Psychology, Public Policy, and Law 2004, Vol. 10, No.

1/2, 3170

Copyright 2004 by the American Psychological Association, Inc. 1076-8971/04/$12.00 DOI: 10.1037/1076-8971.10.1-2.31

PRAGMATIC PSYCHOLOGY, FORENSIC MENTAL HEALTH ASSESSMENT, AND THE CASE OF THOMAS JOHNSON Applying Principles to Promote Quality
Kirk Heilbrun
Drexel University and Villanova School of Law

David DeMatteo
University of Pennsylvania

Geoffrey Marczyk
Widener University Pragmatic psychology provides the opportunity to address the laws demand for individualized justice in the context of forensic mental health assessment (FMHA; K. Heilbrun, 2001). This article describes a particular approach toward achieving this goal: using broad principles of FMHA to promote the quality of forensic assessment in a specic case. Three particular applications of this approach are described: constructing forensic reports, measuring report quality, and measuring the normative characteristics of forensic reports. Each is discussed and illustrated in the context of the case report of Thomas Johnson, which is based on a genuine case but sanitized and otherwise disguised to prevent identication of the defendant or participants.

The eld of forensic mental health assessment (FMHA) has witnessed signicant advances during the past 2 decades. Such advances have been seen in (a) an increasingly sophisticated recognition of the laws demands (Grisso, 1986; Melton, Petrila, Poythress, & Slobogin, 1997); (b) the development of empirically validated tools to assist in the evaluation of individuals on legal questions such as adjudicative competence (Poythress, Monahan, Bonnie, & Hoge, 1999), competence to consent to treatment (Grisso & Appelbaum, 1998), and forensically relevant issues such as response style (Frederick, 1997; Rogers, 1992) and violence risk assessment (Monahan et al., 2000; Quinsey, Harris, Rice, & Cormier, 1998; Webster, Douglas, Eaves, & Hart, 1997); and (c) the development of specialty guidelines for ethics and practice (American Psychological Association, 1994; Committee on Ethical Guidelines for Forensic Psychologists, 1991). One of the enduring conicts between law and the behavioral sciences, however, involves the use of individual cases to advance knowledge. The laws focus on individualized justice and the inclination of behavioral science researchers to study participants across multiple characteristics and outcomes makes it difcult to use a highly relevant source of dataindividual forensic case reportsto systematically gather information from this source in a meaningful way.
Kirk Heilbrun, Department of Psychology, Drexel University and Villanova School of Law; David DeMatteo, Treatment Research Institute, University of Pennsylvania; Geoffrey Marczyk, Department of Psychology, Widener University. Correspondence concerning this article should be addressed to Kirk Heilbrun, Department of Psychology, Drexel University, Mail Stop 626, 245 North 15th Street, Philadelphia, Pennsylvania 19102-1192. E-mail: kirk.heilbrun@drexel.edu

31

32

HEILBRUN, DEMATTEO, AND MARCZYK

In this article, we consider how pragmatic psychology (Fishman, 1999, 2000) can be applied, using recently derived principles of FMHA (Heilbrun, 2001), toward several purposes: (a) using principles to guide the construction of a single case report, (b) measuring the quality of a single case report, and (c) gauging the normative aspects of forensic case reports.

Pragmatic Psychology in the Context of FMHA

Pragmatic psychology, as espoused by Daniel Fishman, attempts to satisfy the demands of empirical procedure and the interpretations of individual behavior by integrating the two approaches (Fishman, 1999, 2000). Fishman (1999, 2000) advocated such an approach to forensic psychology, suggesting that this approach holds promise for improving the quality of forensic practice (Slobogin, 2003). More specically, Fishman (1999, 2000) proposes that (a) forensic evaluators adopt an approach that relies on both empirical base rate and case-specic information and (b) forensic case reports and their respective legal outcomes should be computerized in a database and subject to peer review (Slobogin, 2003). Such case studies could then serve as sources of information for courts, attorneys, researchers, and forensic practitioners. One way to accomplish each of Fishmans (1999, 2000) goals is to use a core set of principles relevant to FMHA that transcends legal questions, forensic issues, and discipline (Heilbrun, 2001). The use of such principles in a single forensic case will demonstrate how both idiographic (case-specic) and nomothetic (group-based) data can be used. Applying such principles collectively can demonstrate how normative and qualitative data may be obtained from a database of forensic reports, serving as a guide for individual case report construction and the improvement of overall quality and the development of policy to promote such quality (Heilbrun, 2001).

Principles of FMHA
A relatively recent question in the eld of FMHA concerns whether there are common principles that can be applied to the shared features of different kinds of FMHA. Several researchers and scholars have addressed this issue in recent years, although their analysis was largely limited to a discussion of principles that would be applicable to the specic types of FMHA being described in their respective works (e.g., Greenberg & Brodsky, in preparation; Melton et al., 1997). Melton et al. (1997) devoted a single chapter to recommended procedures that are specically relevant to psychological testing in FMHA, and Greenberg and Brodsky (in preparation) describe a number of components of a model for forensic examinations in the area of civil forensic psychological assessment. In a recent book, however, Heilbrun (2001) described a broader set of principles that are applicable to all types of FMHA. These principles incorporated the guidelines offered by Melton et al. (1997) and Greenberg and Brodsky (in preparation). They were described in great detail, as they were the focus of the entire book. Subsequently, Heilbrun, Marczyk, and DeMatteo (2002) demonstrated how these broad principles of FMHA can be applied to various types of FMHA across a range of legal questions in civil and criminal contexts. Before briey

FMHA PRINCIPLES

33

describing each of these principles, however, we summarize their derivation and organization. It was initially suggested (Heilbrun, 2001) that identifying broad principles applicable to all kinds of FMHA would serve three important functions. First, identifying principles that are applicable to all types of FMHA is important in training forensic clinicians, as a broad principles model would offer a generalizable approach to FMHA, and it would allow the subsequent development of specic expertise in particular kinds of FMHA. Second, identifying broad principles of FMHA could facilitate research and theory development in forensic assessment. Finally, identifying principles of FMHA could promote the improvement of policy and practice in the eld. The identication of a core set of principles could assist in the shaping or interpretation of legislation or administrative regulations relevant to performing or using forensic assessments, and it could also assist in the development and implementation of court or agency policy intended to improve the quality of FMHA (Heilbrun, 2001). As may be seen in Appendix A, Heilbrun (2001) identied and described 29 broad principles of FMHA. These were organized around the four broad steps within the forensic assessment: (a) preparation, (b) data collection, (c) data interpretation, and (d) communication. Each principle was discussed in terms of its support from sources of authority in ethics, law, science, and standards of practice. The major sources of authority in ethics were the ethical standards for psychology (The Ethical Principles of Psychologists and Code of Conduct; American Psychological Association, 1992), the ethical guidelines most applicable to forensic psychology (The Specialty Guidelines for Forensic Psychologists; Committee on Ethical Guidelines for Forensic Psychologists, 1991), the ethical standards for psychiatry (The Principles of Medical Ethics with Annotations Especially Applicable to Psychiatry; American Psychiatric Association, 1998), and the ethical guidelines for forensic psychiatry (The Ethical Guidelines for the Practice of Forensic Psychiatry; American Academy of Psychiatry and the Law, 1995). Support from law was analyzed with reference to relevant federal case law (particularly from the Supreme Court of the United States and the federal appellate courts), federal statutes, and federal administrative regulations. Such support also included descriptions of model mental health law, such as the Criminal Justice Mental Health Standards (American Bar Association, 1989). Scientic support was analyzed by examining the existing empirical literature in the behavioral sciences. Finally, the analysis using standards of practice considered the extent to which the principle is recognized by various authorities as important, good, or useful for the practice of FMHA. On the basis of the analysis using these sources of authority, Heilbrun (2001) classied each principle as either established (largely supported by research, accepted in practice, and consistent with ethical and legal standards) or emerging (supported in some areas, with mixed or absent evidence from others, or supported by some evidence, with continuing disagreement among professionals regarding their application). Established principles are most appropriately viewed as principles that will change little as the eld matures, whereas emerging principles are seen as those that may change considerably with further development of theory, empirical research, and developments in case law and forensic

34

HEILBRUN, DEMATTEO, AND MARCZYK

practice (Heilbrun, 2001). Each of these 29 FMHA principles are summarized briey below.

Identify Relevant Forensic Issues

This principle concerns the relevant capacities and behaviors that are evaluated as part of an FMHA. This principle notes the distinction between the legal question, which is the ultimate matter to be decided by the court, and the relevant forensic issues, which are the capacities and abilities that are included within the legal question. This principle was considered established.

Accept Referrals Only Within Area of Expertise

This principle is based on the widely accepted professional tenet that mental health professionals should have sufcient expertise in a particular area to provide a service in that area. It describes forensic expertise as having two components: (a) clinical and didactic training and experience with populations similar to the individual(s) being evaluated and (b) previous application of this expertise in a forensic context. The principle was considered established.

Decline the Referral When Evaluator Impartiality Is Unlikely

This principle is based on the importance of evaluator impartiality when a forensic clinician provides an evaluation and possibly testimony; it emphasizes the importance of declining to accept a case when there is something about the clinicians personal beliefs or the circumstances of the case that could signicantly interfere with the attempt to remain impartial throughout that particular evaluation. This principle was considered established when the forensic clinician is either court appointed or an expert for the defense, prosecution, or plaintiff, but it was considered neither established nor emerging when the forensic clinician assumes the role of consultant.

Clarify the Evaluators Role With the Attorney

This principle addresses the problem of the evaluators assuming multiple roles in a given FMHA case and the potentially harmful impact of playing more than a single role in a single case. It suggests that it is cleanest to play only one role in a given FMHA case. The principle was considered emerging.

Clarify Financial Arrangements

It is important to clarify (in advance) the rate or total amount of billing for services and how the fee will be collected. This principle applies whenever the nancial arrangements for FMHA are not specied in law or policy, as they are in some jurisdictions in court-ordered cases. This principle was considered established.

Obtain Appropriate Authorization

Depending on the role being played by the forensic clinician in a particular case, the forensic clinician may need to obtain authorization from the court or from the retaining attorney and client. If the forensic clinician assumes the role of

FMHA PRINCIPLES

35

court-appointed expert, a signed order from the court is needed. When the forensic clinician assumes the role of expert for the defense, prosecution, or plaintiff, the forensic clinician must obtain authorization from both the referring attorney and the individual being evaluated. This principle was considered established.

Avoid Playing the Dual Roles of Therapist and Forensic Evaluator

This principle emphasizes that assuming the roles of both therapist and forensic evaluator with the same individual in a given FMHA case creates signicant problems and should be avoided. This principle was considered established.

Determine the Particular Role to Be Played Within Forensic Assessment if the Referral Is Accepted
Forensic clinicians should select a role to be played at the beginning of the case and maintain that role throughout the case, according to this principle. This can prevent problems of various kinds that result from diminishing the forensic clinicians impartiality, and it can help ensure that the expectations of the attorney and the forensic clinician are comparable. There is one potential exception to this general rule, which involves moving from a role requiring impartiality (e.g., defense expert expected to testify) to a role in which impartiality is not needed (e.g., consultant) if it is clear from the results of the evaluation that the attorney will not request a report or testimony. However, moving from the consultants role, which does not require impartiality, to the testifying experts role, which does, would be far more difcult. This principle was considered emerging.

Select the Most Appropriate Model to Guide Data Gathering, Interpretation, and Communication
This principle underscores the importance of using an appropriate FMHA model during data collection, interpretation, and communication. The use of a model, such as those described by Morse (1978) and Grisso (1986), can be useful in structuring the selection of procedures, interpretation of results, and reasoning. It was considered emerging.

Use Multiple Sources of Information for Each Area Being Assessed

Because individuals being evaluated in legal contexts often have some incentive to distort the accuracy of their self-report, one should use multiple sources of information to assess the consistency of information across these sources. Agreement across several sources of information, such as self-report, collateral records, and collateral interviews, makes it more likely that the agreed-upon information is accurate. This principle was considered established.

Use Relevance and Reliability (Validity) as Guides for Seeking Information and Selecting Data Sources
Two criteria in the law of evidence are frequently cited for the admission of expert testimony: (a) relevance to the question(s) before the court and (b) reliability (which, when used in a legal context, refers to both psychometric

36

HEILBRUN, DEMATTEO, AND MARCZYK

reliability and validity). This principle recommends that the forensic clinician use both relevance and reliability as guides when deciding which sources of information to use, particularly when selecting which third parties to interview and which psychological tests to administer. This principle was considered established.

Obtain Relevant Historical Information

This principle recognizes that it is almost always necessary to obtain historical information about the individual being evaluated in FMHA, and it notes that such historical information is often more extensive than what may be needed in therapeutic evaluation done for diagnostic and treatment-planning purposes. This principle also emphasizes, however, that the extent to which historical information is needed depends largely on the type of FMHA being performed. For example, although some evaluations (e.g., competence to stand trial) can be completed by obtaining a reasonably focused history, other evaluations (e.g., capital sentencing) require much more detailed historical information. This principle was considered established.

