Psychosocial Evaluation

The assessment of psychosocial status has different conceptual bases, depending largely on the age of the child. A multimethod, multisource assessment is critical, as different sources are sensitive to different areas of functioning (107).

3.7

Measures of Adaptive Functioning

Abbreviation: AAMR, American Association on Mental Retardation.

multiple sources of information should be included, such as parents, teachers, and child self-report.

Caveats

One of the trickiest issues in psychosocial assessment in rehabilitation populations is the need to account for the biologic factors on assessment results. Most psychosocial assessment tools are not specifically designed for use with children with disabilities or chronic illness. It must be appreciated that a wide range of adjustment levels exists. While children with chronic physical conditions appear to be at increased risk for psychological adjustment problems, the major­ity of children in this population do not show evidence of maladjustment (107). Furthermore, assumptions based on group membership by disability or medical condition can be inaccurate. For example, intuitive reasoning would indicate that individuals with dis­figurements, such as amputations or burns, would be particularly affected. Such is not the case, however, as demonstrated in research of these groups (108).

It is important to be aware that some items on psychosocial assessment scales can elicit medical as opposed to psychological distress. Particularly in children, “somatization”—or the tendency to express high levels of physical symptoms—is often assessed in scales measuring emotional functioning. A high level of somatization is considered indicative of internaliz­ing problems such as depression and anxiety in gen­eral child populations, and high somatization scores can lead to high scores on composite scales meant to measure general internalizing problems. Obviously, in youth with chronic illness, the extreme physical symptoms relating to the medical condition may, even in the absence of other areas of significant symptomol- ogy, yield a score on the somatization subscale that is high enough to lead to elevated “total” emotional symptoms scores.

Unique to the arena of personality of psychosocial functioning is the empirically based or criterion-group strategy of assessment. This approach grew in response to the serious liabilities presented by self-report tests, which used items that had face validity. For example, an item that asks about arguing with others was a direct question, just as could be asked in a live inter­view. There are great liabilities to that approach; it assumes that subjects can evaluate their own behavior objectively, that they understand the item in the way it was intended, and that they chose to respond candidly. In a radical departure, the developers of what came to be know as the Minnesota Multiphasic Personality Inventory (MMPI) formulated the test with the main premise that nothing can be assumed about the mean­ing of a subject's response to a test item—the meaning can be discerned only through empirical research. Items are presented to criterion groups, such as depressed, schizophrenic, or passive-aggressive personality disor­ders, and control groups.

In young children, temperament is a more cogent concept than that of personality. The dynamics of psychological functioning are the effect of innate temperament in interaction with parents and other caregivers within the basic sensorimotor exploratory nature of infancy and early childhood. If school is chil­dren's work, play is the work of this youngest group. What an interview or a self-report measure yields in older children, the observation of play provides in the preschooler. To quote Knoff (110), “This information reflects the preschooler's unique perceptions of his or her world, perceptions that are important in any comprehensive assessment of a referred child's prob­lems.” Projective techniques such as the Rorschach are not recommended in this population because of the need to interpret ambiguous visual stimuli. The active developmental maturation of visual-perceptual systems and the attendant normative variability miti­gate against the appropriateness in preschoolers.

Individual Assessment Tools

Functional behavior assessment (FBA) is highly appro­priate when young children, as well as older youth, with disability or illness are displaying significant behavior problems (111). When the ability to effectively communicate or independently access one's wants and needs is inhibited by cognitive or physical dis­ability, rates of inappropriate behaviors can increase as the child learns (sometimes subconsciously) that these behaviors can effectively serve a function.

Transdisciplinary play-based assessment (TPBA) (112) is a standardized observation of play. It provides an exhaustive listing of developmentally cogent play behaviors under four domains: cognitive, language and communications, sensorimotor, and social-emotional development. It allows the child to engage in the most natural of activities, but is limited in that there may not be an expression of a specific behavior of inter­est but rather a global picture of the child in interac­tion with the environment. Because of the limitations of individually administered tests in the young child, this acts as cross-validation of parental report and is less influenced by the demanding characteristics of traditional testing. The advantage of hearing sponta­neous language production is particularly useful, for this is often the primary shutdown of younger children in an evaluation setting (113).

