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242 Psychological Assessment in Child Mental Health Settings The third validity scale, Defensiveness, includes 12 de-scriptions of infrequent or highly improbable positive attrib-utes (“My child always does his/her homework on time. [True]”) and 12 statements that represent the denial of com-mon child behaviors and problems (“My child has some bad habits. [False]”). Scale values above 59T suggest that signif-icant problems may be minimized or denied on the PIC-2 profile. The PIC-2 manual provides interpretive guidelines for seven patterns of these three scales that classified virtually all cases (99.8%) in a study of 6,370 protocols. Personality Inventory for Youth The Personality Inventory for Youth (PIY) and the PIC-2 are closely related in that the majority of PIYitems were derived from rewriting content-appropriate PIC items into a first- person format.As demonstrated inTable 11.2, the PIYprofile is very similar to the PIC-2 Standard Format profile. PIY scaleswerederivedinaniterativefashionwith270statements assigned to one of nine clinical scales and to three validity response scales (Inconsistency, Dissimulation, Defensive-ness).AsinthePIC-2,eachscaleisfurtherdividedintotwoor three more homogenous subscales to facilitate interpretation. PIYmaterials include a reusable administration booklet and a separate answer sheet that can be scored by hand with tem-plates, processed by personal computer, or mailed to the test publisher to obtain a narrative interpretive report, profile, and responses to a critical item list. PIY items were intentionally written at a low readability level, and a low- to mid-fourth-grade reading comprehension level is adequate for under-standingandrespondingtothePIYstatements.Whenstudents have at least an age-9 working vocabulary, but do not have a TABLE 11.2 PIY Clinical Scales and Subscales and Selected Psychometric Performance SCALE or Subscale (abbreviation) COGNITIVE IMPAIRMENT (COG) Poor Achievement and Memory (COG1) Inadequate Abilities (COG2) Learning Problems (COG3) IMPULSIVITYAND DISTRACTIBILITY (ADH) Brashness (ADH1) Distractibility and Overactivity (ADH2) Impulsivity (ADH3) DELINQUENCY (DLQ) Antisocial Behavior (DLQ1) Dyscontrol (DLQ2) Noncompliance (DLQ3) FAMILY DYSFUNCTION (FAM) Parent-Child Conflict (FAM1) Parent Maladjustment (FAM2) Marital Discord (FAM3) REALITY DISTORTION (RLT) Feelings of Alienation (RLT1) Hallucinations and Delusions (RLT2) SOMATIC CONCERN (SOM) Psychosomatic Syndrome (SOM1) Muscular Tension and Anxiety (SOM2) Preoccupation with Disease (SOM3) PSYCHOLOGICAL DISCOMFORT (DIS) Fear and Worry (DIS1) Depression (DIS2) Sleep Disturbance (DIS3) SOCIALWITHDRAWAL (WDL) Social Introversion (WDL1) Isolation (WDL2) SOCIAL SKILL DEFICITS (SSK) Limited Peer Status (SSK1) SSK2: Conflict with Peers (SSK2) Items rtt 20 .74 .80 8 .65 .70 8 .67 .67 4 .44 .76 17 .77 .84 4 .54 .70 8 .61 .71 5 .54 .58 42 .92 .91 15 .83 .88 16 .84 .88 11 .83 .80 29 .87 .83 9 .82 .73 13 .74 .76 7 .70 .73 22 .83 .84 11 .77 .74 11 .71 .78 27 .85 .76 9 .73 .63 10 .74 .72 8 .60 .59 32 .86 .77 15 .78 .75 11 .73 .69 6 .70 .71 18 .80 .82 10 .78 .77 8 .59 .77 24 .86 .79 13 .79 .76 11 .80 .72 Subscale Representative Item School has been easy for me. I think I am stupid or dumb. I have been held back a year in school. I often nag and bother other people. I cannot wait for things like other kids can. I often act without thinking. I sometimes skip school. I lose friends because of my temper. Punishment does not change how I act. My parent(s) are too strict with me. My parents often argue. My parents’marriage has been solid and happy. I do strange or unusual things. People secretly control my thoughts. I often get very tired. At times I have trouble breathing. I often talk about sickness. Small problems do not bother me. I am often in a good mood. I often think about death. Talking to others makes me nervous. I almost always play alone. Other kids look up to me as a leader. I wish that I were more able to make and keep friends. Note: Scale and subscale alpha () values based on a clinical sample n = 1,178. One-week clinical retest correlation (r tt) sample n = 86. Selected material from the PIYcopyright © 1995 by Western Psychological Services. Reprinted by permission of the publisher, Western Psychological Services, 12031 Wilshire Boulevard, Los Angeles, California, 90025, U.S.A., www.wpspublish.com. Not to be reprinted in whole or in part for any additional purpose without the expressed, written permission of the publisher. All rights reserved. The Conduct of Assessment by Questionnaire and Rating Scale 243 comparablelevelofreadingability,orwhenyoungerstudents have limited ability to attend and concentrate, an audiotape recording of the PIY items is available and can be completed in less than 1 hr. Scale raw scores are converted to T scores using contemporary gender-specific norms from students in Grades 4 through 12, representing ages 9 through 19 (Lachar & Gruber, 1995). Student Behavior Survey This teacher rating form was developed through reviewing established teacher rating scales and by writing new state-ments