Assess Clinical Characteristics in Relevant, Reliable, and Valid Ways

This principle emphasizes that the choice of which clinical characteristics to assess, and how those characteristics should best be assessed, is facilitated by using relevance and reliability as guides. This principle was considered established.

Assess Legally Relevant Behavior

This principle focuses on the capacities and behavior that are related to the specic legal question being addressed in an FMHA. The criteria of relevance and reliability are applied to determine how to assess those capacities and behavior. In some situations, for example, the forensic clinician may have the option of using a well validated forensic assessment instrument. The principle was considered established.

Ensure That Conditions for Evaluation Are Quiet, Private, and Distraction-Free
Because FMHA is sometimes conducted in settings that have a limited capacity for accommodating mental health evaluations (e.g., correctional facilities with a high emphasis on security), the forensic clinician may nd that conditions can compromise the validity of the evaluation if they are noisy, allow sensitive material to be overheard, or present other distractions. This principle addresses the balance between reasonable evaluation conditions and other inuences (e.g., security, time constraints), and it addresses the issue of when a forensic clinician should seek to improve evaluation conditions that are unacceptably poor. This principle was considered established.

FMHA PRINCIPLES

37

Provide Appropriate Notication of Purpose and/or Obtain Appropriate Authorization Before Beginning
This principle recognizes that whether the forensic clinician provides a notication of purpose or obtains informed consent before beginning the FMHA depends on the role that is being played and the nature of the associated authorization that was obtained. For example, when performing a court-ordered evaluation, the forensic clinician must provide the individual being evaluated with basic information regarding (a) the nature and purpose of the evaluation, (b) who authorized the evaluation, and (c) the associated limits on condentiality, including how the individuals information might be used. In this context, however, the individuals participation in the evaluation is not voluntary, and it would therefore be inappropriate for the forensic clinician to seek informed consent. By contrast, when an attorney retains a forensic clinician to conduct an evaluation of that attorneys client, the evaluation is voluntary, and informed consent should therefore be obtained from the individual before proceeding. This principle was considered established.

Determine Whether the Individual Understands the Purpose of the Evaluation and Associated Limits on Condentiality
Informed consent or notication of purpose, to be meaningful, must be understood by the person being evaluated. This principle describes how the evaluator can determine whether the relevant information was understood by the individual being evaluated and how the evaluator might proceed if it appears that the information was not well understood. The principle was considered established.

Use Third Party Information in Assessing Response Style

One very important aspect of FMHA is the systematic assessment of the response style of the individual being evaluated, particularly whether the individual is deliberately overreporting or underreporting relevant decits or symptoms. This principle recommends (a) using collateral documents and informants in establishing a history from multiple sources of information and (b) determining whether self-reported information is consistent with other sources and therefore more likely to be accurate. This principle was considered established.

Use Testing When Indicated in Assessing Response Style

This principle concerns the use of psychological tests and specialized measures (e.g., measures specically developed to assess malingering or defensiveness of mental disorder or cognitive impairment) in assessing an individuals response style. Because there are relatively few well validated psychological tests or specialized measures that are available for this purpose, this principle was considered emerging.

38

HEILBRUN, DEMATTEO, AND MARCZYK

Use Case-Specic (Idiographic) Evidence in Assessing Clinical Condition, Functional Abilities, and Causal Connection
This principle describes the rst of three ways that science can be applied in FMHA. It describes obtaining information that is specic to the circumstances of the case and present functioning of the individual and then making comparisons to that individuals capacities and functioning at other times. Consistent with the legal goal of individualized justice, this principle was considered established.

Use Nomothetic Evidence in Assessing Clinical Condition, Functional Abilities, and Causal Connection
The second way in which science can be applied to FMHA is through the use of empirical data applicable to populations similar to that of the individual being evaluated and by using tests and instruments that have been developed and validated on similar populations. Assessing forensic capacities using norm-referenced tools enables the evaluator and the legal decision maker to consider how similar such measured capacities are to those in known groups. This principle is particularly important for the goal of using empirical evidence to make informed legal decisions. It was considered established.

Use Scientic Reasoning in Assessing Causal Connection Between Clinical Condition and Functional Abilities
This principle analogizes certain FMHA procedures to those in a scientic study. Specically, when the results of one source of information (e.g., interview or psychological testing) are considered hypotheses to be veried through further information obtained from additional sources of information, this analogy may be useful. Additionally, when hypotheses are accepted or rejected depending on how well they account for the most information with the simplest explanation, the scientic principle of parsimony is applied. This principle was considered established.

Do Not Answer the Ultimate Legal Question Directly

This principle addresses the much-debated question of whether forensic evaluators should answer the ultimate legal questionthe legal question to be decided by the court, such as mental status at the time of the offense or child custody arrangement. There is sharp disagreement within the eld on this issue. Some assert that many judges and attorneys expect the forensic clinician to offer an ultimate opinion (which, with few exceptions, is permitted by the evidentiary laws in most jurisdictions), whereas others stress the importance of the relevant included forensic capacities but add that the ultimate legal decision, which includes moral, political, and community-value components, is not the appropriate focus for the evaluations conclusion. The debate is unresolved at present, therefore this principle was considered emerging.

FMHA PRINCIPLES

39

Describe Findings and Limits so That They Need Change Little Under Cross Examination
This principle emphasizes that FMHA ndings must be described carefully and thoroughly, supported by multiple sources of information, and with appropriate limitations explicitly acknowledged. When this is done, the forensic clinician should nd that his or her ndings do not change signicantly during cross-examination. This principle was considered established.

Attribute Information to Sources

Because a forensic assessment is, by denition, part of a legal proceeding with an adversarial component, it is important that all information in the FMHA report be attributed by source. Attributing information to its source is important both for the evaluators judgment about what information is consistent across multiple sources and for the opposing attorney or the judge to identify what information has been obtained from which sources. This principle was considered established.

Use Plain Language; Avoid Technical Jargon

The consumers of FMHA productsreports or testimony during depositions, hearings, and trialsare either legally trained (e.g., judges, attorneys) or typically without training in either the behavioral sciences or the law (e.g., jurors). Therefore, it is important to avoid using technical jargon or to dene technical terms if their use cannot be avoided. This principle was considered established.

Write Report in Sections, According to Model and Procedures

By organizing information in specic report sections, it is possible to write an FMHA report in a manner that facilitates the application of many of the principles previously described. The following sections were suggested: 1. Referral (with identifying information concerning the individual, his or her characteristics, the nature of the evaluation, and by whom it was requested or ordered) 2. Procedures (times and dates of the evaluation, tests or procedures used, different records reviewed, and third party interviews conducted, as well as documentation of the notication of purpose or informed consent and the degree to which the information was apparently understood), 3. Relevant History (containing information from multiple sources describing areas important to the evaluation), 4. Current Clinical Condition (broadly considered to include appearance, mood, behavior, sensorium, intellectual functioning, thought, and personality), 5. Forensic Capacities (varying according to the nature of the legal questions), and

40

HEILBRUN, DEMATTEO, AND MARCZYK

6. Conclusions and Recommendations (addressed toward the relevant capacities rather than the ultimate legal questions). This principle was considered established.

Base Testimony on the Results of the Properly Performed FMHA

Virtually the entire substantive basis for an experts testimony should be documented in the FMHA report. This enables the presenting attorney to use the experts ndings more clearly and effectively, the opposing attorney to prepare to challenge them, the judge to understand them, and the expert to communicate them. This principle was considered established.

Testify Effectively
This principle addresses both the substantive and stylistic aspects of expert testimony. The substantive part of expert testimony is addressed by many of the preceding principles, whereas the stylistic aspect concerns how the expert presents, dresses, speaks, and otherwise behaves, to make testimony more understandable and credible. For maximum effectiveness, both the substance and style of the expert testimony should be strong. Although both aspects are important, testimony that is substantively weak but stylistically impressive should be identied and accorded little weight if the forensic mental health professions are to contribute meaningfully to better informed legal decision making. Accordingly, this principle was considered established if both substance and style are strong, but it was considered neither established nor emerging if the testimony is based on stylistic strength only.

Discussion
Having described a recently developed body of principles on FMHA, we turn to the question of how these principles might be applied toward some of the goals set forth in pragmatic psychology. More specically, we address three topics: (a) how FMHA principles might be used to guide the construction of a single case report, (b) how the quality of such a report might be measured using these principles as quality indicators, and (c) how principles might be applied toward identifying and systematically measuring the normative aspects of forensic case reports.

FMHA Principles and Report Construction

The principles of FMHA described by Heilbrun (2001) are applicable to the entire process of forensic assessment, from the initial referral to the nal communication of results in the form of a report or testimony. Forensic reports are the most frequent tangible product of this process, and hence most amenable to the kind of systematic review proposed by pragmatic psychology. Nonetheless, not all of the 29 FMHA principles could be applied to the report itself. Inspection of these principles suggests that 22 principles seem directly applicable to report construction. These are as follows (see Appendix A): 1, 2, 6, and 8 26. Consider how each of these principles might be translated into guidelines for

FMHA PRINCIPLES

41

the practice of forensic report writing, using the report in Appendix B as an example. This translation is summarized in Table 1. Principle 1(Identify relevant forensic issues) is applied in the Identifying Information section of the report, in which treatment needs and amenability (forensic issues relevant to juvenile commitment) are cited, and it is also applied less directly by identifying the legal questions (competence to waive Miranda rights and competence to stand trial). A review of the report in light of this guideline might conclude that the rst principle was largely satised but could be improved if the evaluator had explicitly cited the forensic issues underlying the legal questions for Miranda waiver and competence to stand trial in the Identifying Information section rather than doing so only in the Competence to Waive Miranda Rights and Competence to Stand Trial sections later in the report. In accordance with Principle 2 (Accept referrals only within area of expertise), the report listed the degrees of both evaluators (Kirk Heilbrun and Allison Carter) and the board certication status of Kirk Heilbrun. Some evaluators include licensed psychologist on the letterhead or signature line. The Thomas Johnson evaluation required expertise in juvenile forensic assessment, which would be reected by training and experience with juveniles and experience with similar evaluations, as well as with licensure and board certication. The Thomas Johnson jurisdiction did not require that a Curriculum Vitae be submitted with the report or that a separate paragraph in the report address the expertise of the evaluator(s), although these would have been added if they had been required. However, the Curriculum Vitae was submitted to the referring attorney before the formal referral was made, and the experience and expertise of the rst evaluator was discussed by telephone during the initial contact. In accordance with Principle 6 (Obtain appropriate authorization), this evaluation referral was made by Thomass attorney, meaning that informed consent must be obtained. In juvenile cases, the minor can provide assent (in effect, the agreement to participate) but cannot formally consent. The attorney can serve as a substitute decision maker in the authorization of matters related to the juveniles case, therefore the attorneys referral functioned as a substitute for parental guardian consent. If the evaluation had been ordered by the court, then the defense attorney would have been notied and Thomas would have been informed of the information described in Principle 16 (Provide appropriate notication of purpose and/or obtain appropriate authorization before beginning), but neither consent (from the attorney) nor assent (from Thomas) would have been legally required to proceed with the evaluation. Principle 8 (Determine the particular role to be played within forensic assessment if the referral is accepted) is the next principle applicable to the construction of the report. There is an important distinction between the roles of advocate and impartial expert in forensic contexts. In the former role, it is not necessarily important to be impartial; the goal is to assist the attorney in winning the case. In the latter role, whether the forensic clinician has been appointed by court order or by attorney referral, impartiality is importanta report or testimony in such cases is always possible and sometimes certain. Because a report was written and submitted in this case, it can fairly be assumed that the role selected was that of impartial evaluator. This has some implications for the way the report (text continues on page 46)

42

Table 1 Guidelines for Applying Principles to Forensic Case Reports

Guidelines for application Cite legal question and forensic issues in rst section of report.

Principle Identify relevant forensic issues.

Accept referrals only within area of expertise.

Give degree and licensure, board certication status. Provide CV and summary of qualications if requested. Not directly applicable to report Not directly applicable to report Not directly applicable to report Cite basis for evaluation request (e.g., court ordered, attorney requested). Describe whether informed consent was obtained, if evaluation was not court ordered.

Illustration in Thomas Johnson report Legal questions triggering evaluation are cited in Referral Information section Relevant forensic issues are described in the following sections: Competence to Waive Miranda Rights, Competence to Stand Trial, and Treatment Needs and Amenability. Degree and board certication given on signature line CV, documenting experience and licensure, provided to referring attorney prior to evaluation

HEILBRUN, DEMATTEO, AND MARCZYK

Decline the referral when evaluator impartiality is unlikely. Clarify the evaluators role with the attorney. Clarify nancial arrangements. Obtain appropriate authorization.

Attorney requested status cited in Referral Information section Relevant information provided to Thomas and his agreement to be evaluated documented in Procedures section Agreement of his parents to be interviewed documented in Procedures section Tone of report is neither hyperbolic nor argumentative

Not directly applicable to report If report has been submitted into evidence, evaluator should be impartialtone of report should reect this.

