Mash/Wolfe Abnormal Child Psychology, 4 th edition © 2009 Cengage Learning Chapter 4 Assessment, Diagnosis, and Treatment

Mash/Wolfe Abnormal Child Psychology, 4 th edition © 2009 Cengage Learning

Clinical Issues  The Decision Making Process  Begins with clinical assessment, a collaborative process of systematic problem-solving strategies to understand children and their family and school environments  Flexible, ongoing hypothesis testing that assesses  child’s emotional, behavioral, and cognitive functioning  the role of environmental factors  nature, causes, and likely outcomes of the problem  Idiographic case formulation: Assessments focus on obtaining detailed understanding of the child or family as a unique entity  Nomothetic formulation: Emphasizes general inferences that apply to large groups of individuals

Mash/Wolfe Abnormal Child Psychology, 4 th edition © 2009 Cengage Learning Clinical Issues (cont.)  Developmental Considerations  Age, gender, and culture must be considered when making judgments about abnormality and when selecting assessment and treatment methods  Ethnic minority youth are often misdiagnosed  Cultural information is necessary to  establish relationship with child and family  motivate family members to change  obtain valid information  arrive at accurate diagnosis  develop meaningful treatment recommendations  Culture-bound syndromes: recurrent patterns of maladaptive behaviors associated with different cultures or localities

Mash/Wolfe Abnormal Child Psychology, 4 th edition © 2009 Cengage Learning Clinical Issues (cont.)  Developmental Considerations (cont.)  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 pattern of symptoms typically define childhood disorders

Mash/Wolfe Abnormal Child Psychology, 4 th edition © 2009 Cengage Learning Clinical Issues (cont.)  Purposes of Assessment  Description and Diagnosis  First step: 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  Prognosis and Treatment Planning  Prognosis is the formulation of predictions regarding future behavior under specified conditions  Treatment planning and evaluation means using assessment information to generate a treatment plan and evaluating its effectiveness

Mash/Wolfe Abnormal Child Psychology, 4 th edition © 2009 Cengage Learning Assessing Disorders  Clinical assessment relies on a multimethod assessment approach that emphasizes the importance of  obtaining information from different informants  in a variety of settings  using a variety of methods that include interviews, observations, questionnaires, and tests  Clinical assessment helps understand the child’s thoughts, feelings, and behaviors as they occur in specific situations  Comprehensive assessment evaluates a child’s strengths and weaknesses across many domains

Mash/Wolfe Abnormal Child Psychology, 4 th edition © 2009 Cengage Learning Assessing Disorders (cont.)  Clinical Interviews  The most universally used assessment procedure with children and their parents  Information is gathered in a flexible manner over many sessions and integrated with other forms of assessment  Provide a large amount of information during a brief period  Often include a developmental history or family history  Semistructured interviews: Since most interviews are unstructured they lack standardization, which may result in low reliability and selective or biased information  asking specific questions provides consistency to be more reliable

Mash/Wolfe Abnormal Child Psychology, 4 th edition © 2009 Cengage Learning

Assessing Disorders (cont.)  Behavioral Assessment  Evaluates the child’s thoughts, feelings, and behaviors in specific settings to formulate hypotheses of the problem and its treatment  Target behaviors are the primary problems of concern and the factors that control or influence them  “ABCs of assessment”: observe the Antecedents, the Behaviors, and the Consequences of the behaviors  Behavior analysis/functional analysis of behavior  a general approach to organizing and using assessment information  to identify a wide range of antecedents and consequences  the goal: to identify as many potentially contributing factors as possible, and to develop hypotheses about which are most important and/or most easily changed

Mash/Wolfe Abnormal Child Psychology, 4 th edition © 2009 Cengage Learning

Assessing Disorders (cont.)  Behavioral Assessment (cont.)  Checklists and Rating Scales  Standardized reports concerning a child’s behavior and adjustment  Often allow for a child’s behavior to be compared to a normative sample  Economical to administer and score  Lack of agreement between informants is relatively common, and is often highly informative  The Child Behavior Checklist (CBCL) is used cross- culturally and gives clinicians a useful profile

Mash/Wolfe Abnormal Child Psychology, 4 th edition © 2009 Cengage Learning

Assessing Disorders (cont.)  Behavioral Assessment (cont.)  Behavioral Observation and Recording  In natural settings  use baseline data to 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  may not be accurate in part because children often know they are being watched and may react differently as a result  Clinician may set up role-play simulation to observe children and their families

