PSYCHOLOGICAL

TESTING Esther Schwartz, PhD

& David Trotter, PhD
OBJECTIVES
1. Provide essential background information on
psychological assessment domains and common
instruments
2. Help you be informed consumers of psychological
data in your future medical practice
3. Present material that will be covered in the USMLE
Step 1
OVERVIEW
Psychological tests are used to assess intelligence,
achievement, personality, and psychopathology.
Psychological assessment is typically driven by a particular
problem or referral question.
The purpose of assessment is to answer particular
questions related to an individual’s intellectual,
psychological, emotional-behavioral, or psychosocial
functioning, or some combination of these domains.
Referrals generated in the medical setting may include1:
 Evaluate child’s defiant behavior and poor academic performance.
 Patient’s depression screen is positive. Patient has a complicated
psychiatric history. Evaluate.
 Determine psychological readiness to undergo surgical procedure (e.g.,
organ transplants, bariatric, amputation)

ALTMAIER & TALLMAN, 2013

TESTING IN CONTEXT
Psychological testing is one component of psychological
assessment
• Gather information from the patient (clinical
interview/behavioral observations)
• Obtain collateral information (parent, school)
• Administer psychological test instruments
• Test battery will look at functioning in a number of
different functional areas.
• Use tests that have been standardized for a specific
population within a specific context so scores are reliable
and valid in describing abilities.
• Interpret the results
• Report will test combine data with the collateral and
interview data
• This conceptualization is summarized, a diagnosis or a
diagnostic rule-out is offered
• Recommendations are made
LIMITATIONS
Bias
 Psychologist may selectively attend to behaviors that are consistent with
their expectations or theoretical orientation (confirmatory bias)
 Preference and availability of certain instruments

Patient factors
 Motivation
 Effort on a continuum (positive impression management, optimal effort,
passively cooperative, suboptimal effort, negative impression
management, malingering)
 Comfort with the testing situation

Assessment of diverse populations

 Culture, ethnicity, race, primary language, SES, level of education are
variables that that influence test results.
 Validity of test results may be attenuated when instruments are used
inappropriately cross-culturally.
 Stereotype threat2
STEELE & ARONSON, 1995
INTELLIGENCE
INTELLIGENCE
Intelligence is defined as the ability to understand
abstract concepts; reason; assimilate, recall, analyze,
and organize information; and meet the special needs
of new situations.
Is intelligence a single general ability or are there
several distinct kinds of intelligence?
Spearman: General cognitive ability (g factor)
Cattell
 Fluid Intelligence: capacity to acquire new knowledge and
solve new problems, and is partially determined by biological
and genetic factors.
 Crystallized intelligence: knowledge and learning gained over
one’s lifetime through an interaction between fluid intelligence
and environment (i.e., culture, education)
INTELLIGENCE
IQ is determined to a large extent by genetics.
 Substantial heritability of g has been documented in dozens of family, twin,
and adoption studies, with estimates varying from 40 to 80%.
 In 34 twin studies with a total of 4672 pairs of MZ twins, the average MZ
correlation is 0.86, indicating that the identical twins are nearly as similar as
the same person tested twice (test-retest correlation for g is about 0.90). In
contrast, the average DZ correlation is 0.60 in 41 studies, with a total of 5546
pairs of DZ twins.3
 Heritability of g seems to increase with age. Genetic factors account for
approximately 50% of population–level variation in intelligence by the end of
the first decade of life. This proportion increases to 70% by late adolescence. 4

However, poor nutrition and illness during development can

negatively affect IQ.
IQ is relatively stable throughout life.
 G is one of the most reliable, valid, and stable behavioral traits.
 In the absence of brain pathology, an individual’s IQ is essentially the same in
old age as in childhood.
BOUCHARD & MCGUE, 1981; HAWORTH, 2010
INTELLIGENCE AND
MENTAL AGE
Seminal work by Binet and colleagues (Simon) in the early
1900s.
 Binet’s fundamental assumption was that intellectual capacities in children
increased with age on average, so that older children were expected to
perform better than younger children on the same items.

Chronological Age (CA) is the person’s actual age in years.

Mental Age (MA), as defined by Alfred Binet, reflects a
person’s level of intellectual functioning.
 A student with a mental age of 10 performed as well as the average 10-
year old in the normative sample.

