Assessment, diagnosis and treatment of childhood mental illess

PSYC 4410 Assessment, Diagnosis & Treatment Brannen 1

Assessment, Diagnosis and Treatment of Children’s Mental Illness


Learning objectives

• Discuss the connection between research and children’s mental health services• Understand the barriers to children receiving mental health services• Be able to describe the different methods of children’s mental health

service delivery• Describe the different categories of assessment• Define the diagnostic features of the DSM-V• Discuss the difference between prevention and intervention• Understand the major approaches to treatment


Out of the Shadows at Last (Kirby/Keon, 2006)

• “deeply concerned about the capability of the mental health system to respond to the needs of children and youth”

• Early intervention critical• Shortage of mental health professionals• Provider driven model• “much greater investment in children’s mental health is

required… to shed its label as the “orphan’s orphan” within the health care system”


Barriers to children’s mental health services Waiting lists are long

Priority given to children with severe symptomology Children with moderate anxiety are low priority

Cost burden to patients to receive services Time from work Distance from mental health services Incidental costs (Babysitting/meals)

Other barriers Office hours not convenient Stigma associated with receiving care Insufficient primary care of pediatric mental health problems


Models of mental health service delivery

• Craft model:• One to one, sometimes a group• Highly-trained therapist e.g. Ph.D. or MD• Individual treatment planning, decision-making• Satisfying for therapist/patient (parents/child)• Problems: access, costs to family, costs to the system, few receive

treatment, confusing results


Models of mental health service delivery, cont’d.• Industrial model:• Evidence based system for all aspects of service delivery (assessment,

diagnosis and treatment)• Uses skill level required for the specific job• Intake used to place child in appropriate services• Uses technology and quality assurance to ensure effective services are

delivered• Measures outcomes• Problems: can feel impersonal, not suitable for all patients


Clinical decision-making process

• Begins with a clinical assessment - uses systematic problem-solving strategies to understand children with disturbances and their family and school environments• A child’s emotional, behavioral, and cognitive functioning; the role of

environmental factors; nature, causes, and likely outcomes of the problem• Nomothetic evaluation refers to general knowledge about specific

patterns of behaviours, emotions and thoughts that apply to a certain group of individuals, while idiographic evaluation focuses on the unique individual


Best practices for clinical decision making


Developmental considerations

• Age inappropriateness, impairment/severity and patterns of symptoms usually classify a childhood mental illness• Age: what is appropriate at one age, may not be

important at another• Gender: boys and girls express different symptoms

(internalizing vs. externalizing) in general, but need to be aware that this is not always the case• Culture: • Culture-bound syndromes and definitions of mental health

problems vary from our western views


Gender differences in childhood mental health problems

What might be some reasons that Conduct Disorder is reportedly equally among adolescent females and males?


Commonly reported troubling behaviours


Assessment


Purposes of assessment• Difference between assessment and screening• 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

• 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


• 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

Clinical assessment


• 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

Clinical interviews


Structured interview questions


• 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

Behavioural assessment


Behaviour 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


Functional analysis


Behavioural assessment inventories

• 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


Child behavior checklist for Felicia


Behavioural 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• E.g., Strange Situation and “A Closer Look” on p. 97

(Sammy)


• 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.

• 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

Psychological testing


• Evaluating a child’s intellectual and educational functioning• Problems: Many definitions of intelligence and require training, time

and are expensive• 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

• 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)

Intelligence testing


WISC-IV: Spanish version summary


Other types of psychological testing • Projective tests: children “project” their own fears, needs and

stories unto ambiguous images (e.g., CAT)• Little evidence

• Neuropsychological assessment: link brain functioning with objective measures of behavior• Promising, but expensive, need more research

• The “Big 5” personality factors: • Timid or bold • Agreeable or disagreeable• Dependable or undependable• Tense or relaxed• Reflective or unreflective


Self-report personality scale definitions


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


• 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: focus on the

unique child• Nomothetic strategies: determine

which category best describes the child’s problems

Classification and diagnosis


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


Commonly identified dimensions


The Diagnostic and Statistical Manual (DSM)• The current edition: DSM-5• 15 new disorders in the DSM-5

• A multiaxial system consisting of five axes:I. Clinical disorders or conditionsII. Personality disorders and intellectual disabilityIII. General medical conditionsIV. Psychosocial and environmental problemsV. Global assessment of functioning

http://www.marketwatch.com/story/15-new-mental-illnesses-in-the-dsm-5-2013-05-22


DSM advantages and disadvantages

• 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


DSM advantages and disadvantages, cont’d.

• Pros of diagnostic labels• Help clinicians summarize and order observations• Often necessary for health and education services• Facilitate communication among professionals• Aid parents by providing recognition and understanding of

their child’s problem

• 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


Research Domain Criteria (RDoC)


Treatment and prevention

• Prevention programs vs. intervention• Interventions today are planned by combining the

most effective approaches to a particular problem• Growing research on effective treatments, but the

knowledge-to-practice gap remains• Complex cases require complex solutions: treat the

child, family, environment


The Intervention Spectrum


• Development of evidence-based interventions has led to a growing awareness of children’s and families’ contexts• More inclusive prevention and intervention

approaches – question is “is this family structure actually abnormal?”• The cultural compatibility hypothesis• Treatment is likely to be more effective when compatible

with the cultural patterns of the child and family

Contextual considerations


Cultural Values and Parenting Practices


• Outcomes related to child functioning• Reduce or 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• Enhance family support

Treatment goals


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


Ethical and legal considerations

• AACAP/CACAP and APA/CPA ethical codes 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

• Legal issues: risk to self/others, parental abuse/neglect, competency


Ethical Issues in Clinical Work With Children and Families


• 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

• Behavioral Treatments• Assume that behaviors are learned• Focus is on re-educating the child• Procedures include: Positive reinforcement or time-out; modeling;

systematic desensitization and changing the environment

General approaches to treatment


• 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

Cognitive behavioral treatments


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


• View child psychopathology as resulting from psychobiological impairment or dysfunction• Rely primarily on pharmacological and other biological

approaches to treatment

Biological treatments


Descriptions of Common Medications for Children and Youths


Usage of Psychiatric Medication by Children in the United States (1987 – 1996)


Results of Behavioral Role-Play Intervention


• 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

Treatment effectiveness


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


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

Assessment, diagnosis and treatment of childhood mental illess

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