Examination of Construct Validity of ANX and DEP Scales of the PAI-A.

Anxiety and depression are the two most common psychiatric problems of adolescence. The Personality Assessment Inventory, Adolescent Version (PAI-A) is a broadband instrument designed to assist in the detection and differential diagnosis of common psychiatric disorders in adolescents, and it includes a Depression scale (DEP) to detect the presence of major depressive episodes and an Anxiety scale (ANX) designed to detect clinically significant anxiety. However, there is limited research on this measure. The current study examined both the convergent and discriminant validities of the PAI-A Anxiety and Depression scales by observing their relationships to other self-report measures (e.g., PAI-A scales, MMPI-A), observer ratings (e.g., HPRS), and performance-based measures (e.g., Rorschach CS). The sample consisted of 352 records of the psychological assessments of adolescent inpatients between the ages of 13 to 17; the sample was about equally male (51.6%) and female with a mean age of 15.5 years. The sample was ethnically diverse with 48.7% of individuals identifying as Caucasian, 12.9% Black, 16% Hispanic, 2.6% Asian, 3.2% Other, and 16.6% unknown. There is strong evidence for convergent validity for the PAI-A ANX and DEP scales with r's ranging from .11 to .78. There is moderate evidence for discriminant validity for these scales. Results demonstrated that PAI-A scales correlated strongest with self-report, followed by therapist rating scale, and then performance-based measures. Various strengths of the PAI-A for the assessment of anxiety and depression are discussed.

Intellectual performance correlates of trauma exposure in adolescent psychiatric inpatients.

Half of individuals have experienced a trauma adequate to meet criteria for PTSD. Intelligence may correlate with trauma, with the causal direction unclear. The Childhood Trauma Questionnaire (CTQ) was administered to 733 child and adolescent inpatients. Intelligence and academic achievement was assessed using the Wechsler Scales. Clinician diagnoses came from the electronic medical record, as did data on exposure to substance abuse and other stressors. Multivariate analyses assessed associations between intelligence, diagnoses, experiences, and CTQ. Cases who met criteria for physical and sexual abuse performed more poorly across all intellectual domains. Other than for PTSD, there were no diagnostic differences in CTQ scores. Emotional abuse or neglect were not associated with intelligence, although exposure to substance abuse was associated with increased CTQ scores and lower intelligence. Exposure to substance abuse as a covariate did not eliminate the influence of CTQ scores on intelligence, but was consistently related to intelligence beyond CTQ scores. Intelligence and substance abuse are known to have genomic influences and recent studies have suggested a genomic signature associated with childhood abuse. Future genomic studies of the consequences of trauma exposure could add intelligence polygenic scores into their models, while considering genomic and nongenomic elements of family experiences.

Cyberbullying and Its Relationship to Current Symptoms and History of Early Life Trauma: A Study of Adolescents in an Acute Inpatient Psychiatric Unit.

BACKGROUND: Cyberbullying has received wide media attention and appears to be linked to frequent adverse consequences, with multiple suicides reported. This study examined the prevalence of cyberbullying among adolescent psychiatric inpatients and related it to social media usage, current levels of symptoms, and histories of adverse early life experience. METHODS: Data on the prevalence of social media utilization and cyberbullying victimization were collected from adolescent psychiatric inpatients aged 13 to 17 years from September 2016 to April 2017. Fifty adolescent psychiatric inpatients completed 2 surveys assessing childhood trauma (the Trauma Symptom Checklist for Children and the Childhood Trauma Questionnaire) and the Cyberbullying Questionnaire. RESULTS: Twenty percent of participants (10/50) had been victimized by cyberbullying. Access to and engagement in social media or Internet-based communication was extremely common, with most participants engaging on a daily basis or more frequently in at least 1 social media activity. Those who had been bullied endorsed significantly higher scores on posttraumatic stress disorder (PTSD), depression, anger, and fantasy dissociation scales than those who were not bullied (all P values < .05). Subjects who reported having been victims of cyberbullying endorsed significantly higher levels of lifetime emotional abuse on the Childhood Trauma Questionnaire than those who were not bullied (P = .013); however, they did not report a significantly higher level of the other types of trauma (physical abuse, sexual abuse, emotional neglect, or physical neglect). More bullied than nonbullied subjects had clinically and statisticallysignificant elevations in hyperresponse, PTSD, and depression scale scores (P < .05). CONCLUSIONS: Being cyberbullied was associated with greater psychiatric symptom severity. Further, histories of emotional abuse were correlated with recent cyberbullying. These data suggest that individuals with histories of childhood trauma also seem vulnerable to continued adverse experiences during adolescence.