Mash/Wolfe Abnormal Child Psychology, 4 th edition © 2009 Cengage Learning Assessing Disorders (cont.)  Psychological Testing  Tests are tasks given under standard conditions with the purpose of assessing some aspect of the child’s knowledge, skill, or personality  A child’s scores are compared with a norm group, although the norm group may have limitations in terms of race, ethnicity, culture, SES, etc.  Code of Fair Testing Practices presents guidelines that have increased clinicians’ sensitivity to cultural factors in administration and interpretation  Test scores should always be interpreted in the context of other assessment information  Developmental tests: used to screen, diagnose, and evaluate infants and young children and identify those at risk

Mash/Wolfe Abnormal Child Psychology, 4 th edition © 2009 Cengage Learning Assessing Disorders (cont.)  Psychological Testing (cont.)  Intelligence Testing  Evaluating a child’s intellectual and educational functioning is a key component in clinical assessments for a wide range of childhood disorders  Many definitions of intelligence  Wechsler: “the overall capacity of an individual to understand and cope with the world around him”  The Wechsler Intelligence Scale for Children (WISC-IV) is among the most frequently used intelligence scales  emphasizes fluid reasoning abilities, higher order reasoning, and information processing speed  Other commonly administered tests are the Wechsler Preschool and Primary Scale of Intelligence (WPPSI- R), Stanford-Binet-5 (SB5), and the Kaufman Assessment Battery for Children (K-ABC-II)

Mash/Wolfe Abnormal Child Psychology, 4 th edition © 2009 Cengage Learning Assessing Disorders (cont.)  Psychological Testing (cont.)  Projective Testing  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  despite controversy, projective tests are among the most frequently used clinical assessment methods  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

Mash/Wolfe Abnormal Child Psychology, 4 th edition © 2009 Cengage Learning Assessing Disorders (cont.)  Psychological Testing (cont.)  Personality Testing  Personality: an enduring trait or pattern of traits that characterize an individual and determine how he or she interacts with the environment  Some central dimensions of personality 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 (MMPI-A, PIC-2)

Mash/Wolfe Abnormal Child Psychology, 4 th edition © 2009 Cengage Learning Assessing Disorders (cont.)  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 use of comprehensive batteries that assess a full range of psychological functions, including verbal and nonverbal cognitive functions, perceptual functions, motor functions, and emotional/executive control functions  combination of neuroimaging procedures and mixed or inconsistent neuropsychological findings has changed the focus from diagnosis to finding strengths and deficits in functioning

Mash/Wolfe Abnormal Child Psychology, 4 th edition © 2009 Cengage Learning Classification and Diagnosis  Classification: a system for representing the major categories or dimensions of child psychopathology and the boundaries and relations among them  Idiographic strategies (child’s unique situation) and nomothetic strategies (general categories of problems)  Categories and Dimensions  “classical/pure” categorical approach assumes that every diagnosis has a clear underlying cause and that each disorder is fundamentally different from other disorders  dimensional classification approaches assume that many independent dimensions or traits of behavior exist and that all children possess these to varying degrees

Mash/Wolfe Abnormal Child Psychology, 4 th edition © 2009 Cengage Learning

Classification and Diagnosis (cont.)  The Diagnostic and Statistical Manual (DSM)  Began with World Health Organization’s International Classification of Diseases (ICD) in 1948, followed by American Psychiatric Association’s Diagnostic and Statistical Manual (DSM) in 1952  Revised many times over the years; current edition is DSM-IV- TR  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 (GAF)

Mash/Wolfe Abnormal Child Psychology, 4 th edition © 2009 Cengage Learning

Classification and Diagnosis (cont.)  DSM (cont.)  Criticisms of the DSM-IV-TR:  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 capture the interrelationships and overlap known to exist among many childhood disorders  fails to emphasize situational and contextual factors (although it does consider culture, age, and gender)  sometimes improperly used, such as when a specific diagnosis is needed so a child can qualify for special services

Mash/Wolfe Abnormal Child Psychology, 4 th edition © 2009 Cengage Learning Classification and Diagnosis (cont.)  DSM (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:  disagreement about effectiveness of labels to achieve their purposes  negative effects and stigmatization  can influence children’s views of themselves

Mash/Wolfe Abnormal Child Psychology, 4 th edition © 2009 Cengage Learning Treatment  Interventions encompass many theories and practices for helping children and their families adapt more effectively to current and future circumstances  Multiple problems require multiple solutions  Problem-solving strategies are part of a spectrum of activities for treatment, maintenance, and prevention  Interventions are part of an ongoing decision-making approach

