Adolescent mental health and behavior: Getting the most from your assessments

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1 Adolescent mental health and behavior: Getting the most from your assessments Texas Psychological Association Annual Convention November 2016 Presented by: Anise Flowers, PhD Anne-Marie Kimbell, Ph.D. Image by Photographer s Name (Credit in black type) or Image by Photographer s Name (Credit in white type) Agenda Overview of MMPI-A-RF Overview of BASC-3 Family Introduction to BASC-3 Intervention Guide and Flex Monitor Case Study Application MMPI-A-RF Product Overview Assessment of major symptoms of psychological dysfunction, personality characteristics, and behavioral tendencies in adolescents. Administer to: Individuals years old Qualification Level: C PhD psychologists Completion Time: minutes computer-administered minutes paper-and-pencil Reading Level: 4.9 th grade (Lexile average), 4.4 th grade (Flesch-Kincaid) Administration: Scoring Options: Report Options: Q-global, Q Local, paper-and-pencil Q-global, Q Local, Mail-In, Hand-scoring Score and Interpretive Reports MMPI-A-RF Training Slides, University of Minnesota Press, Copyrights for all MMPI and MMPI-A-RF materials are held by the Regents of the University of Minnesota. Features & Enhancements Most up-to date, empirically-based personality assessment for adolescents Mirrors the structure of the MMPI-2-RF, the most current version for use with adults Broad-based, comprehensive assessment includes 48 empirically validated scales 7 validity indicators Linked to current models of psychopathology & personality Developed for use in a variety of clinical, forensic, and school settings Customizable reporting options include: 10 gender-specific comparison groups Comparison group creation User-defined parameters for item-level and critical response reporting Factors in the Development of the MMPI-A-RF Need to reduce the high degree of MMPI-A scale intercorrelation Reduce redundant influence of demoralization factor across scales Reduce item overlap between scales Reduce scale content multidimensionality Develop a test based on roughly 250 items Test length of MMPI-A viewed by some as a significant disadvantage Develop an adolescent self-report measure comparable to the MMPI-2-RF but adapted to include measures uniquely related to adolescent psychopathology 6 TPA

2 MMPI-A-RF Project Project formed in late-2007 by University of Minnesota Press, Kent State University, and EVMS MMPI-2-RF used as a template, e.g., RC, Higher-Order, and Specific Problems Scales Norms based on MMPI-A normative sample Clinical samples from several settings, with data sets used separately for scale development and validation Reduced length from 478 to 241 items Salient differences between the MMPI-A and the MMPI-A-RF Variable MMPI-A MMPI-A-RF Year of Publication Primary Influence MMPI-2 MMPI-2-RF Number of Items Scale Structure Extensive item overlap across scales Non-overlapping items within hierarchical scale structure Norms Gender Specific Non-gendered T-score criterion for clinical elevation T 65 T studies including non-clinical samples ( ) Validity MMPI-A Scales Clinical L F K Hs D Hy Pd Mf Pa Pt Sc Ma Si Mean SD Test responses from 2,256 adolescents Results support consistency in descriptive findings using contemporary sample 9 MMPI-A-RF Structure Hierarchical scale structure 3 Higher-Order scales 9 Restructured Clinical (RC) scales, 25 Specific Problems (SP) scales, Revised versions of the Personality Psychopathology-Five (PSY-5) scales 48 scales 6 Validity scales 42 Substantive scales Critical Items and Critical Responses 241 items MMPI-A-RF Training Slides, University of Minnesota Press, Copyright for all MMPI, MMPI -A, MMPI-A-RF, and MMPI-2-RF materials are held by the Regents of the University of Minnesota. 10 MMPI-A-RF Validity Scales VRIN-r (Variable Response Inconsistency-Revised) - Random responding TRIN-r (True Response Inconsistency-Revised) -Fixed responding CRIN (Combined Response Inconsistency) - Combination of fixed and random inconsistent responding F-r (Infrequent Responses-Revised) - Responses infrequent in the general population L-r (Uncommon Virtues-Revised) - Rarely claimed moral attributes or activities K-r (Adjustment Validity-Revised) - Uncommonly high level of psychological adjustment 11 Higher-Order (H-O) Scales EID(Emotional/Internalizing Dysfunction) - Problems associated with mood and affect THD (Thought Dysfunction) - Problems associated with disordered thinking BXD (Behavioral/Externalizing Dysfunction) - Problems associated with under-controlled behavior 12 TPA

