Psychological Testing in the Service of Disability Determination (2015) / Chapter Skim
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2 Disability Evaluation and the Use of Psychological Tests
2 Disability Evaluation and the Use of Psychological Tests
Pages 33-86
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From page 33... ...
. This chapter describes SSA's process for evaluating applications and determining the disability status of the applicants, including the use of psychological testing in SSA disability evaluations.
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FIGURE 2-2 Disability determination process for adults by the numbers.
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Disabled 25.5% Disabled Yes No NOTE: Other 8.8%, 43.7% allowed at initial determination level. Figure 2-2b Disability Determination Numbers at Each Stage of the Process: Title XVI Adults in 2013, SSI Adults Not 1.
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Applications for disability benefits are made at a local SSA field office. During the first step of the disability determination process, officials in the SSA field offices verify applicants' financial and other nonmedical (e.g., age, work credits)
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, disability examiners have the authority to make the initial disability determination. In most cases, the disability examiners prepare the assessments and have the authority to approve or deny claims without obtaining the signature of a medical or psychological consultant.
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. 3 For mental disorders, functional limitations are used to assess the severity of the impair ment.
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. Notably, more than 50 percent of the initial determinations made at the DDS level in 2013 were made in this final step of the disability determination process, when medical-vocational factors are a primary component of the determination decision.4 SSA is in the process of updating its system for making medical-vocational decisions (SSA, n.d.-l)
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Sequential Disability Determination Process for Children The first two steps of the disability determination process are similar for children younger than 18 years of age and adults. As with SSDI and SSI adult applications, almost no applications are rejected at Step 1 due to prescreening of the nonmedical eligibility requirements by the SSA field offices.
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. The remaining steps of the disability determination process for adults, Steps 4 and 5, do not pertain to children.
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. In 2013, 45.1 percent of disability applicants received a CE as part of the initial disability determination process (SSA, 2014d)
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Approximately 45 percent of 2010 SSI adult applicants and 30 percent of 2010 SSI child applicants who were rejected in the initial determination process appealed their decisions (calculations based on data from the 2013 Annual Statistical Report on the SSI program, Tables 70 and 71 [SSA, 2014k]
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From page 44... ...
Based on data for applicants who filed for benefits in 2010, final award rates for disability benefit applicants are around 55 percent for SSDI workers, including concurrent applicants; 40 percent for SSI adult applicants; and 45 percent for SSI child applicants (SSA, 2014b, Tables 61, 62, 63, 2014k, Tables 70, 71, 72) .12 Variability in Outcomes Across States Although state DDS offices and SSA follow the same disability determination and appeals process, award rates vary significantly by state, reflecting variation in both filing rates (applications per eligible population)
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Disability Evaluation and the Use of Psychological Tests 45 Adult Filing Rate by State - 2013 Percent of eligible adult populaƟon who have filed for disability benefits NH WA MT ND VT ME MN OR MA ID WI NY SD WY MI RI IA PA NE OH CT NV UT IL IN CA CO WV KS VA NJ MO KY TN NC DE AZ OK NM AR SC GA MD MS AL TX LA DC AK FL First Quantile: 1.64 - 2.54 HI Second Quantile: 1.24 - 1.64 Third Quantile: 0.99 - 1.24 Fourth Quantile: 0.60 - 0.99 Child Filing Rate by State - 2013 Figure 2-4a Percent of eligible child populaƟon who have filed for disability benefits NH WA MT ND VT ME MN OR MA ID WI NY SD WY MI RI IA PA NE OH CT NV UT IL IN CA CO WV KS VA NJ MO KY TN NC DE AZ OK NM AR SC GA MD MS AL TX LA DC AK FL First Quantile: 0.68 - 1.56 HI Second Quantile: 0.49 - 0.68 Third Quantile: 0.35 - 0.49 Fourth Quantile: 0.06 - 0.35 FIGURE 2-4 Filing rates by state, fiscal year 2013.
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46 Psychological Testing Adult Allowance Rate by State - 2013 Percent of DeterminaƟons ResulƟng in an Allowance NH WA MT ND VT ME MN OR MA ID WI NY SD WY MI RI IA PA NE OH CT NV UT IL IN CA CO WV KS VA NJ MO KY TN NC DE AZ OK NM AR SC GA MD MS AL TX LA DC AK FL First Quantile: 36.35 - 53.49 HI Second Quantile: 32.64 - 36.35 Third Quantile: 29.70 - 32.64 Fourth Quantile: 23.66 - 29.70 Figure 2-5a Child Allowance Rate by State - 2013 Percent of DeterminaƟons ResulƟng in an Allowance NH WA MT ND VT ME MN OR MA ID WI NY SD WY MI RI IA PA NE OH CT NV UT IL IN CA CO WV KS VA NJ MO KY TN NC DE AZ OK NM AR SC GA MD MS AL TX LA DC AK FL First Quantile: 51.58 - 77.41 HI Second Quantile: 43.20 - 51.58 Third Quantile: 36.47 - 43.20 Fourth Quantile: 26.22 - 36.47 FIGURE 2-5 Allowance rates by state, fiscal year 2013.
