< Evidence-based assessment < Vignettes
Subject classification: this is a psychology resource.

Christopher

Clinical description

Christopher is a 14-year-old White male who lives with his mother and older brother. He is in the accelerated track of courses and skipped a grade. He had been outgoing and popular, and frequently hangs out with his older brother’s friends. He started “hooking up” with women who were friends or acquaintances of his brother. Last year his behavior changed in several ways. He started listening to different music, especially heavy metal, and grunge music. He started dressing differently, wearing spiked leather armbands and boots. Mother reports that he started “hooking” up with girls last year, including older girls who are friends with his older brother. Mom has not confronted him directly about this but believes that he has become sexually active. He has started missing school, sometimes for weeks at a time, complaining of feeling tired and ill, but tests have ruled out bacterial infection and been inconclusive about mononucleosis. The school system has threatened to fail him in all classes for the quarter unless the family can provide a medical explanation for his absences or get him to return to school consistently.

Extended content

History of presenting problem

Conceptualization

Initial treatment plan

Assessment findings

Checklist scores

Christopher, his mother, and his social studies teacher all completed the Achenbach System of Empirically Based Assessment (ASEBA) checklists. Here are the results, reported as T scores (M = 50, SD = 10, compared to other males between 11 and 18 years of age).

ASEBA Scores
Scale Mom Christopher Teacher
Externalizing 58 53 42
Internalizing 54 54 56
Anxious/Depressed 60 54 54
Withdrawn 50 54 50
Somatic Complaints 54 55 65
Attention Problems 86 73 53
Social Problems 51 54 55
Thought Problems 63 70 57
Delinquent/Rule-Breaking 57 53 50
Aggressive Behavior 58 54 50


Extended content

Select more specialized scales to refine probabilities

Updating probabilities

Critical items

Diagnostic interview findings

Diagnoses are based on a LEAD (longitudinal expert evaluation of all data) consensus meeting following a Kiddie Schedule for Affective Disorders and Schizophrenia (KSADS) interview, using DSM-IV criteria. The same interviewer met with Christopher and then his mother, then discussed any differences of opinion with them as needed to use clinical judgment. KSADS results were reviewed with a licensed clinical psychologist to arrive at a final decision.

Cognitive and achievement testing

(Not done as part of the evaluation; may be able to match up information later)

Prediction phase

Let's see how we would apply the EBA principles to Christopher:

Shortlist of probable hypotheses

Based on Christopher's age and the common clinical issues, here are some possible issues:

  • A mood disorder definitely is a leading hypothesis. Within the "mood" category, the hypotheses should consider major depression, dysthymia, and bipolar spectrum disorders, as well as other medical issues that could lead to mood symptoms.
  • Substance misuse should be another hypothesis, based again on its prevalence in his age group.
  • Conduct problems would be a fourth -- they are not immediately suggested by the description of the presenting problem, but they are common in the age group, and they also can be a risk factor for self harm.
  • Attention problems are worth evaluating based on prevalence, though his prior academic performance does not suggest any additional reason for concern.

Risk and protective factors and moderators

Christopher's age increases the probability of a mood disorder, as well as substance misuse, and could be consistent with an adolescent-onset conduct disorder. His solid academic performance previously suggests potential resilience.

Updating probability of diagnoses

Below is a worksheet with the DLRs left blank to be filled in. Answers are below.

Christopher Common Dx Hypotheses (A) Starting Prob. (B) Broad Measure (D) Cross-informant (E) Confirmation (G) Treatment Phase (I), (J), (K)
Base Rate from Merikangas et al. (2010) NCS-A[1] Scale & Score DLR Revised Prob. EAY Check Next Test score DLR Revised Prob. Next Test score DLR Revised Prob. K-SADS Interview
Any Anxiety Specific Phobia 0.19 Specific Phobia - animals (90%)
PTSD 0.05
GAD 0.02 CBCL T

Internalizing 54

 Other measures are better than Achenbach
Panic Disorder 0.02
Social Phobia 0.09
Separation Anxiety 0.08
Any Impulse Control Disorder ODD 0.13 CBCL T

Aggressive 58

 No data about TRF scales for aggressive
CD 0.07 CBCL T

Aggressive 58
ADHD 0.09 CBCL T

Attention 86

 TRF T

Attention 53

 ADHD combined (70%)
Any Mood Disorder MDD 0.12 CBCL T

Anx/Dep 60

 Haven't found data about TRF for internalizing
BP 0.03 CBCL T

Externalizing 58

 YSR T

Externalizing 53

 TRF T

Externalizing 42

 Bipolar I (85%) 7 Up 7 Down Inventory (Christopher)
CMRS-10(Parent)
Dysthymia Included above
Any Substance Abuse Disorder 0.11 CBCL #2 CBCL #99 CBCL #105

Cross-informant perspectives

Mention that these have DLRs. Also unpack the implications of agreement and disagreement for the client (and add a section about treatment implications of disagreement on the Conceptual Model Pages)

Prescription phase

Mental status and clinical observations

(add content)

Genogram and family functioning

Here is a genogram of Christopher's family:

Treatment selection

The diagnostic interview suggests found evidence of a prior manic episode, indicating a diagnosis of bipolar I. This suggests that the periods of low energy and cognitive functioning could be depressive episodes, and interviewing confirmed that they would meet diagnostic criteria for a major depressive episode even though Christopher did not describe himself as "depressed." They clearly were associated with impairment and should be a major focus of treatment.

Moderating factors

Client preferences

***

Process phase

Clinically significant change

Reliable change index

Pick a treatment target and specify what the RCI would be for it. Discuss how you would explain to Christopher.

The treatment target we picked was the self-report of attention problems. For reliable change to be demonstrated with 95% confidence, a decrease of 9 points to 62 would have to be seen.

Nomothetic benchmarks

A, B, Cs of Jacobson definitions. General stuff about limitations would go on the main concept page. Here it is focused on the client -- what are the benchmarks they will focus on? How explained to them?

For self report attention problems, to reach the A, B, and C benchmarks, Christopher's scores would have to decrease to:

A- 45

B- 66

C- 58

Interpreting benchmarks

Minimum important difference (MID)

Note that this section is a dangler -- not originally called out in the 12 steps. Medium d as a rule of thumb from Streiner, Norman, & Cairney (2015). Could work from AUC to d to raw units as a way of estimating, since psychology hasn't done research on this yet. Might be able to back into it with studies that had CSQ and outcome data.

Client goals & tracking

These would be personal goals and idiographic measurement -- YTOPS, etc.

Process measures

This would be traces such as coming to sessions, doing homework assignments. (Not sure of other specifics involved in current IPT protocols?)

Progress measures

YTOPS again and goal setting.

Termination planning and maintenance

Revisit Jacobson benchmarks. Is there much chance of relapse? What things would the client need to pay attention to if they were going to nip that in the bud?|}

References

  1. 1 2 Merikangas, Kathleen Ries; He, Jian-ping; Burstein, Marcy; Swanson, Sonja A.; Avenevoli, Shelli; Cui, Lihong; Benjet, Corina; Georgiades, Katholiki et al.. "Lifetime Prevalence of Mental Disorders in U.S. Adolescents: Results from the National Comorbidity Survey Replication–Adolescent Supplement (NCS-A)". Journal of the American Academy of Child & Adolescent Psychiatry 49 (10): 980–989. doi:10.1016/j.jaac.2010.05.017. PMID 20855043. PMC PMC2946114. https://dx.doi.org/10.1016/j.jaac.2010.05.017.
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