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Psychological assessments shown to be as valid as medical tests
Monitor on Psychology. Volume 32, No. 7 July/August 2001

By Jennifer Daw
Monitor staff

A recent report indicates that psychological assessments are just as predictive of specific, measurable outcomes--sometimes even more predictive--as many medical tests.
Full Article


ADHD children show enhanced and impaired attentional function
Psychol Med 2003; 33: 481-489

German researchers have found that attentional function in children with attention deficit/hyperactivity disorder (ADHD) follows a differential, rather than a deficit, pattern.

The team, led by J Koschack from the University of Göttingen in Germany, assessed 35 children with ADHD aged 9-12 years using a neuropsychological test battery. Their performance was classified according to the data on a normative sample of 187 healthy children of the same age, and compared with the performance of 35 healthy children.

Most of the ADHD patients performed within normal ranges on all attentional measures. However, compared with the healthy controls, they reacted faster on all the tests, with significant differences found for the Go/No Go test and the Divided Attention test.

Importantly, the ADHD patients outperformed their healthy peers on the externally-paced Divided Attention test, whereas they made significantly more errors on the Go/No Go test, the Visual Scanning test, and the Attentional Shift test.

The researchers note that the number of errors on the Go/No Go test was negatively related to the reaction time on this test.

Thus, the impulsivity of the ADHD individuals led to a "more erroneous performance in self-paced attentional tasks, and to a better performance in externally paced attentional tasks," the team writes in the journal Psychological Medicine.

"The impression of inattention in everyday school or home life may evolve because ADHD subjects are hyperactive and often fail to inhibit or delay responding, or to exhibit well paced responding," they add.

Koschack et al also question whether differentiated neuropsychological tests of attention contribute to the clinical diagnosis of ADHD.

Cognitive functioning still good in over-90s
Neurology 2003; 60: 477–480

Contrary to common belief, many people can live well into their 90s without becoming cognitively impaired, study findings indicate.

Bradley Boeve (Mayo Clinic, Rochester, Minnesota, USA) and colleagues found that mild cognitive impairment (MCI) exists as a syndrome in patients aged 90 to 100 years, despite previous suggestions that the greater degree of functional and mental decline in the very old may makes such a diagnosis impossible.

Moreover, the researchers note that, despite advancing age, the relationship between cognitive and functional performance and clinical diagnosis followed patterns similar to those described in younger individuals.

Among 56 normal individuals, 13 with MCI, and 42 with dementia, the ability to carry out activities for daily living was significantly worse among patients with dementia, but was similar for MCI and normal individuals.

Similarly, performances on the Mini-Mental State Examination and the Dementia Rating Scale were significantly impaired among dementia patients, but differed only slightly between the MCI and normal individuals.

These findings show that, although there may be some decline in cognitive performances with age, "dementia or Alzheimer's disease are not inevitable in all those living well beyond 90 years of age," say the researchers.

Indeed, memory was the only measure of cognition among those with MCI that showed levels of impairment similar to patients with dementia.

Reporting in the journal Neurology, the team concludes that the evidence of amnesia in nonagenarians with MCI warrants further investigation into the functional and clinical characteristics of normal and abnormal aging among the very old.

Dementia diagnosis in developing countries made easier
Lancet 2003; 361: 909–917

UK researchers have developed a culturally and educationally sensitive instrument for diagnosing dementia in developing countries.

Conventional tests for dementia rely on "Western" norms such as relatively high educational status, Martin Prince (Institute of Psychiatry, King's College, London) and colleagues note.

To overcome this problem, they developed a "one-stage, culturally and educationally sensitive dementia diagnostic instrument" based on three commonly used instruments – the geriatric mental state, the community screening instrument for dementia, and the modified Consortium to Establish a Registry of Alzheimer's Disease 10-word list-learning task.

The three measures was tested in 2885 people aged 50 years or older, of whom 760 were from India, 367 from China and southeast Asia, 76 from Nigeria, and 1692 from Latin America and the Caribbean.

