1. Chapter 4 Assessment, Diagnosis, and Treatment

2. The Decision Making Process
Typically begins with a clinical assessment, which is directed at differentiating, defining, and measuring the child’s behaviors, cognitions, and emotions of concern, as well as contributing environmental circumstances
Assessments are meaningful to the extent that they result in practical and effective interventions

3. The Decision Making Process (cont.)
Idiographic vs. Nomothetic Case Formulation
idiographic case formulation involves a detailed understanding of the child and family as a unique entity
nomothetic case formulation emphasizes more general inferences that apply to broad groups individuals

4. Developmental Considerations
Age, gender, and culture must be considered when making judgments about abnormality and when selecting assessment and treatment methods
Normative information must be considered
knowledge about normal development needed to make decisions about abnormality
isolated symptoms not typically related to children’s overall adjustment
age inappropriateness and patterns of symptoms typically define childhood disorders

5. Purposes of Assessment
Description and Diagnosis
clinical description summarizes the child’s unique behaviors, thoughts, and feelings that together make up the features of a given psychological disorder
diagnosis involves analyzing information and drawing conclusions about the nature or cause of the problem, and in some cases, assigning a formal diagnosis

6. Purposes of Assessment (cont.)
Prognosis and Treatment Planning
prognosis involves generating predictions regarding future behavior under specified conditions
treatment planning involves making use of assessment information to generate a treatment plan and evaluating its effectiveness

7. Clinical Interviews The most universally used assessment procedure
Often includes a developmental and family history
May incorporate a mental status exam
Differ in degree of structure (e.g., unstructured, semi-structured)

8. Behavioral Assessment
Emphasis on observing child’s behavior directly
“ABCs of assessment” - involves observing the antecedents, the behaviors, and the consequences of the behaviors
Functional analysis of behavior - a more general approach, the goal of which is to identify as many potentially contributing factors as possible, and to develop hypotheses about which are most important and/or most easily changed

9. Behavioral Assessment (cont.)
Figure 4.1 Functional analysis: antecedents, behaviors, consequences.

10. Behavioral Assessment (cont.)
Checklists and Rating Scales
often allow for a child’s behavior to be compared to a normative sample
usually economical to administer and score
lack of agreement between informants is relatively common, which in itself is often informative

11. Behavioral Assessment (cont.)
Behavioral Observations and Recording
provide ongoing information about behaviors of interest in real-life settings
recordings may be done by parents or others, although it may be difficult to ensure accuracy
children often know they are being watched and may react differently as a result

12. Psychological Testing
Tests are tasks given under standard conditions with the purpose of assessing some aspect of the child’s knowledge, skill, or personality
Test scores should always be interpreted in the context of other assessment information
Developmental tests are used for the purpose of screening, diagnosis, and evaluation of early development

13. Psychological Testing (cont.)
Intelligence and Educational Testing
is a central component in clinical assessments for a wide range of childhood disorders
most popular intelligence scale is the Wechsler Intelligence Scale for Children (WISC-IV), which is well-standardized, reliable, valid, and provides measures of verbal comprehension, perceptual reasoning, working memory, and processing speed

14. Psychological Testing (cont.)
Projective Testing
involves presenting the child with ambiguous stimuli and asking the child what he or she sees
it is believed that the child projects his or her own personality, including unconscious fears, needs, and inner conflicts, on the ambiguous stimuli
projective techniques, including figure drawings and play, may be used to help children relax and to make it easier for them to talk about difficult events

15. Psychological Testing (cont.)
Personality Testing
may assess a child in terms of the “Big 5” Factors:
timid-bold
agreeable-disagreeable
dependable-undependable
tense-relaxed
reflective-unreflective
may use interviews, projective techniques, behavioral measures, or objective inventories

16. Psychological Testing (cont.)
Neuropsychological Testing
attempts to link brain functioning with objective measures of behavior that are known to depend on an intact central nervous system
often involves using a comprehensive battery that assesses a full range of psychological functions, including verbal and nonverbal cognitive functions, perceptual functions, motor functions, and emotional/executive control functions

17. Classification and Diagnosis
Categorical vs. Dimensional Classification
“classical/pure” categorical approach assumes that every diagnosis has a clear underlying cause and that each disorder is fundamentally different
dimensional classification systems assume that a number of independent dimensions or traits of behavior exist and that all children possess these to varying degrees

18. Classification and Diagnosis (cont.)
The Diagnostic and Statistical Manual (DSM)
a multiaxial system consisting of five axes:
clinical disorders
personality disorders and mental retardation
general medical conditions
psychosocial and environmental problems
global assessment of functioning

19. Classification and Diagnosis (cont.)
DSM (cont.)
criticisms of the DSM-IV:
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 emphasize situational and contextual factors
fails to capture the comorbidity known to exist among many childhood disorders
sometimes improperly used, such as when a specific diagnosis is needed in order for a child to qualify for special services

20. Classification and Diagnosis (cont.)
Pros and Cons of Diagnostic Labels
pros:
help clinicians summarize and order observations
facilitate communication among professionals
aid parents by providing recognition and understanding of their child’s problem
facilitate research on causes, epidemiology, and treatments of specific disorders
cons:
may lead to negative perceptions and reactions by child and others

21. Treatment of Childhood Disorders
Interventions are problem-solving strategies that involve treatment of current problems, maintenance of treatment effects, and prevention of future problems
Must take into account the cultural context of the child and family
Treatment goals include outcomes related to the child and family, as well as those of societal importance

22. Treatment of Childhood Disorders (cont.)
Models of Delivery
conventional care model: the child is seen individually by a therapist for a limited number of treatment sessions
continuing care model: an alternative to the conventional care model; two examples are the chronic care model and the dental care model

23. Treatment of Childhood Disorders (cont.)
Ethical and Legal Considerations
clinicians who work with children are required to think not only about the impact that their actions will have on the children that they see, but also on the responsibilities, rights, and relationships that connect children and parents

24. Treatment of Childhood Disorders (cont.)
General Approaches to Treatment
more than 70% of clinicians take an eclectic approach
psychodynamic treatment approaches focus on developing awareness of underlying unconscious and conscious conflicts
behavioral approaches emphasizes re-education using behavioral principles
cognitive approaches focus on changing faulty cognitions

25. Treatment of Childhood Disorders (cont.)
General Approaches to Treatment (cont.)
cognitive-behavioral approaches focus on changing maladaptive cognitions, teaching the child to use cognitive and behavioral coping strategies, and helping the child learn self-regulation
client-centered approaches attempt to create a therapeutic setting that provides a corrective experience for the child through unconditional positive regard

26. Treatment of Childhood Disorders (cont.)
General Approaches to Treatment (cont.)
family models focus on the family issues underlying problematic behavior
biological/medical models rely primarily on pharmacological and other biological approaches to treatment
combined treatments make use of two or more interventions

27. Treatment Effectiveness
Positive Findings
therapy leads to significant and meaningful improvements
treatments are equally effective for internalizing and externalizing disorders
treatment effects tend to be long-lasting
specific problems are more amenable to treatment than nonspecific problems
the more outpatient therapy children receive, the more symptoms improve
Negative Finding
community-based clinic therapy far less effective than structured research therapy