Psychological assessment in child mental health settings - a summary of an article by Barry, Frick, & Kamphaus in APA handbook of testing and assessment in psychology

APA handbook of testing and assessment in psychology: testing and assessment in clinical and counseling psychology 2, 253-270
Barry, C. T., Frick, P. J., & Kamphaus, R. W. (2013)
Psychological assessment in child mental health settings

Overview of evidence-based assessment with children and adolescents

The main goal of assessment is to answer the referral question.
This kind of assessment typically involves a clear description of the types of problems a child or adolescent is experiencing and their potential causes.
It typically leads to recommendations for intervention based on this case conceptualization.

From the knowledge of the psychologists should come an assessment that

• Report accurately
• Comprehensively describes a child’s strengths and difficulties
• Provides a road map for efforts to reduce these difficulties
• Is readily understandable to a variety of audiences

Models of evidence-based assessment must consider the diversity of settings and purposes for which psychological assessment is conducted.
Regardless of the practice setting, evidence-based assessment can provide a clear framework to guide how professionals conduct psychological assessments, communicate their findings to others, and evaluate assessment results form other professionals.

A distinction must be made between

• Methods that are evidence-based
• Processes that are evidence-based

The model of evidence-based assessment is guided by three principles

• Every decision made during an assessment with a child or adolescent should be guided by the most current and best available research
• Results from tests should be used only for making interpretations for which they have been validated
• The assessment process should be guided by a hypothesis-testing approach

Evidence-based approaches compared with traditional approaches to psychological assessment

One important implication of an evidence-bases approach to assessment is the need to include an assessment of the child or adolescent’s psychological context.
There is an important influence of context on child development.
Meta-systems approach: an understanding of the various systems involved with the child or available to children and families are considered in a case conceptualization and ultimate intervention plans.

The child’s context is also important for understanding the assessment information obtained on the child’s emotional and behavioural functioning.

Testing should be ‘construct-centred’ as opposed to diagnostic-centred or test-centrred.
Knowledge of current scientific findings regarding specific assessment issues, as well as about child development and psychopathology, should inform the assessment process.
To focus solely on a specific diagnosis would miss a host of factors that may also be present or that most certainly influence the child’s presentation and functioning.
Diagnostic systems are important insofar that they facilitate communication between professionals and also help convey the appropriate level of services for a child.
Diagnostic systems are imperfect and their misuse can have deleterious effects on a child.

Test-centred approaches are problematic

• Tests that yield scores are imperfect and are designed to describe only a certain aspect of the child’s functioning.
  • Considering a child as fully described by his or her performance on a single test misses much critical information.

Diagnoses and test scores should not be the centre-pieces of assessment results.

Focusing on descriptions of primary and secondary difficulties, their apparent underpinnings, and recommended interventions will result in an assessment that is potentially of great benefit to the child and his or her family.
Research in developmental psychopathology can guide this process.

Assessment of treatment outcome

Psychological assessment can involve continued progress monitoring during the course of treatment.
Regular assessment of change during treatment increases treatment fidelity and improves treatment outcomes.

An overarching model of evidence-based assessment can be used to guide this type of assessment as well

• The criteria by which treatment progress is evaluated should be measurable
  The data must be numerical
• Only measures that have proven to be sensitive to change should be used for the purpose of treatment monitoring
• The criteria for evaluating treatment outcome should be meaningful, which can be defined in terms of normative functioning but most often should be defined in terms of the child’s relative functioning.
  Baseline data on the referral issues of concern are essential
• The criteria for evaluating treatment outcome must be feasible

Ethical and professional issues in the assessment of children and adolescents

In conducting research, the scientific demands of a study must always be secondary to a number of important ethical and professional issues.
There are several unique ethical considerations in the assessment of children and adolescents.

Successful execution of the assessment can be facilitated and ethical issues avoided through appropriate planning.
The clinician should first determine whether an evaluation is warranted and whether he or she is suited to conduct it.

