Cognition can be defined as the person’s capacity to acquire and use information to adapt to environmental demands (Lidz, 1987). The process involves many skills, including perceptual discrimination, selective attention, and memory. Cognitive skills may predict a child’s school readiness (Kramer & Hinojosa, 1999) and successful participation at school (Case-Smith, 1996; Law, 2002; Mancini, Coster, Trombly, & Heeren, 2000). Indeed, children with cognitive deficiencies have been shown to experience difficulties in achieving scholastic success (Mancini et al., 2000; Reed, 2001). Hence, in clinical practice, the early screening of cognitive skills among preschool and primary school children may provide a more basic understanding of their school performance (Cook, 1991; Kramer & Hinojosa, 1999) and facilitate early intervention when needed to bolster their subsequent scholastic occupation and school participation (Nelson, Nygren, Walker, & Panoscha, 2006).

People’s brains and minds are shaped by their experiences, which mainly occur in the context of the culture in which they develop and live (Han & Northoff, 2008). Cognitive skills are now understood to represent an ongoing product of the interaction among people, activities, and the environment (Feuerstein & Falik, 2004; Polatajko, Mandich, & Martini, 2000). Various environmental factors, such as culture and sociodemographic factors, determine the type of handling, care, and training given to children; the objects with which they come into contact; and the opportunities available to them for interaction within the environment (Rosenblum, Katz, Hahn-Markowitz, Mazor-Karsenty, & Parush, 2000).

Each culture has its own distinctive pattern of child-rearing practices; cultures vary in attitudes toward and expectations of children and concepts of which behaviors and skills are to be encouraged and developed (Katz, Kizony, & Parush, 2002; Rosenblum et al., 2000). Previous studies have emphasized that children’s cognitive skills appear to be shaped by their specific cultural environment and its demands and values (Mardell-Czudnowski, Chien-Hou, & Tiem-Main, 1986). For example, one early study on first-grade children of Chinese, Jewish, African-American, and Puerto Rican families living in New York City found different patterns of mental abilities in tests of verbal skills, reasoning, number skills, and spatial conceptualization (Lesser, Fifer, & Clark, 1965). Research has suggested considerable cross-cultural differences in cognitive strategies and systematic variations in spatial cognition among both children and adults in accordance with language and culture (Haun, Rapold, Call, Janzen, & Levinson, 2006).

Cognitive evaluations are often based on Western measures of performance (Haun et al., 2006). Although clinicians and researchers use several standardized screening and assessment tools of cognitive skills, the validity of any given tool is questionable when used to evaluate people from a cultural group other than that on which the tool was standardized (Teresi, Cross, & Golden, 1989; Tzuriel, 1999). Cermak et al. (1995)  claimed that when an assessment is standardized for use with a different cultural group, literal translation is not sufficient. Moreover, cross-cultural bias may exist even in countries that share a common language, highlighting the importance of cultural equivalence in testing (Helms, 1992).

In their study with Jamaican children, Baddeley, Gardner, and Grantham-McGregor (1995)  addressed the problems of adapting measures of cognitive performance to Third World conditions. They proposed three novel adaptations, using pictorial material, for speed of sentence comprehension, vocabulary acquisition, and speed of visual search. The validity of the proposed adapted tests was demonstrated by their capacity to predict children’s scholastic performance (Wilkinson & Robertson, 2006), enabling culturally competent practice. Likewise, Hodge and Nadir (2008)  emphasized the need to move toward culturally competent practice in growing populations with specific cultural backgrounds, such as the Muslim population, on which relatively little information exists.

Israel, like many other countries (e.g., the United States, Australia), is a multiethnic, multireligious, and multicultural society, and culturally competent practice is an important consideration there. Cultural and ethnic differences also exist between Israel and the adjacent Palestinian territories. Several studies regarding the contribution of cognitive skills to school readiness have been conducted in Israel. However, few studies have involved Arab children. Sharoni (1996)  compared the sensorimotor and cognitive skills of Bedouin and Jewish children in Israel, ages 6–12, using the Test of Visual–Perceptual Skills (Gardner, 1982), the Developmental Test of Visual–Motor Integration (Beery & Buktenica, 1997), several subtests from the Bruininks–Oseretsky Test of Motor Proficiency (Bruininks, 1978), and the Loewenstein Occupational Therapy Cognitive Assessment (LOTCA; Katz, Itzkovich, Averbuch, & Elazar, 1989). Significant differences between the two groups were found for all test components, with the Bedouin children scoring lower than the Jewish children. Moreover, among the Bedouins, the older group (ages 10–12) performed better than the younger group (ages 6–8; Parush, Sharoni, Hahn-Markowitz, & Katz, 2000).

