Child Adolescent Psychological Evaluation
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Transcript of Child Adolescent Psychological Evaluation
Child / Adolescent Psychological Evaluation
Gary Wautier, PhD, MSCP
Psychological Evaluation
Initial evaluation Interview with youth and parents or
custodial adults of youthReview of appropriate health and
educational documentsCommunication with appropriate
healthcare professionals and educational personnel
Psychological Eval contd.
Psychological Testing Complete all steps as in initial evaluation as well
as appropriate psychological testing Psychoeducational (e.g., rule out specific learning
disorder(s) and potential behavioral health factors contributing to academic difficulty)
Psychological (e.g., assess adolescents emerging personality and psychosocial/emotional functioning; assess youth suspected as having a developmental disorder due to delays in psychosocial, emotional, behavioral, and/or cognitive functioning)
Neuropsychological (e.g., thoroughly assess cognitive functioning and document specific areas of strength/weakness typically associated with head injury of primary CNS disease, such as brain tumor)
When might a child or adolescent need psychological testing?
Parents may feel there is something not quite right with youth
Youth is having difficulties with psychosocial, behavioral, academic, emotional and/or developmental functioning
Youth often referred by primary clinician to help with differential diagnosis as well as treatment planning
Interview
Example Questionnaire Main ConcernPrevious Behavioral Health Treatment and
responseFamily History Pregnancy, delivery, post deliveryMedical History
Present/past conditions (e.g., head injury, metabolic or CNS diseases, hearing and vision, asthma, allergies)
Interview cont’d
Any Neglect/Abuse history
Surgeries, hospitalizations, medical procedures
Medications
Over-the-counter, herbals, and/or supplements
Some Additional factors to consider in etiology
Genetic factors
Prenatal risk factors Nutrition, Maternal age, Viral and Bacterial Infections of Mother,
Medications and Additive substances
Perinatal risk factors Anoxia, Prematurity and postmaturity, Birth injury
Demographic risk factors Gender, adoption, age, neglect, malnutrition, accidents, abuse,
environmental hazards, disease and illness, social factors, family life events, SES, family composition, adolescent parenthood, separation and divorce, parent factors, child factors, parent-child interaction, child care
Developmental Perspectives
Differences in frequency and duration of crying, infant cuddliness and consolability, activity level, alertness, and self-quieting
“goodness of fit” between an infant’s behavioral style and parental tolerance, sensitivity, and methods of childrearing
Developmental Perspectives cont’d
Early maternal behavior influential on later infant-mother attachmentMothers who are sensitive to their infant’s
cues and responsive across a range of situations including feeding, responsiveness of crying, early face-to-face play, and the provision of opportunities to explore, foster the development of a secure attachment relationship
Toddlerhood/Preschool
Excessive and / or ambiguous parental commands are associated with increased noncompliance in childrenYoungsters more likely to comply after a parental suggestion than after a command or prohibitionCompliance even less likely when physical control was paired with command or prohibition
Toddlerhood/preschool cont’dMore physical punishment and prohibitions used by mothers with lower educational levels
Relationship between mother and toddler facilitated when warm and supportive
Some degree of “defiant” or “independent” behavior is both age-appropriate and necessary for child’s normal development (affected by tolerance and awareness of parent)
Attempts by parents at overcontrol can lead to an escalation of noncompliant behavior
Aggressive behavior fairly common among preschoolers – it tends to be successful (majority over property conflicts; this instrumental or object-oriented aggression declines with age as sharing and negotiating skills develop)
Intent may be a factor that differentiates “normal” aggressive behavior from aggressive behavior that is more problematic
Angry, aggressive and apparently unprovoked attacks may be early precursors to more severe social and behavioral problems
Toddlerhood cont’d
Relationships among family members are an important arena in which children learn social skills and social understanding
