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Competency of the professionals who developed the computer-generated scoring program. Ability of the computer to handle respondents who ‘fake-bad.’. The Halstead-Reitan and Luria-Nebraska are specific types of a. Personality inventories. Intelligence tests. Psychology has identified the issue but not the solution.
J Clin Exp Neuropsychol. Author manuscript; available in PMC 2012 Aug 1.
- Halstead-Reitan Norms program - Heaton (HRB) Halstead-Reitan Comprehensive Norms for an Extended Battery (HRB-2)** Hamilton Depression Inventory (HDI) Health Status Questionnaire – 2.0 (HSQ) HVTL-R - Hopkins Verbal Learning Test - Revised. IGT - Iowa Gambling Test.
- In Defense of the Halstead Reitan Battery: A Critique of Lezak’s Review. In addition, one would not know that the CNEHRB uses a computer scoring program or that the HRNES is primarily a computer scoring program. LehmanA comparison of clinical and automated interpretation of the Halstead-Reitan Battery.
Published in final edited form as:
J Clin Exp Neuropsychol. 2011 Aug; 33(7): 793–804.
Published online 2011 Jun 24. doi: 10.1080/13803395.2011.559157NIHMSID: NIHMS276951
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Abstract
Memory and executive functioning are two important components of clinical neuropsychological (NP) practice and research. Multiple demographic factors are known to affect performance differentially on most NP tests, but adequate normative corrections, inclusive of race/ethnicity, are not available for many widely used instruments. This study compared demographic contributions for widely used tests of verbal and visual learning and memory (Brief Visual Memory Test-Revised, Hopkins Verbal Memory Test-Revised), and executive functioning (Stroop Color and Word Test, Wisconsin Card Sorting Test-64) in groups of healthy Caucasians (n = 143) and African-Americans (n = 103). Demographic factors of age, education, gender, and race/ethnicity were found to be significant factors on some indices of all four tests. The magnitude of demographic contributions (especially age) was greater for African-Americans than Caucasians on most measures. New, demographically corrected T-score formulas were calculated for each race/ethnicity. The rates of NP impairment using previously published normative standards significantly overestimated NP impairment in African-Americans. Utilizing the new demographic corrections developed and presented herein, NP impairment rates were comparable between the two race/ethnicities and unrelated to the other demographic characteristics (age, education, gender) in either race/ethnicity group. Findings support the need to consider extended demographic contributions to neuropsychological test performance in clinical and research settings.
Introduction
Learning, memory and executive functioning are core components of comprehensive neuropsychological (NP) assessment batteries. Accurate classification of NP impairment in these domains is especially important for the differential diagnosis of many neurologic conditions. Unfortunately, some of the most widely used neuropsychological tests do not have available norms that are corrected for race/ethnicity differences, despite research showing that differential ethnicity backgrounds affect NP performance, along with other demographic variables such as age, education, and gender (Heaton, Miller, Taylor, & Grant, 2004). Inadequate normative sampling and standards may lead to neuropsychological misclassification and may particularly contribute to misdiagnosis of African-Americans.
Researchers have begun examining demographic influences on learning and memory performance in an effort to produce normative standards among minority groups such as in African-Americans (e.g., California Verbal Learning Test -CVLT)[]; and the Third Edition of the Wechsler Memory Scale, WMS-III [Heaton, Taylor, & Manly, 2003],and in Spanish-speaking Hispanics (Hopkins Verbal Learning Test-Revised—HVLT-Rand Brief Visuospatial Memory Test-Revised—BVMT-R) (). However, data on a wider range of neuropsychological tasks are lacking. Regardless of the domain or racial group under study, race/ethnicity typically influences scores on NP measures ().
Several studies have demonstrated lower NP performance among African-Americans as compared to Caucasians on a wide variety of NP measures (; ; ; Heaton, et al., 2004; Heaton, et al., 2003; ; ). Importantly, it has been shown that these differences persists even when groups were matched for other demographic factors, including age, gender, education, and reading ability to a lesser extent ().
Accurate classification of the level of NP impairment in diverse racial groups has pragmatic clinical relevance to neuropsychologists. Without race/ethnicity-corrected scores in the clinical setting, a substantial number of normal African-Americans patients might be incorrectly classified as neuropsychologically impaired, and misdiagnosed. For example, demonstrated that 46%of African-Americans were classified as NP impaired (i.e., NP test T-score< 40) on the California Verbal Learning Test (CVLT) Trials 1–5 using the original Delis et al.(Delis, Kramer, Kaplan, & Ober, 1987) norms, which were based upon a predominantly Caucasian standardization sample. When CVLT norms were corrected for age, gender, and education, but not race,36% of African-Americans were still classified as NP impaired. Once race was sufficiently accounted for in the equation, only 17.8% of African Americans were classified as neuropsychologically impaired demonstrating that the new CVLT norms clearly improved the proportion of individuals scoring greater than one standard deviation below the mean. Misdiagnoses for neurodegenerative disorders or other conditions that affect brain functions have serious implications in terms of public health consequences as well as social and healthcare consequences for the patients and their families. Accurate classification of NP-impairment among African Americans is equally important in research settings for similar reasons.
Most existing normative data that are published in test manuals, lack information about race/ethnicity influences on test performance. The Hopkins Verbal Learning Test-Revised (HVLT-R) is a widely used task of verbal learning and memory (Brandt & Benedict, 2001), using 12 words belonging to three semantic categories. Six alternate forms facilitate reducing practice effects on repeated administrations. The standardization group’s age range was from 15 to 92 (M = 59.0, SD = 18.6) and education ranged from 2 to 20 years (M = 13.4, SD = 2.9); 79% were women. The normative sample for the HVLT-R included 1,179 adults; however, racial/ethnicity demographics were not provided. In the HVLT-R manual, stepwise multiple regression examined the effects of age, education, and gender for HVLT-R Total Recall, Delayed Recall, Percent Retained, and Recognition Discrimination. Age accounted for a considerable amount of variance, but education and gender were not found to significantly contribute to test performance. Cherner et al. () contend that a limitation of the original norms was that the reference group was highly educated and had suboptimal representation of low levels of education. Because of this reference group limitation, the rate of NP impairment may be erroneously elevated among lower educated persons.
The Brief Visual Memory Test – Revised (BVMT-R) is a short task of visual memory (Benedict, 1997). As with the HVLT-R, there are six different versions that allow for repeat testing with reduced practice effects. Similar to the HVLT-R, the manual describes a standardization group of 588 healthy English-speaking adults (171 college students and 471 community-dwelling participants) between the ages of 18 and 79 (M = 38.6, SD = 18.0) and with a mean education of 13.4 years (SD = 1.8). African-Americans accounted for 14.5% of the standardization sample; however, the authors did not provide information concerning whether and how race/ethnicity related to BVMT-R performance. The BVMT-R and HVLT-R produce indices of Total Recall, Delayed Recall, Percent Retained, and a Recognition Discrimination Index.
The Stroop Color and Word Test consists of speeded trials of Word Reading, Color Naming, and Color-Word Interference. Numerous versions of the Stroop exist, and the version used in the current study assigns a score for each trial based on the number of words read or colors named in forty-five seconds (Golden, 1978). The normative sample mentioned in the 2002 manual (Golden & Freshwater, 2002) includes the previous normative group (n = 100) from the original manual (Golden, 1978) as well as 300 additional cases collected between 1977 and 1997 (Golden & Freshwater, 2002). Age and education showed significant associations with Stroop scores and as such, the manual includes predicted scores for each trial based on these two demographic characteristics. Gender effects on the Stroop have been examined, but have been found to be inconsistent and confounded by sampling concerns; however, the racial characteristics of the original or total normative samples were not described.
The Wisconsin Card Sorting Test – 64 Card Version (WCST-64) is a computerized test of executive function that requires strategic planning and the ability to use environmental feedback to shift cognitive set (Kongs, Thompson, Iverson, & Heaton, 1993). The normative sample for the WCST-64 consisted of 445 adults ages 18–89 (M = 49.83 SD = 17.92). Education ranged from 6 to 20 years (M = 14.95, SD = 2.97) and 23% of the sample was female. Unfortunately, information about race/ethnicity was not routinely collected and therefore was not available for analysis. The manual states that hierarchical polynomial regressions were used to examine the effects of age, gender, and education. Age demonstrated a significant quadratic relationship with WSCT-64 scores and accounted for 1.4% to 18.9% of the variance in scores. Education accounted 1.3% to 7.7% of the variance in scores after adjusting for age. There were no significant gender effects after accounting for age and education.
Ps3 game saves gt5. This current study was designed to provide improved, demographically corrected normative standards among healthy samples of African-Americans and Caucasians on the HVLT-R, BVMT-R, Stroop Color and Word Test, and Wisconsin Card Sorting Test – 64 Card Version. The project has two specific aims: 1) To analyze the effects of demographic variables, including race/ethnicity (i.e., African-American and Caucasian) on test performance and classification accuracy (normal vs. abnormal), and 2) To develop normative equations that correct for all relevant demographic characteristics (age, education, gender, and race/ethnicity) to provide a more accurate classification of NP performance. We predict that Caucasian vs. African-American race/ethnicity will significantly contribute to NP performance, and that these differences will support the assertion that verbal and visual learning and memory as well as executive function measures require race/ethnicity corrections in order to correctly categorize NP impairment among African Americans ().
