What three criteria are commonly used to evaluate psychological assessment procedures?

Psychological Evaluation

The psychological evaluation of ED addresses psychogenic contributions to clinical presentations, essentially psychological and interpersonal factors interfering with erectile function. These aspects should not be underestimated, and it is well documented in population studies that ED is associated with anxiety, depression, low degrees of self-esteem, negative outlook on life, self-reported emotional stress, and a history of sexual coercion (Feldman et al., 1994;Laumann et al., 2007). The urologist's role in initiating a psychological evaluation is not necessarily complicated, and a basic attempt to use queries about a patient's psychological health is helpful in assessing sexual health (Rowland et al., 2005). A two-question scale may be used in every day clinical practice: “During the past month, have you often been bothered by feeling down, depressed, or hopeless? During the past month, have you often been bothered by little interest or pleasure in doing things?” (Whooley et al., 1997).

The diagnostic interview is central to the psychological evaluation, and this process should be handled in a straightforward manner. Readily discernible causes of sexual dysfunction may be elicited, such as fear of failure, performance anxiety (for widowers, this may include complex interactions of dating, new partners, and unresolved mourning/guilt), insufficient sexual stimulation, loss of attraction for the partner, adjustment to a chronic illness or surgery, and relationship conflicts. In addition, causes that are less immediately discernible may be identified to include unresolved parental attachments, sexual identity issues, history of sexual trauma, occurrence of extramarital affairs, and cultural-religious taboos (Laumann et al., 2007;Leach and Bethune, 1996).

The interviewer should be mindful of the possibility of a primary psychogenic ED presentation (Turnbull and Weinberg, 1983). In the absence of organic risk factors, a primary psychogenic ED causation may be suspected. Further support for the diagnosis may follow the confirmation of noncoital erections (i.e., masturbatory, nocturnal, or when awakening). Clinical subtypes of psychogenic ED may be further identified: (1) generalized versus situational and (2) lifelong (primary) versus acquired (secondary, including substance abuse or major psychiatric illness).

The interviewer should also inquire about relationship factors (Rosen, 2001). Relationship conflicts may be the source of psychogenic ED or otherwise may exacerbate organic ED. A couple's issues include intimacy and trust, status and dominance, loss of sexual attraction, ability to achieve sexual satisfaction without erection, and communication problems. Not only is important information derived from interviewing the patient alone, but also interviews with the couple together and of partners separately may provide insight.

Complex intrapsychic causes of sexual dysfunction are often relevant for the ED presentation and may become evident during the diagnostic interview. The clinical history may show a significant traumatic life experience, cultural or religious strife, compulsive sexual behavior, or neurotic process. It may suggest the presence of serious psychiatric comorbidities, such as substance abuse, depressive symptoms, anxiety disorder, or personality disorder. The urologist may not have the professional background, comfort, or time to address these issues definitively, and a referral to a psychological expert for further attention would be appropriate.

Measurement and clinical science in psychological assessment

There are three primary purposes of psychological assessment in clinical settings. The first purpose is to identify, operationally define, and measure a client’s adaptive and maladaptive behaviors and treatment goals. A second purpose is to identify, operationally define, and measure factors that influence a client’s adaptive and maladaptive behaviors and attainment of treatment goals. A third purpose is to integrate assessment information in order to design and evaluate interventions that can improve a client’s quality of life. Consider, for example, the challenging assessment tasks confronting a psychologist with a client who is experiencing intense panic, social isolation, and frequent conflicts with a partner. First, the clinician must select an assessment strategy that will effectively capture and evaluate these multiple problems across the course of the intervention. Further, the assessment strategy must enable the clinician to identify important causal relations associated with these problems in order to understand why the client is experiencing isolation, panic episodes, and conflict. Finally, the assessment strategy and resultant information must be synthesized and then used to design an intervention that will modify causal relations in order to promote a reduction in panic episodes, isolation, and conflict and simultaneously promote an increase in adaptive behaviors. The aforementioned assessment goals exemplify the clinical and research applications of psychological assessment—the systematic measurement of a person’s behavior, variables associated with variance in behavior, and the inferences and judgments based on those measures (see multiple definitions of psychological assessment in Geisinger, 2013; Haynes, Smith, & Hunsley, 2019). We use the term “behavior” to include overt actions, emotions, cognitive processes, and physiological responses. Additionally, the term “variables” includes behavioral, environmental, social, and biological variables.

