interest.\index{diversity!assessment of minority populations}
Moreover, the group comparison approach has been criticized for reinforcing racial stereotypes, reinforcing Whites as the standard group and non-White behavior as deviant, and overlooking within-group variation [@Okazaki1995].\index{diversity!assessment of minority populations}
Thus, decisions about which groups to include, in what proportion, and whether to include a comparison group should be guided by the questions and purpose of the study.\index{diversity!assessment of minority populations}
Practical considerations can come into play, and having a comparison group should not be considered the necessary default for all studies.\index{diversity!assessment of minority populations}
Moreover, White groups should not be considered the default.\index{diversity!assessment of minority populations}

#### Ensuring Fair Group Comparisons {#ensuringFairGroupComparisons}

Another issue is how to achieve fair group comparisons.\index{diversity!assessment of minority populations}
One approach is to match groups by selecting participants a priori to be similar on relevant, secondary characteristics such as demographic characteristics (e.g., age, sex, socioeconomic status) or other abilities (e.g., intelligence).\index{diversity!assessment of minority populations}
The goal of matching is for participants to be as similar as possible in the relevant characteristics apart from their group classification.\index{diversity!assessment of minority populations}
However, there are challenges to matching groups on all relevant characteristics.\index{diversity!assessment of minority populations}
Another approach is to control for these secondary characteristics post hoc in the statistical analysis.\index{diversity!assessment of minority populations}
Which variables to include as control variables is an important question that depends on the goal.\index{diversity!assessment of minority populations}
A key question is which variables to match participants on.\index{diversity!assessment of minority populations}
However, there is not an agreed-upon list of matching variables.\index{diversity!assessment of minority populations}
Generally, researchers recommend controlling for social and demographic characteristics such as educational attainment, income level, and language fluency, when group-related differences exist on those variables and the researcher believes that such differences may moderate the associations of interest [@Okazaki1995].\index{diversity!assessment of minority populations}
When comparing Black and White participants, it is important to control for group differences in socioeconomic status, especially in the U.S.\index{diversity!assessment of minority populations}

In addition to main effects of group status, it may also be important to consider *interaction* effects of group status, consistent with an intersectionality approach.\index{diversity!assessment of minority populations}
However, power to detect interactions tends to be weaker than power to detect main effects, both because of [smaller effect sizes](https://statmodeling.stat.columbia.edu/2018/03/15/need-16-times-sample-size-estimate-interaction-estimate-main-effect) (archived at https://perma.cc/E3KA-SGB7) and because of smaller sample sizes of the intersecting groups.\index{diversity!assessment of minority populations}

#### Sampling {#sampling-diversity}

Researchers face important questions with how to identify, sample, and recruit ethnic minority samples.\index{diversity!assessment of minority populations}
Groups, such as ethnic groups, may be classified at a broad level (e.g., Latinx or Hispanic) or at a more specific level (e.g., Puerto Rican, Mexican American, etc.); however, these approaches do not need to be mutually exclusive.\index{diversity!assessment of minority populations}
Researchers must also determine how to classify people of mixed racial or ethnic backgrounds.\index{diversity!assessment of minority populations}
It is also important to note that it is an incorrect assumption that once people are identified as belonging to a particular ethnic-cultural group, that they share a common understanding of their own ethnicity or culture and identify with the ethnic-cultural group [@Okazaki1995].\index{diversity!assessment of minority populations}

There are challenges of recruiting a sizeable sample size with specific ethnic-cultural groups (e.g., Japanese Americans).\index{diversity!assessment of minority populations}
This is partly a challenge of small overall population size (e.g., American Indians).\index{diversity!assessment of minority populations}
This is also partly a challenge of difficult-to-reach populations who are distrustful of science and researchers.\index{diversity!assessment of minority populations}
Research has exploited under-privileged populations (e.g., the Tuskegee syphilis study in Black men), which has led to changes in the consent process to ensure that participation is voluntary.\index{diversity!assessment of minority populations}
There may also be selection effects, such that the people who are willing to participate in research may differ in important ways from those less willing to participate in research, which is a challenge to generalizability.\index{diversity!assessment of minority populations}
To address sample size challenges, researchers often combine data from multiple ethnic-cultural groups with some common origin.\index{diversity!assessment of minority populations}
For instance, researchers might combine Chinese Americans, Japanese Americans, and Korean Americans into one group.\index{diversity!assessment of minority populations}
Or, researchers might combine people from multiple tribal groups among American Indians.\index{diversity!assessment of minority populations}
However, broadening the ethnic grouping increases the heterogeneity of the groups, so the researcher must decide which are the sources of variability that can and cannot be overlooked [@Okazaki1995].\index{diversity!assessment of minority populations}

Much of the literature in general and on diversity, in particular, is from research on college students.\index{diversity!assessment of minority populations}
There are limitations of conducting research on college students.\index{diversity!assessment of minority populations}
College students are not representative of the broader population.\index{diversity!assessment of minority populations}
Research using college students under-estimates the population heterogeneity in terms of demographic and psychosocial diversity.\index{diversity!assessment of minority populations}

One goal of research is to learn findings that apply to the broader population, with the goal of having a representative sample, where the mean of the sample is approximately the same as the mean of the population.\index{diversity!assessment of minority populations}
However, having a population-representative sample is not as useful for comparing differences between groups.\index{diversity!assessment of minority populations}
To do this, we would need large samples of each group—e.g., equally weighted samples.\index{diversity!assessment of minority populations}
Most research is on participants from WEIRD countries [@Henrich2010]: Western, educated, industrialized, rich, and democratic (WEIRD) societies.\index{diversity!assessment of minority populations}
This further limits the potential generalizability of findings to different cultures.\index{diversity!assessment of minority populations}\index{culture}

