Evaluation and Treatment Planning

2


EVALUATION AND TREATMENT PLANNING


EVALUATION


A comprehensive evaluation includes obtaining a biopsychosocial history (Table 2–1); performing a mental status examination; ordering any additional tests; and obtaining records (with parental permission) from the child’s school, pediatrician, and agencies such as child protective services or the juvenile court. The clinician should request reports of all prior psychiatric, psychological, developmental, and medical evaluations and treatment. Assessment should continue throughout the course of treatment as the child, parents, and situation change. When the presenting problems are urgent or narrowly circumscribed, treatment may be initiated after a focused evaluation with a more detailed assessment completed as time permits.


































































































TABLE 2–1. Outline of biopsychosocial history


Chief symptom and reasons for referral


History of present illness


Development of the symptoms


Attitudes of child and parents toward the symptoms


Effects of the symptoms on the child and family


Stressors


Prior psychological or psychiatric evaluations


Prior treatment


Psychotherapy: type, frequency, duration, effects


Medication: exact doses, schedule, beneficial and adverse effects


Intensive treatments such as hospitalization or residential placement


Environmental changes and effects


Current developmental status


Motor abilities and activity level


Attention


Speech and language


Academic performance


Relationships with peers


Risk-taking behaviors


Sexual development and behavior


Hobbies, activities, athletic interests and skills


Relationships with family members and other significant adults


Review of behavioral and psychological symptoms


Medical review of systems


Past history


Psychiatric


Medical


Neurological


Developmental history


Pregnancy and delivery


Neonatal period, infancy, early childhood


Pubertal status


Sexual interests and activities (for adolescents)


Temperament


Milestones


Motor


Cognitive


Speech and language


Social


Education history


Traumatic events


Psychosocial and psychiatric history of each parent


Developmental history of the couple/family life cycle stage


Family medical history


Current family circumstances, concerns, liabilities, resources


Before the evaluation, the clinician should tell the parents how long the evaluation will take, what it will cost, and what they can expect at the end. The clinician should advise parents on how to prepare the child for the first visit. Some parents invite the child out for an ice-cream cone but bring him or her to the child psychiatry clinic instead. Needless to say, this does not enhance the child’s cooperation, although it does provide the clinician with useful data about the parents.


In conducting an evaluation, the clinician must constantly be mindful of the patient’s developmental level, which may determine whether a behavior (e.g., temper tantrums, separation anxiety) is pathological. Developmental stage influences the nature of symptoms, expectable reactions to stressors, ability to communicate and to understand concepts, and capacity to participate in different types of treatment.


The structure of an evaluation is determined by the child’s age, the nature of the presenting problems, and practical factors. It is often useful to begin by meeting briefly with the child and parents together, to clarify and understand each person’s views of the presenting problems and the goals of the evaluation and to develop an initial impression of family interaction. For children younger than 6 years, it may be convenient to obtain the entire history from the parents before seeing the child. Older children, especially adolescents, should be involved early in the evaluation process. Adolescents are often concerned about confidentiality and should be told that what they say will be shared only with their permission, unless they are at risk for physical harm, such as from suicide, homicide, substance abuse, high-risk sexual behavior, or running away. Clinicians are legally mandated to report suspected physical or sexual abuse to child protection authorities.


Use of Multiple Informants


No single informant or technique can give a full description of a child. Children themselves, teachers, parents, other relatives, community members, and clinicians each have their own point of view and opportunities for observation. Lack of agreement between parents and teachers or between two parents often results from genuine variations in the behavior of children in different settings and with different people. Ideally, both parents should be interviewed, even if they are not living together, because their cooperation will enhance the likelihood of successful treatment, and each parent has a unique perspective on the child’s development and environment. A telephone interview may be substituted if a parent is not available in person.


History From Parents


The elements of a complete history from the parents or caregivers are outlined in Table 2–1. The construction of a time line, including symptoms, life events, and changes in the family and environment, can help organize a complex history.


An important element in the developmental history is the child’s temperament, or “style” of behavior. Children can be rated on each of the nine dimensions listed in Table 2–2. The goodness of fit between the child’s temperament and the parents’ temperament, expectations, and child-rearing skills significantly affects developmental course and outcome. In addition, certain trait clusters (Table 2–3) have predictive value. Both difficult and slow-to-warm-up children are at risk for emotional and behavior problems, whereas easy children are relatively protected.





