Katz et al. (2002)  compared cognitive skills, including visuomotor organization and thinking operations, among school-age Ethiopian, Bedouin, and Israeli children using the LOTCA. Their findings showed that the Israeli children performed significantly better than the Ethiopian and Bedouin children. The researchers suggested that cultural context and schooling (e.g., the age at which children enter the education system is much younger in the Israeli culture; Central Bureau of Statistics, 2008) have a powerful impact on children’s cognitive skills and serve as one possible explanation for the difference. Yet, because in these studies no adaptations were made for the instruments developed outside Israel when testing children from different ethnic groups, the lower performance may reflect the inability of the test to profile the children’s objective abilities because of cultural bias.

To our knowledge, among the few studies conducted in Israel, none have compared the cognitive skills of Israeli and Palestinian children. The two coexisting populations differ in many cultural and lifestyle aspects. Most Palestinian children are Muslim, including 75% of the West Bank population and 99% of the Gaza Strip population (Central Intelligence Agency, 2008). Islamic families’ lifestyle is highly related to religious codes. The construction of the families also differs, on a cultural basis. For example, a man is allowed up to four wives, whereas a woman may have only one husband. In the Islamic family, the father carries the financial responsibility, and the women take care of the household and raise the children (Islamic Council of Western Australia, 2009). This may explain why children stay at home until the age of 4 or 5 and only then enter the education system. Jewish people, however, make up most of Israel’s population and typically lead an urban, Western lifestyle. In most cases, both men and women work outside the home, often in similar types of positions, to financially support their families (Central Bureau of Statistics, 2008). The fact that most of the Jewish women work outside home may also explain why Jewish children enter the education system at a very young age.

Because of political and cultural influences, Israeli and Palestinian educational programs are not equal. Israeli children enter the education system early, starting compulsory prekindergarten at age 3 or private day care even younger. Palestinian children enter the system much later, at about age 5 or 6. Given that schooling has been identified as one of the most important predictors of children’s cognitive achievement (Harkness & Keeper, 2000), the age at which they enter the education system should be examined to determine the impact on their cognitive skills.

In a previous study (Josman, Abdallah, & Engel-Yeger, 2006), we focused on Israeli and Palestinian children’s visual–motor and visual–perceptual performance; the results showed better performance by Israeli children on most measures. Moreover, such sociodemographic variables as grade, place of residence, and parents’ education were shown to have an impact on performance. We recommended the evaluation of additional factors, such as cognitive abilities, to facilitate early screening, evaluation, and treatment and thus enable Israeli and Palestinian children’s optimal functioning at school.

On the basis of this recommendation and the need for occupational therapists (and other health care professionals) to expand their cultural competence and incorporate it into theory and practice (Odawara, 2005; Whiteford & Wilcock, 2000), we aimed to elaborate the role of cultural and sociodemographic parameters in children’s performance by relating them for the first time to Israeli and Palestinian children’s cognitive development. We conducted the investigation with the LOTCA, an assessment tool developed in Israel for use with children ≥ age 6. The study objectives also have applied goals related to clinical practice and instrument testing: We examined the LOTCA’s validity among kindergarten children, who are < age 6, and aimed to determine the test’s feasibility as a screening tool for assessing the cognitive abilities of Palestinian children. This study’s results may assist in establishing further normative data for the LOTCA and, thus, improve its rigor as a screening tool for cognitive differences in children.

We hypothesized that significant differences in cognitive performance would be found in three areas: (1) between the two cultural groups; (2) between each of the three grades, with first-grade children expected to perform better than those in kindergarten, and second-grade children expected to perform better than those in the first grade; and (3) between sociodemographic groups, with children from a higher sociodemographic background expected to achieve significantly better scores than children from a lower sociodemographic background.

Participants were 226 typically developing children (101 Jewish Israeli children and 125 Muslim Palestinian children) in kindergarten through second grade. Children with known neurological, developmental, or learning disabilities were excluded from the study. Inclusion criteria for the Palestinian children were determined on the basis of teachers’ reports; those for the Israeli children were determined according to school psychologists’ reports (in Israel, school psychologists screen all kindergarten-age children for psychological issues before they enter school). The participants constituted a representative sample corresponding to the Israeli census. Each cultural group included participants from three different grades: kindergarten, first, and second. Moreover, the sample for each cultural group was drawn from different places of residence (see Table 1).

