Assessing Child and Adolescent Internalizing Disorders

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Assessing Child and Adolescent Internalizing Disorders

Jennifer L. Hudson, Carol Newall, Sophie C. Schneider, and Talia Morris

Introduction

Internalizing disorders, including anxiety and depression, typically begin early in life and are one of the most common forms of psychopathology found in children and adolescents (Rapee, Schniering, and Hudson 2009). It can be difficult to assess for these disorders in children, as the symptoms are often unseen and can be dismissed as simply a “phase” or part of the child’s personality. In contrast to other childhood disorders, such as oppositional defiant disorder, internalizing disorders can sometimes be missed by parents and teachers as the symptoms are not always observable and children may underreport their experience, to avoid causing trouble. It is vital that clinicians are able to competently detect and assess internalizing disorders, given the considerable interference caused by them within the family and across the lifespan (Merikangas et al. 2010). Undertaking a competent assessment is a fundamental step when determining the child’s diagnostic profile. Moreover, it is during assessment that the therapist will develop a better understanding of the disorder-related maintaining factors, thereby becoming able to select the most appropriate intervention for the child.

Our aim in this chapter is to describe therapist competencies required for conducting a competent and thorough assessment of children and adolescents with anxiety and depressive disorders. First we will outline each of the individual competencies and discuss them in detail. Next we will outline issues that arise when conducting a competent assessment of anxiety and depression. Finally we will discuss some common obstacles to conducting a competent assessment and strategies for overcoming them.

Key Features of Competencies in Assessing Children and Adolescents

Over the last 15 years, clinical psychology has witnessed a paradigm shift toward the use of empirically supported treatments (Chambless and Hollon 1998). Not too far behind this movement is the shift toward adopting evidence-based assessments (EBAs). An evidence-based assessment framework (Hunsley and Mash 2007) demands that the therapist rely on both theory and empirical research in his or her choice of assessment procedures. As a result of this movement, a few key papers have emerged that have documented guidelines for the evidence-based assessment of anxiety and depressive disorders in children and adolescents (Klein, Dougherty, and Olino 2005; Silverman and Ollendick 2005). These guidelines are based on the rich body of research devoted to developing and evaluating assessment procedures for children and adolescents diagnosed with internalizing disorders.

Recently, Sburlati, Schniering, Lyneham, and Rapee (2011, p. 94) have added to these guidelines by outlining five key therapist competencies for conducting a thorough assessment of child and adolescent anxiety and depressive disorder. These competencies are:

the ability to undertake an evidence-based multi-method (e.g., self-report, observational), multi-informant (e.g., child; parent; teacher or allied health professional) psychological assessment of the disorder presentation;
the ability to integrate assessment reports from both the child (or adolescent) and the parent (or other parties);
the ability to determine a clinical diagnosis, with consideration of differential diagnosis;
the ability to undertake a generic assessment of the child’s or adolescent’s current functioning, family functioning, peer relationships, developmental history and stage, and suitability for the intervention;
the ability to assess and manage risk of self-harm and suicide.

Each of these competencies will be discussed in detail.

An evidence-based multi-method, multi-informant psychological assessment of the disorder presentation

Evidence-based assessment

Applying the EBA framework to psychological assessment is a crucial therapist competency, without which the success of treatment cannot be properly established. As mentioned above, there is an abundance of publications detailing different assessment methods for anxiety and depression in children and adolescents (Beidel and Alfano 2011; Brown-Jacobsen, Wallace, and Whiteside 2011; Schniering, Hudson, and Rapee 2000). The large number of assessment tools and the variation in tested populations, however, make it difficult for therapists to judge which assessment methods they should use in clinical practice for any given client. Fortunately, there has been a growing focus in recent years on providing criteria to evaluate the utility of psychological assessment measures by using the EBA framework (Hunsley and Mash 2007). EBA requires that a psychologist’s choice of assessment methods should be guided by a broad set of considerations. First, for a psychological assessment method to accurately capture an internalizing disorder, it must be highly reliable. The reliability of a measure refers to the consistency of a client’s score across differing clinicians (inter-rater reliability), across time points (test–retest reliability), and within the measure itself (internal consistency). For example, if an assessment measure does not have high test–retest reliability, a clinician is unable to conclude whether treatment changes over time reflect real changes for their client or are due to an unreliable measure.

