Law and Human Behavior 2014, Vol. 38, No. 5, 428 – 438

© 2014 American Psychological Association 0147-7307/14/$12.00 DOI: 10.1037/lhb0000074

Performance of Hispanic Inmates on the Spanish Miller Forensic Assessment of Symptoms Test (M-FAST) Orbelin Montes and Michelle R. Guyton

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Pacific University The few psychological assessment measures commercially available for the assessment of Spanishspeaking populations lack strong empirical foundation. This is concerning given the rising numbers of Spanish speakers entering the forensic and correctional systems for whom valid assessment is difficult without linguistically and culturally appropriate measures. In this study, we translated and adapted the Miller Forensic Assessment of Symptoms Test (M-FAST) into Spanish. The general purpose of this study was to investigate the psychometric, linguistic, and conceptual equivalence of the English- and Spanishlanguage versions of the M-FAST in a sample of 102 bilingual Hispanic incarcerated males. Participants were randomly assigned to one of three feigning conditions (honest, uncoached, or coached) and completed the M-FAST in both English and Spanish on two separate occasions. Both language versions were psychometrically, linguistically, and conceptually equivalent. Keywords: feigning, malingering, Hispanic/Latino inmates, Spanish M-FAST, Spanish tests

for purchase in the United States; however, most of these psychological tests have little to no empirical research supporting their use with Spanish-speaking populations (Fernandez, Boccaccini, & Noland, 2007). Currently, the Spanish Structured Interview of Reported Symptoms—2 (SIRS-2; Rogers, Sewell, & Guillard, 2010) is the only commercially available comprehensive measure for the assessment of malingering with Spanish-speaking populations. This measure was standardized in a community outpatient sample comprising Spanish-speaking Hispanic individuals (Correa, Rogers, & Hoersting, 2010). As such, it is unknown whether it generalizes to Hispanics in forensic and correctional settings. Also, the Structured Inventory of Malingered Symptomatology (SIMS; Smith & Burger, 1997), developed to screen for malingered psychopathology and cognitive deficits, was recently translated into Spanish and made commercially available in the United States. Information obtained through communications with a Psychological Assessment Resources permissions specialist revealed that the Spanish SIMS was translated into European Spanish, it is a linguistically and culturally sensitive tool, its normative data was collected primarily in Spain and in some Latin American countries, and this instrument must be scored online through a Spanishlanguage Website (V. McFadden, personal communication, July 3, 2013). Compared with the Spanish SIRS-2 and the Spanish SIMS, the presently developed Spanish-language version of the Miller Forensic Assessment of Symptoms Test (M-FAST; Miller, 2001) can be administered and scored relatively quickly by the clinician, which can save time and resources. In addition, it does not require online scoring and it is being normed with a sample of individuals who reside in the United States. The assessment of malingering is important in forensic and correctional settings because these individuals may malinger for several reasons, including avoidance of criminal responsibility, financial gain, access to psychotropic medication, or placement in less restrictive housing units in jails or prisons. Individuals with mild symptoms of a psychiatric disorder may exaggerate their

According to the most recent census, there are approximately 50.5 million Hispanic individuals living in the United States, composing 16% of the total population (U.S. Census Bureau, 2010). Approximately 34.5 million Hispanics speak Spanish at home and about 16 million of these indicated that they speak English less than “very well” (U.S. Census Bureau, 2007). As the Hispanic population continues to increase, the demand for Spanish-language psychological evaluations is likely to increase as well. Currently, practitioners who conduct psychological evaluations of Spanish-speaking individuals face formidable challenges, ranging from ethical issues such as cultural competence to appropriate test selection and interpretation (Acevedo-Polakovich et al., 2007). The majority of the available psychological assessment tools currently used were developed for English-proficient people and subsequently standardized primarily with White European American individuals (Dana, 2000). Therefore, it is a challenge when using a translated psychological test to assess an individual whose culture and language are different from those of mainstream culture. Discrepancies in score meaning can lead to inaccurate diagnoses and adverse consequences for these individuals (Geisinger, 1994). Undoubtedly, there is a need in the field for culturally appropriate psychological instruments that can provide accurate and reliable results. There are several psychological instruments that have been translated into Spanish and are commercially available

This article was published Online First June 23, 2014. Orbelin Montes and Michelle R. Guyton, School of Professional Psychology, Pacific University. This dissertation research was supported in part by a grant from the Oregon Department of Corrections. Correspondence concerning this article should be addressed to Orbelin Montes, Postdoctoral Fellow at Georgia Regents University/East Central Regional Hospital, 3405 Mike Padgett Hwy. (Building 10), Augusta, GA 30906. E-mail: [email protected] 428

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PERFORMANCE OF HISPANIC INMATES ON SPANISH M-FAST

symptoms when an external incentive is attainable (Rogers, 2008). Although the number of incarcerated Hispanics who are monolingual Spanish speakers (or who communicate primarily in Spanish) is unknown, Hispanic males were incarcerated in prisons at a rate of 1,822 per 100,000 U.S. residents in 2009 (West, 2010). Furthermore, an estimated 15.8% of inmates in local jails across the nation were Hispanic (Minton, 2011). Given the increasing number of Hispanics who become involved in the criminal system, it is likely that the demand for psychological evaluations of Spanish speakers will increase. Professionals in correctional and forensic settings need forensic assessment instruments that are linguistically and culturally appropriate and that are standardized with Spanish-speaking populations. One forensic assessment tool that has received significant attention is the M-FAST (Miller, 2001). The M-FAST was developed to screen for exaggeration or feigning of mental illness. It has been validated with correctional, forensic, and community samples using a wide range of methodologies (Guy & Miller, 2004; Jackson, Rogers, & Sewell, 2005; Miller, 2004; Vitacco, Rogers, Gabel, & Munizza, 2007). For instance, Guy and Miller (2004) examined the M-FAST’s ability to detect malingering in a sample of 50 incarcerated men from a prison psychology clinic. Findings indicated that malingerers (M ⫽ 11.38) obtained significantly higher scores compared with honest responders (M ⫽ 3.00). Furthermore, a cutoff score of total ⱖ6, which generated a sensitivity of .86 and a specificity of .83, was the most effective in discriminating malingerers from honest responders. These findings are consistent with the M-FAST research literature in that most studies demonstrate that malingerers and feigners obtain significantly higher M-FAST total scores compared with genuine responders, and that a cutoff score of total ⱖ6 generates the best classification rates (Guy, Kwartner, & Miller, 2006; Jackson et al., 2005; Miller, 2001, 2004; Vitacco et al., 2007). Most of the research conducted on the M-FAST thus far has used samples primarily composed of Caucasian individuals. Only two studies have examined the utility and generalizability of the M-FAST across ethnicities. Specifically, Guy and Miller (2004) reported similar M-FAST total scores among Caucasian, African American, and Hispanic participants across experimental conditions. Miller (2005) also found comparable classification rates for Caucasian and African American individuals using a cutoff score of total ⱖ6. Although only three Hispanic individuals participated in this study, all three were correctly classified. Taken together, both studies provide modest evidence that the M-FAST can be generalized across Caucasian, African American, and Hispanic individuals. However, these studies used English-speaking samples and are thus limited in their application to Spanish speakers.

