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ORIGINAL RESEARCH ARTICLE
Culture and Brain (2022) 10:167–193
https://doi.org/10.1007/s40167-022-00111-6
Abstract
In modern neuropsychology, the acknowledgment of cultural variables and their 
significant influence on cognitive development and performance spawned the de-
velopment of cross-cultural neuropsychological tests. This article describes the de-
velopment and psychometric properties of the Multicultural Neuropsychological 
Scale (MUNS), a screening scale that includes stimuli common to most cultures in 
the world. It is appropriate for use with adults and the elderly and with lower and 
higher education participants. In the validity study, we compared the performances 
of control and cognitively impaired participants. Test reliability was assessed using 
the standardized regression-based method (n = 71). Norms were developed using 
a regression-based method. One hundred and eighty-four Spanish-speaking par-
ticipants of both sexes were recruited for the normative sample. Participants were 
between 15 and 80 years old. The education range was 4–20 years of schooling. 
Evidence for its cross-cultural utility was obtained by comparing the performance 
of two (Argentinian and American) age and education matched samples. Mean dif-
ferences between the control and clinical groups were significant, yielding a large 
effect size (η2 = 0.20). Raw MUNS retest total scores were predicted by MUNS pre-
test total score and age. Age, reading fluency, and years of schooling significantly 
influenced test scores. The validity study confirmed that the test discriminates be-
tween individuals with and without cognitive impairments, including participants 
with mild cognitive impairments. Reliability is satisfactory. The performance of 
both samples showed no significant differences between them in all subtests except 
for one.
Keywords Multicultural neuropsychological scale · Validity · Reliability · 
Normative data
Accepted: 12 June 2022 / Published online: 8 August 2022
© The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature 2022
The multicultural neuropsychological scale (MUNS): 
validity, reliability, normative data and cross-cultural 
evidence
Alberto Luis Fernández1,2  · Gabriel Jáuregui Arriondo1  · 
Maximiliano Folmer3  · Marcelo Vaiman1,2 · Gazul Rotela Leite1  · 
David J. Hardy4,5
Extended author information available on the last page of the article
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A. L. Fernández et al.
Introduction
Increasing migratory movements resulted in an estimated population of 271,642,105 
migrants around the world in 2019 (United Nations, 2019). Brain impairing condi-
tions that may affect migrants, from traffic or workplace accidents to even stroke and 
dementia, can and will affect a portion of migrants everywhere. Consequently, many 
of them will need neuropsychological services. Unfortunately, most current neuro-
psychological tests are not appropriate for the assessment of migrant populations. As 
an overwhelming majority have been developed in Western cultures, neuropsycho-
logical tests contain culturally specific information that makes them inappropriate 
for use on populations not pertaining to these cultures. Examples of culturally biased 
tests include the Trail Making Test, the Boston Naming Test, the Weschler Memory 
Scale (WMS), and the California Verbal Learning Test. Examples of how cultural 
bias is woven into the fabric of these tests are easy to find. For example, in the WMS, 
the logical memory section tells participants a story of a fictional character named 
Anna Thompson, who lives in South Boston. The name and city of this narrative’s 
character, however commonplace they may be in the United States, are unfamiliar to 
test givers and test subjects who are from or live in the Middle East, Asia or Africa. 
Despite only being appropriate for Western cultures, tests such as the WMS are still 
some of the most used around the world.
Not only are these tests not culturally appropriate, but they are also not devel-
oped for the assessment of participants with lower levels of education. Psycholo-
gists at Western universities designed most of these tests and then used them on the 
population sample most easily accessible in their context: young and highly educated 
students. This population is known for being WEIRD–Western, Educated, Industrial-
ized, Rich, and Democratic–and therefore not representative of the world as a whole 
(Henrich, Hein, & Norenzayan, 2010). The estimated world literacy rate is 86%, 
which means that around 750 million adults, cannot read or write (UNESCO Institute 
for Statistics, 2017). Furthermore, according to the United Nations, one-third of the 
244 million migrants estimated in the world in 2013 only had a few years of educa-
tion, none of which took place at a level higher than secondary education (United 
Nations-OECD, 2013). It is apparent that current neuropsychological tests are appro-
priate only for a minority of the world population.
The most common answer to resolve these issues has been adapting tests, but test 
adaptation involves a long and costly process that is usually not affordable in envi-
ronments where neuropsychology is not well developed (Fernandez & Evans, 2022). 
In addition, while these attempts often address the issue of cultural bias, the issue of 
inadequacy for testing populations with lower education levels urgently remains on 
the table.
An alternative solution is the development of cross-cultural tests (CCTs) which 
are tests developed from the outset for use in different cultural settings. They include 
universal stimuli that are common to most cultures, in an attempt to avoid cultural 
specifics. For example, CCTs avoid the use of letters of the alphabet, proper names, 
currency or specific geographic references such as cities or regions. This approach 
does not resolve all issues since some cognitive domains require cultural or language-
specific tests. For instance, when it comes to language assessment, it is impossible to 
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The multicultural neuropsychological scale (MUNS): validity, reliability,…
conduct a deep analysis of language functions such as grammar, syntax or vocabulary, 
without a test specifically designed for the target language. Such characteristics vary 
in each language. Despite these limitations, CCTs allow for the development of a tool 
that is easy to translate and most likely demands few or no adaptations. This adapt-
ability is particularly important in regions of the world in which neuropsychology 
is not well developed. In addition, it is highly convenient for use in countries where 
neuropsychologists must frequently assess migrants, asylum seekers, refugees and 
immigrants. As it stands, fair and accurate client assessment is more feasible when 
using evaluation tools created with culturally appropriate stimuli and designed in the 
native languages of both neuropsychologists who administer tests and the migrant 
populations that take them.
