Title: Evidence Based Practices for Children and Adolescents with Serious Emotional Disturbances
1Evidence Based Practices for Children and
Adolescents with Serious Emotional Disturbances
- Session 2
- The Role of Assessment In Evidence-Based Mental
Health Practices for Children and Adolescents - Beth Troutman, PhD, ABPP
- Iowa Consortium for Mental Health
- September 1, 2005
2Assessment Data Can Be Used To Enhance Clinical
Decision Making At The Level Of
- System of care
- Program
- Individual patient/family
3Assessments Evaluated According To
- Psychometric Properties
- Reliability
- Validity
4Assessment Data Can Be Used For
- Treatment planning
- Monitoring treatment
- Assessing outcomes
5Using Initial Assessment Data For Treatment
Planning
- What type of intervention does my patient need to
address target symptoms? - What are the appropriate interventions for our
target population?
6Treatment planning
- Assessments can be used to inform
- Type of intervention
- Level of care/service intensity
- Other factors that need to be addressed
7Describing Patient/Target Population
- Diagnosis
- Target Symptoms
- Other Factors
- Functional Status
8Using Initial Assessment Data for Treatment
Planning
9Initial Assessment Treatment Planning
- Diagnosis
- Primary
- Comorbid
10Disadvantages of Diagnosis
- Labels or stigmatizes child
- Labeling or stigmatizing a child with a diagnosis
is of particular concern if the diagnosis does
not lead to effective, evidence-based treatment.
11Disadvantages of Diagnosis
- Poor interrater reliability of clinical diagnosis
- Short-hand method of communicating that fails to
capture special strengths and weaknesses of
particular child and family
12Advantage of Diagnosis
- Clinical eligibility for services
- Funding for services
- Method for organizing vast amount of treatment
data so provider/program can select an effective,
evidence-based intervention
13Using Initial Assessment Data For Treatment
Planning
- Describing Target Symptoms
14Describing Target Symptoms
- Symptom measures
- Broadband
- Symptom specific
15Factors To Consider When Selecting Assessment
Instrument
- Source of information
- Child
- Parent
- Teacher
16Factors To Consider When Selecting Assessment
Instrument
- Clinician rated vs. respondent rated
- Norm-referenced vs. criterion-referenced
17Examples of Broadband Symptom Measures
- Parent Report Measures
- Behavior Assessment System for Children, Second
Edition (BASC-2) (AGS) - Personality Inventory for Children, Second
Edition (PIC-2) (Western Psychological Services) - Achenbach Child Behavior Checklist (ASEBA)
- Note Parent report tends to underestimate
anxiety and depression compared to self report.
18Examples of Broadband Symptom Measures
- Self-Report Measures
- Behavior Assessment System for Children, Second
Edition (BASC-2) (AGS) - Personality Inventory for Youth (Western
Psychological Services) - Achenbach Youth Self Report (ASEBA)
- Note Self-report tends to underestimate
disruptive behavior problems compared to parent
report.
19Examples of Broadband Symptom Measures
- Teacher Report Measures
- Behavior Assessment System for Children, Second
Edition (BASC-2) (AGS) - Achenbach Teacher Report Form (ASEBA)
- Note Teacher report tends to underestimate
anxiety and depression compared to self-report.
20Example of Using Broadband Symptom Measure To
Describe Target Population
- Target population Children aged 5 through 18 in
long-term family foster care in Iowa (gt 6 months
in same foster home) - Broadband symptom measure Achenbach Child
Behavior Checklist completed by foster parents - Source Momany et al., University of Iowa Public
Policy Center
21Rates and Types of Mental Health Problems in
Iowas Family Foster Care Population
Momany et al., University of Iowa Public Policy
Center
22Example of Symptom Specific Measure Attention
Problems
- Parent/teacher report
- Conners rating scales (Psychological Corporation)
23Examples of Symptom Specific Measures - Depression
- clinician ratings
- Childrens Depression Rating Scale - Revised
(CDRS-R) (American Psychiatric Publishing) - self-report
- Child Depression Inventory (CDI) (Psychological
Corporation) - Beck Depression Inventory Second Edition
(BDI-2) (Psychological Corporation) - Reynolds Adolescent Depression Scale Second
Edition (RADS-2) (PAR)
24Using Initial Assessment Data For Treatment
Planning
- Assessing Other Factors That May Affect Treatment
Planning
25Child Factors That May Affect Treatment Planning
- Cognitive functioning
- IQ tests
- Academic functioning
- Standardized academic tests
- Speech and language functioning
- Standardized speech and language tests
26Family Factors That May Affect Treatment Planning
- Parenting stress
- Parenting Stress Index Third Edition (PSI-3)
(PAR) - Maternal or paternal depression
- Beck Depression Inventory Second Edition
(BDI-2) (Psychological Corporation)
27Using Initial Assessment Data For Treatment
Planning
- Assessing Functioning Level and Level of Services
Needed
28Determining Level of Functioning/Level of
Services Needed
- What level of care/service intensity does my
patient need? - What level of care/service intensity do the
patients in our program/system of care need?
29Examples of Functional Assessment/Service
Intensity Instruments
- Clinician ratings
- Childrens Global Assessment Scale (CGAS)
- Child and Adolescent Functional Assessment Scale
(CAFAS) - Child and Adolescent Level of Care Utilization
System (CALOCUS) - Child and Adolescent Needs and Strengths Mental
Health (CANS-MH)
30Using Assessment Data For Program Improvement
31Using Assessment For Program Improvement
- Assessments can be used to
- Monitor treatment
- Assess outcomes
32The Evidence Based Practice Cycle
Optimize Priority Outcomes
33Role of Assessment in EBP Cycle
- Target Population
- Diagnosis
- Target symptoms
- Functional status
- Other factors
- Outcomes
- Identify
- Prioritize
- Quantify
34Treatment Monitoring
- Is my patient benefiting from the intervention?
