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Home > Treatment for Abused and Neglected Children: Infancy to Age 18 > Assessment of Child Maltreatment: Treatment for Abused and Neglected Children: Infancy to Age 18
Treatment for Abused and Neglected Children: Infancy to Age 18
Assessment of Child MaltreatmentThe primary consequence of child maltreatment is the development of "dysfunction" within the developing child – that is, the "functioning" of abused children is set apart or becomes difficult as a result of having experienced abuse and/or neglect. Dysfunction may result in immediate impairment, problems in adjusting to the abusive experience, or it may occur as problems later in development. Therefore, the goal of therapeutic intervention is to address the problems or conflicts within the child's current functioning and/or conflicts that are likely to impair functioning in the future. Therapists work toward providing abused or neglected children with skills or understanding so that they may be better equipped to interact successfully with others (e.g., family, friends, teachers) and deal with their own thoughts and feelings. As stated earlier, in order to do this, therapists must understand basic child development (so they can know what is normal or typical) and psychopathology (so they can know what is not normal or typical). From this base of information, the informed therapist is able to discern which presenting problems are "dysfunctional" and determine if these problems require therapeutic intervention. A careful assessment of the child in his/her environment is key to this process. Typically, the complexity of cases involving child maltreatment requires multidisciplinary input. Many communities have established teams to assist in the assessment of child abuse and neglect cases. These teams may include a pediatrician or other health care provider, a child protective services (CPS) caseworker, a law enforcement officer, an educational psychologist, a child development specialist, a substance abuse specialist, a mental health counselor, and other social service professionals. In conducting an assessment, the therapist needs to tap the resources of the team. If a team does not exist, consultation with professionals representing the key disciplines is strongly recommended. If the therapist and family represent different cultures, it is equally important for the therapist to consult with a professional knowledgeable about the family's culture. Assessment of the Child Within the Context of His/Her EnvironmentThe maltreatment of children does not occur within a vacuum. In nearly every case, it is important to assess the functioning, strengths, and needs of a child within several contexts. Usually the dominant context of the abused child is the child's immediate family. However, there are also many other contexts or cultures that may have a greater or lesser influence on the abused child depending on the child's age (social networks, extended family, etc.). In many cases of child maltreatment, therapists have a negative perception of the family (i.e., parents) because of the harm they have caused the child. The therapist may be angry or think less of the child's parents if they are the source of the child's maltreatment. However, the therapist should negate neither the importance of the family (from the perspective of the child) nor each family member's ability to contribute important information concerning the child's level of functioning. Whether or not they are involved in the abuse, parents are usually one of the most informed sources of information about the child's daily functioning and presenting problems. Similarly, an assessment of the child's functioning within settings such as school, social gatherings, daily after school activities, and day care provide information about the maltreated child from several sources and in several environments. One benefit of developing a multienvironment, multisource assessment of the child is that patterns of behavior, identified across contexts, increase the validity of the presence of a particular behavior or characteristic. For example, reports from a parent that a child is frequently belligerent and noncompliant might be supported by reports from his/her teacher that indicate that the child is frequently involved in physical fights with peers, has temper outbursts, and refuses to complete schoolwork. A valid conclusion that could be drawn from these reports is that this child possesses a relatively stable pattern of oppositional or defiant behavior. Using multiple sources of information to assess an individual's functioning is not unique to clinical assessment or to child abuse.80 81 82 The rationale for this approach is fairly simple – in most cases, abused children do not exhibit a uniform pattern of behavior in response to their abuse. In fact, the response of many children to being victimized may not constitute a significant problem or be sufficiently problematic to require psychological intervention. Therefore, by using multiple sources of information to identify dysfunctional patterns of behavior, the child therapist can focus attention on those behaviors that require intervention. It is important to point out that not all abused children require therapeutic intervention and, when provided, treatment should focus on problems that may impair current or future functioning. Issues to be Considered in AssessmentAs previously described, individual development progresses in an orderly manner that is common to all humans.83 Additionally, there is a continuity to each person's development, which, although it may be subject to periodic changes or fluctuations, is present throughout his/her childhood. Sroufe and Rutter argue that "disordered behavior does not simply spring forth without connection to previous quality of adaptation..." and that "change, as well as continuity, is lawful and, therefore, reflective of coherent development."84 When applying these concepts to child maltreatment, it becomes apparent that the clinical assessment of a child must examine the child and the presenting problem (consequences of abuse) in relation to the child's developmental status and capacity for adaptation. This approach is essential for developing treatment plans appropriate for a specific child's developmental needs. For example, it would be foolish to implement a verbal mode of therapy for a preverbal child, and conversely, it would be just as ineffective to attempt parent training (traditional child discipline skills as might be effective with a preschool-age child) for the parents of a 16-year-old client. As a child changes and adapts throughout his/her childhood, the manner in which he/she expresses dysfunctional or distressing behavior also changes.85 Therefore, the process of identifying psychopathology throughout childhood must be specific to the developmental status of the child. Thus, the therapist must possess a broad knowledge of child development (to understand normal and abnormal behavior throughout childhood). The therapist also needs to use assessment instruments that are sensitive to different age groups. Most published child clinical measures report age limitations for administration and clinical interpretation, and many offer age-specific scores. The most common examples are measures that assess a characteristic that is expected to change throughout childhood. These include the following:
