DIAGNOSIS & ASSESSMENT
The DSM-IV Multiaxial Assessment
The fourth edition of the Diagnostic and Statistical Manual of Mental Disorder (DSM-IV), published by the American Psychiatric Association in 1994, is basic instrument in making and reporting formal mental diagnosis all over the world. It has gone through 5 revisions since it was published first time. A text revision of DSM-IV (DSM-IV-TR) was published in 2000. The DSM-IV attracts controversy and criticism as well as praise. The major advantage of DSM-IV is its multiaxial system divided into five Axes:
Axis I – Major clinical disorders Axis II – Stable, enduring problems Axis III – Medical conditions related to abnormal behavior Axis IV – Psychosocial problems Axis V – Global clinician rating of adaptive functioning
Following are the main characteristics of DSM-IV:
- Five axes describe full clinical presentation.
- Clear inclusion and exclusion criteria have been described for disorders.
- Disorders are categorized under broad headings.
- Empirically grounded prototypic approach to classification is adopted.
- The major advantage in using this multiaxial classification system is that it ensures that attention is given to certain types of disorders, aspects of the environment and areas of functioning that might he overlooked if the focus were on assessing a single presenting problem.
- In addition to diagnosing the client as to mental health, personality disorders, and physical condition, scales have been developed to help the clinician make consistent determinations of the severity of the psychosocial stressors (Axis IV) and the global assessment of functioning (GAF) (Axis V). When using the GAP on Axis V, the clinician should record a current determination and an estimate of the highest GAF for the past year.
- Thus, rather than give a one- or two-word label to a diagnosed person, such as “depressive neurosis,” as was the practice prior to the adoption of the DSM , the practitioner now can come up with a diagnosis such as the following:
DSM-IV: An Example
Axis I: 296.24 Major depression, single episode; severe without psychotic features Axis II: 301.60 Dependent personality disorders Axis III: Diabetes Axis IV: Psychosocial stressors: separated from spouse; conflicts with children Axis V: Current GAF = 44 Highest GAF past year = 55
Use of Tests: A Controversial Issue
Among the ranks of counseling professionals, there also has been a great deal of controversy related to the nature and appropriateness of assessment and diagnosis. Leo Goldman, an expert in the use of tests in counseling, indicates that “there is increased feeling that the use of tests in counseling on the whole is a sad disappointment and that in recent years matters have actually become worse” (Leo Goldman, 1972, p. 213). However, a full understanding of assessment concepts and practices is necessary whether or not counselors choose to use tests and other diagnostic instruments. It is necessary to communicate with those who do use these tools in case conferences, referrals, and correspondence, as well as to understand the professional literature.
Sugarman (1978) points out that the objections to the use of assessment and appraisal techniques are based on five different grounds:
- It is reductionistic, reducing the complexity of the person into diagnostic categories.
- It is artificial.
- It ignores the quality of the relationship between the examiner and the test taker.
- It judges people, casting a label on them.
- It is overly intellectual, relying on complex concepts, often at the expense of a true understanding of the individual.
Businesses and industries have used tests and inventories for many years as primarily aids in the selection of job candidates. Testing has been and continues to be a general accepted function in mental health centers, employment offices, and other private public clinics and agencies. Tests and their use have not changed significantly since objections were raised in 1970s and earlier. Basically, what seems to have changed is the overall attitude of people toward tests. Recent Gallup polls of the U.S. population indicate a general acceptance in the use of standardized tests. In Pakistan also, people feel more satisfied as clients if tests are used for assessing their psychological problems or for career counseling. Assessment procedures of all types are now an accepted form of contemporary society.
Counselors use a variety of techniques and procedures in the process of gathering data. Some can be highly structured and designed so that each time a procedure is used the process is exactly the same. This is called using a standardized format. A less rigorous but also important way of obtaining information is through the use of nonstandardized instruments. Such tools may be idiosyncratic, specific only to a given client or set of circumstances, with a minimal chance for replication. A brief description of some nonstandardized formats follows:
- Observation is the most fundamental assessment procedure. Highly developed skills in the use of other assessment tools are negated if the powers of observation are not well developed.
- Signs vs. samples of behavior: Behavioral observation is common to all psychological approaches. It is the use that is made of the data that distinguishes between approaches. In the psychodynamic orientation behaviors serve as indirect signs of hypothesized underlying dispositions and motives. Behavioral approaches treat observed behavior as a sample, and the focus is on how the specific sample is affected by variations in the stimulus conditions.
- Importance in counseling: Half of the message that a client communicates is nonverbal. Counselors should be attuned to all of the nonverbal cues available and note the discrepancies and inconsistencies between these and verbal messages.
Gibson and Mitchell (1981) describe casual observation and two higher levels:
- Casual Information Observation:
- The daily unstructured and usually unplanned observations that provide casual impressions. Nearly everyone engages in this type of activity. No training or instrumentation is expected or required.
