Download Assessment

Daryl Fujii Ph.D., Honolulu
Paul Lephuoc, Houston (intern)
and the
Multicultural/Diversity Committee (2010-2011)
VA Psychology Training Council
Contact persons:
Daryl Fujii Ph.D., Honolulu ([email protected])
Rachael Guerra Ph.D., Palo Alto ([email protected])
Committee 2010-2011
Loretta E. Braxton Ph.D., Durham (Co-Chair)
Linda R. Mona Ph.D., Long Beach (Co-Chair)
Angelic Chaison Ph.D., Houston
Daryl Fujii Ph.D., Honolulu
Rachael Guerra Ph.D., Palo Alto
Jamylah Jackson Ph.D., North Texas
Monica Roy Ph.D., Boston
Christina Watlington Ph.D., Perry Point
Miguel Ybarra Ph.D., San Antonio
Susana Blanco Ph.D., Bedford (Postdoc)
Nancy Cha, Honolulu (Intern)
Paul Lephuoc, Houston (Intern)
Katherine Hoerster Ph.D., Long Beach (Postdoc)
Overview
 APA Multicultural Guidelines
 Psychometric issues in assessment with ethnic
minorities
 Summary of psychometric issues with MMSE and
MMPI-2
 Diagnostic assessment for PTSD and
schizophrenia
 Case sample
 Important Things to Consider/Self-Reflection
Questions
 Assessment Exercise
 References
APA Multicultural Guidelines
(2003)
Psychologists should be aware of the validity of a given
assessment instrument or diagnostic procedure with
specific ethnic minority groups.
– What is test’s reference sample and what are possible
limitations with other populations
– Be aware of literature on test biases, fairness, and
cultural equivalence
– Data should be interpreted within the context of the
client’s cultural and linguistic characteristics
Psychometric Issues (Fouad & Chan, 1999)
Equivalence Content

Are items relevant for the culture of the client?
e.g. Southeast Asian experience PTSD with co-morbid paniclike attack from fear of death from body dysfunction or
somatic symptoms such as tinnitus attacks (Hinton et al.,
2010)
 Conceptual


Does question hold the same meaning across cultures?
e.g. Many Asian languages do not have subtle emotional
equivalents for “sadness,” “despair”, or “depression” (Yang &
Won Pat-Boria, 2007)
Psychometric Issues: Equivalence
(continued)
 Functional


Is behavior assessed the same across culture?
e.g. Vietnamese Depression Scale has factors of somatic
symptoms and feelings of desperation, and shame (Dinh et al.,
2009)
 Scalar


Are the scores equivalent across cultures?
e.g. Asians scored higher than Whites on BDI, however, no
differences in depression on diagnostic interviews (Lam et al.,
2004; Chung et al., 2003)
Psychometric Issues (continued)
Test bias
 Occurs when tests discriminate against one or more
groups
 Content (item)


Difference in probability that item will be answered correctly
e.g. Persons from Hawaii less likely to get snow on logs item
on WAIS Picture Completion than mainland counterparts
(Fujii, personal communication)
Psychometric Issues: Test bias
(continued)
 Internal structure (factorial)


Factorial structure should be same or test cannot be
interpreted as the same test (different constructs)
e.g. Koreans demonstrated 3 factor solution vs. 4 factors for
Americans on Geriatric Depression Scale Short Form (Jang et
al., 2001)
 Predictive (selection)


Systematic under- or over- prediction
e.g. Asians scored higher than Whites on BDI, however, no
differences in depression on diagnostic interviews (Lam et al.,
2004; Chung et al., 2003)
MMSE and Content Bias
 Hispanics

better scores for "no ifs, ands, or buts," lower scores for "state,
season, serial 7's world backwards" (Teresi et al., 2000)
 African Americans