Methods
Participants
The sample consisted of 246 healthy individuals recruited as comparison participants (HIV uninfected controls) in a longitudinal study of HIV infected participants at the University of California, San Diego (UCSD)HIV Neurobehavioral Research Center (HNRC). One hundred forty three participants self identified as Caucasian and 103 self identified as African-American. Trained research associates used structured interviews and administered screening questionnaires to potential participants to assess inclusion/exclusion criteria prior to study enrollment. Exclusionary criteria for all subjects included any history of neurological disorders, current substance use disorders, and other conditions (e.g., psychiatric disorder with psychotic features, medications with CNS effects) known to affect neurocognitive performance. The UCSD Human Research Protections Program approved the protocol. Download digital fashion pro full version with crack 2014. Demographic information is presented in Table 1. The cross-sectional, stratified sample ranged in age from 20 to 65. The two samples (African American and Caucasian) did not differ significantly in terms of age or education, but the Caucasian group contained a smaller proportion of females (31% vs. 50%).
Table 1A
Demographic information in the two groups (Mean, SD)
Mean (SD) [Range] | Caucasian (n=143) | African American (n=103) | p |
---|---|---|---|
Age | 37.6 (12.3) [20–66] | 40.6 (12.3) [20–69] | 0.06 |
Education | 14.1 (2.4) [8–20] | 13.8(2.1) [8–19] | 0.37 |
Sex (% Female) | 31% | 50% | 0.003 |
Participants were asked to self identify their own race/ethnicity and this identification was used to define the African American and Caucasian groups used in this study. Years of education were determined using a previously defined and standardized procedure where education level ranges from 0–20 based on number of years of schooling completed (Heaton, et al., 2004). For example, a high school graduate receives 12 years of education and a person with a bachelor’s degree receives 16 years of education.
Neuropsychological Assessment
Participants completed an NP test battery of which a subset of two memory and two executive function tests were examined for this study, because these tests lacked race/ethnicity corrections as compared to other tests in the battery. Trained psychometrists following instructions from the respective manuals completed administration and scoring. Analyzed measures included Form A of the Hopkins Verbal Learning Test-Revised (Brandt & Benedict, 2001), Display A from the Brief Visual Memory Test-Revised (Benedict, 1997), the Stroop Color-Word Interference Test (Golden, 1978), and the Wisconsin Card Sorting Test-64 Computer Version (Heaton, Chelune, Talley, Kay, & Curtiss, 1993). We evaluated Total Recall across three learning trials and Delayed Recall for the HVLT-R and BVMT-R. Additionally, total numbers of correct items identified with the 45-second trials were analyzed for StroopWord Reading, Color Naming, and Color-Word formats. For the WCST, scores analyzed included Total Errors, Perseverative Errors, and Conceptual Level Responses.
Data Analysis
The distributions of all scores were examined. Although distributions of test raw scores were non-normal, parametric statistics were confirmed with non-parametric versions of the same statistical comparisons, and tails of distributions were similar between racial groups assuming symmetry in impairment rates. Effect sizes were measured with the unbiased Cohen’s d (Hedges & Olkin, 1985). This study was powered to detect a small effect size.
In the first step, African-American and Caucasian group scores were compared to analyze the effects of race/ethnicity on test performance. Next, linear regression was used to examine the effects of age, education, and gender; this was done separately for African American and Caucasian groups because it was determined that they had somewhat different age effects and (to a lesser degree) education effects. Partial regressions were then run to examine the independent contribution of age, education, and gender on measures in each group (Caucasian and African-American).
HVLT-R, BVMT-R, Stroop, and WCST-64 raw scores for the total subject group were converted into quantiles and mapped into the corresponding quantiles of a standard normal distribution. These scores were then converted into normalized scaled scores with a mean of 10 and standard deviation of 3. We used a subset of individuals (n=208) from the present study and some additional normal subjects from other ethnicities to create census-matched subset of individuals to generate the scaled scores as described below, but results from other ethnicities were not used in subsequent analyses that focused on African Americans and Caucasians. The rationale for adding these additional individuals for raw score to scaled score conversions was to reflect in the scaled scores the major ethnic group composition reported in the 2000 US census. These individuals met the same screening procedures as the study population. The resulting census matched proportions of race/ethnicity categories were 68.7% Caucasian, 13.5% African-American, 13.0% Hispanic, and 4.8% other race/ethnicities. Scaled score conversion tables for all variables are presented in Tables 2–4.
Table 2
Raw-to-Scaled Score conversions for the BVMT-R and HVLT-R
BVMT-R | HVLT-R | |||
---|---|---|---|---|
Scaled | Total Recall Raw | Delayed Recall Raw | Total Recall Raw | Delayed Recall Raw |
17 | 36 | 36 | ||
16 | ||||
15 | 34–35 | 35 | ||
14 | 33 | 12 | 34 | |
13 | 32 | 33 | 12 | |
12 | 30–31 | 31–32 | ||
11 | 28–29 | 11 | 30 | 11 |
10 | 26–27 | 29 | ||
9 | 24–25 | 10 | 27–28 | 10 |
8 | 21–23 | 9 | 26 | |
7 | 19–20 | 8 | 24–25 | 9 |
6 | 16–18 | 7 | 22–23 | 8 |
5 | 14–15 | 5–6 | 21 | 7 |
4 | 10–13 | 4 | 20 | 5–6 |
3 | 0–9 | 3 | 16–19 | |
2 | 0–2 | 0–15 | 4 | |
1 | 0–3 |
Table 4
Scaled | Total Errors | Perseverative Errors | Conceptual Level Responses |
---|---|---|---|
18 | 0–3 | ||
17 | 0–6 | ≥58 | |
16 | 7 | 57 | |
15 | 8 | 56 | |
14 | 4 | 54–55 | |
13 | 9–10 | 53 | |
12 | 11 | 5 | 51–52 |
11 | 12 | 6 | 49–50 |
10 | 13–15 | 7 | 45–48 |
9 | 16–19 | 8 | 39–44 |
8 | 20–22 | 9–10 | 34–38 |
7 | 23–28 | 11–13 | 28–33 |
6 | 29–32 | 14–15 | 20–27 |
5 | 33–35 | 16–18 | 16–19 |
4 | 36–39 | 19–26 | 13–15 |
3 | 40–48 | 26–41 | 6–12 |
2 | ≥49 | ≥42 | ≤5 |
1 |
In the next step, fractional polynomial multiple regression was employed to develop demographically-corrected prediction equations on the Caucasian and African American samples (respective n’s = 143 and 103) for each NP test scaled score using the methods outlined by Royston and Altman (Royston & Altman, 1994; also see Heaton, et al.,2004, and ). Separate regressions were run for each race/ethnicity, and the predictors included age, education, and sex. The fractional polynomial method developed by Royston and Altman (1994) uses an interactive algorithm to evaluate the influence of combinations of predictors with predetermined exponents (−2, −1, −0.5, 0, 0.5, 1, 2, 3) (the coefficient of 0 stands for the natural logarithm transformation). The algorithm compares all sets of predictors using these transformations to generate the final optimal fit. The residuals from the optimal regression equations were converted to T-scores with a mean of 50 and a standard deviation of 10. As designed, the resultant T-scores are not correlated with age, sex, or education for either racial group.
Results
In the first step, African American and Caucasian raw scores on each of the neuropsychological measures examined in this study were compared to analyze the effects of race/ethnicity. Table 5 demonstrates significant Caucasian and African American differences on all measures, such that Caucasians performed better in each instance. Table 5 also depicts medium to large effect sizes on most learning, memory and executive functioning indices; the only exceptions were small to medium effect sizes on HVLT-Delayed Recall and Stroop Color Naming and Word Reading.
Table 5
Neuropsychological test performance (raw scores) in Caucasians and African-Americans (Mean, SD)
Caucasian (n=143) | African-American (n=103) | p | Cohen’s d | |
---|---|---|---|---|
BVMT-R Total Recall | 26.5 (5.9) | 22.7 (6.8) | .0003 | −0.60 |
BVMT-R Delayed Recall | 10.2 (1.7) | 8.7 (2.4) | <.0001 | −0.74 |
HVLT-R Total Recall | 29.2 (3.9) | 26.8 (4.9) | .0002 | −0.55 |
HVLT-R Delayed Recall | 10.4 (1.9) | 9.4 (2.3) | .0016 | −0.48 |
Stroop Word Reading | 101.9 (14.4) | 96.2 (16.9) | .007 | −0.37 |
Stroop Color Naming | 76.4 (10.8) | 70.8 (13.0) | .0008 | −0.47 |
StroopColor-Word | 45.0 (9.5) | 38.2 (10.2) | <.0001 | −0.69 |
WCST-64 Total Errors | 15.6 (7.8) | 22.1 (10.2) | <.0001 | 0.73 |
WCST-64 Perseverative Errors | 7.6 (3.9) | 11.0 (4.2) | .0002 | 0.63 |
WCST-64Conceptual Level Responses | 44.3 (11.3) | 35.5 (14.3) | <.0001 | −0.69 |
For each of the 10 test scores, stepwise linear regressions were then conducted separately for each group (African American & Caucasian) to determine the proportion of variance accounted for by age, education, and gender (Tables 6 & 7). None of the fractional polynomials were significant predictors.
Table 6
Full model R2 and partial R2 for the effect of age, education and gender in each group on memory measures.
