Transcript Business Plan - University of Iowa

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