Often, measures that assess specific characteristics such as sadness, anxiety, fear, etc., do not have age-specific standardizations. Thus, the clinician may erroneously administer an assessment measure to a child who does not have the intellectual or emotional capabilities to accurately report about him/herself. For example, a child's ability to provide information on self-esteem is inconsistent until the child is between the ages of 7 or 8.86 Before age 7, the child's developing self-esteem makes qualitative changes, and the child's ability to provide such an internalized evaluation is inconsistent. It is suggested that the validity and reliability of a child's report of internal states (e.g., feelings, thoughts, perceptions) does not become stable until the child is between 6 to 8 years of age.87 Ethnicity and Socioeconomic Status In general, the therapist should exercise caution when assessing children and families belonging to a different cultural, ethnic, and/or socioeconomic group. Assessment measures typically do not account for different ethnically or culturally based behaviors, such as language usage and culturally based belief systems. For example, it may be easy to interpret quiet and withdrawn behaviors on the part of a client as passivity and/or dependency when, in fact, the origins of the behavior may stem from culturally derived beliefs about polite and respectful interactions with perceived authority. In part, this may mean that the assessment instruments are not well suited for populations that are different from the majority population. For example, children engage in a variety of diverse behaviors along many different continua, including age, sex, and ethnic group. As a result of socioeconomic, cultural, and familial factors as well as association with traditional beliefs and a limited awareness of existing mental health systems, different ethnic groups may encourage or discourage a specific form of child behavior. Thus, ethnically diverse children may exhibit ethnically diverse behavior. A problem results when assessing a child for the presence of a behavioral, emotional, or psychological problem. By failing to be culturally sensitive to the specific behaviors exhibited by a specific ethnic group (or child of a specific cultural heritage), the clinician may erroneously identify the presence of a problem when one does not exist. For example, a clinician may be very concerned about the sexual behavior (and possibly marriage) of a young adolescent Laotian or Thai girl. However, within this girl's culture, early marriages may be culturally appropriate and expected with social stigma attached to a girl who has not become married during her adolescence. Conversely, a child of a specific cultural group may be experiencing significant distress and exhibiting this distress in a culturally acceptable manner, but the clinician may fail to acknowledge or identify this distress because of his/her lack of knowledge about the cultural group. Assessing children and families who are not a part of the majority culture without regard to their ethnic, cultural, and/or socioeconomic distinctions may result in significantly flawed information and, in turn, result in decision making and case management based on flawed information. There have been several attempts on the part of test developers to be sensitive to children of diverse cultural and ethnic backgrounds and, in fact, a few standardized measures have developed alternative scoring and norms specifically for different subgroups. Examples of these scoring techniques include the addition of sociocultural percentile ranking for the Kaufman Assessment Battery for Children and supplementary norms for emotionally disturbed children on the VABS. The VABS also has supplemental norms for hearing-impaired children. Other researchers have developed ethnically specific norms for child assessment measures already in use. Some researchers have developed translated versions of commonly used instruments, while other have developed ethnic-specific norms for these same groups.88 Finally, a few assessments have been developed to specifically address the unique characteristics and qualities of different subgroups [e.g., alternative means of assessment such as the System of Multicultural Pluralistic Assessment (SOMPA) and the Black Intelligence Test for Cultural Homogeneity.]89 90 Although there have been many efforts to make the assessment of children more ethnically and culturally sensitive, these tools have yet to demonstrate reasonable validity and reliability. Social Desirability and Reporting Bias When acquiring assessment information from any source, it is always important to attempt to explore and understand potential bias in the reporting of the data about a client. One source of bias involved in acquiring information directly from clients is known as social desirability, that is, the likelihood that people will provide information so that they will be perceived favorably by the interviewer, assessment administrator, or therapist.91 This phenomenon also has been reported and investigated in clinical research involving children.92 An example of how a child might exhibit socially desirable behavior is demonstrated by the child who is very compliant, polite, and attentive during the initial contact with the therapist. This is often described as a "honeymoon phase" – the child is not yet comfortable within the therapeutic relationship and exerts control over his/her "typical" behavior to present him or herself as "likeable" or "pleasing." Even this phase offers clinical