Clinical Assessment of Children & Adolescents

1. You are going to what!?! Clinical AssessmentofChildren & Adolescents Dale Pietrzak, Ed.D., LPCC Counseling & Psychology in Education University of South Dakota

2. Goals • Introduce practitioners to various tools to aid them in diagnosis, treatment planning and understanding their child and adolescent clients • Evaluate the various tools according to basic guidelines for such tools. And I wanted to do this because ...

3. Areas of Importance • General purpose and ages for tools • Scoring • Response set detection scales • Norms • Reliability • Validity • Additional Comments Wait until you hear this ….

4. Personality Inventory for Children: Revised • The PIC is designed for use with children and adolescents from age 3 to age 17. It is completed by a significant other in the child’s life (usually the mother). Published by Western Psychological Services (800) 648-8857 the PIC can be hand scored (using standard keys/carbon) or computer scored (mail in or PC program). There is a computer generated report. It has a screening administration (130), short scale administration (240), and full administration (420). It has response set detection scales, clinical scales and uses a easily applied cluster typing for configural interpretation. PIC has a long research history.

5. Don’t forget us! Norms • Norms based on Normal Children (2,380) • n ranges from 167 to 298 for each year • Largely form Minnesota (Minneapolis) schools • Educational and occupational breakdown of parents roughly representative of current breakdowns. • No racial breakdown or other demographic data

6. Lie Infrequency Defensiveness Adjustment (general) Achievement Intellectual Screening Development Somatization Depression Family Relations Delinquency Withdrawal Anxiety Psychosis (also autistic) Hyperactivity Social Skills Primary Scales

7. Guide to the levels of reliability: • .70 > fair but acceptable, .80 > is good and .90 > is excellent. Generally want .80 or higher for clinical decisions and .90 or higher for primary placement decisions 1 • Use the type of reliability appropriate to the decision prediction (test-retest) and single scale interpretations (internal consistency). • In calculating SEM, use same procedure or worst coefficient.

8. Clinical Test-Retest (13 to 102 days; m=51 days): < .70: 1 (Som .67) .70-.79: 0 .80-.89: 5 (IS, Dev, Dlq, Anx & Hpr) .90 >: 7 (Adj, Ach, D, Fam, Wdl, Psy & Ssk) Clinical Alpha < .70: 3 (Ach, IS, Hyp) .70-.79: 6 (Adj, Dev, Som, Del, Wdl & Anx) .80-.89: 4 (D, Fam, Psy & Ssk) .90 >: 0 Reliability The point is?

9. Somebody slap me ... Validity • Scales are not normally distributed and various scales have differing “clinical” ranges • Content was reviewed extensively for many scales. But, the concepts have changed some over time. • About 1/2 of the scales were empirically constructed. • Large research data base on various forms of validity and it has held up well.

10. It Stopped! Additional Comments • The Cluster Types provide an excellent means for “configural” interpretation. This includes percentage of type in various educational placements and typical diagnoses. • Norms could be more representative and updated, but as pathology is not “normally” distributed the problems are mediated to some degree. • One of my “desert island” tools primary one for type. I often use it with projectives with younger children.

11. The PIY is a newer self-report measure for children ages 8 to 18 (4th to 12th grade) from WPS. It comes with with both a tape recorded administration or paper-pencil administration (270 items). It can be computer scored, hand scored (“normal” keys and carbonless) and mail-in scored. It has validity scales, 9 major clinical scales and additional subscales. There is a computer generated report. It has a screening administration (80 items) andmodern norming.

12. No Fair! Norms • The norms are from 2,327 school children from around the country. The sample is demographically representative of gender, race, income, region, and guardianship. Extensive analysis of the effects of various demographic was investigated and handled throughout the administration. • Clinical comparison groups are available.

13. Validity Inconsistency Dissimulation Defensiveness Cognitive Impairment Poor Ach. & Memory Inadequate Abilities Learning Problems Impulsivity & Distrac. Brashness Distract. & Overact. Impulsivity Delinquency Antisocial Behavior Dyscontrol Noncompliance Primary Scales Cool!