3 Restructured Clinical (RC) Scales RCd (Demoralization) - General unhappiness and dissatisfaction RC1 (Somatic Complaints) - Diffuse physical health complaints RC2 (Low Positive Emotions) - A distinctive, core vulnerability factor in depression RC3 (Cynicism) - Non-self-referential beliefs that others are bad and not to be trusted RC4 (Antisocial Behavior) - Rule breaking and irresponsible behavior RC6 (Ideas of Persecution) - Self-referential beliefs that others pose a threat RC7 (Dysfunctional Negative Emotions) - Maladaptive anxiety, anger, and irritability RC8 (Aberrant Experiences) - Unusual perceptions or thoughts associated with psychosis RC9 (Hypomanic Activation) - Over-activation, aggression, impulsivity, and grandiosity, uncontrolled behavior Alpha Coefficients Scale Boys Girls Combined RCD (18 items) RC1 (23 items) RC2 (10 items) RC3 (9 items) RC4 ( items) RC6 (9 items) RC7 (11 items) RC8 (8 items) RC9 (8 items) Demoralization (RCd) Test Response T score < 40 Reports a higher-than-average level of life morale and life satisfaction T score Reports feeling sad and dissatisfied with his or her current life circumstances T score 80 Reports feelings of depression, social isolation, low self-confidence, and helplessness Empirical Correlates May experience suicidal ideation Feels life is a strain Feels sad Reports feeling depressed Feels anxious Has low self-esteem Has problems with attention and concentration Reports feeling ineffective in dealing with problems Complains of low energy and fatigue Diagnostic Considerations Evaluate for depression-related disorder Treatment Considerations Evaluate risk for self-harm (if suicide items are endorsed or HLP 60) 15 Somatic/Cognitive Scales MLS (Malaise) - Overall sense of physical debilitation, poor health GIC (Gastrointestinal Complaints) - Nausea, recurring upset stomach, & poor appetite HPC (Head Pain Complaints) - Head and neck pain NUC (Neurological Complaints) - Dizziness, weakness, paralysis, loss of balance, etc. COG (Cognitive Complaints) - Memory problems, difficulties concentrating 16 Internalizing Scales HLP (Helplessness/Hopelessness) - Belief that goals cannot be reached or problems solved SFD (Self-Doubt) - Lack of self-confidence, feelings of uselessness NFC (Inefficacy) - Belief that one is indecisive and inefficacious OCS (Obsessions/Compulsions) - Varied obsessional and compulsive behaviors STW (Stress/Worry) - Preoccupation with disappointments, difficulty with time pressure AXY (Anxiety) - Pervasive anxiety, frights, frequent nightmares ANP (Anger Proneness) - Easily angered, impatient with others BRF (Behavior-Restricting Fears) - Fears that significantly inhibit normal behavior SPF (Specific Fears) Multiple specific fears 17 Externalizing Scales NSA (Negative School Attitudes) - Negative attitudes and beliefs about school ASA (Antisocial Attitudes) - Various anti-social beliefs and attitudes CNP (Conduct Problems) - Difficulties at school and at home, stealing SUB (Substance Abuse) - Current and past misuse of alcohol and drugs AGG (Aggression) - Physically aggressive, violent behavior NPI (Negative Peer Influence) - Affiliation with negative peer group 18 TPA