All participants were tested with the LOTCA. This assessment battery was designed for use by occupational therapists working in neurological rehabilitation and was later adapted for use with children ages 6–12 (Averbuch & Katz, 1991). Age-level standards were determined among 240 participants (40 in each age group). The LOTCA’s discriminant validity was also confirmed, showing a clearly significant developmental sequence in performance on its subtests (Averbuch & Katz, 1998). We chose this particular battery of tests because it is mostly nonverbal and thus may be suitable for evaluating the cognitive skills of people from different cultures. It is a standardized test with validity and reliability studies conducted primarily with adults in both Israel and the United States (Cermak et al., 1995; Katz, Hartman-Maeir, Ring, & Soroker, 2000; Katz et al., 1989).

The test consists of 20 subtests in four areas: (1) orientation of time and place; (2) perception, which includes visual perception of shapes and objects, figure ground perception, object constancy, spatial perception, and praxis; (3) visual–motor organization, which examines perceptual–motor integration with spatial components, including copying of geometric forms, reproduction of two- and three-dimensional models, pegboard construction, colored- and plain-block design construction, reproduction of a puzzle, and drawing of a clock; and (4) thinking operations, which examine categorization and sequence, including pictorial classification, object classification (both unstructured and structured), pictorial sequence, and geometrical sequence. Results are presented as a profile for all subtests. For research purposes, we obtained area scores by totaling the subtest scores in each area. Higher scores suggested higher cognitive performance.

Each subtest uses either a 4-point or a 5-point scoring scale. The summary scores represent four distinct categories: (1) orientation, a composite score including orientation to place and to time (score range = 1–8); (2) perception, a composite score of six subtests (score range = 1–24); (3) visual–motor organization, a composite score of seven subtests (score range = 1–28); and (4) thinking operations, a composite score of five subtests (score range = 1–23). An additional score was given for test administration time for the whole battery.

Revisions of the LOTCA yielded the development of the Dynamic Occupational Therapy Cognitive Assessment for Children (DOTCA; Katz, Golstand, Bar-Ilan, & Parush, 2007) for children ages 6–12. The DOTCA assesses orientation, spatial perception, praxis, visual–motor construction, and thinking operations by using the dynamic aspect of mediation and prompting, which adds valuable clinical features regarding learning potential for children with cognitive and learning difficulties. We used the LOTCA in this study, however, because we examined typically developing children and our main aim was to examine whether the LOTCA could be used as a screening tool for evaluating children’s cognitive performance.

The Israeli Ministry of Education granted institutional review board approval for the study, and we received written approval from parents, teachers, and headmasters before the study was carried out. A bilingual (Arabic and Hebrew) clinician translated the instrument into Arabic, with back-translation into Hebrew. A workshop was conducted for Israeli occupational therapists; it included an Arab occupational therapist, who also received advanced training from Naomi Josman in providing training and supervision for Arab assessors. This clinician became an expert in LOTCA administration and provided training to the Palestinian assessors. The LOTCA’s interrater reliability among assessors was established after the workshop. The assessors administered the LOTCA to children individually in their school, and data collection lasted about an hour for each child

Descriptive statistics (means and standard deviations) were calculated for each performance area according to cultural group, grade, and parents’ education. We used multivariate analysis of variance with the General Linear Model (Mardia, Kent, & Bibby, 1979) to investigate differences according to cultural group, grade, and parents’ education and to test the significance of the interaction between grade and cultural group and between cultural group and parents’ education. Probabilities <.05 were considered significant.

We found a significant difference between the Israeli and Palestinian children (F [5, 184] = 44.59, p < .0001, effect size [ES] − η² = 0.548). The Israeli children obtained significantly higher scores than the Palestinian children in all LOTCA areas except orientation. The time required to administer the LOTCA was significantly shorter for the Israeli children than for the Palestinian children. Table 2 summarizes the significant between-groups differences in performance on the four LOTCA categories and in administration time.

When comparing the LOTCA scores by grade, we found a significant difference (F[10, 364] = 22.27, p < .001, ES − η² = 0.38). As presented in Table 3, we found significant values in all LOTCA areas.

According to post hoc analyses, the first- and second-grade children performed significantly better than the kindergarten children in most areas, and the second-grade children performed significantly better than the first-grade children. LOTCA administration time was significantly shorter for first- and second-grade children than for kindergarten children. Table 4 presents the mean differences in LOTCA scores among children from the different grades.

When we compared the Israeli and Palestinian children’s LOTCA scores, we found a significant Grade × Cultural Group interaction effect (F[10, 364] = 1.73, p < .001, ES − η² = 0.045). We obtained significant values only for the Perception (F[2, 186] = 3.06, p ≤ .05) and the Visual–Motor Organization (F[2, 186] = 3.36, p ≤ .05) areas.

