Chapter 9 –
Assessment:
Integration and Clinical
Decision Making
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Integration and Clinical Decision
Making
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All assessments are designed to address
a question
Psychologist determines the most
appropriate type of assessment based
on this question
As the assessment progresses different
tests or assessments may be added
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Assessment Questions
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The assessment question is a general
guide in assembling pieces of
information
A question about intellectual capacities
leads to assessment that highlights
general intellectual functioning and
more specific cognitive strengths and
weaknesses
Cont-d
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In such intellectual evaluation we would
want to consider emotional factors that may
affect cognitive functioning, but the
cognitive potential is still the focus.
A specific assessment question, for
example, whether a teacher who is
depressed is capable of going back to the
classroom, diagnostic information and
functional capability need to be assessed
Cont-d
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In this context (the depressed teacher)
possible factors that might affect the
teacher’s functioning should be evaluated:
In depression there are cognitive correlates,
such as difficulty in concentration and
decision making, and these may affect the
teacher's functioning
However, these should be seen as
secondary to the emotional issues.
Integrating the Assessment
Information
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The common assessment methods are
Interviews
Observations
Intellectual assessment
Cognitive assessment
Self-report measures
Projective measures
Assessment
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Psychological assessment involves
gathering and integrating multiple
forms of information
Instruments are selected based on the
hypotheses to be explored
The integration of the diverse data
completes the assessment process
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Initial Steps in the Integration
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Examine all assessment information
Consider consistencies and
contradictions and try to reconcile
Generate hypotheses about the client’s
current functioning
Important in assessment –focused
service or intervention-focused service
Integrating Assessment Data
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Descriptive account of the client’s level
of functioning
Importance of understanding client in
his/her social and interpersonal
environment
Often different assessments/tests
provide conflicting results
– Importance of multiple informants
especially with children
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First step: Descriptive Account
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A consideration of the client’s personality
structure
Level of emotional distress
Coping strategies: problem-focused,
emotion-focused, passive, active etc
Intellectual capacity
Possible diagnosis and co-morbidity
How the diagnostic status affects
functioning (e.g. getting custody over a
child)
The pieces of the puzzle often do
not fit together
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Different sources of information and
different informants
Each source of data has strengths,
limitations, and potential biases.
This is seen primarily when gathering
information about children and
adolescents
Assessment of Children and Adolescents:
Using several sources of information:
Study by De Los Reyes et al: p. 267
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Assessment of young children with high
levels of disruptive behaviors
Information came from mothers, teachers
and direct observations
There were discrepancies in the reports of
the different sources
These discrepancies reflected real
differences in behaviors in the different
settings
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Common Purposes of Assessment
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Educational concerns (e.g. assessment
of the need for special education
Vocational concerns: The feasibility of
the client’s career aspirations
Rehabilitation service (e.g. following
head injury)
Referral for psychotherapy
The Purpose of Case Formulation
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The purpose is to formulate hypothesis how
the problems have developed and what
factors seemed to have maintain these
problems
How the current problems fits with the
client’s life-history (e.g. early loss of
parent), and how well the client will be able
to function in the future
Recommendations to improve functioning
Case Formulation
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Case Formulation: A clear hypothesis
that relates to how a problem
developed and how it is maintained
– Suggestions are then made – e.g.,
psychological services, additional
assessment, or planning of other services
for the client
– Often helps guide treatment & specific
interventions
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Case Formulation
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Some Benefits of a case formulation:
– Provides connections between various
problems
– Provides guidance on the type of treatment
– Predicts the patient’s functioning with and
without treatment
– Provides options if difficulties are
encountered in treatment
– Indicates options, outside of psychological
services
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Case Formulation
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Components of a case formulation:
– Description of problems & symptoms
– Events or stressors that led to the symptoms
or problems
– Predisposing life events/ vulnerabilities
– A hypothesized mechanism that links the
problems to the person’s current functioning
Copyright © 2014 John Wiley & Sons, Inc. All
rights reserved.
Copyright © 2014 John Wiley & Sons, Inc. All rights reserved.
