Identification and Referral
· Client’s name, age, marital status, ethnicity, gender.
· Describe the setting, including where the testing took place, how the client travelled there (or if you went to the client’s home).
· Reason for testing at this time, including the referral source (can be a self-referral or a fictitious referrer) and the information sought by the referrer.
· Presenting problems and symptoms.
There should be one or more referral questions to be answered by your assessment. These questions will be answered in your “Recommendations” section and the answers should flow logically from your findings. Some common referral questions for psychological testing include:
· Mental health diagnosis and treatment or management recommendations.
· Disability determination – whether the client is able to work and limitations.
· Vocational/educational assessment – what kind of work would be a good fit for the client’s abilities.
· Learning disability assessment – is a learning disability present and what sort of limitations and accommodations are appropriate.
Preface your history by indicating the source (such as client’s report or family report).
Family History. Include information about current family, current living situation and family of origin.
Educational and Vocational History. Level of education completed, high school and college grades, any history of special education, expulsions and suspensions, occupation and jobs held, last worked, reason for any dismissals, longest time at the same job, vocational aspirations if relevant.
Medical and Mental Health History. The non-psychiatric section should include reports of medical diagnoses and symptoms, current medications, surgeries and overnight hospitalizations, and any head injuries. The mental health section should include psychiatric hospitalizations, outpatient mental health treatment, substance abuse treatment, history of psychotropic medication prescriptions, and suicide attempts. When applicable, indicate that there was “no reported history of …” to show that you inquired about the areas above.
Antisocial Behavior/Substance Abuse. Age, charge, and outcome of any arrests or other legal problems. Current and past use of alcohol and other recreational drugs, 12-step group attendance.
Client’s mode of travel (car, bus, family rides) and ability (short trips by car, uses the bus but needs help to get to a new location, etc.). Client’s daily living skills, including ability to groom, bathe, dress, do household chores, and manage money. Include a general description of the client’s daily activities including job, recreational, and social activities.
Mental Status and Behavioral Observations
Use the Mental Status Exam form as a guide for your interview. This section can be written or dictated directly from this form.
General appearance: Particularly note unusual characteristics that may provide diagnostic information – neglected hygiene, unusual dress or tattoos, or physical characteristics that may affect the person’s social interactions and abilities. Indicate if the client appeared her/his stated age or younger or older than her/his stated age.
Attitude & general behavior: Describe the person’s interaction with you and attitude toward being tested and interviewed.
Mood and affect: Obtain a quote from the client regarding recent mood. Ask about any history of depression and anxiety. Note the range of the client’s affect. Ask about sleep and appetite, and inquire further about depressive or anxious symptoms if a particular disorder is suspected. See the symptom guide at the bottom of the MSE form. For instance, if PTSD were suspected, you would inquire about symptoms, such as nightmares, flashbacks, and startle response.
Stream of mental activity: Most clients will be described as responding in a coherent and relevant fashion and speaking at a normal pace with 100% intelligibility. Note any deviations from this, including psychotic symptoms, slower or faster than normal speech, and problems with speech intelligibility. Note unusual speech content and inquire into delusional thinking (paranoid, reference, control, grandiosity) if psychosis is suspected.
Sensorium and orientation: You will describe most clients as alert and aware of their surroundings; note any deviations from this. Orientation includes awareness of elements such as person, place, time and situation. Do not say the client was “oriented times three” as the meaning of this is not always consistent and clear. Do report the questions you asked and the client’s responses. For instance, “The client reported the current day of the week as Saturday rather than Monday.”
Memory. Use simple tests to assess the client’s long- and short-term memory and report the results of those tests. A useful test of short-term memory is to list three objects, have the client repeat them back, and then ask the client to recall them after five minutes have passed.
Fund of information. Two or three questions will give a rough index of the client’s general knowledge. Easy (intellectual disability suspected): “How many legs on a dog?” or “Where is your nose?”, Average: “How many days in a year?”, Above average: “What is the boiling temperature of water?”
Concentration and attention: Rate the client’s ability to attend to instructions and task persistence. Simple concentration tasks are counting backwards from 20 or, for higher functioning clients, counting backwards from 100 by 7. Note the time required and number of errors. If ADHD is suspected, use the symptom guide at the bottom of the MSE form to inquire further about symptoms.
Perceptual distortions: Ask about any history of auditory or visual hallucinations and determine if they were associated with drug use or mood (mania or depression). If there were hallucinations, note their frequency, when they last occurred, and their content. Note if the client appears to be responding to hallucinations during the assessment.
