1. Assessment, Diagnosis, and Treatment4
Assessment, Diagnosis, and Treatment

2. Clinical Issues The decision-making process
Begins with a clinical assessment - uses systematic problem-solving strategies to understand children with disturbances and their family and school environments
Flexible, ongoing hypothesis testing assesses:
A child’s emotional, behavioral, and cognitive functioning; the role of environmental factors; nature, causes, and likely outcomes of the problem

3. Idiographic and Nomothetic Approaches
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

4. Developmental Considerations
Ethnic minority youth are at greater risk of misdiagnosis
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

5. Developmental Considerations - Culture
Culture-bound syndromes
Recurrent patterns of maladaptive behaviors and/or troubling experiences associated with different cultures or localities
What is considered abnormal may vary between cultures

6. Developmental Considerations - Gender Patterns
Table 4.1 Gender patterns for selected problems of childhood and adolescence
Source: Adapted from Gender Differences in the Diagnosis of Mental Disorders. Conclusions and Controversies of DSM-IV by C. M. Hartung and T. A. Widiger, 1998, Psychological Bulletin, 123, 260–278. Copyright © 1998 by the American Psychological Association. Reprinted with permission. APA is not responsible for the accuracy of this translation.

7. Developmental Considerations – Normative Information
Basic information about child development norms is crucial in understanding why a child may be referred to professionals
Isolated symptoms show little correspondence with children’s overall adjustment
Age inappropriateness and symptoms typically define childhood disorders
Impairment in the child’s functioning is a key consideration

8. Parent- and Teacher-Rated Problems
Table 4.2 Parent- and teacher-rated problems that best discriminate between referred and nonreferred children
Source: From Achenbach, T. M. and Rescorla, L. A. (2001), Manual for the ASEBA School- Age Forms & Profiles, ISBN Burlington, VT: University of Vermont, Research Center for Children, Youth, and Families) p Reprinted by permission.

9. 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 the child’s psychological disorder
Diagnosis involves analyzing information and drawing conclusions about the nature or cause of the problem

10. Purposes of Assessment in Treatment
Prognosis and treatment planning
Prognosis: the formulation of predictions about future behavior under specified conditions
Treatment planning and evaluation apply assessment information to generate a treatment plan and to evaluate its effectiveness

11. Assessing Disorders
Clinical assessment – information is obtained from different informants, in a variety of settings, using various methods
The methods need to be reliable, valid, cost- effective, and useful for treatment
Clinical assessment reveals the child’s thoughts, feelings, and behaviors
Comprehensive assessment evaluates a child’s strengths and weaknesses across many domains

12. Clinical Interviews
Provide a large amount of information during a brief period
Include a developmental or family history
Most interviews are unstructured
May result in low reliability and biased information
Semistructured interviews are more reliable
Include specific questions

13. Structured Interview Questions
Table 4.3 Semistructured interview questions for an older child or adolescent with depression
Source: Adapted from Clinical and Forensic Interviewing of Children and Families: Guidelines for the Mental Health, Education, Pediatric, and Child Maltreatment Fields by J. M. Sattler, pp Copyright © 1998 by Jerome M. Sattler Publisher, Inc. Adapted by permission.

14. Behavioral Assessment
Evaluates the child’s thoughts, feelings, and behaviors in specific settings
Primary problems of concern
Target behaviors and the factors that control or influence them
“ABCs of assessment” are to observe the:
Antecedents
Behaviors
Consequences of the behaviors

15. Behavioral Assessment - Behavior Analysis
A general approach to organizing and using assessment information in terms of the “ABC’s”
Identify a wide range of antecedents and consequences
Develop hypotheses about which are most important and/or most easily changed

16. Functional Analysis
Figure 4.1 Functional analysis: antecedents, behaviors, consequences
Source: Cengage Learning 2016

17. Behavioral Assessment - Checklists and Rating Scales
Allow for a child’s behavior to be compared with a known reference group
Economical to administer and score
Lack of agreement between informants is relatively common, and is highly informative
The Child Behavior Checklist (CBCL) gives clinicians a useful profile of the variety and degree of the child’s problems

18. Child Behavior Checklist
Figure 4.2 Child Behavior Checklist (CBCL) profile for Felicia
Source: Based on Achenbach & Rescorla, 2001

19. Behavioral Assessment - Behavioral Observation
Parents or other observers record baseline data to provide information about behaviors in real-life settings
Recordings may be done by parents or others
May be difficult to ensure accuracy
Clinician may set up role-play simulation to observe children and their families

20. Psychological Testing
Tests: tasks given under standard conditions
The purpose is to assess some aspect of the child’s knowledge, skill, or personality
A child’s scores are compared with a norm group
The norm group may have limitations in terms of race, ethnicity, culture, SES, etc.

