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In Congo, we collected normative data from the healthy population stratified by age, education, sex, and region of residence. We were able to show acceptable internal consistency reliability and found that the ANB was able to distinguish neurologic patients from healthy controls, and detected the impact of poor nutrition, exposure to environmental toxins and contaminated water, meningitis, hypertension, diabetes, and alcohol abuse on cognitive performance. After completing this initial normative and validation study in Congo, and with a grant from the National Academy of Neuropsychology (NAN) Clinical Research Grant Program, we have begun to explore the impact of African enculturation on ANB performance. Enculturation involves the acquisition of the knowledge and skills necessary for functioning competently within a particular culture including the language, values, preferences, rituals, etc., shared by members of the culture (Bolaffi, Bracalenti, Braham, & Gindro, 2003). In common usage, the term refers to acquisition of knowledge about the culture into which one is born. Closely related to this is the concept of acculturation, which refers to the acquisition of knowledge about a culture that is different from one's birth culture that comes about as a result of contact with members of the new culture (Berry, 2015; Bolaffi et al., 2003). Depending upon how similar their birth culture is to the cultural environment of the U.S., African immigrants may be at a disadvantage due to a lack of American acculturation. What happens, however, when the clinical neuropsychological test battery is not the equivalent of a borrowed Somali donkey, but instead is culturally appropriate for the SSA immigrant? This is what, with support from the NAN grant, we are attempting to determine. Our initial results suggested that the relationship between African enculturation and ANB performance is complicated and not always in line with expectation. When asked via a questionnaire about how frequently they engage with African food, music, festivals, etc., not surprisingly, African immigrants show greater African enculturation than do Caucasian Americans, and African Americans score in between these two groups. African enculturation also correlated with the ability to identify fruits and objects common in Africa, but not in the U.S. As we expected, African immigrants are more accurate in identifying African fruits and objects than are Caucasians. African Americans were in the middle in identifying African cultural objects, scoring lower than immigrants and higher than Caucasians, but not differing statistically from either group. For African fruits, African Americans had no advantage over Caucasians, and both groups were worse than immigrants. African enculturation, however, did not correlate with visuospatial memory despite the use of stimuli from Africa. Caucasians performed as well as Africans, but both groups showed a statistical advantage compared to African Americans. Perhaps the most interesting result of all was what we failed to see. We failed to see a difference between African immigrants, African Americans, or Caucasians on the majority of the ANB tests. Even where a statistically significant difference was present, it had little practical significance (e.g., Africans on average could name 1-2 more fruits than African Americans and Caucasians) and what small advantage that was present, favored African immigrants. While failing to reject a null hypothesis does not mean we can say with certainty that the ANB eliminates cultural bias in assessing African and African immigrant populations, the results are encouraging. We have much more normative research to do and anticipate further fine-tuning of the ANB. Nonetheless, we are considerably closer to having an inexpensive, culturally appropriate, and clinically valid battery for comprehensive neuropsychological assessment both in SSA and in the ever- increasing African immigrant population in the USA. Clinical neuropsychologists working with African populations may one day be able to return those borrowed donkeys. References Anderson, M. (2017, Feb 14). African immigrant population in U.S. steadily climbs. Pew Research Center. Retrieved from http://pewrsr.ch/2l55fhT. Berry, J. W. (2015). Acculturation. In J. E. Grusec, & P. D. Hastings, (Eds.), Handbook of socialization: theory and research (2nd ed.) (pp. 520-540). New York: Guilford Press. Bolaffi, G., Bracalenti, R., Braham, P. l., & Gindro, P. (2003). Dictionary of race, ethnicity, and culture. London, Sage. Boivin, M. J., & Giordani, B. (2013). Neuropsychology of children in Africa. Perspectives on risk and resilience. New York, NY: Springer. Feigin, V. L, (2005). Stroke epidemiology in the developing world. Lancet, 365(9478), 2160–2161. Hestad, K. A., Menon, J. A., Serpell, R., Kalungwana, L., Mwaba, S. O. C., Kabuba, N., … Heaton, R. (2015). Do neuropsychological test norms from African Americans in the United States generalize to a Zambian population? Psychological Assessment, 28, 18-38. Maj, M., Janssen, R., Satz, P., Zaudig, M., Starace, F., Boor, D., . . .Sartorius, N. (1991). The World Health Organization's cross cultural study on neuropsychiatric aspects of infection with the human immunodeficiency virus 1 (HIV-1). British Journal of Psychiatry, 159, 351-356. Mpanya, A., Boelaert, M., Baloji, S., Matangila, J., Lubanza, S., Bottieau, E, . . . Hendrickx, D. (2014). Diagnostic work-up of neurological syndromes in a rural African setting: Knowledge, attitudes, and practices of health care providers. PLoS ONE 9(10), e110167. doi: 10.1371/journal.pone.0110167. Unverzagt, F. W., Hall, K. S., Torke, A. M., Rediger, J. D., Mercado, N., Gureje, O, . . . Hendrie, H. C. (1996). The Effects of age, education, and gender on CERAD neuropsychological test performance in an African American sample. The Clinical Neuropsychologist, 10 (2), 180-190. Zong, J, & Batalova, J. (2017, May 3). Sub-Saharan African immigrants in the United States. Migration Information Source. Retrieved from https://www. migrationpolicy.org/article/sub-saharan-african-immigrants-united-states. 22 | Bulletin vol. 33 no. 1

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