14. Family Dysfunction Parent-Child Conflict Parent Maladjustment Marital Discord Reality Distortion Feelings of Alienation Halluc. & Delusions Somatic Concern Psychosomatic Synd. Muscular Ten. & Anx. Preocc. with Disease Psych. Discomfort Fear & Worry Depression Sleep Disturbance Primary Scales Continued Music to my ears ...

15. Social Withdrawal Social Introversion Isolation Social Skills Deficits Limited Peer Status Conflict with Peers Primary Scales Continued Ahhh … finally alone!

16. The reliability is ... Reliability • Clinical Test-retest (7 to 10 days): • < .70: 0 • .70-.79: 3 (Som, Dis, Ssk-.79) • .80-.89: 5 (Cog, Adh, Fam, Rlt & Wdl) • .90 >: 1 (Dlq) • Clinical Alpha • < .70: 0 • .70-.79: 2 (Cog & Adh) • .80-.89: 6 (Fam, Rlt, Som, Dis, Wdl & Ssk) • .90 >: 1 (Dlq) Note: The test-retest reliabilities are slightly higher in Normals.

17. Validity • While it is a “new” tool the criterion related, content and other validity data were collected as the test was developed. As a consequence their validity data are pretty good. A number of criteria were used; other tools and behavioral reports. • As always, more research will be important.

18. Here is what we have... Additional Comments • This is a very solid and useful tool. It is the only broad band self-report pathology measure for children under 13/14. It has the best constructed validity scales for these ages. • It could use scales dealing with substance abuse, suicide and abuse. • It is a often used tool for me.

19. Millon Adolescent Clinical Inventory • The MACI is a complete revision of the Millon Adolescent Personality Inventory to parallel the MCMI-III for adults. It has 31 scales measuring response styles, clinical personality styles, expressed concerns and clinical syndromes. It has 160 items and is designed for youth ages 14 to . It is based on clinical norms and used a standard score called a “Base Rate” (BR). The BR scores are designed to be especially helpful in differential diagnosis.There is a tape recorded administration available. Available from NCS (800) NCS-7271.

20. And so remember ... MACI Continued • It is important to remember that the philosophy underlying the tool is NOT the identification of a disorder but the classification of the disorder. It assumes a clinical subject and is concerned with which disorder is most likely. It can be hand scored (typical keys but complex), computer scored or scored through a mail-in service.

21. Norms • The clinical samples used to norm the MACI included 900+ adolescents from the USA and Canada. They were used to establish, and cross validate, the base rate (BR) scores. They were regionally, racially, educationally and treatment setting diverse. • Base Rate scoresserve as “cutting scores.” • 60 locates the median in the norm group • 75 presence of style/difficulties • 85 the prominence of the style/difficulties.

22. V: Validity X: Disclosure Y: Desirability Z: Debasement 1: Introversive 2A: Inhibited 2B: Doleful 3: Submissive 4: Dramatizing 5: Egotistic 6A: Unruly 6B: Forceful 7: Conforming 8A: Oppositional 8B: Self-Demeaning 9: Borderline Tendency WAH! Primary Scales I wonder where they are?

23. A: Identity Diffusion B: Self-Devaluation C: Body Disapproval D: Sexual Discomfort E: Peer Insecurity F: Social Insensitivity G: Family Discord H: Childhood Abuse AA: Eating Dys. BB: Sub. Abuse Prone. CC: Delinquent Preds. DD: Impuls. Propensity EE: Anxious Feelings FF: Depressive Affect GG: Suicidal Tendency Primary Scales Continued

24. Help…I need some coffee! Reliability • Clinical Test-retest (3 to 7 days): • < .70: 2 (1 & E) • .70-.79: 8 (2A, 4, 6A-.79, 8A, A, D, AA & DD) • .80-.89: 13 (2B, 3, 5, 6B, 8B, B, C, F, G, H, CC, EE & FF) • .90 >: 4 (7, 9, BB & GG) • Clinical Alpha • < .70: 0 • .70-.79: 9 (3,A, D, E, F, G, CC, DD & EE) • .80-.89: 16 (1, 2A, 2B, 4, 5, 6A, 6B, 7, 8A, 9, C, H, AA, • BB, FF, GG) • .90 >: 2 (8B & B)

25. Now let me see… What about this ... Validity • The tool is relatively new (1993) but was constructed with criterion related validity as it’s driving concept. It has been compared to other tools, clinician’s ratings and is being researched. • Additional research is always needed.

