Social Work Practice
Social Work Practice SWRK 6640
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This 13 page Class Notes was uploaded by Ahmed Little on Wednesday September 30, 2015. The Class Notes belongs to SWRK 6640 at Western Michigan University taught by Robin McKinney in Fall. Since its upload, it has received 41 views. For similar materials see /class/216829/swrk-6640-western-michigan-university in Social Work at Western Michigan University.
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4 Assessment Diagnosis and Treatment Chapter Outline 1 II Clinical Issues A The Decision Making Process 1 Typically begins with a clinical assessment which is directed at differentiating de ning and measuring the child s behaviors cognitions and emotions that are of concern as well as the environmental circumstances that may be contributing to these problems 2 Assessments are meaningful to the extent that they result in practical and effective interventions 3 Idiographic versus nomothetic case formulations a Idiographic case formulation involves a detailed understanding of the child or family as a unique entity b Nomothetic case formulation emphasizes more general inferences that apply to broad groups of individuals B Developmental Considerations Age gender and culture must be considered when making judgments about abnormality and when selecting assessment and treatment methods 2 Normative information must also be considered a Need to have a good understanding of normal development of children to make decisions about abnormal development b Isolated symptoms are not typically related to children s overall adjustment c Age inappropriateness and patterns of symptoms typically define childhood disorders C Purposes of Assessment 1 Description and Diagnosis a Clinical description summarizes the child s unique behaviors thoughts and feelings that together make up the features of a given psychological disorder b Diagnosis involves analyzing information and drawing conclusions about the nature or cause of the problem and in some instances assigning a formal diagnosis which is referred to as taxonomic diagnosis 2 Prognosis and Treatment Planning a Prognosis involves generating predictions regarding future behavior under specified conditions b Treatment planning involves making use of assessment Assessing Disorders information to generate a treatment plan and evaluating its effectiveness A Clinical assessment relies on a multimethod assessment strategy which emphasizes obtaining information from different informants in a variety of settings using a variety of procedures B Clinical Interviews 1 The most universally used assessment procedure can provide a large amount of information in a brief period of time 2 Often includes a developmental history or family history 3 May incorporate a mental status exam to assess the child s general mental functioning involves assessing appearance and behavior thought processes mood and affect intellectual functioning and sensorium 4 Differ in degree of structure a In unstructured interviews questions are pursued in an informal and exible manner lack of standardization may result in low reliability and selective or biased gathering of information b In semistructured interviews specific questions are asked to elicit information in a consistent and thorough manner may be susceptible to a loss of spontaneity between the child and clinician and a reluctance to volunteer important information that is not directly related to the particular questions C Behavioral Assessment 1 Emphasis on observing a child s behavior directly 2 Often involves observing the antecedents the behaviors of interest and the consequences of the behaviors the ABCs of assessment 3 The more general approach to behavioral assessment is behavior analysis or functional analysis of behavior the goal of which is to identify as many factors as possible that could be contributing to a child s problem behaviors and to develop hypotheses about which ones are the most important andor most easily changed 4 Checklists and rating scales a Often allow for a child s behavior to be compared to a normative sample b Typically economical to administer and score Lack of agreement between informants is relatively common which in itself is often informative 5 Behavioral observations and recording a Provide ongoing information about behaviors of interest in reallife settings b Recordings may be done by parents or others although it may be difficult to ensure accuracy c Sometimes involve setting up roleplay simulations in the clinic d Children often know when they are being watched and may react differently as a result also the informant the child the nature of the problem and the family context may distort findings D Psychological Testing 1 Tests are tasks given under standard conditions with the purpose of assessing some aspect of the child s knowledge skill or personality tests are standardized on a norm group so that children can be compared to others 2 Test scores should always be interpreted in the context of other assessment information 3 Developmental tests are used to assess infants and young children and are generally carried out for the purpose of screening diagnosis and evaluation of early development 4 Intelligence and Educational Testing a A central component in clinical assessments for a wide range of childhood disorders b The most popular intelligence scale used today with children is the Wechsler Intelligence Scale for Children WISCIV which is wellstandardized reliable and valid provides measures of verbal comprehension perceptual reasoning