Evidence Based Practices for Children and Adolescents with Serious Emotional Disturbances

1. Evidence Based Practices for Children and Adolescents with Serious Emotional Disturbances Session 2: The Role of Assessment In Evidence-Based Mental Health Practices for Children and Adolescents Beth Troutman, PhD, ABPP Iowa Consortium for Mental Health September 1, 2005

2. Assessment Data Can Be Used To Enhance Clinical Decision Making At The Level Of • System of care • Program • Individual patient/family

3. Assessments Evaluated According To • Psychometric Properties • Reliability • Validity

4. Assessment Data Can Be Used For • Treatment planning • Monitoring treatment • Assessing outcomes

5. Using Initial Assessment Data For Treatment Planning • What type of intervention does my patient need to address target symptoms? • What are the appropriate interventions for our target population?

6. Treatment planning • Assessments can be used to inform • Type of intervention • Level of care/service intensity • Other factors that need to be addressed

7. Describing Patient/Target Population • Diagnosis • Target Symptoms • Other Factors • Functional Status

8. Using Initial Assessment Data for Treatment Planning Diagnosis

9. Initial Assessment & Treatment Planning • Diagnosis • Primary • Comorbid

10. Disadvantages of Diagnosis • Labels or stigmatizes child • Labeling or stigmatizing a child with a diagnosis is of particular concern if the diagnosis does not lead to effective, evidence-based treatment.

11. Disadvantages of Diagnosis • Poor interrater reliability of clinical diagnosis • Short-hand method of communicating that fails to capture special strengths and weaknesses of particular child and family

12. Advantage of Diagnosis • Clinical eligibility for services • Funding for services • Method for organizing vast amount of treatment data so provider/program can select an effective, evidence-based intervention

13. Using Initial Assessment Data For Treatment Planning Describing Target Symptoms

14. Describing Target Symptoms • Symptom measures • Broadband • Symptom specific

15. Factors To Consider When Selecting Assessment Instrument • Source of information • Child • Parent • Teacher

16. Factors To Consider When Selecting Assessment Instrument • Clinician rated vs. respondent rated • Norm-referenced vs. criterion-referenced

17. Examples of Broadband Symptom Measures • Parent Report Measures • Behavior Assessment System for Children, Second Edition (BASC-2) (AGS) • Personality Inventory for Children, Second Edition (PIC-2) (Western Psychological Services) • Achenbach Child Behavior Checklist (ASEBA) • Note: Parent report tends to underestimate anxiety and depression compared to self report.

18. Examples of Broadband Symptom Measures • Self-Report Measures • Behavior Assessment System for Children, Second Edition (BASC-2) (AGS) • Personality Inventory for Youth (Western Psychological Services) • Achenbach Youth Self Report (ASEBA) • Note: Self-report tends to underestimate disruptive behavior problems compared to parent report.

19. Examples of Broadband Symptom Measures • Teacher Report Measures • Behavior Assessment System for Children, Second Edition (BASC-2) (AGS) • Achenbach Teacher Report Form (ASEBA) • Note: Teacher report tends to underestimate anxiety and depression compared to self-report.

20. Example of Using Broadband Symptom Measure To Describe Target Population • Target population: Children aged 5 through 18 in long-term family foster care in Iowa (> 6 months in same foster home) • Broadband symptom measure: Achenbach Child Behavior Checklist completed by foster parents • Source: Momany et al., University of Iowa Public Policy Center

21. Rates and Types of Mental Health Problems in Iowa’s Family Foster Care Population Momany et al., University of Iowa Public Policy Center

22. Example of Symptom Specific Measure – Attention Problems • Parent/teacher report • Conners rating scales (Psychological Corporation)

23. Examples of Symptom Specific Measures - Depression • clinician ratings • Children’s Depression Rating Scale - Revised (CDRS-R) (American Psychiatric Publishing) • self-report • Child Depression Inventory (CDI) (Psychological Corporation) • Beck Depression Inventory – Second Edition (BDI-2) (Psychological Corporation) • Reynolds Adolescent Depression Scale – Second Edition (RADS-2) (PAR)

24. Using Initial Assessment Data For Treatment Planning Assessing Other Factors That May Affect Treatment Planning

25. Child Factors That May Affect Treatment Planning • Cognitive functioning • IQ tests • Academic functioning • Standardized academic tests • Speech and language functioning • Standardized speech and language tests