Provide a thorough description of the sample and sampling methodology used.\index{diversity!assessment of minority populations}
For instance, it can be helpful to describe participants on additional dimensions to race and ethnicity, including generational status, acculturation, self-identification, ethnic and cultural composition of the neighborhoods or communities, etc. [@Okazaki1995].\index{diversity!assessment of minority populations}
Acculturation deals with the change that individuals undergo due to contact with members of different cultures, and it includes strategies such as assimilation, separation, marginalization, and integration [@Suzuki2013].\index{diversity!assessment of minority populations}\index{culture}

#### Establishing Equivalence of Measures Across Groups {#measurementEquivalence}

Five key areas need to be empirically evaluated in using or adapting instruments across cultures or groups to reduce or eliminate cultural [bias](#bias) [@Hunsley2007]:\index{diversity!assessment of minority populations}\index{bias}

- Conceptual equivalence\index{diversity!assessment of minority populations}
- Linguistic (or translation) equivalence\index{diversity!assessment of minority populations}
- Psychological equivalence of the items\index{diversity!assessment of minority populations}
- Functional equivalence\index{diversity!assessment of minority populations}
- Metric and scalar equivalence (i.e., [measurement invariance](#measurementInvariance))\index{diversity!assessment of minority populations}\index{structural equation modeling!measurement invariance}\index{structural equation modeling!measurement invariance!metric}\index{structural equation modeling!measurement invariance!scalar}

Conceptual equivalence refers to establishing that the construct has the same meaning across groups.\index{diversity!assessment of minority populations}
Linguistic (or translation) equivalence refers to the measure having the same linguistic meaning in each language to which it has been translated.\index{diversity!assessment of minority populations}
Best practices for establishing translation equivalence include having experts translate and back-translate the measure, comparing both the original and back-translated versions, and revising the translation accordingly [@Okazaki1995].\index{diversity!assessment of minority populations}
Psychological equivalence of the items deals with establishing that the psychological effect each item has for each group or in the different versions.\index{diversity!assessment of minority populations}

Functional equivalence deals with establishing similar [predictive](#predictiveValidity) and [concurrent](#concurrentValidity) [criterion-related validity](#criterionValidity) to prevent [test bias](#bias) (i.e., similar regression intercepts and slopes between measure and criterion).\index{diversity!assessment of minority populations}\index{bias!predictive}\index{validity!predictive}\index{validity!concurrent}\index{validity!criterion}
Functional equivalence can be difficult to establish when both the test and the external criteria of interest are both rooted in the same dominant universalist cultural epistemology or worldview; instead, it may be advantageous to validate tests against external criteria that are grounded in the nondominant group's culture [@Suzuki2013].\index{diversity!assessment of minority populations}

Metric and scalar equivalence (i.e., [measurement invariance](#measurementInvariance)) deal with establishing that the construct is measured on the same metric across groups, that is, a particular score reflects the same level on the construct for people in each group.\index{structural equation modeling!measurement invariance!metric}\index{structural equation modeling!measurement invariance!scalar}
Metric equivalence/invariance deals with establishing that items' [discrimination](#itemDiscrimination) parameters (or factor loadings) are the same across groups.\index{diversity!assessment of minority populations}\index{structural equation modeling!measurement invariance!metric}\index{structural equation modeling!factor loading}\index{item response theory!item discrimination}
Scalar equivalence/invariance deals with establishing that both items' [discrimination](#itemDiscrimination) parameters (or factor loadings) and [difficulty](#itemDifficulty) parameters (or intercepts) are the same across groups.\index{diversity!assessment of minority populations}\index{structural equation modeling!measurement invariance}\index{structural equation modeling!measurement invariance!scalar}\index{structural equation modeling!intercept}\index{item response theory!item difficulty}

#### Methods of Assessment {#methodsOfAsssessment-diversity}

It is debatable whether some assessment methods may be more likely to result in cultural or ethnic [bias](#bias) compared to other assessment methods [@Okazaki1995].\index{diversity!assessment of minority populations}\index{bias}
Certain types of assessment techniques might be more likely to [bias](#bias) or obscure differences between cultural groups.\index{diversity!assessment of minority populations}
This especially depends on who is doing the observing and their own beliefs.\index{diversity!assessment of minority populations}
There may be selection [biases](#bias) regarding the types of people who are willing to participate in in-depth studies that involve [observational](#behavioral) or [psychophysiological](#psychophysiological) assessment.\index{diversity!assessment of minority populations}\index{bias!selection}\index{observation}\index{biological assessment}
It may be worth considering supplementing quantitative measurement approaches with qualitative measurement approaches, such as interviews and life histories, which may be better able to capture cultural factors.\index{diversity!assessment of minority populations}\index{culture}
In general, it is advantageous to assess people using multiple measures and methods to establish [convergent validity](#convergentValidity) of cultural constructs [@Okazaki1995].\index{diversity!assessment of minority populations}\index{culture}\index{validity!convergent}\index{methods!multiple}

#### Interpretation of Data {#interpretationOfData-diversity}

Another challenge deals with how to interpret data from group comparison designs.\index{diversity!assessment of minority populations}
Historically, group differences in scores were most commonly interpreted from a deficit-based narrative rather than a strengths-based narrative [@Byrd2021].\index{diversity!assessment of minority populations}

### APA Guidelines {#APAguidelines-diversity}

There are many disparities in psychological services for under-served populations, including health disparities, diagnostic disparities, and disparities in the use and availability of psychological services [@RiveraMindt2010].\index{diversity!assessment of minority populations}
To help address these disparities, the American Psychological Association (APA) Office of Ethnic Minority Affairs published guidelines for providers of psychological services to ethnic, linguistic, and culturally diverse populations [@APAOfficeEthnicMinorityAffairs1993].\index{diversity!assessment of minority populations}
Their guidelines included suggestions such as:\index{diversity!assessment of minority populations}

