Child Psychopathology

Winter 2024

Chapter 4
Assessment, Diagnosis, and Treatment

Abnormal Child Psychology – 8th Ed.

Mash, Wolfe & Williams (2024)

Dr. Graham J. Reid

2024
1
Objectives

 Understand key elements in the clinical care process including:

clinical decision making, assessment, diagnosis, and treatment.

 Know the modes of treatment for children’s psychosocial

problems.

 Understand differences between types of prevention.

 Know overall results of treatment efficacy research.

 Understand what an effect size is and how it is calculated.
2
Outline: Assessment & Treatment
 Clinical Care Process
 Assessment
 Purposes
 Interviews
 Behavioural Assessment
 Psychological Testing
 Projective
 Checklists & Rating Scales

 Treatment

3
 Clinical Care Process
 Typical steps in clinical care:
 Referral

Presenting problem

 Clinical assessment
Case-formulation/Diagnosis

Feedback

 Treatment

4
Outline: Assessment & Treatment
 Clinical Care Process
 Assessment
 Purposes
 Interviews
 Behavioural Assessment
 Psychological Testing
 Projective
 Checklists & Rating Scales

 Treatment

5
 ASSESSMENT: Purposes
Description and Diagnosis

 Clinical description
summarizes the child’s unique behaviors, thoughts, and
feelings that
make up the features of the child’s psychological disorder
conclusions about the nature or cause of the problem, and
often a

 Diagnosis

6
 ASSESSMENT: Purposes
Prognosis and Treatment Planning

 Prognosis
predictions about future behavior
 Planning and evaluation
assessment to generate a treatment plan and
evaluate its effectiveness
 Ongoing assessment/treatment monitoring is
expected
7
Outline: Assessment & Treatment
 Clinical Care Process
 Assessment
 Purposes
 Interviews
 Behavioural Assessment
 Psychological Testing
 Projective
 Checklists & Rating Scales

 Treatment

8
 Assessment: Interviews

Interviews

 Are the most universally used assessment procedure

 Unstructured or semi-structured

9
Assessment: Interviews
 Vary somewhat based on child age

 Typically include:
 Risk & Protective factors at multiple levels
 Historical & current
 Child competencies

 Proximal processes
 Parent/youth conceptualizations of the problem
 Parenting/Co-parenting

 Routines

10
Outline: Assessment & Treatment
 Clinical Care Process
 Assessment
 Purposes
 Interviews
 Behavioural Assessment
 Psychological Testing
 Projective
 Checklists & Rating Scales

 Treatment

11
 Behavioral Assessment
 Typicallyan emphasis on observing child’s behavior directly
“ABCs of assessment”
 Antecedents
 Behaviors
 Consequences (& Contingencies)

 Functional analysis of behavior

 Skinner (1953) analysis of the stimuli that precede a behaviour
and the consequences that follow it
 Goal
identify as many potentially contributing factors as possible
develop hypotheses about which are most important and/or
easily changed 12
Behavioral Assessment

13
 Behavioral Assessment: Step 1

 Target behaviour
 child interrupting parent

 Operational definition
 “any time parent is occupied in a task or
interaction with another person and the child
repeatedly touches or speaks to the parent or
attempts to get the parents attention”
14
 Behavioral Assessment: Step 2
 ABCs
 Antecedents
Mother on the phone
 Behavior
Child interrupts parent
 Consequences
child
runs to room when mom hangs up
mother chases child into room

Contingencies – child’s behaviour is being

______________ 15
 Behavioral Assessment: An Example

 Christopher is 10 years old, repeating Grade 4, stands about a

head taller than his classmates, and is a bully.

 His peers are afraid of him. Teachers are constantly on the

lookout to prevent other students from being victimized.
 For example, at recess he swaggered over to José – age 8 - who
was playing by the swing set and demanded José give him his
lunch money – or else.
 Shaking with fear, José pulled $2 out of his pocket & handed it
over.
 Laughing, Chris gave him a smack upside the head for good
measure and walked away. Chris’ motley gang laughed along as
he went and bought himself a snack.

