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Essentials of Testing and Assessment A Practical Guide to Counselors, Social Workers, and Psychologists

THIRD EDITION

Edward S. Neukrug Old Dominion University

R. Charles Fawcett Director, Region Ten Fluvanna Counseling Center

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To my father and my brother, the real math experts in the family. —Ed Neukrug

To my loving wife Laura, who makes my life richer. —Charlie Fawcett

Brief Contents

SECTION I UNDERSTANDING THE ASSESSMENT PROCESS: HISTORY, ETHICAL AND PROFESSIONAL ISSUES, DIAGNOSIS, AND THE ASSESSMENT REPORT 1

1 History of Testing and Assessment 3

2 Ethical, Legal, and Professional Issues in Assessment 21

3 Diagnosis in the Assessment Process 43

4 The Assessment Report Process: Interviewing the Client and Writing the Report 59

SECTION II TEST WORTHINESS AND TEST STATISTICS 81

5 Test Worthiness: Validity, Reliability, Cross-Cultural Fairness, and Practicality 83

6 Statistical Concepts: Making Meaning Out of Raw Scores 110

7 Statistical Concepts: Creating New Scores to Interpret Test Data 127

SECTION III COMMONLY USED ASSESSMENT TECHNIQUES 151

8 Assessment of Educational Ability: Survey Battery, Diagnostic, Readiness, and Cognitive Ability Tests 157

9 Intellectual and Cognitive Functioning: Intelligence Testing and Neuropsychological Assessment 190

10 Career and Occupational Assessment: Interest Inventories, Multiple Aptitude, and Special Aptitude Tests 221

11 Clinical Assessment: Objective and Projective Personality Tests 247

12 Informal Assessment: Observation, Rating Scales, Classification Methods, Environmental Assessment, Records and Personal Documents, and Performance-Based Assessment 281

BRIEF CONTENTS v

Contents

PREFACE XV

SECTION I Understanding the Assessment Process: History, Ethical and Professional Issues, Diagnosis, and the Assessment Report 1

1 History of Testing and Assessment 3 Distinguishing Between Testing and Assessment 4

The History of Assessment 5 Ancient History 5 Precursors to Modern-Day Test Development 5 The Emergence of Ability Tests (Testing in the Cognitive Domain) 7

Intellectual and Cognitive Functioning: Intelligence Testing and Neuropsychological Assessment 7

Group Tests of Ability (Group Testing in the Cognitive Domain) 8 The Emergence of Personality Tests (Testing in the Affective Realm) 12

Interest Inventories and Vocational Assessment 12 Objective Personality Assessment 12 Projective Testing 12

The Emergence of Informal Assessment Procedures 13 Modern-Day Use of Assessment Procedures 14

Questions to Consider When Assessing Individuals 17

Summary 17

Chapter Review 18

References 19

2 Ethical, Legal, and Professional Issues in Assessment 21 Ethical Issues in Assessment 22

Overview of the Assessment Sections of the ACA and APA Ethical Codes 22 Choosing Appropriate Assessment Instruments 22 Competence in the Use of Tests 23 Confidentiality 23 Cross-Cultural Sensitivity 24 Informed Consent 24 Invasion of Privacy 24 Proper Diagnosis 24 Release of Test Data 24 Test Administration 25 Test Security 25 Test Scoring and Interpretation 25

Standards for Responsible Testing Practices 26 Making Ethical Decisions 27

Legal Issues in Assessment 28 The Family Education Rights and Privacy Act (FERPA) of 1974 29 The Health Insurance Portability and Accountability Act (HIPAA) 29 Privileged Communication 30 The Freedom of Information Act 30 Civil Rights Acts (1964 and Amendments) 30 Americans with Disabilities Act (ADA) (PL 101-336) 32 Individuals with Disabilities Education Act (IDEA) 32 Section 504 of the Rehabilitation Act 33 Carl Perkins Career and Technical Education Improvement Act of 2006 33

Professional Issues 33 Professional Associations 34 Accreditation Standards of Professional Associations 34 Forensic Evaluations 34 Assessment as a Holistic Process 35 Cross-Cultural Issues in Assessment 36 Embracing Testing and Assessment Procedures 38

Summary 38

Chapter Review 39

References 40

3 Diagnosis in the Assessment Process 43 The Importance of Diagnosis 44

The Diagnostic and Statistical Manual (DSM): A Brief History 45

The DSM-5 46 Single-Axis vs. Multiaxial Diagnosis 47 Making and Reporting Diagnosis 47

Ordering Diagnoses 47 Subtypes, Specifiers, and Severity 47 Provisional Diagnosis 48 Other Specified Disorders and Unspecified Disorders 48

Specific Diagnostic Categories 49

CONTENTS vii

Other Medical Considerations 52 Psychosocial and Environmental Considerations 53 Cultural Considerations 54 Final Thoughts on DSM-5 in the Assessment Process 54

Summary 56

Chapter Review 56

Answers to Exercise 57

References 57

4 The Assessment Report Process: Interviewing the Client and Writing the Report 59 Purpose of the Assessment Report 60

Gathering Information for the Report: Garbage In, Garbage Out 60

Structured, Unstructured, and Semi-Structured Interviews 61 Computer-Driven Assessment 63

Choosing an Appropriate Assessment Instrument 64

Writing the Report 65 Demographic Information 65 Presenting Problem or Reason for Referral 66 Family Background 66 Significant Medical/Counseling History 67 Substance Use and Abuse 67 Educational and Vocational History 68 Other Pertinent Information 68 Mental Status 68

Appearance and Behavior 68 Emotional State 68 Thought Components 70 Cognition 71

Assessment Results 72 Diagnosis 73 Summary and Conclusions 74

Recommendations 75

Summarizing the Writing of an Assessment Report 75

Summary 77

Chapter Review 78

References 78

SECTION II Test Worthiness and Test Statistics 81

5 Test Worthiness: Validity, Reliability, Cross-Cultural Fairness, and Practicality 83 Correlation Coefficient 84

Coefficient of Determination (Shared Variance) 86

viii CONTENTS

Validity 87 Content Validity 87 Criterion-Related Validity 89

Concurrent Validity 89 Predictive Validity 89

Construct Validity 91 Experimental Design Validity 91 Factor Analysis 92 Convergence with Other Instruments (Convergent Validity) 92 Discrimination with Other Measures (Discriminant Validity) 92

Visual Representation of Types of Validity 93

Reliability 94 Test-Retest Reliability 95 Alternate, Parallel, or Equivalent Forms Reliability 96 Internal Consistency 96

Split-Half or Odd-Even Reliability 96 Cronbach’s Coefficient Alpha and Kuder–Richardson 97

Visual Representation of Types of Reliability 97 Item Response Theory: Another Way of Looking at Reliability 98

Cross-Cultural Fairness 99

Practicality 102 Time 102 Cost 102 Format 102 Readability 103 Ease of Administration, Scoring, and Interpretation 103

Selecting and Administering a Good Test 103 Step 1: Determine the Goals of Your Client 103 Step 2: Choose Instrument Types to Reach Client Goals 104 Step 3: Access Information About Possible Instruments 104 Step 4: Examine Validity, Reliability, Cross-Cultural Fairness, and Practicality of the Possible Instruments 105 Step 5: Choose an Instrument Wisely 106

Summary 106

Chapter Review 107

References 107

6 Statistical Concepts: Making Meaning Out of Raw Scores 110 Raw Scores 111

Frequency Distributions 112

Histograms and Frequency Polygons 113

Cumulative Distributions 115

Normal Curves and Skewed Curves 116 The Normal Curve 116 Skewed Curves 117

CONTENTS ix

Measures of Central Tendency 118 Mean 118 Median 118 Mode 119

Measures of Variability 119 Range 120 Interquartile Range 120 Standard Deviation 122

Remembering the Person 124

Summary 125

Chapter Review 126

Answers to Items 5 through 8 126

Reference 126

7 Statistical Concepts: Creating New Scores to Interpret Test Data 127 Norm Referencing versus Criterion Referencing 128

Normative Comparisons and Derived Scores 129 Percentiles 130 Standard Scores 130

z-Scores 131 T-scores 133 Deviation IQ 133 Stanines 135 Sten Scores 136 Normal Curve Equivalents (NCE) Scores 136 College and Graduate School Entrance Exam Scores 136 Publisher-Type Scores 138

Developmental Norms 139 Age Comparisons 139 Grade Equivalents 139

Putting It All Together 140

Standard Error of Measurement 141

Standard Error of Estimate 143

Scales of Measurement 145 Nominal Scale 146 Ordinal Scale 146 Interval Scale 146 Ratio Scale 146

Summary 147

Chapter Review 148

Answers to Items 4 through 10 149

References 149

x CONTENTS

SECTION III Commonly Used Assessment Techniques 151

8 Assessment of Educational Ability: Survey Battery, Diagnostic, Readiness, and Cognitive Ability Tests 157 Defining Assessment of Educational Ability 158

Survey Battery Achievement Testing 159 National Assessment of Educational Progress (NAEP) 160 Stanford Achievement Test 162 Iowa Test of Basic Skills (ITBS) 163 Metropolitan Achievement Test 165

Diagnostic Testing 165 The Wide Range Achievement Test 4 (WRAT4) 166 Wechsler Individual Achievement Test—Third Edition (WIAT-III) 167 Peabody Individual Achievement Test (PIAT-R/NU) 167 Woodcock-Johnson® III 170 KeyMath3™ Diagnostic Assessment 170

Readiness Testing 171 Kindergarten Readiness Test (KRT) (Anderhalter & Perney) 172 Kindergarten Readiness Test (KRT) (Larson and Vitali) 172 Metropolitan Readiness Test (MRT6) 173 Gesell Developmental Observation—Revised 173

Cognitive Ability Tests 174 Otis-Lennon School Ability Test, Eighth Edition (OLSAT 8) 174 The Cognitive Ability Test (CogAT) 177 College and Graduate School Admission Exams 178

ACT 178 SAT 179 GRE General Test 180 GRE Subject Tests 181 Miller Analogy Test (MAT) 181 Law School Admission Test (LSAT) 181 Medical College Admission Test (MCAT) 182

The Role of Helpers in the Assessment of Educational Ability 182

Final Thoughts About the Assessment of Educational Ability 183

Summary 184

Chapter Review 185

References 186

9 Intellectual and Cognitive Functioning: Intelligence Testing and Neuropsychological Assessment 190 A Brief History of Intelligence Testing 191

Defining Intelligence Testing 191

Models of Intelligence 192 Spearman’s Two-Factor Approach 192 Thurstone’s Multifactor Approach 193 Vernon’s Hierarchical Model of Intelligence 193

CONTENTS xi

Guilford’s Multifactor/MultiDimensional Model 193 Cattell’s Fluid and Crystal Intelligence 193 Piaget’s Cognitive Development Theory 195 Gardner’s Theory of Multiple Intelligences 196 Sternberg’s Triarchic Theory of Successful Intelligence 197 Cattell-Horn-Carroll (CHC) Integrated Model of Intelligence 199 Theories of Intelligence Summarized 199

Intelligence Testing 199 Stanford-Binet, Fifth Edition 202 Wechsler Scales 203 Kaufman Assessment Battery for Children 208 Nonverbal Intelligence Tests 208

Comprehensive Test of Nonverbal Intelligence, Second Edition (CTONI-2) 209 Universal Nonverbal Intelligence Test (UNIT) 209 Wechsler Nonverbal Scale of Ability (WNV) 209

Neuropsychological Assessment 210 A Brief History of Neuropsychological Assessment 210 Defining Neuropsychological Assessment 210 Methods of Neuropsychological Assessment 211

Fixed Battery Approach and the Halstead-Reitan Battery 211 Flexible Battery Approach and the Boston Process Approach (BPA) 213

The Role of Helpers in the Assessment of Intellectual and Cognitive Functioning 214

Final Thoughts on the Assessment of Intellectual and Cognitive Functioning 215

Summary 215

Chapter Review 217

References 218

10 Career and Occupational Assessment: Interest Inventories, Multiple Aptitude, and Special Aptitude Tests 221 Defining Career and Occupational Assessment 222

Interest Inventories 222 Strong Interest Inventory® 223

General Occupational Themes 223 Basic Interest Scales 225 Occupational Scales 225 Personal Style Scales 225 Response Summary 225

Self-Directed Search 228 COPSystem 228

Career Occupational Preference System Interest Inventory (COPS) 229 Career Ability Placement Survey (CAPS) 230 Career Orientation Placement and Evaluation Survey (COPES) 230

O*NET and Career Exploration Tools 230 Other Common Interest Inventories 233

Multiple Aptitude Testing 233 Factor Analysis and Multiple Aptitude Testing 233 Armed Services Vocational Aptitude Battery and Career Exploration Program 234 Differential Aptitude Tests 237

xii CONTENTS

Special Aptitude Testing 238 Clerical Aptitude Tests 238 Mechanical Aptitude Tests 239 Artistic Aptitude Tests 240 Musical Aptitude Tests 241

The Role of Helpers in Occupational and Career Assessment 241

Final Thoughts Concerning Occupational and Career Assessment 242

Summary 242

Chapter Review 244

References 244

11 Clinical Assessment: Objective and Projective Personality Tests 247 Defining Clinical Assessment 248

Objective Personality Testing 248 Common Objective Personality Tests 249

Minnesota Multiphasic Personality Inventory-2 249 Millon Clinical Multiaxial Inventory, Third Edition 252 Personality Assessment Inventory® 253 Beck Depression Inventory-II 256 Beck Anxiety Inventory 256 Myers-Briggs Type Indicator® 257 Sixteen Personality Factors Questionnaire (16PF)® 260 The Big Five Personality Traits and the NEO PI-3™ and NEO-FFI-3™ 262 Conners 3rd Edition 264 Substance Abuse Subtle Screening Inventory (SASSI®) 265 Other Common Objective Personality Tests 266

Projective Testing 266 Common Projective Tests 267

The Thematic Apperception Test and Related Instruments 267 Rorschach Inkblot Test 269 Bender Visual-Motor Gestalt Test, Second Edition 270 House-Tree-Person and Other Drawing Tests 272 Sentence Completion Tests 273

The Role of Helpers in Clinical Assessment 274

Final Thoughts on Clinical Assessment 274

Summary 275

Chapter Review 277

References 277

12 Informal Assessment: Observation, Rating Scales, Classification Methods, Environmental Assessment, Records and Personal Documents, and Performance-Based Assessment 281 Defining Informal Assessment 282

Types of Informal Assessment 282 Observation 283

CONTENTS xiii

Rating Scales 284 Numerical Scales 285 Likert-Type Scales (Graphic Scales) 286 Semantic Differential Scales 286 Rank-Order Scales 287

Classification Methods 287 Behavior Checklists 287 Feeling Word Checklists 288 Other Classification Methods 288

Environmental Assessment 290 Direct Observation 290 Situational Assessment 291 Sociometric Assessment 291 Environmental Assessment Instruments 291

Records and Personal Documents 293 Biographical Inventories 293 Cumulative Records 295 Anecdotal Information 295 Autobiography 296 Journals and Diaries 296 Genograms 296

Performance-Based Assessment 297

Test Worthiness of Informal Assessment 299 Validity 299 Reliability 300 Cross-Cultural Fairness 301 Practicality 302

The Role of Helpers in the Use of Informal Assessment 302

Final Thoughts on Informal Assessment 302

Summary 303

Chapter Review 304

References 305

Appendix A Websites of Codes of Ethics of Select Mental Health Professional Associations 306

Appendix B Assessment Sections of ACA’s and APA’s Codes of Ethics 308

Appendix C Code of Fair Testing Practices in Education 314

Appendix D Sample Assessment Report 321

Appendix E Supplemental Statistical Equations 327

Appendix F Converting Percentiles from z-Scores 329

GLOSSARY 331

INDEX 340

xiv CONTENTS

Preface

We have been delighted to update Essentials of Testing and Assessment to its third edition. We believe this new edition brings some important and critical changes, yet we have kept the basic content of the book as is. We hope that by obtaining good input from reviewers and by adding important and new issues that have arisen, the third edition adds value to the previous two editions. Despite the changes and additions, we were careful to keep the core of the book the same and to only cover what can reasonably be learned in a one-semester course on testing and assessment—not more. But don’t let that fool you, as Essentials of Testing and Assessment includes quite a bit of information! We believe this book is written in a down-to-earth fashion that you will hopefully find interesting. In addition, we offer stories and vignettes that highlight learning. Some of the overarching changes include:

• Rearranging the sections of the book. Although the book has kept the basic content from the original 12 chapters, the chapters have been redistributed in the book to better suit classroom teaching and student learning (see descrip- tion of chapters that follows).

• Inclusion of information on two national studies, one on counselors use of assessment instruments and one that focuses on the kinds of assessment instruments that are taught in counseling programs.

• Update of citations and research. • Additional information on cross-cultural assessment. • The addition of new and updated assessment instruments. • Updating the chapter on diagnosis to reflect DSM-5.

The following gives a brief description of the content and the changes to the 3 sections and 12 chapters of Essentials of Testing and Assessment.

SECTION I: UNDERSTANDING THE ASSESSMENT PROCESS: HISTORY, ETHICAL AND PROFESSIONAL ISSUES, DIAGNOSIS, AND THE ASSESSMENT REPORT

Section I introduces the reader to a broad range of issues related to understanding testing and assessment. Chapter 1 provides definitions of assessment and the his- tory of assessment, Chapter 2 provides the reader with important professional, eth- ical, and legal issues in assessment. Chapter 3 offers information on diagnosis, one critical aspect of the assessment process, whereas Chapter 4 presents information on how to write a test report.

Chapter 1: History of Testing and Assessment Chapter 1 begins with a discussion of the differences between testing and assess- ment and then goes on to highlight the historical development of testing and assessment from ancient times to modern-day assessment instruments. Along the way, we discuss some of the people who were critical to the development of assess- ment measures and examine some of the many controversial issues that arose. The chapter nears its conclusion by reviewing the current categories of assessment instruments, including ability testing (achievement and aptitude testing), personal- ity assessment, and informal assessment. We finish by raising a number of con- cerns that continue to face us as we administer assessment instruments. Some of the changes in this chapter include adding the following: additional examples of early types of assessment instruments, quick definitions of types of assessment pro- cedures, and a figure that helps to understand the various kinds of ability, person- ality, and informal assessment procedures.

Chapter 2: Ethical, Legal, and Professional Issues in Assessment Chapter 2 focuses on the complex ethical, legal, and professional issues that are faced by individuals who are assessing others. We begin by discussing the com- plexity of ethical decision making and then identify ethical codes and professional standards critical to testing and assessment. We go on to discuss the importance of wise ethical decision making, and we identify a number of laws that have been passed and lawsuits resolved that impinge on the use of tests in the assessment pro- cess. The chapter concludes with a discussion of professional associations that address assessment, a brief discussion of accrediting bodies that address assess- ment, an introduction to the growing field of forensic evaluation, the importance of viewing assessment as a holistic process, a discussion cross-cultural assessment, and the importance of embracing the testing and assessment process. Some changes to this chapter include updating information from revisions of ethical codes, updat- ing and streamlining important assessment standards, updating relevant laws related to the administration and interpretation of tests, and expanding the discus- sion on cross-cultural issues related to assessment.

xvi PREFACE

Chapter 3: Diagnosis in the Assessment Process Chapter 3 (formerly Chapter 11) has been dramatically changed to reflect the transition from DSM-IV to DSM-5. This chapter starts with a discussion on the importance of making a diagnosis then goes on to offer a brief history of the Diagnostic and Statistical Manual of Mental Disorders. An overview of DSM-5 is then offered, which includes the change to a single axis system; the use of a dimensional assessment (mild, moderate, severe, and very severe); the use of wide spectrum disorders, brief explanations of the specific diagnostic categories; a description of how DSM-5 addresses cross-cultural issues; an explanation of how medical, psychosocial, and environmental conditions can impact diagnosis; and some examples of how to make a diagnosis.

Chapter 4: The Assessment Report Process: Interviewing the Client and Writing the Report Chapter 4 (formerly Chapter 12) was moved to the first section of the book because it seemed to better fit the content of Chapters 1 and 2. Also, many faculty were having students write test reports; thus, we thought it would be best to high- light the test report-writing process near the beginning of the book so students would have an early understanding of how to begin this important project. How- ever, since this chapter and Chapter 3 can stand on their own, you may want to continue to cover them later in the course. Chapter 4 begins with a definition of the purpose of the assessment report. Then, we discuss the importance of accurately iden- tifying the breadth and depth of a client’s issues so that one can make smart decisions in choosing which assessment procedures to use. In this chapter, we also distinguish between conducting a structured, unstructured, and semi-structured interview, and we point out how computers have become increasingly important in the writing of test reports. Finally, we give a detailed description of the categories of a test report and offer suggestions on how to write a report. Included in this description is an expanded explanation of the mental status exam and a new section on assessing lethality. Using a fictitious client, we offer an example of how to right a report. The resulting five-page assessment report can be found in its entirety in Appendix D of the book.

SECTION II: TEST WORTHINESS AND TEST STATISTICS Section II of the book addresses test worthiness and test statistics. The three chap- ters that make up this section examine how tests are created, scored, and inter- preted. These chapters all use test statistics in some manner to explain the concepts being presented. In this section, we demonstrate how collecting and inter- preting test data is a deliberate and planned process that involves a scientific approach to the understanding of differences among people.

Chapter 5: Test Worthiness: Validity, Reliability, Practicality, and Cross-Cultural Fairness Chapter 5 examines four critical areas of test worthiness: (1) validity: whether a test measures what it is supposed to measure; (2) reliability: whether the score an

PREFACE xvii

individual receives on a test is an accurate measure of his or her true score; (3) cross-cultural fairness: whether the score the individual has obtained is a true reflection of the individual and not a function of cultural bias inherent in the test, and (4) practicality: whether it makes sense to use a test in a particular situation. After examining these four factors, we conclude with a discussion of five steps to use to assure test worthiness when selecting a test to administer. The chapter also provides an explanation of two statistics: correlation coefficient and coefficient of determination. We present these statistics as they are foundational to understand- ing much of what is presented in this and future chapters. In this chapter, we enhanced the section on negative correlation to improve readability, and we added figures to visually depict representations of different types of validity.

Chapter 6: Statistical Concepts: Making Meaning Out of Raw Scores Chapter 6 starts by noting that raw scores generally provide little meaningful information about a set of scores. We then provide ways that we can manipulate raw scores to make sense out of a set of data, and we examine how the following concepts are used to help us understand raw scores: frequency distributions; histo- grams and frequency polygons; cumulative distributions; the normal curve; skewed curves; measures of central tendency such as the mean, median and mode; and measures of variability, such as the range, semi-interquartile range, and standard deviation. A couple of the updates to this chapter include an explanation why cal- culators sometimes give a slightly different standard deviation than the standard deviation you will get when you use the formula in the book and a second formula has been added for the calculation of standard deviation.

Chapter 7: Statistics Concepts: Creating New Scores to Interpret Data In Chapter 7 we examine how raw scores are converted to what are called “derived” scores so that individuals can more easily understand what their raw scores mean. We first distinguish between norm-referenced and criterion-referenced testing and then go on to discuss the following derived scores: (1) percentiles; (2) standard scores, including z-scores, T-scores, deviation IQs, stanines, normal curve equivalents (NCE’s), sten scores, college entrance exam scores (e.g., SATs and ACTs), and publisher-type scores; and (3) developmental norms, such as age comparisons and grade equivalents. The chapter then examines standard error of measurement and standard error of estimate, both of which offer ways of understanding the range in which one’s “true score” actually falls. The chapter concludes with a discussion of nominal, ordinal, interval, and ratio scales in which we explore each scale’s unique attributes and note that different kinds of assessment instruments use different kinds of scales. In this chapter, we have updated critical information on a number of standard scores, such as the SATs, GREs, and ACTs.

xviii PREFACE

SECTION III: COMMONLY USED ASSESSMENT TECHNIQUES Section III, which includes Chapters 8 through 12, examines some commonly used assessment procedures. Throughout these chapters, we have carefully updated information on many of the tests discussed. At the beginning of this section, we offer an overview of some studies conducted with counselors and psychologists regarding the kinds of testing and assessment instruments they use and also offer a table that identifies the instruments we will cover in this section of the book. We note that most of the instruments we cover are used by a large portion of counselors and psychologists. Each of the chapters in this section has a specific focus that helps to delineate the kinds of assessment procedures used.

Chapter 8: Assessment of Educational Ability: Survey Battery, Diagnostic, Readiness, and Cognitive Ability Tests Chapter 8 examines tests typically given in schools to measure what students have learned and what they are capable of learning. After defining the various categories of assessment of educational ability, we give examples of survey battery achievement tests, diagnostic tests, readiness tests, and cognitive ability tests. Throughout the chapter, we offer insight into the world of high-stakes testing and some of the important issues raised as the result of such laws as No Child Left Behind. In this chapter, we have added information about the Wechsler Individual Achievement Test (WIAT) and the Woodcock-Johnson® III, expanded the discussion of readiness testing, and provided the latest information about college and graduate school tests.

Chapter 9: Intellectual and Cognitive Functioning: Intelligence Testing and Neuropsychological Assessment Chapter 9 explores intellectual and cognitive functioning. Here, we offer a brief his- tory of intelligence testing and of neuropsychological assessment, define these two areas, and describe differences and similarities between them. The chapter also offers an overview of some of the more popular models of intelligences, and we present some common verbal and nonverbal tests of intelligence as well as types of neuropsy- chological assessments. In this edition, we have added two new theories of intelli- gence, the Cattell-Horn-Carroll (CHC) integrated model of intelligence and the triarchic theory of successful intelligence; added information about the Wechsler Nonverbal Scale of Ability (WNV), and provided an updated discussion of the use of neuropsychological assessment as applied to individuals with traumatic brain injury, such as returning service members from Iraq and Afghanistan.

Chapter 10: Career and Occupational Assessment: Interest Inventories, Multiple Aptitude, and Special Aptitude Tests Chapter 10 examines the kinds of tests that can help individuals make decisions about their occupational or career path. We begin with an examination of interest

PREFACE xix

inventories, which are a type of personality assessment that generally look at indi- viduals’ likes and dislikes as well their personality orientation toward the world of work. We next explore multiple aptitude testing, which can help individuals iden- tify the range of skills and abilities that may be important in choosing an occupa- tion. We conclude with a look at some of the more popular special aptitude tests that look at focused areas of ability, such as clerical skills, mechanical skills, artis- tic skills, and musical ability. In this edition, we added information on O*NET and its Career Exploration Tools and discuss the new computerized version of the Armed Services Vocational Aptitude Battery (CAT-ASVAB).

Chapter 11: Clinical Assessment: Objective and Projective Personality Tests Chapter 11 examines the process of using tests for clinical assessment. We start by underscoring the fact that such assessment has a wide variety of applications and can be an important tool for the clinician or researcher. The chapter then defines clinical assessment and speaks of some of the critical issues that such assessment can address. The meat of the chapter is a review of a number of the more well known and used objective and projective clinical assessment procedures. This edi- tion has added information on the Conners 3 instrument for assessing ADHD and the Beck Anxiety Inventory (BAI).

Chapter 12: Informal Assessment: Observation, Rating Scales, Classification Methods, Environmental Assessment, Records and Personal Documents, and Performance-Based Assessment This final chapter of the book covers informal assessment procedures. We start by defining informal assessment and then identify a number of different kinds of informal assessment techniques, including observation, rating scales, classification methods, environmental assessments, records and personal documents, and perfor- mance-based assessment. The second part of the chapter offers a discussion con- cerning test worthiness of informal assessment. In this edition, we provide an expanded genogram as a model to use to inquire about patterns in family and family assessment.

GLOSSARY AND APPENDICES At the end of the book, we offer a glossary of all of the major words and terms used in the text. This should be helpful in remembering some of the basic concepts you read about. Also, within each chapter, you will find important concepts highlighted in the margins. Essentials of Testing and Assessment offers six appen- dices to enhance some of the issues identified in the text. Appendix A offers the Web sites of major professional associations and their accompanying ethical codes, Appendix B presents the assessment sections of ACA’s and APA’s ethical codes, Appendix C provides the Code of Fair Testing Practices in Education,

xx PREFACE

Appendix D offers an example of a test report that should be helpful as a guide when you write your own report. Appendix E offers supplemental statistical equa- tions to help guide you in some of aspects of tests statistics, and Appendix F pro- vides a conversion table of percentiles from z-scores

FINAL THOUGHTS We believe this book is comprehensive without being overbearing. The text pro- vides an overview of testing and assessment in a readable, and we think, enjoyable fashion. We hope that after reading it, you come away with a new appreciation of testing and assessment.

ACKNOWLEDGEMENTS Every book has a number of people behind the scenes supporting its development. In this edition of Essentials of Testing and Assessment, we would like to acknowl- edge some of these individuals. From Cengage Publishing we would like to thank Jon-David Hague, product director, who helped us get this revision off-the-ground and set direction for the new edition. Also from Cengage, a very special thanks goes to Julie Martinez, product manager, who has given us the dad-to-day support and encouragement needed to complete this book. In addition, Kyra Kane, product assistant from Cengage, assisted with numerous behind the scenes tasks that are needed to be completed to finish any book. Other people were also critical to the book’s completion. Greg Johnson, senior project manager from PreMediaGlobal (PMG), was essential in helping us go through each chapter and ensuring that everything was on time, correct, and ready to go out the door. A special thanks goes to Greg. We would also like to thank the copyeditor from PMG who spent countless hours copyediting our text. A shout-out also goes to all those people who were behind the scenes ensuring completion of the book and whose names we never get to see.

In addition to the individuals just noted, for every revision we rely on a number of faculty to review the text and offer us important feedback about potential changes that need to be made. For this edition, the following individuals were criti- cal to this process: Eric Bruns, Campbellsville University; Laurie Carlson, Colorado State University; David Carter, University of Nebraska Omaha; Mary Ann Coup- land, Sinte Gleska University; Aaron Hughey, Western Kentucky University; Sheri Pickover, University of Detroit Mercy; Clarrice Rapisarda, The University of North Carolina at Charlotte; and Todd Whitman, Shippensburg University. In addition, a special thanks to Peg Jensen for her careful read of Chapter 9: Intellectual and Cognitive Functioning, which led us to make substantial changes in that chapter. Finally, thanks to Martin Baggarly, my nephew, who drew the amazing turtle and shoe for the “Test of Artistic Potential” in Chapter 10.

