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175.782.- CLINICAL PSYCHOLOGY ASSESSMENT

PSYCHOLOGICAL ASSESSMENT IN CHILDHOOD

Psychological assessment of childhood and adolescence stems from the evaluation of

the adult population, inheriting its same problems and limitations. Until well into the

18th century, the child was considered a miniature adult. From the 1970's, this way of

understanding childhood changed, recognising the specific nature of child development

taking into account sensorimotor, cognitive, behavioural, and social variables, although

child assessment remained primarily focused on classification and diagnosis. It is from

the 1980's when evaluation also aimed at specific ways of data collection, evaluation

design and treatment implementation (Shapiro & Kratochwill, 1988; Gregory, 2011).

Adequate child psychological assessment should include multiple methods (multi-

method assessment) like (interviews, direct observation, questionnaires, etc., given to

different people (parents, teachers, children themselves, etc.), referenced to different

contexts (home, school, etc.), and include both familial and extra-familial assessment

(McMahon, 1987). Looking at the specific functions that should be evaluated in the

clinical psychological assessment of children, the following should be considered:

Motor skills (manual dexterity, right-left orientation, orofacial praxis, verbal control of

motor skills), perception (visual, auditory and tactile or haptic), language (receptive and

expressive skills of oral language, academic skills in literacy and numeracy), memory

(verbal and nonverbal, short and long term), general cognition (general intellectual

ability, attention span), relationships and behavioral abnormalities, basic functions

alterations (sleeping, feeding, toilet training), and psychopathology (mood disorders,

psychosis, autism, and borderline cases) (Weissman, 2011; Groth-Marnat, 2009; Kline,

2000; Merrell, 2003).

A psychological assessment covering all the above functions, together with other

relevant information from interviews, medical records, clinical observations, etc., is a

prerequisite for obtaining a complete patient evaluation (Gammon, 2012). Methods of

evaluation are all those scales and standardized tests that provide the child or

adolescent evaluated score points (quantitative measures), as well as those that help

clinicians understand the contents, conflicts and underlying motivations (qualitative

methods). However, one more thing should be considered in the process of

psychological assessment: cost in terms of time and resources. That is the reason why a

some researcher has critisised multi-method evaluation, claiming they have little

empirical grounds for added effectiveness and that the amount of data collected does

not necessarily correlate with information quality (Wicks-Nelson & Israel, 2009). That

said, multi-evaluation is the gold standard in clinical psychology assessment practice for

a very good reason: it makes nothing but all the sense.

Two major diagnostic concepts have been developed for clinical assessment: categorical

classification systems and dimensional-statistical systems. Categorical systems include

different versions of the Diagnostic and Statistical Manual of Mental Disorders (DSM)

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(APA, 1980), the International Classification of Mental Disorders (ICD) developed by the

WHO (1992), and the Group for Advancement of Psychiatry (GAP, 2009) classification

system focused on evolutionary aspects of psychological development. Categorical

systems are based on expert consensus, in literature review and in correlational level

data to establish the inclusion and exclusion criteria that determine an individual's

belonging in one or another category. In contrast, dimensional systems have focused on

creating empirical knowledge for which they performed statistical analyses (like

factorial analysis) by pooling data from many symptoms that are likely belong to each

category (Sadock & Sadock, 2009; APA, 1980; WHO, 1992; GAP, 2009).

Dimensional systems have established three main dimensions for grouping child and

youth disorders: externalizing disorders (hyperactivity, aggression, delinquency),

internalizing disorders (personality disorders, anxiety, inhibition) and mixed or

combined disorders (social problems and attention and memory abnormalities). The

basis for this classification was informed by the Child Behavior Checklist, the Teacher

Report Form, and Youth Self-Report discussed below under the psychometric tests

section (Achenbach et al., 2001).

New Zealand psychologists follow the American Psychiatric Association’s Diagnostic

and Statistical Manual (DSM) categorical diagnostic system (NZPS, 2012) based on a

multiaxial system consisting of five axes: Axis I includes clinical disorders and other

mental conditions requiring clinical attention, which include disorders beginning in

childhood or adolescence. Axis II includes personality disorders and mental retardation.

Axis III includes medical conditions causing mental disorders. Axis IV refers to the

psychosocial and environmental causes of mental disorder and axis V is the global

assessment of functioning (GAF) in the past year (APA, 1980; Sadock & Sadock, 2007;

Wick-Nelson & Israel, 2009).

