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Clinical psychology assessment, full procedure, types of interviews, test battery, ethical issues, can be adapted to any age, it is the format and structure that counts.
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WESTERBERG, V.
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175.782.- CLINICAL PSYCHOLOGY ASSESSMENT
PSYCHOLOGICAL ASSESSMENT IN CHILDHOOD
Psychological assessment of childhood and adolescence stems from the evaluation of
the adult population, inheriting its same problems and limitations. Until well into the
18th century, the child was considered a miniature adult. From the 1970's, this way of
understanding childhood changed, recognising the specific nature of child development
taking into account sensorimotor, cognitive, behavioural, and social variables, although
child assessment remained primarily focused on classification and diagnosis. It is from
the 1980's when evaluation also aimed at specific ways of data collection, evaluation
design and treatment implementation (Shapiro & Kratochwill, 1988; Gregory, 2011).
Adequate child psychological assessment should include multiple methods (multi-
method assessment) like (interviews, direct observation, questionnaires, etc., given to
different people (parents, teachers, children themselves, etc.), referenced to different
contexts (home, school, etc.), and include both familial and extra-familial assessment
(McMahon, 1987). Looking at the specific functions that should be evaluated in the
clinical psychological assessment of children, the following should be considered:
Motor skills (manual dexterity, right-left orientation, orofacial praxis, verbal control of
motor skills), perception (visual, auditory and tactile or haptic), language (receptive and
expressive skills of oral language, academic skills in literacy and numeracy), memory
(verbal and nonverbal, short and long term), general cognition (general intellectual
ability, attention span), relationships and behavioral abnormalities, basic functions
alterations (sleeping, feeding, toilet training), and psychopathology (mood disorders,
psychosis, autism, and borderline cases) (Weissman, 2011; Groth-Marnat, 2009; Kline,
2000; Merrell, 2003).
A psychological assessment covering all the above functions, together with other
relevant information from interviews, medical records, clinical observations, etc., is a
prerequisite for obtaining a complete patient evaluation (Gammon, 2012). Methods of
evaluation are all those scales and standardized tests that provide the child or
adolescent evaluated score points (quantitative measures), as well as those that help
clinicians understand the contents, conflicts and underlying motivations (qualitative
methods). However, one more thing should be considered in the process of
psychological assessment: cost in terms of time and resources. That is the reason why a
some researcher has critisised multi-method evaluation, claiming they have little
empirical grounds for added effectiveness and that the amount of data collected does
not necessarily correlate with information quality (Wicks-Nelson & Israel, 2009). That
said, multi-evaluation is the gold standard in clinical psychology assessment practice for
a very good reason: it makes nothing but all the sense.
Two major diagnostic concepts have been developed for clinical assessment: categorical
classification systems and dimensional-statistical systems. Categorical systems include
different versions of the Diagnostic and Statistical Manual of Mental Disorders (DSM)
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(APA, 1980), the International Classification of Mental Disorders (ICD) developed by the
WHO (1992), and the Group for Advancement of Psychiatry (GAP, 2009) classification
system focused on evolutionary aspects of psychological development. Categorical
systems are based on expert consensus, in literature review and in correlational level
data to establish the inclusion and exclusion criteria that determine an individual's
belonging in one or another category. In contrast, dimensional systems have focused on
creating empirical knowledge for which they performed statistical analyses (like
factorial analysis) by pooling data from many symptoms that are likely belong to each
category (Sadock & Sadock, 2009; APA, 1980; WHO, 1992; GAP, 2009).
Dimensional systems have established three main dimensions for grouping child and
youth disorders: externalizing disorders (hyperactivity, aggression, delinquency),
internalizing disorders (personality disorders, anxiety, inhibition) and mixed or
combined disorders (social problems and attention and memory abnormalities). The
basis for this classification was informed by the Child Behavior Checklist, the Teacher
Report Form, and Youth Self-Report discussed below under the psychometric tests
section (Achenbach et al., 2001).
New Zealand psychologists follow the American Psychiatric Association’s Diagnostic
and Statistical Manual (DSM) categorical diagnostic system (NZPS, 2012) based on a
multiaxial system consisting of five axes: Axis I includes clinical disorders and other
mental conditions requiring clinical attention, which include disorders beginning in
childhood or adolescence. Axis II includes personality disorders and mental retardation.