A post hoc analysis of the perception area revealed that the Israeli kindergarten children obtained significantly higher scores than the Palestinian kindergarten children (mean difference = 2.02, p < .01). Among the Palestinians, the kindergarten children obtained significantly lower scores than the children in the first and second grades. The mean difference between the kindergarten children and the first-grade children was 2.23 (p < .01); the mean difference between the kindergarten children and the second-grade children was 2.4 (p < .001).

For the visual–motor organization area, the Israeli kindergarten children obtained significantly higher scores than the Palestinian kindergarten children (mean difference = 5.95, p < .01). The second-grade Israeli children obtained significantly higher scores than the second-grade Palestinian children (mean difference = 2.67, p < .05). In this area, both the Israeli and the Palestinian kindergarten children performed significantly more poorly than the first- and second-grade children (see Table 4).

When comparing the LOTCA scores according to parents’ education, we found a significant Cultural Group × Mothers’ Education interaction (F[5, 184] = 2.49, p < .05, ES− η² = 0.064). When evaluating each area, we obtained this interaction for the thinking operations area (F[1, 188] = 4.79, p < .05, ES − η² = 0.025). Israeli children whose mothers had a high school education with matriculation (i.e., achieved passing scores on standardized tests of achievement) plus college performed significantly better than Palestinian children whose mothers had a high school education without matriculation or below (mean difference = 4.02, p < .001). We found no significant Cultural Group × Fathers’ Education interaction.

In this empirical study, we compared the cognitive performance of children from two coexisting populations—differing in many cultural aspects and in lifestyles—using the LOTCA, an assessment battery developed in Israel. We also considered the impact of certain sociodemographic parameters—namely, school grade and parents’ education—on children’s cognitive performance as measured by the LOTCA.

The results confirm our first hypothesis. We obtained significant differences between the Israeli and the Palestinian children in most LOTCA areas. The large effect size for culture emphasizes its impact on children’s cognitive performance, thus adding the perspective of such researchers as Feuerstein and Falik (2004)  and Baddeley et al. (1995)  to that of Piaget (1970) . This perspective is supported by the growing evidence from additional research, including studies conducted in Israel, that points to the impact of culture on children’s cognitive performance (Saxe, 1999). For example, Tzuriel (1999)  found that first-grade Israeli-born children performed significantly better than Ethiopian immigrant children in the same grade. Rosenblum et al. (2000)  found that Ethiopian children performed more poorly on perceptual and motor skill tasks than Israeli-born children of the same age. They attributed the disparity in fine motor skills to the underemphasis on visual–motor skills within the Ethiopian culture.

In a previous study by Josman et al. (2006)  with Israeli and Palestinian children, the Israeli children achieved significantly higher scores than the Palestinian children in the area of visual perception, as measured by the Motor-Free Visual Perception Test–Revised (Colarusso & Hammill, 1995). In the current study, only the orientation area failed to differentiate between the children from the two cultural groups. One possible explanation may be that this area examines common knowledge with basic questions that children are trained to answer from a very early age, such as “Where do you live?” and “What day is it today?” Moreover, orientation dysfunctions are more common in people with brain injuries than in the normal population. Familiarity with the items may also explain the differences between the two cultural groups on the other LOTCA subtests, especially among the kindergarten children, and the difference in administration time.

This study’s results demonstrate that service providers around the world should recognize cultural diversity to more fully address their clients’ needs. Moreover, the findings highlight the need to develop suitable assessments of populations from different cultures and to better examine how cultural background influences each child’s abilities (Case-Smith, 1996). Indeed, targeted interventions may lead to culturally meaningful occupational experiences and enhance outcomes for both the child and the family (Law, Steinwender, & Leclair, 1998; Odawara, 2005).

Our second hypothesis was partially confirmed insofar as children from the higher grades performed better than children from the lower grades in most LOTCA areas. Such cognitive development has also been demonstrated in studies that have confirmed the tendency for performance gaps to diminish as grade level increases (e.g., Karlsdottir & Stefansson, 2003). Studies conducted in Israel along the same line include Parush et al. (2000), who used the LOTCA to compare the cognitive performance of Bedouin children and Israeli children in two age groups (6–8 and 10–12). They found significant differences between the younger and the older children in most LOTCA areas and concluded that younger children exhibit reduced performance levels in these areas, regardless of lifestyle and education. Katz et al. (2002)  assessed the cognitive performance of Ethiopian immigrants, Bedouins, and mainstream Israeli children using the LOTCA and found that all the groups showed significant improvement with age in visual–motor organization and thinking operations, albeit not at the same rate. They proposed that as a result of maturation processes and schooling influences, age differences were to be expected within each group.