Professional Guidelines for the Translation and Adaptation of Tests With respect to professional guidelines for the assessment of diverse populations, the Ethical Principles for Psychologists and Code of Conduct (American Psychological Association, 2002) recommends that psychologists conduct psychological assessments that consider language and culture for test selection, administration, and interpretation. Some diverse individuals cannot be assessed validly with English-language tests and many tests do not offer different language versions. This becomes an ethical issue for

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psychologists who are admonished to use culturally and linguistically appropriate measures, even though such instruments may not exist for a particular client. Psychologists cannot refuse services to diverse individuals, but their job is significantly more difficult when the appropriate assessments are unavailable. To date, few well-known psychological assessment instruments have been translated into Spanish and validated with Spanishspeaking populations. Fernandez et al. (2007) identified 30 adult personality and psychopathology assessment instruments that were translated and adapted from English into Spanish and were commercially available for purchase in the United States. Fernandez and colleagues found that 16 of 30 identified tests were being sold without any research supporting their use with Spanish-speaking Hispanics. From these identified translated tests, the Spanish version of the Minnesota Multiphasic Personality Inventory—2 (Lucio, Reyes-Lagunes, & Scott, 1994) and the Spanish version of the Personality Assessment Inventory (Morey, 1991) had seven and three published studies examining their psychometric properties, respectively. Validation studies on the Spanish-language version of the Personality Assessment Inventory have provided inconsistent results, with some evidence indicating construct inequivalence between the English and Spanish versions (Rogers, Flores, Ustad, & Sewell, 1995) and recent research suggesting psychometric equivalence between both language versions (Fernandez, 2007). When conducting psychological evaluations of Spanish speakers, it is recommended that acculturation be assessed (Dana, 1996). Acculturation is generally defined as the process of adapting to a different culture; it permits constant psychosocial exchanges generated from continual interactions among people of different cultures (Berry, 1997). Previous research has demonstrated that acculturation influences the psychological presentation of Hispanics and differentially affects responses to assessment procedures (Cofresi & Gorman, 2004; Cuellar, 2000; Judd et al., 2009). For example, research findings indicate that level of acculturation of Hispanics or Asians differentially influences Minnesota Multiphasic Personality Inventory—2 scores (Calderon, 2002; MendozaNewman, 2000; Telander, 1999; Tsai & Pike, 2000). Information related to acculturation can thus facilitate the selection of standard psychological instruments that are culture-specific (Dana, 1996; Judd et al., 2009). Given the heterogeneity within the Hispanic population, it is recommended that acculturation be formally assessed using measures with demonstrated reliability and validity in the specific Hispanic subgroup to which the examinee belongs (Acevedo-Polakovich et al., 2007). We followed this recommendation and employed the Bidimensional Acculturation Scale for Hispanics (BAS; Marin & Gamba, 1996), which was developed with a sample of individuals of Mexican and Mexican American descent. Our current sample included individuals with similar background characteristics.

Goals of the Present Study The central purpose of the current study was to investigate the psychometric, linguistic, and construct equivalence of the Englishand Spanish-language versions of the M-FAST. A simulation design (i.e., mixed experimental design) was employed to examine the utility of the M-FAST to detect malingered psychopathology in a sample of Hispanic incarcerated men. The first goal of this study was to investigate the psychometric properties of both language

MONTES AND GUYTON

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versions of the M-FAST. The second goal of this study was to examine the ability of both language versions of the M-FAST to accurately discriminate feigners from honest responders and to identify an optimal cutoff score for both language versions that demonstrates adequate sensitivity, specificity, and overall classification accuracy. The third goal of this study was to investigate the language equivalence of the English- and Spanish-language versions of the M-FAST. The final goal of this study was to examine the effects of acculturation on the total scores of both language versions of the M-FAST. To increase the generalizability and external validity of this simulation study, we included a coaching component—providing information to subjects in the form of warning them to not exaggerate psychiatric symptoms too much because this could affect test results—which is a methodology that has been employed in previous studies (Guriel et al., 2004; Guriel-Tennant & Fremouw, 2006). Across settings, it is likely that examinees can gain easy access to information about psychiatric conditions through attorneys, other inmates, or media sources. It is imperative that we have forensic assessment tools that can identify even those who are “educated” about how to respond to a measure to obtain a desired outcome.

Method

8% were taking psychotropic medication at the time of data collection.

Exclusionary Criteria Individuals who were under the age of 18, were not proficient in English and Spanish, had active psychotic symptoms, or were behaviorally unstable to complete both testing sessions were excluded from the study. One participant was excluded because he was unable to complete both testing sessions because he was placed on segregation status and two bilingual participants refused to participate. Twenty inmates were not eligible to participate because they were monolingual Spanish speakers.

