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Evidence Based Practices for Children and
Adolescents with Serious Emotional Disturbances
Session 2:
The Role of Assessment In EvidenceBased Mental Health Practices for
Children and Adolescents
Beth Troutman, PhD, ABPP
Iowa Consortium for Mental Health
September 1, 2005
Assessment Data Can Be Used To Enhance Clinical
Decision Making At The Level Of
System of care
Program
Individual patient/family
Assessments Evaluated According To
Psychometric Properties
Reliability
Validity
Assessment Data Can Be Used For
Treatment planning
Monitoring treatment
Assessing outcomes
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?
Treatment planning
Assessments can be used to inform
Type of intervention
Level of care/service intensity
Other factors that need to be addressed
Describing Patient/Target Population
Diagnosis
Target Symptoms
Other Factors
Functional Status
Using Initial Assessment Data for
Treatment Planning
Diagnosis
Initial Assessment & Treatment
Planning
Diagnosis
Primary
Comorbid
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.
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
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
Using Initial Assessment Data For
Treatment Planning
Describing Target Symptoms
Describing Target Symptoms
Symptom measures
Broadband
Symptom specific
Factors To Consider When
Selecting Assessment Instrument
Source of information
Child
Parent
Teacher
Factors To Consider When
Selecting Assessment Instrument
Clinician rated vs. respondent rated
Norm-referenced vs. criterionreferenced
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.
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.
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.
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 (> 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
Rates and Types of Mental Health
Problems in Iowa’s Family Foster Care
Population
60
40
Total Problems
Externalizing
Internalizing
20
0
Percent in Clinical Range
Momany et al., University of Iowa Public Policy Center
Example of Symptom Specific
Measure – Attention Problems
Parent/teacher report
Conners rating scales (Psychological
Corporation)
Examples of Symptom Specific
Measures - Depression
clinician ratings
Children’s 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)
Using Initial Assessment Data For
Treatment Planning
Assessing Other Factors That May
Affect Treatment Planning
Child Factors That May Affect
Treatment Planning
Cognitive functioning
Academic functioning
IQ tests
Standardized academic tests
Speech and language functioning
Standardized speech and language tests
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)
Using Initial Assessment Data For
Treatment Planning
Assessing Functioning Level and
Level of Services Needed
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?
Examples of Functional
Assessment/Service Intensity Instruments
Clinician ratings
Children’s 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)
Using Assessment Data For
Program Improvement
Using Assessment For Program Improvement
Assessments can be used to
Monitor treatment
Assess outcomes
The Evidence Based Practice Cycle
Quantify
Priority
Outcomes
Regularly
Specify Core
Components
of Practice
Optimize
Priority
Outcomes
Modify Core
components
of Practice
Review
Outcomes
Regularly
Role of Assessment
in EBP Cycle
Target Population
Diagnosis
Target symptoms
Functional status
Other factors
Outcomes
Identify
Prioritize
Quantify
Treatment Monitoring
Is my patient benefiting from the
intervention?
Are there any negative consequences
(side effects/iatrogenic effects)
associated with the intervention?
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.
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
Using Assessment Data For
Program Improvement
Assessing Outcomes
Assessing Outcomes
Did my patient benefit from the
intervention?
Are patients in our program/system of
care benefiting from interventions?
Assessments Used to Evaluate
Outcomes
Diagnosis
Target Symptoms
Other Factors
Functional Status
Use Of Diagnosis To Evaluate Outcome
Recovery/remission of diagnosis is
relevant for some diagnoses:
E.g. depressive episode, adjustment
disorder
Use Of Diagnosis To Evaluate Outcome
Diagnosis may not be useful for
evaluating outcomes for other
disorders
E.g. Attention Deficit Hyperactivity
Disorder
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?
Examples Of Symptom Assessments
Used To Evaluate Outcomes
Depression – self-report
Children’s Depression Inventory
Beck Depression Inventory – Second
Edition (BDI-II)
Examples Of Symptom Assessments
Used To Evaluate Outcomes
Attention and distractibility
Parent report/teacher report
Conners’ Rating Scales
Examples Of Symptom Assessments
Used To Evaluate Outcomes
Anxiety
Self-report
Revised Children’s Manifest Anxiety Scale
Parent report
Achenbach Child Behavior Checklist – internalizing
scale
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)
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
Using Outcome Data For Program
Improvement
Is there a particular group of patients we
should target for improved outcomes?
age
diagnosis
type of problem
Improving Outcomes For Target
Population
Is there an Evidence Based Treatment
available for this group of patients?
Program Improvement Process
Review of outcomes
Systematic modification of
intervention
Most Clinicians Do Not Use
Standardized Assessments
Reference: Garland, A., Kruse, M., &
Aarons, G. (2003). Clinicians and
outcome measurement: What’s the
use? Journal of Behavioral Health
Services & Research, 30(4), 393-405.
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
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
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
Garland, Kruse, & Aarons, 2003
92% of clinicians reported never using
scores from standardized measures for
Treatment planning
Treatment monitoring
Assessing outcomes
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
Barriers to Use of Standardized Outcome
Measures
Cost
Testing materials
Time
Patients
Parents
Teachers
Providers
Barriers to Use of Standardized
Outcome Measures
Difficulty interpreting results of
assessments
Qualifications needed to use
assessments
Additional training needed to use
assessments
CONCLUSIONS
Use of standardized assessments can
improve clinical decision making and
outcomes for children and adolescents
with mental health problems
CONCLUSIONS
In order for standardized assessments to
improve outcomes the following issues need
to be addressed
Feasibility
Training
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