Psychological assessment paradigms differ in their fundamental assumptions, applicability, utility, and preferred assessment strategies. A psychological assessment paradigm refers to the assumptions, beliefs, values, hypotheses, and methods endorsed within an assessment discipline.1 All psychological assessment paradigms are at least partially explanatory. That is, they are designed to elucidate the causes of human behavior. For example, some psychodynamic paradigms may assume that the panic, social isolation, and conflict of the aforementioned client significantly arises from historical, developmental, unconscious, and intrapsychic processes. Within this paradigm it is assumed that these causes can be best identified using the client’s verbal reports of perceptions when asked to view ambiguous stimuli, such as a Rorschach or Thematic Apperception Test. Some personality-based paradigms assume that the client’s problems often result from temporally and situationally consistent patterns of cognitive, emotional, and behavioral dispositions that can be identified through the person’s responses to items on a self-report symptom inventory. Edited books by Hersen (2006) and Geisinger (2013), and other chapters in this book, provide overviews of the conceptual foundations and assessment strategies associated with various psychological assessment paradigms and subparadigms.

This chapter focuses on clinical applications of behavioral assessment with adults for the purposes of identifying behavior problems, treatment goals, and factors that affect them. The ultimate purpose of behavioral assessment in a clinical context is to facilitate the design of a maximally effective intervention for a client. Psychological assessment, and the behavioral assessment paradigm, also play an important role in forensic evaluations (Hart, Gresswell, & Braham, 2011; Heilbrun, DeMatteo, Brooks Holliday, & LaDuke, 2014), parenting competence evaluations in custody, abuse, and neglect cases (Budd, Connell, & Clark, 2011), neuropsychological assessment with traumatic brain injury (Granacher, 2015), personnel selection and evaluation (Guion, 2011; Hough & Oswald, 2000), psychiatric diagnosis (American Psychiatric Association, 2013), and couples and family therapy (Snyder, Heyman, Haynes, Carlson, & Balderrama-Durbin, 2016).

All psychological assessment paradigms involve the measurement of behavior. Although information from psychological assessment is partially qualitative, such as in a clinician’s judgments about a client drawn from interviews, most psychological assessment paradigms also involve the assignment of quantitative values (i.e., measures/scores) to dimensions of a person’s behavior. Dimensions are quantitative aspects of a phenomenon and can include the severity and duration of depressed moods, the amount of alcohol consumed in a week, the level and variability of resting diastolic blood pressure, the frequency and recency of lifetime traumatic life events experienced by a person, the likelihood of a positive contingency for behavior in a classroom, or the onset latency of sleep at bedtime.

In contrast to other psychological assessment paradigms, behavioral assessment emphasizes the measurement of behavior in context (Eckert & Lovett, 2013; Haynes, O’Brien, & Kaholokula, 2011; O’Brien, Kaholokula, & Haynes, 2016). Additionally, the strength of functional relations between behavior and contextual variables is an important quantitative dimension for designing interventions in behavioral assessment. This emphasis on quantitative measurement is a foundation of behavioral assessment in the clinical sciences.2 Without precise measurement, hypothesized functional relations for behavior problems cannot be identified and tested; intervention effects cannot be evaluated; the precision, utility, and applicability of an assessment and intervention paradigm cannot evolve; and clients will not receive the best services.

Behavioral assessment also emphasizes quantification because it strengthens the precision, validity, and utility of clinical judgments and inferences derived from nomothetic research. Measures that have insufficient psychometric quality (e.g., those with poor construct validity, precision, or sensitivity) can lead to erroneous and sometimes harmful judgments about persons seeking treatment for behavior problems. Poor quality measures can also increase the likelihood that a clinician will make errors in clinical judgment, such as misidentifying a client’s problems and treatment goals, drawing incorrect inferences about the causes of behavior, designing ineffective interventions, and inaccurately estimating the effectiveness of interventions.

As discussed in other sources (Fisher, O’Donohue, & Haynes, 2018; Haynes et al., 2019), the psychometric properties of measures from an assessment instrument set upper limits on their utility for clinical judgments. Estimates of causal relations in clinical assessment are particularly important because many interventions attempt to modify causal variables that are judged to exert important influences on behavior problems or goal attainment. Empirically based and quantitatively focused measurement strategies enable the assessor to more adequately operationalize a client’s behavior problems and goals, predict the client’s future behavior, draw inferences about the factors that affect the client’s behavior problems, and identify potential moderators of treatment goal attainment. In turn, these judgments help the clinician to select the best intervention for the client and to evaluate its process, time course, and effectiveness.

