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Suggested Citation:"1 Introduction." Institute of Medicine. 2015. Psychological Testing in the Service of Disability Determination. Washington, DC: The National Academies Press. doi: 10.17226/21704.
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1

Introduction

The U.S. Social Security Administration (SSA) administers two disability programs: Social Security Disability Insurance (SSDI), for disabled individuals and their dependent family members, who have worked and contributed to the Social Security trust funds, and Supplemental Security Income (SSI), which is a means-tested program based on income and financial assets for adults aged 65 years or older and disabled adults and children (SSA, 2012a). Both programs require that applicants have a disability and meet specific medical criteria in order to qualify for benefits.

In 2012, SSA provided benefits to nearly 15 million disabled adults and children (see Table 1-1). The majority of beneficiaries, 8.8 million, received benefits through the SSDI program (SSA, 2013a, Table 20). The remaining beneficiaries received benefits through the SSI program; SSI paid benefits to 4.9 million adults and 1.3 million children (SSA, 2013b, Table 19).

Disability determinations are based on the medical evidence and all other evidence considered relevant by the examiners in a claimant’s case record. Physical or mental impairments must be established by objective medical evidence consisting of medical signs and laboratory findings, which according to SSA may include psychological and other standardized test results (20 CFR § 404.1528). The presence of an impairment requires objective findings and cannot be based solely on an applicant’s statement of symptoms and functional limitations, although such statements are treated as part of the overall evidence. SSA also considers the extent to which such self-reported claims of impairment and functional limitation are consistent with the observations by medical treating sources and collateral observers,

Suggested Citation:"1 Introduction." Institute of Medicine. 2015. Psychological Testing in the Service of Disability Determination. Washington, DC: The National Academies Press. doi: 10.17226/21704.
×

TABLE 1-1 Characteristics of SSDI and SSI Beneficiaries, 2012

Characteristic SSDI Workers SSI Adults—Disability SSI Children
All 8,826,591 4,869,484 1,311,861
Age      
Under 30   2.50%    —    —
30–34   3.40%    —    —
35–39   4.60%    —    —
40–44   7.10%    —    —
45–49 11.00%    —    —
50–54 17.20%    —    —
55–59 23.20%    —    —
60–FRA 31.00%    —    —
18–21    —   7.49%    —
22–25    —   7.24%    —
26–29    —   6.43%    —
30–39    — 14.54%    —
40–49    — 20.07%    —
50–59    — 31.40%    —
60–64    — 12.83%    —
Under 5    —    — 14.90%
5–12    —    — 51.30%
13–17    —    — 34.00%
Gender      
Male 52.18% 46.50% 66.50%
Female 47.82% 53.50% 33.50%

NOTE: FRA = full retirement age; SSDI = Social Security Disability Insurance; SSI = Supplemental Security Income.

SOURCES: SSA, 2013a, Tables 19 and 20, 2013b, Table 19.

such as former employers, teachers, family, or acquaintances. After reviewing all of the evidence relevant to the claim, including medical evidence, the examiner makes a determination about what the evidence shows. In some situations, the examiner is unable to make a determination because the evidence in the case record is insufficient or inconsistent. In such cases, the examiner may ask the applicant to attend a consultative examination, which SSA purchases.1

SSA establishes the presence of a medically determinable impairment in individuals with mental disorders other than intellectual disability through the use of standard diagnostic criteria, which include symptoms and signs. Evidence for claims based on mental impairment, as well as for many other categories of claims, such as those for certain musculoskeletal and connective tissue conditions, relies less on standard laboratory tests than for some other categories of impairment. These impairments are established largely on reports of signs and symptoms of impairment and functional limitation.

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1 SSA guidelines for consultative examination reports are available (SSA, 2015).

Suggested Citation:"1 Introduction." Institute of Medicine. 2015. Psychological Testing in the Service of Disability Determination. Washington, DC: The National Academies Press. doi: 10.17226/21704.
×

TABLE 1-2 SSDI and SSI Beneficiaries by Diagnostic Category, 2012

Diagnostic Category SSDI Workers (%) SSI Adults—Disability (%) SSI Children (%)

Congenital anomalies

  0.20   0.81   5.40

Endocrine, nutritional, and metabolic diseases

  3.40   2.68   0.70

Infectious and parasitic diseases

  1.40   1.35   0.10

Injuries

  4.10   2.62   0.50

Intellectual disability

  4.20 19.15   9.60

Other mental disorder

27.60 38.41 57.90

Neoplasms

  3.10   1.33   1.20

Disease—Blood and blood forming organs

  0.30   0.40   1.10

Disease—Circulatory system

  8.40   4.26   0.50

Disease—Digestive system

  1.70   1.04   1.20

Disease—Genitourinary system

  1.70   1.02   0.30

Disease—Musculoskeletal system and connective tissue

29.80 12.78   0.80

Disease—Nervous system and sense organs

  9.30   7.68   7.80

Disease—Respiratory system

  2.90   2.04   2.80

Disease—Skin and subcutaneous tissue

  0.20   0.17   0.20

Other

  0.20   0.27   7.80

Unknown

  1.40   3.99   2.10

NOTE: SSDI = Social Security Disability Insurance; SSI = Supplemental Security Income.