that focused on content appropriate to teacher observa-tion (Lachar, Wingenfeld, Kline, & Gruber, 2000). Unlike ratings that can be scored on parent or teacher norms (Naglieri, LeBuffe, & Pfeiffer, 1994), the Student Behavior Survey (SBS) items demonstrate a specific school focus. Fifty-eight of its 102 items specifically refer to in-class or in-school behaviors and judgments that can be rated only by school staff (Wingenfeld, Lachar, Gruber, & Kline, 1998). SBS items provide a profile of 14 scales that assess student academic status and work habits, social skills, parental par-ticipation in the educational process, and problems such as aggressive or atypical behavior and emotional stress (see Table 11.3). Norms that generate linear T scores are gender specific and derived from two age groups: 5 to 11 and 12 to 18 years. SBS items are presented on one two-sided form. The rat-ing process takes 15 min or less. Scoring of scales and com- pletion of a profile are straightforward clerical processes that take only a couple of minutes. The SBS consists of two major sections. The first section, Academic Resources, includes four scales that address positive aspects of school adjustment, whereas the second section, Adjustment Problems, generates seven scales that measure various dimensions of problematic adjustment. Unlike the PIC-2 and PIY statements, which are completed with a True or False response, SBS items are mainly rated on a 4-point frequency scale. Three additional disruptive behavior scales each consist of 16 items nomi-nated as representing phenomena consistent with the char-acteristics associated with one of three major Diagnostic and Statistical Manual, Fourth Edition (DSM-IV) disruptive disorder diagnoses: ADHD, combined type; ODD; and CD (Pisecco et al., 1999). Multidimensional Assessment This author continues to champion the application of objec-tive multidimensional questionnaires (Lachar, 1993, 1998) because there is no reasonable alternative to their use for baseline evaluation of children seen in mental health settings. Suchquestionnairesemployconsistentstimulusandresponse demands, measure a variety of useful dimensions, and gener-ate a profile of scores standardized using the same normative reference. The clinician may therefore reasonably assume that differences obtained among dimensions reflect variation in content rather than some difference in technical or stylistic characteristic between independently constructed unidimen-sional measures (e.g., true-false vs. multiple-choice format, application of regional vs. national norms, or statement sets TABLE 11.3 SBS Scales, Their Psychometric Characteristics, and Sample Items Scale Name (abbreviation) Academic Performance (AP) Academic Habits (AH) Social Skills (SS) Parent Participation (PP) Health Concerns (HC) Emotional Distress (ED) Unusual Behavior (UB) Social Problems (SP) Verbal Aggression (VA) Physical Aggression (PA) Behavior Problems (BP) Attention-Deficit/Hyperactivity (ADH) Oppositional Defiant (OPD) Conduct Problems (CNP) Items rtt r1,2 8 .89 .78 .84 13 .93 .87 .76 8 .89 .88 .73 6 .88 .83 .68 6 .85 .79 .58 15 .91 .90 .73 7 .88 .76 .62 12 .87 .90 .72 7 .92 .88 .79 5 .90 .86 .63 15 .93 .92 .82 16 .94 .91 .83 16 .95 .94 .86 16 .94 .90 .69 Example of Scale Item Reading Comprehension Completes class assignments Participates in class activities Parent(s) encourage achievement Complains of headaches Worries about little things Says strange or bizarre things Teased by other students Argues and wants the last word Destroys property when angry Disobeys class or school rules Waits for his/her turn Mood changes without reason Steals from others Note: Scale alpha () values based on a referred sample n = 1,315. Retest correlation (r tt) 5- to 11-year-old student sample (n = 52) with average rating interval of 1.7weeks.Interrateragreement(r1,2), samplen = 60 fourth- and fifth-grade, team-taught or special-education students. Selected material from the SBS copyright © 2000 by Western Psychological Services. Reprinted by permission of the publisher, Western Psychological Services, 12031Wilshire Boulevard, LosAngeles, California, 90025, U.S.A., www.wpspublish.com. Not to be reprinted in whole or in part for any additional purpose with-outtheexpressed,writtenpermissionofthepublisher.Allrightsreserved. 244 Psychological Assessment in Child Mental Health Settings that require different minimum reading requirements). In ad-dition, it is more likely that interpretive materials will be provided in an integrated fashion and the clinician need not selectoraccumulateinformationfromavarietyofsourcesfor each profile dimension. Selection of a multidimensional instrument that docu-ments problem presence and absence demonstrates that the clinician is sensitive to the challenges inherent in the referral process and the likelihood of comorbid conditions, as previ-ously discussed. This action also demonstrates that the clini-cian understands that the accurate assessment of a variety of child and family characteristics that are independent of diag-nosis may yet be relevant to treatment design and implemen-tation. For example, the PIY FAM1 