16
 Behavioral Assessment –
Christopher the “Bully”
 Define the Behaviour
 Bullying

 Antecedents

 Behaviors

 Consequences of the behaviors

17
 Behavioral Assessment –
Christopher the “Bully”
 Antecedents
 sees younger, vulnerable child likely has money

 Behaviors
 threatens child & takes money

 Consequences of the behaviors

 money to spend
 peers give him respect

 Contingencies = the contingencies would be positive reinforcement

18
 Complete the
following sentences

Are these tests?

Why or why not? 19
 House-Tree-Person

https://commons.wikimedia.org/wiki/File:A_tree_-_illustration_for_House-Tree-Person_Test.jpg

https://commons.wikimedia.org/wiki/File:A_house_-_illustration_for_House-Tree-Person_Test.jpg 20
Psychological Testing

 What is a test?

 tasks given under standard conditions

 with the purpose of assessing
 some aspect of the child’s knowledge, skill, or
personality

21
 Psychological Testing: Interpreting

 How can we interpret the rests of a test?

 Normative = comparing patient to a defined

population

 Ipsative = “measuring yourself against yourself”

 In the context of other assessment information

22
Psychological Testing:
Checklists & Rating Scales

 Typically
allow for a child’s behavior to be
compared to a normative sample

 Usually economical to administer and score

 Lack of agreement between informants is

relatively common, which in itself is often
informative

23
 Psychological Testing: Rating Scales

SNAP-IV (Swanson Nolan and Pelham scale - Swanson 1992)

Swanson, J. M. School-based assessments and interventions for ADD students. 1992. Irvine, CA, KC
Publishing. 24
Psychological Testing :
Intelligence and Educational Testing

 Intelligence and Educational Testing

 Intelligence
WPPSI, WISC, WAIS
 Achievement
WRAT, PIAT
 Specific Deficits
vocabulary
phonological awareness
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Treatment of Childhood Disorders

Megan is 16 and was recently stopped by police while driving (without a

license) her parents’ car (stolen) down the 401 to Toronto to visit her
boyfriend.

What would the treatment goals be for Megan?

Who defines the treatment goals?

26
 Treatment of Childhood Disorders
What is a psychological treatment or intervention?

 Problem-solving strategies that involve:

 treatment of current problems
 maintenance of treatment effects
 prevention of future problems

 Treatment goals include outcomes related to:

 child
 family
 society

27
Outline: Assessment & Treatment
 Clinical Care Process
 Assessment

 Treatment
 Types of Treatment
 Prevention & Continuum of Care
 Universal & Selective
 Pharmacological
 CBT
 Parenting
 Combined treatments
 Treatment Outcomes
 Effect sizes
 Efficacy & Effectiveness 28
 Treatment of Childhood
Disorders: Continuum

Figure 4.4
The intervention spectrum for childhood disorders. Adapted from Reducing Risks for Mental Disorders:
Frontiers for Preventive Intervention, by P. J. Mrazek and R. J. Haggerty (Eds.), 1994. Copyright (c)
1994 by National Academy Sciences. Adapted by permission of the National Academy Press.
29
 Treatment of Childhood Disorders

Figure 4.3 The intervention spectrum and settings for childhood disorders 30
Preventive interventions: Summary

AIMS OF:
Mental health promotion
 “enhance individuals’ ability to achieve developmentally
appropriate tasks (competence) and a positive sense of
self-esteem, mastery, well-being, and social inclusion, and
strengthen their ability to cope with adversity”

Preventive interventions
 reduce the likelihood of a future disorder

Based on Box 3-1 from O'Connell, M. E., et al. (2009). Preventing mental, emotional, and behavioral disorders
among young people: Progress and possibilities. Washington, DC. 31
 Preventive interventions: Summary
Type Population When to use
Mental health general public or a whole population
promotion

Universal general public or a whole population  costs per individual are low
preventive  that has not been identified on the basis of  intervention is effective and
individual risk acceptable to the population,
Intervention is desirable for everyone in that group  low risk from the intervention.