Avoid playing the dual roles of therapist and forensic evaluator. Determine the particular role to be played within forensic assessment if the referral is accepted.

Table 1 (continued)
Illustration in Thomas Johnson report Report uses Morse model, describing clinical condition, functional abilities, and causal connection between clinical symptoms and functional decits

Principle Select the most appropriate model to guide data gathering, interpretation, and communication.

Use multiple sources of information for each area being assessed. Use data sources with demonstrated reliability and validity (when this has been researched) and that will provide information relevant to the area being assessed.

Guidelines for application Use the Morse (1978) model (mental disorder, functional abilities, and causal connection) or the Grisso (1986) model (functional, contextual, causal, interactive, judgmental, and dispositional characteristics). Obtain self-report, psychological testing data, third party interviews, and collateral records data.

Use relevance and reliability (validity) as guides for seeking information and selecting data sources.

FMHA PRINCIPLES

Obtain relevant historical information.

Information obtained from self-report, psychological testing, third party interviews, and collateral record review (see Procedures) Psychological tests used (MAYSI2, WRAT3, MMPIA) all have demonstrated reliability and validity Specialized forensic assessment tools (CMR R, CMV, and FRI) have high relevance to functional capacities as well as demonstrated reliability and validity See Procedures section for collateral documents reviewed and interviews conducted

Assess clinical characteristics in relevant, reliable, and valid ways.

Assess legally relevant behavior.

Ensure that conditions for evaluation are quiet, private, and distraction-free.

In a separate section, document the individuals history and previous functioning in areas relevant to current clinical condition and functional legal capacities. Describe clinical characteristics using measures that are reliable, valid for the purpose used, and weighed against information from collateral sources. Document information collected from multiple sources regarding the individuals functional legal capacities. Note any deviation from reasonably quiet, private, and distraction-free conditions. Describe impact on data collected.

43

Self-report and third party interviews yielded information that is weighed against that obtained from psychological testing and gauged in the context of history Self-report and third party interviews yielded information weighed against specialized testing on Miranda rights waiver Conditions at university clinic were quiet, private, and distraction free Conditions did not adversely affect data collection; no need to describe such impact (table continues)

44

Table 1 (continued)
Guidelines for application Describe elements of notication of purpose or informed consent given to individual being evaluated and to third parties who are interviewed. Illustration in Thomas Johnson report

Principle

Provide appropriate notication of purpose and/or obtain appropriate authorization before beginning.

Determine whether the individual understands the purpose of the evaluation and the associated limits on condentiality. Use third party information in assessing response style. Describe the consistency of third party information with self-reported information, and be particularly cautious about self-report when it is signicantly different from third party accounts.

Document how the individuals understanding was assessed, and to what extent he or she understood the relevant information.

HEILBRUN, DEMATTEO, AND MARCZYK

Use testing when indicated in assessing response style.

Use case-specic (idiographic) evidence in assessing clinical condition, functional abilities, and causal connection.

Administer test(s) sensitive to response style, particularly when there is concern about the accuracy of self-report. Describe the individuals clinical condition and functional legal abilities in the context of his or her history of symptoms and demonstrated capacities. Describe the results of psychological tests, structured instruments, and specialized tools validated for assessing (a) clinical condition or (b) functional legal capacities.

Use nomothetic evidence in assessing clinical condition, functional abilities, and causal connection.

Thomas was provided oral notication of purpose, description of procedures, potential uses of evaluation results, and limits on condentialityand he agreed to proceed Third-party interviewees were provided with comparable information and agreed to proceed Thomas was asked to paraphrase information concerning the evaluation, and he did so in a way that indicated a satisfactory basic understanding of this information History obtained from collateral documents and third party interviews suggested signicant history of mental health problems Self-report during evaluation did not offer exaggerated presentation of problems MMPIA administered; did not suggest signicant exaggeration or minimization of problems Detailed history of mental health functioning provided Used as context for previous and current understanding of relevant information about Miranda rights. Results of MAYSI2, WRAT3, and MMPIA described Results of CMR, CMRR, CMV, and FRI described

Table 1 (continued)

Principle Use scientic reasoning in assessing causal connection between clinical condition and functional abilities.

Do not answer the ultimate legal question. Describe ndings and limits so that they need change little under cross examination.

Guidelines for application Describe explanations for clinical condition and functional abilities that have the most supporting evidence and least disconrming evidence. When evidence is mixed or competing explanations seem comparably well-supported, say so. Present conclusions about forensic capacities but not the larger legal question(s). Be careful, impartial, and thorough in presenting data and reasoning. Consider alternative explanations.

Attribute information to sources.

FMHA PRINCIPLES

Use plain language; avoid technical jargon. Write report in sections, according to model and procedures.

Describe data so that the source(s) of any specic nding is clear. Make minimal use of technical language, and dene technical terms when they must be used. Include sections on referral information, sources of information, relevant history, clinical functioning, relevant functional legal capacities, and conclusions. Describe causal relationship between clinical symptoms and functional legal capacities.

Illustration in Thomas Johnson report Reasoning is described in the respective sections on Competence to Waive Miranda Rights, Competence to Stand Trial, and Treatment Needs and Amenability Reasoning reects most likely explanation as supported by multiple sources of information Conclusions about Thomas addressed at level of forensic capacities, not legal questions Data described in detail, and reasoning is typically explicit Alternative explanation(s) for conclusions sometimes addressed explicitly Even within single sentences, the source of each piece of information is given Minimal use of jargon throughout Sections are Referral Information, Procedures, Relevant History, Current Clinical Condition, Competence to Waive Miranda Rights, Competence to Stand Trial, Treatment Needs and Amenability, and Conclusions Decits in functional legal capacities (in Miranda waiver and competence to stand trial) are causally linked to clinical symptoms when indicated

45

Base testimony on the results of the Not directly applicable to report properly performed FMHA. Testify effectively. Not directly applicable to report Note. CV curriculum vitae; MAYSI Massachusetts Youth Screening Inventory (Grisso & Barnum, 2000); WRAT3 Wide Range Achievement Test (3rd ed.; Wilkinson, 1993); MMPIA Minnesota Multiphasic Personality InventoryAdolescent Version (Butcher et al., 1992); CMRR Comprehension of Miranda RightsRecognition (Grisso, 1998); CMV Comprehension of Miranda Vocabulary (Grisso, 1998); FRI Function of Rights in Interrogation (Grisso, 1998); FMHA forensic mental health assessment.

46

HEILBRUN, DEMATTEO, AND MARCZYK

should be constructed; if the evaluator is striving to be as impartial as possible, he or she should avoid using hyperbolic language (e.g., absolutely, unquestionably, totally) or being argumentative (appearing to advocate for an explanation without reasonably considering alternative explanations). The Thomas Johnson evaluation does not contain language that would reect either of these problems. The use of a model in FMHA (Principle 9) can help guide the evaluator at several stages. The works of Morse (1978) and Grisso (1986) offer two of the most useful models. The Thomas Johnson report uses the Morse model, describing Thomass clinical condition (reected both in his history and current presentation), functional legal abilities, and the causal relationship between the two. It also incorporates some of the elements of the Grisso model (functional and causal, which overlap with the Morse model, and contextual, in discussing the differences between Thomass performance on specialized measures presently and his knowledge and reasoning when he was being questioned by police). Multiple sources of information are very important to accurate data interpretation and reasoning in FMHA. Principle 10 suggests that information be obtained from self-report, psychological testing (particularly those tests that are sensitive to response style), record reviews, and third party interviews. The report documents the collection of information in each of these areas (see the Procedures section). Principle 11 provides a two-part test for selecting sources of information: (a) relevance to the forensic capacities being assessed and (b) reliabilityvalidity. Some sources of information (e.g., interview of individual being assessed, interviews of third parties) may not have demonstrated levels of reliability and validity but are used nonetheless because they provide information that cannot be obtained elsewhere and is highly relevant. Other tools used in the Johnson evaluation do have demonstrated reliability and validity, including the psychological tests (Massachusetts Youth Screening Inventory 2 (Grisso & Barnum, 2000), Wide Range Achievement Test (3rd ed.) (Wilkinson, 1993), and Minnesota Multiphasic Personality InventoryAdolescent Version (MMPIA)(Butcher et al., 1992)) and specialized tools (Comprehension of Miranda RightsRecognition (CMRR), Comprehension of Miranda Vocabulary (CMV), and Function of Rights in Interrogation (FRI)(Grisso, 1998)). Obtaining relevant historical information (Principle 12) provides an important context for much of the information in the subsequent clinical condition and forensic capacities sections. There was a great deal of mental health history to be reviewed in Thomass case; the multiple documents considered are itemized in the Procedures section of the report. In addition, the gathering of historical information was facilitated by third party interviews with his parents. There is some question as to what is relevant in the history of an individual such as Thomas. As may be seen in the Thomas Johnson report, our description of his history is detailedsome might even argue that it is too detailed. There are several considerations on this point. First, we suggest that the test of relevance applied in Principle 12 should be somewhat exible. Some evaluators have a style that involves providing more detail than do others, but there should be some allowance for variability as a matter of personal preference. Second, the question of relevance must be guided by the legal question and include forensic issues specic to the evaluation. An evaluation of capital sentencing mitigation, for example, which has a very broad scope, would clearly call for a broader and more

FMHA PRINCIPLES

47

detailed history than would a more focused evaluation such as competence to stand trial. Third, the selection of historical information may be guided by relevance to scientic data or practice standards, particularly when a given tool or characteristic of the individual is informed directly (or even indirectly) by the historical information presented. Finally, we suggest that evaluators consider the trade-off between prejudicial and probative that is weighed on the admissibility of evidence in legal proceedings. In this context, an evaluator might ask whether certain information is probative (helpful in establishing some aspect of history related to the forensic issues being evaluated). If the information is sensitive and potentially harmful to the defendant, then we suggest that it would need to be more clearly relevant and probative to be included than if it were not potentially harmful. A nal example should illustrate this point: A defendant being evaluated to help the court decide whether he or she should be sentenced as a violent sexual predator should be given a very detailed examination of his or her sexual history, including sexual feelings, thoughts, fantasies, and behaviors. Such historical information is arguably prejudicial but it should be included nonetheless because it is obviously probative. By contrast, a defendant being evaluated for trial competence should probably not have such information included in the review of his or her history, or cited in the report even if it should arise, because the information is potentially prejudicial but is much less relevant to the forensic capacities being considered in the evaluation of competence to stand trial. Both clinical characteristics and legally relevant behavior should be assessed in ways that are reliable and valid (Principles 13 and 14). The psychological tests administered in this case measure a relevant construct, and they have established reliability and validity. For many kinds of cases, there are no specialized forensic tools that have been developed and validated for assessing the particular forensic capacities, so evaluators must often rely on other sources of information for assessing such capacities. In Thomass case, one of the legal questions was his competence to waive his Miranda rights. In this area, such tools have been developed (CMRR, CMV, and FRI; Grisso, 1998), and these tools were administered. The conditions under which the Thomas Johnson evaluation was conducted were close to ideal: quiet, private, and entirely free from distraction (see Principle 15). This is often not true in conducting FMHA, particularly when the evaluation is performed in a secure setting. The Thomas Johnson report does not mention evaluation conditions, so the reader could infer that they were not problematic. It might be appropriate to describe briey the evaluation conditions in all reports, however, even when there is no apparent problem, so that the reader can be informed of this. Principles 16 (provide appropriate notication of purpose and/or obtain appropriate authorization before beginning) and 17 (determine whether the individual understands the purpose of the evaluation and the associated limits on condentiality) underscore the importance of determining what authorization is needed (see Principle 6), providing relevant information to the individual being evaluated, determining whether the individual understood this information, and obtaining that individuals consent (if needed). In the last paragraph of the Procedures section of the report, we note the following:

48

HEILBRUN, DEMATTEO, AND MARCZYK

Prior to the evaluation, Thomas was notied about the purpose of the evaluation and the associated limits on condentiality. He appeared to understand the basic purpose of the evaluation, reporting back his awareness that he would be evaluated and that a written report would be submitted to his attorney. Thomas further appeared to understand that the report could be used by his attorney in a competency hearing, and that if it were, copies would be provided to the prosecution and the court. Thomas agreed to proceed with the evaluation. Thomass mother and stepfather were also notied regarding the purpose of the evaluation and the possible legal applications of the report, and they agreed to be interviewed.

