Developmental Psychopathology Assessment of Psychopathology

Terminology Sign: feature that are observable by others Symptom: feature that can be reported by the individuals themselves Syndrome: a set of signs and symptoms that covary across individuals Classification: system for delineating the major categories or dimensions of syndromes Diagnosis: the process of assigning individuals to the categories generated by a classification system

Terminology Etiology  (aetiology, aitiology): the cause(s) of a disorder Prognosis: denotes prediction of how a patient's disorder will progress, and whether there is chance of recovery Comorbidity: presence of more than one mental disorder occurring in an individual at the same time Epidemiology: the study of the patterns of disease in human populations... to estimate the prevalence of disorders and to identify their correlates and causes

Conceptual Framework Value of assessment: Ability to identify characteristics important for decision making Different procedures and sources of data: Projective tests for ideographic portraits Tabulations of overt behaviors Inventories Interviews Structured vs. unstructured diagnostic interviews

Taxonomic Targets for Assessment Which characteristics will be assessed? Reliably assessable Valid indices What are the targets for assessment? Taxonomic groupings (needed to organize relevant information)

Diagnostic Efficiency Determining which indicators will maximize our diagnostic “hits” and which will minimize our diagnostic “misses” is important Presence vs. absence of of a single disorder and a single indicator true positive false positive true negative false negative

Taxonomic Targets for Assessment Error of Measurement Test-retest unreliability: Variability in a measure’s results over brief intervals Different informants (different standards of judgment, perceptions and memories) Different assessment procedures may target different variables (personal experiences, signs) Targeted time intervals (frequency of behaviors in the last 6 months vs. present) Solution?

Taxonomic Targets for Assessment Error of Measurement Solution is aggregating data from different procedures Be alert! Information for consistency and continuity across settings is an important.

Approaches to Conceptualize Child Psychopathology Problem Behaviors Enumerates symptoms Dimensions Symptom clusters Categories Diagnostic criteria

Empirically Based Paradigm “Bottom up” approach is taken to derive syndromes Problems are rated according to frequency and intensity Quantitative approach deals more effectively with measurement error Degree of problem vs. presence or absence Uses norm-referenced profiles: seperate norms for each gender within each developmental level

Cross-Informant Syndrome Constructs (symptom clusters) Example: Parents (CBCL), teachers (TRF) and child (YSR) Undercontrolled (Other-directed) Overcontrolled (Inner-directed) Common dimensions Somatic complaints Thought problems Attention problems Anxious/depressed

Categorical Approach The DSM Paradigm Classifies problems according to diagnostic categories. Each category reflects a taxonomic construct and involves explicit criteria Top-down approach: categories and criteria were negotiated among the committees Field trials affected some cutpoints in latest versions

Classification Systems International Classification of Diseases (ICD); WHO DSM; APA Diagnostic Classification (DC): 0-3 ages; National Center for Clinical Infant Programs

Categories of Child Psychopathology DSM-IV Developmental & learning disorders first diagnosed in infancy, childhood, or adolescence Other disorders usually first diagnosed in infancy, childhood, or adolescence Disorders of childhood or adolescence that are not listed separately as those usually first diagnosed in infancy, childhood, or adolescence Other conditions that may be a focus of clinical attention during childhood or adolescence, but are not defined as mental disorders

Categories of Child Psychopathology Developmental & learning disorders first diagnosed in infancy, childhood, or adolescence Mental retardation Learning disorders Mathematics Motor skills disorder Coordination Communication disorders Stuttering Pervasive developmental disorders Disintegrative

Categories of Child Psychopathology Other disorders usually first diagnosed in infancy, childhood, or adolescence Attention-deficit and disruptive behavior disorders Conduct Feeding and eating disorders Pica Tic disorders Tourette’s Elimination disorders

Categories of Child Psychopathology Disorders of childhood or adolescence that are not listed separately as those usually first diagnosed in infancy, childhood, or adolescence Mood disorders Anxiety disorders Gender identity disorders Schizophrenia Sleep disorders

Categories of Child Psychopathology Other conditions that may be a focus of clinical attention during childhood or adolescence, but are not defined as mental disorders Relational problems Problems related to abuse or neglect Bereavement Borderline intellectual functioning Antisocial behavior Identity problem

Multiaxial Classification Diagnosis is systemized in 5 axes: Axis I: Clinical Syndromes Major mental disorders, developmental disorders and learning disabilities Axis II: Personality Disorders Underlying pervasive or personality conditions Axis III: General Medical Conditions Nonpsychiatric somatic conditions Axis IV: Psychosocial & Environmental Problems Axis V: Global Assessment of Functioning

Axis IV: Psychosocial & Environmental Problems Problems with Primary Support Group Problems Related to the Social Environment Educational Problems Occupational Problems Housing Problems Economic Problems Problems with Access to Health Care Services Problems Related to Interaction with the Legal System/Crime The Global Assessment of Functioning, or GAF scale, is a numeric scale (1 through 100) used by mental health clinicians and doctors to rate the social, occupational and psychological functioning of adults. Children and adolescents under the age of 18 are evaluated on the Children’s Global Assessment Scale, or C-GAS.

