Psychological Test Usage: Implications in

Transcription

Professional Psychology: Research a
2000, Vol. 31, No. 2, 141-154
Copyright 2000 by the American Psychological Association, Inc.
0735-7028/00/55.00 DOI: I0.1037//0735-7028.31.2.I41
Psychological Test Usage: Implications in Professional Psychology
Wayne J. Camara, Julie S. Nathan, and Antonio E. Puente
American Psychological Association
Do psychological assessments require more time than third parties and managed care are willing to
reimburse? A survey of clinical psychologists and neuropsychologists was conducted to evaluate the
current uses of psychological assessment instruments. Respondents reported their use of tests for 8
different areas of assessment, the average time spent in performing various assessment services and other
assessment practices. Results suggested that a majority of neuropsychologists devote a substantial portion
of their time to assessment, but only 12% of clinical psychologists reported spending more than 10 hr in
assessment-related practice each week. The authors describe the typical time required to administer,
score, and interpret various tests and assessments; factors that affect the time required to conduct
assessments; and provide a current ranking of the most frequently used assessments in clinical and
neuropsychology.
How long does it take to conduct comprehensive psychological
sional psychologists. With the advent of managed care, psycho-
assessments? Does the time required for assessment activities
logical services such as assessment services are increasingly com-
depend on the nature of the assessment and the presenting prob-
pensated at standard approved rates that may or may not reflect the
lems? What assessments are most commonly used and do they
level of effort and time required to perform these services. In
differ by the nature and function of the assessment? What are the
today's managed care environment, research-based knowledge of
implications of these issues for psychologists conducting assess-
the time it actually takes clinicians to administer, score, interpret,
ment services in today's managed care environment? What strat-
and write reports could "curb abuse of testing benefits . . . we
egies may psychologists invoke to overcome the multiple obstacles
know has gone on" (R. DeLapp, personal communication, Novem-
imposed by managed care and demonstrate the efficacy and ex-
ber 5, 1991). The present study was designed to provide accurate
tensiveness of comprehensive assessment practices? We examined
information on current psychological test usage.
these and other related questions through a survey of a sample
Louttit and Brown (1947) first documented psychological test
of clinical and neuropsychologists who conducted assessment
usage in 1935 and 1946. Subsequent national surveys to estimate
activities.
psychological test usage were reported in 1961 (Sundberg, 1961)
Psychological assessment has been a defining practice of pro-
and 1969 (Lubin, Wallis, & Paine, 1971). Lubin et al. (1971) found
fessional psychology since the field's inception. Over the past
that the top 10 most often used tests included 4 projective tech-
several decades, national surveys of psychological test usage have
niques, the Rorschach Psychodiagnostic Test (often called the
enriched our knowledge of the assessment practices of profes-
Inkblot Test), Thematic Apperception Test (TAT), the Draw-A-
WAYNE J. CAMARA received his PhD in organizational behavior from the
and the survey content were provided by Thomas Boll, Gordon Chelune,
Lee Anna Clark, Munro Cullum, Elena Eisman, Alan Entin, Larry Fried-
University of Illinois at Urbana-Champaign. He is executive director of
research and development at the College Board in New York City. He is
also president-elect of the American Psychological Association's (APA's)
man,
Douglas Jackson, A. John McSweeney, John Mendoza, Robert
Division of Evaluation, Measurement, and Statistics. This research was
Thompson, Michael Westerveld, Nancy Wilcockson, and members of the
Resnick, Gayle Rettig, Cecil Reynolds, Charles Spielberger, Laetitia
initiated when Dr. Camara was assistant executive director of scientific
executive committees of Divisions 12 (Clinical Psychology). 40 (Clinical
affairs at AP^.
JULIE S. NATHAN received her MSEd in 1998 and will be completing her
Neuropsychology), and 42 (Psychologists in Independent Practice), as well
PhD in school psychology from Fordham University in May 2000. She is
William C. Howell allocated staff and provided financial support for the
currently a clinical psychology intern at Montefiore Medical Center/Albert
Einstein College of Medicine.
survey and study. Jessica Kohout and Marlene Wicheski coordinated the
data collection and mailing. Peter Pfordresher managed the data entry and
ANTONIO E. PUENTE received his PhD from the University of Georgia.
coding of all survey responses. Georgia Sargeant copyedited the mono-
as members from the Board of Professional Affairs. Russ Newman and
He is professor of psychology at the University of North Carolina at
graph. Finally, Geoffrey Reed, Heather Roberts-Fox, Dianne Maranto, and
Wilmington and maintains an independent practice limited to clinical
neuropsychology. He is a past president of the National Academy of
Amy Rabinove assisted in coordinating review and comments from APA
governance on the design of this study and the draft and final reports.
Neuropsychology.
A MUCH MORE COMPREHENSIVE REPORT of the study, with additional data
THIS RESEARCH WAS CONDUCTED with the support of the APA Practice and
and analyses, is available as an unpublished manuscript from the APA
Science Directorates. We thank the many psychologists and neuropsychologists who assisted in reviewing and commenting on the design of the
Practice Directorate (Camara, Nathan, & Puente, 1998).
CORRESPONDENCE CONCERNING THIS ARTICLE should be addressed to Wayne
survey, the study methods, and the definitions and assessment areas used in
J. Camara, College Board, 45 Columbus Avenue, New York, New York
the study. Specifically, recommendations and reviews of the list of tests
10023. Electronic mail may be sent to [email protected].
142
CAMARA, NATHAN, AND PUENTE
Person Test (DAP), and the House-Tree-Person (H-T-P) Projective Technique, as well as 3 intelligence tests, the Wechsler Adult
Intelligence Scale (WAIS), the Wechsler Intelligence Scale for
Children (WISC), and the Stanford-Binet Intelligence Scale. The
others in the top 10 were the Bender Visual Motor Gestalt Test
(hereinafter the Bender Gestalt), the Minnesota Multiphasic Personality Inventory (MMPI), and Sentence Completion tests.
In the 10-year interval between Sundberg's (1961) and Lubin
et al.'s (1971) studies, intellectual measures such as the WAIS
and WISC began to displace some of the traditional projective
personality assessment instruments, but these were still preferred over more empirical measures of personality. The MMPI,
in fact, was the only objective personality test found in the
top-10-ranked instruments of both studies. These earlier studies
examined the rank ordering of tests but did not provide any
information regarding specific test usage. In their 1975 survey
of psychological test usage, Brown and McGuire (1976) asked
professionals from community mental health agencies and hospitals not only which tests were used most often but also which
were used most for intellectual versus personality assessments,
and which were used most for different age groups. Brown and
McGuire's (1976) study found little overall change in the
top-ranked tests from 1969 to 1975. The most notable changes
from 1971 to 1975 were the addition of the Slosson Intelligence
Test for Children and Adults and the Kinetic Drawing System
for Family and Schools to the list of most frequently used tests,
and the increase in popularity of the WISC.
Another national survey of psychological test usage was performed in 1982 (Lubin, Larsen, & Matarazzo, 1984). Of the 6
projective techniques ranked in the top 10 in 1969, 5 were still in
the top 10 in 1982, and the MMPI was ranked second in 1982,
demonstrating its steadily increasing use. For the first time, the
Stanford-Binet was not among the top 10 tests used in the 1982
survey, ranking 15th.
Before 1984, surveys on testing practices had been conducted
with members of APA Division 12; however, now surveys of
assessment practice included members of the Association for
Advancement of Behavior Therapy (AABT) and the Society for
Personality Assessment (SPA; O'Roark & Exner, 1989). Results revealed that projective techniques, specifically the Rorschach, TAT, Sentence Completion, and H-T-P tests, were in
the SPA's top 10 most frequently used testing instruments. The
objective personality measures in the top 10 were the MMPI
(ranked third), the Children's Apperception Test (CAT), and the
Sixteen Personality Factor Questionnaire (16PFQ). For cognitive assessment, the Wechsler scales were ranked first, indicating their growing popularity. The overwhelming majority of
SPA members (90% of those who responded) indicated that
they primarily used assessments for diagnostic purposes, and
53% also used testing as an indicator of what type of therapy
would be most effective.
Addressing a void in the survey research to date, Ball, Archer,
and Imhof (1994) surveyed practitioners for their perceptions of
the time required to administer, score, and interpret psychological
test instruments. They mailed surveys to small samples of clinical
psychologists, neuropsychologists, and SPA members. The instruments listed as typical for test batteries corresponded closely with
the most highly ranked tests in previous surveys (Ball et al., 1994).
