The Clinical Assessment of Children and Adolescents

A Practitioner's Handbook

Steven R. Smith, Leonard Handler, Steven R. Smith, Leonard Handler

• Publisher: Routledge
• Year: 2014
• Print ISBN: 9780805860757
• eBook ISBN: 9781317855972
• Topic: Psychology
• Subtopic: Clinical Psychology
• Index: Psychology

This book highlights assessment techniques, issues, and procedures that appeal to practicing clinicians. Rather than a comprehensive handbook of various tests and measures, The Clinical Assessment of Children and Adolescents is a practitioner-friendly text that provides guidance for test selection, interpretation, and application. With topics ranging from personality assessment to behavioral assessment to the assessment of depression and thought disorder, the leaders in the field of child and adolescent measurement outline selection and interpretation of measures in a manner that is most relevant to clinicians and graduate students. Each chapter makes use of extensive case material in order to highlight issues of applicability.

Chapter

1

THE CLINICAL PRACTICE OF CHILD AND ADOLESCENT ASSESSMENT

Steven R. Smith

University of California, Santa Barbara

Leonard Handler

University of Tennessee

The use of tests and measures to understand our patients is one of the hallmarks of applied psychology. Unlike the practices of psychiatry, social work, and other allied mental health disciplines, psychologists rely on measurement to quantify patient cognitive functioning, psychopathology, behavior, strengths, neuropsychological performance, aptitudes, attitudes, and social contexts. Following the empiricist’s creed, much of applied psychological assessment rests on the assertion of Thorndike (1918) that “whatever exists at all exists in some amount” (p. 16).

However, the clinical practice of psychological assessment with children and adolescents is different from the mere nomothetic measurement ideal proposed by Thorndike. In fact, a distinction must be made between psychological assessment and psychological testing. Although psychological assessment includes testing, it is far more complex and rife with clinical challenges. Handler and Meyer (1998) clarify the important distinction between psychological testing and psychological assessment, and they emphasize that these are hardly synonymous activities. They state:

Testing is a relatively straightforward process wherein a particular test is administered to obtain a specific score. Subsequently, a descriptive meaning can be applied to the score based on normative, nomothetic findings. For example, when conducting psychological testing, an IQ of 100 indicates a person possesses average intelligence... Psychological assessment, however, is a quite different enterprise. The focus here is not on obtaining a single score, or even a series of test scores. Rather, the focus is on taking a variety of test-derived pieces of information, obtained from multiple methods of assessment, and placing these data in the context of historical information, referral information, and behavioral observations in order to generate a cohesive and comprehensive understanding of the person being evaluated. These activities are far from simple; they require a high degree of skill and sophistication to be implemented properly, (pp. 4–5)

A comprehensive psychological assessment includes information from the referring individual; from the child’s or adolescent’s parent(s) (including a thorough interview and history); from the child or adolescent himself or herself; and from his or her teacher(s) and other relevant informants, such as physicians, relatives, or friends. In addition, to complete a thorough and meaningful assessment, the clinician must help the child’s or adolescent’s caretakers, the child or adolescent, and perhaps the referring individual to formulate relevant referral questions to be answered by the assessment. After all this activity, including testing the child or adolescent, the clinician then aggregates and integrates the data, writes the report, and provides feedback to the referral source, as well as to the parents and the child or adolescent tested. Compared with this complex series of activities, psychological testing is a far more simple procedure.

Unique Challenges in the Assessment of Children and Adolescents

It is often the complexity of psychological assessment, rather than psychological testing, that poses several challenges to the assessor, particularly when he or she is working with younger patients. The range of cognitive, affective, and contextual variables that affect a child’s or adolescent’s performance is seemingly limitless and calls upon a wide array of clinical skills on the part of the assessor. Next follows a discussion of the more important issues that assessment psychologists often face when they work with younger patients.

1. Children (and many adolescents) lack the ability to describe their feelings and experiences. They lack the adult’s ability to conceptualize and contextualize their experiences and the ability to describe them to adults. It is difficult to use traditional interviews in the assessment of children, especially young children (although this is less true with adolescents) because children also lack the words with which to express their thoughts and feelings. For example, asking a child how he or she feels about an issue will often result in a response of “I don’t know.” The examiner might erroneously conclude that the child is defensive or is withholding information, even though the child’s response is probably accurate—he or she may not really know how to answer this question. Therefore, poor performance by children may not reflect a lack of knowledge, but, rather, a lack of the capacity to comprehend the complexity of their world and the relevance of various activities to their well-being.

