Chapter 4 Assessment, Diagnosis, and Treatment

The Decision Making Process Typically begins with a clinical assessment, which is directed at differentiating, defining, and measuring the child’s behaviors, cognitions, and emotions of concern, as well as contributing environmental circumstances Assessments are meaningful to the extent that they result in practical and effective interventions

The Decision Making Process (cont.) Idiographic vs. Nomothetic Case Formulation idiographic case formulation involves a detailed understanding of the child and family as a unique entity nomothetic case formulation emphasizes more general inferences that apply to broad groups individuals

Developmental Considerations Age, gender, and culture must be considered when making judgments about abnormality and when selecting assessment and treatment methods Normative information must be considered knowledge about normal development needed to make decisions about abnormality isolated symptoms not typically related to children’s overall adjustment age inappropriateness and patterns of symptoms typically define childhood disorders

Purposes of Assessment Description and Diagnosis clinical description summarizes the child’s unique behaviors, thoughts, and feelings that together make up the features of a given psychological disorder diagnosis involves analyzing information and drawing conclusions about the nature or cause of the problem, and in some cases, assigning a formal diagnosis

Purposes of Assessment (cont.) Prognosis and Treatment Planning prognosis involves generating predictions regarding future behavior under specified conditions treatment planning involves making use of assessment information to generate a treatment plan and evaluating its effectiveness

Clinical Interviews The most universally used assessment procedure Often includes a developmental and family history May incorporate a mental status exam Differ in degree of structure (e.g., unstructured, semi-structured)

Behavioral Assessment Emphasis on observing child’s behavior directly “ABCs of assessment” - involves observing the antecedents, the behaviors, and the consequences of the behaviors Functional analysis of behavior - a more general approach, the goal of which is to identify as many potentially contributing factors as possible, and to develop hypotheses about which are most important and/or most easily changed

Behavioral Assessment (cont.) Figure 4.1 Functional analysis: antecedents, behaviors, consequences.

Behavioral Assessment (cont.) Checklists and Rating Scales often allow for a child’s behavior to be compared to a normative sample usually economical to administer and score lack of agreement between informants is relatively common, which in itself is often informative

Behavioral Assessment (cont.) Behavioral Observations and Recording provide ongoing information about behaviors of interest in real-life settings recordings may be done by parents or others, although it may be difficult to ensure accuracy children often know they are being watched and may react differently as a result

Psychological Testing Tests are tasks given under standard conditions with the purpose of assessing some aspect of the child’s knowledge, skill, or personality Test scores should always be interpreted in the context of other assessment information Developmental tests are used for the purpose of screening, diagnosis, and evaluation of early development

Psychological Testing (cont.) Intelligence and Educational Testing is a central component in clinical assessments for a wide range of childhood disorders most popular intelligence scale is the Wechsler Intelligence Scale for Children (WISC-IV), which is well-standardized, reliable, valid, and provides measures of verbal comprehension, perceptual reasoning, working memory, and processing speed

Psychological Testing (cont.) Projective Testing involves presenting the child with ambiguous stimuli and asking the child what he or she sees it is believed that the child projects his or her own personality, including unconscious fears, needs, and inner conflicts, on the ambiguous stimuli projective techniques, including figure drawings and play, may be used to help children relax and to make it easier for them to talk about difficult events

Psychological Testing (cont.) Personality Testing may assess a child in terms of the “Big 5” Factors: timid-bold agreeable-disagreeable dependable-undependable tense-relaxed reflective-unreflective may use interviews, projective techniques, behavioral measures, or objective inventories

Psychological Testing (cont.) Neuropsychological Testing attempts to link brain functioning with objective measures of behavior that are known to depend on an intact central nervous system often involves using a comprehensive battery that assesses a full range of psychological functions, including verbal and nonverbal cognitive functions, perceptual functions, motor functions, and emotional/executive control functions

Classification and Diagnosis Categorical vs. Dimensional Classification “classical/pure” categorical approach assumes that every diagnosis has a clear underlying cause and that each disorder is fundamentally different dimensional classification systems assume that a number of independent dimensions or traits of behavior exist and that all children possess these to varying degrees

Classification and Diagnosis (cont.) The Diagnostic and Statistical Manual (DSM) a multiaxial system consisting of five axes: clinical disorders personality disorders and mental retardation general medical conditions psychosocial and environmental problems global assessment of functioning

Classification and Diagnosis (cont.) DSM (cont.) criticisms of the DSM-IV: 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 emphasize situational and contextual factors fails to capture the comorbidity known to exist among many childhood disorders sometimes improperly used, such as when a specific diagnosis is needed in order for a child to qualify for special services

Classification and Diagnosis (cont.) Pros and Cons of Diagnostic Labels pros: 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 cons: may lead to negative perceptions and reactions by child and others

Treatment of Childhood Disorders Interventions are problem-solving strategies that involve treatment of current problems, maintenance of treatment effects, and prevention of future problems 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

Treatment of Childhood Disorders (cont.) Models of Delivery conventional care model: the child is seen individually by a therapist for a limited number of treatment sessions continuing care model: an alternative to the conventional care model; two examples are the chronic care model and the dental care model

Treatment of Childhood Disorders (cont.) Ethical and Legal Considerations clinicians who work with children are required to think not only about the impact that their actions will have on the children that they see, but also on the responsibilities, rights, and relationships that connect children and parents

Treatment of Childhood Disorders (cont.) General Approaches to Treatment more than 70% of clinicians take an eclectic approach psychodynamic treatment approaches focus on developing awareness of underlying unconscious and conscious conflicts behavioral approaches emphasizes re-education using behavioral principles cognitive approaches focus on changing faulty cognitions

Treatment of Childhood Disorders (cont.) General Approaches to Treatment (cont.) cognitive-behavioral approaches focus on changing maladaptive cognitions, teaching the child to use cognitive and behavioral coping strategies, and helping the child learn self-regulation client-centered approaches attempt to create a therapeutic setting that provides a corrective experience for the child through unconditional positive regard

Treatment of Childhood Disorders (cont.) General Approaches to Treatment (cont.) family models focus on the family issues underlying problematic behavior biological/medical models rely primarily on pharmacological and other biological approaches to treatment combined treatments make use of two or more interventions

Treatment Effectiveness Positive Findings therapy leads to significant and meaningful improvements treatments are equally effective for internalizing and externalizing disorders treatment effects tend to be long-lasting specific problems are more amenable to treatment than nonspecific problems the more outpatient therapy children receive, the more symptoms improve Negative Finding community-based clinic therapy far less effective than structured research therapy