This notication documents that Thomas was informed of the purpose of the evaluation, its possible uses, and the limits of condentiality, and that he agreed to proceed. The third parties interviewed as collateral informants (in this case, Thomass parents) were also informed of the purpose of the evaluation and the absence of condentiality associated with their comments (specically, that they would be quoted by name in the report). The language in the report also indicates that Thomas appeared to understand the relevant information; his understanding was gauged by the information he was able to repeat back and paraphrase concerning the notication. To the extent that practice guidelines based on these principles call for the relevant information to be provided to those being evaluated (and interviewed as collaterals), their understanding of this information assessed, and both areas documented in the report, these guidelines are met by the reports language. There was a great deal of third party information available in this case. As suggested in Principle 18, this information was considered in assessing Thomass response style. Thomass history was clearly consistent with the presence of signicant mental health problems, which had been diagnosed and treated on multiple occasions. Thomas was in treatment at the time he was interviewed by the police regarding one of his alleged offenses, which provided the unusual opportunity to interview a mental health professional regarding concurrent observations of an individual at a specic time in the past. The history did not appear consistent with any attempt to fabricate or exaggerate symptoms, nor did Thomass presentation during the evaluation suggest that. Instead, the convergence of information from multiple sources strongly indicated that Thomas was presenting his symptoms and capacities accurately. If this nding had been less consistently supported, the evaluation might have included a specialized measure (in addition to the MMPIA) to assess response style (see Principle 19). Principles 20 22 call for the application of different kinds of scientic evidence and reasoning in the forensic assessment. The application of idiographic, case-specic evidence (Principle 20) is particularly useful in legal contexts, given the importance of individualized justice. Such idiographic evidence includes historical and present data that reect the individuals capacities and their functioning, allowing comparisons between how the individual now behaves and how he or she is capable of behaving. Nomothetic evidence, by contrast, uses tests and tools that have been validated on groups of individuals in similar populations, allowing the evaluator to place the performance of the individual being evaluated in the context of this larger group, often expressed as a category or a percentile derived from the score on a test or tool. Provided that the test is relevant to the

FMHA PRINCIPLES

49

forensic issue and has been derived and validated for the purpose for which it is applied, it can add nomothetic evidence that makes the evaluation much stronger. Finally, the use of scientic reasoning (Principle 22) concerns the development and testing of hypotheses regarding forensic issues, with every effort to consider all reasonable hypotheses and to test them through applying multiple sources of information and gauging which hypothesis seems better supported. There has been ongoing controversy in the eld about whether FMHA should address primarily forensic issues or should also include an opinion about the ultimate legal question. Principle 22 recommends the former, and conclusions about Thomas are addressed in the report at the level of forensic issues rather than ultimate legal questions. Considering the ongoing (and unresolved) disagreement in the eld about the ultimate legal question, however, this principle was considered emerging rather than established (Heilbrun, 2001) and would not be weighed as heavily in ratings of report quality as would most of the other principles. The data and reasoning in a forensic mental health report should be thorough, well documented, and reect a consideration of reasonable alternative explanations. When evaluations are conducted and reports written in this way, the evaluator should expect to concede relatively little on cross-examination (Principle 24). However, there will be information presented in the report that can be highlighted in cross-examination. By considering alternative explanations in a thorough fashion, the evaluator will inevitably provide some information that is inconsistent with the reports nal conclusions. This may be seen at various places in Thomass evaluationfor example, in the contrast between his relatively asymptomatic condition at the time he was evaluated and his apparently more severe symptoms at particular times in the past. Information should be attributed by source in virtually every sentence (Principle 25). This makes the report more laborious to write and difcult to read, but it has the important advantage of allowing the reader to learn the precise source(s) of information for each piece of information that is cited. This in turn allows the opposing attorney to prepare to challenge the ndings, which is an ethical consideration in forensic assessment (Committee on Ethical Guidelines for Forensic Psychologists, 1991). This is evident in the Thomas Johnson report. For the most part, technical language is not necessary to convey most ndings and reasoning in FMHA. Indeed, the use of such language can be counterproductive, as it can impair the clarity of communication with those who are not trained in the mental health professions and medical or behavioral sciences. Principle 26 (Use plain language; avoid technical jargon) stresses the importance of communicating almost exclusively in language that does not require technical expertise to understand. In the Thomas Johnson report, there is minimal use of technical language. Finally, it is useful to write the report in sections (Principle 27), using the model and procedures described in the previous principles. The sections in the Thomas Johnson report conform closely to the general recommended template that includes Referral Information, History, Clinical Condition, Forensic Capacities, and Conclusions. This allows the reader to follow the development of context and the progression from history to current clinical condition and their causal relationship to forensic capacities. Each of these 22 principles could be readily translated into a guideline. The

50

HEILBRUN, DEMATTEO, AND MARCZYK

result would be a set of criteria that could be applied toward conceptualizing, teaching, and constructing forensic evaluation reports. In the next section, we address the potential application of these principles in the form of quality indicators for FMHA. Many important practice questions can be identied by applying principles in this way, but such questions will often need to be addressed through research. For example, the nature and depth of an individuals understanding of the forensic assessment process can be estimated only by the procedure used in the Thomas Johnson report. Development of a structured tool (Grisso & Appelbaum, 1998), similar to that created to measure competence to consent to treatment, would make this estimation more meaningful and the communication of results more reliable.

FMHA Principles as Measures of Report Quality

Just as the principles identied in the previous section could be used to shape the writing of forensic reports, they could also be applied toward measuring the quality of existing reports. Several studies have been conducted on the characteristics of forensic reports; these are described in more detail in Nicholson and Norwoods (2000) article. However, apparently only one study (Petrella & Poythress, 1983) applied a systematic set of criteria in the attempt to measure the quality of forensic evaluations. Using the FMHA principles cited in this article would represent an expansion and updating of their pioneering work. Because rating the characteristics of forensic reports requires the use of variables that can be rated from a written document, the set of principles described in the previous section would also be those applied toward rating existing reports. Issues of interrater reliability would need to be addressed for items requiring judgment; relevant questions would include the nature of the rating (e.g., whether it should use two-category ratings such as mostly or entirely yes vs. mostly or entirely no as contrasted with three-category ratings allowing an intermediate option). The systematic development of quality ratings can proceed following the resolution of such methodological considerations. Various congurations of quality ratings are possible. From the broadest to the most specic, these include an overall global rating of quality, summed ratings on principles that are grouped conceptually (e.g., data collection procedures) or empirically (on factors derived through factor analysis), or individual principle-level ratings. Such data could be collected across multiple evaluators and jurisdictions, as we discuss in the next section. They could also be obtained for a single individual evaluator over time, perhaps as one measure of performance improvement over the duration of a training period. The interpretation of quality ratings in the context of performance becomes most meaningful when it can be made both over time (for the same evaluator) and across different evaluators, reports, and jurisdictions.

FMHA Principles as Indicators of Normative Report Characteristics

One goal in pragmatic psychology is systematically collecting work samples (reports) for availability to researchers and practitioners. Such data could be used to develop a large normative database of quality measures of FMHA reports,

FMHA PRINCIPLES

51

using principles as quality indicators in ways that we discussed in the previous two sections. A reasonably large and representative database that used reliable and valid measures of FMHA quality could have useful implications for training, practice, and policy related to forensic assessment. It could provide a range of existing quality and generate additional validation research on how consumers of forensic assessment (judges and attorneys) would rate reports that are measured at different levels of quality. It could offer guidance for courts or entire jurisdictions exploring the question of how to generate the highest quality forensic evaluations. It could also serve to guide policy makers and legislators in decisions concerning resources, time, and associated quality in forensic assessment. There remain signicant challenges before such a database could become a reality. We discuss several: representativeness and generalizability, differential availability of reports depending on referral source (e.g., judge vs. private attorney), the unit-of-analysis problem, consent, privilege and condentiality to the extent applicable, and whether reports will be sanitized or otherwise altered to protect privacy (and, if so, how that would affect the database). The question of how reports would be sampled is very important. Without some version of random sampling (or perhaps stratied random sampling, to accommodate representation from various jurisdictions), it would be difcult to generalize accurately from the database to a given jurisdiction. Random sampling, particularly in sizable numbers and using a product as sensitive as forensic assessments, would in turn create a daunting, expensive logistical task. Nonetheless, the extent of the databases generalizability would be directly linked to the successful implementation of a randomized sampling design, so the effort and expense would be essential. In a related vein, the differential-access problem will quickly be encountered. Some FMHA reports describe the result of court-ordered evaluations, whereas other are referred by attorneys. Reports are sometimes not presented (or even written) in the latter group, making them more difcult to obtain. Unless a reasonable sample of reports of this kind can be obtained and included in the report database, however, generalizability is again limited accordingly. The unit-of-analysis problem refers to the reality that some jurisdictions feature forensic evaluations performed by a reasonably large group of forensic clinicians, whereas others have most of the reports done by a relatively small number of individuals. If the report were considered to be the unit of analysis, then its author could be disregardedthe goal is to provide a representative sample of FMHA reports, even if most of them in a given jurisdiction are done by one or two individuals. However, if the forensic clinician were considered to be the unit of analysisif we wished, for example, to know what percentage of psychologists never perform projective testing in forensic assessmentthen a review of reports without regard to author would provide a misleading answer, biased in favor of the practice of forensic clinicians who conducted more frequent evaluations. One resolution of this problem is to retain information that allows analyses to be conducted, using either the report or the clinician as the unit of analysis, but this would require some unique identier for the evaluating clinician. This leads to a discussion of the next challenge: consent. From whom should consent be obtained to include a report in a large database? One might consider multiple possibilities: the individual being evaluated; his or her attorney; the

52

HEILBRUN, DEMATTEO, AND MARCZYK

judge; the forensic clinician performing the evaluation; and the hospital, practice, agency, or university of which the clinician was a part. The cost of obtaining multiple consents, particularly after the case has concluded (which would be the only reasonable time to consider for including a report in this database), is very signicant. However, if genuine case reports are to be used, then the important legal question of privilege and the related ethical issue of condentiality must be resolved to the satisfaction of all who would contribute to the database. One alternative to obtaining consent to include genuine, unaltered reports is to sanitize them (removing and altering identifying information) or even hybridize them (combining different cases while seeking to preserve the basic data and reasoning from the original case; see Heilbrun, Marczyk, & DeMatteo, 2002). Although this might lessen some concerns regarding privilege and condentiality, it would also create problems for using the database to obtain a representative view of how forensic reports are actually being presented. The creation of a database of forensic evaluation reports, as envisioned by pragmatic psychology, faces both immediate and long-term challenges. The immediate challenges appear resolvable. Using a database to provide guidance on the systematic measurement of FMHA quality, as well as examples of reports of varying quality, can be achieved on a relatively small scale and would still have signicant benets for clinicians in training and those seeking to enhance their competence in forensic assessment. The use of such a database for research purposes faces stiffer challenges, some of which have been discussed in this section. If such challenges could be overcome, however, the development of a database and its associated capacity to answer questions concerning procedures, characteristics, and quality in reports on various forensic issues, across a range of jurisdictions, would provide a tremendous contribution to behavioral science and law.

References
American Academy of Psychiatry and the Law. (1995). Ethical guidelines for the practice of forensic psychiatry. Bloomeld, CN: Author. American Bar Association. (1989). Criminal justice mental health standards. Washington, DC: Author. American Psychiatric Association. (1998). The principles of medical ethics with annotation especially applicable to psychiatry. Washington, DC: Author. American Psychological Association. (1992). Ethical principles of psychologists and code of conduct. American Psychologist, 47, 15971611. American Psychological Association. (1994). Guidelines for child custody evaluations in divorce proceedings. American Psychologist, 49, 677 680. Butcher, J. N., Williams, C. L., Graham, J. R., Archer, R. P., Tellegen, A., Ben-Porath, Y. S., & Kaemmer, B. (1992). Manual for administration, scoring, and interpretation: MMPEA. Minneapolis: University of Minnesota Press. Committee on Ethical Guidelines for Forensic Psychologists. (1991). Specialty guidelines for forensic psychologists. Law and Human Behavior, 15, 655 665. Fishman, D. (1999). The case for pragmatic psychology. New York: New York University Press. Fishman, D. (2000, May 3). Transcending the efcacy versus effectiveness debate: Proposal for a new, electronic Journal of Pragmatic Case Studies. Prevention

FMHA PRINCIPLES

53

& Treatment, 3, Article 8. Retrieved May 20, 2002, from http://journals.apa.org/ prevention/volume3/pre0030008a.html. Frederick, R. (1997). Validity Indicator Prole manual. Minneapolis, MN: National Computer Systems. Greenberg, S., & Brodsky, S. (in preparation). The civil practice of forensic psychology: Torts of emotional distress. Grisso, T. (1986). Evaluating competencies: Forensic assessments and instruments. New York: Plenum Press. Grisso, T. (1998). Instruments for assessing and understanding appreciation of Miranda rights. Sarasota, FL: Professional Resource Press. Grisso, T., & Appelbaum, P. S. (1998). MacArthur Competence Assessment Tool for Treatment (MacCATT). Sarasota, FL: Professional Resource Press. Grisso, T., & Barnum, R. (2000). Massachusetts youth screening instrumentSecond version: Users manual and technical report. Worcester: University of Massachusetts Medical School. Heilbrun, K. (2001). Principles of forensic mental health assessment. New York: Kluwer Academic/Plenum. Heilbrun, K., Marczyk, G., & DeMatteo, D. (2002). Forensic mental health assessment: A casebook. New York: Oxford University Press. Melton, G., Petrila, J., Poythress, N., & Slobogin, C. (1997). Psychological evaluations for the courts: A handbook for mental health professionals and lawyers (2nd ed.). New York: Guilford. Monahan, J., Steadman, H. J., Appelbaum, P., Robbins, P., Mulvey, E., Silver, E., et al. (2000). Developing a clinically useful actuarial tool for assessing violence risk. British Journal of Psychiatry, 176, 312319. Morse, S. (1978). Crazy behavior, morals, and science: An analysis of mental health law. Southern California Law Review, 51, 527 654. Nicholson, R., & Norwood, S. (2000). The quality of forensic psychological assessments, reports, and testimony: Acknowledging the gap between promise and practice. Law and Human Behavior, 24, 9 44. Petrella, R. C., & Poythress, N. (1983). The quality of forensic evaluations: An interdisciplinary study. Journal of Consulting and Clinical Psychology, 51, 76 85. Poythress, N., Monahan, J., Bonnie, R., & Hoge, S. K. (1999). MacArthur Competence Assessment ToolCriminal Adjudication. Odessa, FL: Psychological Assessment Resources. Quinsey, V., Harris, G., Rice, M., & Cormier, C. (1998). Violent offenders: Appraising and managing risk. Washington, DC: American Psychological Association. Rogers, R. (1992). Structured Interview of Reported Symptoms. Odessa, FL: Psychological Assessment Resources. Slobogin, C. (2003). Pragmatic forensic psychology: A means of scientizing behavioral anecdata? Psychology, Public Policy, & Law, 9, xxxxxx. Webster, C., Douglas, K., Eaves, D., & Hart, S. (1997). HCR-20 : Assessing risk for violence (Version 2). Burnaby, British Columbia, Canada: Mental Health, Law, and Policy Institute, Simon Fraser University. Wilkinson, G. S. (1993). Wide Range Achievement Test (3rd ed.). Itasca, IL: Riverside Publishing.

