Izben C. Williams, MD, MPH Instructor. Clinical Assessment INTRODUCTION -1 There are two systematic...

BEHAVIORAL SCIENCE

Izben C. Williams, MD, MPHInstructor

Clinical Assessment INTRODUCTION -1

There are two systematic methods for evaluating behavioral, emotional, and cognitive processes1. The Mental Status Examination

(MSE)2. Psychometric evaluation

(psychological testing) Both are important in understanding a

patient’s current mental status


The MSE and Psychometric evaluation are always used in conjunction with:A complete medical historyA complete physical examinationA neurologic examinationVarious laboratory and radiologic

studies


In this context……The MSE is part of a broader

psychiatric examination, The psychometric evaluation part of

the broader perspective of psychological assessment

There is overlap in item content and complex interpretation may be necessary to arrive at a conclusion

The Psychometric Evaluation

Clinical Assessment of Intelligence, Personality

and Achievement


• Definition: • Psychometric evaluation is a set of test

techniques by which a sample of behavior is elicited, observed, recorded, analyzed, and interpreted.


• Purposes of Psychometric Evaluation: 1. To provide descriptive information about a

individual2. To enhance understanding of psychological dynamics3. To assist in establishing a diagnosis4. To assist in making decisions (eg competency,

placement)5. To assist in treatment and discharge planning6. For prognostic and predictive purposes 7. To establish baseline performance levels in

monitoring change8. To evaluate changes in brain-behavior relationship


• Principles of Psychometric Evaluation: • Three very important principles of

psychometric measurement in general, are……a. Standardization

• Collecting normative data from a representative population group, under controlled conditions

b. ReliabilityConsistency and accuracy of the test

c. ValidityWhether the test measures what it is intended to


Types of Psychological Tests: • Psychological tests differ in

1. The nature of the information obtained (the focus of the test), and

2. The processes of the assessment procedure


• 1. The nature of the information obtained: a. Cognitive ability tests (the most common

are tests for intellectual functioning and academic achievement)

b. Personality assessment tests (reveal information that may be descriptive of the individual or his ongoing personality dynamics)


• 1. The nature of the information obtained: c. Vocational tests assess interests attitudes and aptitude in the context of a more general understanding of the individual, to assist in making vocational choicesd. Neuropsychological tests assess brain-behavior relationship e. Behavioral assessment refers to assessment techniques that minimize inference and have particular emphasis on observable, quantifiable measures


• 2. The Process of the assessment procedure: a. Individual versus group tests. Individually administered tests yield better understanding of the individual patient. Group tests, while more time efficient, may be less informative in understanding an individual b. Objective versus projective testsc. Potential ability versus typical performance


• 2. The Process of the assessment procedure: b. Objective versus Projective testsi. Objective tests are highly standardized for

administration, scoring and interpretation and are usually highly structured in format. All response possibilities are obvious and scorers can agree on the result

ii. Projective tests, in contrast, are less structured and allow greater leeway for expressing individuality and important individual dynamics. These tests are based on the projective hypothesis, revealing unconscious issues and aspects of his personality and cognitive style


• Major Psychological testsA. Tests of intellectual ability (eg,

Wechsler, and Stanford-Binet Scales) B. Achievement tests (eg, WRAT, SAT,

USMLE)C. Tests of personality functioning (eg,

MMPI, Rorschach, TAT, Sentence completion, projective drawings, etc)

D. Vocational testsE. Neuropsychological assessment

The Psychometric EvaluationMajor Psychological Tests

• A. Tests for intellectual ability -1 of 14• Intelligence is an individual’s ability to adapt

and constructively solve problems in the environment. It is a multidimensional performance construct, which includes:

• The capacity to acquire, store, access and manipulate information

• The ability to learn from experience• Insight; Abstract reasoning• The capacity to adapt to new situations, and• The ability to focus and sustain direction in

activities


• A. Tests of Intellectual Ability -2:• Measured intelligence tends to be quite

stable after adolescence, and test-retest reliabilities are quite high, even in young children.

• However IQ is not static and may change considerably in children over a period of years


• A. Tests of Intellectual Ability -3:• Basic definitions• Chronologic age (CA) is a persons actual

age in years• Mental Age (MA) is the age level of

intellectual functioning of an individual (the age at which an average person reaches the same ability)

• Intelligence quotient (IQ) is the ratio of MA to CA times 100 (ie IQ = MA/CA x 100)


• A. Tests of Intellectual Ability -4:• Intelligence Quotient (IQ) • Genetics play a major role in

determining IQ. • IQ is relatively stable throughout life. An

individuals IQ remains essentially the same in old age as in childhood, in the absence of brain disease

• Influences on IQ test scores may include cultural background and emotional response to testing situations


• A. Tests of Intellectual Ability -5:• Mental retardation-1 • Normal or average IQ in a given

population is within the range 90-109• The standard deviation in IQ scores is 15. • More than two standard deviations below

the mean (ie, an IQ of 70 or less) is considered mental retardation

IQ Ranges & Distribution

IQ Descriptor ApproximatePercentage

Percentile range

≥ 130 Very superior 2% 98-100

120-129

Superior 7% 91-98

110-119

High average 16% 75-90

90-109 Average 50% 25-95

80-89 Low average 16% 10-25

70-79 Borderline 7% 2-9

< 70 Mentally retarded 2% 0-2


• A. Tests of Intellectual Ability -6:• Mental Retardation-3 • The most common genetic causes of mental

retardation are Down Syndrome and Fragile X syndrome.