information because it demonstrates that the child has the ability to exert some short-term control over his/her behavior. Another source of reporting bias involves a parent who denies the existence of a problem and/or is reluctant to provide complete information to the clinician. When parents are accused of harming their child or placing their child in a dangerous situation, they may be very suspicious of the clinician's intent and/or involvement. For example, parents may deny the presence of a significant behavioral problem because they are concerned that their child may be removed from their care. By limiting the amount of information they disclose, these parents may be attempting to protect themselves from the perceived or real threat of losing custody of their child. Furthermore, although parents may be good reporters of behaviors and events concerning their child (e.g., fights, bullying, being suspended from school), they may not be as accurate about less tangible characteristics (e.g., sadness, anxiety, fears). Therefore, a parent may evaluate his/her child on the basis of significant or major events (e.g., noncompliance, chronic fighting) rather than present a more comprehensive representation of the child. Finally, although children usually demonstrate a consistent pattern of behavior, some children respond well in some environments and less well in other environments. For example, a child can be cooperative and compliant within the daily routine and structure of the classroom environment, but he/she has chronic problems in less structured environments (e.g., playground, home, neighborhood play). In circumstances such as these, a teacher may report that a child has no problem in completing schoolwork, getting along with peers, or in relating to adults. This report results in a limited and incomplete picture of the child and his/her behavior. Professional Roles in the Assessment Process Because of the multidisciplinary nature of child abuse and neglect, effective case management, assessment, and treatment require that the professional has a clear understanding of his/her own and other professionals' roles and responsibilities. Because professional roles often overlap and provide similar or the same services, these distinctions are often difficult to make. For example, when interviewing a maltreated child, many professionals may interact with the abused child in a similar manner, but for different purposes. Law enforcement officers may interview the child to determine if the offender should be arrested; attorneys may interview a child to determine whether to prosecute a case; child welfare caseworkers may interview a child to determine whether the child's safety in the home is at risk; a psychologist may interview a child for an assessment; and a therapist may interview a child to begin to understand the child's perspective about the abuse and to support the child's resilient responses. Acknowledgment and respect of the unique responsibilities of the professionals involved in cases of child abuse and neglect is essential. The management of each case requires establishing and maintaining open communication among professionals to minimize the duplication of services, obtain complete assessment information, and develop treatment and case management plans. The amount of cooperation and coordination among professionals directly affects the experiences of the child in "the system." Use of Standardized Measures During the past 30 years, there has been consistent debate regarding the benefits of the clinician's judgment versus the use of actuarial methods.93 94 Using standardized assessment techniques and combining these techniques with sound judgment based on clinical experience and training has been shown to be the best approach. Therefore, the clinician must become familiar with assessment instruments, their development, applicability to different populations, psychometric properties, and limitations. The clinician can obtain this knowledge by attending special training sessions or workshops, by pursuing formal education, and/or by having formal supervision. Usually, it is sound clinical practice for a clinician to use an unfamiliar measure under the supervision of some other professional who is familiar with its use. The clinician should also invest some effort to acquire understanding of the applications of the measures to be used. By using a new or unfamiliar measure in conjunction with a familiar or more well-known measure, the clinician can begin to develop an understanding of the new instruments in relation to a well-understood instrument. Multiaxial Assessment Multiaxial assessment is comprised of information from many different sources including the following:
With the exception of physical assessment (typically conducted by trained medical personnel), discussion follows on all of these sources. Assessment Information from Children Perhaps the most important single source of information comes from the abused or neglected child. Often, information about the child's level of functioning, skills, needs, and/or problems can be acquired simply by asking or observing the child. There are several standardized instruments that can be administered directly to the child and interpreted by the trained clinician. Although obtaining assessment information directly from the child may present problems concerning validity and reliability (especially with younger children), the experienced clinician can still acquire much information from this process, especially when this information is supplemented by parent, teacher, or other assessment data. The following is a brief overview of some common techniques and measures. None of the instruments described in the following sections should be considered exhaustive nor comprehensive. Rather, they are simply a sample of techniques within several common categories. The reader is cautioned that the material in this manual represents an overview of issues related to child maltreatment and is in no way meant to replace formal training in social work, psychology, counseling, psychological assessment, or any other discipline. Behavior Report and/or Observation A few behavioral/observational and screening measures for the more common childhood disturbances are presented in this section. It is important to note that the results of a single measure should not form the basis for diagnosis or treatment recommendations. Rather, proper assessment involves cross-situational data from multiple sources.
