Empirical Methods for Empirical Methods for Assessing CSTAssessing CST

Kimberly MillerKimberly Miller

Forensic NeuropsychologyForensic Neuropsychology

June 8June 8thth, 2006, 2006

Dusky StandardDusky Standard

Competency defined as:Competency defined as: Ability to assist lawyer in own defenseAbility to assist lawyer in own defense RATIONAL as well as FACTUAL RATIONAL as well as FACTUAL

understanding of proceedings against understanding of proceedings against him/herhim/her

What does rational mean?What does rational mean?

Florida Rules of Criminal Procedure Florida Rules of Criminal Procedure 3.211 A3.211 A

In considering competence to proceed, examining experts shall consider In considering competence to proceed, examining experts shall consider and include in their report defendant’s capacity to:and include in their report defendant’s capacity to:

Appreciate allegations against him/herAppreciate allegations against him/her Appreciate possible penaltiesAppreciate possible penalties Understand adversary nature of legal Understand adversary nature of legal

processprocess Disclose to counsel facts pertinent to the Disclose to counsel facts pertinent to the

proceedingsproceedings Manifest appropriate courtroom behaviorManifest appropriate courtroom behavior Testify relevantlyTestify relevantly

Link between Incompetence and Link between Incompetence and Mental DiseaseMental Disease

Expert must show:Expert must show: Incompetence due to mental illness or Incompetence due to mental illness or

retardationretardation Must specify how this illness affects Must specify how this illness affects

competencycompetency

Competency Screening TestCompetency Screening Test

22-item sentence completion task: “When 22-item sentence completion task: “When I go to court, the lawyer will…”I go to court, the lawyer will…”

Time: ~25minTime: ~25min Each item scored on 3-point scale in terms Each item scored on 3-point scale in terms

of competency reflected in responseof competency reflected in response Designed to be used as screener, with Designed to be used as screener, with

Competency Assessment Instrument as a Competency Assessment Instrument as a follow-up semistructured interview (13 Qs follow-up semistructured interview (13 Qs about legal knowledge and case specifics)about legal knowledge and case specifics)

Competency Screening Test: ProsCompetency Screening Test: Pros

Good as general screener to recognize Good as general screener to recognize those who are clearly competentthose who are clearly competent

Excellent inter-rater reliability (70-85%; Excellent inter-rater reliability (70-85%; see Nicholson, Robertson, Johnson, & Jensen, 1988see Nicholson, Robertson, Johnson, & Jensen, 1988))

Good agreement with forensic Good agreement with forensic examiners (71-86% correctly classified; examiners (71-86% correctly classified; see Nicholson, Robertson, Johnson, & Jensen, 1988see Nicholson, Robertson, Johnson, & Jensen, 1988))

Competency Screening Test: ConsCompetency Screening Test: Cons

Criticized for subjective scoring and Criticized for subjective scoring and idealized view of legal systemidealized view of legal system

Many validity concerns: high false Many validity concerns: high false positive rate, inconsistent factor positive rate, inconsistent factor structures (structures (reviewed in Melton et al., 1997reviewed in Melton et al., 1997))

Fitness Interview Test- Revised Fitness Interview Test- Revised (FIT-R)(FIT-R)

70 questions divided into 3 main areas:70 questions divided into 3 main areas: Ability to understand nature of the proceedings/ Ability to understand nature of the proceedings/

knowledge about criminal procedureknowledge about criminal procedure Ability to understand the possible Ability to understand the possible

consequences of proceedingsconsequences of proceedings Ability to communicate with counsel/assist in Ability to communicate with counsel/assist in

own defenseown defense Evaluator rates on 3-point scale level of Evaluator rates on 3-point scale level of

impairmentimpairment Designed as a screenerDesigned as a screener Time: ~ 30minTime: ~ 30min

FIT-R: ProsFIT-R: Pros

Inter-rater reliability across 4 Inter-rater reliability across 4 professions: for most items in .80- .9 professions: for most items in .80- .9 range, overall score reliability .98 range, overall score reliability .98 ((Viljoen, Roesch, Zapf, 2002Viljoen, Roesch, Zapf, 2002))

Good convergent validity with Good convergent validity with MacArthur Competency Assessment MacArthur Competency Assessment Tool (Tool (Zapf & Roesch, 2001Zapf & Roesch, 2001))

Good sensitivity and negative predictive Good sensitivity and negative predictive power: identified 82% of individuals power: identified 82% of individuals clearly CST (clearly CST (Zapf & Roesch, 1997Zapf & Roesch, 1997))

FIT-R: ConsFIT-R: Cons

Designed for Canadian jurisdictionsDesigned for Canadian jurisdictions No normsNo norms No scoring criteriaNo scoring criteria Other cons???Other cons???