SOURCES: SSA, 2013a, Table 21, 2013b, Tables 20, 35, 36.

SSA establishes the severity of functional limitations through a combination of self-reports on what an applicant can and cannot do in work and work-like settings and related reports from others. The consistency of such evidence with the evidence of signs, symptoms, and laboratory findings from other sources is what SSA uses to determine disability. Mental disorders other than intellectual disabilities and certain musculoskeletal system and connective tissue disorders together account for about 57 percent of SSDI claims, 41 percent of SSI adult claims, and 59 percent of SSI child claims (see Table 1-2) (SSA, 2013a, Table 21, 2013b, Tables 20, 35, 36).

SSA maintains a list of criteria2 for specific conditions that an applicant with one or more of those conditions must meet in order to receive disability benefits based solely on medical criteria. SSA currently requires psychological test results, specifically intelligence test results, in the listing criteria for intellectual disability in children and adults and in the criteria for cerebral palsy, convulsive epilepsy, and meningomyelocele and related

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2Disability evaluation under Social Security—Part III Listing of Impairments. http://www.ssa.gov/disability/professionals/bluebook/listing-impairments.htm (accessed October 3, 2014).

Suggested Citation:"1 Introduction." Institute of Medicine. 2015. Psychological Testing in the Service of Disability Determination. Washington, DC: The National Academies Press. doi: 10.17226/21704.
×

disorders. SSA questions the value of purchasing psychological testing in cases involving mental disorders, other than for intellectual disability, and it does not require testing either to establish or to assess the severity of other mental disorders.

Nevertheless, disability examiners and consultative examiners may request psychological testing, within the confines of the rules of each state’s Disability Determination Services (DDS), if they think the test results would inform the adjudication of an individual’s disability claim. Aside from the use of intelligence tests as described in the listings for intellectual disability and certain neurological impairments, SSA does not require or specify the purchase of any type of (or individual) psychological test. SSA provides general guidance that good psychological tests are valid and reliable and have appropriate normative data. Because each DDS issues its own rules regarding the tests that may be purchased, there is variation among states about when and which tests can be purchased.

When objective medical evidence cannot substantiate the credibility of an applicant’s statements about his or her symptoms (and their effects on his or her functioning), SSA rules require disability examiners to consider all of the evidence in the case record. Examiners are directed to consider:

  • The applicant’s medical history, diagnosis, and prescribed treatment;
  • The applicant’s daily activities and efforts to work;
  • Any other evidence showing how the applicant’s impairment(s) and any related symptoms affect his or her ability to work (or, for a child, his or her ability to function compared to that of other children the same age who do not have impairments); and
  • Any observations about the applicant recorded by SSA claims representatives during interview (in person or by telephone).3

Disability examiners are experts at assessing the consistency of all evidence and making a determination of its validity. As described more fully later in the chapter, there are two types of validity tests that might assist in this process. Performance validity tests (PVTs) provide information about an individual’s effort on cognitive and other performance-based tests. Symptom validity tests (SVTs) provide information about the consistency and accuracy of an individual’s self-report of symptoms he or she is experiencing. Both types of validity testing have generated controversy with respect to SSA policy.

There are differences of opinion on the use of validity tests and their value for work disability evaluations. SSA’s current position is not to

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3 See Social Security Ruling (SSR) on the Evaluation of Symptoms in Disability Claims: Assessing the Credibility of an Individual’s Statements (SSA, 1996).

Suggested Citation:"1 Introduction." Institute of Medicine. 2015. Psychological Testing in the Service of Disability Determination. Washington, DC: The National Academies Press. doi: 10.17226/21704.
×

purchase validity tests to address issues of credibility or malingering as part of a consultative examination. Although SSA does not purchase validity tests, claimants and their representatives sometimes submit them in support of their claims. Professional organizations of neuropsychologists and psychologists, such as the American Academy of Clinical Neuropsychology (AACN), the National Academy of Neuropsychology (NAN), the American Psychological Association (APA), the Association for Scientific Advancement in Psychological Injury and Law, and the British Psychological Society, have issued position statements and guidance advocating for the use of validity tests in clinical and medicolegal contexts (APA, 2013; British Psychological Society, 2009; Bush et al., 2005, 2014; Heilbronner et al., 2009). Two of these organizations, the AACN and the NAN, along with Division 40 (Neuropsychology) of the APA and the American Board of Professional Neuropsychology have challenged SSA’s institutional prohibition on ordering validity tests (IOPC, 2013). In addition, a September 2013 report from SSA’s Office of the Inspector General concluded that although SSA does not allow the purchase of validity tests, “medical literature, national neuropsychological organizations, other federal agencies, and private disability insurance providers support the use of [validity tests] in determining disability claims” (Office of the Inspector General, SSA, 2013, p. ii).

