© cengage learning 2016 eric j. mash david a. wolfe assessment, diagnosis, and treatment 4

© Cengage Learning 2016 © Cengage Learning 2016

Eric J. MashDavid A. Wolfe

Assessment, Diagnosis, and Treatment

4

© 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


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


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


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


Developmental Considerations - Gender Patterns


• 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

Developmental Considerations – Normative Information


Parent- and Teacher-Rated Problems


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


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


• 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

Assessing Disorders


• 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

Clinical Interviews


Structured Interview Questions


• 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

Behavioral Assessment


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


Functional Analysis


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


Child Behavior Checklist


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


• 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.

Psychological Testing


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


• 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

Psychological Testing - Intelligence Testing


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)


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


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


Psychological TestingSelf-Report Personality Scale Definitions


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


• 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

Classification and Diagnosis


• 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

Ideographic and Nomothetic Strategies


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


Classification and DiagnosisCommonly Identified Dimensions


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


The Diagnostic and Statistical ManualNeurodevelopmental Disorders


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


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


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


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


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


Treatment - The Intervention Spectrum


• 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

Cultural Considerations


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


Cultural Values and Parenting Practices


• Outcomes related to child functioning– Reduce or eliminate symptoms

– Reduce degree of impairment in functioning

– Enhance social competence

– Improve academic performance

Treatment Goals


• Outcomes related to family functioning– Reduce level of family dysfunction

– Improve marital and sibling relationships

– Reduce stress

– Enhance family support

Treatment Goals (cont’d.)


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


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


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)


Ethical Issues in Clinical Work With Children and Families


• 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

General Approaches to Treatment


• 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

Behavioral Treatments


• View abnormal behavior as the result of deficits and/or distortions in the child’s thinking

• Focus is on changing faulty cognitions

Cognitive 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

Cognitive Behavioral Treatments


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


• View child psychopathology as resulting from psychobiological impairment or dysfunction

• Rely primarily on pharmacological and other biological approaches to treatment

Biological 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

Combined Treatments


Descriptions of Common Medications for Children and Youths


Usage of Psychiatric Medication by Children in the United States (1987 – 1996)


Results of Behavioral Role-Play Intervention


• 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

Treatment Effectiveness


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


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


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 eric j. mash david a. wolfe assessment, diagnosis, and treatment 4

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