Results showed that clinicians in private practice were administering longer test batteries than clinicians in primary employment
settings. These data raised questions "as to whether clinical, financial, or some other consideration may underlie test selection" (Ball
et al., p. 247).
Overall, data suggest surprisingly little substantive change in
the ranking of the most often used (i.e., popular) instruments
over the last several decades. For example, the Stanford-Binet
and the Rorschach have been in the top 20 since 1935. According to Lubin et al. (1984), the rank-order correlation between
ranks in 1969 and 1982 was .89 (p < .001). The use of
projective techniques has persisted in popularity since 1969.
Specifically, the Rorschach, TAT, H-T-P, and DAP tests have
been among the top 10 test instruments used in each decade
(Lubin et al., 1984). The instruments that clinical psychologists
use the most seem to cluster consistently into a core battery that
includes the WAIS or WISC, the MMPI, and several of the
more popular projective tests, including the Rorschach and TAT
(Watkins, 1991). This has not changed much since the 1960s.
Watkins noted that though the data suggest a steady decline in
the percentage of time that practicing psychologists devote to
assessment (from 44% in 1959, down to 22% in 1982 over all
five settings) most of them currently spend a fair portion of
their time conducting assessment services.
The Test Usage Survey
The present study was designed to gather information on the
current use of psychological assessment instruments by clinical
psychologists and neuropsychologists. This study diverged from
previous studies of psychological test usage in several ways. First,
the sample was limited to clinical psychologists and neuropsychologists who reported that assessment services accounted for a
substantial part of their practice. Second, this survey asked more
specific questions, such as (a) the amount of time spent per week
conducting assessments and (b) whether assessments were intellectual, developmental, adaptive-functional, or neuropsychological in nature.
Participants included 1,002 members of the National Association of Neuropsychology (NAN) and 1,500 clinical psychologists
from the American Psychological Association (APA), randomly
selected from the respective databases of each institution. The
neuropsychologists were randomly selected from among approximately 2,300 NAN members. The clinical psychologist sample
was randomly selected from a population of approximately 35,000
doctoral members of APA in independent practice who specialize
in providing mental health services as their primary or secondary
positions.
Instrumentation
We mailed all participants the six-page "Survey of Test and
Assessment Use in Professional Psychology." The initial draft of
this survey was reviewed by more than 20 psychologists who were
members of APA Division 40 (Clinical Neuropsychology), Division 42 (Psychologists in Independent Practice), and APA gover-
SPECIAL SECTION: PSYCHOLOGICAL TEST USAGE
143
nance groups with expertise in assessment.1 In addition to evalu-
appropriate intervention strategies. Assessments may entail obtaining
ating the proposed questions, reviewers were asked to study the
an overall index of development or securing a detailed assessment of
the child's level of functioning across different areas (e.g., motor
draft list of tests and identify additional instruments that should be
development, language development, social development, etc.). The
added to the list. We pilot tested a revised survey with an addi-
focus may be on documenting changes over time through repeated
tional 20 practitioners, and they also identified a number of addi-
assessments (Johnson & Goldman, 1990).
tional tests to be included in the list of tests for the final survey.
5. Intellectual or achievement. Intelligence tests assess learning that
Their comments and suggestions were incorporated, raising the
occurs in a wide variety of life experiences. Achievement tests are
number of tests for the final survey from 75 to 120.
heavily dependent on formal learning acquired at school or home.
The survey included items inquiring about (a) the amount of
With children, the main goal(s) of intellectual or achievement assess-
time devoted to assessment services in a typical week, (b) use of
ments include determining the nature of the child's learning or be-
tests for eight different areas of assessment and the use of specific
havior problems (i.e., the child's strengths and weaknesses in abilities
assessments, and (c) participant's credentials and experience. Par-
related to learning). With adults, these assessments are used to deter-
ticipants devoting 4 hr a week or less to assessment services were
mine the level of intellectual functioning or knowledge in one or more
asked to stop and return the survey, because the survey designers
specific domains (e.g., math, science). Evaluations are usually based
felt that individuals who engaged minimally in assessment services
on norms for similar-aged individuals (e.g., young children, older
might not have enough recent experience to estimate the time
adults). A comprehensive battery should include a measure of global
required for completing different services. Those engaged in as-
intelligence and measures of the information-processing skills involved in comprehension, visualization, memory, reasoning, and
sessment services for more than 4 hr per week completed the
judgment (Sattler, 1992).
remaining survey items.
6. Neurobehavioral clinical examinations. These instruments are used
to evaluate the extent that individual's social and emotional function-
We asked participants about the use of assessments for eight
different areas of assessment. We decided on these practice areas
ing are affected by the brain and potential brain-impaired processes.
for assessment services through a consensus process involving 45
The participants are most often adults and young adults who may have
members of APA divisions and governance groups with expertise
encountered a head injury or are suspected of some degenerative
in assessment. The areas and brief definitions adapted from the
illness. These assessments are used to examine daily problem-solving
survey are
strategies (e.g., daily living tasks, independence) and reasoning abilities as they may be affected by the brain and any brain impairment.
Assessments in this area are similar to those used in more generalized
1. Adaptive-functional behavior. The assessment of adaptive behavior
is concerned with the degree to which individuals function indepen-
neuropsychological assessment in that they involve a variety of in-
dently and meet satisfactorily the demands of personal and social
formal and formal measures about a person's level of neurological
responsibility imposed by the culture. Assessments are designed to
functioning.
determine a person's competence in meeting the independence-related
7. Neuropsychological assessments. Most participants of these assess-
needs and social demands of the environment (e.g., communication,
ments are suspected of having had some type of physical brain injury,
daily living skills, socialization, and motor skills). Instruments such as
such as a blow to the head, a stroke, or carbon monoxide poisoning.
behavior scales, behavioral checklists, and direct observation are used
These assessments rely on many of the same techniques, assumptions,
and theories as do other psychological assessments. The distinction
to assess independent functioning skills, physical development, language development, and academic competencies (Sattler, 1992).
lies in the focus on brain function as the point of departure (Lezak,
2. Aphasia. Aphasia is the loss or impairment of language due to some
type of brain injury. The purpose of this type of evaluation is to
1995). The goal is to be able to evaluate the full range of basic
physical and mental abilities that are controlled directly by the brain.
determine the language areas affected and to provide a starting point
Reducing the symptomatology of the brain-impaired individual to its
basic processes requires not only a general understanding of the
for language retraining. Most aphasia tests describe what the patient
can do, so that remaining functions (not defects) are tested. A typical
functional aspects of behavior and cognition but also a specific
aphasia evaluation may include assessments of (a) perception and
understanding of how these functions relate to the brain and to brain
recognition of language (auditory and visual); (b) performance of
dysfunction in particular (Golden, Zillmer, & Spiers, 1992).
motor functions pertaining to language (speaking and writing); (c)
8. Personality-psychopathology. These assessments are usually conducted when a person's behavior problems, emotional difficulties,
ability to use language symbols in reading, handwriting, and mathematics; and (d) formulation and comprehension of prepositional lan-
social interactions, or ability to function independently become so
guage (oral and written; Agranowitz, McKeown, & Nielsen, 1964).
significantly disruptive or disrupted that mental health intervention
3. Behavioral medicine or rehabilitation. Behavioral medicine is an
appears warranted (Knoff, 1986). Personality assessment helps iden-
"interdisciplinary field concerned with the integration of behavioral
tify and characterize an individual's social-emotional status and atti-
and biomedical science knowledge and techniques relevant to health
tudes, behaviors, and reactions to specific and recent or general and
and illness and the application of this knowledge and these techniques
long-existing situations or environments. Personality assessments in-
to prevention, diagnosis, treatment, and rehabilitation. Assessments
clude formal or informal observation, interviews, and evaluation
within this domain seek to appraise the medical patient's present
status within the context of the past and within his or her larger social
processes addressing an individual's behavior, social-emotional development or progress, or self-concept formation.
framework or environment, including current physical and psychosocial stressors. Objective instruments are used to assess the patient's
overt behaviors and evaluate self-reported feelings and biophysical
Respondents indicated the approximate number of times per
year they administer a "full battery" of tests in each of the eight
processes (Schneiderman & Tapp, 1985).
4. Developmental. Developmental assessment can be characterized as
a process for obtaining clinical information about a child in order to
provide answers to development-related questions and to generate
1
The Board of Professional Affairs, the Board of Scientific Affairs, and
the Committee on Psychological Tests and Assessment.
