Case Study: Psychological Assessment
Stubborn Sara
Fourteen-year-old Sara was referred to our clinic by her pediatrician because of chronic problems with her physical health. Since the beginning of the academic year, Sara has complained of recurrent headaches, stomachaches, and nausea that have interfered with her ability to attend school. Sara experiences symptoms when she wakes in the morning, she begs her mother to allow her to stay home, and then she appears better by midday. Sara’s pediatrician determined that there was nothing physically wrong with her and suggested that she be assessed by a psychologist to determine the source of her complaints.
“Last week was the breaking point,” exclaimed her mother. “My husband needed to attend an appointment, and I was already late for work when Sara again reported being sick. She begged to stay home and when I refused, she had a tantrum like a 2-year-old.”
Sara’s absences have begun to interfere with her academic performance. “She’s missed a lot of school and is falling behind her classmates in math,” reported her teacher. “She’s such a sweet, caring girl. I really hope that we can find out how to help her.”
©iStockphoto.com/lathuric
Principles of Assessment
The most accurate understanding of children’s behavior comes from multimethod assessment. Multimethod assessment involves gathering data in a number of different ways to obtain the most complete picture possible (Butcher, 2019). Ideally, multimethod assessment involves four components:
1 Interviewing children and caregivers;
2 Observing children’s behavior;
3 Collecting behavioral ratings from children, parents, and teachers; and
4 Administering norm-referenced tests to assess specific areas of functioning.
Multimethod assessment would be extremely helpful in identifying the cause of Sara’s physical complaints and school refusal. First, we would probably want to interview Sara and her mother to learn more about her family and developmental history. How long has Sara had this problem? How are her grades? Does she have friends at school?
Second, we might want to observe Sara’s school refusal firsthand. Perhaps we could find a way to intervene and make mornings go more smoothly for her family.
Third, we might administer behavioral rating scales to Sara’s parents and teachers, to assess Sara’s functioning at home and school, respectively. Maybe she is having problems in other areas.
Finally, we might administer some psychological tests to assess Sara’s cognitive abilities, academic skills, or social–emotional functioning. Does she have a learning disability that is causing academic problems and embarrassment at school? Does Sara avoid school because she is depressed or anxious?
Multi-informant assessment is equally necessary to provide a complete picture of a child’s functioning. Data should be gathered from different people. Previous research has shown low correlations between parents, teachers, and children’s ratings of child behavior. The overall correlation across informants is only .28. Consequently, a clinician who relies only on information provided by one informant will likely obtain an inaccurate picture of a child’s functioning (de Los Reyes et al., 2015).
Why do informants disagree so much in their reports? There are at least two reasons. First, informants are privy to different types of information about children’s functioning. For example, parents and teachers are able to observe children’s overt actions but may not be able to accurately assess children’s thoughts and feelings.
Second, children’s behavior can vary dramatically across settings. For example, children may seem anxious at school but appear relaxed at home. Similarly, children may be defiant and disrespectful toward parents but be courteous and compliant toward teachers. In fact, informant agreement is higher between two parents observing a child in the same setting (r = .58) than between a parent and a teacher observing a child in two different settings (r = .28). Disagreement between informants, therefore, often reflects differences in informants’ knowledge of the child and variability in the child’s behavior across settings. As a result, clinicians must gather and integrate information from multiple people (Villabø, Gere, Torgersen, March, & Kendall, 2012).
Multi-informant assessment would be useful to test our initial hypotheses regarding the source of Sara’s problems. For example, Sara’s parents might report that she has chronic headaches, stomachaches, and nausea at home, whereas her teacher might report no such problems at school. In fact, her teacher might say that Sara has well-developed social skills and several friends at school. Such data might suggest that bullying is not the cause of Sara’s school refusal. We need to revise our hypotheses and look elsewhere.
Review
Psychological assessment has several purposes: (1) to screen for problems, (2) to reach a diagnosis, (3) to plan treatment, and (4) to monitor progress.
Multimethod assessment involves collecting data by interviewing children and families, observing children’s behavior, collecting behavioral ratings, and administering norm-referenced tests.
Multi-informant assessment involves collecting data from caregivers, teachers, and (if applicable) children themselves.
What Is a Diagnostic Interview and Mental Status Exam?
Diagnostic Interview
The most important component of psychological assessment is the diagnostic interview. The interview usually occurs during the first session, and it can extend across multiple sessions. The interview usually involves the child and his or her parents, and it can sometimes include extended family members, teachers, and other people knowledgeable about the child’s functioning. Some clinicians prefer to interview children and parents together, whereas other clinicians interview them separately (Sommers-Flanagan, 2018).
One purpose of the interview is to begin to establish rapport with the family. By the end of the interview, the family members should feel that the therapist understands their concerns, that she offers a viable solution to address these concerns, and that they can work together to help the child. Rapport is especially important when treating children and adolescents, because many youths are reluctant to participate in therapy. For example, Sara may feel angry, resentful, or embarrassed that her parents brought her to therapy. Her parents, in turn, are likely exasperated by Sara’s school refusal. To build rapport, the therapist will acknowledge these feelings and offer hope that therapy will improve the situation (Allen & Becker, 2020).
A second purpose of the interview is to identify the family’s presenting problem—that is, the family’s primary reason(s) for seeking help. The therapist will gather information about when the problem began, how long it has lasted, and what steps the family has taken to solve it. The therapist also assesses whether all family members agree on the presenting problem. For example, Sara’s parents might identify Sara’s school refusal as the main problem, whereas Sara might view her parents’ nagging as more concerning. Therapists often give each family member time to explain the problem from his or her perspective (Kearney, Freeman, & Bacon, 2020).
A third purpose of the interview is to obtain information about the child’s psychosocial history and current functioning (Table 4.1). Typically, clinicians interview the child, parents, and teachers to gather this information. Sometimes, clinicians will also review the child’s academic and medical records. A thorough psychosocial history assesses the child’s functioning at home, at school, and with peers in the community (Reynolds & Kamphaus, 2015).
Very often, a final purpose of the interview is to arrive