PREFACE xxi

S E C T I O N IUnderstanding theAssessment Process: History, Ethical and Professional Issues, Diagnosis, and the Assessment Report

Section I of this book includes four chapters: Chapter 1: History of Testing and Assessment; Chapter 2: Ethical, Legal, and Professional Issues in Assessment; Chapter 3: Diagnosis in the Assessment Process; and Chapter 4: The Assessment Report Process: Interviewing the Client and Writing the Assessment Report.

In the first chapter, we define testing and assessment and examine the history of testing and assessment starting with ancient times and working our way to the development of modern-day assessment instruments. Near the end of the chapter, we examine current categories of assessment instruments, including ability testing (testing in the cognitive realm), personality assessment (testing in the affective realm), and informal assessment techniques. The chapter concludes by raising a number of concerns that continue to face us today as we administer assessment instruments.

Chapter 2 examines the many complex ethical, legal, and professional issues that confront individuals who are assessing others. We identify aspects of major ethical codes that focus on assessment; summarize standards that have been devel- oped to help guide the practitioner when administering, scoring, and interpreting assessment procedures; and discuss the process of ethical decision making. We then examine legal issues that have impinged on the use of tests, professional asso- ciations that focus on assessment, and organizations that accredit programs that teach assessment. A discussion on the professional field of forensic evaluation then ensues and the chapter concludes with a discussion of assessment as a holistic pro- cess and issues of bias in testing.

In Chapter 3, we begin by discussing the importance of making a diagnosis. We then go on to introduce the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5), which is the common diagnostic tool used by almost all clinicians. We offer a brief history of the DSM, discuss the recent changes that took place in the development of DSM-5 from DSM-IV-TR, offer a brief overview of the various diagnostic classifications, and demonstrate how DSM-5 is used in assessing a client. We conclude the chapter with a discussion of the importance of diagnosis in the total assessment process.

Chapter 4 highlights the importance of the assessment report and suggests the report is the “deliverable” or “end product” of the assessment process. Here, we offer guidelines for conducting an effective interview, and we distinguish among structured, unstructured, and semi-structured interviews. In Chapter 4, we discuss the importance of choosing assessment measures that match the client’s presenting issues, and we stress the importance of considering the breadth and depth of cli- ents’ issues when choosing assessment procedures. The rest of Chapter 4 is dedi- cated to ways of writing effective test reports, and we delineate topics that should be covered to create a thorough assessment of a client. An example of a fictitious client is offered as we show how each section of the assessment report should be written. The complete assessment report can be found in Appendix D of the book.

2 SECTION I Understanding the Assessment Process

C H A P T E R 1History of Testing andAssessment

You walk into the room, prepared to take the test and know that the results will impact your future. You can feel your heart begin to pound and your stomach being to churn. “OMG, I hope I can do well, you say to yourself.”

With millions of children and adults frightened by the thought of taking a test, this is not a pretty picture. But is there value in this sometimes-terrifying experience? We’ll let you answer that question after you have finished reading this book. But how did test-taking start? That question will be answered in this chapter.

(Ed Neukrug)

In this chapter we will examine the history of testing and assessment. First, we will explore the differences between testing and assessment and point out how their cur- rent definitions are directly related to their history. We will then take a ride through the history of assessment, starting with ancient history and working our way to the development of modern-day assessment instruments. Along the way, we will highlight some of the people who were pioneers in the development of assessment measures and discuss some of the controversial issues that arose. As the chapter nears its conclusion, we will examine the current categories of assess- ment instruments, and we will finish by raising a number of ongoing concerns sur- rounding the use of assessment instruments.

DISTINGUISHING BETWEEN TESTING AND ASSESSMENT Today, the term assessment includes a broad array of evaluative procedures that yield information about a person (Hunsley, 2002). Assessment procedures include the clinical interview; informal assessment techniques such as observation, rating scales, classification methods, environmental assessment, records and personal documents, and performance-based assessment; personality tests such as objective tests, projective tests, and interest inventories; and ability tests such as achievement tests and aptitude tests (see Figure 1.1).

Tests are a subset of assessment techniques that yield scores based on the gath- ering of collective data (e.g., finding the sum of correct items on a multiple-choice exam). Assessment procedures can be formal, which means they have been well- researched and shown to be scientifically sound, valid, and reliable, or informal, which implies that such rigor has not been demonstrated, although the procedure might still yield some valuable information.

Generally, the greater the number of procedures used in assessing an individ- ual, the greater the likelihood that they will yield a clearer snapshot of the client. Thus, using multiple assessment procedures, or a holistic approach to assessment,

FIGURE 1.1 | Assessment Procedures

Assessment A broad array of eval- uative procedures

Tests Instruments that yield scores based on col- lected data—a subset of assessment

4 SECTION I Understanding the Assessment Process

should always be considered when making important decisions about a client’s life (Association for Assessment and Research in Counseling, 2012; Joint Committee on Testing Practices, 2004). In this text we will examine a broad array of formal and informal assessment procedures, all of which can be used in the decision- making process. But let’s start at the beginning and see how events of the past have moved us toward our current use of assessment instruments.

THE HISTORY OF ASSESSMENT Although the modern era of assessment began near the beginning of the twentieth century, assessment procedures can be found in ancient times. Let’s examine some of the changes in assessment that have taken place over the centuries.

Ancient History He said, “Take your son, your only son Isaac, whom you love, and go to the land of Moriah, and offer him there as a burnt offering on one of the mountains that I shall show you” (Genesis 22:5, New Revised Standard Version).

Assessment has been around for as long as humans have walked the earth. In fact, one might say that Abraham’s loyalty was assessed when God asked him to kill his son Isaac. From a more down-to-earth perspective, the Chinese government is given credit for developing one of the first widely used tests when it began to assess indi- viduals for fitness to work in government positions in approximately 2200 B.C.E. (DuBois, 1970; Higgins & Sun, 2002). With testing done under grueling conditions in hundreds of small cubicles or huts, it was not unusual that examinees would die from exhaustion (Cohen, Swerdlik, & Sturman, 2012). This kind of testing was not abolished until 1905. In the Western world, passages from Plato’s (428–327 B.C.E.) writings indicate the Greeks assessed both the intellectual and physical abil- ity of men when screening for state service (Doyle, 1974).

Precursors to Modern-Day Test Development As experimental and controlled research spread throughout the scientific commu- nity during the 1800s, physicians and philosophers began to apply these research principles to the understanding of people, particularly in the area of cognitive func- tioning. For instance, working in mental asylums, the French physician Jean Esquirol (1772–1840) examined how language ability of individuals with intellec- tual disabilities was related to intelligence (Zusne, 1984; Drummond, 2009). Seen as having a condition called “idiocy,” (Esquirol, 1838, p. 38), these individuals were viewed as having intellectual deficits as compared to a “normal” person reared in a similar environment. Esquirol’s focus on language ability is often seen as the beginning of what later became known as the assessment of “verbal IQ.” At around the same time, Edouard Seguin (1812–1880), also from France, sug- gested that the prognosis regarding intellectual deficits in children was worse if such deficits were associated with physiological problems. He suggested that physi- cians should “watch for a swinging walk, ‘automatically busy’ hands, saliva drip- ping from a ‘meaningless mouth,’ a ‘lustrous and empty’ look, and ‘limited’ or

Multiple assessment procedures should always be considered

Jean Esquirol Used language to identify intelligence— forerunner of “verbal IQ”

Edouard Seguin Developed the form board to increase motor control— forerunner of “performance IQ”

CHAPTER 1 History of Testing and Assessment 5

‘repetitive’ speech” (Zenderland, 1987, p. 54). Eventually, Seguin developed the form board to increase his patients’ motor control and sensory discrimination and to compare children and individuals with severe intellectual deficits to average chil- dren at different age groups (see Figure 1.2). Considered by some to be the forerun- ner of “performance IQ” measures (DuBois, 1970), versions of the form board, which is similar to the toy in which children place shapes in their respective grooves, are still used today in some performance-oriented IQ test.

Meanwhile, intrigued by Charles Darwin’s (1809–1882) theory of evolution, scientists during the mid-1800s became engrossed in trying to understand the devel- opment of the human species (Juve, 2008; Kerr, 2008). For instance, Sir Francis Galton (1822–1911), Darwin’s cousin, became fascinated by differences among people and eventually came to believe that people inherited physical and mental characteristics (Gillham, 2001; Murdoch, 2007). He hypothesized that some inher- ited physical traits, such as reaction time and stronger grip strength, might be related to superior intellectual ability. His curiosity led him to examine the relation- ship among such characteristics, and his research spurred others to develop the sta- tistical concept of the correlation coefficient, which describes the strength of the relationship among variables (DuBois, 1970; Kerr, 2008). Calculating the correla- tion coefficient has become an important tool in the development and refinement of tests.

Wilhelm Wundt (1832–1920), another scientist intrigued with human nature, set out to create “a new domain of science” that he called physiological psychol- ogy. Around 1875, at the University of Leipzig in Germany, Wundt developed one of the first psychological laboratories that used experimental research (Nicolas, Gyselinck, Murray, & Bandomir, 2002). Many of the experiments in Wundt’s lab- oratory studied reaction time of hearing, sight, and other senses in response to sti- muli (Watson, 1968). A number of students who worked with Wundt helped to

FIGURE 1.2 | Reproduction of Sequin’s Form Board Task: Children, or individuals with intellectual disabilities, would be given ten blocks, in three piles, and asked to place them in the slots as fast as they can. They would then determine intel- lectual age by finding which age group the individual was most similar to.

Sir Francis Galton Examined relationship of sensory motor responses to intelligence

Wilhelm Wundt Developed one of the first psychological laboratories

20 15

6 SECTION I Understanding the Assessment Process

foster in the new age of psychological science. For instance, James McKeen Cattell (1860–1944), a doctoral student under Wundt who was later greatly inspired by Galton, became one of the earliest American psychologists to use statistical concepts in understanding the person (Goodwin, 2008; Roback, 1961). Cattell’s main emphasis became the assessment of what he termed mental tests and included exam- ining individual differences of such things as memory span and reaction time. Another important figure, G. S. Hall (1844–1924), also worked with Wundt and eventually set up his own experimental lab at Johns Hopkins University. Hall became a mentor to other great American psychologists and was the founder and first president of the American Psychological Association in 1892 (Benjamin, 2008).

The Emergence of Ability Tests (Testing in the Cognitive Domain) Influenced by the new scientific approach to understanding human nature, researchers at the beginning of the twentieth century began to develop instruments that could scientifically measure an individual’s abilities. This era saw the emer- gence of ability tests, including individual intelligence tests, neuropsychological assessments, and group tests of ability.

Intellectual and Cognitive Functioning: Intelligence Testing and Neuro- psychological Assessment Although commonplace today, the first intelligence tests were developed by Alfred Binet (1857–1911) who, in 1904, was commissioned by the Ministry of Public Education in Paris, to construct a test that could be of assistance in integrating what they called “subnormal” children into the schools (Binet & Simon, 1916). Highly critical of the manner in which “mental deficiency” was diagnosed in children, Binet and his colleague Theophile Simon developed a scale that could be administered one-on-one and which would measure higher men- tal processes by assessing responses to a variety of different kinds of tasks (e.g., tracking a light, asking the individual to distinguish between different types of words) (Ryan, 2008). The information gained from their observations was then used to develop the first modern-day intelligence test (Watson, 1968). A relatively short time later, Lewis Terman (1877–1956), from Stanford University, began ana- lyzing and methodically gathering extensive normative data on Binet and Simon’s scale from hundreds of children in the Stanford, CA area (Jolly, 2008; Kerr, 2008). Based on the data, Terman made a number of revisions to the Binet and Simon scale. Originally called the Stanford Revision of the Binet and Simon scale, the test later became known as the Stanford-Binet, the name by which the revised version continues to be known as today. Terman was the first to use the term intelligence quotient, or “IQ,” which used a ratio of mental age to chronological age (see Box 1.1).

Intelligence tests are sometimes used in neuropsychological assessment, which examines changes in brain function as the result of injury or disease process. Interest in how the brain impacts cognitive and behavioral functions, however, can be traced back to early Egypt where observations of behavioral changes following head inju- ries are recorded in 5,000-year-old Egyptian medical documents (Hebben & Milberg, 2009). In modern times, research conducted during World War I examined

James McKeen Cattell Brought statistics to mental testing— coined term mental test

G. S. Hall Early experimental psychologist. First president of APA

Alfred Binet Created first modern intelligence test

Lewis Terman Enhanced Binet’s work to create Stanford-Binet intelligence test

Intelligence quotient Mental age divided by chronological age

CHAPTER 1 History of Testing and Assessment 7

behaviors of soldiers who suffered from brain injuries. At that time, with the test- ing movement in full swing, it is not surprising that new screening and diagnostic measures to assess behavioral changes due to brain trauma were created (Lezak, Howieson, Bigler, & Tranel, 2012). During the twentieth century, as individuals became more interested in the nature of the brain and spurred on by the use of X-rays and other forms of brain imaging, the field of neuropsychology, or the study of brain function as it relates to behavior, was established. Today, when suspected changes occur in brain function due to disease, accidents, or violence, a “neuropsych” assessment, which sometimes includes an intelligence test, is often used.

Group Tests of Ability (Group Testing in the Cognitive Domain) Realizing the importance of obtaining accurate information from examinees, early test developers, such as Terman and others, devised standardized directions to use in testing and stressed the importance of having trained examiners administer tests individually (Geisinger, 1994; Jolly, 2008). However, it was soon evident that individual testing, such as that conducted when doing intelligence testing, often took a particularly long time and was costly. During World War I, these practical concerns came to a head as it became critical to quickly administer tests of cognitive ability in order to place large groups of recruits in the military. At that time, Robert Yerkes, the president of the American Psychological Association, chaired a special committee to create a screening test for these new recruits. The committee, composed of many well- known psychologists, including Terman, prepared a draft of the test in just four months (Geisinger, 2000; Jones, 2007). The original test the committee developed was known as the Army Alpha (see Box 1.2 and Illustration 1.1).

Although the Army Alpha clearly had its problems, it was a large step toward the mass use of tests in decision-making and was administered to more than 1.7 million recruits in less than two years (Haney, 1981). Since there were many foreign-born recruits and large numbers of people who could not read, a second

BOX 1.1 Developing the Notion of “IQ”

Lewis Terman wanted to develop a logical and rela- tively easy way of expressing an individual’s intelli- gence. Using the data from his research, he quickly realized that he could compute a ratio score for each child by dividing a child’s mental score (the age score at which the child performed) by the child’s actual age. Thus, if a child was performing at the level of the average 12-year-old but was actually 9 years old, the ratio would be 12/9 or 1.33. Multiply- ing this number by 100 to eliminate the decimal point would yield an intelligence quotient (“IQ”) of 133*.

Use this method to determine the IQs of the children below, based on their mental age scores and their actual ages.

Child 1: mental age of 6 and chronological age of 8.

Child 2: mental age of 16 and chronological age of 16.

Child 3: mental age of 10 and chronological age of 9.

Answers: Child 1: 75 (6/8 3 100), Child 2: 100 (16/16 3 100), Child 3: 111 (10/9 3 100).

*Note: IQ is no longer determined in this manner, and the current method of calculation will be discussed later in the text.

Robert Yerkes Chairman of the com- mittee that developed the Army Alpha

Army Alpha First modern group test—used during WWI

8 SECTION I Understanding the Assessment Process

BOX 1.2 The Army Alpha Test

The Army Alpha test was created to place recruits in the military (Jones, 2007; Mckean, 1985). Based on this test, it was found that average mental age of the

recruit was 13. Take the test below in the 3-minute time allotment given, then consider potential issues of bias and cultural fairness of the questions on the test.

Source: McKean, K. (1985). Intelligence: New ways to measure the wisdom of man. Discover Magazine, 6(10), 28. Reprinted by permission of Disney Publications.

The Army Alpha was used to determine placement in the armed forces during WWI. Below is an adaptation of the test, as printed in Discover magazine. Take the test and discuss your thoughts about it.

The average mental age of the recruits who took the Army Alpha test during WWI was approxi- mately 13. Could you do better? You have three minutes to complete these sample questions, drawn verbatim from the original exam. (McKean, 1985)

The following sentences have been disarranged but can be unscrambled to make sense. Rearrange them and then answer whether each is true or false.

1. Bible earth the says inherit the the shall meek. true false 2. a battle in racket very tennis useful is true false

Answer the following questions: 3. If a train goes 200 yards in a sixth of a minute, how many feet does it go in a fifth of a second? 4. A U-boat makes 8 miles an hour under water and 15 miles on the surface. How long will it take to

cross a 100-mile channel if it has to go two-fifths of the way under water? 5. The spark plug in a gas engine is found in the: crank case manifold cylinder carburetor 6. The Brooklyn Nationals are called the: Giants Orioles Superbas Indians 7. The product advertised as 99.44 per cent pure is:

Arm & Hammer Baking Soda Crisco Ivory Soap Toledo 8. The Pierce-Arrow is made in: Flint Buffalo Detroit Toledo 9. The number of Zulu legs is: two four six eight

Are the following words the same or opposite in meaning? 10. vesper–matin same opposite 11. aphorism–maxim same opposite

Find the next number in the series: 12. 74, 71, 65, 56, 44, Answer: 13. 3, 6, 8, 16, 18, Answer:

14. Select the image that belongs in the mirror: 15. & 16. What’s missing in these pictures?

Answers: 1. true, 2, false, 3. twelve feet, 4, nine hours, 5. cylinder, 6. superbas, 7. Ivory Soap, 8. Buffalo, 9. two, 10. opposite, 11. same, 12. 29, 13. 36, 14. A, 15, spoon, 16. gramophone horn Scoring: All items except 3, 4, 10, and 11 = 1.25 points. Items 3 and 4 = 1.875 points, Items 10 & 11 = .625 points. Add them all up, they equal your mental age. What is wrong with this test? Examine it for problems with content, history, cross-cultural contamination, and so forth.

15. 16.

CHAPTER 1 History of Testing and Assessment 9

language-free version of the test, known as the Army Beta, was created. The Army Beta applied the use of form boards and mazes, and directions were given by pan- tomime so recruits could take the entire test without reading (Goodwin, 2008). Although crude by today’s standards, the Army Alpha and Army Beta ushered in the era of group tests of ability.

In contrast with neuropsychological assessments and individual intelligence tests, which are given one-to-one, group tests of cognitive ability tend to be multi- ple choice and true-false measures given to groups of individuals simultaneously in an effort to assess the academic promise of each individual in the group. Probably the most well known of these has been the Scholastic Aptitude Test (now the SAT Reasoning Test, or SAT). Developed by the Educational Testing Service after World War II, the test in many ways was the brain child of James Bryant Conant, president of Harvard. Believing in a democratic, classless society, Conant thought that such tests could identify the ability of individuals and ultimately help to equal- ize educational opportunities (Frontline, 1999). Unfortunately, many have argued that instead of fostering equality, the SATs have been used to separate the social classes, and many in the testing movement were not as magnanimous as James Bryant Conant (see Box 1.3).

ILLUSTRATION 1.1 | Recruits Taking an Examination at Camp Lee, 1917 Source: U.S. Signal Corps photo number 11-SC-386 in the National Archives.

James Bryant Conant Developed SAT to equalize educational opportunities

10 SECTION I Understanding the Assessment Process

Paralleling the rise of group tests of cognitive ability was the administration of group tests of achievement in the schools. Traditionally, such tests had been given orally, and later in essay fashion, but the practicality of administering objective tests of academic performance to large groups of students was obvious. With the new scientific approach to testing on the rise, Edward Thorndike (1874–1949), one of the pioneers of modern-day educational and psychological assessment, and others, thought that such tests could be given in a format that was more reliable than previous tests. This move toward group testing culminated with the develop- ment of the Stanford Achievement Test in 1923 (Armstrong, 2006). Today, these tests are commonplace and are given to students en masse in school systems throughout America.

One last area where group testing became popular was in vocational counsel- ing. With Frank Parsons (1909/1989) at its helm, vocational counseling became increasingly important at the turn of the twentieth century as large numbers of peo- ple moved to the bigger cities in search of employment. With vocational counseling seen as a process of (1) acquiring self-knowledge, (2) acquiring knowledge of the world of work, and (3) finding a suitable match through a process called “true rea- soning,” thousands of individuals were anxious to discover what jobs might be a suitable match for them. And tests that could quickly measure large groups of peo- ples’ likes and dislikes, as well as their abilities, could help do that. Thus, we began to see the rise of “multiple aptitude” tests. For example, the General Aptitude Test

BOX 1.3 Eugenics and the Testing Movement

As scientists tried to make sense of the relatively new theory of evolution and as they began to examine differences among people, a number of them began attributing these differences to genetics. This information was used to bolster support for the emerging Eugenics Movement, whose members espoused a belief in selective breeding in order to improve the human race.

Individuals such as Galton, Terman, and Yerkes believed that the data retrieved from tests could help distinguish those who were naturally bright from those who, they argued, were less fortunate. Test results were used to advocate for providing incen- tives for the upper class to procreate and in finding methods to prevent the lower classes from having children (Gillham, 2001). Based on flimsy evidence and misguided thinking, this movement is also seen today as having racist undertones.

Believing that the Army Alpha and Army Beta measured innate ability, Terman, Yerkes, and others

used the results of these tests to support the Eugenics Movement. However, the tests were a far cry from being a measurement of intelligence, as they were saturated with cultural bias and were largely based on measuring achievement, or what had been learned, as opposed to some kind of raw, inherent intelligence. Unfortunately, their beliefs about the test and what should be done as a result of the test data may have been one of many influ- ences that led the U.S. government to manipulate whom it would allow to immigrate to the United States (Sokal, 1987). As a result, thousands— perhaps millions—of individuals were unable to emi- grate from tyrannical governments in Europe and other parts of the world (Gould, 1996).

Question to Ponder: Do you prefer partnering with someone who is bright? And, if so, are you practicing your own, individualized eugenics?

Edward Thorndike Developer of the Stanford Achievement Test

Frank Parsons Leader in vocational counseling

CHAPTER 1 History of Testing and Assessment 11

Battery (GATB) was developed by the United States Employment Service to mea- sure abilities in a number of specific areas. These areas of ability could be directly matched with job characteristics to identify appropriate occupational choices.

The Emergence of Personality Tests (Testing in the Affective Realm) Paralleling the rise of tests in the cognitive domain, personality tests (or tests in the affective realm) began to be devised. Thus, around the turn of the twentieth cen- tury three types of personality assessment instruments were developed: interest inventories, objective personality tests, and projective personality tests. Let’s take a brief look at each of these areas.

Interest Inventories and Vocational Assessment In 1912, Edward Thorndike, one of the first to conduct research in the field of vocational assessment, published the results of a study that examined the interests of 100 students as they progressed from elementary school through college (DuBois, 1970). As the relationship of inter- ests to vocational choice became more obvious, in 1922, J. B. Miner developed one of the first formal interest blanks (inventories) that was used to assist large groups of high school students in selecting occupations. Miner (1922) understood that his test was only part of the total assessment process, and he explained that his inven- tory was “the basis for individual interviews with vocational counselors” (p. 312).

On the heels of Miner’s interest blank, in the mid-1920s Edward Strong (1884–1963) teamed up with a number of other researchers to develop what was to become the most well-known interest inventory (Cowdery, 1926; DuBois, 1970; Strong, 1926). Known as the Strong Vocational Interest Blank, the original inven- tory consisted of 420 items. Strong spent the rest of his life perfecting his voca- tional interest inventory. Having undergone numerous revisions over the years, this inventory continues to be one of the most widely used instruments in career counseling. Today, interest inventories like the Strong are often used in conjunction with multiple aptitude tests as part of the career counseling process.

Objective Personality Assessment Although Emil Kraeplin developed a crude word association test to study schizophrenia in the 1880s, Woodworth’s Personal Data Sheet is considered to be the ancestor of most modern-day personality inven- tories. Woodworth’s instrument, which was developed to screen WWI recruits for their susceptibility to mental health problems (DuBois, 1970), had 116 items to which individuals were asked to respond by underlining “yes” or “no” to indicate whether or not the statement represented them (see Box 1.4). These rather obvious questions were then related to certain types of neuroses and pathologies. Although the test had questionable validity compared to today’s instruments, it became an early model for a number of other, better-refined instruments including the Minnesota Multiphasic Personality Inventory (MMPI).

Projective Testing Experiments such as these allow an unexpected amount of illumination to enter into the deepest recess of the character, which are opened and bared by them like the

GATB Developed by U.S. Employment Service to measure multiple aptitudes

J. B. Miner Developed one of the first group interest inventories

Edward Strong Founder of the Strong Vocational Interest Blank—derivative still used today

Emil Kraeplin Developed early word association test

Woodworth’s Personal Data Sheet First modern person- ality inventory—used during WWI

12 SECTION I Understanding the Assessment Process

anatomy of an animal under the scalpel of a dissector in broad daylight (Galton, 1879, p. 431).

These words of Galton speak to the premise of projective testing: present a stim- ulus to an individual in an attempt to tap into the unconscious mind and discover the inner world of that person. Recognizing the importance of Galton’s work, Cat- tell examined the kinds of associations that mentally healthy individuals made to a standard list of words (DuBois, 1970).

By 1904, Carl Jung (1875–1961) had come up with 156 stimulus words that he used in one of the earliest word association tests. Examining the responses of his cli- ents to his list of words, Jung came up with the word complex to describe sets of unusual and delayed responses that individuals had to these stimulus words that seemed to point to a problematic or neurotic area in their lives (Jung, 1918/1969; Jung & Riklin, 1904; Storr, 1973). However, it was Herman Rorschach (1884–1922), a student of Jung, who developed the most well-known projective test—the Rorschach Inkblot test. Rorschach created this test by selecting ten inkblots “thrown on a piece of paper, the paper folded, and the ink spread between the two halves of the sheet” (Rorschach, 1942, p. 1). He believed the interpretation of an individual’s reactions to these forms could tell volumes about the individual’s unconscious life. This test was the precursor to many other kinds of projective tests, such as Henry Murray’s Thematic Apperception Test, or TAT, which asks a subject to view a number of standard pictures and create a story that explains the situation.

The Emergence of Informal Assessment Procedures The twentieth century saw the increased use of informal assessment procedures, which are assessment instruments that are often developed by the user and designed to meet a particular testing situation. For instance, as business and industry expanded during the 1930s, the situational test became more prevalent. In these tests, businesses

BOX 1.4 Items from Woodworth’s Personal Data Sheet

Although crude by today’s standards, Woodworth’s Personal Data Sheet was one of the first instruments that attempted to assess one’s personality. Below are some of the original 116 items.

Answer the questions by underlining “Yes” when you mean yes, and by underlining “No” when you mean no. Try to answer every question.

1. Do you usually feel well and strong?

YES NO

3. Are you often frightened in the middle of the night?

YES NO

27. Have you ever been blind, half-blind, deaf or dumb for a time?

YES NO

51. Have you hurt yourself by masturbation (self abuse)?

YES NO

80. At night are you troubled by the idea that some- body is following you?

YES NO

112. Has any of your family been a drunkard?

YES NO

Source: Adapted from A History of Psychological Testing (pp. 160–163), by P. DuBois, 1970, Boston: Allyn and Bacon.

Carl Jung Used word associa- tions to identify mental illness

Herman Rorschach Developed famous Rorschach Inkblot test

Henry Murray Developed Thematic Apperception Test (TAT)

Informal assessment procedures User-created and situational

CHAPTER 1 History of Testing and Assessment 13

took individuals who were potential hires or candidates for promotion and placed them into “contrived naturalistic situations” to assess their ability to respond to real- life situations. Meanwhile, as treatment of mental health clients improved, another informal procedure, the clinical interview, became prominent. The clinical interview became especially important as clients were increasingly being assessed for a diagno- sis through the use of the Diagnostic and Statistical Manual of Mental Disorders (DSM), first developed by the American Psychiatric Association in 1952 (Neukrug & Schwitzer, 2006).

During the 1960s and 1970s the use of tests in schools greatly increased and laws were passed that called for the assessment of students with disabilities. It was then that a number of informal techniques became popular, including observation, rating scales, classification techniques, and the review of records and personal docu- ments to assess learning problems of children. Conducting an environmental assess- ment where many of these informal tools are used has also become popular in recent years. For instance, knowing whether a particular home (the “environment”) is a healthy place to raise a child has become an important aspect of the Child Protective Service worker’s role. Finally, in recent years, performance-based assessment as an alternative to the more traditional cognitive-based assessments (e.g., multiple choice tests) has become increasingly popular. Today, informal assessment techniques, such as those already mentioned, are used in a variety of settings in numerous ways.

Modern-Day Use of Assessment Procedures As complex statistical analyses became possible through the use of computers, the quality of assessment instruments advanced rapidly. Today, assessment instruments can be found in every aspect of society and their uses have been vastly expanded. Although one can categorize such instruments in many ways, we have found it helpful to classify them into the following groups: (1) testing in the cognitive domain, often called “ability testing,” (2) testing in the affective domain, usually called “personality assessment,” and (3) informal assessment procedures. Figures 1.3–1.5 are graphic displays of these domains and are followed in Box 1.5 by short definitions of the various categories.

