1. Chapter 9 – Assessment: Integration and Clinical Decision Making
Chapter 9 – Assessment: Integration and Clinical Decision Making
Copyright © 2014 John Wiley & Sons, Inc. All rights reserved.

2. Integration and Clinical Decision Making
All assessments are designed to address a question
Psychologist determines the most appropriate type of assessment based on this question
As the assessment progresses different tests or assessments may be added
Copyright © 2014 John Wiley & Sons, Inc. All rights reserved.

3. The assessment question is a general guide in assembling pieces of information
A question about intellectual capacities leads to assessment that highlights general intellectual functioning and more specific cognitive strengths and weaknesses

4. Cont-d
In such intellectual evaluation we would want to consider emotional factors that may affect cognitive functioning, but the cognitive potential is still the focus.
A specific assessment question, for example, whether a teacher who is depressed is capable of going back to the classroom, diagnostic information and functional capability need to be assessed

5. Cont-d
In this context (the depressed teacher) possible factors that might affect the teacher’s functioning should be evaluated: In depression there are cognitive correlates, such as difficulty in concentration and decision making, and these may affect the teacher's functioning
However, these should be seen as secondary to the emotional issues.

6. Integrating the Assessment Information
The common assessment methods are
Interviews
Observations
Intellectual assessment
Cognitive assessment
Self-report measures
Projective measures

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Assessment
Psychological assessment involves gathering and integrating multiple forms of information
Instruments are selected based on the hypotheses to be explored
The integration of the diverse data completes the assessment process
Copyright © 2014 John Wiley & Sons, Inc. All rights reserved.

8. Initial Steps in the Integration
Examine all assessment information
Consider consistencies and contradictions and try to reconcile
Generate hypotheses about the client’s current functioning
Important in assessment –focused service or intervention-focused service

9. Integrating Assessment Data
Descriptive account of the client’s level of functioning
Importance of understanding client in his/her social and interpersonal environment
Often different assessments/tests provide conflicting results
Importance of multiple informants especially with children
Copyright © 2014 John Wiley & Sons, Inc. All rights reserved.

10. First step: Descriptive Account
A consideration of the client’s personality structure
Level of emotional distress
Coping strategies: problem-focused, emotion-focused, passive, active etc
Intellectual capacity
Possible diagnosis and co-morbidity
How the diagnostic status affects functioning (e.g. getting custody over a child)

11. The pieces of the puzzle often do not fit together
Different sources of information and different informants
Each source of data has strengths, limitations, and potential biases.
This is seen primarily when gathering information about children and adolescents

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Assessment of Children and Adolescents: Using several sources of information: Study by De Los Reyes et al: p. 267
Assessment of young children with high levels of disruptive behaviors
Information came from mothers, teachers and direct observations
There were discrepancies in the reports of the different sources
These discrepancies reflected real differences in behaviors in the different settings
Copyright © 2014 John Wiley & Sons, Inc. All rights reserved.

13. Common Purposes of Assessment
Educational concerns (e.g. assessment of the need for special education
Vocational concerns: The feasibility of the client’s career aspirations
Rehabilitation service (e.g. following head injury)
Referral for psychotherapy

14. The Purpose of Case Formulation
The purpose is to formulate hypothesis how the problems have developed and what factors seemed to have maintain these problems
How the current problems fit with the client’s life-history (e.g. early loss of parent), and how well the client will be able to function in the future
Recommendations to improve functioning

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Case Formulation
Case Formulation: A clear hypothesis that relates to how a problem developed and how it is maintained
Suggestions are then made – e.g., psychological services, additional assessment, or planning of other services for the client
Often helps guide treatment & specific interventions
Copyright © 2014 John Wiley & Sons, Inc. All rights reserved.

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Case Formulation
Some Benefits of a case formulation:
Provides connections between various problems
Provides guidance on the type of treatment
Predicts the patient’s functioning with and without treatment
Provides options if difficulties are encountered in treatment
Indicates options, outside of psychological services
Copyright © 2014 John Wiley & Sons, Inc. All rights reserved.

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Case Formulation
Components of a case formulation:
Description of problems & symptoms
Events or stressors that led to the symptoms or problems
Predisposing life events/ vulnerabilities
A hypothesized mechanism that links the problems to the person’s current functioning
Copyright © 2014 John Wiley & Sons, Inc. All rights reserved.

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Case Formulation
Steps of a case formulation:
1. Develop a comprehensive problem list
2. Determine the origin, precipitants, and consequences of the problems
3. Identify patterns among the problems
4. Develop working hypotheses to explain the problems
5. Evaluate and refine the hypotheses
6. In treatment, the hypotheses should be reconsidered, re-evaluated, and revised

19. Threats to the Validity of Case Formulations
Client Factors:
Clients may try and under-pathologize themselves
Problems clearly recalling a problem behavior or memories from their past (retrospective recall)
Can’t assume clients are accurately perceiving/portraying reality
Copyright © 2014 John Wiley & Sons, Inc. All rights reserved.

20. Threats to the Validity of Case Formulations
Clinician Factors:
Self-serving attributional bias: Bias to make internal, stable and global attributions for positive events (can seriously affect how clinicians evaluate their effectiveness)
Overuse of heuristics (mental short cuts)
Biases (gender, ethnic, socioeconomic, etc.)
Several common decision making biases (see text table 9.3)
Copyright © 2014 John Wiley & Sons, Inc. All rights reserved.

21. Improving the Accuracy of Clinical Judgment
Some Important strategies:
Use directly relevant psychometrically sound tests
Check for scoring errors
Use normative data and base rate information
Use DSM criteria when making diagnosis
Use decision trees or clinical guidelines.
In unstructured interviews be as systematic as possible
Be aware of relevant research
Be aware of personal biases and preconceptions.
Search for alternative explanations for hypotheses
Seek consultation
Don’t rely on memory and don’t rush to a conclusion
Copyright © 2014 John Wiley & Sons, Inc. All rights reserved.

22. Important Concepts in Assessment Reports
Important to remember the ‘audience’ of the report
Privacy is important – avoiding stigmatizing labels, using multiple sources
Exercising caution with computer-based interpretations (CBI’s) – problematic to include this in a testing report
Copyright © 2014 John Wiley & Sons, Inc. All rights reserved.

23. Important Concepts in Assessment Reports
Contents of a typical assessment report
Identifying patient/client information
Reason for referral
Background information (including, developmental history, educational & employment history, family & relationship history, medical history, etc.)
Assessment methods (including tests administered)
Interview data and behavioral observations
Test results (including interpretation of test scores)
Diagnostic impressions
Summary
Recommendations
Copyright © 2014 John Wiley & Sons, Inc. All rights reserved.

24. Important Concepts in Assessment Reports
Purpose of giving feedback on an assessment report
Verify the general accuracy of the assessment results
Refine the interpretation of the results
Put the individual’s symptoms, in the context of his/her life history and current life circumstances
Provide some psychological relief for the individual by presenting an integrated picture
Provide concrete information about steps to address personal difficulties
Help the individual identify potentially stressful situations
Collaborate to design goals that build on personal strengths
Copyright © 2014 John Wiley & Sons, Inc. All rights reserved.