Evidence-based assessment/Vignettes/Tamika

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Tamika - Assessment Phase

Clinical description

Tamika is an 11 year old African American female in regular education. Her mother sought treatment for her increased anger, aggression, being “hyper,” having trouble sleeping, lying, talking to herself, and stealing. At home, she was often cranky and refused to share things with her two siblings and younger cousin, who were all living in the same house. When she had tantrums, she screamed, threw things, broke a plate and some toys, and escalated to the point that the mother worried she might injure someone. Tamika is starting to have problems at school, including lower grades and disruptive classroom behaviors such as talking out of turn, getting easily distracted, and frequently arguing with peers and some teachers.

Checklist scores

Tamika, her mother, and her teacher all 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).

ASEBA Scores

Scale	Mom	Tamika	Teacher
Externalizing	82	75	56
Internalizing	70	66	54
Anxious/Depressed	60	64	59
Withdrawn	64	61	50
Somatic Complaints	76	68	50
Attention Problems	68	66	63
Social Problems	74	73	50
Thought Problems	75	70	57
Delinquent/Rule-Breaking	76	53	50
Aggressive Behavior	91	54	59

Prediction phase

Let's see how we would apply the Evidence-Based Assessment principles to Tamika.

Shortlist of probable hypotheses

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

• Oppositional defiant disorder is a leading hypothesis, based on her high externalizing scores across different reporting groups, and especially from her mother. It also is common.
• Conduct problems would be a second possible diagnosis.
• Attention problems are worth evaluating based on prevalence, though her prior academic performance does not suggest any additional reason for concern.
• Post traumatic stress disorder would be worth considering based on prevalence; nothing immediately suggests it in the presenting problem, but it could explain a similar set of symptoms.
• Parent-child conflict or an adolescent acting out in a somewhat chaotic home environment also should be a contending hypothesis.

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 Tamika, 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.

• PTSD (100% confidence post interview)
• ADHD (65% confidence post interview)
• ODD (70% confidence post interview)
• Rule out: reactive attachment disorder (49% confidence post interview)    
• Rule out: mood NOS (33% confidence post interview)

Narrative summary of interview (spoilers)

Extended content

The flow of the interview proceeded from overview and informed consent/assent with Tamika and mom together, followed by KSADS interview with mom while Tamika completed scales, and then interview with Tamika. During the interview with mom, the main symptoms endorsed were in the oppositional defiant disorder section, some ADHD symptoms (but not clear how chronic they were, versus being mostly a more recent change in functioning), and some conduct symptoms. Mom did not report any significant trauma history. During the interview with Tamika, she also agreed that there had been a lot of conflict at home and things had gotten rougher at school, and she endorsed symptoms in the ODD and ADHD sections. When doing the trauma screen, Tamika asked for the interviewer to repeat the explanation of confidentiality and the exceptions to it from the beginning of the interview. After hearing that everything was confidential with the exceptions of disclosure of intent to harm herself or someone else, or that someone was hurting her (i.e., abuse), she asked what would happen in any of those scenarios. After the interviewer explained mandated reporting and safety procedures, Tamika divulged that she was being repeatedly sexually molested by an "uncle" (not a biological relative) who was often in and out of the household. He had threatened to kill her if she told anyone, so mom was unaware of the abuse. After contacting appropriate authorities and making sure there would be no further contact between her and the perpetrator, the diagnostic interview and formulation confirmed: (a) she met sufficient symptoms to warrant a diagnosis of PTSD, (b) the abuse was the trigger that led to the changes in Tamika's behavior, demoting ODD from being the primary treatment focus (c) the PTSD might also be contributing to apparent agitation, impulsivity, and difficulty concentrating that could also be attributed to ADHD. Because mom was not aware of the abuse and its timeline, it was ambiguous whether Tamika's case conceptualization would be better including prior ADHD comorbid with PTSD, versus PTSD alone as a parsimonious formulation. The revised treatment plan based on the interview was to provide support to the family and acute treatment for PTSD, with a plan to re-assess symptoms of ADHD after a good "dose" of trauma-focused CBT or similar work targeting PTSD and its symptoms.