- Whenever possible, provide information in writing along with oral explanations.\index{diversity!assessment of minority populations}
- Whenever possible, provide the information and interact in the language that is understandable to the client.\index{diversity!assessment of minority populations}
If that is not feasible, make an appropriate referral.\index{diversity!assessment of minority populations}
If this is not possible, provide a translator with cultural knowledge and an appropriate professional background.\index{diversity!assessment of minority populations}
When no translator is available, then use a trained paraprofessional from the client's culture as a translator.\index{diversity!assessment of minority populations}
- If you do not possess knowledge and training about an ethnic group, seek consultation with, and/or make referrals to, appropriate experts as necessary.\index{diversity!assessment of minority populations}
- Consider the [validity](#validity) of a given instrument or procedure and interpret the resulting data, while keeping in mind the cultural and linguistic characteristics of the client.\index{diversity!assessment of minority populations}\index{validity}
- Be aware of the test's reference population and possible limitations of using the instrument with other populations.\index{diversity!assessment of minority populations}
- Seek to help clients determine whether a "problem" stems from racism or [bias](#bias) in others so that the client does not inappropriately personalize problems.\index{diversity!assessment of minority populations}

The APA has also published guidelines for working with particular groups, including:\index{diversity!assessment of minority populations}

- Groups based on [race and ethnicity](https://www.apa.org/about/policy/guidelines-race-ethnicity.pdf) (\index{diversity!assessment of minority populations}archived at https://perma.cc/4LM9-X6JN)
- [People with low income](https://www.apa.org/about/policy/guidelines-low-income.pdf) (\index{diversity!assessment of minority populations}archived at https://perma.cc/PZQ5-8YFG)
- [People with disabilities](https://www.apa.org/pi/disability/resources/assessment-disabilities) (\index{diversity!assessment of minority populations}archived at https://perma.cc/5YZ8-FNJT; PDF: https://perma.cc/KYY4-CQFQ)
- [People who are transgender or gender nonconforming](https://www.apa.org/practice/guidelines/transgender.pdf) (\index{diversity!assessment of minority populations}archived at https://perma.cc/E9VH-QG3W)
- [Sexual minorities](https://www.apa.org/about/policy/psychological-sexual-minority-persons.pdf) (\index{diversity!assessment of minority populations}archived at https://perma.cc/4BJD-QZCF)
- [Girls and women](https://www.apa.org/about/policy/psychological-practice-girls-women.pdf) (\index{diversity!assessment of minority populations}archived at https://perma.cc/AYA4-KB5W)
- [Boys and men](https://www.apa.org/about/policy/boys-men-practice-guidelines.pdf) (\index{diversity!assessment of minority populations}archived at https://perma.cc/6HWK-W9R6)
- [Older adults](https://www.apa.org/practice/guidelines/guidelines-psychological-practice-older-adults.pdf) (\index{diversity!assessment of minority populations}archived at https://perma.cc/EQ95-Y78Y)

### Seek Training and Consultation {#trainingAndConsultation}

Research has shown that relatively few practitioners receive extensive training in multicultural assessment and few use frameworks for multicultural assessment [@Brickman2006; @Edwards2017a].\index{multicultural assessment}\index{diversity!assessment of minority populations}
Researchers have encouraged increasing multicultural education, training, awareness, and knowledge, increasing multicultural psychological research, and increasing the provision of culturally competent psychological services to ethnic minorities [@RiveraMindt2010].\index{multicultural assessment}\index{diversity!assessment of minority populations}
It can also be worthwhile to consult with informal support systems, including churches, ethnic clubs, family associations, and community leaders [@Leong2016].\index{multicultural assessment}\index{diversity!assessment of minority populations}

### Develop Awareness of Cultural Differences {#awarenessOfCulturalDifferences}

One goal should be to develop cultural competence with the groups, communities, and individuals with which one works or interacts.\index{multicultural assessment}\index{diversity!assessment of minority populations}
It can be helpful to be aware of cultural differences, including cultural differences in communication style and use of language [@Leong2016].\index{multicultural assessment}\index{diversity!assessment of minority populations}

### Show Cultural Humility {#culturalHumility}

Another goal should be to show cultural humility.\index{diversity!assessment of minority populations}
@Tervalon1998 describe three key aspects of cultural humility: (1) a life-long commitment to self-evaluation and self-critique, (2) fixing power imbalances, and (3) developing mutually beneficial and nonpaternalistic partnerships with communities who advocate for others.\index{diversity!assessment of minority populations}
For instance, it is important to be aware of one's [biases](#bias) and stereotypical beliefs.\index{diversity!assessment of minority populations}\index{bias}
Cultural humility involves treating the client as the expert on their experience.
Therefore, cultural humility involves collaboration between the clinician and client, because each brings important knowledge.\index{diversity!assessment of minority populations}
The client brings their knowledge of their situation, and their preferences.\index{diversity!assessment of minority populations}
The clinician brings their scientific knowledge about strengths and difficulties, and about behavior change.\index{diversity!assessment of minority populations}

### Do Not Assume or Stereotype {#avoidAssumptions}

It is important to consider cultural factors; at the same time, groups are not monolithic and every person is unique.\index{diversity!assessment of minority populations}
Do not assume about someone based on their demographics, which is stereotyping.
Just because a person comes from a particular group does not mean the person shares all beliefs, behaviors, etc. with the group [@Okazaki1995].\index{diversity!assessment of minority populations}
Thus, it is important to be aware of within-group differences, as well [@Leong2016; @Okazaki1995], which are often as large or larger than between-group differences [@Zuckerman1990].\index{diversity!assessment of minority populations}
Show genuine interest and curiosity to get to know a person as an individual.\index{diversity!assessment of minority populations}