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Only 6 percent of the total variation in SSI child allowance rates is accounted for by the time-varying independent variables included in his model. Year fixed effects account for an additional small share of the variation in adult allowance rates (SSDI and SSI)
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by variability in the federal disability determination process, there is some evidence that states differ in how they manage claims. For example, there are significant differences across states in the percentage of cases requiring a CE as part of the initial determination.
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. PSYCHOLOGICAL TESTING IN SSA DISABILITY EVALUATIONS Policy Relevant to Evaluations of Disability for Mental Disorders Adults who file for SSA disability on the basis of mental disorders and meet the nonmedical eligibility criteria are evaluated at Step 2 for the presence of a medically determinable mental impairment, the severity of the functional limitation it imposes on the individual's ability to work, and a determination that the impairment has lasted or will last for 12 or more continuous months (SSA, 2012d, n.d.-e)
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50 Psychological Testing New SSDI Worker Beneficiaries by Diagnostic Group, 2013 Intellectual Disability 1% Other Mental 16% Other 28% Circulatory System 11% Nervous Systems and Sense Organs 8% Musculoskeletal 36% New SSI Adult Beneficiaries by Diagnostic Group, 2013 Figure 2-6a Intellectual Disability 4% Other Mental 27% Other 36% Musculoskeletal 26% Nervous Systems and Sense Organs 7% Figure 2-6b
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. These areas correspond to the Paragraph B criteria,14 which are part of the listings of impairments for mental disorders assessed at Step 3.
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Step 2 is the first point at which the results of cognitive and noncognitive tests can help inform SSA's disability determination process. The results of such tests can help support the identification and documentation of the presence and severity of medically determinable mental impairments.
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Assessment of residual functional capacity is another area of the determination process that the results of psychological testing could inform. The determination process differs somewhat for children at Step 3.
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. Psychological Testing SSA understands "standardized psychological tests" to be psychological test measures that have "appropriate validity, reliability, and norms" representative of relevant populations (SSA, n.d.-e, section D5)
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In addition, SSA notes that intelligence test results can help to confirm the presence of intellectual disability and organic mental disorders as well as the severity of cognitive impairment. SSA states that standardized personality measures (e.g., Minnesota Multiphasic Personality Inventory-2)
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. In practice, CEs for mental disorders generally consist of nonstandardized diagnostic interviews and mental status exams, with little to no standardized psychological testing other than intelligence testing (Chafetz, 2008; Chafetz et al., 2007; Griffin et al., 1996; Heiser, 2014; McLaren, 2014; Price, 2014; Ward, 2014)
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SSA then assesses whether the medically determinable impairment could reasonably be expected to produce the reported symptoms. In cases where objective medical evidence does not substantiate the person's statements, SSA considers the same types of evidence described for pain and other symptoms.
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. Use of Validity Tests With rare exceptions, such as a court order, current SSA policy precludes the purchase of (validity)
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and SVTs by DDS and consultative examiners with statements such as the following: • "Malingering cannot be proven with tests"; • "Malingering is one aspect of the larger sphere of inaccurate self reporting"; • "No test … conclusively determines the presence of inaccurate patient self-report"; and • "Even a high likelihood of malingering does not preclude se vere limitations resulting from a genuine medically determinable impairment."20 On the other hand, SSA acknowledges that validity test results can "provide evidence suggestive of poor effort or intentional symptom manipulation" and states that it will consider validity test results that are already in an applicant's file, along with all other relevant evidence. In fact, the statement that no one test "conclusively determines the presence of inaccurate patient self-report" seems to run counter to SSA's dedication to obtaining as much evidence as possible and taking account of all the information when making a disability determination.
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For this reason, the discussion in this section focuses on studies of "malingering" in the disability context. The studies described here suggest that anywhere from 19 to 68 percent of SSA disability applicants may be performing below their capability on cognitive tests or inaccurately reporting their symptoms.
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. In a sample of adult SSA disability applicants, Chafetz and Abrahams found that 13.8 percent scored below chance performance and 58.6 percent failed two or more validity indicators (Chafetz and Abrahams, 2005, reported in Larrabee, 2007)
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Malingering Rating Scale 20.5–30.4 percent Below chance (adults) ; 15.4–32.5 percent (children)
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At or below chance Malingering Rating Scale SSA adult and child disability applicants, most with low cognitive functioning TOMM (n = 136 adults, 96 children) MSVT (n = 58 adults, 27 children)
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. In the context of SSA disability evaluations, it is important to note that even if an applicant performs below his or her capability on cognitive tests or inconsistently reports symptoms, neither scenario means the individual is not disabled.
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Data interpretation Once data have been collected -- whether clinical data, mechanical data, or some combination of both -- they must be interpreted
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In short, actuarial combination of clinical data, mechanical data, and especially of both clinical and mechanical data performs better than clinical interpretation of clinical data, mechanical data, or even both kinds of data. Why Are Actuarial Methods Controversial?
