Chapter 9 – Assessment: Integration and Clinical Decision Making Chapter 9 – Assessment: Integration and Clinical Decision Making Copyright © 2014 John Wiley & Sons, Inc. All rights reserved.

Integration and Clinical Decision Making All assessments are designed to address a question Psychologist determines the most appropriate type of assessment based on this question As the assessment progresses different tests or assessments may be added Copyright © 2014 John Wiley & Sons, Inc. All rights reserved.

The assessment question is a general guide in assembling pieces of information A question about intellectual capacities leads to assessment that highlights general intellectual functioning and more specific cognitive strengths and weaknesses

Cont-d In such intellectual evaluation we would want to consider emotional factors that may affect cognitive functioning, but the cognitive potential is still the focus. A specific assessment question, for example, whether a teacher who is depressed is capable of going back to the classroom, diagnostic information and functional capability need to be assessed

Cont-d In this context (the depressed teacher) possible factors that might affect the teacher’s functioning should be evaluated: In depression there are cognitive correlates, such as difficulty in concentration and decision making, and these may affect the teacher's functioning However, these should be seen as secondary to the emotional issues.

Integrating the Assessment Information The common assessment methods are Interviews Observations Intellectual assessment Cognitive assessment Self-report measures Projective measures

Copyright © 2014 John Wiley & Sons, Inc. All rights reserved. Assessment Psychological assessment involves gathering and integrating multiple forms of information Instruments are selected based on the hypotheses to be explored The integration of the diverse data completes the assessment process Copyright © 2014 John Wiley & Sons, Inc. All rights reserved.

Initial Steps in the Integration Examine all assessment information Consider consistencies and contradictions and try to reconcile Generate hypotheses about the client’s current functioning Important in assessment –focused service or intervention-focused service

Integrating Assessment Data Descriptive account of the client’s level of functioning Importance of understanding client in his/her social and interpersonal environment Often different assessments/tests provide conflicting results Importance of multiple informants especially with children Copyright © 2014 John Wiley & Sons, Inc. All rights reserved.

First step: Descriptive Account A consideration of the client’s personality structure Level of emotional distress Coping strategies: problem-focused, emotion-focused, passive, active etc Intellectual capacity Possible diagnosis and co-morbidity How the diagnostic status affects functioning (e.g. getting custody over a child)

The pieces of the puzzle often do not fit together Different sources of information and different informants Each source of data has strengths, limitations, and potential biases. This is seen primarily when gathering information about children and adolescents

Copyright © 2014 John Wiley & Sons, Inc. All rights reserved. Assessment of Children and Adolescents: Using several sources of information: Study by De Los Reyes et al: p. 267 Assessment of young children with high levels of disruptive behaviors Information came from mothers, teachers and direct observations There were discrepancies in the reports of the different sources These discrepancies reflected real differences in behaviors in the different settings Copyright © 2014 John Wiley & Sons, Inc. All rights reserved.

Common Purposes of Assessment Educational concerns (e.g. assessment of the need for special education Vocational concerns: The feasibility of the client’s career aspirations Rehabilitation service (e.g. following head injury) Referral for psychotherapy

The Purpose of Case Formulation The purpose is to formulate hypothesis how the problems have developed and what factors seemed to have maintain these problems How the current problems fit with the client’s life-history (e.g. early loss of parent), and how well the client will be able to function in the future Recommendations to improve functioning

Copyright © 2014 John Wiley & Sons, Inc. All rights reserved. Case Formulation Case Formulation: A clear hypothesis that relates to how a problem developed and how it is maintained Suggestions are then made – e.g., psychological services, additional assessment, or planning of other services for the client Often helps guide treatment & specific interventions Copyright © 2014 John Wiley & Sons, Inc. All rights reserved.

Copyright © 2014 John Wiley & Sons, Inc. All rights reserved. Case Formulation Some Benefits of a case formulation: Provides connections between various problems Provides guidance on the type of treatment Predicts the patient’s functioning with and without treatment Provides options if difficulties are encountered in treatment Indicates options, outside of psychological services Copyright © 2014 John Wiley & Sons, Inc. All rights reserved.

Copyright © 2014 John Wiley & Sons, Inc. All rights reserved. Case Formulation Components of a case formulation: Description of problems & symptoms Events or stressors that led to the symptoms or problems Predisposing life events/ vulnerabilities A hypothesized mechanism that links the problems to the person’s current functioning Copyright © 2014 John Wiley & Sons, Inc. All rights reserved.

Copyright © 2014 John Wiley & Sons, Inc. All rights reserved. Case Formulation Steps of a case formulation: 1. Develop a comprehensive problem list 2. Determine the origin, precipitants, and consequences of the problems 3. Identify patterns among the problems 4. Develop working hypotheses to explain the problems 5. Evaluate and refine the hypotheses 6. In treatment, the hypotheses should be reconsidered, re-evaluated, and revised

Threats to the Validity of Case Formulations Client Factors: Clients may try and under-pathologize themselves Problems clearly recalling a problem behavior or memories from their past (retrospective recall) Can’t assume clients are accurately perceiving/portraying reality Copyright © 2014 John Wiley & Sons, Inc. All rights reserved.

Threats to the Validity of Case Formulations Clinician Factors: Self-serving attributional bias: Bias to make internal, stable and global attributions for positive events (can seriously affect how clinicians evaluate their effectiveness) Overuse of heuristics (mental short cuts) Biases (gender, ethnic, socioeconomic, etc.) Several common decision making biases (see text table 9.3) Copyright © 2014 John Wiley & Sons, Inc. All rights reserved.

Improving the Accuracy of Clinical Judgment Some Important strategies: Use directly relevant psychometrically sound tests Check for scoring errors Use normative data and base rate information Use DSM criteria when making diagnosis Use decision trees or clinical guidelines. In unstructured interviews be as systematic as possible Be aware of relevant research Be aware of personal biases and preconceptions. Search for alternative explanations for hypotheses Seek consultation Don’t rely on memory and don’t rush to a conclusion Copyright © 2014 John Wiley & Sons, Inc. All rights reserved.

Important Concepts in Assessment Reports Important to remember the ‘audience’ of the report Privacy is important – avoiding stigmatizing labels, using multiple sources Exercising caution with computer-based interpretations (CBI’s) – problematic to include this in a testing report Copyright © 2014 John Wiley & Sons, Inc. All rights reserved.

Important Concepts in Assessment Reports Contents of a typical assessment report Identifying patient/client information Reason for referral Background information (including, developmental history, educational & employment history, family & relationship history, medical history, etc.) Assessment methods (including tests administered) Interview data and behavioral observations Test results (including interpretation of test scores) Diagnostic impressions Summary Recommendations Copyright © 2014 John Wiley & Sons, Inc. All rights reserved.

Important Concepts in Assessment Reports Purpose of giving feedback on an assessment report Verify the general accuracy of the assessment results Refine the interpretation of the results Put the individual’s symptoms, in the context of his/her life history and current life circumstances Provide some psychological relief for the individual by presenting an integrated picture Provide concrete information about steps to address personal difficulties Help the individual identify potentially stressful situations Collaborate to design goals that build on personal strengths Copyright © 2014 John Wiley & Sons, Inc. All rights reserved.