Alternatives to Diagnostic Interview

While the Kiddie Schedule for Affective Disorders and Schizophrenia (KSADS) interview is the gold standard for assessing children and adolescents for psychological disorders, its length makes it impractical for most clinical settings. Instead, the Child Behavior Checklist (CBCL) is used to assess for mental illness, which is also problematic because this scale has no trauma sub-scale. Had this assessment scale been used to evaluate Tamika, it is likely her trauma would have been missed. The scales below are specific trauma measurements that can be used in addition to the CBCL.

Measures for Screening and Assessing PTSD in Youth

Measure Ages Assessment Subscales Versions Comments/Source Subscales Thresholds Tamika's Subscale scores Child PTSD Symptom Scale (CPSS-5) - Wikipedia Overview - Wikiversity Overview - Blank Symptom Scale - HGAPS CPSS-5 Survey - Tamika's filled out CPSS-5 8–18 years Symptoms (re-experiencing, avoidance, hyperarousal) - 17 items - Composite score ranges 0-51 Below Threshold [0-10]   Subclinical-Mild [11-15] Mild [16-20] Moderate [21-25] Moderately Severe [26-30] Severe [31-40] Extremely Severe [41-51] 36; severe Child Self Report Clinician Interview Caregiver Report (in development) English Language Multiple languages for DSM-IV version Good correspondence between the versions; PTSD rates higher with child report. Foa et al. (2018) Functional Impairments - 7 Items - Composite score ranges 0-7 Impairment is measured from 0 to 7 4 UCLA Child/ Adolescent PTSD Reaction Index for DSM-5 (PTSD-RI-5) - Wikiversity Overview - Blank UCLA C/A PTSD Index 7-18 years Criteria A, Exposure to Traumatic Event - Trauma History (Items 1-13) & Peritraumatic Distress (Items 14-23, not scored) - Includes scores for Dissociative Symptoms If ≥ 1 Dissociative Symptoms, assign Dissociative Subtype Child Self Report ( ≤ 6 years) Clinician Interview Caregiver Report   English, Spanish, German, Arabic, Japanese, Simplified Chinese, Korean, DSM-5 Criteria B, Re-Experiencing - 5 items - 0 (None) - 4 (Most) - Cumulative score ≥ 38 indicates likely PTSD - Diagnosis Requirement of: ≥ 1 Criteria B symptom; ≥ 1 Criteria C symptom; ≥ 2 Criteria D symptoms; ≥ 1 Criteria E DSM-5 Criteria C, Avoidance/ Numbing - 2 items - 0 (None) - 4 (Most) DSM-5 Criteria D, Hyperarousal - 13 items (7 scored) - 0 (None) - 4 (Most) DSM-5 Criteria E, Alterations in Arousal and Reactivity - 7 items (6 scored) - 0 (None) - 4 (Most) Young Child PTSD Checklist (YCPC) - Blank YCPC Checklist 1-6 years Trauma Exposure - 13 items - Not scored, but done to facilitate recall of total trauma exposure NA NA Caregiver Report Scheering & Haslett (2010) Available at: http://www.midss.org/content/young-child-ptsd-checklist This scale is intended for children ages 1-6 which is not applicable to Vignette Tamika. PTSD Symptoms - 23 items rated from 0 (Not at all) to 4 (Everyday) Sum score ≥26 NA Functional Impairments - 6 Items rated from 0 (Hardly ever/none) to 4 (Everyday) Sume score ≥4 NA Child Behavior Checklist-Posttraumatic Stress Disorder Scale (CBCL-PTSD) 11-18 years PTSD Symptoms (14 item version is recommended) Parent report Youth report (Teacher report not recommended) Strongest support is for the Youth Self Report version of this measure; mixed findings for this measure with preschool aged children.   Ruggiero & McLeer (2000); You et al. (2017). International Trauma Questionnaire Child and Adolescent Version (ITQ-CA) - Blank ITQ-CA - Tamika's filled out ITQ-CA 7-17 years PTSD Score with Functional Impairment - 6 items scored from 0 (Never) to 4 (Almost always) - Scores ≥2 indicate presence of symptom - 5 Items assessing impairment in life domains - Rated Yes/No Presence of at least one symptom in each PTSD symptom cluster accompanied by at least one functional impairment Youth report The measure has been found to have strong psychometric properties, as well as strong discriminant validity between PTSD and DSO. Self-Organization Score with Functional Impairment - 6 Items scored from 0 (Never) to 4 (Almost always) - Scores ≥2 indicate presence of symptom - 5 Items assessing impairment in life domains - Rated Yes/No Presence of at least one symptom in each PTSD symptom cluster accompanied by at least one functional impairment Complex PTSD Score - 12 items scored from 0 (Never) to 4 (Almost always) - Scores ≥2 indicate presence of symptom - This subscale encompasses both the PTSD and Self-Organization subscaless PTSD score and Self-Organization score meet or exceed clinical threshold