subscale (Parent-Child Conflict) may be applied to determine whether a child’s par-ents should be considered a treatment resource or a source of current conflict. Similarly, the PIC-2 and PIYWDL1 subscale (Social Introversion) may be applied to predict whether an adolescent will easily develop rapport with his or her ther-apist, or whether this process will be the first therapeutic objective. Multisource Assessment The collection of standardized observations from different informants is quite natural in the evaluation of children and adolescents. Application of such an approach has inherent strengths, yet presents the clinician with several challenges. Considering parents or other guardians, teachers or school counselors,andthestudentsthemselvesasthreedistinctclasses of informant, each brings unique strengths to the assessment process. Significant adults in a child’s life are in a unique posi-tiontoreportonbehaviorsthatthey—notthechild—findprob-lematic. On the other hand, youth are in a unique position to report on their thoughts and feelings. Adult ratings on these dimensionsmustofnecessityreflect,orbeinferredfrom,child language and behavior. Parents are in a unique position to describe a child’s development and history as well as observa-tions that are unique to the home.Teachers observe students in an environment that allows for direct comparisons with same-age classmates as well as a focus on cognitive and behavioral characteristics prerequisite for success in the classroom and the acquisitionofknowledge.Collectionofindependentparent and teacher ratings also contributes to comprehensive assess-ment by determining classes of behaviors that are unique to a givensettingorthatgeneralizeacrosssettings(Mash&Terdal, 1997). Studies suggest that parents and teachers may be the most attunedtoachild’sbehaviorsthattheyfindtobedisruptive(cf. Loeber&Schmaling,1985),butmayunderreportthepresence of internalizing disorders (Cantwell, 1996). Symptoms and behaviors that reflect the presence of depression may be more frequently endorsed in questionnaire responses and in stan-dardized interviews by children than by their mothers (cf. Barrett et al., 1991; Moretti, Fine, Haley, & Marriage, 1985). In normative studies, mothers endorse more problems than their spouses or the child’s teacher (cf. Abidin, 1995; Duhig, Renk, Epstein, & Phares, 2000; Goyette, Conners, & Ulrich, 1978).Perhapsmeasuredparentagreementreflectstheamount of time that a father spends with his child (Fitzgerald, Zucker, Maguin,&Reider,1994).Teacherratingshave(Burns,Walsh, Owen, & Snell, 1997), and have not, separated ADHD sub-groups (Crystal, Ostrander, Chen, & August, 2001). Perhaps this inconsistency demonstrates the complexity of drawing generalizations from one or even a series of studies. The ulti-mate evaluation of this diagnostic process must consider the dimension assessed, the observer or informant, the specific measure applied, the patient studied, and the setting of the evaluation. An influential meta-analysis byAchenbach, McConaughy, andHowell(1987)demonstratedthatpooragreementhasbeen historically obtained on questionnaires or rating scales among parents, teachers, and students, although relatively greater agreementamongsourceswasobtainedfordescriptionsofex-ternalizing behaviors. One source of informant disagreement between comparably labeled questionnaire dimensions may be revealed by the direct comparison of scale content. Scales similarly named may not incorporate the same content, whereas scales with different titles may correlate because of parallel content. The application of standardized interviews often resolves this issue when the questions asked and the criteriaforevaluatingresponsesobtainedareconsistentacross informants. When standardized interviews are independently conducted with parents and with children, more agreement is obtained for visible behaviors and when the interviewed children are older (Lachar & Gruber, 1993). Informant agreement and the investigation of comparative utility of classes of informants continue to be a focus of considerable effort (cf. Youngstrom, Loeber, & Stouthamer-Loeber, 2000). The opinions of mental health professionals and parents as to the relative merits of these sources of infor-mation have been surveyed (Loeber, Green, & Lahey, 1990; Phares, 1997). Indeed, even parents and their adolescent chil-dren have been asked to suggest the reasons for their disagreements. One identified causative factor was the delib-erate concealment of specific behaviors by youth from their parents (Bidaut-Russell et al., 1995). Considering that youth seldom refer themselves for mental health services, routine assessment of their motivation to provide full disclosure would seem prudent. The Conduct of Assessment by Questionnaire and Rating Scale 245 The parent-completed Child Behavior Checklist (CBCL; Achenbach,1991a)andstudent-completedYouthSelf-Report (YSR;Achenbach,1991b),assymptomchecklistswithparal-lel content and derived dimensions, have facilitated the direct comparison of these two sources of diagnostic information. ThestudybyHandwerk,Larzelere,Soper,andFriman(1999) is at least