Selective individuals or a population subgroup  most appropriate if

preventive  whose risk of developing mental disorders  cost is moderate and
 is significantly higher than average  risk of negative effects is
minimal or nonexistent

Indicated high-risk individuals having:  might be reasonable even if

preventive  minimal but detectable signs or symptoms  intervention costs are high
foreshadowing mental, emotional, or behavioral  intervention entails some risk
disorder,
 biological markers indicating predisposition
disorder
 do not meet diagnostic levels at the current time 32
Based on Box 3-1 from O'Connell, M. E., et al. (2009). Preventing mental, emotional, and behavioral disorders among young people: Progress and possibilities.
Washington, DC.
Outline: Assessment & Treatment
 Clinical Care Process
 Assessment

 Treatment
 Types of Treatment
 Prevention & Continuum of Care
 Universal & Selective
 Pharmacological
 CBT
 Parenting
 Combined treatments
 Treatment Outcomes
 Effect sizes
 Efficacy & Effectiveness 33
 Universal Prevention:
I CAN DO

Purpose: Implemented and evaluated a 13-session school-based primary prevention

program designed to teach children coping skills.

Method: Practice of the skills was applied to 5 stressful experiences that are likely
to occur to a significant number of children:

 parental separation/divorce, loss of a loved one, move to a new home or school,

spending significant time in self-care, and being different (e.g., ethnically,
physically).

Subjects: 88 4th graders were assigned to either an immediate- or delayed-

intervention group.
Dubow et al. (1993). Teaching children to cope with stressful experiences: Initial implementation and
evaluation of a primary prevention program. Journal of Clinical Child Psychology. 22(4), 428-440. 34
Dubow et al. (1993). Teaching children to cope with stressful experiences: Initial implementation and35
evaluation of a primary prevention program. Journal of Clinical Child Psychology. 22(4), 428-440.
© Dubow (2005) I CAN DO
Problem-solving Workbook.
Bowling Green State University,
Bowling Green OH

36
 I CAN DO: Worry Warts
Some kids use WORRY WARTS as reasons to not ask for help. This does not help solve
kids’ problems. In fact, WORRY WARTS may make the problem worse.

1) “Asking for help is embarrassing.”

 Maybe, but if you ask someone who cares about you for help, they won’t make
fun of you or stop liking you.

2) “Your problem isn’t important”

 If a problem bothers you, it is important

3) “You’re a baby if you can’t solve your own problems”

 Nobody can solve all of their problems. Asking for help is one way to solve
problems
© Dubow (2005) I CAN DO Problem-solving Workbook. Bowling Green State University, 37
Bowling Green OH
 Universal Prevention:
I CAN DO

Results: Program effects were found on:

 improvement in children's ability to generate a repertoire of
effective solutions to the stressful situations,
 as well as in their self-efficacy to implement effective
solutions.
 Most of these effects were maintained or strengthened at 5-
mo follow-up.
 No effects were found on knowledge of facts about the
stressors or size of children's support networks.

Dubow et al. (1993). Teaching children to cope with stressful experiences: Initial implementation and
evaluation of a primary prevention program. Journal of Clinical Child Psychology. 22(4), 428-440. 38
 Selective Prevention:
Carolina Abecedarian Project (Horacek and Ramey, 1987)

Risk & Protective Factors: Academic failure, lack of readiness

for school, economic deprivation, & low level of
commitment to school
Targeted Population Group
 prenatal clinic & Dept of Social Services

Research Design
1) control/control = no intervention (n = 22)
2) control/txt = only school-age txt (n = 21)
3) txt /control group = only preschool txt (n = 24)
4) txt/txt = preschool & school-age txt (n = 25)

