Minnesota Multiphasic
changes. For the most part, this is the first scale with item content that is distinctive from the first three.
Scale 5, Mf Masculinity-Femininity. This scale was originally developed on a sam- ple of adult men, described by Hathaway (1956) as “male sexual inverts” (Butcher et al., 1992). Presumably, males with high scores are more feminine, and women with clinically significant scores are thought to have more masculine interests. Item con- tent includes topics such as lack of inter- est in mechanics magazines, reluctance to incriminate oneself, a desire to be of the opposite gender, interest in love stories and poetry, sensitive feelings, lack of inter- est in forest ranger work, being a soldier or hunter, expressing the need to argue to make a point, attending few parties, dislike for wagering, interest in gardening and cooking, maintaining a diary, fear of snakes, worry, and talks about sex. This scale is, to say the least, unique, and, by most current understanding, out of step with the times.
Therefore, it is not particularly useful for clinical interpretation.
Scale 6, Pa: Paranoia. This scale is designed to assess paranoid symptoma- tology. The scale includes item content such as feelings of persecution, having evil thoughts, feeling misunderstood, emotional lability, feeling possessed by evil spirits, unhappiness, sensation seek- ing, distrust of others, crying easily, feel- ing as though one is being followed or poisoned by someone, ideas of reference, and history of legal trouble.
Scale 7, Pt: Psychasthenia. This scale assesses anxiety, particularly a tendency to worry obsessively. The item content of Scale 7 includes health worries, loss of inter- est in activities, having shameful thoughts, emotional lability, poor concentration, fatigue, unhappiness, low self-esteem, feelings of regret, guilt, impaired reading comprehension, impaired memory, worry, restlessness, excitability, fear of speaking in front of others, being easily embarrassed,
impatience, counting unimportant things, rumination, and overreaction to failure.
This scale has many items in common with scales 2, 3, and 8.
Scale 8, Sc: Schizophrenia. This scale was designed to identify patients with diagno- ses of various forms of psychosis (Butcher et al., 1992). Scale 8 items sample content such as lack of interest in daily activities, having unwanted thoughts, desire to leave home, poor concentration, bizarre experiences, stealing, feelings of persecution, avoidance of others, day-dreaming, muscle twitching, urges to do something socially unaccept- able, changes in speech pattern, decreased reading comprehension, impaired mem- ory, blackout spells, fear of losing control, impaired balance, restlessness, difficulty initiating activity, excitability, numbness, de-creased taste sensitivity, sexual preoc- cupations, impaired relationships with par- ents and other family members, loneliness, lack of intimacy, impatience, and feelings of unreality. This scale shares many items with scales 2, 3, and 7. It is a long scale with 77 items, making item overlap with other scales a central characteristic. Its high cor- relations with other scales are discussed in a later section. Some of the items that dif- ferentiate this scale from others have to do with impaired social relationships and poor reality contact.
Scale 9, Ma: Hypomania. This scale assesses a tendency toward excitability and includes items assessing tension, desire to leave home, crying spells, urges to do some- thing socially unacceptable, indecision, sensation seeking, racing thoughts, feel- ings of persecution, lack of fear of heights, blackout spells, occasional ability to make decisions very easily, self-righteousness, restlessness, satisfaction with personal appearance, sweatiness, excitability, exces- sive thirst, and admiration for cleverness even if it is criminal.
Scale 10, Si: Social Introversion. Si score elevations are produced by content such as failure to face crises or problems, poor
concentration, poor sociability, unhap- piness, fear of ridicule, lack of interest in parties, easily losing arguments, low sen- sation seeking, change in speech pattern, distrust of others, indecision, shyness, dif- ficulty with small talk, brooding, concerns about personal appearance, embarrassment in front of groups, failure to initiate con- versation, difficulty making friends, lone- liness, envy of others’ successes, and low self-esteem.
Content scales are a relatively unique feature of the MMPI that were developed differently from the original clinical scales.
