Psychological assessment is an important aspect in the diagnosis and treatment of psychiatric conditions. The focus of this article is to describe how the Personality Assessment Inventory- Adolescent (PAI-A) can be integrated into psychological assessment and treatment planning. The PAI-A is a self-report measure used to assess psychopathology, interpersonal styles (e.g., warmth or dominance), and treatment related issues (e.g., stress, treatment rejection). The author also presents a clinical case example of an adolescent patient diagnosed with Attention Deficit Hyperactivity Disorder and Mood Disorder to demonstrate the clinical utility of the PAI-A.

Turner EA (2014) Use of the PAI-A in the Diagnosis and Treatment of Psychiatric Disorders: A Clinical Application. Ann Psychiatry Ment Health 2(1): 1007.

•    Assessment
•    Adolescents
•    Psychiatric treatment
•    PAI-A
•    Personality assessment

Psychological assessment is an important part of psychiatric diagnosis and treatment. In clinical practice, assessment has many purposes: to determine whether there is a problem (i.e., to differentiate normal and aberrant behavior), to delineate the individual’s strengths and weakness, to predict future behavior or course of the disorder, to classify the problem, and to provide guidelines for intervention [1]. Some scholars have emphasized that in the current mental health system mental health professionals face a challenge of providing effective treatment and delivering treatment in a time-limited manner [2,3]. Psychological assessment may provide one potential benefit to mental health professionals who provide services to adolescents and their families. According to Quirk and colleagues [3], in the age of managed mental health care, psychological assessment may contribute to behavioral health care’s capacity to provide positive payoffs such as reduced medical cost and improved treatment outcomes. However, insurance companies often prevent psychologists from incorporating lengthy assessments into the treatment process. Although this isn’t the scope of this article, billing issues unfortunately impact the treatment process in many ways. In order to survive in the era of managed mental health care, psychologist (specifically) must market themselves on the basic of the clinical utility of a comprehensive assessment within psychological practice [3].

Tiegreen and colleagues [4] describe psychological assessment as “a tool for clinicians to gather information from clients”. The most widely used assessment measures among adolescents to screen for psychopathology and personality characteristics are the Minnesota Multiphasic Personality Inventory – Adolescent (MMPI-A) [5], the Millon Clinical Multiaxial Inventory (MACI) [6], and the Adolescent Psychopathology Scale (APS) [7]. More recently, the Personality Assessment Inventory – Adolescent (PAI-A) [8] was developed as a comparable measure to examine adolescent behavior and psychopathology. The PAI-A reflects advances in test-construction methods and measures unique areas relative to the above mentioned [2].

The PAI-A is a self-report measure used to assess psychopathology, interpersonal styles, and treatment related issues [8]. The PAI-A is an extension of the adult version, the Personality Assessment Inventory (PAI) [9]. The PAI-A was standardized using a community sample of 707 adolescents ages 12-18 who were attending junior high, high school, or college; and a clinical sample of 1,160 adolescents who were being treated in clinical or correctional settings (see Morey [8] for complete details related to test development). The PAI-A, similar to the parent measure (the PAI), is intended to reflect clinical constructs that are important in diagnosis of psychiatric disorders. The measure includes 264-items that are rated on a 4-point Likert scale ranging from “not at all true” and “slightly true” to “mainly true” and “very true”. The PAI-A contains 22 non-overlapping scales: 4 validity scales, 11 clinical scales, 5 treatment consideration scales, and 2 interpersonal scales. See Table 1 for a brief description of the PAI-A clinical scales and subscales.

Although the PAI-A is a fairly recent assessment instrument, the parent measure (i.e., PAI) has shown considerable clinical utility. Extensive research has been conducted with the PAI demonstrating the validity and clinical utility in numerous groups such as veterans with chronic pain [10], traumatic brain injury patients [11], psychiatric populations [12], college students [13], and rural populations [14]. Emerging research using the PAI-A provides promising finding for the use of the measure in diagnosis and treatment of adolescents [15,16]. A recent study examined PAI-A indicators of response distortion among adolescents instructed to fake having a diagnosis of Attention-Deficit Hyperactivity Disorder (ADHD) [15]. Overall, the study indicated that participants who feigned ADHD tended to report more psychopathology across diverse areas than those actually receiving an ADHD diagnosis.

Table 1: PAI-A Clinical Scales and Subscales.

The following description presents an actual patient that received outpatient psychotherapy provided by the author (referred to as the clinician throughout the remainder of this section). The patient’s name and personal information has been removed to maintain confidentiality. The PAI-A data was obtained through an assessment that was completed to assist the clinician with treatment planning.

Background information and presenting concerns

John is 13-year old Caucasian male referred by his legal guardians for treatment to address concerns with oppositional/ rule-breaking behavior, and mood dysregulation (e.g., irritability and depressed mood). At the time of the referral, John was not receiving outpatient psychotherapy and had not attended therapy for approximately a year. However, he was prescribed medications (methylphenidate and oxcarbazepine) to manage his symptoms. John presented with a diagnosis of Attention-Deficit Hyperactivity Disorder (ADHD) and Mood Disorder, NOS (based on DSM-IV-TR criteria). He previously attended therapy for about 5-months and did not have any history of inpatient hospitalization. The PAI-A was administered at the second appointment and procedures were followed consistent with a therapeutic assessment approach for test administration [17,18]. Prior to the administration, the patient provided the clinician with several questions he wanted to answer from the assessment (these questions will not be discussed in this article due to the clinical nature). Following the test administration, the clinician provided feedback at the next therapy session with the patient and his parents to discuss the results as described below.