Experimenter The experimenter, a bilingual and bicultural Mexican psychology advanced doctoral student at the time, completed all the interviews in this study. Prior to administering study measures to participants, the investigator reviewed and practiced several times the administration of both language versions of the M-FAST. The principal investigator had clinical assessment experience with correctional populations prior to the beginning of the study.

Participants and Setting

Measures

Prior to the start of the study, all procedures were approved by both university and prison research committees. A sample of 105 correctional inmates on intake status was recruited from a northwestern state prison facility. All participants were consecutively admitted to the intake unit of the prison (from April to July 2012), had charges ranging from possession of controlled substances to murder, and averaged fewer than one (M ⫽ 0.90) previous incarcerations. Two bilingual participants refused to participate and one participant was excluded from this study because he was unable to complete the second testing session because of placement in segregation. The final sample included 102 incarcerated Hispanic men between the ages of 18 and 54 years (M ⫽ 29.70 years, SD ⫽ 8.96), all of whom were bilingual in English and Spanish and averaged 24 years of permanent residency in the United States (range ⫽ 3 to 54 years). Regarding random assignment, a random order sequence was used to assign 34 participants to the honest condition, 34 individuals to the uncoached condition, and 34 people to the coached condition. With respect to ethnicities, the sample consisted of 30.2% Mexicans, 61.8% Mexican Americans,1 2.0% Guatemalans, 2.0% Salvadorians, 2.0% Puerto Ricans, 1.0% Nicaraguans, and 1.0% Peruvians. Regarding education, 21% of the participants indicated that they had obtained a high school diploma, 29% of them reported that they had earned their GED, and 50% of the sample did not have a high school diploma or a GED. Of note, 2% of the participants reported that they had not received formal education. In terms of marital status, 74% were single, 15% were married, 6% were separated, and 5% were divorced. With respect to psychiatric variables, 21% of the participants reported that they had received mental health treatment in the past, whereas 79% had not. The majority of the sample had no history of prior psychiatric hospitalizations (94%). Regarding psychotropic medication use, 18% of the subjects reported taking medication in the past; only

M-FAST (Miller, 2001). The M-FAST is a 25-item structured interview that was developed to screen for feigned mental health symptoms. It contains seven rationally derived scales: Reported Versus Observed Symptoms, Extreme Symptomatology, Rare Combination, and Unusual Hallucinations. The remaining three scales include the Unusual Symptom Course, Negative Image, and Suggestibility. Each item is scored either 0 or 1 for the absence or presence of a symptom based on the examinee’s response. Most of the test items require the examinee to provide true/false, always/sometimes/never, or yes/no responses. On three of the items, the examiner asks a yes/no question and subsequently observes the evaluee to judge the reliability between self-report and observed behavior. Spanish M-FAST. The Spanish version of the M-FAST is parallel to the English version. It contains the same number of items and scales, each item is scored either a 0 or 1 for the absence or presence of a symptom, and it requires an examinee to provide answers in a similar format as in the English version. Prueba de Afasia para Bilingües (Test of Aphasia in Bilinguals). The Prueba de Afasia para Bilingües (American Spanish version; Paradis & Ardila, 1989) is a widely used instrument designed to reveal differential ability across two languages. We adapted and used 14 items of Part C of this instrument to assess bilingual fluency of the participants. We used a section of this tool because we needed to get a quick assessment of bilingualism. Specifically, 10 one-word translation items and four sentence translation items were used to assess participants’ proficiency in both English and Spanish. The participants were required to correctly translate all 10 one-word items and three of four sentences correctly to be eligible to participate in the study. The 1 Mexican Americans are individuals who are born in the United States and are of Mexican descent.

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PERFORMANCE OF HISPANIC INMATES ON SPANISH M-FAST

participants translated half of all items from English into Spanish and the other half of the items from Spanish into English. All participants correctly translated all 14 items and no subject was excluded for failing this bilingualism test. Demographic questionnaire. A short demographic questionnaire was administered to all participants. Data obtained from this questionnaire included age, years of education, marital status, number of children, country of origin, years of residence in the United States, and past and present psychiatric history. BAS (Marin & Gamba, 1996). The BAS is a 24-item selfreport measure designed to assess the level of acculturation of Hispanic individuals. This measure comprises three languagerelated subscales: Language Use, Linguistic Ability, and Electronic Media. This tool uses a Likert-type response format ranging from 1 (almost never) to 4 (almost always) for the Language Use and Electronic Media subscales and 1 (very poorly) to 4 (very well) for the Linguistic Ability subscale. The normative sample (n ⫽ 254) for this measure was composed primarily of individuals of Mexican and Central American descent. This scale was developed empirically and its items reflect two cultural orientations: a Hispanic domain and a non-Hispanic domain. Authors of the BAS reported internal consistency reliabilities for the three languagerelated subscales of .90 for the Hispanic domain and.96 for the non-Hispanic domain. In terms of scoring, the responses to the 12 items that assess each cultural domain are averaged across items for each participant. Each participant receives two scores, one for the average of the 12 items composing the Hispanic domain and a second score for the 12 items forming the non-Hispanic domain. A person’s total score on each cultural domain can range from 1 to 4. Averaged scores on each of the domains can be used to define the level of acculturation of the examinee. The authors recommend using a cutoff score of 2.5 to determine someone’s level of acculturation. In this study, if a participant scored greater than 2.5 on one domain (e.g., Hispanic domain) and scored equal to or lower than 2.5 on the other domain (e.g., non-Hispanic), he was classified as belonging to the low acculturated group/Hispanic domain, and vice versa. If an individual obtained scores greater than 2.5 on both Hispanic and non-Hispanic cultural domains, then that individual was classified as being bicultural. Manipulation check. At the conclusion of the second interview administration, participants’ compliance with the experimental instructions was assessed via a manipulation check. Specifically, participants were asked to respond yes or no to the following three questions: Did I ask you to respond honestly when completing these [M-FAST] questions? Did I tell you to fake mental health symptoms to appear crazy? Did I tell you to not exaggerate too much your mental health symptoms? None of the participants were eliminated from the study for failure to remember the experimental instructions. The manipulation check was applied after the second interview session only because the experimental instructions were relatively brief and simple across both administrations.

