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Chapter 4

Chapter4- Assessment, Diagnosis & Treatment.docx

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Psychology 2320A/B
Elizabeth Hayden

4- Assessment, Diagnosis and Treatment January-21-13 11:06 AM CLINICAL ISSUES Decision-Making Process Finding answers to immediate and long-term questions abt nature and course of child's disorder and optimum treatment  Clinical Assessment: use systematic problem -solving strategies to understand children with disturbances and their family/ school environments o Assessment of child's emotional, behavioural and cognitive functioning, including enviro factors o Testing regarding nature of problem, causes, likely outcomes if left untreated  Clinical assessment broader than interviewing/testing alone  Goal- achieve effective solutions to the problems being faced and promote and enhance their well being  Clinical assessment meaningful to extent that they result in practical and effective interventions, assessment and intervention NOT viewed as separate  Idiographic case Formulation: clinical assessment to obtain a detailed understanding of individual child or family as unique entity  Nomothetic Formulation: emphasizes broad general inferences apply to large groups of individuals  Clinicians begin decision making- clinical interview, behavioural assessments, or psychological testing, NOT something done to a child but a collaborative process where child and family play an active role Developmental Considerations  Age, Gender and Culture o Childs age has implications for judgments about deviancy also selecting most appropriate assessment and treatment methods (age 13, school refusal is imp, time-out for 3yr old vs. school age child) o Gender differences in rates and expression of childhood disorders (pg. 84, Table 4.1)  Boys- over activity and aggression, may be over-referred for "clowning around, disturbing pupils"  Girls commonly overlooked for their less visible forms of suffering  Difficulty in distinguishing b/w true gender differences and differences in reporting  Social aggression in girls- insults, gossip, ostracism getting even, "relational aggression" third party retaliation  Children who engage in social aggression not typical for their sex significantly more maladjusted then children who engage in gender-normative forms of aggression o Cultural patterns reflect learned behaviours and values that are shared among members, distinguish group members of one group from another  Culture includes: ethnicity, language, religion, race, gender, SES, age, sexual orientation geographic origin, group history, education and upbringing and life experiences Ethnic minority youth greater risk of being misdiagnosed- diagnosed with more  organic/mood disorders and less likely to receive treatment  Clinicians must examine their own belief systems and culturally based assumptions guide clinical prac  Cultural information necessary to establish relationships, obtain accurate info, accurate diagnosis and treatment, role of culture in child's expression of symptoms  Cultural values may have impact on relationship b/w child, family and clinician - must consider ethnic identity and racial socialization  Culture-bound syndromes: recurrent patterns of maladaptive behaviours and/or troubling experiences specifically associated with different cultures or localities (i.e. "evil eye")  Childs adjustment defined by child's culture, identifies certain coping styles as acceptable or behaviours as problems, what's considered abnormal varies depending on group  Difficult to engage parents if mental health issues seem as taboo intervention into personal family matters is viewed negatively or causes of illness in culture seen as physical/spiritual  Lover level of ones acculturation, higher scores on measures of psychopathology esp. with edu/SES  Match children to same cultured clinician or customize treatment to cultural values, beliefs & customs  Understanding cultural context essential for identifying treatment- optimal goals for children of colour would be to moderate racial stress and adversity through collectivism, racial/ethnic pride…  Normative Information o Knowledge, experience, basic info about norms of child development/behaviour problems- crucial beginning to understanding how children's problems or needs come to the attention of professionals o Parent face difficulty determining whether child's condition is chronic/common and deciding when to seek help and what's the best type of treatment  More difficult for immigrant parents with children navigating two cultures o Isolated symptoms of behavioural/emotional problems show little correspondence with children overall adjustment o Age-inappropriateness and pattern of symptoms rather than ind, define childhood disorders, also extent to which symptoms result in impaired functioning o Some behaviours occur to some extent in all children- sadness, lack of concentration, demands for attention top.  