In Section III of the text, we will demonstrate how all of the assessment catego- ries noted in Figures 1.3–1.5 and Box 1.5 are used today in a variety of ways. And the following shows how the chapters in Section III of the text correspond to the categories:

Chapter 8: Assessment of Educational Ability: Survey Battery, Diagnostic, Readiness, and Cognitive Ability Tests

Chapter 9: Intellectual and Cognitive Functioning: Intelligence Testing and Neuropsychological Assessment

Chapter 10: Career and Occupational Assessment: Interest Inventories, Multiple Aptitude, and Special Aptitude Tests

Chapter 11: Clinical Assessment: Objective and Projective Personality Tests

Chapter 12: Informal Assessment: Observation, Rating Scales, Classification Methods, Environmental Assessment, Records and Personal Documents, and Performance-Based Assessment

14 SECTION I Understanding the Assessment Process

ASSESSMENT OF ABILITY (What one can do)

ACHIEVEMENT TESTING (What one has learned)

APTITUDE TESTING (What one is capable of learning)

Survey Battery

Diagnostic Readiness

Intelligence

Testing

Neuropsychological

Assessment

Intellectual and Cognitive

Functioning

Cognitive Ability

Multiple Aptitude

Special Aptitude

FIGURE 1.3 | Assessment in the Cognitive Domain

PERSONALITY ASSESSMENT (Temperament, Habits, Likes, Disposition, Nature)

Objective ("Paper and Pencil")

Projective (Unstructured Responses)

Interests (Likes and Dislikes)

FIGURE 1.4 | Assessment in the Affective Domain

INFORMAL ASSESSMENT INSTRUMENTS

Environmental Assessment

Performance- Based

Assessment

Records and Personal

Documents

Classification methods

Observation Rating scales

FIGURE 1.5 | Informal Assessment Procedures

CHAPTER 1 History of Testing and Assessment 15

BOX 1.5 Brief Definitions of Assessment Categories

Assessment of Ability: Tests that measure what a person can do in the cognitive realm.

Achievement Testing: Tests that measure what one has learned.

Survey Battery Tests: Tests, usually given in school settings, which measure broad content areas. Often used to assess progress in school.

Diagnostic Tests: Tests that assess problem areas of learning. Often used to assess learning disabilities.

Readiness Tests: Tests that measure one’s readiness for moving ahead in school. Often used to assess readiness to enter first grade.

Aptitude Testing: Tests that measure what one is capable of learning.

Intellectual and Cognitive Functioning: Tests that measure a broad range of cognitive functioning in the following domains: general intelligence, intel- lectual disabilities, giftedness, and changes in overall cognitive functioning. Includes intelligence testing that leads to an “IQ” score and neuro- psychological assessment that assesses changes in cognitive functioning over time.

Cognitive Ability Tests: Tests that measure a broad range of cognitive ability. These tests are usually based on what a student has learned in school and are useful in making predictions about the future (e.g., whether an individual might succeed in college).

Special Aptitude Tests: Tests that measure one aspect of ability. Often useful in determining the likelihood of success in a vocation (e.g., a mechanical aptitude test to determine potential success as a mechanic).

Multiple Aptitude Tests: Tests that measure many aspects of ability. Often useful in deter- mining the likelihood of success in a number of vocations.

Personality Assessment: Tests in the affective realm used to assess habits, temperament, likes and dislikes, character, and sim- ilar behaviors.

Objective Personality Testing: Multiple choice and true-false tests that assess various aspects of personality. Often used to increase client insight, to identify psychopathology, and to assist in treatment planning.

Projective Personality Tests: Tests that present a stimulus to which individuals can respond. Personality factors are interpreted based on the individual’s response. Often used to identify psy- chopathology and to assist in treatment planning.

Interest Inventories: Tests that measure likes and dislikes as well as one’s personality orien- tation toward the world of work. Generally used in career counseling.

Informal Assessment Instruments: Often developed by the user, these tests tend to assess broad areas of ability or personality and tend to be specific to the testing situation.

Observation: Observing an individual in order to develop a deeper understanding of one or more specific behaviors (e.g., observing a stu- dent’s acting-out behavior in class or assessing a client’s ability to perform eye-hand coordina- tion tasks as a means of determining potential vocational placement).

Rating Scales: Scales developed to assess any of a number of attributes of the examinee. Can be rated by the examinee or someone who knows the examinee well (e.g., rating a faculty member’s teaching ability or a student’s ability to make empathic responses).

Classification Methods: A tool whereby an individual identifies whether he or she has, or does not have, specific attributes or character- istics (e.g., from a list, checking adjectives that seem to be most like you).

16 SECTION I Understanding the Assessment Process

QUESTIONS TO CONSIDER WHEN ASSESSING INDIVIDUALS It is clear that today’s assessment instruments have widespread applications. With the knowledge that many individuals have used assessment instruments for less than honorable reasons (e.g., the Eugenics Movement), it is critical that we remain vigilant about the use of such instruments. Keeping this in mind, we should contin- ually be asking ourselves some important questions regarding the use of assessment instruments, including the following:

1. How valid is the information gained from assessment instruments, and how should that information be applied?

2. How do assessment instruments invade an individual’s privacy, and does the government have, at times, the right to insist that an individual be assessed?

3. Can the use of some assessment instruments lead to labeling, and what are the implications for individuals who are “labeled”?

4. Are assessment procedures used to foster equality for all people, or do they tend to reinforce existing societal divisions based on class?

SUMMARY We began this chapter by defining assessment and pointing out that assessment encompasses a broad range of techniques, including testing. We noted that modern-day assessment has been greatly influenced by the long history of assessment. Going back to 2200 B.C.E., we pointed out that the Chinese developed one of the first widely used tests and that hundreds of years ago the Greeks assessed intellectual and physical ability of men for state service. As we neared the modern era of testing, we pointed out that individuals such as Esquirol examined the relationship between language ability and intelligence, while others, such as Seguin, looked at the relationship between

motor control and intelligence. We noted that Darwin’s theory of evolution spurred on others such as Galton, Wundt, Cattell, and Hall to examine individual differences, a focus that would be critical to the nature of assessment.

We next pointed out that some of the first ability tests were neuropsychological assessments and intelligence testing. We noted that interest in brain functioning could be traced by to early Egypt, around 2500 B.C. and moving forward in time, we noted that the late 1800s saw Alfred Binet develop the first intelligence test. Later revised by Terman, the Stanford-Binet compared an individual’s chronological age to his or her

Environmental Assessment: A naturalistic and systemic approach to assessment in which information about clients is collected from their home, work, school, or other places through observation, self-reports, and checklists.

Records and Personal Documents: Items such as diaries, personal journals, genograms, and school records that are examined

to gain a broader understanding of an individual.

Performance-Based Assessment: The evalu- ation of an individual using informal assessment procedures based on real-world activities that are not highly loaded for cognitive skills. These procedures are seen as an alternative to stan- dardized testing (e.g., a portfolio).

CHAPTER 1 History of Testing and Assessment 17

mental age. We pointed out that intelligence test- ing was also sometimes used as one aspect of neuropsychological assessments, which became more important with the advent of brain- imaging techniques and the use of additional methods to assess the relationship of brain func- tion to behavior.

As the chapter continued, we noted that the early 1900s saw the development of group tests of ability, including the Army Alpha and Army Beta, achievement tests in the schools, and multiple aptitude tests. We then noted that during the 1900s, individuals such as Galton, Yerkes, and Terman were influential in the Eugenics Movement. This misguided venture attempted to use test data to show intellectual differences among cultural groups and ended up influencing government policy, including laws regarding who would be allowed to immigrate to the United States.

We pointed out that many of the first person- ality tests paralleled the development of ability tests. For instance, the early 1900s saw Thorndike, Miner, and Strong research the area of vocational assessment and develop some of the first interest inventories. Kraeplin developed a crude word association test, and Woodworth developed his

“personal data sheet,” which many consider the precursor of modern-day personality inventories. These early assessment instruments were soon followed by the development of one of the first projective tests, a word association test by Carl Jung who sought to uncover what kinds of reac- tions caused complexes. Other early projective tests included Rorschach’s Inkblot Test and Murray’s Thematic Apperception Test. As the twentieth century continued, a number of informal assessment instruments were developed, including observational techniques, rating scales, classifica- tion schemes, records and personal documents, environmental assessments, and performance- based assessments.

Near the end of the chapter, we reviewed the definitions of the various assessment categories, including those assessment techniques that are found in the following domains: ability testing (achievement and aptitude), personality testing, and informal assessment instruments. The chapter concluded by highlighting a number of important issues in assessment, including test validity, inva- sion of privacy, caution regarding labeling, and the importance of assuring that assessment proce- dures foster equality.

CHAPTER REVIEW 1. Identify some of the ancient precursors to

assessment. 2. Identify some of the precursors to modern-

day assessment during the 1800s. 3. Discuss how the work of Darwin, Galton,

Wundt, and Cattell has influenced the devel- opment of modern-day testing.

4. Identify some of the individuals involved and describe the precursors to modern-day intel- ligence testing.

5. What was the Eugenics Movement, and how did it influence government policy in the United States?

6. Identify some of the early group tests of ability, the main players in their development, and their uses.

7. Identify some of the early personality tests and the main players involved in their development.

8. Describe the contributions of some of the early developers of projective testing.

9. Draw three diagrams (see Figures 1.3–1.5) that list the various kinds of achievement testing, aptitude testing, personality assess- ment, and informal assessment. Define each type of assessment category on your diagrams.

10. Make a list of every historical figure discussed in this chapter, and define each person’s contribution to testing and assessment.

18 SECTION I Understanding the Assessment Process

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Gould, S. J. (1996). The mismeasure of man (revised and expanded). New York: Norton.

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Higgins, L. T., & Sun, C. H. (2002). The development of psychological testing in China. International Journal of Psychology, 37, 246–254.

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Joint Committee on Testing Practices. (2004). Code of fair testing practices in education. Washington, DC: American Psychological Association.

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Jung, C. G., & Riklin, F. (1904). Untersuchungen iiber assoziationen gesunder. Journal fur Psychologie uiind Neurologie, 3, 55–83.

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CHAPTER 1 History of Testing and Assessment 19

handbook (Vol. 1, pp. 374–382). Thousand Oaks, CA: Sage Publications.

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20 SECTION I Understanding the Assessment Process

C H A P T E R 2Ethical, Legal, andProfessional Issues in Assessment

A friend of mine, a psychologist, complained to the ethics committee of her state licensing board that a colleague of hers was continually writing incompetent test reports. She reported her colleague as incompetent, and referred to her ethical code which stated the following:

“Psychologists provide services, teach and conduct research with populations and in areas only within the boundaries of their competence, based on their education, train- ing, supervised experience, consultation, study or professional experience. (American Psychological Association, [APA], 2010, Section 2.01a), and that Psychologists under- take ongoing efforts to develop and maintain their competence” (Section 2.03).

My friend felt a sense of self-righteousness for having reported this psychologist. Much to her surprise, the colleague decided to report my friend on the grounds that she had not first approached her and tried to work out the situation informally. The colleague of my friend was not sanctioned, but my friend was!

“When psychologists believe that there may have been an ethical violation by another psychologist, they attempt to resolve the issue by bringing it to the attention of that individual …” (Section 1.04).

Whether it’s psychology, counseling, or social work, the professional associations’ ethical codes are in agreement in suggesting that if you have a concern about a col- league’s ethical behavior, if reasonable, you should first speak to that person prior to reporting him or her (American Counseling Association [ACA], 2005; APA, 2010; National Association of Social Workers, [NASW], 2008).

Whether a concern about testing or another area, ethical dilemmas are by their very nature, complex. Thus, in this chapter we examine the sometimes per- plexing ethical, legal, and professional issues that confront individuals who are assessing others. We start by examining some of the ethical codes and standards that drive ethical decision-making and then we review the ethical decision- making process as it relates to assessment. We next examine some of the many laws and legal issues that have affected testing and assessment over the years. The chapter concludes with an overview of some professional issues, including a quick look at associations and accreditation bodies that focus on assessment, a review of forensic evaluation, the importance of viewing testing as a holistic process, a look at a number of important cross-cultural issues related to assess- ment, and a discussion about the fear that many clinicians have concerning their use of assessment techniques.

ETHICAL ISSUES IN ASSESSMENT This section of the chapter offers (1) a brief overview of some aspects of the American Counseling Association’s (ACA) and American Psychological Association’s (APA) ethical codes that highlight assessment, (2) a quick look at the many standards that have been developed to help guide the practitioner in the ethical use of assess- ment procedures, and (3) a discussion on the process of ethical decision-making.

Overview of the Assessment Sections of the ACA and APA Ethical Codes The ethical codes of our professional associations provide us with guidelines about how to respond under certain situations. For instance, both the ACA (2005) and APA (2010) codes include guidelines that specifically address issues of testing and assessment. The following discussion summarizes some of the more salient aspects of the assessment portions of these codes, including choos- ing appropriate assessment instruments, competence in the use of assessment instruments, confidentiality, cross-cultural sensitivity, informed consent, invasion of privacy, proper diagnosis, release of test data, test administration, test secu- rity, and test scoring and interpretation. Please review the ethical guidelines of the professional associations, the Web sites of which can be found in Appendix A, as well as the actual portions of the assessment guidelines of ACA and APA that can be found in Appendix B.

Choosing Appropriate Assessment Instruments Ethical codes stress the importance of professionals choosing assessment instruments that show test worthi- ness, which has to do with the reliability (consistency), validity (the test measuring what it’s supposed to measure), cross-cultural fairness, and practicality of a test. Professionals must take appropriate actions when issues of test worthiness arise during an assessment so that the results of the assessment are not misconstrued. Test worthiness and how to choose an appropriate assessment instrument will be examined in detail in Chapter 5.

Ethical codes Professional guidelines for appropriate behavior

Attend to test worthiness in choosing assessment instruments

22 SECTION I Understanding the Assessment Process

Competence in the Use of Tests Competence to use tests accurately is another aspect that is stressed in the codes. The codes declare that professionals should have adequate knowledge about testing and familiarity with any test they may use. To establish who is qualified to give specific tests, the APA, in 1954, adopted a three-tier system for establishing test user qualifications. Although APA reevaluated this system and currently provides rather extensive guidelines of test user qualifications (see Turner, DeMers, Fox, & Reed, 2001), many test publishers continue to use the original three-tier system, although they take into account the more involved guidelines. The original system labeled some tests according to the following three levels:

• Level A tests are those that can be administered, scored, and interpreted by responsible nonpsychologists who have carefully read the test manual and are familiar with the overall purpose of testing. Educational achievement tests fall into this category.

• Level B tests require technical knowledge of test construction and use and appropriate advanced coursework in psychology and related courses (e.g., statistics, individual differences, and counseling).

• Level C tests require an advanced degree in psychology or licensure as a psychologist and advanced training/supervised experience in the particular test. (American Psychological Association, 1954, pp. 146–148)

More specifically, an individual with a bachelor’s degree who has some knowl- edge of assessment and is thoroughly versed with the test manual can give a Level A test and, under some limited circumstances, a Level B test. For example, teachers can administer most survey battery achievement tests. The master’s-level helping professional who has taken a basic course in tests and measurement can administer Level B tests. For example, counselors can administer a wide range of personality tests, including most interest inventories and many objective person- ality tests. However, they cannot administer tests that require additional training, such as most individual tests of intelligence, most projective tests, and many diagnostic tests. These Level C tests are reserved for those who have a minimum of a master’s degree, a basic testing course, and advanced training in the special- ized test (e.g., school psychologists, learning disabilities specialists, clinical and counseling psychologists, and master’s-level counselors who have gained addi- tional training) (ACA, 2003).

Confidentiality Whether giving one test or conducting a broad assessment of a client, keeping information confidential is a critical part of the assessment process and follows similar guidelines to how one would keep information con- fidential in a therapeutic relationship. The importance of keeping information confidential is a professional responsibility, but sometimes it is contradicted by the law. Thus, professionals must sometimes grapple with difficult dilemmas pitting professional responsibility against the law (Remley & Herlihy, 2014). When can one reveal confidential information? Although one should always check the laws of the state in which one practices, practitioners are generally

Competence in using tests Requires adequate knowledge and train- ing in administering an instrument

Confidentiality Ethical guideline to protect client information

CHAPTER 2 Ethical, Legal, and Professional Issues in Assessment 23

on fairly solid professional and legal ground in revealing information under the following conditions:

1. If a client is in danger of harming himself or herself or someone else; 2. If a client is a minor or is legally incompetent and the law states that parents or

guardians have a right to information about that person; 3. If a client asks you to break confidentiality (e.g., your testimony is needed in court); 4. To defend oneself against charges filed by a client; 5. If you are asked by the court to break confidentiality and privileged communi-

cation does not exist (privileged communication is when there is a statute ensuring clients that information shared is confidential);

6. To reveal information about your client to clerical help, colleagues, or supervi- sor to benefit the client;

7. When you have a written agreement from your client to reveal information to specified sources (e.g., the court has asked you to send a test report to them).

Cross-Cultural Sensitivity In reference to cross-cultural sensitivity, the codes tend to focus on the potential biases of assessment procedures when selecting, administering, and interpreting assessment instruments. In addition, they stress the importance of professionals being aware of and attending to the effects of age, color, cultural identity, disability, ethnicity, gender, religion, sexual orienta- tion, and socioeconomic status on test administration and test interpretation. Later in this chapter, and in Chapter 5, we discuss this important topic in greater detail.

Informed Consent Informed consent involves ensuring that clients obtain infor- mation about the nature and purpose of all aspects of the assessment process and for clients to give their permission to be assessed. Although there are times when informed consent does not need to be obtained, such as when it is implied (e.g., giving an achievement test in schools), or when testing is mandated by the courts (e.g., custody battles), generally test administrators should give their clients infor- mation about the assessment process and have obtained the client’s permission to be assessed.

Invasion of Privacy The codes generally acknowledge that, to some degree, all tests invade one’s privacy and they highlight the importance of clients under- standing how their privacy might be infringed upon. Concerns about invasion of privacy are lessened if clients give informed consent, have real choice in accepting or refusing testing, and know the limits of confidentiality, as noted earlier.

Proper Diagnosis Due to the delicate nature of diagnoses, the codes emphasize the important role that professionals play when deciding which assessment techni- ques to use in forming a diagnosis for a mental disorder and the ramifications of making such a diagnosis.

Release of Test Data Test data can be, and have been, misused. Thus, the codes assert that data should only be released to others if clients have given

Cross-cultural sensitivity Ethical guideline to protect clients from discrimination and bias in testing

Informed consent Permission given by client after assessment process is explained

Invasion of privacy Testing is an invasion of a person’s privacy

Proper diagnosis Choose appropriate assessment techni- ques for accurate diagnosis

Release of test data Test data are protected—client release required

24 SECTION I Understanding the Assessment Process

their consent. The release of such data is generally only given to individuals who can adequately interpret the test data and to those who will not misuse the information.

Test Administration As you might guess, the codes reinforce the notion that tests should be administered in a manner that is in accord with the way that they were established and standardized. Alterations to this process should be noted and interpretations of test data adjusted if testing conditions were not ideal.

Test Security The codes remind professionals that it is their responsibility to make reasonable efforts to ensure the integrity of test content and the security of the test itself. Professionals should not duplicate tests or change test material with- out the permission of the publisher.

Test Scoring and Interpretation Ethical codes highlight the fact that when scoring tests and interpreting their results, professionals should reflect on how test worthiness (reliability, validity, cross-cultural fairness, and practicality) might affect the results. Results should always be couched in terms that reflect any potential problems with test interpretation. (These issues will be discussed in detail in Chapter 5).

Test administration Use established and standardized methods

Test security Ensure integrity of test content and test itself

Test scoring and interpretation Take into consider- ation problems with tests

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CHAPTER 2 Ethical, Legal, and Professional Issues in Assessment 25

Standards for Responsible Testing Practices Partly a response to criticism of the manner in which tests have been used and abused over the years, a number of standards in assessment to help guide practices have been developed in recent years. These standards delineate the proper use of assessment techniques in educational, agency, and private practice settings. As an example of one standard, we have included the Code of Fair Testing Practices (JCTP, 2004) in Appendix C. Table 2.1 defines the purpose of a number of well- known standards and offers ways of accessing the standards should you want to examine them in more detail:

• Standards for Qualifications of Test Users • Responsibilities of Users of Standardized Tests • Standards for Multicultural Assessment • Code of Fair Testing Practices • Rights and Responsibilities of Test Takers • Standards for Educational and Psychological Testing • Competencies for testing in School Counseling; Mental Health Counseling;

Marriage, Couples, and Family Counseling; Career Counseling, and Substance Abuse Counseling

TABLE 2.1 Standards of Responsible Test Usage

Name of Standard Purpose of Standard

Developed/ Endorsed by* and Citation for

Standards for Qualifications of Test Users (5 pages)

Addresses qualifications of counselors to use assessment instruments in following areas: test theory, test construction, test worthiness, test statistics, administration and interpre- tation of tests, cross-cultural issues, knowledge of standards and ethical codes.

ACA (2003)

Responsibilities of Users of Standardized Tests (RUST) (5 pages)

“The intent of ‘RUST’ is to help counselors and other edu- cators implement responsible testing practices … in the following areas: qualifications of test users, technical knowl- edge, test selection, test administration, test scoring, inter- preting test results, communicating test results.” (p. 1)

AARC (2003)

Standards for Multicultural Assessment (8 pages)

Focuses on advocating for proper use of instruments and taking steps to address systemic issues, ensuring those who conduct assessments understand test biases and the bar- riers facing diverse populations; choosing appropriate instruments for diverse clients, considering clients’ cultural backgrounds when administering and scoring instruments, providing culturally accurate interpretation of instruments, and ensuring cultural competence in the training and super- vision of testing.

AARC (2012a)

(Continued)

Standards in Assessment Used to further ethical application of assessment techniques

26 SECTION I Understanding the Assessment Process

Making Ethical Decisions Because ethical codes can be limiting in their ability to guide a practitioner who is faced with a thorny ethical dilemma, it is important that other avenues are avail- able to aid in ethical decision-making. For instance, some practitioners might use moral models in guiding their ethical decision-making process. One moral model, described by Kitchener (1984, 1986; Urofsky, Engels, & Engebretson, 2008), suggests that there are six critical moral principles one should consider when making difficult ethical decisions. They include autonomy, which has to do with protecting the independence, self-determination, and freedom of choice of clients; nonmaleficense is the concept of “do no harm” when working with clients; benefi- cence is related to promoting the good of society, which can be at least partially

TABLE 2.1 Standards of Responsible Test Usage (continued)

Name of Standard Purpose of Standard

Developed/ Endorsed by* and Citation for

Code of Fair Testing Practices (6 pages)

Intended to ensure that professionals “provide and use tests that are fair to all test takers regardless of age, gender, dis- ability, race, ethnicity, national origin, religion, sexual orientation, linguistic background, or other personal charac- teristics” (para. 1). Provides guidance for test developers and test users in four areas: developing and selecting appropriate tests, administering and scoring tests, reporting and inter- preting test results, and informing test takers.

JCTP (2004)

Rights and Responsibilities of Test Takers (10 pages)

Delineates and clarifies “the expectations that test takers may reasonably have about the testing process, and the expectations that those who develop, administer, and use tests may have of test takers.” ( p. l)

JCTP (1998)

Standards for Educational and Psychological Testing (194 pages)

“… to provide criteria for the evaluation of tests, testing practices, and the effects of test use” (p. 2). Extensive explanation of testing practices in three broad areas: test construction, evaluation, and documentation; fairness in testing; and testing applications.

AERA/APA/ NCME (1999)

Competencies in the following counseling areas: School; Mental Health; Marriage, Couple, and Family; Career; and Substance Abuse

Each competency tends to be a few-pages long and covers such things as how to adequately choose assess- ment instruments, proper administration and scoring of instruments, appropriate interpretation of results, diversity issues and assessment, and the use of instruments in diagnosis.

ASCA AMHCA IAMFC NCDA IAAOC AARC (2012b)

*ACA ¼ American Counseling Association; AARC ¼ Association of Assessment in Research in Counseling; JCTP ¼ Joint Commission on Testing Practices; AERA ¼ American Educational Research Association; APA ¼ American Psychological Association; ASCA ¼ American School Counseling Association; AMHCA ¼ American Mental Health Counselors Association; IAMFC ¼ International Association of Marriage and Family Counseling; NCDA ¼ National Career Development Association; NCME ¼ National Council on Measurement in Education; IAAOC ¼ International Association of Addiction and Offender Counselors.

Moral model Consider moral princi- ples involved in ethical decision-making

CHAPTER 2 Ethical, Legal, and Professional Issues in Assessment 27

accomplished by promoting the client’s well-being; justice refers to providing equal and fair treatment to all clients; fidelity is related to maintaining trust (e.g., keeping conversations confidential) in the counseling relationship and being committed to the client within that relationship; and veracity has to do with being truthful and genuine with the client, within the context of the counseling relationship. Consider these principles if you had just assessed a client and had determined that she poten- tially might cause harm to her children. How might each of these moral principles play into the decisions you make regarding your client. For instance, after consider- ing each of the principles, how and to whom would you communicate your results? To make things a bit more complicated, Remley and Herlihy (2014) go on to note that the culture of the client might impact your understanding of your results and how you apply the principles. Autonomy, for individuals from some cultures, may have to do with individual behaviors whereas individuals from other cultures might view autonomy within the context of their extended family or community. As you can see, ethical decision-making can be a complex and difficult process.

In addition to the moral model just noted, a number of other ethical decision- making models exist (Neukrug, 2012). One hands-on, practical, problem-solving model espoused by Corey, Corey, Corey, and Callanan (2015) suggests that the practi- tioner go through the following eight steps when making complex ethical decisions:

1. Identify the problem or dilemma 2. Identify the potential issues involved 3. Review the relevant ethical guidelines 4. Know the applicable laws and regulations 5. Obtain consultation 6. Consider possible and probable courses of action 7. Enumerate the consequences of various decisions 8. Decide on what appears to be the best course of action

Finally, in addition to the moral and practical models mentioned earlier, some suggest that regardless of the approach one takes in ethical decision-making, the ability to make wise ethical decisions may well be influenced by the clinician’s level of ethical, moral, and cognitive development (Linstrum, 2005; Neukrug, Lovell, & Parker, 1996) (see Exercise 2.1). Those who are at higher levels of cogni- tive development, they state, view ethical decision-making in more complex ways than others. Certainly, this has broad implications for the training that takes place in clinical programs, as it would be hoped that students are challenged to make decisions that are comprehensive and thoughtful (McAuliffe & Eriksen, 2010).

LEGAL ISSUES IN ASSESSMENT A number of laws about testing have been passed and lawsuits resolved that impinge on the use of tests. Most of these legal decisions speak to issues of confidentiality, fairness, and test worthiness (reliability, validity, practicality, and cross-cultural fairness) (Swen- son, 1997; Greene & Heilbrun, 2011). In this section of the chapter, we summarize some of the more important laws that have been passed and legal cases resolved over the years, including the Family Educational Rights and Privacy Act (FERPA); the Health Insurance Portability and Accountability Act (HIPAA); privileged communication laws;

Corey, Corey, Corey, and Callanan Recommend an eight- step decision-making model

Wise ethical decisions reflect higher cognitive development

Laws about testing Created to protect the client or examinee

28 SECTION I Understanding the Assessment Process

the Freedom of Information Act; various Civil Rights Acts (1964 and amendments); the Americans with Disabilities Act (ADA) (PL 101-336); the Individuals with Disabilities Education Improvement Act (IDEA), which was an expansion of PL 94-142; Section 504 of the Rehabilitation Act; and the Carl Perkins Act (PL 98-24).

The Family Education Rights and Privacy Act (FERPA) of 1974 Passed in 1974 and sometimes called the Buckley Amendment, FERPA assures the right of privacy of student records, including test records, and applies to almost all schools that receive federal funds (K-12 and institutions of higher education) (U.S. Department of Education, n.d.a). The law also gives the right to parents of students, or to the stu- dents themselves once they reach the age of 18 and are beyond high school, to review their records. If parents or the eligible student believe that school records are incorrect or misleading, they have the right to challenge them. If the school decides not to change the records, the parent or eligible student can ask for a formal hearing.

The law also states that if records are to be released, schools must receive written permission from parents or the eligible student, except in some specific circumstances (e.g., school officials acting in the educational interest of the student, access by organizations, to comply with a subpoena, for purposes of school evaluation, and other reasons).

The Health Insurance Portability and Accountability Act (HIPAA) In 1996 Congress passed the HIPAA, and three main rules that underscore HIPAA’s purpose subsequently went into effect (privacy, transaction rule, and secu- rity rules) (U.S. Department of Health and Human Services, n.d.; Zuckerman, 2008). In general, HIPAA restricts the amount of information that can be shared

Exercise 2.1 Making Ethical Decisions

After reading the section on ethical decision-making, in small groups in class or as a homework assignment, use the moral principles identified and Corey’s model of ethical decision-making to decide on your course of action in the following situation. Share your answers in class. You will have the opportunity to respond to additional vignettes in Exercise 2.2 near the end of the chapter.

Situation: You have been asked to provide a broad per- sonality assessment of a 17-year-old high school student who has been truant from school and has a history of acting-out behaviors. After meeting with her, conducting a clinical interview, and administering a number of

projective tests and an MMPI-2 (an objective personality test), you find evidence that an uncle, who is five years older than the client, had sexually molested her when she was 12 years old. In addition, you believe that the young woman has been involved in some petty crimes, such as shoplifting and stealing audio equipment from the school. In writing your report, what should you include regarding her being molested and the crimes she has allegedly committed? Are you obligated to report this case to Child Protective Services? Do you have any obligation to contact the police? What are your obligations to this young person’s parents, to the school, and to society?

FERPA Affirms right to access test records in the school

HIPAA Ensures privacy of medical and counsel- ing records

CHAPTER 2 Ethical, Legal, and Professional Issues in Assessment 29

without clients’ consent and allows clients to have access to their records, except for process notes used in counseling. In fact, HIPAA requires agencies to show how they have complied with this act. Although HIPAA has far-reaching implica- tions for the privacy and security of records and how confidential transactions are made, relative to testing, some of the more salient features of the law includes ensuring that (1) clients are given information regarding their right to privacy, (2) agencies have clear procedures established to protect client privacy, (3) employees are trained to protect the privacy of clients, and (4) client records are secure.