Procedure Translation of the M-FAST into Spanish. Permission to adapt the M-FAST was granted by Psychological Assessment Resources, the test publisher. Authors followed the International Test Commission Guidelines for Translating and Adapting Tests (International Test Commission, 2010) to translate and adapt the

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M-FAST. These guidelines recommend that a process of translation and back-translation be followed when a translation of a test occurs. We implemented a multistep approach for the independent translation and back-translation of the M-FAST. First, a Peruvian bilingual and bicultural advanced doctoral student and an Argentinean bilingual and bicultural psychologist with expertise in the psychological assessment of Hispanics provided an independent forward Spanish translation (English into Spanish) of the M-FAST. Next, the principal investigator examined any discrepancies in the forward translations, made minimal corrections based on cultural and linguistic appropriateness, and generated a final forward Spanish translation. The finalized forward Spanish translation was provided to a Mexican bilingual and bicultural advanced doctoral student and a Mexican bilingual and bicultural psychologist (and former professional translator) for an independent back-translation (Spanish into English). All translators worked independently. The principal investigator again examined these back-translated versions, observed minimal discrepancies, made very small corrections, and produced a finalized backtranslated version of the M-FAST. The final back-translated version was highly comparable to the English version of the M-FAST. Psychological Assessment Resources approved the forward Spanish translation and back-translation of the M-FAST. Regarding participant selection, the intake staff at a northwestern state prison facility provided a weekly updated list of all male inmates housed at this facility during the course of this study. The researcher selected the names of inmates with Hispanic surnames. These identified individuals were individually approached in their cells, were asked whether they were bilingual, were given a brief description of the study, and were invited to participate. If they met criteria and indicated interest, the first data collection appointment was scheduled. During the first test session, the informed consent document was read aloud in the language preference of the participant and consent was garnered. Each participant was randomly assigned to either the honest, uncoached, or coached condition. Next, the experimenter administered the Prueba de Afasia para Bilingües (bilingualism test), a brief demographic questionnaire, and the BAS for Hispanics. On completion of these measures, the researcher introduced and read aloud the experimental instructions to each subject, explaining how they were supposed to respond to M-FAST test items. Three sets of instructions in English and Spanish were developed, one for each study condition. For instance, if a participant first completed the interview in Spanish, he then received instructions in Spanish to respond to test items according to the experimental instructions for that condition. This procedure was similar if the participant first completed the interview in English. In all experimental conditions, the researcher administered instructions verbally to participants. The participants randomly assigned to the honest condition were asked to respond honestly to M-FAST items in English and Spanish. The participants randomly assigned to the uncoached condition were instructed as follows: Now, I am going to ask you some questions about your mental health. I want you to pretend and act as if you have a serious mental illness. Before I start asking you these questions, you can take a moment to think about how you will answer the questions to appear “crazy.” Be

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nificant differences were found for age, years of education, years of residence in the United States, or number of reported children (see Table 1). Additional preliminary analyses revealed no significant differences between individuals who reported previously receiving mental health treatment and those who indicated no prior receipt of such services on either the English, t(100) ⫽ 0.48, p ⫽ .64, or the Spanish M-FAST total scores, t(100) ⫽ 0.67, p ⫽ .51. Similarly, no significant differences were observed between participants who reported previous placement at a psychiatric hospital and those without such history on either the English, t(8.34) ⫽ 0.29, p ⫽ .78, or the Spanish M-FAST total scores, t(14) ⫽ 0.88, p ⫽ .39. Also, no significant differences were found between individuals who reported past use of psychotropic medication and subjects who did not report prior use of psychotropic medication on either the English, t(100) ⫽ 0.12, p ⫽ .90, or the Spanish M-FAST total scores, t(100) ⫽ 0.14, p ⫽ .89. In addition, no significant differences were found between participants who reported current use of psychotropic medication and individuals who were not currently taking such medication on either the English, t(100) ⫽ 0.27, p ⫽ .79, or the Spanish MFAST total scores, t(100) ⫽ 0.30, p ⫽ .77. Country of origin of the participants (U.S. born vs. foreign born) did not significantly affect total scores on either the English, t(100) ⫽ 1.04, p ⫽ .30, or the Spanish M-FAST, t(100) ⫽ 0.87, p ⫽ .38. The order of administration of the M-FAST, English or Spanish, did not have a significant impact on the scores obtained, t(100) ⫽ 0.30, p ⫽ .76, and t(100) ⫽ 0.06, p ⫽ .94, respectively.

as believable and convincing as possible. I really want you to convince me that you are “crazy.”

Likewise, the individuals randomly assigned to the coached condition were read the following instructions:

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Now, I am going to ask you some questions about your mental health. I want you to pretend and act as if you have a serious mental illness. Before I start asking you these questions, you can take a moment to think about how you will answer the questions to appear “crazy.” Be as believable and convincing as possible, but be careful to not exaggerate too much because the test can pick this up. I really want you to convince me that you are “crazy,” but not too crazy.

After hearing these instructions, each participant was asked whether he understood the instructions before proceeding to the next task. Next, the researcher administered the English or Spanish version of the M-FAST to the participants. The order of administration of the M-FAST (English or Spanish) was counterbalanced (i.e., participants whose identification code ended with an odd number completed the Spanish version first and those whose identification code ended with an even number completed the English version first). The experimental instructions were read in the language in which the M-FAST was administered. After completing the English or Spanish M-FAST, the interviewer scheduled a second interview appointment to occur within 2 days to complete the other language version of the M-FAST. The time to complete the first interview was approximately 20 min. In the second interview session, which occurred 2 days later, the researcher first read aloud the instructions under which the participant was to complete the remaining language version of the M-FAST, and again, asked the participant whether he understood the instructions prior to proceeding. Next, the researcher administered the remaining language version of the M-FAST, performed a manipulation check, debriefed each participant, and provided information about available resources in case participation caused psychological distress (e.g., Behavioral Health Services). Participants were thanked and paid $3 via their institutional accounts. The time to complete this second interview was approximately 5 min.