the twenty-first such published comparison, join-ing 10 other studies of samples of children referred for evalu-ation or treatment. These studies of referred youth have consistently demonstrated that the CBCL provides more evi-dence of student maladjustment than does the YSR. In con-trast, 9 of the 10 comparable studies of nonreferred children (classroom-based or epidemiological surveys) demonstrated the opposite relationship: The YSR documented more prob-lemsinadjustmentthandidtheCBCL.Onepossibleexplana-tion for these findings is that children referred for evaluation often demonstrate a defensive response set, whereas nonre-ferred children do not (Lachar, 1998). Because the YSR does not incorporate response validity scales, a recent study of the effect of defensiveness on YSR profilesofinpatientsappliedthePIYDefensivenessscaletoas-sign YSR profiles to defensive and nondefensive groups (see Wrobeletal.,1999,forstudiesofthisscale).Thesubstantialin-fluence of measured defensiveness was demonstrated for five of eight narrow-band and all three summary measures of the YSR. For example, only 10% of defensiveYSR protocols ob- tainedanelevated(>63T)TotalProblemsscore,whereas45% of nondefensive YSR protocols obtained a similarly elevated Total Problems score (Lachar, Morgan, Espadas, & Schomer, 2000).Themagnitudeofthisdifferencewascomparabletothe YSR versus CBCL discrepancy obtained by Handwerk et al. (1999; i.e., 28% of YSR vs. 74% of CBCL Total Problems scores were comparably elevated). On the other hand, youth may reveal specific problems on a questionnaire that they deniedduringaclinicalorstructuredinterview. Clinical Issues in Application Priority of Informant Selection When different informants are available, who should partici-pate in the assessment process, and what priority should be assigned to each potential informant? It makes a great deal of sense first to call upon the person who expresses initial or primary concern regarding child adjustment, whether this be a guardian, a teacher, or the student. This person will be the most eager to participate in the systematic quantification of problem behaviors and other symptoms of poor adjustment. The nature of the problems and the unique dimensions as- sessedbycertaininformant-specificscalesmayalsoinfluence the selection process. If the teacher has not referred the child, report of classroom adjustment should also be obtained when the presence of disruptive behavior is of concern, or when academic achievement is one focus of assessment. In these cases, such information may document the degree to which problematic behavior is situation specific and the degree to which academic problems either accompany other problems or may result from inadequate motivation.When an interven-tion is to be planned, all proposed participants should be in-volved in the assessment process. Disagreements Among Informants Even estimates of considerable informant agreement derived from study samples are not easily applied as the clinician processes the results of one evaluation at a time. Although the clinician may be reassured when all sources of information converge and are consistent in the conclusions drawn, resolv-ing inconsistencies among informants often provides infor-mation that is important to the diagnostic process or to treatment planning. Certain behaviors may be situation spe-cific or certain informants may provide inaccurate descrip-tions that have been compromised by denial, exaggeration, or some other inadequate response. Disagreements among fam-ily members can be especially important in the planning and conduct of treatment. Parents may not agree about the pres-ence or the nature of the problems that affect their child, and a youth may be unaware of the effect that his or her behavior has on others or may be unwilling to admit to having prob-lems. In such cases, early therapeutic efforts must focus on such discrepancies in order to facilitate progress. Multidimensional Versus Focused Assessment Adjustment questionnaires vary in format from those that focus on the elements of one symptom dimension or diagno-sis(i.e.depression,ADHD)tomorecomprehensivequestion-naires. The most articulated of these instruments rate current and past phenomena to measure a broad variety of symptoms and behaviors, such as externalizing symptoms or disruptive behaviors, internalizing symptoms of depression and anxiety, and dimensions of social and peer adjustment. These ques-tionnaires may also provide estimates of cognitive, academic, and adaptive adjustment as well as dimensions of family function that may be associated with problems in child ad-justment and treatment efficacy. Considering the unique chal-lenges characteristic of evaluation in mental health settings discussed earlier, it is thoroughly justified that every intake or baseline assessment should employ a multidimensional instrument. 