Looking now at children’s psychological assessment processes, these usually include an

interview with the parents (one or more), an interview with the child (play time

diagnosis), direct observation, a test battery (projective and/or psychometric tests) and

a return interview (parent – child with the psychologist), all of which will inform the

written report. These will first be described in general, focusing on the process more

than on the contents, and then specific mention will be done to assessment instruments

(Weissman, 2011; Gingsburg, 1997; Greenspan & Greenspan, 2003).

Children evaluation processes are longer than adults’. The starting point is usually a

categorical approach, that is, an interview with the parents because children are usually

not aware of having any problem at all and it is third parties who detect the problem

and refer the child to the psychologist for evaluation (Weissman, 2011; Gingsburg,

1997; Greenspan & Greenspan, 2003).

The interview is a pre-diagnostic technique essential in the psychological assessment

process because of the amount of information and personal knowledge that is obtained

in very little time. It develops through a purposeful conversation focusing on the

explanation of the problem of the subject. It openly reflects the request for assistance of

the interviewee. The information collected from the client is part wide and general and

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in part specific and concrete. The goal of the interviewer is to identify and clarify the

reason for consultation. The interview takes place at a predetermined time and location,

and usually lasts one hour.

The role of the psychologist conducting the interview includes a responsibility to gather

information to obtain knowledge about the client and his or her environment. The

clinician must exert control of the direction of the interview at the same time that he or

she is flexible with its contents and with his/her interaction with the client. The act of

interviewing involves an interpersonal relationship with the client where they mutually

influence and learn from each other. This interpersonal relationship functions as a

gestalt. Ethical issues like informed consent to diagnosis and treatment, and

confidentiality must be addressed at this point and will be considered later together

with the clinical report discussion (Weissman, 2011; Gingsburg, 1997; Greenspan &

Greenspan, 2003; Sommers-Flanagan & Sommers-Flanagan, 2008).

Interviews can be structured (Diagnostic Interview Schedule for Children and

Adolescents [DICA], Diagnostic Interview Schedule for Children Revised [DISC-R], Child

Assessment Schedule [CAS]) or semi-structured (Interview Schedule for Children [ISC],

Schedule for Affective Disorders and Schizophrenia for School-age children [K-SADS]).

Structured interviews have the advantage of being highly yielding in terms of objective

information, have greater validity and reliability than semi- and non-structured

interviews, and are used as an instrument not just for diagnosing but for screening,

clinical research and clinical training support. The disadvantages include those of

communication issues on the part of both the interviewer and the interviewee like

speech impairments, language used not being mother tongue, taboo questions (sex,

habits, drugs) being too direct, and social desirability (Weissman, 2011; Weller et al.,

2000; Achenbach & Rescorla, 2001; Wick-Nelson & Israel, 2009; Gingsburg, 1997).

At the end of the interview with the parents, the psychologist suggests treatment plan

options, agrees to one with the parents, and parents, then, commit themselves to

complying with the treatment for their child. Usually a minimum of two interviews are

held with the parents: the first one is focused on what is happening with the child

(explanation or description of issues, duration, identification of triggering and

maintenance factors when possible, etc.), and a second one to take additional relevant

history like pregnancy, development, family history of psychological or medical

conditions, social and cultural aspects relevant to the case, and inquires about the

parents or caregivers, relationships in the family, the position the child occupies in the

family, etc., with the aim to get additional valuable information and achieve a greater

rapport with and involvement of the parents (Gammon, 2012; Sommers-Flanangan &

Sommers-Flanagan, 2008; Weissman, 2011; Hodges, 1993; Shaffer, 1994; Lubin, Larsen,

& Matarazzo, 1998; Greenspan & Greenspan, 2003).

