Introduction

When conducting assessments, the developmental systems lens can appear overwhelming at first, considering the various levels of systems at play (e.g., micro, mezzo, macro, etc.) and the developmental norms for a given age group. To help us navigate this, we will employ the bio-psycho-social framework. This model originated with George Engel (1977) who during his career sought to change the paradigm of medical practice away from the biomedical approach to an approach that incorporated social, psychological, and behavioral dimensions of illness. Engel (1977) argued that the traditional medical model was reductionist and that the multifaceted nature of human needs requires an approach that is contextual and interdisciplinary. He articulated that there is definitely a place for biomedical inquiry and that much of the advances in medicine can owe their origins with that model; however, this biomedical approach cannot be the only approach (Engel, 1977). We will explain more about the model in the formulation section in this chapter.

Considering the developmental aspect of our guiding theory, the clinical interview will vary greatly depending on the age of the child. Infant and toddler assessment is a specialty and will be discussed further within this chapter; however, it is challenging to discern what the baby is communicating to you unless you have studied and been trained in infant diagnostics. The quality of the information gathered may vary greatly depending on the interviewer/evaluator skills. There is even a different diagnostic manual developed around this age group. The DSM-5 does not claim to diagnose prior to age two or three and even then, reliability and validity are questionable. Zero to Three is an organization that has developed and published criteria and standards for diagnosing infant mental health.

When conducting and using assessments to guide diagnosis and treatment, it is essential to examine the potential social, cultural, and racial biases reporters, instruments and therapists may hold. Diverse communities may be targets of such biases and stereotypes which influence how their difficulties are perceived. For example, research shows that girls tend to be underdiagnosed with autism spectrum disorder while boys tend to be over diagnosed with Conduct Disorder. African American individuals tend to be underdiagnosed with Depression Disorder while over diagnosed with Substance Use Disorders due to what is often considered “typical” presentations of these conditions (Garb, 2021). Moreover, it is possible that the instruments themselves carry biases and limitations related to their development and methodology (Reynolds, Altmann, & Allen, 2021). Therapists, then, should select instruments and interpret results carefully considering the child’s background, present context, possible limitations, and their own biases towards diverse groups.

The chapter is broken down into sections about age-specific approaches to assessment, data collection approaches, aspects related to formulation, diagnosis, and treatment planning. Age-specific approaches will span infants to adolescence; data collection will cover screening versus assessment, global versus specific measurement approaches, domains of functioning, and the role of collateral data; and the final sections will span the time-axis method in the biopsychosocial approach, the process of differential diagnosis, and the SMART approach to treatment planning.

In the process of an assessment, we may uncover a lot that is outside of our scope or purview, and it is important to note at the beginning of the chapter that we need to own our part of the service continuum; we can only work within the realm of a behavioral health provider. Skills as an advocate or as a connector to other services can broaden our influence on the various systems in the child’s life, while still maintaining our focus on behavioral health. We can follow up on referrals made or received by us beyond initial assessment and make sure that the family and child are following through and doing well. If there are other referrals for therapy, we can check in with parents or caregivers regarding keeping their initial appointment. If we continue to work with the child, we can facilitate the family’s ability to get to appointments and keep with any other types of therapy needed such as speech, primary care, or occupational or physical therapy.

Age-Specific Assessment

We want to preface any discussion of assessment by saying that working directly with the child and building a relationship is essential (Hilsenroth et al., 2004). A relationship with caregivers or any involved family member is also usually helpful. There are many barriers that families with young children may face to bring them to outpatient therapy. It is time consuming and can cost money to get back and forth. Home visitation is sometimes the only way that a parent or guardian of a young child would receive therapy. Not all programs will reimburse or even allow home visits so that varies with the agency or organization we are working with. Now that remote therapy has been more widely accepted, this may be a new trend. On the other hand, remote assessment through phone or videoconference is not ideal. Conducting therapy after meeting and assessing in person would be preferable if remote therapy is used.

Two child development theories will be weaved throughout this section, with a brief overview here and more commentary in the sections that follow. Piaget’s theory of cognitive development (Piaget & Inhelder, 1972) and Erikson’s theory of psychosocial development (Erikson, 1950). Piaget outlines four major stages of acquiring knowledge and building intelligence, with the sensorimotor stage spanning birth to 2 years, the preoperational stage spanning ages 2 to 7, the concrete operational stage spanning ages 7 to 11, and the formal operational stage spanning ages 12 and up (Piaget & Inhelder, 1972). Erikson (1950) articulated a lifespan theory that involves developmental tasks needed to master in order to maintain a healthy development, and these tasks include Trust vs. Mistrust (first year) Autonomy vs. Shame/doubt (1to -3 years); Initiative vs. Guilt (3 to 5 years); Industry vs. Inferiority (6 to 12 years); identity versus role confusion (12 to 19 years); Intimacy vs. Isolation (20 to 39 years); Generativity vs. Stagnation (40 to 59 years); and Ego Integrity vs. Despair (60+ years).

Assessing Infants and Early Years

Dulcan (2014) states that the most important assessment information when working with infants and toddlers comes from understanding the interactions and relationship between caregiver and infant. According to the author, the quality and consistency of care has the most impact on the physical and mental health of infants. Caregivers would perform the ego functions for infants and toddlers processing and organizing external and internal stimuli. The infant and toddler are extremely dependent on their caregivers physically, socially, and psychologically. Thus, family work is essential in the specialized field of infant mental health.

Understanding the relationship between infants and caregivers is key to assessing the well-being of the child (Larrieu, Middleton, Kelley & Zeenah, 2010). The nature of the relationship between the caregiver and infant can reveal a great deal about the child’s present and indicate future functioning. The Working Model of the Child Interview (WCMI) is designed to assess quality of attachment relationship and can be administered as a clinical interview with the parents/caregivers. Larrieu et al. (2010) studied the test validity of the WCMI and reported that it has concurrent validity with the Strange Situation classifications of attachment and predictive validity for distinctions between clinical and nonclinical groups of infants. The WCMI (Zeanah & Benoit, 1995) was first developed in 1986 and updated in 1993, and it consists of 19 open-ended items aiming to assess the caregivers’ internal representation of the infant and their relationship. These perceptions are hypothesized to predict the relationship between caregiver and infant and the infant’s mental health. Another tool, the Infant Mental Status Exam, is an instrument that utilizes the clinician’s observations of the infant’s physical appearance, mood, and behaviors. A short interview with caregivers is also part of this assessment.

Evaluating the emotional and mental health of infants and toddlers includes assessment of very subtle and ambiguous symptoms. What infants and toddlers are expressing is difficult to determine because we must rely on nonverbal cues, and we cannot verify our intuitive interpretations. Parents and caregivers can be helpful when they seem knowledgeable, but even parents may struggle with interpreting infant and toddler expressions and communication accurately. Infant and toddler’s nonverbal and preverbal expressions of emotional and cognitive processing are among the most ambiguous information. Many of the expressions of internalized disorders like depression, anxiety, or some trauma reactivity are communicated through affect, but infants only have a limited repertoire of behavior and expression of affect. Because infants are pre-verbal, they cannot tell us their internal feelings or thoughts, so any concern about a depressive or anxious syndrome can only be directly investigated by observing and recording behavior like sleeping, waking, affect, bids for attention, and other nonverbal communication. We rely on parental reports and collateral information from other adults.

