PPT

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PPT

  1. 1. Assessment, Diagnosis, and Treatment
  2. 2. Who First Notices Abnormal Behaviour? <ul><li>A close family member… </li></ul><ul><li>Parents - children or adolescents with behaviour problems </li></ul><ul><li>Self- referrals - most adult cases </li></ul><ul><li>Spouses, significant others </li></ul><ul><li>Children - elderly parents </li></ul><ul><li>Otherwise, it’s usually the legal system (court cases) </li></ul>
  3. 3. Professionals Involved in Assessment <ul><li>Referral Stage </li></ul><ul><li>Family doctor - source of initial referral </li></ul><ul><li>Teachers - referrals for behaviour </li></ul><ul><li>School Counselors </li></ul><ul><li>Service Stages </li></ul><ul><li>Psychiatrists - assessment, diagnosis, treatment </li></ul><ul><li>Psychologists - assessment, treatment </li></ul><ul><li>Social Workers - treatment </li></ul>
  4. 4. Assessment
  5. 5. What is Assessment? <ul><li>Multiple strategies: </li></ul><ul><li>Measurements (tests) are taken </li></ul><ul><li>Needs or goals of the patient are determined, if applicable </li></ul><ul><li>Decisions are made regarding classification, diagnosis, placement, and treatment </li></ul><ul><li>Follow-up to determine the efficacy of treatment </li></ul><ul><li>Adjustments made if necessary </li></ul>
  6. 6. Test Results and Interpretation <ul><li>Only approximations to real phenomena. </li></ul><ul><li>Any type of assessment method is subject to error. </li></ul><ul><li>Chance error can occur. </li></ul><ul><li>Systematic error or bias . </li></ul>
  7. 7. Standards for Assessment <ul><li>Reliability </li></ul><ul><li>Validity </li></ul><ul><li>Utility </li></ul>
  8. 8. Reliability <ul><li>Repeatability: Comparable scores each time a test is administered </li></ul><ul><li>When is a test unreliable? </li></ul><ul><li>Ambiguous assessment procedures </li></ul><ul><li>Poorly trained evaluators </li></ul><ul><li>Varying behaviour of the patient </li></ul><ul><li>Growth and development </li></ul><ul><li>Varying assessment conditions </li></ul><ul><li>Learning effects </li></ul>
  9. 9. Validity <ul><li>Is test accurately assessing what is was designed to assess? </li></ul><ul><li>Many types: </li></ul><ul><li>Concurrent: vary with other measures of the same phenomenon </li></ul><ul><li>Content: how comprehensive the measure is </li></ul><ul><li>Predictive: future outcomes (GRE, LSAT, MCAT) </li></ul>
  10. 10. Validity <ul><li>What can affect validity? </li></ul><ul><li>Sampling the wrong or irrelevant content area </li></ul><ul><li>The measure’s reactivity – extent to which the measure makes the patient want to respond a certain way </li></ul><ul><li>A mismatch between test difficulty and developmental level (ceiling or floor effects). </li></ul><ul><li>Low reliability = lowers validity </li></ul>
  11. 11. Utility <ul><li>Usefulness: impact on appropriate placement and treatment </li></ul><ul><li>Also relates to issues of time and money. </li></ul><ul><li>Three Questions of Utility </li></ul><ul><li>What is the percentage of correct decisions made using this instrument? </li></ul><ul><li>What are the costs involved in getting the assessment information? </li></ul><ul><li>What are the values or costs associated with making a correct decision? </li></ul>
  12. 12. How do you reduce assessment error? <ul><li>Rule of Multiples: </li></ul><ul><li>Multiple Tests – use more than one test </li></ul><ul><li>Multiple Evaluators </li></ul><ul><li>Multiple Times –more than once, if possible </li></ul>
  13. 13. A. Neuropsychiatric Approaches <ul><li>Psychiatrists specialized in brain-based diseases or disorders </li></ul><ul><li>Steps in assessment </li></ul><ul><li>Clinical Interview </li></ul><ul><li>Behavioural Observations (during interview) </li></ul><ul><li>Medical Status (physical) </li></ul><ul><li>Mental Status Exam </li></ul><ul><li>Referral to neurologist if necessary </li></ul>