Caucasian (n=143) | African American (n=103) | ||||
---|---|---|---|---|---|
R2 | Partial R2 | 95% CI | R2 | PartialR2 | 95% CI |
BVMT-R Total Recall | .11** | .02, .20 | .28*** | .14, .42 | |
Age | .05** | .00, .12 | .21*** | .07, .35 | |
Education | .05** | .00, .12 | .05** | .00, .13 | |
Sex | .02 | .00, .06 | .03* | .00, .09 | |
BVMT-R Delayed Recall | .06* | .00, .13 | .29*** | .15, .43 | |
Age | .03* | .00, .08 | .24*** | .10, .38 | |
Education | .04* | .00, .10 | .03* | .00, .09 | |
Sex | .00 | .00, .02 | .03* | .00, .09 | |
HVLT-R Total Recall | .19*** | .07, .30 | .15*** | .03, .27 | |
Age | .00 | .00, .02 | .07** | .00, .16 | |
Education | .18*** | .06, .29 | .05* | .00, .13 | |
Sex | .03* | .00, .08 | .03* | .00, .09 | |
HVLT-R Delayed Recall | .18*** | .06, .29 | .14*** | .02, .26 | |
Age | .01 | .00, .04 | .05* | .00, .13 | |
Education | .14*** | .04, .24 | .08** | .00, .18 | |
Sex | .05** | .00, .12 | .01 | .00, .05 |
**p≤ .01
Table 7
Full model R2 and partial R2 for the effect of age, education and gender in each group on executive measures. Gloucester mt extra condensed font free download.
Caucasian (n=143) | African-American (n=103) | ||||
---|---|---|---|---|---|
R2 | Partial R2 | 95% CI | R2 | Partial R2 | 95% CI |
Stroop Measures | |||||
Word Reading | .01 | .00, .04 | .20*** | 07, .33 | |
Age | .00 | .00, .02 | .12*** | .00, .24 | |
Education | .00 | .00, .02 | .06* | .00, .15 | |
Sex | .00 | .00, .02 | .03 | .00, .09 | |
Color Naming | .01 | .00, .04 | .26*** | .12, 40 | |
Age | .00 | .00, .02 | .16*** | .03,.29 | |
Education | .01 | .00, .04 | .04* | .00, .11 | |
Sex | .00 | .00, .02 | .05** | .00, .13 | |
Color-Word | .15*** | .04, .25 | .39*** | .25, .53 | |
Age | .11*** | .01, .20 | .28*** | .14 .42 | |
Education | .04* | .00, .10 | .03* | .00, .09 | |
Sex | .00 | .00, .02 | .10*** | .00, .21 | |
WCST-64 Measures | |||||
Total Errors | .22*** | .10, .34 | .19** | .06, .32 | |
Age | .17*** | .06, .28 | .13** | .01, .25 | |
Education | .07*** | .00, .15 | .06** | .00, .15 | |
Sex | .00 | .00, .02 | .00 | .00, .03 | |
Perseverative Errors | .20*** | .09, .31 | .14** | .02, .26 | |
Age | .17*** | .06, .28 | .09** | .00, .19 | |
Education | .05** | .00, .12 | .05* | .00, .13 | |
Sex | .00 | .00, .02 | .00 | .00, .03 | |
Conceptual Level Responses | .20*** | .09, .31 | .20*** | .07, .33 | |
Age | .15*** | .04, .26 | .13*** | .01, .25 | |
Education | .07*** | .00, .15 | .07** | .00, .16 | |
Sex | .00 | .00, .02 | .00 | .00, .03 |
**p≤ .01
Memory
Table 6 shows information related to the demographic influences on learning and memory performance in Caucasians and African Americans independently. When considering the partial R2 results, only the African-American group showed a significant effect of age, and this was true for all measures (especially robust for BVMT-R measures). Total demographic effects (R2s) were higher for African Americans due to greater age effects on the BVMT-R, whereas more comparable effects were seen for the HVLT-R. Although education was a significant independent predictor of memory test performance for all measures in both groups, the education effects on the verbal (HVLT-R) measures were especially robust for the Caucasian group. Gender effects were absent or modest for both groups on most measures, with women performing better, and there were no systematic differences for the Caucasians versus African Americans.
Executive Functioning
Comparable results for Stroop and WCST-64 measures are presented in Table 7. As was the case for measures of visual learning and memory (BVMT-R), only the African American groups showed very large independent effects of age on all of the Stroop indices (Word Reading, Color Naming, and Color-Word). Only the African American group also showed significant gender effects on Stroop Color-Word (Interference condition) and Color Naming, with women performing faster. On the WCST-64 measures, both race/ethnicity groups demonstrated medium sized age effects (typically somewhat larger for Caucasians), and usually small to medium education effects. Neither racial/ethnicity group showed gender effect on this test.
Normative T-Score Derivation
As described in the Methods section, fractional polynomial regression analyses were conducted to derive normative scores that would correct for the observed demographic effects on normal test performance. This procedure began with the conversion of raw scores to normalized scaled scores (mean = 10, SD = 3) on all test measures (see Tables 2–4 for these conversions).
To examine the diagnostic (“normal” versus “abnormal”) classification accuracy of the new T-score conversions with more complete demographic corrections, we compared the impairment rates in both samples with those using previously published normative data (Benedict, 1997; Brandt & Benedict, 2001; Golden & Freshwater, 2002; Kongs, et al., 1993) that did not correct for race/ethnicity. The formulas used to generate the results for the new T-scores are included in Appendix A. Subjects were considered impaired if their T-Score was less than 40(Heaton, et al., 2004; ).
Figure 1 shows the results for the African American group. When applying previously published normative corrections to this sample, 24–49% of normal individuals were classified as NP impaired depending on the test score examined. Using our newly generated normative data the impairment rates significantly improved and ranged from 13–16%. The impairment rates for the African American sample with the previously published norms are significantly greater than what would be expected from the normal distribution with the selected 1 SD cutoff (Golden, 1978). All comparisons of impairment rates among African Americans using previously published normative corrections as compared to the newly generated normative corrections were statistically significant with the exception of the HVLT-R Delayed Recall measure that approached significance (p=0.08).
Percent of normal African American sample classified as “impaired” (1 SD cutoff) by published norms versus new, demographically corrected norms.
*p≤.05
**p≤ .01
***p≤ .001
The new normative correction formulas improved the consistency of impairment rates across test scores for the Caucasian sample as well (see Figure 2). Impairment rates for these norms ranged from 12 to 17% as compared to 8 to 26% using previously published normative data. The newly developed WCST-64 norms produced impairment rates more aligned with the expected impairment rates and were significantly lower than impairment rates with previously published norms on all WCST-64 indices.
Percent of normal Caucasian sample classified as “impaired” (1 SD cutoff) by published norms versus new, demographically corrected norms.
*p≤ .05
**p≤ .01
***p≤ .001
Discussion
This study complements previous literature on demographic corrections for neuropsychological test norms by examining a broader range of memory and executive functioning measures and specifically examining the effect of African American versus Caucasian race/ethnicity on test performance. These findings strongly support the use of separate norms for African-American and Caucasian examinees on the tests used here and, when combined with previously published results in the same ability domains, on learning, memory and executive functioning measures more generally. Consistent with prior findings on the Wechsler Intelligence and Memory Scales (Heaton, et al., 2003) and expanded Halstead-Reitan Battery (Heaton, et al., 2004), we found, in our sample of 103 African-Americans and 143 Caucasians, that African-American participants obtained lower raw scores on visual and verbal learning and memory and executive functioning measures.
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There are multiple background differences between African American and Caucasian adults within U.S. society today that may place African Americans at a disadvantage on standardized NP testing. The observed raw NP score differences may be consistent with disparities in quality of formal and informal educational experiences; however, other factors may also contribute to these discrepancies. It is considered unlikely that race has a direct causal effect on differences in adult cognition, so race/ethnicity is viewed as a proxy for other factors, much like has been discussed about education (). Factors potentially contributing to raw NP score differences between African American and Caucasian groups may include academic exposure, education quality, academic resources, acculturation, socioeconomic status, social exposure, “test wiseness”, societal discrimination (; ) and lifelong experiences contributing to low group and self-expectations ().
There are few opportunities in the literature to compare our raw score results with those reported by other investigators. Whereas this study found about a 2-point (raw score) difference on HVLT-R Total Recall performances between Caucasians and African-Americans, Morgan et al. () found a 4-point difference and less variability. The current study demonstrated moderate to large race/ethnicity effect sizes, but the raw score differences between Caucasians and African Americans do not seem to be especially large (e.g., an average of only 1.5 points on BVMT-R Delayed Recall is associated with a medium to large effect size; see Table 5). However, these differences were sufficiently robust to cause unacceptably large “impairment” classification rates in the African American sample (Figure 1).
Although concerns might be raised that the method of raced-based norming could “overcorrect” performances of neurologically impaired African Americans (making them less sensitive to disease), this could be said as well for norms that correct for older age, lower education levels, or any demographic characteristic that is associated with lower test performance in normal people. In our view, the most important function of norms is to maintain an acceptable and consistent level of diagnostic specificity (accuracy in classifying normal people as normal) for people regardless of their demographic characteristics. Our data suggest that the norms presented here result in rates of impairment that are comparable, and are within statistical expectations for a healthy population, for both our Caucasian and African American participants.
As addressed by Byrd et al. () and others, the term “race” is an arbitrary distinction and difficult to operationalize. Often race is based on skin color and self-identification. As notes, race is a social definition rather than a scientific classification and race is not homogeneous. Devising ways to understand the influences of ethnicity and race on NP tests will become increasingly complex as rates of self-identified multiracial individuals rise.