Toddlers present with larger nonverbal skills and a growing set of verbal skills, but their concept of time, space, emotion, and the world are preoperational. This stage of cognitive development is formative (Piaget & Inhelder, 1972). The child can take in more than just through their senses and motor skills now that they have moved out of the sensorimotor stage of infancy. Once infants and toddlers gain object permanence, they form an internal representation of the object even when it is not present; this operation is the beginning of symbolic representations. However, as long as they are in the preoperational stage of cognitive development (generally ages of 2 to 6), they cannot operate in the symbolic world completely. According to Piaget and Inhelder (1972), children operate most of the time in the concrete world. Directed play therapy and narrative stories can elicit thoughts and emotions that the child is experiencing. Clinicians should take particular care in offering interpretation given their power in the therapeutic relationship, as it should reflect the client’s world and not a projection of our own.

There are tools and trainings specifically designed for therapists who want to work with infant and toddler mental health. The DC:0–3 Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood was originally published in 1994. The organization ZERO TO THREE: National Center for Infants, Toddlers, and Families was established in 1977 with only $12,000 of grant money and one employee. The Center has grown and been recognized by national organizations such as Head Start, who relied on their training and consultation regarding mental health issues in infants and toddlers. The organization offers training and holds a large annual conference each year. The American Academy of Child and Adolescent Psychiatry task force on research diagnostic criteria has also published diagnostic criteria for infancy and preschool children (Eger & Emde, 2011).

Assessment During Early Childhood (Ages 3 to 5) 

The quality and nature of interactions between caregivers and the child remain critical parts of the assessment of preschool-age children. Thus, direct observations of these interactions are necessary during the assessment process. Measures like the Parent-Child Early Relational Assessment (Clark, 1985) rate observations and inform the clinician about the style and pace of both caregiver and infant, balance between autonomy and interdependence, as well as the qualities of attachment and bonding. The child’s motor skills, language development and cognitive development can also be observed during this assessment.

The development of communication skills is exponential as the infant moves into toddlerhood and early childhood. The human brain grows 80% of its size by 36 months (Guide, Shaw, et al., 2006). In their first years, young children are learning about basic concepts such as space and time. As their concepts are constructed, each child creates a unique and somewhat magical understanding of the world, which is characteristic of the preoperational stage of development (Piaget & Inhelder, 1972). For instance, children may attribute superpowers to adults because they watched adults with superpowers on TV; this points to the concrete thinking children in this age group use to generalize knowledge about the world. Using and interpreting communication, particularly abstract and metaphoric, is still in development among young children, and they rely on concrete language. Similarly, their emotional life and self-concept are also developing, and evaluation of mood, affect and self-esteem may be challenging.

During early childhood, children are constantly changing and acquiring new knowledge and skills. As clinicians, we should be attentive to their development in multiple domains: speech and language, motor and fine-motor skills, toilet training and personal care, and ability to self-regulate. Knowing the expected developmental milestones of the child’s age can help to identify possible challenges or delays. Assessments of adaptive functioning such as the Vineland-3 (Sparrow et al., 2016) aim to evaluate multiple skills that are expected for the child’s age and allow them to function in their environment. Results can inform the need for early interventions and additional services for the child such as in-home visitations, physical therapy, speech therapy and others.

Evaluations for developmental disorders including autism are also common during early childhood as some repetitive behaviors and restricted interests start to be more evident. Instruments such as the Social Communication Questionnaire (SCQ, Eaves et al., 2006) is a useful screening tool that can be completed by caregivers and indicate if a child needs further assessment for autism. A comprehensive evaluation for autism would also include specific instruments such as the Autism Diagnostic Observation Schedule, Second Edition (ADOS-2; Lord et al., 2012) and the Autism Diagnosis Interview-Revised (ADI-R; Lord et al., 1994).

It is important to use different strategies to assess the internal emotional life of young children. The direct interview methods used with older children and adults may not be productive or engaging. Play can reveal themes throughout childhood, and in assessing three- to five-year-old children, it is crucial to include play. Interactive, nondirective, and directive play can reveal themes such as experiences, feelings about relationships and events, and self-concept. Like playing, drawing is an interesting activity for many young children that can provide valuable information about them and their environment. After you develop a rapport with your new child client, a request to draw a self or family scene can be used to get a glimpse of the child’s self-image and to begin to assess family tenor, make-up, rules, and style of interactions in the family.

Bettman and Lundhall (2007) review narrative assessments for young children, finding over ten that exist with varying degrees of reliability and validity. They report that the MacArthur Story Stem Battery (MSSB) (Bretherton et al., 1990) is the most widely used narrative assessment instrument for young children. Following the presentation of the story stem, the examiner asks the child to “show me and tell me what happens now.” Story stems address a number of content areas, including child injury, oppositionality, exclusion, and parental conflict. Children are presented with the beginnings of a sequence in a story with matching doll, animal, and miniature household figures set up to dramatize the story. Then, the child is invited to complete the story in their own way and to use the toy figures to illustrate their sequence of events. Wolf et al. (2003) caution that we should not interpret the story as a direct observation of the child, but there are recognized correlations between the way the child completes the story and events in the child’s life. For example, Toth and colleagues (1997) assessed representations of self and others among a sample of maltreated preschoolers and identified differences between those with and without a history of abuse.

Another measure, the Story Stem Assessment (Lees, 2016) was developed in the 1990s and includes themes of being lost, getting injured, and crying. An example of a story sequence is entitled “Picture from school.” The story begins with the child making a picture in school and taking it home “When the child gets to the front door of her house holding her picture, someone comes to the door.” Then, the assessor asks the child “Then, what happened?” There are official scoring manuals to provide additional validity to your interpretation (Lees, 2016).

Assessment During Middle Childhood

Middle childhood is marked by formal education through school or homeschooling. During this period, children usually learn how to read and write and are exposed to various fields of knowledge including mathematics, social sciences, and biological sciences. They develop operational thinking which allows them to better understand concepts such as time, area, and volume by using observations, comparisons, and logic (Piaget & Inhelder, 1972). Socially, children strengthen peer relations through more collaborative and complex play and games. They start learning about rules and their role in governing social interactions.

Critical developmental tasks of middle childhood occur in these years, such as development of self-esteem/ self-efficacy, social identity, internalization of evaluation of performance at many levels by both adults and peers, academic and athletic abilities, and behavioral and social/emotional competencies.

By later middle childhood (age 12 years or over), children grow in independence and can get dropped off or even use public transportation either on their own (if mature enough) or with siblings.

Throughout your therapeutic relationship with child/youth and their family, part of the ongoing assessment process includes good communication from the beginning and being proactive about contacting and staying in relationship with the family/child and remembering the many facets of their biopsychosocial make-up. This developmental period serves a critical juncture in terms of the individual biological and ecological factors. The gene-environment interaction is critical through childhood and adolescence, as genetic predispositions are susceptible to stressors and can emerge when triggered, or they may remain only predisposition and not develop when emotional and social environments are nurturing and supportive of the youth (Kalin, 2020). Some disorders are more likely to develop as a result of environmental factors during childhood and, if onset is not until adulthood, are less severe (Kalin, 2020). About half of those who develop a mental health disorder over their lifetime experience onset by age 14 (Kessler et al., 2005). Children between ages 6 and 13 years spend most of their time at school or engaging in educational activities so learning, social, behavioral and emotional challenges become salient to educators. As a consequence, this age group is frequently referred to school counselors, school psychologists, social workers, and other mental health professionals when issues arise.