Georgia Court Competency Test Georgia Court Competency Test (GCCT-MSH)(GCCT-MSH)

Revised from original GCCTRevised from original GCCT 21 questions assessing knowledge of 21 questions assessing knowledge of

criminal procedure, current changes, criminal procedure, current changes, relationship with attorneyrelationship with attorney

Time: ~ 20 minTime: ~ 20 min

GCCT-MSH: ProsGCCT-MSH: Pros

High test-retest reliability, inter-rater High test-retest reliability, inter-rater reliability, and internal consistency reliability, and internal consistency (Nicholson, 1992)(Nicholson, 1992)

Good criterion validity: 82% Good criterion validity: 82% agreement with classification by agreement with classification by forensic staff (forensic staff (Nicholson, Robertson, Johnson, Nicholson, Robertson, Johnson,

& Jensen, 1988& Jensen, 1988)) Quick screenerQuick screener

GCCT-MSH: ConsGCCT-MSH: Cons

Assesses factual knowledge about Assesses factual knowledge about legal system, but not legal system, but not rational/decisional knowledgerational/decisional knowledge

Susceptible to malingering: Gothard, Susceptible to malingering: Gothard, Rogers, & Sewell added Atypical Rogers, & Sewell added Atypical Presentation ScalePresentation Scale

Take home message: screener only, Take home message: screener only, to augment competency assessmentto augment competency assessment

Competence Assessment for Competence Assessment for Standing Trial for Defendants with Standing Trial for Defendants with

Mental Retardation (CAST-MR)Mental Retardation (CAST-MR) Designed to overcome problems with using Designed to overcome problems with using

open-ended questions with MR defendantsopen-ended questions with MR defendants 50 items: 40 multiple choice basic legal 50 items: 40 multiple choice basic legal

concepts/ skills to assist defense, 10 MC of concepts/ skills to assist defense, 10 MC of defendant’s specific casedefendant’s specific case

Normed on 4 groups: not MR, MR but not Normed on 4 groups: not MR, MR but not referred for evaluation, MR- CST, MR- ISTreferred for evaluation, MR- CST, MR- IST

Time: ~30-40 minTime: ~30-40 min

CAST-MR: ProsCAST-MR: Pros

Excellent internal consistency, inter-Excellent internal consistency, inter-rater reliability, test-retest reliability rater reliability, test-retest reliability ((Everington, 1990Everington, 1990))

Agreement with forensic examiners: Agreement with forensic examiners: 63-72% (decent)63-72% (decent)

CAST-MR: ConsCAST-MR: Cons

Probably easy to fake incompetencyProbably easy to fake incompetency No research into impact of No research into impact of

malingering on resultsmalingering on results

MacArthur Competency MacArthur Competency Assessment Tool- Criminal Assessment Tool- Criminal Adjudication (MacCAT-CA)Adjudication (MacCAT-CA)

22 items in 3 domains: 22 items in 3 domains: General legal General legal understandingunderstanding ReasoningReasoning about legal relevance about legal relevance AppreciationAppreciation (legal factors applied to one’s (legal factors applied to one’s

own case)own case) Scores for first two domains involve case Scores for first two domains involve case

vignettevignette Appreciation domain involves individual’s Appreciation domain involves individual’s

own circumstancesown circumstances Time: 30-60 minTime: 30-60 min

MacCAT-CA: ProsMacCAT-CA: Pros Has standardized administrationHas standardized administration Criterion scoringCriterion scoring Normed on a large competent/ incompetent, Normed on a large competent/ incompetent,

mentally ill/healthy forensic sample (over 700 mentally ill/healthy forensic sample (over 700 people), large age range, 6 states, not just people), large age range, 6 states, not just CaucasiansCaucasians

Manual has cut-off scores, sensitivity, specificity, Manual has cut-off scores, sensitivity, specificity, NNP, PPPNNP, PPP

Good inter-rater reliability (.75-90; Good inter-rater reliability (.75-90; Poythress et al., Poythress et al.,

19991999)) Good internal consistency (~ .8; Good internal consistency (~ .8; Otto et al., 1998Otto et al., 1998)) Takes into consideration both decisional and Takes into consideration both decisional and

factual knowledgefactual knowledge

MacCAT-CA: ConsMacCAT-CA: Cons

Low IQ individuals or those with poor Low IQ individuals or those with poor mental flexibility may have difficulty mental flexibility may have difficulty with case vignette portionwith case vignette portion

This may also reduce real-life utility This may also reduce real-life utility of measureof measure

Discussion QuestionDiscussion Question

Can neuropsych measures alone be Can neuropsych measures alone be used to determine CST?used to determine CST?

Case exampleCase example

Discussion QuestionDiscussion Question

Can neuropsych measures add Can neuropsych measures add anything to a traditional competency anything to a traditional competency evaluation? If so, what?evaluation? If so, what?