Second, it is important that the assessment measure selected by the therapist has established normative data or criterion-related cut-off scores to aid a clinician in correctly interpreting his or her client’s score against a larger relevant population. Norms may be used to compare a client to the general population or to specific subgroups. It is important, too, that these norms have been created from both clinical and nonclinical samples and are sensitive to age and gender. A clinician also needs to consider the child’s cultural background, as norms can differ across cultures, some behaviors being considered desirable in one culture and atypical in another. Furthermore, without these norms, it is difficult for a clinician to competently conclude if his or her client’s symptoms or functioning differ from those of the general population.

Third, the EBA framework requires that an assessment method have high validity. Specifically, is it measuring what it purports to measure? For instance, a scale that purports to measure anxiety might merely be capturing state arousal. A competent clinician should examine both the content validity (the degree to which a measure indexes all components of the construct being measured) and the construct validity (the degree to which the theoretical construct being assessed was actually measured) of a measure. A particularly good measure will also show evidence of incremental validity, that is, evidence that the measure adds unique information over and above other assessment methods. Furthermore, the EBA framework suggests that a measure should give evidence of validity generalization, which supports the use of that measure across age, gender, socioeconomic status, ethnic groups, and differing contexts – home, school, primary care, and inpatient settings.

Using the EBA framework, a competent clinician must also decide if an assessment measure demonstrates clinical utility. When the practical aspects of the measure are taken into account – and these include costs, administration difficulty, duration, availability of the measure, and norms – are the data gained from this measure going to demonstrate satisfactory clinical benefit? In particular, is there published evidence that the measure in question is able to detect clinical change? Table 7.1 provides therapists with a list of evidence-based assessment measures that are commonly utilized in the assessment of anxiety, depression, and related self-harm and suicide and can be used within a multi-method, multi-informant EBA.

Table 7.1 Examples of evidence-based measures for anxiety, depression, depression and self-harmself-harm/suicide.^a

*Measure*	*Delivery method*	*Reporter*	*Age group*	*Length*
Anxiety
ADIS C/P-IV (Silverman and Albano 1996)	Semi-structured interview	C/P	All	1–3 hours
SPAI-C (Beidel, Turner, and Morris 1995)	Self-report scale	C	8–14 years	20–30 minutes
SASC–R (la Greca and Stone 1993)	Self-report scale	C	7–13 years	10 minutes
MASC (March, Parker, Sullivan, Stallings, and Conners 1997)	Self-report scale	C	8–19 years	15 minutes
SCAS (Spence 1998)	Self-report scale	C/P	6–18 years	10 minutes
SCARED (Birmaher et al. 1997)	Self-report scale	C/P	8–18 years	10 minutes
PAS (Edwards, Rapee, Kennedy, and Spence 2010)	Self-report scale	P/T	3–5 years	10 minutes
Depression
K-SADS (Puig-Antich and Chambers 1978)	Semi-structured interview	C/P	6–18 years	20–60 minutes
CDRS-R (Poznanski and Mokros 1999)	Self-report scale	C/P	6–12 years	15–20 minutes
CDI (Kovacs 1992)	Self-report scale	C	7–17 years	15–20 minutes
SMFQ (Angold, Costello, Messer, and Pickles 1995)	Self-report scale	C/P	8–18 years	5–10 minutes
RADS (Reynolds 1987)	Self-report scale	C	12 years +	5–10 minutes
Self-harm and suicide
SITBI (Nock, Holmberg, Photos, and Michel 2007)	Structured interview	C/P	12–19 years	3–15 minutes
BSI (Beck and Steer 1991)	Self-report scale	C	12–17 years	5–10 minutes
SIQ (Reynolds 1988)	Self-report scale	C	12–18 years	10 minutes

^aEquivalences:

C = Child;

P = Parent;

T = Teacher;

ADIS C/P-IV = Anxiety Disorders Interview Schedule for Children for DSM-IV;

SPAI-C = Social Phobia and Anxiety Inventory for Children;

SASC-R = Social Anxiety Scale for Children-Revised;

MASC = Multidimensional Anxiety Scale for Children;

SCAS = Spence Children’s Anxiety Scale;

PAS = Preschool Anxiety Scale-Revised;

SCARED: Screen for Child Anxiety-Related Emotional Disorders;

K-SADS = Schedule for Affective Disorders and Schizophrenia for School-Age Children;

CDRS-R = Children’s Depression Rating Scale-Revised;

CDI = Children’s Depression Inventory;

SMFQ = Short Mood and Feelings Questionnaire;

RADS = Reynolds Adolescent Depression Scale;

SITBI = Self-Injurious Thoughts and Behaviors Interview;

BSI = Beck Scale for Suicide Ideation;

SIQ = Suicidal Ideation Questionnaire.