246 Psychological Assessment in Child Mental Health Settings Questionnaires selected to support the planning and mon-itoring of interventions and to assess treatment effectiveness must take into account a different set of considerations. Re-sponse to scale content must be able to represent behavioral change, and scale format should facilitate application to the individual and summary to groups of comparable children similarly treated. Completion of such a scale should represent aneffortthatallowsrepeatedadministration,andthescalese-lected must measure the specific behaviors and symptoms that are the focus of treatment. Treatment of a child with a single focal problem may require the assessment of only this onedimension.Insuchcases,abriefdepressionorarticulated ADHD questionnaire may be appropriate. If applied within a specialty clinic, similar cases can be accumulated and sum-marized with the same measure.Application of such scales to the typical child treated by mental health professionals is unlikely to capture all dimensions relevant to treatment. SELECTION OF PSYCHOLOGICALTESTS Evaluating Scale Performance Consult Published Resources Although clearly articulated guidelines have been offered (cf. Newman, Ciarlo, & Carpenter, 1999), selection of opti-mal objective measures for either a specific or a routine assessment application may not be an easy process. An ex-panded variety of choices has become available in recent years and the demonstration of their value is an ongoing ef-fort. Manuals for published tests vary in the amount of detail that they provide. The reader cannot assume that test manuals provide comprehensive reviews of test performance, or even offer adequate guidelines for application. Because of the growing use of such questionnaires, guidance may be gained from graduate-level textbooks (cf. Kamphaus & Frick, 2002; Merrell, 1994) and from monographs designed to review a variety of specific measures (cf. Maruish, 1999). An intro-duction to more established measures, such as the Minnesota Multiphasic Personality Inventory (MMPI) adapted for ado-lescents (MMPI-A; Butcher et al., 1992), can be obtained by reference to chapters and books (e.g., Archer, 1992, 1999; Graham, 2000). Estimate of Technical Performance: Reliability Test performance is judged by the adequacy of demonstrated reliability and validity. It should be emphasized from the onset that reliability and validity are not characteristics that reside in a test, but describe a specific test application (i.e., assessment of depression in hospitalized adolescents). A number of statistical techniques are applied in the evaluation of scales of adjustment that were first developed in the study of cognitive ability and academic achievement. The general-izability of these technical characteristics may be less than ideal in the evaluation of psychopathology because the underlying assumptions made may not be achieved. The core of the concept of reliability is performance con-sistency; the classical model estimates the degree to which an obtained scale score represents the true phenomenon, rather than some source of error (Gliner, Morgan, & Harmon, 2001). At the item level, reliability measures internal con-sistency of a scale—that is, the degree to which scale item responses agree. Because the calculation of internal consis-tencyrequiresonlyonesetofresponsesfromanysample,this estimateiseasilyobtained.Unlikeanachievementsubscalein whichallitemscorrelatewitheachotherbecausetheyaresup-posedtorepresentahomogenousdimension,theinternalcon-sistencyofadjustmentmeasureswillvarybythemethodused to assign items to scales. Scales developed by the identifica-tion of items that meet a nontest standard (external approach) will demonstrate less internal consistency than will scales de-veloped in a manner that takes the content or the relation be-tween items into account (inductive or deductive approach; Burisch, 1984).An example is provided by comparison of the two major sets of scales for the MMPI-A (Butcher et al., 1992). Of the 10 profile scales constructed by empirical key-ing,6obtainedestimatesofinternalconsistencybelow0.70in a sample of referred adolescent boys. In a second set of 15 scalesconstructedwithprimaryconcernformanifestcontent, onlyonescaleobtainedanestimatebelow0.70usingthesame sample. Internal consistency may also vary with the homo-geneity of the adjustment dimension being measured, the items assigned to the dimension, and the scale length or range of scores studied, including the influence of multiple scoring formats. Scale reliability is usually estimated by comparison of re-peated administrations. It is important to demonstrate stabil-ity of scales if they will be applied in the study of an intervention. Most investigators use a brief interval (e.g., 7–14 days) between measure administrations. The assump-tion is made that no change will occur in such time. It has been our experience, however, with both the PIY and PIC-2 that small reductions are obtained on several scales at the retest, whereas the Defensiveness scale T score increases by a comparable degree on retest. In some clinical settings, such as an acute inpatient unit, it would be impossible to calculate test-retest reliability estimates in which an underlying change would not be expected. In such situations, interrater compar- isons, when feasible, may be more appropriate. In this design ... - tailieumienphi.vn