### Ensure Adequate Representation of Under-Represented Groups in Research {#adequateReprentations}

There are important issues of generalizability of research findings.\index{diversity!assessment of minority populations}
Participant samples historically have been largely White and middle or upper middle class.\index{diversity!assessment of minority populations}
This reduces the potential generalizability of findings, and limits effectiveness of treatments to under-represented populations, many of whom have experienced discrimination and social disadvantage.\index{diversity!assessment of minority populations}
Many groups, including people who are Black or Latinx, and gender and sexual minorities have not been adequately represented in research studies.\index{diversity!assessment of minority populations}
As a result, the knowledge gained from unrepresentative studies may not generalize to other under-represented groups.\index{diversity!assessment of minority populations}
Science plays an important role in advancing knowledge that can lead to the development of new treatments.\index{diversity!assessment of minority populations}
However, groups who are under-represented in research are less likely to benefit from the new treatments because the knowledge upon which the treatments were developed and tested may not generalize to the under-represented groups.\index{diversity!assessment of minority populations}
Moreover, the lack of inclusion of under-represented groups in studies leads to inappropriate [normative data](#norm).\index{diversity!assessment of minority populations}\index{norm}
Thus, it is crucial to have better representation of historically marginalized and minoritized groups in science, including people who are Black or Latinx, and gender and sexual minorities.\index{diversity!assessment of minority populations}

People from Finland and Sweden are often studied to examine health-related questions.\index{diversity!assessment of minority populations}
Because they have a socialized health care system, the government keeps medical records on all citizens, so researchers can examine millions of participants, and can study rare conditions and behaviors with a low [base rate](#baseRate), like suicide [@Lysell2018].\index{diversity!assessment of minority populations}
However, there are questions of generalizability from the Scandinavian population and health care system to those of other countries, including the United States.\index{diversity!assessment of minority populations}
One could hypothetically use propensity score matching for matching their sample to other populations, but one cannot really do that because they have too many empty cells for propensity score matching due to too few people of various under-represented racial/ethnic groups.\index{diversity!assessment of minority populations}

### Use Appropriate Measurement {#appropriateMeasurement}

#### Do Not Use Offensive Content or Procedures {#offensiveContent}

It is important to use stimuli that are [valid](#validity) for the populations being tested.\index{diversity!assessment of minority populations}
It is important to avoid using content or procedures that are culturally or racially insensitive, or that are racist, sexist, heteronormative, and/or ableist [@Byrd2021].\index{diversity!assessment of minority populations}
When developing assessments, it may be important to evaluate stimuli in focus groups to ensure they are not offensive.\index{diversity!assessment of minority populations}

One of the most widely used standardized assessments in psychological assessment is the Boston Naming Test, a measure of visual confrontation naming that is used to assess cognitive impairment, aphasia, and dementia.\index{diversity!assessment of minority populations}
The Boston Naming Test includes a noose as one of the items.\index{diversity!assessment of minority populations}
Historically, lynchings with a noose were used in the United States as a form of racial terror against Black people.\index{diversity!assessment of minority populations}
Thus, the use of a noose as an item in the Boston Naming Test is racially insensitive and inappropriate for use because it is deeply offensive and has a harmful nature.\index{diversity!assessment of minority populations}
It can have a strong negative impact on Black respondents in terms of distress, performance disparities, and health disparities [@Byrd2021].\index{diversity!assessment of minority populations}

Culturally offensive stimuli can lead to stereotype threat and compromise the [validity](#validity) of the assessment.\index{diversity!assessment of minority populations}
Stereotype threat occurs when people are or feel at risk of conforming themselves to stereotypes about their social group, thus leading them to show poorer performance in ways that are consistent with the stereotype.\index{diversity!assessment of minority populations}\index{stereotype threat}
Moreover, the use of offensive procedures likely contributes to greater distrust of the scientific and medical fields among under-served communities, which acts as a barrier to health care and to health disparities.\index{diversity!assessment of minority populations}
Thus, removing and replacing offensive stimuli may be necessary from a moral and [ethical](#ethics) perspective to do no harm and to ensure [valid](#validity) assessment, even if it risks modifying the standardized procedure from which the [norms](#norm) were developed [@Byrd2021].\index{diversity!assessment of minority populations}
When deviating from standardized procedures, it is important to describe such deviations in resulting papers or reports.\index{diversity!assessment of minority populations}

#### Use Culturally Valid Measures {#culturallyValidMeasures}

Most measures originated from Western societies [@Suzuki2013] and have been validated only among non-Latinx, English-speaking Whites [@Manly2005].\index{diversity!assessment of minority populations}
It is important to use measures that have been validated for the populations with whom they will be used.\index{diversity!assessment of minority populations}
Many measures have been used for different populations than the populations with which the instruments were developed and validated, such as with immigrants, refugees, or when exporting measures to different countries or cultural contexts.\index{diversity!assessment of minority populations}
Exporting measures for use with people from different cultures assumes universality (i.e., cross-cultural [validity](#validity)).\index{diversity!assessment of minority populations}\index{validity!cultural}
More work should examine adaptation and [validation](#validity) of measures for other cultures, countries, languages, etc. [@Leong2016].\index{diversity!assessment of minority populations}
However, some measures may not be able to be applied [validly](#validity) across cultures.\index{diversity!assessment of minority populations}
Using [valid](#validity) measures for the target population may in some cases mean using culturally specific (etic) instruments rather than universal (emic) instruments.\index{diversity!assessment of minority populations}\index{multicultural assessment!etic}\index{multicultural assessment!emic}
If using measures whose [validity](#validity) and [measurement equivalence](#measurementEquivalence) has not been established, it is important to interpret results with caution and to provide disclaimers in any resulting papers or reports [@Leong2016].\index{diversity!assessment of minority populations}

As described in Section \@ref(culturalValidity), it is also important for measures to have [cultural validity](#culturalValidity), which refers to "the effectiveness of a measure or the accuracy of a clinical diagnosis to address the existence and importance of essential cultural factors." [@Leong2016, p. 58].\index{diversity!assessment of minority populations}\index{validity!cultural}
Essential cultural factors may include values, beliefs, experiences, communication patterns, and approaches to knowledge (epistemologies).\index{diversity!assessment of minority populations}\index{validity!cultural}

