Week 3: Assessment & formulation with children & adolescents
- 1. Assessment & formulation with children & adolescents Factor-Inwentash Faculty of Social Work Social Work Practice With Children & Adolescents SWK 4620 May 9, 2021 Week 3
- 2. Psychosocial assessment • Thinking process that seeks out meaning of case situations, puts the information in some sort of order, & leads to a plan of intervention – Assessments are integral to treatment plans & should be carried out on an ongoing basis throughout the work – Exploration of all factors that may contribute to and maintain problems – Analysis of interrelationship between biological, psychological & socio-cultural factors, (Biopsychosocial Model, Webb, 2003) – Identification of strengths/weaknesses (risk/protective factors) (Jordan & Hickerson, 2003) • Way to avoid jumping from problem to solution without understanding the mechanisms underlying the difficulty (Howe, 1995)
- 4. Who should be part of a child’s/teen’s assessment ? Type and order of assessment is determined by theoretical model of practice General Guidelines: 1) Intake interview & form completion 2) Parent information/interview 3) Child/teen interview (play/talking, depending on age) 4) Entire family 5) Reports from collateral contacts (teacher, daycare, pediatrician) 5) Info from or referral to specialized testing (Psychological, Speech, OT, Audiology) (Webb, 2003)
- 5. Common Assessment Tools Interviews (Structure-Unstructured) Observations-school or home visits Categorical Classification Systems (DSM) Empirically Based Rating Scales (CBCL) Diagnostic Drawings Genograms Ecomaps Collateral information with consents/releases History of experiences with other agencies/service providers
- 6. Interviews – Purpose-collect information & develop relationship/alliance with parents/caregivers • Parents are major influence on lives of children – Structured (Interview Schedule for Children) and semi-structured (Clinical Interview for Children and Adolescents) or Mental Status Exam – Collect developmental history – Important to ask about pregnancy-infancy-early milestones – Covers presenting problem, antecedents, strengths, weaknesses, context (Jordan & Hickerson, 2003)
- 7. Interviews • Some work happens even when setting up interview – prepare parents – set mood – begin engagement process – help parents prepare child
- 8. Mental Health Status Exam • Very specific and in-depth interview • Level of consciousness (alert, lethargic, comatose etc.) • Attention (focus on stimulus without distraction) • Behaviour (level of activity, affective expression and mood) • Speech & language (quality, flow, spontaneity, receptive, expressive, articulation) • Thought (Circumstantial-wandering, Tangential, Perseveration, Looseness of association-disorganized, Flight of ideas-continuous with sudden changes, Thought Blocking, Neologisms-new words created for emotional reasons) • Memory (short term, long term, working memory) • Orientation (time, person, place, situation) • Judgment and insight (Timberlake & Cutler, 2001)
- 9. Parent Interview – Alliance with parent(s) is a must, when possible – Parents are best source of info. for family history, developmental history, school history, social exposure, environmental stressors – How parents tell stories gives insight into how they operate & what they value (i.e. sensitivity, acceptance, pride, joy, fear) – The use of Genograms or Ecomaps can facilitate dialogue & enhance the understanding of the family’s past/present relationships and functioning within an environmental context. (Webb, 2003)
- 10. Bob 65 Betty 63 Stan 18 Sue 21 Sally 25 Div 2004 Alcohol Victim Sexual Abuse Cancer 1999 Learning Disability Genogram
- 12. Interview with the child/teen • Establishing a relationship is a must • Be CHILD FRIENDLY (office, dress, mannerisms, goals, expectations)-but not child-like! • Consider the child’s developmental level to determine assessment activity • Your rapport building should be congruent with the assessment activity. • Use your time wisely to find out about the child • Conservation of questions with young children (Webb, 2003)
- 13. Observations • Unstructured observation time-lots of information • Waiting room, hallway, entering/exiting room – Helpful to see “natural” dynamics – Instruct the child that there is X amount of free time and can play with toys in many ways. – Instruct families to interact as they normally might at home. Remember to place the parent in charge of safety & give time limit
- 14. Play-based assessment • Free play plus: – Individual Play Genogram – Sand Therapy (“Make a world in the sand”) – Color Your Feelings – Self Portraits – Kinetic Family Drawings