  14. 14. 1. Clinical Interviews and Observation <ul><li>Standardized : explicit instructions/procedures </li></ul><ul><li>Same questions, same order </li></ul><ul><li>Not standardized : based on clinical judgment </li></ul><ul><li>Time constraints </li></ul><ul><li>Omit irrelevant questions </li></ul><ul><li>May be loosely based on standardized measures </li></ul>
  15. 15. Purpose of Interview <ul><li>Initial meeting with the patient, their family, or caregiver </li></ul><ul><li>Conversational approach that gauges concerns of patient </li></ul><ul><li>Big emphasis on social skills, body language, nature of difficulties in a “casual” setting. </li></ul><ul><ul><li>Personality issues regarding treatment </li></ul></ul>
  16. 16. 2. Behavioural Observations <ul><li>Examine many domains : </li></ul><ul><ul><li>appearance </li></ul></ul><ul><ul><li>motoric behaviour </li></ul></ul><ul><ul><li>mood and affect </li></ul></ul><ul><ul><li>verbal output </li></ul></ul><ul><ul><li>thought </li></ul></ul><ul><ul><li>perception </li></ul></ul>
  17. 17. Appearance <ul><li>dress (style and amount) </li></ul><ul><li>emotional display (appropriate, flat, over aroused) </li></ul><ul><li>attitude toward examination and questioning (cooperative, aloof, hostile, guarded) </li></ul><ul><li>motor activity (agitated, flat, appropriate) </li></ul>
  18. 18. Motor behaviour <ul><li>gait (walking, balance) </li></ul><ul><li>posture </li></ul><ul><li>spontaneous movement (tics, tremors) </li></ul><ul><li>speech </li></ul><ul><ul><li>speed, fluency, latency of reply, stuttering </li></ul></ul>
  19. 19. Mood and Affect <ul><li>Mood = emotion as reported by patient </li></ul><ul><li>Affect = emotion manifested nonverbally </li></ul><ul><ul><li>tone of voice, behaviour, facial expression </li></ul></ul>
  20. 20. Content of Thoughts… <ul><li>repetition </li></ul><ul><li>delusions, perseveration, obsessions </li></ul><ul><li>word salad </li></ul><ul><li>Coprolalia: involuntary utterance of obscenities </li></ul><ul><li>autistic thinking (personally idiosyncratic thought not related to reality) </li></ul><ul><li>loosening of associations (unrelated thoughts) </li></ul><ul><li>poverty of expression </li></ul><ul><li>thought blocking </li></ul><ul><li>flight of ideas (connection through rhyme, etc.) </li></ul><ul><li>tangential thinking </li></ul>
  21. 21. Perception <ul><li>Modality: visual, auditory, tactile, gustatory, olfactory, vestibular </li></ul><ul><li>Valence : </li></ul><ul><ul><li>Positive = present - e.g. hallucinations (generated from mind), illusions (distortions of existing stimuli) </li></ul></ul><ul><ul><li>Negative = absent - e.g. neglect, blindness, agnosias (inability to recognize stimuli) </li></ul></ul>
  22. 22. 3. Medical Status <ul><li>Psychiatrist or primary care physician </li></ul><ul><li>Additional tests: ECG, blood pressure, reflexes, vision and hearing exams, etc. </li></ul><ul><li>Are symptoms the result of a physical ailment that can be treated with medication or surgery? </li></ul>
  23. 23. 4. Mental Status Exam <ul><li>Screening test of neuropsychological functions </li></ul><ul><li>Particular responses suggest affected brain areas </li></ul><ul><li>Must be aware of education level, socioeconomic status, and test awareness </li></ul>
  24. 24. Domains Tested <ul><li>Attention and Concentration </li></ul><ul><ul><li>Drowsiness (reticular formation) </li></ul></ul><ul><ul><li>Distractibility/Mental Control (frontal lobe) </li></ul></ul><ul><ul><li>Unilateral neglect –thalamus, parietal lobe </li></ul></ul><ul><ul><li>Tests: digit span, saying months of the year backwards, line bisection test </li></ul></ul>