Given the unclear relationship of “race” on cognition, some suggest recording, quantifying, and modeling the effects of all background factors that can influence cognitive development and test performance. Gasquoine () and others have advocated that an alternative approach to race/ethnicity-based norms is to estimate preexisting neuropsychological status based on a case-by-case basis from regular normative tables. On the other hand, Gasquoine acknowledges that there is little empirical support for this technique, and there is no agreed upon method for establishing NP status on a case-by-case basis. Furthermore, accurate retrospective collection of such complex data across the lifespan is very difficult ().
Also, a subjective interpretation of cognitive deficit will most likely have the effect of wide variations in the impairment classifications of minorities between different clinical neuropsychologists. Instead, the use of the more general race/ethnicity proxy (with all its shortcomings) in normative corrections should at least enhance consistency/reliability and may greatly reduce the probability of incorrectly attributing cognitive and possibly central nervous system abnormalities to normal African Americans.
Of course, clinical interpretation of neuropsychological data should not strictly rely upon use of norms, but also consider the appropriateness of available norms in relation to each person’s background, including social, educational and medial history, and other factors (i.e., psychiatric, substance use, etc.). In particular, diagnostic sensitivity and specificity are likely to vary when norms are applied to people whose backgrounds differ significantly from those represented in the normative sample populations (Heaton et al., 2004).
In addition, it is important to note that demographically corrected norms are intended to reflect the difference between current performance and a best estimate of the person’s expected “normal” performance (i.e., in the absence of CNS abnormality). Such norms are less appropriate, at best, when the goal is to determine the person’s absolute level of ability (e.g., in relation to requirements of specific everyday tasks and activities).
Following the derivation of separate normative equations and confirming adequate normative distributions, we found that our new demographically corrected formulas provided significantly improved impairment estimates. These data suggest that scores that have not been corrected for race/ethnicity classify 31–32% of the African-American sample with visual learning and memory impairment, 25–26% as having verbal learning and memory impairment, and 24–49% as having executive dysfunction. These percentages are substantially higher than expected values in any normative population. In contrast, when the African-American scores were corrected for race/ethnicity, the average impairment frequencies dropped to expected levels. The over estimation of impairment with existing normative data can lead to misclassification and/or misdiagnosis of African American individuals and can have serious negative consequences for the patients and their families. Misdiagnosis and misclassification is problematic in clinical, forensic, and research applications of neuropsychology; however, few NP norms account for these demographic variables.
The present study also demonstrated that the demographic contributions of age, education and gender to NP test performances were somewhat different for African Americans as compared to Caucasians. The contribution of age tended to be stronger for African-American participants on the BVMT-R, HVLT-R, and Stroop tests, but less pronounced on the WCST-64. The current study was not designed to explore why demographic factors exhibit stronger influences among African Americans, although large age effects for African Americans as compared to Caucasians have been observed in other large U.S. samples and on other neuropsychological tests (Heaton et al., 2004). Because these differential effects of demographics are not well understood, they require additional careful investigation (especially taking into account age related medical conditions and associated treatments that could differ across ethnicity groups).
The current study is limited, as are others of the same type, in terms of failing to provide insights into the factors that contribute to racial differences on these memory and executive function measures. As discussed earlier, Manly (1998) and others suggest that educational quality, exposure, and other factors might play a role in the poorer observed performance of African Americans on these neuropsychological tests. The amount of education may be less important than the quality of one’s education, as measured by reading scores. Dotson et al. () and Manly et al. (; ) found that literacy was a better predication of cognitive scores than education. In an African-American sample, used memory, naming, fluency, visuospatial, attention, and psychomotor scores and regressed them on sex, age, literacy, and education scores. They did not find a unique contribution of education after literacy was added to the model; however, this study only included African-American participants. The present study did not measure literacy, but as with previous studies, education was found to be a significant predictor to cognitive scores. The measurement of these factors remains elusive, however, as effects of educational opportunities and importance within the cultural experience, and other potentially important factors are complex and difficult to determine retrospectively (e.g., asking an adult about parental influences and early school experiences; ). On the other hand, current attempts at understanding these factors are starting to emerge and multifactorial models involving psychological factors, stress factors, social and cognitive factors have been proposed (Mays et al., 2007). An additional complexity is that it is likely that some or all of the factors influencing NP test performance have changed over generations and continue to do so. For example, it is likely that the educational quality for 30 year-old and 60 year-old African Americans has been quite different (probably more so for than for Caucasians in the U.S.).
An additional limitation in this research is the ambiguity in classifying race or ethnicity. While “race” and “ethnicity” are often interchangeably used in this area of research, they are not equivalent terms. Given that there are no biological race/ethnicity markers, group identification has been pragmatically based on self-identification – and this is the approach that was used on the current study. Race is more than just skin color and there may be multiple ethnic groups within a race. Some argue that the inability to specifically identify and characterize race/ethnicity should preclude demographic corrections; however, even with this limitation, the current data demonstrate excessive rates of diagnostic error if clinicians use norms that are not corrected for race/ethnicity. In particular, our findings with the new T-score conversions suggest greater and more equal specificity, with regard to race/ethnicity, within the healthy population than was achieved by the published norms. Although we have no data concerning sensitivity of the new norms to CNS compromise, sensitivity also is likely to be more equivalent among demographic groups (e.g., (Heaton, Ryan, & Grant, 2009). Despite limitations, we believe that the current quantitative standards provide a substantial improvement for the classification of neurocognitive impairment status in self identified African-Americans.
Finally, it is important to acknowledge that our current sample size was relatively small, and we were unable to cross-validate the normative distribution with an independent sample. We recommend caution when using these normative data with individuals over age 60 or with other groups not well represented in our normative sample. There were relatively few individuals with less than 10 years of education enrolled in this study and therefore caution should be used when applying these normative corrections to persons with such low levels of education. In addition, all participants in this study were from the San Diego area and participants were carefully screened to exclude anyone with neuromedical or developmental histories suggesting any increased risk for CNS compromise. As such, generalizability of these results and associated normative standards to other, ostensibly normal, African American and Caucasian groups cannot be assumed. To partially address this question, we applied the demographically corrected norms in the WAIS-III/WMS-III/WIAT-II Scoring Assistant program (The Psychological Corporation, 1999; Heaton Taylor and Manly, 2003) to the current samples’ results on three WAIS-III subtests (Letter-Number Sequencing, Digit Symbol Coding, and Symbol Search). These latter norms were based upon a large, national standardization sample from all U.S. regions, and correct for all demographic variables that were examined in the current study (age, education, gender and African American versus Caucasian race/ethnicity). We reasoned that application of these norms to the current samples’ WAIS-III results would provide some indication of their representativeness of the much larger national sample. Ideally, the mean (SD) T-scores would approach 50 (10) and would not differ for the two race/ethnicity groups in the study.
For Letter-Number Sequencing, the mean (SD) T-scores were 53.0 (9.8) for our African American Group and 51.8 (9.4) for our Caucasian group (p-value for group difference = 0.35). On the WAIS-III Processing Speed Index (which combines Digit Symbol and Symbol Search), the respective scores were 54.6 (10.7) for our African American group and 52.6 (9.9) for our Caucasian group (p=.14). The fact that both of our race/ethnicity groups performed slightly better than the national standardization samples on these WAIS-III tests may reflect our (arguably) more stringent neuromedical screening procedures and/or slight regional differences. Also, however, these results indicate that, relative to normal expectations for African American and Caucasians in the U.S., our race/ethnicity groups performed comparably. This suggests that our groups’ findings on the memory and executive function tests are unlikely to be overestimating the race/ethnicity bias in the previously published norms.
Our results for the HVLT-R and BVMT-R are limited to Form A of these measures, and future studies will focus on assessing the need for specific corrections for all the multiple forms of these measures. Additionally, it is important to assess whether or not the demographic corrections can be validated in a clinical sample, showing equivalent results across the various demographic categories.
Table 1B
Education | Age Range | ||||
---|---|---|---|---|---|
<30 | 30–39 | 40–49 | 50–59 | 60+ | |
< 10 | 0 | 1 | 1 | 0 | 0 |
10–11 | 4 | 2 | 2 | 1 | 0 |
12 | 5 | 6 | 5 | 5 | 2 |
13–15 | 12 | 4 | 13 | 7 | 0 |
16 | 7 | 5 | 4 | 5 | 0 |
>16 | 2 | 6 | 6 | 6 | 0 |
Table 1C
Education | Age Range | ||||
---|---|---|---|---|---|
<30 | 30–39 | 40–49 | 50–59 | 60+ | |
< 10 | 0 | 1 | 0 | 0 | 0 |
10–11 | 1 | 1 | 4 | 1 | 1 |
12 | 6 | 4 | 6 | 3 | 1 |
13–15 | 8 | 9 | 10 | 8 | 4 |
16 | 4 | 4 | 5 | 1 | 1 |
>16 | 0 | 3 | 1 | 2 | 2 |
Table 3
Raw-to-Scaled Score conversions for the Stroop Color and Word Test
Stroop Color and Word Test | |||
---|---|---|---|
Scaled | Word Reading Raw | Color Naming Raw | Color-Word Raw |
18 | ≥145 | ≥107 | |
17 | 134–144 | 100–106 | ≥65 |
16 | 128–133 | 97–99 | 63–64 |
15 | 123–127 | 93–96 | 59–62 |
14 | 118–122 | 89–92 | 56–58 |
13 | 114–117 | 85–88 | 53–55 |
12 | 109–113 | 80–84 | 49–52 |
11 | 106–108 | 76–79 | 46–48 |
10 | 101–105 | 74–75 | 42–45 |
9 | 97–100 | 70–73 | 39–41 |
8 | 89–96 | 66–69 | 36–38 |
7 | 83–88 | 62–65 | 32–35 |
6 | 77–82 | 58–61 | 29–31 |
5 | 71–76 | 49–57 | 25–28 |
4 | 67–70 | 43–48 | 22–24 |
3 | 66 | 40–42 | 0–21 |
2 | <66 | 0–39 |
Acknowledgments
The HIV Neurobehavioral Research Center (HNRC) is supported by Center award MH 62512 from NIMH.