Several key factors will determine how to approach assessment techniques with this age group. To assess these concerns, we should focus on establishing good rapport with the child by engaging in drawing or playing. We can rely more on the child’s report by asking them questions about their routines, thoughts, and feelings. Asking the child to draw their family and themselves continues to be an interesting way to explore their family system and self-concept. Gathering information about the child’s history and behaviors across different contexts is extremely valuable as well. We can notice variations in how a child behaves at school and at home. This may indicate challenges and strengths that are specific to certain environments or relationships (e.g., a supportive teacher or a caring family member). Depending on the child’s literacy, they may be able to fill out self-report measures that have been validated to their age group. A mental status exam for children starting during middle childhood (6 to 12) can be most useful.

Cognitive and Intellectual Functioning. As mentioned, a hallmark of the middle childhood period is formal education. Assessments of cognitive and intellectual functioning, as well as academic achievement are commonly conducted during these years, particularly when the child experiences difficulties in learning. Individualized Educational Programs (IEP) are important documents that provide additional services in school to students including speech therapy, occupational therapy, reading remediation, and counseling. These plans rely on psychological evaluations that usually assess intellectual functioning and academic achievement.

Intelligence or cognitive functioning tests are often used to determine if a child is placed in an appropriate educational setting, if there are any learning or developmental disabilities present, and to help families and educators develop educational strategies to best help a child succeed. Many of the most common intelligence tests that are used today have been largely influenced by the psychometric approach, which is based on the premise that there are certain mental factors that make up a person’s intelligence that then influence performance on specific intellectual tasks (Whiston, 2017). Spearman (1927) first postulated that all people possess a general ability factor, or g, that is made up of different cognitive abilities and influence overall performance on mental ability tests. Following Spearman, Thurstone (1938) proposed a model of seven factors that collectively accounted for most of the variation in level of intelligence, including verbal comprehension, word fluency, number facility, perceptual speed, memory, space, and reasoning. The Cattell-Horn-Carroll model, perhaps the most well-known contemporary theories of intelligence, expanded on Spearman’s g factor theory by proposing that g included both a fluid intelligence factor, which refers to cognitive abilities that involve being able to reason, analyze, and manipulate novel information, and a crystallized intelligence factor, which refers to specific skills and knowledge that are acquired over time through educational experiences, culture, and the social environment.

The Wechsler scales of intelligence are the most widely used tests to measure individual intelligence in youth (Archer & Newsom, 2000). He developed a series of three instruments designed for specific age groups: The Wechsler Preschool and Primary Scale of Intelligence IV (WPPSI-IV; Wechsler, 2012), for ages 2.5 to 7, the Wechsler Intelligence Scale for Children, Fifth Edition (WISC-V; Wechsler, Raiford, & Holdnack, 2014), for ages 6 to 16, and the Wechsler Adult Intelligence Scale, Fourth Edition (WAIS-IV; Wechsler, 2008) for ages 16 to 90. The Wechsler all include the calculation of the Full-Scale IQ (FSIQ) score which represents a global and aggregate measure of cognitive abilities and is considered the most representative indicator of an individual’s overall intellectual functioning. In addition, all of these instruments are made up of a certain number of subtests that aim to measure different domains of cognitive functioning and intelligence. For example, the subtests on the WISC-V map onto five indices that the assessment is trying to capture: Verbal Comprehension Index (VCI), Visual Spatial Index (VSI), Fluid Reasoning Index (FRI), Working Memory Index (WMI), and Processing Speed Index (PSI). The VCI measures an individual’s ability to verbalize meaningful concepts, think about verbal information, and express oneself using words. The VSI measures a child’s visual-spatial reasoning, integration and synthesis of part-whole relationships, attentiveness to visual detail, and visual-motor integration. The FRI measures a child’s inductive and quantitative reasoning abilities, broad visual intelligence, simultaneous processing, and abstract thinking. The WMI measures a child’s ability to identify verbal and visual information, maintain information within immediate memory, and re-sequence information to problem solve. The PSI measures a child’s accuracy and speed of incoming visual information, decision making, and decision implementation.

Interpreting scores on the Wechsler scales of intelligence not only includes an analysis of the results of the FSIQ, primary index scores, and subtest scores. It also involves identifying a child’s areas of strength and weakness, and comparison of scores both within indexes and between indexes to get a better understanding of a child’s overall cognitive functioning. In addition, behavioral observations during testing administration are crucial in helping a clinician interpret scores—for example, if a 7-year-old child is observed to have difficulty following instructions, is fidgeting throughout, and is easily distracted during testing, it would be important to note in the assessment report whether this could have impacted their performance on the WISC-V and thus could be an underestimate of their true cognitive abilities. Additionally, children with attention-deficit/ hyperactivity disorder (ADHD) tend to score lower on WMI and PSI because the subtests on these two indices measure aspects of executive functioning (working memory and processing speed), which is commonly impaired in individuals with ADHD. If behavioral observations during testing align with lower scores in WMI and PSI, a clinician may be better able to make a stronger argument for a diagnosis of ADHD.

Other tools and batteries that are commonly used for assessment of cognitive and intellectual functioning in youth include academic achievement tests such as the Woodcock-Johnson IV Tests (WJ-IV; Schrank et al., 2014) and the Wechsler Individual Achievement Test-III (WIAT-III; Wechsler, 2009). Both assessments specifically measure a child’s reading, writing, math, and oral language skills and have both grade-based and age-based norms in order to assess patterns of strengths and weaknesses in a child’s academic functioning. Academic achievement tests may also help in the diagnosis of Specific Learning Disorders that are classified in the DSM-5, such as Specific Learning Disorder with impairment in reading. If a specific learning disorder or language disorder is suspected, assessments may be administered that are specifically tailored to measure language domains. Language and phonological processing tests such as the Comprehensive Test of Phonological Processing- Second Edition (CTOPP-2; Wagner et al., 2013), the Test of Word Reading Efficiency- Second Edition (TOWRE-2; Torgeson et al., 2012), and the Clinical Evaluation of Language Fundamentals- Fifth Edition (CELF-5; Wiig et al., 2013) can help in ruling out language and communication disorders.

Assessment During Adolescence and Early Adulthood

Adolescence can be considered a dramatic developmental transition. Bodies are changing triggered by puberty and brains are transforming in various areas (Arain et al., 2013). Their use of cognitive skills is being consolidated in relation to gathering and organizing information, planning, modulating behaviors, regulating emotions, and navigating interpersonal relationships. According to the cognitive stage model (Piaget & Inhelder, 1972), adolescents employ more consistently abstract thinking (e.g., reasoning, hypothetical scenarios) and manipulate theoretical concepts to understand and explain the world. Moral and ethical reasoning also become more prevalent during this period, nuancing their views on social, political, and philosophical issues. Psychologically, adolescence is marked by the development of identities which may lead to confusion but also to deeper understanding of self and one’s role vis-a-vis others (Meeus et al., 1999).

