4
Assessment, Diagnosis, and
Treatment
Eric J. Mash
A. 2016
Wolfe
©David
Cengage Learning
© Cengage Learning 2016
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
© Cengage Learning 2016
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
© Cengage Learning 2016
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
© Cengage Learning 2016
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
© Cengage Learning 2016
Developmental Considerations - Gender
Patterns
© Cengage Learning 2016
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
© Cengage Learning 2016
Parent- and Teacher-Rated Problems
© Cengage Learning 2016
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
© Cengage Learning 2016
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
© Cengage Learning 2016
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, costeffective, 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
© Cengage Learning 2016
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
© Cengage Learning 2016
Structured Interview Questions
© Cengage Learning 2016
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
© Cengage Learning 2016
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
© Cengage Learning 2016
Functional Analysis
© Cengage Learning 2016
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
© Cengage Learning 2016
Child Behavior Checklist
© Cengage Learning 2016
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
© Cengage Learning 2016
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.
© Cengage Learning 2016
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
© Cengage Learning 2016
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
© Cengage Learning 2016
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 (KABC-II)
© Cengage Learning 2016
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
© Cengage Learning 2016
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
© Cengage Learning 2016
Psychological Testing
Self-Report Personality Scale Definitions
© Cengage Learning 2016
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
© Cengage Learning 2016
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
© Cengage Learning 2016
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
© Cengage Learning 2016
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
© Cengage Learning 2016
Classification and Diagnosis
Commonly Identified Dimensions
© Cengage Learning 2016
The Diagnostic and Statistical Manual
(DSM)
• The current edition: DSM-5
• A multiaxial system consisting of five axes:
I.
Clinical disorders or conditions
II. Personality disorders and intellectual
disability
III. General medical conditions
IV. Psychosocial and environmental problems
V. Global assessment of functioning
© Cengage Learning 2016
The Diagnostic and Statistical Manual
Neurodevelopmental Disorders
© Cengage Learning 2016
The Diagnostic and Statistical Manual
Criticisms
• 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
© Cengage Learning 2016
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
© Cengage Learning 2016
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
© Cengage Learning 2016
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
© Cengage Learning 2016
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
© Cengage Learning 2016
Treatment - The Intervention Spectrum
© Cengage Learning 2016
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
© Cengage Learning 2016
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
© Cengage Learning 2016
Cultural Values and Parenting Practices
© Cengage Learning 2016
Treatment Goals
• Outcomes related to child functioning
– Reduce or eliminate symptoms
– Reduce degree of impairment in functioning
– Enhance social competence
– Improve academic performance
© Cengage Learning 2016
Treatment Goals (cont’d.)
• Outcomes related to family functioning
– Reduce level of family dysfunction
– Improve marital and sibling relationships
– Reduce stress
– Enhance family support
© Cengage Learning 2016
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
© Cengage Learning 2016
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
© Cengage Learning 2016
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)
© Cengage Learning 2016
Ethical Issues in Clinical Work With
Children and Families
© Cengage Learning 2016
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
© Cengage Learning 2016
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
© Cengage Learning 2016
Cognitive Treatments
• View abnormal behavior as the result of
deficits and/or distortions in the child’s
thinking
• Focus is on changing faulty cognitions
© Cengage Learning 2016
Cognitive Behavioral Treatments
• View psychological disturbances as the
result of:
– Faulty thought patterns
– Faulty learning and environmental
experiences
• Focus on:
– Identifying and changing maladaptive
cognitions; teaching the child to use cognitive
and behavioral coping strategies; and helping
the child learn self-regulation
© Cengage Learning 2016
Client-Centered and Family Treatments
• Client-centered treatments:
– Focus on creating a therapeutic setting which
provides unconditional acceptance of the child
• Family treatments:
– View individual disorders as manifestations of
disturbances in family relations
– Focus on the family issues underlying
children’s problematic behavior
© Cengage Learning 2016
Biological Treatments
• View child psychopathology as resulting
from psychobiological impairment or
dysfunction
• Rely primarily on pharmacological and
other biological approaches to treatment
© Cengage Learning 2016
Combined Treatments
• The use of two or more interventions, each
of which can stand on its own as a
treatment strategy
• More communities are now implementing
comprehensive mental health programs
for children
– Often delivered through schools
© Cengage Learning 2016
Descriptions of Common Medications for
Children and Youths
© Cengage Learning 2016
Usage of Psychiatric Medication by Children
in the United States (1987 – 1996)
© Cengage Learning 2016
Results of Behavioral Role-Play Intervention
© Cengage Learning 2016
Treatment Effectiveness
• Best practice guidelines
– Systematically developed statements to assist
practitioners and patients
• Two main approaches in developing best
practice guidelines
– The scientific approach derives guidelines
from a review of current research findings
– The expert-consensus approach uses experts’
opinions to fill gaps in scientific literature
© Cengage Learning 2016
Positive Findings
• Children’s changes achieved through
therapy are greater than changes for
children not receiving therapy
• Children receiving therapy are better off
after therapy
• Treatments are equally effective for
internalizing and externalizing disorders
• Treatment effects tend to be long-lasting
© Cengage Learning 2016
Negative Findings
• Fewer than 20% of treatments
demonstrate evidence for reducing
impairment in life functioning
• Community-based clinic therapy is far less
effective than structured research therapy
• Conventional services for children may
have limited effectiveness
© Cengage Learning 2016
New Directions
• As many as 70% to 80% of children and
families with significant mental health
needs do not receive any specialized
assessment or treatment services
• New initiatives:
– Increase recognition of children's mental
health needs
– Develop a wider range of service delivery
models
© Cengage Learning 2016