Mash/Wolfe Abnormal Child Psychology, 4 th edition © 2009 Cengage Learning

Treatment (cont.)  Cultural Considerations  As evidence-based interventions have developed there has been a growing awareness of children’s and families’ cultural contexts  The cultural compatibility hypothesis: treatment is likely to be more effective when compatible with the cultural patterns of the child and family  Sometimes treatment is more effective if child’s caregiver and the therapist are ethnically similar  Important to consider cultural values/norms/expectations and religious beliefs/practices

Mash/Wolfe Abnormal Child Psychology, 4 th edition © 2009 Cengage Learning

Treatment (cont.)  Treatment Goals  Outcomes related to child functioning:  reduce/eliminate symptoms  reduce degree of impairment in functioning  enhance social competence  improve academic performance  Outcomes related to family functioning:  reduce level of family dysfunction  improve marital and sibling relationships  reduce stress  improve quality of life  reduce burden of care  enhance family support

Mash/Wolfe Abnormal Child Psychology, 4 th edition © 2009 Cengage Learning Treatment (cont.)  Treatment Goals (cont.)  Outcomes of societal importance:  improve child’s participation in school-related activities  decrease involvement in juvenile justice system  reduce need for special services  reduce accidental injuries or substance abuse  enhance physical and mental health

Mash/Wolfe Abnormal Child Psychology, 4 th edition © 2009 Cengage Learning Treatment (cont.)  Ethical and Legal Considerations  Clinicians who work with children are required to think about the impact their actions will have on their clients and also on the responsibilities, rights, and relationships that connect children and parents  APA ethical code provides minimum ethical standards:  select treatment goals/procedures that are in the best interest of the client  make sure participation is active and voluntary  keep records to document treatment effectiveness  protect confidentiality  ensure therapist’s qualifications and competencies  Also determine when a minor is competent to make decisions  Be cautious about the potential for harm  Comply with federal, state, and local laws, especially regarding clients with disabilities

Mash/Wolfe Abnormal Child Psychology, 4 th edition © 2009 Cengage Learning Treatment (cont.)  General Approaches to Treatment  More than 70% of clinicians use an eclectic approach  Psychodynamic treatments focus on underlying unconscious and conscious conflicts  Behavioral treatments see behaviors as learned and so emphasize re-education using learning theories or changing the child’s environment  Cognitive treatments focus on changing faulty cognitions

Mash/Wolfe Abnormal Child Psychology, 4 th edition © 2009 Cengage Learning Treatment (cont.)  General Approaches to Treatment (cont.)  Cognitive-behavioral treatments focus on identifying and changing maladaptive cognitions, teaching the child to use cognitive and behavioral coping strategies, and helping the child learn self-regulation  Client-centered treatments attempt to create a therapeutic setting that provides unconditional, nonjudgmental, and genuine acceptance of the child, often using play activities (young children) or verbal interaction (older children) to enhance personal growth and adaptive functioning

Mash/Wolfe Abnormal Child Psychology, 4 th edition © 2009 Cengage Learning Treatment (cont.)  General Approaches to Treatment (cont.)  Family treatments focus on the family issues/disturbances underlying children’s problematic behavior  Biological/medical treatments view child psychopathology as resulting from biological impairment or dysfunction and rely primarily on pharmacological and other biological approaches to treatment  Combined treatments make use of two or more interventions

Mash/Wolfe Abnormal Child Psychology, 4 th edition © 2009 Cengage Learning

Treatment (cont.)  Treatment Effectiveness  Best practice guidelines assist practitioners and patients with decisions about appropriate treatment for specific conditions  Evidence-based approach from review of current research findings  Expert-consensus approach from opinions of experts to fill gaps in scientific literature

Mash/Wolfe Abnormal Child Psychology, 4 th edition © 2009 Cengage Learning

Treatment (cont.)  Treatment Effectiveness (cont.)  Positive Findings  children’s changes achieved through therapy are greater than changes for children not receiving therapy  children receiving therapy are better off after therapy than approximately 75% of children not receiving therapy  treatments are equally effective for internalizing and externalizing disorders  treatment effects tend to be long-lasting  treatment of specific targeted problems is about twice as effective as for nonspecific problems  the more outpatient therapy children receive, the more symptoms improve

Mash/Wolfe Abnormal Child Psychology, 4 th edition © 2009 Cengage Learning Treatment (cont.)  Treatment Effectiveness (cont.)  Negative Findings  community-based clinic therapy far less effective than structured research therapy  conventional services for children may have limited effectiveness