In total, 729 participants had dementia, with the remaining patients free of the condition. In addition, 702 individuals had depression, and 694 had a high- and 760 a low-level of education.

While each measure independently predicted a diagnosis of dementia, the researchers found that an algorithm derived from all three measures gave better results than any individual measure.

Indeed, the algorithm identified 94% of dementia cases with false positive rates in the depression, high education, and low education groups at 15%, 3%, and 6%, respectively.

"Our algorithm is a sound basis for culturally and educationally sensitive dementia diagnosis in clinical and population-based research, supported by translations of its constituent measures in most languages used in the developing world," the team concludes in The Lancet.


Mini-Mental State Examination & Dementia
Br J Gen Practice 2002; 52: 1002–1003

MMSE for screening elderly dementia patients questioned

Researchers have found that using the Mini-Mental State Examination (MMSE) to screen elderly people for dementia may not be as accurate as previously thought, raising a question mark over its potential use in primary care.

Nia White and colleagues from the University of Wales in Bangor found that using the MMSE for screening dementia in the elderly gave a false-positive result in 86% of cases.

The validity of the test was investigated in 709 patients aged over 75 years, and was administered by a member of the primary care team during annual health checks.

In all, 286 (40%) of the participants were considered to have dementia due to scoring at or below the cut-off point, which was set at 26/30 on the MMSE test.

For comparison, 202 of these patients were assessed further using the well-validated Geriatric Mental Schedule Automated Geriatric Examination for Computer Assisted Taxonomy.

This identified 173 of the patients as not having dementia, while only 29 (14%) were diagnosed with the condition.

These results indicate an 86% false-positive rate with the MMSE, and "raise concerns regarding the utility of the MMSE as a screening instrument for dementia in primary care," say the researchers in the British Journal of General Practice.

"Simply adding the MMSE to existing assessments of people over 75 is unlikely to be helpful, leading to a high rate of older people apparently requiring further assessment and high rate of false positives," they add.

The team reports that it was possible to lower the rate of false positives to 59%, by using a lower cut-off point of 21; however, this resulted in over half of the true positives being missed.

They recommend that assessments based on history and complaints of memory problems from patients and carers may be as reliable as a full MMSE.

Neuropsychological tests 'fine-tune' dementia diagnosis
Psychol Med 2003; 119: 217-223

British researchers have discovered that certain neuropsychological tests are able to distinguish between different forms of dementia, and may be particularly useful in the detection of mild cognitive impairment (MCI).

Early diagnosis of dementia is clearly important for optimal management, particularly since the advent of specific anti-dementia drugs. To assess the sensitivity and specificity of available tests, Celeste de Jager and colleagues at the University of Oxford in the UK administered a battery of tests to individuals referred to the Oxford Project to Investigate Memory and Ageing (OPTIMA).

Assessment included both validated and novel tests aimed at gauging episodic, semantic, and working memory, sustained and selective attention, executive function, speed, perception, praxis, and visuospatial skills.

Participants comprised 51 healthy controls, 29 subjects with MCI, 12 with cerebrovascular disease (CVD), and 60 with "possible" or "probable" Alzheimer's Disease (AD). All had a score of at least 25 on the Mini-Mental State Examination.

Patients with AD performed worse than controls on all tests except attention tasks, the authors report in Psychological Medicine. Both the Hopkins Verbal Learning Test and The Placing Test for episodic memory were able to discriminate between controls and patients.

Furthermore, attention and processing speed tests accurately discriminated between those with CVD and controls. And category fluency, episodic memory tests, and the CLOX test for executive function distinguished between MCI and AD.

Finally, Spearman's correlation showed a negative association between age and processing speed. Years of education affected performance on all tests except The Placing Test.

"The present study has shown that a neuropsychological battery can be used to screen for mild and later stages of cognitive impairment as well as help to differentiate various subtypes of dementia," the team concludes.

