Lea is an 18 year old White female in regular education. She self-referred to the clinic because she has been having a lot of trouble with attention and focusing on course material. Her grades are dropping rapidly, and she is getting anxious and worried about graduating (and IF she will graduate). As her anxiety spirals up, her grades are coming down.
History of presenting problem
Initial treatment plan
Lea's older sister and Lea both completed the Achenbach System of Empirically Based Assessment (ASEBA) checklists. Here are the results, reported as T scores (M = 50, standard deviation (SD) = 10, compared to other women between 11 and 18 years of age). Note that Lea is estranged from her mother, and has been living with her older sister for more than a year. The clinician had to make a decision whether to have mom fill out the CBCL (which would have been a better match to the normative data, but would not have had as much current information) versus having the older sister fill out the form. Lea's sister could provide more recent information, but her perspective might be different from that of other caregivers (usually mothers) making up the normative sample used to estimate the T scores.
Select more specialized scales to fefine probabilities
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 Lea and then her 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.
- Bipolar II (major depression + hypomanic episode) (85% confidence post interview)
- Attention-Deficit/Hyperactivity Disorder (ADHD), Inattentive (85% confidence)
- Past substance misuse (75% confidence)
- Current alcohol and marijuana use (70% confidence)
- Past non-suicidal self-injury (NSSI) (65% confidence)
Cognitive and achievement testing
(Not done as part of the evaluation; may be able to match up information later)
Let's see how we would apply the EBA principles to Lea:
Shortlist of probable hypotheses
Based on Lea's age and the common clinical issues, here are the possible issues:
- A mood disorder definitely is a leading hypothesis. The suicide attempt also suggests evaluating 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.
- Substance misuse should be another hypothesis, based again on its prevalence in her age group.
- Anxiety disorders would be a third hypothesis.
- 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 her prior academic performance does not suggest any additional reason for concern.
- The family conflict is also important to assess, as well as potential cultural issues (and differences of opinion between Lea and her parents that might be influenced by differing degrees of acculturation).
Lea's gender and age increase the probability of a mood disorder, and may reduce the chances of conduct disorder. Her solid academic performance previously suggests potential resilience.
Her conflict with her father, and her keeping things secret from her parents, would be considerations before doing family therapy, and they may complicate consent for treatment (Lea is still a minor).
Some data suggest that Interpersonal Psychotherapy (IPT) may be particularly effective with Hispanic teens, perhaps moreso than Cognitive Behavioral Therapy (CBT), because of the greater emphasis on family (and familism). IPT would have an advantage of not requiring active participation of the father (unlike family therapy), since IPT is designed as an individual therapy.
Below is a worksheet with the DLRs left blank to be filled in. Answers are below.
|Lea||Common Dx Hypotheses (A)||Starting Prob. (B)||Broad Measure (D)||Cross-informant (E)||Confirmation (G)||Treatment Phase (I), (J), (K)|
|Base Rate from Kessler et al. (2005) NCS-R||Scale & Score||DLR||Revised Prob.||EAY Check||Next Test score||DLR||Revised Prob.||MINI|
|Any Anxiety||Any Anxiety||0.29||YSR T
|Any Impulse Control Disorder||ODD||0.10|
|ADHD Predominanatly Inattentive Type|
|Any Mood Disorder||MDD||0.15||YSR T
|Major Depressive Episode|
|Hypomanic Episode --> Bipolar II|
|Any Substance Abuse Disorder||0.17||CBCL #2: 0
CBCL #99: 2 CBCL #105: 1.5
|CBCL #2: 0
CBCL #99: 1 CBCL #105: 1
|Substanc Abuse - past cannabis and XanaxTM abuse|
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)
Mental status and clinical observations
Genogram and family functioning
Here is a genogram of Lea's family. All of the information comes from Lea.
The diagnostic interview suggests a combination of a major depressive episode and a prior dysthymia, sometimes referred to as a "double depression." This suggests that Lea's stress and mood problems have persisted for a long time, and may be more difficult to treat. The mood disorders clearly are associated with impairment and should be a major focus of treatment.
The double depression is a moderating factor suggesting worse prognosis, along with potential demoralization and early drop out from treatment.
Lea was originally leaning towards an antidepressant medication, thinking that she could take it without telling her parents. After discussing the pros and cons of medication (including the effect size in youths, the potential side effects, and the fact that her parents would find out as part of the consent process), as well as the pros and cons of different evidence based therapies, she elected to try IPT. She wanted to revisit the possibility of a stimulant helping with her inattention, but she opted to wait and see if that improved along with her mood if the IPT helped.
Reliable change index
Pick a treatment target and specify what the RCI would be for it. Discuss how you would explain to Lea
Looking at Lea's self-report internalizing score on the CBCL, she scores 1.04 SD's away from the clinical mean of people her age. In order to say that she is making clinically significant change with 95% confidence we want to see a score reduction of 8.4 post-treatment. To say that she is making clinically significant change with 90% confidence we want to see a score reduction of 7.1 points.
Looking at Lea's self-report attentional problems on the CBCL, she scores1.5 SD's above the mean of people her age with clinical significance. In order to say that she is making clinically significant change with 95% confidence we want to see a score reduction of 8.3 post-treatment. To say that she is making clinically significant change with 90% confidence we want to see a score reduction of 7.0 points.
When reporting this to Lea, a clinician should take her desire for improvement into account. Asking Lea for her desired decrease in scores could be insightful for a clinician when working with Lea. The goal in treatment outcome is for an RCI of 1.96, but client perception of incremental growth when it comes to health is also important. Therefore, the benchmarks of clinically significant change could be framed as client "goals" for self-improvement.
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?
The benchmarks for Lea's treatment with a treatment focus of internalizing behaviors are as follows:
A = 39.0
B = 70.1
C = 55.6
In order for Lea to move "away" (A) from the clinical population on her internalizing scores, she needs to meet the benchmark A = 39.0. This can be a daunting task and should not be considered the primary goal of treatment.
In order to get Lea "back" (B) into the normal distribution of nonclinical samples for internalizing scores, she needs to meet the benchmark B= 70.1. This is an easy benchmark to meet; however, it is not within the realm of clinically significant change (RCI = 1.96). Therefore, a clinician cannot be 95% certain that the treatment is working unless she is able to reduce her score from 78 to a 65.6.
In order for Lea to be "closer" (C) to the nonclinical mean than the clinical mean of women her age, she needs to meet the benchmark of C=55.6. This benchmark is potentially the most useful for the clinician, although not necessarily for Lea.
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.
This would be traces such as coming to sessions, doing homework assignments. (Not sure of other specifics involved in current IPT protocols?)
YTOPS again and goal setting.
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?
- Kessler, Ronald C.; Berglund, Patricia; Demler, Olga; Jin, Robert; Merikangas, Kathleen R.; Walters, Ellen E. (2005-06-01). "Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication". Archives of General Psychiatry 62 (6): 593–602. doi:10.1001/archpsyc.62.6.593. ISSN 0003-990X. PMID 15939837. https://www.ncbi.nlm.nih.gov/pubmed/15939837.