Privileged Communication Privileged communication is a conversation conducted with someone who state or federal law identifies as a person with whom conversations may legally be kept confidential (i.e., therapist-patient, attorney-client, doctor-patient, clergy-penitent, husband-wife, etc.). In the case of clinicians, the goal of the law is to encourage the client to engage in conversations without fear that the clinician will reveal the contents of the conversation (e.g., in a court of law), thus ensuring the privacy and efficacy of the counseling relationship. The privilege belongs to the client, and only the client can waive that privilege (Remley & Herlihy, 2014). Privileged communi- cation should not be confused with confidentiality, which is the ethical, not legal, obligation of the counselor to keep conversations confidential (Glosoff, Herlihy, & Spence, 2000).

A 1996 ruling upheld the right to privileged communication (Jaffee v. Redmond, 1996). In this case, the Supreme Court upheld the right of a licensed social worker to keep her case records confidential. Describing the social worker as a “therapist” and “psychotherapist,” the ruling has bolstered the right of all licensed therapists to have privileged communication (Remley, Herlihy, & Herlihy, 1997; Remley & Herlihy, 2014) (see Box 2.1).

The Freedom of Information Act Originally passed in 1967 and amended in 2002, this law assures the right of indi- viduals to access their federal records, including test records, if an individual makes a request in writing (U.S. Department of Justice, 2011). All states have enacted sim- ilar laws that assure the right to access state records.

Civil Rights Acts (1964 and Amendments) In 1964 the federal government passed the first of a number of laws to ban a broad spectrum of discrimination in the United States. This first act was focused on banning racial segregation in schools, public places, and employment. Since that time, a number of far-reaching amendments of the original law have been passed. Relative to testing, the laws assert that any test used for employment or promotion must be shown to be suitable and valid for the job in question. If not, alternative means of assessment must be provided. Differential test cutoffs are not allowed unless such scores can be shown to be based on valid educational principles (see Box 2.2).

Privileged communication Legal right to maintain privacy of conversation

Jaffee v. Redmond Affirms privileged communication laws

Freedom of Information Act Affirms right to access federal and state records

Civil Rights Act Test must be valid for job in question

High-Stakes Testing The use of cutoff scores in important client decisions

30 SECTION I Understanding the Assessment Process

BOX 2.1 Jaffee v. Redmond

“Mary Lu Redmond, a police officer in a village near Chicago, responded to a ‘fight in progress’ call at an apartment complex on June 27, 1991. At the scene, she shot and killed a man she believed was about to stab another man he was chasing. The family of the man she had killed sued Redmond, the police department, and the village, alleging that Officer Redmond had used excessive force in violation of the deceased’s civil rights.

When the plaintiff’s lawyers learned that Redmond had sought and received counseling from a licensed social worker employed by the village, they sought to compel the social worker to turn over her case notes and records and testify at the trial. Redmond and the social worker claimed that their communications were privileged under an Illinois statute.

They both refused to reveal the substance of their counseling sessions even though the trial judge rejected their argument that the communications were privileged. The judge then instructed jurors that they could assume that the information withheld would have been unfavorable to the policewoman, and the jury awarded the plaintiffs $545,000.” (Remley et al., 1997, p. 214)

After a series of appeals, the Supreme Court heard the case on February 26, 1996. The court decided that the licensed therapist did indeed hold privilege and that the judge’s instruction to the jury was therefore unwarranted.

BOX 2.2 The Civil Rights of High Stakes Testing

Out of concern that college athletes were being recruited to play sports without regard for how they might do academically, in 1986, the National Collegiate Athletic Association (NCAA) implemented a rule stating that high school athletes would have to exceed specific scores on SAT or ACT college entrance exams to be eligible for athletic-based scholarships and interscho- lastic competition (Waller, 2003). This affected the abil- ity of many high school athletes, particularly African- American athletes, to obtain sports scholarships and be accepted into college. On the other hand, a higher percentage of African-American athletes were found to graduate college after this rule went into effect.

With federal civil rights law asserting that the use of tests could not disproportionately affect one group unless such use could be shown to be educationally sound, the NCAA was sued by African-American stu- dents for discrimination. Although the court has never definitively settled the cases, the uproar over the cutoff scores seems to have affected how the NCAA applied the rule. Now the NCAA uses a floating score: The higher your high school GPA, the lower the SAT or ACT score that the athlete is allowed (Paskus, 2012).

With continuing concerns about the use of cutoff scores for athletic scholarships, advancing in public school, and admission to college, the battle in the courts will probably continue. What do you think about the use of such high-stakes testing?

1. Should SAT and ACT scores be used to prevent student athletes from playing sports so that they can spend more time on their studies?

2. Should standardized test scores (e.g., SATs, ACTs, GREs, state achievement tests) be used to make educational decisions about placement into grade level, college, or graduate schools? Why or why not?

3. As the result of laws like No Child Left Behind that mandate that school systems assure that all stu- dents achieve, there has been a slight increase in the average scores of minorities on some tests. What are the drawbacks and benefits of the continued use of such high-stakes testing?

4. How might the use of high-stakes testing affect those who are involved in the test-preparing process, such as teachers and administrators?

CHAPTER 2 Ethical, Legal, and Professional Issues in Assessment 31

Americans with Disabilities Act (ADA) (PL 101-336) In the United States, close to 19% of noninstitutionalized Americans have a disability (U.S. Census Bureau, 2012), including 15.6 million (6.4%) with a sight or hearing disability, 38.3 million (12.6%) with a severe disability, and 12.3 million (4.4%) with a disability that affects their ability to dress, bathe, or get around their home. Despite such large numbers, prejudice and discrimination has been commonplace for individuals with disabilities. As a result, in 1990, Congress passed the ADA.

Implemented in 1992, the ADA bans discrimination in employment, public ser- vices and public transportation, public accommodations, and telecommunications for individuals with disabilities. One of its biggest impacts was in the area of employment, where the law prohibits employers “from discriminating against qual- ified individuals with disabilities in job application procedures, hiring, firing, advancement, compensation, job training, and other terms, conditions and privi- leges of employment” (U.S. Equal Employment Opportunity Commission, 2008, para. 1). Because testing is often used in the hiring and promotion of individuals in jobs, the law asserts that accommodations must be made for individuals with disabilities who are taking tests for employment and that testing must be shown to be relevant to the job in question.

Individuals with Disabilities Education Act (IDEA) In 1975 Public Law 94-142 was passed and guaranteed the right to a free and pub- lic education, with appropriate accommodations, for children with disabilities (U.S. Department of Education, 2007a). Over the years, the law was expanded and even- tually became known as the Individuals with Disabilities Education Act (IDEA). IDEA is far reaching and impacts individuals with disabilities from birth through 21 in many ways. Part B of the law focuses on testing in the schools and assures the right of a student between the age of 3 and 21 to be tested, at the school sys- tem’s expense, if he or she is suspected of having a disability that interferes with learning (U.S. Department of Education, n.d.b). The law asserts that if a student is assessed and found to have a disability, schools must ensure that the student is given accommodations for his or her disability and taught within the “least restric- tive environment,” which is often a regular classroom.

Students who are suspected of having a disability are generally referred for medi- cal, psychological, communication, and/or vision and hearing evaluations. Any assess- ment that is conducted should be cross-culturally appropriate, and parents should be informed of the kinds of tests being used and give permission for the child to be tested. If the assessments indicate that special education eligibility requirements are met and if parental consent given, an individualized education plan (IEP) must be developed within 30 calendar days of the evaluation (Assistance to the States for the Education of Children with Disabilities, 2011). The plan should address what services are needed and how they can be provided within the least restrictive environment. The team that develops the plan often includes the parent(s), the child’s teacher(s), a district represen- tative who is able to provide or oversee the delivery of special education services, the child (when appropriate), representatives from the evaluation team, possible service providers, and other relevant people chosen by the parent or school.

ADA Accommodations for testing must be made

IDEA Assures right to be tested for learning disabilities in schools

32 SECTION I Understanding the Assessment Process

Section 504 of the Rehabilitation Act This act applies to organizations and employers that receive financial assistance from the federal government and was established to create a “level playing field” and prevent discrimination based on disability. Based on this law, employers and organizations cannot:

• Deny qualified individuals the opportunity to participate in or benefit from federally funded programs, services, or other benefits.

• Deny access to programs, services, benefits, or opportunities to participate as a result of physical barriers.

• Deny employment opportunities, including hiring, promotion, training, and fringe benefits, for which they are otherwise entitled or qualified. (U.S. Department of Health and Human Services, 2006, p. 2)

Relative to assessment, any instrument used to measure appropriateness for a pro- gram or service must measure the individual’s ability, not be a reflection of his or her disability.

Carl Perkins Career and Technical Education Improvement Act of 2006 This federally funded program, which gives financial grants to the states, assures that individuals in six identified “special populations” can have access to voca- tional assessment, counseling, and placement so that these individuals will be more likely to succeed in technical education programs and in their careers (U.S. Depart- ment of Education, 2007b). Originally passed in 1984, this fourth reiteration of the Carl Perkins Act applies to the following populations: (a) individuals with disabil- ities; (b) individuals from economically disadvantaged families, including foster children; (c) individuals preparing for nontraditional fields; (d) single parents, including single pregnant women; (e) displaced homemakers; and (f) individuals with limited English proficiency.

PROFESSIONAL ISSUES This section of the chapter begins by highlighting two professional associations in the field of assessment: The Association for Assessment and Research in Counseling (AARC) and Division 5 of the American Psychological Association: Evaluation, Measurement, and Statistics. We then briefly mention two accrediting bodies that focus on assessment. This is followed by a discussion about the growing profes- sional field of forensic evaluation. Then, we underscore the importance of recogniz- ing that assessment works best when it is a holistic process; that is, when consideration is given for the use of multiple procedures while assessing an individ- ual. The use of assessment techniques with minorities and women is then highlighted, and the chapter concludes with a discussion about importance of embracing the use of testing and assessment.

Section 504 Assessment for pro- grams must measure ability—not disability

Carl Perkins Act Ensures access to vocational assess- ment, counseling, and placement

Major professional associations AARC of ACA and Division 5 of APA

CHAPTER 2 Ethical, Legal, and Professional Issues in Assessment 33

Professional Associations Although there are literally dozens of professional associations in the field that might pique your interest (see Appendix A), few specifically focus on assessment. Although we encourage you to join the professional association with which you feel the closest affinity, if you have a strong interest in assessment you might want to consider joining the following two associations.

The Association for Assessment and Research in Counseling (AARC), a divi- sion of ACA, “is an organization of counselors, educators, and other professionals that advances the counseling profession by promoting best practices in assessment, research, and evaluation in counseling” (AARC, 2012c, para. 1). Consider joining AARC if you are interested in testing, diagnosis, the training, and supervision of those who do assessment, and if you are fascinated by the process of developing and validating assessment products and procedures. AARC publishes two journals, Counseling Outcome Research and Evaluation (CORE) and Measurement and Evaluation in Counseling and Development (MECD). AARC also publishes a newsletter called NewsNotes.

Division 5 of the American Psychological Association: Evaluation, Measurement, and Statistics is devoted to “promoting high standards in both research and practical application of psychological assessment, evaluation, measurement, and statistics” (APA, 2013a, para. 1). Division 5 publishes two journals, Psychological Assessment, which is geared toward assessment, and Psychological Methods, which is research- oriented. Division 5 also publishes a quarterly newsletter, The Score, which focuses on business issues of the association as well as new issues in the field.

Accreditation Standards of Professional Associations A number of the professional associations have accreditation standards that specifi- cally speak to curriculum issues in the area of assessment. Such standards help to establish a common core of experience for students who enter their programs, regardless of the institution in which the program is housed. Thus, we find organiza- tions such as the APA (2009), the National Association of School Psychologists (2010), and the Council for the Accreditation of Counseling and Related Educational Programs (CACREP, 2013), setting standards that drive the curriculum for their graduate programs. In fact, much of what is covered in this book is a result of the authors examining these curriculum standards and trying to ensure that we cover them as fully as possible. If you get a chance, you may want to visit the Web sites listed in the references and examine the standards for each of these organizations.

Forensic Evaluations Increasingly, counselors, psychologists, and other mental health professionals are becoming involved in a wide range of evaluation activities related to law enforce- ment and legal issues. To do this competently, they must have accurate knowledge of assessment, legal issues, and ethical issues when dealing with such cases (Packer, 2008; Patterson, 2006; Roesch & Zapf, 2013). What areas do such specialists deal with? Packer identifies a wide range of common areas that such experts will often testify about (see Box 2.3).

Accreditation bodies Assist in setting cur- riculum standards (APA, NASP, and CACREP)

Forensic evaluations Completed by forensic health evaluators and forensic psychologists

34 SECTION I Understanding the Assessment Process

Forensic evaluators and forensic psychologists need to know how to conduct forensic evaluations, which include the use of specific tests for the situation at hand, interviewing techniques that are focused on the goals of the court case, knowledge of ethical and legal issues relevant to expert testimony and the specific case, and how to write forensic reports that will be used in court. Although many of the tests and interviewing techniques used in this book can be applied to such evaluations, know- ing how and when to use them is crucial. In addition, other assessment procedures are often involved in forensic evaluations. Thus, to assure the accuracy of such eva- luations, the National Board of Forensic Evaluators (NBFE, 2009) certifies mental health counselors, marriage and family counselors, and social workers as forensic health evaluators. In addition, psychologists interested in forensics can now do resi- dencies in forensic psychology and also become board certified in forensic psychol- ogy (American Board for Forensic Psychology, 2013). Finally, Specialty Guidelines for Forensic Psychologists have been established by the APA “to improve the quality of forensic psychological services; enhance the practice and facilitate the systematic development of forensic psychology; encourage a high level of quality in professional practice; and encourage forensic practitioners to acknowledge and respect the rights of those they serve” (APA, 2013b, para. 3).

Assessment as a Holistic Process As we stress throughout this book, assessment of clients is much broader than sim- ply giving an individual a test. In fact, one should generally “avoid using a single test score as the sole determinant of decisions …” and one should “Interpret test scores in conjunction with other information about individuals” (JCTP, 2004, Section C-5). A good assessment will often involve a number of different kinds of instruments, including formal tests, informal assessment instruments, and a clinical interview. In addition, tests tend not to measure certain aspects of a person, such as an individual’s motivation, intention, and focus of attention and one should always consider how cultural factors can impact test results (AARC, 2012a; Preston,

BOX 2.3 Common Areas for Forensic Health Evaluators and Forensic Psychologists

Civil Criminal

• Child custody • Juvenile waiver (from juvenile to adult court)

• Civil commitment • Juvenile sentencing

• Deprivation of parental rights • Competence to stand trial

• Divorce mediation • Competence to be sentenced

• Employment litigation • Competence to waive Miranda rights

• Guardianship • Insanity defense

• Personal injury • Diminished capacity

• Testamentary capacity • Sentencing (including special issues related to capital sentencing)

• Harassment and discrimination • Evaluation of violence risk

Holistic process The importance of using multiple measures

CHAPTER 2 Ethical, Legal, and Professional Issues in Assessment 35

2005). Ultimately, the examiner should take into account test scores, multiple assessment procedures, individual traits, and cultural factors that can impact results when making suggestions and decisions about the client. This holistic process can help us obtain a broader and more accurate view of the client than if we were to rely on just one test (Mislevy, 2004; Moss, 2004).

In addition, assessment is not a static process; instead, it should be seen as continu- ous and ongoing. The assessment of a client occurs at a specific point in time; however, if we believe that a person can change, that point represents only a small sample of an individual’s total functioning. Viewing assessment in this way allows us to understand that an individual’s cognitive functioning and personality may, and probably will, change significantly throughout the life span. Seeing a client in this manner helps us develop treatment plans for the client in the here and now, while reminding us not to be held hostage to labels and diagnoses—for the individual may, and probably will, change.

Cross-Cultural Issues in Assessment [Mental health professionals] need to examine the quality and usefulness of available assessment activities relative to how such assessments may negatively affect clients, no matter the population group to which they may belong. Needed is a reorientation of assessment practices to promote the development of human talent and resources for all who are assessed. (Loesch, 2007, p. 204)

A review of contemporary articles on testing and assessment will quickly reveal that there has been increased attention to bias in testing and how it disproportionately affects minorities and women. Lawsuits have questioned the accuracy of some tests (see Box 2.2), laws have been passed preventing the use of other tests, and research has been conducted that demonstrates the negative impact that some tests can have on minorities and women. In response to these problems, as you saw earlier in this chap- ter, ethical codes and standards that address assessment always include statements con- cerning how to choose, administer, and interpret tests and assessment instruments for minorities and women. Such codes and standards have stressed that individuals who give tests and use assessment procedures should, at the minimum, keep the following in mind (International Test Commission, 2008; AARC, 2012a):

1. Assume that all tests hold some bias. 2. Be in touch with your own biases and prejudices. 3. Only use tests that have been shown to be constructed using sound research

procedures. 4. Only use tests that have good validity and reliability. 5. Know there are times when it is appropriate to test and times when it is not. 6. Know how to choose good tests that are relevant to the situation at hand. 7. Know how to administer, score, and interpret tests within the cultural context

of the client. 8. View assessment as a holistic process, and whenever possible and reasonable,

include interviews, formal testing, and informal testing. 9. Know and consider the implications that testing may have for the client.

10. Advocate for clients when tests are shown to be biased. 11. Treat people humanely during the assessment process.

Assessment is a snapshot; clients continually change

Cross-cultural issues Bias in tests, bias in examiner, understanding affects on client

36 SECTION I Understanding the Assessment Process

In Chapter 5, we will discuss a number of matters related to cross-cultural issues and test worthiness. We will highlight the fact that a test should accurately measure a construct across such attributes as class, race, religion, or gender. We will discuss how the U.S. court system, public law, federal acts, and constitu- tional amendments have all supported the notion that testing must be fair for all groups of people and free from bias. We will note how tests cannot be used to track students and that as a result of the Supreme Court case of Griggs v. Duke Power Company (1971), tests used for hiring and advancement at work must show that they can predict job performance for all groups. Also, as we have highlighted in this chapter and will discuss in Chapter 5, a number of laws have been passed that impinge on the use of tests and assert the rights of all individuals to be tested fairly. In the future, we are likely to see an increased emphasis on understanding the inherent bias in tests, the creation of new tests that are less biased, and new efforts to properly administer, score, and interpret tests with the understanding that they will, to some degree, have bias.

Exercise 2.2 Making Ethical Decisions

Review the situations below, and then using the moral principles identified in the chapter, Corey’s models of ethical decision-making, and your knowledge of legal and professional issues decide on your probable course of action. Share your answers with the rest of the class.

Situation 1: A graduate-level mental health professional with no training in career development is giving interest inventories as she counsels individuals for career issues. Can she do this? Is this ethical? Professional? Legal? If this professional happened to be a colleague of yours, what, if anything, would you do?

Situation 2: During the taking of some routine tests for promotion, a company learns that there is a high prob- ability that one of the employees is abusing drugs and is a pathological liar. The firm decides not to promote him and instead fires him. He comes to see you for counsel- ing because he is depressed. Has the company acted ethically? Legally? What responsibility do you have toward this client?

Situation 3: An African-American mother is concerned that her child may have an attention deficit problem. She goes to the teacher, who supports her concerns, and they go to the assistant principal requesting testing for a possible learning disorder. The mother asks if the child could be given an individual intelligence test that can screen for such problems, and the assistant principal

states, “Those tests have been banned for minority stu- dents because of concerns about cross-cultural bias.” The mother states that she will give her permission for such testing, but the assistant principal says, “I’m sorry, we’ll have to make do with some other tests and with observation.” Is this ethical? Professional? Legal? If you were a school counselor or school psychologist and this mother came to see you, what would you tell her?

Situation 4: A test that has not been researched to show that it is predictive of success for all potential graduate students in social work is used as part of the program’s admission process. When challenged on this by a poten- tial student, the head of the program states that the test has not been shown to be biased and the program uses other, additional criteria for admission. You are a member of the faculty at this program. Is this ethical? Professional? Legal? What is your responsibility in this situation?

Situation 5: An individual who is physically challenged and wheelchair bound applies for a job at a national fast-food chain. When he goes in to take the test for a mid-level job at this company, he is told that he cannot be given this test because it has not been assessed for its predictive ability for individuals with his disability. You are hired by the company to do the testing. What is your responsibility, if any, to this individual and to the company?

CHAPTER 2 Ethical, Legal, and Professional Issues in Assessment 37

Embracing Testing and Assessment Procedures It’s not a secret that many students are fearful of, and maybe even dreading, a course in assessment (Davis, Chang, & McGlothlin, 2005; Wood & D’Agostino, 2010). And, if many students have this fear, one has to wonder if they also leave a training program with an aversion to using tests and assessment procedures in their professional practice. If you are one of those students, then this speaks directly to you. If you’re not, our hats go off to you!

The bottom line: If you have an aversion to using assessment procedures, and you act on it, then you are not being fair to your clients. This is because testing and assessment procedures can help clients know who they are, why they behave the way they do, what they are good at, and what choices to make in their future. It can help clinicians decide on the most appropriate treatment plans, and it can help friends and families support our clients in loving and effective ways. Probably, multiple assessment procedures should always be considered for our clients if we are to give them the most effective services possible. To not do so is bringing your fears and biases into the helping relationship.

SUMMARY This chapter examined ethical, legal, and profes- sional issues involved in assessment. We began by exploring ethical concerns, and first summarized ACA’s and APA’s assessment sections of their eth- ical codes, including (1) choosing assessment instruments, (2) competence in the use of tests, (3) confidentiality, (4) cross-cultural sensitivity, (5) informed consent, (6) invasion of privacy, (7) proper diagnosis, (8) release of test data, (9) test administration, (10) test security, and (11) test scoring and interpretation. We next briefly highlighted the purposes of a number of important standards in assessment, including Standards for Qualifications of Test Users, Responsibilities of Users of Standardized Test, Standards for Multicultural Assessment, Code of Fair Testing Practices, Rights and Responsibilities of Test Takers, Standards for Educational and Psychological Testing, and competencies in school counseling; mental health counseling; marriage, couple and family counseling; career counseling; and substance abuse counseling.

As the section on ethical issues continued, we discussed the fact that good ethical decision- making is more than just relying on a code of ethics. We presented a moral model of ethical decision-making, which has to do with the

importance of focusing on the autonomy, or self-determination, of the client; nonmaleficence, or ensuring that you “do no harm”; beneficence, or promoting the well-being of society; justice, or providing equal and fair treatment; fidelity, or being loyal and faithful to your clients; and veracity, which means dealing honestly with your clients. We noted that one’s use of moral models should take into account the cultural dif- ferences of clients. We then presented Corey’s eight-step model, which includes identifying the problem or dilemma, identifying the potential issues involved, reviewing the relevant ethical guidelines, knowing the applicable laws and reg- ulations, obtaining consultation, considering possible and probable courses of action, enumer- ating the consequences of various decisions, and deciding on what appears to be the best course of action. We suggested that the ability to make wise ethical decisions might well be influenced by the counselor’s level of ethical, moral, and cognitive development.

The next part of the chapter examined impor- tant legal issues involving the use of tests, including the FERPA; the HIPAA; privileged communication laws; the Freedom of Information Act; various Civil Rights Acts (1964 and amendments); the

Use assessment instruments! They allow clients better understanding of self

38 SECTION I Understanding the Assessment Process

ADA (PL 101-336); the IDEA, which was an expansion of PL 94-142; Section 504 of the Rehabilitation Act; and the Carl Perkins Act (PL 98-24). Most of these laws have to do with issues of confidentiality, fairness, and test worthiness. This section of the chapter also offered a discussion of some of the implications of high-stakes testing.

In this chapter, we examined a number of professional issues. First, we highlighted two professional associations in the field of assess- ment: the AARC, which is a division of ACA; and Division 5 of the APA. We next highlighted three accrediting bodies in the helping profes- sions that address curriculum standards in assessment: APA, NASP, and CACREP. We then talked about the increasingly important field of forensics and the significance of becom- ing properly trained as a forensic evaluator or psychologist if one is to conduct such evaluations accurately. We next spoke of the importance of viewing assessment as a holistic process that should involve assessing the client in multiple ways, including the use of formal tests, informal

assessment instruments, and the clinical inter- view. We pointed out that assessment should be viewed as an ongoing process because people change as they live and learn.

Relative to cross-cultural issues, we stressed that individuals who give tests and use assessment procedures should, at the minimum, only use tests that have been shown to be constructed using sound research procedures; only use tests that have good validity and reliability; know there are times when it is appropriate to test and times it is not; know how to choose good tests that are relevant to the situa- tion at hand; know how to administer, score, and interpret tests within the cultural context of the cli- ent; view assessment as a holistic process; know and consider the implications that testing may have for the client; advocate for clients when tests are shown to be biased; and treat people humanely during the assessment process. We noted that Chapter 5 would expand on the discussion of cross-cultural issues in assessment. Finally, we suggested that clinicians should remain open to using assessment instruments as part of their counseling process.

CHAPTER REVIEW 1. Relative to testing and assessment, identify

and discuss some of the major themes addressed in ethical codes.

2. In addition to the ethical codes, other standards have been developed to guide individuals in test selection, administration, and interpretation. Describe some of these standards.

3. Describe APA’s levels of test user competence.

4. Describe the moral model and Corey’s problem-solving model of ethical decision- making.

5. Compare and contrast how individuals at different cognitive developmental levels would go about making ethical decisions.

6. Identify some of the major legal issues that have affected the selection, administration,

and interpretation of assessment instruments.

7. List and briefly describe two professional associations that specifically address assess- ment issues.

8. What is the role of accreditation in the deliv- ery of curriculum content in the area of assessment?

9. What are some of the unique issues involved in forensic evaluation?

10. What is needed for a good assessment of an individual?

11. Why should assessment procedures often be considered when working with clients?

12. Describe the importance of having an under- standing of cross-cultural issues when using assessment procedures.

CHAPTER 2 Ethical, Legal, and Professional Issues in Assessment 39

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American Educational Research Association, American Psychological Association, & National Council on Measurement in Education. (1999). Standards for educational and psychological testing. Washington, DC: AERA.

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American Psychological Association. (2013b). Specialty guidelines for forensic psychology. Retrieved from http://www.apa.org/practice/guidelines/forensic- psychology.aspx?item=1

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Association for Assessment and Research in Counseling. (2003). Responsibilities of users of standardized tests (RUST) (3rd ed.). Retrieved from http:// aarc-counseling.org/resources

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Corey, G., Corey, M. S., Corey, C. & Callanan, P. (2015). Issues and ethics in the helping professions (9th ed.). Belmont, CA: Brooks/Cole, Cengage Learning.

Council for Accreditation of Counseling and Related Education Programs (CACREP). (2013). Resources: Download a copy of the 2009 CACREP Standards. Retrieved from http://www.cacrep.org/template /index.cfm

Davis, K. M., Chang, C. Y., & McGlothlin, J. M. (2005). Teaching assessment and appraisal: Human- istic strategies and activities for counselor educators. Journal of Humanistic Counseling, Education and Development, 44, 94–101. doi:10.1002/j.2164-490X .2005.tb00059.x

Glosoff, H. L., Herlihy, B., & Spense, B. E. (2000). Privileged communication in the counselor-client relationship. Journal of Counseling and Development, 78, 454–462. doi:10.1002/j.1556-6676.2000.tb01 929.x

Greene, E., & Heilbrun, K. (2011). Wrightsman’s psychology and the legal system (7th ed.). Belmont, CA: Cengage.

Griggs V. Duke Power Company, 401 U. S. 424 (1971). International Test Commission. (2008). Guidelines.

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Jaffee v. Redmond, 518 U.S. 1 (U.S. Supreme Ct., 1996). Joint Committee on Testing Practices. (1998). Rights

and responsibilities of test takers: Guidelines and expectations. Retrieved from http://aarc-counseling .org/resources

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Kitchener, K. S. (1984). Intuition, critical evaluation and ethical principles: The foundation for ethical decisions in counseling psychology. The Counseling Psychologist, 12(3), 43–45. doi:10.1177/0011000084123005

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40 SECTION I Understanding the Assessment Process

Linstrum, K. S. (2005). The effects of training on ethi- cal decision making skills as a function of moral development and context in master-level counseling students. Dissertation Abstracts International Section A: Humanities & Social Sciences, 65(9-A), 3289.

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McAuliffe, G., & Eriksen, K. (Eds.). (2010). Handbook of counselor preparation. Thousand Oaks, CA: Sage Publications.

Mislevy, R. J. (2004). Can there be reliability without “reliability?” Journal of Educational and Behavioral Statistics, 29, 241–244. doi:10.3102/107699860290 02241

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National Association of School Psychologists (NASP). (2010). NASP Professional standards/training. Retrieved from http://www.nasponline.org/standards /2010standards.aspx

National Association of Social Workers. (NASW). (2008). Code of ethics. Retrieved from http://www .naswdc.org/pubs/code/default.asp

National Board of Forensic Evaluators. (2009). About NBFE. Retrieved from http://www.nbfe.net/overview .php

Neukrug, E. (2012). The world of the counselor. Belmont, CA: Brooks/Cole.

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CHAPTER 2 Ethical, Legal, and Professional Issues in Assessment 41

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42 SECTION I Understanding the Assessment Process

C H A P T E R 3Diagnosis in theAssessment Process*

It was 1975, and part of my job as an outpatient therapist at a mental health center entailed answering the crisis counseling phones every ninth night. I would sleep at the center and answer a very loud phone that would ring periodically throughout the night, usually with a person in crisis on the other end. Every once in a while, a former client of the center would call in and start to read aloud from his case notes, which he had stolen from the center. Parts of these notes were a description of his diagnosis from what was then the second edi- tion of the Diagnostic and Statistical Manual (DSM-II). In a sometimes angry, sometimes funny tone, he would read these clinical terms that were supposed to be describing him. I could understand his frustration when reading these notes over the phone, as in some ways, the diagnosis seemed removed from the person—a label. “Was this really describing the person, and how was it helpful to him?” I would often wonder.

(Ed Neukrug)

An important aspect of the clinical assessment and appraisal process is skillful diagnosis. Today, the use of diagnosis permeates the mental health professions, and although there continues to be some question as to its helpfulness, it is clear that making diagnoses and using them in treatment planning has become an integral part of what all mental health professionals do. Thus, in this chapter we examine the use of diagnosis.