IQ is the ratio of MA to CA multiplied by 100 (i.e., IQ = MA/CA

x 100)
An IQ of 100 means that the person’s mental and
chronological ages are equivalent.
QUESTION
A child is tested and found to have a mental age of 12
years. The child’s chronological age is 10 years. What is
the IQ of this child?
(A) 40
(B) 60
(C) 80
(D) 100 Answer:
(E) 120 IQ = MA/CA x 100
=12/10 x 100
120
 IQ RANGES

• The standard deviation in IQ IQ RANGES

scores is 15.
• Normal or average IQ is in the Normal/Average (IQ 90-109)
range of 90-109. Borderline (IQ 71-84)
• Intellectual disability = IQ that
Mild (IQ 50-70)
is more than 2 standard
deviations below the mean (IQ Moderate (IQ 35-55)
<70)
Severe (IQ 20-40)
• Superior intelligence= IQ more
than two standard deviations Profound (IQ < 20)
 QUESTION
A 12-year old child who is having difficulty in
school is given an intelligence test. The test
determines that the child is functioning mentally
at the level of an 8-year old child. What category
of intellectual function bests describes this child?
(A) Severely intellectually disabled
(B) Moderately intellectually disabled Answer:
IQ= MA/CA x 100
(C) Mildly intellectually disabled =8/12 x 100
=66
(D) Borderline
(E) Normal or average Mild Intellectual
disability (IQ 50-
70)
COMMON INTELLIGENCE
TESTS
The Wechsler Adult Intelligence Scale-Fourth Edition (WAIS-
IV) is the most commonly used intelligence test for adults
and older adolescents (16-90 years of age).
 Standardization sample for WAIS-IV (N=2,200) was selected
according to 2005 U.S. Census Data and was stratified according
to age, sex, race/ethnicity, geographic region, and educational
level.
 The Wechsler Intelligence Scale for Children (WISC) is used to test
intelligence in children 6-16 ½ years of age.
 The Wechsler Preschool and Primary Scale of Intelligence (WPPSI)
is used to test intelligence in children 4-6 ½ years of age.
Stanford-Binet Intelligence Scales
Non-verbal tests include: Leiter International Performance,
Universal Nonverbal Intelligence Test, Naglieri Nonverbal
Ability Test
IQ test scores are less reliable for populations that approach
the extreme ends of the spectrum of ability.
WAIS-IV
INDEXES Verbal Perceptual Working Processing
Comprehensi Reasoning Memory Speed
on
SUBTESTS Vocabulary Block Design Digit Span Coding

Similarities Matrix Arithmetic Symbol

Reasoning Search
Information Visual
Puzzles
INDEX Verbal Ability to Immediate Ability to
DESCRIPTIO knowledge interpret and memory and process
NS and organize ability to visually and
understanding visually sustain perceived
obtained perceived attention, nonverbal
through material and concentrate, information
informal and to generate and exert quickly with
formal and test mental concentratio
education hypotheses control n and rapid
related to eye-and
problem coordination
 INTELLECTUAL
DISABILITY
Intellectual Disability (Intellectual Disability Disorder)
3 criteria:
 Deficits in intellectual functions (e.g., reasoning, planning, judgment)
confirmed by clinical assessment and standardized intelligence testing.
 Deficits in adaptive functioning (e.g., communication, social participating,
independent living)
 Onset of intellectual and adaptive deficits during the developmental period.

Specify Mild, Moderate, Severe, Profound

 Specifiers of severity are based on adaptive functioning NOT IQ scores,
because it is adaptive functioning that determines the level of supports
required.
 Of those with ID, 85% have mild impairment, 10% have moderate, and 5%
have severe to profound impairments.

Prevalence of ID
 Worldwide prevalence: ~1% (estimates vary between countries, income levels,
etc)
 ID is approximately 5 times higher for males than for females.
ADAPTIVE BEHAVIOR
ASSESSMENT
Assessment of adaptive behavior is necessary for
diagnosis of intellectual disability.
Provides information about a person’s strengths and
weaknesses that can inform educational and
intervention efforts.
Among the very large number of adaptive behavior
scales on the market, very few have adequate norms
and reliability to diagnose intellectual disability in
people with IQs in the <70 range.
 Vineland Adaptive Behavior Scales-Survey Form
 Scales of Independent Behavior
VINELAND ADAPTIVE
BEHAVIOR SCALES
The Vineland Adaptive Behavior
Scales is a test of adaptive
functioning often used in
assessments of intellectual and
developmental disabilities.
Age range: Birth-90; Interview,
Parent/Caregiver, Teacher forms
Vineland-3 examines 3 domains:
Communication, Daily Living, and
Socialization.
A diagnosis of intellectual disability
requires a both an IQ score of 70 or
below and significant deficits in
adaptive functioning (scores two or
more standard deviations below the
mean).
ACHIEVEMENT

“I dreamed I was being chased by a giant standardized test.”