It is against this background that SSA asked the Institute of Medicine (IOM) to convene a committee of relevant experts to review selected psychological tests, including validity tests, and to provide guidance on the use of such testing in the adjudication of claims submitted to the SSA Disability Programs (see Box 1-1 for the statement of task). In carrying out this task, the Committee on Psychological Testing, Including Validity Testing, for Social Security Administration Disability Determinations was asked by the sponsor to address several specific topics, including testing norms, the administration of relevant tests and the qualifications for administering them, the interpretation and reporting of test results, and economic considerations relevant to the use of such tests for the disability evaluation process.4 The 11-member committee included experts in the areas of adult and pediatric neuropsychology, psychology, psychiatry, disability medicine, behavioral economics, and economics (see Appendix B).

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4 In the project background material, the sponsor asked the committee to consider topics such as the cost of administering these tests, whether the cost varies by location, and the cost effectiveness (including cost per claim) of requiring a single test or a combination of tests in the disability evaluation process for physical and mental impairments (Revised project background, submitted by Joanna Firmin, Social Security Administration, May 23, 2014).

Suggested Citation:"1 Introduction." Institute of Medicine. 2015. Psychological Testing in the Service of Disability Determination. Washington, DC: The National Academies Press. doi: 10.17226/21704.
×

BOX 1-1
Statement of Task

An ad hoc committee will:

  1. Perform a critical review of selected psychological tests, including symptom validity tests (SVTs), that could contribute to Social Security Administration (SSA) disability determinations;
  2. Provide guidance on the general relevance and applicability of psychological tests, including SVTs, in the context of other relevant evidence to SSA disability determinations in claims involving physical and mental disorders; and
  3. Provide guidance on how to use the results of psychological tests, including SVTs, in the context of disability determinations.

To accomplish these objectives, the committee shall consider the following topics: (1) use of psychological testing, (2) testing norms, (3) qualifications for administration of tests, (4) administration of tests, (5) reporting results, and (6) use of tests for the disability evaluation process.

COMMITTEE’S APPROACH TO ITS CHARGE

Terminology and Parameters of Study

Terminology that is fundamental to the committee’s report, including the concept of disability, a variety of psychological terms, and the concept of credibility, is described in the following sections. Appendix C of the report contains a glossary of definitions for a number of terms that are particularly relevant to the committee’s work.

Concept of Disability

SSA defines disability in adults as

The inability to engage in any substantial gainful activity … by reason of any medically determinable physical or mental impairment(s) which can be expected to result in death or which has lasted or can be expected to last for a continuous period of not less than 12 months. (SSA, n.d., see also 2012b)

Substantial gainful activity is work that “involves doing significant and productive physical or mental duties” and “is done (or intended) for pay

Suggested Citation:"1 Introduction." Institute of Medicine. 2015. Psychological Testing in the Service of Disability Determination. Washington, DC: The National Academies Press. doi: 10.17226/21704.
×

or profit” (20 CFR § 416.910). A medically determinable physical or mental impairment is defined as “an impairment that results from anatomical, physiological, or psychological abnormalities which can be shown by medically acceptable clinical and laboratory diagnostic techniques” (SSA, n.d.). Disability in children under 18 years of age is defined as

a medically determinable physical or mental impairment or combination of impairments that causes marked and severe functional limitations, and that can be expected to cause death or that has lasted or can be expected to last for a continuous period of not less than 12 months. (SSA, n.d., see also 2012b)

The concept of disability is complex and reflects the interplay between an individual with a mental or physical health condition and all aspects of his or her biology, behavior, and environment. The World Health Organization (WHO) developed the International Classification of Functioning, Disability and Health (ICF) framework (WHO, 2001) “using a global consensus-building process that involved multiple stakeholders, including people with disabilities” (IOM, 2007b, p. 37). Endorsed by the World Health Assembly in May 2001, the ICF is a part of the WHO’s family of International Classifications, which includes the International Statistical Classification of Diseases and Related Health Problems, 10th Revision (ICD-10) (IOM, 2007b, p. 37; WHO, 1992).

Consistent with previous disability frameworks, including those from prior IOM reports (IOM, 1991, 1997, 2007a) and Nagi (1965, 1976), “the ICF attempts to provide a comprehensive view of health-related states from a biological, personal, and social perspective” (IOM, 2007b, p. 37). Human functioning and disability are portrayed “as the product of a dynamic interaction between various health conditions and environmental and personal contextual factors” (IOM, 2007b, p. 37). The ICF framework differs from previous frameworks in that its components are described using both positive and negative terms (IOM, 2007b, p. 37) (see Box 1-2). Thus, it refers to health and functioning as well as disability.