"The results of this study await replication and extension to larger groups of patients with MCI and CVD."




Personnel Psychology. 2006 Spring 59(I): 189-225

Unproctored Internet Testing in Employment Settings

Tippins NT, Beaty J, Drasgow F, Gibson WM, Pearlman K, Segall DO, Shepherd W.

As the Internet has become more accessible to individuals and organizations, the use of computerized testing has become more feasible. Computerized testing has brought with it a demand for unproctored testing that allows test takers to take employment tests at times and places convenient to them. However despite the advantages of costs and convenience, unproctored Internet testing (UIT) introduces a number of issues, many of which have not yet been resolved. These problems range from hardware and software issues to concerns about the security of the test content, the identity of candidates, and cheating. This article explores the pros and cons of unproctored, Internet testing. Six panelists share their opinions and experiences regarding issues around UIT and offer suggestions for appropriate use and future research.

(Harcourt Assessment, Inc.
Position on Un-proctored Internet Testing (UIT) for Cognitive Ability Tests
Effective April 24, 2006)

Report of the Internet Task force for the Board of Scientific Affairs and Board of Professional Affairs,
American Psychological Association, 2003

Psychological Testing on the Internet: New Problems, Old Issues

Jack A. Naglieri, George Mason University; Fritz Drasgow, University of Illinois; Mark Schmit, SHL USA, Inc; Len Handler, University of Tennessee; Aurelio Prifitera, The Psychological Corporation; Amy Margolis, Brooklyn Learning Center; Roberto Velasquez, San Diego State University.

The past decade has witnessed a rapid expansion of the Internet. This revolutionary communication network has significantly changed the way people conduct business, communicate, and live. In this report we have focused on how the Internet influences the practice of psychology as it relates to testing and assessment. The report includes topics such as test security, how technical issues may compromise test validity and reliability, and hardware issues. Special attention is paid to ethical and legal issues, with particular emphasis on implications for people with disabling conditions and culturally and linguistically diverse persons. The report also covers issues specific to areas of practice such as neuropsychology, industrial-organizational, educational, and personality. Illustrative examples of Internet test use concretize the implications of this new medium of testing and its assessment limitations and potential. The most salient conclusion from this report is that the current psychometric standards, particularly those regarding test reliability and validity, apply even though the way in which the tests are developed and used may be quite different. Still, new methods made possible by emerging technologies will push the boundaries of existing psychometric theory and it is up to psychologists to test and expand the limits of psychometrics to keep pace with these innovations. The Internet provides a tremendous opportunity for testing but with opportunity there is a corresponding need for the ethical and professional use of test results. We encourage psychologists to think creatively about how their research and practice can be improved by Internet testing. Although there are many issues that await resolution, psychologists should look forward to this new medium with excitement and enthusiasm.

Full Report

Clin Neuropsychol. 2002 Feb;16(1):57-63.

Practice effects on the WAIS-III across 3- and 6-month intervals.

Basso MR, Carona FD, Lowery N, Axelrod BN.
Department of Psychology, University of Tulsa, Tulsa, OK 74104, USA.

Fifty-one participants (age M = 24.6; education M = 14.4 years) were administered the Wechsler Adult Intelligence Scale - Third Edition (WAIS-III) at baseline and at an interval of either 3 or 6 months later. Full Scale IQ (FSIQ), Verbal IQ (VIQ), Performance IQ (PIQ), Verbal Comprehension Index (VCI), Perceptual Organization Index (POI), and Processing Speed Index (PSI) scores improved significantly across time, whereas no significant change occurred on the Working Memory Index. Specifically, test scores increased approximately 3, 11, 6, 4, 8, and 7 points, respectively on the VIQ, PIQ, FSIQ, VCI, POI, and PSI for both groups. Notably, the degree of improvement was similar regardless of whether the inter-test interval was 3 or 6 months. These findings suggest that prior exposure to the WAIS-III yields considerable increases in test scores. Reliable change indices indicated that large confidence intervals might be expected. As such, users of the WAIS-III should interpret reevaluations across these intervals cautiously.