Judgment & insight. Use a simple, standard question to test judgment, such as “What would you do if your neighbor’s house were on fire?” Also, note any history that would indicate impaired judgment, such as arrests or job dismissals. Insight is whether the client has an accurate understanding of his or her mental health status. If there are mental health problems, a client with good insight attributes symptoms to these problems, and is aware of the need for treatment. For instance, a man diagnosed as schizophrenic would demonstrate good insight if he understands that his auditory hallucinations are caused by his illness and that psychiatric medication would help. An alcoholic demonstrates good insight if she admits her illness and recognizes the need to attend AA or other treatment.
When discussing the WAIS-IV results, be sure to include a discussion of the Full Scale Intelligence Quotient (FSIQ), Verbal Comprehension Index (VCI), Perceptual Reasoning Index (PRI), Working Memory Index (WMI), and Processing Speed Index. You will need to discuss the client’s strengths and weaknesses with regard to subtest variability, if applicable.
Refer to the WAIS-IV PowerPoint, Psych Report Writing, and the Sample Report as a guide. Start with the FSIQ, indicate its percentile rank and classification (Low Average, Superior, etc.). If a change in functioning is suspected due to head injury or other problem, compare the FSIQ to estimated pre-morbid functioning.
Compare the VCI to the PRI, and indicate if they are significantly different. Briefly interpret this comparison. If they are not significantly different, you can say, “The VCI and PRI were not significantly different from each other, reflecting about equal facility with tasks requiring words as with tasks requiring non-verbal reasoning and performance.” If they are significantly different, indicate why you think this is. Is it consistent with a suspected diagnosis? Does it reflect cultural differences or a physical impairment?
When discussing the WRAT4 results, be sure to include a discussion of the WRAT4 scores. Present the Standard Scores, Percentile ranks, and Classifications for each subtest of the WRAT4 (Word Reading, Spelling, Sentence Comprehension, Math Computation). You also want to talk about scores that are out of the normal range and what that might suggest. It is helpful to give examples of the client’s abilities, particularly on Math Computation (i.e., “able to perform arithmetic operations with whole numbers, but unable to work with decimals or fractions”). If a WRAT4 subtest differs significantly from IQ (at least 20 points lower), a diagnosis of learning disorder is likely, unless you feel that the difference is better explained by other factors.
When discussing the MMPI-2 results, be sure to include a discussion of the validity scales (you can refer to your text for further guidance). Then interpret/discuss the clinical scales that are clinically significant, which are a T-score of 65 or greater. Your text and the powerpoint of the MMPI-2 (found under the additional resources tab) list interpretive paragraphs of such scores.
When discussing the PAI results, be sure to include a discussion of the validity scales (you can refer to the PAI powerpoint for further guidance). Then, report significant clinical elevations, that is, scales that are clinically significant in the profile summary (rather than all of the scales of the PAI). Similarly, report results from clinically significant elevations in subscales. When reporting results, it is important to clinically analyze these with the client’s history, rather than simply reporting numbers. It is best to provide a narrative of the elevations and possible symptoms and patterns.
Provide a complete DSM-5 diagnosis to include the WHODAS 2.0 (p. 747 on the DSM-5). Your diagnoses should be clearly supported by the material you have presented to this point. Your assessment is very likely the most thorough psychodiagnostic procedure the client will ever undergo, so it is important that you come to a decision and not expect that another clinician will be better able to do this.
· This section should not introduce any new information. It needs to integrate and present an overall picture of the client, in regard to the referral question.
· Provide a summary of Frank’s psychosocial history and MSE.
· Provide a summary of the test results from the WAIS, WRAT, MMPI, PAI, and WHODAS.
· The most significant and pressing problem should be listed first and should be in the context of the referral question.
· Do not make recommendations about issues that are outside the purview of your training and competency. For instance, you would not recommend an imaging study or a specific medication. You might recommend referral to a neurologist or psychiatrist for evaluation and possible treatment.
· Make recommendations that take practical and financial limitations into account. It may be tempting to recommend “further testing” because you feel unsure of your recommendations. But keep in mind that testing can be expensive and time consuming. Additional testing should only be recommended if it is for a specific purpose and is necessary for important decision-making.
· As much as possible, your recommendations should take your test findings into account and should answer questions that could not have been answered before the assessment was done. You do not need to suggest that the client see a physician because she reported occasional headaches.
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