39
 Carolina Abecedarian Project
(Horacek and Ramey, 1987)

Description of the Preventive Intervention

 Preschool program
1. Developmental day care
2. Toy-lending library
3. Home-visiting program
4. Parent group meetings
 School-age program
 Home/school resource teacher for each child
40
 Carolina Abecedarian Project
(Horacek and Ramey, 1987)

Selected Outcomes
 Retained at least 1 yr: 50% controls
 vs 16% in the treatment/treatment group

 Reading: 75% of control/control in the bottom quartile

 vs to 44 % for treatment/treatment group

41
Cognitive Behavioural Therapy

Coping with Depression in Adolescence (CWDA)

 Group format – psychoeducational
 Groups of mixed sex
 4-10 individuals per group
 Ages 12-18

 16 - 2-hour sessions
 typically over an 8-week period
 with mixed gender groups of 4 to 10 youths.

42
http://www.kpchr.org/research/public/acwd/acwd.html
 CBT - Coping with Depression in Adolescence (CWDA)

DEALING WITH NEGATIVE THOUGHTS

2) Using Positive Counterthoughts
Negative thoughts can make you feel depressed and unhappy.
Positive thoughts make you feel “up” and cheerful. When you think
positively about yourself and the world, you feel better. When you
catch yourself thinking negatively, replace the negative thought with
a positive “counterthought.”

Definition: A POSITIVE COUNTERTHOUGHT relates to the SAME TOPIC

as the negative thought, but it's MORE REALISTIC and MORE
POSITIVE. Negative thoughts and positive counterthoughts have the
same sort of relationship between them as “Good News” and “Bad
News” stories.

43
Clarke, Lewinsohn, and Hops 1990 Coping with depression course
To practice, work through the cartoons below.
 CBT - Coping
with
Depression in
Adolescence
(CWDA)

Clarke, Lewinsohn, and Hops 1990 Coping with

depression course

44
 Parenting
Defiant Children (Barkley, 1987)
1) Overview - Treatment Rationale
2.1) Paying attention to your child’s good behaviour
2.2) Giving positive feedback & approval
3.1) Paying attention to your child’s compliance
3.2) How to give effective commands
4) Paying attention when your child is not bothering you
5) Home poker chip/point system
6) Time out
7) Managing your child in public places
8) Managing future behaviour problems

45
Parenting for
children with
oppositional-
defiant
problems

Barkley 1987 Defiant Children:

Parent-Teacher Assignments,
Guilford, NY 46
Operant Conditioning: Theory

Stimulus

Behaviour Applied Removed

Increases + reinforcement - reinforcement

Decreases + punishment - punishment

47
Parenting for children with
oppositional-defiant problems

Parent Behaviour:

Nagging & threats

• ________________

Acquiescence

• ________________

Barkley 1987 Defiant Children:

Parent-Teacher Assignments, 48
Guilford, NY
Parenting for children with
oppositional-defiant problems

Child Behaviour:

Non-compliance
• ________________

Compliance
• ________________

Barkley 1987 Defiant Children:

Parent-Teacher Assignments, 49
Guilford, NY
 Parenting for children with ODD
3.2) How to give effective commands

1) Make sure you mean it!

2) Do not present the command as a question or a favour
3) Do not give too many commands at once
4) Makes sure the child is paying attention to you
5) Reduce all distractions before giving the command
6) Ask the child to repeat the command

Barkley 1987 Defiant Children:

Parent-Teacher Assignments,
50
Guilford, NY
 Combined treatments
Description of FIRST
The five core elements of FIRST are as follows:
 1. Feeling Calm (calming, relaxation, emotion regulation)
 2. Increasing Motivation (incentivizing behavior change, e.g., via
attention, praise, or rewards)
 3. Repairing Thoughts (cognitive reappraisal)
 4. Solving Problems (systematic steps of problem solving)
 5. Trying the Opposite (practicing positive opposites that lead to
corrective experiences
 e.g., behavioral activation for depression, exposure for anxious avoidance).