PMID: 11992227 [PubMed - indexed for MEDLINE]

Assessment. 2000 Sep;7(3):227-35.

Psychological test usage with adolescent clients: survey update.

Archer RP, Newsom CR.
Department of Psychiatry and Behavioral Sciences, Eastern Virginia Medical School, Norfolk 23507, USA.

In 1991, Archer, Maruish, Imhof, and Piotrowski presented survey findings based on the responses of a national sample of psychologists who performed psychological assessment with adolescent clients. The current survey was designed to update their results by examining the test use practices reported by 346 psychologists who work with adolescents in a variety of clinical and academic settings. These respondents represented an adjusted survey return rate of 36% and predominantly consisted of doctoral prepared psychologists (95%) in private practice settings (51%). The survey respondents had a mean of 13.6 years of post-degree clinical experience, and spent an average of 45% of their clinical time working with adolescents. Survey results reveal a substantial similarity in test usage between the 1991 survey and the current investigation. For example, the Wechsler Intelligence Scales, Rorschach, Thematic Apperception Test (TAT), and Minnesota Multiphasic Personality Inventory (MMPI) remain among the widely used tests with adolescents. However, several changes were also noted including a reduction in the use of the Bender-Gestalt and increases in the use of parent and teacher rating instruments. The current findings are used to estimate the relative popularity of an extensive list of test instruments, compare current findings to 1991 survey results, and to examine several issues related to general effects of managed care procedures and policies on test usage with adolescents.

PMID: 11037390 [PubMed - indexed for MEDLINE]

J Pers Assess. 1998 Jun;70(3):441-7.

The impact of "managed care" on the practice of psychological testing: preliminary findings.

Piotrowski C, Belter RW, Keller JW.
Department of Psychology, University of West Florida, USA.

Although the impact of managed care constraints on assessment practices has received recent attention, a review of the literature found no data-based articles that address this issue. We report survey data on 137 members of the National Register of Health Service Providers in Psychology (Council for the National Register of Health Service Providers in Psychology, 1996) on current testing practices. The majority (72%) reported that their use of tests has changed in the last 5 years due to managed care directives. These clinicians are doing less testing overall and restrict their pool of assessment instruments. The Rorschach inkblot technique (Rorschach, 1942), the Thematic Apperception Test (Murray, 1943), and the Wechsler Intelligence scales (Matarazzo, 1972) were the instruments most noted for disuse. Apparently, practitioners are relying more on short, brief self-report measures that tap targeted symptoms or problem areas, and less on tests that demand considerable clinicians' time. Implications and limitations of the findings are discussed.

PMID: 9760737 [PubMed - indexed for MEDLINE]

J Pers Assess. 1994 Oct;63(2):239-49.

Time requirements of psychological testing: a survey of practitioners.

Ball JD, Archer RP, Imhof EA.
Department of Psychiatry, Eastern Virginia Medical School, Virginia Beach 23462.

Surveys regarding practitioner perceptions of time requirements for psychological testing were mailed to a national sample of clinical psychologists. There were 228 (36%) returns from 630 mailings actually received. On the basis of 151 usable returns from respondents who conduct psychological testing services, data are presented separately for time requirements associated with administering, scoring, and interpreting the 24 most commonly used tests. Data are also presented regarding the composition of typical test batteries and practitioner usage of technician and/or computer assistance in psychological testing. The implications of these data for research and practice are discussed.

PMID: 7965569 [PubMed - indexed for MEDLINE]

J Clin Psychol. 1992 Sep;48(5):666-72.

Neuropsychological battery choice and theoretical orientation: a multivariate analysis.

Retzlaff P, Butler M, Vanderploeg RD.
University of Northern Colorado.