• Other causes include factors affecting mother or fetus such as infections (eg rubella), metabolic factors affecting mother or fetus, and substance abuse,


• A. Tests of Intellectual Ability -7:• Mental Retardation-4 • Down syndrome: Typically, the nucleus of each

cell contains 23 pairs of chromosomes, half of which are inherited from each parent. Down syndrome occurs when an individual has a full or partial extra copy of chromosome 21.

• This additional genetic material alters the course of development and causes the characteristics (qv) associated with Down syndrome


• A. Tests of Intellectual Ability -8:• Mental Retardation-5 • Fragile X: Fragile X syndrome is a genetic

condition involving the X chromosome and causing a range of developmental problems including learning disabilities and cognitive impairment. Usually, males are more severely affected by this disorder than females


• A. Tests of Intellectual Ability -9:• Wechsler Intelligence Tests • In practice the most widely used individually

administered intelligence measure performance in several different areas.

• The Wechsler intelligence scales serves as a good example


• A. Tests of Intellectual Ability -10:• Wechsler Intelligence Tests • The currently used tests are:• Wechsler Adult Intelligence Scale – (WAIS-III)• Wechsler Adult Intelligence Scale for Children

– (WISC-III); children 6-16½ years• Wechsler Preschool and Primary Scale of

Intelligence (WPPSI-R); children 4-6½ years Wechsler intelligence tests are adapted

for age


• Wechsler Intelligence Tests • The WAIS-R and the WISC-R are each divided into 2

sections, verbal and performance• Each section has its separately computed intelligence

quotient (IQ) • Each sections is further divided into 11 normalized

subtests • Verbal section: general information, comprehension,

similarities, arithmetic, digit span and vocabulary• Performance section: digit symbol, block design,

picture completion, object assembly and picture arrangement


• Wechsler Intelligence Tests • The currently used tests are:• Wechsler Adult Intelligence Scale – Revised

(WAIS-R)• Wechsler Adult Intelligence Scale for Children

– Revised (WISC-R); children 6-16½ years• Wechsler Preschool and Primary Scale of

Intelligence (WPPSI); children 4-6½ years The scales of Wechsler intelligence tests

are adapted for age


• A. Tests of Intellectual Ability -13:• Vineland Social Maturity Scale • The Vineland Social Maturity Scale is a

non-projective personality measure designed to help in the assessment of social competence (ie, to evaluate skills for daily living)


• A. Tests of Intellectual Ability -14:• The Stanford-Binet Scale is used with

individuals ages 2 thru 18 (best in the under 6): • To test general intellectual ability, • To assess giftedness, and • to address educational placement issues

• Comprises 142 brief tests, sampling a variety of skills

• Content arranged in age-appropriate levels• Best used with very young, very impaired or very

bright


• B. Achievement tests -1 of 2:• Measurement of achievement is the

evaluation of mastered information and skills that have been part of specific instruction.

• These tests:• Are widely used in the education system but

may be useful also in counseling and industry and may be included as part of neuropsychological batteries

• does not assess aptitude or future performance


• B. Achievement tests -2:• Examples of Achievement tests:• Wide-Range Achievement Test (WRAT)• Stanford Achievement test• Iowa Test of Educational Development• California Achievement test• Peabody Individual Achievement Test


• C. Tests of Personality functioning -1 of 3:• MMPI: An objective self-report test for obtaining

diagnostic, clinical information on psychiatric and medical patients and in research. (the most [ab]used)• Often utilized in forensic evaluations, in assessment of

treatment outcomes, substantive issues of malingering and in evaluating psychological determinants of chronic pain

• Rorschach Inkblot Test: is the major projective test of personality assessment• The Rorschach is used to assess personality dynamics

and organization as well as cognitive style


• C. Tests of Personality functioning -2:• TAT: Used in assessment of personality

functioning A way of evaluating drives, emotions, sentiments and conflicts of which an individual may be unaware

• Sentence completion test: An economical way of surveying a patient’s thoughts, feelings, motivations, and behavior along a number of psychological dimensions


• C. Tests of Personality functioning -3:• Projective drawings: These types of

procedures are used more to assess personality adjustment than aspects of intelligence

• Other tests of personality functioning:• Beck Depression Inventory• The Sixteen Personality Factors Inventory• The Symptom Checklist-90 • Milton Clinical Multiaxial Inventory


• D. Vocational Tests:• Infrequently used in medical settings• Tests of aptitude and ability; used in

career counseling• Information may be yielded on general

interest areas and on interest areas that are analogous to various occupations


• E. Neuropsychological assessment:• The evaluation of brain injury and

dysfunction in humans through the use of psychological tests has become a specialty of psychology

• The major approaches to assessment have been through the use of standardized batteries eg, Halstead-Reitan Neuropsychological Test Battery (HRB)


• E. Neuropsychological assessment -2:• The Halstead-Reitan

Neuropsychological Test Battery (HRB) addresses questions of the presence, absence, and localization of brain dysfunction.

• Prognostic and rehabilitative statements are often made on the basis of HRB and other supplementary neuropsychological tests

Izben C. Williams, MD, MPH Instructor. Clinical Assessment INTRODUCTION -1 There are two systematic...

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