Child / Adolescent Psychological Evaluation

Gary Wautier, PhD, MSCP

Psychological Evaluation

Initial evaluation Interview with youth and parents or

custodial adults of youthReview of appropriate health and

educational documentsCommunication 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 ConcernPrevious Behavioral Health Treatment and

responseFamily History Pregnancy, delivery, post deliveryMedical 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 attachmentMothers 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 childrenYoungsters more likely to comply after a parental suggestion than after a command or prohibitionCompliance even less likely when physical control was paired with command or prohibition

Toddlerhood/preschool cont’dMore 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 youthPositive 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 AssessmentWechsler 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 DisorderMathematics DisorderDisorder 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 DisordersThorough diagnostic interview of anxiety disorders (e.g., separation, OCD, GAD, Social, Situational)Rating scales from multiple informantsObservation during interview and testingAssess stressors, trauma, adjustments, abuse, neglect, parent/child historyConsider youth’s progress with daily functioning and expectationsRule out co-morbid depressive disorderConsider medical conditions potentially contributingAssess 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 StudyTwelve 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’dPatient 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 ImpressionAxis I

Attention deficit hyperactivity disorder, predominantly inattentive typeDepressive disorder not otherwise specified with dysthymic disorder traitsAnxiety disorder not otherwise specifiedParent/child relational problems with oppositional defiant disorder traits, particularly in the home environmentMathematics disorder

Axis IIBorderline and antisocial personality disorder features

Axis IIINone reported

Axis IVSevere 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 VCurrent 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