Evidence Based Practices for Children and Adolescents with Serious Emotional Disturbances

1
Evidence 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

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Assessment Data Can Be Used To Enhance Clinical
Decision Making At The Level Of

• System of care
• Program
• Individual patient/family

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Assessments Evaluated According To

• Psychometric Properties
• Reliability
• Validity

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Assessment Data Can Be Used For

• Treatment planning
• Monitoring treatment
• Assessing outcomes

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Using 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?

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Treatment planning

• Assessments can be used to inform
• Type of intervention
• Level of care/service intensity
• Other factors that need to be addressed

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Describing Patient/Target Population

• Diagnosis
• Target Symptoms
• Other Factors
• Functional Status

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Using Initial Assessment Data for Treatment
Planning

• Diagnosis

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Initial Assessment Treatment Planning

• Diagnosis
• Primary
• Comorbid

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Disadvantages 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.

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Disadvantages 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

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Advantage 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

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Using Initial Assessment Data For Treatment
Planning

• Describing Target Symptoms

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Describing Target Symptoms

• Symptom measures
• Broadband
• Symptom specific

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Factors To Consider When Selecting Assessment
Instrument

• Source of information
• Child
• Parent
• Teacher

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Factors To Consider When Selecting Assessment
Instrument

• Clinician rated vs. respondent rated
• Norm-referenced vs. criterion-referenced

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Examples 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.

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Examples 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.

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Examples 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.

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Example 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

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Rates and Types of Mental Health Problems in
Iowas Family Foster Care Population
Momany et al., University of Iowa Public Policy
Center
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Example of Symptom Specific Measure Attention
Problems

• Parent/teacher report
• Conners rating scales (Psychological Corporation)

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Examples 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)

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Using Initial Assessment Data For Treatment
Planning

• Assessing Other Factors That May Affect Treatment
  Planning

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Child Factors That May Affect Treatment Planning

• Cognitive functioning
• IQ tests
• Academic functioning
• Standardized academic tests
• Speech and language functioning
• Standardized speech and language tests

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Family 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)

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Using Initial Assessment Data For Treatment
Planning

• Assessing Functioning Level and Level of Services
  Needed

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Determining 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?

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Examples 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)

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Using Assessment Data For Program Improvement
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Using Assessment For Program Improvement

• Assessments can be used to
• Monitor treatment
• Assess outcomes

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The Evidence Based Practice Cycle
Optimize Priority Outcomes
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Role of Assessment in EBP Cycle

• Target Population
• Diagnosis
• Target symptoms
• Functional status
• Other factors

• Outcomes
• Identify
• Prioritize
• Quantify

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Treatment Monitoring

• Is my patient benefiting from the intervention?
• Are there any negative consequences (side
  effects/iatrogenic effects) associated with the
  intervention?

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Example 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.

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Example 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

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Using Assessment Data For Program Improvement

• Assessing Outcomes

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Assessing Outcomes

• Did my patient benefit from the intervention?
• Are patients in our program/system of care
  benefiting from interventions?

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Assessments Used to Evaluate Outcomes

• Diagnosis
• Target Symptoms
• Other Factors
• Functional Status

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Use Of Diagnosis To Evaluate Outcome

• Recovery/remission of diagnosis is relevant for
  some diagnoses
• E.g. depressive episode, adjustment disorder

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Use Of Diagnosis To Evaluate Outcome

• Diagnosis may not be useful for evaluating
  outcomes for other disorders
• E.g. Attention Deficit Hyperactivity Disorder

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Use 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?

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Examples Of Symptom Assessments Used To Evaluate
Outcomes

• Depression self-report
• Childrens Depression Inventory
• Beck Depression Inventory Second Edition
  (BDI-II)

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Examples Of Symptom Assessments Used To Evaluate
Outcomes

• Attention and distractibility
• Parent report/teacher report
• Conners Rating Scales

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Examples Of Symptom Assessments Used To Evaluate
Outcomes

• Anxiety
• Self-report
• Revised Childrens Manifest Anxiety Scale
• Parent report
• Achenbach Child Behavior Checklist
  internalizing scale

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Use 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)

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Use 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

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Using Outcome Data For Program Improvement

• Is there a particular group of patients we should
  target for improved outcomes?
• age
• diagnosis
• type of problem

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Improving Outcomes For Target Population

• Is there an Evidence Based Treatment available
  for this group of patients?

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Program Improvement Process

• Review of outcomes
• Systematic modification of intervention

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Most 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.

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Garland, 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

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Garland, 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

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Garland, 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

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Garland, Kruse, Aarons, 2003

• 92 of clinicians reported never using scores
  from standardized measures for
• Treatment planning
• Treatment monitoring
• Assessing outcomes

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Barriers 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

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Barriers to Use of Standardized Outcome Measures

• Cost
• Testing materials
• Time
• Patients
• Parents
• Teachers
• Providers

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Barriers to Use of Standardized Outcome Measures

• Difficulty interpreting results of assessments
• Qualifications needed to use assessments
• Additional training needed to use assessments

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CONCLUSIONS

• Use of standardized assessments can improve
  clinical decision making and outcomes for
  children and adolescents with mental health
  problems

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CONCLUSIONS

• In order for standardized assessments to improve
  outcomes the following issues need to be
  addressed
• Feasibility
• Training

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CONCLUSIONS

• 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