• Determine who has the right to consent for the assessment to be conducted
• Communicate to relevant parties the potential need to have documentation to that effect
• The clinician must be effective in establishing and maintaining rapport with parents, children and teachers
• Everyone who will provide information in the assessment should be informed about what to expect and who information they provide will be used
  This information would be relayed to a child in developmentally appropriate language
• Expectations for confidentiality should be discussed with all participating parties at the outset

In short, the professional should

• Ensure that they have appropriate training for the assessment methods to be used
• Consider the client’s background in interpreting assessment results
• Receive informed consent before initiating the assessment
• Consider to whom assessment feedback should be provided
• Take appropriate steps to maintain the client’s confidentiality
• Obtain releases to provide information from the assessment to outside parties

Assessment methods and measures for use with children and adolescents

General issues in selecting measures

Psychological assessments of children and adolescents necessitate the use of multiple methods of gathering information on the construct(s) of interest.
An empirical foundation exists for the initial selection of measures, but the available evidence is much more limited in how a clinician should appropriately integrate information provided by the chosen tools.

Selection of methods and measures must take into account that the meaning of a child’s presenting difficulties is based partly on the child’s developmental context.
Whether a behavioural problem is atypical for a developmental context or represents an exaggeration of a more typical developmental process is a critical factor for case conceptualization.

Basic psychometric characteristics of a measure are important in deciding whether it should be part of an assessment battery.
But client-specific information not captured by a measure as well as clinical skill and clinical judgment, are important aspects of the assessment process.
The clinician is charged with integrating multiple sources of information.
Professionals need to consider the appropriateness of any assessment measure based on the purpose of the evaluation and the child’s developmental level.

Tests themselves are not ‘reliable’ or ‘valid’.
Specific uses of test scores can yield reliable or valid results that other uses may not.
When selecting measures for an evaluation, an assessor must consider whether the scores from the test have proven to have acceptable reliability in the population for which he or she wants to use it and whether the evidence support the validity of the interpretations he or she would lie to make form the test scores.

Also important is evaluating the clinical utility of a particular tool.
Clinical utility: the extent to which a measure ‘will make a meaningful difference in relation to diagnostic accuracy, case formulation considerations, and treatment outcomes’.
Incremental validity: the extent to which the addition of a measure provides unique additional information that aids in the assessment process.

Assessment techniques vary in their utility for certain interpretations.
There is no such thing as a perfect test.

Clinical interviews

Historically, a critical part of an assessment battery is the clinical interview with the child, his or her parent, and with other important adults who interact with the child.
Those interviews are by nature unstructured and idiosyncratic. They are often unreliable.
Still, they provide invaluable information about the client’s

• Particular history
• Problems and strengths

They do not allow for conclusions about the extent to which the child’s difficulties are significant relative to same-aged peers.
They set the stage for further assessment activities in that allowing the caretaker to articulate his or her concerns helps the clinician determine specific issues in need of further evaluation.

The flexibility and client-centred nature of unstructured clinical interviews make them ideal for determining important features of the child’s presentation.

• The onset of the problem
• The relation of the problem to significant environmental events or stressors
• The course of the problem
• The child’s previous assessment or treatment history
• Family and psychiatric history

The interview should be guided by the most recent research on development and psychopathology.

Structured diagnostic interviews: interviews that provide a specific script for the interviewer to follow while still covering relevant symptomatology, onset, and impairment related to the symptoms.
They include specific guidelines on how a child’s responses are to be scored.
Structured and standard formats lead to information that has shown to be more reliable than what is obtained form unstructured interviews.

Disadvantages of the structured interview

• The amount of time required to administer the interview
• The reliance on the informant’s subjective report as to whether a symptom is present and when it first emerged
• The lack of direct translation between meeting diagnostic criteria, and the most appropriate interventions for a specific child
• Norm-references interpretation are not possible
• Many issues that might be worthy of clinical attention in children do not fall neatly within a diagnostic category, making sole reliance on diagnostic interviews unwise

Behavioural observations

An important part of the assessment of children and adolescents are behavioural observations of the child either during testing, in interactions with their parents, in the classroom, or all of the above.