As in the 1991 and 1997 IOM frameworks,

the ICF identifies multiple levels of human functioning and disability: at the level of body or body parts, at the level of the whole person, and at the level of the whole person who is functioning in his or her environment. These levels, in turn, involve three aspects of human functioning that the ICF terms body functions and structures, activities, and participation. (IOM, 2007b, pp. 37–38)

Within the ICF, the term disability is used to denote decrements in all three aspects of human functioning, which are labeled impairments, activity limitations, and participation restrictions (IOM, 2007b, p. 38). For the purposes of SSA, disability in adults refers to the inability to work at any

Suggested Citation:"1 Introduction." Institute of Medicine. 2015. Psychological Testing in the Service of Disability Determination. Washington, DC: The National Academies Press. doi: 10.17226/21704.
×

BOX 1-2
Major Concepts in the International Classification of
Functioning, Disability and Health

Health condition: Umbrella term for disease, disorder, injury, or trauma

Functioning: Umbrella term for body functions and structures, activities, and participation

Disability: Umbrella term for impairments, activity limitations, and participation restrictions

Body function: Physiological functions of body systems (including psychological functions)

Body structure: Anatomical parts of the body such as organs, limbs, and their components

Impairment: Problems in body function or structure such as a significant deviation or loss

Activity: Execution of a task or action by an individual

Activity limitations: Difficulties an individual may have in executing activities

Participation: Involvement in a life situation

Participation restriction: Problems an individual may experience in involvement in life situations

Environment: The physical, social, and attitudinal environment in which people live and conduct their lives

Personal factors: Contextual factors that relate to the individual such as age, gender, social status, and life experiences

SOURCE: WHO, 2001, pp. 10, 211–214. Reprinted from IOM, 2007b, p. 38.

job for a continuous period of 12 or more months. On this definition, disability refers to a participation restriction, namely, an inability to participate in work-related activity. Disability in children refers to “marked and severe functional limitations” relative to typically functioning peers of the same age.

Noteworthy is the dynamic interaction between the different components of the ICF model and various environmental (social and physical) and personal contextual (biological and behavioral) factors (see Figure 1-1) (IOM, 1991; WHO, 2001, p. 19). Movement among the components is mediated by these factors and may occur in either direction—disabling or enabling (IOM, 1991, 1997; WHO, 2001). Someone who lost a leg to disease or injury, for example, would then have a limitation with respect to walking, but that limitation might be reversed by the provision of a

Suggested Citation:"1 Introduction." Institute of Medicine. 2015. Psychological Testing in the Service of Disability Determination. Washington, DC: The National Academies Press. doi: 10.17226/21704.
×

image

FIGURE 1-1 ICF model of disability and functioning.

SOURCE: Adapted from WHO, 2001, p. 18.

prosthetic leg. Similarly whether an individual is disabled as a result of his or her functional or activity limitations depends on the accommodations available to the individual that permit the person to engage in activities he or she otherwise would be unable to perform (IOM, 1997).

For this reason, disability is not tightly correlated with the presence of impairment. Both need to be evaluated, but the measures are fundamentally different, including objective measures (performance and anatomical) and self-report measures that help determine how usual roles are disrupted. The linkages among an individual’s anatomy, diagnosis, and impairment are not sufficient to determine the presence of work disability. As the 2007 IOM report Improving the Social Security Disability Decision Process states with respect to work disability:

Work disability … results from the interaction of individuals’ impairments, functional limitations resulting from the impairments, assistive technologies to which they may have access, and attitudinal and other personal characteristics (such as age, education, skills, and work history) with the physical and mental requirements of potential jobs, accessibility of transportation, attitudes of family members and coworkers, and willingness of an employer to make accommodations. (IOM, 2007c, p. 26)

Given the complex interaction among the variety of factors that underlie a disability, it is clear that disability determinations are multidimensional and always involve some element of judgment (IOM, 1987). Although objective medical evidence can indicate the presence of physical or mental

Suggested Citation:"1 Introduction." Institute of Medicine. 2015. Psychological Testing in the Service of Disability Determination. Washington, DC: The National Academies Press. doi: 10.17226/21704.
×

impairments, the decision about whether those impairments result in a disability is an administrative or legal one (IOM, 1987; IOM and NRC, 2007).

Psychological Terms

Psychological assessment refers to

the comprehensive integration of information from a variety of sources—including formal psychological tests, informal tests and surveys, structured clinical interviews, interviews with others, school and/or medical records, and observational data—to make inferences regarding the mental or behavioral characteristics of an individual or to predict behavior. (Furr and Bacharach, 2013; Hubley and Zumbo, 2013)

Psychological testing refers to “the use of formal, standardized procedures for sampling behavior that ensure objective evaluation of the test-taker regardless of who administers the test” (Furr and Bacharach, 2013; Hubley and Zumbo, 2013).

Major categories of psychological tests include (1) intelligence tests, (2) neuropsychological tests, (3) personality tests, (4) disorder-specific tests (e.g., depression, anxiety), (5) achievement tests, (6) aptitude tests, and (7) occupational or interests tests. The first four categories capture the tests that are most relevant to disability determinations. Standardized psychological tests can be divided into measures of typical behavior and tests of maximal performance. Measures of typical behavior, such as personality, interests, values, and attitudes, may be referred to as non-cognitive measures. Tests of maximal performance ask people to answer questions and solve problems as well as they possibly can. Because tests of maximal performance typically involve cognitive performance, they are often referred to as cognitive tests. It is through these two lenses—non-cognitive measures and cognitive tests—that the committee examined psychological testing for the purpose of disability evaluation in this report. Intelligence tests and neuropsychological tests are examples of cognitive-based measures, while depression, anxiety, or personality inventories are examples of non-cognitive measures. Psychological tests may also be categorized as performance based and self-report. Cognitive tests tend to be performance based, and non-cognitive measures tend to be based on self-report.

