SCCAP/Miami International Child & Adolescent Mental Health (MICAMH) Conference/2018/Day 3

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Day 3[edit | edit source]

Keynotes[edit | edit source]

School Mental Health Services Are Central to Best Practices for Youth with Emotional and Behavioral Problems[edit | edit source]

Presenter: Steven W. Evans, Ph.D., Ohio University


Learning Outcomes:

Explain the definition of school mental health and how it is similar and different than other mental health services for children
  • School is best place to intervene and we need to have interprofessional collaboration
  • 3 T’s of being a successful person working with children
  • School mental health? Direct and indirect services that help children in schools scced
  • Direct- target student directly like counseling
  • Indirect- such as classroom teaching strategies
  • School mental health professionals- school psychologists, counselors, special education teachers, but it can be anyone in a school who is making a difference in the children’s mental health
  • History of school mental health (SMH)
  • Prior to 1990’s- focus on prevention such as bullying and psychoeducation
  • Realized children’s needs weren’t being met by clinics
  • Now- we can provide interventions from clinics in schools
  • Care at clinics- most children with emotional or behavioral problems don’t receive care and only get 1 to 2 session on average and up to 6 to 7 which still didn’t usually improve school performance
  • Addressing access to care issue- Schools with masters level professionals often referred to masters level clinicians who the children would never see anyway
  • 2 models of SMH- both still exist today
  • School employed SMH- someone does things in school like a clinic
  • Strengths- school relationships, communication, and investment internal resources by training
  • Weaknesses- Lack of mental health backup (at clinic clinician can ask a more experienced person hard questions) and confidentiality and record keeping difficult (people might be offended you can’t share about students)
  • Contracting with external agencies- gets a number of hours per week to get clinician in schools
  • Strengths- have mental health backup and easy referral back to the clinic if the SMH professional comes from the clinic
  • Weaknesses- Clinicians don’t really know schools well so little training in SMH, challenging team integration (might be colocated but not integrated), costs, and competing policies (billing)
  • SMH professionals’ time
  • More than half spent doing administrative tasks- counselors often do scheduling, report generation, and attendance tracking
  • Often because counselor reports to principal who is administrative so delegates tasks to counselor
  • Responding to crises
  • “Girl drama” who said what about who
  • In other words, not helping children with mental health needs
  • What are counselors’ priorities and what do they think the principals’ priorities are?
  • Counselors’ priorities- responding to crisis, meeting with parents, student drop-ins, career counseling, individual MH counseling
  • Perception of principals’ priorities- responding to crisis, meeting with parents, scheduling classes, doing standardized tests…. Individual MH interventions last
  • Need to shift administrative tasks to administrator so counselors can do their jobs
  • SMH has so much potential- if done well, much more accessible than a clinic
  • Assessment-
  • In clinic- give rating scales, maybe get teacher report
  • Schools- Observe in multiple settings, review records, talk with teachers, observe over time- see causes of challenges
  • Treatment-
  • In clinic- 50 minute sessions usually <6 sessions and don’t know if they’ll come back
  • In schools- Session length can vary, duration can vary longer, support of others in schools, more likely to show up, see why intervention isn’t working or intervene if problem occurs
  • 2 Examples of interventions
  • First step next
  • For young children
  • Challenging horizons program
  • Targets adolescents with ADHD in secondary schools
  • Part of it is after school program
  • In trial- after school care had gap of .2 GPA points at one year post intervention- also GPA was maintained for 2 years instead of decreasing as is typical of ADHD over time
  • Frequent services on IEP’s
  • Extended test time, small group instruction, prompting/cueing, test aids, read aloud, breaks
  • Most interventions just to help with tests or to expect less of students
  • Study on expectations for students with ADHD with special and general ed teachers
  • Special education teachers expect much less from general education for kids with ADHD
  • If we just reduce expectations impairment appears to disappear but functioning really doesn’t change but it’s a pseudo-solution because no employer will let children get by with anything
  • But we should help students meet expectations- reducing time or homework in lowering expectations and removes the need to do better, when we have interventions that will help them move closer to accomplishing the high expectations
  • How do we know what works? Impairment is a function of individual competencies and expectation of setting
  • So, does it fix the problem?- not a good metric
  • Does it enhance the skills of the student to meet age appropriate expectations? Better metric!
Explain the advantages and disadvantages of providing mental health services at schools instead of clinics
Critically discuss the role of accommodations and interventions in secondary schools for students with IEPs and 504 plans for emotional or behavioral problems
Describe at least two examples of evidence-based practices in schools at the universal and targeted level
Explain the Life Course Model and how it applies to school mental health
  • Focusing on, in order of what to try
  • foundation strategies and environmental barriers,
  • psychosocial interventions
  • medications
  • accommodations
  • Example- if person has back injury and is in wheelchair much easier to have a surgery to fix it than make the whole school accessible
  • Lowering expectations is making a statement that you don’t care enough to help student grow
  • Keys to success-
  • Provide effective SMH strategies/interventions
  • Relationship of SMH professional with students so interventions can be delivered- What predicted good results in the new horizons program?
  • Dose- more program sessions better they did
  • Parent conflict- worse results with more conflict
  • Student ratings of relationship with counselor- predicted many outcomes well- need to build relationship so you can give children services but need to be professional still. Needs to be maintained and to pace intervention at rate student can handle
  • Take care of yourself- stressful work
  • So three keys-
  • Relationship- student cares what you think
  • Interventions- Effective practices delivered over time
  • Self- take care of yourself