144
designated areas of assessment, and individual tests used. For
example, a participant using tests for intellectual assessment would
indicate the number of times he or she had conducted such assessments in a year, as well as the average time spent for each of the
Table 1
Hours Spent Individually Administering, Scoring, and
Interpreting Psychological Tests During a Typical Week
Clinical
psychologists
three assessment services: administration, scoring, and interpretation. In addition, the questionnaire asked participants to indicate
which tests they had used from a list of 120 individual tests, to
identify which of the eight practice areas the test-was used for, and
to identify the average time spent for each of the three assessment
services. Participants provided information about the mode of
testing (computer or paper and pencil) and were also asked to write
in the names of any additional tests they had used that were not on
the list.
Hours
0-4
5-9
10-14
15-20
More than 20
No response
Total
n
Neuropsychologists
%
n
37
4
116
62
92
105
188
4
933
100
4
567
755
81
62
7
4
39
36
4
%
21
11
16
19
33
100
Procedure
We first mailed the "APA Survey" questionnaires in late 1994,
accompanied by a cover letter from the APA president at the time,
excess of 20 hr per week on assessment activities, with another
third of them spending 10—20 hr per week on assessment. The final
Ronald E. Fox, explaining that the purpose of the study was to
31 % devote 10 hr per week or less to assessment.
estimate the frequency of use of psychological and neuropsycho-
We conducted the remaining analyses for only those 447
neuropsychologists and 179 clinical psychologists who reported
engaging in assessment activities for 5 hr or more in a typical
logical assessment and the approximate amount of time required
for assessment services (administration, scoring, and interpretation). We sent two mailings. We received responses from 1,499
(56%) of the total of 2,700 individuals selected, 933 clinical
psychologists (62% of the sample of 1,500), and 566 neuropsychologists (47% of the sample of 1,200).
Of the 1,499 respondents, 754 of the clinicians and 119 of the
neuropsychologists reported conducting assessment services for
under 5 hr in a typical week; these questionnaires were set aside.
We conducted analyses only on questionnaires from the participants who engaged in 5 hr or more of assessment-related services
in a typical week. Therefore, 179 clinicians and 447 neuropsy-
week. Table
2 shows that neuropsychologists most often
conduct assessments for purposes of neuropsychological assessment (95%), intellectual-achievement assessment (79%),
personality-psychopathology (79%), and neurobehavioral clinical
assessment (51%). Even so, more than a quarter of all neuropsychologists report conducting assessments for each of the eight
purposes listed in the survey. Table 2 reports the mean and median
number of full test or assessment batteries conducted by neuropsychologists who practice in a given assessment area. The median
is by far the better indicator of central tendency for assessment
chologists qualified for the remaining analyses. Nine additional
tests "written-in" by 5 or more respondents were added to the
initial list of tests, resulting hi a final list of 129 tests used in the
analyses.
services provided by neuropsychologists. In seven of the eight
practice areas, approximately 20% of neuropsychologists account
for greater than 50% of assessments being conducted. In these
areas, the mean number of assessments per respondent exceeds the
We conducted all analyses separately for the clinical psychologist and neuropsychologist samples. The types and uses of assess-
median by 50% or more.
ments and the assessment services provided by these two groups of
psychologists differ greatly, so responses from these groups are not
Among neuropsychologists, there was substantial variation in
the number of times they annually administer a full battery of
assessments in each of the practice areas. For example, for neu-
combined for any analysis. However, comparisons of the types of
assessment services provided, time required for completing ser-
ropsychological assessment batteries and intellectual-achievement
batteries, some respondents had conducted only a few assessments
vices, and frequency and types of assessments used by these
groups are reported later.
annually, whereas one neuropsychologist conducted more than 400
full assessment batteries in the past year. Most of the variation
was due to 10% of neuropsychologists who reported conducting
Frequency in Conducting Assessments
well more than 200 neuropsychological assessment batteries,
intellectual-achievement batteries, and neurobehavioral clinical
Table 1 illustrates the number of hours clinical psychologists
and neuropsychologists devote to assessment during a typical
examination batteries annually.
Clinical psychologists involved in assessment services for 5 or
week. As shown in Table 1, more than 80% of clinical psychologists reported spending less than 5 hr during a typical week in
more hr per week are most often involved in personality-
administering, scoring, reporting, and interpreting psychological
tests, whereas more than 80% of neuropsychologists spend an
average of 5 or more hr per week in providing these assessment
services.
Of the clinical psychologists, approximately 4% of respondents
engage in assessment for 10-14 hr, 15-20 hr, or more than 20 hr
during a typical week, with 7% spending 5-9 hr providing assessment services. More than a third of neuropsychologists spend hi
psychopathology testing (93%) and intellectual-achievement testing (88%), followed by neuropsychological assessment (47%),
adaptive-functional behavioral assessment (40%), and developmental assessment (30%). There was substantial variation in the
number of full psychological batteries they administered in some
areas, mostly because of the number of assessments performed by
the most productive 10% to 20% of clinicians in each area. Clinical
psychologists differed most in how often they conducted neuropsychological assessments, intellectual-achievement assessments,
145
Table 2
Number and Percentage of Full Assessment Batteries Administered Annually
Clinical psychological
Practice area
Adaptive-functional behavior assessment
Aphasia
Behavioral medicine-rehabilitation
Developmental
Intellectual-achievement
Neurobehavioral clinical examination
Neuropsychologic al
Personality-psychopathology
Total
Neuropsychological
«(%)
Mdn
M
SO
n(%)
Mdn
M
SD
72(40)
30(17)
20.0
13.5
13,5
20.0
50.0
30.0
30.0
50.0
36.3
28.4
28.3
35.9
87.3
59.1
63.6
80.4
47.8
46.4
30.8
47.0
110.0
73.5
116.0
101.0
194 (43)
205 (46)
127 (28)
115(27)
354 (79)
228(51)
427 (95)
353 (79)
20.0
25.0
30.0
20.0
60.0
50.0
70.0
50.0
36.9
53.6
70.3
46.2
90.4
88.9
96.8
87.5
54.4
70.4
92.2
91.7
96.7
87.9
91.3
115.0
26(15)
53 (30)
158 (88)
30(17)
84 (47)
166(93)
447
179
and personality-psychopathology assessments. Figures 1 and 2
illustrate total activity within each assessment area. Assessments
for intellectual-achievement, personality-psychopathology, and
neuropsychological purposes account for the great majority of
testing for both clinical psychologists and neuropsychologists.
Earlier research reporting on reasons for referral suggested that
most referrals were requests for a complete assessment, personality
assessment, or intellectual assessment {Lubin et al., 1984). Requests in 1982 for a neuropsychological assessment, across the five
settings, yielded a composite overall low of 3%. In the current
study, however, clinical psychologists involved in assessment services were testing most often for personality-psychopathology
(93%) and intellectual-achievement (88%), followed by neuropsychological assessment (47%). Moreover, neuropsychologists were
most often involved in neuropsychological assessment (95%), followed by intellectual-achievement and personality-psychopathology
assessment (both 79%). These data suggest that neuropsychological
assessments have become increasingly popular within the last decade.
Given the wide variation in the frequencies and patterns of
assessment services provided by clinicians and neuropsychologists, it is extremely difficult to characterize the "typical amount of
assessment activity" of these practitioners. The median provides a
more accurate picture of the amount of assessment activity in these
areas for most practitioners in both groups, yet there is a small
Beh. Med/Rehabilitation
2%
Aphasia
Neurobehavioral 2%
4%
Developmental
5%
Intellectual/Achievement
34%
Adaptive/Functional
Neuropsychological
13%
Personality/Psychopathology
32%
Figure 1. Proportion of assessment services, by area, conducted by clinical psychologists. Beh. Med.
behavioral medicine.
146
Beh. Med/Rehabilitation
6%
Intellectual/Achievement
20%
Neurobehavioral
13%
Developmental
3%
Personality/Psychopathology
20%
Adapt! w/Functional
Neurops ychological
26%
Figure 2. Proportion of assessment services, by area, conducted by neuropsychologists. fleh, Med.
behavioral medicine.
percentage (10%-20%) of practitioners who conduct twice as
many assessments as the typical practitioner in this study. It is also
important to remember that practitioners providing less than 5 hr
of assessment services in a typical week, 80% of clinicians, and
20% of neuropsychologists already have been excluded from these
analyses.