There are a number of successful CCTs, including the Rowland Universal Demen-
tia Assessment (RUDAS), the Cross-Cultural Dementia Screening (CCD), and the 
European Cross-Cultural Neuropsychological Test Battery (CNTB). RUDAS, a brief 
cognitive screening test created to minimize effects of cultural learning and language 
differences when it comes to evaluating baseline cognitive performance, has dem-
onstrated high sensitivity across multicultural samples and has been translated into 
around a dozen languages (Komalasari, Chang & Traynor, 2019). The CCD, a neu-
ropsychological tool designed in Europe for the screening of dementia in immigrant 
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The multicultural neuropsychological scale (MUNS): validity, reliability,…
Authors and Affiliations
Alberto Luis  Fernández1,2 · Gabriel Jáuregui  Arriondo1 · Maximiliano  Folmer3 · 
Marcelo  Vaiman1,2 · Gazul Rotela  Leite1 · David J.  Hardy4,5
 
 Alberto Luis Fernández
neuropsicologia.filo@ucc.edu.ar
1 Department of Neuropsychology, Universidad Católica de Córdoba, Córdoba, Argentina
2 Psychometrics Department, Universidad Nacional de Córdoba, Córdoba, Argentina
3 School of Psychology, University of Padua, Padua, Italy
4 Department of Psychological Science, Loyola Marymount University, Los Angeles, USA
5 Department of Psychiatry and Biobehavioral Sciences, University of California, Los 
Angeles, Los Angeles, USA
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	The multicultural neuropsychological scale (MUNS): validity, reliability, normative data and cross-cultural evidence
	Abstract
	Introduction
	Methods
	Study 1. Development of materials
	Sample
	Procedure
	Data analysis
	Study 2. Validity
	Study 3. Reliability
	Study 4. Normative study
	Study 5. Cross-cultural comparison
	Results
	Discussion
	Appendix
	Referencespres-
ent (Goudsmit et al., 2017). The CNTB, created for use on populations in Western 
Europe to identify cognitive impairments for various subtypes of dementia, is yet 
another example of a successful CCT (Nielsen et al., 2018). These tests are all exam-
ples of CCTs that are useful when evaluating immigrant populations.
However, most current CCTs, including the examples previously mentioned, are 
aimed at assessing the elderly as most of them have been devised to diagnose demen-
tia. There are no CCTs developed for adults or young adults to date. The Multicul-
tural Neuropsychological Scale (MUNS) was developed as a CCT that is suitable 
for ages 15 to 90 and over (Fernandez et al., 2018). The MUNS was projected as a 
neuropsychological assessment tool that is (a) a cross-cultural test; (b) a screening 
test; (c) capable of providing more information than a brief test; (d) appropriate for 
use with adults and elderly; (e) able to assess major cognitive functions; (f) appropri-
ate for lower and higher education subjects; (g) psychometrically robust; (h) able to 
accurately discriminate patients with mild cognitive dysfunctions from healthy par-
ticipants; (i) easy for test administrators to implement and (j) inexpensive.
The MUNS is a short scale devised with universal stimuli that are easy to trans-
late into different languages. It consists of seven subtests evaluating five cognitive 
domains: attention, memory, executive functioning, constructional praxis, and lan-
guage. In comparison to existing CCTs the MUNS was designed to convey more 
information. For example, three subtests cover memory, and each subtest includes 
several items. Moreover, some subtests, such as the Word List, have a similar format 
to current standard tests for memory assessment. It also has two versions, one that is 
appropriate for lower education participants, and another for higher education par-
ticipants. This article describes the following features of the MUNS: (a) the develop-
ment of materials; (b) the validity characteristics; (c) the reliability characteristics; 
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(d) normative data for Argentinian higher education participants, and; (e) a cross-
cultural study.
Methods
Study 1. Development of materials
Figure 1 describes the whole process of the development of the MUNS. The MUNS 
includes seven subtests evaluating five cognitive domains: attention (1 subtest), 
memory (1 visual and 2 verbal subtests), executive functioning (1 subtest), construc-
tional praxis (1 subtest) and language (1 subtest). The subtests are the following: 
Arrows, for attention; Personage and Word List, for verbal memory; Visual Memory; 
Party, for executive functioning; Dots and Lines, for constructional praxis; and Ani-
mals, for language (see Table 1 for a detailed description of each test).