We begin this chapter by discussing the importance of diagnosis in the assess- ment process and then provide a brief overview of the history of the Diagnostic and Statistical Manual of Mental Disorders (DSM) and its evolution over the past

*Updated and revised by Katherine A. Heimsch & Gina B. Polychronopoulos

Diagnosis adds clarity to the assessment process

several decades. We then introduce the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) and note some of the differences from previous versions, such as the use of a single axis and factors that now come into play when making and reporting diagnosis. Next, we highlight the DSM-5 diagnostic categories and follow up with other important considerations when making a diag- nosis, such as medical concerns, psychosocial and environmental concerns, and cross-cultural issues. There are several case studies and exercises that will help to hone some of your diagnostic skills. At the end of the chapter, we relate the impor- tance of formulating a diagnosis within the overall assessment process.

THE IMPORTANCE OF DIAGNOSIS • John is in fifth grade and has been assessed as having a conduct disorder and

attention-deficit/hyperactivity disorder (ADHD). John’s mother has panic disorder and is taking antianxiety medication. His father has bipolar and is taking lithium. Jill is John’s school counselor. John’s individualized education plan (IEP) states that he will work with Jill individually and in small groups to address behavior, attention, and social skills deficits. Jill must also periodically consult with John’s mother, father, and teachers.

• Tamara has just started college. After breaking up with her boyfriend, she became severely depressed and unable to concentrate on her schoolwork; her grades have dropped from As to Cs. She comes to the college counseling center and sobs during most of her first session with her counselor. She admits having always struggled with depression but states that “This is worse than ever; I need to get better if I am going to stay in school. Can you give me any medication to help me so I won’t have to drop out?”

• Benjamin goes daily to the day treatment center at the local mental health center. He seems fairly coherent and generally in good spirits. He has been hospitalized for schizophrenia on numerous occasions and now takes risperdone to relieve his symptoms. He admits to Jordana, one of his counse- lors, that he doesn’t take his medication because he believes that computers have consciousness and are conspiring through the World Wide Web to take over the world. His insurance company pays for his treatment. He will not receive treatment unless Jordana specifies a diagnosis on the insurance form.

As you can see from these examples, diagnosis is an essential tool for profes- sionals in a wide range of settings. In fact, current research suggests that up to 20% of all children and adults struggle with a diagnosable mental disorder each year (Centers for Disease Control and Prevention [CDC], 2013; Substance Abuse and Mental Health Services Administration, 2012), and approximately 50% of adults in the United States will experience mental illness in their lifetime (CDC, 2011). There- fore, all persons serving in helping roles will encounter persons dealing with a mental disorder and will need to be familiar with a common diagnostic language to best serve these individual and to effectively communicate with other professionals. Today, the importance of an accurate diagnosis is related to a number of changes that have occurred over the past years. Some of these include the following:

1. Interventions and accommodations for children with emotional, behavioral, and learning disorders are now required by federal and state laws (e.g., PL94-142, Individuals with Disabilities Education Act [IDEA]) and a diagnosis is generally

There are many reasons to diagnose

44 SECTION I Understanding the Assessment Process

necessary if professionals are to identify students with such disorders. Today, teachers, school counselors, school psychologists, child study team members, and other school professionals are often the first to recognize and diagnose young people with these disorders.

2. Today, a diagnosis is viewed as one aspect of holistically understanding the client. Along with testing, interviews, and other measures, it can be used to help conceptualize client problems and assist in the accurate development of treatment plans.

3. Due to laws like the Americans with Disabilities Act (e.g., U.S. Department of Justice, n.d.), employers are now required to make reasonable accommodations for individuals with disabilities, including those with mental disorders. Mental health professionals must know about diagnosis if they are to help individuals maintain themselves at work and assist employers in understanding the condi- tions of individuals with mental disorders.

4. In the past 50 years, a mental disorder diagnosis has generally become mandatory if medical insurance is to reimburse for treatment. Accurate diagnosing is important because the insurance carrier often allows only a certain number of treatments per particular diagnosis.

5. The diagnostic nomenclature of the DSM has increasingly become an essential and effective way of communicating with community partners who may be part of the client’s same treatment team (e.g., other mental health professionals, doctors, representatives of the legal system).

6. It has become increasingly evident that accurately and appropriately commu- nicating a mental health diagnosis to a client can help the individual under- stand his or her prognosis and aid in forming reasonable expectations for treatment.

These items show why it is important for a wide range of professionals to understand diagnosis. Although the DSM-IV-TR (4th ed. with text revisions; American Psychiatric Association [APA], 2000) had been the most well-known diagnostic classification sys- tem, with the recent release of DSM-5 (APA, 2013), a revised nomenclature was devel- oped. But what is the DSM and how does it work?

THE DIAGNOSTIC AND STATISTICAL MANUAL (DSM): A BRIEF HISTORY

Derived from the Greek words dia (apart) and gnosis (to perceive or to know), the term diagnosis refers to making an assessment of an individual from an outside, or objective, viewpoint (Segal & Coolidge, 2001). One of the first attempts to classify mental illness occurred during the mid-1800s when the U.S. Census Bureau started counting the incidence of “idiocy” and “insanity” (Smith, 2012). However, it was not until 1943 that a formal classification system called the Medical 203 was devel- oped by the U.S. War Department (Houts, 2000). Revised over the next few years, in 1952 this publication became the basis for APA’s first DSM (DSM-I), which included 106 diagnoses in three broad categories (APA, 1952; Houts, 2000). In 1968 DSM-II was released (APA, 1968), which created 11 diagnostic categories with 185 discrete diagnoses and included a large increase in childhood diagnoses. In an effort to improve the science behind diagnosis as well as increase the

DSM-I First edition published in 1952 with three broad categories

DSM-III Introduced multiaxial diagnosis in 1980

CHAPTER 3 Diagnosis in the Assessment Process 45

compatibility with the American Medical Association’s International Classification of Disease (ICD) manual, the third edition of the DSM was released in 1980 (APA, 1980), which included 265 diagnoses and a multiaxial approach to diagnosis. In 1994 DSM-IV was released, and in 2000 an additional text revision of DSM-IV became available (DSM-IV-TR) and contained 365 diagnoses (APA, 1994, 2000). Although there were many critics of the DSM-IV-TR (Beutler & Malik, 2002; Thyer, 2006; Zalaquett, Fuerth, Stein, Ivey, & Ivey, 2008), it became the most widely utilized diag- nostic classification system for mental health disorders (Seligman, 1999, 2004). A DSM-IV diagnosis consisted of five axes that included clinical disorders, personality disorders and mental retardation, medical conditions, psychosocial and environmental factors, and a global assessment of functioning (GAF) scale (see Table 3.1).

The practice of utilizing the multiaxial diagnostic system allowed mental health professionals to present a thorough description of clients and communicate their concerns and symptoms to other professionals (Neukrug & Schwitzer, 2006). However, there were drawbacks to a multiaxial approach and the DSM-5 moved toward a one-axis approach.

THE DSM-5 The newest diagnostic manual, DSM-5 (APA, 2013), was under development from 1999 to 2013 (Smith, 2012) and was first published in May of 2013. The DSM-5 includes a sleeker, more computer-friendly name, which replaces the Roman numeral tradition of the DSM. Subsequent editions, like computer software, will follow with editions 5.1, 5.2, 5.3, and so on. In addition to the print version of DSM-5, an online component (www.psychiatry.org/dsm5) is now available for supplemental materials such as assessment measures, but it also includes related news articles, fact sheets, and audiovisual materials. Another important change that has been made to the DSM-5 is an effort to align it with the ICD-9, and later, the ICD-10 (release date: October 1, 2014). This serves to unify the diagnostic and billing process between psychological and medical professions. Thus the DSM-5 gives both the ICD-9 and ICD-10 codes, and when making a diagnosis, one may want to list the ICD-9 code first and place the ICD-10 code in parenthesis. Clearly, it is important to know which version of the ICD is being used when making your diagnosis.

TABLE 3.1 Former Five-Axis Diagnostic System

Axis Category Examples

Axis I Clinical disorders Depression, anxiety, bipolar, schizophrenia, etc.

Axis II Personality disorders and mental retardation

Borderline personality disorder, antisocial personality disorder, etc.

Axis III General medical conditions High blood pressure, diabetes, sprained ankle, etc.

Axis IV Psychosocial and environmental factors

Recent loss of job, recent divorce, homelessness, etc.

Axis V Global assessment of functioning A single score from 1 to 100 summarizing one’s functioning and symptoms

DSM-IV-TR Used a five-axis diagnosis

DSM-5 Accepted diagnostic classification system for mental disorders

20 15

46 SECTION I Understanding the Assessment Process

Single-Axis vs. Multiaxial Diagnosis Perhaps the most significant change in the DSM-5 was the return to a single-axis diagnosis (APA, 2013; Wakefield, 2013). This was done for a number of reasons. First, the separation of personality disorders to Axis II under DSM-IV gave these disorders undeserved status and the misguided belief that they were untreatable (Good, 2012; Krueger & Eaton, 2010). Clients who met the criteria for an Axis II diagnosis may now find it easier to navigate mental health treatment as they will no longer be seen as having a diagnosis that is more difficult to treat than a host of other disorders. In DSM-5, medical conditions are no longer listed on a separate axis (Axis III in DSM-IV). Thus, they will likely take a more significant role in mental health diagnosis as they can be listed side-by-side with the mental disorder (Wakefield, 2013). Also, psychosocial and environmental stressors, previously listed on Axis IV of DSM-IV, will be listed alongside mental disorders and physical health issues. In fact, DSM-5 has increased the number of “V codes” (Z codes in ICD-10), which are considered nondisordered conditions that sometimes are the focus of treatment and often are reflective of a host of psychosocial and environ- mental issues (e.g., homelessness, divorce, etc.). As for the GAF score, previously on Axis V of DSM-IV, the APA intended to replace this historically unreliable tool with a different scaling assessment altogether. One assessment instrument, now being researched, is the World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0). This 36-item, self-administered questionnaire assesses a cli- ent’s functioning in six domains: understanding and communicating, getting around, self-care, getting along with people, life activities, and participation in soci- ety (APA, 2013). Disorders and other assessments that are under review for further research can be found in Section III of the DSM-5.

Making and Reporting Diagnosis In the next section of the chapter, we discuss specific diagnostic categories, but first let’s look at other factors involved in making and reporting diagnoses, including how to order the diagnoses; the use of subtypes, specifiers, and severity; making a provisional diagnosis; and use of “other specified” or “unspecified” disorders.

Ordering Diagnoses Individuals will often have more than one diagnosis, so it is important to consider their ordering. The first diagnosis is called the principal diagnosis. In an inpatient setting, this would be the most salient factor that resulted in the admission (APA, 2013). In an outpatient environment, this would be the reason for the visit or the main focus of treatment. The secondary and tertiary diagnosis should be listed in order of need for clinical attention. If a mental health diagnosis is due to a general medical condition, the ICD coding rules require listing the medical condition first, followed by the psychiatric diagnosis, due to the general medical condition.

Subtypes, Specifiers, and Severity Subtypes for a diagnosis can be used to help communicate greater clarity. They can be identified in the DSM-5 by the instruction “Specify whether” and represent mutually exclusive groupings of symptoms (i.e., the clinician can only pick one). For example, ADHD has three different subtypes to choose from: predominantly inattentive, predominantly hyperactive/impulsive, or a combined presentation. Specifiers, on the other hand, are not mutually exclusive, so

Single-axis diagnosis Attempt to make clini- cal diagnoses and personality disorders on par with medical codes

Medical conditions Can list, using ICD codes, along with DSM diagnosis

Principal diagnosis The reason the person came to treatment is listed first

Subtype “Specify whether”— only choose one

Specifier “Specify if”—pick as many as apply

CHAPTER 3 Diagnosis in the Assessment Process 47

more than one can be used. The clinician chooses which specifiers apply, if any, and they are listed in the manual as “Specify if.” The ADHD diagnosis offers only one specifier that is “in partial remission” (APA, 2013, p. 60). Some diagnoses will offer an opportunity to rate the severity of the symptoms. These are identified in the DSM as “Specify current severity.” Referencing the ADHD diagnosis, there are three options of severity: mild, moderate, or severe. The DSM-5 authors have attempted to offer greater flexibility in rating severity through dimensional diagnosis. For exam- ple, some diagnoses offer greater options when rating severity. The Autism Spectrum Disorder has “Table 2 Severity levels of autism spectrum disorder” (APA, 2013, p. 52), which classifies autism on three levels of severity “requiring support,” “requiring substantial support,” and “requiring very substantial support.” Similarly, schizophrenia has the user go to a “Clinician-Rated Dimensions of Psychosis Symp- tom Severity” chart (pp. 743–744) to rate symptoms on a five-point Likert scale. It is easy to see how insurance companies might use severity classification as one method of determining which clients they will fund for treatment. In summary, the three types of specifiers are identified by:

• Subtype: “Specify whether”—only choose one, • Specifier: “Specify if”—pick as many as apply, and • Severity: “Specify current severity”—choose the most accurate level of

symptomology.

Provisional Diagnosis Sometimes, the clinician has a strong inclination that a client will meet the criteria for a diagnosis, but does not yet have enough informa- tion to make the diagnosis. This is when the clinician can make a provisional diagnosis. Once the criteria are later confirmed, the provisional label can be removed. These situations often occur when a client is not able to give an adequate history or further collateral information is required. In addition, there are informal diagnostic labels not listed in the DSM-5 that are helpful in communicating addi- tional information. They are generally found in a diagnostic summary or when communicating informally with other clinicians. They include the following:

• Rule-out—the client meets many of the symptoms but not enough to make a diagnosis at this time; it should be considered further (e.g., rule-out major depressive disorder).

• Traits—this person does not meet criteria; however, he or she presents with many of the features of the diagnosis (e.g., borderline traits or cluster B traits).

• By history—previous records (another provider or hospital) indicate this diagnosis; records can be inaccurate or outdated (e.g., alcohol dependence by history).

• By self-report—the client claims this as a diagnosis; it is currently unsubstantiated; these can be inaccurate (e.g., bipolar by self-report).

For example, you may receive a fax from a hospital or other provider that might say, “Provisional Borderline Personality Disorder. Bipolar Diagnosis by self-report—no manic symptoms identified.”

Other Specified Disorders and Unspecified Disorders The DSM-IV had a diagnosis of not otherwise specified (NOS) to capture symptomology that did not fit well into a structured category. In lieu of the NOS diagnosis, the DSM-5 offers two

Dimensional diagnosis Offers ability to note symptom severity

Severity “Specify current severity”—choose the most accurate level of symptomology

Provisional diagnosis Used when strong inclination but can’t yet confirm

48 SECTION I Understanding the Assessment Process

options when these situations arise. The other specified and unspecified disorders should be used when a provider believes an individual’s impairment to functioning or distress is clinically significant; however, it does not meet the specific diagnostic criteria in that category. The “other specified” should be used when the clinician wants to communi- cate specifically why the criteria do not fit. The “unspecified disorder” should be used when he or she does not wish, or is unable to, communicate specifics. For example, if someone appeared to have significant panic attacks but only had three of the four required criteria, the diagnosis could be “Other Specified Panic Disorder—due to insuf- ficient symptoms.” Otherwise, the clinician would report “Unspecified Panic Disorder.”

Specific Diagnostic Categories Section II of DSM-5 offers an in-depth discussion of 22 broad diagnostic categories and their subtypes as well as descriptions of medication-induced disorders and what is called “other conditions that may be a focus of clinical attention.” The fol- lowing offers a brief description of these disorders and is summarized from DSM-5 (APA, 2013). Please refer to the DSM-5 for an in-depth review of each disorder. When you finish reviewing these diagnoses, the class may want to do Exercise 3.1.

• Neurodevelopmental Disorders. This group of disorders typically refers to those that manifest during early development, although diagnoses are sometimes not assigned until adulthood. Examples of neurodevelopmental disorders include intel- lectual disabilities, communication disorders, autism spectrum disorders (incorpo- rating the former categories of autistic disorder, Asperger’s disorder, childhood disintegrative disorder, and pervasive developmental disorder), ADHD, specific learning disorders, motor disorders, and other neurodevelopmental disorders.

• Schizophrenia Spectrum and Other Psychotic Disorders. The disorders that belong to this section all have one feature in common: psychotic symptoms, that is, delusions, hallucinations, grossly disorganized or abnormal motor behavior, and/or negative symptoms. The disorders include schizotypal person- ality disorder (which is listed again, and explained more comprehensively, in the category of personality disorders in the DSM-5), delusional disorder, brief psychotic disorder, schizophreniform disorder, schizophrenia, schizoaffective disorder, substance/medication-induced psychotic disorders, psychotic disorders due to another medical condition, and catatonic disorders.

• Bipolar and Related Disorders. The disorders in this category refer to distur- bances in mood in which the client cycles through stages of mania or mania and depression. Both children and adults can be diagnosed with bipolar disor- der, and the clinician can work to identify the pattern of mood presentation, such as rapid-cycling, which is more often observed in children. These disor- ders include bipolar I, bipolar II, cyclothymic disorder, substance/medication- induced, bipolar and related disorder due to another medical condition, and other specified or unspecified bipolar and related disorders.

• Depressive Disorders. Previously grouped into the broader category of “mood disorders” in the DSM-IV-TR, these disorders describe conditions where depressed mood is the overarching concern. They include disruptive mood dys- regulation disorder, major depressive disorder, persistent depressive disorder (also known as dysthymia), and premenstrual dysphoric disorder.

Other specified disorder Doesn’t fit a standard diagnosis with an explanation why not

Unspecified disorder Doesn’t fit a standard diagnosis without explanation

Diagnostic categories Twenty-two categories included in one axis

CHAPTER 3 Diagnosis in the Assessment Process 49

• Anxiety Disorders. There are a wide range of anxiety disorders, which can be diagnosed by identifying a general or specific cause of unease or fear. This anxiety or fear is considered clinically significant when it is excessive and per- sistent over time. Examples of anxiety disorders that typically manifest earlier in development include separation anxiety and selective mutism. Other exam- ples of anxiety disorders are specific phobia, social anxiety disorder (also known as social phobia), panic disorder, and generalized anxiety disorder.

• Obsessive-Compulsive and Related Disorders. Disorders in this category all involve obsessive thoughts and compulsive behaviors that are uncontrollable and the client feels compelled to perform them. Diagnoses in this category include obsessive- compulsive disorder, body dysmorphic disorder, hoarding disorder, trichotilloma- nia (or hair-pulling disorder), and excoriation (or skin-picking) disorder.

• Trauma- and Stressor-Related Disorders. A new category for DSM-5, trauma and stress disorders emphasize the pervasive impact that life events can have on an individual’s emotional and physical well-being. Diagnoses include reac- tive attachment disorder, disinhibited social engagement disorder, posttrau- matic stress disorder, acute stress disorder, and adjustment disorders.

• Dissociative Disorders. These disorders indicate a temporary or prolonged dis- ruption to consciousness that can cause an individual to misinterpret identity, surroundings, and memories. Diagnoses include dissociative identity disorder (formerly known as multiple personality disorder), dissociative amnesia, deper- sonalization/derealization disorder, and other specified and unspecified disso- ciative disorders.

• Somatic Symptom and Related Disorders. Somatic symptom disorders were previously referred to as “somatoform disorders” and are characterized by the experiencing of a physical symptom without evidence of a physical cause, thus suggesting a psychological cause. Somatic symptom disorders include somatic symptom disorder, illness anxiety disorder (formerly hypochondriasis), conver- sion (or functional neurological symptom) disorder, psychological factors affecting other medical conditions, and factitious disorder.

• Feeding and Eating Disorders. This group of disorders describes clients who have severe concerns about the amount or type of food they eat to the point that serious health problems, or even death, can result from their eating beha- viors. Examples include avoidant/restrictive food intake disorder, anorexia ner- vosa, bulimia nervosa, binge eating disorder, pica, and rumination disorder.

• Elimination Disorders. These disorders can manifest at any point in a person’s life, although they are typically diagnosed in early childhood or adolescence. They include enuresis, which is the inappropriate elimination of urine, and encopresis, which is the inappropriate elimination of feces. These behaviors may or may not be intentional.

• Sleep-Wake Disorders. This category refers to disorders where one’s sleep pat- terns are severely impacted, and they often co-occur with other disorders (e.g., depression or anxiety). Some examples include insomnia disorder, hypersom- nolence disorder, restless legs syndrome, narcolepsy, and nightmare disorder. A number of sleep-wake disorders involve variations in breathing, such as sleep- related hypoventilation, obstructive sleep apnea hypopnea, or central sleep apnea. See the DSM-5 for the full listing and descriptions of these disorders.

50 SECTION I Understanding the Assessment Process

• Sexual Dysfunctions. These disorders are related to problems that disrupt sex- ual functioning or one’s ability to experience sexual pleasure. They occur across sexes and include delayed ejaculation, erectile disorder, female orgasmic disorder, and premature (or early) ejaculation disorder, among others.

• Gender Dysphoria. Formerly termed, “gender identity disorder,” this category includes those individuals who experience significant distress with the sex they were born and with associated gender roles. This diagnosis has been separated from the category of sexual disorders, as it is now accepted that gender dys- phoria does not relate to a person’s sexual attractions.

• Disruptive, Impulse Control, and Conduct Disorders. These disorders are characterized by socially unacceptable or otherwise disruptive and harmful behaviors that are outside of the individual’s control. Generally, more common in males than in females, and often first seen in childhood, they include oppo- sitional defiant disorder, conduct disorder, intermittent explosive disorder, antisocial personality disorder (which is also coded in the category of person- ality disorders), kleptomania, and pyromania.

• Substance-Related and Addictive Disorders. Substance use disorders include disruptions in functioning as the result of a craving or strong urge. Often caused by prescribed and illicit drugs or the exposure to toxins, with these dis- orders the brain’s reward system pathways are activated when the substance is taken (or in the case of gambling disorder, when the behavior is being per- formed). Some common substances include alcohol, caffeine, nicotine, canna- bis, opioids, inhalants, amphetamine, phencyclidine (PCP), sedatives, hypnotics or anxiolytics. Substance use disorders are further designated with the follow- ing terms: intoxication, withdrawal, induced, or unspecified.

• Neurocognitive Disorders. These disorders are diagnosed when one’s decline in cognitive functioning is significantly different from the past and is usually the result of a medical condition (e.g., Parkinson’s or Alzheimer’s disease), the use of a substance/medication, or traumatic brain injury, among other phenomena. Examples of neurocognitive disorders (NCD) include delirium, and several types of major and mild NCDs such as frontotemporal NCD, NCD due to Parkin- son’s disease, NCD due to HIV infection, NCD due to Alzheimer’s disease, substance- or medication-induced NCD, and vascular NCD, among others.

• Personality Disorders. The 10 personality disorders in DSM-5 all involve a pattern of experiences and behaviors that are persistent, inflexible, and deviate from one’s cultural expectations. Usually, this pattern emerges in adolescence or early adulthood and causes severe distress in one’s interpersonal relationships. The personality disorders are grouped into the three following clusters based on similar behaviors: • Cluster A: Paranoid, schizoid, and schizotypal. These individuals seem

bizarre or unusual in their behaviors and interpersonal relations. • Cluster B: Antisocial, borderline, histrionic, and narcissistic. These indivi-

duals seem overly emotional, are melodramatic, or unpredictable in their behaviors and interpersonal relations.

• Cluster C: Avoidant, dependent, and obsessive-compulsive (not to be con- fused with obsessive-compulsive disorder). These individuals tend to appear anxious, worried, or fretful in their behaviors.

CHAPTER 3 Diagnosis in the Assessment Process 51

In addition to these clusters, one can be diagnosed with other specified or unspecified personality disorder, as well as a personality change due to another medical condition, such as a head injury.

• Paraphilic Disorders. These disorders are diagnosed when the client is sexually aroused to circumstances that deviate from traditional sexual stimuli and when such behaviors result in harm or significant emotional distress. The disorders include exhibitionistic disorder, voyeuristic disorder, frotteurisitc disorder, sexual sadism and sexual masochism disorders, fetishistic disorder, transvestic disorder, pedophilic disorder, and other specified and unspecified paraphilic disorders.

• Other Mental Disorders. This diagnostic category includes mental disorders that did not fall within one of the previously mentioned groups and do not have uni- fying characteristics. Examples include other specified mental disorder due to another medical condition, unspecified mental disorder due to another medical condition, other specified mental disorder, and unspecified mental disorder.

• Medication-Induced Movement Disorders and Other Adverse Effects of Medications. These disorders are the result of adverse and severe side effects to medications, although a causal link cannot always be shown. Some of these disorders include neuroleptic-induced parkinsonism, neuroleptic malignant syndrome, medication-induced dystonia, medication-induced acute akathisia, tardive dyskinesia, tardive akathisia, medication-induced postural tremor, other medication-induced movement disorder, antidepressant discontiunation syndrome, and other adverse effect of medication.

• Other Conditions That May Be a Focus of Clinical Assessment. Reminiscent of Axis IV of the previous edition of the DSM, this last part of Section II ends with a description of concerns that could be clinically significant, such as abuse/neglect, relational problems, psychosocial, personal, and environmental concerns, educational/occupational problems, housing and economic problems, and problems related to the legal system. These conditions, which are not con- sidered mental disorders, are generally listed as V codes, which correspond to ICD-9, or Z codes, which correspond to ICD-10.

Sometimes, mental health conditions can co-occur or be “comorbid.” For example, suppose a client presents with an anxiety disorder but also abuses alcohol. In this situa- tion, it would be appropriate to denote both disorders when making a diagnosis (e.g., generalized anxiety disorder and alcohol abuse). Sometimes disorders can even exacer- bate each other. An example of this could be someone who meets the criteria for depression, but his or her symptoms only present while withdrawing from cocaine use. Rather than diagnosing this as a major depressive episode, it is more appropriate that he or she be diagnosed with a substance-induced mood disorder (see Exercise 3.1).

Other Medical Considerations Sometimes, physical symptoms caused by a medical condition may look a lot like one or more of the mental disorders. For example, some of the symptoms for depres- sion include appetite disturbance (increase or decrease), irritability or restlessness, hyper or insomnia (i.e., sleeping too much or too little), difficulty concentrating, and fatigue or decreased energy. Interestingly, all of these symptoms can also be attrib- uted to hypothyroidism or underactive thyroid. Thus, in addition to clients being assessed for mental health problems, it is also important for them to be assessed for

Co-occurring disorders Disorders may coexist and can sometimes exacerbate one another

Be cognizant of medi- cal factors that may influence mental health

52 SECTION I Understanding the Assessment Process

potential medical problems. One way to address this is to obtain specific details about when the client began experiencing his or her symptoms. Such information will help determine whether symptoms began while a medical condition was present and whether it is likely that the medical condition was the cause of the mental disor- der. For instance, suppose you have a client who is presenting with all of the criteria for an anxiety disorder (such as restlessness, irritability, and insomnia), but you know that these symptoms began when the client’s thyroid began declining and he or she found out it was underactive. If the client’s anxiety disorder only came about because of the hypothyroidism, then it would be appropriate to designate it as such, that is, anxiety disorder due to a general medical condition, hypothyroidism. Of course, it is always prudent to refer a client to his or her primary care physician if there is any suspicion that a medical problem may be the source of a psychological issue (see Exercise 3.2). If reporting a medical problem, the ICD code for the particu- lar problem can be used along with the DSM-5 mental health disorder diagnosis.

Psychosocial and Environmental Considerations As a part of a complete diagnosis, it is imperative for the clinician to assess the client’s psychosocial and environmental stressors. Such a focus promotes a holistic view of the client, provides important diagnostic clues, and can help to identify important issues in treatment planning. Not considered mental disorders, some of the many psychosocial and environmental concerns may include problems with the client’s primary support group, social environment, education, occupation, housing, economic situation, access to health care, crime or the legal system, or other significant psychosocial and environ- mental considerations (APA, 2013). Whereas these concerns were previously listed on Axis IV of DSM-IV, they are now denoted in the single-axis system, are now mostly listed under “Other conditions that may be a focus of clinical attention” discussed ear- lier, and are correlated to V codes in DSM-5 (which matches ICD-9) or Z codes (which matches ICD-10 ) (e.g., Z59.0 Homelessness; Z65.1 Imprisonment; Z55.3 Underachievement in school).

To illustrate the importance of psychosocial and environmental considerations, consider a 48-year-old male experiencing severe anxiety and depression. He explains

Exercise 3.1 Diagnosing a Disorder

Once the class has become familiar with the various disorders, the instructor may ask the students to prac- tice identifying and diagnosing disorders by performing

role-plays in dyads or small groups. You may want to use DSM-5 as a guide for acting out the criteria.

Exercise 3.2 Diagnosing Medical Conditions

After practicing formulating a diagnosis in Exercise 3.1, the instructor may ask the students to role-play again, incorporating a medical condition this time. Identify the

medical condition as well as the mental health condition, and be sure to note whether it is separate or if it is the cause of the mental health diagnosis.

Psychosocial/ environmental factors Stressors that are crucial for under- standing the whole person

V & Z codes Allows psychosocial stressors to be listed in diagnosis

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CHAPTER 3 Diagnosis in the Assessment Process 53

that his symptoms started immediately after a tornado caused severe damage to his home and neighboring farm (natural disaster). The man and his family have been staying with relatives about 70 miles away from home (homelessness), and have had no source of income for the past three months (economic issues) since their crop of soy was also destroyed in the tornado (occupational problem). By understanding the client’s psychosocial and environmental considerations, his anxiety and depression can be viewed in the context of his life circumstances.

Cultural Considerations Because people from diverse cultures may express themselves in different ways, symptomatology may vary as a function of culture (Mezzich & Caracci, 2008). Thus, some have argued that although diagnosis can be helpful in treatment plan- ning, it can lead to the misdiagnosis of culturally oppressed groups when clinicians do not fully take into account cultural, gender, and ethnic differences (Eriksen & Kress, 2005, 2006, 2008; Kress, Eriksen, Rayle, & Ford, 2005; Madesen & Leech, 2007; Rose & Cheung, 2012).