working memory and processing speed 5 Proj ective Testing a Involves presenting the child with ambiguous stimuli and asking the child to describe what he or she sees it is believed that the child projects his or her own personality including unconscious fears needs and inner con icts on the ambiguous stimuli b Although there is controversy surrounding their use projective tests continue as one of the most frequently used clinical assessment tools c Proj ective techniques especially figure drawings and play may be used to help children relax and to make it easier for them to talk about events that they may have difficulty expressing verbally 6 Personality Testing a Several dimensions of personality have been identified including whether a child or adolescent is timid or bold agreeable or disagreeable dependable or undependable tense or relaxed re ective or unre ective the Big 5 factors b May use interviews projective techniques behavioral measures or objective inventories that focus specifically on personality 7 Neuropsychological Testing a Attempts to link brain functioning with objective measures of behavior that are known to depend on an intact central nervous system b Often involves using a comprehensive battery that assesses a full range of psychological functions including verbal and nonverbal cognitive functions perceptual functions motor functions and emotional executive control functions III Classi cation and Diagnosis A Classification refers to a system for representing the major categories or dimensions of child psychopathology and the boundaries and relations among them diagnosis refers to the assignment of cases to categories of the classification system B There is still no single agreedupon reliable and valid worldwide classification system for childhood disorders C D Childhood disorders have been classi ed using categories and dimensions Categorical classi cation systems are based primarily on informed professional consensus classicalpure categorical approach assumes that every diagnosis has a clear underlying cause and that each disorder is fundamentally different from every other disorder Dimensional classification approaches assume that a number of independent dimensions or traits of behavior exist and that all children possess these to varying degrees The Diagnostic and Statistical Manual DSM The DSMIVTR utilizes a multiaxial system consisting of five axes clinical disorders personality disorders and mental retardation general 39 l 1 medical J p J 39 and 39 problems and global assessment of functioning Criticisms of DSMIVTR a Fails to capture the complex adaptations transactions and setting in uences that have been identified as crucial to understanding and treating child psychopathology Gives less attention to disorders of infancy and childhood than to those of adulthood Fails to emphasize the situational and contextual factors surrounding and contributing to various disorders Fails to capture the comorbidity known to exist among many childhood disorders Sometimes improperly used such as when a specific diagnosis is needed in order for a child to qualify for special services Pros and Cons of Diagnostic Labels a On the positive side diagnostic labels help clinicians summarize and order observations facilitate communication among professionals aid parents by providing more recognition and understanding of their child s problem and facilitate research on the causes epidemiology and treatment of specific disorders On the negative side diagnostic labels may lead to negative perceptions and reactions by others and can in uence children s views of themselves and their behavior Treatment of Childhood Disorders Interventions are problemsolving strategies that involve treatment of current problems maintenance of treatment effects and prevention of future problems Growing awareness has arisen of the need to give greater attention to the cultural context of children and families receiving psychological services Treatment goals include outcomes related to the child and family as well as those of societal importance Models of Delivery In the conventional model of treatment the child is seen individually by a A B l 2 therapist for a limited number of treatment sessions in the clinic An alternative to the conventional model is the continuing care model of treatment two examples of continuing care models are the chronic care model ongoing treatment is provided to ensure that the bene ts of treatment are maintained and the dental care model ongoing followups are carried out on a regular basis following initial treatment Both ethically and legally clinicians who work with children are required to think not only about the impact that their actions will have on the children that they see but also on the responsibilities rights and relationships that connect children and parents General Approaches to Treatment 1 More than 70 of clinicians identify themselves as eclectic 2 Psychodynamic approaches view child psychopathology as determined by underlying unconscious and conscious con icts treatment focuses on developing an awareness of these con icts 3 Behavioral approaches assume that most abnormal child behaviors are learned through operant and classical conditioning treatment emphasizes reeducation using behavioral principles 4 Cognitive approaches view abnormal child behavior as the result of de cits and distortions in the child s thinking including perceptual biases irrational beliefs and faulty interpretations emphasis in treatment is in changing faulty cognitions 5 Cogniti v 39 39 39 Fr 39 view I J 39 39 disturbances as partly the