In most states, adolescents have legal confidentiality and should assent to their treatment. Fostering their self-determination and empowerment is the goal. On the other hand, the combination of an excitable limbic system, growing sexual hormones, and inclination to risk-taking may lead adolescents to display more impulsive behaviors and experience intense emotions (Casey et al., 2008). Their skills to regulate their behaviors and emotions is still developing and consolidating which may lead to difficulties and poor decisions (e.g., drug abuse, risky behaviors). Nevertheless, therapists should respect the self-determination of the adolescent even if they feel protective of their inexperience. Adolescents who are struggling with disruptive emotional or learning disorders are having to negotiate difficult terrain as they grow up.

Regarding the assessment process, adolescents become the primary source of information regarding their functioning, social interactions, and problems. Building rapport with your teen client then becomes vital, which requires flexibility and creativity to engage them in the process. Self-report measures assessing psychological symptoms such as depression, anxiety, and attention and hyperactivity tend to be reliable sources of information. Personality inventories that examine developing personality traits in adolescents can also be helpful to explore internal representations of self and their relationship with others. These instruments provide insight into adolescent’s internal world organization and patterns of interactions which may inform appropriate treatments.

Balancing between their autonomy, confidentiality, and ensuring their safety may be a delicate process. This is particularly true when conducting risk assessment and asking about substance use and alcohol drinking, sexual behaviors, trauma history, suicidality, and homicidality. In most states, therapists have the mandate to report to child protective services and other authorities’ cases of maltreatment, neglect, and abuse. Thus, it is important to consult and be knowledgeable about your responsibility as a provider. Additionally, adolescents may disclose self-harm thoughts and behaviors which should be addressed in therapy and, if needed due to higher or imminent risk, referred to psychiatric services or emergency rooms.

The Columbia-Suicide Severity Rating Scale (C-SSRS; Posern et al., 2008) a questionnaire used to assess suicide risk and is available in multiple languages. It can be completed by the adolescent or the therapist as a semi-structured interview. Such an instrument helps therapists to determine the immediate level of suicide risk a person may be experiencing so that appropriate steps can be taken. In case of positive risk, therapists should conduct safety planning with the adolescent. Safety planning is a brief intervention that aims to reduce suicide risk by identifying triggers to suicidal thoughts and helpful coping strategies including internal strategies (e.g., distraction), contacting social supports (e.g., calling friends or family members), contacting mental health providers, and restricting access to lethal means (Stanley & Brown, 2011). It is helpful to collaboratively construct the safety plan with the adolescent to make it more relevant, accessible, and meaningful for them. Additionally, having it written and providing the adolescent with a copy of it can increase the chances of them using it when needed.

Talking about suicidal ideation and behaviors can be daunting for adolescents, so it is important that therapists are comfortable with bringing up these topics and normalizing their experiences. Inconsistencies in reporting past self-injurious thoughts and behaviors may exist and be even adaptive among youth (Klimes-Dougan et al., 2022). Moreover, screening tools such as the C-SSRS may not fully capture the spectrum and complexity of suicidality and related behaviors, missing important signs relevant to clinical practice (Giddens et al., 2014). When working with those at risk for self-injurious thoughts and behaviors, the therapist should conduct the assessment carefully and thoughtfully, using follow-up questions, indirect assessment, and collateral information from caregivers and significant others.

Data Collection

Conducting assessment with children and adolescents requires using multiple strategies of data collection and sources of information. Data collection is meant to quantify information related to the frequency, duration, and intensity of behaviors, as well as the contexts in which they occur and the various facilitators and moderators involved. From a developmental systems perspective, we would consider this as looking for the proximal processes (see Chapter 1).

The clinical interview is an opportunity to ask and answer questions from the child and caregiver(s). Although there is a focus on gathering information, it is a unique moment to build rapport by creating a safe and accepting environment for the family. Therapists should be aware of potential cultural differences and personal styles when conducting clinical interviews. For example, it may be disrespectful to sustain eye contact with a person in authority such as the clinician among diverse families (Alcantara & Gone, 2014). Thus, the clinical interview should be carefully carried out combining the clinician’s expertise, developed through case experience and ongoing supervision, with the data made available by the child and their family, including their identities, background history, and communication styles.

How do we begin with collecting data in a systematic way? There are multiple semi-structured interview protocols tailored to assist clinicians in systematically collecting data. The Kiddie-Schedule for Affective Disorders and Schizophrenia – Lifetime Version (K-SADS-PL; DSM-5; Kaufman et al., 2016) is a comprehensive semi-structured interview that aims to assist clinicians in identifying current and past mental health symptoms. The interview should be conducted with children ages 6 to 18 years old and their caregiver(s) separately. Being familiar with the protocol is essential before administering it since the questions and probes should be adapted to the developmental level of the child, family unique characteristics, and the clinical hypothesis.

Rating scales and instruments are another way for clinicians to provide systematic coverage of behaviors for comparison over time, setting, and context. These tools offer helpful structure to the clinical interview and may allow youth to more easily disclose worrisome or covert symptoms. Rating scales can provide language and normalize thoughts and feelings experienced by the youth, perhaps for the first time. Many agencies routinely employ scales and other instruments for intake and monitoring purposes. It is important to be familiar with the tools used in the agency where you work and integrate them into your assessment and clinical interview.

The use of rating scales does not come without some drawbacks or limitations. There can be limitations with self-report or collateral report. How many times has a child just circled all zeros or a teacher circled “all the time” on the classroom rating scale of a disruptive child (also known as exaggerated response bias or, more commonly, “a cry for help”)? The numerical scores may not be accurate, and clinical interpretation is required. For some children, it can be extremely exhausting to complete long batteries, especially for those with inattention problems. Therapists working with children should include other significant people in the assessment process such as caregivers, teachers, and extended family. However, this may also lead to disagreement between respondents. To further complicate, your observations of the child may similarly differ from reports from caregivers or teachers. While discrepancies may be due to lack of observational capacity, awareness, concern about the symptoms themselves, or sometimes rifts in the family system, discordance is normal (Hahn et al., 2019). The rating scale can at least provide a common language when talking about the presenting problem.

There are a few key considerations when selecting a rating scale. First, the instrument should have good validity and reliability to assess the child’s presenting problems. These terms refer to the extent to which the instruments measure what they intend to measure (validity) and that they are consistent across time and across items (reliability). Secondly, ensure that the measure uses language and terms accessible to the child and family. They may have limited English fluency, literacy, or comprehension, especially if you are working with low-resourced or immigrant communities. As an alternative, reading items for the respondent, clarifying questions, and using pictorial rating scales can be helpful. Lastly, make sure the instrument is relevant and feasible for you and the client. Clinicians should be familiar and comfortable with the content of the measure so they can explain items to the child or caregiver.

Instruments can be used to monitor progress throughout treatment. The systematic and repeated use of instruments would fall under the category of measurement-based care. Measurement-based care involves the routine assessment of the severity of symptoms with rating scales. It also entails the use of assessment in treatment decision-making in order to generate clinician workflows, decision-trees, and uniform protocols for action (Aboraya et al., 2018; Lewis et al., 2019; Waldrop & McGuiness, 2017). Clients benefit from this approach through improved psychotherapy outcomes, and better identification of the patients who are improving and those who need additional services, as well as enhanced therapeutic relationships and better communication between providers and clients (Aboraya et al., 2018; Lewis et al., 2019; Waldrop & McGuiness, 2017). Clinicians stand to benefit because it enables them to monitor symptom reduction, improve collaborative care efforts among providers, improve the accuracy of clinical judgment, and enhance their decision-making process (Aboraya et al., 2018; Lewis et al., 2019; Waldrop & McGuiness, 2017).