The Bayley Scales of Infant and Toddler Development, 3rd Edition (86) provides a normative framework for this domain by providing scaled scores for the popular Greenspan Social-Emotional Growth Chart (114), which is a parent-report instrument to assess early indicators of social-emotional functioning in children ages 0-42 months.

The Minnesota Multiphasic Personality Inventory MMPI-A (115) is based on the criterion group strat­egy described in the introductory comments to this section. It is the first revision of the original MMPI specifically for use with adolescents. For the original test (MMPI), adolescent norms were developed in the 1970s, but it was only a downward extension at best. Now, new items tap specific adolescent developmen­tal or psychopathologic issues. There are new supple­mental scales that give feedback relative to alcohol and drug problems and immaturity. There are 15 new content scales in addition to the original 10 clinical scales. Development of the validity and response bias of the subject was expanded by devising response­inconsistency scales.

The original MMPI interpreted with adolescent norms had been used extensively with adolescent med­ical populations, including those with physical disabil­ity (116). For the development of the MMPI-A, extensive rewriting and some revision of test items were done. A national representative adolescent sample was used for normative data (not the case in the original MMPI). The new length is 478 test items presented in a booklet form, with true/false response. Reading level required is best considered to be seventh grade, although it had been designed with the goal of fifth-grade compre­hension. In actuality, the range is from fifth to eighth grade. The test is available in an audiotape format as well, which takes about 90 minutes. Each item is read twice. This aspect was designed for access by the visu­ally impaired, but doubles for individuals who have reading comprehension problems. Language compre­hension level required for the audiotape format is fifth grade. A computer-administered form is also available that presents items singly and with a response entered on the keyboard.

The effective use of the MMPI-A with pediatric rehabilitation patients is contingent upon cautious interpretation. For example, elevated scores on scales such as “hypochondriasis” or “lassisitude-malaise” will be interpreted differently in a patient with chronic illness than in general populations. A correction fac­tor is recommended for use with spinal cord injury to obviate responses to items that reflected the reality of the medical condition, as opposed to the criterion value assigned to the item (117). Recommended uses for the MMPI-2, which would also appear appropri­ate for the MMPI-A, in medical assessments include assessment of response bias, as the validity scales allow for assessment of the accuracy of the patient's self-report, identification of emotional distress factors relating to the medical condition that may influence recovery, and comorbid psychiatric conditions that would be expected to affect recovery and participation in rehabilitation. Attempts to use the MMPI-2 (and likely the MMPI-A) to differentiate between organic and functional conditions are discouraged, as research suggests that elevated scores on scales suggestive of somatic preoccupation can reflect the effects of the medical condition (118).

The Personality Inventory for Children, 2nd Edition (119) is a behavior rating scale for children ages 5-19. It is comprised of 275 items to be completed by a par­ent. There is a brief form that takes about 15 minutes to complete. Composite scales include cognitive impair­ment, impulsivity and distractibility, delinquency, fam­ily dysfunction, reality distortion, somatic concern, psychological discomfort, social withdrawal, and social skill deficits. Three validity scales are designed to assess response biases, including inconsistency, dissimula­tion, and defensiveness, that may invalidate responses. Sattler (120) finds that additional research is needed on the reliability and validity of this new version of the scale, and there have been some concerns noted about the use of previous versions with specific rehabilitation populations—notably those with brain injury.