Behavioural observations provide information on a child’s behaviour that is not filtered through the perspective of an informant.
They can also be conducted in a naturalistic setting, allowing for an understanding of the environmental factors that might influence or even trigger the child’s behaviour.

Behavioural observations can be conducted informally based on the observer’s descriptions of the child’s behaviour or through available structured observational systems.
If a clinician opts for an informal approach, it is still important to capitalize on the relative strengths of observations by noting the features of

• The environment in which the observation takes place
• The specific behaviours of note
• The antecedents of those behaviours
• The responses of others in the environment to the behaviour

Structured systems often prescribe parameters such as

• The approach to coding
• The target behaviours to be coded
• The number of observation periods

Often, these systems call for the use of more than one observer as well as the observation of another child to offer a comparison between behaviour exhibited by the target child and another child’s behaviour in the same context.

The clinician must consider reactivity on the part of the child being observed as well as others in the observation setting.
To address this issue, the clinician should consult with others in the observation setting about the best time to conduct the observation and how to best avoid disrupting the setting.
The clinician should also consider who best to conduct the observation.
Even without behavioural observation in outside settings, observation during testing regardless of the client’s age should always be incorporated in the assessment report.

Tests of intellectual functioning and academic achievement

If a main task of child assessment is to understand the child’s difficulties and strengths within the context of his or her developmental level, then a key piece of information in many cases is the child’s current cognitive or intellectual functioning.

Well-normed standardized intelligence tests have

• Advantages of
  • Clear procedures for administration and scoring
  • Providing unique and important information in terms of the level at which the child’s verbal and non-verbal reasoning abilities have developed
• Disadvantages
  • Requiring specialized training to administer and score
  • Taking more time than many other assessment techniques

Measures of intellectual functioning can be critical for understanding a child’s adjustment and treatment planning in a number of ways

• Intellectual functioning is a critical consideration in the design of interventions for youth with autism spectrum disorders
• Intelligence influences the manifestations of child conduct problems

Depending on the referral question, an evaluation may also include a standardized test of academic achievement.
Learning disability evaluations included these tools so that a direct comparison to intellectual functioning could be made.
They can provide important metric of the impairment that is presumably caused by a child’s attention, behavioural, or emotional problems.

Behaviour rating scales

Behaviour rating scales have become a centrepiece of child psychological assessments because of their

• Convenience
• Ability to assess a large number of domains relevant to a child’s psychological adjustment
• Sound standardization and norming processes

Validity scales capture tendencies to present the child in an overly positive or negative light, inconsistency across similar items, and a tendency to respond carelessly.

Broadband, or omnibus rating scales: those that have a number of subscales assessing different domains of functioning.
Omnibus rating scales have historically focused on evaluating the presence of problems in adjustment.

Several improvements have been made over recent years in the available child self-report rating scales

• Many of the commonly used child self-report inventories are closely aligned with parent and teacher counterparts
• Many child self-report inventories were derived from adult inventories that have seen extensive use and research over many years.

Overall, omnibus rating scales, particularly those that cover theoretically relevant domains and have good psychometric properties, generally have the advantage of providing norm-referenced information in a reliable and cost-effective manner.

Information from rating scales is filtered through the perspective of an informant, and lack the depth of client-specific information necessary to ultimately arrive at an individualized case conceptualization.

Because single-domain scales are geared toward the evaluation of a specific problem, they are not as widely used and often not as widely known as broadband scales.
They have greater depth but do not indicate the presence of other issues.

Laboratory tasks

Laboratory tasks are designed to elicit performance that will help confirm or disconfirm the presence of a specific problem.
The tasks are based on theoretical ideas of how an individual with a particular problem would behave in a contrived situation.

Performance-based tasks should not replace the other elements of a comprehensive assessment.

Benefits and challenges of a comprehensive assessment battery

• A child’s emotional and behavioural functioning may vary across different situations.
• Children with problems in one domain are likely to have problems in other areas of adjustment
• There is not a single best method for assessing all of the important constructs that contribute to understanding a child or adolescent’s emotional and behavioural functioning.