ACHIEVEMENT TESTS
Achievement tests are used to assess academic
achievement (e.g., evaluate how well an individual has
mastered specific subject areas, such as reading and
mathematics).
Achievement tests include the Scholastic Aptitude Test
(SAT), Medical College Admission Test (MCAT), and the
United States Licensing Examination (USMLE).
The Wide Range Achievement Test (WRAT), which is often
used clinically, evaluates arithmetic, reading, and spelling
skills.
Achievement tests often used by school systems include
the California, Iowa, Stanford, and Peabody Achievement
Tests.
 LEARNING DISORDERS
Ability-achievement Discrepancy
 Traditionally, learning disability was defined as significantly lower
academic achievement relative to one’s measured intellectual ability. 6
 But, this assumes that factors that negatively affect academic
achievement scores do not influence scores on IQ tests.

Specific learning disorders

 Difficulties of learning and using specific academic skills in certain
learning domains (i.e., word reading, reading comprehension, spelling,
written expression, number sense, mathematical reasoning) that are
substantially below individual's chronological age, and cause
significant interference with academic or occupational performance.
 Although intellectual assessment has been the core of psychological
assessment for LD for decades, it is no longer required for a DSM-­5
diagnosis of SLD, except when Intellectual Disabilities are suspected.

APA, 2000
PSYCHOPATHOLOGY

 In medical settings the most common psychopathology

you will encounter will relate to symptoms of depression,
anxiety, and substance abuse.
 Evaluation of patients with emotional symptoms involves:
 Psychiatric history
 Includes mental illness, drug and alcohol use, sexual
activity, current living situation, and sources of stress.
 Mental Status Exam
 Data from personality testing and symptom inventories
DEPRESSION SCALES
Major depression and symptoms of depression are
common among patients presenting in medical
settings.
 Pearson et al. (1999) demonstrated that 20% of patients
identified as high utilizers of medical care experienced
major depression or major depression in partial
remission.
Objective rating scales of depression that are
commonly used include the Hamilton, Raskin, Zung,
and Beck.
 In the Hamilton and Raskin scales, an examiner rates the
patient.
 In the Zung and Beck scales the patient rates self.
ITEMS IN THE BECK
DEPRESSION INVENTORY-II
BDI-II
• Most common screening tool to identify severity of depression
in medical settings.
• 21-item self-report scale of depressive symptoms.
• Acceptable psychometric qualities among medical
populations and minority populations
• BDI-II assesses:
Sadness punishment crying Irritability

Pessimism Dislike of self Agitation Appetite

changes
Sense of Self-blame Loss of interest
failure Concentration
Self- Indecisiveness problems
Loss of criticalness
pleasure Worthlessness Fatigue
Suicidal
Guilt ideation Loss of energy Low level of
sexual interest
Expectation of Episodes of Sleep changes
ANXIETY SCALES
Anxiety disorders are also highly prevalent in medial
settings.
Several assessment methods detect symptoms of
anxiety.
 Generalized Anxiety Disorder Scale (GAD-7)
 Patient Health Questionnaire (PHQ-9)
REFERENCES
Altmaier, E.M., & Tallman, B.A. (2013). Psychological assessment in medical settings.
In APA Handbook of Testing and Assessment in Psychology: Volume 2. Testing and
Assessment in Clinical and Counseling Psychology, 285-302).
Bouchard, T.J. and McGue, M.J. (1981) Familial studies of intelligence: A review.
Science, 1055-1059.
Froehlich, L., Martiny, S.E., Keaux, K., Goetz, T., Mok, S.Y. (2016). Being smart of
getting smarter. Implicit theory of intelligence moderates stereotype threat and
stereotype lift effects. British Journal of Social Psychology, 55, 564-587.
Haworth, C. M. A., Wright, M. J., Luciano, M., Martin, N. G., de Geus, E. J. C., van
Beijsterveldt, C. E. M., . . . Plomin, R. (2010). The heritability of general cognitive
ability increases linearly from childhood to young adulthood. Molecular Psychiatry, 15,
1112–1120.
Maltzman, S. (2013). The assessment process. In APA Handbook of Testing and
Assessment in Psychology: Volume 2. Testing and Assessment in Clinical and
Counseling Psychology, 19-34).
Steele, C.M., & Aronson, J. (1995). Stereotype threat and the intellectual test
performance of African Americans. Journal of Personality and Social Psychology, 69,
797-811.