Screening Versus Assessment

Time is a scarce asset of clinicians and the families, especially when under the constraints of the billable hour. In an ideal world, we would be able to spend hours with a family across multiple sessions to conduct a comprehensive assessment. However, the reality is that our time and the family’s time is extremely limited. Thus, therapists have to consider the amount of time that will be dedicated to assessment. This involves deciding between employing short screenings versus comprehensive and longer assessment. Screening is an excellent strategy to determine whether to further assess a particular cluster of problems. For instance, the PHQ-2 (Kroenke et al., 2001) is a two-question screener for depression, and if the patient does not have a significant score, it saves the clinician time and resources that would be needed to complete a longer battery, such as the 47 questions on the full Revised Child Anxiety and Depression Scale.

One of these systematic approaches is known as Screening, Brief Intervention, and Referral to Treatment (SBIRT; SAMHSA, 2011). SBIRT is meant to be brief, universal, and targeted, thus making it a feasible and effective practice in a variety of settings like primary care or community health centers (SAMHSA, 2011; Agerwala & McCance-Katz, 2012). This approach may improve access to care and brief interventions for those who are at risk for developing or already experience a problematic behavior or disorder. It has mostly been used for detecting and intervening with substance use disorders (SAMHSA, 2011; Agerwala & McCance-Katz, 2012). In this context, the clinician may quickly determine the level of risk of substance use and the appropriate level of treatment based on that risk level (SAMHSA, 2020). The brief intervention aims to increase insight and awareness of the target behavior and to increase motivation towards change. Lastly, referral to treatment entails determining those clients who require access to specialty care. Some studies show that the screening and referral to long term care aspects of the model is effective for other conditions such as depression and trauma (SAMHSA, 2011; Sterling, Kline-Simon, Weisner et al., 2018; Russo et al., 2013).

What about those that need more than a screening or more than a brief intervention? Or, what if you received a client who was referred after the screening? Comprehensive assessment provides a deeper look at the client’s presentation and attempts to evaluate the nature of the problem as opposed to its potential existence (which is the focus of screening). Assessment involves understanding the frequency, intensity, and duration of symptoms through further probing to determine alignment with diagnostic criteria or to gain clarification from the client about their initial screening responses. The symptom screening then is viewed while taking contextual factors into account. Risk formulation also requires contextual factors in light of the responses. For instance, if someone is assessing for suicidality, the suicidal ideations reported by the youth would be viewed against risk factors such as previous suicide attempts, recent self-injurious behavior, preparatory behaviors like writing a note or giving away possessions, or even consider things like the youth’s age (e.g., adolescents have more likelihood of suicide attempts than children). It is not enough to base clinical decision making solely on the child’s report of ideation. Risk factors are also not enough. Protective factors need to be considered, and, in the case of the suicidal child, are they engaged in treatment? Is there restricted access to lethal means? Do they have a support network? Furthermore, the level of functioning plays an important role in the assessment. Is the child having difficulty regulating their emotions, or do they require assistance from an adult or teacher’s aide?

On a diagnostic level, let’s say you use the PHQ-9 for depression (Kroenke et al., 2001), and the child scores in a clinically significant range. How much of that score is influenced by the items related to inability to concentrate or feeling fidgety and restless (i.e., items that could be better explained by ADHD)? This is a scenario where you would do a deeper dive into depression symptoms using a tool like the RCADS, or, if you are confident in the presentation representing a depressive disorder, you may want to rule out ADHD through a different battery of questions.

Global versus Specific Measures

Global rating scales cover various symptom clusters across diagnoses, such as including both internalizing and externalizing problems. There are global screeners such as the Pediatric Symptom Checklist (Jellinek et al., 1988) and the Strengths and Difficulties Questionnaire (Goodman, 1997) that can highlight which types of behaviors or challenges warrant further assessment. These global rating scales can also be called cross-cutting measures, as they “cut across” different symptom profiles. Specific measures focus on symptoms related to specific diagnoses (e.g., depression, anxiety, post-traumatic stress disorder). Clinicians often employ these instruments when they already have a clinical hypothesis regarding the issues experienced by the client or when they would like to rule out certain diagnoses.

Global rating scales or specific symptom screeners can indicate the need for a more thorough investigation into the child’s problems. For instance, a child is given the PHQ-9 (Kroenke et al., 2001), a commonly used depression screener, and if they score above a particular clinical threshold, further assessment is warranted to understand the severity or specificity of the potential disorder. Scales such as the Revised Child Anxiety and Depression Scale (RCADS) (Chorpita et al., 2000) or the Mood and Feelings Questionnaire (Wood et al., 1995) look at self-concept, depressive thought patterns, and more detailed responses about difficulties, being adequate tools following the PHQ-9.

Collateral Information

Let’s revisit the beginning of this chapter. If we are looking at the developmental systems lens, it can be overwhelming trying to cover all the domains and the potential information that could contribute to the presenting problem. This is where the art of assessment comes into play. Too little information, and we cannot have any certainty what is contributing to the presenting problem. Too much information, and we may still think we do not have enough to make a clinical decision. While too little information may lead to biases such as reliance on perceptions of recent or archetypical cases, there are also biases that may emerge from too much information. There is a measurement bias known as information bias, in which a researcher believes that more information is required in order to decrease uncertainty and guide clinical decisions (Lighthall & Vazquez-Guillamet, 2015).

With children, there are important thresholds, not necessarily in the overall amount of information, but from the information as it pertains to the different domains in a child’s life. There are several other sources of information about the child we should include in the assessment beyond caregivers. School collateral is critical, whether this comes from school officials or teachers, or reviewing the report cards or attendance report provided by the caregiver. There are times when extended family members care for the child, so it would be important to incorporate their observations, particularly if the child lives with them or spends weekends or after school time with them. There can also be other prominent adult or community figures who can provide valuable information, such as prosocial behaviors on a sports team or in an afterschool program.

There are several ways to gather and incorporate collateral information in the assessment process when working with children. One way is to talk directly with caregivers, teachers, and other past or current health providers to gain more insight into the presenting concerns about the child. Additionally, several measures of social-emotional functioning and academic achievement often have separate forms for the child, caregivers, and teachers to fill out. For example, the Behavioral Assessment System for Children, third edition (BASC-3; Reynolds et al., 2015) is a comprehensive assessment tool that includes child’s self-report, caregiver and teacher rating scales, and clinician observations to gain a holistic understanding of a child’s behavioral and emotional skills across school and home settings.

There are times when more formal and comprehensive testing is required that involves other professionals. For instance, psychological testing that covers intelligence testing or certain tests of adaptive functioning require clinicians with advanced training in assessment. At times, a medical etiology may be underlying the behavioral symptoms, so physical assessment and laboratory tests by a physician may be necessary.

Telling the Clinical Story from the Data

Clinicians are not just data collectors who facilitate checklists and measurements. Our clinical judgment is our key skill, and this judgment is on display most with the steps of clinical formulation, diagnosis, and treatment planning. These three components of the assessment process help to make sense of the phenomena presented by the child and family, as well as provide organization and explanation and offer a way forward.