Bailin et atl Principle-Guided Psychotherapy for Children and Adolescents (FIRST): study protocol for a randomized controlled effectiveness 51
trial in outpatient clinics. Trials. 2023 Oct 21;24(1):682. doi: 10.1186/s13063-023-07717-y. PMID: 37864269; PMCID: PMC10589969.
Treatment Outcome Terminology

Treatment efficacy
 Degree to which a treatment can produce changes under
well-controlled conditions

Treatment effectiveness
 Degree to which a treatment can be shown to work in actual
clinical practice

 EBT – Evidence-based treatment

52
 Treatment Efficacy & Effectiveness:
Meta-analysis
 Meta-analysis
 quantitative statistical technique
 combines results from large number of studies
 relevant outcome measures

 Firststep is to convert results from each individual study

into a common metric

53
 Treatment Efficacy & Effectiveness:
Meta-analysis

Effect size (ES) = M (Txt) - M (control)

SD (Control)
M (Txt) = M of treatment group at post-treatment
• IF lower scores reflect better outcome, reverse sign.
• (- ES becomes +)

Equates various outcomes using the same metric

• ES scores are in SD (Standard Deviation) units

•ES = 0  No difference between treatment & controls

•ES > 0  Treatment group better than control
•ES < 0  Control better than treatment
54
 Effect sizes
Dr. Smith does a study that finds patients who received CBT for depression were
less depressed (M = 40 ) than patients who were on a wait list control (M= 60;
SD at baseline = 20) when measured using the Smith Depression Scale (SDS)
that gives scores ranging from:
 0 to 100 higher scores = higher depression.

Dr. Berger does another study that finds patients who received CBT for depression
were less depressed (M = 10) than patients who were on a wait list control (M=
20; SD at baseline = 10) when measured using the Berger Depression Inventory
(BDI) that gives scores ranging from
 0 to 50 higher scores = higher depression.

Which treatment is better?

Effect size (ES) = M (Txt Follow-up) - M (control Follow-up)
SD (Control)
Smith ES for SDS = 40-60/20 =
Berger ES for BDI = 10-20/10 =
55
 Visualizing Effect
sizes
https://rpsychologist.com/d3/cohend
Deviation & Normal distribution

-3 -2 -1 0 +1 +2 +3 Z
50%
84%
97.7%
 99.9%
57
 Effect sizes
Dr. Smith does a study that finds patients who received CBT for depression were
less depressed (M = 40 ) than patients who were on a wait list control (M= 60;
SD at baseline = 20) when measured using the Smith Depression Scale (SDS)
that gives scores ranging from:
Dr. Berger does another study that finds patients who received CBT for depression
were less depressed (M = 10) than patients who were on a wait list control (M=
20; SD at baseline = 10) when measured using the Berger Depression Inventory
(BDI) that gives scores ranging from

Which treatment is better?

What we are not told:

 How much change occurred within the treatment and control groups?
 How much variability in change was there within each group?

58
Computing an M
control
M Before
treatment treatment
effect size (Baseline)

Control Treatment
group group

-3 -2 -1 0 +1 +2 +3

Z-scores
(SD units of control at baseline)

No difference between groups at baseline 59

After treatment (Follow-up)
Control
-Improvement for the Control group
group

M M
Baseline Follow up

-3 -2.5 -2 -1.5 -1 -0.5 0 0.5 1 1.5 2 2.5 3

How much did the control group change over time?

M Follow-up (post treatment) – M Baseline
60
0.5 – 0 = 0.5 SD
After treatment (Follow-up) Treatment
-Improvement for the Treatment Group group

M
Follow up
M
Baseline

-3 -2.5 -2 -1.5 -1 -0.5 0 0.5 1 1.5 2 2.5 3

How much did the treatment group change over time?

M Follow-up (post treatment) – M Baseline
61
1.5 – 0 = 1.5 SD
 M treatment
After treatment M
(Follow-up) control

Control Treatment
group group

-3.5 -2.5 -1.5 0.5 +1.5 +2.5 +3.5

Z-scores
(SD units of control at baseline)

What is the effect size for this study?