After the interview with the parents, an interview with the child is scheduled. With very

young children or children with lack of verbal expression, diagnostic play is used

because it has equivalent symbolic capacity to words, it is easy to perform and engages

the child in the diagnostic process without unnecessary stress. Thus, by observing

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which toys the child selects, how he uses them and what he does with them, the

specialist can see his development, fears, defenses, anxiety, and his strategies for

change. After the age of about 12 years of age interviews are often used because the

individual has the capacity to express what is happening to him (Gammon, 2012;

Reynolds, 1998; Greenspan & Greenspan, 2003; Lubin, Larsen, & Matarazzo, 1998;

Merrell, 2003; Weissman, 2011). During the interview, the clinician also observes how

the child behaves and interacts with parents and psychologist. Direct observation in the

child’s environment (home, school, playground) can provide very useful information

but it is difficult to obtain directly by the psychologist, so it is parents and teachers who

do so (Achenbach & Rescorla, 2001).

The next session would be the test battery, of which the order of application is usually

first projective, then psychometric tests. The rationale for this order is that projective

tests are open, that is, the individual constructs them from a free, general perspective.

Projective tests have the advantage of all responses being valid, correct and good, and of

having no time constraints. As they imply a non-structured task, the child finds them

easy to do and does not feel judged or critisised, because the purpose of the test is not

revealed or clear for the child. The application of projective tests usually starts with

graphic (drawing) tests (Buck’s HTP, Machover’s DPT, Corman’s DFT), followed by

verbal tests (Duss fables, Pigem test), Rorschach test, and aperceptive tests (Bellack’s

CAT, Corman’s Black Paw). Other commonly used projective test is Phillipson ORT

(Murstein, 1965; Lubin, Larsen & Matarazzo, 1984; Klopfer, 2006).

Projective tests have the added strength of increasing the rapport between child and

psychologist, they are cost-time effective and when conducted by experienced

professionals they yield very useful, robust and unique results. These techniques are

used to study overall trait behaviour, that is, personality. The limitations of the

projective tests are the same for all of them: their validity and reliability is limited

because of the reduced amount of research backing them, the subjectivity of their

interpretation reflected in extremely low inter-rater reliability, the limited amount of

hypotheses that can be drawn from them, and the high influence in results of contextual

variables (culture, ethnicity). Buck’s HTP test deserves a special mention as literature

review has shown a high correlation with intelligence tests (WISC-R and WAIS) and

there is some evidence that the HTP can differentiate people with specific types of brain

damage like that present in individuals with schizophrenia (Kline, 2000; Merrell, 2003;

Klopfer, 2006; Butcher, 2010; Hojnoski, 2006).

Psychometric tests are applied afterwards, as it is much easier to move from a non-

structured field to a structured one. It should be highlighted that, as evidenced in this

work and contrarily to common belief among students, psychometric testing is only one

part of the psychological assessment process.

Psychometric tests are “closed” techniques where answers are true or false, right or

wrong, the psychologist interprets them, and comes up with an overall score. There are

time limits, time is measured with a stopwatch and when the time is up, the test is

interrupted even if the subject has not ended. The purpose of the test is clear for the

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individual, he knows what he is being asked and what is expected of him, and may feel

anxious when responding. Psychometric tests tend to generate a relationship of

dependence with the psychologist. These tests are specific for analyzing traits, states,

and attitudes (Groth-Marnat, 2009; Kline, 2000; Lubin, Larsen, & Matarazzo, 1984;

Klopfer, 2006) and results may be used to inform axis I and II of the DSM-IV-TR

disorder diagnoses. A review and comparison of the most commonly used psychometric

tests follows:

Intelligence: Wechsler Intelligence Scale for Children Revised (WISC-R), Wechsler

Preschool and Primary School Scale of Intelligence (WPPSI), Stanford-Binet Intelligence

Scale (SB5), Raven’s Progressive Matrices (RPM) and Kaufman’s Assessment Battery for

Children (K-ABC) (Groth-Marnat, 2009). These intelligence scales vary in theoretical

approach, item number, design, clarity, length, age range application and skills required

for completion. A major criticism to the WISC-R is that the working memory assessment

includes only auditory tasks and does not include non-verbal tasks such as McCarthy’s

xylophone test or K-ABC’s spatial memory evaluation. Wechsler tests are redundant in

that too many sections are focused on the analysis of almost exclusively quantitative

general intelligence, marginalizing other aspects of intellectual functioning. The RPM

has the added advantage over Wechsler, Kaufsman and Stanford-Binet tests in that it

requires no manipulative skills, it aims to measure not general intelligence but an

important aspect of it, the ability to deduct relations, and in that it fits into Cattell’s

category of non-cultural psychological assessment tests. Additionally, RPM and K-ABC

differ from WISC-R and SB5 in that, in the former, the child requires minimal to no

language abilities, respectively, to complete the tests (Groth-Marnat, 2009; Kline, 2000;

Sadock & Sadock, 2007, Weller et al., 2000; Wicks-Nelson & Israel, 2009).