Clinical Formulation

Formulation is the process of synthesizing a) information that was collected, b) considerations of a provisional diagnosis, c) understanding of the various risk and protective factors that could be contributing to the problem, and d) clinical reasoning guided by a theoretical approach. This synthesis creates the context or narrative of the client’s presenting issue: the diagnosis (if any), contributing factors, and possible prognosis. This ultimately will lead to a differential diagnosis. The formulation serves as the foundation for treatment recommendations, as it explains the given diagnosis and provides background on how intervention should target particular parts of the problem.

In the biopsychosocial model, there are variables that encompass biological factors like medical issues; genetic or family predispositions; natal variables (e.g., prenatal exposure to substances, complications in labor and delivery, or early postnatal CNS infection); psychological factors such as the child’s coping style and the family’s belief system; social factors including peer influence, culture, and racial and ethnic identities; and community resources.

Part of the biopsychosocial formulation are the four Ps, which are part of the time-axis approach to organize risk factors in relation to how the factors unfolded across the client’s history. Most of these factors come from the biopsychosocial domains, but the emphasis here is on the influence of timing and history of the given factors. Predisposing factors are those risk factors that create a vulnerability towards a negative health outcome. For instance, there may be biological vulnerabilities such as in utero exposure to substances. Precipitating factors are much like the activating event in the plot of the story; for instance, if a child has aggressive episodes, those episodes may have been precipitated by recent instances of victimization (e.g., being bullied) or life stressors such as a recent move, family death, or separation. Perpetuating factors are those that maintain the problem. For example, a child facing a death in their family may utilize avoidant coping strategies that, in fact, contribute to the presenting behavioral issues. Protective factors, on the other hand, are those that increase the likelihood of positive health or developmental outcomes. These can range from motivation for treatment, good physical health, to parental involvement, or a supportive school environment.

As mentioned above, recommendations should flow from the narrative created in the clinical formulation. There are times when extravagant intervention recommendations can miss the point, such as when manualized protocols and wrap-around services become the go-to intervention, when all the child may need is an IEP and a positive adult figure to develop social skills. Consider that structural interventions may significantly change a mental health presentation, such as if a child is facing homelessness and presents as anxious. Although Cognitive-Behavior Therapy is indicated to treat anxiety, it will not address the structural problem of homelessness that is driving the anxiety.

Relatedly, a thorough clinical formulation includes careful assessment of all cultural identity factors and influences. Patricia Hays (2001) introduced the ADDRESSING model as a framework that can be used to conceptualize the complex, multidimensional aspects of one’s identity and how they can influence one’s mental health and symptomology. Specifically, ADDRESSING urges the clinician to consider a client’s Age, Developmental and acquired Disabilities, Religion, Ethnicity, Socioeconomic status, Sexual orientation, Indigenous heritage, National origin, and Gender to make a culturally responsive diagnosis and treatment plan.

Diagnosis

Diagnosis is the identification of an illness through examination of symptoms. The debate about diagnosis ranges from the politics of how diagnostic criteria are developed, what it means to diagnose someone with a disorder, and the overall utility of diagnosis given the broad variability and need for stronger evidence (Zachar & Kendler, 2007; Stein et al., 2010). The diagnostic process requires clinical judgment, and following a set protocol helps to improve accuracy. Differential diagnosis is the process of differentiating conditions that can share similar signs, symptoms, or features. It is important to differentiate mental health disorders to provide more adequate recommendations and treatment.

According to the DSM-5 Handbook of Differential Diagnosis (First, 2014), differential diagnosis requires six steps:

1. Ruling out Malingering and Factitious Disorder,

2. Ruling out a substance etiology,

3. Ruling out an etiological medical condition,

4. Determining the specific primary disorder(s),

5. Differentiating Adjustment Disorder from the residual Other Specified and Unspecified conditions, and

6. Establishing the boundary with no mental disorder.

With the first step, it is critical to understand if the client has motivation for deception in their presentation. Malingering is considered a goal, such as compensation or avoidance of responsibility or incarceration, that may be achieved by receiving a mental health diagnosis. Factitious disorder is considered a mental health disorder and is characterized by deception without obvious external rewards. Oftentimes, the client may enjoy being a patient and only knows how to be taken care of if they are seen as sick.

The second step looks at the potential influences of substances on the presenting problem. For instance, the effects of methamphetamine lead to manic- or psychotic-like symptom; however, the treatment is significantly different. Step three works in a similar way by attempting to rule out if a medical condition is the underlying cause for the behavior. For instance, someone who may appear anxious may have a hyperactive thyroid, and treatment should focus on the endocrine system.

Once these preliminary factors are ruled out, the clinician moves to step three to consider the primary disorder that could explain the symptomatology. For instance, a clinician may observe low mood, irritability, and decreased sleep in a client and consider a depressive disorder. Step five attempts to understand if there is impairment related to a known stressor (like an adjustment disorder) or if there is not enough specific information, which then would point to one of the residual Other Specified or Unspecified categories (American Psychiatric Association, 2013). The last step is attempting to discern whether there is enough evidence that the impairment is significant to justify a mental disorder. Not all mental health issues are disorders. Clinical judgment is required to distinguish the boundary between pathology versus normative behavioral response.

When making a diagnosis, it is important to consider the implications that the diagnosis can have for the child in terms of gaining accessibility to systemic supports and services. The assessing clinician should be knowledgeable of the laws and regulations related to special education as a psychoeducational assessment and diagnosis can often be a determining factor on whether a child is eligible for special education services. For example, the majority of school districts in the United States use guidelines in the Individuals with Disabilities Education Act (IDEA) to determine eligibility for special education services (U.S. Department of Education, 2022). IDEA was a piece of legislation that was passed in 1975 to legally guarantee a free appropriate public education in the least restrictive environment, as well as related services such as occupational therapy to all eligible students who possess a disability falling with one of 14 disability categories. Notably, there has been a history of discrepancies between IDEA guidelines and the DSM regarding criteria for developmental disorders such as autism spectrum disorder (Tsai, 2014). The most recent DSM-5 attempted to address some of these discrepancies for autism by revising the diagnostic category from Pervasive Developmental Disorders in the DSM-IV to Autism Spectrum Disorder and removing subtypes of ASD including Asperger’s Disorder and Pervasive Developmental Disorder Not Otherwise Specified (PDD-NOS). This decision has been met with some controversy, as some have argued that it may disqualify higher functioning children with ASD from receiving a diagnosis that would meet eligibility criteria for IDEA (Grant & Nozyce, 2013; Prykanowski et al., 2015). Diagnostic criteria are constantly being revised as we have more nuanced understandings of psychiatric disorders, and it is imperative that clinicians stay up to date on the most current information while also considering how these criteria may be impacted by cultural context.

Treatment Planning

The treatment plan should start with the end in mind; clinicians should ask themselves, “what would tell me this client no longer needs treatment?” That is, the clinician should define specific treatment goals and indicators that would address the issues identified in the assessment. There are a few main considerations. One is time and figuring out how to benchmark progress. There are long-term goals which tend to be more global, and short-term goals are typically more specific aspects or behaviors. Another consideration is scope; that is, whether or not the goals are achievable through counseling work or changes in the environment such as implementing school supports, improving parenting, and increasing access to extracurricular activities. Lastly, treatment plans should consider the level of risk and functioning; for instance, acute crises, significant safety concerns, and issues that have a high impact on functioning (e.g., depressive symptoms that prevent adequate eating or sleeping) should be prioritized.