Diagnostic Psychologic Testing

The formal diagnosis of ID requires the administration of individual tests of intelligence and adaptive functioning.

TheBayley Scales of Infant and Toddler Development (BSID-III), the most commonly used infant intelligence test, provides an assessment of cognitive, language, motor, behavior, social-emotional, and general adaptive abilities between 1 mo and 42 mo of age. Mental Developmental Index (MDI) and Psychomotor Development Index (PDI, a measure of motor competence) scores are derived from the results. The BSID-III permits the differentiation of infants with severe ID from typically developing infants, but it is less helpful in distinguishing between a typical child and one with mild ID.

The most commonly used psychologic tests for children older than 3 yr are the Wechsler Scales. TheWechsler Preschool and Primary Scale of Intelligence, Fourth Edition (WPPSI-IV) is used for children with mental ages of 2.5-7.6 yr. TheWechsler Intelligence Scale for Children, Fifth Edition (WISC-V) is used for children who function above a 6 yr mental age. Both scales contain numerous subtests in the areas of verbal and performance skills. Although children with ID usually score below average on all subscale scores, they occasionally score in the average range in one or more performance areas.

Several normed scales are used in practice to evaluate adaptive functioning. For example, theVineland Adaptive Behavior Scale (VABS-3) uses semistructured interviews with parents and caregivers/teachers to assess adaptive behavior in 4 domains: communication, daily living skills, socialization, and motor skills. Other tests of adaptive behavior include theWoodcock-Johnson Scales of Independent Behavior–Revised, the AAIDD DiagnosticAdaptive Behavior Scale (DABS), and theAdaptive Behavior Assessment System (ABAS-3). There is usually (but not always) a good correlation between scores on the intelligence and adaptive scales. However, it is important to recognize that adaptive behavior can by influenced by environmentally based opportunities as well as family or cultural expectations. Basic practical adaptive skills (feeding, dressing, hygiene) are more responsive to remedial efforts than is the IQ score. Adaptive abilities are also more variable over time, which may be related to the underlying condition and environmental expectations.

Increasing Awareness of Anger and Anger–Alcohol Connections

Some clients are emotionally disengaged and have limited insight into how they feel, think, and react. Rarely do they appear for therapy on their own. They are often referred by others—spouses, employers, and schools—because of the impact of their anger and alcohol use on others.

Readiness enhancement activities focus on the clients becoming more aware of how they feel, think, and express themselves when angry and how alcohol is interlaced in this fabric. For example, clients may be encouraged to self-monitor anger and anger expression. Clients might keep track of the situations that elicit anger, the thoughts, and feelings experienced, along with how anger was expressed. Over time, they might add monitoring the immediate and delayed consequences to themselves and others.

In addition, clients might be encouraged to ask others in their immediate environment for feedback on their anger. Others frequently notice very specific things of which clients are unaware. These might include changes in level or tone of voice, type of language used, body language like frowning or dirty looks and glares, or certain types of behavior such as stomping off, clenching teeth, or slamming doors. Once such behaviors are identified, then they can be added to self-monitoring.

In session, the therapist may create a strong anger experience by having the client visualize or reenact some angering event. When anger is experienced, the therapist and client explore the feelings, thoughts, images, urges, and real behavior involved. Doing this several times increases the client’s immediate experience and awareness of anger and how this may relate to alcohol use.

Standardized psychological assessment instruments (see Chapter 5: Assessment Instruments and Considerations) may be used in at least two ways. First, clients’ scores may be compared normatively to others. Clients can then be asked to explore how their scores compare to other people and why. Second, clients can be asked to explain why they marked specific items the way that they did. Since items tend to be somewhat general, clients can be asked for specific examples and how they think, feel, and express anger-related emotions in those situations.

Therapist tip

Therapists should monitor their surprise when clients have low insight and understanding of their emotions and behaviors. Therapists as a group tend to be emotionally oriented and self-aware. Some clients are not. These clients often need frequent, gentle, repeated exposure to become more self-aware.