The stimuli were selected to be understood by people from most cultures. For 
instance, for the Word List subtest, the words included were taken from the Swadesh 
Fig. 1 Flowchart of the different 
stages in the developement of the 
MUNS
 
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list, which is a lexicostatistical list that represents the Basic Core Vocabulary exist-
ing in any language (Swadesh, 1971). Therefore, this subtest is easily translated into 
probably every language. The Visual Memory test includes pictures of the following 
elements: hand, leaf, flower and building. These are stimuli easily recognizable by 
habitants of most cultures. Most of the administration materials are included in a 
stimulus book. Five answer sheets are needed for the Party, Visual Memory, immedi-
ate and delayed, and the Dots and Lines subtests. Four out of the seven subtests have 
Table 1 MUNS subtests description
Word List 
subtest (WL)
The version for LE comprises 10 words while for HE contains 14 words. All the words 
included in this list were taken from the Swadesh list, which is a lexicostatistical list 
that represents the Basic Core Vocabulary existing in any language. They belong to 
two semantic categories (natural elements such as wind or cloud, and body parts). The 
examiner reads the list for three learning trials. A delayed free recall trial is given after 
20 minutes. A recognition trial follows the free recall. Three scores are obtained: Im-
mediate (learning trials 1–3), Delayed and Recognition (individuals are presented with 
a list containing the learning trials words and distractors. Subjects must recognize the 
words in the learning trials list).
Personage 
subtest (Per)
In this verbal memory test, a short paragraph with personal information about a ficti-
tious character is read to the testee whose task is to remember this information. Words 
for the information were also taken from the Swadesh list. There is not an immediate 
trial but a delayed free recall trial after 15–20 minutes and a cued recall trial with 
questions about the information that the testee did not remember spontaneously. Two 
scores can be obtained: Spontaneous Recall and Cued Recall.
Visual Mem-
ory subtest 
(VM)
This subtest consists of a series of 4 pictures of universal elements (flower, leaf, hand, 
building). The pictures are divided into several sections and some of them are filled. 
Subjects are shown the picture for 10 seconds and immediately after the picture is 
removed they are presented with the same picture but with all the sections blank. The 
task of the subjects is to fill in the blanks as shown in the previous picture. There is an 
immediate and a delayed essay. The number of hits is computed to obtain the score for 
the immediate and delayed trials.
Arrows sub-
test (Arr)
This is an attention subtest with two parts: in part I a series of pictures containing 
arrows pointing in different directions are shown every two seconds. The testee must 
count the arrows pointing to the right. In part II the subject has to count arrows point-
ing up and to the left. The LE subjects are asked to carry on a single account (adding 
both arrows), while HE individuals are asked to keep two separate accounts. 
Party Subtest 
(P)
In this executive functioning test, the subject is given a sheet containing a map of a 
fictitious downtown. On the map, there are marked spots indicating shops where the 
following items can be purchased: food, drink, silverware, table, chairs and dessert. 
There is more than one option where to buy these items and the price in number of 
coins (indicated beside each item) is different for each one. Subjects are asked to buy 
one item of each category trying not to exceed a 100 coins budget. In addition, the 
subjects have to indicate the route that they will take to buy all these items with a line 
on the map. They are asked to take the shortest possible route. The scoring system of 
the Party subtest is based on a combination of scores obtained according to the number 
of items purchased, the blocks traveled to complete the route, and the number of occa-
sions in which the participant crosses the line over a block instead of using the streets.
Dots and 
Lines subtest 
(DL)
In this visuoconstructional praxis subtest subjects are shown four designs comprised 
of a set of points that are connected with lines. Their task is to copy the figure in a set 
of points that are adjacent to the design. The number of correctly connected lines is 
scored.
Animals test 
(A)
In this case, subjects are asked to say as many animals as they can in two minutes. The 
two minute period was selected on the basis that names of animal differ in their length 
across languages. One point per item is given.
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two versions depending on the educational level of the testee (Word List, Person-
age, Party and Arrows). The development of different versions for lower and higher 
education participants was based on previous research showing that participants with 
lower education have difficulty solving some of the current neuropsychologicaltests 
in use around the world (Julayanont & Ruthirago, 2016; Nell, 2000). This usually 
produces a floor effect on their performance. The two versions differ in extension 
(verbal memory and executive functioning subtests) or in the cognitive load (atten-
tion test). Pilot trials were run in order to determine the extension and difficulty level 
for each version. For example, on the Word List subtest, participants with lower edu-
cation are presented with a 10 word list, while the participants with higher education 
are asked to remember 14 words. For the Personage subtest, participants with lower 
education are presented with a story containing 10 items of information about a fic-
tional character, while the story for participants with higher education contains 15 
items. In the Party test, lower education participants are presented with fewer options 
of items to purchase. While higher education participants are given three options per 
item, lower education participants are given just two. The educational level of the 
testee was based on the formal years of schooling completed. Those with less than 
eight years of schooling were included in the lower education group (LE); whereas 
those with more than seven years of schooling were included in the higher education 
group (HE).
Sample
The MUNS was administered to 72 Argentinian adults of both sexes (65% female) 
and an educational range between 1 and 20 years of education (M = 9.1 SD = 4.1), who 
gave their consent to participate. The MUNS was also administered to a participant 
who was illiterate. He was not amenable to testing, therefore he was not included 
in the analyzed data. The age range was 15–87 (M = 34.54 SD = 19.3). The sample 
was comprised of participants recruited from several sources: university students, 
individuals attending teaching programs, workers from medical institutions, teaching 
programs for older adults, as well as acquaintances or relatives of test administra-
tors. The inclusion of each participant required that the health backgrounds of the 
participant were explored through a set of questions. Participants with any of the 
following diagnoses were excluded from this sample: stroke, loss of consciousness 
(at least 20 minutes), traumatic head injury, central nervous system disease, chronic 
renal insufficiency, hepatic encephalopathy, non-treated thyroid disease, epilepsy, 
non-treated high blood pressure, severe cardiac failure, severe sleep disorders, coma, 
diagnosed psychiatric disease or illegal drug consumption. Several participants from 
a rural area were included in the sample. The participants included in this study were 
not included in the samples of the subsequent studies.