Appendix A: Normative Formulas for Caucasians and African Americans
Caucasian T-score formulas
BVMT Total Recall:
[(Total learning scaled score − (0.2589 ∗ (edu − 14.11) + (−0.0515) ∗ (age − 37.62) + 0.9276 ∗ sex + 10.0712))/2.8912] ∗ 10 + 50
BVMT Delayed Recall
[(Delayed recall scaled score − (0.2084 ∗ (edu − 14.11) + (−0.0286) ∗ (age − 37.62) + + 10.3007))/2.6989] ∗ 10 + 50
HVLT Total Recall
[(Total learning scaled score − (0.5225 ∗ (edu − 14.11) + 1.0035 ∗ gender + 10.1738))/2.5927] ∗ 10 + 50
HVLT Delayed Recall
[(Delayed recall scaled score − (0.5414 ∗ (edu − 14.11) + 1.7324 ∗ genter + 9.9285))/2.6989] ∗ 10 + 50
Stroop Word Reading
[(Word reading scaled score − (0.0819 ∗ (edu − 13.92) + 0.0038 ∗ (age − 36.17) + (−0.4022) ∗ gender + 10.2102)−(−0.00003))/2.9435] ∗ 10 + 50
Stroop Color Naming
[(Color naming scaled score − (0.0941 ∗ (edu − 13.92) + 10.4444))/2.8101] ∗ 10 + 50
Stroop Color-Word
Halstead Reitan Neuropsychological Test Pdf
[(Color − word scaled score − (0.2479 ∗ (edu − 13.92) + (−0.0828) ∗ (age − 36.22) + + 10.3968))/2.6002] ∗ 10 + 50
Stroop Interference
Halstead Reitan Battery Assessment
[(Interference scaled score − (0.2346 ∗ (edu − 13.92) + (−0.0762) ∗ (age − 36.22) + 0.7465 ∗ sex + 9.9952))/2.6342] ∗ 10 + 50
WCST-64 Total Errors
[(Total Errors Scaled score − (0.3187 ∗ (edu − 14.13) + (−0.01) ∗ (age − 37.37) + 0.1608 ∗ gender + 10.4049)−(−0.0017))/2.674] ∗ 10 + 50
WCST-64 Perseverative Errors
Halstead Reitan Trail Making Test
[(Perseverative Errors Scaled Score − (0.2357 ∗ (edu − 14.13) + (−0.0941) ∗ (age − 37.37) + 0.0341 ∗ gender + 10.33)−(−0.0012))/2.5506] ∗ 10 + 50
WCST-64 Conceptual Level Responses
[(Conceptual Level Responses scaled score − (0.3223 ∗ (edu − 14.13) + (−0.0941) ∗ (age − 37.37) + 0.0577 ∗ gender + 10.4292)−(−0.0016))/2.568] ∗ 10 + 50
African-American T-score formulas
BVMT Total Recall:
[(Total learning scaled score − (0.2834 ∗ (edu − 13.86) + (−0.1125) ∗ (age − 40.63) + 1.0394 ∗ sex + 8.0679))/2.5701] ∗ 10 + 50
BVMT Delayed Recall
[(Delayed recall scaled score − (0.2267 ∗ (edu − 13.86) + (−0.12.62) ∗ (age − 40.63) + 0.8593 ∗ sex + 7.691))/2.5197] ∗ 10 + 50
HVLT Total Recall
[(Total learning scaled score − (0.2917 ∗ (edu − 13.86) + (−0.0644) ∗ (age − 40.63) + 1.1462 ∗ sex + 8.3063))/2.8333] ∗ 10 + 50
HVLT Delayed Recall
[(Delayed recall scaled score − (0.3986 ∗ (edu − 13.86) + (−0.0733) ∗ (age − 40.63) + .9145 ∗ sex + 8.2753))/3.1354] ∗ 10 + 50
Stroop Word Reading
[(Word reading scaled score − (0.3557 ∗ (edu − 13.92) + (−0.0866 ∗ (age − 40.67) + 1.2315 ∗ sex + 8.3263)−(0.00095))/2.8127] ∗ 10 + 50
Stroop Color Naming
[(Color namimg scaled score − (0.3102 ∗ (edu − 13.92) + (−0.1006) ∗ (age − 40.67) + 1.4915 ∗ sex + 8.2672))/2.6643] ∗ 10 + 50
Stroop Color-Word.
[(Color − Word scaled score − (0.2363 ∗ (edu − 13.94) + (−0.1219) ∗ (age − 40.67) + 1.9479 ∗ sex + 7.449))/2.2658] ∗ 10 + 50
Stroop Interference.
[(Interference scaled score − ((−0.0303) ∗ (age − 40.67) + (1.4688 ∗ sex + 8.1343))/2.663] ∗ 10 + 50
WCST-64 Total Errors
[(Total Errors Scaled score − (0.3321 ∗ (edu − 13.97) + (−0.0838) ∗ (age − 40.7) + 0.3215 ∗ sex + 8.1621)−(−0.0006))/2.7911] ∗ 10 + 50
WCST-64 Perseverative Errors
[(Perseverative Errors Scaled Score − (0.3599 ∗ (edu − 13.97) + (−0.0776) ∗ (age − 40.7) + (−0.1093) ∗ sex + 8.5524)−(0.0006))/3.0124] ∗ 10 + 50
WCST-64 Conceptual Level Responses
[(Conceptual Level Response scaled score − (0.4002 ∗ (edu − 13.97) + (−0.0874) ∗ (age − 40.7) + 0.2546 ∗ gender + 8.2248)−(0.0006))/2.5887] ∗ 10 + 50
Notes
Education
Years of education were determined using a previously defined and standardized procedure where education level ranges from 1–20 based on number of years of schooling completed (Heaton, et al., 2004).
Footnotes
*The San Diego HIV Neurobehavioral Research Center [HNRC] group is affiliated with the University of California, San Diego, the Naval Medial Center, San Diego, and the Veterans Affairs San Diego Healthcare System, and includes: Director: Igor Grant, M.D.; Co-Directors: J. Hampton Atkinson, M.D., Ronald J. Ellis, M.D., Ph.D., and J. Allen McCutchan, M.D.; Center Manager: Thomas D. Marcotte, Ph.D.; Jennifer Marquie-Beck, M.P.H.; Melanie Sherman; Neuromedical Component: Ronald J. Ellis, M.D., Ph.D. (P.I.), J. Allen McCutchan, M.D., Scott Letendre, M.D., Edmund Capparelli, Pharm.D., Rachel Schrier, Ph.D., Terry Alexander, R.N., Debra Rosario, M.P.H., Shannon LeBlanc; Neurobehavioral Component: Robert K. Heaton, Ph.D. (P.I.), Steven Paul Woods, Psy.D., Mariana Cherner, Ph.D., David J. Moore, Ph.D.; Matthew Dawson; Neuroimaging Component: Terry Jernigan, Ph.D. (P.I.), Christine Fennema-Notestine, Ph.D., Sarah L. Archibald, M.A., John Hesselink, M.D., Jacopo Annese, Ph.D., Michael J. Taylor, Ph.D.; Neurobiology Component: Eliezer Masliah, M.D. (P.I.), Ian Everall, FRCPsych., FRCPath., Ph.D., Cristian Achim, M.D., Ph.D.; Neurovirology Component: Douglas Richman, M.D., (P.I.), David M. Smith, M.D.; International Component: J. Allen McCutchan, M.D., (P.I.); Developmental Component: Ian Everall, FRCPsych., FRCPath., Ph.D. (P.I.), Stuart Lipton, M.D., Ph.D.; Participant Accrual and Retention Unit: J. Hampton Atkinson, M.D. (P.I.), Rodney von Jaeger, M.P.H.; Data Management Unit: Anthony C. Gamst, Ph.D. (P.I.), Clint Cushman (Data Systems Manager); Statistics Unit: Ian Abramson, Ph.D. (P.I.), Florin Vaida, Ph.D., Reena Deutsch, Ph.D., Tanya Wolfson, M.A.
The views expressed in this article are those of the authors and do not reflect the official policy or position of the Department of the Navy, Department of Defense, nor the United States Government.