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, making it important for the evaluator to collect and consider relevant mechanical data along with other objective data in making such assessments. USE OF PSYCHOLOGICAL TESTS IN NON SSA DISABILITY EVALUATIONS To better understand the potential role of standardized psychological testing, including validity testing, for SSA disability determinations, the committee looked at current practices surrounding the use of psychological testing in several other settings that involve, or might involve, an element of secondary gain.
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In contrast to disability evaluations for SSA and the Veterans Benefits Administration (VBA) , discussed in the following section, military assessments for mental and behavioral health are performed to assess combat or duty readiness.
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, clinical interview and behavioral observations, and information from collateral sources. Psychological or neuropsychological testing is required in cases involving reported traumatic brain injury (TBI)
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or not. Also unlike SSA, recipients of veterans' disability benefits may work with no limit on their earnings.
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(VHA Directive 2012-021, August 27, 2012) For all initial PTSD disability evaluations, the examiner is instructed to review the veteran's claims file (C-file)
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Private Disability Insurance Unum is the largest commercial disability insurer in the United States for both short-term and long-term disability. The committee looked to its processes to gain an understanding of how private disability insurers approach the use of psychological testing in adjudicating claims.27 In evaluating a claim, examiners, who are clinicians, are required to consider all of the information in the claimant's file, including the results of previously administered psychological and neuropsychological tests.
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For this reason, examiners are mandated to look at all of the information collectively. Invalid results on validity measures indicate that the remaining test results are not valid for clinical interpretation.
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. As noted in a statement from the Association for Scientific Advancement in Psychological Injury and Law, "Measures of performance and symptom validity are still in their relative infancy … [and]
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In this setting as well, the decision of whether to administer psychological tests and, if so, which particular test to use is determined by the individual psychologists according to the practice standards in that area of inquiry. The Canadian Academy of Psychologists and Disability Assessment standards related to psychological testing include the following: • A psychologist shall employ standardized psychometric tests when ever possible; • Psychologists whenever possible shall employ psychometric proce dures that measure response bias and symptom validity; and • Psychologists shall address any apparent discrepancies between the results of psychometric tests and other information.
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Although the use of psychological testing must be understood in the context of each system's goals, each of the systems encourages a comprehensive evaluation, as determined by the evaluator, in an effort to answer these questions and each permits a broad range of evaluations. Whether to order psychological tests and the selection of which tests to administer are left to the discretion of the professional performing the evaluation or examination.
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records Testing at providers' who sacrificed; hence, may Psychologists Clinical interview with discretion not test or validate Neuropsychologists observation Malingering charge may lead Psychiatrists to lengthy legal battle 77 continued
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TABLE 2-3 Continued 78 Policy on Psychological Who Performs the What Are the Psychological Tests or Neuropsychological Setting Assessments Assessments Employed Tests Concerns/Conflicts Private Disability evaluators: Clinical files or Any relevant, Evaluator determines Industry has additional Neuropsychologists recordsa scientifically valid necessary testing resources Psychologists tests PVTs/SVTs required Each company makes its own Psychiatrists policy Social workers Forensic: Mental health Hired by defense or Civil and professionals hired prosecution to support Criminal by defense or position favorable to that prosecution: side Psychologists Psychiatrists Social workers NOTE: DDS = Disability Determination Services; IDES = Independent Disability Examination System; NP = nurse practitioner; PA = physician assistant; PTSD = posttraumatic stress disorder; PVT = performance validity test; SVT = symptom validity test; TBI = traumatic brain injury. a Some require standard tests, such as the AMA Guide (see, for example, Rondinelli, 2008)
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From page 79... ...
• There currently are no data on the rates of false positives and false negatives in SSA disability determinations. • Identification and documentation of the presence and severity of medically determinable mental impairments at Step 2 of SSA's disability determination process could be informed by results of standardized psychological tests.
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From page 80... ...
With the exception of SSA, all of the systems permit, or in some cases require, the use of validity testing to provide infor mation about the validity of the results of other psychological tests being administered. Nevertheless, all agree that although validity tests yield important information, the results of such tests are only one piece of data that needs to be assessed and interpreted in the context of all the other information available.
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Presentation to the IOM Committee on Psychological Testing, Including Validity Testing, for Social Security Administration Disability Determinations, August 11, 2014, Washington, DC.
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Presentation to the IOM Committee on Psychological Testing, Including Validity Testing, for Social Security Administration Disability Determinations, June 25, 2014, Washington, DC. Meehl, P
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military. Presentation to the IOM Committee on Psychological Testing, Including Validity Testing, for Social Security Administration Disability Determinations, June 25 2014, Washington, DC.
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Data prepared by ORDP, ODP, and ODPMI. Data submitted to the IOM Committee on Psychological Testing, Including Validity Testing, for Social Security Administration Disability Determinations by Joanna Firmin, Social Security Administration, on October 8, 2014.
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. Data submitted to the IOM Committee on Psychological Testing, Including Validity Testing, for Social Security Administration Disability Determinations by Joanna Firmin, Social Security Administration, on October 21, 2014.
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Presentation to the IOM Committee on Psychological Testing, Including Validity Testing, for Social Security Administration Disability Determinations, August 11, 2014, Washington, DC. Wedding, D., and D
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