In addition, although children may be able to say, for example, “my teacher is mean,” they will typically be unable to describe why they feel that way, or may not be able to explain what the teacher does that makes the teacher “mean.” To make matters even more complicated, this opinion of the teacher, or of other people in the child’s life, may be transitory, changing with the next positive interaction he or she has with this person.

2. Siegel (1987) makes a very important point concerning the assessment of children. She states, “Children do not appear for a psychological evaluation of their own volition” (p. 15). She adds, “During the early stages of the examination [and perhaps in later stages as well] the child communicates, in open or hidden ways, feelings of trepidation about the unfamiliar experience that awaits him [her]” (p. 23).

Children and some adolescents have little ability to conceptualize the reasons they are being assessed. They typically compare the assessment process with the only similar experience they have had—school testing. Therefore, they come to the assessment sessions with anxiety and concern about giving correct answers. This is especially so if the child or adolescent has one or another kind of learning problem, because the child fears even more the possibility that he or she will “fail” the examiner’s tests. In addition, given that the examiner is not to provide feedback concerning whether the child’s response is correct or incorrect, the child cannot determine whether he or she has responded successfully. Most often, however, children conclude that their answers are incorrect, and they often feel “dumb” or “retarded.”

This problem is especially troublesome when the child takes a projective test, such as the Rorschach or a storytelling test, because there are few or no right or wrong answers. Therefore, the child is left guessing even more so about whether his or her responses were correct. This situation therefore engenders even more anxiety than the child had upon first entering what was already experienced as an unusual and strange situation. Often, children take a defensive stance to deal with their underlying anxiety, calling the tests and/or the examiner “stupid” or otherwise criticizing the tests.

3. The assessor must work quite hard to assist the child or adolescent with his or her anxiety, providing a “holding environment” (a setting of safety and comfort; Winnicott, 1965), as much as this is possible to do with a relative stranger. Schafer (1954, 1956) indicates that even adults find the assessment relationship stressful, and they respond with regressive and self-blaming behavior. Thus, the assessor must make every effort to make the assessment process more like play rather than like school-related work and tests. In addition, the assessor must accomplish this feat without changing the standardized administration directions. Although this is possible to do with some tests (e.g., the Draw-A-Person Test, the House-Tree-Person Test, the Kinetic Family Drawing Test, and some storytelling tests), it is more difficult to make some tests, such as the Rorschach or some self-report measures, playful.

4. Often, to maintain rapport and cooperation, examiners must process the child’s experience with each test the child experienced as problematic or anxiety-producing. In addition, in order to decrease resistance, some examiners provide for the child or adolescent posttest exploration of his or her responses, finding ways in which the child can derive more successful answers to questions he or she had previously failed (see Handler, 1998, 1999, 2002,2004b, 2005 for a discussion of this approach). This gives the child a feeling of success and provides the examiner additional clues concerning the child’s problems.

It is also important to note that the children and adolescents we test are typically children with emotional and social problems of different kinds and therefore they are more vulnerable to the pressures engendered in the assessment situation. These children and adolescents tend to degrade themselves when they feel they have missed test items, and often berate themselves. Children and some adolescents have a poorly developed sense of self. Therefore, they are very sensitive to what they might perceive as their poor performance, especially because the examiner cannot offer them feedback concerning the adequacy of their responses. Children evaluate their success by focusing on the adult’s feedback to them (Kohut, 1977). If this is not forthcoming, they almost automatically believe they are wrong or at fault.

5. Children and many adolescents do not understand why they are being assessed, despite the fact that parents and/or assessors attempt to explain the reason(s) they are being tested. What they are aware of is that their parents or their teachers are unhappy with some aspect of their performance or their behavior. However, they do not see the relevance of the assessment, nor can they comprehend that by these procedures the answers to their problem issues will be understood. Therefore, they are often not ego-involved in the process, which can make them even more restless and avoidant during the assessment sessions.

6. Some children and adolescents somehow understand that the assessor is someone who might help fix the problem they are having and will sometimes be able to tell the assessor directly, but more often indirectly, through metaphor, what is wrong. However, in traditional assessment, because the assessor needs time to evaluate the data and write a report, the child or adolescent leaves without helpful feedback. Therefore, because the child or adolescent cannot comprehend the complexity of the assessment process for the assessor, he or she leaves the assessment sessions disappointed and might well view the experience as an empathic failure. D. W. Winnicott writes about this problem in the following quote:

It often happens that we find a child has given all to the psychologist who is performing an intelligence test, and the fact that the material presented has not led to understanding (this not being included in the psychologist’s aims) has proved traumatic to the child, leading to a strengthening of suspicion and unwillingness to give the appropriate clues [about his or her problem]. This especially applies in TAT tests in which the patient has reached to unexpected ideas, fears, states. For this reason I have always seen my patients first, referring them to the psychologist where necessary, after I have come to grips with the case by doing something significant in the first interview or first few interviews. (Winnicott, 1989, pp. 319–320)

7. Many children have separation anxiety as one of their problems. They might therefore refuse to separate from the parent or parents who bring them for the assessment. Although most children accompany the assessor without any apparent problem, many others are fearful, with feelings ranging from mild uneasiness to complete terror about separating from the parent. These emotions can persist in the assessment room, permeating the relationship, affecting test results, and making the assessment experience tolerable at best.

Although most children and adolescents will comply, albeit reluctantly, with the examiner, there are nevertheless a significant number of children and adolescents who are very difficult to test because of resistance or behavioral noncompliance. They resist the examiner in various ways, both directly and indirectly. Although this resistance may be due to the cognitive issues, interpersonal problems, or anxiety discussed above, children and adolescents who are behaviorally difficult call for the utmost creativity, flexibility, and clinical skill on the part of the assessor.

Case examples illustrate this point nicely. For example, Roxanna was a 16-year-old girl I (SRS) saw on an acute-care inpatient psychiatric unit. A full assessment was requested in order to assess for disordered thinking or other serious mental illness that might help to explain her erratic and self-destructive behavior prior to hospitalization. She struck a tough pose with me, her peers, and the other clinical staff and referred to all of the assessment materials as “kid stuff” and “bullshit.” When I would encourage her and praise her performance during cognitive testing, she would sarcastically respond, “Yeah, like I was really trying.”

The Rorschach was particularly difficult for Roxanna. The unstructured and somewhat “mysterious” nature of the test brought about the anxiety normally masked by her somewhat antisocial presentation. She immediately rejected Card I, and it was clear that she would not be a willing participant in the assessment. The following day, I met again with Roxanna, but this time, I brought along some paint and paper. Although initially reluctant (because this was “bullshit,” too), she agreed to make inkblots with me, using lots of color and eagerly folding each paper in half to see what she had made. After “defusing” the inkblots in this manner, I was able to convince her to give the Rorschach another try.

The reason for her initial anxiety about engaging in the Rorschach task was immediately clear, because she produced a profile that was rife with aggressive and personalized responses with very poor form and reality testing (e.g., on Card VI, she responded, “This is my father hitting my mother; I’m down here trying to stop him”). It was evident from her responses and score profile that she was struggling with a psychotic process that was tinged with primitive aggression. After completion of the Inquiry portion, she asked if we could make inkblots again, and I agreed to do so. As a way of taking ownership of her fears, she kept these “homemade” blots and hung them on the walls of her room at the hospital.

Another case example is provided by Kelly (1999):

When the examiner came to get Virginia, [an eight year-old girl, she announced] that she was busy and that [the examiner needed] to wait. From the outset Virginia attempt[ed] to be in control [of the assessment process], want[ed] to know if she [was] giving the right answers [to] the WISC-R [questions], and pout[ed] when the examiner suggested] she just try and do her best. At times she [was] distractible, inattentive, hyperactive, and markedly impulsive. Her ability to tolerate frustration [was] frequently taxed and she [responded] with derisive comments about the test and the examiner (e.g., “Your dress is ugly and so are your earrings.”). The examiner [found] it necessary to allow frequent breaks so [Virginia could] play with a nearby doll house.

Virginia did better on structured tests, but had increasingly more difficulty with the unstructured tests. For example when she saw the first Rorschach card she shielded her face with it and impulsively stated, “A stupid, dumb, dumb bat with holes in its body.” She threw the card across the table, announced she would not look at any more cards, and walked around the room, and then [stared] out the window. The examiner invited her to return to the testing, telling her the evaluation would not take much longer, but Virginia still refused to continue. The examiner expressed to Virginia that she understood how difficult the testing was for her, but suggested it would be nice to finish the testing that same day, and told her she could get a snack when the testing was completed. She told Virginia she could keep track of the time and could work the stopwatch, and could take another break if it was necessary. In addition, the examiner told Virginia that other girls also found the testing difficult, but that ...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Dedication
• Table of Contents
• Preface
• Contributors
• Chapter 1. The Clinical Practice of Child and Adolescent Assessment
• Part I: Issues and Concepts in Child and Adolescent Assessment
• Part II: Assessment Techniques
• Part III: Specific Syndromes, Issues, and Problem Areas
• Part IV: Special Populations
• Author Index
• Subject Index