A variety of validity tests have been developed to assist examiners in interpreting the results of different psychological tests. The committee distinguishes in this report between performance validity tests (PVTs), which provide information about an individual’s effort on tests of maximal performance, such as cognitive tests, and symptom validity tests (SVTs), which provide information about the consistency and accuracy of an individual’s self-report of symptoms he or she is experiencing. PVTs are stand-alone or

Suggested Citation:"1 Introduction." Institute of Medicine. 2015. Psychological Testing in the Service of Disability Determination. Washington, DC: The National Academies Press. doi: 10.17226/21704.
×

embedded or derived measures that are used to assess whether an examinee is performing at a level consistent with his or her actual abilities (Larrabee, 2014). Measures of performance validity, often referred to as “effort” in the literature, generally are associated with neuropsychological or cognitive testing. As discussed in Chapter 5, PVTs help the examiner to interpret the validity of an individual’s neuropsychological or cognitive test results. If an individual has not given his or her best effort in taking the test, the results may not provide an accurate picture of the person’s neuropsychological or cognitive functioning. SVTs are measures embedded in non-cognitive psychological measures (e.g., personality, mood scales) that are used to assess whether an examinee is providing an accurate report of his or her actual symptom experience (Larrabee, 2014).

The distinction between performance validity and symptom validity was first introduced in the literature in 2012 (Larrabee, 2012). Prior to that time, the term symptom validity often encompassed the concept of performance validity as well as the consistency and accuracy of symptom self-report. The committee has made every effort to maintain the distinction between performance validity and symptom validity and to use the terms consistently throughout the report. In some cases, doing so required interpreting published literature, particularly older literature, in light of the revised terminology. For this reason, the report, when appropriate, may refer to performance validity when discussing a particular publication, despite the original source using the term symptom validity.

Table 1-3 provides a summary of the psychological terms discussed in this section, and Figure 1-2 shows the relationships among the different terms.

Credibility

In situations involving the potential for secondary gain—such as monetary gain from a SSA disability payment—there may be motivation for individuals intentionally to feign or exaggerate symptoms or to exert suboptimal effort on performance measures in order to present a stronger need for support or disability benefits. Malingering is the intentional presentation of false or exaggerated symptoms, intentionally poor performance, or a combination of the two, motivated by external incentives (American Psychiatric Association, 2013; Bush et al., 2005; Heilbronner et al., 2009). Two key elements of malingering are intention to deceive or mislead and motivation to do so for the purpose of achieving some type of secondary gain.

It is important to distinguish between malingering and the credibility or noncredibility of an individual’s performance or symptom report, even in situations of potential secondary gain. Individuals might over- or under-report symptoms or not give their best effort on cognitive-based measures

Suggested Citation:"1 Introduction." Institute of Medicine. 2015. Psychological Testing in the Service of Disability Determination. Washington, DC: The National Academies Press. doi: 10.17226/21704.
×

TABLE 1-3 Definitions of Psychological Terms

Term Definition Description
Performance validity tests (PVTs) Stand-alone or embedded/ derived tests used to assess whether a test-taker is performing at a level consistent with his or her actual abilities

Assesses validity in tests of maximal performance, e.g., cognitive tests:

  • Intelligence testsa
  • Neuropsychological testsa
Psychological assessment “The comprehensive integration of information from a variety of sources—including formal psychological tests, informal tests and surveys, structured clinical interviews, interviews with others, school and/ or medical records, and observational data—to make inferences regarding the mental or behavioral characteristics of an individual or to predict behavior” (Furr and Bacharach, 2013; Hubley and Zumbo, 2013).  
Psychological tests Formal, standardized procedures for sampling behavior that ensure objective evaluation of the test-taker regardless of who administers the test

Major categories:

  • Non-cognitive
    • Personality testsa
    • Clinical/Diagnostic tests (e.g. depression, anxiety)a
    • Occupational or interest tests
  Can be divided into cognitive tests and non-cognitive measures
  • Cognitive
    • Intelligence testsa
    • Neuropsychological testsa
    • Achievement tests
    • Aptitude tests
Symptom validity tests (SVTs) Embedded in self-report psychological tests (e.g., personality, mood scales) and used to assess whether an examinee is providing an accurate report of actual symptom experience

Assesses validity in self-report measures, e.g., non-cognitive measures:

  • Personality testsa
  • Clinical/Diagnostic testsa

a Most relevant to disability determinations.

SOURCES: Bush et al., 2005; Furr and Bacharach, 2013; Hubley and Zumbo, 2013; Larrabee, 2014.

Suggested Citation:"1 Introduction." Institute of Medicine. 2015. Psychological Testing in the Service of Disability Determination. Washington, DC: The National Academies Press. doi: 10.17226/21704.
×

image

FIGURE 1-2 Components of psychological assessment.