Procedure
On average, administration of the Spanish version of the MUNS took between 30 
and 40 minutes. Administration was performed by several undergraduate psychol-
ogy students and graduate psychologists. To ensure standardized administration and 
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The multicultural neuropsychological scale (MUNS): validity, reliability,…
scoring, all administrators underwent training sessions with the test developers. After 
reviewing test administration instructions, testers practiced administering the instru-
ment, first with other testers and then with individuals who matched the sample used 
in the final studies. The same test administration procedure was followed for the data 
collection of all the studies described in this article.
Test administration was carried out in different settings based on availability 
(classrooms, laboratories, and so forth), under standardized conditions defined as a 
quiet, well-lit room containing only the administrator and participant.
Data analysis
In order to equate the score ranges between educational groups all scores were 
transformed to percentages. For the Animals subtest, a hypothetical maximum of 60 
points was set to obtain the percentage. The subtests scores were added to compose 
the total score.
Study 2. Validity
Sample
Two groups of Argentinian participants, control (C) (n = 51) and clinical (Cl) (n = 39), 
were compared. All participants gave their informed consent to be tested. Both 
groups were matched for years of education, reading fluency, and age. Table 2 shows 
the demographic characteristics of both groups. The recruiting procedure and exclu-
sion criteria were identical to Study 1. Handedness was distributed as follows: 86% 
right-handed, 12% ambidextrous, and 2% left-handed.
The Cl group was comprised of diverse clinical cases including mild cognitive 
impairment, neurologic diseases such as epilepsy, stroke, multiple sclerosis, Parkin-
son’s disease, dementia and head trauma, and a subgroup of non-neurologic con-
ditions affecting cognition. This last group included participants who had diverse 
conditions possibly affecting cognition (i.e. hypertension, diabetes, hypothyroidism, 
among others), and had at least two neuropsychological tests with z scores below 
− 1.5. The final Cl sample was comprised of mild cognitive impairment (MCI) 
(n = 9), neurologic disease (n = 13) and non-neurologic conditions affecting cognition 
Demographic Variables Descriptive Statistics
C
n = 51
Cl
n = 39
Age 46.7 ± 18.3; range 
(19–80)
52.3 ± 19.3; 
range (19–86)*
Years of schooling 13.05 ± 3.8; range 
(6–20)
11.6 ± 3.3; 
range (7–20)*
Reading fluency 135.1 ± 19.9; range 
(103–186)
127.9 ± 18.5; 
range 
(99–173)*
Male 21 (41%) 16 (41%)
Female 30 (59%) 23 (59%)
Table 2 Demographic character-
istics of the Control and Clinical 
groups
* p > .05
 
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(n = 18). Handedness was distributed as follows: 80% right-handed, 18% ambidex-
trous, and 2% left-handed.
Participants of the Cl group were recruited from a neuropsychology clinical ser-
vice. They underwent a full neuropsychological assessment that determined if they 
had a cognitive impairment in any cognitive domain. This evaluation comprised (1) 
a comprehensive neuropsychological test battery assessing memory, attention, con-
structional praxis, verbal fluency (phonological and semantic), reading, writing, cal-
culation, and executive functioning; and (2) a detailed review of participants’ medical 
history, including current symptoms, patient medical records, and present life circum-
stances. In many cases, additional medical procedures such as neurological assess-
ments, psychiatric assessments, electrophysiological studies (EEG), imaging studies 
(MRI, CT scan, or SPECT), and laboratory examinations were available for review.
The educational level of the testees was determined according to their reading 
fluency ability (RF). RF was adopted as an index of the quality of the education 
level, and it has demonstrated a correlation with MUNS scores that is higher than 
that of number of years of education (Fernandez & Jauregui, 2021). The RF task 
consisted of a text that described the weather of a city (Córdoba, Argentina). The text, 
in Spanish, contained 215 words, separated into 5 paragraphs. It was extracted from 
a free content web page and was modified in order to achieve a neutral emotional 
tone. The text was presented in 12-point “Times New Roman” font on an A4 size 
sheet (see Table 3). Participants were asked to place the text at a comfortable reading 
distance and read it aloud at their usual reading pace. We then operationalized RF 
as the number of words read correctly per minute. Reading performance was audio 
recorded to accurately score for errors and reading time. Omissions, substitutions, 
insertions, and self-corrections were deemed as errors. The score was the number of 
words read correctly per minute. The following formula was used to obtain the score: 
(60 × (215 − errors))/total time in seconds. Participants who obtained an RF score 
below 95 were included in the LE group. This cut-off score was obtained through the 
analysis of the pilot sample that showed that 95 was the score that best matched RF 
and lower education (participants with less than 8 yearsof schooling). Due to the 
insufficient number of LE participants recruited up to date, the analyses presented in 
this article will be based only on the performance of HE participants.
Procedure
Administration settings and procedures were identical to the ones described in Study 
1. The scoring system was modified with regard to Study 1 (see Table 4). All subse-
quent statistical analyses were performed using the new scoring system. In Study 1, 
correct answers were given one point and incorrect answers were given zero points. 