The Achenbach System of Empirically Based Assessment (121,122), including the Child Behavior Checklist for Ages 6-18 (CBCL/6-18), the Child Behavior Checklist for ages 1.5-5 (CBCL/1.5-5), the Youth Self-Report (YSR), and Caregiver-Teacher Report Forms (TRF), are commonly used measures of psy­chosocial adjustment. They were each developed through factor analysis (or the statistical grouping of items into clusters/scales, as opposed to using clini­cal judgment to group items), but also include DSM- oriented scales developed through clinical judgment. Broad domains include internalizing symptoms and externalizing symptoms. The CBCL/6-18, TRF, and YSR each include 112 items in eight scales. The CBCL and TRF are designed for completion by parents or teachers, respectively, of children ages 6-18 years. The YSR is designed for self-report of adolescents ages 11-18, and requires a fifth-grade reading level. The CBCL∕1½-5 and Caregiver-Teacher Form, for use with younger children, each consist of 100 items, separated into seven and six scales, respectively. The scales are commonly used in children with chronic physical con­ditions (107). Limitations of its use with children in this population include limited sensitivity to milder adjustment problems, a possible confound by medical symptoms, incomplete assessment of social function­ing, and methodological concerns (123).

The Behavior Assessment System for Children-2 (BASC-2) (124) includes three parent rating scales (Preschool, ages 2-5 years; Child, ages 6-11; and Adolescent, ages 12-21); three teacher rating scales, following the same age ranges; and three self-report of personality scales (Child, ages 8-11 years; Adolescent, ages 12-21 years; and Young Adult, ages 18-25 years, attending a post-secondary school). Each scale takes 20-30 minutes to complete and requires a third grade reading level. Parent rating scales include compos­ite scores for adaptive skills, behavioral symptoms, externalizing problems, and internalizing problems. Teacher rating scales measure these four areas and add a school problems scale. The self-report scales include composite measures of emotional symp­toms, inattention/hyperactivity, internalizing prob­lems, personal adjustment, and school problems. The BASC-2 scales also include several indexes to measure response sets that would indicate invalid scores, such as high rates of negative answers, high rates of positive statements, endorsement of nonsensical or implausible items, or inconsistent responses. The BASC-2 system is well validated and provides an integrated multisource system of assessment (120).

The Rorschach Inkblot Technique (125) remains a widely used test in children and adolescents. It is the classic technique of 10 inkblots presented with the instruction to say what it looks like to the examinee. An alteration in administration with younger people is to follow up each card with the inquiry, asking why it looked like whatever the response was, whereas with adults, this is done only after all blots are viewed. Normative data on this technique for children and adolescents began appearing in the 1970s; however, these are not representative of the general popula­tion, being overrepresentative of children with above­average intelligence, with incomplete attention to race and socioeconomic status (125). Despite the fact that some norms exist down to age 2 years, most authors agree that the Rorschach should not be used with chil­dren below the age of 5 years. There is little experience with this type of test in assessing the type of adjust­ment issues common to the rehabilitation population. Therefore, it should be used guardedly.

Children’s Apperception Test (CAT) and Thematic Apperception Test (TAT) (126) represent another type of projective test, but this time, the stimuli are ambiguous pictures and the subject is asked to make up a story concerning what is happening, what led up to the scene in the picture, and what will happen next. It requires considerable skill on the part of the examiner, and should be given only by the profes­sional, as is the case with all projective techniques. There is usually follow-up questioning about the story given, and the recording is verbatim. There are no real normative data on the CAT, but some authors believe that it remains a powerful technique in dis­cerning children’s personalities (127). Some believe it taps themes of confusion and conflict, with the child’s resolution being a central focus of interpre­tation. It is based on the author’s personality theory as opposed to a pathologic model. The entire set con­tains 20 cards, although a standard administration uses only selected pictures. Over the years, individ­ual cards have been identified as being particularly useful with certain age groups. There are concerns regarding lack of adequate reliability and validity data (120).