21. Psychological Testing - Fairness, Context, and Development
Code of Fair Testing Practices
Guidelines which increase clinicians’ sensitivity to cultural factors
Test scores should always be interpreted in the context of other assessment information
Developmental tests are used in:
Screening, diagnosing, and evaluating infants and young children and identify those at risk

22. Psychological Testing - Intelligence Testing
Evaluating a child’s intellectual and educational functioning
Many definitions of intelligence
The Wechsler Intelligence Scale for Children (WISC-IV): one of most frequently used intelligence scales
Emphasizes fluid reasoning abilities, higher order reasoning, and information processing speed

23. Psychological Testing - Other Common Intelligence Tests
Other commonly administered tests
Wechsler Preschool and Primary Scale of Intelligence (WPPSI-R)
Stanford-Binet-5 (SB5)
Kaufman Assessment Battery for Children (K- ABC-II)

24. Psychological Testing - Projective Testing
Present the child with ambiguous stimuli and asking the child to describe what he or she sees
The child projects his or her own personality, including unconscious fears, needs, and inner conflicts, on the ambiguous stimuli
Projective tests are among the most frequently used methods

25. Psychological Testing - Personality Testing
Central dimensions of personality - the “Big 5” factors
Timid or bold
Agreeable or disagreeable
Dependable or undependable
Tense or relaxed
Reflective or unreflective

26. Psychological Testing Self-Report Personality Scale Definitions
Table 4.4 Self-report of Personality Scale Definitions
Source: Behavior Assessment System for Children, Second Edition (BASC-2). Copyright © 2004 NCS Pearson, Inc. Reproduced with permission. All rights reserved. “BASC” is a trademark, in the US and/or other countries, of Pearson Education, Inc. or its affiliates(s).

27. Psychological Testing - Neuropsychological Assessment
Attempts to link brain functioning with objective measures of behavior known to depend on an intact central nervous system
Involves use of comprehensive batteries
Assess a full range of psychological functions

28. Classification and Diagnosis
Classification: a system for representing the major categories or dimensions of child psychopathology
Strategies for determining the best plan for a given individual
Ideographic strategies
Nomothetic strategies

29. Ideographic and Nomothetic Strategies
Idiographic strategies highlight a child’s unique situation
Nomothetic strategies – employed to:
Benefit from all the information accumulated on a given problem or disorder
Determine the general category to which the problem belongs

30. Categories and Dimensions
Categorical classification systems are based primarily on informed professional consensus
A “classical/pure” categorical approach
Every diagnosis has a clear underlying cause
Each disorder is fundamentally different from other disorders
Dimensional classification
Many independent dimensions exist

31. Classification and Diagnosis Commonly Identified Dimensions
Table 4.5 Commonly identified dimensions of child psychopathology and examples of items that reflect each dimension
Source: Achenbach, T. M. & Rescorla, L. A. (2001). Manual for the ASEBA School-Age Forms and Profiles. (Burlington, VT: University of Vermont, Research Center for Children, Youth, and Families, Reprinted with permission.

32. The Diagnostic and Statistical Manual (DSM)
The current edition: DSM-5
A multiaxial system consisting of five axes:
Clinical disorders or conditions
Personality disorders and intellectual disability
General medical conditions
Psychosocial and environmental problems
Global assessment of functioning

33. The Diagnostic and Statistical Manual Neurodevelopmental Disorders
Table 4.6 Categories that apply to children
Source: Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition

34. The Diagnostic and Statistical Manual Criticisms
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

35. The Diagnostic and Statistical Manual - Pros and Cons
Pros 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

36. The Diagnostic and Statistical Manual - Pros and Cons (cont’d.)
Cons of diagnostic labels
Disagreement about effectiveness of labels to achieve their purposes
Negative effects and stigmatization
Can negatively influence children’s views of themselves and their behavior

37. Treatment
Interventions today are planned by combining the most effective approaches to a particular problem
The most useful treatments are based on what we know about a particular childhood disorder
Data is needed to show that interventions work

38. Treatment (cont’d.) 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

39. Treatment - The Intervention Spectrum
FIGURE 4 .4 | The intervention spectrum and settings for childhood disorders.
Based on Weisz, J. R., Sandler, I. N., Durlak, J. A., and Anton, B. S. (2005). Promoting and protecting youth mental health through evidence-based prevention and treatment.

40. Cultural Considerations
Development of evidence-based interventions has led to 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

41. Cultural Considerations (cont’d.)
Evidenced-based treatments have been adapted and implemented to meet the needs of specific cultural groups
Treatment services for children must:
Attend to presenting problem
Consider the specific cultural practices of the family
Must be careful not to stereotype individuals of any cultural group

42. Cultural Values and Parenting Practices
Table 4.8 Cultural values and parenting practices and beliefs
Sources: Adapted from Forehand and Kotchik, 1996; and from Yasui and Dishion, 2007.