- Guided Observation:
- It is planned and directed observations for a purpose. Observation at this level is usually facilitated by simple instruments such as checklists or rating scales. This is the highest level used in most counseling programs. Some training is desired.
- Clinical Level:
- These are the observations, often prolonged, and frequently under controlled conditions. Sophisticated techniques and instruments are utilized, with training usually at a doctoral level.
The purpose of a checklist is to focus the observer’s attention to the presence or absence of predetermined characteristics. A simple check mark or “yes” or “no” indicates whether the characteristic is observed.
• A rating scale is a special kind of checklist on which the observer can note not only the presence of a given characteristic or attribute but also the degree to which it manifests itself. Rating scales can be particularly helpful in making observations of individuals. A sample rating scale format is given below:
1___ 2____ 3____ 4_____ 5____ Never Rarely Sometimes Usually Always
- The benefits of rating scales and checklists include having an easy to use approach for making objective observations of selected characteristics. They also offer the possibility of comparing the observations of more than one observer using identical criteria.
- There are also some limitations in the use of such instruments, including
1) often poor and unclear directions for the scales’ use;
2) a failure to define terms adequately;
3) limited scales for rating;
4) items that tend to prejudice how one responds;
5) overlapping items;
6) excessive length;
7) tendency to endorse middle rating, which means playing it safe by giving a middle or average rating to everyone on every item;
8) biased ratings.
• Anecdotal reports are subjective descriptions of a client’s behavior at a specific time or for a specific situation. These reports generally start out by noting the time, date, and place. These are followed by a general description of the event and the manner in which the client participated in it. The report ends with observer comments that may be evaluative in nature.
They can be short enough to be filled out by a client a few minutes before the first visit to a counselor and can be designed to provide a variety of data. A few sellf-reported instruments are described below:
Questionnaires can be used to collect vital information to determine the counseling or consulting needs of groups or organizations.
An interview is a form of questionnaire that is read to a client by a counselor. The client is encouraged to respond as directly as possible to all questions, and the counselor has the opportunity to ask for clarification or elaboration of any question. Such an interview may be required of all first time clients by a mental health agency as part of a case management process. One purpose is to assign the client to the staff member or program that best meets the needs of the client. Another type of interview focuses on a specific issue or syndrome, such as depression or alcoholism, and the questions are designed to highlight related aspects of behavior. Careful records, including tape recordings, are generally made in the case of interviews to be sure that all comments are noted and that nonverbal behaviors are also included.
Personal Essays and Autobiographies
More extensive written material, such as having a client write a personal essay on a given topic (for example, “the kind of job that I believe I would enjoy the most”), is another way to gather useful data in a short time and can be given as a homework assignment. A more elaborate version of the personal essay is to have the client write an autobiography.
Having a client keep a journal on a regular basis and noting new issues and changes provides another method of obtaining self-report data on an ongoing basis. A journal is more than a diary or log of daily events. It is an opportunity to record thoughts and feelings.
Standardized Assessment Techniques
There is also a need for assessment devices that can be administered in a consistent manner to a wide variety of people. Many different tests, usually published instruments, are standardized. A standardized test is one that has detailed, specific directions for the administration of the instrument, including the exact words with which to introduce the instrument to the client and any time limits. The procedures for scoring are also specifically detailed so that all people scoring a given test will record results in the same manner. There are two basic categories of standardized tests: norm-referenced and criterion-referenced tests:
Another characteristic of most published instruments is that they have norms to which test scores can be compared. Norms, or normative tables, are generally included in the manual accompanying published tests. These tables provide data on the performance of various groups of people taking the same instrument during the period of time when the test was being developed. Norm groups are often nationwide samples, but they can also be regional or local. Test items are carefully tested and analyzed before being included in the final instrument. The reliability, or consistency, of scores and the instrument’s validity, the ability of a test to measure what it purports to measure, are determined for constructing a standardized measure.
Three concepts, reliability, validity and standardization, determine the Value of assessment. Figure given below illustrates this:
A criterion-referenced test is a test that is used to ascertain an individual’s status with respect to a well-defined behavioral domain. A well-constructed criterion-referenced test yields a clear description of what a client can or cannot actually do.
Types of Standardized Instruments
Assessment instruments have been developed to measure virtually all aspects of humans. Published standardized instruments are generally catalogued and reviewed in a series of volumes entitled the Mental Measurement Yearbook.
Achievement tests are designed to assess what a person has learned in a given subject, such as music, mathematics, or German, as a result of specific curricular experience. The instrument can be designed for one subject or can include a variety of subjects. Examples of the latter type of instrument are the Iowa Tests of Basic Skills and the Metropolitan Achievement Tests.