Whereas empirical approaches, includ- ing empirical criterion keying, were used for the development of the original scales, content scales depend more on a rational/
theoretical approach to test development (Williams et al., 1992) in which scale con- tent considers both empirical factor load- ings and homogeneity of content within scales.
The first step in the content scale devel- opment process was to select 22 content categories based on a review of the adult experimental version (the predecessor to the MMPI-2). In the second step, a total of three raters assigned items from the adult experimental form to the 22 categories (Williams et al., 1992). A group consensus was reached on the assignments, and some items were discarded. A total of 21 content scales remained after this step. In the next step, correlations and reliability indices were used to enhance the reliability and homogeneity of each scale. The fourth stage involved another “rational review”
of the items in response to the aforemen- tioned statistical data. Some scales were renamed and some dropped at this stage.
In the fifth and final step, items that cor- related higher with a scale of which they were not a member were removed. The result was 15 MMPI-2 content scales for the adult measure (Williams et al., 1992).
These same procedures were applied to the development of the MMPI-A content
scales, with the MMPI-2 content scales serving as the foundation. Items were added and removed, and some new scales were developed (Williams et al., 1992).
This step resulted in the retention of the majority of the MMPI-2 content scales for adolescents and the addition of three scales- Alienation, Low Aspirations, and School Problems. Descriptions of the MMPI-A content scales are shown in Table 6.6.
There are also six supplementary scales on the MMPI-A (Butcher et al., 1992):
Anxiety (A): distress, discomfort, con- formity, being upset by social situations.
Repression (R): tendency toward sub- missiveness and conventionality, avoidance of conflict
MAC-R, MacAndrew Alcoholism Scale-Revised: substance abuse problems, willingness to take risks, extraversion
Alcohol/Drug Problem Acknowledge- ment(ACK): items that directly refer to drug and alcohol use
Alcohol/Drug Problem Proneness (PRO): stimulus seeking, negative peer group influence, rule-breaking, negative attitudes toward achievement
Immaturity (IMM): orientation to the present instead of future, lack of insight, hostility, self-centeredness
Administration and Scoring
The MMPI-A is unusually long (i.e., 478 items) compared to other self-report inventories designed for children and ado- lescents, which calls for special adminis- tration guidelines. In total, the MMPI-A takes approximately 90 min to administer, and some adolescents may have to take the test in more than one session (Butcher et al., 1992). Furthermore, because many adolescents require supervision during the administration of these scales, con- siderably more examiner time may be required. Substantial administration time savings, however, can be gained by using
a computerized adaptive administration format (Forhey, Handel, & Ben-Porath, 2000). In fact, time savings of 50–123 items may be possible, with research sug- gesting no significant differences in aver- age scale scores or in the distributions of scale scores (Hays & McCallum, 2005).
Checks on the adolescent’s reading comprehension level are also required.
Readability analyses of individual items show readability at approximately the fifth to sixth grade level in most cases. However, when in doubt, an examiner may ask the child to read some items aloud to get some sense of the child’s ability to comprehend the item content. The validity checks pro- vide another useful alert to possible read- ability problems.
Table 6.6 MMPI-A Content Scales
Scale Description
Anxiety (A-anx) Includes excessive worry, problems sleeping, problems concentrating, tension
Obsessiveness (A-obs) Unreasonable worry, rumination, difficulty making deci- sions, reports that others are impatient with them, regret Depression (A-dep) Includes frequent crying, fatigue, self-deprecating
thoughts, hopelessness
Health Concerns (A-hea) Physical complaints including nausea, dizziness, constipa- tion, difficulty hearing, headaches
Alienation (A-aln) Feeling disliked and misunderstood by others, feeling that others are out to get them, preferring to be alone
Bizarre Mentation (A-biz) Strange thoughts and experiences, hallucinations, paranoia Anger (A-ang) Starting fights, cursing, destroying things, irritability,
impatience with others
Cynicism (A-cyn) Mistrust of others, feeling that others are unfair, feeling that
others are jealous
Conduct Problems (A-con) Stealing, lying, disobeying rules, shoplifting, being disre- spectful toward others
Low self-esteem (A-lse) Feeling unattractive, lacking self-confidence, feelings of uselessness
Low Aspirations (A-las) Dislike of studying and reading, giving up quickly, dif- ficulty starting tasks
Social Discomfort (A-sod) Shyness, avoidance of others, dislike of crowds or social gatherings
Family Problems (A-fam) Family discord, feeling that one cannot depend on family members, jealousy, limited family communication School Problems (A-sch) Poor grades, negative attitudes toward teachers, suspen-
sions, truancy, belief that school is a waste of time.