The APA (2013) has attempted to combat some of these problems by asking clin- icians to understand and acknowledge “culturally patterned differences in symptoms” (p. 758). For example, Latin American culture acknowledges that ataque de nervios (“attack of nerves”) is a common disorder related to difficult and burdensome life experiences and may exhibit itself through “headaches and ‘brain aches’ (occipital neck tension), irritability, stomach disturbances, sleep difficulties, nervousness, easy tearfulness, inability to concentrate, trembling, tingling sensations, and mareos (dizzi- ness with occasional vertigo-like exacerbations)” (p. 835). A clinician who ignores the client’s culture could easily misdiagnose a client who presents with symptoms like this and begin to treat the client with inappropriate strategies. Best practice for multicul- tural counseling suggests that the clinician have some understanding of differences in cross-cultural expression of symptoms and that the clinician explore the client’s culture with him or her when deciding on appropriate treatment strategies.

Finally, DSM-5 offers a section entitled Cultural Formulation Interview (CFI) that helps clinicians understand the kinds of values, experiences, and influences that have come to shape the client’s worldview and provides an outline for how to appropriately interview clients from diverse backgrounds. In addition, DSM-5 offers definitions of some cross-cultural symptoms and identifies how cross-cultural issues impact a wide- range of diagnoses.

Final Thoughts on DSM-5 in the Assessment Process DSM-5 is one additional piece of the total assessment process. Along with the clini- cal interview, the use of tests, and informal assessment procedures, it can provide a broad understanding of the client and can be a critical piece in the treatment plan- ning process. Consider what it might be like to establish a treatment plan if only one test were used. Then, consider what it would be like if two tests were used, then two tests and an informal assessment procedure; then two tests, an informal assessment procedure, and a clinical interview; and finally, two tests, an informal assessment procedure, a clinical interview, and a diagnosis. Clearly, the more “pieces of evidence” we can gather, the clearer our snapshot of our client becomes and this, in turn, yields better treatment planning (see Exercise 3.3).

Cultural considerations Use CFI and info from DSM to understand differences in symptomatology

Some “abnormal” behaviors may be considered “normal” in other cultures

54 SECTION I Understanding the Assessment Process

Exercise 3.3 Practice Making a Diagnosis

On your own, in pairs, or as a class, read the following case studies and formulate a diagnosis for each person using the DSM-5 as a guide. Discuss how you came to this diagnosis, what other diagnoses you considered but ruled out, and what additional information would have been helpful in assessing the scenario. Answers can be found at the end of the chapter.

I. Mikayla Mikayla is an 8-year-old girl in the second grade. She lives with her parents and younger brother, and her mother describes her as “a handful, but very sweet.” Mikayla had to repeat second grade due to behavioral issues in class, which also resulted in lower test scores and poor grades. She is a popular child among her peers, but she continually struggles with her teacher to follow directions, stay on task, and remain seated. Mikayla’s teacher has consulted with her kindergarten and first-grade teachers and does not think that Mikayla has communication issues or a specific learning disorder because she performs above grade-level expectations in small group or with one-on-one attention. In a large classroom situation, she is in constant motion, shouts when she should be talking quietly, and is easily distracted, which prevents her from meeting expectations. Most recently, Mikayla was referred to the school counselor after she broke the classroom fish tank during a silent read- ing activity. “I was just trying to feed Flipper,” she explained.

II. Tracey Tracey is a 25-year-old single working mother. Her daughter, Alicia, is 3 years old and in day care during the work week. Tracey was recently divorced from Alicia’s father and has sole custody of their child because her ex-husband was physically abusive. In the past few years, when the marital problems began, Tracey became overwhelmed with anxiety but was so busy that she stated she just didn’t have time to deal with it. She starts her day at 5:30 a.m. to get Alicia dressed, packed, and ready for day care so that she can get to work by 7:00 a.m. Tracey usually has break- fast on the road, and she frequents the drive-through on her way to work for convenience. At work it’s “go, go, go,” and Tracey doesn’t usually have time to break

for lunch. By the time she picks up Alicia from day care and gets home, it’s about 6:00 p.m. Tracey cooks din- ner by 7:00 p.m., which usually consists of a healthy, balanced meal. Once she gives Alicia a bath and puts her to bed, Tracey finally gets a breather to relax on the couch and watch TV. Now that she is alone, she feels an uncontrollable urge to snack and often goes through a large bag of potato chips followed by a quart of ice cream before she realizes it. Sometimes, she finishes eating that amount before her favorite half-hour sitcom is over. “I just can’t stop. It’s like I zone out, and I don’t even realize how much I’ve eaten. I feel like I can’t con- trol myself. Usually, I feel physically sick by the end of it and just pass out, like a food coma.” Tracey doesn’t like to eat junk food in front of others because she’s ashamed that she has gained so much weight since the divorce and feels self-conscious. She’s been eating in secret like this for the past year since the divorce, and it happens almost every night. It’s gotten to the point where she has begun isolating herself, preferring to go home and snack all night in front of the TV instead of spending time with family and friends.

III. Alan Alan is a 37-year-old banker, who was divorced from his wife two years ago. Alan reported that his wife left him after he became disengaged from the marriage. He recalled that he and his wife were college sweethearts and were previ- ously very active in their community. Then, approximately five years ago, Alan said, “I just ran out of steam.” He has since been constantly irritable, started sleeping excessively, gained about 45 pounds, and lost interest in being social and engaging in pleasurable activities. Alan smokes mari- juana approximately two to four times per day and drinks vodka nightly to “relax and take my mind off of things.” He recently was arrested for possession of marijuana and driv- ing under the influence, put on probation for one year, and was referred to counseling by the court. Alan admits to being mildly depressed, but insists, “It’s nothing I can’t handle.” He does not wish to discontinue his marijuana or alcohol use but has thoughts about stopping due to monthly drug screens, which will soon be required by his probation officer.

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CHAPTER 3 Diagnosis in the Assessment Process 55

SUMMARY We began this chapter by discussing the impor- tance that diagnosis plays in the professional life of mental health professionals. We noted that a large percentage of Americans are diagnosed, yearly, with a mental disorder, and highlighted some reasons that diagnosis has become impor- tant for professionals, such as their significance in identifying children in schools with emotional, behavioral, and learning disorders; the fact that a diagnosis can help in case conceptualization and treatment planning; the fact that professionals can help employers make accommodations for and understand individuals with mental disorders; because they are critical to insurance reimburse- ment; because they assist professionals in accurately communicating to one another; and because they can help clients understand their prognosis and expectations for treatment planning.

Next, we offered a brief history of the DSM starting with the U.S. Census Bureau counting those who were “idiots” and “insane” during the mid-1800s. However, we noted that it wasn’t until 1943, with the military’s Medical 203, that a formal classification system was developed. We then noted that DSM-I was developed in 1952 and underwent a number of revisions up through the most recent edition, the DSM-5 in 2013. We then introduced the DSM-5 and began noting some of the differences from its predecessors, particularly the move from a five-axes system in DSM-IV to a one-axis system in DSM-5.

A large portion of the chapter described DSM-5. We began by explaining why DSM-5 moved to a one-axis system and discussed making and reporting a diagnosis. In this process, we dis- cussed how to order diagnoses; the use of sub- types, specifiers, and severity; how to make a provisional diagnosis; and the use of other speci- fied or unspecified disorders. Next, we offered very brief descriptions of the 22 diagnostic cate- gories. We also offered a brief discussion about co-occurring or comorbid disorders. This was fol- lowed by a discussion about the importance of understanding how medical conditions can cause or exacerbate a diagnosis. We then noted that whereas psychosocial and environmental consid- erations were placed on Axis IV of DSM-IV, they are now correlated to an ICD code, are often given a V or Z code, and included in the single- axis system. Finally, we noted that individuals may present symptoms in varying ways as a func- tion of their culture and talked about the impor- tance of taking into consideration one’s cultural background when making a diagnosis. We pointed out that DSM-5 offers a Cultural Formu- lation Interview (CFI) that can help in the process of understanding diverse clients, provides some examples of cross-cultural symptoms, and identi- fies how cross-cultural issues impact a wide range of diagnoses. We ended the chapter by noting that DSM-5 is one piece in the total assessment process and offered an exercise where students could try to diagnose three hypothetical clients.

CHAPTER REVIEW 1. Consider how a mental health diagnosis

could be beneficial to a client. What might be potential harm from a diagnosis?

2. Why is it important for clinicians, medical doctors, legal professionals, and so on to use a common diagnostic language?

3. Explain why it is an ethical responsibility for clinicians to be knowledgeable about diagnosis.

4. Give examples of how you might utilize a diagnosis when formulating a treatment plan.

5. Describe how medical conditions can be rel- evant to a mental health diagnosis.

6. Describe how psychosocial and environ- mental considerations are now included in DSM-5.

7. Explore how you can include multicultural considerations into a diagnosis.

56 SECTION I Understanding the Assessment Process

8. Discuss the difference between use of subtypes, specifiers, and severity.

9. Explain how provisional diagnoses can be made.

10. Discuss the use of other specified or unspecified disorders.

11. Describe how a one-axis system can be used to encapsulate all of the five axes from DSM-IV.

12. Identify a diagnosis from any category that makes you personally feel uncomfortable. Explore where these feelings come from and how you might go about working with a cli- ent who has this diagnosis.

ANSWERS TO EXERCISE I. 314.01 (F90.2) Attention-deficit hyperactivity

disorder, combined presentation; V62.3 (Z55.9) Academic underachievement.

II. 307.51 (F50.8) Binge eating disorder, moderate; V61.03 (Z63.5) Disruption of family by divorce (recent); V60.2 (Z59.7) Low income; V62.9 (Z60.9) Unspecified problem related to social environment: Social isolation.

III. 300.4 (F34.1) Persistent depressive disorder (dysthymia); 303.90 (F10.20) Alcohol use disorder, moderate; 304.30 (F12.20) Cannabis use disorder, moderate; V61.03 (Z63.5) Disruption of Family by Divorce (two years ago); V62.5 (Z65.0) Conviction in civil or criminal proceedings without imprisonment: Probation.

REFERENCES American Psychiatric Association. (1952). Diagnostic

and statistical manual of mental disorders. Washington, DC: Author.

American Psychiatric Association. (1968). Diagnostic and statistical manual of mental disorders (2nd ed.). Washington, DC: Author.

American Psychiatric Association. (1980). Diagnostic and statistical manual of mental disorders (3rd ed.). Washington, DC: Author.

American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author.

American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text revision). Washington, DC: Author.

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.

Beutler, L. E., & Malik, M. L. (Eds.). (2002). Rethink- ing the DSM: A psychological perspective. Washing- ton, DC: American Psychological Association.

Centers for Disease Control and Prevention. (2011). U.S. adult mental illness surveillance report. Retrieved from http://www.cdc.gov/Features/ MentalHealthSurveillance/

Centers for Disease Control and Prevention. (2013). Mental health surveillance among children—United States, 2005–2011. Retrieved from http://www.cdc. gov/mmwr/preview/mmwrhtml/su6202a1.htm?s_cid= su6202a1_w

Eriksen, K., & Kress, V. (2005). Beyond the DSM story: Ethical quandaries, challenges, and best prac- tices. Thousand Oaks, CA: Sage.

Eriksen, K., & Kress, V. (2006). The DSM and the professional counseling identity: Bridging the gap. Journal of Mental Health Counseling, 28, 202–217.

Eriksen, K., & Kress, V. (2008). Gender and diagnosis: Struggles and suggestions for counselors. Journal of Counseling and Development, 86, 152–162.

Good, E. M. (2012). Personality disorders in the DSM-5: Proposed revisions and critiques. Journal of Mental Health Counseling, 34, 1–13.

Houts, A. C. (2000). Fifty years of psychiatric nomen- clature: Reflections on the 1943 War Department Technical Bulletin, Medical 203. Journal of Clinical Psychology, 56, 935–967. doi.org/10.1002/1097- 4679(200007)56:7<935::AID-JCLP11>3.0.CO;2-8

Kress, V., Eriksen, K., Rayle, A., & Ford, S. (2005). The DSM-IV-TR and culture: Considerations for

CHAPTER 3 Diagnosis in the Assessment Process 57

counselors. Journal of Counseling and Develop- ment, 83, 97–104.

Krueger, R. F., & Eaton, N. R. (2010). Personality traits and the classification of mental disorders: Toward a more complete integration in DSM-5 and an empirical model of psychopathology. Per- sonality Disorders: Theory, Research, and Treat- ment, 1(2), 97–118. doi:10.1037/a0018990

Madesen, K., & Leech, P. (2007). The ethics of labeling in mental health. Jefferson, NC: MacFarland & Company.

Mezzich, J. E., & Caracci, G. (Eds.) (2008). Cultural formation: A reader for psychiatric diagnosis. Lan- ham, MD: Jason Aronson.

Neukrug, E., & Schwitzer, A. (2006). Skills and tools for today’s counselors and psychotherapists: From natural helping to professional counseling. Pacific Grove, CA: Brooks/Cole.

Rose, A. L., & Cheung, M. (2012). DSM-5 research: Assessing the mental health needs of older adults from diverse ethnic backgrounds. Journal of Ethnic & Cultural Diversity in Social Work: Innovation in Theory, Research & Practice, 21, 144–167. doi:10.1080/15313204.2012.673437

Segal, D. L., & Coolidge, F. L. (2001). Diagnosis and classification. In M. Hersen & V. B. Van Hasselt, (Eds.), Advanced abnormal psychology (2nd ed., pp. 5–22). New York: Kluwer Academic/Plenum Publishers.

Seligman, L. (1999). Twenty years of diagnosis and the DSM. Journal of Mental Health Counseling, 21, 229–239.

Seligman, L. (2004). Diagnosis and treatment planning in counseling (3rd ed.). New York: Plenum.

Smith, T. A. (2012, October 15). Revolutionizing diagnosis & treatment using DSM-5. Workshop presented at CMI Education Institute, Newport News Marriott, Newport News, VA.

Substance Abuse and Mental Health Services Adminis- tration. (2012). Results from the 2011 National Survey on Drug Use and Health: Mental Health Findings. Retrieved from http://www.samhsa.gov/ data/NSDUH/2k11MH_FindingsandDetTables/2K11 MHFR/NSDUHmhfr2011.htm#2.1

Thyer, B. A. (2006). It is time to rename the DSM. Ethical Human Psychology and Psychiatry, 8, 61–67. doi:10.1891/ehpp.8.1.61

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58 SECTION I Understanding the Assessment Process

C H A P T E R 4The Assessment ReportProcess: Interviewing the Client and Writing the Report

When I began working with clients in the early 1970s, I was dutiful about writing my case notes on lined paper and typing more involved client reports. Soon it was the mid-70s, and I got a job as an outpatient therapist at a mental health center. I was compulsive about conducting thorough clinical interviews, and religious about dictating my case notes, my intake summaries, my quarterly summaries, and my test reports. My dictations were care- fully typed out by secretaries and placed in client folders. Ten years later, now in private practice, I was still compulsive about conducting a thorough interview, about writing my case notes, and about typing my client reports. But soon an innovation arrived I hadn’t expected—the computer. I started doing my notes and my reports on the computer—that was a relief for me, although not everyone felt the same way. Soon laws were passed that protected the client’s right to confidentiality of his or her case notes and reports and the rights of clients to view them. Over the years, the methods we use to write reports and the ways we secure them have certainly changed dramatically, but one thing has remained the same—the examiner decides what the report will say!

(Ed Neukrug)

As you can see from the vignette, over the years the process of writing notes and reports has changed and the laws protecting clients’ right to view notes and reports have evolved. Despite these changes, there is little question that “paperwork,” whether it be on lined paper, typed, or written on the computer, continues to be a major part of what all practitioners do. In this chapter, we examine one important aspect of the paperwork process—how to write an assessment report. First, we

discuss the purpose of the assessment report and then discuss the process of gather- ing information for the report, including conducting the interview and choosing appropriate assessment techniques. Then, we suggest ways to write effective test reports and supply an example of such a report.

PURPOSE OF THE ASSESSMENT REPORT The assessment report is the “deliverable” or “end product” of the assessment pro- cess whose purpose is to synthesize an assortment of assessment techniques so that a deeper understanding of the examinee is made and recommended courses of action are offered (Goldfinger & Pomerantz, 2010; Lichtenberger, Mather, Kaufman, & Kaufman, 2004; Spores, 2013). Such courses of action can vary dramatically, based on the reason the individual is being assessed. For instance, some of the many purposes of reports include the following:

1. To respond to the referral questions being asked; 2. To provide insight to clients for therapy; 3. To assist in the case-conceptualization process; 4. To develop treatment options in counseling (e.g., type of counseling, use of

medications, and so on); 5. To suggest educational services for students with special needs (e.g., for stu-

dents who are mentally retarded, learning disabled, or gifted); 6. To offer direction when providing vocational rehabilitation services; 7. To offer insight about and treatment options for individuals who have incurred

a cognitive impairment (e.g., brain injury, senility); 8. To assist the courts in making difficult decisions (e.g., custody decisions, sanity

defenses, and determination of guilt or innocence); 9. To provide evidence for placement in schools and at jobs; and

10. To challenge decisions made by institutions and agencies (social security disability, Individual Educational Plans (IEPs) in schools).

Because complex decisions regarding clients’ lives are often based on the assess- ment report, synthesizing the information gathered and placing it in the report is only accomplished after the examiner can conduct interviews successfully, adminis- ter assessment procedures proficiently, and write reports skillfully. One of the first steps in this process is to ensure that any information gathered is directly related to the purpose of the assessment and is of high quality.

GATHERING INFORMATION FOR THE REPORT: GARBAGE IN, GARBAGE OUT

Gathering information for the report is as important as writing the report, because your report will reflect the methods you used to obtain your information. If you choose inappropriate instruments or conduct a poor interview (“garbage in”), your report will be filled with error and bias (“garbage out”). To help ensure that the information you are gathering is of high quality, you should always take into account the breadth and depth of your assessment procedures.

Assessment report Written summary, synthesis, and recom- mendations from the assessment

60 SECTION I Understanding the Assessment Process

The breadth of the assessment has to do with casting a wide enough net to ensure that the examiner has done all that is necessary to adequately assess what he or she is looking for. Breadth should be based on the purpose of the assessment. For instance, if a middle school student came to see a school counselor to examine career possibilities, the counselor would likely conduct an interview focused on vocational interests and offer a broad-based career interest inventory to gather information from the student about his or her general interests. However, if an adult came to a counseling center as a result of depression, anxiety, and general discontent in life, a very broad assessment might be called for to help establish a diagnosis and deter- mine treatment goals. In this case, it would not be unusual to conduct a clinical interview, administer a number of objective and projective personality tests, and per- haps interview others to assess the client’s relationships at home and at work.

The depth of the assessment has to do with ensuring that one is using techni- ques that reflect the intensity of the issue(s) being examined. As with breadth, depth is also dependent on the purpose for which the client is being assessed. For instance, conducting an in-depth clinical interview and offering a rather complex interest inventory that helps the middle school student determine a career would be too involved—too much depth. On the other hand, offering a personality inven- tory like the Myers–Briggs for the individual suffering from depression, anxiety, and discontentment in life would not entail enough depth. You could simply miss too much because you have not delved more deeply into this client’s issues.

In establishing the breadth and depth of the interview, it is important that you are able to establish trust and rapport and assure confidentiality within the limits of the purpose the individual is being assessed. The better the interviewer is able to build trust, the more likely the information obtained will be reliable. With these points in mind, examiners need to determine whether a structured, unstructured, or semi-structured interview would be best when assessing the client.

STRUCTURED, UNSTRUCTURED, AND SEMI-STRUCTURED INTERVIEWS

Determining the kind of interview to conduct is critical to gathering information successfully because the clinical interview accomplishes a number of tasks not pos- sible through the use of other assessment techniques. For instance, the interview

1. sets the tone for the types of information that will be covered during the assessment process,

2. allows the client to become desensitized to information that can be very inti- mate and personal,

3. allows the examiner to assess the nonverbal signals of the client while he or she is talking about sensitive information, thus giving the examiner a sense of what might be important to focus on,

4. allows the examiner to learn firsthand the problem areas of the client and place them in perspective, and

5. gives the client and examiner the opportunity to study each other’s personality style to assure that they can work together.

Breadth Covering all important or relevant issues; wide net

Depth Extent and seriousness of a concern

Clinical interview Offers ability to obtain reliable information from clients

CHAPTER 4 The Assessment Report Process: Interviewing the Client and Writing the Report 61

Interviewers generally have a choice between three kinds of interviews: struc- tured, unstructured, or semi-structured. With advantages and disadvantages to both, which one to choose is not always easy (Bruchmuller, Margraf, Suppiger, & Schneider, 2011; Goldfinger & Pomerantz, 2010; Lichtenberger et al., 2004). For instance, completed verbally or in response to written items, the structured interview has the examiner ask the examinee to respond to preestablished items. This kind of interview can provide the following benefits:

• It offers broad enough areas of content to cover topics a practitioner may oth- erwise have missed or forgotten to ask (assures breadth of coverage).

• It increases the reliability of results by ensuring that all prescribed items will be covered.

• It ensures that the examiner will cover all of the items because they are listed in detail and there is an expectation that they all will be covered.

• It ensures that items will not be missed due to interviewer or interviewee embarrassment.

On the other hand, the structured interview can have the following drawbacks:

• The examiner may miss information due to the fact that items are predeter- mined and the examiner does not feel free to go off on a tangent or a “hunch.”

• Clients may experience the interview as dehumanizing. • Clients, particularly minorities, may misinterpret or be unfamiliar with certain

items. • Follow-up by the examiner to alleviate any confusion on the part of the exam-

inee is less likely as compared to other kinds of interviewing. • It does not always allow for depth of information to be covered because the

interviewer is more concerned with gathering all the information than going into detail about one potentially sensitive area.

Contrast the structured interview with the unstructured interview, where the examiner does not have a preestablished list of items or questions to which the client can respond. In this case, examinee responses to inquiries will set the direc- tion for follow-up questioning. The unstructured interview offers the following advantages:

• It creates an atmosphere that is more conducive to building rapport. • It allows the client to feel as if he or she is directing the interview, thus allow-

ing the client to discuss items that he or she deems important. • It offers the potential for greater depth of information because the clinician can

focus on a potentially sensitive area and possibly uncover underlying issues that the client might otherwise avoid revealing.

On the other hand, the unstructured interview may have the following disadvantages:

• Because it does not allow for breadth of coverage, the interviewer might miss information because he or she is “caught up” in the client’s story instead of following a prescribed set of questions.

• The interviewer may end up spending more time on some items than he or she might like.

Structured interview Uses preestablished questions to assess broad range of behaviors

Unstructured interview Examiner asks questions based on client responses

62 SECTION I Understanding the Assessment Process

Drawing from the advantages of both the structured and unstructured interview, examiners will often conduct a semi-structured interview. This kind of interview uses prescribed items, which allows the examiner to obtain the necessary information within a relatively short amount of time. However, it also gives leeway to the exam- iner should the client need to “drift” during the interview process. Allowing the client to discuss potentially emotion-filled topics can be cathartic, open up new issues of importance, and be an important tool in the rapport-building process. The skilled examiner can easily flow back and forth between structured and unstructured approaches. If time is not an issue, a semi-structured interview can provide the breadth and depth needed when interviewing clients while still allowing the examiner to focus in on building the relationship (see Box 4.1).

Computer-Driven Assessment Today, computers are frequently used when conducting a structured or semi-structured interview and in the report generation. For instance, many agencies now use electronic health records (EHR) where information about a client is stored on a computer. Inter- viewers and interviewees can jointly sit down and complete specific items included in the EHR, and this information can be stored with other, related, medical and psycho- logical information (Cimino, 2013). There are also programs for purchase that can assist in the interview process. One such program has the interviewer or the client com- plete 120 items that requests information about a wide range of personal issues, and the user receives a computer-generated report that describes the client’s presenting problems, legal issues, current living situation, tentative diagnosis, emotional state, treatment recommendations, mental status, health and habits, disposition, and behavioral/physical descriptions (see Schinka, 2012). Computer-assisted questioning is as reliable, or some- times more reliable, than structured interviews and can provide an accurate diagnosis at a minimal cost (Farmer, McGuffin, & Williams, 2002).

In addition to assisting in the interviewing process, computers can generate test reports, and oftentimes pieces of these reports can be moved directly into the exam- iner’s written assessment report (Berger, 2006; Michaels, 2006). Final assessment reports generated by computer-driven programs have become so sophisticated that most well-trained clinicians cannot tell them apart from reports written by sea- soned professionals. However, whether it is a computer-generated report that

BOX 4.1 Missing Substance Abuse

When I first started doing counseling I tended to use unstructured interview style. I believed it was critical to let the client take the interview where he or she wanted it to go. However, after a number of years of missing alcohol abuse as well as other “hidden” issues, I slowly began to make the switch to a more semi-structured interview style where I would go through a list of predetermined items and also have clients complete a genogram (see

Chapter 12). I had learned that clients were often embarrassed about revealing some very important information that sometimes ended up being the focus of treatment. The switch to a semi- structured interview style allowed me to quickly pick up on these issues and immediately address what in the past had been hidden.

—Ed Neukrug

Semi-structured interview Allows flow between structured and unstructured approaches

Computer-driven assessment Can result in sophisticated assessment and well-written report

CHAPTER 4 The Assessment Report Process: Interviewing the Client and Writing the Report 63

resulted from a client interview or a report that includes aspects of computer- generated tests reports, it is still up to the examiner to make sure that the correct questions are being asked of the client, the correct assessment procedures are being used, and that the material used in the development of the examiner’s assessment report is chosen wisely by the examiner.

While the computer may administer these [tests] and even prepare a report, what the test looks like, how it responds, what it achieves and any reports generated, are prede- termined by the author, and it is a person who puts it all together to make the interpre- tation. (Berger, 2006, p. 70)

CHOOSING AN APPROPRIATE ASSESSMENT INSTRUMENT

After the interview, clinicians can consider the purpose of their assessment as well as the breadth and depth of other needed information. Then clinicians can choose from a broad array of assessment instruments, such as those we will examine later in this book, including assessment of educational ability (Chapter 8), assessment of intellectual and cognitive functioning through intelligence testing and neuropsychological assess- ment (Chapter 9), career and occupational assessment (Chapter 10), clinical assessment (Chapter 11), and informal assessment (Chapter 12). During this process, it is important that clinicians carefully reflect on which are the most appropriate instruments to use, for it is unethical to assess an individual using instruments that are not related to the pur- pose of the assessment being undertaken (see American Counseling Association [ACA], 2005; American Psychological Association [APA], 2010) (see Box 4.2).

Counselors are responsible for the appropriate application, scoring, interpretation, and use of assessment instruments relevant to the needs of the client, whether they score and inter- pret such assessments themselves or use technology or other services. (ACA, Section E.2.b)

and

Psychologists administer, adapt, score, interpret, or use assessment techniques, interviews, tests, or instruments in a manner and for purposes that are appropriate in light of the research on or evidence of the usefulness and proper application of the techniques. (APA, Section 9.02.a)

BOX 4.2 Proper Assessment of a Client

I was once hired to write an assessment report for the expressed purpose of challenging the denial of a client’s social security disability payments despite the fact that she had been diagnosed as having a multiple personality disorder (also discussed in Chapter 11). Aware of her disorder, and having worked hard to integrate her various personalities in therapy, she was, however, quite depressed and at

times would dissociate. Because the task at hand was to assess the client’s ability to work rather than to affirm her diagnosis, it was important to choose instruments that would only address the assessment question: Could this client effectively hold down employment?

—Ed Neukrug

Only choose assessment technique to match purpose of testing

64 SECTION I Understanding the Assessment Process

WRITING THE REPORT After you have conducted a thorough assessment of your client, you will be ready to write your report. Reports are scrutinized today more than ever before because they are the mechanism used by the interviewer to communicate his or her assessment to stake- holders and are often used by funding agencies and supervisors when evaluating a clini- cian’s work. In addition, as a result of laws passed over the years, such as the Family Educational Rights and Privacy Act (FERPA), the Freedom of Information Act, and the Health Insurance Portability and Accountability Act (HIPAA) (see Chapter 2), clients will generally have access to their records if they choose to review them. Keeping all of this in mind, Box 4.3 offers a summary of a number suggestions concerning how to write a report (Lichtenberger et al, 2004; Wiener & Costaris, 2012).

Although many clinicians these days are asked to write involved reports, the actual format of the report tends to vary from setting to setting. For example, a large mental health clinic may specify a preferred or required format for its thera- pists. Similarly, a social worker in private practice may be driven to a particular format by insurance provider requirements, while a school counselor may have to use an established format required by the system-wide school counseling director.

Although report formats vary, they will often include some or all of the follow- ing sections: (1) demographic information, (2) presenting problem or reason for refer- ral, (3) family background, (4) significant medical/counseling history, (5) substance use and abuse, (6) educational and vocational history, (7) other pertinent information, (8) mental status, (9) assessment results, (10) diagnosis, (11) summary and conclusions, and (12) recommendations. Let’s take a look at each of these areas in more detail.

Demographic Information In this section, we find basic information about the client, including such items as the client’s name, address, phone number, e-mail address, date of birth, age, sex, ethnicity, and date of interview. Also, it is in this section that the name of the

BOX 4.3 Fifteen Suggestions for Writing Reports

1. Omit passive verbs. 2. Be nonjudgmental. 3. Reduce the use of jargon. 4. Do not use a patronizing tone. 5. Increase the use of subheadings. 6. Reduce the use of and define acronyms. 7. Minimize the number of difficult words. 8. Try to use shorter rather than longer words. 9. Make sure paragraphs are concise and flow

well. 10. Point out strengths and weaknesses of your

client.

11. Don’t try to dazzle the reader of your report with your brilliance.

12. When possible, describe behaviors that are representative of client issues.

13. Only label when it is necessary and valuable to do so for the client’s well-being.

14. Write the report so a non–mental-health pro- fessional can understand it (e.g., a teacher).

15. Don’t be afraid to take a stand if you feel strongly that the information warrants it (e.g., the information leads you to believe a client is in danger of harming self).