Effect size (ES) = M (Txt Follow-up) - M (control Follow-up) 62

SD (Control)
 M treatment
After treatment M
(Follow-up) control

Control Treatment
group group

-3.5 -2.5 -1.5 0.5 +1.5 +2.5 +3.5

Z-scores
(SD units of control at baseline)

What is the effect size for this study?

Effect size (ES) = 1.5 – 0.5 = 1.0 63

1
 M M treatment
After treatment control
(Follow-up)
After treatment

Control Treatment
group group

-3 -2 -1 0 +1 +2 +3
What does an ES of 1.0 mean?
 Average person in the treatment group scores were 1 SD greater at
post treatment than the average person in the control group
 Average person in the treatment group is better off than 84% of the
control group
 Treatment Efficacy & Effectiveness
 There are treatments for all major child mental health
problems
 that have demonstrated positive effects in controlled
research studies

 After treatment:
 Children are better off than before treatment
 Children are doing better those who did not receive
treatment

 Treatment effects tend to be long-lasting

65
 Treatment Effectiveness:
Negative Findings

 Community-based clinic therapy is

 less effective than structured research therapy

 Conventional services for children may

 have limited effectiveness

66
 Treatment Effectiveness

 Li et al. 2019 Predictors of functional improvement

in children and adolescents at a publicly funded
specialist outpatient treatment clinic in a Canadian
Prairie City

 An example of an effectiveness study

67
Li et al. 2019 Predictors of functional improvement in children and adolescents at
a publicly funded specialist outpatient treatment clinic in a Canadian Prairie City

SETTING

Child and Youth Mental Health and Addictions Services (CYMHAS)

Saskatoon

 Wide range of out patient treatments

 “common and over-arching treatments provided include
cognitive behavioral therapy, exposure therapies, play therapy,
parent education, behavioral therapy, pet therapy, art therapy,
and neuro-sequential model of therapeutics.”
Administrative data
2011 – 2014 enrolled in treatment, 1st Episode
Li et al. Predictors of functional improvement in children and adolescents at a publicly funded specialist outpatient treatment
clinic in a Canadian Prairie City. Psychiatry Res, 2019. 273: p. 613-623.
Li et al. 2019 Predictors of functional improvement in children and adolescents at a
publicly funded specialist outpatient treatment clinic in a Canadian Prairie City

CASES
 61% male
 Children (6-11) 48%

Presenting problems
 Anxiety 25%
 Depression 9%
 Aggression 11%
 Behavioral Concerns 31%
 Trauma 12%
 Relationship difficulties 6%
 Cognitive difficulties 6%
 Other 2%

# of problems
 2 or 3+ problems 68%

Li et al. Predictors of functional improvement in children and adolescents at a publicly funded specialist outpatient treatment
clinic in a Canadian Prairie City. Psychiatry Res, 2019. 273: p. 613-623.
Li et al. 2019 Predictors of functional improvement in children and adolescents at a
publicly funded specialist outpatient treatment clinic in a Canadian Prairie City

OUTCOME
 Child and Adolescent Functional Assessment Scale
(CAFAS)
 Initial,
 every 3 months
 Final

Li et al. Predictors of functional improvement in children and adolescents at a publicly funded specialist outpatient treatment
clinic in a Canadian Prairie City. Psychiatry Res, 2019. 273: p. 613-623.
 Li et al. 2019 Predictors of
functional improvement in
children and adolescents at a
publicly funded specialist
outpatient treatment clinic in
a Canadian Prairie City

Fig. 3. Area graph of the distribution of initial and exit CAFAS Total Scores
for both child and adolescent age groups.
Li et al. 2019 Predictors of functional improvement in children and adolescents at a publicly
funded specialist outpatient treatment clinic in a Canadian Prairie City

NC = No Change

Changes in the Median scores

• Significant decrease in scores
• for all but substance use