Negative Treatment Indicators (A-trt) Negative attitudes toward doctors and mental health professionals, feeling that faults and bad habits cannot be overcome, unwillingness to face problems
From Butcher et al. (1992).
Validity Scales
The MMPI series has a long tradition of the use of validity indexes which is reflected in the adolescent version. Brief descrip- tions of the validity scales follow (Butcher et al., 1992):
Cannot Say (?). This scale is comprised of the total number of items that the respon- dent either failed to answer or endorsed as both true and false. If there are a large number of items fitting this description, the clinician should attempt to ascertain the reason (e.g., carelessness, discomfort, difficulty with comprehension, defiance).
LIE (L). This scale is intended to detect naive attempts by adolescents to put them- selves in an overly favorable light.
F, Fl, and F2 (Infrequency). The F scale is the antithesis of the L scale in that it assesses the tendency of individuals to place themselves in an unfavorable light, or “fake bad.” Items were selected for this scale if they were endorsed in their deviant direction by less than 20% of the norma- tive sample.
K (Defensiveness). According to Butcher et al. (1992), “This scale was designed originally to identify adults in psychiatric settings who displayed significant degrees of psychopathology, but produced profiles that were within normal limits” (Meehl
& Hathaway, 1946, p. 40). Butcher et al.
(1992), however, suggest that an MMPI-A profile should not be invalidated solely on the basis of an elevated K score, particu- larly if used with individuals who are not in a restrictive mental health or psychiatric setting.
VRIN (Variable Response Inconsistency).
The VRN scale consists of pairs of items that have either similar or opposing item content. The score yielded by the VRIN scale reflects the number of item pairs answered inconsistently. A high score may reveal a careless response style on the part of the client.
TRIN (True Response Inconsistency). This scale is analogous to the VRIN scale in
that it is made up of pairs of items. It dif- fers in that the TRIN scale consists solely of items with opposite content. An elevated score may reveal an acquiescence response set, or the tendency for the test subject to indiscriminately answer True to the items.
Conversely, a low TRIN score may reveal non-acquiescence.
Some validity evidence exists to sup- port the use of MMPI-A validity scales; a strength of these scales relative to similar scales from other measures. The L and K scales have been shown to be reasonably good at assessing symptom underreport- ing (Baer, Ballenger, & Kroll, 1998; Stein
& Graham, 2005). Validity scale cut scores had to be lowered somewhat to detect a fake good response set when evaluat- ing adolescents in a correctional facility (Stein & Graham, 1999). The F, Fl, F2, and VRIN scales were best for assessing random responding for a sample of 354 adolescents (Archer & Elkins, 1999).
Norming
The MMPI-A was normed in eight states in the continental United States on 1,620 adolescents. One state, however (Wash- ington), contributed only 14 cases to the norming.
The distribution of the sample by variables such as gender, age, grade, and parental education and occupation are given in the manual. These variables were not, however, used as stratification vari- ables in order to match US Census or other criteria as is common for clinical test instruments. The Hispanic population, for example, is clearly under-sampled, consti- tuting only 2.2% of the female sample and 2.0% of the male sample, which is smaller than the sample of Native American chil- dren. However, a great deal of subsequent research on the MMPI-A has been con- ducted with Hispanic individuals, increas- ing the confidence one can have in using this instrument with Hispanic clients (see
Butcher, Cabiya, Lucio, & Garrido, 2007).