Casual Observations Within the therapeutic or assessment setting, one of the more informative sources of information involves direct observation of the child before and after the appointment. This approach may include observing the child and the parent or caretaker sitting in the waiting room, walking to or from the appointment, interacting with other children and agency personnel (e.g., receptionist, other therapists). These observations allow the clinician to examine how the child engages with other individuals while not being formally evaluated. These pseudonatural observations are often informative because they reveal behaviors and actions that the child may conceal or inhibit during the assessment or therapy session. Projective Assessments Although empirical research has consistently demonstrated that projective techniques fail to demonstrate an adequate level of reliability and validity, clinicians continue to use these forms of assessment. Therefore, the question regarding why clinicians continue to use a form of assessment that has consistently proven to yield unreliable or invalid data. One possible reason is the relative ease of use of these instruments, supported by the ease with which they can be informally interpreted. Similarly, when using a projective assessment instrument, a clinician may selectively interpret the test materials, adapting them to "fit" the case. Therefore, after repeated administrations and selective interpretations, a clinician may develop the belief that the projective measure has accurately provided valuable information about several cases and thus, artificially elevate the validity of the projective measure. Projective assessment techniques offer a unique opportunity to interact with the child in a semistructured format. These techniques allow the child to direct the conversation by either responding to a stimulus presented by the clinician or to direct the topic through a drawing or action. The following projective assessment techniques can all be adapted to facilitate communication either as part of the formal administration or immediately afterward in conjunction with an interpretation. Projective Drawings There are several variations of projective drawings that incorporate the use of a figure, person, or other images (e.g., house, tree, family). Each of these forms of assessment centers on providing the child with a basic set of instructions, which is typically kept to a minimum. The child is provided with paper and a pencil, crayons, or markers. The child is then provided the opportunity to draw a representation of what was asked of him/her. For example, Hammer suggests requesting the child to draw a house, then a tree, and finally, a person.95 The house is drawn to elicit or arouse associations with the home or family and consequent familial relationships. The tree symbolizes life and growth, and is reported to reflect the child's relatively deeper and more unconscious feelings about him/herself. Finally, the person is reported to represent the self-representation of the child within the family and/or environment. Other forms of human figure projective assessments include Kinetic Family Drawing and the Draw-A-Person.96 97 Projective Storytelling/Apperception Tests The Thematic Apperception Test (TAT), for 5- to 18-year-olds, developed by Murray, and the parallel Children's Apperception Test (CAT), developed by Bellack, are designed to reflect internal states or constructs of the child.98 99 With the TAT, the test administrator shows the child a card with a drawing or photograph and asks the child to tell a story about what he/she thinks is happening in the picture. The child then creates a story, which is believed to be representative of his/her cognitive-emotional processing. The TAT has approximately 20 separate pictures or cards, all or some of which may be administered to the child. The CAT, administered in a similar manner, was designed specifically for children and has themes more common to children. CAT presents animals in the pictures rather than human representations. Rorschach The Rorschach, for use with 5- to 18-year-olds, consist of 10 cards with black on white or multicolored images on each card. The test administrator gives each card, one at a time, to the child and asks the child what he/she sees in the inkblot. The child then describes his/her perception while the administrator records the verbatim response. The child may see a single percept or several connected or unconnected percepts on each card. After completing this phase, the test administrator then reviews each card again, asking for clarification about how the child perceived each card. There have been several different scoring systems developed for the Rorschach, with specific scoring for children. The most popular scoring system has been developed by Exner.100 Cognitive Assessments The overall objective of intelligence testing is to provide an index of a child's intellectual functioning in relation to other children within his/her age group. Because intelligence is such a significant factor in a child's development, any concern about cognitive deficits should be identified and addressed. The child's intellectual functioning influences the approach to treatment. Certainly, not every abused or neglected child should receive an intellectual assessment. But if limitations in the child's intellectual capacity impair the ability to obtain, process, or retain information acquired from therapy, then alternate therapeutic plans may be necessary. For example, a child with a significant learning disability and a poor ability to verbally mediate thoughts and ideas is probably not well-suited to a verbal or didactic therapeutic plan. In addition to the overall objective of providing information about intellectual functioning, intelligence tests offer a means of assessing other areas of the child's functioning. By providing a structured environment, the evaluator can assess the child's ability to stay on task, follow directions, and change from format to format. Because most intelligence tests begin with relatively simple items and then become increasingly difficult, the evaluator also has the opportunity to observe the child's response to frustration and failure. Finally, intelligence tests often use items that require some type of social judgment. For example, on the Wechsler Intelligence Scale for Children-III (WISC-III), the subtest on comprehension asks questions about how a child might react in certain situations (e.g., "What would you do if you were at the movies and you saw a fire?" "What would you do if a child, smaller than yourself, tried to fight with you?"). This scale asks the child to provide an underlying rationale for common phenomenon (e.g., "Why should you trust a friend?" "Why is it better to give money to a well-known charity than to a beggar on the street?"). By responding to these questions, the child often reveals his/her values, cognition, and perceptions of the world and others. A common criticism of intelligence tests involves their applicability to children of ethnic minorities. Several studies have demonstrated that intelligence tests are inappropriate and