Threats to [cultural validity](#culturalValidity) of assessments includes: [pathoplasticity](#pathoplasticity) of psychological disorders, [bias in clinical judgment](#biasClinicalJudgment), [language capability](#linguisticallyAppropriate) of the client, [biased](#bias) measures, or inappropriate use or interpretation of measures [@Leong2016].\index{diversity!assessment of minority populations}\index{validity!cultural}\index{clinical judgment!bias}\index{bias!clinical judgment}

#### Use Linguistically Appropriate Assessment {#linguisticallyAppropriate}

It is important to use assessment approaches that are linguistically appropriate for the examinee [@Leong2016].\index{diversity!assessment of minority populations}
First, the measure should be in a language that is understood by the examinee.
Second, the measure should be consistent with the examinee's language ability.
Sometimes interpreters or translators may be necessary.\index{diversity!assessment of minority populations}
However, use of interpreters has been shown to lead to under-estimations of patients' emotion suffering and despair [@Leong2016].\index{diversity!assessment of minority populations}
In addition, clients and therapists can attach different meanings to the same words.\index{diversity!assessment of minority populations}
It is thus important not to assume that you know what the client means by various terms and not to assume that the client knows what you mean by various terms.\index{diversity!assessment of minority populations}

#### Use Follow-Up As Necessary {#followUp-diversity}

As described by @Suzuki2013, it may be necessary to use follow-up procedures to clarify people's responses to items or to test the limits by readministering items with additional supports (e.g., modifying instructions to involve more or fewer cues, adjusting the pace of information presented, adjusting memory demands, changing the response format) [@Sattler2006].\index{diversity!assessment of minority populations}
When deviating from standardized procedures, it is important to describe such deviations in resulting papers or reports.\index{diversity!assessment of minority populations}

#### Examine and Correct for Test Bias {#bias-diversity}

As described in Chapter \@ref(bias), there are two types of [test bias](#bias): [predictive test bias](#predictiveBias) and [test structure bias](#testStructureBias).\index{diversity!assessment of minority populations}\index{bias!correcting for}
It is important to evaluate the possibility of both when using assessments across groups.\index{diversity!assessment of minority populations}

It is important to establish [measurement invariance](#measurementInvariance) across groups to ensure that scores have the same meaning for each group [@Burlew2019].\index{diversity!assessment of minority populations}\index{structural equation modeling!measurement invariance}
If measures are non-invariant, the means (i.e., level) and or associations between constructs could appear to (artifactually) differ across groups, when in reality they do not [@Chen2008].\index{diversity!assessment of minority populations}\index{structural equation modeling!measurement invariance}
[Measurement invariance](#measurementInvariance) can be examined in terms of item intercepts, item factor loadings, and item residuals.\index{diversity!assessment of minority populations}\index{structural equation modeling!measurement invariance}\index{structural equation modeling!intercept}\index{structural equation modeling!factor loading}\index{structural equation modeling!residual}
Establishing measurement invariance of just intercepts or factor loadings (or vice versa) is not sufficient to establish measurement invariance because tests can show strong [bias](#bias) in one dimension (e.g., intercepts) even if the test does not show bias in other dimensions (e.g., factor loadings) [@Wicherts2010].\index{diversity!assessment of minority populations}\index{structural equation modeling!measurement invariance}\index{structural equation modeling!intercept}\index{structural equation modeling!factor loading}
Approaches for evaluating [measurement invariance](#measurementInvariance) across groups are described by @Han2019.\index{diversity!assessment of minority populations}\index{structural equation modeling!measurement invariance}
To help minimize the potential for [test bias](#bias), reseachers are encouraged to develop the scales simultaneously across the different groups or cultures [@Fernandez2018].\index{diversity!assessment of minority populations}\index{bias}

It is also important to determine whether the measure's scores show similar relations to meaningful external criteria [@Burlew2019].\index{diversity!assessment of minority populations}\index{bias!predictive}

@Fernandez2018 provide strategies to address cross-cultural [bias](#bias), such as excluding words or concepts that are specific to one language or culture.\index{diversity!assessment of minority populations}\index{bias}
Use of North American neuropsychological tests in other countries has shown to lead to considerable [false positives](#falsePositive), and the extent of misdiagnosis differs by country [@Daugherty2017].\index{diversity!assessment of minority populations}\index{false positive}

It is important to examine factors that moderate the [validity](#validity) of assessment, e.g., groups for whom the assessment is [biased](#bias).\index{diversity!assessment of minority populations}\index{validity!cultural}\index{bias}
Ways to investigate and detect [bias](#bias) are described in Section \@ref(detectBias).\index{diversity!assessment of minority populations}\index{bias}
The number of potential moderating variables is so large, that it is not realistic to develop an assessment base that encompasses all of these factors and their interactions.\index{diversity!assessment of minority populations}
Evidence should be used regarding which factors seem to matter for a given assessment purpose—that is, the factors that have a medium-to-large effect size.\index{diversity!assessment of minority populations}
It is valuable to examine the effect size of moderators; if the effects are small, it might not be sufficient to scrap the instrument for the population.\index{diversity!assessment of minority populations}
Gender and cultural differences have shown a number of statistically significant effects for a number of different assessment purposes, but many of the observed effects are quite small and likely trivial, and they do not present compelling reasons to change the assessment [@Youngstrom2016].\index{diversity!assessment of minority populations}
Nevertheless, if you do find evidence of [bias](#bias), it is important to correct for it.\index{diversity!assessment of minority populations}\index{bias!correcting for}
Ways to correct for [bias](#bias) using score adjustment and other approaches are discussed in Section \@ref(correctForBias).\index{diversity!assessment of minority populations}\index{bias!correcting for}

### Consider Pathoplasticity of Constructs {#pathoplasticity}

Constructs can manifest differently across cultures.\index{diversity!assessment of minority populations}
Pathoplasticity of mental disorders refers to the variability in symptoms, course, outcome, and distribution of mental disorders among various cultural groups [@Leong2016].\index{diversity!assessment of minority populations}
Some syndromes are considered culture-bound—that is, they exist in some cultures but not in other cultures.\index{diversity!assessment of minority populations}\index{culture!cultural bound syndrome}
Hwabyung is a Korean culture-bound syndrome in which suppressed negative emotions manifest themselves in bodily ways such as chest pains and difficulty breathing.\index{diversity!assessment of minority populations}\index{culture!cultural bound syndrome}
In addition, features associated with a disorder, including the content, severity, or frequency of symptoms, may vary across cultures.\index{diversity!assessment of minority populations}