4 Interpersonal Scales FML (Family Problems) - Conflictual family relationships IPP (Interpersonal Passivity) - Being unassertive and submissive SAV (Social Avoidance) - Avoiding or not enjoying social events SHY (Shyness) - Feeling uncomfortable and anxious around others DSF (Disaffiliativeness) - Disliking people and being around them Personality Psychopathology Five (PSY-5) Scales AGGR-r (Aggressiveness-Revised) - Instrumental, goal-directed aggression PSYC-r (Psychoticism-Revised) - Disconnection from reality DISC-r (Disconstraint-Revised) - Under-controlled behavior NEGE-r (Negative Emotionality/Neuroticism-Revised) - Anxiety, insecurity, worry, and fear INTR-r (Introversion/Low Positive Emotionality- Revised) - Social disengagement and anhedonia Forbey and Ben-Porath MMPI-A-RF Critical Items Content Area # of Item Aggression 2 Anxiety 4 Cognitive Problems 2 Conduct Problems 7 Depression/Suicidal Ideation 7 Eating Problems 2 Family Problems 2 Hallucinatory Experiences 3 Paranoid Ideation 6 School Problems 4 Self-Denigration 2 Somatic Complaints 6 Substance Use/Abuse 5 Unusual Thinking 1 Total Items MMPI-A-RF Interpretation Topic MMPI-A-RF Source I. Protocol Validity a. Content Non-Responsiveness CNS, VRIN-r, TRIN-r, CRIN b. Over-Reporting F-r c. Under-Reporting L-r, K-r II. Substantive Scale Interpretation a. Somatic/Cognitive Dysfunction RC1, MLS, GIC, HPC< NUC, COG b. Emotional Dysfunction 1. EID 2. RCd, HLP, SFD, NFC 3. RC2, INTR-r 4. RC7, STW, AXY, ANP, BRF, SPF, OCS, NEGE-r c. Thought Dysfunction 1. THD 2. RC6 3. RC8 4. PSYC-r d. Behavioral Dysfunction 1. BXD 2. RC4, NSA, ASA, CNP, SUB, NPI 3. RC9, AGG 4. AGGR-r, DISC-r e. Interpersonal Dysfunction 1. FML 2. RC3 3. IPP 4. SAV 5. SHY 6. DSF f. Diagnostic Considerations Most Substantive Scales g. Treatment Considerations All Substantive Scales 22 MMPI-A-RF Profiles Comprehensive Behavior Management Solution Behavioral and Emotional Screening System (BESS) BASC 3 Rating Scales Teacher Rating Scales (TRS) Parent Rating Scales (PRS) Self Report of Personality (SRP) Parenting Relationship Questionnaire (PRQ) Structured Developmental History (SDH) Behavior Intervention Guide Behavioral and Emotional Skill Building Guide Parent Tip Sheets Intervention Report Flex Monitor Student Observation System (SOS) Documentation Checklist Student Observation System (SOS) TPA

5 BASC-3 Components RATING SCALES (PRS, TRS, SRP) Parent Rating Scale Preschool, Child, Adolescent All available in Spanish as well as English BASC-3 Teacher Rating Scales (TRS), Parent Rating Scales (PRS), and Self-Report of Personality (SRP) BASC-3 Student Observation System BASC-3 Structured Developmental History BASC-3 Parenting Relationship Questionnaire all ages BASC-3 Behavioral and Emotional Screening System (Teacher, Parent, Student Forms) BASC-3 Behavior Intervention Guide Behavioral and Emotional Skill-Building Guide, part of the BASC-3 family BASC-3 Flex Monitor (Teacher, Parent, and Student Forms) Teacher Rating Scale Preschool, Child, Adolescent Self-report of Personality Interview, Child, Adolescent, College Child & Adolescent also in Spanish MOMENTUM NSM15 Systematic Approach to Interpretation 1. Interpret Validity Indexes 2. Interpret Composite Scores 3. Interpret Scale Scores 4. Interpret Items Copyright 2016 Pearson Education, Inc. or its affiliates. All rights reserved. Rating Scales: Interpretation principles Most raters are truthful. Person with the most deviant ratings is the person who knows the child best Referral Bias: (schools) Teacher ratings are going to be the most deviant Parents will identify smaller number of problems Child will identify none Have a conversation with the raters for qualitative information Embrace disagreeable ratings because they enhance your qualitative perspective 28 MOMENTUM NSM15 Q-global And The BASC-3 Q-global is a secure, online, web-based system used to administer and score the TRS, PRS, SRP, SDH, SOS, and PRQ forms. Administration Options OSA (on screen administration ROSA (remote on screen administration Sends an to the respondent containing a web link needed to complete the form Then you will receive an indicating the form is complete Paper form & manual response entry BASC-3 Q-Global Report Features Validity Indexes Clinical and Adaptive Scales Content Scales Clinical Probability Indexes Executive Functioning Indexes Validity Index Item Lists Clinical And Adaptive Scale Narratives Content Scale Narratives Target Behaviors For Intervention Critical Items DSM-5 Diagnostic Considerations Items By Scale Item Responses TPA

6 Additional Reports FREE! Multi-rater Report Allows you to compare results from the BASC-3 PRS and TRS across multiple raters BASC-3 Multirater Report Progress Report Allows you to compare the same rater across multiple time points Integrated Summary Report Combines results from individual components including the SRP. MOMENTUM NSM Copyright 2016 Pearson Education, Inc. or its affiliates. All rights reserved. Copyright 2016 Pearson Education, Inc. or its affiliates. All rights reserved 33 Copyright 2016 Pearson Education, Inc. or its affiliates. All rights reserved. 34 BASC-3 Integrated Report Up to 5 BASC-3 TRS, PRS, & SRP records Includes: Validity Index Summary Table* Scaled score Summary Table* Shared Items Comparison section** Administration selections must be from same report level (Preschool, Child, Adol) Only one SRP can be included; no COL Administration selections must be in Report Generated status * Always prints on report ** Only prints when significant discrepancies exist in responses TPA