In these days of cost-efficiency considerations, more specific measures are of great utility. The choice of a specific construct is often suggested by the results of other examinations or by knowl­edge of the presenting problem. Anxiety is a com­mon correlate of chronic physical conditions (128). The Revised Children’s Manifest Anxiety Scale for Children (RCMAS) (129) is a single-construct mea­sure of anxiety. The RCMAS has 37 short statements to which the child responds yes or no. There is a total anxiety score, as well as a lie subscale that examines the candidness and honesty of the response set. The brevity of the instrument results in the three anxi­ety subscales that can be generated but are of lim­ited use. The standardization sample was large and representative of socioeconomic status, demograph­ics, race, and gender. Validity and reliability are extensively reported in the manual and are helpful in informed interpretation. Reading level is third grade, so a wide variety of children and adolescents can use this device. Because of its brevity and specificity, it should be only one part of a battery.

The Children’s Depression Inventory (CDI) (130) is a well-recognized self-report measure of depres­sive symptoms in children ages 7-17 years. There are five subscales: negative mood, interpersonal problems, ineffectiveness, anhedonia, and negative self-esteem. Reliability for the total score is stron­ger than for subscales. Though a popular measure, questions have been raised about the psychometric properties (120).

The Behavior Rating Inventory of Executive Function (BRIEF)system (131) includes a preschool ver­sion of Parent and Teacher Rating Scales (ages 5-18) that can be completed by parents or teachers/daycare providers (ages 2-5) and a Self-Report (ages 11-18). The behavioral rating of executive functioning is an important addition to the assessment of psychological functioning in any child with neurologic impairment. Soliciting the observation of executive functioning in natural environments is especially important in light of previously mentioned concerns regarding ecologi­cal validity of clinical tests of executive functioning due to the highly structured, directive nature of clini­cal assessment. The preschool version of the BRIEF includes three broad indexes—inhibitory self-control, flexibility, and emergent metacognition—and a global composite, as well as two validity scales to identify excessive negativity or inconsistency in respond­ing. The other versions have two broad indexes— metacognition and behavioral regulation—and a global composite, as well as the two validity scales. Table 3.8 provides a complete listing.

Family Environment

The instruments noted here are part of the ever­growing recognition of the pivotal importance of fam­ily functioning in the face of a child’s disability and adjustment. The most dramatic impetus has been the requirement of a family service plan in all early- intervention services for children up to 3 years of age. Beyond the case to be made in the youngest age group, many studies show a strong relationship between fam­ily functioning and a child’s psychological adjustment across a number of different medical conditions (132). The importance of such considerations is clear. The fol­lowing are synopses of two widely used instruments for populations often within the scope of a rehabilita­tion practice.

The Home Observation for Measurement of the Environment Sale (HOME) (133) is a checklist designed to assess the quality of a child’s home environment. It is an involved process including observation of the home setting and interview with parents. Six areas are assessed: responsiveness of parent, parental accept­ance of child, organization of physical environment, provision of appropriate play materials, parental involvement with child, and opportunities for variety in stimulation. In young children, the home setting is a strong predictor of later functioning.

The Family Environment Scale (FES) (134) rates parental perception of the social climate of the fam­ily, and is rooted in family systems theory. It contains 90 true-false items that break down into 10 sub­scales: cohesion, expressiveness, conflict, indepen­dence, achievement orientation, intellectual-cultural orientation, active-recreational orientation, moral­religious orientation, family organization, and family rules. Scores are plotted on a profile, with two forms available—the actual state of the family as perceived by individual members and the ideal state. Profiles derived from each parent can be compared, from which the family incongruence score is calculated.

There has been controversy about the psycho­metric properties of the FES relative to the stabil­ity of its factor structure. It was suggested that the factor structure varies, depending on which family member’s perceptions were used. There is some cau­tion expressed about its use as a clinical diagnos­tic tool in a rehabilitation setting with adults (135). Others have used it successfully in studies of children with chronic medical conditions. In one such study by Wallander and colleagues (136), family cohesion made a significant contribution to social function­ing in children with spina bifida. A measure of fam­ily functioning specific to children with disabilities

3.8

Measures of General Psychosocial Functioning

(PCDI) is presented in the following section on popu­lation-specific assessments. Table 3.9 provides a full listing of these tests.