Response to Intervention (RTI) Process and Strategies for Elementary School[edit | edit source]

Presenter: George J. DuPaul, Ph.D., Lehigh University. Dr. DuPaul has been at Lehigh University College of Education since 1992.

Learning Outcomes:

Understand the conceptual and empirical foundations of response-to intervention (RTI) frameworks in elementary school
  • What is RTI? :
  • Comprehensive, multi-tiered approach based on standards
  • methodology used for school change for all kids,
  • bridging the gap
  • It starts with universal screening and who is doing what is or isn't expected of them.
  • Looking at needs of the students, Pyramid Model evolves in 3 different tiers, 3 tiers of reading instruction, Tier 1 enrichment 2 strategic interventions, Tier 3 intensive smaller groups
  • More needs kids have the higher tier they have
  • Alternative to aptitude-achievement discrepancy model for the identification of kids with intellectual disabilities
  • Core characteristics of RTI
  • Standards aligned with instruction in a research-based program
  • Want all students to receive high-quality instruction
  • Universal screening for academics and behavior
  • Developing measurement techniques to keep up with progress in given grade level in given community
  • Curriculum based measurement- probes into student progress, for reading using words correct per minute (WCPM) so we can monitor periodically to see progress
  • Shared ownership of all students for all of them to get what they need
  • Not just students in general or special education
  • Data-based decision making- to help decide what kinds of interventions kids will need using benchmarks
  • Benchmark and outcome assessment- more often for children in higher tiers
  • Progress monitoring- helps to learn of intervention effectiveness based on math or reading performance
  • Tiered intervention and service delivery system- fidelity of implementation, flexible grouping, and research based intervention
  • MTSS- multi-tiered systems of support
  • Parental engagement
  • Start building parent engagement from the start to build support for school personnel
  • Why RTI? Why is this model continuing to be pushed?
  • Emphasis on prevention and early intervention- don’t want kids to fail and then get services but screen for issues and then intervene to hopefully lead to less long-term problems
  • Addresses the ability/achievement discrepancy problem
  • Systematic approach for all students
  • Provides standard aligned core instruction
  • Encourages team-based problem solving in schools
State steps and processes used to implement a unified model of RTI to address academic and behavior problems exhibited by elementary school students
  • Factors to consider for tier 1-
  • Was the core program aligned to state standards- are kids at risk given instruction based on state standards?
  • Were kids given adequate dosage of that instruction?
  • Were teachers trained to deliver the system?
  • Were they effective at using it?
  • Were data analysis teams used to support delivery of interventions?
  • Factors for tiers 2 and 3
  • Were interventions supported by scientific research?
  • Were treatment protocols followed (fidelity)?
  • Were the people intervening trained in the intervention?
  • Adequate dose of intervention?
  • Were the decisions to intervene made by a team?
  • Documentation of instructional sufficiency and fidelity
  • Under IDEA have to demonstrate that interventions being put in place and delivered for appropriate amount of time with fidelity
  • IDEA says if those criteria not met then do not consider special education
  • Ideally to decrease the number of students in special education
  • Determination of rate of improvement
  • How to decide how far words per minute needs to go up and how fast the rate of growth needs to be to indicate that the intervention is working ( for resources from American Institute of Research)
  • What is too low? Too slow?
  • Looking at level of performance and rate of growth- no federal or state guidelines
  • What level does a kid need to be at to move to from tier to tier?
  • We don’t have an agreement
  • In the meantime- Student should be severely deficient in level and not progressing at a rate enough to reach next benchmark- look at data and needed improvement to get back on track- if child cannot reach it then might consider tier 2
  • Examples of essential instructional strategies (9)
  • RTI management teams-
  • Teacher is not on an island by themselves, there are other bridges to connect to others
  • Teams involved in screening, data analysis, grouping, and ensuring that instruction is delivered with fidelity
Identify examples of RTI implementation in the context of multi-tiered systems of support
  • Three examples- Elliot, Rob, and Kendra using DIBELS (reading test; Dynamic indicator of ) tier one monitored 3x per year, tier 3 once per week
  • Elliot- tier 1- performing at grade level
  • Responders- continued effective practices
  • Not responding- tier 2 intervention or maybe tier 3 (probable special education
  • Tier 2 would be increasing support with increased time to learn, small group learning, more regular monitoring, standard protocol intervention (based in research and will likely produce improvement)
  • Rob- started low and rate of growth not enough to catch up and is already in tier 2 so need to go to tier 3
  • Then was placed in tier 3 and made substantial progress
  • Non responders to tier 3? If not in special education then can change to that or adjust interventions
  • Kendra- low at beginning but has tier 2 support and is exceeding necessary rate of growth to catch up
  • Could move to tier 1 or more likely keep her in tier 2
  • RTI applied to behaviors- positive behavior support (PBS or PBIS)
  • Works same as academic RTI with different screening measures and interventions
  • RTI outcomes from the literature-
  • Has a myriad of benefits for reading, writing, and math especially with reading
  • Progress monitoring and fidelity (implementation of evidence based instruction, so if general education teachers fail to use them) are key components
  • Behaviorally, decreased disciplinary referrals and suspensions/expulsions