(Appendixes follow)

54

HEILBRUN, DEMATTEO, AND MARCZYK

Appendix A Principles of Forensic Mental Health Assessment (Heilbrun, 2001)

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. Identify relevant forensic issues. Accept referrals only within area of expertise. Decline the referral when evaluator impartiality is unlikely. Clarify the evaluators role with the attorney. Clarify nancial arrangements. Obtain appropriate authorization. Avoid playing the dual roles of therapist and forensic evaluator. Determine the particular role to be played within forensic assessment if the referral is accepted. Select the most appropriate model to guide data gathering, interpretation, and communication. Use multiple sources of information for each area being assessed. Use relevance and reliability (validity) as guides for seeking information and selecting data sources. Obtain relevant historical information. Assess clinical characteristics in relevant, reliable, and valid ways. Assess legally relevant behavior. Ensure that conditions for evaluation are quiet, private, and distraction-free. Provide appropriate notication of purpose and/or obtain appropriate authorization before beginning. Determine whether the individual understands the purpose of the evaluation and the associated limits on condentiality. Use third party information in assessing response style. Use testing when indicated in assessing response style. Use case-specic (idiographic) evidence in assessing clinical condition, functional abilities, and causal connection. Use nomothetic evidence is assessing clinical condition, functional abilities, and causal connection. Use scientic reasoning in assessing causal connection between clinical condition and functional abilities.

FMHA PRINCIPLES

55

23. 24. 25. 26. 27. 28. 29.

Do not answer the ultimate legal question. Describe ndings and limits so that they need change little under cross examination. Attribute information to sources. Use plain language; avoid technical jargon. Write report in sections, according to model and procedures. Base testimony on the results of the properly performed FMHA. Testify effectively.

Appendix B Evaluation of Thomas Johnson

The following evaluation was conducted by Kirk Heilbrun and a graduate student under his supervision in the MCP Hahnemann University Department of Psychology Forensic Clinic. The report is based on genuine material but has been altered in several important ways. First, all potentially identifying information (i.e., names, places, and dates) has been changed to prevent the defendant or any of those involved in the case from being identied. Second, the report has also been hybridizedsome features of the case described in the report were actually observed in other cases rather than this one. However, the latter alteration was done while making every effort to preserve the integrity of the data and reasoning described in the original evaluation.

Forensic Evaluation
January 21, 2001 Re: Thomas Johnson Juvenile # 99 881

Identifying Information
Thomas Johnson is a fourteen-year-old Caucasian male (DOB: 5/4/86) who is currently charged with Possession of Weapons on School Property, allegedly occurring between March and April of 1999. He was previously charged with Indecent Assault, allegedly occurring on 10 19 00, and that remains an active case. A request for a mental health evaluation to provide the defense with information relevant to Thomass competence to waive his Miranda rights at the time he was interrogated on the Indecent Assault charge, his present competence to stand trial, and his treatment needs and amenability in the context of public safety, pursuant to Pennsylvania Code, was made by Thomass attorney, Andrea Jacobs, Esq.

Procedures
Thomas was evaluated for approximately 5 hours on 1/4/01 at MCP Hahnemann University in Philadelphia, Pennsylvania. In addition to a clinical interview, Thomas was administered a structured screening instrument for adolescent symptoms of mental and

56

HEILBRUN, DEMATTEO, AND MARCZYK

emotional disorders (the Massachusetts Youth Screening Inventory 2, or MAYSI2), a standard test of current functioning in relevant academic areas (the Wide Range Achievement Test [3rd ed.], or WRAT3), a standard test of mental and emotional functioning in adolescents (Minnesota Multiphasic Personality InventoryAdolescent Version, or MMPIA), and several tests which measure capacities to understand and appreciate Miranda rights (the Comprehension of Miranda Rights, or CMR; Comprehension of Miranda Rights Recognition, or CMRR, the Comprehension of Miranda Vocabulary, or CMV, and the Function of Rights in Interrogation, or FRI). In addition, Thomass stepfather, Mr. Karl Peters, was interviewed for approximately 45 minutes at MCP Hahnemann University on 1/5/01, and Thomass mother, Ms. Ann Peters, was interviewed via telephone on 1/6/01 for approximately 30 minutes and again on 120 01 for another 30 minutes regarding Thomass history and current functioning. Finally, Thomass therapist, Andrew Walters, M.A., was interviewed on 222 01 for approximately 25 minutes regarding Thomass mental health history. The following documents, obtained from the defense attorney, were reviewed as part of the evaluation: (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13) (14) (15) (16) Court of Common Pleas, 7th Judicial District, Juvenile Petitions (dated 6/12/ 99, 10/27/00), Court of Common Pleas, 7th Judicial District, Allegation/Complaint (dated 6/11/99), Handwritten Statement by Thomas Johnson (dated 6/13/99), Juvenile Division, Charge Sheet (dated 6/14/99), Transcript of Detention Hearing (dated 6/14/99), Court of Common Pleas of Jackson County, Transcript of Proceeding (dated 7/18/99), Court of Common Pleas of Jackson County, Juvenile Division, Court Order (dated 7/18/99), Police Notice of Disposition (dated 7/18/99), Court Orders (dated 6/14/99, 3/2/00, 3/31/00, and one undated), Superior Court of Pennsylvania Briefs (dated 3/31/00, 4/15/00), Opinion, Superior Court of Pennsylvania (dated 12/12/01), Commonwealth of Pennsylvania, County of Jackson, Summons (dated 12/4/01), Wales School District, Comprehensive Evaluation Report (dated 11/17/00), Notices of Recommended Assignment (dated 2/22/00, 6/22/99, 10/20/94, 4/2/93), Individualized Education Program Reports (dated 2/22/00, 5/7/99, 10/31/98, 9/25/94, 4/29/93), Central Academy, Comprehensive Evaluation Reports (dated 1/10/00, 9/5/97),

FMHA PRINCIPLES

57

(17) (18) (19) (20) (21) (22) (23) (24) (25) (26) (27) (28)

Comprehensive Reevaluation ReportParent Agreement (dated 5/2/99), Childrens Service Center, Psychological Evaluations prepared by Andrew Walters, M.A. and John Eaves, M.A. (dated 3/20/00, 6/27/99), Psychological Evaluation prepared by David Hart, Ph.D., and Steve Cook (dated 2/5/00), Jackson County, Psychological Evaluation prepared by Samuel Cates, M.A. (dated 12/20/99), Psychiatric Assessment prepared by Stanton Giles, M.D. (dated 12/11/99), Psychiatric Evaluation prepared by James Law, M.D. (dated 6/22/ 99), Pediatric Neurology Center Outpatient Notes (dated 12/30/99), Pediatric Cardiology Outpatient Notes (dated 12/17/99), Central Academy, Monthly Assessments (dated 1/31/00, 11/9/99), Central Academy, Individual Service Plan Agreements (dated 1/2/00, 8/6/99), Central Academy, 3 Month Review (dated 10/2/99), Central Academy, 6 Month Review (dated 12/19/99),

(29) Central Academy, Education Program Information and Report (dated 12/17/99), (30) (31) (32) (33) (34) (35) (36) (37) (38) (39) (40) (41) (42) (43) Regional Hospital of Utah Valley Psychiatric Assessment (dated 8/13/95), Regional Hospital of Utah Valley, Discharge Summaries (dated 10/28/91, 8/24/92, 9/1/92, 7/17/93, 8/13/95, 9/26/95), Childrens Hospital, Diagnostic Summary (dated 11/15/93), Childrens Hospital, Psychiatric Update (dated 11/14/93), Childrens Hospital, Biopsychosocial Summary (dated 10/29/93), Childrens Hospital, Psychiatric Evaluation (dated 9/10/93), Childrens Hospital, Discharge Summary (dated 11/19/93), St. Marys Hospital, Discharge Summary (dated 6/26/94), St. Marys Hospital, Social Assessment (dated 7/7/94), St. Marys Hospital, History and Physical Record (dated 6/3/94), Harrison General Hospital, Final Narrative Summary (dated 4/25/95), Harrison General Hospital, Social Service Discharge Summary (dated 4/9/95), Harrison General Hospital, History and Physical Report, (dated 3/31/95), Harrison General Hospital, History and Physical Report (dated 3/31/95),

58

HEILBRUN, DEMATTEO, AND MARCZYK

(44) (45) (46)

Childrens Treatment Center, Psychological Evaluations (dated 9/28/93, 12/ 24/94, 5/3/96, 8/17/96, 10/23/97, 2/19/98, 8/28/98), Childrens Treatment Center, Psychiatric Evaluations (dated 8/19/93, 10/10/ 93, 9/4/94, 4/27/96, 7/29/97), and Childrens Treatment Center, Psychological Re-evaluation, dated 3/17/00.

Prior to the evaluation, Thomas was notied about the purpose of the evaluation and the associated limits on condentiality. He appeared to understand the basic purpose of the evaluation, reporting back his awareness that he would be evaluated and that a written report would be submitted to his attorney. Thomas further appeared to understand that the report could be used by his attorney in a competency hearing, and, if it were, copies would be provided to the prosecution and the court. Thomas agreed to proceed with the evaluation. Thomass mother and stepfather were also notied regarding the purpose of the evaluation and the possible legal applications of the report, and they agreed to be interviewed.

Relevant History
Historical information was obtained from the collateral sources noted in the previous section as well as from Thomas. Whenever possible, we have assessed the consistency of self-reported information with that obtained from collateral sources. If further information is obtained prior to Thomass hearing, a supplemental report will be led. Family history. Thomas Johnson was born in Wilmington, Delaware to Ms. Jody Peters and Mr. John Stallone. He has one younger half sister, Sarah Johnson (4 years old), and one younger stepsister, Annie Peters (10 years old). Thomas reported that his parents never married and that they separated when he was approximately 2 years old. He stated that he has seen his father a couple of times but that he has not had a relationship with his father since his parents separated. According to the St. Marys Hospital Social Assessment (dated 7/7/94), Ms. Peters abused alcohol until Thomas was 18 months old, when she decided to stop drinking and leave Mr. Johnson. The Social Assessment also indicates that Ms. Peters then moved from New Jersey to a drug and alcohol halfway house in Pennsylvania. During this time, according to the Social Assessment, Thomas spent more time with other relatives than with either her or Mr. Johnson. According to the Biopsychosocial Summary (dated 10/29/93), Thomas lived with Ms. Peterss sister for one month while she received treatment for both substance and alcohol abuse. Thomas reported that he has been told that his father drank heavily and that he has been incarcerated several times for drug-related offenses. Thomas reported that Ms. Peters dated several men after she and his father separated. When Thomas spoke of Sarahs father, he stated, I didnt like him at all because he raped my mother. Ms. Peters reported that she began dating Mr. Peters in 1996 and that they were married in 1998. Currently, Thomas reported that he lives with his mother, stepfather, and half-sister in Levittown, Pennsylvania. He also stated that his stepsister visits every other weekend and on some holidays. When asked to describe himself as a child, Thomas stated that he was mostly good but sometimes bad. He explained that he was trouble a lot and has been hospitalized for bad behavior many times. When asked to elaborate, Thomas reported that he has always been hyperactive and that he used to have difculty following his mothers rules and instructions. Thomas reported that he was easily frustrated and would throw tantrums. Thomas was vague in his reports of specic bad behaviors or in describing instances during which he was hyperactive. However, Thomas did report that he would often ght with his mother when they argued. He stated that once, when his mother grabbed him after he had been running from her, he kicked her, which resulted in her arm breaking.