Multi-method assessment

The above criteria can be used to select high-quality assessment tools, including interviews, questionnaires, and observational methods. It is generally agreed that a competent assessment is one in which multiple methods of data collection are conducted (Kazdin 2003; Silverman and Ollendick 2005). Selecting which combination of measures to use for assessment should be guided by a consideration of the strengths and limitations of each method.

Structured or semi-structured interviews:

Structured or semi-structured interviews are considered the gold standard of assessment for internalizing disorders (Morris and Greco 2002). Research has shown that clinicians conducting unstructured interviews will often not ask about all-important elements of the relevant psychopathology and will make fewer diagnoses than in a semi-structured interview (Zimmerman 2003). A semi-structured interview ensures that a clinician covers the relevant disorder they are assessing, while also allowing for clinical judgment on differential diagnoses. During the interview the clinician is required to make an assessment of the frequency, severity, and duration of symptoms, as well as of the situations in which the child’s symptoms occur. In addition, the therapist must also assess functional impairment as a consequence of the child’s symptoms.

Self-report questionnaires:

Although questionnaire methods typically don’t provide enough information for making a diagnosis in isolation, they are useful tools to quickly gain information on a client’s current symptoms. Due to the standardization of such measures, self-report measures are also useful for tracking changes in these symptoms over time. Therapist training for the administration and interpretation of self-report measures is less than is required for structured interviews. These factors, together, make self-reports particularly valuable in clinical settings.

Observational methods:

Observational methods are an under-utilized method for the diagnosis of anxiety disorders or depressive disorders. However, they possess clinical utility and can be useful for examining the level of fear and anxiety displayed by a client when exposed to threatening stimuli. Behavioral approach tests (i.e., client-led steps of increasing difficulty toward a feared object or situation, in a controlled environment) for fears such as of dogs, needles, talking in front of others, and separation from caregivers can be conducted in clinical settings (Ollendick, Lewis, Cowart, and Davis 2012). Observational methods can also be useful for understanding specific factors – such as parental over-involvement – that may be maintaining the child’s anxiety (Hudson and Rapee 2001).

Multi-informant assessment

Competent clinicians should utilize a multi-informant approach to assess for internalizing disorders in children and adolescents (Kazdin 2003; Silverman and Ollendick 2005). It is standard to assess the child and at least one parent or caregiver. This is because children may have a limited repertoire in their vocabulary to fully articulate the extent of their internalizing difficulties, or may exhibit reluctance to discuss the functional impairments related to their internalizing problems. Parents are often very helpful when filling in the narrative gaps of the child’s ongoing problems across situations and across time. They are also sometimes the only source of information for certain assessment queries, such as first onset of the disorder – which may have occurred very early in the child’s life, before the child was able to remember it. There are also certain diagnoses that can only be established through parent report; these include oppositional defiant disorder and conduct disorder.

Teachers and other health care providers can give additional information, though it is not always practical – or even possible – to access this information. Sending a questionnaire and consent form to parents to release information to the teacher or other health care workers can be a practical method. Engaging a child’s teacher is particularly helpful in determining whether problems are context-specific to the home. This can be important for case formulation and sometimes diagnosis, in disorders such as attention deficit/hyperactivity disorder.

It is important that therapists not disregard the importance of gaining the child’s perspective on the problem. Internalizing disorders, by nature, are not always observable. A child’s report is sometimes more critical than those gleaned from parents and teachers, as the child often reports lower levels of internalizing symptoms (Jensen et al. 1999). Also, depressed parents may have a lower threshold for detecting depression in their children (Klein et al. 2005). Taken together with reports from other sources, such as parent and teachers, the child’s perspective can provide important information, which may not be accessible if one consults only those other sources.

Integrating different sources of data

When undertaking a multi-method, multi-informant approach to assessment, data from all sources need to be integrated to generate a well-informed diagnostic profile. However, this is often a challenge for clinicians. Therapists are encouraged to be aware that some children may not be comfortable with revealing sensitive information in a face-to-face setting. In such cases self-report measures can be incrementally useful for filling in the gaps from the structured interview.

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