Families and ADHD[edit | edit source]

Presenter: Charlotte Johnston, Ph.D., University of British Columbia

Learning Outcomes:

Acquire knowledge of possible mechanisms, including genetic and environmental influences that may underlie parent-child interaction difficulties in families with members with ADHD symptoms
  • Families and ADHD
  • Model of parent-child interactions in families with ADHD
  • Child ADHD effects- bidirectional effects with parenting
  • Parent ADHD effects- negative and positive effects
  • 2 way street between parents and kids, not one or the others fault, biological factors, it is parent and genes
  • ADHD
  • Significant biological influences - 80% heritability rate
  • Gene X environment interactions- genes and environment interact to form a diathesis
  • Factors- characteristics of child, family dynamics, parent characteristics- all influence parent-child interaction
  • Child effects- kids with ADHD make parenting hard (manipulation of child ADHD behavior improves interactions for lower symptoms, for instance medication improves interactions)
  • Study- after interacting with kid mimicking ADHD symptoms then offered alcohol those who interacted with ADHD kid drank significantly more than interacting with a typically behaving child
  • Parent effects- greatest impact is changing probability of child developing a comorbid disorder such as ODD or CD
  • Parenting causally linked to the development of these problems
  • Parenting interventions reduces levels of oppositionality and might reduce some symptoms of ADHD (might just be perception of ADHD symptoms after psychoeducation)
  • Longitudinally- parenting difficulties predicts child disruptive behavior
  • Attributions- “Why did he do that?”
  • Parents of kids with ADHD more likely to blame child for misbehaviour, and more of these attributions leads to more negative parenting
  • Parent ADHD
  • 50-75% of kids with ADHD will continue to have the disorder in adulthood
  • About 50% of adults with ADHD have kids with ADHD and about 50% of kids with ADHD have a parent with ADHD symptoms
  • Study- Mothers that all had kids with ADHD and measured inconsistent discipline, poor monitoring and problem solving- mothers with ADHD had much bigger issues with these problems
  • Does it matter if mothers’ have inattentive or hyperactive? For inconsistent discipline, inattention was significant factor so most related to the problems
  • Parent ADHD and ineffective parenting control-
  • Parent ADHD linked to
  • Poor monitoring, problem solving, and discipline
  • What about fathers?
  • Study- 179 2 parent families (so already higher functioning) with boys 5-13 75% with ADHD, middle-upper class, mostly white
  • Assessed parenting based on self and spouse and child report and observation and making a composite score (some observations done in things associated with mothers and some with fatherly things like chores versus sports skills)
  • Child ADHD assessed with parent and child report
  • Parent ADHD assessed dimensionally (some were just below symptom threshold)
  • Four groups of families
  • Mother and father ADHD problems
  • Mom problems dad none
  • Dad problems mom none
  • Neither have ADHD problems
  • If any parent has ADHD, the mother has parenting problems
  • Dad does well if no one has ADHD or if both do and not too bad if only the mother does
  • So, if he has ADHD and has partner with ADHD then things are fine
  • Applies to ineffective parenting and disagreement
  • Parental ADHD and positive parenting
  • Some studies find no links between levels of positive parenting and parent ADHD, some negative correlations (for paternal ADHD only), and some claim positive correlations
  • Similarity fit? Does parent having same level of symptoms help parenting?
  • Interactions between child ADHD symptoms with parents’: Mothers (and fathers) with high inattention have more empathy when the have kids with ADHD
  • Parents with ADHD may be better able to understand and empathize with their children, even though they are still having issues so there’s a strength to work from
  • Summary and next steps (take-home messages)
  • Kids with ADHD affect parenting
  • Parenting affects outcomes
  • Should pay attention to ADHD levels in parents as it has effects for both mothers and fathers
  • Possible strength if they have similar levels of symptoms in parents and kids
  • Future directions
  • Child gene x parent gene x parenting associations
  • Effects of maternal vs. paternal ADHD
  • Co-parenting
  • Modify treatments to understand that parents may have same kinds of problems as kids
Develop an understanding of the influence of child and parent comorbidities on parent-child interactions in families of members with ADHD symptoms
Recognize possible ways in which ADHD symptoms in parents and/or children may impact treatment engagement and treatment outcomes for the children