After scoring each answer, an analysis was run in which the performance of both 
clinical and control groups on each item was compared. This procedure was followed 
in order to increase the difference in the scores between both groups, thus improving 
the sensitivity of the scale to differentiate them. Items in which the mean score of 
both groups differed significantly were awarded more points for each correct answer. 
These items were awarded three points for the Word List, Visual Memory and Dots 
and Lines subtests. For the Personage subtest, these special items were awarded five 
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1 3
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A. L. Fernández et al.
points. For all subtests, in the items in which no significant difference was found, 
correct answers were awarded one point. For Arrows and Animals subtests, one point 
was given for every correct answer. The scoring system of the Party subtest is based 
on a combination of scores obtained according to the number of items purchased, 
the blocks traveled to complete the route, and the number of occasions in which the 
participant crosses the line over a block instead of using the streets.
Data analysis
A contrasted group method was performed. The performance of both groups was 
compared using ANOVA. The sensitivity and specificity indexes were also calculated.
Study 3. Reliability
Sample
The sample included 71 healthy Argentinian participants recruited by snowball 
sampling. The recruiting procedure and exclusion criteria were identical to Study 1. 
The mean age was 27.35 ± 14.12, and the mean years of education was 14.87 ± 2.76. 
Education level was also estimated through RF, which ranged between 113.16 and 
189.09 words read correctly per minute (M = 148.22 ± 17.56). Seventy-six percent of 
the subjects were female. There were no statistically significant differences between 
Subtest Old Scoring System New Scoring System
Personage 1 point for correct 
answers; 0 point for 
incorrect answers
1 or 5 points for correct 
answers; 0 points for incor-
rect answers
Word list 1 point for correct 
answers; 0 point for 
incorrect answers
1 or 3 points for correct 
answers; 0 points for incor-
rect answers
Visual 
Memory
1 point for correct 
answers; 0 point for 
incorrect answers
1 or 3 points for correct 
answers; 0 points for incor-
rect answers
Arrows 1 point for correct 
answers; 0 point for 
incorrect answers
1 point for correct answers; 
0 point for incorrect 
answers
Animals 1 point for correct 
answers; 0 point for 
incorrect answers
1 point for correct answers; 
0 point for incorrect 
answers
Dots & 
lines
1 point for correct 
answers; 0 point for 
incorrect answers
1 or 3 points for correct 
answers; 0 points for incor-
rect answers
Party A combination of 
scores including: (a) 
the number of items 
purchased, (b) the 
blocks traveled to 
complete the route, (c) 
and amount saved in 
coins.
A combination of scores 
including: (a) the number 
of items purchased, (b) the 
blocks traveled to complete 
the route, (c) the number 
of occasions in which the 
participant crosses the line 
over a block instead of 
using the streets.
Table 4 Description of the 
MUNS old and new scoring 
system
 
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176
The multicultural neuropsychological scale (MUNS): validity, reliability,…males and females. Handedness was distributed as follows: 87% right-handed, 10% 
left-handed, and 3% ambidextrous.
Procedure
Administration settings and procedures were identical to the ones described in Study 
1. Test-retest interval was 32.90 ± 4.01 days, with a minimum of 28 and a maximum 
of 49 days. The scoring system was the same that was used in the validity study.
Data analysis
Reliable change was assessed using a multivariate version of the standardized regres-
sion-based (SRB) methodology described by McSweeny et al. (1993) to predict the 
subjects’ MUNS retest total scores based on MUNS pretest total scores, age, years 
of schooling, and RF. This methodology was chosen due to its statistical advantages 
which address the phenomenon of regression towards the mean as well as the practice 
effects, and because it has been widely used in the neuropsychology field (Hammers 
& Duff, 2019; Hinton-Bayre, 2010). A retest z-score above or below ± 1.64 (i.e., a 
90% confidence interval) was considered a significant change.
Study 4. Normative study
Sample
One hundred and eighty-four healthy Argentinian participants were included in the 
sample. Participants were recruited from a variety of Argentinean cities and states. 
The recruiting procedure and exclusion criteria were identical to Study 1.
Mean age was 32.22 ± 16.16. Age range was 15–80 years old. The mean years of 
education was 13.84 ± 3.22, and the education range was 4–20 years. Sixty-six per-
cent of the sample were female. Regarding handedness, 86% were right-handed, 9% 
ambidextrous, and 5% left-handed.
Procedure
Administration settings and procedures were identical to the ones described in Study 
1. The scoring system was the same that was used in the validity study.
Data analysis
For the normative data analysis, the regression-based method was followed. The mul-
tiple linear regression model’s statistical assumptions of homoscedasticity, normal 
distribution of the residuals, absence of multicollinearity, and absence of influential 
cases, were tested. The Kolmogorov-Smirnov normality test was significant for the 
MUNS Total Scaled Score (p = .03), however, the Shapiro-Wilks was non-significant 
(p = .23). The corresponding asymmetry and kurtosis indexes were − 0.1 and − 0.11. 
As regards multicollinearity, the Variance Inflation Factors and condition indexes 
1 3
177
A. L. Fernández et al.
were computed. The following indexes were obtained for the former: 1.24 and 1; 
whereas 14.19 and 20.7 were obtained for the latter. They indicate null or mild mul-
ticollinearity problems. The average Cook’s distance was 0.006, which indicates an 
absence of outliers influencing the model. Finally, homoscedasticity was tested. The 
correlation between standardized residuals and standardized predicted residuals was 
plotted. This diagram showed that residuals were homoscedastic across the scores.