Comparisons between the Minnesota Multiphasic Personality Inventory-Adolescent-Restructured Form (MMPI-A RF) and MMPI-A in adolescent psychiatric inpatients.

This study explored the association between the Minnesota Multiphasic Personality Inventory (MMPI)-Adolescent-Restructured Form (MMPI-A-RF) and the MMPI-Adolescent (MMPI-A) form in a sample of 3,516 adolescents receiving inpatient psychiatric treatment, including 2,798 adolescents meeting validity inclusion cutoffs for both measures. There was 92.5% agreement rate with respect to global identification of cases as valid or invalid and some empirical support for lowering interpretive cutoffs for validity scales on the MMPI-A-RF. The MMPI-A-RF Demoralization Scale (RCd) was shown to correlate significantly less strongly with Restructured Clinical (RC) scales than with MMPI-A clinical scales. RC scales also demonstrated significantly lower mean interscale correlations than MMPI-A clinical scales. As expected, this greater level of scale independence resulted in significantly fewer profiles with multiple scale elevations. As was anticipated, with the exception of RC1 predicting MMPI-A hypochondriasis, correlational and classification agreement analyses suggested moderate associations between the RC and MMPI-A clinical scales, but somewhat stronger agreement between comparable PSY-5 scales. Changes in interpretive cutoff procedures for the RC scales, including RCd, also resulted in 5.5% fewer "within normal limits" profiles than the use of MMPI-A with all 10 clinical scales. Finally, stepwise linear regression analyses indicated that MMPI-A-RF Higher-Order scales were best predicted by those MMPI-A clinical scale combinations that they are purported to be linked with in the MMPI-A-RF manual. (PsycINFO Database Record

Discovery of previously undetected intellectual disability by psychological assessment: a study of consecutively referred child and adolescent psychiatric inpatients.

Intellectual disability is associated with an increased risk of behavioral disturbances and also complicates their treatment. Despite increases in the sophistication of medical detection of early risk for intellectual disability, there is remarkably little data about the detection of intellectual disability in cases referred for psychiatric treatment. In this study, we used a 10-year sample of 23,629 consecutive child and adolescent admissions (ages between 6 and 17) to inpatient psychiatric treatment. Eleven percent (n=2621) of these cases were referred for psychological assessment and were examined with a general measure of intellectual functioning (i.e., WISC-IV). Of these cases, 16% had Full Scale IQs below 70. Of the cases whose therapists then referred them for formal assessment of their adaptive functioning (i.e., ABAS-II) 81% were found to have composite scores below 70 as well. Only one of the cases whose Full Scale IQ was less than 70 had a referral diagnosis of intellectual disability. Cases with previously undetected intellectual disability were found to be significantly more likely to have a diagnosis of a psychotic disorder and less likely to have a diagnosis of mood disorder than cases with IQs over 70. Disruptive behavior disorder diagnoses did not differ as a function of intellectual performance. These data suggest a high rate of undetected intellectual disability in cases with a psychiatric condition serious enough to require hospitalization and this raises the possibility that many such cases may be misdiagnosed, the basis of their problems may be misconceptualized, and they may be receiving treatments that do not take into account their intellectual level.

Apathy correlates with cognitive performance, functional disability, and HIV RNA plasma levels in HIV-positive individuals.

