The document outlines clinical assessment, diagnosis, and treatment approaches for children with psychological disorders, emphasizing the importance of understanding individual and cultural contexts. It discusses idiographic and nomothetic formulation, various assessment methods, and the pros and cons of diagnostic labels. Treatment strategies are highlighted, with a focus on evidence-based interventions tailored to cultural needs and the necessity of addressing family dynamics and ethical considerations in the therapeutic process.

1. © Cengage Learning 2016 © Cengage Learning 2016
Eric J. Mash
David A. Wolfe
Assessment, Diagnosis, and
Treatment
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2. © Cengage Learning 2016
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

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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

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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

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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

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Developmental Considerations - Gender
Patterns

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• 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
Developmental Considerations – Normative
Information

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Parent- and Teacher-Rated Problems

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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

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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

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• 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
Assessing Disorders

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• 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

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Structured Interview Questions

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• 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
Behavioral Assessment

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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

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Functional Analysis

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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

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Child Behavior Checklist

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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

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• 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.
Psychological Testing

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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

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• 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
Psychological Testing - Intelligence Testing

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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)

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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

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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

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Psychological Testing
Self-Report Personality Scale Definitions

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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

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• 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
Classification and Diagnosis

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• 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
Ideographic and Nomothetic Strategies

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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

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Classification and Diagnosis
Commonly Identified Dimensions

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

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The Diagnostic and Statistical Manual
Neurodevelopmental Disorders

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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

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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

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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

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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

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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

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Treatment - The Intervention Spectrum

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• 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
Cultural Considerations

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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

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Cultural Values and Parenting Practices

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

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

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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

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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

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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)

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Ethical Issues in Clinical Work With
Children and Families

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• 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
General Approaches to Treatment

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• 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
Behavioral Treatments

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

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• 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

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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

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

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• 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
Combined Treatments

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Descriptions of Common Medications for
Children and Youths

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

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Results of Behavioral Role-Play Intervention

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• 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

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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

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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

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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