NOTE: Performance validity tests do not measure cognition but are used in conjunction with performance-based cognitive tests to examine whether the examinee is exerting sufficient effort to perform well and responding to the best of his or her capability. Similarly, symptom validity tests do not measure non-cognitive status but are used to examine whether a person is providing an accurate report of his or her actual symptom experience. Because cognitive tests frequently are performance based and non-cognitive measures generally involve self-report, performance validity tests and symptom validity tests are shown as being associated with these types of tests.

for any number of reasons. SVTs and PVTs do not in themselves provide information about the motivations of an examinee5 or the reasons why his or her performance or symptom report may appear to be noncredible. Throughout the report, the committee has avoided use of the term malingering when discussing the results of PVTs and SVTs, opting instead to refer to the credibility or accuracy of an individual’s performance or symptom report. The committee intends such terms to be value-neutral with respect to the examinee, referring only to whether the examinee exerted sufficient effort for the test results to be considered valid and to the consistency and accuracy of the individual’s statements about the experience of symptoms.

_____________

5 Although below chance scores on a PVT can speak to an examinee’s intention—the individual knew the answer and deliberately chose the wrong one—they cannot speak directly to the individual’s motivation (reason) for intentionally choosing the wrong answer.

Suggested Citation:"1 Introduction." Institute of Medicine. 2015. Psychological Testing in the Service of Disability Determination. Washington, DC: The National Academies Press. doi: 10.17226/21704.
×

Study Focus

Although the report focuses primarily on the use of psychological tests in disability determinations in adults, the use of such tests in children is also addressed. There are three areas in SSA’s disability determination process where psychological testing could be of value: (1) identification of a “medically determinable impairment,” (2) evaluation of functional capacity for work, and (3) assessment of the validity of claimants’ psychological test results or the accuracy of statements about self-reported symptoms. Although the report addresses all three areas, the committee focuses on the second and the third, where questions about the use of psychological tests are more complex.

In considering its task, the committee observed that the vast number (in the hundreds) of cognitive and non-cognitive psychological tests available for use precludes a detailed analysis of each specific test and recommendations about the use of specific tests. In addition, decisions about which specific tests are most appropriate for particular individuals in a particular set of circumstances properly fall in the realm of clinical decision making. Instead, the committee reviewed categories of psychological tests, including validity tests, and this report provides general guidance on the use of such tests in SSA disability determinations for claims involving physical and mental disorders.

It is important to note that SSA specifically requested that the committee not address the use of intelligence tests in making determinations about intellectual disability since that topic was previously examined in a 2002 National Research Council (NRC) report titled Mental Retardation: Determining Eligibility for Social Security Benefits (NRC, 2002). Consideration of intelligence tests with respect to embedded validity measures, however, was deemed to be within the committee’s purview.

Information-Gathering Process

The committee conducted an extensive review of the literature pertaining to the use of psychological tests, including PVTs and SVTs, in disability determinations. The committee began with an English-language literature search of online databases, including PubMed, Embase, Medline, Web of Science, Scopus, PsychINFO, Government Accountability Office (GAO), Congressional Research Service, Google, Google Scholar, and Legistorm (GAO reports, congressional memorandums). Additional literature and other resources were identified by committee members and project staff using traditional academic research methods and online searches. Attention was given to consensus and position statements issued by relevant experts and professional organizations.

The committee used a variety of sources to supplement its review of the literature. It met in person five times and held two public workshops to hear

Suggested Citation:"1 Introduction." Institute of Medicine. 2015. Psychological Testing in the Service of Disability Determination. Washington, DC: The National Academies Press. doi: 10.17226/21704.
×

from invited experts in areas pertinent to the topic (see Appendix A for the open session agendas and speaker lists). Speakers included neuropsychologists with expertise in performance and symptom validity testing in adults and children, the use of psychological and validity tests in culturally diverse populations, and the use of such tests in non-SSA disability determination contexts (e.g., private disability insurance programs, Canadian auto insurance, U.S. military disability or return-to-duty decisions, veterans’ disability compensation). The committee also heard from SSA and DDS representatives about the SSA disability determination process and its current policies surrounding the use of psychological and validity testing.

In addition, the committee commissioned two papers to provide additional critical analysis in areas relevant to the committee’s work. One paper addresses issues of diversity (e.g., in terms of culture, language, gender and gender identity, educational or socioeconomic status) and multiculturalism in the use of psychological tests (self-report measures and performance-based cognitive tests as well as corresponding validity tests) in making disability determinations. The authors were asked to discuss the use of psychological tests in diverse populations in terms of their validity, fairness, and other characteristics. They also were asked to address whether, when, and/or how to use such measures, despite any limitations, in disability determinations for diverse populations in the United States.