- 15. Multiple/collateral informants • Parent, teacher, physician, standardized measures, self reports (age dependent), extended family • Contact in person, by phone, narrative letter, questionnaire • External reports of interest – Psychoeducational/Psychologist/ Neuropsychologist/Neurologist – Speech/OT/PT
- 16. What to look for In the biological realm 1) brain functioning & maturation 2) biochemistry 3) physical health & development 4) temperament 5) genetic endowment • Usually determined through developmental & family history, observation & collateral reports (Timberlake & Cutler, 2001)
- 17. What to look for In the cognitive realm --How child uses language, memory, imagination, problem solving –Determine representational thought, symbolic knowledge –Determine through interaction, observation, activity and collateral –School history
- 18. Gender/sexual development • Gender development – Gender/biological sex assignment – Gender based bullying – Body image issues • Sexual development – Timing/experiences of puberty – Sexual interests/behaviours/relationships – Level of sexual activity – Pornography use – High risk sexual behaviour – Generation conflict over sexual development/behaviour
- 19. What to look for In the social realm –History & current relationship functioning –Number of relationships –With whom –How close, quality, structure, affective tone, sensitivity to others, operational style (i.e. authoritarian/authoritative), attachment style (secure, insecure) (Timberlake & Cutler, 2001)
- 20. What to look for In the emotional realm – Different at each stage of development – Preschool: what you see is what you get – School age (latency): may learn to suppress emotions – Teenagers: begin to amplify emotions. – Gender norms exist around emotion expression – Determine if emotional coping is ego syntonic (stress reducing) or ego dystonic (stress increasing) (Timberlake & Cutler, 2001)
- 21. Religion/spirituality/culture • Identified religion – Family/child’s involvement – How issues may be characterized by religion • Identified culture – Mainstream/marginalized – Proximity/access – Identity with culture – How issues may be characterized by culture
- 22. Community/structural issues • Family resources/supports • Housing (quality, stability, safety) • Network of kin & kith • Neighborhood/community connectedness • Crime/violence • Local school conditions • Accessibility of services
- 23. Categorical assessment system • DSM-V or ICD-10 or DC:0-3 • Derived from clinician/expert knowledge • Problems are judged absent or present • Does not account well for gender or age differences. • Describes symptoms, features of disorder, age of onset, prevalence • Provides a common language • Low predictive validity, low reliability of classifications • Social functioning in children not considered • Comorbidity rates can be high (Jordan & Hickerson, 2003,)
- 24. DSM Categorical Clusters • 1.2Section II: diagnostic criteria and codes • 1.2.1Neurodevelopmental disorders • 1.2.2Schizophrenia spectrum and other psychotic disorders • 1.2.3Bipolar and related disorders • 1.2.4Depressive disorders • 1.2.5Anxiety disorders • 1.2.6Obsessive-compulsive and related disorders • 1.2.7Trauma- and stressor-related disorders • 1.2.8Dissociative disorders
- 25. DSM Categorical Clusters • 1.2.9Somatic symptom and related disorders • 1.2.10Feeding and eating disorders • 1.2.11Sleep–wake disorders • 1.2.12Sexual dysfunctions • 1.2.13Gender dysphoria • 1.2.14Disruptive, impulse-control, and conduct disorders • 1.2.15Substance-related and addictive disorders • 1.2.16Neurocognitive disorders • 1.2.17Paraphilic disorders • 1.2.18Personality disorders
- 26. Empirically Based Testing • Conners’, BRIEF, CDI, MASC, CBCL, ADHD Rating Scale-IV, WISC, WIAT , ADOS/ADI, BASC, BCFPI • Problems are scored quantitatively • Syndromes derived from statistical procedures (factor analysis) • Cut points (inclusion or exclusion) are normed to age, gender etc. • Sensitive to sub clinical concerns not picked up by DSM • Comparable scores (T scores) • Rater reliability can often be problematic (Jordan & Hickerson, 2003) • Social Worker’s generally do not test but should know how to refer for testing, understand results and be able to integrate findings into Tx planning (Webb, 2003)
- 29. Compedium of child and adolescent assessment materials • Mental Health Screening and Assessment Tools for Primary Care 20 pages of assessment tools used in pediatric care • https://www.aap.org/en-us/advocacy- and-policy/aap-health-initiatives/Mental- Health/Documents/MH_ScreeningChart. pdf
- 30. Asking questions • Not an investigation! – Open ended – Clear, direct, developmentally appropriate terminology • Normalize when possible • It’s ok to be silent • Clients may need time to think or compose themselves