Data suggest that more positive, inductive, and child centered parenting styles are associated with more pro-social behavior in the peer group
Toddlerhood cont’d
Youngsters having more difficulty separating from mother at 3 years may likely tend to be less competent with peers – they tend to initiate less interaction with peers and less responsive to peers and tend to withdraw or engage in aggressive interactions
School age youthPositive psychological, emotional, and social functioning facilitates academic functioning
Rejected children tend to engage in inappropriate, disruptive, and aggressive behaviors (may bully peers and tend to violate social norms)
Neglected children tend to appear shy and withdrawn
School age youth
Aggressive boys are more likely to attribute aggressive intentions to others in ambiguous situations and then retaliate aggressively
Impulsive and inattentive characteristics of hyperactive children interfere with social information processing and peer relational problems
Longitudinal perspective
Externalizing, but not internalizing problems tended to persist in approximately 30% of children identified as having difficulties 7 years earlier in preschool
Early problems involving management and self-control have been implicated in the onset of later more pervasive and serious externalizing disorders The importance of modulating variables such as parenting
style, family dysfunction, parent-child conflict, and parental mental health problems have been noted
Internalizing disorders including neurotic, withdrawn, anxious and psychosomatic complaints appear less persistent
Cognitive/Intellectual Assessment
Bayley Scales of Infant and Toddler Development – 3rd ed. 1-42 months
Wechsler Pre-school and Primary Scale of Intelligence – 3rd ed. (WPPSI-III) 2:6 – 7:3
Wechsler Intelligence Scale for Children – 4th ed. (WISC-IV) 6:0 – 16:11
Primary areas assessed Verbal, Perceptual (nonverbal), Working memory, Processing
Speed
Classification of Cognitive Level of Functioning
Very superior (130 and above)
Superior (120 – 129)
High Average (110 – 119)
Average (90 – 109)
Low Average (80 – 89)
Borderline (70 – 79)
Mildly Impaired (55 – 69)
Moderately Impaired (40 – 54)
Severely Impaired (25 – 39)
Profoundly Impaired (less than 25)
Academic AssessmentWechsler Individual achievement test, 2nd edition (WIAT-2) Word Reading Reading comprehension Mathematics calculation Mathematics reasoning Spelling Written expression Reading speed Word fluency with written expression
WIAT provides direct comparison of scores with Wechsler intelligence scales
Learning Disorders (DSM-IV)Reading DisorderMathematics DisorderDisorder of Written Expression
Additional terms used to describe Dyslexia (disorder of basic skills involved in reading, including letter-
word recognition and identification, phonetic analysis and comprehension)
Dyscalculia (disorder of basic skills involved in mathematics, including both computational and reasoning abilities)
Dysgraphia (disorder of written expression)
“Learning disabilities” school-based definition – not dependent on cognitive/academic discrepancy – use of functional assessment occurs with “STAT” meeting(s) and consideration of learning disability status based in part on students response to intervention strategies.
Psychosocial, Emotional, Behavioral, Clinical and Interpersonal assessment
Millon pre-adolescent clinical inventory – M-PACI Millon Adolescent Clinical Inventory – MACI Minnesota Multiphasic Personality Inventory, Adolescent
Version (MMPI-A) Child Apperception Test (CAT) Thematic Apperception Test (TAT) Incomplete Sentences Blank – High School Form Rorschach Inkblot Test Family Drawing House-Tree-Person Drawing Rating Scales (Child Behavior Checklist, CBCL; Teacher
Report Form, TRF; ADHD rating scale for parents and teachers; Reynold’s Child Depression Scale, RCDS; Reynold’s Adolescent Depression Scale, 2nd ed., RADS-2; Reynold’s Child Manifest Anxiety Scale, 2nd ed., RCMAS-2; Trauma Symptom Checklist for Children, TSCC; Youth Self-report, YSR)
Autistic Disorder
Interview – Clinical observation
Assess cognitive level of functioning
Assess social-emotional functioning
Rating scales (CBCL, TRF, Gilliam autism rating scale, 2nd ed. (GARS-2), Child Autism rating scale (CARS), Gilliam Asperger’s Disorder Scale (GADS)
Autism diagnostic observation schedule (ADOS)
Multidisciplinary approach – e.g., Marquette General Health System Multidisciplinary Developmental Specialty Clinic