Axis III includes medical conditions causing mental disorders. Axis IV refers to the
psychosocial and environmental causes of mental disorder and axis V is the global
assessment of functioning (GAF) in the past year (APA, 1980; Sadock & Sadock, 2007;
Wick-Nelson & Israel, 2009).
Looking now at children’s psychological assessment processes, these usually include an
interview with the parents (one or more), an interview with the child (play time
diagnosis), direct observation, a test battery (projective and/or psychometric tests) and
a return interview (parent – child with the psychologist), all of which will inform the
written report. These will first be described in general, focusing on the process more
than on the contents, and then specific mention will be done to assessment instruments
(Weissman, 2011; Gingsburg, 1997; Greenspan & Greenspan, 2003).
Children evaluation processes are longer than adults’. The starting point is usually a
categorical approach, that is, an interview with the parents because children are usually
not aware of having any problem at all and it is third parties who detect the problem
and refer the child to the psychologist for evaluation (Weissman, 2011; Gingsburg,
1997; Greenspan & Greenspan, 2003).
The interview is a pre-diagnostic technique essential in the psychological assessment
process because of the amount of information and personal knowledge that is obtained
in very little time. It develops through a purposeful conversation focusing on the
explanation of the problem of the subject. It openly reflects the request for assistance of
the interviewee. The information collected from the client is part wide and general and
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in part specific and concrete. The goal of the interviewer is to identify and clarify the
reason for consultation. The interview takes place at a predetermined time and location,
and usually lasts one hour.
The role of the psychologist conducting the interview includes a responsibility to gather
information to obtain knowledge about the client and his or her environment. The
clinician must exert control of the direction of the interview at the same time that he or
she is flexible with its contents and with his/her interaction with the client. The act of
interviewing involves an interpersonal relationship with the client where they mutually
influence and learn from each other. This interpersonal relationship functions as a
gestalt. Ethical issues like informed consent to diagnosis and treatment, and
confidentiality must be addressed at this point and will be considered later together
with the clinical report discussion (Weissman, 2011; Gingsburg, 1997; Greenspan &
Greenspan, 2003; Sommers-Flanagan & Sommers-Flanagan, 2008).
Interviews can be structured (Diagnostic Interview Schedule for Children and
Adolescents [DICA], Diagnostic Interview Schedule for Children Revised [DISC-R], Child
Assessment Schedule [CAS]) or semi-structured (Interview Schedule for Children [ISC],
Schedule for Affective Disorders and Schizophrenia for School-age children [K-SADS]).
Structured interviews have the advantage of being highly yielding in terms of objective
information, have greater validity and reliability than semi- and non-structured
interviews, and are used as an instrument not just for diagnosing but for screening,
clinical research and clinical training support. The disadvantages include those of
communication issues on the part of both the interviewer and the interviewee like
speech impairments, language used not being mother tongue, taboo questions (sex,
habits, drugs) being too direct, and social desirability (Weissman, 2011; Weller et al.,
2000; Achenbach & Rescorla, 2001; Wick-Nelson & Israel, 2009; Gingsburg, 1997).
At the end of the interview with the parents, the psychologist suggests treatment plan
options, agrees to one with the parents, and parents, then, commit themselves to
complying with the treatment for their child. Usually a minimum of two interviews are
held with the parents: the first one is focused on what is happening with the child
(explanation or description of issues, duration, identification of triggering and
maintenance factors when possible, etc.), and a second one to take additional relevant
history like pregnancy, development, family history of psychological or medical
conditions, social and cultural aspects relevant to the case, and inquires about the
parents or caregivers, relationships in the family, the position the child occupies in the
family, etc., with the aim to get additional valuable information and achieve a greater
rapport with and involvement of the parents (Gammon, 2012; Sommers-Flanangan &
Sommers-Flanagan, 2008; Weissman, 2011; Hodges, 1993; Shaffer, 1994; Lubin, Larsen,
& Matarazzo, 1998; Greenspan & Greenspan, 2003).
