Assessment, Diagnosis, and Treatment 4 Assessment, Diagnosis, and Treatment

Clinical Issues The decision-making process Begins with a clinical assessment - uses systematic problem-solving strategies to understand children with disturbances and their family and school environments Flexible, ongoing hypothesis testing assesses: A child’s emotional, behavioral, and cognitive functioning; the role of environmental factors; nature, causes, and likely outcomes of the problem

Idiographic and Nomothetic Approaches Idiographic case formulation Assessments focus on obtaining detailed understanding of the child or family as a unique entity Nomothetic formulation Emphasizes general inferences that apply to large groups of individuals

Developmental Considerations Ethnic minority youth are at greater risk of misdiagnosis Cultural information is necessary to: Establish relationship with child and family Motivate family members to change Obtain valid information Arrive at accurate diagnosis Develop meaningful treatment recommendations

Developmental Considerations - Culture Culture-bound syndromes Recurrent patterns of maladaptive behaviors and/or troubling experiences associated with different cultures or localities What is considered abnormal may vary between cultures

Developmental Considerations - Gender Patterns Table 4.1 Gender patterns for selected problems of childhood and adolescence Source: Adapted from Gender Differences in the Diagnosis of Mental Disorders. Conclusions and Controversies of DSM-IV by C. M. Hartung and T. A. Widiger, 1998, Psychological Bulletin, 123, 260–278. Copyright © 1998 by the American Psychological Association. Reprinted with permission. APA is not responsible for the accuracy of this translation.

Developmental Considerations – Normative Information Basic information about child development norms is crucial in understanding why a child may be referred to professionals Isolated symptoms show little correspondence with children’s overall adjustment Age inappropriateness and symptoms typically define childhood disorders Impairment in the child’s functioning is a key consideration

Parent- and Teacher-Rated Problems Table 4.2 Parent- and teacher-rated problems that best discriminate between referred and nonreferred children Source: From Achenbach, T. M. and Rescorla, L. A. (2001), Manual for the ASEBA School- Age Forms & Profiles, ISBN 978-0-938565-73-4. Burlington, VT: University of Vermont, Research Center for Children, Youth, and Families) p. 144. Reprinted by permission.

Purposes of Assessment Description and diagnosis First step: clinical description summarizes the child’s unique behaviors, thoughts, and feelings that together make up the features of the child’s psychological disorder Diagnosis involves analyzing information and drawing conclusions about the nature or cause of the problem

Purposes of Assessment in Treatment Prognosis and treatment planning Prognosis: the formulation of predictions about future behavior under specified conditions Treatment planning and evaluation apply assessment information to generate a treatment plan and to evaluate its effectiveness

Assessing Disorders Clinical assessment – information is obtained from different informants, in a variety of settings, using various methods The methods need to be reliable, valid, cost- effective, and useful for treatment Clinical assessment reveals the child’s thoughts, feelings, and behaviors Comprehensive assessment evaluates a child’s strengths and weaknesses across many domains

Clinical Interviews Provide a large amount of information during a brief period Include a developmental or family history Most interviews are unstructured May result in low reliability and biased information Semistructured interviews are more reliable Include specific questions

Structured Interview Questions Table 4.3 Semistructured interview questions for an older child or adolescent with depression Source: Adapted from Clinical and Forensic Interviewing of Children and Families: Guidelines for the Mental Health, Education, Pediatric, and Child Maltreatment Fields by J. M. Sattler, pp. 938-940. Copyright © 1998 by Jerome M. Sattler Publisher, Inc. Adapted by permission.

Behavioral Assessment Evaluates the child’s thoughts, feelings, and behaviors in specific settings Primary problems of concern Target behaviors and the factors that control or influence them “ABCs of assessment” are to observe the: Antecedents Behaviors Consequences of the behaviors

Behavioral Assessment - Behavior Analysis A general approach to organizing and using assessment information in terms of the “ABC’s” Identify a wide range of antecedents and consequences Develop hypotheses about which are most important and/or most easily changed

Functional Analysis Figure 4.1 Functional analysis: antecedents, behaviors, consequences Source: Cengage Learning 2016

Behavioral Assessment - Checklists and Rating Scales Allow for a child’s behavior to be compared with a known reference group Economical to administer and score Lack of agreement between informants is relatively common, and is highly informative The Child Behavior Checklist (CBCL) gives clinicians a useful profile of the variety and degree of the child’s problems

Child Behavior Checklist Figure 4.2 Child Behavior Checklist (CBCL) profile for Felicia Source: Based on Achenbach & Rescorla, 2001

Behavioral Assessment - Behavioral Observation Parents or other observers record baseline data to provide information about behaviors in real-life settings Recordings may be done by parents or others May be difficult to ensure accuracy Clinician may set up role-play simulation to observe children and their families

Psychological Testing Tests: tasks given under standard conditions The purpose is to assess some aspect of the child’s knowledge, skill, or personality A child’s scores are compared with a norm group The norm group may have limitations in terms of race, ethnicity, culture, SES, etc.