We examined the relationship of apathy with neurocognitive performance, age, disease markers, and functional disability in 116 HIV-infected individuals. Apathy was assessed with the Apathy Evaluation Scale and was significantly associated with highest HIV plasma level, functional disability, and neurocognitive performance. Individuals with higher apathy levels demonstrated a stronger association between age and processing speed performance. Our findings suggest that apathy is related to poor neuropsychological functioning, HIV plasma levels, and increased functional disability in individuals with HIV. Additionally, to our knowledge, this is the first study to demonstrate an interactive effect of age and apathy on neuropsychological performance in HIV.

Prevalence and precursors of the use of restraint and seclusion in a private psychiatric hospital: comparison of child and adolescent patients.

The use of restraint and seclusion is highly regulated in psychiatric inpatient settings. However, the majority of studies of restraint and seclusion are based on public hospitals serving adult patients, with some limited data available on adolescents and children. This paper presents prospectively collected data on restraint and seclusion over a 2-year period at a private psychiatric hospital whose patients include large numbers of both adolescents and pre-adolescent children. 2 years of restraint and seclusion data were analyzed on a total of 2,411 unique patients. Types of seclusion included in-room seclusion on the treatment unit and off-unit seclusion in a separate seclusion annex. Restraints consisted solely of short term (<15 min) and longer term (>14 min) manual restraints. The use of IM medication was also recorded. The precipitants of these events were examined. These included physical and verbal threats, stabbing or throwing objects, attempts to elope, attempts to hurt one's self or another, or property destruction. Out of 2,411 child and adolescent in-patients admitted during the period under review, only 703 (29%) experienced restraint or seclusion. Among these, the modal number of events per patient was one (n = 156), but the maximum number of occurrences was 163. Child patients had a much higher frequency of events (n = 396, 53%) than adolescents (n = 307, 19%). There were notable differences in the types of seclusion events, with children typically experiencing in-room seclusion on the unit. When age was examined as a continuous variable, younger patients had a higher prevalence of restraint and seclusion, significantly more restraint and seclusion, and these restraint and seclusion events were significantly shorter than those seen in older patients. Multiple other potential determinants of these events were examined, including diagnosis, symptom severity at admission, age, and gender, but none of these predicted these events. Restraint and seclusion events were more common for children and less so for adolescents, with robust age effects for the likelihood of any seclusions, the number of seclusions and restraints, and the duration of seclusions and restraints. Patients who experienced restraint or seclusion typically required it only once during their hospitalization. Only age was found to be a predictor of the restraint and seclusion variables. Given these findings, it appears that management of agitated behavior in children and adolescents may be a qualitatively different phenomenon. Future research should be directed at understanding the determinants of high frequency agitated behavior and developing alternatives to seclusion or restraint.

Response character styles in adolescents: a replication of convergent validity between the MMPI-A and the Rorschach.

This study explored the extent to which similar or discordant response character styles (RCS) affected convergence between MMPI-A and Rorschach findings in a sample of 673 adolescents from a psychiatric inpatient setting. Meyer's (Meyer, 1997; Meyer, Riethmiller, Brooks, Benoit, & Handler, 2000) findings for adult samples were generally replicated in that adolescents showing similar RCS across both measures showed moderate to strong relationships between Rorschach and MMPI-A indicants of affective distress, psychosis, and interpersonal wariness, whereas those showing discordant RCS demonstrated negligible or negative correlations between these indicants. This pattern was evident for conceptually similar, but not conceptually unrelated variable pairs. Similarity and discordance of RCS was also found to have an impact on relationships with external criterion variables, including therapist ratings and discharge diagnoses. Moderated regression analysis supports the hypothesis that RCS moderates the strength of the relationship between Rorschach and MMPI-A. Implications for practice and future research are discussed.

The factor structure of clinical symptoms in depressed inpatients with unipolar or bipolar spectrum disorders: a preliminary study.