unfair for lower socioeconomic groups and children of ethnic minorities. Although these biases appear to be relevant to all intelligence tests, some test developers have attempted to minimize this phenomenon by reducing the culturally biased items, decreasing the verbal component of the tests, and providing specific norms for certain ethnic minority groups.101 Nevertheless, the clinician should be cautious when using intelligence tests with lower socioeconomic groups and children of ethnic minorities. As a rule, the use of intellectual assessments for clinical purposes is restricted to professionals (psychologists, psychometrists) who have formal training in the application, administration, and interpretation of these assessment tools. However, some professionals without formal training may attempt to interpret or reinterpret reports of an intellectual assessment. Obviously, this practice is unethical and belies the underlying rationale for all assessments – the careful and informed use of an assessment measure for specific and appropriate purposes. Bayley Scales of Infant Development (BSID) The BSID is used to acquire a multidimensional assessment (i.e., mental, motor, and behavior indices) of infants and toddlers from birth through approximately age 2 years. A highly trained administrator presents the infant with a series of brief, individual tasks that increase in developmental complexity. By determining how many of these tasks the infant can perform successfully, the administrator compares the infant's demonstrated developmental ability to standardized scores. Although the BSID is the most popular measure of infant development, it is only indirectly related to intelligence and has not been shown to be a good predictor of later intelligence for all infants. However, infants who score very poorly on the BSID have demonstrated significant difficulty in later years. Wechsler Series of Intelligence Tests for Children These intelligence assessment instruments, the Primary Preschool Scale of Intelligence-Revised (WPPSI-R) for 3- to 6-year-olds and the WISC-III for 6- to 15-year-olds, were developed to yield an overall intelligence score (full-scale IQ) and to provide a means to assess both verbal and performance IQs. Both of these instruments are administered directly to the child by a trained clinician (typically a psychologist, educational psychologist, psychometrist) and yield three scores – a performance IQ, a verbal IQ, and a full-scale IQ. Both the performance and verbal IQs consist of several subtests that assess different cognitive abilities. The full-scale IQ is a combination of the performance and verbal scores. (All three scores have a mean of 100 and a standard deviation of 15.) Kaufman Assessment Battery for Children (K-ABC) The K-ABC, for 3- to 12-year-olds, was developed to more accurately reflect research in the area of children's intelligence, which suggested that an individual's intelligence was better assessed by examined mental processes than by verbal and performance domains. As a result, the K-ABC has a mental processing composite score consisting of simultaneous processing and sequential processing. In addition, the K-ABC yields an achievement score, based on six school-related subtests. The K-ABC also provides supplemental norms for hearing-impaired children and children from different sociocultural backgrounds. Clinical Interviews The clinical interview is a common method for obtaining information directly from a child. The interview may take on a variety of forms, including a nondirected play session, an open-ended dialogue, a verbal account of client history and presenting problems, and a structured psychiatric diagnostic interview. Perhaps most frequently, a clinician may combine several of these interview approaches in developing a broad base of information (both observational and reported) concerning the child. Interviews are also dependent on the developmental status and abilities of the child. Nondirective Play Sessions Play sessions that are nondirective and that require little verbal information from the child are most beneficial for young children. Typically, during the play session with a preschool or early school-age child, the clinician will assess the child's expressive and receptive language ability. The play session will help to answer questions such as the following:
With children of all ages, it is usually best to use toys as a part of the clinical interview. These toys may include dolls, small play figures, drawing equipment (e.g., pens, markers, crayons), blocks, marbles, cars and trucks, etc. Because it is difficult to predetermine which type of toys a child might enjoy playing with, it is usually best to have a small assortment of toys that have traditionally appealed to a child. For the evaluator, one objective is to use toys as a means of eliciting conversation from the child and to engage the child in some type of cooperative activity. Certain toys or objects are more conducive to this task than others. For example, dolls, play figures, and blocks can easily be incorporated into play involving people, homes, friends; musical instruments and computer games may inhibit the interaction between the child and the evaluator. By using a limited assortment of toys and manipulative objects, the experienced clinician/evaluator can also develop a common set of expectations regarding a child's interaction with those toys. For example, when provided with a small house and a family of play figures, most children will begin to manipulate these toys in a manner that reflects their perception of family interaction. Stereotypically, this interaction may include the mother cooking dinner in the kitchen, the father going off to work, etc. If the child begins to use these toys in an atypical manner, this behavior may reflect the child's perception of a family constellation or structure. This might be exemplified by the child living with a divorced single-parent mother who chooses to exclude the father in play and have the father on the periphery of the play session. There are two important issues to remember when conducting a play session with a child. The first issue is that there are no specific goals or objectives within the session, other than the careful observation and examination of the child. It may not be beneficial to establish a specific task as part of the play session because this approach may inhibit the child's demonstration of internal processing in favor of accomplishing the task. The second issue involves incorporating or facilitating the child as the leader of the play session. This can be structured by having the therapist/evaluator demonstrate that he/she will follow the lead of the child in playing with whatever toys the child would like to use. For some children, the process of taking the lead in a play situation may not be easy or comfortable. Certain children may require encouragement to explore the boundaries of what they can play with and to test their freedom to choose a pretend situation in which to play. It is important that the therapist/evaluator refrain from interjecting the direction or form of play and that they remain as a willing