This study’s results point to the LOTCA’s usefulness as a potential tool for discriminating between preschoolers and children in the early primary grades. When examining the Culture × Grade effect, two LOTCA areas—Perception and Visual–Motor Organization—exhibited more of a developmental or grade effect in each cultural group. Similar results were reported in studies that used other tools, such as the Visual–Motor Integration Test and the two supplemental Visual Perception and Motor Coordination instruments (Dankert, Davies, & Gavin, 2003).

The Culture × Grade effect also revealed that children from higher grades performed better than children in lower grades within each culture. These results suggest that early schooling for Palestinian children comparable to that of their Israeli counterparts might encourage the development of these skills. That a large percentage of Palestinian children do not enter the education system before age 5 may negatively affect their cognitive performance. Additional studies found support for this conclusion. Sharoni (1996)  and Parush et al. (2000), who found gaps in perceptual, motor, and cognitive skills between Bedouin children and Jewish children in Israel, suggested that the diminished stimulation in the Bedouin schooling experience and cultural lifestyle constrains perceptual, motor, and cognitive development. These researchers recommended encouraging early childhood education at the preschool and kindergarten levels to facilitate the sensorimotor and cognitive development that is essential for future academic and cognitive activities.

As for the impact of sociodemographic parameters on children’s LOTCA scores, our third hypothesis was supported only in regard to mothers’ education, for which we found a small effect size. Interestingly, the Cultural Group × Mothers’ Education interaction revealed that Israeli children with more highly educated mothers scored significantly better than their Palestinian counterparts only in the thinking operations area, which includes such elements as classification and sequencing. One may assume that highly educated mothers more readily encourage their children’s development of these skills. These results support those of other studies emphasizing the impact of mothers’ education on their children’s academic success and behavioral adjustment outcomes (Ferguson, Jimerson, & Dalton, 2001; Loeb, Fuller, Kagan, & Carrol, 2004; Ramey-Craig & Landesman, 1999).

In summary, our study supports previous reports suggesting that cognitive performance may be influenced by environmental factors, such as culture and sociodemographic parameters. Thus, although we found the Palestinian children’s cognitive performance to be poorer than that of the Israeli children, it does not necessarily indicate a differential level of intelligence among the Palestinian children. Rather, it more strongly suggests a relative environmental deprivation and socioeconomic status, as expressed by the gaps that exist between the two study groups and between the different grades. However, these gaps do not diminish as children grow older. Practically, and in line with previous reports regarding the great impact of schooling on the development of cognitive performance (Bjorklund, 2000; Feuerstein & Falik, 2004), this study emphasizes the important contribution of early kindergarten schooling to children’s cognitive development. This study also underscores the need for early screening of cognitive abilities among Palestinian children in preschool and in the early primary grades. By instituting routine screening procedures in kindergarten and the early grades, therapists may identify children with developmental lags and better understand their school performance. On the basis of this knowledge, early intervention programs may be designed, promoting children’s optimal participation in the education system and improving their scholastic outcomes. Early evaluation and treatment may serve to preempt subsequent, more costly interventions.

No standard assessment exists for use with Palestinian children in determining their school readiness or ability to progress in grade level. The LOTCA, which was developed in Israel as an assessment tool for evaluating the cognitive performance of Israeli children, has successfully differentiated between Israeli and Palestinian children according to their cultural and sociodemographic variables. Thus, it may be suggested as a screening tool for assessing the cognitive abilities of Palestinian children to provide information needed for intervention, grade promotion, or both. Indeed, more normative data need to be acquired to improve the LOTCA’s rigor as a tool in screening for cognitive differences in children; however, according to our results, the LOTCA may serve as part of a sound assessment battery for determining children’s school readiness and aptitude for grade promotion. Further studies should examine its ability to screen for lower cognitive performance and its suitability as part of an evaluation battery for Palestinian children, together with more elaborate tests of motor proficiency, visual–motor integration, and visual perception.

This study has several limitations that should be considered in interpreting the results. First, the LOTCA has not been validated in Arabic, although it was translated and back-translated for this study. Second, the proportion of children in each grade and gender varied within the two cultural groups. Further studies with more representative and larger samples of children from these cultures, and from additional cultures and sociodemographic backgrounds, should be performed to firmly establish which of these parameters has a primary impact on children’s cognitive performance.

This research was supported by the Netherlands–Israel Development Research Program (98–3.1). We also thank all the assessors for data collection, Rachel Nadler for her help in coordination of the project, and all the children for their participation.