Child / Adolescent Psychological Evaluation

Gary Wautier, PhD, MSCP

Psychological Evaluation

Initial evaluation
Interview with youth and parents or custodial adults of youth Review of appropriate health and educational documents Communication 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 Concern Previous Behavioral Health Treatment and response Family History Pregnancy, delivery, post delivery Medical History

Present/past conditions (e.g., head injury, metabolic or CNS diseases, hearing and vision, asthma, allergies)

Interview contd
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 Anoxia, Prematurity and postmaturity, Birth injury 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

Perinatal risk factors

Demographic risk factors

Developmental Perspectives
Differences in frequency and duration of crying, infant cuddliness and consolability, activity level, alertness, and self-quieting goodness of fit between an infants behavioral style and parental tolerance, sensitivity, and methods of childrearing

Developmental Perspectives contd

Early maternal behavior influential on later infant-mother attachment

Mothers who are sensitive to their infants cues and responsive across a range of situations including feeding, responsiveness of crying, early face-toface 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 children Youngsters more likely to comply after a parental suggestion than after a command or prohibition Compliance even less likely when physical control was paired with command or prohibition

Toddlerhood/preschool contd
More 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 ageappropriate and necessary for childs 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 contd 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 prosocial behavior in the peer group

Toddlerhood contd 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 youth

Positive 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 selfcontrol 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 6:0 16:11

Wechsler Intelligence Scale for Children 4th ed. (WISC-IV)

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 Assessment
Wechsler 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 Disorder Mathematics Disorder Disorder of Written Expression Additional terms used to describe

Dyslexia (disorder of basic skills involved in reading, including letterword 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; Reynolds Child Depression Scale, RCDS; Reynolds Adolescent Depression Scale, 2nd ed., RADS-2; Reynolds Child Manifest Anxiety Scale, 2nd ed., RCMAS-2; Trauma Symptom Checklist for Children, TSCC; Youth Selfreport, 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 Aspergers 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 ADHDlike 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 patients demographics

Anxiety Disorders
Thorough diagnostic interview of anxiety disorders (e.g., separation, OCD, GAD, Social, Situational) Rating scales from multiple informants Observation during interview and testing Assess stressors, trauma, adjustments, abuse, neglect, parent/child history Consider youths progress with daily functioning and expectations Rule out co-morbid depressive disorder Consider medical conditions potentially contributing Assess 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 / Tourettes Disorder Medical conditions Hearing and vision problems

Case Study
Twelve 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 contd

Patient 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 contd

Patients 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 Patients 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 patients functioning

Case study contd

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 contd

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 contd

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 contd

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 contd

Diagnostic Impression Axis I
Attention deficit hyperactivity disorder, predominantly inattentive type Depressive disorder not otherwise specified with dysthymic disorder traits Anxiety disorder not otherwise specified Parent/child relational problems with oppositional defiant disorder traits, particularly in the home environment Mathematics disorder Axis II Borderline and antisocial personality disorder features Axis III None reported Axis IV Severe 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 V Current GAF = 52

Case study contd

Recommendations 1. Outpatient psychotherapy. Therapist should maintain communication with primary physician. Continue to closely monitor patients safety and make appropriate diagnostic and treatment alterations as indicated. Therapist should also communicate with appropriate school personnel as indicated to facilitate patients 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 GrothMarnat (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