TABLE 2–2. Dimensions of temperament


1. Activity level


2. Rhythmicity (regularity and predictability of biological functions)


3. Approach to or withdrawal from novel stimuli


4. Adaptability to environmental change


5. Intensity of reaction


6. Threshold of responsiveness (intensity of stimulation required to evoke a response)


7. Quality of mood (positive, neutral, or negative)


8. Distractibility


9. Attention span and persistence


Source. Adapted from Thomas A, Chess S: Temperament in Clinical Practice. New York, Guilford, 1986.










































TABLE 2–3. Temperament clusters


Easy


Positive mood


Regular biological rhythms


Adaptable


Low intensity of reactions


Positive approach to novelty


Difficult


Negative mood


Irregular biological rhythms


Slow to adapt


Intense reactions


Negative response to novelty


Slow to warm up


Gradual adaptation after repeated contact


Mild intensity of reactions


Negative response to novelty


Source. Adapted from Thomas A, Chess S: Temperament in Clinical Practice. New York, Guilford, 1986.


Patient Interview


During the patient interview, the child provides his or her view of the history and his or her current symptoms, strengths, and concerns while the clinician makes observations. Children and adolescents often report their anxiety and depression, clandestine conduct problems, and drug use more accurately than their parents do. Parents typically report history, observable behavior problems, and family background more accurately than the child does. The details of the interview vary with developmental stage. The content of the mental status examination is outlined in Table 2–4.








































TABLE 2–4. Mental status examination


Physical appearance and grooming


Interactions with clinician


Understanding of the purpose of the interview


Motor activity level and coordination


Tics, stereotypies, mannerisms


Mood and affect


Anxiety


Obsessions or compulsions


Attention, persistence, frustration tolerance


Impulsivity


Oppositionality


Verbal or physical aggression


Speech and language


Hallucinations, delusions, thought disorder


Clinical estimate of intelligence


Judgment and insight


The therapist should begin the patient interview by informally discussing nonthreatening topics before focusing on the presenting symptoms. For patients who are not very verbal, an opportunity to draw (with pencils, crayons, or washable markers) can help them feel comfortable enough to engage in conversation. Young children initially may want the parent to be present and may be more comfortable with play materials (e.g., dollhouse, stuffed animals, blocks, clay) than with a formal interview. Asking children direct questions about their symptoms is not harmful and will not create new symptoms that the child does not already have. Clinicians need to ask children direct questions (using wording that is adapted to the child’s developmental level) to understand their emotional states.


Family Evaluation


Each person living with the patient, as well as noncustodial parents, grandparents, and siblings who are no longer living at home, may be crucial to understanding family dynamics, including both unexpected sources of emotional support and areas of conflict. Meeting simultaneously with all significant family members to collect information and to observe interactions is often useful. Families with young children may benefit from the use of role playing, family drawings, or puppet play. The clinician may ask the family to complete a task during the session in order to assess family interactions. A family tree or genogram helps the clinician to organize data on family members and their relationships.


Regardless of a family’s structure or members, the well-being of the child requires that certain tasks be accomplished (Table 2–5). Well-functioning families respond resiliently to stress, communicate effectively, assign roles that suit the needs and abilities of each family member, respond appropriately to emotions, solve problems both within and outside the boundaries of the family, and find effective and humane ways to control the behavior of family members.



















TABLE 2–5. Family developmental tasks


Forming a “marital coalition” to meet the needs of the adults for intimacy, sexuality, and emotional support


Establishing a “parental coalition” to form flexible relationships with children and present a consistent disciplinary front


Providing for nurturance, enculturation, and emancipation of children


Coping with crises


Source. Adapted from Fleck S: “A General Systems Approach to Severe Family Pathology.” American Journal of Psychiatry 133:669–673, 1973.


Tasks of the initial session of a family assessment include the following:



  • Ascertain each family member’s view of the problem.
  • Begin to establish a relationship with each family member to facilitate the treatment alliance.
  • Gather data by observation and with questions.
  • Make test interventions and assess their effects.
  • Propose and negotiate a provisional plan for the next steps.


Mental health care for young people is unlikely to succeed without considering their parents’ needs. Parents struggling with their own untreated psychiatric disorders may be unable to meet the child’s emotional and physical needs, and there may be a “contagious” effect on the child. The clinician’s most important contribution may be to arrange for the parent to receive psychiatric assessment and pharmacological and/or psychotherapeutic treatment. The clinician may need to use both empathy and judicious persuasion to induce the parent to assume a “patient” role.


