Questionnaires are commonly used to assist in screening, evaluation and the analysis of behavior. There exist standards commonly recognized by licensed psychologists and qualified researchers. The use of computers to interview,  analyze behavioral histories and process questionnaires is an accepted evaluation method in psychology, health care and behavioral science fields.

Face-to-face interview and testing using paper-and-pencil methods can consume a great deal of professional time, with considerable associated expense: As much as $150 per hour. Using computers greatly reduces the time necessary to complete an evaluation. However, saving time has not made evaluations any more accessible and affordable to the general public. There is a scarcity of mental health professionals or health care professionals who can provide screening and evaluations. There is also a scarcity of professionals who are trained to work with children.

Recent development and advancement of the Internet and Web offer new possibilities to extend the use of computers for screening and evaluation. Online testing, interviews and questionnaires are increasingly available on the Web. Online evaluation services are being developed by lay people, health care professionals, businesses and human services organizations. Many of the existing services are manifestly unfit and do not meet important and established standards for development and operation of an online evaluation service.

There are a number of benefits to the use of online screening methods. Online methods are potentially useful for individuals and patients who

• live in remote or isolated areas

• do not have quick access to qualified health care

• cannot financially afford face-to-face interviews and evaluations

• need a reliable means to identify and document behavior and problems

• need information, answers and guidance quickly

Behavioral ratings and checklists are a frequently used and well established means of screening children, adolescents and adults. The use of multiple informants can provide estimates of the reliability and, therefore, the validity of results. Behavioral rating and multi-informant instruments can be used effectively to identify symptoms and signs of behavioral problems, syndromes and psychopathology. Behavioral observations and ratings over time and from multiple sources can provide information about the variability and consistency of symptoms, potential problems and disorders. Online behavioral screening, evaluation and analysis can be developed to

• identify individuals who exhibit behaviors associated with psychiatric disorders

• identity patterns of behaviors associated with specific behavioral, emotional and psychological problems that are not psychiatric disorders

• identify individuals who exhibit specific behaviors associated with a risk of violence, injury, accidental death or suicide

• monitor and evaluate progress or deterioration in behavior

• provide users with education and recommendations necessary to seek qualified consultation and evaluation

• educate parents, caretakers and professionals regarding referral, intervention and treatment options

• help users document a child’s history, behavior, problems and needs

• support parents, caretakers and professionals who are seeking information and resources for youth with emotional, behavioral and psychological problems

• provide guidance and options for professionals conducting interventions for youth at-risk

Professional and Ethical Issues

Online behavioral screening, evaluation and assessments are offered by professionals and nonprofessionals. Unlike unlicensed providers of these services, health care professionals have certain professional and ethical issues that must be considered when developing and offering online services. These issues can be identified through review of the professional literature, ethical principles set forth by professional organizations and professional codes of conduct. The issues and recommendations outlined are not exacting - especially in areas where advancements in health care and new technology is being introduced. Due diligence and work respecting professional and ethical guidelines require continuous effort. This is especially true in the area of emerging health care technologies.

Risk Management and Quality Assurance. Professionals developing online evaluation systems cannot anticipate every possibility or potential problem but they must make a good faith effort to explore, identify and address issues so as to minimize the risk and degree of harm to those using these services. Ongoing research and quality assurance activities are the best ways to assure the quality of emerging technology-based health care services. Professional consultation and oversight are excellent means to accomplish these goals. MRI has established a consultation and research relationship with StepOne, LLC.

MRI is working with StepOne providing consultation, review of program development activities and support of ongoing research activity.

Initial Issues and Guidelines For Development and Operation of StepOne

The following is a summary review of professional issues and concerns that have potential bearing on the development and operation of StepOne. The primary resource for this overview is by Barak (2003a, 2003b). Issues are identified below along with potential guidelines. Additional "white papers" have been written to outline issues in greater detail. For additional information see StepOne statements regarding privacy,  terms of use and proper use. The primary source of information for the following discussion is based on the references that follow.

Computer and Internet Skills. Completing an online screening questionnaire or behavioral assessment requires certain skills. The lack of computer skills could be a handicap in some circumstances. StepOne is designed to be used by any person who can operate an Internet Web browser, complete a form on a Web site or use a simple word processor. An expert user would be a person who can complete online forms or purchase goods or information on the Internet.