  25. 25. Domains Tested <ul><li>Language (frontal, temporal lobes) </li></ul><ul><ul><li>Spontaneous speech </li></ul></ul><ul><ul><li>Comprehension – token test </li></ul></ul><ul><ul><li>Repetition </li></ul></ul><ul><ul><li>Naming </li></ul></ul><ul><ul><li>Reading </li></ul></ul><ul><ul><li>Writing </li></ul></ul><ul><ul><li>Word list generation </li></ul></ul><ul><ul><li>Speech prosody (tone, rhyme, emotion) </li></ul></ul>
  26. 26. Domains Tested <ul><li>Memory (Hippocampus, medial thalamus) </li></ul><ul><ul><li>Orientation </li></ul></ul><ul><ul><li>Short word lists – increasing delays </li></ul></ul><ul><ul><li>Visual Memory </li></ul></ul><ul><ul><li>Personal history </li></ul></ul>
  27. 27. Domains Tested <ul><li>Constructions (Right parietal lobe) </li></ul><ul><ul><li>Copying drawings </li></ul></ul><ul><ul><li>Clock drawing </li></ul></ul><ul><li>Calculation (Left parietal lobe) </li></ul><ul><ul><li>Mental and written arithmetic </li></ul></ul>
  28. 28. Domains Tested <ul><li>Abstraction (Frontal lobes) </li></ul><ul><ul><li>Proverbs </li></ul></ul><ul><ul><li>Metaphors </li></ul></ul><ul><li>Insight and Judgment (Frontal lobes) </li></ul><ul><ul><li>Usually asked in relation to symptoms </li></ul></ul>
  29. 29. Domains Tested <ul><li>Apraxia </li></ul><ul><li>Ideomotor– inability to perform commands despite good motor function </li></ul><ul><li>Ideational– inability to synthesize a series of individual actions into a complex activity </li></ul><ul><li>Both are seen in dementias, other diseases involving diffuse brain damage </li></ul>
  30. 30. Domains Tested <ul><li>Executive Function (Dorsolateral prefrontal) </li></ul><ul><ul><li>Semantic memory </li></ul></ul><ul><ul><li>Complex constructions </li></ul></ul><ul><ul><li>Problem solving </li></ul></ul><ul><ul><li>Rhythm tapping </li></ul></ul><ul><ul><li>Verbal fluency </li></ul></ul>
  31. 31. Domains Tested <ul><li>Mental Status is often determined through use of the Mini Mental State Exam (MMSE) </li></ul><ul><li>11 questions, 5-10 minutes to administer </li></ul><ul><li>Total score 30, <23 implies clinical impairment </li></ul>
  32. 32. 5. Referral to Neurologist <ul><li>If brain damage is suspected </li></ul><ul><li>Will either confirm or disconfirm results of MMSE </li></ul><ul><li>Includes tests of sensory and motor functioning </li></ul>
  33. 33. Neurological Tests <ul><li>Cranial nerve function – smell, visual fields, visual acuity, pupillary responses, facial musculature, auditory testing, facial reflexes </li></ul><ul><li>Motor system examination – muscle bulk, strength, muscle tone, gait, posture </li></ul>
  34. 34. More Neurological Tests <ul><li>Electroencephalogram </li></ul><ul><li>Neuroendocrine tests </li></ul><ul><li>Magnetic resonance imaging (MRI) </li></ul><ul><li>Positron emission tomography (PET) </li></ul>
  35. 35. B. Neuropsychological Approaches <ul><li>Clinical Interviews </li></ul><ul><li>Assessment of Cognitive Function </li></ul><ul><li>Brief assessment of social, emotional function </li></ul><ul><li>Correlations with Neurological findings </li></ul>
  36. 36. 1. Clinical Interviews <ul><li>Determine current level of cognitive and emotional functioning </li></ul><ul><li>Less diagnostically inclined </li></ul><ul><li>Determine areas of concern, strengths and weaknesses </li></ul>
  37. 37. 2. Assessment of Cognitive Function <ul><li>Assessment of neuropsychiatric domains </li></ul><ul><li>Also intellectual, academic, and adaptive functioning </li></ul>
  38. 38. Intelligence Tests <ul><li>WAIS – Wechsler Adult Intelligence Scale </li></ul><ul><li>WISC-IV - Wechsler Intelligence Scale for Children </li></ul><ul><li>WPPSI-R - Wechsler Preschool and Primary Scale of Intelligence </li></ul><ul><li>Stanford-Binet Intelligence Test - 4th edition </li></ul><ul><li>Leiter International Performance Scale (non-verbal) </li></ul>