For instance, Asian Americans tend to report a greater degree of psychological disturbance than Whites, which could be due to several reasons [@Leong2016].\index{diversity!assessment of minority populations}
It is possible that Asian Americans (a) show higher rates of mental health problems than other groups, (b) under-utilize mental health services, and/or (c) are more likely than other groups to be misdiagnosed due to miscommunication, use of [invalid](#validity) instruments for Asian Americans, and/or lack of cultural knowledge on the part of therapists.\index{diversity!assessment of minority populations}
In addition, how clients act in a diagnostic interview may depend on cultural factors, and it thus may be important to sample the clients more broadly than a diagnostic interview [@Leong2016].\index{diversity!assessment of minority populations}\index{interview}

For a case example of pathoplasticity, there is a disorder among the traditional Navajo called "Moth Madness" [@APAOfficeEthnicMinorityAffairs1993].\index{diversity!assessment of minority populations}
Symptoms of Moth Madness include seizure-like behaviors.\index{diversity!assessment of minority populations}
This disorder is believed by the Navajo to be the supernatural result of incestuous thoughts or behaviors.\index{diversity!assessment of minority populations}
Both differential diagnosis and intervention should take into consideration the traditional values of Moth Madness.\index{diversity!assessment of minority populations}

### Formulate a Culturally Informed Case Conceptualization {#culturallyInformedCaseConceptualization}

It can be helpful to discuss your diagnosis and case conceptualization with the client.\index{diversity!assessment of minority populations}\index{case conceptualization}
For instance, you may learn that some behaviors are normative in their culture and may not be distressing or concerning to them.\index{diversity!assessment of minority populations}
It can thus be helpful to consider client preferences in terms of what to address and how to address it, while adhering to [evidence-based](#evidence-based) approaches.\index{diversity!assessment of minority populations}\index{evidence-based assessment}
 
### Bias in Clinical Judgment {#biasClinicalJudgment}

As reviewed by @Garb1997, there is evidence of race [bias](#bias), social class [bias](#bias), and gender [bias](#bias) in clinical judgment.\index{clinical judgment!bias}\index{bias!clinical judgment}
Race [bias](#bias), social class [bias](#bias), and gender [bias](#bias) in clinical judgment occurs when the accuracy of judgments varies as a function of client race, social class, or gender.\index{clinical judgment!bias}\index{bias!clinical judgment}
That is, clinical judgment [bias](#bias) occurs when the accuracy of judgments varies as function of other variables (e.g., race, social class, gender).\index{clinical judgment!bias}\index{bias!clinical judgment}
[Bias](#bias) is not when the *judgments* themselves vary as a function of other factors, but when the *accuracy* of those judgments varies.\index{clinical judgment!bias}\index{bias!clinical judgment}
Examining how judgments differ across groups does not control for differences in clinical severity between the groups.\index{clinical judgment!bias}\index{bias!clinical judgment}
If a clinician rates more people in one group as having a disorder than another group, this is not necessarily evidence of [bias](#bias) because the true prevalence of the condition could differ across groups.\index{clinical judgment!bias}\index{bias!clinical judgment}
Thus, it is important to compare groups with similar levels of symptomatology or to control for level of symptomatology.\index{clinical judgment!bias}\index{bias!clinical judgment}
If clinical judgments are more accurate for White clients than Black clients, we would say that race [bias](#bias) exists.\index{clinical judgment!bias}\index{bias!clinical judgment}

Accuracy of judgments could vary by the client's race, social class, or gender for several reasons [@Garb1997].\index{clinical judgment!bias}\index{bias!clinical judgment}
One way in which judgments could be biased is if the diagnostic criteria are [biased](#bias)—for instance, if the diagnoses are more [valid](#validity) for one group (e.g., White clients) than for another group (e.g., Black clients).\index{clinical judgment!bias}\index{bias!clinical judgment}
Another reason that accuracy of judgments could vary as a function of client race, social class, or gender is if the judgments are made based on a [biased](#bias) instrument.\index{clinical judgment!bias}\index{bias!clinical judgment}
Another way that accuracy of judgments could vary as a function of client race, social class, or gender is related to confirmation [bias](#bias) or [biases](#bias) introduced during the usage of a measure.\index{clinical judgment!bias}\index{bias!clinical judgment}
This could occur, for instance if clinicians do not consider alternative hypotheses, and based on their hypotheses, they choose the data to collect that support their hypotheses rather than collecting data that could refute their hypotheses.\index{clinical judgment!bias}\index{bias!clinical judgment}
[Bias](#bias) could also occur in the way that data are integrated from multiple measures or methods.\index{clinical judgment!bias}\index{bias!clinical judgment}
Another form of [bias](#bias) could arise from how test results are used, in terms of inequitable social consequences [@Suzuki2013].\index{clinical judgment!bias}\index{bias!clinical judgment}

Many studies do not find [bias](#bias) in clinical judgments as a function of race, social class, or gender, but some studies do find evidence of [bias](#bias) [@Garb1997].\index{clinical judgment!bias}\index{bias!clinical judgment}