Similarly, the SES distribution may be skewed toward higher levels of SES than the national population. The authors noted that, “This rough classification of occupa- tions suggests that mothers and fathers are described by many children as having pro- fessional and managerial occupations, while relatively low percentages are recorded for the homemaker and unskilled” (Butcher et al., 1992, p. 13). The age distribution of the sample is also highly variable. At age 18, only 42 male cases and 45 female cases were collected.
The small sample at age 18 may con- tribute to flawed estimates of psychopa- thology. A study by Shaevel and Archer (1996) revealed that 18-year olds scored substantially differently on the MMPI-A and MMPI-2. More evidence of pathology was obtained on the MMPI-2 with cor- respondingly lower validity scale values.
Differences in T-scores between the two instruments were sometimes as high as 15 points for the same scales.
At the opposite end of the age range, one study of an inpatient population of 13-year olds found little difference in scores in comparison to a matched group of 14-year olds (Janus, de Groot, & Toepfer, 1998). Another investiga- tion found little effect of demographic vari- ables on MMPI-A T-scores (Schinka, Elkins,
& Archer, 1998). However, Archer (2005) dis- cussed the tendency across several samples for symptom endorsement on the MMPI-A to be inversely correlated with age.
The norm sample also included 193 individuals who had received mental health services, leading to a relatively large pro- portion of adolescents who do not appear elevated on the MMPI-A (Archer, 2005).
However, removing these individuals and recalculating norms does not appear to change the pattern of results a great deal (Hand, Archer, Handel, & Forbey, 2007).
The US clinical normative sample con- sisted of 420 boys and 293 girls. All of the clinical cases were taken from the Minne- apolis area (Butcher et al., 1992). Further
details regarding the clinical sample can be found in Williams et al. (1992). The major- ity of cases (i.e., 71% of the boys and 56%
of the girls) were undergoing treatment in alcohol/drug units (Williams et al., 1992), suggesting that the clinical sample could be reconceptualzied to more accurately reflect the preponderance of substance abuse cases.
Reliability
There are distinct scale differences in the internal consistency estimates for the MMPI-A (see Table 6.7). Some of the clin- ical scales (e.g., Hs, Pt, Si) have respectable estimates. In direct contrast, some of the scales have internal consistency estimates that raise questions about their content.
The desirability of including a scale that possesses more error than reliable vari- ance is not clear. The Mf coefficients of .43 (boys) and .40 (girls) are the worst of those reported. The Pa, D, and Ma scales are also less reliable than most of the scales described in this chapter.
Internal consistency estimates for the validity scales range from unacceptably low to impressively high, with most being mod- erate (.70s and .80s). According to Butcher et al. (1992), the lowest coefficients were obtained for the L scale, where coefficients ranged from .53 in the female clinical sam- ple to .64 in the male normative sample. In contrast, the F scale produced coefficients ranging from .81 (female clinical sample) to .90 (male normative sample).
The internal consistency estimates for the “content” scales of the MMPI-A are generally better than those for the original clinical scales (see Table 6.7). The A-dep scale coefficients are considerably better than those of the original D scale, ranging from a low of .80 for the normative sample of boys to a high of .89 for the clinical sam- ple of girls (see Butcher et al., 1992).
The lowest internal consistencies of the content scales are produced by the A-las
scale, which has coefficients ranging from .55 to .66. These coefficients, however, are better than those of the MF clinical scale.
Some of the supplementary scales are also plagued by poor reliability estimates.