result of faulty thought patterns and partly the result of faulty learning and environmental experiences treatment focuses on changing maladaptive cognitions teaching the child to use cognitive and behavioral coping strategies and helping the child learn selfregulation 6 Clientcentered approaches view psychopathology as the result of social or environmental circumstances that are imposed on the child and interfere with his or her basic capacity for personal growth and adaptive functioning the therapeutic setting provides a corrective experience for the child through unconditional positive regard 7 Family models view psychopathology as determined by variables operating in the family system treatment often focuses on the family issues underlying problem behaviors 8 Biologicalmedical models view psychopathology as resulting from biological impairment or dysfunction and rely primarily on pharmacological and other biological approaches to treatment 9 Combined treatments make use of two or more interventions each of which can stand on its own as a treatment strategy Treatment Effectiveness I 1 Positive findings regarding effectiveness of treatments with children a therapy leads to significant and meaningful improvements for children b treatments have been shown to be equally effective for internalizing and externalizing disorders treatment effects tend to be longlasting d specific problems are more amenable to treatment than nonspecific problems 0 2 e the more outpatient therapy children receive the more symptoms 39mprove On the negative side communitybased clinic therapy for children has been found far less effective than structured research therapy 12 Health Related and Substance Abuse Disorders Chapter Outline 1 Sleep Disorders A The Regulatory Functions of Sleep 1 Sleep is the primary activity of the brain during the early years of development by about age 5 a more even balance emerges between sleep and wakefulness 2 Sleep serves a fundamental role in brain development and regulation 3 Sleep disorders can cause other psychological problems or can result from other disorders or conditions 4 Transient sleep problems are normal and are usually alleviated by reducing stress ensuring safety and providing reassurance and consistent limits 5 Sleep deprivation impairs the functioning of the prefrontal cortex leading to decreased concentration and diminished ability to inhibit or control basic drives impulses and emotions 6 Sleep produces an uncoupling of neurobehavioral systems allowing for retuning of the components of the central nervous system B Maturational Changes 1 Sleep patterns needs and problems change over the course of maturationiinfants and toddlers have more nightwaking problems preschoolers more falling asleep problems younger schoolage children more goingtobed problems and adolescents more difficulty going to or staying asleep or not having enough time to sleep 2 Adolescents have increased physiological need for sleep however they often get less sleep than needed and are chronically sleepdeprived C Features of Sleep Disorders 1 Two major categories dyssomnias and parasomnias 2 DSMIVTR criteria for sleep disorders not typically met in full by younger children due to the transitory nature of sleep problems 3 Diagnostic criteria emphasize the presence of clinically significant distress or impairment in functioning and the requirement that the sleep disturbance cannot be better accounted for by another disorder or condition 4 Dyssomnias a Disorders of initiating or maintaining sleep characterized by difficulty getting enough sleep not sleeping when one wants to not feeling refreshed from sleep b Most of these sleep problems resolve themselves as the child matures c Quite common in childhood with the exception of narcolepsy 5 Parasomnias a Disorders in which behavioral or physiological events intrude upon ongoing sleep b Common af ictions of early to midchildhood children typically grow out of them c Include nightmares often called REM parasomnias sleep terrors and sleepwalking often referred to as arousal parasomnias D Treatment 1 Behavioral interventions and establishing good sleep hygiene can help children with difficulty going to sleep or staying asleep 2 Behavioral interventions for circadian rhythm disorders can be effective when adolescent and family are highly motivated 3 Prolonged treatment of child and adult parasomnias is usually not necessary 4 Treatment of nightmares consists of providing comfort at the time of occurrence and making efforts to reduce daytime stressors 5 Parents of children who sleepwalk should take precautions to avoid chances of child being injured brief afternoon naps may be beneficial II Elimination Disorders A Enuresis l The involuntary discharge of urine during the day or night 2 Because bedwetting is quite common diagnostic criteria stipulate that the problem occur at least twice a week for three months or be accompanied by significant distress or impairment in a child at least 5 years of age or equivalent developmental level 3 Nocturnal enuresis in which wetting occurs during sleep at night typically the rst third of the night is most common about 1333 of all 5yearolds and affects boys more than girls 4 Diurnal enuresis in which wetting occurs during waking hours is more common in girls and is uncommon after age 9 it is believed to be due to social anxiety or preoccupation with a school event 5 Nocturnal and diurnal enuresis can exist in combination 6 Prevalence of enuresis declines rapidly with maturity 7 Higher prevalence among less educated lower socioeconomic groups and institutionalized children 