education and intellectual functioning in an ethnically diverse adult

ASSOCIATION BETWEEN REPORTEDEDUCATION AND INTELLECTUALFUNCTIONING IN AN ETHNICALLYDIVERSE ADULT PSYCHIATRIC

INPATIENT SAMPLEF. M. Baker, MD, MPH, Daryl Fulii, PhD, and Earl S. Hishinuma, PhD

Salisbury, Maryland, Kaneohe, Hawaii, and Manoa, Hawaii

Patients' pre-existing survival skills, educational attainment, and intellectual functioningshould be included in the development and implementation of treatment planning for adultpsychiatric inpatients. When considering culturally diverse inpatient populations with possiblecultural and language barriers, these variables may attain additional importance. Utilizing asample (N = 60) primarily consisting of Asian/Pacific Islander inpatients, the present studyinvestigated: (a) the rate at which professionals from different disciplines inquired about educa-tional attainment; (b) the association between self-reported education and standardized mea-sures of intelligence; and (c) the correspondence between different IQ scores. Axis 1 diagnosesincluded schizophrenia (N = 19; 32%), schizoaffective disorder or bipolar disorder (N = 23;38%), and organic or substance-related disorders (N = 1 8; 30%). Thirty-five percent of thesample (N = 21) had dual diagnoses. The results indicated that only psychologists whoadministered IQ tests consistently inquired about educational attainment. An expected overallpositive association between self-reported education and standardized intelligence measureswas found. High correlations between the Test of Nonverbal Intelligence, 2nd edition (TONI-2)and Wechsler Adult Intelligence Test-Revised (WAISQ-R) lQs suggested that both tests were validin the assessment of intellectual functioning. Implications included the need for more systematicassessment and incorporation of pre-existing skill-based information and the utility of self-reported education and different measures of intellectual functioning (including TONI-2). (J NatlMed Assoc. 2002;94:47-53.)

Key words: Native Hawaiians * Pacific Islanders* Asians * IQ * education * cultural diversity

© 2002. From the Lower Shore Clinic, Salisbury, Maryland, HawaiiState Hospital, Kaneohe, Hawaii, and John A. Burns School of Medi-cine, University of Hawaii at Manoa Manoa, Hawaii. Requests forreprints should be addressed to Dr F. M. Baker, Medical Director,Lower Shore Clinic, 505 East Main Street, Salisbury, MD 21 804.

Adult patients of inpatient psychiatric settingstypically possess lower levels of survival skills, educa-tional attainment, and intellectual functioning.These characteristics likely impact the patients' abil-ity to function on a daily basis (e.g., basic readingand math skills) and their ability to benefit frominterventions in an inpatient environment (e.g.,comprehend medication information; understandand participate in treatment planning, participate

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EDUCATION AND IQ

in psychosocial rehabilitation, vocational training,occtupational retraining, ouitpatient transition pro-grams, etc.).

Despite this link between function-ing level andinpatient benefit, only minimal research has fo-cused oIn issues related to assessing or inquiringabotut edtucational attainment (e.g., reading),' andwhether there is a correspondence between patientself-reported edtucation level and intellectual func-tioning.2--' The latter association is of particular in-terest given that self-reported educational attain-ment may not correspond well to standardizedintelligence mneasures, either because of invalid pa-tient self-reports of education level, invalid assess-mnent of initellectual functioning, or simply a genu-ine lack of congruence between valid measures ofself-reported edtucation- and standardized intelli-gence for the population in question (i.e., adultpsychiatric inpatients). The greater the lack of asso-ciation between these two measures, the greater theneed to examine both indicators, which in turn mayhave clinical implications for such interventions asrehabilitation and vocational training.

These types of issues are magnified when provid-ing services to a cuLlturally diverse group of adultpatients (e.g., given the controversy surroundingthe intellectual assessment of individuals from var-ied backgrounds). In many inpatient psychiatricUlnits in the United States, the patient populatioin iscomprised mainly of individuals of white, African-American, and Hispanic-American ancestry. Only instates with significant Asian American, Native Ha-waiian, Pacific Islander, or Native Amnerican Indianand Alaska Native poptulations are these groups rep-resented in sufficient ntumbers among inpatientpoptulationis to answer specific questions concerningtheir care and clinical coturse.

