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Chapter 4
Assessment, Diagnosis, and
Treatment
Clinical Issues
The Decision-Making Process
Mental health clinicians have to systematically consider many NB questions to understand a
child’s basic problem and to make diagnoses and devise treatment plans
This process requires sorting through factors that bring a child to the attention of professionals,
and checking out alternative hypotheses and plans
This process is aimed at finding answers to both immediate and long-term questions about the
nature and course of the disorder and its optimal treatment
Process typically begins with a clinical assessment, which uses systematic problem-solving
strategies to understand children with disturbances and their env
o Strategies include:
An assessment of child’s emotional, behavioural, and cognitive functioning
Role of env factors
o Strategies form the basis of a flexible and ongoing process of hypothesis testing regarding
the nature of the problem, its causes, and the likely outcomes
The ultimate goal of assessment is to achieve effective solutions to the problems faced and to
promote and enhance well-being
A close and continuing partnership between assessment and intervention is NB
Focus of clinical assessment is to obtain a detailed understanding of the individual child as a unique
entity, referred to as idiographic case formulation
o This contrasts nomothetic formulation, which emphasises broad general inferences that
apply to large groups of individuals
Nomothetic knowledge is likely to result in better hypotheses to test at the
idiographic level
Clinicians begin their decision making with an assessment: a collaborative process in which the
child, family, and teacher all play active roles
o V NB to establish rapport with them
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Developmental Considerations
In assessment of children, one needs to be sensitive to child’s age, gender, and cultural
background as well as to normative info about both typical and atypical development
o = Context for evaluating and understanding the behaviour and circumstances of an
individual child and family
Age, Gender, and Culture
NB to recognise diversity within children’s developmental functions and capacities at various ages
Age has implications both for judgements about deviancy, and for selecting the most appropriate
assessment and treatment methods
Gender presents differences in the rates and expression of childhood disorders
o Some are more common in one sex than the other, while others are equally common in
both sexes
Most childhood disorders are identified and defined by adults, because adults find the symptoms
particularly salient
NB boys may receive an excess of referrals, and girls may be overlooked because of their less
visible forms of suffering
o Interventions must be sensitive to possible referral biases related to gender and gender
differences
NB to remember that there is great variability both between girls and boys, and within each group
o Gender differences in emotional expression and behaviour have shown to vary
depending on the age of the child, the interpersonal context, and the personal relevance
and demands of the situation
o It’s also NB to study both girls and boys as distinct groups in their own right
An exclusive focus on sex differences could delay careful study of the expression
of and underlying processes associated with specific disorders in one group or
the other
When adjustment problems are studied in rln to girls, it has been shown that they
experience significant problems such as relational aggression during childhood
This, combined with physical aggression, is the strongest predictor of
future psychological-social adjustment problems in girls
Children who engage in forms of social aggression not typical of their sex are
significantly more maladjusted that children who engage in gender-normative
forms of aggression
Cultural factors are v important in consideration
o Rapidly changing demographic and cultural landscape
o Expanded cultural emphasis in the most recent revision of the DSM
This includes a framework for developing a cultural formulation of the disorder
based on:
The child’s cultural identity
Their cultural concepts of distress
Psychosocial stressors and cultural features of vulnerability and
resilience
Cultural aspects of the rxp between the child, family, and clinician
An overall cultural assessment including a culturally appropriate plan
for treatment
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o Cultural patterns reflect learned behaviours and values that are shared among members,
are transmitted to group members over time, and distinguish the members of one group
from those of another
o Children who are ethnic minorities run a greater risk of being mis-/under-diagnosed
o Culturally competent assessment and treatment practices require that clinicians examine
their own belief systems and the culturally based assumptions that guide their clinical
practice
o A cultural formulation is NB to establish a rxp with the child and family, motivate family
members to change, obtain valid info, arrive at an accurate diagnosis, and develop
meaningful recommendations for treatment
o Ethnic identity and racial socialisations are key factors to consider in the assessment of all
children and families, including those from the dominant culture
o Cultural syndromes refer to a pattern of co-occurring, relatively invariant symptoms
associated with a particular cultural group, community, or context
It is NB that clinicians assess extent to which a child’s cultural background and
context affect the expression of both individual symptoms and clinical disorders
What is considered abnormal child behaviour may vary from one cultural group
to the next
o It may be difficult to engage parents from some cultures if MH issues are seen as taboo, if
intervention by strangers is viewed negatively, or if the causes of the illness in that culture
are seen as physical or spiritual
Generalisations about cultural practices frequently fail to capture differences
An individual’s acculturation level can also impact assessment and subsequent
interventions
The lower the level of one’s acculturation, the higher one scores on
measures of psychopathology, particularly in conjunction with low SES
and education level
Normative Information
Knowledge, experience, and basic info about norms of child development and behaviour problems
are the crucial beginning to understanding how children’s problems come to the attention of
professionals
Parents are faced with determining what difficulties are likely to be chronic versus those that are
common and transient, deciding when to seek advice, and determining what treatment is best
Isolated symptoms generally show little correspondence with children’s overall adjustment
o Usually, the age inappropriateness, severity, and pattern of symptoms, rather than individual
symptoms, define childhood disorders
o Extent to which symptoms result in impairment in functioning is also a key consideration
o Certain symptoms do occur more frequently in children referred for assessment and
treatment
Some symptoms are relatively common behaviours that occur to some extent in all children
Purposes of Assessment
Purposes guide the assessment process, including decisions regarding the use of particular
assessment methods
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