In order to investigate the tests selected by neuropsychologists to make up clinical batteries, a large survey of neuropsychological test usage was cluster analyzed. This provided groupings of tests that are endorsed in common. Theoretical orientation within neuropsychology also was included in the analysis to determine which tests and clusters of tests are more and less associated with the reported orientation of the neuropsychologist. Fifteen clusters of tests were found. Strong and appropriate associations with the eclectic, hypothesis testing, process approach, Halstead-Reitan, Luria, and Benton orientations were seen.

PMID: 1401153 [PubMed - indexed for MEDLINE]

Special Topics

Chronic Pain

See Topics in Chronic Pain


See Topics in Malingering


Obesity Surgery. In press.

Psychological Evaluation of Bariatric Surgery Applicants: Procedures and Reasons for Delay or Denial of Surgery

Steven Walfish
Independent Practice, Atlanta, Georgia

Dana Vance
Georgia State University

Anthony N. Fabricatore
University of Pennsylvania School of Medicine

Background: Psychologists play an important role as members of the bariatric surgery team. The current investigation examined the frequency with which psychologists recommend delay or denial of surgery for psychological reasons, the procedures they use in making their clinical decisions, and the reasons for such conclusions.
Method: A sample of 103 psychologists with experience in conducting presurgical psychological evaluations responded to a brief survey.

Results: There was significant variability in the number of evaluations psychologists complete and the instruments they use to make their clinical decisions. For most candidates, the evaluation results in psychological clearance for surgery. However, approximately 15%, on average, are delayed or denied for psychological reasons. The most common reasons for delaying or denying surgery were significant psychopathology (including psychosis or bipolar disorder), untreated or undertreated depression, and lack of understanding about the risks and postoperative requirements of surgery, which were reported by 51%, 39%, and 30% of respondents, respectively. Several other reasons were reported less frequently and many appeared to be idiosyncratic.

Conclusion: Psychologists differ in their preoperative evaluation practices. Further research is needed to determine the reasons for the variability in clinical decision-making and the long-term medical and psychosocial outcomes associated with the recommendation to delay or deny surgery for psychosocial reasons. When patients receive such a recommendation, they can be encouraged to seek a second opinion from a mental health professional with bariatric expertise.

Reprints available from:
Steven Walfish, Ph.D.
2004 Cliff Valley Way, Suite 101
Atlanta, Georgia 30329

Obesity Surgery. Springerlink New York, May 10, 2008

Limitations of the Millon Behavioral Medicine Diagnostic (MBMD) with Bariatric Surgical Candidates

Steven Walfish (1,4), Edward A. Wise (2) and David L. Streiner (3)

(1) Independent Practice, Atlanta, GA, USA
(2) Mental Health Resources, Memphis, TN, USA
(3) Baycrest Centre, University of Toronto, Toronto, Canada
(4) Present address: 2004 Cliff Valley Way, Suite 101, Atlanta, GA 30329, USA

Received: 17 March 2008  Accepted: 15 April 2008  Published online: 10 May 2008

Background  In this paper, we critique the Millon Behavioral Medicine Diagnostic’s (MBMD) psychometric characteristics for use with bariatric surgery patients.

Methods  The reliability data presented by the test authors in their manual were examined.

Results  The results found 16 of 32 scales of have internal consistency reliability coefficients that do not meet minimal standards for use with bariatric populations. Of the remaining 16 scales, 13 do not have any compelling evidence that they are reliable. We suggest that if a test is not psychometrically reliable then its validity is called into question. Based on these data, 16 of the MBMD’s 32 scales have inadequate reliability and 13 are lacking evidence of reliability. We urge clinicians to carefully consider these findings and the implications for their work with bariatric surgery patients. 


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HIPPA and releasing test data
Martin H. Williams, Ph.D.
Forensic and Clinical Psychologist
Reprinted by permission of the Division of Independent Practice, American Psychological Association.