Reliability of the English-Language Version of the M-FAST The first goal of this study was to examine the psychometric properties of both language versions of the M-FAST. Alpha coefficients were computed on the total score and four of the seven scales that contain more than one item: Reported Versus Observed, Extreme Symptomatology, Rare Combinations, and Unusual Hallucinations. The remaining three scales contain only one item each and thus internal reliability was not assessed. As illustrated in Table 2, internal consistency for the English M-FAST total score was very high (␣ ⫽ .97), with average interitem correlations in the optimal range (M ⫽ .44). The Reported Versus Observed (␣ ⫽ .77), Extreme Symptomatology (␣ ⫽ .85), Rare Combinations (␣ ⫽ .91), and Unusual Hallucinations (␣ ⫽ .88) scales demonstrated good internal consistency, with high interitem correlations.

Results Sample Characteristics Preliminary one-way analyses of variance (ANOVAs) were conducted to investigate potential differences on demographic characteristics among the three experimental conditions. No sig-

Table 1 Demographic Characteristics of Participants by Condition Uncoached (n ⫽ 34)

Honest (n ⫽ 34)

Coached (n ⫽ 34)

Variable

M

SD

M

SD

M

SD

F(2, 99)

p

␩2

Age (years) Education (years) U.S. residence (years) Number of children

30.94 10.12 24.88 2.47

9.87 1.89 11.06 2.57

28.38 10.38 25.41 1.50

7.88 2.54 6.62 1.76

29.76 9.97 24.35 1.91

9.12 2.46 10.23 1.29

0.69 0.28 0.11 2.13

.50 .76 .90 .13

.01 .00 .00 .04

PERFORMANCE OF HISPANIC INMATES ON SPANISH M-FAST

Table 2 Internal Consistency and Mean Interitem Correlations for English Miller Forensic Assessment of Symptoms (M-FAST) Total and Four Scales Scale

Items (n)

␣

Mean interitem correlations

M-FAST total RO ES RC UH

25 3 7 7 5

.97 .77 .85 .91 .88

.44 .46 .48 .43 .40

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Note. RO ⫽ Reported Versus Observed; ES ⫽ Extreme Symptomatology; RC ⫽ Rare Combinations; UH ⫽ Unusual Hallucinations.

Reliability of the Spanish-Language Version of the M-FAST With respect to the psychometric properties of the Spanish M-FAST, alpha coefficients were computed on the total score and the Reported Versus Observed, Extreme Symptomatology, Rare Combinations, and Unusual Hallucinations scales. Internal reliability was not assessed for the three scales that contain only one item. As illustrated in Table 3, internal consistency for the M-FAST total score was very high (␣ ⫽ .97), with average interitem correlations in the optimal range (M ⫽ .42). The Reported Versus Observed (␣ ⫽ .77), Extreme Symptomatology (␣ ⫽ .84), Rare Combinations (␣ ⫽ .92), and Unusual Hallucinations (␣ ⫽ .87) scales demonstrated good internal consistency, with very high interitem correlations.

Discriminant Validity of the English and Spanish M-FAST The second goal of this study was to investigate the ability of the English and Spanish versions of the M-FAST to discriminate feigners from honest responders. A one-way ANOVA was significant, F(2, 99) ⫽ 340.10, p ⬍ .001, ␩2 ⫽ .87. Games–Howell post hoc tests indicated that uncoached participants (M ⫽ 21.68, SD ⫽ 4.29) had significantly higher English M-FAST total scores compared with honest (M ⫽ 0.82, SD ⫽ 1.24, p ⬍ .05, d ⫽ 6.60, 95% CI [5.39, 7.81]) and coached subjects (M ⫽ 10.62, SD ⫽ 3.55, p ⬍ .05, d ⫽ 2.80, 95% CI [2.13, 3.47]). Likewise, coached participants (M ⫽ 10.62, SD ⫽ 3.55) scored significantly higher compared with honest responders (M ⫽ 0.82, SD ⫽ 1.24, p ⬍ .05, d ⫽ 3.68, 95% CI [2.90, 4.46]). The same analysis was used to determine the ability of the Spanish M-FAST to discriminate among the three experimental groups. This ANOVA also was significant, F(2, 99) ⫽ 339.30, p ⬍ .001, ␩2 ⫽ .87. Games–Howell post hoc tests indicated that participants in the uncoached condition (M ⫽ 21.44, SD ⫽ 4.43) obtained significantly higher M-FAST total scores compared with honest (M ⫽ 0.82, SD ⫽ 1.14, p ⬍ .05, d ⫽ 6.37, 95% CI [5.20, 7.54]) and coached participants (M ⫽ 9.44, SD ⫽ 3.37, p ⬍ .05, d ⫽ 3.04, 95% CI [2.34, 3.74]). In addition, coached participants (M ⫽ 9.44, SD ⫽ 3.37) scored significantly higher than honest responders (M ⫽ 0.82, SD ⫽ 1.14, p ⬍ .05, d ⫽ 3.42, 95% CI [2.67, 4.17]). A series of one-way ANOVAs also were conducted to investigate the relationship between experimental condition and Spanish

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M-FAST individual scale scores. Inspection of Table 4 reveals that uncoached feigners scored significantly higher across all individual scales relative to genuine and coached responders. Similarly, coached feigners obtained significantly higher scores on all individual scales compared with genuine responders. Table 4 presents the means, standard deviations, effect sizes, and confidence intervals for the Spanish M-FAST total score and its individual scales. Given that this sample comprised bilingual incarcerated Hispanic men and was different from original standardization samples (Miller, 2001), we calculated utility estimates (see Table 5) to evaluate the usefulness of the English M-FAST to identify feigned mental illness. In this study, we adopted a cutoff score of total ⱖ5 (instead of the recommended total ⱖ6; Miller, 2001). The cutoff score of total ⱖ6 was not employed because it generated slightly lower sensitivity and negative predictive power estimates (.91 and .85, respectively). In contrast, a cutoff score of total ⱖ5 produced optimal utility estimates (sensitivity ⫽ .93, specificity ⫽ .97). That is, 93% of feigners and 97% of honest responders were correctly classified. Interestingly, four of the five false negatives (i.e., classified as honest, but were feigners) were coached simulators. In other words, 88% of coached feigners were correctly identified. Overall, the M-FAST correctly classified 94% of the entire sample. In addition, positive predictive power and negative predictive power were well balanced with .98 and .87, respectively. As shown in Table 6, we adopted a cutoff score of total ⱖ5 for the Spanish M-FAST, which generated a sensitivity of .91 and a specificity of .97. That is, 91% of feigners and 97% of honest responders were correctly classified. Of the misclassifications, five of the six false negatives were coached simulators, which meant that 85% of coached simulators were correctly identified. Overall, the Spanish M-FAST correctly classified 93% of the entire sample. Positive predictive power was .98 and negative predictive power was .85.