Following the method described by Testa et al. (2009), in order to normalize the 
score distribution, raw scores were transformed to scaled scores (mean = 10, SD = 3) 
based on the cumulative frequency of the normative sample. The resulting scores are 
exhibited in Table 5. Next, using the scaled scores as the dependent variable and age, 
reading fluency, and gender as predictive variables, a multiple regression analysis 
was performed. Gender was dummy coded with female = 1 and male = 2. An addi-
tional regression analysis was performed using number of years of schooling instead 
of RF as an independent variable. This was made to allow the estimation of z scores 
in those situations in which the participant cannot read.
Study 5. Cross-cultural comparison
Sample
Argentinian (n = 55) and U.S.A (n = 22) samples were administered the MUNS. There 
were no significant differences between samples in age, years of education and gen-
der. Argentinians were administered the Spanish version of the MUNS while North 
Americans were administered the English version. Participants for whom Spanish 
(Argentina) or English (U.S.A) was not their first language were not included in 
the samples. Although the MUNS contains two versions depending on the education 
level of the participant (higher or lower) in this study only higher education partici-
Raw Score Cumulative Percentiles Scaled 
Score
> 389 100 18
374–389 99 17
369–373 97–98 16
363–368 94–96 15
350–362 89–93 14
336–349 81–88 13
321–335 69–80 12
313–320 57–68 11
290–312 44–56 10
277–289 31–43 9
256–276 21–30 8
231–255 13–20 7
213–230 7–12 6
195–212 4–6 5
189–194 2–3 4
170–188 1 3
143–169 0 2
Table 5 Equivalence for the 
Transformation of Raw Scores 
into Scaled Scores
 
1 3
178
The multicultural neuropsychological scale (MUNS): validity, reliability,…
pants were included. The recruiting procedure and exclusion criteria were identical 
to Study 1.
The samples were age and education matched. An ANOVA showed that there were 
no significant differences in age (p = .20) or number of years of schooling (p = .06) 
between both samples.
Procedure
Administration settings and procedures were identical to the ones described in Study 
1. The scoring system was the same that was used in the validity and reliability stud-
ies. As well as in the administration of the Spanish version, for the English ver-
sion administration was performed by several undergraduate psychology students 
and graduate psychologists who were native English speakers. To ensure standard-
ized administration and scoring, all administrators underwent training sessions with 
the test developers. After reviewing test administration instructions, testers practiced 
administering the instrument, first with other testers and then with individuals who 
matched the sample used in the final studies.
For the English version, a forward translation procedure was followed. First, the 
Spanish version was translated into English by a professional translator. Next, the test 
developers checked this version with another professional translator and made cor-
rections. Finally, native English-speaking psychologists, along with the test develop-
ers, checked the second review and made final adjustments to ensure the appropriate 
inclusion of the terms inherent to the neuropsychology field.
Data analysis
An ANOVA was performed. The independent variable was the cultural group (Argen-
tina vs. the U.S.A) and the dependent variables were the seven subtests scores and the 
total score of the MUNS.
Results
Study 1. Development of materials
Overall, participants understood the instructions and were able to perform the tasks, 
even the elderly with very low education. Different ANOVA analysis, in which the 
educational level (higher-lower) was the independent variable, showed that the mean 
scores for each subtest for which the activities were different according to the educa-
tion group were not significantly different across groups. Therefore, each version of 
the test represented the same level of difficulty for each group. Mean and standard 
deviations are exhibited in Table 6. The Shapiro–Wilk W-test for normality of the 
Total Score score was non-significant (p = .06), indicating that the distribution can 
be considered normal (Shapiro, 1965). However, the same normality test indicated 
that the Visual Memory-delayed, Arrows, Dots and Lines and Party subtests were 
negatively skewed.
1 3
179
A. L. Fernández et al.
Age and education were not significantly correlated. Age had a significant cor-
relation with immediate (-0.32) and delayed Visual Memory (-0.32), the Recogni-
tion trial of the Word List (-0.28), the Delayed trial of the Word List (-0.27) and 
the Total Score (-0.24). Education was significantly correlated to the performance 
on the following subtests: Animals (0.59), Visual Memory immediate (0.49), Visual 
Memory delayed (0.37), Arrows (0.25), Dots and Lines (0.44) and Total Score (0.52). 
However, these correlations changed when lower and higher education groups were 
analyzed separately. In the lower education group(n = 31) education correlated sig-
nificantly with Word List immediate (0.39), Word List delayed (0.41), Personage 
(0.45), Visual Memory immediate (0.44), Arrows (0.52), Dots and Lines (0.82), Party 
(0.40) and the Total Score (0.78). In the higher education group (n = 41) it corre-
lated with Animals(0.48), Word List immediate (0.32), Visual Memory immediate 
(0.34), Visual Memory delayed (0.38), Arrows (0.46) and the Total Score (0.54). 
An ANOVA confirmed that there were no significant differences in the performance 
between males and females, F(1, 70) = 0.11, p = .75.
Study 2. Validity
Significant differences between both groups were found in all the subtests except for 
the Arrows and the Recognition Trial of the Word List. Table 7 shows these differ-
ences. In agreement with these results, the MUNS Total Score is the result of the sum 
of the scores of the following subtests: Word List (trials 1–3), Word List (delayed 
trial), Personage, Animals, Visual Memory (immediate and delayed trials), and Party. 