Standardized Evaluation Instruments


Selected parent, teacher, and self-report behavior checklists, questionnaires, and rating scales supplement the clinical evaluation by providing a systematic review of behaviors and psychiatric symptoms. Scores may be compared with norms obtained from large community-based samples or groups of clinically referred children. Ratings may also be done at intervals to measure progress. The most commonly used broad-spectrum package consists of the Child Behavior Checklist (CBCL) parent rating form, the Teacher Report Form (TRF), and the Youth Self-Report (YSR) Form (Achenbach System of Empirically Based Assessment; www.aseba.org). More specific instruments are available for one or more diagnoses. Structured and semistructured diagnostic interview protocols (see Table 2–6) are more commonly used in research but often have clinical usefulness.























TABLE 2–6. Examples of standardized diagnostic assessment interviews


Structured diagnostic interview


Diagnostic Interview Schedule for Children (DISC)


Semistructured diagnostic interviews


Child and Adolescent Psychiatric Assessment (CAPA)


Diagnostic Interview for Children and Adolescents (DICA)


Schedule for Affective Disorders and Schizophrenia for School-Aged Children and Adolescents (Kiddie-SADS)


Note. For references and more detail, see “Diagnostic Interviews” (Chapter 7) in Dulcan’s Textbook of Child and Adolescent Psychiatry (Carlisle and McClellan 2010).


Medical Evaluation


A standard evaluation includes a medical history and physical examination (within the past year or more recently if the onset of problems is acute) to identify any medical causes of symptoms or coexisting medical disorders. Neurological consultation or testing (e.g., electroencephalogram, brain scan) is indicated only if focal neurological signs or symptoms are present or if the history suggests seizures, loss of cognitive or physical skills, or sequelae of brain injury. Laboratory tests may be obtained, especially if pharmacological treatment is anticipated. Urine testing for drugs and, in female adolescents, a pregnancy test are often indicated. Scientific evidence does not support the use of brain imaging in clinical diagnosis or treatment of psychiatric disorders in youth.


School Assessment


School reports are almost always useful. Attention, learning, quality and quantity of homework and classwork, behavior in class and on the playground, and social relationships are sensitive indicators of the presence of psychiatric symptoms and of developmental status. After obtaining parental consent, the clinician may talk with the teacher or school counselor, obtain school records (educational testing, behavior, grades, and attendance), arrange for teachers to complete standardized checklists, and perhaps even visit the school to observe the youngster.


Psychological Testing


Standardized tests administered by a clinical psychologist are used to assess intellectual potential, cognitive skills, fund of knowledge, and adaptive functioning (Table 2–7). Individually administered tests provide a more accurate evaluation than those given to children in the classroom. Tests have been criticized because of cultural influences on performance, unresponsiveness to “creative” responses, the dangers of using a rigid construct of intelligence that masks individual strengths, the use of test results to exclude children from mainstream education, and potential insults to developing self-esteem. Despite these concerns, IQ tests provide a global assessment that has clinical predictive value, particularly when combined with an evaluation of adaptive behavior. Projective tests such as the Children’s Apperception Test (CAT) or the Rorschach Inkblot Technique are not useful in making diagnostic or treatment decisions. The most commonly used test for assessing infants (ages birth to 3 years) is the Bayley Scales of Infant Development, Third Edition. It is used to evaluate motor (fine and gross), language (receptive and expressive), and cognitive development.

















































































TABLE 2–7. Individually administered tests of intellectual capacity, learning, and adaptive functioning


Intelligence



Differential Ability Scales, Second Edition (DAS-II)


2.6–17 years


Subtests estimate General Cognitive Ability (GCA) and the subdomains of Verbal, Nonverbal, and Spatial Ability


Kaufman Adolescent and Adult Intelligence Test (KAIT)


11 years through adulthood


Distinguishes between learned information and capacity to solve novel problems


Kaufman Assessment Battery for Children, Second Edition (K-ABC-II)


3–18 years


Subtests estimate general Mental Processing and the subdomains of Sequential and Simultaneous Processing, Learning, Planning, and Knowledge


Kaufman Brief Intelligence Test, Second Edition (KBIT-2)


4 years through adulthood


Screening test to estimate IQ


Leiter International Performance Scale—Third Edition


3 years through adulthood


Nonverbal test for use with persons who are hearing impaired or autistic or who do not speak English