Language Equivalence of the English and Spanish Versions of the M-FAST The third goal of the present study was to investigate the language equivalence of the English and Spanish versions of the M-FAST. Statistical analyses were conducted on the honest condition because it was assumed that individuals who answered honestly to M-FAST items on one language version would respond in a similar fashion on the other language version of the test because there was no experimental manipulation. A significant

Table 3 Internal Consistency and Mean Interitem Correlations for Spanish Miller Forensic Assessment of Symptoms (M-FAST) Total and Four Scales Scale

Items (n)

␣

Mean interitem correlations

M-FAST Total RO ES RC UH

25 3 7 7 5

.97 .77 .84 .92 .87

.42 .42 .44 .42 .41

Note. RO ⫽ Reported Versus Observed; ES ⫽ Extreme Symptomatology; RC ⫽ Rare Combinations; UH ⫽ Unusual Hallucinations.

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Table 4 Discriminant Validity in the Spanish Miller Forensic Assessment of Symptoms (M-FAST) Total and Scale Scores by Experimental Group Honest (n ⫽ 34)

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Scale Total RO ES RC UH USC NI S

M

SD b

0.82 0.18c 0.41c 0.12c 0.03c 0.03c 0.06c 0.00c

1.14 0.39 0.50 0.41 0.17 0.17 0.24 0.00

Uncoached (n ⫽ 34) M

SD b

21.44 2.47c 5.79c 6.15c 4.38c 0.97c 0.91c 0.76c

4.43 0.86 1.20 1.54 1.07 0.17 0.29 0.43

Coached (n ⫽ 34) M b

9.44 1.15c 3.00c 2.53c 1.79c 0.29c 0.41c 0.26c

SD

F(2, 99)

3.37 0.82 1.37 1.71 0.98 0.46 0.50 0.45

339.30 86.38 207.05 171.97 228.68 88.11 48.10 39.86

a

Honest vs. uncoached d [95% CI]

Honest vs. coached d [95% CI]

Uncoach vs. coached d [95% CI]

6.37 [5.20, 7.54] 3.42 [2.68, 4.17] 5.85 [4.76, 6.94] 5.35 [4.33, 6.36] 5.67 [4.61, 6.74] 5.52 [4.48, 6.57] 3.19 [2.47, 3.91] 2.49 [1.86, 3.13]

3.42 [2.67, 4.17] 1.51 [0.97, 2.04] 2.51 [1.87, 3.14] 1.93 [1.36, 2.51] 2.50 [1.86, 3.13] 0.74 [0.25, 1.24] 0.89 [0.39, 1.39] 0.81 [0.32, 1.31]

3.04 [2.34, 3.74] 1.57 [1.02, 2.11] 2.16 [1.56, 2.76] 2.22 [1.61, 2.82] 2.52 [1.88, 3.16] 1.96 [1.38, 2.53] 1.22 [0.70, 1.74] 1.13 [0.62, 1.64]

Note. RO ⫽ Reported Versus Observed; ES ⫽ Extreme Symptomatology; RC ⫽ Rare Combinations; UH ⫽ Unusual Hallucinations; USC ⫽ Unusual Symptom Course; NI ⫽ Negative Image; S ⫽ Suggestibility. All F values are statistically significant at p ⬍ .001. b Means in the same row that share superscripts differ at p ⬍ .001. c Means in the same row that share superscripts differ at p ⬍ .05. a

positive relationship was found between the English and Spanish M-FAST total scores (r ⫽ .96, p ⬍ .01). Also, significant correlations, ranging from .85 to 1.00, were found between English and Spanish M-FAST same-content scales. Pearson correlation analyses also were conducted on both of the feigning conditions to determine whether participants responded consistently across both language versions of the M-FAST. Significant positive correlations were found between the total scores of the English- and Spanish-language versions of the M-FAST for the uncoached (r ⫽ .92, p ⬍ .01) and coached (r ⫽ .81, p ⬍ .01) conditions. In addition, a paired-samples t test was conducted to evaluate whether the mean total score on both language versions of the M-FAST differed for participants in the control condition. The results indicated that the mean total score for the English M-FAST (M ⫽ 0.82, SD ⫽ 1.24) was not significantly different from the mean total score for the Spanish M-FAST (M ⫽ 0.82, SD ⫽ 1.14), t(33) ⫽ 0.00, p ⫽ 1.0. The standardized effect size index, d, was 0.00. Together, these findings provide strong evidence for the language equivalence of the English and Spanish M-FAST.

Effects of Acculturation on the English and Spanish Versions of the M-FAST We used the recommended cutoff score of 2.5 on the BAS to classify individuals as low acculturated, highly acculturated, or bicultural (Marin & Gamba, 1996). This cutoff score classified 11 participants as low acculturated, 19 individuals as high acculturated, and 72 people as bicultural. For the English M-FAST, there was a tendency for the highly acculturated group (M ⫽ 12.95, SD ⫽ 9.10) to endorse more items compared with the bicultural group (M ⫽ 11.43, SD ⫽ 8.89), which in turn tended to endorse more items than the low acculturated group (M ⫽ 5.18, SD ⫽ 7.78), but these differences did not reach statistical significance, F(2, 99) ⫽ 2.82, p ⫽ .06. Likewise, for the Spanish M-FAST, the highly acculturated group (M ⫽ 12.26, SD ⫽ 10.04) endorsed more items than the bicultural group (M ⫽ 10.90, SD ⫽ 8.85), which in turn endorsed more items than the low acculturated group (M ⫽ 5.45, SD ⫽ 7.87), but these differences also were not statically significant, F(2, 99) ⫽ 2.16, p ⫽ .12.