FMHA PRINCIPLES

59

Ms. Peters reported that Thomas was an extremely hyperactive child who was difcult to control. She stated that he had difculty sitting still, even when watching television at the age of three. Mr. and Ms. Peters reported that Thomas was also aggressive during his childhood. For example, Mr. Peters reported that Thomas would break things around the house and put holes in doors. Both Mr. and Ms. Peters reported that Thomass behaviors have improved in some respects as he has gotten older. They explained that Thomas is no longer physically aggressive. However, they both also reported that Thomas is now more argumentative and belligerent and that Thomas continues to have difculty controlling impulsive behaviors (e.g., stealing items from the home). Overall, Mr. Peters reported that Thomass behavioral problems continue to require a lot of supervision by both mother and stepfather. Thomas reported that he has good relationships with his family members. He stated that he is able to get along with his mother better than when he was younger and that he is no longer aggressive towards her. Thomas described Mr. Peters as being a father gure to him, stating that he has a very good relationship with Mr. Peters. Ms. Peters reported that Thomas and Mr. Peters spend a lot of time together (e.g., going to hockey games and watching football). Thomas also reported that he has a good relationship with his sister, Sarah. He stated that he sometimes plays games or Barbie dolls with Sarah and that they rarely argue with one another. According to Ms. Peters, however, Thomas often agitates Sarah, teasing her, keeping her from going where she wants, or ignoring her when she is nice to him. Regarding his relationship with his stepsister, Tory, Thomas reported that he is able to get along with her, although he does not know her as well since they are such different ages, have different interests and friends, and because they do not live together. Ms. Peters described Thomas and Torys relationship as a love hate relationship. She explained that they are either inseparable or they hate each other. Thomas denied any prior experience of being physically abused. However, according to the Childrens Treatment Center Psychiatric Evaluation (dated 8/19/93), a report was led in 1993 indicating that the treatment team suspected child abuse against Thomas by Ms. Peters. Also, in 1996, a case manager was apparently assigned to the family because of four indicted counts of child abuse against Thomas, according to the Childrens Treatment Center Psychological Evaluation (dated 5/3/96). Regarding sexual abuse, Thomas indicated that a 10-year-old boy in respite care coerced him into engaging in sexual behaviors when he was approximately 7 or 8 years old. When asked to elaborate, Thomas reported that he could not remember the incident but also reported that the boy was not forceful with him. Educational history. Thomas reported that he attended one elementary school (Utah Valley West) and one middle school (Jefferson) before his commitment to Central Intermediate Secured Unit (Central) in July of 1999 (described below). Regarding his performance in elementary and middle school, Thomas reported that he made good grades (As and Bs) and was rarely absent. However, Thomas also reported that his behavior was bad, which resulted in his being placed in emotional support classes when he was in the rst grade. Thomas explained that he was often involved in ghts with peers and that he argued with teachers. Mr. Peters also reported that Thomas was often in trouble for such behaviors as ghting, being disrespectful to and argumentative with teachers, teasing others, and other aggressive behaviors, such as poking a classmate with a pencil. Both Thomas and Mr. Peters reported that Thomas has been suspended a number of times because of his behavior problems. Thomas indicated that he has occasionally been placed in regular classes; however, because of his continued behavior problems, he has largely continued to be returned to emotional support classes. Following his release from Central, Thomas began the 9th grade at Wales High School in August of 2000. Ms. Peters reported that Thomas had difculties adjusting to Wales. Specically, she described Thomas as very anxious during the rst week, stating

60

HEILBRUN, DEMATTEO, AND MARCZYK

that he became physically ill (i.e., vomiting) each afternoon during the rst week of school. Ms. Peters also reported that Thomas was mainstreamed into regular classes for four months, which was the longest period during which he had ever stayed in regular classes. However, because of his behaviors (e.g., talking back to teachers, lateness, refusing to do work), Ms. Peters reported that Thomas was returned to emotional support classes. Thomas reported that his last report card was good (Bs and Cs), with the exception of Science, in which he made an F. Ms. Peters reported that Thomas has not received any suspensions during this school year, although she reported that Thomas has received many detentions for lateness and for talking back to teachers. Also, in October of 2000, Thomas was expelled for bringing weapons to school (his current charge). Thomas reported that he is supposed to begin school at Upper Moreland High School this week because of his familys recent move to Levittown, Pennsylvania. When asked, Thomas stated that he was somewhat nervous about attending a new school but that he thought he could handle the change because several of his friends attend Upper Moreland. Medical history. Ms. Peters reported that Thomas was born one month premature by Caesarian section. She stated that Thomas had uid in his lungs, which resulted in his staying in neonatal care for several days after he was born. According to the St. Marys Hospital Social Assessment (dated 7/7/94), Ms. Peters reported that she drank during pregnancy but when Thomas was tested for Fetal Alcohol Syndrome the results were negative. Also, according to this Social Assessment, Ms. Peters reported that Thomas was given neurological tests to test for the possibility of a seizure disorder and that his EEG was borderline. More recently, according to Clinic Notes from the Pediatric Neurology Center (dated 12/17/99 and 12/30/99), Thomas was given cardiology and neurology examinations; results of both examinations were both described as within normal limits. Thomas reported a history of several injuries and hospitalizations. The rst, according to Thomas, occurred when he was approximately 3 or 4 years old, when he fell off a couch and hit his head while playing with his mother. He stated that he was hospitalized for several days because of a broken skull in the back of his head. According to Ms. Peters, Thomas had been walking backwards when he banged his head on the back of the couch. She described the wound as a surface wound and stated that Thomass scalp was treated with staples. Ms. Peters reported that Thomas was not hospitalized overnight and did not have any signicant difculties as a result of this incident (e.g., concussion). Thomass second reported injury occurred at the age of 12 years, when he fell out of a tree and hurt his knee. Both Thomas and Ms. Peters stated that Thomas was hospitalized for several hours and that he had stitches. Thomass most recent injury occurred while he was detained in Jackson County Detention Center at the age of 13 years. He stated that another resident had stabbed him in the chest with a sharpened toothbrush when they were playing basketball. Thomas reported that he required no stitches for this incident and that he was released from the hospital after a few hours. Thomas also reported that he has had many surgeries on his eyes, beginning at the age of six. According to Ms. Peters, Thomas had two surgeries in 1992 for a lateral strabismus of the right eye. Thomas reported that he continues to have difculty seeing because of his problems with his eyes. Psychiatric history. Thomas has an extensive psychiatric history. Ms. Peters stated that she rst took Thomas to the doctor when he was three years old because he couldnt stay still and could not sleep for longer than two or three hours at a time. According to the Childrens Treatment Center Psychiatric Evaluation (dated 4/27/96), Thomass rst contact with mental health professionals occurred in March of 1990, at the age of 3 years and 11 months, subsequent to complaints from his mother that he had become more aggressive, was throwing tantrums, and had difculty sitting still. The evaluation also indicates that Thomas was diagnosed in 1990 with Attention-Decit/Hyperactivity Disorder (ADHD) and Developmental Disorder NOS; it was recommended that Thomas be placed

FMHA PRINCIPLES

61

in the partial hospital program of the Childrens Treatment Center. Also, according to the psychiatric evaluation, Thomas was given a psychological evaluation in August 1990, which showed that he performed in the Average range of intellectual functioning. Thomas was released from the partial hospital program in May 1991 to enter the YMCA summer program and kindergarten in the fall, according to the psychiatric evaluation. Ms. Peters reported that Thomas continued to receive psychiatric treatment at the Childrens Treatment Center throughout his early childhood. She reported that Thomas received a variety of diagnoses and medications, including Ritalin for hyperactivity and Benadryl for his sleeping difculties. Ms. Peters also reported that Thomass behavior continued to worsen, however, which required a number of hospitalizations and partial hospitalizations (or respite care) over the years, which are described below. According to the Regional Hospital of Utah Valley Discharge Summary (dated 10/28/91), Thomas was admitted for his Regional inpatient psychiatric hospitalization on 9/28/91, when he was 512 years old. The Summary indicates that his admission was prompted by an escalation in behavioral problems (e.g., engaging in behaviors that could lead to injury, hitting and kicking his mother, and throwing household items). At the time of discharge, Thomas was diagnosed with ADHD and prescribed Imipramine. Thomass second inpatient psychiatric hospitalization, according to the Regional Hospital of Utah Valley Discharge Summary (dated 8/24/92), occurred on 7/16/92, when he was six years old. The Summary indicates that he was admitted because of such behaviors as cruelty to others (i.e., throwing rocks at daycare workers), threatening to urinate on other children, shouting profanities, and hitting himself. According to the Discharge Summary, Thomas was diagnosed with ADHD but was not prescribed medication when he was discharged. Thomass third inpatient psychiatric hospitalization, according to the Regional Hospital of Utah Valley Discharge Summary (dated 7/17/93), occurred on 6/2/93 when he was seven years old. The Discharge Summary indicates that this hospitalization was due to continued aggressive behaviors (e.g., breaking windows, striking people, damaging property with a bat), sleeping difculties, and mood disturbances and uctuations. At the time of discharge, Thomas was diagnosed with Conduct Disorder and ADHD and was prescribed Clonidine and Benadryl. Approximately one month after his discharge from Regional Hospital, Thomas was seen for an emergency psychiatric evaluation at the Childrens Treatment Center, according to the Childrens Treatment Center Psychiatric Evaluation (dated 8/19/93). At that time, Ms. Peters complained that she was fearful that a family member would be hurt if Thomas stayed in their home overnight. According to the psychiatric evaluation, Thomas had been in respite care for two days prior to the emergency evaluation. This evaluation recommended that Thomass respite care continue for another week and that the family begin participation in an intensive home-based family treatment program. Thomas was diagnosed with ADHD and provisionally with Depressive Disorder and Childhood Schizophrenia. According to the Childrens Treatment Center Psychological Evaluation (dated 9/28/93), Thomass level of intellectual functioning was estimated to be in the Borderline range, although this estimate was believed to be low because of behavior problems during testing. Also, according to this psychological evaluation, Thomas was diagnosed with ADHD, Depressive Disorder, and Anxiety Disorder; his medications at the time included Haldol, Cogentin, Clonidine, and Atarax. Thomas was seen again for an emergency evaluation on 10/10/93, according to the Childrens Treatment Center Psychiatric Evaluation (dated 10/10/93). At that time, Thomas was diagnosed with Intermittent Explosive Disorder, ADHD, and Specic Developmental Disorder, NOS. According to the Childrens Hospital Psychiatric Evaluation (dated 10/10/93), Thomas was voluntarily admitted to the Childrens Hospital following this emergency evaluation. Thomas remained hospitalized at this facility until 11/19/93,

62

HEILBRUN, DEMATTEO, AND MARCZYK

according to the Childrens Hospital Discharge Summary (dated 11/19/93). The Discharge Summary indicates that Thomas had difculty adjusting to a different hospital, as evidenced by displays of anxiety which manifested itself in self-induced vomiting episodes that lasted for approximately a week. According to the Discharge Summary, Thomas eventually participated well in treatment, as did his mother through frequent phone sessions (she apparently lived too far away to visit frequently for family sessions). At the time of discharge, Thomas was diagnosed with Intermittent Explosive Disorder, ADHD, and Specic Developmental Disorder, NOS; his medications were Dexedrine Hydrocholoride and Vistaril. Thomass fth inpatient psychiatric hospitalization occurred on 6/2/94, according to the St. Marys Hospital Discharge Summary (dated 6/26/94), and was due to impulse control problems, hyperactivity, depression, and some thinking disorder. According to the St. Marys Hospital Social Assessment (dated 7/7/94), Thomas had exhibited a variety of aggressive behaviors, including destroying his room, cutting off a cats whiskers, threatening his mother with a knife and scissors, hiding knives throughout the home, and setting a couch on re. The St. Marys Hospital Discharge Summary (dated 6/26/94) indicates that Thomas received intensive individual psychotherapy and group therapy during this hospitalization. Also, upon discharge, Thomas was diagnosed with ADHD and was prescribed Dexadrine, Tofranil, and Mellaril, according to the discharge summary (according to St. Marys Hospital Discharge Summary [dated 6/26/94]). Thomas was hospitalized for a sixth time on 3/28/95, according to the Harrison General Hospital Report of Final Narrative Summary (dated 4/25/95), due to violent, uncontrollable behavior at home. The narrative summary indicates that during his hospitalization, Thomas tried to act tough to impress the older peers by telling them that he tortured birds, poisoned a cat, and ran away. The narrative summary also indicates that Thomas was hyperactive and deant. Upon discharge, according to the narrative summary, Thomas was diagnosed with Atypical Depression and Hyperkinetic Conduct Disorder, with Bipolar Disorder to be ruled out; his medications were Ritalin, Tegretol, Vistaril, and Clonidine. Thomass seventh inpatient psychiatric hospitalization, according to the Regional Hospital of Utah Valley Psychiatric Assessment (dated 8/13/95), occurred on 9/13/95 and was due to violence towards peers and adults (e.g., punching and kicking peers and his mother, threatening to kill his mothers fetus) as well as reports that he was hearing voices. According to the Regional Hospital of Utah Valley Discharge Summary (dated 9/26/95), Thomas showed mood lability, angry outbursts, antagonism to limit-setting, and poor response to redirection. Upon discharge, Thomas was diagnosed with ADHD, Atypical Bipolar Disorder, and Conduct Disorder; his medications were Mellaril, Hydroxyzine, and Dexedrine. According to Ms. Peters, Thomas continued to receive outpatient psychiatric treatment at Childrens Treatment Center. She further reported that Thomas resided in a group home for approximately 9 months in 1995 or 1996 because of his behavioral problems. According to the Childrens Treatment Center Psychological Evaluation (dated 8/28/98), Thomas had been attending respite care on weekends prior to being admitted to the group home for nine months in 1996. The next period during which he received residential care was apparently when he was committed to Central on 7/18/99 (described in more detail later in this report). Prior to being released from Central, Thomas received a psychological evaluation to determine his treatment needs upon his discharge and transition back into the community (i.e., Childrens Treatment Center Psychological Re-evaluation, dated 3/17/ 00). Thomas was described in this evaluation as argumentative with Central staff and, during the interview, as anxious, having restricted affect, lacking in impulse control, and experiencing delusions of grandeur and of unrealistic control by others. According to the psychological re-evaluation (dated 3/17/00), Thomas met criteria for Schizoaffective

