Assessment, Diagnosis, and Treatment

1. 4 Assessment, Diagnosis, and Treatment

2. 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

3. 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

4. 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

5. 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

6. Developmental Considerations - Gender Patterns

7. 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

8. Parent- and Teacher-Rated Problems

9. 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

10. 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

11. 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

12. 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

13. Structured Interview Questions

14. 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

15. 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

16. Functional Analysis

17. 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

18. Child Behavior Checklist

19. 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

20. 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.

21. 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

22. Psychological Testing - Intelligence 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

23. 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)

24. 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

25. 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

26. Psychological TestingSelf-Report Personality Scale Definitions

27. 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

28. 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

29. 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

30. 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

31. Classification and DiagnosisCommonly Identified Dimensions

32. 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

33. The Diagnostic and Statistical ManualNeurodevelopmental Disorders

34. The Diagnostic and Statistical ManualCriticisms • 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

35. 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

36. 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

37. 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

38. 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

39. Treatment - The Intervention Spectrum

40. 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

41. 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

42. Cultural Values and Parenting Practices

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

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

45. 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

46. 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

47. 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)

48. Ethical Issues in Clinical Work With Children and Families

49. 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

50. 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