In this regard, Hawaii offers a particularly richenvironment to sttudy the issues of educational at-tainment and intellectual fulnctioning. Hawaii is thegeographical gateway to the Pacific and Asia.'i Itsculturally diverse population is comprised of per-sons of Japanese (20.3%), Hawaiian/part-Hawaiian(20.6%), Filipino (10.0%), Chinese (3.1%), AfricanAmerican (1.4%), Korean (0.8%), Pacific Islander(Samoan or Tongan) (0.8%), Puerto Rican (0.1%),and White (22.1 %) heritage.7 This culttural diversityis reflected in both the inpatient population8 andstaff of the Hawaii State Hospital. Many patients arebilingual and a few are new immigrants to theUnited States. Frequently, persons sensitive to the

cultural isstues and culttural clues for a given patientare members of the nursinig staff working with pa-tients of similar cultural background. This sensitivitycan facilitate patient education, compliance, andidentification of improvement as well as decompen-sation.

The purposes of the present study were: (1) todetermine the rate at which different professionalsassess educational attainment for a diverse adultpsychiatric inpatient sample; (2) to ascertain theassociation between self-reported education andstandardized intelligence scores; (3) to determinethe correspondence between different standardizedmeasures of intelligence, where data were availablefor this sample; and (4) to provide clinical implica-tionls for the findings obtained.

METHODSSetting

The Hawaii State Hospital (HSH) is a 167-bedinpatient psychiatric hospital in the State of Hawaiilocated on the island of Oahu. It is the only public,adult, inpatient psychiatric facility serving the Stateof Hawaii. The hospital beds of the HSH are distrib-uted within seven inpatient units. The psychiatricintensive care unit (PICU), a locked admission unit,is composed of 12 beds with the potential for 2-to-Istaffing for psychotic, disorganized, assaultive indi-viduals who do not have orders for treatment withinvoluntary medications. WAhen stabilized, patientsmay be moved to a 24-bed, locked step-dowrn unitfor further stabilization before transfer to the nextlevel of care in the remaining 5 units. A 24-bed,locked geriatric unit provides long-term care forolder persons with dementing illness and behavioralproblems. Another 24-bed, locked unit provides in-tensive care for patients with personality disordersand a forensic history. Two locked units with a com-bined total of 48 beds comprise a behaviorally ori-ented, psychosocial, rehabilitation program. Theonly open unit is a 36-bed unit with an intensivepsychosocial rehabilitation program based upon aHawaiian cultural model termed the Kulia Program,wvhich means striving for excellence.

ParticipantsAll patients on the open psychosocial rehabilita-

tion unit (N = 36) and all patients on the step-downunit (N = 24), the usual referral source to the open,psychosocial rehabilitation unit, comprised the sam-

48 JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION VOL. 94, NO. 1, JANUARY 2002

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ple. In gener-al, the average len-gth of stay on thestep-down Unlit is 30 days and the average length ofstay on the open psychosocial rehabilitation unit is14 months.

Patients were categorized into the following eth-nic groups: Asian = Japanese, Chinese, Korean, Fil-ipino, or Vietnamese; Hawaiian/Pacific Islan-der =

Hawaiian, part-Hawaiian, Samoan, or Tongan;White = those of only White heritage; and "other"= Portuguese, African American, or three or moreheritages (e.g., Hawaiian, PortuLguese, Native Amer-ican, and African Amnerican).

All patients had attained clinical stability at thetime of transfer to either the step-down uinit or theopen, psychosocial rehabilitation unit. At the timeof assessment, all patients were on stable medica-tions (that included antipsychotic and mood stabi-lizers) and the majority of patients were stable dur-ing their evaluation. Only a few patients were sopsychotically disorganized that they were unable toanswer specific questions about their educationalattainmenit and to sustain attention sufficiently toparticipate in a psychological assessment. Intelli-gence testing data were not available for only sevenpatients due to their refusal to be tested or to theirpsychotically disorganized state.