lower scores for sentence completion (Teresi et al., 2000)
 Asian Americans

67% cognitively intact second generation Japanese-Americans
living in Hawaii could not say "no ifs, ands, or buts“ (Valcour,
et al., 2002)
MMSE and Factorial Structure
Studies have varied on factorial structure of MMSE with
whites and ethnic minorities
 Studies with primarily white samples have reported 1,2,
and 5 factor models.
 Shigemori (2010) and Yi (2001) reported 3 factor models
with Japanese and Taiwanese elders
 Castro-Costa (2009) reported a 5 factor model with
Brazilian elders
MMSE and Predictive Validity
 African-American elders
 Sensitivity and specificity of MMSE for diagnosing
dementia lower with African American elders
 Lower scores believed to be associated with lower
education and quality of education
 Frequently higher false-positive rate, does not always
disappear with cut-off adjustments
MMSE and Scalar Issues
 Hispanic elders
 May score lower but scores mediated by language,
acculturation, education, and quality of education
 Native American elders
 May score lower but scores mediated by language,
acculturation, education, quality of education,
quantum levels
 Asian-American elders
 Scores mediated by language, acculturation, and
education
MMPI-2: African-Americans
 Differences small between AA and whites when
matched for age and socioeconomic status, AA tend to
be higher, but not clinically meaningful
 When differences exist, tend to be associated with
characteristics versus test biases, exception is
MacAndrew Alcoholism-R (MAC) scale, both alcoholic
and nonalcoholic AA tend to score high
(as summarized in Graham, 2006)
MMPI2: Hispanics
 Moderately elevated scores (T=50-60) may be
associated with low acculturation
 Hispanics tend to have high L scale scores, thus
clinician should not infer defensiveness for L score
below T=60
 Elevated scores on clinical scales (T>65) likely to
reflect similar psychopathology as whites
(as summarized in Graham, 2006)
MMPI2: Native Americans
 NA tend to score moderately higher than whites, thus
scores at this level likely reflect cultural factors versus
psychopathology
 Elevated scores on clinical scale (T>65) likely to reflect
similar psychopathology as whites
(as summarized in Graham, 2006)
MMPI2: Asian-Americans
 Scores for nonclinical AA are likely to fall within the
normal range
 Some moderately high scores (T=50-60) may be
present and likely reflect experienced stress or level of
acculturation versus psychopathology
 Elevated scores on clinical scales (T>65) likely to
reflect similar psychopathology as whites
(as summarized in Graham, 2006)
PTSD: African-Americans &
Hispanics
 AA (21%, 43% lifetime) and H (28%, 39% lifetime)
have higher rates of PTSD than whites (14%, 24%
lifetime)
 AA greater exposure to war stresses, predisposing
factors, largely disappeared after factors controlled
 H greater exposure to war stresses, remained after
controlling for predisposing factors
(as summarized by Loo, 2007)
PTSD: Native Americans
 Native Americans 22%-25% (45-57% lifetime)
 Incidence varies by tribe
 PTSD associated
 Greater war zone stresses (e.g atrocities, violence,
combat)
 Psychological conflict identification with enemy
 Differences disappeared when controlling for war zone
stresses
 Rural Northern Plains Indians express high
satisfaction with telepsychiatry (Shore, 2004)
(as summarized by Loo, 2007)
PTSD: Asian-Americans
 Rates differ among specific ethnicities
 Mixed Asian group (Chinese, Filipino, Korean, Japanese, Hawaiian,
Chamorro, Asian-mixed 37%) vs. Japanese only 9%
 PTSD often associated with race related stressors (Vietnam
war veterans)
 Racial prejudice, stigmatization, or harassment for resembling
Vietnamese
 Veteran reminded of family member, relatives, or friends when
seeing a Vietnamese who was alive, wounded, or killed,
 Clinician need to assess for experience of being a minority
 Failure to assess for race-related stressors AAPI miss as 20% of
symptoms
(as summarized by Loo, 2007)
Schizophrenia: African Americans
 VA database African Americans 4x more likely to be
diagnosed with schizophrenia and receive dual diagnosis
than whites (Blow et al., 2004)
 Possible reasons for misdiagnosis (Strakowski et al., 2003)
 Failure to obtain adequate information
 AA’s “healthy paranoia” (reluctance to disclose too much
information) may be interpreted as psychosis
 AA with affective disorder more likely to have prominent first-rank
psychotic sx
 Non-schizophrenic AA more likely to dissociate
 AA do not seek treatment until sx severe
Schizophrenia: Hispanics
 Hispanics 3x more likely to be diagnosed with
schizophrenia than whites (Blow, 2004)
 Hispanics have a higher frequency of psychotic
symptoms in absence of formal thought disorder and
associated with mood disorder (Marin et al., 2006
review)
 Hispanics demonstrated later onset, higher
somatization, and shorter hospitalization (Escobar,
1986)
Schizophrenia: Asians
 Asians seek mental health service tend to be more
severely ill than whites (Durvasula et al., 1996)
 Psychiatric illness brings shame and stigma to family,
thus family members for psychiatric services only
when they become unmanageable (Sue, 1999)
Schizophrenia: Native Americans
 Similar rates of schizophrenia when compared to
whites in two Southwestern tribes (Robin, 2007)
Case Sample
 Joe is a 85 year-old African-American male who was admitted to the
Community Living Center for wound care. He has a history of diabetes
and hypertension. Upon admission, Joe scored a 20/30 (missed date,
day of week, all serial 7’s, 1/3 recall, writing a sentence, intersecting
pentagrams) on the MMSE (general cutoff 23/20) and was referred for a
further cognitive work up for dementia. In his evaluation, psychologist
HM reported Joe had a 9th grade education in a small rural southern
school where there was only one classroom and teacher for the entire
high school . He dropped out to work after his father passed away. Joe
was living independently with his wife prior to his admission, paying
bills, regularly attending church functions, and was still driving. His
son denied noticing any significant decline in cognitive functioning,
although his father was a little more “forgetful”. On the Clinical
Dementia Rating, a functional evaluation for dementia, Joe scored all
0’s which comfortably placed him in nondemented range. HM
concluded that Joe did not have a dementia.
Important things to consider
 Clinicians should be aware of literature on equivalence,