#### Race Bias {#raceBias-clinicalJudgment}

One pattern of race [bias](#bias) is that Black and Latinx patients with a psychotic affective disorder are more likely than White patients to be misdiagnosed as having schizophrenia [@Garb1997].\index{clinical judgment!bias}\index{bias!clinical judgment}
That is, Black and Latinx patients are less likely than White patients to be diagnosed with psychotic affective disorder (with the same symptoms) and are more likely to be diagnosed as having schizophrenia, even when the measures do not indicate that a diagnosis of schizophrenia is justified.\index{clinical judgment!bias}\index{bias!clinical judgment}
Another pattern of race [bias](#bias) is that the risk of violence is over-estimated for Black patients but not for White patients [@Garb1997].\index{clinical judgment!bias}\index{bias!clinical judgment}
In addition, cases of child abuse are more likely to be reported when children are White than when they are Black (even when comparing similar behavior) [@Garb1997].\index{clinical judgment!bias}\index{bias!clinical judgment}
Race [bias](#bias) has also been observed with respect to antipsychotic medication.\index{clinical judgment!bias}\index{bias!clinical judgment}
Antipsychotic medications are more often prescribed for Black patients than for other patients even for similar levels of psychosis [@Garb1997].\index{clinical judgment!bias}\index{bias!clinical judgment}
Moreover, affective symptoms in patients who are severely ill are more often under-treated for Black or Latinx patients than for White patients [@Garb1997].\index{clinical judgment!bias}\index{bias!clinical judgment}
Another potential pattern of race [bias](#bias) is that, compared to non-Hispanic White children, racial/ethnic minorities appear to be more likely to be diagnosed with a disruptive behavior disorder rather than attention-deficit/hyperactivity disorder (ADHD) [@Fadus2020]; however, it is not yet known whether this holds when comparing individuals with the same symptom presentation.\index{clinical judgment!bias}\index{bias!clinical judgment}

#### Social Class Bias {#socialClassBias-clinicalJudgment}

One pattern of social class [bias](#bias) is that child abuse is more likely to be reported if a child is from a lower-class background rather than a middle- or upper-class background (even when comparing similar behavior) [@Garb1997].\index{clinical judgment!bias}\index{bias!clinical judgment}
In addition, middle-class children are more likely to be referred to special education programs compared to lower-class children [@Garb1997].\index{clinical judgment!bias}\index{bias!clinical judgment}
There is also social class [bias](#bias) in clinicians' decisions about psychotherapy.\index{clinical judgment!bias}\index{bias!clinical judgment}
Referrals for psychotherapy are more often made for middle-class clients than for lower-class clients [@Garb1997].\index{clinical judgment!bias}\index{bias!clinical judgment}
Clinicians are more likely to recommend psychotherapy and expect a client to do well in psychotherapy when the client is from a middle- or upper-class background compared to when the client is from a lower-class background, leading to a tendency for clinicians to refer clients to different types of treatments based on the client's social class [@Garb1997].\index{clinical judgment!bias}\index{bias!clinical judgment}
Specifically, lower-class clients are more likely to be referred for supportive psychotherapy, whereas middle-class clients are more likely to be referred for insight-oriented psychotherapy.\index{clinical judgment!bias}\index{bias!clinical judgment}

#### Gender Bias {#genderBias-clinicalJudgment}

One pattern of gender [bias](#bias) is that women are more likely than men to be diagnosed with a histrionic personality disorder, whereas men are more likely than women to be diagnosed with antisocial personality disorder, even when female and male clients do not differ in symptomatology [@Garb1997].\index{clinical judgment!bias}\index{bias!clinical judgment}
Another pattern is that clinicians tend to over-estimate likelihood of violent behavior for male clients and under-estimate likelihood of violent behavior for female clients [@Garb1997; @McNiel1995].\index{clinical judgment!bias}\index{bias!clinical judgment}
Although males tend to show more violence than females, studies have shown that [false positives](#falsePositive) tend to be more common for male patients than female patients, whereas [false negatives](#falseNegative) tend to be more common for female patients than male patients [@McNiel1995].\index{clinical judgment!bias}\index{bias!clinical judgment}

In terms of autism, some conceptualizations of autism consider it to be a manifestation of "extreme male brain" [@BaronCohen2002; @BaronCohen2010; @Greenberg2018].\index{clinical judgment!bias}\index{bias!clinical judgment}
Girls diagnosed with autism tend to be more severely affected than boys diagnosed with autism.\index{clinical judgment!bias}\index{bias!clinical judgment}
People are less likely to notice autism in girls.\index{clinical judgment!bias}\index{bias!clinical judgment}
This could possibly be due to girls with autism having fewer restricted interests and lower levels of repetitive behavior compared to boys.\index{clinical judgment!bias}\index{bias!clinical judgment}
Research has tried to develop assessments to equate boys and girls, but girls and boys appear to be unequal in their underlying autism process—that is, boys and girls appear to show sex-specific autism phenotypes [@Frazier2014].\index{clinical judgment!bias}\index{bias!clinical judgment}

#### Recommendations for Reducing Bias in Clinical Judgment {#reducingBias-clinicalJudgment}

Below are recommendations for reducing [bias](#bias) in clinical judgment [@Garb1997], including:\index{clinical judgment!bias!reducing}

- Be aware of [biases](#bias) that have been reported in the clinical judgment literature.\index{clinical judgment!bias!reducing}
- Give the clinician timely and specific feedback on their judgments.\index{clinical judgment!bias!reducing}
- Use standardized and structured assessment approaches and attend strictly to diagnostic criteria when making diagnoses.\index{clinical judgment!bias!reducing}
- Use [actuarial approaches](#actuarial) and statistical prediction rules.\index{clinical judgment!bias!reducing}\index{actuarial}

### Use Appropriate Normative Data {#appropriateNorms}

When group-referenced judgments will be used, it is important to consider what the appropriate [norm](#norm) is.\index{diversity!assessment of minority populations}\index{norm}
The question of whether separate [norms](#norm) should be used for various racial/ethnic minority groups is of considerable controversy [@Burlew2019].\index{diversity!assessment of minority populations}\index{norm}\index{norm-referenced!race}
Pros and cons of using group-specific [norms](#norm) are discussed in Section \@ref(withinGroupNorming) and reviewed by @Manly2005.\index{diversity!assessment of minority populations}\index{norm}\index{norm-referenced}
The question about which [norms](#norm) to use is complex, and psychologists should evaluate the cost and benefit of each [norm](#norm), and use the [norm](#norm) with the greatest benefit and the least cost for the client [@Manly2007].\index{diversity!assessment of minority populations}\index{norm}\index{norm-referenced}
@Burlew2019 recommend limiting the use of measures that require the use of [norms](#norm) to interpret, and to note in the limitations of a paper or report if a [norm](#norm) based on one group is used to evaluate a person from a different group.\index{diversity!assessment of minority populations}\index{norm}\index{norm-referenced}