- Are there any negative consequences (side
effects/iatrogenic effects) associated with the
intervention?
35Example of Symptom Scale Used For Treatment
Monitoring Disruptive Behavior
- Eyberg Child Behavior Inventory administered at
each session in Parent Child Interaction Therapy - Parent rates a series of specific items
addressing noncompliance and disruptive behavior
according to - How often the behavior occurred.
- Whether it was a problem for the parent.
36Example of Assessment Used For Treatment
Monitoring Separation Anxiety
- Exposure treatments for anxiety have child or
adolescent rate items on their systematic
desensitization hierarchy at each session - E.g. walking from front door of school to
classroom alone, walking from car to school alone
37Using Assessment Data For Program Improvement
38Assessing Outcomes
- Did my patient benefit from the intervention?
- Are patients in our program/system of care
benefiting from interventions?
39Assessments Used to Evaluate Outcomes
- Diagnosis
- Target Symptoms
- Other Factors
- Functional Status
40Use Of Diagnosis To Evaluate Outcome
- Recovery/remission of diagnosis is relevant for
some diagnoses - E.g. depressive episode, adjustment disorder
41Use Of Diagnosis To Evaluate Outcome
- Diagnosis may not be useful for evaluating
outcomes for other disorders - E.g. Attention Deficit Hyperactivity Disorder
42Use Of Symptom Specific Measures To Assess
Outcomes
- The more reliable the symptom measure is, the
better it will be at detecting improvement - Important that symptom measure is valid for
intervention i.e. does it assess what your
intervention is targeting?
43Examples Of Symptom Assessments Used To Evaluate
Outcomes
- Depression self-report
- Childrens Depression Inventory
- Beck Depression Inventory Second Edition
(BDI-II)
44Examples Of Symptom Assessments Used To Evaluate
Outcomes
- Attention and distractibility
- Parent report/teacher report
- Conners Rating Scales
45Examples Of Symptom Assessments Used To Evaluate
Outcomes
- Anxiety
- Self-report
- Revised Childrens Manifest Anxiety Scale
- Parent report
- Achenbach Child Behavior Checklist
internalizing scale
46Use of Other Assessments to Assess Outcomes
- Some intervention studies have assessed changes
in parenting stress or mood - Parenting Stress Index Third Edition (PSI-3)
- Beck Depression Inventory Second Edition
(BDI-2)
47Use of Functional Assessments To Assess Outcome
- CGAS is most widely used assessment of
functioning in treatment outcome studies - Often a delay between symptom improvement and
improvement in functioning
48Using Outcome Data For Program Improvement
- Is there a particular group of patients we should
target for improved outcomes? - age
- diagnosis
- type of problem
49Improving Outcomes For Target Population
- Is there an Evidence Based Treatment available
for this group of patients?
50Program Improvement Process
- Review of outcomes
- Systematic modification of intervention
51Most Clinicians Do Not Use Standardized
Assessments
- Reference Garland, A., Kruse, M., Aarons, G.
(2003). Clinicians and outcome measurement
Whats the use? Journal of Behavioral Health
Services Research, 30(4), 393-405.
52Garland, Kruse, Aarons, 2003
- Interviews and focus groups conducted with
clinicians providing publicly funded mental
health services in California after law was
passed requiring collection of standardized
assessment data performance outcome project - at intake
- follow-up intervals
53Garland, Kruse, Aarons, 2003
- Required Assessments for California Performance
Outcome Project - Achenbach Child Behavior Checklist/Youth Self
Report - Child and Adolescent Functional Assessment Scale
(CAFAS) - Client Satisfaction Questionnaire
54Garland, Kruse, Aarons, 2003
- Estimated costs of California Performance Outcome
Project - 15 to 62 per patient
- Approximately 1 million to 3 ½ million dollars
per year - Since outcome project mandate did not include
additional funding for collecting outcome
measures costs were assumed by agencies and
clinicians
55Garland, Kruse, Aarons, 2003
- 92 of clinicians reported never using scores
from standardized measures for - Treatment planning
- Treatment monitoring
- Assessing outcomes
56Barriers to Use of Standardized Outcome Measures
- Feasibility
- As clinicians, we are burdened by more and more
paperwork to prove what we do, which takes a big
hunk of time away from doing what we do - Garland, Kruse, Aarson, 2003
57Barriers to Use of Standardized Outcome Measures
- Cost
- Testing materials
- Time
- Patients
- Parents
- Teachers
- Providers
58Barriers to Use of Standardized Outcome Measures
- Difficulty interpreting results of assessments
- Qualifications needed to use assessments
- Additional training needed to use assessments
59CONCLUSIONS
- Use of standardized assessments can improve
clinical decision making and outcomes for
children and adolescents with mental health
problems
60CONCLUSIONS
- In order for standardized assessments to improve
outcomes the following issues need to be
addressed - Feasibility
- Training
61CONCLUSIONS
- In order for standardized assessments to improve
outcomes the following issues need to be
addressed - Process that uses assessment data to improve
outcomes - Process that informs patients, families, and
clinicians of how assessment data has been used
to improve outcomes