Screening For Appropriate Use. Professional and ethical codes call for checking the applicability of and instrument and procedures as well as adapting those procedures to specific individuals with regard to such things as age, gender, language, education, etc.. To ensure appropriate use the Website home page has been designed to identify potential users. To access the StepOne reports and questionnaires users must read and agree to rules and terms of use. They must also pass a test that measures their understanding of the terms of use. Users are notified of the minimum requirements in order to expect a reliable and valid result. Potential users have the option to obtain non-urgent consultation from StepOne before using these resources.

Personal Intervening Factors. While completing an online questionnaire it important that the user be informed of personal limitations that could affect the results. StepOne attempts to gather personal information to disqualify or qualify the user. This information includes language, education, reading levels, etc.. A user completing surveys and questionnaires should be well rested, free from distraction and should not be under the influence of any medication, drug or substance that could impair their mental or emotional status. Information is provided to exclude potential users as well as qualify the result in the reports generated. The Website policy states that potential users should not complete any questionnaire against their will or under coercion.

Cultural Bias. Internet is global, providing access to potential users everywhere. Significant cultural differences can have a potential affect on the outcome of questionnaires. For this reason, StepOne should be used by people who speak fluent English as a primary language. They should be residents of the United States. Users who do not meet this criteria are cautioned as this may affect the results.

Privacy. Historical concerns regarding the use of the Internet have centered around the ability to insure privacy and confidentiality. Since 2002, improvements and enhancements make it virtually impossible to intercept and read information transmitted between computers and Web sites using secure socket layers and 128 bit encryption. To further enhance security, the Website is also hosted on a dedicated server that is managed and administered by StepOne. They system is located in a secure key card access facility in which data is contractually private. StepOne is designed to be more secure than postal mail and a locked file cabinet.

Use of Results. StepOne does not provide treatment, emergency, crisis, evaluation or diagnostic services and is not a health care provider. Only a qualified or licensed health professional in a face to face contact can legally diagnose and treat mental health problems. StepOne software helps systematically gather and organize information. The reports identify issues and raise concerns that a user can discuss with a qualified professional. As part of a contractual agreement, behavioral and health survey information gathered at this site will not be viewed or released to third parties.  With the exception of  internal research, your consent, your explicit written permission or a valid court order is necessary for such a release. Identifying information is removed from all files during research activities.

Technical Failures. There is no evidence to suggest that StepOne will be any less reliable than a large number of professionals conducting the same number of evaluations. In fact StepOne questionnaires are probably more reliable. Computer crashes are less common as the technology, backup system and self-correcting nature of operating systems improve. StepOne is hosted on dedicated server that provides routine backup on a secure Web site. The entire Web site has been developed on a stable platform using state of the art software and hardware. In addition, non-urgent technical support is available by phone. Support staff have the resources to recover, restore and process saved files from mirrored files and daily backups.

Contracted Relationship. The Internet is difficult to regulate. For this reason, StepOne provides a limited contractual agreement to provide limited technical support, fee-for-service consultation, security and privacy for users.

Terms of Use (Informed Consent). Virtually any professional evaluation service requires not only consent but informed consent. StepOne aspires to provide information that will allow a potential consumer to locate a qualified health care professional and make an informed decision with that person. For this reason, the user must agree to our terms of use in order to access the questionnaires. While it is not possible to foresee every potential problem in an emerging technology, it is possible to provide information about the benefits, the risks and potential for harm. StepOne provides explicit information and a disclaimer as a condition for using these resources. Users can only gain access to the questionnaires and reports after correctly responding to questions that measures the users understanding of the terms of use. In addition, users can request nonurgent fee for service consultation with a professional before or after using StepOne services.

Information about StepOne Questionnaire and Reports. A few potential clients will be interested in reading information about the purpose, developers, basic statistical properties, applicability and possible use, limitations and privacy of results generated in our reports. StepOne expects that few if any clients will be interested in detailed description of the clinical logic and programming of StepOne. The programming and logic used by StepOne is extremely complicated. It is practically impossible to provide a detailed description that would be comprehensible to the lay person or even to most professionals. Potential clients who want such information should not use these resources and are advised to contact a professional who is familiar with online testing and StepOne. Detailed information specific to the clinical, psychometric and internal logic of StepOne is proprietary and is not available except for legitimate research and contracted oversight. StepOne research and oversight activities are provided by Mentor Research Institute, an independent nonprofit charitable organization.