The revised MacAndrew (MAC-R) scale yields a median coefficient of .48, which is, again, lower than most of the scales cited in this chapter. This lack of reliabil- ity also makes the MAC-R scale difficult to validate because reliability is a necessary condition for validity. The MMPI-A manual cautions that a cut-off raw score of 28 on the MAC-R may result in false positives;
the existence of such poor reliability esti- mates makes one question the reliability of any cut score or, for that matter, the inclu- sion of the scale. Reliability coefficients in
the .40s are typically not seen as adequate for clinical decision making.
If one orders all of the MMPI-A clini- cal and content scales by their reliability estimates, some implications for interpre- tation become clear. Scales can be grouped by reliability coefficients with guidance for interpretation as shown:
This reliability-based interpretive hierarchy is, of course, overly simplistic because the validity of these scales is not equivalent for all purposes. The hierarchy, however, is useful in that there is a relation between reliability and validity. The four scales with median coefficients below .60 are less likely to be the beneficiaries of sub- stantial validity evidence, as will be noted in the next section.
Table 6.7 MMPI-A Median Internal Consistency Reliability Estimates
Clinical Scale Boys (N = 805) Girls (N = 815) Content Scale Girls and Boys
Scale 1, Hs .78 .79 A-anx .80
Scale 2, D .65 .66 A-ohs .74
Scale 3, Hy .63 .55 A-dep .83
Scale 4, Pd .63 .68 A-hea .82
Scale 5, Mf .43 .40 A-aln .74
Scale 6, Pa .57 .59 A-biz .75
Scale 7, Pt .84 .86 A-ang .72
Scale 8, Sc .88 .89 A-cyn .80
Scale 9, Ma .61 .61 A-con .73
Scale 10, Si .79 .80 A-lse .74
A-las .61
A-sod .78
A-fam .82
A-sch .70
A-trt .76
A .89
R .53
MAC-R .48
ACK .66
PRO .69
IMM .82
Note: From Butcher et al. (1992).
For the MMPI-A, the preceding charts suggest that the clinician could have more confidence in the information obtained from the content scales than the clinical scales. The higher internal consistency reli- ability of the content scales may very well be an artifact of the sometimes substantial item overlap in the clinical scales. In light of this issue, for clinical scale elevations, caution must be taken to determine what sorts of symptoms led to the elevations.
As is typical for such scales, test-retest coefficients differ from internal consis- tency estimates. Test-retest coefficients are somewhat more difficult to interpret, however, because it is unclear whether or not some scales measure traits that theo- retically should be stable over at least short periods of time. Regardless, test-retest data can be of value when gauging changes from one evaluation to another.
One scenario might involve an ado- lescent who was hospitalized with para- noid ideation that was reflected by a high T-score (78) on the Pa scale. It is conceiv- able that this individual would obtain a lower score of 61 on re-test prior to dis- charge two weeks after the initial assess- ment. One interpretation of these results is that treatment has been effective. Another interpretation is that Pa scale results are relatively unstable (r = .65) and that the T-score of 78 was spuriously high or the 61 was erroneously low. These test-retest data do provide an alternative hypothesis for this score difference that, in this case, may have implications for discharge plan- ning. In such a scenario, when MMPI-A results may not be well-corroborated by other clinical findings, more careful outpa- tient follow-up may be warranted to ensure that paraniod ideation has abated signifi- cantly enough so as to not adversely affect functioning in school or other settings.
Overall, the reliability estimates for the MMPI-A are more variable than might be expected. Such variability requires a more discerning user who evaluates the reliability Good Reliability (median coefficient .80)
Scale 7, Pt Scale 8, Sc A-anx A-dep A-cyn A-hea A-fam A
Adequate Reliability
(median coefficient = .70 to .79) Scale 1, Hs
Scale 10, Si A-obs A-aln A-biz A-ang A-con A-lse A-sod A-sch A-trt
Poor Reliability (median coefficient = .60 to .69)
Scale 2, D Scale 3, Hy Scale 4, Pd Scale 9, Ma A-1as ACK PRO
Inadequate Reliability (median coefficient .59)
Scale 5, Mf Scale 6, Pa R
MAC-R