Developmental: Newborg et al.’s Developmental Inventory and McCarthy’s Scales of

Children Abilities (MSCA) are similar in orientation and age range but differ in that the

former can be given to children with or without cognitive or sensorimotor disabilities

and has a screening and full mode of application, and in that the latter is presented in a

stress-preventing ludic way (Kline, 2000; Sadock & Sadock, 2007, Weller et al., 2000;

Wicks-Nelson & Israel, 2009).

Memory: Wide Range Assessment of Memory and Learning (WRAML), Children’s

Memory Scales (CMS), and Benton’s visual retention test (BVRT). These are the most

commonly used memory assessment tests in children. They have high criterion validity

when compared with medical imaging techniques, like MRI. They are used to assess the

diagnosis of brain pathology and Benton’s test assesses premorbid intelligence status

(Groth-Marnat, 2009; Kline, 2000; Sadock & Sadock, 2007, Weller et al., 2000; Wicks-

Nelson & Israel, 2009).

Neuropsychological: Halstead-Reitan battery for older children, Reitan-Indiana battery

for young children, Quick Neurological Screening Test (QNST), Luria’s Neuro-

Psychological test for children (NEPSY), and the Luria-Christensen test are widely used,

researched and validated neuropsychological instruments that assess superior cortical

processes. Research shows that Luria tests have a very high degree of overlapping with

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Reitan batteries in the identification of neuropsychological deterioration due to

traumatic brain injuries and psychiatric disorders (Costa et al., 2004), which is

interesting given that their factorial structure is completely different. Similarly,

overlapping between Luria-Nebraska and WISC-R is significant in some scales, like E11

and global IQ. Luria’s NEPSY test also correlates with K-ABC test in academic skills

scales but only moderately, and correlations are negligible in the remaining scales. With

the exception of the QNST, these tests are time and attention-ability consuming and

some children with neurological impairment may not finish them (Kline, 2000; Weller

et al., 2000; Costa et al., 2004; Wicks-Nelson & Israel, 2009).

Academic-educational: Thorndike, Hagen and Lorge Cognitive Ability Test, Wechsler

Individual Achievement Test (WIAT-II), Woodcock-Johnson Achievement Test (WJ-III),

and Kaufman Test of Educational Achievement (KTEA-II) are all collective, normed tests

that assess basic skills and attitudes for learning. Their validity and reliability is good in

the United States, but generalisability to other countries with different educational

systems and syllabuses poses a limitation to their applicability (Kline, 2000; Sadock &

Sadock, 2007, Weller et al., 2000; Wicks-Nelson & Israel, 2009).

Behaviour: Child Behavior Check-list (CBCL) (Achenback & Edelbrock, 1985) and

Youth Self Report (YSR) (Achenback & Edelbrock, 1987). The CBCL evaluates a wide

range of adaptive and problem behaviours of children. There is a version for parents

and another for teachers (TRF) and can be used with both clinical and non-clinical

individuals. The CBCL informs three groups of disorders: externalizing (hyperactivity,

aggression, delinquency and other problems), internalizing (depression, isolation,

obsession-compulsion, somatic complaints, and schizophrenia) and the combined or

mixed type which encompasses sexual problems and social isolation. The psychometric

characteristics of the scale are robust in terms of test-retest reliability (Achenbach et al.,

2001), concurrent validity and discriminant validity. The YSR is a scale that refers to

social adjustment and behavior problems whose content is similar to the Child Behavior

Checklist (CBCL) but is applied to adolescents. Likewise, the indices of reliability and

validity of the YSR are similar to those of the CBCL (Achenbach & Rescorla, 2001; Wick-

Nelson & Israel, 2009; IESC, 2012).

ADHD: Conners Teachers Rating Scale (CTRS) and/or Abbreviated Teachers

Questionnaire and Conners Parent Rating Scale, when combined, they are said to

provide robust evidence of ADHD in children (Conners & Jett, 2006). However, in a

current research article Silva (2011) claims that, based on the DSM-IV-TR criteria, CTRS

has limited ability to predict ADHD in schoolchildren, a view opposed by researchers

like Hale et al. (2001) and Ghassemi et al. (2009) who find the scales valid, practical,

easy to apply and relatively inexpensive.