26. Yak Yak Yak Additional Comments • The MACI is the only tool of it’s type for this age group (aside from he MCMI-III any age group). It is an ideal tool for anyone working in outpatient, inpatient, private practice or correctional settings. • Caution is needed not to over diagnose pathology with the tool (assumes client has a disorder it is a mater of type). • My “desert island” tool with adolescents.

27. MMPI-A • The MMPI-A is a 478 item self-report measure intended for adolescents age 14 to 18. It has 36 typically scored scales (13 “clinical” scales which parallel the MMPI-2). It can be hand scored, computer scored or scored through a mail-in service. It is a downward extension of the MMPI-2/MMPI. There is a tape recorded administration available. Available from NCS.

28. And so, this looks pretty good ... Norms • 805 male adolescents and 815 female adolescents were obtained from schools in 7 states in the USA. 13 year olds were found to have difficulty completing the material and were eliminated. The norms are approximately representative of the USA in ethnic and several socioeconomic variables.

29. L: Lie F: Infrequency (3) K: Defensiveness 1: Hypochondriasis 2: Depression 3: Hysteria 4: Psych. Deviate 5: Masculin./Faminin. 6: Paranoia 7: Psychasthenia 8: Schizophrenia 9: Hypomaina 0: Social Introversion A-anx: Anxiety A-obs: Obsessiveness A-hea: Health Con. Cool names! Primary Scales

30. A-biz: Bizarre Ment. A-ang: Anger A-cyn: Cynicism A-aln: Alienation A-con: Conduct Probs. A-lse: Low Self-Esteem A-las: Low Aspirations A-sod: Social Discom. A-fam: Family Probs. A-sch: School Probs. A-trt: Neg. Treat. Inds. A: Anxiety R: Repression Mac-R PRO: Alc./Drg Prone. ACK: Alc/Drg Ack. IMM: Immaturity Looks good... Primary Scales Continued

31. Reliability: Clinical & Content • Normal Pop. Test-retest (1 week): • < .70: 7 (Pa, A-biz, A-aln, A-con, A-las, A-sch, A-trt) • .70-.79: 10 (Hs, D, Hy, Ma, A-obs, A-hea, A-ang, A-cyn, • A-lse & A-sod) • .80-.89: 8 (Pd, Mf, Pt, Sc, Si, A-anx, A-dep & A-fam) • .90 >: 0 • Normal Pop. Alpha • < .70: 9 (D, Hy, Pd, Mf, Pa, Ma, A-ang, A-las & A-sch) • .70-.79: 8 (Hs, A-obs, A-biz, A-aln, A-con, A-lse, A-sod, • & A-trt) • .80-.89: (Pt, Sc, Si, A-anx, A-dep, A-hea & A-fam) • .90 >: 0 Note: Clinical alphas were slightly higher (1 below .70)

32. Hum ...This isn’t adding up. Validity • The MMPI-A has little research completed on it at this time. There is a great deal of research under way. The use of code type data from previous research with MMPI are being applied, but this practice is currently not very supported. The applicability of previous research to it is unknown. Psychometrically it is the weakest tool covered here. If used reliance on the content and validity scales seems the most justified practice.

33. They won’t like this. Additional Comments • The reading level of over a quarter of the items is at the 8th grade or higher. • This is not one of the tools I use very often for a number of reasons. • Psychometric weaknesses • Length • Myths MYTHS

34. Other Scales & Thoughts • There are currently no good “teacher’s” checklist available. • The Achenbach CBCL is widely used, but has no validity indicators (to my knowledge). • The Basic Personality Inventory (BPI) is another sound choice (if computer scored) for adolescents age 12 or older (WPS).

36. References 1Cicchetti, D. (1994). Guidelines, criteria, and rules of thumb for evaluating normed and standardized instruments in psychology. Psychological Assessment, 6, 284-290. Heilbrun, K. (1992). The role of psychological testing in forensic assessment. Law and Human Behavior, 16, 257-272. Walsh, W. & Betz, N. (1995). Tests and assessment (3rd ed.) Englewood Cliffs, NJ: Prentice Hall.