- 31. Pitfalls • Closed, yes/no questions • Multiple choice questions • Complex, multi-part questions • Avoidance of difficult questions • Pacing too slowly or quickly • Too much prompting • Looking for problems when they may not be there
- 32. Remember MI skills • Empathy • Pacing • Open questions (how, what, why, tell me more…) • Affirming (shine a light on the positive) • Reflecting (repeat in different words) • Be curious • Noticing as a conversation is veering toward change • Summarize 32
- 33. Role of Theory • Dictates how one views: a child/family, the problems and how one conceptualizes an assessment • Data gathering without theory can be “an inconsequential exercise in gathering inconsequential facts” • Guides intervention approach (Jordan & Hickerson, 2003)
- 34. Cognitive Theories • Information assimilated or accommodated • Information processing, cognitive distortion versus deficits • Piaget’s stages (sensorimotor, preoperational, concrete operations, formal operations) (Jordan & Hickerson, 2003)
- 35. Affective Theories • The role of feelings in human behaviour • ID, Ego, Superego • Freud’s & Erikson’s Stages of Development (Jordan & Hickerson, 2003
- 36. Learning Theory • Focuses on acting and behaviour • Classical Conditioning: natural stimulus paired with conditioned stimulus—Pavlov • Operant Conditioning—behaviour is learned through rewards or punishment— Skinner • Social learning—vicarious learning— Bandura (Jordan & Hickerson, 2003
- 37. Family Theories • Children’s problems are related to family stressors • Changes within the systems (i.e. unemployment, mental health) change the system (Jordan & Hickerson, 2003
- 38. Environmental Theories • Each level of society interacts with and influences others- Bronfenbrenner (Jordan & Hickerson, 2003
- 39. Attachment Theory • Via attachment relationship the infant develops an internal working model of self and others--Bowlby (Mash & Dozois, 2003)
- 40. Constitutional/ Neurobiological • Genetic influences, neuroanatomy, neurochemical, medical • Using twin studies, and family studies (Mash & Dozois, 2003)
- 41. Case Formulation • Definition: A tentative explanation or hypothesis of the way an individual with a certain disorder or condition comes to present at a particular point in time (Weerasekara, 1993) • Places the child’s problem within the context of his/her world • Interpretation/hypothesis about the child’s problem that explains the symptoms (Timberlake & Cutler, 2001) • Higher Tx success when Tx plan congruent with client’s way of operating • Four P’s of a good formulation – Predisposing, precipitating, perpetuation, and protective factors, that look both at the individual and systems associated with the individual
- 42. Assessment assignment • Basic case information: the agency setting, the referral process, your role and contact with the client and his/her significant others. • The client’s (or family’s) presenting concerns: the precipitating events or circumstances that brought the client to see you. • Using an ecological developmental approach (including biological, psychological, developmental, familial, and social/cultural dimensions), contextualize the client’s presenting concerns.
- 43. Assessment assignment • This discussion should include risk factors, strengths, and specific examples of if and how the client demonstrates resilience in the face of significant adversities. • Articulate your working hypothesis of the client’s presenting concerns (i.e., why you think this is happening) and a theory of change for improving/changing the circumstances or the client’s response to them (i.e., what you think needs to happen). • Integrate course readings or additional materials where appropriate, but this assignment should reflect your own assessment and thinking and should not be a research paper.
- 44. Possible assessment format for the assignment • Reason for referral-context of the referral (agency details) • Background-about the client and family • Developmental history • Family history • Manifestation of problem at home, school, community • Review of theories used • Tentative explanation of how you understand the case (formulation) • Applying theory to information above
- 45. Class exercise • Assessment practice • Groups of 3 – One member is the client – Other members rotate being social workers or observers • 30 minute assessment • 15 minute debrief – What didn’t get discussed? – What else do you need to know? – What do you think is happening for this client?? What do you think is the context for the central issue?
- 46. Video (if time we’ll watch in class) • In Treatment Session 1: Sophie • https://www.youtube.com/watch?v=M1i ev0zph3o • In Treatment: Session 1: Oliver • http://www.bing.com/videos/search?q=i n+treatment+oliver+week+1&view=detai l&mid=C42D1AD566DA834319FFC42D 1AD566DA834319FF&FORM=VIRE1