Behaviours of referred similar to those in less extreme forms in pop'n Purposes of Assessment Description and Diagnosis o First step to identifying child's problem is Clinical description: summarizes unique behaviours, thoughts, and feelings that together make up the features of the child's psychological disorder  Attempts to establish basic info about child's presenting complaints, especially how child's behaviour or emotions are different from or similar to those of other children some age, sex, SES, cultural backend o Describe how behaviour differs from normal children: 1. Assessing and describing the intensity, frequency and severity of the problem 2. Age of onset and duration of their difficulties 3. Convey full picture of their different symptoms and their configuration (know entire profile child's weaknesses and strengths to make informed choices about course, outcome, treatment) o Next want to determine whether description meets criteria for diagnosis of 1+ psychological disorders o Diagnosis: analyzing info and drawing conclusions about the nature or cause of the problem, or assigning a formal diagnosis o Diagnosis acquired 2 formal meanings  Taxonomic Diagnosis: focuses on the formal assignment of cases to specific categories dram from DSM-IV-TR or from empirically derived categories  Solving Analysis: broader, views diagnosis as process of gathering info used to understand nature of ind problem, possible causes, treatments options and outcome o Major Depressive Disorder: posses characteristics that link her to similar youths presumed to have the same disorder o Commodity exists when certain disorders among children/adolescents are likely to co-occur within the same individual especially disorders that share many common symptoms  Conduct disorder and ADHD. Autism and intellectual disability, childhood depression and anxiety  Prognosis and Treatment Planning o Prognosis: formation of predictions about future behavior under specified conditions  Clinicians weigh probability that circumstances will remain the same improve, deteriorate, with/without treatment & the course of treatment should be followed  Treatment focuses on enhancing child development rather than merely removing symptoms or restoring previous level of functioning o Treatment Planning & Evaluation: using assessment info to generate a plan to address the child's problem and evaluate its effectiveness  Involve further specification and measurement of possible contributors to the problem, determination of resources, motivation for change and recommendations for treatments likely to be feasible ASSESING DISORDERS  Clinical settings use multidisciplinary team approach to assessment- ind with specific expertise in psychological testing/interpretation work together to generate most complete picture of child's mental health needs o Include: psychologist, physician, educational specialist, speech pathologist & social worker  May need medial exam to determine whether physical problem is related to disorder. EX: psychological problem may cause bed-wetting or sleep disorder  Multimethod Assessment Approach: obtaining info from different informants in variety of settings, using variety of methods including interviews, observations, questionnaires and tests  Deciding what assessment method is best based on whether assessment is for - diagnosis, treatment, planning, treatment evaluation, if problem is observable or internal, child/family characteristics and abilities  Methods used must be reliable, valid, cost-effective and useful for treatment  Clinical interviews with child/family/both help establish good working relationship with child and family, obtaining basic info about existing concerns and directions for further inquiry  Behavioural assessments, checklists, rating scales, psychological tests used in accordance with decision-making ape  Information attained from teachers and significant individuals who interact with child in various settings o Obtain most complete picture of the child  Comprehensive assessment requires evaluating child's strengths/weaknesses ranging from basic language and self-care skills, coping and lead ship abilities, if a particular are of functioning requires more attention it is given also if initial assessments indicate functioning is not a problem later assessment not given Clinical Interviews  Children/adolescents are referred by people b/c of their impact on others, often don’t experience distress or recognize concern Behavioural Assessment Clinicians develop 1st hypotheses based on info provided, pursue hypotheses by using behavioural  assessment- behaviour checklist, rating scales, observations of behaviour in real-life/ role-play situations  Checklists and Rating Scales o Global behaviour checklist- ask parent/teacher/youth to rate presence or absence of variety chill behaviours, frequency and intensity of these behaviours o Use of checklist strengthened by standardization and opportunities to compare ind score with known reference group of children of similar age, gender o Economical to administer and score - provide information of different reports of parents in same family (interact with child differently) o CHILD BEHAVIOUR CHECKLIST(CBCL)  Thomas Achenbach leading checklist for assessing behavioural problems in children/adolescents  Reliable and valid widely used in treatment in settings and schools  Parent- completed for child 6-18 includes teacher/youth self-report, classroom observation measure and interview  Used to assess children in 80+ cultural groups  Scales of CBCL used to form profile of overall degree of child's behavioural problems  Brief Problem Checklist- brief rating scale/interview, practical and cost effective way to monitor ongoing progress in treatment and to modify treatment as necessary o Other rating scales focus mainly on specific disorders- depression, anxiety, autism, ADHD, conduct problems , or particular areas of functioning- school competence, adaptive behaviour, school performance o Questionnaires administered to adolescents b/c find it more interesting, younger children handed cards showing their emotion o Rating scales provide more focuses look at specific problems than global behaviour  Behavioural Observation and Recording o Parents, teachers, clinicians may keep records of specific target behaviours for young children o Observers record "baseline"- (prior to intervention) data on 1/2 problems that they wish to change - how often