MeasuresEach patient admitted to the HSH receives a

series of assessments by a psychiatrist, nutr-se, socialworker, and psychologist. Within the first 14 days ofadmission, psychological testing is attempted. If thepatient is cooperative and consents to the interview,psychological testing is completed. If tolerated, theWechsler Adult Intelligence Test-Revised (WAIS-R)" is administered. An alternative is the KaufmanBrief Intelligence Test (K-BIT) "'-a much briefer,but valid measure of IQ.3 If there is substantialconcern that cultural factors may invalidate the re-sults of the WAIS-R or K-BIT due to the level ofEnglish comprehension or other cultural vari-ables, "1-'2 the Test of Nonverbal Intelligence, 2ndEdition (TONI-2) is routinely administered.'3 Theclinical condition of the patient may also result inuse of the TONI-2. If the patient's clinical conditionprevents the completion of the psychological assess-ment on the PICU unit, then the evaluationi is com-pleted after transfer to the step-down unit, usuallywithin 6 weeks of admission. Twvo psychologistscover the acute admissions at the PICU and one

psychologist covers the step-down uinit. All psychol-ogists are doctorally prepared in clinical psychologyor cotunseling psychology.

The following information were extracted fromthe medical records of the patients: age, gender,ethnicity, diagnoses, self-reported education (innumber of grades completed and number of semes-ters of college completed), and results of the intel-ligence testing. The data were obtained from thepsychiatric, nursing, social work, and psychologicalassessments completed upon admission. The differ-ent professional disciplines that inqtuired about thepatient's self-reported education- were recorded aswell.

Eduicational level was determined by patient self-report. As a validation of the self-reported educa-tion data, family members of 10 patients (6%) of thesample were contacted and all confirmed the edu-cational level reported by these 10 patients.

ProceduresThe charts of all patients on the two units were

extracted during a 1-week period in November of1998.

Statistical AnalysesSubsequent to the description of the sample, the

percent of professionals who obtained the patients'eduLcation level was calculated for psychologists, psy-chiatrists, nurses, and social workers. To determinethe association between education level and the IQmeasures, Pearson correlations were calculated be-tween education level and all IQ scores. Similarly,correlations were computed between the TONI-2and all WAAIS-R IQ measures.

RESULTSA total of 60 charts were reviewed from the 36-

bed, open psychosocial unit, and the 24-bed, closedreferral unit. Only 4 patients in the sample werewomen. The 30 patients who were 20 to 39 years ofage constituited 50% of the sample. These patientshad the following ethnic breakdown (% based ontotal sample of 60 patients): Asian (N 11; 18%),Hawaiian/Pacific Islander (N = 9; 15%), White(N= 6; 10%), and other (N = 4; 7%). Among theremaining 30 patients who were 40 to 59 years inage, the racial composition was as follows: Asian(N= 9; 15%), Hawvaiian/Pacific Islander (N= 8;13%),WArhite (N= 6; 10%), and other (N= 7; 12%).


EDUCATION AND IQ

Table 1. Comparison of Percentage of Racial Groups forthe Hawaii State Hospital Sample vs. State of Hawaii

HawaiiState Hospital

Racial group (N = 60) State of Hawaii

Asian 33% 35%Hawaiian and 28% 21%

Pacific IslanderWhite 20% 22%Other 19% 22%Total 100% 100%

Table 1 presents the percentage of each racialgroup in the sample and for the State of Hawaii. Ingeneral, Hawaiians and Pacific Islanders wereslightly over-represented at the HSH.

Table 2 presents the frequency and percent ofpatients with Axis I diagnoses for the open unitversus the step-down unit. Thirty-five percent (N =21) of the sample with schizophrenia, schizoaffec-tive disorder, or bipolar disorder, were also polysub-stance dependent (i.e., alcohol, marijuana, crystalmethamphetamine, and/or cocaine). Although thepercentages of schizophrenic, schizoaffective or bi-polar, and organic or substance disorders were notstatistically different when comparing the open unitversus the step-down unit (X2[2] = 1.32, p = .52),more patients on the step-down unit (N= 6) werediagnosed with psychosis not otherwise specified.Because the step-down unit was the transition unitfrom the acute admission unit, this was not an un-expected finding.

Seventy-two percent (N = 43) of the sample re-ported completing a high-school education or be-yond; 28% (N= 17) had less than an 11th gradeeducation. When intellectual functioning basedupon psychological testing was assessed, 34% (N=20) of the sample were found to have IQs of 100 orhigher. Fifteen percent (8 of 53) of the patients withhigher education had WAIS IQs in the extremelylow or borderline range. For this population, thiswas not an unexpected finding, and could be atleast partially due to a history of head trauma orchronic polysubstance abuse for years with its toxiceffect. Nine patients had required special educationclasses and had not completed the equivalent of ahigh-school education or had less than a sixth gradeeducation.