43. Treatment Goals Outcomes related to child functioning
Reduce or eliminate symptoms
Reduce degree of impairment in functioning
Enhance social competence
Improve academic performance

44. Treatment Goals (cont’d.)
Outcomes related to family functioning
Reduce level of family dysfunction
Improve marital and sibling relationships
Reduce stress
Enhance family support

45. Treatment Goals (cont’d.)
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

46. Ethical and Legal Considerations
AACAP and APA ethical code provide minimum ethical standards
Select treatment goals and procedures that are in the best interest of the client
Ensure participation is active and voluntary
Keep records to document treatment effectiveness
Protect confidentiality
Ensure therapist’s qualifications and competencies

47. Ethical and Legal Considerations (cont’d.)
Determine when a minor is competent to make decisions
Be cautious about ineffective or potentially harmful treatment
Comply with federal, state, and local laws
Education for All Handicapped Children Act (1975)
Individuals with Disabilities Education Improvement Act (2004)

48. Ethical Issues in Clinical Work With Children and Families
Table 4.9 Core ethical issues in clinical work with children and families
Source: Reprinted from Psychiatric Clinics of North America, 32, Belitz, J. & Bailey, R. A., Clinical ethics for the treatment of children and adolescents: A guide for general psychiatrists, 243–257, Copyright 2009, with permission from Elsevier.

49. General Approaches to Treatment
More than 70% of clinicians use an eclectic approach
Psychodynamic treatments
View child psychopathology as determined by underlying unconscious and conscious conflicts
Focus is on helping the child develop an awareness of unconscious factors contributing to problems

50. Behavioral Treatments
Assume that behaviors are learned
Focus is on re-educating the child
Procedures include:
Positive reinforcement or time-out
Modeling
Systematic desensitization
Changes in the child’s environment

51. Cognitive Treatments
View abnormal behavior as the result of deficits and/or distortions in the child’s thinking
Focus is on changing faulty cognitions

52. Cognitive Behavioral Treatments
View psychological disturbances as the result of:
Faulty thought patterns
Faulty learning and environmental experiences
Focus on:
Identifying and changing maladaptive cognitions; teaching the child to use cognitive and behavioral coping strategies; and helping the child learn self-regulation

53. Client-Centered and Family Treatments
Client-centered treatments:
Focus on creating a therapeutic setting which provides unconditional acceptance of the child
Family treatments:
View individual disorders as manifestations of disturbances in family relations
Focus on the family issues underlying children’s problematic behavior

54. Biological Treatments
View child psychopathology as resulting from psychobiological impairment or dysfunction
Rely primarily on pharmacological and other biological approaches to treatment

55. Combined Treatments
The use of two or more interventions, each of which can stand on its own as a treatment strategy
More communities are now implementing comprehensive mental health programs for children
Often delivered through schools

56. Descriptions of Common Medications for Children and Youths
Table 4.10 Descriptions of common medications for children and youths
Source: Based on Psychiatric medication for children and adolescents. II: Types of medications, American Academy of Child & Adolescent Psychiatry, 2004.

57. Usage of Psychiatric Medication by Children in the United States (1987 – 1996)
Figure 4.4 Usage of psychiatric medication by children in the United States between 1987 and 1996
Source: Adapted from Journal of the American Academy of Child and Adolescent Psychiatry, 41, A Olfson, M., Marcus, S. C., Weissman, M. M., & Jensen, P. S., National trends in the use of psychotropic medications by children, 514–521, Copyright 2002, with permission from Elsevier.

58. Results of Behavioral Role-Play Intervention
Figure 4.6 Results of behavioral role-play intervention
Source: Adapted from Depression by D. J. Kolko, In M. Hersen and V. B. Van Hasselt (Eds.), “Behavior Therapy with Children and Adolescents: A Clinical Approach”, pp. 163–164. Copyright © 1987 by John Wiley & Sons, Inc. Reprinted by permission of John Wiley & Sons, Inc.

59. Treatment Effectiveness
Best practice guidelines
Systematically developed statements to assist practitioners and patients
Two main approaches in developing best practice guidelines
The scientific approach derives guidelines from a review of current research findings
The expert-consensus approach uses experts’ opinions to fill gaps in scientific literature

60. 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
Treatments are equally effective for internalizing and externalizing disorders
Treatment effects tend to be long-lasting

61. Negative Findings
Fewer than 20% of treatments demonstrate evidence for reducing impairment in life functioning
Community-based clinic therapy is far less effective than structured research therapy
Conventional services for children may have limited effectiveness

62. New Directions
As many as 70% to 80% of children and families with significant mental health needs do not receive any specialized assessment or treatment services
New initiatives:
Increase recognition of children's mental health needs
Develop a wider range of service delivery models