Psychological Testing - Fairness, Context, and Development Code of Fair Testing Practices Guidelines which increase clinicians’ sensitivity to cultural factors Test scores should always be interpreted in the context of other assessment information Developmental tests are used in: Screening, diagnosing, and evaluating infants and young children and identify those at risk

Psychological Testing - Intelligence Testing Evaluating a child’s intellectual and educational functioning Many definitions of intelligence The Wechsler Intelligence Scale for Children (WISC-IV): one of most frequently used intelligence scales Emphasizes fluid reasoning abilities, higher order reasoning, and information processing speed

Psychological Testing - Other Common Intelligence Tests Other commonly administered tests Wechsler Preschool and Primary Scale of Intelligence (WPPSI-R) Stanford-Binet-5 (SB5) Kaufman Assessment Battery for Children (K- ABC-II)

Psychological Testing - Projective Testing Present the child with ambiguous stimuli and asking the child to describe what he or she sees The child projects his or her own personality, including unconscious fears, needs, and inner conflicts, on the ambiguous stimuli Projective tests are among the most frequently used methods

Psychological Testing - Personality Testing Central dimensions of personality - the “Big 5” factors Timid or bold Agreeable or disagreeable Dependable or undependable Tense or relaxed Reflective or unreflective

Psychological Testing Self-Report Personality Scale Definitions Table 4.4 Self-report of Personality Scale Definitions Source: Behavior Assessment System for Children, Second Edition (BASC-2). Copyright © 2004 NCS Pearson, Inc. Reproduced with permission. All rights reserved. “BASC” is a trademark, in the US and/or other countries, of Pearson Education, Inc. or its affiliates(s).

Psychological Testing - Neuropsychological Assessment Attempts to link brain functioning with objective measures of behavior known to depend on an intact central nervous system Involves use of comprehensive batteries Assess a full range of psychological functions

Classification and Diagnosis Classification: a system for representing the major categories or dimensions of child psychopathology Strategies for determining the best plan for a given individual Ideographic strategies Nomothetic strategies

Ideographic and Nomothetic Strategies Idiographic strategies highlight a child’s unique situation Nomothetic strategies – employed to: Benefit from all the information accumulated on a given problem or disorder Determine the general category to which the problem belongs

Categories and Dimensions Categorical classification systems are based primarily on informed professional consensus A “classical/pure” categorical approach Every diagnosis has a clear underlying cause Each disorder is fundamentally different from other disorders Dimensional classification Many independent dimensions exist

Classification and Diagnosis Commonly Identified Dimensions Table 4.5 Commonly identified dimensions of child psychopathology and examples of items that reflect each dimension Source: Achenbach, T. M. & Rescorla, L. A. (2001). Manual for the ASEBA School-Age Forms and Profiles. (Burlington, VT: University of Vermont, Research Center for Children, Youth, and Families, 2001. Reprinted with permission.

The Diagnostic and Statistical Manual (DSM) The current edition: DSM-5 A multiaxial system consisting of five axes: Clinical disorders or conditions Personality disorders and intellectual disability General medical conditions Psychosocial and environmental problems Global assessment of functioning

The Diagnostic and Statistical Manual Neurodevelopmental Disorders Table 4.6 Categories that apply to children Source: Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition

The Diagnostic and Statistical Manual Criticisms Fails to capture the complex adaptations, transactions, and setting influences crucial to understanding and treating child psychopathology Gives less attention to disorders of infancy/childhood Fails to capture the interrelationships and overlap known to exist among many childhood disorders

The Diagnostic and Statistical Manual - Pros and Cons Pros of diagnostic labels Help clinicians summarize and order observations Facilitate communication among professionals Aid parents by providing recognition and understanding of their child’s problem

The Diagnostic and Statistical Manual - Pros and Cons (cont’d.) Cons of diagnostic labels Disagreement about effectiveness of labels to achieve their purposes Negative effects and stigmatization Can negatively influence children’s views of themselves and their behavior

Treatment Interventions today are planned by combining the most effective approaches to a particular problem The most useful treatments are based on what we know about a particular childhood disorder Data is needed to show that interventions work

Treatment (cont’d.) Multiple problems require multiple solutions Problem-solving strategies are part of a spectrum of activities for treatment, maintenance, and prevention Interventions are part of an ongoing decision-making approach

Treatment - The Intervention Spectrum FIGURE 4 .4 | The intervention spectrum and settings for childhood disorders. Based on Weisz, J. R., Sandler, I. N., Durlak, J. A., and Anton, B. S. (2005). Promoting and protecting youth mental health through evidence-based prevention and treatment.

Cultural Considerations Development of evidence-based interventions has led to a growing awareness of children’s and families’ cultural contexts The cultural compatibility hypothesis Treatment is likely to be more effective when compatible with the cultural patterns of the child and family

Cultural Considerations (cont’d.) Evidenced-based treatments have been adapted and implemented to meet the needs of specific cultural groups Treatment services for children must: Attend to presenting problem Consider the specific cultural practices of the family Must be careful not to stereotype individuals of any cultural group

Cultural Values and Parenting Practices Table 4.8 Cultural values and parenting practices and beliefs Sources: Adapted from Forehand and Kotchik, 1996; and from Yasui and Dishion, 2007.