Although the educational level of each patientwas obtained by each psychologist who completed

IQ testing (100%; N = 53), only 68% (N = 39) ofpsychiatrists, 63% (N = 38) of nurses, 58% (N = 33)of social workers, and 54% (N = 31) of psycholo-gists completing the initial assessments recordedpatients' educational level. Current reading levelwas assessed in only three patients. These patientshad an occupational therapy assessment, which in-cluded an evaluation of current reading and arith-metic skills.

Association Between Education and IQGiven the relatively small Nsize, correlations be-

tween education and IQ measures were completedfor a group combining Hawaiians, Pacific Islanders,and Asians, and for a group of all subjects (Table 3).For the entire sample, the correlations between ed-ucation and IQ were all in the moderate (0.44-0.59) range, with the coefficient between educationand the K-BIT being the highest but nonsignificantdue to the small N size of 11; all other correlationswere statistically significant. For the group consist-ing of Hawaiians, Pacific Islanders, and Asians,slightly lower correlations were obtained with theexception of the coefficient between education andthe TONI-2. The correlation between educationand the WAIS-R Verbal IQ was the only statisticallysignificant relationship, with the association be-tween education and the WAIS-R Full Scale IQ andbetween education and the TONI-2 approachingsignificance (p = 0.057). The stronger relation be-tween education and verbal ability was expectedgiven the reliance on verbal language skills for suc-cessful performance in both domains.

Data were also available on the correspondencebetween the TONI-2 and the three WAIS-R IQ mea-sures. As displayed in Table 3 for the entire sampleand for the group consisting of Hawaiians, PacificIslanders, and Asians, substantial correlations (r '0.83) were obtained that were all statistically signif-icant.

DISCUSSIONThese data are limited by the sample size which

resulted in small numbers for each of the culturalsub-populations. This study does provide initial dataon the most reliable IQ tests to use with multi-cultural populations who are bilingual, some withEnglish as a second language. The investigation wasdesigned as a pilot study to assess the extent towhich this state hospital was effectively utilizing data


EDUCATION AND IQ

Table 2. Comparison of Axis I Diagnosis By Psychiatric Unit

Open unit Step-down unit Total

Axis I diagnosis N % N % N %Schizophrenia 13 * 36% 6* 25% 19 32%Schizo-affective or bipolar 14* 39% 9* 37% 23 38%Organic or substance disorders 9 25% 9 37% 1 8 30%Total 36 100% 24 100% 60 100%

*Category contains patients with dual diagnosis of substance abuse and another Axis diagnosis (N = 21; 35% of thesample).

from the initial, multi-disciplinary, assessmnents of itspatients upon admissions.

The assessment of educational level is important.Inpatients who are asked to provide informed con-sent for the medications that they take and thetreatments that they receive need to understand theinformnation that they are given. Increasing empha-sis has been placed on the active participation ofpatients in treatment planning. The language usedby therapists in individual and group sessions as wellas the language used during treatment planningsessions must be adjusted to the educational level ofthe patient. A patient from Vietnam, China, or thePhilippines may have completed a high-school edu-cation in their country of origin. If their currentEnglish language skills are at the seventh gradelevel, explanations in English should be at a seventhgrade level or below. Where preferable, a bilingualprofessional translator my be indicated.

This study provided additional documentation ofthe fact that clinicians of all mental health disci-plines are inconsistent in their obtaining pertinenthistorical information. Incomplete information oneducation attainment can result in inappropriatetreatment referrals and can contribute to misdiag-

nosis. In addition, the formnal assessment of IQ inculturally diverse populations is important to avoidmislabeling a given patient as having mild mentalretardation or cognitive slowing because the pa-tient's knowledge of English language usage andAmerican societal customs is developing. IQ testingdocumenting the intellectual capacity of the patientaids the treatment team in its communication withthe patient. Further, discharge planning can indi-cate specific activities to include formal languageeducation and acculturation experiences to enablethe patient to function at his or her maximum po-tential. The discharge planning and the expectedability to effectively manage financial resources(e.g., social security disability insurance benefits)will need readjustment for the patient who is read-ing at a seventh grade level and has math skills at athird grade level. Thus, knowledge of educationallevel influences communication with the patientabotit the patient's treatment. Formal IQ testingprovides formal documentation of the patient's in-tellectual capacity that aids in both inpatient treat-ment planning and in effective discharge planning.