Aptitude (Intelligence) Tests
A test used as a predictor of some future performance is called an aptitude test. Aptitude tests are designed to measure the propensity to perform certain tasks that may not already be a part of a person’s repertoire. Aptitude tests can be considered a form of ability testing, measuring the potential ability that a person has in a specific area. Intelligence tests can be considered measures of general ability. There is no generally agreed-on definition of intelligence; however, most intelligence tests are designed to be indicators of the ability to be successful in school. Intelligence tests are used primarily as screening devices in counseling and are followed by more specialized aptitude tests that assess aptitude in particular area.
Examples of Aptitude Tests:
- Differential Aptitude Test (DAT)
- Aptitude Classification Test (ACT)
- Scholastic Aptitude Test (SAT) which was renamed the Scholastic Achievement Test in 1993.
Examples of Intelligence Tests:
- Stanford-Binet Intelligence Scale: Stanford Binet is the father of American Intelligence tests. It is a revision of Binet-simon scales, and was published in 1916 by Terman and colleagues. It has traditionally been used with children than adults. In 1986, it underwent a fourth revision to include More material for adults.
- Wechsler Adult Intelligence Scale-Third Edition (WAIS-III): It is the most popular test of intelligence which is used worldwide for assessment and research.
Problems with intelligence tests
According to Anastasi (1982) intelligence tests are usually overloaded with certain functions, such as verbal ability and they are validated against scholastic ability.
Personality Assessment Instruments
Thorndike and Hagen (1977) describe several characteristics of personality other than abilities that can be identified and assessed, including temperament, character, adjustment, interests, and attitudes:
Attitude questionnaires are designed to assess the intensity of a person’s sentiments with regard to a specific subject such as women’s liberation, abortion, or gun control. A major limitation of questionnaires is their low reliability. The responses people make to the statements on a questionnaire may not correspond to their actions.
Interest/ Career Inventories
- Instruments designed to determine patterns or tendencies that an individual has with regard to personal interests are called interest inventories. Interest inventories can be designed for almost any purpose—to determine interest in music, art, or athletics. Many inventories have been designed for use in counseling and, in particular, for use in helping clients make career choices. Interest instruments are usually constructed in the form of checklists or forced choice questions, on which the client has to select a preference from a choice of activities.
- There is generally a very low correlation between interest and ability, so having an interest in an area does not guarantee success in it. The reverse is also true. Having a high degree of ability in an area does not guarantee that a person will be satisfied with a career in that area. However, some people maintain that a person’s achievement in a learning situation or a career is greatly influenced by his interests (Anastasi, 1982).
Strong Vocational Interest Blank (SVIB)
Instruments that measure career/ interests began in a systematic and standardized way with the 1928 publication of SVIB. The revised form, SVII (Strong Vocational Interest Inventory) includes description about 207 occupations. The manual suggests ways to deal with different cultures and special populations and has more specific and general ways of examining people’s interests.
Self-directed Search (Holland, 1985) It is self administered, self scored and sometimes self interpreted. A total of 228 items are divided into three sets: activities, competencies, and occupations. After scoring the client examines a three-letter occupational code.
Kuder Occupational Interest Survey (1939)
Kuder Occupational Interest Survey (1939) provides 10 broad career areas: social services, persuasive, clerical, computational, musical, artistic, literary, mechanical, outdoor, and scientific.
California Occupational Preference System
A number of self-report instruments have been developed that are related to personal adjustment and temperament, such as the Guilford-Zimmerman, MMPI, etc. There are two types of personality tests: objective and projective
The scoring in objective tests is independent of any judgment of the scorer. A few examples are:
Woodworth’s Personal Data Sheet
The prototype of personality test was a self-report inventory developed during World War I.
The most widely used test in the world. Norms have been developed according to geographically end ethically diverse population. It has 10 clinical and 3 validity scales. The client responds to 567 items, and answers in three ways: true, false, cannot say.
Edwards Personal Preference Schedule (EPPS, 1938)
The EPPS is based on the need-press theory of personality developed by Henry Murray (1938). There are 225 forced choice items that examine the strength of 15 individual needs in relation to a person’s other needs.
Myers Briggs Type Indicator
This test reflects Carl Jung’s theory of personality. There are 166 two-choice items concerning preferences in feeling and behavior. It yields 4 bipolar scales, e.g., extroversion or introversion, thinking or feeling, etc.
- California Psychological Inventory (CPI)
- Guilford-Zimmerman Temperament Survey
- Sixteen Personality Factor Questionnaire (16 PF)
Projective tests have following characteristics:
- Project aspects of personality onto ambiguous stimuli, like inkblots, pictures, and incomplete sentences.
- Roots in psychoanalytic tradition
- High degree of inference in scoring and interpretation
- Examples include the Rorschach Inkblot Test, Thematic Apperception Test
- Reliability and validity data tend to be mixed