The Dots and Lines score was excluded from the Total Score because of its extremely 
asymmetric score distribution. The MUNS Total Score should be interpreted as an 
index that reflects general cognitive functioning excluding attention, recognition and 
constructional praxis.
The analysis of the contrasted group study demonstrated a statistically significant 
difference between the C and Cl groups on the MUNS Total Score. Figure 2 shows 
this difference. The eta-squared was 0.20, which can be considered a large effect size.
Using the MUNS Total Score, the sensitivity and specificity indexes were obtained 
by applying the Youden Index (J) to determine the optimal cut-off score. This cut-
off score was set at 282. The resulting sensitivity was 88%, whereas the specificity 
was 51%. With this cut-off score, the positive likelihood ratio, defined as the ratio 
between the probability of a positive test result given the presence of the disease and 
Word List (Trials 1–3) 58.8 ± 12
Word List Delayed Trial 62.3 ± 19.7
Visual Memory Inmediate 80.2 ± 9.8
Visual Memory Delayed 76.7 ± 11.5
Animals 43.9 ± 14
Arrows 78.5 ± 14.8
Party 79.3 ± 7.9
Dots and Lines 96.3 ± 13.8
Personage 52.7 ± 18
Total Score 628.7 ± 71.1
Table 6 Mean and standard 
deviations for the entire group 
on each subtest
 
1 3
180
The multicultural neuropsychological scale (MUNS): validity, reliability,…
the probability of a positive test result given the absence of the disease, was 1.78. 
The negative likelihood ratio, defined as the ratio between the probability of a nega-
tive test result given the presence of the disease and the probability of a negative test 
result given the absence of the disease, was 0.25 (see Fig. 3).
Study 3. Reliability
A multivariate regression analysis was performed to predict participants’ raw MUNS 
retest total scores based on raw MUNS pretest total scores, age, years of school-
ing, and RF. The predictors contributing significantly were MUNS pretest total score 
(B = .51, p = .000) and age (B = -1.62, p = .000). The results of the regression (R2) 
indicated that the model explained 57% of the variance. F(4,66) = 24.13, p = .000, 
Fig. 2 Mean Scores on the Multi-
cultural Neuropsychological Scale 
Total Score by Group
 
C
(n = 51)
Cl
(n = 39)
p
Word List (Trials 1–3) 51 ± 12.93 42.97 ± 12.61 0.00*
Word List Delayed 
Trial
8.51 ± 2.85 6.61 ± 3.11 0.00*
Word List Recognition 7.76 + 5.77 8.52 + 3.04 0.49
Personage 22.90 ± 9.89 17.15 ± 10.21 0.00*
Animals 30.53 ± 8.08 23.92 ± 6.26 0.00*
Visual Memory 
Inmediate
31.94 ± 8.63 26.30 ± 9.07 0.00*
Arrows 24.70 ± 3.55 23.80 ± 3.61 0.23
Visual Memory 
Delayed
12.74 ± 5.28 10.23 ± 5.12 0.02*
Party 117.53 ± 31,76 93.92 ± 41.93 0.00*
Dots and Lines 183.45 ± 1.85 179.76 ± 8.61 0.00*
MUNS Total Score 275.16 ± 49.75 221.13 ± 62.23 0.00*
Table 7 Means and Standard 
Deviations for all MUNS Sub-
tests and the MUNS Total Score
*pA. L. Fernández et al.
As in the previous analysis, gender did not contribute significantly to the predic-
tion of the dependent variable.
Additional multiple regression analyses were performed for each subtest score. 
The results of these analyses have been included in the Appendix. These analyses are 
provided to interpret the scores yielded by each single subtest.
Study 5. Cross-cultural comparison
The ANOVA did not show significant differences between the samples in all the 
scores except for the attention subtest. Table 10 shows the means and standard devia-
tions of each group on all of the scores under analysis. The score range for the MUNS 
total score in the Argentinian sample was 216–340; whereas it was 203–330 for the 
American sample.
Discussion
The data reported in this article show that the MUNS achieves all the projected objec-
tives. First, it uses universal stimuli that are familiar to most cultures in the world. 
The use of the Swadesh list for the verbal memory subtests makes it possible to 
Table 9 Multiple Regression Analysis Results for the Normative Data with Number of Years of Schooling 
as the Independent Variable
β SE B SE t(180) p
Intercept 7.9607 1.0579 7.5243 0.000
Age -0.3970 0.0631 -0.0732 0.0116 -6.2875 0.000
Gender 0.0052 0.0631 0.0331 0.3958 0.0836 0.933
Number of years of schooling 0.3384 0.0631 0.3140 0.0586 5.3585 0.000
R = .53, R² = 0.28, F(3, 180) = 23.733, pMoreover, 
frequently the individuals diagnosed with MCI revert to normal in subsequent assess-
ments (Koepsell & Monsell, 2012). Therefore, the sensitivity and specificity of the 
MUNS were tested in populations whose cognitive functioning is similar to control 
populations. It is unsurprising to find a significant degree of overlap between both 
populations, with low-performing control participants falling under the cut-off score. 
What seems to be more valuable is that the scale correctly identifies most cognitively 
impaired participants even if they have a mild impairment.
