Bias in Stroke Evaluation: Rethinking the Cookie Theft Picture

Abstract

Despite a current emphasis on equity in stroke care, one of the most common stroke assessment tools that is used both nationally and internationally, includes an anachronistic image that projects cultural, linguistic, and socioeconomic bias. This image, titled The Cookie Theft picture, is included in the National Institutes of Health Stroke Scale and was originally developed in 1972. Now, 50 years later, it does not reflect our current diverse, linguistically rich, and multicultural patient population.

Neuropsychological endpoints for clinical trials in methylmalonic acidemia and propionic acidemia: A pilot study

“…The stimulus test picture has been criticized for its use in assessment of stroke victims and for not reflecting a diverse, linguistically rich, and multicultural population [ 23 ]. Despite this flaw, the test has shown potential to be applied in other circumstances.…”

New Picture Stimuli for the NIH Stroke Scale: A Validation Study

“…12 As the use of the NIHSS has expanded into communities of speakers of Chinese, German, Spanish, Cantonese, Estonian, Hindi, Hungarian, Italian, Marathi, Portuguese, Korean, Kannada, and Telugu (among others), the acceptability of these stimuli both socially and culturally also has been an area of scrutiny. 3,19 After all, not all countries have cacti. Moreover, describing a picture reminiscent of suburban life in midcentury America, wherein a dress-clad woman is gazing wistfully at her lawn from her kitchen window while her sink overflows and her children conspire furtively to access topshelf cookies, does not similarly inspire people whose lived experiences may bear little resemblance to that depiction.…”