and responsive playmate (and an observing and examining evaluator). Structured Psychiatric Diagnostic Interviews One alternative in obtaining information about a maltreated child is the use of a structured diagnostic interview. Typically, these instruments involve administering a detailed set of questions about the child by first interviewing the parent or child's caretaker and then interviewing the child. Because they require the child to report about internal states and to respond to questions primarily within a verbal format, these interview methods are not appropriate for children who have not reached school-age. Most of these instruments have adapted the child psychiatric diagnoses of the Diagnostic and Statistical Manual of Mental Disorders, Third Edition, Revised (DSM-III-R) to specific behaviors and then developed a set of questions that determine if the behaviors presented by the child fulfill specific diagnostic criteria.102 These interviews commonly are administered to the parent or caretaker; this information is then confirmed, supplemented, or rejected based on a second interview with the child. The final determination of whether the child has a formal DSM-III-R diagnosis is based on information acquired from either or both of these sources of information. Three of the most common structured diagnostic interviews are the Diagnostic Interview Schedule for Children (DISC) for 6- to 18-year-olds, the Schedule for Affective Disorders and Schizophrenia (K-SADS) for 6- to 18-year-olds, and the Diagnostic Interview for Children and Adolescents (DICA).103 104 Clinicians and evaluators familiar with these instruments will have a general format by which to inquire about specific troublesome presenting behaviors. By being familiar with one or several of these instruments, the clinician or evaluator can quickly identify or eliminate the presence of a psychiatric disorder or, if necessary, question further about a problem area. The basic format of these interviews is typically sequential and information-oriented (versus rapport-oriented). However, they can be adapted to fit the needs of the individual clinician. For example, a clinician concerned about the presence of an affective disorder can begin asking questions from the affect/mood disturbance portion of the K-SADS. However, parents appear to be better at reporting external, behaviorally manifested problems about their children (e.g., aggression, crying) than they are at reporting problems that are more intangible (e.g., low mood, anxiety, grief). Assessment Information from Parents One of the most common sources of information about a child is the child's parents or caretakers. Usually, parents have the most consistent and reliable perspective of their child and are invested in providing valuable information. For a comprehensive assessment of a child, it is essential to interview each parent and obtain information about the child's functioning in a variety of settings (e.g., home, neighborhood, school, or church). Parents, like all reporters, are subject to bias in providing information about their child. Therefore, it is important to assess both the information provided by a parent and the parent's ability to provide valid and reliable information. Several standardized child assessment measures have been developed for parents to complete concerning their child. Some of these measures are discussed below. The Child Behavior Checklist (CBCL) Developed by Achenbach and Edelbrock, the CBCL is a 118-item instrument that asks parents to report the presence and frequency of a wide range of behavioral problems.105 This instrument has different norms for both boys and girls within three different age groups (2- to 3-year-old children, preschool-age children, and school-age children). It yields different scores on several factor-analytic narrow-band scales (e.g., delinquent, sex problems, withdrawal, or hyperactivity) as well as three social competence scales. Scores are plotted on a child behavior profile, which has T-scores in which clinically significant problem behavior is indicated by more than 20 points above the mean (T>70). The benefits of the CBCL are the frequency of its use with child clinical populations, its application to a large and diverse number of children, separation of norms with regard to both age and sex, and the relative ease of administration. The CBCL may be used as a means to assess both pre- and posttreatment functioning to determine the effectiveness of the treatment program and achievement of individual treatment goals. The Vineland Adaptive Behaviors Scales (VABS) The VABS is usually administered within a structured interview format, asking parents about behaviors of their children.106 The VABS provides developmental information about the child's level of functioning within three domains – communication, daily living skills, and socialization. For children younger than age 6, the VABS also provides information about gross and fine motor skills. There is an adaptive behavior composite, which reflects scores in each of the individual domains. For children aged 5 and older, the VABS identifies maladaptive behaviors in relation to an age-appropriate normative group. Family Assessment One of the most essential elements in understanding a child is the assessment of his/her family. Traditionally, the family is the most consistent and important contributor in a child's life. It is important for clinicians to remember that as children develop within their family system, the family as a whole goes through a process of changing and adapting. In addition, interactions and dynamics within a family are multidimensional. Parents not only have an important influence on their children; children also have a significant influence on their parents. Given this information, an accurate assessment of a child should also include information from and about the child's family. It is acknowledged, however, that with abused and neglected children, such an assessment may not always be possible. The Purpose/Intent of Family Assessment Without a clear understanding of the problems, capacities, and abilities of the entire family, it is difficult to determine a treatment plan for the child. The general purpose of a family assessment should be to acquire a more complete understanding of the child within the environment in which he/she lives. This assessment includes gathering information about the family's values and experiences, particularly experiences related to loss and grief in recent years. Additionally, because one of the primary outcomes of the assessment process is the identification of problems, strengths and needs, and capacities, the parents (and family as a whole) reflect these characteristics for the child. For example, it would be unwise to identify a problem and suggest a therapeutic response to that problem that is beyond the capacity of the child or the family. Thus, a recommendation to increase the structure and responsiveness to a child-related problem of noncompliance is inappropriate if it is beyond the parents' abilities to implement the recommendations because of poor parenting skills and/or the parents' own disorganization. Finally, through a family assessment, the clinician has the opportunity to examine the parents and assess their abilities and problems. Standardized Measures of Family Assessment Several measures of assessment are available that reflect many different areas of family functioning. Most of these measures assess constructs such as family cohesion, independence, power, and adaptability. Two of the more common standardized measures of family assessment are the Family Adaptability and Cohesion Evaluation Scales (FACES) and the Family Environment Scale (FES). The FACES consists of 20 items and measures 3 dimensions of family behavior as follows:
The FES consists of 90 items and has 10 subscales that assess different social and environmental characteristics within a family. These include the following:
There are many other valuable, standardized family assessment measures that are not included in this section. The interested reader is encouraged to explore texts that assess family assessment measures.107 Clinical Interviews In conducting a clinical interview with a family, it is important to use many skills concurrently. The clinician must be able to:
Perhaps foremost among these tasks is the observation of each family member separately as well as the observation of the family as a combined unit. Because the standardized assessment of family interactions are typically beyond the ability of many clinicians, a less formal assessment of family interactions is usually undertaken. By conducting a clinical interview with the child and family together, the clinician can assess a variety of child-family interactions and factors. For example, if a family member is absent, this raises the question of position within the family, commitment to family activities, and perceived sense of membership in the family. Often during a family clinical interview, one individual emerges as a spokesperson for the entire family. Typically, this is a parent who responds to general family-directed questions or takes the lead in clarifying information. However, the clinician should be alert to an imbalance in relationships within the family (e.g., a single member dominating the conversation, speaking over other members, responding to questions directed to other family members, or reframing responses in his/her own words). In many cases, adults and older children present themselves (either verbally or behaviorally) in a socially acceptable and desirable manner, but some children, especially very young children, may be less skilled or conscious of this process. Children often talk and act in a manner that is more consistent with their actions in a nonclinical or natural setting. Therefore, it is important that the clinician refrains from focusing solely on the identified child or on the parents throughout the family assessment session. The clinician must also incorporate all members into the interview, either by direct questioning or by requesting their perspective on the topic being discussed. Supplemental Information In addition to the child and the child's immediate family, other professionals are able to provide important information about abused and neglected children. This section identifies the potential contributions that school personnel, social service workers, and foster parents can make in assessing the functioning of the child, developing treatment plans, and assisting in case management. Teachers/School Personnel Because a child spends a great deal of time within the school setting, teachers and school personnel have the opportunity to observe him/her within a variety of school-related settings. Interviewing teachers about a specific child often yields information about social skills, peer relations, intellectual ability, cooperative skills, behavior management techniques, attentiveness, emotional stability, and response to authority. Teachers can provide information about their observations of a child within a classroom setting, on the playground, at the cafeteria, and before and after school. Teachers are also able to provide general information about the child's daily living such as cleanliness, eating habits, grooming, and problems related to encopresis or enuresis. Furthermore, because schools typically attempt to maintain regular contact with parents, teachers are often able to provide supplemental information about their interactions with the child's parents. This may include an assessment of the parents' level of involvement, concern about parenting ability, and overall stability of the parents. Child Behavior Checklist–Teacher Report Form This behavioral checklist was developed as a parallel form of the parent version of the CBCL. It has similar behavioral problems scales and internalizing and externalizing factors. By comparing a child's score on both the parent- and teacher-reported version, the assessor can acquire a more comprehensive assessment of the identified child. Child Welfare Caseworkers Typically, child welfare caseworkers are required to obtain sufficient information about children in their caseload to be able to determine the level of risk to the child and the child's treatment needs, offer opinions to the court, and develop and administer therapeutic and reunification plans. To accomplish these tasks, caseworkers must rely on information provided by a broad spectrum of sources familiar with the maltreated child. These sources may include foster parents, caretakers who are relatives of the child, home visiting agencies, or law enforcement agencies, etc. Because caseworkers usually have large caseloads, it is difficult for them to maintain intensive and consistent contact with all their cases. Therefore, caseworkers may not be able to provide abundant direct information about a child, but be an excellent source of indirect information. Because of their position, caseworkers are often the center of the flow of information about a child. Therefore, they may be informed of the child's behavior from a variety of sources and be able to integrate this information in making informed case management decisions. Foster Parents/Supplemental Caretakers One assessment problem for children in substitute care (e.g., those in foster care or those receiving care or temporary shelter care) concerns the ability of a new caretaker to provide valid and reliable information.108 In situations in which a child is exhibiting a severe or acute problem such as suicidal ideation, hallucinations, or aggressiveness, this becomes fairly easy to identify. However, most problematic behaviors require consistent exposure to the child in order to assess the severity and stability of possible problem behaviors. An example is the child who, after being placed in a foster home, demonstrates a poor appetite and gradually begins to lose weight. This reaction might be the child's expression of distress as a result of being separated from his/her family or reflective of sadness or depression, anxiety resulting from not feeling safe in an unusual environment, a lack of familiarity or dislike of a new type of food, or the beginning of an eating disorder. Without consistent exposure to the daily activities of this child, it would be