Time Required to Administer, Score, and Interpret a Full
Assessment Battery
The amount of time required for completing a full psychological
or neuropsychological assessment battery may vary widely, for a
number of obvious reasons; (a) the number and types of tests used
in an assessment; (b) the mode of administration (e.g., paper and
pencil, computer based); (c) the intended use(s) of the assessment
(e.g., a quick neurological screening vs. a full neuropsychological
examination, a full psychoeducational evaluation vs. a reevaluation); (d) the characteristics, symptoms, and abilities of the client
or patient being tested; (e) the setting; and (f) the level of reporting
and interpretation required (e.g., written reports, oral briefings,
court reports), to name just a few. However, though the time
requirements for specific tests and assessments also were examined, it is also important to provide some estimates of both the
number of full assessments completed, by area, and the time
requirements for administration, scoring, and interpretation, if we
are to understand the general demands of assessment services.
It is rare that clinical psychologists or neuropsychologists use
only one or two tests ia completing an assessment. They are more
likely to use several tests in conducting brief reevaluations or
screenings, or to use an extensive array of tests in completing a full
assessment battery for diagnostic or evaluative purposes. Table 3
provides (a) the number of clinicians who administer, score, and
interpret assessments in the eight areas; (b) the average amount of
time (in min) that is required to provide these services for a full
battery of assessments; and (c) the standard deviation of the time
required. Table 4 provides an identical breakdown for the
neuropsychologists.
First, nearly all clinical psychologists administer, score, and
interpret assessments when conducting a full psychological assessment battery. Some have suggested that an increasing proportion
of clinicians may be only interpreting assessment results, while
giving the duties of administration and scoring to another provider
(someone with less training who might operate at a lower cost, or
another vendor who provides computehzed administrative services). Our evidence suggests that most clinicians are directly
responsible for administering, scoring, and interpreting assessments in each assessment area.
Second, test administration required the greatest amount of time
in each assessment area, followed closely by the time required for
interpretation and the time required for scoring. We used the
following definitions for these services in the instructions included
in the questionnaire:
Administration: time required in the preparation for testing (selecting
tests, preparing testing materials and test site) and actual administration of a test or assessment. Do not include time required for the client
to complete self-administered tests.
SPECIAL SECTION: PSYCHOLOGICAL TEST USAOE
147
Table 3
Minutes Required by Clinical Psychologists to Administer, Score, and Interpret a Full Psychological Assessment Battery
Administer
Practice area
Aphasia
Developmental
Neuropsychological
Personality—psychopathology
Total
n
59
30
24
52
156
30
84
162
607
Score
Interpret
M
Mdn
SD
n
M
Mdn
SD
72.8
77.3
151.0
99.8
115.0
85.1
208.0
104.0
97.4
60.0
37.5
120.0
72.5
100.0
67.5
180.0
90.0
82.8
113.0
145.0
98.1
68.3
60.5
144.0
76.4
70
30
24
53
156
25
83
163
602
34.2
36.2
45.7
35.1
31.3
36.2
59.4
49.9
42.0
20.0
17.5
30.0
30.0
30.0
20.0
45.0
45.0
42.5
65.8
58.2
41.3
32.6
57.8
60.5
37.8
n
71
30
24
53
156
28
85
166
613
M
Mdn
SD
47.4
63.2
107.0
69.6
65.0
67.5
99.1
87.8
75.9
30.0
20.0
60.0
30.0
45.0
40.0
60.0
60.0
58.1
147.0
159.0
113.0
78.6
77.4
111.0
93.6
Scoring: time required to score individual responses and derived
the average clinical assessment did. Interpretation and repotting of
scores (including subscale scores, standardization scores, normreferenced scores, or comparisons) and to collaborate with test administrator or psychometrician when necessary. When scoring services (computer-based scoring or machine scoring) are used, scoring
results from assessments conducted for behavioral medicine and
rehabilitation purposes, neuropsychological assessment, and personality or psychopathology assessments consumed substantially
more time than assessments in other areas (an average of 93 min
includes the time required to forward raw test data to the service,
review and verify score reports, and any follow-up interactions required with the service.
across these areas compared with an average of 62 min for the
remaining five assessment areas). Most of the variation is due to
the number and choice of tests selected by clinicians for inclusion
Interpretation and reporting: time required to review raw test data
(quantitative and qualitative) and scoring reports and time required to
in a full psychological battery.
For the neuropsychological sample (see Table 4), the time
synthesize all relevant data (e.g., medical, historical), complete written and oral reports, and provide interpretation to client, family, or
referral source. When services provide interpretative reports, interpretation time also includes the review, verification, and elaboration of
required for administering full assessment batteries (55% of the
total time spent providing assessment services) far exceeded the
average time required for scoring (16%) and interpretation-
the report.
reporting results (28%). The time required for assessments conducted for neuropsychological purposes or behavioral medicine-
Across assessment areas, administration accounted for 45% of
rehabilitation purposes far exceeded the time required for other
the overall time required in conducting assessment services. Scoring and interpretation-reporting accounted for 36% and 19%,
uses of assessment. The times required by neuropsychologists for
respectively. Most notably, there was substantial variation among
providing assessment services were more uniform than the times in
practitioners in the time required to administer and interpret full
the clinical sample, perhaps indicating more uniformity in the
psychological assessment batteries but less variation in scoring
numbers and types of assessment instruments used.
The times required for providing assessment services are sub-
time.
The time required for clinical psychologists to administer and
stantially similar across areas for both the clinical and neuropsy-
interpret-report assessment results differed across assessment ar-
chological samples but vary widely according to the intended
eas, whereas the time required for scoring assessments remained
purpose of the assessment (Camara, Nathan, & Puente, 1998). The
fairly consistent, across all areas of assessment. Neuropsycholog-
time required to complete a full neuropsychological assessment
ical assessment consumed the most time, on average requiring
battery requires substantially more time than assessments in other
50% more time to administer (M = 208 min, Mdn =180 min) than
areas. Assessments conducted for personality-psychopathology,
Table 4
Minutes Required by Neuropsychologists to Administer, Score, and Interpret a Full Psychological Assessment Battery
Practice area
Aphasia
Developmental
Neuropsychological
Personality-psychopathology
Total
n
88
202
123
114
350
227
422
335
1,961
Interpret
Score
Administer
M
Mdn
SD
73.6
60.7
110.0
113.0
122.0
80.0
304.0
103.0
140.83
60.0
45.0
90.0
90.0
120.0
60.0
300.0
90.0
87.6
52.1
77.0
80.8
76.3
67.1
136.0
97.6
n
87
203
123
111
348
200
420
48
1,940
M
Mdn
SD
32.2
23.6
35.3
35.8
33.4
25.8
78.5
46.0
41.74
20.0
15.0
30.0
30.0
30.0
20.0
60.0
30.0
74.2
19.0
24.9
27.7
24.8
22.5
51.6
38.7
n
88
202
124
114
350
223
425
350
1,976
M
Mdn
SD
48.0
39.1
58.2
59.4
61.3
46.8
135.0
74.9
71.66
30.0
30.0
45.0
30.0
40.0
30.0
120.0
60.0
82.4
40.0
44.6
55.7
73.9
38.5
115.0
78.2
148
behavioral medicine-rehabilitation, intellectual-achievement, and
clinicians using the Rorschach Psychodiagnostic Test ("inkblot
developmental evaluation purposes required more time on average
test") and 107 using the TAT, followed by the H-T-P Protective
than assessments
Technique (60 users), Human Figures Drawing Test (49 users),
conducted for adaptive-functional behavior.
aphasia, and neurobehavioral clinical purposes. Assessments con-
Rotter Incomplete Sentences Blank (45 users), Sentence Comple-
ducted in the latter three areas can often be characterized as briefer
(ion Test (40 users), and the CAT (38 users). The Bender Visual
screenings or examinations used to assess behavioral functioning
Motor Gestalt Test was the third most frequently used test, with
or specific diagnoses, requiring less time than the more exhaustive
112 users, but this use may be divided among neuropsychological
diagnostic assessments used in the former applications.
screening, projective assessment, and intellectual-achievement as-
Frequency of Use of Individual Tests and Assessments
sessment. Several intelligence and achievement tests were among
the most frequently used assessments: the WAIS-R, with 151
Table 5 provides a rank-ordered list of the top 20 tests used by
clinical psychologists or neuropsychologists who conduct assessment services for 5 or more hr in a typical week. Only 161 of the
users; the
W^C-II, with 135 users; ^ *« Wide Rmie Achieve(WRAT), with 86 users. Finally, a few inventories and
screening tests were also often cited for use by the clinical sample.
ment Test
Aese were me
179 respondents completed this section of the survey. Clinical
Among
psychologists indicated they used an average of 13.4 (Mdn = 13.0)
separate tests. The MMPI was the most frequently used test used
user
Wechsler Memory Scale—Revised (58
by 138 clinical psychologists (more than 86%). The Beck Depression Inventory (53 users), the Millon Clinical Multiaxial Inventory
Behavior Scales (37 users).