Writing assessment reports Know “tips” to good report writing

FERPA, HIPAA, Freedom of Information Act Increase clients’ ability to access records

CHAPTER 4 The Assessment Report Process: Interviewing the Client and Writing the Report 65

interviewer is placed. Often, this information is included at the top of the report. The following is an example of the demographic information gathered from a ficti- tious client, Mr. Unclear.

Name: Eduardo (Ed) Unclear Address: 223 Confused Lane

Coconut Creek, Florida Phone: 954-969-5555 E-mail: [email protected] Name of Interviewer: Sigmund Freud, MD

DOB: 1/8/1966 Age: 48 Sex: Male Ethnicity: Hispanic

(Cuban-American) Date of Interview: 10/22/2014

Presenting Problem or Reason for Referral In this section, the person who referred the client is generally noted (e.g., self- referred, physician, counselor, etc.) and an explanation is given as to why the indi- vidual has come for counseling and/or why the examiner has been asked to do the assessment. For instance, here it might be explained that a social worker has been asked to do a court assessment of a child for a custody hearing; a school psycholo- gist has been asked to assess a child who has been exhibiting severe behavioral pro- blems at school, for a possible diagnosis of emotional disturbance; or a licensed clinician in private practice might suggest to a client an assessment to help sort out a diagnosis and to set treatment goals. Continuing with our example of Mr. Unclear, we might include the following information:

Eduardo Unclear is a 48-year-old Hispanic male of average stature and build. He was self- referred to counseling due to stress and inability to sleep. The client reported feeling anxious for approximately two years and intermittently depressed for approximately seven or eight years. He states that he feels discontent with his marriage and confused about his future. Mr. Unclear appeared appropriately dressed and was attentive during the session. An assessment was conducted to determine differential diagnosis and the course of treatment.

Family Background The family background section of the report is an opportunity to give the reader an understanding of possible factors concerning the client’s upbringing that may be related to his or her presenting problem. Trivial bits of information should be left out of this section, and opinions regarding this information should be saved for the summary and conclusions section of the report.

In this section, it is often useful to mention where the individual grew up, sexes and ages of siblings, whether the client came from an intact family, who were the major caretakers, and significant others who may have had an impact on the client’s life. The examiner may also want to relay important stories from childhood that have affected how the client defines himself or herself. For adults, one should also include such items as marital status, marital or relationship issues, ages and sexes of any children, and sig- nificant others. Using our example, we might include the following information:

Mr. Unclear was raised in Miami, Florida. When he was five years old, his parents fled from Cuba on a fishing boat with him and his two brothers, José, who is two years older, and Juan, who is two years younger. Mr. Unclear comes from an intact family. He reports that his father was a bookkeeper and his mother was a stay-at-home mom.

66 SECTION I Understanding the Assessment Process

He states that his parents were “loving but strict” and notes that his father was “in charge” of the family and would often “take a belt to me.” He reports that he and his brothers were always close and that both brothers currently live within 1 mile of his home. He states that his younger brother is married and has two children. He describes his other brother as single and “gay but not out.” He and his brothers went to Catholic school, and he states that he was a good student and had the “normal” number of friends. His father died approximately four years ago of a “heart disorder.” His mother currently resides in a retirement community in North Miami Beach.

Mr. Unclear notes that he met his wife Carla in college when he was 20. They married when he was 21 and quickly had two children, Carlita and Carmen, who are now 27 and 26. Both daughters are college-educated, have professional jobs, and are married. Carlita has two children aged 3 and 4, while Carmen has one child aged 5. He notes that both daughters and their families live close to him, and he maintains positive relationships with them. He states that although his marriage was “good” for the first 20 years, in recent years he has found himself feeling unloved and depressed. He wonders if he should remain in the marriage.

Significant Medical/Counseling History This section of the report delineates any significant medical history, especially any physical conditions that may be affecting the client’s psychological state. Any pre- scribed medication, with dosage, should be noted. In addition, any history of counseling should be noted in this section. Mr. Unclear’s medical and counseling history is summarized below:

Mr. Unclear reports that approximately four years ago he was in a serious car accident that subsequently left him with chronic back pain. Although he is prescribed medication for the pain (Flexeril, 5mg), he prefers not to take it, stating that he mostly tries to “live without drugs.” He notes that he often feels fatigued and has trouble sleeping, usually sleeping around four hours a night. He reports that a recent medical exam revealed no apparent medical reason for his fatigue and sleep difficulties. He notes that in the past two years he has had obsessive worry related to fears of dying of a heart attack. He describes his eating habits as “normal” and reports no other significant medical history.

Mr. Unclear explained that after the birth of his second child, his wife required surgery to repair vaginal tears. He states that since that time she has experienced pain during intercourse and their level of intimacy has significantly decreased. He notes that he and his wife attended couples counseling for about two months approximately 15 years ago. He feels that counseling did not help, and he reports that it “particularly did nothing to help our sex life.”

Substance Use and Abuse This section reports the use and abuse of any legal or illegal substances that may be addictive or potentially harmful to the client. Thus, the interviewer should note the use or abuse of food, cigarettes, alcohol, prescription medication, and illegal drugs. In reference to Mr. Unclear, we include the following information:

Mr. Unclear states that he does not smoke cigarettes but does occasionally smoke cigars, adding that he “will never smoke a Cuban cigar.” He describes himself as a moderate alcohol user, stating that he has a “couple of beers a day” but rarely drinks “hard liquor.” He reports taking prescription medication intermittently for chronic back pain, and he denies the use of illegal substances.

CHAPTER 4 The Assessment Report Process: Interviewing the Client and Writing the Report 67

Educational and Vocational History This section describes the client’s educational background and delineates his or her job path and career focus. For Mr. Unclear, we include the following information:

Mr. Unclear attended Catholic school in Miami, Florida. He reports that he excelled in math but had difficulty with reading and spelling. After high school, he attended college at the University of Miami, where he majored in business administration. After gradu- ating with his bachelor’s degree, he obtained a job as an accountant at a major tobacco import company, where he worked for 17 years. During that time, he began to work on his master’s in business administration but stated he never finished his degree because it was “boring.” Approximately eight years ago he changed jobs to “make more money.” He obtained employment as an accountant at a local new car company.

Mr. Unclear states that as an accountant, his “books were always perfect,” although he went on to note that he was embarrassed by his inability to prepare a well-written report. He expresses dissatisfaction with his career path and wants to “do something more meaningful with his life.” He adds, however, that “I am probably too old to change careers now.”

Other Pertinent Information This “catch-all” category addresses any significant information that has not been noted elsewhere. Issues that might be addressed in this section could be related to sexual orientation, changes in sexual desires, sexual dysfunction; current or past legal problems that may be affecting functioning; and financial problems the client may be having. For Mr. Unclear we include the following information:

Mr. Unclear states that he is unhappy with his sex life and reports limited intimacy with his wife. He denies an extramarital affair but states “I would have one if I met the right person.” He notes that he is “just making it” financially and that it was difficult to support his two children through college. He denies any problems with the law.

Mental Status A mental status exam is an assessment of the client’s appearance and behavior, emotional state, thought components, and cognitive functioning. This assessment is used to assist the interviewer in making a diagnosis and in treatment planning (Akiskal, 2008; Polanski & Hinkle, 2000; Sommers-Flanagan & Sommers- Flanagan, 2012). A short synopsis of each of the four areas of the mental status exam follows and definitions of common words used in mental status exam can be found in Table 4.1.

Appearance and Behavior This part of the mental status exam reports the client’s observable appearance and behaviors during the clinical interview. Thus, such items as manner of dress, hygiene, body posture, tics, significant nonverbal behaviors (eye contact or the lack thereof, wringing of hands, swaying), and manner of speech (e.g., stuttering, tone) are often reported.

Emotional State When assessing emotional state, the examiner describes the cli- ent’s affect and mood. The affect is the client’s current, prevailing feeling state (e.g.,

Mental status exam Assesses appearance and behavior, emo- tional state, thought, and cognitive functioning

68 SECTION I Understanding the Assessment Process

TABLE 4.1 Common Terms and Definitions or Descriptions Used in the Mental Status Exam

Category Term Definition or Description

Appearance and Behavior Appearance Appropriate or baseline, eccentric or odd, abnormal movement or gait, good or poor grooming, or hygiene

Eye contact Good or poor

Speech Within normal limits, loud, soft, pressured, hesitant

Emotional State—Affect Appropriate or inappropriate Appropriate or inappropriate to mood (e.g., laughing while talking of recent death)

Full and reactive Full range of emotions correctly associated with the conversation

Labile Uncontrollable crying or laughing

Blunted Reduced expression of emotional intensity

Flat No or very little expression of emotional intensity

Emotional State—Mood Euthymic Normal mood Depressed Sad, dysphoric, discontent Euphoric Extreme happiness or joy Anxious Worried Anhedonic Unable to derive pleasure from previously

enjoyable activities

Angry/hostile Annoyed, irritated, irate, etc.

Alexithymic Unable to describe mood

Thought Components—Content

Hallucinations False perception of reality: may be auditory,

visual, tactile (touch), olfactory (smell), or taste

Ideas of reference Misinterpreting casual and external events as being related to self (e.g., newspaper headlines, TV stories, or song lyrics are about the client)

Delusions False belief (e.g., “satellites are tracking me”); may be grandiose, persecutory (to be harmed), somatic (physical symptom with no medical condition), erotic

Derealization External world seems unreal (e.g., watching it like a movie)

Depersonlization Feeling detached from self often with no control (e.g., “I feel like I’m living a dream”)

Suicidality and homicidality Ranges from none, ideation, plan, means, preparation, rehearsal, and intent

(Continued)

CHAPTER 4 The Assessment Report Process: Interviewing the Client and Writing the Report 69

happy, sad, joyful, angry, depressed, etc.) and may also be reported as constricted or full, appropriate or inappropriate to content, labile, flat, blunted, exaggerated, and so forth. The client’s mood, on the other hand, represents the long-term, underlying emotional well-being of the client and is usually assessed through client self-report. Thus, a client may seem anxious and sad during the session (affect) and report that his or her mood has been depressed.

Thought Components The manner in which a client thinks can reveal much about how he or she comes to understand and make meaning of the world. Thought components are generally broken down into the content and the process of thinking. Clinicians will often make statements about thought content by addressing whether the client has delusions, distortions of body image, hallucina- tions, obsessions, suicidal or homicidal ideation (see Box 4.4), and so forth. The kinds of thought processes often identified include circumstantiality, coherence, flight of ideas, logical thinking, intact as opposed to loose associations, organiza- tion, and tangentiality.

TABLE 4.1 Common Terms and Definitions or Descriptions Used in the Mental Status Exam (continued)

Category Term Definition or Description

Thought Components—Process

Logical and organized Normal state where one’s thoughts are rational and structured

Poverty Lack of verbal content or brief responses

Blocking Difficulty or unable to complete statements Clang Emphasis on using words that rhyme together

rather than on meaning Echolalia “Echoing” clients own speech or your speech;

repeating Flight of ideas Rapid thoughts almost incoherent Perseveration Thoughts keep returning to the same idea Circumstantial Explanations are long and often irrelevant but

eventually get to the point Tangential Responses never get to the point of the question Loose Thoughts have little or no association to the con-

versation or to each other Redirectable Responses may get off track, but you can direct

them back to the topic

Cognition Orientation Knows who they are, where they are, and date Memory Ability to remember events from recent, immediate,

and long-term Insight Ability to recognize his or her mental illness; good,

limited, or none Judgment Ability to make sound decisions; good, fair,

or poor

20 15

70 SECTION I Understanding the Assessment Process

Cognition Cognition includes a statement as to whether the client is oriented to time, place, and person (knows what time it is, where he or she is, and who he or she is); an assessment of the client’s short- and long-term memory; an evaluation of the client’s knowledge base and intellectual functioning; and a statement about the client’s level of insight and ability to make judgments.

Although much more can be said about each of these four areas, generally, when incorporating a mental status into a report, all four areas are collapsed into a one- or two-paragraph statement about the client’s presentation. Usually, a state- ment about the client’s demeanor, orientation, affect, intellectual functioning, judg- ment, insight, and suicidal or homicidal ideation are included. Other areas are generally reported only if they are deemed significant (see Exercise 4.1). A descrip- tion of Mr. Unclear’s mental status follows:

Eduardo Unclear appeared for his appointment casually but neatly dressed and groomed. He was able to maintain appropriate eye contact and was oriented to time, place, and person. Visual acuity appeared to be within normal limits; audition and speech were unremarkable. During the interview he appeared anxious, often rubbing his hands together. Mr. Unclear was cooperative with the examiner and demonstrated satisfactory levels of motivation, interest, and energy. He is currently prescribed pain medication, which he only takes occasionally for chronic back pain.

BOX 4.4 Assessment of Lethality

It is important to assess for the risk of suicide or homicide. Both of these can be thought of occurring along a continuum ranging from ideation (thinking about it), developing a plan, means to carry out the plan, prep- aration stage, rehearsing the plan, and finally acting it out (Commonwealth of Virginia Knowledge Center [COVKC], 2010). Hence, determining where the client might be on the continuum is helpful in determining how much risk he or she may have for harming self or others.

It can also be important to evaluate both risk and protective factors (COVKC). Risk factors can include having a history of psychiatric treatment, non-medication compliance, substance abuse, prior attempts, recent losses, or other significant problems. Protective factors to consider are strong family or social supports, adherence to med- ications, stable employment, children under the age of 18, religious beliefs, or fear of killing one’s. Finally, deter- mine if this individual will contract for safety in verbal or written format.

A c t

N o t h o u g

h ts

T h o u g

h ts

P la

M e a n s

P re

p a ra

ti o n

R e h e a rs

a l

20 15

CHAPTER 4 The Assessment Report Process: Interviewing the Client and Writing the Report 71

was intact. His judgment seemed fair and his insight fair to good. He stated that he has some suicidal ideation but denies he has a plan or would kill himself, noting that it is “against my religion.” He denied homicidal ideation.

Assessment Results It is often helpful to begin this section with a simple list of the assessment proce- dures that were used. Next, the results of the assessment procedures are generally presented. When presenting test results, it is important to not just give out raw scores. Instead, offering converted or standardized test scores that the reader will understand is usually more helpful (discussed in Chapter 7). It should be remem- bered that the client, parents, or some other nonprofessional may read these results, so it is important to state the results in language that is unbiased and understand- able to the reader. An example might be, “Johnny scored a 300 on his SAT, which is 2 standard deviations below the mean and places him at about the 2nd percentile as compared to his peers in the 12th grade.”

The results of the assessment should be concise, yet cover all items that are clearly relevant to the presenting concerns or that stand out as a result of the assessment. Results should be presented objectively, and interpretations should be kept to a mini- mum, if used at all. In the summary and conclusions section, the examiner will have the opportunity to hypothesize about what is happening with the client. The following is an example of the assessment section of the report for Mr. Unclear. (We will discuss these specific tests in Section III of this book. For now pay attention to the formatting as these examples will be more meaningful near the end of the semester.)

Mr. Unclear was administered a battery of objective and projective personality tests, including the Beck Depression Inventory-II (the BDI-II), the Minnesota Multiphasic Personality Inventory-II (the MMPI-II), the Rorschach Inkblot Test (the Rorschach), the Thematic Apperception Test (TAT), the Kinetic Family Drawing (KFD), the Sentence Completion Test, the Strong Interest Inventory (the Strong), and the Wide Range Achievement Test-4 (the WRAT).

Through self-report of the past two weeks, Mr. Unclear’s score on the BDI-II indicates that he has moderate depression (raw score ¼ 24). His responses showed some evidence of possible suicidal ideation. The BDI-II is not only able to diagnose depression due to its consistency with the DSM diagnostic criteria, but it can also determine the severity of depressive symptoms. The MMPI-II supports this finding of moderate to severe depression and also indicates some mild anxiety. The MMPI-II, which reveals dissatisfaction with one’s life, demonstrates that Mr. Unclear is generally “discontent with the world” and feels a lack of intimacy in his life. It suggests assessing for possible suicidal ideation.

Exercise 4.1 Writing the Mental Status Report

Your instructor may ask a student to role-play a client being interviewed. (It might also help if the student chose to reflect a diagnosis in the DSM-5.) After the role-play is complete, all other students in class should write a mental-status report. Share your reports with the

instructor, and come up with one mental status report for the class. Compare your own report to the final ver- sion produced in class. This type of role-play can be repeated in small groups if you would like to gain further practice writing mental-status exams.

Assessment results Provide results that will be understandable to reader

72 SECTION I Understanding the Assessment Process

The Rorschach and the TAT are projective assessment tools used to evaluate psychological functioning. Both demonstrated that Mr. Unclear is grounded in reality and open to testing, as evidenced by his willingness to readily respond to initial inkblots and TAT cards, his ability to complete stories in the TAT, and the fact that many of his responses were “common” responses. Feelings of depression and hopelessness are evident in a number of responses, such as not readily seeing color in many of the responses to the “color cards” of the Rorschach and making a number of pessimistic stories that generally had depressive endings to them on the TAT.

When he was administered the KFD, a projective test that asks the client to draw his family all doing something together, Mr. Unclear placed his father as an angel in the sky and included his wife, mother, children, and grandchildren. His mother was standing next to him while his wife was off to the side with the grandchildren. He also placed himself in a chair and when describing the picture stated, “I’m sitting because my back hurts.” The picture showed the client and his family at his mother’s house having a Sunday dinner while it rained outside. Rain could be indicative of depressive feelings. A cross was prominent in the background and was larger than most of the people in the picture, which is likely an indica- tion of strong religious beliefs and could also indicate a need to be taken care of.

On the Sentence Completion Test Mr. Unclear made a number of references to missing his father, such as “The thing I think most about is missing my father.” He also referenced continual back pain. Finally, he noted discontent with his marriage, including the statement, “Sex is nonexistent.”

On the Strong, a self-report assessment tool used to evaluate both personality and career interest, Mr. Unclear’s two highest personality codes were Conventional and Enterprising, respectively. All the other codes were significantly lower. Individuals of the Conventional type are stable, controlled, conservative, sociable, and like to follow instructions. Enterprising individuals are self-confident, adventurous, and sociable. They have good persuasive skills, and prefer positions of leadership. Careers in business and industry where persuasive skills are important are good choices for these individuals.

On the WRAT-4, Mr. Unclear scored at the 86th percentile in math, 75th percentile in reading, 64th percentile in sentence comprehension, and 42nd percentile in spelling. His reading composite score was at the 69th percentile. These results could indicate a possible learning disorder in spelling, although cross-cultural considerations should be taken into account due to the fact that Mr. Unclear was an immigrant to this country at a young age.

Diagnosis This is the section where a clinical diagnosis is generally made using the criteria from the Diagnostic and Statistical Manual for Mental Disorder, fifth edition (DSM-5; APA, 2013) (see Chapter 3). The diagnosis is an outgrowth of the whole assessment process and is based on the integration of all of the knowledge gained (Seligman, 2004). As mentioned in Chapter 3, the older DSM-IV-TR (APA, 2000) offered sepa- rate axes that included medical conditions, psychosocial and environmental condi- tions, and global assessment of functioning. Although the current DSM uses a single mental disorder axis, you may want to include V (or Z) codes, which reflect psycho- social and environmental conditions. In addition, you may want to provide medical diagnoses from the International Classification of Disease, ninth revision (ICD-9) or ICD-10, dependent on the audience of the report. For example, if this report is for a court or some portion of the medical community, it might be useful to include the ICD diagnosis and codes. However, if the report is going to a mental health profes- sional or directly to a client, reporting medical conditions in layman’s terms may be

Older DSM-IV diagnosis Be familiar with for reading charts prior to DSM-5

CHAPTER 4 The Assessment Report Process: Interviewing the Client and Writing the Report 73

more helpful. There is a fine balance between making the report accurate and profes- sional using correct terminology while also keeping it readable and understandable for the end user. Below we list Mr. Unclear’s diagnosis. Note that the first diagnostic number is the ICD-9 code and ICD-10 is followed in parenthesis.

296.22 (F32.1) Major depression, single episode, moderate

309.28 (F43.23) Rule out: Adjustment disorder with mixed Anxiety and depressed mood

V62.29 (Z56.9) Problems related to employment

V61.10 (Z63.0) Relationship distress with spouse

722.0 Displacement cervical intervertebral disc (Chronic Back Pain)

In this example, the diagnosis describes a client who is experiencing symptoms of a moderate episode of major depression, including ongoing feelings of depres- sion, fatigue, and sleep problems; may be having difficulty adjusting to a new life circumstance; has problems related to work and his relationship with his wife, and has difficulties with chronic back pain.

Summary and Conclusions This section is the examiner’s chance to pull together all of the information that has been gathered. Often, this is the only section of the report that is read by others, so it is important that it is accurate and does not leave out any main points. However, it should not be excessively long. Making it accurate, succinct, and rele- vant is the key to writing a good summary. One major error in writing summaries, we have found, is adding information that has not been included elsewhere. The summary should have no new information. Although inferences can be made in this section, they must be logical, sound, defendable, and based on facts that are mentioned in your report. We also generally recommend writing a paragraph or two about the strengths of the individual. All too often, we have found that this is left out of reports. The following might be a summary and conclusions section based on the information we have gathered from Mr. Unclear:

Mr. Unclear is a 48-year-old married male who was self-referred due to feelings of depression, anxiety, and discontent with his job and his marriage. Mr. Unclear fled from Cuba to Miami, Florida with his parents and two siblings when he was 5 years old. He describes his family as close, and he continues to live near his children, siblings, and mother. His father died approximately four years ago. He married while in college. He and his wife subsequently raised two girls who are now in their mid-20s, married, and have their own children.

Mr. Unclear finished college with a degree in business and has been working as an accountant for the past 25 years. He reports feeling dissatisfied in his career and states that he wants to “do something more meaningful with his life.” He also reports marital discord, which he attributes partly to medical problems his wife had after the birth of their second child. These problems, he states, resulted in diminishing sexual relations with his wife.

Mr. Unclear was oriented during the session but appeared anxious and talked about feelings of depression. He noted that he often feels fatigued, has difficulty sleep- ing, and has fleeting thoughts of suicide, which he states he would not act upon. Recently, he has had obsessive worries about having a heart attack, although there is

Report summary should have no new information

74 SECTION I Understanding the Assessment Process

no medical reason to support his concerns. Chronic back pain due to a car accident a few years ago seems to exacerbate his current feelings of depression.

Throughout testing the consistent themes of depression, isolation, and hopelessness emerged. High scores on the BDI-II and the MMPI-II depression scale evidenced this. This was additionally indicated by specific responses to the Rorschach, TAT cards, the KFD, and the sentence completion.

Dissatisfaction with his marriage, sadness about the loss of his father, and chronic pain were also major themes that arose during testing. Testing also revealed a person whose career is a good match for his personality. However, he might be more chal- lenged if he entered a position requiring additional responsibilities and leadership skills. Such a change may be disadvantageous if Mr. Unclear does not receive treatment for his depression. Finally, testing also shows a possible learning disability in spelling, although cross-cultural issues may have affected his score.

On a positive note, testing and the clinical interview showed a man who was neatly dressed and open to collaborating with the examiner. He has worked hard in his life and is proud of the family he has raised. He was grounded in reality, willing to engage interpersonally, and showed fair to good judgment and insight. He seems to be aware of many of his most pressing concerns and showed some willingness to address them.

Recommendations This last section of the report should be based on all of the information gathered. It should make logical sense to the reader. Although some prefer writing this section in paragraph form, we prefer listing each recommendation, as we believe this for- mat is clearer to the reader. The signature of the examiner generally follows this last section. The following might be some recommendations for Mr. Unclear:

1. Counseling, 1 hour a week for depression, possible anxiety, marital discord, and career dissatisfaction.

2. Possible marital counseling with particular focus on sexual relations of the couple. 3. Referral to a physician/psychiatrist for medication, possibly antidepressants. 4. Possible further assessment for learning problems. 5. Long-term consideration of a career move following alleviation of depressive feel-

ings and addressing possible learning problems. 6. Possible orthopedic reevaluation of back problems.

Signature of the Examiner

SUMMARIZING THE WRITING OF AN ASSESSMENT REPORT As you can see, a great deal of information is gathered from the client, and much of it is included in the report. Although one could probably write a short novel about a client after gathering information from an in-depth interview, generally the skilled examiner will keep the report between two and five pages, single- spaced. Box 4.5 summarizes the major points that should be gathered in an assess- ment report, and in Appendix D you can see Mr. Unclear’s report in its entirety.

CHAPTER 4 The Assessment Report Process: Interviewing the Client and Writing the Report 75

BOX 4.5 Summary of Assessment Report

The following categories are generally assessed in a report:

Demographic Information Name: DOB.: Address: Age: Phone: Sex: Ethnicity: E-mail address: Date of interview: Name of interviewer:

Presenting Problem or Reason for Referral 1. Who referred the client to the agency? 2. What is the main reason the client contacted the

agency? 3. Reason for assessment

Family Background 1. Significant factors from family of origin 2. Significant factors from current family 3. Some specific issues that may be mentioned:

where the individual grew up, sexes and ages of siblings, whether the client came from an intact family, who were the major caretakers, important stories from childhood, sexes and ages of current children, significant others, and marital concerns

Significant Medical/Counseling History 1. Significant medical history, particularly anything

related to the client’s assessment (e.g., psychi- atric hospitalization, heart disease leading to depression)

2. Types and dates of previous counseling

Substance Use and Abuse 1. Use or abuse of food, cigarettes, alcohol, pre-

scription medication, or illegal drugs 2. Counseling related to use and abuse

Educational and Vocational History 1. Educational history (e.g., level of education and

possibly names of institutions) 2. Vocational history and career path (names and

types of jobs) 3. Satisfaction with educational level and career

path

4. Significant leisure activities

Other Pertinent Information 1. Legal concerns and history of problems with the

law 2. Issues related to sexuality (e.g., sexual orienta-

tion, sexual dysfunction) 3. Financial problems 4. Other concerns

The Mental Status Exam 1. Appearance and behavior (e.g., dress, hygiene,

posture, tics, nonverbals, and manner of speech) 2. Emotional state (e.g., affect and mood) 3. Thought components (e.g., content and pro-

cess: delusions, distortions of body image, hal- lucinations, obsessions, suicidal or homicidal ideation, circumstantiality, coherence, flight of ideas, logical thinking, intact as opposed to loose associations, organization, and tangentiality)

4. Cognitive functioning (e.g., orientation to time, place, and person; short- and long-term mem- ory; knowledge base and intellectual function- ing; insight and judgment)

Assessment Results 1. List assessment and test instruments used 2. Summarize results 3. Avoid raw scores and state results in unbiased

manner 4. Consider using standardized test scores and

percentiles

Diagnosis 1. DSM-5 diagnoses 2. Include V and/or Z codes if appropriate 3. Include other diagnoses such as medical,

rehabilitation, or other salient factors

Summary and Conclusions 1. Integration of all previous information 2. Accurate, succinct, and relevant 3. No new information

76 SECTION I Understanding the Assessment Process

SUMMARY This chapter began by describing some of the pur- poses of the assessment report, including respond- ing to the referral question, providing insight to clients, developing case conceptualization, devel- oping treatment options, suggesting educational services, providing vocational rehabilitation ser- vices, offering insight and treatment options for those with cognitive impairment, assisting courts in decision-making, helping with placement in schools and jobs, and challenging decisions made by institutions and agencies.

We pointed out that putting “garbage” into the assessment report process leads to a flawed report (garbage out) and that it is important to assure that the breadth and depth of the report is being attended to. Thus, we noted the impor- tance of providing a wide enough net to appropri- ately address the breadth of the intended assessment and to provide testing instruments that reflect the intensity or depth of the issue(s) being examined. We also stated that it is critical to establish trust and rapport and assure confi- dentiality if one is to gather reliable information.

We noted that examiners can generally choose from three kinds of interviews: structured, unstruc- tured, and semi-structured. We pointed out that interviews set the tone for the gathering of informa- tion process and allow clients to become desensitized to sometimes very personal information, allow the examiner the ability to assess clients nonverbally, allow the examiner to understand the client “first- hand” and place the client’s issues in perspective, and afford the examiner and client the opportunity to see if they can work together.

Distinguishing among the different kinds of interviews, we noted that a structured interview

asks the examinee to respond to preestablished items or questions, whereas an unstructured inter- view is more open-ended. The semi-structured interview uses prescribed items but also gives lee- way to the examiner should the client need to “drift” during the interview process. We pointed out some strengths and weaknesses of each of these approaches, especially as they relate to gath- ering information that has breadth and depth. We also noted that computer-assisted assessment, such as electronic health records (EHR) and computer-driven assessment reports, can help in the information-gathering process and can be integrated into the examiner’s assessment report.

We next examined the process of selecting an appropriate assessment technique, which often will be based on the clinical interview you had with your client. We stressed the importance of considering the breadth and depth of information provided by the chosen instruments and noted that clinicians will often choose from a broad array of instruments, such as the ones examined in this book. We pointed out that clinicians should carefully reflect on which are the most appropriate instruments and that it is unethical to assess an individual using instruments that are not related to the purpose of the assessment being undertaken.

As the chapter continued, we discussed how to write the actual assessment report. We pointed out that laws such as FERPA, HIPAA, and the Freedom of Information Act mean that clients often will have access to their records. We also noted that reports today are scrutinized more than ever before and stressed the importance of developing a writing style that is clear, concise, and easy to understand. We suggested an array of points to consider when

4. Inferences that are logical, sound, defendable, and based on facts in the report

5. At least one paragraph that speaks to the cli- ent’s strengths

Recommendations 1. Based on all the information gathered 2. Should make logical sense to reader 3. In paragraph form or as a listing 4. Usually followed by signature of examiner

CHAPTER 4 The Assessment Report Process: Interviewing the Client and Writing the Report 77

writing a report, including omitting passive verbs, being nonjudgmental, reducing jargon, not being patronizing, using subheadings, reducing acronyms, minimizing difficult words, using shorter sentences, being concise and having good flow, pointing out client strengths and weaknesses, not dazzling the reader with your brilliance, describing behaviors, avoiding labeling if possible, writing for a nonmen- tal health professional, and being able to take a stand when necessary.