fairness, biases, and predictive validity when administering
a test to an ethnic minority.
Despite limited biases, many tests are found to be valid with
ethnic minorities.
Clinicians should include caveats in their report if they are
not certain about the potential for test biases.
Psychiatric diagnosis may not present the same in an ethnic
minority and may have different associated features or comorbidities. Specific behaviors may present differently or be
difficult to elicit or observe.
Psychiatric presentation may be affected by differences in
help seeking behaviors.
Self-Reflection Questions When
Assessing an Ethnic Minority
 Are there any cultural considerations when administering a
specific test to a veteran of color? What does the literature
reveal? If studies demonstrate cultural considerations, how
close does that veteran’s background match with the study
sample? Are there any caveats to your findings, or
interpretations? What are cultural considerations in
providing recommendations?
 How does a veteran’s ethnic background and associated
experiences, idioms of distress, interface with clinical
presentation or criteria for different psychiatric disorders?
Would cultural factors mask or make eliciting certain
diagnostic criteria more difficult? Are there any specific
issues or unique experiences you need to explore?
Diagnostic Exercise
(Lopez, 2002)
 Mrs. Ramirez is a 26-year-old married OEF veteran
who is a first generation immigrant from Mexico. She
has a 1 year-old son. She presents with multiple
problems including physical problems (numbness in
the jaw), problems with her marriage (her husband is
having an affair, sometimes leaves and does not return
until the next day), and depressive problems (loss of
interest in her usual activities).
Exercise - Part I
 Make a clinical judgment regarding the severity of the
client’s problems (e.g., marital adjustment, anger,
somatization, and likelihood of having a physical
problem), and the likelihood of benefitting from
therapy.
 Assume that the presenting problems are related to
the patient’s (Mexican) cultural background.
Exercise - Part II
 Re-rate the client again this time assuming that her
presenting problems had nothing at all to do with his
cultural background.
Discussion
 Did your ratings change?
 Discuss whether and how your judgments were
influenced by taking culture into account or failing to
take culture into account.
Sample Cultural Explanations
 In light of machismo or traditional marital roles, the
husband’s involvement in extramarital relationships
may be more acceptable for women of Mexican origin,
i.e., less marital distress?
 Latinos may tend to express psychological distress as
physical distress, i.e., somaticize
Literature on Latina/os
• The best available data does not support the view that
Mexican Americans adhere to machismo and traditional
marital roles (Cromwell & Ruiz, 1979)
• Somatization is not as prominent among Mexican
Americans as some clinical writings suggest. (Escobar,
Burnam, Karno, Forsythe, & Golding, 1987).
• There is little empirical support for many of the cultural
notions that clinicians might have for Mexican-origin
patients.
• Furthermore, Mexican-origin people are quite
heterogeneous in terms of their cultural beliefs, norms,
and practices.
Cautions
• Imposing notions of what is culture and what is not culture
based strictly on ethnicity can be detrimental to their
clients.
• Clinicians may then tend to minimize or underpathologize
actual problems and distress (López, 1989; López &
Hernandez, 1986).
• Having a husband who is involved in extramarital
relationships, for example, can be most distressing to many
Mexican women and may not at all be part of their cultural
world. Assuming that men’s extramarital relations are
culturally acceptable behavior is strictly an assumption.
Value of Exercise
• Consider how you conceptualize culture (general or
specific) in a given clinical context.
• How do your cultural considerations affect your clinical
judgment.
References
 American Psychological Association. (2003 ). Guidelines
on multicultural education, training research, practice, and
training for organizational changes for psychologists.
American Psychologist, 58, 377-402.
 Blow, F. et al., (2004). Ethnicity and diagnostic patterns in
veterans with psychoses. Social Psychiatry and Psychiatric
Epidemiology, 39, 841-851.
• Castro-Costa, E.., et al. (2009). Dimensions Underlying the
Mini-Mental State Examination in a Sample With LowEducation Levels: The Bambui Health and Aging Study.
American Journal of Geriatric Psychiatry, 17, 863-872.
References
 Chung, H., et al., (2003). Depression symptoms and
psychiatric distress in low income Asian and Latino