  39. 39. About intelligence tests… <ul><li>Good test-retest reliability </li></ul><ul><li>Good inter-rater reliability </li></ul><ul><li>Good concurrent, predictive validity </li></ul><ul><li>Questionable content validity </li></ul><ul><li>Tests measure academic aspects </li></ul>
  40. 40. About intelligence tests… <ul><li>Infant and young children’s tests do not predict school performance very well. </li></ul><ul><li>No clear relationship between IQ and behaviour problems. </li></ul><ul><li>Not diagnostic – never use IQ tests alone to diagnose a disorder </li></ul><ul><li>Utility is questionable for people from different cultures </li></ul>
  41. 41. Projective Tests for Children <ul><li>Projective hypothesis: child behaviour is driven by underlying sexual and aggressive urges. </li></ul><ul><li>Association: what they see in a stimulus (inkblots), or word association. </li></ul><ul><li>Construction: Thematic Apperception Test, Draw a Person Test </li></ul><ul><li>Expressive :create product of their own choice </li></ul>
  42. 43. Personality Tests for Children <ul><li>Personality Inventory for Children (PIC) </li></ul><ul><li>Filled out by primary caregiver </li></ul><ul><li>Several questions correlate or cluster with each other during the standardization phase – indicates a trait </li></ul><ul><li>Valid and reliable, not necessarily predictive </li></ul>
  43. 44. Educational Tests <ul><li>Achievement tests - assess what a child has learned up until the point of testing. </li></ul><ul><ul><li>Woodcock Johnson, Wide-Range Achievement Test </li></ul></ul><ul><li>Measure reading, spelling, arithmetic </li></ul><ul><li>Good reliability and content validity </li></ul>
  44. 45. 4. Correlation with Neurological Findings <ul><li>Compile own findings into a report </li></ul><ul><li>Compare areas of strengths and weakness with known neurological damage </li></ul><ul><li>Be careful not to infer neurological underpinnings of behaviour </li></ul>
  45. 46. Diagnosis
  46. 47. Diagnosis of Disorders <ul><li>Diagnosis = process of using an accepted classification system </li></ul><ul><li>match a person’s atypical behaviour characteristics to a set of operational definitions </li></ul><ul><li>Match of symptoms to criteria for disorders </li></ul>
  47. 48. Arriving at at diagnosis <ul><li>Neurological and academic status determined </li></ul><ul><li>Neuropsychiatrist and neuropsychologist: </li></ul><ul><ul><li>DISC (Diagnostic Interview Schedule for Children) or SCID (adult version) clinical interview used for diagnosis in DSM-IV categories </li></ul></ul><ul><ul><li>Child Behaviour Checklist (CBCL) for children </li></ul></ul><ul><ul><li>Minnesota Multiphasic Personality Inventory (MMPI) </li></ul></ul><ul><ul><li>California Personality Inventory or Personality Inventory for Children </li></ul></ul><ul><ul><li>self reports - depression, anxiety </li></ul></ul>
  48. 49. Diagnosis <ul><li>DSM-IV </li></ul><ul><ul><li>Diagnostic and Statistical Manual – 4 th edition </li></ul></ul><ul><ul><li>lists known causes </li></ul></ul><ul><ul><li>Statistics:gender, age at onset, and prognosis </li></ul></ul><ul><ul><li>Optimal treatment approaches </li></ul></ul><ul><ul><li>North American </li></ul></ul><ul><li>Other systems: ICD-10 </li></ul><ul><ul><li>International Classification of Disorders </li></ul></ul><ul><ul><li>Used more often in England and Europe </li></ul></ul>
  49. 50. DSM-IV Classification <ul><li>Diagnostic and Statistical Manual of Mental Disorders (4th Ed) </li></ul><ul><li>Multiaxial system – other dimensions can be coded with the principal diagnosis. </li></ul><ul><ul><li>Axis I – principal diagnosis </li></ul></ul><ul><ul><li>Axis II – developmental and personality disorders (long term effects) </li></ul></ul><ul><ul><li>Axis III – physical disorders </li></ul></ul><ul><ul><li>Axis IV – psychosocial stressors (family, employment status) </li></ul></ul><ul><ul><li>Axis V – highest level of functioning </li></ul></ul>