Case Formulation
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Steps of a case formulation:
– 1. Develop a comprehensive problem list
– 2. Determine the origin, precipitants, and
consequences of the problems
– 3. Identify patterns among the problems
– 4. Develop working hypotheses to explain the
problems
– 5. Evaluate and refine the hypotheses
– 6. In treatment, the hypotheses should be
reconsidered, re-evaluated, and revised
Threats to the Validity of
Case Formulations
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Client Factors:
– Clients may try and under-pathologize
themselves
– Problems clearly recalling a problem behavior
or memories from their past (retrospective
recall)
– Can’t assume clients are accurately
perceiving/portraying reality
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Threats to the Validity of Case
Formulations
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Clinician Factors:
– Self-serving attributional bias: Bias to
make internal, stable and global attributions
for positive events (can seriously affect how
clinicians evaluate their effectiveness)
– For example: I am capable and got an A on
my paper but the teacher is picky and he
gave me a C…It is not my fault
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Common Decision-Making Biases
and Heuristics
Table 9.3
– Overuse of heuristics: Heuristics are
mental short cuts that people do to ease
the burden of decision-making.
– Biases (gender, ethnic, socioeconomic)
involve judgments that are systematically
different from what a person should
conclude on the basis of logic or
probability.
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The Fundamental Attribution Error
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When we attempt to attribute causes to
other people’s behavior, we over estimate
the influence of personality traits and
underestimate the influence o f situational
factors.
“She fell because she is clumsy but I fell
because the sidewalk was slippery”
(This is also known as the observer-actor
effect)
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Inattention to Base-Rate
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A “base-Rate” means how many cases
has the clinician seen
If there are few cases, there is less
familiarity with pattern of tests
responses ( Is this a pattern seen in
this or that condition? How can we
know- we have seen just few) and less
familiarity with the diagnosis.
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Belief in the Law of Small Numbers
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Results drawn from small numbers are likely
to be more extreme and less consistent than
those obtained from large samples
The clinician’s direct experience with a small
number of cases may feel more relevant
and compelling though it is likely to give
less accurate information that the one
drawn from large samples.
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Regression to the Mean
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Because there is always a
measurement error, a person who
obtains an extreme score on a test at
one point is likely to obtain a less
extreme score when taking the same
test next time
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Inferring Causation from
Correlation
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A correlation does NOT indicate causeand effect relationship!!
It is possible that the connection
between be two variables comes from
a 3rd variable that we have not
identified
The second variable may affect the
information provided earlier.
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Improving the Accuracy of Clinical
Judgment
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Some Important strategies:
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Use directly relevant psychometrically sound tests
Check for scoring errors
Use normative data and base rate information
Use DSM criteria when making diagnosis
Use decision trees or clinical guidelines.
In unstructured interviews be as systematic as
possible
Be aware of relevant research
Be aware of personal biases and preconceptions.
Search for alternative explanations for hypotheses
Seek consultation
Don’t rely on memory and don’t rush to a conclusion
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Hindsight Bias and Confirmatory Bias
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1. Information gathered after a
diagnostic decision has been made
cannot be used o validate the original
decision. (hindsight)
2. Once a clinical decision has been
made, it is tempting to gather
information to conform it; we need to
look for information tat may refute it.
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Heuristics (Mental Shortcuts)
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Representativeness: relying on small
numbers to make decisions
Availability: making decisions on he basis
of easily recalled information
Affect: Judgment based on emotional
considerations
Anchoring and Adjustment: First
impressions affect how later impressions are
judged.
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Important Concepts in Assessment
Reports
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Important to remember the ‘audience’ of
the report
Privacy is important – avoiding
stigmatizing labels, using multiple sources
Exercising caution with computer-based
interpretations (CBI’s) – problematic to
include this in a testing report
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Important Concepts in Assessment
Reports
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Contents of a typical assessment report
– Identifying patient/client information
– Reason for referral
– Background information (including, developmental
history, educational & employment history, family &
relationship history, medical history, etc.)
– Assessment methods (including tests administered)
– Interview data and behavioral observations
– Test results (including interpretation of test scores)
– Diagnostic impressions
– Summary
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Important Concepts in Assessment
Reports
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Purpose of giving feedback on an assessment
report
– Verify the general accuracy of the assessment results
– Refine the interpretation of the results
– Put the individual’s symptoms, in the context of
his/her life history and current life circumstances
– Provide some psychological relief for the individual by
presenting an integrated picture
– Provide concrete information about steps to address
personal difficulties
– Help the individual identify potentially stressful
situations
– Collaborate to design goals that build on personal
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strengths
rights reserved.