Factor analysis of symptom structure has proven to be a valuable tool to identify dimensions of symptoms in various psychiatric conditions. This study used exploratory and confirmatory factor analysis to examine symptom structures in depressed inpatients with unipolar (n = 718) or bipolar (n = 134) spectrum disorders who were rated at admission with a psychiatric rating scale. No differences in overall symptom severity on the scale were found in the 2 samples, although different factor structures were detected with exploratory analyses. These models were modified in a confirmatory modeling procedure to improve their fit to the data, resulting in models with good, but not perfect, fits. For people with bipolar disorders, a 5-factor model fit best, with depression loading with anxiety symptoms and in people with unipolar disorders, a 4-factor model with depression loading with vegetative symptoms was found. Our results suggest that similar levels of symptom severity may have different underpinnings in the 2 groups and suggest that more comparative studies of symptoms in these 2 conditions may be useful.

Six-year outcomes in first admission adolescent inpatients: clinical and cognitive characteristics at admission as predictors.

Persistent functional disability is common after even a single psychiatric admission in people with schizophrenia or bipolar disorder, but less is known about other conditions and about adolescent onset patients. This study examined clinical symptoms and cognitive performance at the time of the first admission for the prediction of 6-year outcomes. First admission adolescent patients with a variety of psychiatric diagnoses were assessed with comprehensive clinical ratings of psychopathology, a neuropsychological assessment, and received clinical diagnoses while experiencing their first psychiatric admission. They were contacted 6 years after discharge and examined with a structured assessment of psychiatric symptoms and functioning. Despite the low levels of overall impairment at follow-up, at least 20% of the variance in depression, psychosis, poor peer relationships and poor school attendance 6 years after the hospital admission were predicted by information collected during the hospitalization. Attentional deficits during admission predicted the presence of psychosis at follow-up more substantially than psychotic symptoms during admission, as well as predicting risk for relapse. Attentional deficits during a first psychiatric admission predicted risk for manifesting psychosis at 6-year follow-up to a more substantial degree than either a psychosis diagnosis or psychotic symptoms at admission. In contrast to psychosis, depression at follow-up was predicted by admission symptomatology, but not by cognitive deficits.

Rates and predictors of adherence with atypical antipsychotic medication: a follow-up study of adolescent inpatients.

BACKGROUND: The use of atypical antipsychotics is increasing in adolescent populations, but little is known about adherence with these treatments. This study examined postdischarge adherence of adolescents treated as inpatients with either olanzapine or risperidone. METHODS: Eighty-six (86) adolescent inpatients (43 per treatment) were contacted an average of 10 months (range, 90 days to 18 months) after discharge from the hospital. A structured interview examined compliance, side effects, and subjective impressions regarding the efficacy of treatment. Clinical symptoms rated by clinicians, self-reports from patients, hospital chart diagnosis, treatment group (risperidone/olanzapine), and demographic factors were used to predict compliance, as were the occurrence of side effects and subjective impressions of the efficacy of treatment. RESULTS: Forty-five percent (45%) of the patients were adherent with their medications, while only 12% discontinued treatment on their own, and 43% stopped medication at the request of their parent or a physician. Medication status and symptom severity did not predict nonadherence, and the only diagnosis related to adherence was substance abuse. The only side effect that predicted nonadherence was rapid weight gain during the hospitalization; this was slightly more common in olanzapine-treated patients. Nonadherent patients' subjective impressions of efficacy were no different from the patients who continued their medications, but the patients who stopped medication on their own were more likely to also have failed to attend recommended psychotherapy as well. IMPLICATIONS: Failure to continue recommended treatment with atypical antipsychotics was most common in cases who did not comply with other aspects of the discharge plan. Efficacy of the medication did not predict nonadherence, as half of the noncompliant subjects stated that the medication had been helpful. Rapid weight gain also predicted nonadherence, but subjective impression of long-term weight gain was not different across adherence or treatment status. These data tentatively suggest that in adolescent patients, tendencies toward general uncooperativeness and substance abuse may be at least as important as the occurrence of common side effects in the determination of medication adherence.

Field reliability of comprehensive system scoring in an adolescent inpatient sample.

