1. 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

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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.

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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

21. 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?