26. Family Factors That May Affect Treatment Planning • Parenting stress • Parenting Stress Index – Third Edition (PSI-3) (PAR) • Maternal or paternal depression • Beck Depression Inventory – Second Edition (BDI-2) (Psychological Corporation)

27. Using Initial Assessment Data For Treatment Planning Assessing Functioning Level and Level of Services Needed

28. Determining Level of Functioning/Level of Services Needed • What level of care/service intensity does my patient need? • What level of care/service intensity do the patients in our program/system of care need?

29. Examples of Functional Assessment/Service Intensity Instruments • Clinician ratings • Children’s Global Assessment Scale (CGAS) • Child and Adolescent Functional Assessment Scale (CAFAS) • Child and Adolescent Level of Care Utilization System (CALOCUS) • Child and Adolescent Needs and Strengths – Mental Health (CANS-MH)

30. Using Assessment Data For Program Improvement

31. Using Assessment For Program Improvement • Assessments can be used to • Monitor treatment • Assess outcomes

32. Specify Core Components of Practice The Evidence Based Practice Cycle Optimize Priority Outcomes

33. Target Population Diagnosis Target symptoms Functional status Other factors Outcomes Identify Prioritize Quantify Role of Assessment in EBP Cycle

34. Treatment Monitoring • Is my patient benefiting from the intervention? • Are there any negative consequences (side effects/iatrogenic effects) associated with the intervention?

35. Example of Symptom Scale Used For Treatment Monitoring – Disruptive Behavior • Eyberg Child Behavior Inventory administered at each session in Parent Child Interaction Therapy • Parent rates a series of specific items addressing noncompliance and disruptive behavior according to: • How often the behavior occurred. • Whether it was a problem for the parent.

36. Example of Assessment Used For Treatment Monitoring – Separation Anxiety • Exposure treatments for anxiety have child or adolescent rate items on their systematic desensitization hierarchy at each session • E.g. walking from front door of school to classroom alone, walking from car to school alone

37. Using Assessment Data For Program Improvement Assessing Outcomes

38. Assessing Outcomes • Did my patient benefit from the intervention? • Are patients in our program/system of care benefiting from interventions?

39. Assessments Used to Evaluate Outcomes • Diagnosis • Target Symptoms • Other Factors • Functional Status

40. Use Of Diagnosis To Evaluate Outcome • Recovery/remission of diagnosis is relevant for some diagnoses: • E.g. depressive episode, adjustment disorder

41. Use Of Diagnosis To Evaluate Outcome • Diagnosis may not be useful for evaluating outcomes for other disorders • E.g. Attention Deficit Hyperactivity Disorder

42. Use Of Symptom Specific Measures To Assess Outcomes • The more reliable the symptom measure is, the better it will be at detecting improvement • Important that symptom measure is valid for intervention – i.e. does it assess what your intervention is targeting?

43. Examples Of Symptom Assessments Used To Evaluate Outcomes • Depression – self-report • Children’s Depression Inventory • Beck Depression Inventory – Second Edition (BDI-II)

44. Examples Of Symptom Assessments Used To Evaluate Outcomes • Attention and distractibility • Parent report/teacher report • Conners’ Rating Scales

45. Examples Of Symptom Assessments Used To Evaluate Outcomes • Anxiety • Self-report • Revised Children’s Manifest Anxiety Scale • Parent report • Achenbach Child Behavior Checklist – internalizing scale

46. Use of Other Assessments to Assess Outcomes • Some intervention studies have assessed changes in parenting stress or mood • Parenting Stress Index – Third Edition (PSI-3) • Beck Depression Inventory – Second Edition (BDI-2)

47. Use of Functional Assessments To Assess Outcome • CGAS is most widely used assessment of functioning in treatment outcome studies • Often a delay between symptom improvement and improvement in functioning

48. Using Outcome Data For Program Improvement • Is there a particular group of patients we should target for improved outcomes? • age • diagnosis • type of problem

49. Improving Outcomes For Target Population • Is there an Evidence Based Treatment available for this group of patients?

50. Program Improvement Process • Review of outcomes • Systematic modification of intervention