8 Enuresis may be primary if the child never attained continence applies to 85 of cases or secondary if established continence was lost 9 Causes a Nocturnal enuresis has been linked to a deficiency during sleep in antidiuretic hormone which helps concentrate urine during sleep hours b Primary enuresis may be associated with immature signaling mechanisms making it difficult to detect the need to urinate c Family and twin studies suggest primary enuresis is inherited 10 Treatments a Behavioral training methods using either an alarm or reinforcement contingencies are often very effective at teaching bladder control b Drybed training based on operant conditioning principles III Encopresis l c A synthetic antidiuretic in the form of a nasal spray can be administered before bedtime however this treatment is less effective than psychological treatments The passage of feces into inappropriate places such as clothing or the oor Diagnostic criteria stipulate that it occur at least once per month for at least 3 months in a child at least 4 years of age or equivalent developmental level Two DSMIVTR subtypes with or without constipation and over ow continence the former is more common Occurs in 15 to 3 of children and is 5 to 6 times more common in boys frequency declines rapidly with age Like enuresis it can be categorized as primary or secondary May be associated with significant psychological problems which likely result from rather than cause the encopresis Causes a May be related to untreated constipationichild may try to avoid bowel movements because they have been painful in the past which only serves to make the next time painful too because unpassed feces become large hard and dry Furthermore over time the stretched muscles and nerves give fewer and fewer signals to the child about the need to have a bowel movement b About 50 of cases are associated with abnormal defecation dynamics in which the child contracts rather than relaxes the external sphincter Treatment a Fiber enemas laxatives or lubricants may be given to help relieve constipation b Behavioral methods involving teaching a toilettraining procedure may be effective c A combination of laxatives and behavioral treatment has shown significant improvements within the first two weeks and over 75 maintain the improvement Chronic Childhood Illness A chronic illness is one that persists longer than 3 months in a given year or requires a period of continuous hospitalization of more than 1 month DSMIVTR identifies two healthrelated categories A B l Somatoform disorders a group of related problems involving physical symptoms that resemble or suggest a medical condition but lack organic or physiological evidence includes somatization hypochondriasis and pain disorders Psychological factors affecting physical condition disorders in which psychological factors are presumed to cause or exacerbate a physical condition does not apply to most children with chronic health conditions If a medical condition is accompanied by significant adjustment or behavioral problems a child may be diagnosed with Adjustment Disorder Normal Variations in Children s Health 1 2 3 Children experience pain in the same way as adults Children may use pain for secondary gains One of the most common ways for children to express their fears dislikes and avoidance is through somatic complaints Girls show more symptoms of pain and anxiety than boys a difference which is likely due to socialization expectations rather than physiological differences Family in uences can impact children s expressions of pain and physical symptoms likely through social learning Chronic illnesses and medical conditions constitute a major stressor that challenges and absorbs both the child s and the family s available coping resources Affect from 10 to 20 of the child population about 13 have moderate to severe conditions Asthma is the most common chronic illness in childhood Social class and ethnicity do not in uence who is affected by chronic illness with the exception of specific conditions that are genetically determined by racial or ethnic decent such as sicklecell disease but there is a relationship between SES and survival rates Diabetes Mellitus l 2 3 Childh l 2 3 4 A lifelong metabolic disorder in which the body in unable to metabolize carbohydrates as a result of inadequate pancreatic release of insulin Affects boys and girls equally A progressive disease with the more chronic complications occurring in young adulthood or beyond life expectancy is 13 less than of the general population Requires daily treatments to maintain metabolic control such as blood glucose monitoring dietary restraints insulin injections and learning how to balance energy demands with insulin needs ood Cancer In comparison to adults the onset of cancer in children is more sudden and the disease is often at a more advanced stage when first diagnosed The most common form is acute lymphoblastic leukemia Requires intensive medical treatment especially during the first 23 years Approximately 80 of pediatric cancer patients survive 50 will have serious physical or mental illness as adults and will require longterm care Development and Course 1 Children with chronic illness especially those with physical disabilities have an increased risk of secondary psychological adjustment difficulties most often internalizing problems although the incidence of DSMIV TR type disorders among children with chronic illness is actually low Most children are able to adapt successfully to the course and consequences of their illness Chronic illness may precipitate PTSD in family