difficult to determine the cause of the appetite and weight loss. However, a foster parent or supplemental caretaker (i.e., family friend, grandparent or other relative) may be able to provide such information after having this child in his/her care for a sufficient period of time. The minimum amount of time for a caretaker to be able to report on a child's behavior is approximately 4 to 6 weeks.109 110 111 This time frame enables the child's caretaker to report on a pattern of daily behaviors (i.e., daily living skills) as well as a range of potential dysfunctional behaviors. Assessing Risk of Harm to Self and/or Others As part of the assessment of any new client, it is essential to determine the client's potential to harm him/herself and/or others. The difficulty in acquiring clinical information directly from the child client may require consultation with other important people in the child's life (e.g., parents, teachers, child care providers). It is important to investigate both the child's behavior and the motivations or cognitions related to his/her behavior. Because of the child's limited intellectual abilities, he/she may engage in dangerous or harmful behavior without a clear understanding of the consequences of his/her actions. For example, a younger child may be excited by fire and be very interested in playing with matches. However, he/she may have a poor appreciation of the potential damage he/she could cause by burning him/herself or property. The assessment of danger to self and/or others should be conducted directly with the child and with other people who have contact with the child. In addition, the mental health professional should inquire about any prior aggressive, suicidal, and/or other dangerous/harmful behaviors (e.g., playing with knives, playing with matches, climbing tall trees). This should be done in the early stages of therapy (optimally during the first session), and any potential harm to self or others should be incorporated into the treatment plan. In addition, any concern about harm to self or others requires regular reevaluation and specific actions to address this concern (e.g., increased supervision, evaluating placement appropriateness). Suicide Although the threat of suicide among children is relatively low, it is nonetheless important to make a clear and focused inquiry regarding the child client's potential to harm him/herself. The mental health professional should directly ask the child if he/she has ever thought about hurting him/herself in any manner and/or taken any action that could result in death or serious harm. Although some professionals may feel uncomfortable about such a line of questioning, the difficulty in correctly predicting suicidality based only on behaviors and reports from others is great. It is not unusual for a child to harbor thoughts of self-harm and not discuss them with friends, parents, or siblings. Therefore, it is strongly recommended that the therapist make a direct inquiry of the child's threat to harm him/herself. Similarly, the therapist may also want to inquire about past thoughts or desires that are reflective of hopelessness, sadness, having 'given up', and passive statements about suicide (e.g., "Maybe it would be better if I weren't around"). Careful and conscious inquiry should also be made of parents and other individuals who are familiar with the child. This line of inquiry should include questions about dangerous behaviors (e.g., running into the street, playing with sharp objects) and previous statements concerning suicide. Whenever a concern is raised about suicide, it is important to carefully evaluate the situation and take appropriate action. This may involve increasing supervision, removing dangerous objects from the child's environment, increasing therapeutic contact, and/or evaluating the need for psychiatric hospitalization. Self-Destructive Behavior In some situations, the child may have no discernable intent to commit suicide, but nevertheless engages in behaviors that are dangerous, potentially harmful, and/or 'risky' (e.g., climbing tall trees or buildings, ingesting nonfood substances, cutting skin with a knife or other sharp object). These types of behaviors may reflect underlying self-destructive tendencies and should also be carefully assessed in a manner that is similar to the assessment for suicide. While the intent of these behaviors may not necessarily be suicidal, they may result in significant injury and/or death. Danger to Others Often, a child who experiences intense hostile affects but has limited ability to verbally mediate his/her feelings may express him/herself through behavior. This may result in acts of aggression directed toward specific individuals (i.e., the individual with whom the child is angry) and/or displaced anger towards others. Special concern is raised about actions of aggression that may be directed toward younger or weaker individuals in the child's environment (e.g., a younger sibling, babies). The therapist should inquire about the history of aggression, whether the aggression is planned or impulsive, the seriousness of the assault on others (i.e., whether injury occurred), the use of weapons, and the frequency of such aggressive acts. This may also require investigation into the child's living environment and the parents' ability to manage acts of aggression (e.g., level of supervision, assessment of parenting skills). A specific plan should be developed to ensure that the aggressive child will not have the opportunity to become aggressive to younger children and that he/she can be placed in a setting that can manage his/her assaults. This may require an evaluation of the appropriateness of the child's placement and alternative living situations. Special concern is raised for a child who has a history of engaging in sexually aggressive acts. Such a child may require extra supervision and careful case management decisions. Revictimization A frequent symptom of some children who have been sexually abused is to engage in sexually inappropriate behaviors. These behaviors may include increased masturbation, exposing themselves, increased sex play with peers, and/or being seductive with adults. Such behaviors, which arise from the child's distorted perceptions of appropriate interactions with others, may result in this child being at increased risk of being revictimized. The therapist should inquire about the presence of any type of sexually inappropriate behavior and carefully observe the child during the clinical interview for behaviors that may be inappropriate. Parents should be asked about the type and frequency of their child's sexual behaviors within the home, with specific attention to the family's sexual attitudes and values. In addition, the parents' ability to recognize inappropriate sexual behaviors should also be assessed. This may include an examination of the parents' ability to supervise their child and degree of concern of their child's sexuality. As with other forms of harm to the child, a specific program should be developed to address sexuality, sexual safety, and appropriate sexual boundaries.
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