### Contextualize Group-Related Differences {#contextualizeGroupDifferences}

When conducting research and identifying different scores between groups, it is important to be cautious not to assume that differences in the scores between groups are caused by the group membership.\index{diversity!assessment of minority populations}
That is, correlation does not necessarily mean causation!\index{diversity!assessment of minority populations}\index{correlation!causation}
For instance, if the researcher identifies higher rates of suicide in transgender than cisgender individuals [as has been observed, @Toomey2018], it is important not to automatically assume the higher suicide rate is *because of* the person's transgender status, per se.\index{diversity!assessment of minority populations}
Rather, there are likely many aspects of discrimination and victimization that transgender individuals experience that, unfortunately, may increase their suicide rate relative to cisgender individuals.\index{diversity!assessment of minority populations}

It is important to contextualize test score differences between groups within sociocultural and historical inequities rather than interpreting group-related differences in tests scores from a deficit-based narrative [@Byrd2021].\index{diversity!assessment of minority populations}
It is important to avoid interpretive [bias](#bias) and to pay attention not to over- or under-pathologize [@Okazaki1995].\index{diversity!assessment of minority populations}
Over-pathologizing can lead to stigmatization and institutionalization.\index{diversity!assessment of minority populations}
Under-estimating psychopathology can deprive patients of treatments or services that they would benefit from.\index{diversity!assessment of minority populations}
For instance, one should be aware of the danger of under-estimating psychopathology for clients from different cultures (from that of the therapist) through over-attributing bizarre behavior or thought patterns to the client's culture [@Okazaki1995].\index{diversity!assessment of minority populations}

### Dissemination and Implementation {#disseminationImplementation-diversity}

Dissemination and implementation deals not just with finding differences between groups, but what to do about these differences.\index{diversity!assessment of minority populations}
Aspirationally, we would successfully be able to custom-tailor treatments to individuals based on their individual characteristics.\index{diversity!assessment of minority populations}
The goal is to identify the best treatment for each group, or ideally, each individual.\index{diversity!assessment of minority populations}

### Use Inclusive and Bias-Free Language {#inclusiveLanguage}

It is important to use bias-free language, as discussed in the Publication manual of the American Psychological Association [APA; @APA2020].\index{diversity!assessment of minority populations}
Guidelines for bias-free language include the following:\index{diversity!assessment of minority populations}

1. Describe at the appropriate level of specificity\index{diversity!assessment of minority populations}
    a. Focus on relevant characteristics\index{diversity!assessment of minority populations}
    b. Acknowledge relevant differences that exist\index{diversity!assessment of minority populations}
    c. Be appropriately specific\index{diversity!assessment of minority populations}
2. Be sensitive to labels\index{diversity!assessment of minority populations}
    a. Acknowledge people's humanity\index{diversity!assessment of minority populations}
    b. Provide operational definitions and labels\index{diversity!assessment of minority populations}
    c. Avoid false hierarchies\index{diversity!assessment of minority populations}
    
When writing reports, manuscripts, or in conversation, it can be helpful to use [inclusive](#inclusion) and person-first language.\index{diversity!assessment of minority populations}
The aim of people-first language is to reduce stigma because it treats everyone as a human first.\index{diversity!assessment of minority populations}
People-first language puts the person before the disability and describes the difficulties a person has rather than who a person is.\index{diversity!assessment of minority populations}
For instance, say "a child with intellectual disability" instead of "an intellectually disabled child".\index{diversity!assessment of minority populations}
That said, some individuals may prefer identity-first labels (e.g., autistic person) rather than person-first labels for their own identities.\index{diversity!assessment of minority populations}
Thus, it is important to use the labels preferred by the particular client.\index{diversity!assessment of minority populations}
The APA guidelines for inclusive language are located here:\index{diversity!assessment of minority populations} https://www.apa.org/about/apa/equity-diversity-inclusion/language-guide.pdf (archived at https://perma.cc/82QH-ED96).

## Conclusion {#conclusion-diversity}

Diverse samples provide stronger tests of theories and better generalizability of findings ([external validity](#externalValidity)).\index{diversity}\index{validity!external}
We need measures that are [reliable](#reliability) and [valid](#validity) for all people we use them with.\index{reliability}\index{validity}
There are various [multicultural frameworks to assessment](#multiculturalFrameworks).\index{multicultural assessment}
[Guidelines for assessment of diverse populations](#guidelinesForAssessmentWithDiversePopulations) are discussed.\index{diversity!assessment of minority populations}
Recommendations include developing and using [appropriate](#appropriateMeasurement) and [valid](#validity) measures for the target population(s), [ensuring fair group comparisons](#ensuringFairGroupComparisons), seeking [training and consultation](#trainingAndConsultation), developing [awareness of cultural differences](#awarenessOfCulturalDifferences), showing [cultural humility](#culturalHumility), avoiding [assuming or stereotyping](#avoidAssumptions), ensuring [adequate representation](#adequateReprentations) of under-represented minorities, considering [pathoplasticity](#pathoplasticity) of constructs, formulating a [culturally informed case conceptualization](#culturallyInformedCaseConceptualization), using [appropriate normative data](#appropriateNorms), [contextualizing group-related differences](#contextualizeGroupDifferences), and using [inclusive language](#inclusiveLanguage).\index{diversity!assessment of minority populations}

## Suggested Readings {#readings-diversity}

@Burlew2019; @Byrd2021; @Okazaki1995