FMHA PRINCIPLES

63

Disorder, Bipolar Type. It was recommended in this evaluation that Thomas continue to receive intensive treatment, preferably at a residential facility. Currently, Mr. Peters reported that Thomas has been prescribed Dexedrine for symptoms related to ADHD and Remeron for symptoms related to depression. Ms. Peters reported that Thomas takes Dexedrine but that he has not taken Remeron in a while because she did not believe the medication was effective. Substance abuse history. Thomas denied ever experimenting with or selling drugs. He reported that he drank alcohol once at a friends house. On that occasion, Thomas stated that he had several beers and tried a blue liquid he believed to be liquor. Thomas reported that he did not become drunk and added that he would never drink liquor again because he did not like the taste. Social history. Thomas reported that he has no difculty in meeting new people or in maintaining friendships. He stated that he has several friends, despite the fact that they say I dont have any and make no attempt to have any. When asked to elaborate, Thomas reiterated that he has friends at his old school (Wales) and his new school (Upper Moreland), although he did not describe any particular friendships. According to Mr. and Ms. Peters, however, Thomas has always preferred more solitary activities, such as the computer, video games, reading, and television. They also reported that when Thomas does interact with peers, he often initiates arguments with them. His mother commented that Thomas does not seem to understand others emotions or the impact he can have on others. Ms. Peters also reported that several girls have been calling the house lately but that Thomas tells his mother to tell the girls that he is not home. Also, according to Ms. Peters, Thomas has invited the girls to come over at times; however, on the day they are supposed to come over, he changes his mind and makes excuses to them. Overall, Ms. Peters reported that Thomas appears to be more comfortable interacting with Mr. Peters than with peers his age. When asked about persons with whom Thomas interacts at school, Ms. Peters reported that Thomas tends to associate with children who have been involved in juvenile offending, which she believes has worsened Thomass behaviors since he has returned from Central. For example, Ms. Peters reported that Thomas is gullible and easily manipulated and that when peers bring stolen items to school and tell him that they bought the items, Thomas readily believes them. Ms. Peters reported that Thomas has been in trouble on several occasions for selling the items (e.g., jewelry) for the peers who brought them to school. Employment history. Thomas has never been employed. He said that his future goals are to attend college and become an NFL football player. Thomas was able to describe several other career options, such as becoming a zoo operator or joining the army. In his spare time, Thomas reported, he enjoys playing football, wrestling, riding dirt bikes, playing video games, and playing and chatting on the Internet. Thomas also reported an interest in weapons, particularly from the Civil War era. He said that he enjoys going to fairs that display old weapons and collecting and selling a variety of valuable collectors weapons, such as stun guns, night sticks, switchblades, buttery knifes, and Civil War bullets and ries. According to Mr. Peters, Thomas also enjoys reading in his spare time. Juvenile history. Thomass rst arrest occurred in June of 1999, when he was charged with the Indecent Assault of his sister, Sarah. According to court transcripts (dated 6/14/99), Thomas was found delinquent and ordered to be detained for the purposes of undergoing evaluations and preparation of a treatment plan. According to the court order (dated 6/14/99), Thomas was detained at the Luzerene County Juvenile Detention Center for these purposes. On 7/18/99, Thomas was committed to Central Intermediate Secured Unit (Central), according to court transcripts on that date. Thomas reported that he did not like living at Central and added that larger boys often picked ghts with him. According to the Central 6 Month Review (dated 12/19/99), Thomas had difculty meeting several of the treatment goals, which included anger management, sex offender

64

HEILBRUN, DEMATTEO, AND MARCZYK

treatment, improvement of condence and self-esteem, and the development of appropriate decision-making and coping skills, positive peer relations, and an honest relationship with his counselor. Although he was described as having improved somewhat (e.g., requiring less physical assistance in controlling angry impulses than he had upon admission), Thomas was reported to have acted on angry impulses, agitated his peers, and lied and/or justied his behaviors to staff. When asked about his school performance while at Central, Thomas stated, I dont know, they didnt tell you. According to the Six Month Assessment, Thomas was described as deant and disrespectful in classes. However, in terms of grades, Thomas was reported to have earned one A, four Bs, and one C. Thomas reported that he was released from Central on May 3/31/00. Thomass most recent arrest occurred on 10/27/00, when he was charged with Possession of Weapons on School Grounds.

Current Clinical Condition

Thomas Johnson is a 14-year-old Caucasian male with a slender build, who appeared his stated age. He was dressed casually, wearing loose blue jeans, a long-sleeve shirt, and baseball cap, and was well groomed when seen for the evaluation on 1/4/01. Thomas reported that he has several scars: one on his right knee, which resulted from falling out of a tree at 13 years of age; one on his left knee, which resulted from falling on concrete at 8 years of age; and one on his chest, which resulted from being stabbed while held in detention when he was 13 years old. Thomas reported that he has two piercings in his left ear. He also reported that he pierced his eyebrow with a sharpened comb while in detention several months ago but that the piercings are now closed. Thomas denied having any tattoos. Thomas was cooperative and answered all of the examiners questions throughout the evaluation. His speech was clear, coherent and relevant, and he was oriented to person, place, and time. Thomass mood throughout the evaluation was largely neutral, and he showed an appropriate range of emotional expression. Thomas often appeared somewhat distracted during conversations and testing situations (e.g., looking around the room, changing the topic, asking a wide range of questions). However, Thomas was easily redirected, appeared to exhibit good effort, and, with frequent encouragement, was able to complete the tasks of the evaluation. It would appear, therefore, that the present evaluation provides a valid reection of his current functioning. Thomass basic academic skills, as measured by the WRAT3, showed decits in all areas: Reading (grade equivalent 7th grade), Spelling (grade equivalent 6th grade), and Arithmetic (grade equivalent 5th grade). Thomas worked steadily and was particularly persistent during the administration of the Reading and Spelling subsections of the WRAT3. On the Mathematics section, Thomas appeared to begin daydreaming while working on several of the problems. Thomas was easily redirected during these times, however. Thus, the results should be a valid indicator of his academic abilities. Each of these three areas should be considered to be in need of remediation. Thomas denied experiencing perceptual disturbances (visual or auditory hallucinations) and also denied the existence of any bizarre thoughts. His thought process was clear and goal directed. On a structured inventory of symptoms of mental and emotional disorders specically designed for use with adolescents (the MAYSI2), Thomas reported that he has felt lonely at times because he does not know anyone in his new neighborhood. Thomas also reported that he feels nervous at school at times because he worries about getting into trouble. When asked about becoming easily frustrated and difculties related to controlling his anger, Thomas stated, I have been trying to change that. He reported that the last time he had signicant difculties controlling his temper was when he was in Central, approximately eight months ago. Thomas reported that he is able to stop himself

FMHA PRINCIPLES

65

from behaving aggressively because its wrong. Thomas further explained that he thinks about the effects his behavior would have on his family and potential victims. Thomas completed the MMPIA as part of the current evaluation. Thomas appears to have understood the questions asked of him and to have responded in an open an honest manner. Thus, his prole appears to be valid (Welsh Code 341926:8570# K/LF:). Individuals with proles similar to Thomass typically do not report having currently experienced severe mental or emotional problems. Particularly during times of stress, however, individuals with such proles are likely to become defensive and reluctant to admit to problems. During such times, such individuals are likely to become more resistant to mental health intervention. As part of this evaluation, Thomas was screened for the presence of ADHD. Thomas reported that he has always been hyperactive and indicated that his hyperactivity have caused signicant difculties for him (e.g., frequent accidents). Thomas further reported that he has difculty sustaining attention on tasks and that he is easily distracted. These reports are consistent with the behaviors observed during the evaluation, as well as reports from Thomass stepfather, Mr. Peters, school records, and previous psychological evaluations, which indicate that Thomas has had a signicant history of symptoms related to ADHD. Thus, based on his history and self-report, Thomas appears to meet diagnostic criteria for ADHD, Predominately Hyperactive Type. Given his history of aggressive behaviors, Thomas was also assessed for symptoms of Conduct Disorder. As described above, Thomas reported being involved in, and initiating, many ghts with peers throughout his life. He also admitted to being physically aggressive towards his mother, peers, and, on one occasion, towards a pet (e.g., cutting a cats whiskers off). Although Mr. and Ms. Peters reported an improvement in Thomass behaviors since his release from Central eight months ago (e.g., he is no longer physically aggressive or violent), they also reported that Thomas has become more argumentative and belligerent, both at home and in school. Ms. Peters also stated that Thomas steals items (e.g., jewelry, money) from their home, often blames others for his behaviors, and even when he admits to misbehavior, he does not appear to show concern or to understand the impact his behaviors have on others. Overall, given his history, self-report, and reports of Mr. and Ms. Peters, Thomas appears to meet diagnostic criteria for Conduct Disorder. When asked about symptoms of affective disturbance (i.e., depression, elevated mood), Thomas reported that he has not had periods during which he has been depressed. However, Thomas did report that he has had periods of time (approximately one to two weeks) during which he becomes quite irritable and/or talks excessively, becomes more active than usual, and during which his thoughts are racing. Mr. Peters also reported that Thomas experiences episodes during which he is on the go and always talking. Mr. Peters was unable to describe very specically the frequency of these episodes. Ms. Peters also reported that Thomas has had a signicant history of sleep disturbance and periods of agitation. Overall, based on his history, self-report, and the report of Mr. Peters, Thomas appears to meet diagnostic criteria for Bipolar I Disorder, Not Otherwise Specied.

Competence to Waive Miranda Rights

Thomas was presented with each component of his Miranda rights. After each right was presented to him, he was asked to explain his understanding of the meaning and implications of each. When Thomas was asked to dene a right, he reported that a right means that you are allowed to. When Thomas was asked to explain the right to remain silent, he replied that it meant you dont have to say stuff until you talk to your lawyer. Thomas stated that if a person did not want to talk, the police should call a lawyer. When Thomas was asked if the police tried to force a person to talk, Thomas stated, I dont know . . . I guess he doesnt have to talk.