Attention-Deficit / Hyperactivity Disorder
Cognitive/Intellectual assessment
Continuous performance test (e.g., Integrated Visual/Auditory continuous performance test, plus version (IVA+)
Often, academic achievement assessment
Rating scales (multiple sources – parents, teachers)
Observation
Interview
Differential diagnosis measure(s) as indicated (further assess potential conditions that contribute to ADHD-like symptoms)
Oppositional Defiant Disorder / Conduct Disorder
Interview
Observation
Rating Scale data from multiple informants
Assess for potential co-morbid conditions and stressors inside and outside of the family
Assess family dynamics and parenting styles
Closely consider specific diagnostic criteria and patient’s demographics
Anxiety DisordersThorough diagnostic interview of anxiety disorders (e.g., separation, OCD, GAD, Social, Situational)Rating scales from multiple informantsObservation during interview and testingAssess stressors, trauma, adjustments, abuse, neglect, parent/child historyConsider youth’s progress with daily functioning and expectationsRule out co-morbid depressive disorderConsider medical conditions potentially contributingAssess emerging personality functioning
Depressive Disorders
Thorough clinical diagnostic interview
Observation
Rating scales from multiple informants
Assess emerging personality functioning
Assess for current stressors, adjustments, trauma, history of abuse, neglect
Consider and assess as indicated cognitive and educational functioning
Some Additional Disorders To consider
Eating disorders
Elimination disorders
Mood cycling disorders
Tic disorder / Tourette’s Disorder
Medical conditions
Hearing and vision problems
Case StudyTwelve year old female adopted at 4 months of age
Described by parents as friendly and would talk to anyone when younger
Biological mother had history of “emotional difficulties” and reportedly smoked, used alcohol and used drugs during pregnancy
No behavioral health or medical problems for adoptive parents noted
No current family stressors noted
No history of developmental delay; no known history of abuse/neglect
History of behavioral health treatment for cutting behavior, some refusal of following directions, disorganization, and disrespectful behavior; also patient has experienced bullying, particularly last school year.
Most recently patient has continued to be quite irritable with mood swings, overeating at times, easily frustrated, tantrums and aggressive behavior noted at times as well as defiance. Patient also described as disorganized, distractible, indecisive, with occasional lying; she has stole from a store in the past, but not more recently. She often has a negative attitude and is impulsive.
Patient received inpatient psychiatric hospitalization in 2009 due to self injurious behavior, feelings of hopelessness and deterioration in daily academic and psychosocial functioning
Case study cont’dPatient currently has ongoing marked conflicts with parents
Patient not currently taking psychotropic medication. She took fluoxetine approximately 2 years ago with some benefit
Patient has hard time paying attention in class and there are problems with her academic performance
She lacks motivation concerning academics
Patient never repeated a grade
She does have friends at school
She does not complain of health problems to stay home
Is not afraid to go to school and does not try to skip school
Patient does enjoy spending time with friends and listening to music
Case study cont’d
Patient’s thoughts clear, logical, appropriately sequenced, orientation x3
Dressed in casual jeans and black shirt
Good attention during interview
Mood somewhat sad, irritable at times, particularly when parents in session
Affect appropriate to more irritable – when parents present
No odd, peculiar perceptual experiences noted
Denied thoughts of harm to self/others upon assessment
Patient’s effort good during testing
Vision, hearing and manual control appear within normal limits upon gross assessment
Performance rate average to more rapid at times
Showed some anxiety, but managed to control it
She showed adequate flexibility shifting from one task to another
Attention generally undisturbed during evaluation
Patient was somewhat impulsive at times
Overall obtained findings should be considered reliable sample of patient’s functioning
Case study cont’d
WISC-IV
Verbal comprehension composite = 108, 70th percentile, average range