It is essential that an assessment battery includes procedures that provide data from multiple informants who interact with the child in different settings and who may have different perceptions of the child’s adjustment.
It is important to use different methods so that the strengths of one method can compensate for limitations in another

Parent informants

For children before adolescence, a parent is thought to be the most useful and critical informant.
At the very least, they can provide a developmental history.
At most, the parent can continue to serve as a source on many areas of the child or adolescent’s functioning in a manner that informs treatment.

Factors that might affect the validity of parental reports that should be considered by the clinician conducting the assessment of the child

• Parental depression or psychopathology may influence the parent to view the child in a particularly negative light across domains of functioning
• Parent ratings may be influenced by the view that the parent takes regarding the cause of the child’s difficulties

Even if parent reports are influenced by factors not related to the child’s actual functioning, the source of this influence may be useful for case conceptualization.

Teacher informants

Through much of the childhood and adolescence, a child may spend more time in school than in any other setting.
The school setting provides many demands that may not be present to the same degree in other settings.
Many emotional and behavioural problems are most evident and cause greatest level of impairment at school.
Therefore, obtaining information form teachers is often vital in child and adolescent psychological assessments.

There are limitations in the information provided by teachers.

• They are typically good informants concerning attention problems and hyperactivity based on the unique demands of the classroom setting
• They often have less of an opportunity to observe some forms of antisocial behaviour or internalizing problems
• The age of the child influences the usefulness of teacher reports
  An individual teacher has more of an opportunity to interact with and observe a younger child

Teachers are in a unique position of interacting with many children at a particular age or developmental level.
They have a normative reference against which to compare the child client.
The specific population with which the teacher has worked is an important consideration for interpreting the teacher’s normative perspective.

Child informants

Children and adolescents can provide useful information on some clinical constructs, particularly covert conduct problems, and internalizing symptoms that may be unknown to other informants.
But, their motivation to participate and provide information may be suspect because they typically are urged to get an evaluation by someone else.

Peer informants

Ratings of the child by his or her peers through nominations by a group of peers on criteria of interest.
The most convenient setting in which to use peer information is the classroom.

Because of limited access, time, and ethical concerns about engaging a group of peers in an assessment of a particular child, the feasibility of peer informants is significantly constrained.
But, peers provide a unique perspective on the child’s social functioning and may reveal interpersonal issues that inform intervention efforts.

In determining whether to use peer informants, the professional must take care

• To minimize the disruptiveness of the process to the peer group’s normal routine
• Should make every effort to ensure that peer informants are not aware of the target of the assessment
• That the peers understand the importance of keeping their responses confidential even after the procedure is complete

One way to obtain peer reports while managing the potential drawbacks of this method might be to obtain nominations or ratings from a relatively small group of peers.

Institutional records

In the case of documented problems, records provide a clear indicator of impairment in the setting from which records are obtained.
The clinician may find information form records critical in validating referral concerns.
But, the records are essentially limited in that they will not include contextual information regarding the antecedents or consequences of the issue noted by the record.
Records are merely descriptive and may be devoid of important contextual considerations.

Integration across informants

Clinicians should attempt to ascertain the issues most central to the child’s functioning based on multiple pieces of data and must consider multiple reasons for informant discrepancies, some of which may have important implications for intervention.

A multistep process for integrating findings across tests and informants

1. The clinician should document all clinically significant findings across constructs and informants
2. Any areas in which convergence is evident across sources are noted and likely point to an area of concern
3. The clinician should try to determine the reasons behind any discrepancies, which may point to concerns about the informant, the test, or differences in the child’s functioning across settings
   The discrepancies may be indicative of important issues in the case of conceptualization and plans for intervention
   The clinician should consider cultural or other systemic influences on the information obtained as well as other potential influences on the responses on assessment measures
4. The clinician should develop a hierarchy of problems form primary to secondary
   Secondary problems may be considered separate from the primary clinical issue or may be considered additional manifestations of the core, primary concern
5. The clinician determines the relevant information that should be in the assessment report, attempting to achieve balance between concise explanations and a clear outline of how the case conceptualization was developed and diagnostic decisions were made.