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Psychological Testing Evaluation with Children and Adolescents

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Psychological Testing Evaluation with Children and Adolescents Powered By Docstoc
					Child / Adolescent Psychological
Evaluation




       Gary Wautier, PhD, MSCP
    Psychological Evaluation

Initial evaluation
 Interview with youth and parents or
  custodial adults of youth
 Review of appropriate health and
  educational documents
 Communication 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 Concern
 Previous Behavioral Health Treatment and
  response
 Family History

 Pregnancy, delivery, post delivery

 Medical 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 attachment
   Mothers 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 children
Youngsters more likely to comply after a
parental suggestion than after a
command or prohibition
Compliance even less likely when
physical control was paired with
command or prohibition
Toddlerhood/preschool cont’d
More 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 youth
Positive 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 Assessment
Wechsler 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 Disorder
Mathematics Disorder
Disorder 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 Disorders
Thorough diagnostic interview of anxiety disorders
(e.g., separation, OCD, GAD, Social, Situational)
Rating scales from multiple informants
Observation during interview and testing
Assess stressors, trauma, adjustments, abuse,
neglect, parent/child history
Consider youth’s progress with daily functioning and
expectations
Rule out co-morbid depressive disorder
Consider medical conditions potentially contributing
Assess 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 Study
Twelve 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’d
Patient 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 Impression
Axis I
    Attention deficit hyperactivity disorder, predominantly inattentive type
    Depressive disorder not otherwise specified with dysthymic disorder traits
    Anxiety disorder not otherwise specified
    Parent/child relational problems with oppositional defiant disorder traits, particularly in the
    home environment
    Mathematics disorder
Axis II
    Borderline and antisocial personality disorder features
Axis III
    None reported
Axis IV
    Severe 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 V
    Current 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

				
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