PAI-A results and clinical interpretation

Before determining whether a PAI-A profile can be interpreted, the item responses should be inspected for missing items. Per the PAI-A manual [8], profiles should not be interpreted if 14 or more items were omitted by the respondent. Of note, John did not omit any item responses. Subsequently, the PAI-A validity scales are examined for elevated scores. In general, the interpretation manual states that validity scale scores more than 2 SD above the mean suggest serious attempts by the respondent to distort the profile. All PAI-A scales and subscales have a mean score of 50T and standard deviation of 10T. Per the PAI-A manual [8], scores greater than 50T suggest that the respondent endorsed items to a greater extent than typical for his/her age group. In clinical decision making, it is important to note the importance of these problems confronting the respondent [8]. According to Morey [8], in clinical settings the majority of adolescents will score below the “clinical skyline” [provided on the PAI-A profile form]; any score that approaches or exceeds the skyline represents a marked elevation. Furthermore, scores do not need to be greater than 70T to warrant clinical attention. Given the nature of this article, readers are referred to the PAI-A manual [8] for a complete description of the interpretation guidelines. Tables 2 and 3 present the PAI-A results for John.

On the PAI-A, John’s validity profile (ICN, INF, NIM, and PIM scales) suggested that he attended to the item content; and responded in a candid and forthcoming manner. Furthermore, he did not attempt to overly present himself in a negative or positive light. Validity scale T scores ranged from 47T to 55T. Given John’s scores on the validity scales, there are no problems with interpreting the PAI-A profile.

On the PAI-A clinical scales, John’s profile revealed no elevations above the clinical skyline that would indicate the presence of clinical psychopathology in the areas that are tapped by the individual clinical scales. The interpretation in this section is based on subscale scores given full-scale scores were below 60T. Based on interpretation of John’s scores, he reported some preoccupation with physical symptoms and bodily complaints (elevated SOM-H); it is possible that he may express his psychological distress through somatic symptoms. John reported high perceived stress, a great deal of tension, and having difficulty relaxing (elevated ANX-A). He appears to have a tendency to be impulsive and his impulsive behaviors may interfere with interpersonal problems and school functioning (elevated BOR-S). As a result of his desire for excitement and stimulation, John may often become easily bored by routine activities (elevated ANT-S). Furthermore, John’s profile suggests that he tends to be egocentric and have little regard for others. Although he may feel guilt over past misbehaviors, he may feel little long standing remorse (elevated ANT-E). On the treatment consideration scales, John’s NON score suggests that he generally feels his family is a source of social support. However, he may have few close interpersonal relationships. Finally, John’s RXR score suggests that he acknowledges the need to make changes and reports having a generally positive attitude towards making personal change. Given the patient’s diagnosis of ADHD and Mood Disorder, the patient’s PAI-A profile appears to explain some of his classic symptoms such as concentration difficulties, stimulus seeking, irritability, and impulsive behavior.

Future directions for research and practice

The current article describes the clinical utility of the PAI-A in the diagnosis and treatment of psychiatric disorders in adolescents. To date, limited research on the PAI-A exists to demonstrate its external validity and use in clinical settings. However, promising findings on the PAI-A has shown its potential to improve the diagnosis and treatment of psychiatric conditions [16,17]. Given the limited research available on the PAI-A, future studies should examine the validity of the measure in both community and clinical samples. For example, Farwell [19] completed a literature review on PAI-A scales that may describe adolescent male behavior in forensic populations and reported that forensic adolescent males tended to score higher on PAI scales measuring aggression, alcohol and drug use, and antisocial behaviors. However, this has not been empirically studied using the PAI-A. Given the vast amount of research on the parent measures (PAI), there are endless possibilities to develop research examining the use of the PAI-A in a variety of settings and populations.

In clinical practice, good treatment begins with a thorough assessment. The PAI-A can provide clinicians with an opportunity to obtain important information to assist with treatment and examine potential risk behaviors (e.g., substance use, suicidal ideation, and aggression). As noted in the case example, the patient’s PAI-A profile not only allowed the clinician to assess the patient’s level of insight but also provided a gauge for the level of social support and interest in the therapy process. Furthermore, it has been noted that the PAI-A has several advantages compared to comparable measures such as improved test development (combines rational, empirical, and statistical approaches), minimal demands on reading ability, and administration time is typical to an actual clinical session [2]. Although the PAI-A has limited independent research available, the research on the PAI bodes well for PAI-A utility given its downward extension from the parent measure.

Table 2: PAI-A Clinical Scale and Subscale Scores for John.

Table 3: PAI-A Treatment Consideration and Interpersonal Scale Scores for John.

The author would like to thank the family of the child described in this article for graciously allowing their information to be presented as a case example.

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