Axis V: Global Assessment of Functioning 100 Superior functioning. No symptoms 91 80 Symptoms are present, transient, expectable 71 60 Moderate symptoms 51 40 Some impairments in reality or communication 31 20 Some danger of hurting 11 10 Persistent danger of hurting 1 91-100 Superior functioning in a wide range of activities, life's problems never seem to get out of hand, is sought out by others because of his or her many qualities. No symptoms. 90-81 Absent or minimal symptoms, good functioning in all areas, interested and involved in a wide range of activities, socially effective, generally satisfied with life, no more than everyday problems or concerns. 80-71 If symptoms are present they are transient and expectable reactions to psychosocial stresses; no more than slight impairment in social, occupational, or school functioning. 70-61 Some mild symptoms OR some difficulty in social, occupational, or school functioning, but generally functioning pretty well, has some meaningful interpersonal relationships. 60-51 Moderate symptoms OR any moderate difficulty in social, occupational, or school functioning. 50-41 Serious symptoms OR any serious impairment in social, occupational, or school functioning. 40-31 Some impairment in reality testing or communication OR major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood. 30-21 Behavior is considered influenced by delusions or hallucinations OR serious impairment in communications or judgment OR inability to function in all areas. 20-11 Some danger of hurting self or others OR occasionally fails to maintain minimal personal hygiene OR gross impairment in communication. 10-1 Persistent danger of severely hurting self or others OR persistent inability to maintain minimum personal hygiene OR serious suicidal act with clear expectation of death. 0 Not enough information available to provide GAF.

Axis V: Global Assessment of Functioning 91-100 Superior functioning in a wide range of activities, life's problems never seem to get out of hand, is sought out by others because of his or her many qualities. No symptoms. 90-81 Absent or minimal symptoms, good functioning in all areas, interested and involved in a wide range of activities, socially effective, generally satisfied with life, no more than everyday problems or concerns. 80-71 If symptoms are present they are transient and expectable reactions to psychosocial stresses; no more than slight impairment in social, occupational, or school functioning. 70-61 Some mild symptoms OR some difficulty in social, occupational, or school functioning, but generally functioning pretty well, has some meaningful interpersonal relationships. 60-51 Moderate symptoms OR any moderate difficulty in social, occupational, or school functioning. 50-41 Serious symptoms OR any serious impairment in social, occupational, or school functioning. 40-31 Some impairment in reality testing or communication OR major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood. 30-21 Behavior is considered influenced by delusions or hallucinations OR serious impairment in communications or judgment OR inability to function in all areas. 20-11 Some danger of hurting self or others OR occasionally fails to maintain minimal personal hygiene OR gross impairment in communication. 10-1 Persistent danger of severely hurting self or others OR persistent inability to maintain minimum personal hygiene OR serious suicidal act with clear expectation of death. 0 Not enough information available to provide GAF.

Multiaxial Classification Axis I: Clinical Syndromes Major Depressive Disorder Axis II: Personality Disorders No diagnosis Axis III: General Medical Conditions Hypothyroidism Axis IV: Psychosocial & Environmental Problems Parent-child problem Axis V: Global Assessment of Functioning GAF = 35 (serious impairment in school, family relations, judgment and thinking)

DSM Diagnostic Interviews DSM does not provide formal assessment procedures Diagnostic Interview Schedule for Children-Child Version (DISC-C) DISC-P Uses a highly structured DSM-based protocol

Other Structured Diagnostic Interviews Child & Adolescent Psychiatric Assessment (CAPA) Interviewer based: interviewer has to ensure that the respondent understands the questions Requires more training and sophistication Requires extensive coding: each symptom at a level of severity is specified in the glossary

Assessment according to categorical criteria Test-retest attenuation effect: major declines in symptoms from initial interviews to repeat interviews Sources of error: Problem of threshold Example: 6 out of 9 criteria must be met for DSM-IV diagnosis of ADHD

Inattention: 6 or more of the following symptoms of inattention have been present for at least 6 months to a point that is disruptive and inappropriate for developmental level: Often does not give close attention to details or makes careless mistakes in schoolwork, work, or other activities. Often has trouble keeping attention on tasks or play activities. Often does not seem to listen when spoken to directly. Often does not follow instructions and fails to finish schoolwork, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions). Often has trouble organizing activities. Often avoids, dislikes, or doesn't want to do things that take a lot of mental effort for a long period of time (such as schoolwork or homework). Often loses things needed for tasks and activities. Is often easily distracted. Is often forgetful in daily activities.

DSM Diagnostic Interviews Other potential sources of error: Difficulty in understanding questions 16% of 9 yo can understand DISC questions for depression 11 yo -> 31% Some disorders have criteria which require multiple symptoms: “5 of the following must be present in the same 2-week period” increases low agreement rates and test-retest attenuaton effect

Problems with Classification Systems Social stigmatization Labels stick and follow people around. Labels remain even after clinical improvement has been made Self-fulfilling prophecy: diagnostic labels remove responsibility from the patient

Problems with the DSM System Proliferation of categories and “overdefined” pathology Increasing addition of everyday problems: e.g., caffeine-induced sleep disorder, disorder of written expression

Problems with the DSM System Inattention to culture, gender and developmental level Diagnostic criteria are the same for all groups. There is a section that alerts clinicians to possible variations.