Risk and protective factors and moderators

Tamika's gender and age make her on the bubble between oppositional defiant disorder and conduct disorder, for which she is on the younger side of the range.

Updating probability of diagnoses

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

Worksheet
Tamika	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.	Next Test score	DLR	Revised Prob.	K-SADS Interview
Any Anxiety	Specific Phobia	0.15
	PTSD	0.09							PTSD (100%)
	GAD	0.10	CBCL T Internalizing 70	0.98	?	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 91	4.18	?	No data about TRF scales for aggressive			ODD (70%)
	CD	0.25	CBCL T Aggressive 91	4.18	?
	ADHD	0.38	CBCL T Attention 68	6.92	?	TRF T Attention 63	0.73	0.76	ADHD combined (65%)
Any Mood Disorder	MDD	0.26	CBCL T Anx/Dep 60	3.78	?	Haven't found data about TRF for internalizing
	BP
	Dysthymia	0.08
Any Substance Abuse Disorder		0.30	CBCL #2 CBCL #99 CBCL #105

Click below for filled out chart.

Answers

Tamika 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. Next Test score DLR Revised Prob. K-SADS Interview Any Anxiety Specific Phobia 0.15 PTSD 0.09 PTSD (100%) GAD 0.10 CBCL T Internalizing 70 0.98 0.11 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 91 4.18 0.72 No data about TRF scales for aggressive ODD (70%) CD 0.25 CBCL T Aggressive 91 4.18 0.58 ADHD 0.38 CBCL T Attention 68 6.92 0.81 TRF T Attention 63 0.73 0.76 ADHD combined (65%) Any Mood Disorder MDD 0.26 CBCL T Anx/Dep 60 3.78 0.57 Haven't found data about TRF for internalizing BP Dysthymia 0.08 Any Substance Abuse Disorder 0.30 CBCL #2 CBCL #99 CBCL #105

Prescription phase

Genogram and family functioning

Here is a genogram of Tamika's family:

Mom is effectively a single parent raising Tamika and three brothers and a sister. The kids have three different fathers; none of them are currently in the home or contributing directly to child support. On the other hand, there is not any significant conflict with Tamika's father, and she sees him intermittently.

The plot twist hinges around the "uncle" who is shown as being both in and out of the house. Skip to the diagnostic interview section if you want the details.