Psychological Testing

If necessary, psychological testing may be performed.4,67 Some people have little difficulty adapting to the idea of losing a limb, whereas others have great difficulty accepting the fact that they have lost a limb. This acceptance may be related to how the patient lost the limb (trauma [suddenly] or from long-term problems, such as peripheral vascular disease), how active and independent the patient was before the amputation, or the patient’s age (in general, children adapt much better to amputation and a prosthesis than adults). Sometimes, a psychological screening test, such as the Minnesota Multiphasic Personality Inventory (MMPI), may be used to determine the presence of depression, situational anxiety, and possible hysterical reaction to limb loss.54 Research has shown that there is a significant need to improve psychological screening and early treatment of anxiety symptoms before amputation surgery, as well as screening for depression and traumatic stress symptoms following lower limb amputation. Social support is recommended to promote adjustment to the amputation.68

Access to care and telehealth

Three key barriers to receiving psychological assessment are geographic distance from a qualified provider, the cost of assessment, and wait times between requesting an appointment and actually being seen. The growth of telehealth in medicine has far outpaced the exploration of remote assessment in psychology. According to the website eVisit (eVisit, 2016), in the year 2018, 7 million patients will receive services through telemedicine and as of August 2015, 29 states require health insurers to pay for telemedicine services. Unfortunately, clinical neuropsychology has fallen way behind in addressing this need.

A new medium for delivering psychological assessments has emerged as a result of the Internet. Recent surveys have revealed that over 3.1 billion people now have access to the Internet. The distribution of this number by country reveals the following: China=642 million; United States=280 million; India=243 million; Japan=109 million; Brazil=108 million; Russia=84 million, among others (Stats, 2015). In the United States 86.75% of residents have access to the Internet. Telemedicine is an area that has developed for the use and exchange of medical information from one site to another via electronic communications, information technology, and telecommunications. When researchers are discussing “telemedicine,” they typically mean synchronous (interactive) technologies such as videoconferencing or telephony to deliver patient care. When the clinical services involve mental health or psychiatric services, the terms “telemental health” and “telepsychiatry” are generally used (Yellowlees, Shore, & Roberts, 2010).

Normal aging

A key issue in psychological assessment of elderly patients is the need to discriminate between normal age-related intellectual changes and those changes that are clinically significant. The aged are at least as varied a population as teens, college students, or middle-aged individuals. Some will change very little as they age, others a great deal, and still to others the change will be in only a few areas. Therefore it is useful to know what cognitive functions normally decline with age as well as what impairments are common for age-related conditions like AD.

Although some cognitive functions decline as a part of the normal aging process (Wechsler, 1997a, 1997b), the extent and pattern of the decline varies according to both the individual and the type of function being examined. Cognitive abilities that deal with well-rehearsed, overlearned information change very little across the lifespan. Cognitive abilities such as vocabulary remain preserved as individuals age. In fact, more recent evidence suggests that these abilities may even improve slightly in later years (Salthouse, 2012). Other cognitive functions, including memory, executive abilities, and processing speed tend to decline as individuals age (Harvey & Dahlman, 1998; Salthouse, 2012).

Memory assessments typically focus on declarative or nondeclarative memory abilities. Declarative memory, or explicit memory, is the recall or recognition of facts or events, such as knowing a dog is an animal or the name of your first-grade teacher. Declarative memory has been shown to decline with normal aging (Ronnlund, 2005). Nondeclarative memory, or implicit memory, does not require conscious thought and is often procedural in nature, such as riding a bike or brushing your teeth. Nondeclarative memory is not as susceptible to age-related declines in the same way as declarative memory (Cargin, 2007; Price, 2004).

Executive functioning encompasses varied higher order abilities including planning, reasoning, cognitive flexibility, abstraction, inhibition, and initiation (Lezak et al., 2012).

The considerable individual differences in cognitive changes with aging indicate not only the difference between normal and impaired changes over time, but also differences between normal and successful changes as individuals age. Using the example of normative standards on the Logical Memory subtest from the Wechsler Memory Scale (Wechsler, 1997b), it becomes clear that those individuals who performed at high levels (99th percentile) in their youth on a variety of cognitive domains tend to decline very little throughout their lifespan. Individuals who performed at lower levels (15th percentile) in their youth exhibit not only a decline, but a sharper decline than individuals in the upper percentile scores. The individuals at the top of the distribution consistently outperform those at the lower levels by a progressively greater extent as they become older.