All of these considerations underscore providing the best treatment in the most efficient way, and we want to be precise with our interventions and other palliatives. Precision care has its origins in medicine, but its approach can be applied to psychosocial treatments. Precision care is understanding which approaches will be effective for particular patients based on their genetic, environmental, and lifestyle factors (MedlinePlus, 2020). As psychosocial clinicians, we will not administer genetic testing, but we can understand genetic influences when capturing a family history. The approach is only as good as its planning and execution. Once the approach to care is clearly identified, goals should be just as precise. The SMART goals technique is a way to gain specificity and relevance with goal setting. SMART stands for Specific, Measurable, Achievable, Realistic, and Timely. Goal setting can only go so far. Matching the goal with the appropriate intervention puts the treatment plan in motion.

Typically, when elaborating a treatment plan, a clinician tends to consider the child problem area or what is known as a disorder-driven approach (Deleiden & Chorpita, 2009). For the clinician, it is important to understand the common practice elements of EBPs as well as understanding which common elements are most representative of the approach for a particular disorder (Deleiden & Chorpita, 2009). These considerations will guide the clinician towards designing a plan that can be tailored to the child’s distinct presentation and also be responsive to the changes that occur in client presentation over the course of a treatment episode (Deleiden & Chorpita, 2009; Ng et al., 2016). Furthermore, because clients’ needs vary, it is critical for the clinician to match particular EBP components to each client, in order to enhance the uptake and use of coping strategies or other potential palliatives for the youth to use consistently (Ng et al., 2016).

Clinical Dialogues: Talking about Assessment of Youth with Emily Hunt

Sean E. Snyder, LCSW: The clinical dialogue around assessment is with Emily Hunt, who finds her home in counseling psychology. So, Emily, could you start with introducing yourself, and how does assessment fit into your clinical practice?

Emily Hunt, MA/MSEd.: I’ll start off by saying, I’m a trainee as a fourth-year doctoral student in counseling psychology. I am still learning about how to incorporate assessment into my clinical work, but what I’ve really appreciated about assessment is that I mostly work with youth and their families. Assessment has really been helpful in allowing families to feel empowered in understanding their presenting concerns about their child. So, this past year, I worked at the Child Mind, and I did an assessment-focused externship at their branch called the Healthy Brain Network. We provide free assessments to members of the community in New York City. I worked with a range of families from diverse backgrounds and helped them navigate the assessment process in order to help their children get services that they needed in and outside of school. At Child Mind, I did full neuropsychological assessments, and these assessments can really provide a lot of support for diagnoses, which can help families feel empowered as they navigate mental health and the school system.

Snyder: It can definitely open a lot of doors for folks, and then that also gives relief, clarity, or even the knowledge of a rule out; at least we know it’s not X, Y or Z thing. We will talk about assessment in more routine care settings, but you mentioned neuropsychology, which we don’t delve into with this book. What are neuropsychological assessments? What’s their utility?

Hunt: These evaluations are probably the most comprehensive type of evaluation a child can get because they include both psychological and psychoeducational assessment, and we are testing many domains like behavioral, cognitive, neurological, and motor functioning. We’re measuring things like attention; memory; visual, spatial, and motor abilities; language; learning; personality; emotion; and social and emotional functioning. One way that this has been phrased to me is through this example: Let’s say that you have a child with some learning difficulties. A psychoeducational assessment might help to determine if a child qualifies for special education service, but a neuropsychological evaluation will tell you why they need those services. For instance, they may qualify for services, but the neuropsychological evaluation can pin down that this child has a visual processing difficulty or a language deficit. It could very well be anxiety, or it could be a weakness in working memory. So, it really helps to understand why a child needs particular support and services.

Snyder: It gets on a very granular level to tailor interventions, to match them to the specific supports that they need. Thank you for explaining that very unique type of assessment. So now onto our general assessment found in routine care assessment. One of the core themes of the book is engaging families within the scope of the chapter topic. So, for this dialogue, how do we engage folks around assessment? Do you prep families before doing an evaluation? Or are there any engagement strategies you have with assessment when you think about the nuances of presentations across the lifespan?

Hunt: Open communication with the family is probably one of the most important things, especially if you’re working with families from more historically marginalized backgrounds in psychology. When you’re talking with families beforehand, what’s most important is to keep going back to the referral question: what is the family or the child’s main presenting concern? How long has it been going on? How’s that impacting functioning? And how often are the symptoms happening? As you’re talking with the family and prepping them for the assessment process, be very clear about your rationale for why you’re evaluating each domain that you’re choosing measurements and assessments for. Taking the mystique out of that process is really important, and you do that by going back to the rationale. The family can really understand why you’re doing each thing and what the purpose of each thing is.

Snyder: I think of the imagination for children and families when they envision psychological testing and assessment in those popular depictions of a child wearing an EEG cap or that it is an 8-hour multiple choice standardized test. It’s being clear, and I’m sure that fosters collaboration.

Hunt: If you have a client in psychotherapy, it can be very helpful that you are not the person that’s doing the assessment as well. It separates something that can help the treatment from being a part of individual psychotherapy treatment itself. For instance, things like more cognitive intelligence testing, which is something that is not meant to be done in a psychotherapy session. Keeping those roles separate is very helpful with the overall process of helping a family.

Snyder: Diagnostics is very different from assessment of needs within psychotherapy. Practitioners get the referral, but they have to assess how can my particular approach or service help this client with their particular problem. It’s always an ongoing process.

Assessment is different with different age groups. The common elements about transparency and openness are great standards for any age group, but do you have any nuggets of wisdom when it comes to assessing a 5-year-old versus a teenager versus a transition age youth?

Hunt: The biggest difference I saw was that the middle schoolers and high schoolers were really nervous that this was a test in school, that they were being graded. Or they were in that mindset that there was a consequence of taking this assessment. I will be really open and not frame it as a test. For example, I may say to a youth, “We’re trying to understand maybe how your brain works, and I know that you and your family were talking about how you’re having some difficulty in math or paying attention in school. Doing these activities is actually going to help us understand you better and find the best ways that we can help you.” Framing it as something that can really, really help them gets buy-in and gets their guard down.

Snyder: Reminds me a lot of the teens I see who automatically think you’re judging them or say, “Stop analyzing me!”

Hunt: For older clients that have a little bit more capacity to understand what a psychiatric diagnosis might mean, again, be transparent about the process and say that for the most part, an assessment is not a diagnosis. If you have a certain score on a test, it does not mean that you have a diagnosis; that’s not how these assessments work. It’s really about the whole picture. A scale or test is one piece of the puzzle that can help us understand the whole picture.

Snyder: As youth get younger, parent involvement in assessment and treatment should go up. Collateral is particularly important. I work a lot with child-welfare-system youth. What’s your approach like when we have blended families or nontraditional families?

Hunt: Trust the caretaker of the child as the expert or the child as well. It’s much of the same with more traditional families: allow them to tell you their story and what they’re observing, ask a lot of open-ended questions, and give them the ability to tell you what’s going on in their own words. And with blended families, or nontraditional families, unfortunately, psychological assessment and psychoeducational assessments have had a history of being marginalizing and oppressive towards certain groups of people, especially people of color, communities of color, LGBTQ communities. When you’re working with families that are less traditional, make more of a concerted effort to really collaborate and destigmatize the assessment process. For blended families, collateral is even more important to especially make sure everyone feels like they’re included in the process for those that want to be included in it.