Workshops[edit | edit source]

School Mental Health Services for Adolescents with ADHD[edit | edit source]

Presenter: Steven W. Evans, Ph.D., Ohio University

Powerpoint: Treatment for Adolescents with ADHD

Learning Outcomes:

Explain the limitations of applying current evidence-based practices for elementary-aged children with ADHD (e.g., behavioral classroom management) in secondary schools with adolescents
  • Why not make summer treatment program from Dr. Pelham during the school year? This inspired Dr. Evans to go work in the schools and work with interventions
  • Works with people with comorbid ADHD and adolescence at a time when mistakes they make might alter the course of their lives like substance abuse
  • Background
  • Before 90’s many physicians advised parents that kids would just grow out of ADHD after puberty, but actually problems can get much more difficult and parent influence tends to decrease
  • Problems associated with adolescents with ADHD (treatment targets)
  • Anger
  • Lack of motivation
  • Communication
  • Stigma- hard to admit and talk about during a time when they are developing their identity (social world, self-reliance/autonomy)
  • Commitment to tasks (completion)
  • Autonomy
  • Below grade level
  • Managing conflict
  • Negative peers
  • Learning problems
  • Sleep hygiene
  • Bad behavior
  • Distractibility
  • Organization of time and materials
  • Self-awareness
  • Self esteem- based on amount of successes in life
  • Less likely to go to college or graduate if they make it
  • Home problems- dangerous driving, drug use, hard to keep jobs, delinquency, parent conflict, parent defiance
  • Lots of data about driving because it doesn’t mix well with inattention, hyperactivity, and impulsivity. Also, if they drive at night and take a stimulant to help, they’ll be up most of the night
  • Study about a device that records driving behaviors to determine if the teen gets car privileges- so there’s promise for possible results
  • 2016 was first large study of psychosocial treatments for adolescent ADHD
  • History of treatment development
  • Medication studies in 80’s
  • Psychosocial
  • 92 for family therapy- actually not recommended
  • 95 for note taking- taught students to take notes
  • First large trials of psychosocial approaches (2015-2017)
  • 2 large trials for Family therapy
  • 2 for cognitive therapy without promising results
  • 2 for school-based treatment- most promising
  • Well established treatments for children are behavior management (elementary school age)
  • Behavior management relies on adult monitoring to know behaviors, rewards and punishments that the kid cares about, and consistent implementation by teachers and parents
  • For example- token economy, daily report cards, verbal feedback, first step program

Application to adolescents?