Treatment Goals Outcomes related to child functioning Reduce or eliminate symptoms Reduce degree of impairment in functioning Enhance social competence Improve academic performance

Treatment Goals (cont’d.) Outcomes related to family functioning Reduce level of family dysfunction Improve marital and sibling relationships Reduce stress Enhance family support

Treatment Goals (cont’d.) Outcomes of societal importance Improve child’s participation in school-related activities Decrease involvement in juvenile justice system Reduce need for special services Reduce accidental injuries or substance abuse Enhance physical and mental health

Ethical and Legal Considerations AACAP and APA ethical code provide minimum ethical standards Select treatment goals and procedures that are in the best interest of the client Ensure participation is active and voluntary Keep records to document treatment effectiveness Protect confidentiality Ensure therapist’s qualifications and competencies

Ethical and Legal Considerations (cont’d.) Determine when a minor is competent to make decisions Be cautious about ineffective or potentially harmful treatment Comply with federal, state, and local laws Education for All Handicapped Children Act (1975) Individuals with Disabilities Education Improvement Act (2004)

Ethical Issues in Clinical Work With Children and Families Table 4.9 Core ethical issues in clinical work with children and families Source: Reprinted from Psychiatric Clinics of North America, 32, Belitz, J. & Bailey, R. A., Clinical ethics for the treatment of children and adolescents: A guide for general psychiatrists, 243–257, Copyright 2009, with permission from Elsevier.

General Approaches to Treatment More than 70% of clinicians use an eclectic approach Psychodynamic treatments View child psychopathology as determined by underlying unconscious and conscious conflicts Focus is on helping the child develop an awareness of unconscious factors contributing to problems

Behavioral Treatments Assume that behaviors are learned Focus is on re-educating the child Procedures include: Positive reinforcement or time-out Modeling Systematic desensitization Changes in the child’s environment

Cognitive Treatments View abnormal behavior as the result of deficits and/or distortions in the child’s thinking Focus is on changing faulty cognitions

Cognitive Behavioral Treatments View psychological disturbances as the result of: Faulty thought patterns Faulty learning and environmental experiences Focus on: Identifying and changing maladaptive cognitions; teaching the child to use cognitive and behavioral coping strategies; and helping the child learn self-regulation

Client-Centered and Family Treatments Client-centered treatments: Focus on creating a therapeutic setting which provides unconditional acceptance of the child Family treatments: View individual disorders as manifestations of disturbances in family relations Focus on the family issues underlying children’s problematic behavior

Biological Treatments View child psychopathology as resulting from psychobiological impairment or dysfunction Rely primarily on pharmacological and other biological approaches to treatment

Combined Treatments The use of two or more interventions, each of which can stand on its own as a treatment strategy More communities are now implementing comprehensive mental health programs for children Often delivered through schools

Descriptions of Common Medications for Children and Youths Table 4.10 Descriptions of common medications for children and youths Source: Based on Psychiatric medication for children and adolescents. II: Types of medications, American Academy of Child & Adolescent Psychiatry, 2004.

Usage of Psychiatric Medication by Children in the United States (1987 – 1996) Figure 4.4 Usage of psychiatric medication by children in the United States between 1987 and 1996 Source: Adapted from Journal of the American Academy of Child and Adolescent Psychiatry, 41, A Olfson, M., Marcus, S. C., Weissman, M. M., & Jensen, P. S., National trends in the use of psychotropic medications by children, 514–521, Copyright 2002, with permission from Elsevier.

Results of Behavioral Role-Play Intervention Figure 4.6 Results of behavioral role-play intervention Source: Adapted from Depression by D. J. Kolko, 1987. In M. Hersen and V. B. Van Hasselt (Eds.), “Behavior Therapy with Children and Adolescents: A Clinical Approach”, pp. 163–164. Copyright © 1987 by John Wiley & Sons, Inc. Reprinted by permission of John Wiley & Sons, Inc.

Treatment Effectiveness Best practice guidelines Systematically developed statements to assist practitioners and patients Two main approaches in developing best practice guidelines The scientific approach derives guidelines from a review of current research findings The expert-consensus approach uses experts’ opinions to fill gaps in scientific literature

Positive Findings Children’s changes achieved through therapy are greater than changes for children not receiving therapy Children receiving therapy are better off after therapy Treatments are equally effective for internalizing and externalizing disorders Treatment effects tend to be long-lasting

Negative Findings Fewer than 20% of treatments demonstrate evidence for reducing impairment in life functioning Community-based clinic therapy is far less effective than structured research therapy Conventional services for children may have limited effectiveness

New Directions As many as 70% to 80% of children and families with significant mental health needs do not receive any specialized assessment or treatment services New initiatives: Increase recognition of children's mental health needs Develop a wider range of service delivery models