After the interview with the parents, an interview with the child is scheduled. With very
young children or children with lack of verbal expression, diagnostic play is used
because it has equivalent symbolic capacity to words, it is easy to perform and engages
the child in the diagnostic process without unnecessary stress. Thus, by observing
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which toys the child selects, how he uses them and what he does with them, the
specialist can see his development, fears, defenses, anxiety, and his strategies for
change. After the age of about 12 years of age interviews are often used because the
individual has the capacity to express what is happening to him (Gammon, 2012;
Reynolds, 1998; Greenspan & Greenspan, 2003; Lubin, Larsen, & Matarazzo, 1998;
Merrell, 2003; Weissman, 2011). During the interview, the clinician also observes how
the child behaves and interacts with parents and psychologist. Direct observation in the
child’s environment (home, school, playground) can provide very useful information
but it is difficult to obtain directly by the psychologist, so it is parents and teachers who
do so (Achenbach & Rescorla, 2001).
The next session would be the test battery, of which the order of application is usually
first projective, then psychometric tests. The rationale for this order is that projective
tests are open, that is, the individual constructs them from a free, general perspective.
Projective tests have the advantage of all responses being valid, correct and good, and of
having no time constraints. As they imply a non-structured task, the child finds them
easy to do and does not feel judged or critisised, because the purpose of the test is not
revealed or clear for the child. The application of projective tests usually starts with
graphic (drawing) tests (Buck’s HTP, Machover’s DPT, Corman’s DFT), followed by
verbal tests (Duss fables, Pigem test), Rorschach test, and aperceptive tests (Bellack’s
CAT, Corman’s Black Paw). Other commonly used projective test is Phillipson ORT
(Murstein, 1965; Lubin, Larsen & Matarazzo, 1984; Klopfer, 2006).
Projective tests have the added strength of increasing the rapport between child and
psychologist, they are cost-time effective and when conducted by experienced
professionals they yield very useful, robust and unique results. These techniques are
used to study overall trait behaviour, that is, personality. The limitations of the
projective tests are the same for all of them: their validity and reliability is limited
because of the reduced amount of research backing them, the subjectivity of their
interpretation reflected in extremely low inter-rater reliability, the limited amount of
hypotheses that can be drawn from them, and the high influence in results of contextual
variables (culture, ethnicity). Buck’s HTP test deserves a special mention as literature
review has shown a high correlation with intelligence tests (WISC-R and WAIS) and
there is some evidence that the HTP can differentiate people with specific types of brain
damage like that present in individuals with schizophrenia (Kline, 2000; Merrell, 2003;
Klopfer, 2006; Butcher, 2010; Hojnoski, 2006).
Psychometric tests are applied afterwards, as it is much easier to move from a non-
structured field to a structured one. It should be highlighted that, as evidenced in this
work and contrarily to common belief among students, psychometric testing is only one
part of the psychological assessment process.
Psychometric tests are “closed” techniques where answers are true or false, right or
wrong, the psychologist interprets them, and comes up with an overall score. There are
time limits, time is measured with a stopwatch and when the time is up, the test is
interrupted even if the subject has not ended. The purpose of the test is clear for the
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individual, he knows what he is being asked and what is expected of him, and may feel
anxious when responding. Psychometric tests tend to generate a relationship of
dependence with the psychologist. These tests are specific for analyzing traits, states,
and attitudes (Groth-Marnat, 2009; Kline, 2000; Lubin, Larsen, & Matarazzo, 1984;
Klopfer, 2006) and results may be used to inform axis I and II of the DSM-IV-TR
disorder diagnoses. A review and comparison of the most commonly used psychometric
tests follows:
Intelligence: Wechsler Intelligence Scale for Children Revised (WISC-R), Wechsler
Preschool and Primary School Scale of Intelligence (WPPSI), Stanford-Binet Intelligence
Scale (SB5), Raven’s Progressive Matrices (RPM) and Kaufman’s Assessment Battery for
Children (K-ABC) (Groth-Marnat, 2009). These intelligence scales vary in theoretical
approach, item number, design, clarity, length, age range application and skills required
for completion. A major criticism to the WISC-R is that the working memory assessment
includes only auditory tasks and does not include non-verbal tasks such as McCarthy’s
xylophone test or K-ABC’s spatial memory evaluation. Wechsler tests are redundant in
that too many sections are focused on the analysis of almost exclusively quantitative
general intelligence, marginalizing other aspects of intellectual functioning. The RPM
has the added advantage over Wechsler, Kaufsman and Stanford-Binet tests in that it
requires no manipulative skills, it aims to measure not general intelligence but an
important aspect of it, the ability to deduct relations, and in that it fits into Cattell’s
category of non-cultural psychological assessment tests. Additionally, RPM and K-ABC
differ from WISC-R and SB5 in that, in the former, the child requires minimal to no
language abilities, respectively, to complete the tests (Groth-Marnat, 2009; Kline, 2000;
Sadock & Sadock, 2007, Weller et al., 2000; Wicks-Nelson & Israel, 2009).