  50. 51. DSM-IV Classification <ul><li>Advantages: </li></ul><ul><li>Based on research findings </li></ul><ul><li>Systematically tested </li></ul><ul><li>More disorders for children than in previous versions. </li></ul><ul><li>Multiaxial system addresses complexity of diagnosis. </li></ul><ul><li>Disadvantages: </li></ul><ul><li>Atheoretical – based on medical model </li></ul><ul><li>Includes educational problems that may be transitory. </li></ul><ul><li>Not reliable for more specific disorders – true for broader disorders </li></ul><ul><li>Distinctions between Axis I and II often unclear </li></ul>
  51. 52. Statistically Based Classification Systems <ul><li>Child Behavior Checklist (CBCL) </li></ul><ul><ul><li>Parents, teachers, or child are asked to rate child’s behaviour among predetermined dimensions </li></ul></ul><ul><ul><li>Compared to other children </li></ul></ul><ul><li>MMPI </li></ul><ul><ul><li>Self-report questionnaire with items randomly presented to examinee </li></ul></ul><ul><ul><li>Use of scales to determine if responses indicate clinical significant findings </li></ul></ul>
  52. 53. About these other tests… <ul><li>Behaviour dimensions were determined through statistical sampling and factor analysis </li></ul><ul><li>Good validity – construct and content </li></ul><ul><li>Good reliability (over .90) </li></ul><ul><li>Prone to cultural differences </li></ul><ul><li>CBCL - No scales to determine if person is over or underreporting problem behaviour </li></ul>
  53. 54. The Effects of Labeling through Classification <ul><li>Assumptions of behaviour that may not be present. </li></ul><ul><li>Can restrict a child to dead-end placements. </li></ul><ul><li>Self-fulfilling prophecy. </li></ul><ul><li>Focus on negative personal traits. </li></ul><ul><li>Damage self-esteem. </li></ul>
  54. 55. Treatment
  55. 56. 1. Psychopharmacology <ul><li>Usually administered by a psychiatrist </li></ul><ul><li>Some U.S. states have given prescription rights to psychologists </li></ul><ul><li>Most drugs are nonspecific and are used for a number of disorders </li></ul>
  56. 57. What do drugs do? <ul><li>to suppress dangerous behaviours </li></ul><ul><li>to suppress behaviours that interfere with education </li></ul><ul><li>to suppress bizarre behaviours </li></ul><ul><li>to promote prosocial behaviour </li></ul><ul><li>The don’t cure but can control disease </li></ul><ul><li>Still controversy over the treatment of children with drugs </li></ul>
  57. 58. Effectiveness of Drug Treatments <ul><li>Treatment compliance </li></ul><ul><li>Side effects </li></ul><ul><li>Long-term goals </li></ul>
  58. 59. 2. Psychiatric Therapies <ul><li>1. Psychodynamic/psychoanalytic </li></ul><ul><li>Resolve internal conflict caused by repression </li></ul><ul><li>Assessment by projective approaches or personality inventories </li></ul><ul><li>45-50 minute sessions 3-5 times per week, over months or years </li></ul>
  59. 60. Psychiatric Therapies <ul><li>2. Client-Centred (insight-oriented) Therapy </li></ul><ul><li>Therapist must accept client as they are and encourages expression of feelings </li></ul><ul><li>1-2 one-hour sessions per week </li></ul>
  60. 61. 3. Psychological Therapies <ul><li>“ Cognitive behavioural therapy” </li></ul><ul><li>Many approaches based on Skinnerian reinforcement principles </li></ul><ul><li>Little or no concern for discovering the origins of internal drives. </li></ul>
  61. 62. Using well-know behaviouristic approaches: <ul><li>Extinction/response cost: removal of reinforcement </li></ul><ul><li>Token reinforcement </li></ul><ul><li>Negative reinforcement </li></ul>