Based on its review of the literature, the presentations from invited experts on PVT and SVT research at its open sessions, and the expertise of several of its members, the committee understood the arguments and evidence supporting the inclusion of validity tests in psychological and neuropsychological tests and test batteries. Because the committee found very little published literature critiquing the use of SVTs and PVTs, they felt it was important to seek more information about potential concerns or questions pertaining to their use. To this end, they commissioned a second paper and asked the author to address a number of questions designed to probe any challenges or cautions about the use of validity tests for disability determinations in different populations. The questions posed by the committee included the following:

  • For whom are PVTs and SVTs useful for informing disability determinations? In what way?
  • How or in what way do the results of PVTs or SVTs correlate with assessing functional limitations (such as limitations in a person’s ability to do basic work activities, activities of daily living, social functioning, and concentration, persistence, or pace) due to an impairment?
  • Given the historical context in which PVTs and SVTs were developed for forensic use in litigation settings, can they be adapted for
Suggested Citation:"1 Introduction." Institute of Medicine. 2015. Psychological Testing in the Service of Disability Determination. Washington, DC: The National Academies Press. doi: 10.17226/21704.
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  • use in disability determinations? Discuss the transferability of PVTs and SVTs given the differences in evidence use and decision making among fields (legal versus mediated or negotiated).

  • How should one interpret validity test scores or results in the “grey area” between clear failures (e.g., below chance scores) and clear passes on SVTs or PVTs? How many people fail completely versus at the margins?
  • When interpreting PVT or SVT failures, particularly in the “grey zone,” are there factors aside from malingering or intentionally poor performance that may explain the results (e.g., stems from symptoms, fatigue, apathy)?
  • How does the current norming of SVTs and PVTs affect their usefulness in a variety of different populations (e.g., a diversity of race, ethnicity, culture, and educational or socioeconomic status)? Are there ways to resolve or mitigate the challenges posed by lack of norming for particular populations?

The committee’s work was further informed by previous IOM and NRC reports, including Pain and Disability: Clinical, Behavioral, and Public Policy Perspectives (IOM, 1987); Disability in America: Toward a National Agenda for Prevention (IOM, 1991); Enabling America: Assessing the Role of Rehabilitation Science and Engineering (IOM, 1997); PTSD Compensation and Military Service (IOM and NRC, 2007); The Future of Disability in America (IOM, 2007b); Improving the Social Security Disability Decision Process (IOM, 2007c); A 21st Century System for Evaluating Veterans for Disability Benefits (IOM, 2007a); Mental Retardation: Determining Eligibility for Social Security Benefits (NRC, 2002); and Survey Measurement of Work Disability: Summary of a Workshop (NRC, 2000).

REPORT ORGANIZATION

Chapter 2 describes the current SSA disability determination process, focusing on areas relevant to the use of psychological tests. It also discusses the use of psychological tests in disability evaluations in non-SSA contexts. Chapter 3 provides an overview of psychological tests, including the different types of tests and their use, psychometrics and norms, and the administration of tests. Chapter 4 reviews the use of standardized psychological self-report measures and SVTs in the context of SSA disability determinations. Chapter 5 addresses standardized cognitive tests and the use of PVTs. Chapter 6 explores economic considerations related to the use of psychological testing in SSA disability determinations. Chapter 7 contains the committee’s conclusions and recommendations.

Suggested Citation:"1 Introduction." Institute of Medicine. 2015. Psychological Testing in the Service of Disability Determination. Washington, DC: The National Academies Press. doi: 10.17226/21704.
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REFERENCES

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APA (American Psychological Association). 2013. Specialty guidelines for forensic psychology. American Psychologist 68(1):7-19.

British Psychological Society. 2009. Assessment of effort in clinical testing of cognitive functioning for adults. Leicester, UK: British Psychological Society.

Bush, S. S., R. M. Ruff, A. I. Tröster, J. T. Barth, S. P. Koffler, N. H. Pliskin, C. R. Reynolds, and C. H. Silver. 2005. Symptom validity assessment: Practice issues and medical necessity. NAN Policy & Planning Committee. Archives of Clinical Neuropsychology 20(4):419-426.

Bush, S. S., R. L. Heilbronner, and R. M. Ruff. 2014. Psychological assessment of symptom and performance validity, response bias, and malingering: Official position of the Association for Scientific Advancement in Psychological Injury and Law. Psychological Injury and Law 7(3):197-205.

Furr, R. M., and V. R. Bacharach. 2013. Psychometrics: An introduction. Thousand Oaks, CA: Sage Publications, Inc.

Heilbronner, R. L., J. J. Sweet, J. E. Morgan, G. J. Larrabee, S. R. Millis, and Conference Participants. 2009. American Academy of Clinical Neuropsychology consensus conference statement on the neuropsychological assessment of effort, response bias, and malingering. The Clinical Neuropsychologist 23(7):1093-1129.

Hubley, A. M., and B. D. Zumbo. 2013. Psychometric characteristics of assessment procedures: An overview. In APA handbook of testing and assessment in psychology, Volume 1—Test theory and testing and assessment in industrial and organizational psychology, edited by K. F. Geisinger, N. R. Kuncel, S. P. Reise, M. C. Rodriguez. Washington, DC: American Psychological Association.

IOM (Institute of Medicine). 1987. Pain and disability: Clinical, behavioral, and public policy perspectives. Washington, DC: National Academy Press.