Table 5 Classification Table for English Miller Forensic Assessment of Symptoms Presumed feigned

Presumed honest

Classified as feigned responders

True positives TP ⫽ 63

False positives FP ⫽ 1

Classified as honest responders

False negatives FN ⫽ 5

True negatives TN ⫽ 33

Total

68 Sensitivity TP/(TP ⫹ FN) 63/(63 ⫹ 5) ⫽ .93

34 Specificity TN/(TN ⫹ FP) 33/(33 ⫹ 1) ⫽ .97

Positive predictive power ⫽ TP/(TP ⫹ FP) ⫽ 63/(63 ⫹ 1) ⫽ .98 Negative predictive power ⫽ TN/(TN ⫹ FN) ⫽ 33/(33 ⫹ 5) ⫽ .87 102

Note. Base rate (i.e., proportion of individuals in this sample presumed to have feigned) was approximately 67%; overall accuracy (i.e., hit rate) at this base rate was 94%. If the base rate changes, then utility estimates also change.

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Table 6 Classification Table for Spanish Miller Forensic Assessment of Symptoms Presumed feigned

Presumed honest

Classified as feigned responders

True positives TP ⫽ 62

False positives FP ⫽ 1

Classified as honest responders

False negatives FN ⫽ 6

True negatives TN ⫽ 33

Total

68 Sensitivity TP/(TP ⫹ FN) 62/(62 ⫹ 6) ⫽ .91

34 Specificity TN/(TN ⫹ FP) 33/(33 ⫹ 1) ⫽ .97

Positive predictive power ⫽ TP/(TP ⫹ FP) ⫽ 62/(62 ⫹ 1) ⫽ .98 Negative predictive power ⫽ TN/(TN ⫹ FN) ⫽ 33/(33 ⫹ 6) ⫽ .85 102

Note. Base rate (i.e., proportion of individuals in this sample presumed to have feigned) was approximately 67%; overall accuracy (i.e., hit rate) at this base rate was 93%. If the base rate changes, then utility estimates also change.

Discussion Although small advances have been made in developing psychological assessment measures that are linguistically and culturally sensitive, psychology as a discipline lacks assessment measures (e.g., personality, neuropsychological, intelligence, or forensic tools) that are developed and standardized with ethnically diverse populations. As mentioned in the introduction, the few psychological tests that are commercially available in Spanish lack rigorous empirical support (Fernandez et al., 2007). Specifically with respect to the forensic arena, the SIRS-2 (Rogers et al., 2010) and the Spanish SIMS (Smith & Burger, 1997) are commercially available in the United States. As previously noted, it is unclear how well these Spanish feigning tools apply to forensic and correctional populations. The task of discriminating between honest and feigned presentations of mental illness is of paramount importance among incarcerated populations, and yet there is no reliable and valid screening tool available for Spanish speakers. This study investigated the metric, construct, and linguistic equivalence of the English- and Spanish-language versions of the M-FAST. This study contained several related goals rather than specific hypotheses. The first goal of this study was to investigate the psychometric properties of both language versions of the M-FAST. Regarding the English version of the M-FAST, internal consistency estimates were higher in this sample compared with those found in the original nonclinical validation sample (Miller, 2001). Specifically, Miller (2001) reported an alpha coefficient of .92 for the M-FAST total score and alphas ranging from .44 to .82 for the four scales that have more than one item (i.e., Reported Versus Observed Symptoms, Extreme Symptomatology, Rare Symptom Combination, and Unusual Hallucinations). In contrast, the alpha coefficient obtained for the English M-FAST total score was .97, with alphas ranging from .77 to .91 for its four scales that contain more than one item. For the Spanish M-FAST, an alpha coefficient of .97 also was found for the total score, with alphas ranging from .77 to .92 for the four scales previously mentioned. One possible explanation for the higher alphas in the present study relative to those found in the M-FAST manual is that the time interval between the first and the second M-FAST administrations

was brief (i.e., 2 days). Given this brief time period, it is possible that the participants were able to more easily remember the M-FAST items during the second administration, and as noted, this may have generated higher internal consistency coefficients. Despite the possible memory effects, these findings are noteworthy as it appears that both language versions of the M-FAST seem to be reliable screening measures for the detection of feigning (or malingering) with incarcerated bilingual Hispanic inmates. Next, we found that both language versions of the M-FAST accurately discriminated feigners from honest responders and identified 5 as the optimal cutoff score, which generated good sensitivity, specificity, and overall classification accuracy. Across both language versions of the M-FAST, simulators (coached and uncoached) obtained significantly higher total scores than honest responders. In addition, uncoached participants scored significantly higher compared with both coached and honest individuals. In general, these results are similar to those observed in previous studies that have employed simulation and known-groups designs (Guy et al., 2006; Guy & Miller, 2004; Jackson et al., 2005; Miller, 2001; Vitacco et al., 2007). Importantly, because each language version was similarly able to discriminate feigners from honest responders, we can extrapolate that both language versions are conceptually equivalent. In other words, both versions appear to be measuring the psychological construct of symptom exaggeration and feigning. Sensitivity was lower than specificity across both language versions, which is not ideal for a screening tool. In practice, we are more concerned with identifying malingerers and less so with identifying honest responders. Nonetheless, the difference between sensitivity and specificity is small and well balanced across both language versions. Although the utility estimates were high in the present sample possibly due to the short time interval between test administrations and/or memory effects, this identified cutoff score of total ⱖ5 is different from Miller’s (2001) recommended score of total ⱖ6. Based on the International Test Commission Guidelines for Translating and Adapting Tests, translated and adapted tests need to be revalidated in the new language and targeted population (International Test Commission, 2010). This cutoff