Standardization. In order to ensure the results of any test or questionnaire are reliable it is important that all users be given identical instructions and that similar questionnaire administration procedures are consistently used. Online procedures for gathering information may vary from one Website service to the next. StepOne procedures for all questionnaires are nearly identical. The questionnaire and procedures have been designed by expert professionals. Alpha and beta testing is routinely implemented by StepOne to ensure the look, feel and process is standardized and reasonable. The questionnaire has been designed to be completed in a reasonable amount of time. The user is encouraged to complete each section of the questionnaire in one session. Each section is designed to be taken independently of other sections.

Meaning and Use of Reports. StepOne reports are not intended or designed to be diagnostic or treatment tools. The questionnaires and surveys are designed to reliably gather and organize information in a meaningful manner for parents and caregivers. Potential problems and issues are raised and presented in a manner that must be considered tentative findings. The findings must ultimately be reviewed or discussed with a qualified health care professional. Recommendations are structured to facilitate contact and communication between the user and a qualified health care professional. StepOne services should not be used as a substitute for face-to-face evaluations and recommendations, nor should they be used to interfere with existing health care relationships.

Commercial/Non-profit Activity. StepOne was developed by a a commercial enterprise. However, screening services are offered to parents and caregivers in Oregon at no charge. StepOne is working to minimize the cost for services. A fixed number of screenings will be donated for charitable use in other states. Up to 10% of profit is donated as a charitable contribution to support youth programs. The cost of StepOne reports is very low and a very good value relative to the cost of similar information processing activities. The Website is the result of research activities conducted since 1989.

Copyrights. The questions used by StepOne have been developed three ways. All questions were developed clinically by a licensed clinical psychologist over a 10-year research period. These questions were then compared and contrasted with the diagnostic criteria in the Diagnostic and Statistical Manual of Mental Disorder version 4 revised (DSM-IVTR) and the International Classification of Disorder version 9 (ICD-9). Critical sections were then reviewed by a group of psychologists. Additional questions were developed by reviewing other questionnaires for content suggestions. Permission to adapt and modify questionnaires developed by other authors was obtained in all cases. No questionnaires were adopted in total for use by StepOne. Normative data and protocols were derived clinically and empirically relying on noncopyrighted empirical data as guidelines. Initial testing of the Website also includes modifications based on information gathered as part of the Website's research mission. All information, procedures and normative data used by StepOne is considered proprietary and the intellectual property of StepOne, LLC.

Personal Assistance and Support. StepOne recognizes that some clients or potential clients will need to speak with a person who is knowledgeable about the processes, results and all other questions that would help a client make an informed decision. Potential clients should obtain consultation if they have any questions before purchasing services and if they have any reservations or concerns. StepOne offers nonurgent fee-for-service consultation to clients and potential clients. StepOne does not provide diagnostic, treatment or emergency services of any any kind. StepOne cannot guarantee the ability to respond to all requests for consultation. Potential users should contact a qualified health care professional if they have urgent concerns and problems. Nonurgent technical support is available without charge by email.

References

American Psychological Association (2002). Ethical principles of psychologists and code of conduct. American Psychologist, 57, 1060-1073.

American Psychological Association (2004). Psychological testing on the Internet, 59, 150-162.

Anastasi, A. (1997) Psychological testing (7th ed.) Upper Saddle River, NJ: Prentice Hall.

Barak, A., & Buchanan, T. (2004). Internet-based psychological testing and assessment. In R. Kraus, G. Stricker, & J. Zack (Eds.), Online counseling: A handbook for mental health professionals. San Diego, CA: Academic Press/Harcourt.

Barak, A. (2003b). Ethical and professional issues in career assessment on the Internet. Journal of Career Assessment, 11, 3-21.

Kier, F. & Molinari, V. (2004). Do-it-yourself testing for mental Illness: Ethical issues, concerns, and recommendations. Professional Psychology: Research and Practice, 35, 261-267.