Developmental: Newborg et al.’s Developmental Inventory and McCarthy’s Scales of
Children Abilities (MSCA) are similar in orientation and age range but differ in that the
former can be given to children with or without cognitive or sensorimotor disabilities
and has a screening and full mode of application, and in that the latter is presented in a
stress-preventing ludic way (Kline, 2000; Sadock & Sadock, 2007, Weller et al., 2000;
Wicks-Nelson & Israel, 2009).
Memory: Wide Range Assessment of Memory and Learning (WRAML), Children’s
Memory Scales (CMS), and Benton’s visual retention test (BVRT). These are the most
commonly used memory assessment tests in children. They have high criterion validity
when compared with medical imaging techniques, like MRI. They are used to assess the
diagnosis of brain pathology and Benton’s test assesses premorbid intelligence status
(Groth-Marnat, 2009; Kline, 2000; Sadock & Sadock, 2007, Weller et al., 2000; Wicks-
Nelson & Israel, 2009).
Neuropsychological: Halstead-Reitan battery for older children, Reitan-Indiana battery
for young children, Quick Neurological Screening Test (QNST), Luria’s Neuro-
Psychological test for children (NEPSY), and the Luria-Christensen test are widely used,
researched and validated neuropsychological instruments that assess superior cortical
processes. Research shows that Luria tests have a very high degree of overlapping with
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Reitan batteries in the identification of neuropsychological deterioration due to
traumatic brain injuries and psychiatric disorders (Costa et al., 2004), which is
interesting given that their factorial structure is completely different. Similarly,
overlapping between Luria-Nebraska and WISC-R is significant in some scales, like E11
and global IQ. Luria’s NEPSY test also correlates with K-ABC test in academic skills
scales but only moderately, and correlations are negligible in the remaining scales. With
the exception of the QNST, these tests are time and attention-ability consuming and
some children with neurological impairment may not finish them (Kline, 2000; Weller
et al., 2000; Costa et al., 2004; Wicks-Nelson & Israel, 2009).
Academic-educational: Thorndike, Hagen and Lorge Cognitive Ability Test, Wechsler
Individual Achievement Test (WIAT-II), Woodcock-Johnson Achievement Test (WJ-III),
and Kaufman Test of Educational Achievement (KTEA-II) are all collective, normed tests
that assess basic skills and attitudes for learning. Their validity and reliability is good in
the United States, but generalisability to other countries with different educational
systems and syllabuses poses a limitation to their applicability (Kline, 2000; Sadock &
Sadock, 2007, Weller et al., 2000; Wicks-Nelson & Israel, 2009).
Behaviour: Child Behavior Check-list (CBCL) (Achenback & Edelbrock, 1985) and
Youth Self Report (YSR) (Achenback & Edelbrock, 1987). The CBCL evaluates a wide
range of adaptive and problem behaviours of children. There is a version for parents
and another for teachers (TRF) and can be used with both clinical and non-clinical
individuals. The CBCL informs three groups of disorders: externalizing (hyperactivity,
aggression, delinquency and other problems), internalizing (depression, isolation,
obsession-compulsion, somatic complaints, and schizophrenia) and the combined or
mixed type which encompasses sexual problems and social isolation. The psychometric
characteristics of the scale are robust in terms of test-retest reliability (Achenbach et al.,
2001), concurrent validity and discriminant validity. The YSR is a scale that refers to
social adjustment and behavior problems whose content is similar to the Child Behavior
Checklist (CBCL) but is applied to adolescents. Likewise, the indices of reliability and
validity of the YSR are similar to those of the CBCL (Achenbach & Rescorla, 2001; Wick-
Nelson & Israel, 2009; IESC, 2012).
ADHD: Conners Teachers Rating Scale (CTRS) and/or Abbreviated Teachers
Questionnaire and Conners Parent Rating Scale, when combined, they are said to
provide robust evidence of ADHD in children (Conners & Jett, 2006). However, in a
current research article Silva (2011) claims that, based on the DSM-IV-TR criteria, CTRS
has limited ability to predict ADHD in schoolchildren, a view opposed by researchers
like Hale et al. (2001) and Ghassemi et al. (2009) who find the scales valid, practical,
easy to apply and relatively inexpensive.