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Front | Back |
Diagnostic systems allow clinicians and scientists to a. conduct psychotherapy.b. communicate accurately with one another about cases andresearch.c. understand the role of cultural bias.d. All of the above are correct. | b. communicate accurately with one another about cases and research. |
Jim was given an intelligence test in March andre-administered the same test one year later. His score both times was thesame. This indicates that the intelligence test has a. high test-retest reliability.b. high interrater agreement.c. internal consistency.d. None of the above is correct. | |
Generally it is impossible for measures to be a. reliable but not valid.b. valid but not reliable.c. neither reliable nor valid.d. both reliable and valid. | |
Britney was taking a test to measure levels ofdepression. All of the items coveredtypical symptoms of depression. Thisinventory would be said to have a. high construct validity.b. high content validity.c. high criterion validity.d. high statistical validity. | |
In 1994, the DSM-IV was published by the a. American Psychopathological and Statistical Association.b. World Health Organization.c. Congress of Mental Science.d. American Psychiatric Association. | |
In 2000, the DSM-IV-TR was published a. to clarify issues surrounding prevalence rates, course,and etiology.b. to describe diagnoses in objective terms.c. to include response to treatment in the descriptions ofdiagnoses.d. for use by laypersons as well as professionals. | a. to clarify issues surrounding prevalence rates, course, and etiology. |
The letters in the abbreviation DSM refers to a. Diseases and Symptoms of the Mind.b. Diagnostic and Statistical Manual.c. Diseases and Symptoms Manual.d. Disorders and Symptoms Manual. | |
Axes I and II are separated a. to distinguish mood disorders from psychotic disorders.b. to allow distinctions between medical conditions andpsychological conditions.c. to distinguish longstanding disturbances from acuteproblems.d. All of the above are correct. | c. to distinguish longstanding disturbances from acute problems. |
In DSM-IV-TR, long-standing diagnoses such as personalitydisorders are identified on a. only Axis I.b. only Axis II.c. only Axis III.d. Axis II and III. | |
Axis V is included to a. provide a current rating of functioning.b. estimate probability of recovery.c. assist in clarifying diagnoses made on Axis I or II.d. None of the above is correct. | |
Without Axis IV, which of the following would not beincluded in the DSM-IV-TR diagnosis? a. a developmental disorderb. alcoholismc. diabetesd. homelessness | |
Jose has major depression and has multiple sclerosis. He would be diagnosed on a. Axis I: major depression and Axis III: multiplesclerosis.b. Axis I: major depression; Axis II: multiple sclerosis.c. Axis I: major depression and multiple sclerosis. d. Axis II: major depression and Axis III: multiplesclerosis. | a. Axis I: major depression and Axis III: multiple sclerosis. |
Sheila was recently robbed and subsequently developed anacute stress disorder. She was blinded during the robbery and is now unable tofind work because of her loss of sight. Using DSM-IV, how would Sheila'sproblems be diagnosed? a. Axis I: no diagnosis; Axis II: Acute Stress Disorder;Axis III: blindnessb. Axis I: Acute Stress Disorder; Axis II: blindnessc. Axis I: Acute Stress Disorder; Axis II: blindness; AxisIII: Psychosocial and Environment Problem: robberyd. Axis I: Acute Stress Disorder; Axis III: blindness; AxisIV: Psychosocial and Environmental Problem: robbery | d. Axis I: Acute Stress Disorder; Axis III: blindness; Axis IV: Psychosocial and Environmental Problem: robbery |
Axis V of the DSM-IV-TR considers all but which of thefollowing? a. social relationshipsb. use of leisure timec. occupational functioningd. psychosocial problems experienced | |
The multiaxial approach in DSM-IV-TR encourages cliniciansto make assessment judgments a. on the most appropriate axis.b. based on ethnic and cultural considerations.c. considering a wide range of information.d. using a variety of assessment measures. | |
Major improvements since the DSM-III include all of thefollowing EXCEPT a. more specific diagnostic criteria.b. more extensive descriptions of diagnosis on Axes I andII.c. decrease in diagnostic categories.d. more emphasis on laboratory findings and results fromphysical exams. | |
Which of the following diagnostic categories were at onetime included in the DSM and were then removed from the DSM? a. homosexualityb. bipolar disorderc. panic disorderd. None of the above is correct. | |
Previous editions of the DSM were criticized for their a. lack of attention to childhood disorders.b. lack of attention to cultural and ethnic variations inpsychopathology.c. inability to accurately diagnose individuals withschizophrenia.d. overemphasis on mood disorders. | b. lack of attention to cultural and ethnic variations in psychopathology. |
Which of the following statements is TRUE? a. Culture can have a large influence on which symptoms of agiven disorder are expressed.b. For most diagnoses in the DSM-IV-TR, it is advised not toconsider cultural context.c. Most symptoms of psychiatric disorders manifestthemselves in similar ways across cultures.d. The DSM-II was the first edition of the DSM to considercultural and ethnic variations in psychopathology. | a. Culture can have a large influence on which symptoms of a given disorder are expressed. |
Culture bound syndromes a. are coded on Axis II.b. are listed in the appendix of the DSM.c. are only found in cultures outside the United States.d. are very, very rare. | |
A dissociative episode found primarily among men thatinvolves brooding followed by violent episodes is called a. brain fag.b. koro.c. amok.d. dhat. | |
In the DSM-IV, anxiety about the penis receding into thebody is termed a. amok.b. ghost sickness.c. dhat.d. koro. | |
Studies of psychopathology in other cultures suggest that a. people diagnosed with a culture-bound syndrome may alsomeet DSM criteria for a specific disorder.b. the prevalence of eating disorders in West Africanadolescents is approximately the same as the prevalence in Americanadolescents.c. worldwide, depression is more common in men.d. koro is quite common in Native American cultures. | a. people diagnosed with a culture-bound syndrome may also meet DSM criteria for a specific disorder. |
The DSM-IV-TR includes approximately _____ differentdiagnostic categories. a. 300b. 490c. 125d. 75 | |
Some critics of the DSM-IV-TR believe that a. there are not enough different diagnoses.b. the DSM-IV-TR has pathologized too many problems withoutgood justification.c. there is not enough comorbidity in diagnoses.d. another diagnostic category should be added titled “Conditions that may be a focus of clinical attention in elderly populations.” | b. the DSM-IV-TR has pathologized too many problems without good justification. |
Comorbidity refers to a. the likelihood that a given psychological disorder willresult in death.b. how long a person is expected to live with a givenpsychological disorder.c. the presence of a second diagnosis.d. the absence of an Axis I disorder. | |
The DSM-IV-TR is an example of which approach toclassification? a. categoricalb. dimensionalc. quantitatived. atheoretical | |
Which of the following is a dimensional classificationsystem? a. genderb. college majorc. telephone numberd. grade point average | |
Dr. Kline classified her patients according to hair color. Somewere classified as blonde, some brunette, some red- haired. This is an example of a a. continuous classification.b. etiological classification.c. categorical classification.d. dimensional classification. | |
You are relying on a dimensional classification scheme andwork with individuals who struggle with delusions. Your diagnoses are going tobe based upon _________ of delusions. a. presence or absenceb. social consequencesc. underlying caused. severity | |
The fact that SSRI’s often relieve symptoms of anxiety aswell as depression suggests to some clinicians and researchers that a. SSRI’s are inadequate drugs for depression.b. anxiety and depression should be part of the samediagnostic category.c. anxiety should be treated with anxiolytics.d. Axis I and II should be a dimensional diagnostic system. | b. anxiety and depression should be part of the same diagnostic category. |
What is one reason categorical systems are popular? a. Freud was a proponent of such a system.b. They define a certain threshold for treatment.c. They describe the degree to which an entity is present.d. It is more helpful to know severity of a symptom ratherthan whether or not it is present. | b. They define a certain threshold for treatment. |
Caleb went to see two different psychologists about hisdepressive symptoms. One told him that he suffered from major depressivedisorder and the other told him that he had bipolar disorder. This is anexample of a problem with ____________ a. interrater reliability.b. content validity.c. internal consistency.d. construct validity. | |
In order to study the reliability of a diagnostic category,we would study whether a. it acknowledges the uniqueness of each individual.b. it has explicitly stated criteria.c. patients with the label respond to treatment the same.d. diagnosticians apply it consistently. | |
Reliability, as used in diagnosis, is the same as a. agreement.b. validity.c. judgment.d. utility. | |
If a diagnosis helps clinicians make good predictions andinforms them of the likely course of the disorder, psychologists would say thatthe diagnosis has a. interrater reliability.b. construct validity.c. test validity.d. internal consistency. | |
Which of the following situations is most similar to theconcept of reliability in making psychiatric diagnoses? a. You see identical twins that have identical mannerisms.b. After watching a new T.V. show, you and a friendindependently decide that it is lousy.c. You're not sure what time a baseball game is on and guessit is at 1:00. You look in the T.V. guide and it is, in fact, at 1:00.d. You meet someone new at a party and decide she/he is ashy person. Sure enough, she/he hardlyspeaks to anyone at the party. | b. After watching a new T.V. show, you and a friend independently decide that it is lousy. |
A line judge in a football game calls a player forholding. The head linesman disagrees,but instead calls a player for unnecessary roughness. These referees have aproblem with a. reliability.b. etiological validity.c. concurrent validity.d. predictive validity. | |
A valid classification system is one that a. has clear criteria for making diagnoses.b. ensures that two or more people will agree on aclassification.c. leads to accurate predictions and statements.d. has a clear purpose. | |
Just before he died, several physicians were treating Joefor a stroke; an autopsy showed he had Alzheimer's disease. Joe's physicians showed a. neither reliability nor validity.b. validity but not reliability.c. reliability but not validity.d. both reliability and validity (despite very bad luck). | |
Construct validity of a diagnosis refers to a. diagnoses that arise due to known medical factors.b. the consistency of diagnosing the same condition.c. an inference regarding a diagnosis on the basis of a setof observed symptoms.d. the likelihood that two diagnosticians would come up withthe same diagnosis. | c. an inference regarding a diagnosis on the basis of a set of observed symptoms. |