Respondents were asked to indicate the number of times they
(53 users), and the Millon Adolescent Personality Inventory (38
use (i.e., administer, score, and interpret-report) each test annu-
users) were the next most often cited personality tests. Projective
assessments were also used by a majority of respondents, with 124
ally. This question attempts to determine the highest utilization
rate among psychologists using the various tests. Among tests used
s>- && Trailmaking Test A&B (52 users), the Conners' Parent
and Teacher Rating Scales (37 users), and the Vineland Adaptive
Table 5
Frequency and Rank Order of Tests Used by Clinical Psychologists and Neuropsychologists
Clinical
psychologists
Neuropsychologists
Test
Rank
n
Rank
Aphasia Screening Test0
Beck Depression Inventory
Bender Visual Motor Gestalt Test
Boston Naming Test
California Verbal Learning Test
Category Test
Children's Apperception Test (CAT-A)
Conners' Parent and Teacher Rating Scales
FAS Word Fluency Test
Finger Tapping Test"
Grooved Pegboard Test"
Halstead-Reitan Neuropsychological Test Battery
Hand Dynamometer (Dynamic Hand Grip Strength Test)
Hooper Visual Organization Test
House-Tree-Person (H-T-P) Projective Technique
Human Figures Drawing Test
Millon Adolescent Clinical Inventory
Millon Clinical Multiaxial Inventory
Minnesota Multiphasic Personality Inventory (MMPI) I and II
Peabody Picture Vocabulary Test—Revised
Rey Complex Figure Test
Rorschach Inkblot Test
Rotter Incomplete Sentences Blank
Sentence Completion Test
Thematic Apperception Test (TAT)
Trail Making Test A&B°
Vineland Adaptive Behavior Scales
Wechsler Adult Intelligence Scale—Revised (WAIS-R)
Wechsler Intelligence Scale for Children—Revised (WlSC-R-ni)
Wechsler Memory Scale—Revised
Wide Range Achievement Test—Revised and III
Wisconsin Card Sorting Test
23
10
18
37
27
53
112
13
18
20
38
37
17
29
22
17
11
25
8
14
9
60
39
5
6
15
7
20
19
31
41
56
24
1
28
12
18
51
5
42
36
31
16
44
23
44
59
8
13
16
10
2
20
25
4
14
15
6
12
18
1
3
9
7
33
12
27
12
8
60
49
38
53
138
34
25
124
45
40
107
52
37
151
135
58
86
19
n
Total n
156
186
200
253
208
222
207
223
67
94
258
250
192
241
148
153
138
104
73
153
96
209
189
203
29
57
241
228
180
214
136
145
78
55
35
100
359
89
196
153
41
497
123
221
177
86
42
54
94
26
4
44
91
246
51
2
16
3
331
178
257
9
203
12
196
198
298
8$
482
313
315
289
215
Note. Only tests ranked in the top 20 by either the clinical or neuropsychology sample are listed in the table. * A subtest of the Halstead-Reitan and the
Reitan-Indiana Neuropsychological Batteries. b A subtest of the Halstead-Russell Neuropsychological Evaluation System. c A subtest of the HalsteadReitan Neuropsychological Battery,
by a substantial portion of the clinical sample, the Bender Qestalt,
the Human Figures Drawing Test, the Rotter Incomplete Sentences
Blank, the MMPI, the Rorschach, and the H-T-P Projective Technique were used an average of over 65 times across users.
Finally, regarding frequency of test use, the current study suggests very little change since the 1960s. The Rorschach, TAT, and
H-T-P were among the top 10, indicating the sustained popularity
of projectives. Also unchanged from previous research were the
inclusions of the WAIS and WISC, Bender Gestalt, MMPI, and
WRAT in the top 10. One change was the inclusion of the Millon
Clinical Multiaxial Inventory in the top 10. For further details,
Table 5 provides the top rank ordering of tests ranked in the top 20
by either clinical psychologists or neuropsychologists.
Neuropsychologists use an average of 17.6 (Mdn = 15.0) different tests in their assessment practice, with 10% of respondents
using over 30 different tests. Neuropsychologists were much more
likely than clinical psychologists to write in additional tests that
were not on the original list provided in the survey; over 100
respondents wrote in five or more tests. A total of 18 respondents
did not complete this section. Table 5 also provides a rank ordering
of the top 20 tests used by the remaining 430 neuropsychologists.
Overall, a large number of neuropsychological batteries and
individual neuropsychological assessments used for screening specific functions were used by a large percentage of these respondents: the Wechsler Memory Scale—Revised (257 users), Trail
Making Test A&B (Halstead-Reitan; 246 users), FAS Word Fluency Test (also known as the Controlled Word Association Test,
Spreen & Strauss, 1991; 237 users), Finger Tapping Test2 (228
users), Halstead—Reitan Neuropsychological Test Battery (214 users), Boston Naming Test (20& users), Category Test (209 users),
Wisconsin Card Sorting Test (196 users), Rey Complex Figures
Test (196 users), California Verbal Learning Test (189 users),
Grooved Pegboard Test3 (180 users), Aphasia Screening Test4
(159 users), Hooper Visual Organization Test (145 users), and the
Hand Dynamometer (Dynamic Grip Strength Test; 136 users).
As with the clinical sample, the MMPI was the most frequently
used test (359 users). Additional personality tests often used by
this sample were the Beck Depression Inventory (200 users) and
the Millon Clinical Multiaxial Inventory (100 users). The Rorschach Inkblot Test and the TAT were the most frequently used
projective instruments, with 153 and 91 users, respectively. The
WAIS-R, WRAT, and WISC-H were the most commonly used
intelligence and aptitude tests (with 331, 203, and 178 users,
respectively).
The following several instruments had the highest utilization
rates among all tests used by a substantial percentage (25% or
more) of the sample: Trail Making A&B (Halstead-Reitan),
WAIS-R, MMPI, Wechsler Memory Scale—Revised, Rey Complex Figures Test, FAS Word Fluency Test, and the WRAT. Each
of these was used an average of 90 or more times annually by test
users.
It should be noted that test use varied markedly by assessment
area. The frequency and rank order of tests used within each of the
eight assessment areas show some substantial disparities from the
overall list. For example, the Bender Gestalt, which ranked fifth
among clinical psychologists, was the most frequently used assessment for intellectual and achievement assessments and neurobehavioral clinical examinations. Similarly, the Aphasia Screening
Test and the Vineland Adaptive Behavior Scales were the tests
149
most often used by neuropsychologists when assessment was
conducted for aphasia screening and adaptive-functional behavior.
However, these tests ranked 17th and 44th, respectively, in total
use by neuropsychologists (Camara et al., 1998).
Unfortunately, when the data are sorted by assessment area, the
number of responses in each area is so low that the reliability of the
rankings within many assessment areas is also extremely low.
Fewer than 50 respondents provided specific rankings and
frequency-of-use data for assessments in five of the eight areas,
and between zero and seven tests were used by three or more
respondents for each assessment area. Therefore, results of test use
frequencies and rank ordering lack sufficient reliability to indicate
relative use within these five areas: adaptive-functional behavioral
assessment, aphasia assessment, behavioral medicine and rehabilitation, developmental assessment, and neurobehavioral clinical
examinations.
Use of Computer-Based Testing
Both clinical psychologists and neuropsychologists indicated
low rates for utilization of computer-based testing. The most
common application of computers in testing is computer-based
scoring of tests and assessments. More than 10% of tests are scored
using computer-based services (e.g., in-house computer scoring,
machine scanning of responses, and electronic or digital transmission of scores) for both clinical and neuropsychological practitioners. However, the administration and interpretation of tests (e.g.,
generating interpretive reports) are conducted much less often by
computer, as illustrated in Figure 3.
Computer-based scoring services were most often used with testing
conducted for purposes of personality-psychopathology assessment.
Relatively few practitioners indicated using computer- based services
for applications other man personality-psychopathological assessment, so comparisons of mean differences in time required for administration, scoring, and interpretation are primarily restricted to this
area. Although computer-based services required slightly less time
(mean differences ranged from approximately 1 to 4 min less time), in
nearly all comparisons these differences were not significant.
Time Required to Administer, Score, and Interpret-Report
Individual Assessments
The actual times required for particular psychological tests were
also collected from both samples. Tables 6 and 7 provide the mean
and median times required for administration, scoring, and
interpretation-reporting for the 50 most frequently used tests.