Personality: Millon’s Pre-Adolescent Clinical Inventory III (M-PACI) is the only
relatively commonly used screening instrument for the assessment of specific
psychopathologies or emotional problems in children, and correlates highly with the
TAT, which enhances the criterion validity of the latter. Recent publications defend the
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use of projective techniques in the evaluation of children’s personality (Trull, 2005;
Klopfer, 2009).
Relationships: Jones, Reid and Patterson’s Family Interaction Coding System (FICS),
the Robinson and Eyberg’s Dyadic Parent-Child Interaction Coding System (DPCICS) and
Vineland’s Adaptive Behavior Scales (VABS). The FICS is a classical coding system that
assesses family, school and laboratory environment interactions between parents and
child (La Greca & Stone, 1992), whereas the DPCICS focuses on the evaluation of
behaviours in the parent-child dyad interaction. The main advantage of the VABS over
the FICS and the DPCICS is its comprehensiveness, as it includes evaluation of daily life
activities and abilities in personal, family, and social contexts, as well as the study of free
time activities. The limitation of these psychometric tests leads to their restricted
application because of the extensive training required to administer and interpret them.
Structured observations are more yielding and cost-effective (Jacob, Tennenbaum, &
Bargiel, 1995; IESC, 2012).
Continuing with the psychological assessment procedure for children, after the
interviews and the psychological tests, a repeat interview is done where the results of
the evaluation process, along with further guidance is explained the parents and the
child. As in the case of the first interview, it is first done with the parents and then with
the child. Some discrepancies arise at this point, as some clinicians, depending on the
child’s age, choose to speak first with the child, claiming that the child is their patient is
the first one who should know what the outcome of the process is. However, a child is
not responsible enough to understand a diagnosis or comply with a therapy, and it is the
parents in any case who have to agree to it. In the case of adolescents it is best to talk to
them directly because they have the capacity to understand and to ask questions about
their therapy. With regard to a joint interview, again, controversy arises in that some
clinicians claim that a different language should be used when speaking with the
parents than when speaking with the child and that the privacy of both should be
preserved (Merrell, 2003; Westwater, 2012; Reynolds, 1998; Weller et al., 1999).
The written report is a professionally written explanation of the case history, evaluation
process, diagnostic impression, proposed therapeutic approach/es, and
recommendations. Sometimes, an informal, non-technical letter summarising the
contents of the report is sent to the parents (or the patient depending on age) on
request (Babbage, 2012). Section 29 of the NZ Law Commission addresses the issue of
report writing, making special emphasis on Family Court reports (NZLII, 2012). At this
point the critical issue of ethics arises again. It is particularly important to make a clear
diagnosis of the child and that it is adjusted to the child’s age and disorder, as
psychological diagnoses have the risk of having pervasive influences, influencing the
child’s future particularly in terms of academic / professional development and
integration in society. Diagnoses and treatments have a special impact on pediatric
population because children are undergoing maturation and mere labelling, non-
resolution or chronicity of the disease could create a situation of disability throughout
life (Gingsburg, 1997; Roberts, Moar, & Scott, 2011; Greenspan & Greenspan, 2003;
Sachse & von Suchodoletz, 2008)
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Child psychologists face critical ethical questions like, who is my client? The parents or
the child? What to do when a mature child’s will regarding treatment opposes that of
the parents’? Does a mature child, like an adult, have the right to refuse treatment when
non-treatment may result in harm to self and / or others? What type of information
must be included in the clinical report and who owns it? Should confidentiality be
breached to inform third parties with regard to risk issues to self (suicide and special
needs) or others? (Sondheimer, 2010; Sommers-Flanagan & Sommers-Flanagan, 2008;
Brierley & Larcher, 2010).
Clinicians, particularly those specialised in children and adolescents’ psychology,
understand psychological assessment in a holistic and practical way. They evaluate
themselves for best clinical practices, technical knowledge, continuing professional
education and professional practice updates, and, very importantly, aim to abide by
Beauchamp and Childress’ (1994) deontological principle: primun non noscere (first of
all, do not harm).
[Word count without references: 3620]
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