Unlike most conversations with a friend, a clinicalinterviewer would focus on a. structure.b. how the person responds.c. objectivity.d. humor. | |
In clinical interviews, most clinicians pay particularattention to a. manner of responding.b. truthfulness.c. childhood.d. current social functioning. | |
Which of the following is true regarding interviewing theclinical interview? a. It enables one to obtain vast amounts of information.b. It is too subjective to be of much value in assessment.c. It provides the most valid information in assessment.d. Behavioral clinicians consider it unnecessary, thoughclinicians from other paradigms find it useful. | a. It enables one to obtain vast amounts of information. |
Which of the following guides a clinical interview? a. time of dayb. location of interviewc. paradigm used by interviewerd. structured instrument used by interviewer | |
Which of the following is a structured interview? a. SRRSb. SCIDc. ADEd. Rorschach | |
Which of the following is not a measure of psychologicalstress? a. Social Readjustment Rating Scale b. Assessment of Daily Experiencec. Life Events and Difficulties Scheduled. Thematic Apperception Test | |
Why has the Social Readjustment Scale been criticized? a. It is a self-report measure.b. It contains items that are both outcomes and antecedentsof stress.c. It contains items that most people have neverexperienced.d. It relies on prospective methods. | b. It contains items that are both outcomes and antecedents of stress. |
Ava creates a scale that assesses stress during the firstyear of college. She plans to administer this scale to graduating seniors. Whatis a likely criticism of her methods? a. She will have low interrater reliability.b. She will be collecting retrospective reports which aresubject to considerable distortion.c. Most graduating seniors will not have the time tocomplete such a scale.d. She should use a validated scale like the MMPI. | b. She will be collecting retrospective reports which are subject to considerable distortion. |
The ADE was most helpful in addressing which of thefollowing issues? a. retrospective reportsb. prospective reportsc. internal consistencyd. clinical interviews | |
An advantage of the Life Events and Difficulties Schedule(LEDS) over other life stress assessments is that a. it is a very structured interview.b. it takes a shorter time to complete.c. it allows for the evaluation of life events in thecontext of a person’s unique life circumstances.d. it relies less on determining when an event actuallyoccurred. | c. it allows for the evaluation of life events in the context of a person’s unique life circumstances. |
The Bedford College Life Events and Difficulties Schedule(LEDS) was designed to measure stress a. in response to major life changing events.b. in the context of the individual’s circumstances.c. as it occurs in the individual’s routine daily life.d. over especially long periods of time. | b. in the context of the individual’s circumstances. |
The LEDS has led researchers to conclude that a. life events are robust predictors of severalpsychological and medical symptoms.b. stress is mediated by one’s childhood experiences.c. a given life event has the same impact acrossindividuals.c. the correlation between life events and stress is low. | a. life events are robust predictors of several psychological and medical symptoms. |
You have developed a new personality inventory that will beused to match roommates in order to minimize conflict. You are almost ready to market the test, butfirst must administer it to several hundred individuals to establish normativeinformation. This phase of testdevelopment is referred to as a. branching.b. psychometrics.c. validation.d.standardization. | |
These types of tests have not traditionally been standardized. a. intelligence testsb. objective Personality testsc. projective Personality Testsd. All of the above have been standardized. | |
You decide that you wish to use the MMPI to form a scalewithin the instrument to distinguish potential professional wrestlers fromthose without the potential to be wrestlers. Using the same method as that usedto develop the MMPI, you would a. identify items that were about wrestling.b. identify items that distinguish pro wrestlers fromnon-wrestlers.c. find all the items that wrestlers answered as trueregarding themselves.d. look for consistency among items endorsed by wrestlers astrue. | b. identify items that distinguish pro wrestlers from non-wrestlers. |
The MMPI is an example of a (n) a. projective test.b. personality inventory.c. intelligence test.d. structured clinical interview. | |
One reason for revising the MMPI was to a. make scoring easier and more reliable.b. accommodate changes in DSM criteria.c. eliminate objectionable wording.d. reduce possibilities for cheating. | |
Which of the following was not a change made in the revisedversion of the MMPI? a. Increase representation from different racial groups inthe norm sample.b. Alter the format for answering questions.c. Alter the norm sample to reflect the composition of theUS.d. Altering items to make the content more current. | |
Which of the following is a limitation of computer generatedscoring of the MMPI? a. Competency of the professionals interpreting the scorereport.b. Competency of the professionals who developed thecomputer-generated scoring program.c. Ability of the computer to handle respondents who‘fake-bad.’d. Usefulness of computer- generated report in developingcomprehensive reports | a. Competency of the professionals interpreting the score report. |
The MMPI detects individuals attempting to fake the test by a. including special scales to detect lying.b. inferring the lying behavior from answers left blank.c. re-administering the test.d. examining highly unusual responses. | |
Compared to the original MMPI, the MMPI-2 a. is almost identical except for the deletion of sexistwording and updated language on some items.b. has a much larger and more diverse standardizationsample.c. has completely new scales and norms.d. has turned out to be much less valid at discriminatingpsychiatric patients. | b. has a much larger and more diverse standardization sample. |
Which of the following is an example of an item that mightbe included in the MMPI lie scale? a. 'Sometimes I feel nauseous for no apparentreason.'b. 'I enjoy reading detective novels.'c. 'I have never used a foul word.'d. 'I often walk after dinner.' | |
How does the MMPI attempt to determine if a particularperson is responding to the test in a valid way? a. By having a large enough standardization sample.b. By conducting the interview in a structured andstandardized way.c. By including special validity scales to detect responsebiases.d. By providing ambiguous stimuli so the person does notknow which answer is right or wrong. | c. By including special validity scales to detect response biases. |
The projective hypothesis assumes a. responses to highly structured tasks reveal hiddenattitudes and motivations.b. preferences for unstructured stimuli reveal unconsciousmotives.c. unstructured stimuli provoke anxiety.d. responses to ambiguous stimuli are influenced byunconscious factors. | d. responses to ambiguous stimuli are influenced by unconscious factors. |
The projective hypothesis is derived from which paradigm? a. neuroscienceb. cognitivec. psychoanalyticd. diathesis-stress | |
Dr. Gallagher was interpreting the results of a Rorschachtest, and reported that the client was probably fixated at the anal stagebecause he saw bathroom items in many of the cards. This is an example of a. the projective hypothesis.b. the unreliability of the Rorschach.c. the Exner scoring system.d. a standardized interpretation. | |
73. The stimulus materials in the Thematic Apperception Testare ambiguous a. to increase the likelihoodthat the individual is not giving responses that are consciously mediated.b. for greater precision.c. to increase rapport.d. to create discomfort in the client and thereby encouragea closer relationship with the therapist. | a. to increase the likelihood that the individual is not giving responses that are consciously mediated. |
The Rorschach Inkblot Test is an example of a(n) a. intelligence test.b. diagnostic inventory.c. neuropsychological test.d. projective test. | |
In an effort to make the Rorschach more objective,researchers have focused a. more on how respondents identify form over symboliccontent.b. on methods of standardizing symbolic content.c. on methods for diagnosis with different diagnosticgroups.d. their energy on training clinicians in methods for makingobjective conclusions. | a. more on how respondents identify form over symbolic content. |
Under what circumstances are respondents more likely toreport engaging in illegal behaviors? a. When the exam is a face-to-face interview.b. When the exam is computer administered.c. When the exam is self-report.d. When the respondent is in the presence of otherexaminees. | |
You are being tested, and the examiner is showing youpictures and you are asked to tell complete stories about the photos. You are probably taking a. the Rorschach.b. the MMPI-2.c. the Thematic Apperception Test.d. The Wechsler Adult Intelligence Scale –III. | |
Brian is taking a test inquiring about high-risk sexbehaviors. Under which circumstance willBrian be more likely to give answers endorsing more high-risk sex behaviors? a. in a paper-and-pencil format.b. when the test is given as an interview.c. when the test is computer-administered.d. in a one-to-one self-report setting. | |
Intelligence tests were originally developed for the purposeof a. determining which psychiatric patients could benefit from'talk' therapy.b. predicting which children have special academic needs.c. determining the age at which a child should enter school.d. segregating people of low intelligence so they would nothave children. | b. predicting which children have special academic needs. |
Intelligence tests were originally designed to measure a. brain dysfunction.b. innate aspects of IQ.c. cognitive effectiveness.d. academic potential. | |
The construct validity of intelligence tests is limited by a. how psychologists define intelligence.b. the nature of the population tested with the instruments.c. their generally low reliability.d. None of the above choices are correct. | |
Two children are administered the same IQ test. Assuming all factors to be equal exceptracial differences between the children, what factor has been found to explainany difference in scores between these children? a. stereotype threatb. role stereotypec. attention difficultiesd. None of these. There should not be any difference. | |
Average intelligence is associated with a score ofapproximately a. 130.b. 70.c. 100.d. Average intelligence cannot be determined. | |
A group of 8th grade boys and a group of 8thgrade girls are administered the same math test. According to this phenomenon, the girls mightperform more poorly than the boys. a. stereotype threat.b. standardization.c. gender awareness.d. self-monitoring. | |
Awareness of stereotypes tends to develop a. in infancy.b. between ages 6-10.c. in early adolescence.d. between ages 4-6. | |
Before taking an IQ test, one group of African Americanstudents (Group A) is told that African Americans tend to do poorly on IQtests, while the other group of African American students (Group B) is toldnothing. Group A performs significantlyworse on the IQ test than Group B. This is likely a result of a. self-monitoring.b. chance.c,. stereotype threat.d. ethnic awareness. | |