Peabody Picture Vocabulary Test, Fourth Edition (PPVT-4)


2.6 years through adulthood


Brief test of receptive vocabulary used to estimate verbal intelligence


Shipley-2


7 years through adulthood


Brief pencil-and-paper test that does not require a psychologist to administer


Subtests estimate general cognitive functioning and the subdomains of Crystallized/Verbal and Fluid/Nonverbal cognitive ability


Stanford-Binet Intelligence Scale, Fifth Edition


2 years through adulthood


Subtests estimate Verbal IQ, Nonverbal IQ, and Full Scale IQ, as well as the subdomains of Fluid Reasoning, Knowledge, Quantitative Reasoning, Visual Spatial Processing, and Working Memory


Universal Nonverbal Intelligence Test, Second Edition (UNIT-2)


5–21 years


Subtests estimate Full Scale IQ and the subdomains of Memory, Reasoning, Symbolic, and Quantitative Ability


Wechsler Abbreviated Scale of Intelligence, Second Edition (WASI-II)


6 years through adulthood


Both 4-subtest and 2-subtest versions estimate Full Scale IQ; 4-subtest version also estimates the Verbal Comprehension Index and Perceptual Reasoning Index


Wechsler Adult Intelligence Scale, Fourth Edition (WAIS-IV)


16 years through adulthood


Subtests estimate Full Scale IQ and the subdomains of Verbal Comprehension, Perceptual Reasoning, Working Memory, and Processing Speed


Wechsler Intelligence Scale for Children, Fifth Edition (WISC-V)


6–16 years


Subtests estimate Full Scale IQ and the subdomains of Verbal Comprehension, Visual Spatial, Fluid Reasoning, Working Memory, and Processing Speed


Wechsler Preschool and Primary Scale of Intelligence, Fourth Edition (WPPSI-IV)


2.6–7.7 years


Subtests estimate Full Scale IQ and the subdomains of Verbal Comprehension, Visual Spatial, Working Memory, Fluid Reasoning, and Processing Speed


Woodcock-Johnson Tests of Cognitive Ability, Fourth Edition (WJ IV)


2 years through adulthood


Frequently used by schools


Subtests estimate General Intellectual Ability and the subdomains of Comprehension Knowledge, Fluid Reasoning, Short-Term Working Memory, and Cognitive Efficiency


Academic achievement



Kaufman Test of Educational Achievement, Third Edition (KTEA-3)


4 years through adulthood


Subtests estimate academic mastery of reading, writing, math, and oral language skills


Wechsler Individual Achievement Tests, Third Edition (WIAT-III)


4–50 years


Subtests estimate academic mastery of reading, writing, math, and oral language skills


Wide Range Achievement Test, Fourth Edition (WRAT-4)


5 years through adulthood


Subtests screen for academic mastery of reading, writing, math, and oral comprehension skills


Woodcock-Johnson Tests of Achievement, Fourth Edition (WJ IV)


2 years through adulthood


Subtests estimate academic mastery of reading, writing, math, academic knowledge, and oral language skills


Adaptive behavior (required to diagnose intellectual disability)



Adaptive Behavior Assessment System, Third Edition (ABAS-III)


Birth through adulthood


Estimates overall adaptive functioning (General Adaptive Composite) and functioning in the subdomains of Conceptual, Social, and Practical skills


Parent and teacher report forms


Vineland Adaptive Behavior Scales, Second Edition


Birth through adulthood


Semistructured interview with parent (or brief written form for teacher)


Estimates overall adaptive functioning (Adaptive Behavior Composite) and functioning in the subdomains of Communication, Daily Living Skills, Socialization, and Motor Skills


Woodcock-Johnson Scales of Independent Behavior—Revised (SIB-R)


Birth through adulthood


Semistructured interview with caregiver


Estimates overall adaptive functioning (Broad Independence Index) and functioning in the subdomains of Motor, Social Interaction and Communication, Personal Living, and Community Living skills



In neuropsychological testing, a neurodiagnostic battery of tests is used to provide a detailed assessment of a patient’s cognitive strengths and weaknesses and compare them with patterns seen in individuals with developmental, neurological, or other medical conditions. It can assist in the diagnosis, localization, and monitoring of neurodevelopmental, neurodegenerative, or acquired disorders of brain functioning or adverse effects of treatments such as cranial radiation and chemotherapy. Neuropsychological testing is not indicated as a diagnostic procedure for attention-deficit/hyperactivity disorder, although it can assist in the assessment of specific learning disabilities.