Perceptual reasoning composite = 90, 25th percentile, average range
Working memory composite = 83, 13th percentile, low average range
Processing speed composite = 100, 50th percentile, average range
Full scale composite = 95, 37th percentile, average range
WIAT-II
Word Reading standard score (SS) = 97, 42nd percentile, average range
Reading comprehension SS = 112, 79th percentile, high average range
Numerical Operations SS = 68, 2nd percentile, mildly impaired range
Math Reasoning SS = 78, 7th percentile, borderline range
Mathematics Composite SS = 71, 3rd percentile, borderline range
Spelling SS = 88, 21st percentile, low average range
Written expression SS = 107, 68th percentile, average range
Written language composite SS = 96, 39th percentile, average range
Case Study cont’d
IVA+
Full scale response control – extremely impaired range
Auditory response control – severely impaired range
Visual response control – extremely impaired range
Full scale sustained attention – extremely impaired range
Auditory and visual sustained attention – extremely impaired range
M-PACI
Significant dependency needs with high degree of independence striving
Tendency to engage in emotionally charged interactions with others
Likely often seeks reassurance from others – however has expectations she may loose support from those who have provided it
Likely vacillates between irritability, sensitivity and rebellious behavior with complaints of feeling treated unfairly quite often
Tends to keep others close to her on edge, not knowing if she will react more agreeable or sulky
Her testing behavior may likely tend to alienate those she depends on
Case study cont’d
Depression (RADS-2)
Overall moderately clinically significant self-reported depression (T=75)
Anxiety (RCMAS-2)
Overall mildly clinically significant level of self-reported anxiety (T=64)
Behavioral rating scales
CBCL
Aggressive behavior (T=75)
Attention problems (T=68)
Rule breaking behavior (T=67)
Anxious/depressed symptoms (T=65)
YMRS-P
Patient obtains 5 hours of sleep on average; is hard to awaken in morning; patient is grouchy and crabby quite often; she seems more talkative at times, more demanding; parents did not particularly endorse significant manic symptoms for patient
ADHD rating scale for parents – moderately significant for ADHD, predominantly inattentive type symptoms
Case study cont’d
TRFx2 ADHD problems (T=67) and (T=71) Teachers reported patient not working up to potential with motivation
problem She is working much less hard, learning much less, happiness slightly less
than others She is friendly and seems to generally like being in school and being with
classmates, in particular
ADHD rating scale for teachers – mild to moderately significant for ADHD predominantly inattentive type symptoms
Case study cont’d
Diagnostic ImpressionAxis I
Attention deficit hyperactivity disorder, predominantly inattentive typeDepressive disorder not otherwise specified with dysthymic disorder traitsAnxiety disorder not otherwise specifiedParent/child relational problems with oppositional defiant disorder traits, particularly in the home environmentMathematics disorder
Axis IIBorderline and antisocial personality disorder features
Axis IIINone reported
Axis IVSevere psychosocial stressors for patient with regards to ongoing conflict with parents. Also, stressors associated with marked difficulties with more efficient, effective academic work completion.
Axis VCurrent GAF = 52
Case study cont’d
Recommendations
1. Outpatient psychotherapy. Therapist should maintain communication with primary physician. Continue to closely monitor patient’s safety and make appropriate diagnostic and treatment alterations as indicated. Therapist should also communicate with appropriate school personnel as indicated to facilitate patient’s receipt of appropriate services and accommodations in the school environment.
2. Psychotropic treatment consult
3. STAT meeting at patients school
4. Encouraged/facilitated for positive pro-social activity involvement
References
Assessment of Childhood Disorders (3rd) Ed. Eric J. Mash and Leif Terdal (1997). The Guilford Press, New York/London.
Handbook of Psychological Assessment (5th) Ed. Gary Groth-Marnat (2009). John Wiley and Sons, Inc. Hoboken, New Jersey.
Interviewing Children and Adolescents: Skills and Strategies for Effective DSM-IV Diagnosis. James Morrison and Thomas F. Anders (1999). The Guilford Press, New York/London.
Professional practice of Dr. Gary Wautier at Marquette General Hospital