  • Rewards- more expensive so might use privileges or make kid work towards bigger thing over a period of time- but delayed gratification doesn’t matter as much to kids with ADHD (rather have $5 now than $100 in a week possibly)
  • For privileges based on school performance- can be hard for parents to get good feedback from school. Also can be a double edged sword with teens taking away a privilege because taking something can make them worse like the basketball team so humiliating when they fail and their response is to stop caring so cascading effect
  • Adolescents with ADHD have less intrinsic motivation to participate in trying to get external rewards like suckers given for correct responses but doesn’t want to fail and be embarrassed
  • Implementation- Most adolescents have many teachers not just one and kids might behave differently in different classes, and high school teachers see more students per day
  • Parents grow tired of the fight by adolescence when they might have been super involved in previous years
  • Evans’s attempt with 10 session parent training- only session above 50% attendance was first session with average of about 4
  • Why don’t they come? Learned helplessness (it will just fail), parent ADHD, SES
  • Parent depression negatively correlated with attendance as well as parent stress and free or reduced lunch
  • Caregiver employment positively correlated with attendance- so if they had a job they came to more, also parental education level and if there were both biological parents with parenting responsibilities
  • Many studies of treatments have over 50% over parents with bachelor’s degrees when population average is 29%, so not representative of the population
  • If not behavior management, then what? (besides medication) Training
  • How do people get good at something? Instruction, practice, coaching, performance feedback (verbal and video), encouragement
  • In other words- Training like in sports, music, or diving
  • But for people who don’t want to do it, why is that?
  • No one expects them to do these things
  • Apathetic and resistant
  • Things that don’t work
  • Cogmed- kids sit at computer and practice sustained attention and look at boring stimuli. Theory is to train cognitive processes of working memory, but the computer thing is only thing they get better at. So good that there’s reps and feedback, but goal is irrelevant.
  • Social skills training- meet in small group and work on specific skill like starting conversations ,but missing reps and feedback in useful settings
  • Characteristic of things that work
  • Reps, coaching and performance feedback, relevant to daily activities
  • Developing the training horizons program (based in training)
  • Elements- studying, organizational, and interpersonal skills
  • Delivery models- after school program, mentoring, and integrated
  • Mentoring involves recruiting a school employee to meet with a student individually one on one
  • Hard to do in clinic because of reps needed
  • Studying- passive approach to active learning
  • Kids with ADHD are often very passive
  • Strategies- best delivered in ~15 minute reps many times
  • Comprehension- note taking from class presentations and text as well as feedback discussions about what they wrote down as main ideas etc.
  • Making them more active learners by making them describe stories to college students who then asked questions- helps them critically think about reading as if you have to tell it to someone who knows nothing about it
  • Note taking- teacher wrote main ideas and details on board then started asking students and then letting students be independent
  • Memorization- flashcards
  • Many classes are fact-based
  • Make games with the cards
  • Organization
  • First priority for development because disorganization made catching up difficult
  • Often the issue was either a binder or iPad, but sometimes notebooks, bookbags, lockers, and evening homework time
  • Training- reps and feedback with binder organization so made a checklist for binders
  • Checks only took a few minutes
  • Let them change things a little as long as it’s organized
  • Want to start with adult leading and then switch to student led
  • Outcomes-
  • Rapid responders- shoot to perfect and maintain
  • Honeymoon- really good after a month or so and fall back a little and then work back up to mastery
  • Slow and steady- most common- up and down until mastery- persistence is key
  • Homework management plan-
  • How to let parents help without arguments
  • Accept things they cannot change- can’t know what kid is supposed to do every night, can’t always understand the content, and can’t make kid complete everything
  • Courage to change what they can- support and increase likleood kid will spend some time every night on schoolwork
  • Wisdom to know the difference- frequently tempted to do things you can’t do
  • Main elements of HMP- work with parents to decide how much time child should spend every day, where are acceptable locations, when can child complete schoolwork (needs to be at a time when parent is home), and negotiation strategy (should start low like 15 minutes)
  • Negotiate contract- 20 minutes per day, no privileges after dinner till time over, if no schoolwork then assign something like a newspaper article or book or study something, maybe make weekend privileges based on success during week
  • Renegotiate contract after each report card- e.g. if they get lower than C’s then the time will increase per day
  • Interpersonal skills group (ISG)-
  • Hardest to help- Traditional social skills training not helpful for those with ADHD
  • Based on idea that poor interpersonal skills come from disorganization
  • Model of how it works
  • Ask adolescents how they want their peers to see them such as smart or nice or strong or funny but sometimes mean
  • Operationally define it- what to do to seem that way when hanging out with other kids by asking who they think is nice or smart and why you think of them that way
  • Give them things to do like games to play and then pull them out to review goals and how well they did the things they wanted to do
  • If they say funny then they might get mixed results where kid gets laughed at and thinks he’s succeeded so then staff has to explain how to distinguish being funny and laughed at
  • If they say mean the staff might rate them poorly on meanness and say they saw them smiling and it gets old and they change their goal
  • Can be run by general education teachers
  • For program as a whole- ability to control ability to get environmental rewards is a reinforcer
  • Models of changing horizons program (CHP)
  • Mentoring-
  • Challenges
  • Getting staff to meet with the students
  • Sometimes sessions got off task
  • So, weaker dose than intended and did about the same as control condition
  • Survival analysis- made for death but in this case “death” is GPA under 1.0 for kids with ADHD
  • Started with no students “dead” and then starts to fall
  • Kids with ADHD 40% were below 1 while healthy control was 15%
  • Integrated model of mentoring and afterschool
Describe typical areas of impairment for secondary students with ADHD and methods for measuring them
List feasible and effective tier-1 practices for students with ADHD
Describe the evidence-based school mental health targeted practices for adolescents with ADHD
Describe the application of the Life Course Model to school mental health practices for adolescents with ADHD