TREATMENT PLANNING


Treatment plans are based on both psychiatric diagnosis and identified target symptoms. The strengths and vulnerabilities of the patient and the resources and liabilities of the family are critical factors in treatment planning. The social environment, including school, neighborhood, and social support networks, strongly influences choice of treatment strategy. The practical realities of the quality and availability of community resources and the family’s ability to pay for or to attend treatment sessions often compel the clinician to modify an “ideal” or comprehensive plan. Realistic and efficient selection and sequencing of treatment modalities are central to effective decision making. Clinical judgments regarding anticipated treatment effectiveness, efficiency, and risk–benefit ratio may lead to selection of a single form of treatment or multimodal therapies. Interventions may be administered simultaneously or sequentially, as the child or family requires or is able to make use of additional treatment.


Parental motivation or ability to carry out the treatment plan may strongly influence treatment decisions. For example, unusual strengths of a family may avert hospitalization of a psychotic or suicidal child or family limitations may prevent implementation of family therapy or maintenance of the child living at home. For children from disrupted homes or abusive or neglectful environments, the first priority may not be psychiatric care, but social services, such as a safe and stable home, food, supervision, and medical care. In complex cases, a case manager who coordinates the involvement of various agencies and services (sometimes called “wraparound”) may be able to maintain a child in the community, which may result in a better outcome at a lower overall cost.


Each of a child’s symptoms may appear to call for a different intervention. In setting priorities, factors to consider include the following:



  • Risk of physical harm to the child or to others
  • Symptoms that will likely increase in severity and chronicity if not treated rapidly (e.g., school avoidance)
  • Patient and family motivation and resistance
  • Symptoms or family members that are most accessible to treatment
  • Problems that are most urgent to the patient or family

Treatment planning is an ongoing process. Continual reassessment is necessary as the effects of interventions are seen and as additional information about the child and family comes to light.



FEEDBACK


The clinician’s findings and recommendations are typically presented to both the parents and the child. The clinician decides whether to meet with them together or separately, and in what order. Depending on the ability of each to listen or understand, parents and child are educated about the nature of the child’s and the family’s strengths, psychiatric liabilities or disorders (including DSM-5 diagnoses), and the expected course and possible complications of the disorder. The clinician should answer questions about etiology at the level that scientific knowledge allows, while assiduously avoiding blaming or being judgmental. Parents and many children already feel guilty about real or perceived failures, and the empathic clinician is cautious to ameliorate these feelings. It is important to address possible opinions and information (which may or may not be correct) that parents have learned from relatives, friends, and the Internet.


Parents, and usually the child, should help determine which treatment strategy to follow. The clinician describes recommended and alternative interventions in terms of the process (duration, costs) and the anticipated benefits and risks. A successful feedback conference helps the family to understand their strengths and weaknesses, respect their child’s abilities and the difficulties he or she faces, sense the interplay of multiple etiological factors, realize the implications of the child’s diagnosis and prognosis, ponder the practicalities involved, acknowledge hopes and fears, and integrate the recommendations with the rest of their lives. Even the best treatment has little chance of success without the cooperation of the family and the child (to the extent possible for developmental stage and psychopathology). The treatment plan should be consistent with the family’s resources. Finding areas in which improvement may be quickly attained builds the family’s confidence in themselves and in the therapeutic process.



REFERENCE


Carlisle L, McClellan JM: Diagnostic interviews, in Dulcan’s Textbook of Child and Adolescent Psychiatry. Edited by Dulcan MK. Washington, DC, American Psychiatric Publishing, 2010, pp 79–88


ADDITIONAL READING


Caplan R, Bursch B: “How Many More Questions?”: Techniques for Clinical Interviews of Young Medically Ill Children. New York, Oxford University Press, 2013


Cepeda C, Gotanco L: Psychiatric Interview of Children and Adolescents. Arlington, VA, American Psychiatric Association Publishing, 2017


Dulcan MK (ed): Part I: Assessment and Diagnosis, in Dulcan’s Textbook of Child and Adolescent Psychiatry, 2nd Edition. Arlington, VA, American Psychiatric Association Publishing, 2016, pp 3–104


Gerson R, McGoldrick M, Petry S: Genograms: Assessment and Intervention, 3rd Edition. New York, WW Norton, 2008

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Nov 25, 2018 | Posted by in PSYCHIATRY | Comments Off on Evaluation and Treatment Planning
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