Generally, there was substantial consistency between clinical psychologists and neuropsychologists on self-reported time required
to provide assessment services. Instruments such as the Halstead—
Reitan Neuropsychological Test Battery and the Luria-Nebraska
Neuropsychological Battery, used primarily for neuropsychologi-
2
A subtest that appears in both the Halstead-Reitan Neuropsychological
Battery and the Reitan-Indiana Neuropsychological Battery.
3
A subtest of the Halstead-Russell Neuropsychological Evaluation Sys-
tem.
4
A subtest that appears in both the Halstead-Reitan Nenropsychological
Battery and the Reitan-Indiana Neuropsychological Battery.
150
12.0% -f
10.4%
0 Clinical Psychologists
D Neuropsychologists
10.3%
10.0%-
8.0%-
6.0%3.9%
3.6%
3.1%
4.0%2.4%
2.0%-
1.J
0.0%
Administration
Figure 3.
Scoring
Interpretation
Percentage of testing services conducted with computers.
cal assessments, required the most time for administration, scoring,
and interpretation (an average of 6.5 hr and over 4 hr, respectively). Next in consumption of time were intelligence tests such as
the Kaufman Assessment Battery for Children, the Stanford-Binet
Intelligence Scale, and the various Wechsler scales. The Rorschach
Inkblot Test and the Woodcock-Johnson Psycho-Educational Battery—Revised required, on average, over 2 hr for completion.
Conclusions and Implications for Professional Practice
This study provides a broad survey of the assessment practices
for clinical psychologists and neuropsychologists today. Nearly
80% of neuropsychologists reported providing assessment services
for more than 4 hr weekly, with one third of them spending over 20
hr per week in this area. Assessment services account for a
relatively minor aspect of practice for the over 80% of clinical
psychologists who spend 4 hr or less each week conducting assessment services. However, assessment services are a substantial
component of practice for the more than 12% of clinicians who
spend 10 or more hr in this practice area.
Patterns of assessment practice reveal that evaluations of
personality-psychopathology and intellectual-achievement account for over two thirds of assessments conducted by clinical
psychologists. Not only do most psychologists conduct assessments in these two areas, but the ratio of assessments per psychologist practicing in these areas (87.3 and 80.4 assessments per
practitioner, respectively) far exceeds the ratios in the remaining
six assessment areas. Neuropsychological assessments and
adaptive-functional behavior assessments are the next most popular use of psychological testing, with approximately 50% of
clinical psychologists practicing in these areas.
Assessment practice by neuropsychologists is somewhat more varied as to area, with neuropsychological, personality-psychopathology,
and intellectual-achievement evaluations each accounting for 20%
or more of all assessments. Neurobehavioral clinical examinations
were the next most frequent use of assessment, accounting for an
additional 13% of all assessment practice in the field. More than
half of all neuropsychologists practice in all of these four assessment areas. The ratio of testing among neuropsychologists practicing in assessment areas was consistent across these four areas,
ranging from 87.5 to 96.8 assessments per practitioner. In addition, neuropsychologists report taking substantially more time to
interpret-report results from assessments than do clinical psychologists, whereas time required for administration and scoring are
more comparable.
Results from this project have implications for the reimbursement of psychological assessment services by third parties and
reimbursement-authorization of such services by managed care.
This study empirically determined that the mean time required to
administer, score, and interpret a full psychological or neuropsychological battery was more than 3.5 hr by experienced clinical
psychologists and 4.25 hr for neuropsychologists, with additional
time required for assessments conducted in some practice areas.
Psychological assessment faces enormous obstacles in the current health care delivery system, ranging from outright refusal to
reimburse assessment, difficulties in gaining preauthorization for
testing, or requirements that practitioners use medication for differential diagnosis (Eisman et al., 1998). Current guidelines issued
by most managed care organizations do not provide separate
reimbursement of assessment services, either requiring the psychologist to reduce treatment time if assessment services are
151
Table 6
Minutes Required to Administer, Score, and Interpret Individual Tests: Clinical Psychologists
No. of uses per
year
Test
Aphasia Screening Test"
Boston Naming Test
Category Test
Child Behavior Checklist
Children's Apperception Test (CAT- A)
Children's Depression Inventory
Developmental Test of Visual-Motor
Integration
FAS Word Fluency Test
Finger Tapping Test"
Grooved Pegboard Test6
Halstead-Reitan Neuropsychological Battery
Hand Dynamometer (Dynamic Hand Grip
Strength Test)
House-Tree-Person (H-T-P) Projective
Technique
Kaufman Assessment Battery for Children
Kinetic Drawing System for Family and
School: A Handbook
Luria-Nebraska Neuropsychological Battery
Memory Assessment Scales
Millon Adolescent Clinical Inventory
Millon Clinical Multiaxial Inventory
Minnesota Multiphasic Personality Inventory
(MMPI) I and n
Myers-Briggs Type Indicator
Peabody Picture Vocabulary Test—Revised
Personality Inventory for Children
Rey Complex Figures Test
Reynolds Adolescent Depression Scale
Roberts Apperception Test for Children
Symptom Checklist-90—Revised
(SCL-90-R)
Shipley Institute of Living Scale
Sixteen Personality Factor Questionnaire
Stanford-Binet Intelligence Scale
Strong Interest Inventory (4th Ed.)
Stroop Neuropsychological Screening Test
Test of Visual-Motor Integration (TVMI)
Vineland Social Maturity Scale
Wechsler Adult Intelligence Scale—Revised
(WAIS-R)
Wechsler Intelligence Scale for Children—
Revised and m (WISC-R and m)
Wechsler Memory Scale—Revised
Wide Range Achievement Test—Revised
Woodcock-Johnson Psycho-Educational
Battery —Revised
Min to score
Min to administer
No. of
psychologists
M
SD
Mdn
M
SD
27
53
112
13
18
20
29
38
14
37
30.3
48.2
79.1
41.5
39.8
35.7
54.8
23.4
45.7
57.4
43.0
49.0
95.1
52.8
36.9
36.7
43.8
39.0
80.2
75.6
20.0
25.0
40.0
20.0
27.5
17.5
36.0
13.5
20.0
30.0
24.8
11.1
15.7
18.8
30.6
43.0
13.1
36.2
11.6
11.2
11.9
10.0
20
17
22
12
27
32.6
69.1
58.5
71.8
38.4
34.5
61.5
48.0
51.0
44.8
24.0
50.0
50.0
55.0
20.0
19.2
15.1
12.5
24.2
27.5
15.0
13.0
7.0
8.5
9.6
4.1
237.8
135.5
10.0
10.0
240.0
8.3
6.2
4.7
12
56.4
62.4
50.0
6.3
3.1
60
49
19
65.5
73.8
20.4
70.6
81.0
43.8
40.0
40.0
10.0
17.3
14.7
70.3
7.7
23.9
25
14
12
38
53
66.4
15.7
29.0
27.2
41.8
63.7
21.0
19.2
35.9
49.2
50.0
14.0
126.8
53.8
14.8
19.4
66.8 93.4
16.1 28.2
23.7
35.9
29.8 30.9
42.8
40.6
28.4
14.7
29.2 25.8
66.1 103.9
70.8 122.6
36.0
10.0
20.0
40.0
25.0
20.0
32.5
35.0
67.1
89.6
54.0
57.8
80.8 147.8
19.6
16.5
20.6 24.9
40.0
30.0
40.0
20.0
10.0
138
10
34
10
25
11
25
124
45
12
8.0
35.0
15.0
24.5
5.0
Mdn
M
SD
10.0
14.0
10.0
14.1
12.5
12.3
5.0
9.6
7.4
15.0
10.0
20.0
15.0
10.0
10.0
34.6
20.3
23.3
29.7
10.4
14.7
69.8
16.9
16.1
29.0
10.0
12.3
3.2
2.4
7.6
7.8
4.9
9.0
7.5
6.1
2.0
10.0
5.0
5.0
5.0
57.3
36.5
60.0
81.9
74.7
60.0
5.0
4.9
2.7
5.0
5.3
2.6
5.0
15.0
15.0
60.0
11.0
12.3
27.1
10.6
13.8
24.5
10.0
10.0
20.0
15.0
14.1
8.5
9.6
37.1
30.2
15.0
10.0
30.0
15.0
120.0
50.0
10.0
10.0
8.1
62.1
19.9
17.3
21.6
34.3
17.5
16.0
18.8
11.3
23.6
30.0
15.0
15.0
15.0
13.3
53.9
21.3
32.4
29.3
10.0
33.8
17.8
17.3
10.0
52.5
20.0
30.0
25.0
29.8
14.0
22.9
37.0
12.6
10.5
10.0
10.0
20.0
5.5
7.2
8.8
2.5
20.0
17.5
10.0
20.0
10.0
10.0
20.0
37.5
10.0
36.1
46.0
15.4
20.5
24.2
17.3
33.8
50.6
17.8
32.9
47.7
10.9
13.4
60.0
18.1
22.8
45.7
12.1
30.0
27.5
15.0
15.0
10.0
10.0
30.0
30.0
15.0
10.0
10.0
10.0
15.0
20.0
18.5
17.6
18.7
17.9
21.5
19.9
11.4
29.4
25.7
16.9
10.1
15.0
15.0
15.0
20.0
30.0
20.0
10.0
10.0
30.0
10.0
30.0
10.0
19.9
16.8
39.8
45.3
16.6
7.9
11.8
11.9
13.5
17.9
18.5
8.0
15.6
8.1
6.3
16.5
17.4
20.6
12.2
11.3
8.8
16.7
13.1
20.0
19.2
9.6
12.2
21.9
18.0
12.4
21.5
14.9
12.3
21.6
44.8
12.1
7.3
7.2
7.5
7.4
8.6
8.7
11.2
21.1
5.0
7.3
12.5
14.1
5.0
13.8
16.2
16.5
12.1
6.5
15.6
8.3
7.2
15.9
31.7
12.2
8.8
5.0
5.0
9.9
8.9
6.5
11.2
8.6
10.0
10,0
10.0
10.0
17.5
15.0
20.0
27.5
10.0
10.0
5.0
5.0
5.0
75.0
22.9
15.7
20.0
35.3
40.1
30.0
25.7
25.3
20.2
12.6
80.0
45.0
30.0
30.0
24.7
19.6
15.7
20.4
18.5
11.2
11.4
16.0
20.0
15.0
15.0
15.0
39.2
23.5
17.7
19.3
44.1
14.5
14.5
14.1
30.0
20.0
15.0
15.0
68.6
72.5
33.4
22.9
30.0
36.9
28.2
30.0
5.0
52.0
22.3
47.4
46.6
27.4
10.8
39.9
22.4
86.6
54.9
36.1
9.6
50.0
15.0
20.0
26.0
19.0
10.0
151
53.1
60.4
25.0
78.6
22.1
135
58
86
19
56.9 69.0
45.4
40.7
68.4 105.5
49.9
68.3
30.0
20.0
30.0
30.0
82.4
48.7
31.9
31.3
55.3
30.0
90.5
Note. Only the top 50 most popular tests were included in this table.