members as well as marital distress although most families adapt favorably Factors associated with children s situations like family stress and resources may be more critical to their adaptation than the challenges posed by the illness alone healthy parental adjustment related to healthy child adjustment Siblings of children with a chronic illness experience heightened social and mental health problems Children with more severe disruptive illnesses tend to suffer most in terms of social adjustment Children with chronic illness may demonstrate academic problems which may be due to the primary effects of the illness or treatment or the secondary effects of the illness such as fatigue absenteeism or psychological stress How Children Adapt A Biopsychosocial Model 1 The transactional stress and coping model shows how children s adaptation to chronic illness is in uenced by the nature of the illness as well as personal and family resources Illness parameters include severity prognosis and functional status Personal characteristics eg age gender ethnicity SES intellectual ability selfconcept coping abilities Family adaptation and functioning including how parents manage daily stress whether parents use active solutionfocused coping strategies the degree of support and cohesion among family members parent perceptions of illness and the availability of utilitarian and psychological resources Intervention 41 I 39I Child and family J J quot can be by p J interventions that reduce stress enhance social problemsolving skills promote effective childrearing methods and empower families Families are kept in the forefront of children s intervention needs not the background There are two main psychological approaches to helping children cope with stressful medical procedures and chronic and recurrent pain providing information eg verbal explanations and demonstrations and training in coping skills e g deep breathing attention distraction muscle relaxation relaxing imagery emotive imagery and behavioral rehearsal IV Adolescent Substance Abuse Disorders A Substance Use Disorders SUDs l I 1 1 I SUDs in J 39 include r abuse resulting from selfadministration of any substance that alters mood perception or functioning Canleadtop 39 39 39 39 dr39 quot 39 39Jr J toreceivea diagnosis of substance dependence an adolescent has to show a maladaptive pattern of substance use for at least 12 months with three or more clinical signs of distress such as tolerance or withdrawal Criteria for substance abuse involves one or more harmful and repeated negative consequences of substance abuse over the last 12 months given if individual does not meet criteria for dependence Prevalence and Course 1 10 Causes 4 Alcohol is the most prevalent substance used and abused by adolescents 4 out of 5 high school seniors have used alcohol cigarettes are the second most common 60 of high school seniors have smoked Illicit substance use also common over half of high school seniors have used drugs other than alcohol or cigarettes typically marijuana is used but the use of other illicit drugs such as MDMA opiates cocaine and crack is increasin 8 of adolescents aged 1217 met criteria for substance abuse or dependence in 2001 survey Alcohol use before age 14 is a strong predictor of subsequent alcohol abuse or dependence especially if followed by rapid increase of alcohol consumption Sex differences converging due to increased substance use among girls Notable ethnic differences substance use highest among Native Americans boys and girls lower among White Hispanic Latin and AfricanAmerican and lowest among AsianAmerican adolescents Rates peak around late adolescence and begin to decline during young adulthood Similar to conduct disorders concern greatest when highrisk behaviors begin well before adolescence are ongoing and occur among peer group with similar behaviors Adolescents diagnosed with SUDs tend to use more than one drug at a time have problems related to poor academic achievement higher rates of academic failure higher rates of delinquency and more parental con ict heavy drinking in midteens may disturb ongoing neurodevelopmental processes High comorbidity with ADHD and conduct problems Personality characteristics such as increased sensation seeking a preference for novel complex and ambiguous stimuli Positive attitudes about substance abuse and having friends with similar attitudes perceiving oneself to be physically older than sameage peers and school connectedness Lack of parental involvement and parentchild affection inconsistent parenting and poor monitoring negative parentchild and interparent interactions and low parental expectations for abstaining Association with deviant and substance using peers Treatment and Prevention 1 Half of patients with SUDs relapse within first three months and only 20 30 remain abstinent Family based approaches that seek to modify negative reactions between family members improve communication and develop effective problem solving skills to deal with areas of con ict Multisystemic Therapy MST involves intensive intervention that targets family peer school and community systems Adolescents with more severe levels of abuse and unstable living conditions or comorbid psychopathology require inpatient or residential setting Life skills training emphasizes building drug resistance skills personal and social competence and altering cognitive expectancies around substance abuse Prevention efforts target social environment via community and school norms and include parent involvement and education to improve parent child communication about substance use