The idea that normal adults who perform at higher baseline levels of intellectual function will exhibit little cognitive decline with age is supported by Rowe and Kahn’s (1987, 1997) reports on successful aging. They define successful aging as including three main components: low probability of disease and disease-related disability, high cognitive and physical functioning, and active engagement with life. Continuing engagement with life has two major elements: maintenance of interpersonal relations and productive activities. Membership in a social network is an important determinant of longevity (House, Landis, & Umberson, 1988). Network membership research (Cassel, 1976; Glass, Seeman, Hertzog, Kahn, & Berkman, 1995; Kahn & Byosiere, 1992) has demonstrated that two types of supportive transactions may be prophylactic in aging: socio-emotional and instrumental. Socio-emotional transactions include expressions of respect and affection, while instrumental transactions are comprised of direct giving of services or money.

It is critical in the assessment of elderly individuals to take into account the relative nature of observed deficits; relative, that is, to the patient’s own previous levels of functioning. Current functioning, in terms of engagement in life as well as presence/absence of disease and cognitive normalcy, must be viewed against the individual’s overall level of previous functioning. Even a clinical interview of the patient combined with neuropsychological testing may be not be enough to fully assess what the patient may have been like prior to the onset of symptoms (Harwood, Hope, & Jacoby, 1997a; Harwood, Hope, & Jacoby, 1997b; Williams, 1997). For this reason, there is a trend to include caregiver ratings of patients as part of the assessment process. There are many caregiver ratings available for use that cover a variety of abilities such as activities of daily living [Caregiver Assessment of Function and Upset (CAFU), Gitlin et al., 2005; Bristol Activities of Daily Living Scale (BADLS), Bucks et al., 1996; Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE), 1989], behavioral issues (Frequency of Behavior Problems Scale, Neiderehe & Fruge, 1984), and quality of life [DEMQOL, Smith et al., 2007; Alzheimer’s Disease-related Quality of Life scale (Qol-AD), Logsdon et al., 1999].

Assessment

The authors intended to conduct psychological assessments of the children in the Wellness workshops on the anniversaries of Hurricane Katrina. Neurological assessments of cohorts of survivors of natural disasters were also planned at the time of Superstorm Sandy that hit New York and New Jersey in the United States. However as many researchers find, the logistics of such situations prioritize the need for intervention over assessment. Such measurement in the future would be extremely valuable for planning purposes. These results could form a more holistic assessment of survivors’ status, including comparing and integrating neuropsychological results (e.g., measures of executive functioning) with psychological functioning (e.g., measures of anxiety and depression).

Because anxiety is a primary factor interfering with problem-solving skills, assessment is critical. A resiliency questionnaire was developed by Pastrana and Nemeth (Nemeth & Olivier, 2017, p. 68) to evaluate resilience and coping in the aftermath of the Louisiana Great Flood of 2016. This was orally administered to very young children, whereas adolescents and adults completed the questionnaire on their own.

Assessments need to be conducted over time as the long-lasting neurocognitive effects of such environmental traumas deserve more longitudinal examination and study (Brandes et al., 2002; Helton & Head, 2012; Liu et al., 2012; Nemeth, Hamilton, et al., 2012).

Abstract

This chapter explains the process of conducting psychological assessments from an evidence-based biopsychosocial approach. Included in the discussion are guidelines for considering the basic purposes of assessment, appropriate breadth of assessment, best sources for reliable and useful assessment information, thoroughness of that information, severity of patient needs and strength of resources, and process of integrating all the assessment data collected. The discussion focuses on the conceptual rationale and framework for conducting psychological assessment generally, across all clinical populations and all general and specialized areas of practice. These foundational issues apply across all types of assessment, even though psychological assessment is conducted for a wide variety of clinical, legal, educational, and other purposes and one’s approach to assessment needs to be customized to each individual case. Case examples of the biopsychosocial approach to assessment are also presented.

Conclusion

This chapter provided an update on psychological assessment of neurocognitive disorders in older adults across a range of domains, including cognition, capacity, and emerging psychological constructs relevant to the lives of people living with dementia and cognitive impairment. The assessment of cognition remains one of the most common reasons for assessment in older adults, along with assessment of the capacity to make important decisions. The field of clinical geropsychology and neuropsychology has made tremendous contributions toward accurate identification of cognitive decline and ways to maintain and improve the quality of life in people experiencing neurocognitive disorders. The coming years will witness the continued development of assessment methods that minimize time demands and maximize accuracy and lead to maintenance of quality of life for an increasingly diverse and large population of older adults.