• A subtest of the Halstead-Reitan and the Reitan-Indiana Neuropsychological Batteries.
Evaluation System. " A subtest of the Halstead-Reitan Neuropsychological Battery.
8.2
30.0
10.0
5.1
76.0
20.0
10.0
35.0
45.0
15.0
11.4
Mdn
25.7
15.4
7.1
30
20.0
10.0
15.0
15.0
30.0
45.0
10.0
30.0
10.0
10.0
SD
19.9
10.3
12.4
14.2
15
22
15
19
25
107
52
37
13
11
Mdn
22.5
21.8
18.4
25.0
31.3
30.0
13.9
12.9
34.2
13.8
26.6
13.2
15.2
15.3
15.9
36.1
68.8
25.0
15.3
15.5
38.4
14.3
51.1
24.6
40
M
Min to interpret
16.4
10.5
13.0
36.7
31.1
23.5
10.3
12.0
10.5
16.3
22.6
137.7
10.5
11.6
19.5
19.7
10.7
12.5
15.0
10.0
30.0
60.0
15.0
15.0
15.0
30.0
12.5
45.0
20.0
6.1
4.3
19.2
8.7
b
9.5
10.2
7.6
8.3
11.0
349.3
6.9
4.7
5.0
10.0
10.0
15.0
5.0
8.4
A subtest of the Halstead-Russell Neuropsychological
152
Table 7
Minutes Required to Administer, Score, and Interpret Individual Tests: Neuropsychologists
No. of uses per
Min to administer
year
Test
Aphasia Screening Test"
Benton Judgment of Line Orientation Test
Benton Revised Visual Retention Test
Boston Diagnostic Aphasia Examination
Boston Naming Test
Category Test
Child Behavior Checklist
Dementia Rating Scale
Developmental Test of Visual-Motor
Integration
Finger Tapping Test
Grooved Pegboard Testb
Halstead-Reitan Neuropsychological Battery
Hand Dynamometer (Dynamic Hand Grip
Strength Test)
Hooper Visual Organization Test
House-Tree-Person (H-T-P) Projective
Technique
Luria-Nebraska Neuropsychological Battery
Memory Assessment Scales
MUlon Clinical Multiaxial Inventory
Minnesota Multiphasic Personality Inventory
(MMPI) I and 11
Neuropsychological Questionnaire
(Adult Form)
Paced Auditory Serial Addition Test
Peabody Picture Vocabulary Test— Revised
Peabody Individual Achievement
Test—Revised
Rey Complex Figures Test
Rhythm Test"
Symptom Checklist-90— Revised (SCL-90-R)
Sensory Perceptual Examination"
Shipley Institute of Living Scale
Speech Sounds Perception Testc
Stroop Neuropsychological Screening Test
Tactile Finger Localization Test
Tactile Performance Test
Test of Visual-Motor Integration
Wechsler Adult Intelligence Scale— Revised
(WAIS-R)
Wechsler Memory Scale — Revised
Wechsler Intelligence Scale for Children—
Revised and HI (WISC-R and HI)
Wide Range Achievement Test— Revised
Woodcock-Johnson Psycho-Educational
Battery— Revised
Min to score
No. of
psychologists
M
SD
Mdn
M
SD
159
200
96
90
80
66
209
189
203
52
57
120
69.0
69.2
68.6
50.3
54.1
34.1
81.3
71.9
59.8
83.3
59.4
46.4
88.2
84.9
85.5
64.0
80.0
41.5
85.8
65.6
69.4
114.0
89.5
51.8
35.0
42.5
40.0
30.0
30.0
20.0
50.0
50.0
35.0
50.0
40.0
25.0
21.5
10.4
16.5
15.7
18.2
46.8
16.8
32.4
38.1
10.0
19.8
8.3
8.0
5.0
5.0
38.3
18.4
35.0
13.8
43
66.8
81.8
74.5
76.1
37.5
50.0
50.0
40.0
14.7
12.6
5.9
8.8
5.0
250.0
136.5
15.0
10.0
10.0
240.0
12.2
18.7
214
62.6
78.3
77.8
67.1
136
145
66.0
63.5
67.1
70.1
40.0
50.0
7.3
13.7
6.7
7.6
10.0
78
55
64
50
100
55.9
60.3
24.0
43.6
52.3
53.7
57.6
41.7
51.1
62.0
35.0
42.5
12.0
22.5
40.0
19.7
14.8
160.2
51.5
22.3
22.5
359
94.3
121.8
50.0
49
88.6
60.2
47.6
97.3
68.5
66.5
43.6
92.7
70.7
54.4
76.9
56.7
88.2
75.1
66.3
66.6
60.9
70.5
61.5
40.2
43.9
99.2
28.9
228
180
9.2
14.3
6.4
15.3
36.7
15.3
15.7
18.9
16.3
Mdn
15.0
10.0
15.0
15.0
15.0
40.0
15.0
30.0
35.0
5.0
M
SO
9.5
5.9
11.4
8.8
4.5
7.9
Min to interpret
M
SD
Mdn
5.0
5.0
13.2
11.9
10.0
9.5
9.2
5.0
10.0
14.6
30.8
10.0
5.6
9.1
Mdn
5.9
4.1
5.0
7.9
12.6
19.8
8.7
15.5
10.0
15.0
10.9
22.7
7.6
6.1
5.0
9.3
7.7
8.0
17.2
10.2
13.8
11.0
15.0
10.0
12.5
10.0
15.0
17.0
13.1
13.1
12.1
19.1
15.8
15.2
15.0
10.0
10.0
10.0
15.0
9.9
6.5
8.2
5.2
7.3
22.7
8.9
10.3
9.4
5.0
10.0
15.0
8.3
3.1
4.6
10.0
10.3
11.1
10.0
5.0
4.8
5.0
5.0
7.0
6.2
5.4
4.0
5.0
5.0
54.4
37.6
60.0
95.3
94.4
60.0
4.3
6.5
2.9
6.2
5.0
5.0
5.8
8.8
4.5
7.1
5.0
5.0
12.2
10.9
16.9
12.0
62.1
20.8
27.2
11.0
56.7
12.3
23.7
15.0
10.0
45.0
20.0
20.0
9.8
8.1
94.9
22.1
21.8
15.0
15.0
157.5
50.0
15.0
46.5
19.4
19.2
42.2
10.0
21.5
10.0
10.0
30.0
20.0
15.0
38.5
44.5
15.0
24.7
54.9
15.0
30.4
21.4
30.0
50.0
40.0
20.0
27.2
22.7
22.1
27.9
11.9
20.0
20.0
20.0
10.4
12.7
6.4
10.3
6.1
10.0
10.0
10.0
23.3
10.3
11.6
23.3
9.7
15.0
10.0
10.0
54.2
91.2
77.7
71.3
103.9
53.3
97.3
119.5
97.2
79.4
57.0
93.3
73.6
45.2
52.1
92.6
33.7
20.0
70.0
40.0
35.0
37.5
50.0
50.0
37.5
27.5
35.0
50.0
30.0
35.0
25.0
20.0
70.0
15.0
42.7
17.7
12.1
47.4
12.2
12.7
23.1
13.4
18.3
18.7
11.7
24.0
10.0
40.0
15.0
10.0
45.0
16.3
14.4
11.3
15.0
15.0
16.7
12.2
12.1
9.8
6.8
34.6
37.3
16.9
11.5
45.0
94.5
93.1
92.0
85.9
70.0
60.0
203
196
59.7
89.1
77.5
63.6
88.4
69.3
58
51.2
47.9
110
89
50
196
79
153
41
43
87
54
57
75
118
48
76
91
73
246
51
331
257
178
8.7
9.9
7.3
8.5
9.4
12.5
10.0
5.7
3.8
5.0
7.6
5.3
5.0
47.7
35.9
40.0
41.9
5.0
8.0
15.6
6.3
8.4
4.0
9.4
7.9
9.9
5.6
9.3
6.2
4.4
8.2
3.3
5.1
30.0
15.0
10.0
10.0
15.0
10.0
29.9
19.7
16.3
15.1
24.7
10.0
20.0
10.0
20.0
15.0
10.0
10.0
30.0
30.0
15.0
10.0
40.0
45.0
12.9
12.4
10.5
17.5
11.6
20.5
11.6
83.4
53.3
35.1
23.0
30.0
51.0
50.0
81.6
30.8
30.3
30.0
80.2
Note. Only the top 50 most popular tests were included in this table.