Possible Treatment Selection

• Additional Resource: Evidence-Based PTSD Treatments

TF-CBT stands for Trauma-focused Cognitive Behavioral Therapy and it was developed by Dr. Anthony Mannarino, Dr. Judith Cohen, and Dr. Esther Deblinger. It is an evidence-based treatment intended to reduce trauma symptoms in children ages 3 to 18 that have been exposed to at least one traumatic event. This treatment focuses on processing the memories, thoughts, and behaviors associated with the traumatic event. It incorporates cognitive therapy, behavioral therapy, family therapy, attachment theory, and developmental neurobiology. TF-CBT is typically provided over 12 to 16 weekly sessions but may take longer for children with complex trauma (i.e., chronic or multiple experiences).

MATCH-ADTC stands for Modular Approach to Therapy for Children with Anxiety, Depression, Trauma, or Conduct Problems developed by Dr. Bruce Chorpita & Dr. John Weisz. It is an evidence-based treatment designed for children ages 6 to 15 designed to specifically target/treat anxiety, depression, trauma, PTSD, and behavioral problems. This treatment is based on years of past empirically-based research and treatments, and the therapy can also address related issues that could arise during therapy treatment. This therapy is a type of Cognitive Behavioral Treatment (CBT).

CFTSI stands for Child and Family Traumatic Stress Intervention and was developed by the Yale Child Study Center. It is an evidence-based treatment designed for children ages 7 to 18 and is intended for all trauma types, including single, chronic, or multiple event exposures. This therapy centers around improving communication between child and caregiver and providing behavioral skills for both parties to cope with the symptoms caused by trauma. CFTSI is typically provided over 4 sessions and materials have been translated into Spanish.

ITCT-A stands for Integrative Treatment of Complex Trauma for Adolescents and was developed by Dr. John Briere and Dr. Cheryl Lanktree. It is an evidence-based treatment designed for children ages 12 to 21 and is applicable for those with complex trauma, physical abuse, sexual abuse, emotional abuse and neglect, community violence, domestic violence, medical trauma, and traumatic loss. It may also be used for those with a history of parental substance abuse. This therapy focuses on increasing self-esteem, managing triggers, improving relationships, and affect regulation. ITCT-A is provided over 16 to 36 sessions and has been adapted for Spanish-speakers.

TARGET stands for Trauma Affect Regulation: Guide for Education and Therapy and was developed by Dr. Julian Ford and Dr. Josephine Hawke for children ages 10 and up and it is applicable for those with complex trauma, as well as those with traumatic loss. This therapy focuses on affect and emotional regulation, reducing PTSD, depression, anxiety, anger symptoms and reducing behavioral incidents. TARGET is provided over 10 sessions and has been translated into Spanish. It also has the cultural characteristics for those with low SES and those in the Juvenile and Adult Criminal Justice system, Foster Families, and Single Parent Family situations.

CCT stands for Cue-Centered Therapy and was developed by Dr. Victor Carrion, Dr. Hilit Kletter, and Dr. Ryan Matlow. It is an evidence-based treatment designed for children ages 8 to 18 and is intended for those with chronic traumatic experiences. This therapy focuses on the allostatic load, or the compounding effect of traumas throughout their lives, rather than singling out particular traumatic experiences. CCT is provided over 15 sessions and includes joint sessions for the child and their caregiver.

DCS stands for D-cycloserine, which is an antibiotic and partial N-methyl-d-aspartic acid (NMDA) agonist. This antibiotic is currently being studied in adults and children for the reduction of PTSD symptoms. In conjunction with CBT, DCS was found to reduce the adverse symptoms of PTSD; and when compared to CBT + placebo, CBT + DCS was found to maintain stability of symptoms for a longer period of time. The antibiotic is believed to reduce PTSD symptoms by increasing the rate of adverse memory extinction.

PT stands for Play Therapy which was first introduced by Anna Freud and has been designed for children ages 3 to 13 who have experienced traumatic events. This therapy focuses on building self-confidence within the child and allowing the child to relax...

EMBR stands for Eye Movement Desensitization and Reprocessing...

REM Deprivation...

Psychopharmacological Options include...