Personality: Millon’s Pre-Adolescent Clinical Inventory III (M-PACI) is the only

relatively commonly used screening instrument for the assessment of specific

psychopathologies or emotional problems in children, and correlates highly with the

TAT, which enhances the criterion validity of the latter. Recent publications defend the

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use of projective techniques in the evaluation of children’s personality (Trull, 2005;

Klopfer, 2009).

Relationships: Jones, Reid and Patterson’s Family Interaction Coding System (FICS),

the Robinson and Eyberg’s Dyadic Parent-Child Interaction Coding System (DPCICS) and

Vineland’s Adaptive Behavior Scales (VABS). The FICS is a classical coding system that

assesses family, school and laboratory environment interactions between parents and

child (La Greca & Stone, 1992), whereas the DPCICS focuses on the evaluation of

behaviours in the parent-child dyad interaction. The main advantage of the VABS over

the FICS and the DPCICS is its comprehensiveness, as it includes evaluation of daily life

activities and abilities in personal, family, and social contexts, as well as the study of free

time activities. The limitation of these psychometric tests leads to their restricted

application because of the extensive training required to administer and interpret them.

Structured observations are more yielding and cost-effective (Jacob, Tennenbaum, &

Bargiel, 1995; IESC, 2012).

Continuing with the psychological assessment procedure for children, after the

interviews and the psychological tests, a repeat interview is done where the results of

the evaluation process, along with further guidance is explained the parents and the

child. As in the case of the first interview, it is first done with the parents and then with

the child. Some discrepancies arise at this point, as some clinicians, depending on the

child’s age, choose to speak first with the child, claiming that the child is their patient is

the first one who should know what the outcome of the process is. However, a child is

not responsible enough to understand a diagnosis or comply with a therapy, and it is the

parents in any case who have to agree to it. In the case of adolescents it is best to talk to

them directly because they have the capacity to understand and to ask questions about

their therapy. With regard to a joint interview, again, controversy arises in that some

clinicians claim that a different language should be used when speaking with the

parents than when speaking with the child and that the privacy of both should be

preserved (Merrell, 2003; Westwater, 2012; Reynolds, 1998; Weller et al., 1999).

The written report is a professionally written explanation of the case history, evaluation

process, diagnostic impression, proposed therapeutic approach/es, and

recommendations. Sometimes, an informal, non-technical letter summarising the

contents of the report is sent to the parents (or the patient depending on age) on

request (Babbage, 2012). Section 29 of the NZ Law Commission addresses the issue of

report writing, making special emphasis on Family Court reports (NZLII, 2012). At this

point the critical issue of ethics arises again. It is particularly important to make a clear

diagnosis of the child and that it is adjusted to the child’s age and disorder, as

psychological diagnoses have the risk of having pervasive influences, influencing the

child’s future particularly in terms of academic / professional development and

integration in society. Diagnoses and treatments have a special impact on pediatric

population because children are undergoing maturation and mere labelling, non-

resolution or chronicity of the disease could create a situation of disability throughout

life (Gingsburg, 1997; Roberts, Moar, & Scott, 2011; Greenspan & Greenspan, 2003;

Sachse & von Suchodoletz, 2008)

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Child psychologists face critical ethical questions like, who is my client? The parents or

the child? What to do when a mature child’s will regarding treatment opposes that of

the parents’? Does a mature child, like an adult, have the right to refuse treatment when

non-treatment may result in harm to self and / or others? What type of information

must be included in the clinical report and who owns it? Should confidentiality be

breached to inform third parties with regard to risk issues to self (suicide and special

needs) or others? (Sondheimer, 2010; Sommers-Flanagan & Sommers-Flanagan, 2008;

Brierley & Larcher, 2010).

Clinicians, particularly those specialised in children and adolescents’ psychology,

understand psychological assessment in a holistic and practical way. They evaluate

themselves for best clinical practices, technical knowledge, continuing professional

education and professional practice updates, and, very importantly, aim to abide by

Beauchamp and Childress’ (1994) deontological principle: primun non noscere (first of

all, do not harm).

[Word count without references: 3620]

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