Outline: Lecture 4 – Jan. 28/03 [Chapter 4 - Classification & Assessment] 1. The Decision Making Process Idiographic vs Nomothetic Case Formulation Developmental considerations 2. Classification & Diagnosis clinical vs empirical approach 3. Assessment Purpose Methods 4. Treatment of Childhood Disorders General approaches

The Decision Making Process Typically begins with a clinical assessment Assessments are meaningful to the extent that they result in practical and effective interventions Idiographic vs Nomothetic Case Formulation Developmental considerations Age, gender, and culture [Table 4.1] Normative information

Classification & Diagnosis Emphasizes description and grouping of disorders for scientific study (classification) or clinical purposes (diagnosis). Terms are often used interchangeably. Issues in classification & diagnosis: Diagnostic reliability Diagnostic validity Diagnostic bias

Dangers of classifying Why classify? facilitate understanding of disorders facilitate treatment of disorders identify important distinctions among mental health problems enable planning of resources Dangers of classifying label a child, may lead to negative perceptions only information consistent with label is noticed

Categorical vs Dimensional Classification Categorical classification systems [Clinical] based primarily on informed professional consensus assumes that every diagnosis has a clear underlying cause and that each disorder is fundamentally different [“classical/pure” approach] Dimensional classification systems [Empirical] assume that a number of independent dimensions or traits of behaviour exist and that all children possess these to varying degrees

Clinically-derived Systems [categorical approach] based on informed, clinical consensus Diagnostic & Statistical Manual of Mental Disorders [DSM-IV] International Classification of Diseases [ICD-10] Diagnostic Classification: 0 – 3

The DSM-IV Multiaxial [5 axes]: [Axis I] Principal psychiatric diagnosis [Axis II] Developmental or personality disorders [Axis III] Current medical conditions [Axis IV] Psychosocial / Environmental problems [Axis V] Overall level of functioning

Evaluation of the DSM-IV Gives less attention to disorders of infancy and childhood Fails to emphasize the situational and contextual factors Sometimes improperly used [e.g. a specific diagnosis is needed in order for a child to qualify for special services] empirical reliability & validity of subcategories in question problem of comorbidity

Empirically-derived Systems [dimensional approach -use multivariate statistical techniques to cluster symptoms] Child Behaviour Checklist [CBCL] Conner’s Parent Questionnaire, Revised Behaviour Problem Checklist Two Broad Band Clusters identified: Externalizing Problems Internalizing Problems

The CBCL 1. Internalizing Syndromes 2. Externalizing Syndromes [overcontrolled, anxiety-withdrawal] Narrow Band Syndromes: Withdrawn; Somatic Complaints; Anxious/Depressed 2. Externalizing Syndromes [undercontrolled, conduct disorder] Delinquent Behaviour; Aggressive Behaviour 3. Mixed Syndromes Social Problems; Thought Problems; Attention Problems

Evaluation of CBCL three versions: Parent, Teacher, & Self-Report normative samples 2 sets of norms for age & sex on both broad and narrow-band syndromes [nonreferred and children referred for mental health services] reliability test-retest and inter-rater good validity scores predict outcomes six year later e.g.academic problems, use of mental health services, police contacts

Criticisms … of the categorical approach: Categories are static May not be helpful to meet needs Wording of criteria not specific enough Not useful for the very young … of the dimensional approach: Informant problems Context problems … of both approaches: impact of labels

Pros and Cons of Labels Positive Side 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 facilitate research on causes, epidemiology, and treatments of specific disorders Negative Side of Diagnostic Labels : may lead to negative perceptions and reactions by child and others

Purposes of Assessment Three common purposes: 1. Diagnosis - formal act of identifying or naming a disorder for clinical purposes. 2. Prognosis - a prediction about the outcome of a treatment for a particular disorder. 3. Treatment planning and evaluation - using the available information to plan an appropriate treatment and a way of assessing the effectiveness of the treatment.

2. Historical/archival data Methods of Assessment 1. Clinical Interviews -The most universally used assessment procedure -Can be unstructured, semi-structured, or structured e.g. the DISC, the CAS -Can be done with different informants: child, parent, teacher 2. Historical/archival data medical records, school records

Methods of Assessment 3. Observational/Behavioural assessment Emphasis on observing child’s behavior “ABCs of assessment” - involves observing the antecedents, the behaviors, and the consequences of the behaviors - See Figure 4.1 Functional analysis of behavior - goal is to identify as many potentially contributing factors as possible, and to develop hypotheses about which are most important and/or easily changed

Methods of Assessment 4. Formal Assessment Measures Checklists and rating scales: self- and other-report measures, e.g. CBCL Psychological tests Objective Tests: measures of intelligence, achievement, personality e.g. WISC-III Projective Tests: ambiguous stimuli presented & child projects unacceptable thoughts & impulses on stimulus, e.g Rorschach Neuropsychological Tests: indirect assessment of brain function, e.g. Halstead-Reitan Neurological Tests: direct assessment of brain function, e.g. MRI

Treatment of Childhood Disorders Interventions are problem-solving strategies, involve treatment of current problems, maintenance of treatment effects, and prevention of future problems Approach used with adults often inappropriate - lack of self-referral; developmental issues important Must take into account the cultural context of the child and family Treatment goals include outcomes related to the child and family, as well as those of societal importance Models of Delivery include Conventional Care, Chronic Care, and Dental Care models See Figure 4.4

General Approaches to Treatment Psychodynamic - awareness of unconscious conflicts Behavioral - re-education based on learning principles Cognitive - changing faulty cognitions Cognitive-behavioral - changing faulty cognitions plus re-education based on learning principles Client-centered - unconditional positive regard Family models - underlying family issues Biological/medical - pharmacological Combined treatments - two or more interventions More than 70% of clinicians take an eclectic approach

Treatment Effectiveness Positive Findings therapy leads to significant & meaningful improvements treatments are equally effective for internalizing and externalizing disorders treatment effects tend to be long-lasting specific problems more amenable to treatment than is global functioning the more outpatient therapy children receive, the more symptoms improve Negative Finding changes found in structured therapy studies have not been found in unstructured community settings

Different Orientations Problem: You have an 8-year-old son who is aggressive. He hits other children to get their toys and when he is upset with them, and often acts out at home. How would he be treated by someone with: a psychodynamic approach? a learning approach? a family systems approach?