IOM. 1991. Disability in America: Toward a national agenda for prevention. Washington, DC: National Academy Press.

IOM. 1997. Enabling America: Assessing the role of rehabilitation science and engineering. Washington, DC: National Academy Press.

IOM. 2007a. A 21st century system for evaluating veterans for disability benefits. Washington, DC: The National Academies Press.

IOM. 2007b. The future of disability in America. Washington, DC: The National Academies Press.

IOM. 2007c. Improving the social security disability decision process. Washington, DC: The National Academies Press.

IOM and NRC (National Research Council). 2007. PTSD compensation and military service. Washington, DC: The National Academies Press.

IOPC (Inter Organizational Practice Committee). 2013. Use of symptom validity indicators in SSA psychological and neuropsychological evaluations. Letter to Senator Tom Coburn. https://www.nanonline.org/docs/PAIC/PDFs/SSA%20and%20Symptom%20Validity%20Tests%20-%20IOPC%20letter%20to%20Sen%20Coburn%20-%202-11-13.pdf (accessed February 8, 2015).

Larrabee, G. J. 2012. Performance validity and symptom validity in neuropsychological assessment. Journal of the International Neuropsychological Society 18(4):625-630.

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Larrabee, G. J. 2014. Performance and symptom validity. Presentation to the IOM Committee on Psychological Testing, Including Validity Testing, for Social Security Administration Disability Determinations, June 25, 2014, Washington, DC.

Nagi, S. Z. 1965. Some conceptual issues in disability and rehabilitation. In Sociology and rehabilitation, edited by M. B. Sussman. Washington, DC: American Sociological Association. Pp. 100-113.

Nagi, S. Z. 1976. An epidemiology of disability among adults in the United States. Milbank Memorial Fund Quarterly Health and Society 54(4):439-467.

NRC (National Research Council). 2000. Survey measurement of work disability: Summary of a workshop. Washington, DC: National Academy Press

NRC. 2002. Mental retardation: Determining eligibility for social security benefits. Washington, DC: The National Academies Press.

Office of the Inspector General, SSA (Social Security Administration). 2013. The Social Security Administrations policy on symptom validity tests in determining disability claims. Washington, DC: SSA. http://oig.ssa.gov/sites/default/files/audit/full/pdf/A-08-13-23094. pdf (accessed March 27, 2015).

SSA (Social Security Administration). 1996. SSR 96-7p: Policy interpretation ruling Titles II and XVI: Evaluation of symptoms in disability claims: Assessing the credibility of an individuals statements. http://www.socialsecurity.gov/OP_Home/rulings/di/01/SSR9607-di-01.html (accessed October 3, 2014).

SSA. 2012a. DI 00115.001 Social Security Administration’s (SSA) disability programs. Program Operations Manual System (POMS). https://secure.ssa.gov/poms.nsf/lnx/0400115001 (accessed October 2, 2014).

SSA. 2012b. DI 00115.015 Definitions of disability. Program Operations Manual System (POMS). https://secure.ssa.gov/poms.nsf/lnx/0400115015 (accessed October 3, 2014).

SSA. 2013a. Annual statistical report on the Social Security Disability Insurance program, 2012. http://www.socialsecurity.gov/policy/docs/statcomps/di_asr/2012/index.html (accessed September 26, 2014).

SSA. 2013b. SSI annual statistical report, 2012. http://www.socialsecurity.gov/policy/docs/statcomps/ssi_asr/2012/index.html (accessed September 26, 2014).

SSA. 2015. DI 22510.000 Development of consultative examinations (CE). Program Operations Manual System (POMS). https://secure.ssa.gov/apps10/poms.nsf/lnx/0422510000 (accessed January 27, 2015).

SSA. n.d. Disability evaluation under social security; Part I—General information. http://www.ssa.gov/disability/professionals/bluebook/general-info.htm (accessed November 14, 2014).

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The United States Social Security Administration (SSA) administers two disability programs: Social Security Disability Insurance (SSDI), for disabled individuals, and their dependent family members, who have worked and contributed to the Social Security trust funds, and Supplemental Security Income (SSSI), which is a means-tested program based on income and financial assets for adults aged 65 years or older and disabled adults and children. Both programs require that claimants have a disability and meet specific medical criteria in order to qualify for benefits. SSA establishes the presence of a medically-determined impairment in individuals with mental disorders other than intellectual disability through the use of standard diagnostic criteria, which include symptoms and signs. These impairments are established largely on reports of signs and symptoms of impairment and functional limitation.

Psychological Testing in the Service of Disability Determination considers the use of psychological tests in evaluating disability claims submitted to the SSA. This report critically reviews selected psychological tests, including symptom validity tests, that could contribute to SSA disability determinations. The report discusses the possible uses of such tests and their contribution to disability determinations. Psychological Testing in the Service of Disability Determination discusses testing norms, qualifications for administration of tests, administration of tests, and reporting results. The recommendations of this report will help SSA improve the consistency and accuracy of disability determination in certain cases.

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