Classroom Management Strategies for Students with ADHD and Disruptive Behavior[edit | edit source]

Presenter: George J. DuPaul, Ph.D., Lehigh University. Dr. DuPaul has been at Lehigh University College of Education since 1992. He is co-author with Dr. Thomas Power of the ADHD Rating Scale–5[1].


Learning Outcomes:

1.) Identify the typical academic, behavioral, and social difficulties experienced by students with ADHD and related disorders
2.) Understand the need for a balanced approach to intervention that emphasizes positive behavior support including preventive and consequence-based strategies
3.) Identify evidence-based school intervention strategies for children and adolescents with ADHD and related disorders including contingency management, daily report card, peer tutoring, organizational skills support, and self-regulation techniques

Building Social and Behavioral Competencies in the Elementary School Setting[edit | edit source]

Presenter: Erika K. Coles, Ph.D., Florida International University

Learning Outcomes:

  1. Recognize how Tier 1 and Tier 2 behavioral strategies contribute to social and emotional learning in children
  2. Define trauma-informed schools and how using a trauma-informed framework can build social and behavioral competencies in the school setting
  3. Implement evidence-based strategies for building social and behavioral competencies

Promoting Homework Success: Strategies for Parents, Teachers, and Students[edit | edit source]

Presenter: Thomas J. Power, Ph.D., ABPP, Children's Hospital of Philadelphia


Learning Outcomes:

  1. Learn the potential benefits of homework
  2. Learn strategies for helping parents and teachers to promote student success with homework
  3. Learn strategies for training students in organization, time management, and planning skills to improve homework performance

Using What We Know from Evidence-Based Approaches to Assist Children and Adolescents in Coping with Marginalization, Discrimination, and Oppression[edit | edit source]

Presenter: Sannisha K. Dale, Ph.D., University of Miami

Learning Outcomes:

  1. Describe the link between marginalization/oppression and negative affect/emotions
  2. Learn some evidence-based strategies that can enhance coping with marginalization, discrimination, and oppression
  3. Note the limitations of some techniques in the context of oppression

Other 2018 Resources[edit | edit source]

References[edit | edit source]

  1. DuPaul, George J.; Reid, Robert; Anastopoulos, Arthur D.; Lambert, Matthew C.; Watkins, Marley W.; Power, Thomas J.. "Parent and teacher ratings of attention-deficit/hyperactivity disorder symptoms: Factor structure and normative data.". Psychological Assessment 28 (2): 214–225. doi:10.1037/pas0000166.