Evidence-based assessment/Vignettes/Deshawn

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Deshawn

Clinical description

Deshawn is a 7 year old African American male attending regular education in the second grade. He lives with his mother and two younger brothers. His mother scheduled the appointment because of concerns about explosive violence toward family members and pets.

History of presenting problem

Deshawn's mother works as a psychiatric nurse, and describes him as always being high energy and on the go, and teachers have described him as being a handful from preschool on. He frequently is out of his seat, running around, messing with other children’s hair or belongings, and acting out in ways that may be seeking attention. However, the reason that the family is coming for an evaluation is because Deshawn can get explosively violent. Mom describes him chasing the family cat with scissors and cutting an inch and a half off of his tail. When mom tried to get the scissors away, he chased her with them. He got enraged arguing with his younger brother about playing a videogame, and snapped his brother’s wrist, requiring an emergency room visit and a cast. However, he is not always like that, and frequently can be loving and affectionate. Mom describes him as having “spells” where his mood and energy seem clearly different from normal, and everyone has learned to “tiptoe on eggshells” around him when he gets in those states, because his mood swings can be so strong. She says that the feel of the house changes to become like she’s working on the hospital unit. She is worried because Deshawn’s father has been diagnosed with bipolar disorder. She reports that the father has been taking a combination of lithium and divalproex for several years, and he appears to be doing well on the combination. She has heard that bipolar disorder runs in families, and she is worried that it might be what is starting with Deshawn.

Assessment findings

Checklist scores

Deshawn's mother and his teacher completed the Achenbach System of Empirically Based Assessment (ASEBA) checklists. Deshawn is too young to read the questions, so we don't have Youth Self Report scores (where the normative data starts at age 11). Here are the results, reported as T scores (M = 50, standard deviation (SD) = 10, compared to other males between 11 and 18 years of age).

ASEBA Scores

Scale	Mom	Teacher
Externalizing	82	74
Internalizing	65	61
Anxious/Depressed	59	55
Withdrawn	73	68
Somatic Complaints	53	50
Attention Problems	71	69
Social Problems	70	65
Thought Problems	71	50
Delinquent/Rule-Breaking	81	70
Aggressive Behavior	87	74

**Interpret parent and teacher reports.

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.

• Cyclothymic Disorder (65% confidence)
• Conduct Disorder (90% confidence)
• ADHD NOS (65% confidence)
• Enuresis (100% confidence)
• Rule out: sexual abuse (20% confidence)

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 Evidence-Based Assessment principles to Deshawn:

Shortlist of probable hypotheses

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

• A mood disorder is a leading hypothesis. The suicide attempt also suggests evaluating for a mood disorder (although not everyone who attempts suicide has a mood disorder). 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.
• Conduct problems could be a fourth mood disorder-- they are not immediately suggested by the description of the presenting problem, but they are common in Deshawn's age group, and they also can be a risk factor for self harm.
• Attention problems are worth evaluating based on prevalence, though her prior academic performance does not suggest any additional reason for concern.

**The info here is about another vignette...fill in info for Deshawn.

Risk and protective factors and moderators

Deshawn's sex and age decrease the probability of a mood disorder, and he is young to already have developed a conduct disorder.

Updating probability of diagnoses

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

DeShawn	Common Dx Hypotheses (A)	Starting Prob. (B)	Broad Measure (D)				Cross-informant (E)			Confirmation (G)	Treatment Phase (I), (J), (K)
	Base Rate from Rettew et al. (2009) SDI		Scale & Score	DLR	Revised Prob.	EAY Check	Next Test score	DLR	Revised Prob.	K-SADS Interview
Any Anxiety	Specific Phobia	0.15
	PTSD	0.09
	GAD	0.10	CBCL T Internalizing 65	0.98	0.11	0.10	Other measures are better than Achenbach
	Panic Disorder	0.11
	Social Phobia	0.20
	Separation Anxiety	0.18
Any Impulse Control Disorder	ODD	0.38	CBCL T Aggressive 87	4.18	0.72	0.72	No data about TRF scales for aggressive
	CD	0.25	CBCL T Aggressive 87	4.18	0.58	0.58				Conduct d/o (90%)
	ADHD	0.38	CBCL T Attention 71	6.92	0.81	0.81	TRF T Attention 69			ADHD nos (65%)
Any Mood Disorder	MDD	0.26	CBCL T Anx/Dep 59	0.39	0.12	0.12	Haven't found data about TRF for internalizing
	BP									Cyclothymic d/o (65%)
	Dysthymia	0.08
Any Substance Abuse Disorder		0.30	CBCL #2 CBCL #99 CBCL #105

Answers

DeShawn Common Dx Hypotheses (A) Starting Prob. (B) Broad Measure (D) Cross-informant (E) Confirmation (G) Treatment Phase (I), (J), (K) Base Rate from Rettew et al. (2009) SDI Scale & Score DLR Revised Prob. EAY Check Next Test score DLR Revised Prob. K-SADS Interview Any Anxiety Specific Phobia 0.15 PTSD 0.09 GAD 0.10 CBCL T Internalizing 65 0.98 0.11 0.10 Other measures are better than Achenbach Panic Disorder 0.11 Social Phobia 0.20 Separation Anxiety 0.18 Any Impulse Control Disorder ODD 0.38 CBCL T Aggressive 87 4.18 0.72 0.72 No data about TRF scales for aggressive CD 0.25 CBCL T Aggressive 87 4.18 0.58 0.58 Conduct d/o (90%) ADHD 0.38 CBCL T Attention 71 6.92 0.81 0.81 TRF T Attention 69 0.73 0.76 ADHD nos (65%) Any Mood Disorder MDD 0.26 CBCL T Anx/Dep 59 0.39 0.12 0.12 Haven't found data about TRF for internalizing BP Cyclothymic d/o (65%) Dysthymia 0.08 Any Substance Abuse Disorder 0.30 CBCL #2 CBCL #99 CBCL #105 0.56 0.28 0.26

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 Deshawn's family:

Client preferences

*** Write out what Deshawn's mother chose, synchronizing with slides from 2017 Miami/Indianapolis***

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 Deshawn and his mother

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?

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?