Reliability was also satisfactory. Age was found to be a significant predictor of the 
retest scores, i.e., the higher the age, the lower the gain in retest scores. This is probably 
related to the fact that as age increases, learning ability diminishes (Naveh-Benjamin, 
2000). This presents an advantage of the SRB methods as when compared to the tra-
ditional test-retest procedure, they capture the influence of demographic variables on 
the retest scores. One of the disadvantages of SRB methods is their calculation com-
plexity. To address this challenge, a user-friendly Excel calculator for deriving SRB 
change indices for individuals was developed. This easy-to-use Excel spreadsheet 
allows the neuropsychologist practitioner to enter a participant’s age and MUNS total 
score to automatically calculate their SRB index. The supplementary calculator is 
available online at https://drive.google.com/drive/folders/1VorlbnPLENTWa8--SAH
5VSKuJC3cmkzX?usp=sharing, and it is free to use.
As expected, normative data were influenced by age and education. The data 
reported here allow for the assessment of participants with a wide range of ages 
and education levels. The performance of participants can be assessed by including 
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https://drive.google.com/drive/folders/1VorlbnPLENTWa8--SAH5VSKuJC3cmkzX?usp=sharing
https://drive.google.com/drive/folders/1VorlbnPLENTWa8--SAH5VSKuJC3cmkzX?usp=sharing
The multicultural neuropsychological scale (MUNS): validity, reliability,…
data on their RF or their number of years of schooling. In the first case, the analysis 
is based on an index of the quality of their education, whereas in the second case, it 
is based on a quantitative assessment of their education. The authors of this article 
recommend RF as the first option. However, in some cases, participants will not be 
able to read as a result of different conditions such as alexia, aphasia or poor vision. 
Moreover, the RF reported here was estimated for Spanish speakers. It is expected 
that RF varies across languages.
It is important to highlight that the inclusion of a qualitative index of the education 
level as a variable in the development of normative data is an innovative procedure 
included in this article. To the extent of our knowledge there are no studies published 
to date in which normative data were developed based on an index of the quality of 
their education.
Seventh, although not fully explored yet, some preliminary data indicates that 
when demographically matched samples from different cultures are compared, their 
performance does not differ significantly. Data from study 5 demonstrated that the 
MUNS scores did not show significant differences except for the Arrows subtest. The 
differences in this subtest probably respond to the psychometric problems showed by 
the Arrows subtest and not to cultural related issues. Although these results need fur-
ther study because of the samples size (especially the American sample), they suggest 
that the MUNS could be applied in English-speaking environments. Further studies 
are needed to confirm its utility in other cultural settings.
Eighth, the MUNS does not require complex materials or instructions. The MUNS 
package contains the manual, the booklet which contains most of the stimuli and 
instructions for the tester, and only five additional sheets. These features make the 
package portable and inexpensive. Moreover, the materials are available from the 
authors upon request. In addition, an effort was made to present the testees with 
ecologically valid stimuli. Many of the stimuli such as the Visual Memory pictures, 
the Party, Animals, and Personage tasks, were designed to resemble daily activities. 
This characteristic makes the stimuli more familiar for the testees, especially for 
those with lower education levels who may not be familiar with cognitive testing 
procedures.
One of the limitations of the research reported in this article is the lack of data 
for the lower education population. One of the goals of the MUNS is to provide 
clinicians with an instrument that is prepared for the assessment of lower education 
participants. Future articles should report data on this population.
Another limitation is the lack of discrimination in the attention subtest between 
the C and Cl groups. The data reported here show that the task resulted equally dif-
ficult for both groups. For this reason, the score of this subtest was excluded from the 
MUNS Total Score. An improvement of the current subtest or the development of a 
new subtest should help resolve this shortcoming.
It is imperative for the future direction of the MUNS to test the performance of 
samples recruited from different cultures. There is a need for translation of the materi-
als to even more languages so they may be administered to demographically matched 
samples in other countries.
One other possible future development is the testing of the reliability of clinical 
samples. The performance of clinical samples tends to be more variable than that 
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of control samples over time. Therefore, the performance of some specific clinical 
groups on the MUNS should be tested, allowing for the collection of more accurate 
data on the variability of their scores.
As demonstrated, the MUNS is a valid and reliable test for the assessment of cog-
nitive impairment. In the present study, we obtained a significant normative sample 
using Argentinean participants representing a wide range of ages and education lev-
els as well as both genders. The MUNS appears as a potentially useful screening test 
for the assessment of diverse cultural samples.
Appendix
Table A1 Multiple Regression Analysis Results for the Normative Data with Reading Fluency as the Inde-
pendent Variable – Word List subtest – Sum Trials 1–3
β SE B SE t(181) p
Intercept 10.7783 1.9209 5.6108 0.000
Age -0.2892 0.0783 -0.0527 0.0142 -3.6915 0.000
Reading Test 0.0414 0.0783 0.0060 0.0114 0.5296 0.597
R = .31, R² = 0.09, F(2, 181) = 9.581, p4.2312 1.8870 2.2422 0.026
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Table A5 Multiple Regression Analysis Results for the Normative Data with Reading Fluency as the Inde-
pendent Variable – Personage subtest
β SE B SE t(181) p
Age -0.1653 0.0750 -0.0309 0.0140 -2.2030 0.028
Reading Test 0.3130 0.0750 0.0469 0.0112 4.1708 0.000
R = .41, R² = 0.17, F(2, 181) = 18.540, p