a
A subtest of the Halstead-Reitan and the Reitan-Indiana Neuropsychological Batteries.
Evaluation System. c A subtest of the Halstead-Reitan Neuropsychological Battery.
6.1
8.6
8.4
20.6
12.8
12.1
30.2
12.8
10.0
22.5
10.2
b
6.8
6.6
11.4
5.0
15.0
5.0
10.0
10.0
5.0
5.0
7.9
10.6
7.3
7.6
7.6
12.2
6.8
6.4
8.7
5.1
8.0
5.0
10.0
5.0
6.3
22.3
10.3
10.0
15.0
10.0
12.6
27.8
10.5
24.5
16.4
6.1
7.8
5.0
8.0
6.5
5.0
5.0
19.8
11.9
15.0
33.0
43.5
15.0
90.0
60.0
24.6
21.4
29.2
11.0
20.0
20.0
29.3
21.6
23.9
14.5
25.0
20.0
30.1
19.3
15.0
75.0
30.0
30.0
21.8
13.1
16.8
11.3
29.9
14.6
14.3
24.6
11.2
11.7
20.0
10.0
15.0
9.5
25.0
10.0
10.0
58.6
60.0
22.5
11.2
20.0
31.4
30.2
20.0
7.4
5.0
10.0
25.0
A subtest of the Halstead-Russell Neuropsychological
153
provided, to "eat these costs," or to simply pass on costs to the
client. Other managed care organizations stipulate that behavioral
interviews are the only necessary diagnostic assessment because
the Diagnostic and Statistical Manual of Mental Disorders (4th
ed.; DSM-IV; American Psychiatric Association, 1994) makes no
reference to other psychological or neuropsychological assessments (Eisman et al., 1998).
When assessment services are reimbursed limits of less than 2 hr
are most typical. Such guidelines from managed care are clearly
inconsistent with the empirical research from this study demonstrating that comprehensive assessment services require approximately 4 or more hr of time by a trained professional. Because
practitioners can be reimbursed for the actual time required to
conduct comprehensive assessment services under existing managed care guidelines there is a danger that assessment services will
be dramatically restrained or eliminated from intake and treatment
planning. This study showed that less than 12% of clinical psychologists spend 5 or more hr on assessment services. In the future,
fewer practitioners may engage in such services for less time than
currently reported. Clinical psychologists may also reduce the
number of assessments used and possibly reduce the time expended in interpretation and reporting of results if reimbursement
is not provided.
The economic barriers created under managed care may continue to reduce the quality of assessment services and the extent
that such services are provided in some areas (e.g., intake, diagnosis, treatment planning). There are several general strategies that
the profession of psychology and individual practitioners can
consider to more directly affect these economic and health care
policy issues.
First, practitioners must be creative in incorporating assessment
as a central component within their interventions and treatments so
that is not considered an option or supplemental service that must
be justified and added onto reimbursement for treatment. Assessment services are often medical necessities and not an option.
Practitioners should view and portray assessments as an integral
component of effective treatment planning and mental health interventions. Practitioners should explore ways of incorporating and
describing such services as a component of treatment plans.
Second, evidence of the efficacy of psychological and neuropsychological assessment in the treatment of patients and the
disposition of treatment is needed. Barlow (1994) and Broskowski
(1995) observed that in the present managed care era, mental
health services that do not have strong empirical support are not
likely to be reimbursed. Practitioners must be able to justify the
benefits of comprehensive assessment services in terms of treatment focus, treatment duration, and cost-to-benefit ratio. Has a
comprehensive assessment aided in the initial diagnosis and effectiveness of treatment planning in ways that both focus the subsequent psychological interventions and reduce the overall length of
treatment for a client? Has assessment been effectively used to
inform treatment and make the necessary adjustments throughout
the intervention, or to provide summative evidence of the efficacy
of treatment? Practitioners can advance such arguments with managed care by submitting case records and other data that support
the effectiveness of assessment practices. Evidence demonstrating
that assessment services in diagnosis or treatment have been effective in reducing the duration of treatment or reducing the
recidivism of mental health problems will be viewed as compelling
by managed care because of its economic relevance.
An APA task force has recently summarized evidence of the
benefits of psychological assessment in assessing current functioning, in confirming or disconfirming clinical impressions, in differential diagnosis, in identifying appropriate treatments, in monitoring treatment, in risk management, and as a therapeutic intervention (Meyer et al., 1998). More constructive interactions with
mental health care systems are needed to reduce the misunderstandings and biases against assessment and to help define criteria
for medical necessity of assessment services. Just as practitioners
must advance such evidence when arguing for the reimbursement
of assessment services, the profession must advocate more forcefully with the use of such evidence of the effectiveness and utility
of assessment services in addressing mental health problems.
Finally, assessment services must be viewed as a more integrated component of professional practice rather than an independent service. Practice guidelines, and discussion of such guidelines, issued by the Agency for Health Care Policy and Research
(AHCPR), the American Psychiatric Association, and a Task
Force of APA's Division 12 generally put little if any emphasis on
the use of assessment services in treatment planning and evaluation. Whereas such guidelines have been highly controversial
within the mental health profession, the absence of assessment
services has not been a primary concern of mental health professionals at this time. Such guidelines strive to reflect best practices,
advocate empirically supported treatment, and improve the standard of care (Nathan, 1998). Objective and comprehensive assessments are essential in aiding the profession and professionals in
guiding treatment and determining the efficacy of treatment. Preand postassessment strategies can help practitioners objectively
demonstrate the effect of treatment. The lack of attention to assessment services in existing practice guidelines is troubling and
must be addressed if the influence of such guidelines increase.
Eisman et al. (1998) proposed a number of additional strategies
to reduce obstacles for reimbursement and precertification of assessment services. These recommendations include enhanced legislation and advocacy, public education to make customers and
patients aware of the benefits of psychological assessment, expanded and continuing training of psychologists to ensure they are
skilled in assessment and aware of current practice standards and
ethical requirements, and criteria to help decision makers recognize under what circumstances assessment is most helpful and
appropriate. Critics have argued that assessment is time consuming, expensive, and not useful (Griffith, 1997), and it is clear that
until practitioners and the profession develop more effective empirically based methods of advocacy the current misconceptions
about the utility of psychological and neuropsychological assessments will remain.
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Barlow, D. H. (1994), Psychological intervention in the era of managed
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