The extent to which the Comprehensive System for the Rorschach is reliably scored has been a topic of some controversy. Although several studies have concluded it can be scored reliably in research settings, little is known about its reliability in field settings. This study evaluated the reliability of both response-level codes and protocol-level scores among 84 adolescent psychiatric inpatients in a clinical setting. Rorschachs were originally administered and scored for clinical purposes. Among response codes, 87% demonstrated acceptable reliability(> .60), and most coefficients exceeded .80. Results were similar for protocol-level scores, with only one score demonstrating less than adequate reliability. The findings are consistent with previous evidence, indicating reliable scoring is possible even in field settings.

Intellectual functioning in adolescents with indicators of psychosis: evidence for decline in functioning related to number of psychotic features?

Substantial research has demonstrated that adults with schizophrenia display intellectual decline compared to their premorbid levels of functioning. Research of this type, however, is not as common in adolescents with psychotic disorders. Since many first-episode adolescents with psychotic disorders other than schizophrenia may eventually meet criteria for this diagnosis, we examined first admission adolescents with variable psychiatric diagnoses. In this study, current intellectual functioning was compared to estimated premorbid functioning (estimated with word recognition reading), and the difference between these scores was related to the number of indicators of psychosis that was present in each case. Subjects consisted of 513 inpatients, ranging in age from 13 to 17 years, who were admitted to the adolescent service of a private psychiatric hospital. Indicators of psychosis came from clinical diagnoses, self-report measures, and clinical rating scales. Across the entire sample of 513 subjects the greater the number of indicators of psychosis that was present, the greater the estimated premorbid/current intelligence quotient (IQ) discrepancy. Type of IQ test, differences in intellectual premorbid functioning, demographic variables, and type of treatment were all unassociated with risk for IQ discrepancy. Within the limitations of estimation of premorbid intellectual functioning, these data suggest that intellectual decline is present at the time of the first psychiatric admission in psychotic adolescent patients who do not necessarily meet diagnostic criteria for schizophrenia and that this discrepancy is greater in patients with more indicators of psychosis.

The Rorschach Ego Impairment Index: prediction of treatment outcome in a child psychiatric population.

In this study, we investigated the treatment utility of the revision of Perry and Viglione's (1991) Rorschach Ego Impairment Index (EII-2) in a sample of 53 child psychiatric inpatients. Parent ratings of symptomatic functioning on the Devereux Scales of Mental Disorders (DSMD; Naglieri, LeBuffe, & Pfeiffer, 1994) were obtained at admission, 30 days postdischarge, and 120 days postdischarge. EII-2 scores correlated with initial symptom elevations on the Critical Pathology at admission. EII-2 scores did not predict short-term response to treatment. However, EII-2 scores demonstrated moderate correlations with long-term outcome and relapse. EII-2 was related to prediction of worsening of symptoms between 30-day and 120-day follow-up as measured by Reliable Change Index scores that were computed for the Externalizing, Internalizing, Critical Pathology, and Total DSMD scales.

Convergence of different versions of the continuous performance test: clinical and scientific implications.

The Continuous Performance Test has been used for the last 40 years to measure sustained attention or vigilance in many different populations. Different versions of the test have been developed, but little is known about how similar these tests are, and to what extent performance on different versions of these tests overlaps. In order to examine convergence of the different versions of the CPT, three different CPTs were administered in both the Auditory and Visual Sensory Modalities. Subjects were selected from consecutive admissions to adolescent acute care units at a private psychiatric hospital (n=100). Auditory test modalities uniformly elicited poorer performance than visual tests, while each set of task demands consistently elicited differences in performance. Despite the high test-retest reliability of the individual subtests, the average correlation between tests was r=.42, with the average correlation between visual tests at r=.48 and the average correlation between the auditory tests was r=.45. The correlations within task demands across sensory modalities ranged from a low of.37 to a high of.52. Controlling for IQ did not influence the correlations to a substantial degree. These data suggest different versions of the CPT are correlated with each other at a level consistent with construct validity, but that they do not constitute alternate forms of the same test.

A comparison of the PAI and MMPI-2 as predictors of faking bad in college students.