Snyder: It’s a lot about participation, the bigger picture, not making assumptions. Any last things with the engagement with assessment of youth?

Hunt: Speaking of the bigger picture, be transparent about who you are including in obtaining collateral, like a school member, or be transparent about who is getting your report if it is for a court setting. Make sure there are connections so that all this valuable information can further engage a child in care.

Snyder: Now what about predictability for yourself? How much preplanning goes into an assessment for you versus how much is it based on run-time adjustments?

Hunt: It’s mostly preplanning. There is typically a triage or intake interview that can give you a sense of what the presenting concerns are and what they’re looking for. For a neuro psych assessment, there are standard assessments that you do in each area of functioning. Once you get a picture of what the symptoms are in each area of functioning, you can start building a case conceptualization. Typically, you have a pretty good sense of what you’re going to be administering before you start the process.

Snyder: Right, it’s tying all this back to the rationale for the assessment and trying to be targeted.

Hunt: The practical issue is that assessments are really tiring because they take a long time. You don’t want to keep adding assessments as you go along because it’s probably going to affect how the clients report their symptoms. If they are exhausted, you’re not going to get an accurate picture of what’s going on.

Snyder: And the clinician can get exhausted too and that impacts the assessment process. So, let’s look at the opposite side, the fun of doing assessments. Do you have any favorite assessments you do? And then go-to batteries you use?

Hunt: I love administering the Purdue Pegboard test that tests fine motor functioning. The child puts pegs in a board in a row, and then they do their other hand. That test usually engages clients, especially younger clients in the assessment process, because they think this is fun. The Bender Visual-Motor Gestalt Test is also a really great one to engage clients, where the child looks at pictures on a card, memorizes them, and then draws them. I like more tactile assessments because you can they see clients getting really engaged in them, and it helps a buy-in. As far as the go-to batteries, for instance with emotional behavioral functioning, the Beck inventory is usually a go-to.

Snyder: That paints the picture of assessment as not checking off boxes. I like those interactive tests; reminds me of the mini mental status exam, where the client draws shapes or does the three- step instruction.

Those tactile tests make me think of lifespan considerations and seeing how to engage different age groups or what goes into assessments for each group. What does your assessment approach look like, considering that there are different needs across the lifespan?

Hunt: The first things that come to mind are engaging teachers and parents. If you can speak with a teacher and get a sense of the child in the classroom, and then talk with the parents around the child at home, that can tell you so much, especially if there’s incongruence in their reports. Also, if the child has been in therapy, being able to talk with the therapist can be really helpful collateral to have. There are assessments that are specifically designed to get information from these sources; the Behavior Assessment System for Children (BASC) is an example that can get those different viewpoints.

Snyder: So, after we get all this data, we need to formulate. What does a good formulation entail?

Hunt: There are different ingredients to it: a really thorough intake interview of background history, having a sense of what functioning looks in multiple settings, interpreting the data from assessment instruments or the child performance on the tests, and then noting if there is anything particular that’s happening during the day that could be impacting the child’s participation in the assessment (for instance, were they especially tired or hungry, were there any stressors right before the test, or are they in a great mood and were really engaged in the process). Behavioral observations are huge. Make sure that you’re making observations about the client’s behavior throughout the process, especially in a case like a child with performance anxiety.

Snyder: Absolutely, those contexts of what literally is happening in the room are huge. I’ve known youth in the justice system being assessed while being shackled at court. That’s a huge factor in how that interview goes. Then we need to think of the big picture: what’s happening in a child’s neighborhood, what’s the temperature of current events.

Hunt: Absolutely, all to make sure you’re really getting the whole picture.

Snyder: In treatment, there will be ongoing assessment. For instance if there is a measurement-based care model being used in a clinic. Do you see measurement-based care being done in training programs? Is it being used in the field in the settings you’re in?

Hunt: My initial training was in a person-centered psychodynamic lens, which can discourage use of measurements throughout treatment. As I’ve switched to working more from a behavior orientation, like with CBT and DBT, measurements are used quite often. In my CBT cases, we’ll do a mood check first thing. How would you rate your overall mood on a scale of one to 10? It helps the client track their own process, and it helps the therapist as well.

Snyder: You bring up a really good point, too, that points to my own bias because I am very CBT oriented. I realize that all the readers out there don’t have the same theoretical perspective as me. What would you say for folks in a more dynamic orientation if they want to track progress?

Hunt: In that perspective, most of the tracking is supervision based and thinking about your countertransference. Progress tracking is a little more subjective because clients gain insight into their defense mechanisms, and so there are more therapeutic markers or signposts in sessions, like when the clients becoming more self-aware of those insights and bringing them up in sessions; you may notice moments of catharsis. So, you might not be measuring them, but supervision can be the way to help you track countertransference, track insights, cathartic moments.

Snyder: Great points, and we need to merge both our subjective judgment with the more objective measures. Both really inform each other, so that’s critical to note; any objective measure does require subjective interpretation and clinical judgment.

This can lead into how our biases can develop too. With seeing a lot of cases, someone can develop a set of case history or archetypes. How do you buffer against bias your own personal bias with case histories, other types of anchoring biases? How do you keep yourself sharp?

Hunt: Supervision is one of the best ways to do that consultation, and supervision helps to make sure that you’re getting another person’s perspective. Case conceptualization is so key because you are creating specifically for that client. Even if they do remind you of a previous client, when you conceptualize that case uniquely to that person, it prevents the bias a little bit more. As we mentioned with dynamic theory, the idea of doing your own work and noticing counter transference and transference is useful.

Understanding your own biases that you have in terms of stereotypes that you might have internalized without realizing it, that you might be projecting onto the client. Be honest with yourself about examining those biases and how assessment might be affected by those biases. For instance, you may see that gender non-conforming clients or transgender clients may score higher on paranoia subscales of personality assessments. If you look at the societal context that they’re in, where they’re facing extreme discrimination for these identities, the paranoia makes sense. When you’re conceptualizing the personality instrument in that way, it can be really pathologizing if you don’t examine the societal context and some of your own biases that you might have.

Snyder: That was a very developmental systems perspective right there, considering macro forces and how that influences an individual assessor/clinician behavior and how those forces produce a behavior in a client.

Our time is coming to an end soon, so I think it would be great to hear more about any last clinical nuggets you have. Are there things you wish you knew earlier in your training?

Hunt: Counseling psychology, as a whole, is not known as much for using assessment a lot, so I was really nervous going into it, thinking that I wasn’t going to enjoy it, that it was going to be too data driven, too numbers focused and pathologizing. After experiencing the process and seeing how much it helps, it is so powerful. I think of the first client that I had an assessment with a client, who was a boy who that we ended up giving a provisional diagnosis of autism spectrum disorder. We were able to see how relieved the mom was to finally hear that from someone, that something that she’d been, suspecting all along but felt like the school wasn’t helping her. Being able to go through the assessment process and really help him get the services that he needed really highlighted how helpful assessment can be in opening the door for opportunity and growth. As an aside, I wasn’t expecting administering them to be fun. When you build a nice rapport with your client, it’s a really fun process, and you can develop a nice bond.

Snyder: It’s a very intimate experience when you’re asking all these types of questions. When we work with kids, it’s helpful to remind us that we can have fun; we don’t need to be so serious in order to get the work done. We might need to let our fun side out to really join with the client, knowing that it is about them and hopefully opening those doors, hopefully being an empowering gatekeeper.

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