  62. 63. 4. Social Worker Interventions <ul><li>Adopting new response habits between family and other people close to the patient </li></ul><ul><li>Family systems therapy </li></ul><ul><li>problems due to atypical family interactions </li></ul><ul><li>Understand and modify family dynamics </li></ul><ul><li>Behavioural family therapy </li></ul><ul><li>increase positive reinforcement between family members </li></ul><ul><li>decreasing use of coercion and negative reinforcement </li></ul>
  63. 64. 5. Educational Interventions <ul><li>For children or adolescents in school setting </li></ul><ul><li>Address academic and behavioural difficulties </li></ul><ul><li>In-class educational assistants </li></ul><ul><li>Behavioural therapy by a psychologist or trained student </li></ul><ul><li>Not usually done by primary teacher </li></ul>
  64. 65. 6. Cognitive Rehabilitation <ul><li>Individualized remediation of cognitive difficulties to improve memory, attention, executive function </li></ul><ul><li>In a private clinic or through a hospital </li></ul><ul><li>Dementia, traumatic brain injury, epilepsy </li></ul><ul><li>Usually administered by psychologists or occupational therapists </li></ul>
  65. 66. 7. Electroconvulsive Therapy <ul><li>Controlled seizure: Low-voltage electric current passed through the brain for 1-2 seconds </li></ul><ul><li>Effective in depression, mania, schizophrenia </li></ul><ul><li>Used there is resistance to drug treatments </li></ul><ul><li>“Resets” the electrochemical conductivity of neurons </li></ul><ul><li>Truth: not sure why it works </li></ul>
  66. 67. 8. Psychosurgery <ul><li>Removal of parts of the brain that are malfunctioning </li></ul><ul><li>Frontal lobotomies – not done any more </li></ul><ul><li>Used primarily for seizure and movement disorders </li></ul><ul><li>Procedure of last resort </li></ul><ul><li>May also produce side effects: confusion, epilepsy, personality change </li></ul>
  67. 68. Psychosurgery: Other Diseases <ul><li>Depression </li></ul><ul><li>OCD </li></ul><ul><li>Anorexia nervosa </li></ul><ul><li>Anxiety </li></ul><ul><li>Pain </li></ul><ul><li>Addiction </li></ul><ul><li>Violence/rage attacks </li></ul><ul><li>Sexual aggression/pedophilia </li></ul>
  68. 69. 9. Non-conventional therapies <ul><li>Nonprofessional Family Support </li></ul><ul><li>Preventive intervention e.g. Head Start program </li></ul><ul><li>Decrease expense, increase availability of educational mental health care for adults and children </li></ul><ul><li>Formed by parent volunteers </li></ul><ul><li>e.g. family counseling, drop-in centres, information programs </li></ul><ul><li>Partially effective </li></ul>
  69. 70. More non-conventional therapies <ul><li>2. Residential Treatment </li></ul><ul><li>last resort for intractable problems </li></ul><ul><li>Large centres, group homes, or community residences </li></ul><ul><li>Usually try to change living circumstances in addition to problems of patient </li></ul><ul><li>Used when patient is a danger to self and others </li></ul><ul><li>Very expensive and poor availability </li></ul><ul><li>For adults only </li></ul>
  70. 71. More non-conventional therapies <ul><li>3. Parent Training </li></ul><ul><li>Behavioural Training for parenting skills </li></ul><ul><li>Usually combined with direct intervention with child </li></ul><ul><li>individual or group setting </li></ul><ul><li>Particular effective for parents of young children </li></ul>
  71. 72. More non-conventional therapies <ul><li>4. Therapeutic Foster Family Treatment </li></ul><ul><li>Removal of child from family home and placement in a foster home </li></ul><ul><li>Foster parents have been trained on psychological techniques and are supervised </li></ul><ul><li>Efficacy unknown </li></ul>

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