Assessment

1. 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 (Daryl.Fujii@va.gov) Rachael Guerra Ph.D., Palo Alto (Rachael.Guerra@va.gov)

2. Multicultural/Diversity Committee 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)

3. 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

4. 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

5. 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 panic-like 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)

6. 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)

7. 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)

8. 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)

9. 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)

10. 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

11. 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

12. 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

13. MMPI2

14. 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)

15. 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)

16. 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)

17. 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)

18. PTSD

19. 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)

20. 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)

21. 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)

22. Schizophrenia

23. 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

24. 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)

25. 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)

26. Schizophrenia: Native Americans • Similar rates of schizophrenia when compared to whites in two Southwestern tribes (Robin, 2007)

27. CASE SAMPLE

28. 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.

29. CLINICAL CONSIDERATIONS

30. 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 co-morbidities. Specific behaviors may present differently or be difficult to elicit or observe. • Psychiatric presentation may be affected by differences in help seeking behaviors.

31. 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?

32. ASSESSMENT EXERCISE

33. 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).

34. 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.

35. 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.

36. 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.

37. 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

38. 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.

39. 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.

40. 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.

41. 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 Low-Education Levels: The Bambui Health and Aging Study. American Journal of Geriatric Psychiatry, 17, 863-872.

42. 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.

43. 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).

44. 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.

45. References • Loo, C. (2007). PTSD among ethnic minority veterans. Retrieved 2/23/011. http://www.ptsd.va.gov/professional/pages/ptsd-minority-vets.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.

46. 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/1471-244X/7/30/prepub

47. 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-64 • Strakowski, S., et al., (2003). Ethnicity and diagnosis in patients with affective disorders. Journal of Clinical Psychiatry, 64, 747-754.

48. 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. 82-89). 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.

49. 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.