66

HEILBRUN, DEMATTEO, AND MARCZYK

Thomas was then asked to explain his understanding of the consequences of giving up the right to remain silent; that is, whether he was aware that if he gave up the right to remain silent, anything he said could be used against him in a court of law. Thomass understanding of the consequences of giving up the right to remain silent initially seemed to be more concrete. Thomas reported that if you say you didnt do it, it could be used against you in a court of law. When questioned further, Thomas eventually reported that what you say could be used as evidence to show you are a criminal. When asked what would happen if the judge found out that a person wouldnt talk to the police at questioning, Thomas stated, I dont know . . . nothing. However, Thomas reported that if the judge were to tell a person to talk about what he did that was wrong, the person would have to talk about it because they are in court. Thomas was then asked about his right to have an attorney present during the interrogation. When Thomas was asked to explain this component of his Miranda rights, he stated. when you are in court, you can have an attorney before you talk to the judge. Thomas had difculty dening the word interrogation, stating that it meant right before the court . . . when you talk to the lawyer or public defender. When presented with the various phases of the legal process (i.e., being arrested, taken to the police ofce for questioning, going to court, and being detained) and then asked when he could have an attorney during these phases, Thomas stated that he could have an attorney during questioning. Thomas was also asked about his right to have an attorney appointed to him if he could not afford an attorney. He reported, they have a public defender . . . theyll give you a public defender. When asked why a public defender would be appointed, Thomas stated, to explain your rights and defend you in court. Overall, it seems apparent that Thomas has some awareness of his Miranda rights and the way in which they would apply. Thomass reading ability, as measured by the WRAT3, is somewhat below average (grade 7 equivalent). However, according to the psychological evaluation prepared by Dr. Samuel Cates (dated 12/20/99), Thomass overall level of intellectual functioning, as measured by the Wechsler Intelligence Scale for Children (3rd ed.; WISCIII), is in the Average range (Verbal IQ 92, Performance IQ 117, and Full Scale IQ 104). Thus, it seems likely that Thomass ability to understand and communicate material that is relevant to his Miranda rights would be adequate. Results of the Comprehension of Miranda rights (CMR) and Comprehension of Miranda Vocabulary (CMV) indicate that Thomas has an understanding of the Miranda rights that is similar to others his age (CMR score 60th percentile and CMV score 53rd percentile). Further, his ability to recognize the meaning of the Miranda rights, using simpler language, is above average, when compared to others his age (CMRRecognition score 89th percentile). Finally, Thomass ability to appreciate the signicance of the adversarial nature of the relation of police ofcers, the advocacy nature of the attorney client relationship, and that the right to silence is an entitlement that cannot legally be violated were all above average, when compared to others his age (the average score for juveniles on the Function of Rights in Interrogation Scale is 23.13; Thomass score was 29). At the time of the Indecent Assault offense, Thomas was 13 years old and had no prior arrests. Thomas reported that he was not read his Miranda rights, although Ms. Peters reported that she accompanied her son to the interrogation and recalled having the rights read aloud. When asked if he remembered signing the Miranda Rights Waiver form, Thomas reported that he remembered someone telling me to write what I did on this form and to sign it. According to Ms. Peters, Thomas was read his Miranda rights and was asked to sign a form indicating that he waived his Miranda rights after she signed the waiver form. Ms. Peters reported that Thomas was anxious at the time and that she didnt think Thomas was focused on what was happening. She also reported her belief that he

FMHA PRINCIPLES

67

signed the form because she had signed the form (i.e., he said yes [to waive his rights] because I said yes). Thomas may have been signicantly more disorganized and tangential at the time he was interrogated than at the time of the present evaluation. Presently, he appears reasonably intact and stable in his mental functioning, although continuing to show some symptoms of ADHD. However, according to Andrew Walters, his observations of Thomas around the time of summer 1999, when he was interrogated, suggest that Thomas was receiving a different medication combination and was less stable. Specically, Mr. Walters observed cognitive disorganization, tangential speech, and difculty in absorbing information. If these observations are accurate, then Thomass anxiety (as observed by his mother) would have been compounded by active symptoms of a Bipolar Disorder, which would have made it much more difcult for Thomas to apply the knowledge of Miranda rights he demonstrated in a reasoned and voluntary fashion.

Competence to Stand Trial

Thomas was rst asked about the nature of his charges. He reported that he was charged with indecent assault in the spring of 1999 and a weapons charge in October 2000. Thomas was then asked about the possible penalties that could result from a conviction for these charges. Thomas responded that for charges of Indecent Assault, a person could go to jail, which he described as a bad place that is locked down all the time . . . like Juvenile Security. Thomas then explained that he heard of some people being sent to Juvenile who said that it was a 23 hours per day lock-down facility. When asked if a juvenile could be sent to an adult facility, Thomas replied, with the new laws, probably. He then explained that he had heard of a 14-year-old juvenile who had killed someone who went to an adult jail. When asked if a juvenile could be sent to an adult facility for a charge similar to his (i.e., Indecent Assault), Thomas stated, I dont know, maybe, maybe not. Thomas was then asked about the possible penalties for his Weapons charge, to which he replied, I could be sent away again, get probation, do community service. When asked if anything more serious could happen, Thomas responded, I dont know, anything can happen. It would appear, therefore, that Thomas understands that he has been charged with two offenses and could be incarcerated if he is convicted. Moreover, Thomas appears to have some understanding of the distinction between juvenile incarceration and adult incarceration. Thomas was asked to name the relevant court personnel. He reported that there is a person who types, a judge, police, and probation ofcers. With prompting, he also reported that there are lawyers. Thomas was then asked to describe the respective roles of the judge, prosecutor, and defense attorney in the adversarial context. Thomas reported that the judges job is to view the charges and to see what is a t punishment. He also reported that the judge is supposed to be honest and to do what is t and then asked, isnt there a book hes supposed to go by? Thomas reported that the defense attorneys job is to argue the case, do research . . . to get the minimum accountability, like nes or a couple of days in detention, community service, or probation. Finally, Thomas reported that the role of the district attorney is to have everything ready for the judge, to make suggestions, and to read the charges for the judge. Thomas had some difculty explaining the role of the district attorney upon further questioning, stating, shes for everybody . . . shes just there. At this point, the adversarial nature of the defendants relationship to the district attorney was explained to Thomas. He appeared to understand this explanation, reporting back that the district attorney is against you. Overall, Thomass understanding and description of the respective roles of the judge, defense attorney, and district attorney in the adversarial context appears to be limited, but reasonably accurate. Thomas was also questioned about appropriate courtroom demeanor. When Thomas

68

HEILBRUN, DEMATTEO, AND MARCZYK

was asked how he would behave in court, he reported that he would be respectful, honest, speak when necessary, and not interrupt. He also reported that if he wanted to say something to the judge, he would wait until no one was talking. Thomas then asked if there a break during which he could speak to his attorney if he wanted to say something to the judge. Thomas was then asked what he would do if he needed to tell the judge something immediately; that is, if he could not wait for a break. Thomas then reported that he would whisper to his attorney. When asked about the possibility of testifying, Thomas reported that he did not testify during the rst trial but he believed that he could do so, if needed. Thomas was able to name the possible pleas of guilty and not guilty. When Thomas was asked to explain the meaning of a guilty plea, he reported that a guilty plea is saying that you did it . . . youre responsible . . . you did the crime. Thomas reported that a not guilty plea is saying you didnt do it. When asked if a guilty person could plead not guilty, he stated, yeah, if you want to lie. Thomas was then presented with a variety of scenarios in which a guilty person might plead not guilty. Each time, Thomas stated that it was not possible to plead not guilty and not lie. Finally, Thomas was asked about his plea preference. When questioned about his plea preference for the Indecent Assault charge, Thomas reported that he pled guilty and would do so in the future; he offered a reasonable basis for this preference. Thomas also reported that he would plead guilty even if his attorney advised him to plead not guilty, however, because Id do what is right so I could get it [the sentence] over with. When asked if he would consider a not guilty plea if he was facing a much longer sentence and if the evidence against him was poor, Thomas stated, theyd still nd out . . . . and you could get sentenced longer for lying because it shows no remorse and makes them think youd do it again. Thomas was then asked about his plea preference for the Weapons charge. Thomas stated that he would plead guilty and again offered a reasonable basis for this preference. When asked about his plea preference if his attorney advised him to plead not guilty, Thomas stated, Id still plead guilty because the evidence was really good. Finally, when asked if the evidence was not good, Thomas stated, I dont know . . . part of me would want to plead not guilty and part of me wouldnt. Overall, it would appear that Thomass overall capacity to assist counsel in his own defense is somewhat limited but largely intact. Thomas has a basic understanding of the relevant aspects of the adjudicatory process, although he also has some specic decits that may interfere with his capacity to assist counsel in his own defense. These decits include difculty with attention and concentration, limited frustration tolerance, and difculty in understanding and weighing the factors involved in deciding upon a plea. It is possible, however, that these decits would not prevent Thomas from assisting counsel in his own defense if relevant information could be provided to him using simple language and concrete examples, and by discussing the possible consequences his decisions may have on the outcome of the case (including disposition and sentencing).

Treatment Needs and Amenability

There are ve areas in which Thomas has treatment/rehabilitation needs which, if addressed, may reduce his risk for future antisocial behavior. These areas include ongoing assessment and treatment for symptoms of ADHD, Conduct Disorder, and Bipolar Disorder; educational and vocational remediation; anger-management, impulse control, and other skills-based training; alcohol and substance abuse prevention and education; and family intervention. First, Thomas has a signicant history of symptoms and problems associated with ADHD, Conduct Disorder, and Bipolar I Disorder. Thomas needs ongoing assessment and

FMHA PRINCIPLES

69

treatment for these disorders, delivered in a program which can provide some degree of specialization in mental health treatment. Second, Thomas may benet from education and vocational training. Thomass basic academic skills in the areas of reading, spelling, and arithmetic are below what would be expected for a boy of his age. These decits may be the result of his problems with attention/concentration and his behavioral problems in school. Thomas clearly has several strengths, including a history of making good grades, having interests in a variety of areas, and enjoying reading in his spare time. Thomas is also able to verbalize a variety of career options that he believes would be rewarding for him. Thomass educational training and vocational remediation should be considered in the contexts of these strengths and weaknesses (including his tendency to become easily bored) and, if successful, would serve to decrease his risk for engaging in antisocial behavior in the future. Third, Thomas may also benet from anger management and other skills-based training to help him better handle everyday stressors, understand the consequences of his behavior and its impact on others, and select more adaptive ways to solve his problems. Thomas appears to become easily frustrated and have difculty controlling behavioral impulses (e.g., to steal, to agitate others, to become verbally and physically aggressive). Thomas also has a tendency to minimize his current difculties with angry feelings and behavior and has a minimal understanding of the impact of his behavior on others. Further, Thomas appears to have difculties in developing and maintaining appropriate relationships with peers his age. Specically, Thomas seems to fear developing an honest, trusting relationship with others, which apparently results in his isolating himself from others. When he does have contact with others, Thomas often becomes involved with negative peers and engages in more antisocial behavior, perhaps in an attempt to win their approval. Overall, training in anger management should focus on identifying and avoiding high risk situations that may make it more likely that he will become involved in aggressive or antisocial behavior; identifying alternative and more direct and appropriate responses to feelings of frustration, irritability, and anger; and understanding the consequences that aggressive behaviors and his minimization of these behaviors and associated feelings may have on himself and on others. One option for this type of intervention is group therapy, in which Thomass interactions with others could be observed and targeted directly. Training and treatment in this area are directly relevant to Thomass risk for future antisocial behavior. If he responds favorably to such interventions, it may serve to reduce his risk for future offending. Fourth, Thomas would benet from participation in a drug awareness/education program. Although Thomas reported that he has never experimented with any substances and has only used alcohol once, his difculties with frustration tolerance and impulsivity place him at high risk for abusing drugs and alcohol. In addition, his mother has a history of signicant substance abuse. Thus, a drug awareness/ education program may reduce Thomass chances of abusing drugs and alcohol in the future. Fifth, Thomas is in need of ongoing family intervention. Thomas clearly considers his mother and stepfather to be important and Mr. and Ms. Peters are just as clearly concerned about his welfare. However, this family has experienced a number of difculties over the past 10 years. Although the familys functioning appears to have improved as Thomas has grown older, many stressors (e.g., strained relationships, frustrations regarding Thomass misbehavior, their recent move, his current legal situation) remain. Such stressors may exacerbate Thomass emotional and behavioral problems and increase his risk for antisocial behavior, school problems, and exposure to negative peers. It would be helpful if interventions delivered in the community could be delivered across domains and involve his family to a signicant extent.

70

HEILBRUN, DEMATTEO, AND MARCZYK

Conclusions
In the opinion of the undersigned, based on all of the above: (1) Thomas appeared to understand his basic Miranda rights and how they are implemented. Thomas further appeared able to communicate material relevant to his Miranda rights, both verbally and in writing. However, at the time of the charge, Thomas was chronologically and developmentally younger, had a signicant history of emotional and behavioral problems, may have experienced active symptoms of Bipolar Disorder, and appears to have been anxious and easily inuenced by others, particularly his mother, to waive his Miranda rights. As a consequence, it appears unlikely that his waiver of rights was knowing and intelligent. (2) Thomas appears to have a basic understanding of his current legal situation. His ability to assist counsel in his own defense is somewhat limited by his difculties with attention, concentration, and decision-making abilities, as well as his limited frustration tolerance. Thus, in order for Thomas to assist counsel in his own defense, it would be necessary for his attorney to discuss with him the advantages/disadvantages and possible consequences (both short term and long term) of his decisions. (3) Thomas has diagnoses of ADHD, Conduct Disorder, and Bipolar I Disorder that are in need of ongoing monitoring and treatment. In addition, Thomas has treatment/ rehabilitation needs in the areas of educational and vocational remediation; anger-management, impulse-control, and other skills-based training; alcohol and substance abuse prevention and education; and family-based intervention. (4) Thomas should be at a lower risk for future criminal offending if these recommendations, with appropriate monitoring to ensure adherence, can be implemented. Thank you for the opportunity to evaluate Thomas Johnson. Kirk Heilbrun, Ph.D. Diplomate in Forensic Psychology Diplomate in Clinical Psychology American Board of Professional Psychology Allison Carter, M.A. Psychology Graduate Student MCP Hahnemann University