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score of total ⱖ5 seems appropriate because this sample differs linguistically and culturally from standardization samples. One possible cultural explanation for a lower score on the Spanish version of the M-FAST is that the translated items may have been perceived as being especially pathological in nature because they reflect symptoms and concepts less familiar in Hispanic culture; therefore, Hispanic participants were less likely to endorse a higher number of items relative to standardization samples. It is important to note that the present sample was designed to have a high base rate of feigning to be able to detect how the M-FAST performed across a range of scores. Clearly, the base rate of feigning will impact the utility of estimates of the tools used to assess for it. In the present study, the 67% base rate of malingering led to similar utility estimates for the English-and Spanishlanguage versions of the M-FAST, including comparable overall classification rates (94% and 93%, respectively). The English and Spanish M-FAST also performed well in classifying coached participants who were explicitly asked to avoid exaggeration of symptoms to avoid detection, with 88% and 85% classification rates, respectively. In sum, both language versions of the M-FAST appeared to efficiently classify simulators, including coached participants, as well as honest responders. These results are consistent with a prior study in which investigators administered the M-FAST in English and employed a similar coaching methodology (Messer & Fremouw, 2007). We included a coaching component to mimic real-world situations in which examinees may learn information about psychiatric symptoms from a variety of sources (e.g., attorneys, Internet, etc.). In addition, our experimental instructions were consistent with those included in other studies in which investigators either have provided diagnostic criteria for a mental disorder or have warned the examinees to be careful when responding to questions (Guriel et al., 2004; Jackson et al., 2005). Overall, the current data suggest that the two language versions of the M-FAST are linguistically and conceptually equivalent. The Spanish-language version in particular shows promise in being able to discriminate feigners from honest responders. The availability of the Spanish M-FAST is important in that it is the first valid and reliable screening tool for detecting symptom feigning with Spanish speakers, and as such, it may guide examiners to conduct comprehensive malingering evaluations on those clients who demonstrate elevated scores on the Spanish M-FAST, thereby saving valuable resources. Although prior studies indicate that acculturation influences the psychological presentation of Hispanics and differentially affects responses to assessment procedures (Cofresi et al., 2004; Cuellar, 2000), no significant effects of acculturation were found on either language version. An explanation for the lack of acculturation effects may be that the majority of participants were well acculturated. It is possible that with a larger group of less acculturated individuals or with monolingual Spanish speakers, acculturation effects may be observed. A plausible explanation as to why the relationship between acculturation and English M-FAST scores approached statistical significance is that the low acculturated group was rather small (n ⫽ 12) and approximately half of these participants were randomly assigned to the honest condition, which by nature obtained lower overall scores relative to bicultural and highly acculturated individuals. As with all studies, there were some limitations that may have impacted the results or conclusions. First, differences exist be-

tween bilingual and monolingual speakers such that bilingual individuals may use their knowledge of the other language if they experience comprehension difficulties, whereas monolingual speakers do not have this option. As a result, more research is needed to determine whether the Spanish M-FAST remains an effective tool for screening malingered psychopathology with monolingual Spanish speakers who, by nature, are less acculturated to mainstream society. Similarly, individuals may have relied on their knowledge of both languages when responding to one language version, which potentially inflates the correlations between the two versions. Second, the present sample did not include women; thus, it is unknown whether these findings generalize to bilingual or monolingual Spanish-speaking female correctional populations. Third, the majority of the individuals in this sample are of Mexican descent; therefore, additional research is needed to assess whether the present findings extend to Hispanics of nonMexican descent. Fourth, an inherent limitation of the M-FAST is that it was developed in the United States and does not contain items that assess culturally bound syndromes or culturally congruent modes of distress, and so it is unlikely that the Spanish M-FAST will detect Spanish-speakers who feign symptoms of a culturally bound syndrome. Thus, Spanish speakers may be less likely to endorse these symptoms because they are less relevant to their own cultural expressions of psychopathology. Finally, as noted by Rogers (2008), a limitation of simulation designs in malingering research is that such methodology generally produces findings and effect sizes that are larger than what is observed in genuine clinical populations. This likely explains why such large score differences were observed, particularly between the uncoached and coached groups in this study. Despite these limitations, this study is the first to develop a screening Spanish-language tool for symptom feigning and preliminarily demonstrate its effectiveness. Further, this study presented solid data demonstrating that the Spanish version of the M-FAST is psychometrically sound and linguistically equivalent to the English version of the M-FAST. This study also serves as a first step in the direction of conducting additional research that addresses the growing need among forensic and correctional practitioners to have more linguistic and culturally appropriate valid tests for Spanish speakers. Based on the findings of this study and the limitations mentioned above, some recommendations for future research are proposed. First, investigators could employ the Spanish version of the M-FAST to examine its psychometric properties utilizing samples of monolingual incarcerated males and females. Second, to improve the Spanish M-FAST’s external validity, use of knowngroups designs would yield more naturalistic data. Third, the utility of the Spanish M-FAST in clinical and community samples of monolingual Spanish speakers remains unknown. Studies employing both the Spanish SIRS-2 and the Spanish M-FAST with Spanish speakers could examine the convergent validity of the Spanish version of the M-FAST. In conclusion, taken together, the present findings suggest that the English- and Spanish-language versions of the M-FAST appear to be psychometrically, linguistically, and conceptually similar. The Spanish-language version demonstrates promise as an effective screening measure to detect malingered presentations among bilingual incarcerated Hispanic men. Although the Spanish M-FAST has yet to be validated with male and female monolin-

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gual Spanish-speaking correctional and forensic samples, it can be used with caution with Spanish speakers until additional validational research is conducted. If used appropriately in conjunction with multiple sources of information, then the Spanish M-FAST can assist in the determination of malingering among Spanish speakers. This is significant given the increasing numbers of Hispanic inmates in the criminal justice system, the high prevalence of mental illness among inmates and forensic patients, and the importance of discriminating true from feigned mental illness.

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Received May 18, 2013 Revision received October 5, 2013 Accepted October 8, 2013 䡲