Compared to traditional personality assessment, behavioralassessment a. does not use self-report data because of its lack ofreliability.b. relies more heavily on self-report data.c. focuses on situational determinants rather than traits.d. focuses on what a person says, rather than how it issaid. | c. focuses on situational determinants rather than traits. |
Why do behavioral assessors sometimes set up contrivedsituations in which to observe behavior? a. They do not think the setting is an important influenceon people's behavior.b. Such assessments avoid the problem of reactivity.c. They want to see how people respond in unusualsituations.d. It is often difficult to control the conditions innatural settings. | d. It is often difficult to control the conditions in natural settings. |
What behavioral assessment procedure creates the mostreactivity? a. self-monitoringb. personality inventoryc. projective testd. structured clinical interview | |
Joe’s therapist has him keep a log of everything he eats aspart of a weight loss program. This isan example of the behavioral assessment technique of a. self-monitoring.b. reactivity.c. direct observation.d. ecological momentary assessment. | |
Miranda is trying to quit smoking. As part of her behavioral assessment, she isasked to maintain a diary and record what occurred before, during andimmediately following each time she smoked a cigarette, in real time. In order to do this, she had structuredrecord sheets for each day. This type of assessment is referred to as a. ecological momentary assessment.b. self-report.c. direct observation.d. behavioral interview. | |
Cognitive assessment measures are usually used to a. identify psychopathology.b. explore the projective hypothesis.c. test theories about how people think.d. measure people's intelligence. | |
Xavier is recording his thoughts each time he feelsdepressed. This is also referred to as a__________ assessment. a. projectiveb. behavioralc. cognitived. neuropsychological | |
Which of the following is an advantage of the ArticulatedThoughts in Simulated Situations cognitive assessment procedure, in whichsubjects talk out loud about their thoughts during a tape-recorded scene? a. The ambiguous stimuli enable the clinician to tapeunconscious stimuli.b. The increased structure provides more detailedinformation than would be possible in a self-report questionnaire.c. The subject's thoughts about specific situations can betaped in an immediate way.d. All of the above are correct. | c. The subject's thoughts about specific situations can be taped in an immediate way. |
An example of a self-report cognitive assessment consistentwith Beck’s theory of depression is a.Internal-External Attribution Questionnaire.b. DysfunctionalAttitudes Scale.c. AttributionalStyle Questionnaire.d. Cognitive Thought Record. | |
Which is most similar to an X-ray? a. MRIb. EEGc. CT scand. PET scan | |
PET and MRI are specific types of a. projective tests.b. personality inventories.c. neuropsychological tests.d. neurological tests. | |
Functional MRI (fMRI) differs from ordinary MRI in that a. fMRI records metabolic changes in the brain.b. ordinary MRI can only be done annually.c. fMRI relies upon other tests to assess brain function.d. ordinary MRI is invasive | |
PET is to CT scan as a. structure is to function.b. function is to structure.c. cognitive is to behavioral.d. projective is to objective. | |
As part of a biological assessment, Emma is asked to providea urine analysis, which is examined for levels of metabolites of differentneurotransmitters. This is a type of a. neurological test.b. neurotransmitter assessment.c. metabolic assessment.d. PET test. | |
A common method assessing neurotransmitters is a. analyzing metabolites.b. CT scan.c. X-ray.d. measuring dopamine. | |
One of the problems with measuring metabolites from blood orurine is that a. the presence of a given metabolite tends to beoverestimated.b. this type of measuring does not reflect levels ofneurotransmitters in the brain.c. the presence of a given metabolite tends to beunderestimated.d. blood and urine samples are not always easy to collect. | b. this type of measuring does not reflect levels of neurotransmitters in the brain. |
One of the major problems with drawing conclusions frommetabolite studies is that a. they are inaccurate.b. metabolite levels change significantly over time.c. they are correlational.d. they provide little data. | |
Which of the following is a common way of studyingneurotransmitters in the brain? a. Observe electrical activity in specific areas of thebrain.b. Measure metabolic byproducts in the urine.c. Study individuals genetically unable to produceneurotransmitters.d. Direct observation during brain surgery. | |
To compensate for the correlational problem of metabolitestudies, Paul should consider running a study where he a. measures metabolites over time using a CT scanner.b. administers drugs that increase or decrease the brainlevels of neurotransmitters.c. examines whether individuals with depression also havelow levels of serotonin.d. examines whether individuals with schizophrenia also havelow levels of dopamine. | b. administers drugs that increase or decrease the brain levels of neurotransmitters. |
Current results from brain imaging studies a. are useful in diagnosing psychopathology.b. indicate that most disorders affect only a tiny portionof the brain.c. suggest that most psychopathology is due to deficits inthe frontal lobe.d. are not strong enough for these methods to be used indiagnosing psychopathology. | d. are not strong enough for these methods to be used in diagnosing psychopathology. |
Which kind of assessment is illustrated here? Dr. Leeassesses the possibility that Joe has brain damage by measuring Joe'sperformance on a number of tasks including copying symbols, rememberingnumbers, and recognizing nonsense syllables. a. physiological assessmentb. neurological assessmentc. psychologicalassessmentd.neuropsychological assessment | |
Which of the following are designed to measure behavioraldisturbances resulting from brain dysfunction? a. brain imaging techniquesb. electrocardiogramsc. neuropsychological testsd. neurotransmitter assessment | |
Which of the following specializes in medical diseases thataffect the nervous system? a.neuropsychologistb. neurologistc. psychiatristd. psychologist | |
Amelia went to see a specialist who specifically studies howdysfunctions of the brain affect the way people think, feel and behave. Ameliamost likely visited a(n) a. internist.b. psychiatrist.c. neuropsychologist.d. neurologist. | |
The Halstead-Reitan and Luria-Nebraska are specific types of a. personality inventories.b. intelligence tests.c. neuropsychological assessments.d. neurological procedures. | |
Two people the same age, Sarah and Carrie, were administeredthe Luria-Nebraska neuropsychological test battery. Sarah graduated with aPh.D., while Carrie did not complete high school. Assuming all other factors equal, the scoresthey receive on the Luria-Nebraska a. should differ. Sarah should score higher based oneducation.b. should differ. Carrie should score higher as it is notbased on education.c. should not differ since education level is controlledfor.d. It is impossible to predict the differences from theinformation provided. | c. should not differ since education level is controlled for. |
Why should we not expect a one-to-one relationship betweenpsychological and physical measures of brain functioning? a. They cannot measure brain functioning during normal dailyactivity.b. Little is known about the functioning of individualneurons.c. Psychological measures have low reliability and validity.d. Individuals differ in how well they cope with braindysfunctions. | d. Individuals differ in how well they cope with brain dysfunctions. |
Psychophysiology is the study of a. somatic treatments for psychological problems.b. the neurological basis of psychological problems.c. bodily changes associated with psychological events.d. phenomena such as extrasensory perception. | c. bodily changes associated with psychological events. |
Heart rate and skin conductance is preferable aspsychophysiological measures as they a. do not interfere with other things the person is doing.b. can differentiate between different emotions.c. indicate unconscious motivations.d. are more objective than other psychological measures. | a. do not interfere with other things the person is doing. |
A problem with some psychophysiological assessments is a. clients are unwilling to have the electrodes attached formeasurement.b. the measures do not clearly differentiate betweenemotional states.c. each instrument determines the base rate of reliability.d. the assessments are highly dependent on situationalfactors, rather than enduring features. | b. the measures do not clearly differentiate between emotional states. |
Cultural bias is problematic in assessment in that a. most psychological tests have been rendered invalid whenused with different cultures.b. a lack of awareness of cultural factors can createdifficulties in reaching conclusions from assessment.c. clinicians cannot be aware of different cultures inevaluation.d. cultural differences cloud objectivity. | b. a lack of awareness of cultural factors can create difficulties in reaching conclusions from assessment |
In reviewing cultural and ethnic diversity issues inassessment, the text concludes that a. psychologists routinely over estimate psychologicalproblems when assessing people from other cultures.b. psychologists routinely under estimate psychologicalproblems when assessing people from other cultures.c. new DSM criteria encourage culture-specific diagnoses.d. psychology has identified the issue but not the solution. | d. psychology has identified the issue but not the solution. |
Jose, a Puerto Rican living in New York, was being assessedby Dr. Jones, an American doctor. Josecasually states that he feels there are spirits surrounding him. Dr. Jones may a. misdiagnose him as schizophrenic if he fails to takecultural factors into account.b. ignore this information if he fails to take culturalfactors into consideration.c. correctly diagnose him as schizophrenic if he considerscultural factors.d. None of these choices are correct. | a. misdiagnose him as schizophrenic if he fails to take cultural factors into account. |
If a clinician is informed that a prospective client, who isseeing things that are not actually there, is black and in a lower incomebracket, the clinician is more likely to a. suggest a diagnosis of mood disorder.b. suggest a diagnosis of schizophrenia.c. suggest that there is a good prognosis for treatment.d. recommend a second opinion. | |
If a Hispanic client is being examined by an assessor from adifferent cultural background, the examiner should a. schedule fewer sessions to remain objective.b. refer the client to a psychiatrist.c. obtain a different test battery.d. schedule additional sessions to ensure adequate rapport. | d. schedule additional sessions to ensure adequate rapport. |
The best way for clinicians to avoid bias in the diagnosisof patients from ethnic minority groups is to a. avoid seeing such patients in their practice.b. avoid diagnosing such patients.c. employ only those personality measures which have beenspecifically designed for that ethnic group.d. learn to consider and test alternative hypotheses whenevaluating clients from different ethnic groups. | d. learn to consider and test alternative hypotheses when evaluating clients from different ethnic groups. |
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