Survival skills refer to the ability of an individualfrom another culture to enter a new culture and

Table 3. Correlations Between Education and IQ Measures By Group

All subjects Hawaiians, Pacific Islanders, & Asians

Education TONI-2 Education TONI-2

IQmeasures r p N r p N r p N r p NWAIS-R full scale 0.465 0.011 29 0.912 <0.0001 12 0.445 0.057 19 0.908 <0.0001 10WAIS-R performance 0.436 0.042 22 0.888 0.001 10 0.298 0.281 15 0.894 0.003 8WAIS-R verbal 0.590 0.004 22 0.832 0.003 10 0.556 0.031 15 0.845 0.008 8TONI-2 0.475 0.040 19 0.484 0.057 16K-BIT 0.591 0.056 11 0.375 0.534 5


EDUCATION AND IQ

obtain the basic requirements of life: food, clothing,and shelter. Having attained these, is the personable to establish new relationships, become a part ofa community, and obtain healthcare as needed?Communication is an essential survival skill, partic-ularly in a new culture as well as the ability to com-prehend the formal communication of the new cul-ture. Persons with higher levels of education have awider repertoire of survival skills so that reportededucational attainment in the country of origin canaid the clinician in assessing the probable func-tional capacity of the patient. The advantage of IQtesting to the clinician is that it provides baselinedata about the cognitive capacity that the patientpossesses to understand the role of psychiatric pa-tient, to function within the structure of an inpa-tient setting, and to transition to the role of outpa-tient working toward reintegration into the largercommunity-initially, as a person recovering from amental illness and, subsequently, as a student,worker, and/or community member.

Given these perspectives, it is a concern that onlypsychologists consistently assessed educational at-tainment during their initial interview with the pa-tient. In this setting, each discipline (psychiatry,psychology, nursing, and social work) completes aseparate initial assessment of each patient. The ratefor other professionals (i.e., psychiatrists, nurses,and social workers) ranged from 54% to 68%. Di-rect measures of reading and math achievementwere assessed for only three of the inpatients byoccupational therapists. Although the possibility ex-ists that educational attainment was not assesseddue to the belief that such data are not valid, espe-cially when self-reported by patients who are se-verely mentally ill, family members corroboratedthe patients' self-reports (on a sub-sample of 10participants), and moderately positive correlationsbetween educational attainment and IQ measuressuggested that the self-reported education levelswere valid for this sample. In addition, given theimportance of formal educational attainment to in-formed consent and treatment planning, a moresystematic effort may be needed to assess and toutilize such data.

The overall positive relationship between self-re-ported education and standardized IQs confirmedthat higher levels on one measure were associatedwith higher scores on the other for this adult psy-chiatric inpatient sample. The occurrences of non-significant findings were primarily due to low statis-

tical power. The comparable correlations betweeneducation and the WAIS-R Verbal IQ for bothgroups may have reflected the emphasis on verballanguage skills in our educational system. The highcorrespondence between the TONI-2 and WAIS-RIQ measures suggested that both tests were valid inthe assessment of intellectual functioning for thissample. Given that the TONI-2 is a brief and easilyadministered IQ test relative to the WAIS-R, consid-eration should be given to the use of the TONI-2 inculturally diverse populations such as this sample.However, the slightly lower correlations betweeneducation and the WAIS-R Performance IQ andbetween education and the K-BIT, indicated theneed for further research in this area (e.g., largersample size).

Comprehensive individualized assessment com-pleted by professionals with expertise in psychiatry,nursing, social work, and psychology provides animportant database for treatment planning. Thepresent study underscored the potential need forsystematic assessment of educational achievement,including self-reported grade-level completion,standardized reading and math achievement, andstandardized intelligence measures. The need maybe magnified for patients who have less than agrade-school education, who required special edu-cation, or who are recent immigrants to the UnitedStates. Further research is needed to determine thedirect and indirect links between educational andintellectual abilities with negative symptomatologyand functional life-skills outcomes, as well as thevalidity of educational and intellectual tests for cul-turally diverse populations.

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