child obeys or throws a tantrum o Recordings by parents advantage- ongoing info about behaviours of interest in life settings that might not otherwise be accessible by clinician  Secondary benefits- teaching parents better observation skills, assessing parental motivation, realistic estimates of their child's rate of responding and feedback regarding treatment o "Role play simulation"- see how child/family might behave in daily situations encountered at home/school or problem solving situation like figuring out how to play game together o Observing families who beat children, choose actives likely to elicit cooperation and conflict Psychological Testing  Test: task or set of tasks given under standard conditions with purpose of assessing some aspect of the child's knowledge, skill, personality o Most standardized on clearly defined reference group- children of specific age, sex or SES- "norm group"  Individuals child's score compared to a comparable group of children determine how much it deviates from norm  Prevalence and test use in culture lead to mistaken view testing and psychological assessment are the same NOT o Tests only represent one part of overall despise-making process  Psychological tests have been "normed" may not be appropriate to use with ind from racial, ethnic or cultural groups other than those whom the test had been normed with  IQ tests culturally biased especial for children whose family SES and cultural background from Euro-American o Test develops now select normative groups representative of population, test items free of cultural bias  Developmental Testing o Developmental test: used to assess infants, young children generally carried out for purposes of screening, diagnosis and evaluation of early development o Screening: identification of children at risk, who are then referred through evaluation o Assessment of infants/young children at risk has increased as need for early identification and prevention o Early screening for autism  Intelligence Testing o Evaluating child's intellectual and educational functioning key in clinical assessments for range of disorders o Impairments in thinking and learning may result from behavioral or motional problems o For children with intellectual disabilities or learning/language disorders problems in thinking and learning may be part of disorder o Intelligence: overall capacity of an individual to understand and cope with the world around them o Intelligence tests used clinically for identifying children who have difficulty succeeding in a classroom  Wechsler Intelligence Scale for Children (WISC-IV) most popular and recent - 10 mandatory, 5 supplementary subtests span 6-16 yrs. - good predictors of academic achievement  Subtests assess child's global capacity in different ways, do not represent different types of intelligence  Places greater emphasis on fluid, higher-order reasoning, info processing speed and less on external or culturally influenced factors like arithmetic  Full scale IQ derived: Verbal comprehension index, perceptual reasoning index, working memory index, processing speed index- key indicators of cognitive strengths/weaknesses imp to various medical and neurological concerns o Overall general intelligence score should be favoured over individual indices when interpretation o Clinician determines how test scores used in treatment and educational planning  Projective Testing o Projective Tests: present child with ambiguous stimuli (inkblots) , then asked to describe what they see o hypothesis child will "project" own personality (unconscious fears, needs inner conflicts) on the stimuli that would otherwise not be revealed in direct questioning o Most controversy of any clinical assessment method, either strong +/- view-- some believe rich source of information others see them as inadequate with respect to minimum standards for reliability and validity o One of most frequently used methods- human figure drawings, inkblot test, hematite picture test (children tell stories in response to pictures of children in everyday situations), puppet play to asses child's inner life  Personality Testing o Enduring trait/pattern of traits that characterize the ind and determine how they interact with environment o Childs early temperament provides foundation on which personality is built o Several dimensions of personality including- timid/ bold, agreeable/disagreeable, dependable/undependable, tense/relaxed, reflective/unreflective- "BIG 5 FACTORS" o Many objective inventories focus specifically on personality- Minnesota Multiphasic Personality Inventory- Adolescent (MMPI-A) and the Personality Inventory for Children, Second edu (PIC-2)  Content includes: anxiety, attitude to school, attitude to teachers, atypicality (bizarre thoughts. Behaviours considered odd), depression, interpersonal relations, locus of control, relations with parents, self-esteem  Neuropsychological Testing o Neuropsychology: study of brain-behaviour relations o Neuropsychological assessment- attempts to link brain functioning with objective measures of behavior known to depend on an intact CNS o Behavioural measures can be used to make inferences about CNS system dysfunction and consequences of dysfunction for the child- carrying out certain actions involving CNS difficult due to brain injuries/disorders  Use this info to determine diagnosis, planning treatment, documenting the course of recovery, measuring subtle significant improvements, follow up on children with neurological impairments or learning disorders o Neurological assessments assess full range of psychological functions: o verbal/nonverbal cognitive functions language, abstract reasoning, problem solving o Perceptual functions - visual, auditory, tactile-kinesthetic o Motor functions- strength, speed of performance, coordination, dexterity o Emotional/executive control- attention, concentration, frustration, tolerance, emotional functioning CLASSIFICATION AND DIAGNOSIS  Classification: system for representing major categories or dimensions of child psychopathology, boundaries and relations among them  Diagnosis- categories of a classification system  "Idiographic strategy"- highlight child's unique circumstances, personality, cultural background, other features that pertain to their particular situation  "Nomothetic strategy"-benefit from all the info accumulated on a given problem or disorder and to determine general category of problems to which the presenting problem belongs o Classify problem using existing system of diagnosis such as DSM-IV-TR  Classifying problem leads to foundation of knowledge from which we can draw upon to understand the child/family; helps with communication; helps to select an effective intervention meets child's difficulties  NO single, agreed upon, reliable and valid worldwide classification system, in NA DSM-IV-TR used but issues raised about limited coverage of childhood disorders and changes in symptom expression with age Categories and Dimensions  Categorical Classification systems based primarily on informed professional consensus, an approach that has dominated and continues to dominate field of child (and adult) psychopathology  "Classical" (pure) Categorical Approach- assumes every diagnosis has clear underlying cause such as an infection or malfunction of the nervous system and each disorder is fundamentally different from other disorders o so individual cases can be placed in distinct categories o Disadvantage is child's behaviour seldom falls neatly into established categories, confusion remains  Categories of behaviour (opposed to medical) do not typically share same underlying causes; mental health field has to modify classical categorical approach to accommodate current state of knowledge  Children given same diagnosis don’t share same etiology, respond to the same treatment  "Dimensional Classification Approach- assumes that many independent dimensions or traits of behaviour exist, that all children possess them to varying degrees- instead of saying they fit a category it is said they are within "clinical range", above average on the dimensions of depression and anxiety o Traits and dimensions derived using statistical methods from samples drawn from both clinically referred and nonreferred child populations to establish ranges along each dimension o Dimensional classification objective and potentially more reliable than clinically derived categorical systems, also have limitations:  Dependent on sampling, method and informant characteristics, age, sex  Integrating info obtained from different methods and various informants jobber time or across situation can be challenging  Insensitive to contextual influences- doesn’t allow you to expand, give answers "never, sometimes, lot" o Provide useful estimate of degree to which child displays certain traits not others, yet tailored to the child's unique circumstances and developmental opportunities o Many dimensions of child psychopathology identified- "internalizing behaviour" & "externalizing behaviour" which reflect aggressive/rule-breaking behaviours, anxious, withdraw/depressed behaviours  Common dimensions page 103, table 4.5  Each approach has value in classifying disorders and that combined approach may be needed  Depending on whether purpose is clinical diagnoses or research one approach may be more useful o Dimensional approach of conceptualizing psychological factors and cognitive abilities is compatible with research methods that determine the degree of association b/w 2 or more variable, preferred by those conducting psychological research o Categorical approach more compatible with clinical purposes- objective to incorporate the whole pattern of the child's behaviour into meaningful diagnosis and treatment, useful for communication among clinicians The Diagnostic and Statistical Manual (DSM)  Terminology and focus of prior systems reflected major theoretical views of mental illness at the timely a shift to a more objective, informed approach had occurred by the 1980's  DSM-IV-TR ("TR"- Text Revision) includes same diagnostic criteria as DMS-IV and updates the text info/wording to reflect new info/findings about prevalence and associated features since DSM-IV 1994  DSM-IV-TR- multiaxial system consisting of 5 axes of info about child assist in planning treatment, add further context/detail to description of circumstance by organizing info and describing diversity of ind with same disorder 5 AXES:  o AXIS I  various "clinical disorders/conditions" reported, except intellectual disability and personality disorders reported on axis 2 b/c presumed to be stable  Axis I diagnostic categories usually first diagnosed in infancy, childhood, or adolescence- Mental retardation, Learning disorders, Communication disorders, Pervasive disorders, Attention Deficit disorder, Feeding/Eating disorders, Elimination disorders  Mood, anxiety, sleep and eating disorders not strictly youth also adult  Child often receives more than one axis 1 diagnosis with principle diagnosis listed first o AXIS II  Used to report "personality disorders and intellectual disability"- given different axis to ensure they are given proper consideration , esp. when more visible axis disorder present  Used for diagnosing children with intellectual disability  Personality disorders rarely diagnosed until late adolescence/early adulthood - less stable in children
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