The 2002 APA Ethics Code, which takes effect on June 1, 2003, differs substantially from the current 1992 Code regarding release of test data. Most of the changes in sections 9.04 and 9.11 of the new Code were implemented to comply with HIPAA. Psychologists, under the new Code and HIPAA, must release patients’ test data pursuant to a signed patient request to do so. This represents a major change from the old Code.

The old Code held, in section 2.02b, that psychologists had a duty not to release test data to untrained individuals who might misuse it. This was stated in the Code as follows:

“This includes refraining from releasing raw test results or raw data to persons, other than to patients or clients as appropriate, who are not qualified to use such information.”

A specific example of those “not qualified to use such information” might be attorneys. Psychologists who carried out psychological assessments in the context of litigation would customarily refuse to release their test data to attorneys, who might misunderstand and misuse the findings in court. Instead, psychologists would insist on releasing the test data only to another psychologist who would be designated by the attorney seeking the data. Often, though, psychologists would be compelled by court order to release the data anyway.

The new Code recognizes that HIPAA gives patients a great degree of control over their medical information. Psychologists can no longer refuse to release test data and must release it to anyone the patient designates, regardless of the psychologist’s opinion regarding the qualifications of the individual who would receive the data. The new Code states, in Section 9.04, the following:

“Pursuant to a client/patient release, psychologists provide test data to the client/patient or other persons identified in the release.”

Test data is defined as follows:

"The term test data refers to raw and scaled scores, client/patient responses to test questions or stimuli, and psychologists’ notes and recordings concerning client/patient statements and behavior during examination."

The Code goes on to state that psychologists can hold back release of test data if they believe it will lead to harm or misuse or misrepresentation. This is stated as follows:

“Psychologists may refrain from releasing test data to protect a client/patient or others from substantial harm or misuse or misrepresentation of the data or the test, recognizing that in many instances release of confidential information under these circumstances is regulated by law.”

However, for those psychologists who come under HIPAA, concerns about misuse or misrepresentation do not apply, and are not sufficient reason to refuse to release test data. This is explained by Celia Fisher, Ph.D., director of the Fordham University Center for Ethics Education, Vice-Chair of the Board of Trustees for the APA Insurance Trust, and Chair of APA's Ethics Code Task Force. Dr. Fisher is the architect of the latest Code revision and was referenced in a recent article on the new Ethics Code that appeared in the APA Monitor.

“The 2002 code does permit psychologists to withhold test data to protect the client from ‘substantial harm or misuse or misinterpretation of the data or the test.’ However, Fisher cautions that HIPAA does not recognize the misuse or misinterpretation of tests as a legitimate reason to withhold health records, so psychologists should take caution in such situations.” (APA Monitor, January, 2003, p. 62).”

The new Code also distinguishes between “test materials,” which psychologists are required to protect from release, and “test data” which must be released under certain circumstances. Test materials and test security are covered in section 9.11 as follows:

“The term test materials refers to manuals, instruments, protocols, and test questions or stimuli and does not include test data as defined in Standard 9.04, Release of Test Data. Psychologists make reasonable efforts to maintain the integrity and security of test materials and other assessment techniques consistent with law and contractual obligations, and in a manner that permits adherence to this Ethics Code.”

Although psychologists are required to guard the integrity and security of test materials, they should note that any test materials that contain patient/client responses become redefined as test data and, hence, become releasable. This is stated in section 9.04 as follows:

“Those portions of test materials that include client/patient responses are included in the definition of test data.”

As an example, the Rorschach scoring sheets contain small representations of the actual Rorschach plates. A blank scoring sheet would be considered “test materials” and would be subject to security. In contrast, once the same scoring sheet contains “notes and recordings concerning client/patient statements and behavior during examination,” it would become “test data” and would be releasable.

Finally, since ethical and legal decision-making sometimes involves very complex circumstances, always consult with colleagues or appropriate authorities whenever the ethical or legal course of action seems unclear.

The new Code was published in the December, 2002, American Psychologist and is online at

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