Both the Minnesota Multiphasic Personality Inventory-2 (MMPI-2; Butcher et al., 2001) and Personality Assessment Inventory (PAI; Morey, 1991) offer a large set of scales devoted to the identification of response styles. This study directly compared the effectiveness of the 2 inventories as indicators of overreporting. The 2 measures were administered to 52 college students instructed to fake bad under conditions describing either a forensic (n = 24) or psychiatric (n = 28) setting as well as to 432 psychiatric patients. Results indicated that the MMPI-2 F - K index and Fp Scale were the best single indicators of a faking bad response style and that the MMPI-2 scales were the better indicators as a set. However, the PAI scales demonstrated a significant level of incremental validity over the MMPI-2 indicators in every analysis conducted. The findings suggest that either inventory offers an effective approach to the detection of overreporting, and administering both inventories can enhance the accuracy of prediction further.

Development of a short form for the MMPI-2 based on scale elevation congruence.

The length of the Minnesota Multiphasic Personality Inventory (MMPI) is often considered a barrier to its use, leading to the development of short forms. Two methods of abbreviating the revised MMPI have now been developed. One agrees poorly with the long form in terms of which scales are elevated. The second ensures perfect congruence in which scales are elevated but requires computer administration. This article describes the development of a short form representing a compromise approach. The short form was derived using 800 psychiatric inpatients and cross-validated with samples of 658 inpatients and 266 outpatients. It is briefer than the computerized short form but does not achieve perfect congruence with the full inventory. It is longer than earlier noncomputerized short forms but demonstrates greater scale elevation congruence with the full inventory and allows estimates of more scales. The short form offers a reasonable alternative when the full inventory is impractical.

MMPI-A structural summary variables: prevalence and correlates in an adolescent inpatient psychiatric sample.

This study examined the prevalence and correlates of Archer and Krishnamurthy's MMPI-A Structural Summary (SS) dimensions in a sample of 632 adolescent psychiatric inpatients through a series of correlational analyses. These analyses examined the relationship between factor dimensions and categorically defined dimension elevations and external criterion measures that included chart review data, therapist ratings, chart diagnoses, and cognitive test performance. The SS dimensions provided additional interpretive yield for some within-normal-limits profiles. An examination of the pattern of correlations revealed small to moderate relationships between all SS variables and external criterion measures.

Incremental validity of selected MMPI-A content scales in an inpatient setting.

To date, relatively few studies have been published evaluating the validity or incremental validity of the content scales from the adolescent version of the Minnesota Multiphasic Personality Inventory (MMPI-A; J. N. Butcher et al., 1992). A sample of 629 psychiatric inpatient adolescents who had completed the MMPI-A was used to evaluate the ability of selected clinical and content scales to predict conceptually related clinical variables. Criteria were based on clinician ratings, admission and discharge diagnoses, and chart reviews. Results from hierarchical multiple and logistic regression analyses indicated the content scales offered incremental validity over the clinical scales and supported the use of the content scales as an adjunct to the traditional clinical scales.

A comparison of MMPI-2 high-point coding strategies.

High-point coding refers to the popular practice of classifying Minnesota Multiphasic Personality Inventory (Hathaway & McKinley, 1983) profiles based on which clinical scales are the most elevated. A previous review of high-point code studies (McGrath & Ingersoll, 1999a) noted marked discrepancies across studies in the rules used to define high-point codes. This study was conducted to evaluate the costs and benefits of different strategies for high-point coding. The impact of 4 rules for high-point coding on effect sizes and group sizes was evaluated. The 4 rules included requiring a minimum elevation, excluding potentially invalid protocols, restricting coding to well-defined codes, and replacing the lower scale in infrequently occurring codes with the next most elevated scale. The evidence supported the clinical utility of requiring a minimum elevation for code scales. The results were more equivocal concerning the value of well-defined coding and for not replacing the lower scale in infrequent codes. Results were surprisingly negative concerning the utility of excluding potentially invalid protocols, suggesting that guidelines developed in situations in which there is a clear motivation to distort results may not generalize to other settings.