In the last section of the chapter, we exam- ined the format of the report. We noted that the

areas addressed when gathering information from a client often parallel the areas included in the actual report. They include (1) demographic information, (2) presenting problem or reason for the report, (3) family background, (4) significant medical/ counseling history, (5) substance use and abuse, (6) vocational and educational history, (7) other pertinent background information, (8) mental sta- tus, (9) assessment or test results, (10) diagnosis, (11) summary and conclusions,and (12) recommen- dations. We discussed each area and offered a case example.

CHAPTER REVIEW 1. Describe some purposes of the assessment

report. 2. Relative to the assessment report process,

describe what is meant by “garbage in, gar- bage out.”

3. Describe what it means to choose an assess- ment instrument with “breadth and depth.”

4. Discuss some of the tasks associated with conducting clinical interviews that are not associated with other kinds of assessment techniques.

5. Compare and contrast structured, semi-structured, and unstructured interview techniques.

6. What place can computer-generated reports take in the assessment report process?

7. Explain the impact of laws such as the Family Educational Rights and Privacy Act (FERPA), the Freedom of Information Act, and the Health Insurance Portability and Accountability Act (HIPAA) on the preparation of assessment reports.

8. Write down as many of the suggestions for writing a report that you can remember.

9. Make a list of the kinds of information gen- erally obtained in an assessment report.

10. Describe the four components of a mental-status exam. Interview a student in class and then write a one- or two-paragraph mental-status exam.

11. Conduct an assessment of a client and use the categories listed in this chapter to write an assessment report.

REFERENCES Akiskal, H. S. (2008). The mental status examination.

In S. H. Fatemi, & P. J. Clayton (Eds.), The medical basis of psychiatry (pp. 3–16). Totowa, NJ: Humana. doi.org/10.1007/978-1-59745-252-6_1

American Counseling Association (ACA). (2005). Code of ethics. (Rev. ed.). Alexandria, VA: Author.

American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text revision). Washington, DC: Author.

American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders (5th ed). Washington, DC, Author.

American Psychological Association. (2010). Ethical principles of psychologists and code of conduct including 2010 amendments. Retrieved from http:// www.apa.org/ethics/code/index.aspx

Berger, M. (2006). Computer assisted clinical assess- ment. Child and Adolescent Mental Health, 11(2), 64–75. doi.org/10.1111/j.1475-3588.2006.00394.x

Bruchmuller, K., Margraf, J., Suppiger, A., & Schneider, S. (2011). Popular or unpopular? Therapists’ use of structured interviews and their estimation of patient acceptance. Behavior Therapy, 42, 634–643. doi: 10.1016/j.beth.2011.02.003

78 SECTION I Understanding the Assessment Process

Cimino, J. J. (2013). Improving the electronic health record—Are clinicians getting what they wished for? The Journal of the American Medication Association, 309, 991–992. doi:10.1001/jama.2013.890.

Commonwealth of Virginia Knowledge Center (2010). Department of Behavioral Health and Developmental Services. Assessing the risk of serious harm to self module 10. Retrieved from https://covkc.virginia .gov/dbhds/external/Kview/CustomCodeBehind/base /courseware/scorm/scorm12courseframe.aspx

Farmer, A., McGuffin, P., & Williams, J. (2002). Measuring psychopathology. New York: Oxford University Press.

Goldfinger, K., & Pomerantz, A. M. (2010). Psychological assessment and report writing. Los Angeles, CA: Sage.

Lichtenberger, E. O., Mather, N., Kaufman, N. L., & Kaufman, A. L. (2004). Essentials of assessment report writing. Hoboken, NJ: John Wiley & Sons.

Michaels, M. H. (2006). Ethical considerations in writing psychological assessment reports. Journal of Clinical Psychology, 62(1), 47–58. doi.org/10.1002/jclp.20199

Polanski, P. J., & Hinkle, J. S. (2000). The mental status examination: Its use by professional counse- lors. Journal of Counseling and Development, 78, 357–364. doi.org/10.1002/j.1556-6676.2000. tb01918.x

Schinka, J. A. (2012). Mental status checklist-adult. Lutz, FL: Psychological Assessment Resources.

Seligman, L. (2004). Diagnosis and treatment planning in counseling (3rd ed.). New York: Plenum. doi.org/10.1007/978-1-4419-8927-7

Sommers-Flanagan, J., & Sommers-Flanagan, R. (2012). Clinical interviewing. Hoboken, NJ: John Wiley & Sons.

Spores, J. M. (2013). Clinician’s guide to psychological testing and assessment: With forms and templates for effective practice. New York: Springer.

Wiener, J., & Costaris, L. (2012). Teaching psycholog- ical report writing: Content and process. Canadian Journal of School Psychology, 27(2), 119–135. doi: 10.1177/0829573511418484

CHAPTER 4 The Assessment Report Process: Interviewing the Client and Writing the Report 79

S E C T I O N IITest Worthiness and TestStatistics

In Section II, we examine how tests are created, scored, and interpreted. Chapters 5, 6, and 7 explain a number of important concepts related to test statistics. Being able to understand these statistics and how they are applied to the assessment process is crucial if one is to interpret test data appropriately. As you read these chapters, we will show you that the development of tests and the interpretation of test data is a deliberate and planned process that involves a scientific approach to the understanding of differences among people. We try to present this information in a down-to-earth and comprehensible fashion.

Chapter 5 defines test worthiness as an involved, objective analysis of a test. To do this objective analysis, however, we first highlight the importance of correla- tion coefficient and show how this important statistic is used to conduct an analy- sis of many aspects of the four factors of test worthiness that are examined in this chapter: (1) validity: whether the test measures what it’s supposed to measure; (2) reliability: whether the score an individual has received on a test is an accurate measure of his or her true score; (3) cross-cultural fairness: whether the score the individual has obtained is a true reflection of the individual, and not a function of cultural bias inherent in the test or in the examiner; and (4) practicality: whether it makes sense to use a test in a particular situation. The chapter concludes with a list of five steps to use in test selection to assure test worthiness.

Chapter 6 starts with the basics: an examination of raw scores. We first show that raw scores generally provide little meaningful information about a set of scores, and then we look at various ways that we can manipulate raw scores to

make sense out of a set of data. Thus, in this chapter we examine how a variety of basic statistics and graphs can help us understand raw scores. Some of these include frequency distributions; histograms and frequency polygons; cumulative distributions; the normal curve; skewed distributions; measures of central tendency such as the mean, median, and mode; and measures of variability such as the range, interquartile range, and standard deviation.

Chapter 7 is a natural extension of Chapter 6, and in it we examine derived scores and explore how they are used to help us understand raw scores. We start by distinguishing norm-referenced testing and criterion-referenced testing because these two ways of understanding test scores are quite different, and derived scores are mostly associated with norm-referenced testing. Next, we discuss specific types of derived scores: percentiles; standard scores, including z-scores, T-scores, devia- tion IQs, stanines, sten scores, college and graduate school entrance exam scores (e.g., SATs, GREs, and ACTs), NCE scores, and publisher-type scores; and devel- opmental norms such as age comparisons and grade equivalents. The chapter nears its conclusion with a discussion of standard error of measurement and stan- dard error of estimate. The chapter ends with a brief discussion of nominal, ordi- nal, interval, and ratio scales of measurement as we describe how each type of scale has unique attributes that may limit the statistical calculations one can per- form, and we mention that different kinds of assessment instruments use different kinds of scales.

82 SECTION II Test Worthiness and Test Statistics

C H A P T E R 5Test Worthiness: Validity,Reliability, Cross-Cultural Fairness, and Practicality

I’m walking down a Cincinnati street, and a man walks up to me and asks, “Want to take a test?” “Sure,” I reply. He takes me to a storefront, gives me a test, and then goes to a back room to score it. A few minutes later he reappears and tells me, “Well, you’re pretty bright and have a fairly good personality, but if you take Ron Hubbard’s course in Scientology, you will be brighter and have a better personality.” I tell him, “No thanks.” A few years later, I’m walking down a street in Minneapolis and a man comes up to me and inquires, “Want to take a test?” This time I say, “If you can show me that this test is a good test— that is, it has good reliability and validity—I’ll take it.” He says, “I’m sure it has good reliability and validity.” I say, “Show me.” He says, “Well, I know our New York office must have that information.” I say, “Well, I tell you what, I’ll buy Ron Hubbard’s book, Dianetics, and if and when you can get me the information from the New York office, I’ll read the book.” I gave him my name and address. I never heard from him again.

(Ed Neukrug)

As you might expect from this example, this chapter is about test worthiness, or how good a test actually is. Demonstrating test worthiness requires an involved, objective analysis of a test in four critical areas: (1) validity: whether it measures what it’s supposed to measure; (2) reliability: whether the score an individual receives on a test is an accurate measure of his or her true score; (3) cross-cultural fairness: whether a person’s score is a true reflection of the individual and not a function of cultural bias inherent in the test; and (4) practicality: whether it makes sense to use a test in a particular situation. After examining these four factors, we

Test worthiness Based on validity, reliability, cross- cultural fairness, and practicality

conclude the chapter with a discussion of five steps to use in test selection to assure test worthiness. However, prior to examining the four critical factors of validity, reliability, cross-cultural fairness, and practicality, and before discussing test selec- tion, we examine the concept of correlation coefficient because it is central to understanding much of what is presented in this chapter.

CORRELATION COEFFICIENT Correlation coefficient, which shows the relationship between two sets of scores, is a statistical concept frequently used in discussions of the critical factors just listed. Correlation coefficients range from �1.00 to þ1.00 and generally are reported in decimals of one-hundredth. A positive correlation shows a tendency for scores to be related in the same direction. For instance, if a group of individuals took two tests, a positive correlation would show a tendency for those who obtained high scores on the first test to obtain high scores on the second test, for those who obtained low scores on the first test to obtain low scores on the second test, and so forth. On the other hand, a negative correlation shows an inverse relationship between sets of scores; for instance, individuals who obtain high scores on the first test would be likely to obtain low scores on the second test.

Let’s take a look at real world examples of positive and negative correlations. For instance, researchers have generally found positive correlations between social connect- edness and other variables such as subjective well-being (Yoon, Lee, & Goh, 2008), longevity (Zunzunegui, Beland, Sanchez, & Otero, 2009), and life satisfaction (Park, 2009). This makes sense as people who are more connected, tend to be happier, live lon- ger, and are more satisfied. These are positive correlations that move in the same direc- tion. (See Figure 5.1.) In contrast, we can expect a negative correlation between social connectedness and depression (Glass, Mendes de Leon, Bassuk, & Berkman, 2006); that is, as people connect more with others, they tend to be less depressed. Since social connectedness and depression move in opposite directions, this makes them inversely related or negatively correlated. In the school setting, students with attention deficit hyperactivity disorder (ADHD) are likely to have a negative correlation with their school performance. The more severe their ADHD symptoms are, the more likely aca- demic achievement will decrease. These variables move in opposite directions that make them correlate negatively or inversely as seen in Figure 5.1.

A correlation that approaches �1.00 to þ1.00 demonstrates a strong relation- ship, while a correlation that approaches 0 shows little or no relationship between two measures or variables. (See Figure 5.2.) For instance, if I wanted to show that SAT scores predict college performance, I would have to show that the correlation coefficient does not approach zero and is significant enough to warrant its use. (See Kobrin & Patterson, 2011; Maruyama, 2012.) Similarly, if I wanted to show that my newly made test of depression was worthwhile, I could correlate scores on my new test with an established test of depression. In this case, I would expect to find a relatively high correlation coefficient as evidenced by the fact that individuals who scored high on my test would have a tendency to score high on the established test, individuals who scored low on my test would have a tendency to score low on the established test, and so forth. As we discuss the four critical factors of validity, reliability, cross-cultural fairness, and practicality, you will see that correlation

Correlation coefficient Relationship between two sets of test scores

Positive correlations Move in the same direction

Negative correlations Move in opposite direction

84 SECTION II Test Worthiness and Test Statistics

coefficient often plays an important role in many of them. If you would like to find out how to calculate a correlation coefficient, see Appendix E.

A correlation between two sets of variables, or test scores, can also be plotted on a graph. By placing an individual’s first score on the horizontal (x) axis and second score on the vertical (y) axis, you can plot this person’s scores on the graph. If you continue doing this for the remaining members of a group of people, each of whom has two sets of scores, you will end up with what’s called a scatterplot. (See Figure 5.3.)

As illustrated in Figure 5.3, as the dots come close to forming a diagonal line, the scores on the x-axis are more closely related to scores on the y-axis, or the

0 to 10.3 5 weak 0 to 20.3 5 weak

10.4 to 10.6 5 medium 20.4 to 20.6 5 medium

10.7 to 11.0 5 strong 20.7 to 21.0 5 strong

StrongStrong

21.0 0 11.0

Inverse Direct

Weak

FIGURE 5.2 | Correlation Coefficient

Positive Correlations Move in the Same Direction

Negative Correlations Move in Opposite Directions

Social Connectedness

Subjective Well-Being

Life Satisfaction

Subjective Well-Being

Life Satisfaction

OR Social

Connectedness

Social

Connectedness

Social

Connectedness

Attention Deficit

Hyperactivity

Disorder

Depression

Academic

Achievement

Depression

Academic

Achievement

Attention Deficit

Hyperactivity

Disorder

FIGURE 5.1 | Examples of Positive and Negative Correlations

Scatterplot Graph showing two or more sets of test scores

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CHAPTER 5 Test Worthiness: Validity, Reliability, Cross-Cultural Fairness, and Practicality 85

correlation becomes closer to plus or minus 1.0. As the dots become more random (little relationship between scores on the two tests), the correlation approaches zero. Additionally, it is called a positive correlation if the general slope of the dots rises from left to right and a negative correlation if it rises from the right to the left.

COEFFICIENT OF DETERMINATION (SHARED VARIANCE)

Squaring the correlation coefficient gives you the coefficient of determination, or shared variance between two variables. This variance is a statement about underly- ing factors that account for the relationship between two variables. Thus, if the correlation is 0.70, the square is 0.49, which represents a percentage of shared variance—in this case, 49 percent. For instance, in one study, a correlation of 0.85 was found between scores on a test of depression and scores on a test that mea- sured anxiety (Cole, Truglio, & Peeke, 1997). Therefore, in this case it can be said that 72% of the variance is shared variance (0.85 squared), or, in other words, a large percentage of similar factors underlie feelings of depression and anxiety as measured by these tests. (See Figure 5.4.) What might some of these factors be? An educated guess might lead us to think that they could be environmental stres- sors (e.g., job loss, relationship problems, etc.), cognitive schemata (ways of under- standing the world), chemical imbalance, and so forth. All of these factors could trigger feelings of depression and of anxiety. Of course, we need to keep in mind that 28% of the variance is not shared, which means that other factors differen- tially affect whether one feels depressed or anxious. Keep the concept of coefficient of determination in mind when you read the next section on validity.

r 5 1.0 r 5 0.70

r 5 0.0 r 5 20.40

r 5 0.30

r 5 21.0

FIGURE 5.3 | Scatterplot Charts and Correlational Estimates

Coefficient of determination Common factors that account for a relationship; square of the correlation coefficient

86 SECTION II Test Worthiness and Test Statistics

VALIDITY Validity is a unitary concept. It is the degree to which all of the accumulated evidence supports the intended interpretation of test scores for the intended purpose. (American Educational Research Association, [AERA], 1999, p. 11)

How well does a test measure what it’s supposed to measure? That is the primary question that validity attempts to answer. Over the years, a number of methods have been developed to determine the validity of a test. Logically, it makes sense that the more methods one can use to provide evidence that a test is valid, the stronger the case one can make that the interpretation of test scores is accurate for the manner in which the test is being used (AERA, 1999). Various types of validity that help to provide the evidence needed to demonstrate the worthiness of a test include content validity; criterion-related validity, which includes con- current validity and predictive validity; and construct validity, which includes methods of experimental design, factor analysis, convergent validity, and dis- criminant validity.

Content Validity Probably the most basic form of validity is content validity. As with all types of validity, its name is reflective of what it attempts to show: Is the content of the test valid for the kind of test it is? In assuring content validity, a process is used to develop items for a test, such as examining established books in the field, gathering information from experts, and examining curriculum guides. In demonstrating con- tent validity, test publishers need to do the following:

Step 1: Show that the test developer adequately surveyed the domain (e.g., examining books and curriculum guides, consulting with experts, etc.)

Step 2: Show that the content of the test matches what was found in the survey of the domain.

Step 3: Show that test items accurately reflect the content.

Depression Anxiety

Shared trait variance

FIGURE 5.4 | Shared Variance Between Depression and Anxiety(r ¼ 0.85, r 2 ¼ 0.72)

Validity Evidence supporting the use of test scores

Content validity Evidence that test items represent the proper domain

CHAPTER 5 Test Worthiness: Validity, Reliability, Cross-Cultural Fairness, and Practicality 87

Step 4: Show that the number of items for each content area matches the relative importance of these items as reflected in the survey of the domain (Wolfe & Smith, 2007).

To illustrate this process, let’s look at the creation of a fourth-grade math achievement test to be used nationally. In demonstrating content validity, the test developer should do the following:

Step 1: Show that information for the test was gathered from places such as fourth-grade math books, teachers of fourth-grade math, curriculum specialists in the schools, professors at colleges who are training fourth-grade math tea- chers, and so forth.

Step 2: Show that the content was chosen based on the information that was gath- ered (e.g., addition, subtraction, multiplication, division, decimals, and fractions).

Step 3: Show that the items reflect the content chosen.

Step 4: Show that the number of items for each content area reflects the rela- tive importance of that area (e.g., multiplication and division might be empha- sized more than the other items). (See Figure 5.5.)

Despite one’s painstaking attempts to assure content validity, not all fourth-grade teachers would be teaching the same math content, so the test might hold more valid- ity for some fourth-grade classes than for others. Thus, content validity is somewhat contextual and depends on who is taking the test (Goodwin, 2002a, 2002b).

Face validity, which is not considered an actual type of validity, is sometimes confused with content validity. Face validity has to do with how the test superfi- cially looks. If you were examining the test, would it appear to be measuring what it is supposed to measure? Although most tests should have face validity, some tests could be valid yet not have it. For instance, there might be some items on a

Survey of domain

Item 1 Item 2 Item 3 Item 4 Item 5

3 3

3 2

3 1

3 2

3 2.5

Step 3: Test items reflect content

Step 4: Adjusted for relative importance

Content matches domain

Step 1: Survey the domain

Step 2: Content matches domain

FIGURE 5.5 | Establishing Content Validity

Face validity Superficial appearance of a test— not true validity

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88 SECTION II Test Worthiness and Test Statistics

personality test that, on the surface, do not seem to be measuring a quality that the test is attempting to assess. Look, for example, at the following hypothetical item below that is assessing whether or not an individual may have a panic disorder:

In the past week, check the following symptoms that you have experienced: _____a. sweaty _____c. racing heart _____e. distracted myself _____b. left event early _____d. trouble breathing _____f. avoided events

Even though the symptoms listed in the item might not seem obvious to a per- son unfamiliar with panic disorder, they are often associated with the disorder, as noted in the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5; American Psychiatric Association, 2013). On the surface, this item might not seem to be measuring the construct, but individuals with panic disorder often have some or all of these symptoms, and thus such a question is conceivable and might be important to ask. Therefore, the item might be important to the content validity of the test. (See Exercise 5.1.)

Criterion-Related Validity What is the relationship between a test and a criterion (external source) that the test should be related to? That is the essence of criterion-related validity. Two types of criterion-related validity generally described are concurrent validity and predictive validity.

Concurrent Validity Concurrent, or “here and now,” validity occurs when a test is shown to be related to an external source that can be measured at around the same time the test is being given. For instance, suppose I develop a test to measure the ten- dency toward alcohol abuse. I might give this test to 500 individuals and then have the examinee’s friends and family rank order the examinee’s use of alcohol to see if there is a correlation between his or her alcohol abuse score and use of alcohol (e.g., num- ber of drinks per day). Clearly, I would suspect a high correlation (the higher the score, the more one drank), and if I did not find one, my test would be suspect.

Predictive Validity Whereas concurrent validity relates a test to a “here and now” measure, predictive validity relates a test to a criterion in the future. This kind of validity is clearly important if a test should be predicting something about an individ- ual. For instance, the Graduate Record Examine (GREs) should have predictive validity for grade point average (GPA) in graduate school; otherwise the scores would not be valuable and should not be used. In actuality, the correlation between the GREs and GPA in graduate school is about 0.34, which is not very high. (See Table 5.1.) However, when placed in the context of other possible predictors of

Exercise 5.1 Demonstrating Content Validity

In small groups, discuss how you might show content validity for a test that measures depression. Share your ideas in class.

Criterion-related validity Relationship between test scores and another standard

Concurrent validity Relationship between test scores and another currently obtainable benchmark

Predictive validity Relationship between test scores and a future standard

CHAPTER 5 Test Worthiness: Validity, Reliability, Cross-Cultural Fairness, and Practicality 89

graduate school success (e.g., undergraduate GPA, extracurricular activities, and inter- views), it’s not so bad. And, if we combine the use of predictors of graduate school GPA, we increase our ability to make a prediction about students’ success. For instance, the correlation between undergraduate GPA and grades in graduate school is 0.37, and when we combine the GRE scores and GPA in undergraduate school, we find a correlation of 0.46 with grades in graduate school. (See Table 5.1.)

A practical application of predictive validity is the standard error of the esti- mate (SEest), which, based on one variable, allows us to predict a range of scores on a second variable. For example, if we know students’ GRE scores and the corre- lation between GRE scores and first-year grades in graduate school, we can predict the range of GPAs students are likely to obtain in graduate school. This range of scores is sometimes referred to as a confidence interval (e.g., where students GPAs will fall 68% of the time). Actually “seeing” how well one set of scores predicts a second set of scores can give us a more realistic sense of the whether or not such scores should be used in making important decisions about individuals’ lives. In Chapter 7, we will show how a SEest is actually determined.

Another concept in the application of predictive validity is false positives and false negatives. A false positive is when an instrument incorrectly predicts a test taker will have an attribute or be successful when he or she will not. A false negative is when a test forecasts an individual will not have an attribute or will be unsuccessful when in fact he or she will. For example, let’s say you are working in a high school and use the adolescent version of the Substance Abuse Subtle Screening Inventory (SASSI, 2008–2009) to flag students who may have an addiction. After giving the instrument to 100 students, 10 are identified as having a high likelihood of having a substance dependency. If two of those students do not, in fact, have an addiction, that would be considered a false positive. If one of the 90 students whose scores indicated

TABLE 5.1 Average Estimated Correlations of GRE General Test (Verbal, Quantitative, and Analytical) Scores and Undergraduate Grade Point Average with Graduate First-Year Grade Point Average by Department Type

Type of Department

Number of Departments

Number of Examinees

Predictors

V Q A U VQA* VQAU*

All Departments 1,038 12,013 0.30 0.29 0.28 0.37 0.34 0.46

Natural Sciences 384 4,420 0.28 0.27 0.26 0.36 0.31 0.44

Engineering 87 1,066 0.27 0.22 0.24 0.38 0.30 0.44

Social Sciences 352 4,211 0.33 0.32 0.30 0.38 0.37 0.48

Humanities and Arts 115 1,219 0.30 0.33 0.27 0.37 0.34 0.46

Education 86 901 0.31 0.30 0.29 0.35 0.36 0.47

Business 14 196 0.28 0.28 0.25 0.39 0.31 0.47

V ¼ GRE verbal, Q ¼ GRE quantitative, A ¼ GRE analytical, U ¼ undergraduate grade point average *Combination of individual predictors.

Source: Graduate Record Examinations, 2004–2005. GRE materials selected from 2004–2005. Guide to the Use of Scores, p. 22. Reprinted by permission of Educational Testing Service, the copyright owner. Copyright © 2013 Educational Testing Service. www.ets.org

90 SECTION II Test Worthiness and Test Statistics

a low probability of a dependency, but in actuality had a diagnosable substance dependence, that would be considered a false negative. Although it would be better to have neither false positives or negatives, in the case of the SASSI, the designers chose to err toward having a greater chance of false positives than false negatives. Why do you think that is? (See Exercise 5.2.)

Construct Validity What is intelligence? When teaching an assessment class, we have found that this often becomes a “hot” topic for discussion, with students arguing over what they believe actually makes up this construct. Construct validity is the scientific basis for showing that a construct (idea, concept, or model), such as intelligence, is being measured by a test. Showing evidence of construct validity is particularly important when developing tests that measure abstract domains, such as intelli- gence, self-concept, depression, anxiety, empathy, and many other personality char- acteristics. On the other hand, construct validity becomes much less of an issue when one is measuring well-defined areas, such as achievement in geometry.

To demonstrate construct validity, it is often useful to provide multiple sources of evidence that the construct we are measuring is indeed being exposed. Although some have argued that almost any kind of validity is evidence that the construct being measured exists (Goodwin, 2002a), a more restrictive definition of construct validity includes an analysis of a test through one or more of the following methods: (1) experimental design, (2) factor analysis, (3) convergence with other instruments, and/or (4) discrimination with other measures.

Experimental Design Validity You’ve just developed your new test of depres- sion, and you’re very proud of it. Of course, you want to show that it is indeed valid. You already have shown that it has content validity by developing items through an examination of DSM-5, scholarly journal articles, and consultation with experts. However, now you want to show that the test indeed works—that it measures your construct. So you approach a number of expert clinicians who work with depressed clients and ask them to identify new clients on their caseloads who are depressed. You then request that they administer your depression test prior to and at the end of six months of treatment. What should you expect to find? Clearly, if the test is good and does measure the construct depression, it should be

Exercise 5.2 Demonstrating Criterion-Related Validity

In class, form small groups, some of which will examine concurrent validity while others will examine predictive validity. In your groups, choose a test from the following list or come up with another test. Next, discuss criteria with which you might compare your test.

Possible Tests:

High school achievement test

Test of anxiety

SATs, GREs, MATs Test of hypochondriasis

Intelligence test Clerical aptitude test

Depression test First-grade reading test

Construct validity Evidence that an idea or concept is being measured by a test

Experimental design validity Using experimentation to show that a test measures a concept

CHAPTER 5 Test Worthiness: Validity, Reliability, Cross-Cultural Fairness, and Practicality 91

able to accurately reflect the change in these clients—in this case, a significant decrease in depression. If not, you need to go back to the drawing board. Experi- mentally based construct validity thus confirms the hypothesis you developed to scientifically show that your construct exists. Sometimes, when a number of studies are completed, you will find authors conducting a “meta-analysis,” which statisti- cally analyzes all of these studies in an effort to offer broader evidence of the exis- tence of the construct being examined.

Factor Analysis Factor analysis, another method to show construct validity, demonstrates the statistical relationship among subscales or items of a test. Suppose, for instance, that your depression test has subscales that measure hopelessness, suicidal ideation, and self-esteem. Theoretically, you would expect them all to be related to your larger test score that measures depression. In addition you would expect them to be somewhat related, but not largely related, to one another. After all, they are mea- suring something different from one another (although they all make up the larger test “depression”). So after giving your new depression test to a sample of 100 people, you run a statistical program that shows that each of the items measuring the domain of hopelessness correlates fairly highly with the domain; that is, people who score high on hopelessness tend to score high on each of the items in that domain. You find the same for suicidal ideation. However, you find one of the items that is supposed to be measuring self-esteem does not correlate highly with that domain (i.e., doesn’t load for that factor). So you decide to delete that item or rewrite it and try again. In addition, you also find that the three subscales do not correlate particularly highly with one another, thus showing that they are discrete, or separate scales (although, they all cor- relate highly with the total test score, which is a combination of the three scales).

Convergence with Other Instruments (Convergent Validity) Believing that your test does measure depression, you would, of course, expect your test to be related to other existing well-known valid measures of depression. Thus, you decide to correlate your test with the Beck Depression Inventory II (BDI-II) (Beck, Steer, & Brown, 2004), a well-known test of depression. You give the BDI-II and your test to 500 subjects and you find a relatively high correlation between the two scores, perhaps 0.75. You’re satisfied, perhaps even glad you didn’t get a higher correlation. After all, isn’t your test different (and a little better!) than the well-known existing test? Thus, you expect your correlation to be less than perfect. Thus, convergent validity occurs when you find a significant pos- itive correlation between your test and other existing measures of a similar nature. Sometimes this relationship involves very similar kinds of instruments, but other times you would be looking for correlations between your test and variables that may seem only somewhat related. For instance, if you correlate your test with a test to measure despair, you would expect a positive correlation. However, because despair is theoreti- cally different from depression, you would expect a lower correlation—maybe 0.4.

Discrimination with Other Measures (Discriminant Validity) With convergent validity you’re expecting to find a relationship between your test and other variables of a similar nature. Discriminant validity, in a sense, is the opposite in that you’re looking to find little or no relationship between your test and measures of constructs that are not theoretically related to your test. For instance, with your test of depres- sion, you might want to compare your test scores with an existing test that measures

Factor analysis Statistically examining the relationship between subscales and the larger construct

Convergent validity Relationship between a test and other similar tests

Discriminant validity Showing a lack of relationship between a test and other dissimilar tests

92 SECTION II Test Worthiness and Test Statistics

anxiety. In this case, you give 500 subjects your test of depression as well as a valid test to measure anxiety, looking to find little or no relationship. Consider how important discriminant validity might be if you’re working with clients. Clients who are dealing with high amounts of anxiety will often present with depressive features. If you were able to give your client a test that could discriminate depression from anxiety, you would get a better picture of your client. Making a more accurate diag- nosis could dramatically affect your treatment plan, as approaches to working with depressed clients will vary from approaches to working with anxious clients.

Visual Representation of Types of Validity Figure 5.6 is a visual representation of the seven types of validity across the three broader categories. For content validity, you will notice a previous figure that

Content Validity

Criterion-Related Validity

Construct Validity

New Test