primary care patients. Prevalence and recognition.
Community Mental Health Journal, 39, 33-46.
 Cromwell, R. E.,& Ruiz, R. E. (1979). The myth of macho
dominance in decision making within Mexican and
Chicano families. Hispanic Journal of Behavioral Sciences,
1, 355–373.
 Dinh, Q., et al., (2009). A culturally relevant
conceptualization of depression: An empirical
examination of the factorial structure of the Vietnamese
Depression Scale. International Journal of Social
Psychiatry, 55, 495-505.
References
 Durvasula, R., & Sue, S. (1996). Severity of Disturbance Among
Asian American Outpatients. Cultural Diversity and Mental
Health, 2, 43-51.
 Escobar, J., et al., (1986). Symptoms of schizophrenia in Hispanic
and Anglo veterans. Culture and Medical Psychiatry, 10, 259-76.
 Escobar, J. I., Burnam, A., Karno, M., Forsythe, A., & Golding, J.
(1987). Somatization in the community. Archives of General
Psychiatry, 44, 713–718.
 Fouad, N., & Chan, P. (1999). Gender and ethnicity: influence on
test interpretation and reception. In J. Lichtenberg & R.
Goodyear (eds.). Scientists-practitioner perspective on test
interpretation. Boston: Allyn & Bacon. (pp. 31-58).
References
 Graham, J. (2006) MMPI2: Assessing personality and
psychopathology 4th. Oxford University Press.
 Hinton, D., et al., (2010). Khyal attacks: A key idiom of
distress among traumatized Cambodia refugees. Culture,
Medicine, & Psychiatry, 34, 244-278.
 Jang, Y., ea., (2001). Cross-cultural comparability of the
Geriatric Depression Scale: Comparisons between older
Koreans and older Americans. Aging & Mental Health, 5,
31-37.
 Lam, C. et al., (2004). Case identification of mood
disorders in Asian American and Caucasian American
college students. Psychiatric Quarterly, 75, 361-373.
References
 Loo, C. (2007). PTSD among ethnic minority veterans.
Retrieved 2/23/011.
http://www.ptsd.va.gov/professional/pages/ptsd-minorityvets.asp
 López, S. R. (1989). Patient variable biases in clinical
judgment: A conceptual overview and methodological
considerations. Psychological Bulletin, 106, 184–203.
 López, S. R. (2002). Teaching culturally informed
psychological assessment: Conceptual issues and
demonstrations. Journal of Personality Assessment, 79(2),
226–234.
References
 López, S. R., & Hernandez, P. (1986). How culture is
considered in the evaluation of mental health patients.
Journal of Nervous and Mental Disease, 174, 598–606.
 Marin, H. et al., (2006). Mental illness in Hispanics: A
review of the literature. Focus, 4, 26-37.
 Robin, R. et al., (2007). Schizophrenia and psychotic
symptoms in families of two American Indian tribes. BMC
Psychiatry, 7:30. http://www.biomedcentral.com/1471244X/7/30/prepub
References
 Shigemori, K., et al. (2010). The factorial structure of the
mini mental state examination (MMSE) in Japanese
dementia patients. BMC Geriatrics, 10:36.
http://www.biomedcentral.com/1471-2318/10/36
 Shore, J., & Manson, S. (2004). Telepsychiatric Care of
American Indian Veterans with Post-Traumatic Stress
Disorder: Bridging Gaps in Geography, Organizations, and
Culture. Telemedicine Journal and e-Health, 10.
http://www.liebertonline.com/doi/abs/10.1089/tmj.2004.10.S
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 Strakowski, S., et al., (2003). Ethnicity and diagnosis in
patients with affective disorders. Journal of Clinical
Psychiatry, 64, 747-754.
References
 Sue, S. (1999). Asian American mental health: What we know
and what we don't know. Merging past, present, and future in
cross-cultural psychology. In W. Lonner, et al., (Eds.), Merging
past, present, and future in cross-cultural psychology: Selected
papers from the Fourteenth International Congress of the
International Association for Cross-Cultural Psychology, (pp. 8289). Lisse, Netherlands: Swets & Zeitlinger Publishers.
 Teresi, et al., (2000). Applications of item response theory to the
examination of the psychometric properties and differential item
functioning of the comprehensive assessment and referral
evaluation dementia diagnostic scale among samples of Latino,
African American, and White non-Latino elderly. Research on
Aging November 2000 22: 738-773.
References
 Valcour, V., Masaki, K., & Blanchette, P. (2002). The phrase:
"No ifs, ands, or buts" and cognitive testing. Lessons from
an Asian-American community. Hawaii Medical Journal, 61,
72-74.
 Yang, L., et al., (2007). Psychopathology among Asian
Americans. In F. Leong, et al., (Eds.), Handbook of Asian
American psychology (2nd ed.) (pp. 379-405). Thousand
Oaks, CA: Sage.
 Yi, S. & Yip, P., (2001). Factor structure and explanatory
variables of the Mini-Mental State Examination (MMSE) for
elderly persons in Taiwan. Journal Formosan Medical
Association, 100, 676-83.