7 Q-Global - Intervention Report Adds Intervention Report section to BASC-3 Report Intervention Report section content: Table with Primary & Secondary improvement areas and Adaptive Strengths Intervention Summary Section Walks through some different Intervention Options, using information from Intervention Guide Does not cover every Intervention suggested in Guide in every report 37 BASC-3 Behavior Intervention Guide Kimberly Vannest, Cecil Reynolds, Randy Kamphaus Comprehensive set of empirically-based interventions for a variety of behavioral and emotional problems Organized around scales included on the BASC-3 TRS, PRS, and SRP forms Intervention Components include: Behavior Intervention Guide (Paper and Digital) Parent Tip Sheets Documentation Checklist Intervention Summary software report for TRS, PRS, and SRP 39 MOMENTUM NSM15 40 BASC-3 Behavior Intervention Guide What is in the Guide? 78 Interventions across eleven of the most common problems of children and youth. Step by step procedures (prep implementevaluate) Considerations for practice and troubleshooting. Elementary and Secondary illustrations. Annotated bibliographies of research studies. Aggression Conduct Hyperactivity Attention Academic Problems Anxiety Depression Somatization Adaptability Functional Communication Problem Social Skills Problems 41 Each of the 78 Interventions: THE BASICS - Descriptions of essential concepts, about resources and skills needed The PIE approach PREP what do I need to get started or use this intervention (training? Materials? Skill sets?) IMPLEMENT step by step directions, examples for elementary and secondary grades, practical suggestions from actual implementers with students EVALUATE what do I need to check on to see if this worked? What do I trouble shoot if I m not sure I got the results I wanted 42 TPA

8 Parent Tip Sheets Supports professional practice by enhancing communication skills. Provides support and partnership between home and school. Includes: obrief explanation of the nature and cause of problem behavior osuggestions for working with their child othree or four corresponding, evidence based strategies appropriate for a home setting. ochart to track and monitor progress owebsites and additional resources for parents and families 43 Recent research summarized in the APA clinician s digest Including an extensive meta-analysis, demonstrates that when parents are included as part of the treatment/intervention process for children and adolescents with EBDs, treatment effects improve between.5 and 1.0 SDs. BASC-3 Parent Tip Sheets 45 Tools For Partnership Aggression Conduct Problems Academic Problems Adaptability Anxiety Attention Problems Depression Functional Communication Hyperactivity Somatization Leadership/Social Skills 46 We must monitor Treatment Fidelity or it will not occur Along with the Intervention Guides, the Documentation Checklist is available to document and assess treatment fidelity in for individual cases. BASC-3 Flex Monitor: What is it? A psychometrically sound means of developing user- customized behavior rating scales and selfreport of personality forms tailored to the needs of: 1) the individual practitioner 2) an individual case 3) an individual program need Reliability data and standardized scores are then obtainable for each unique form developed for your unique need. TPA

9 49 BASC-3 Flex Monitor Can be used to monitor behavioral and emotional functioning over a desired period of time Users will have the ability to: Choose an existing monitoring form (ADHD, Ext., Int., Adaptive) Create a form using an item bank Choose a rater (teacher, parent, or student) Administer digital or paper forms Set up recurring administrations over a specified time period Generate monitoring reports to evaluate change over time 50 BASC-3 Flex Monitor How does it work? For custom forms, a user will be able to choose from our item pool and start building a form Items can be filtered/searched When building the form, the user will be able to compute the estimated reliability of the form, based on the standardization data sample Adjustments can be made to the form based on the user s needs BASC-3 Flex Monitor How will it work? BASC-3 Flex Monitor Why choose the Flex Monitor? Forms can be saved, and shared with other users within a school or hierarchy Reports will include T scores that are generated based on the TRS/PRS/SRP standardization samples This enables comparisons with a normative population, describing the extremeness of scores Intra-individual comparisons (i.e., comparing time 1 vs. time 2, etc.) are also provided 51 Based on the authors desires to move the field toward better practice In every other area of assessment, psychometric properties of the instruments being used are paramount; however, we tend to ignore it when using monitoring tools The BASC-3 Flex Monitor will be a unique offering that is exclusive to the BASC-3 52 Stephen Psychiatric Outpatient 15 year old boy Mother died in auto accident when he was 6 years Separation anxiety regarding father Received time-limited therapy As Stephen grew older, he became increasingly fearful and anxious, socially isolated, withdrawn Target of bullying Father concerned about refusal to participate in after school activities Referred for outpatient evaluation & treatment TPA

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11 61 62 Stephen s SRP F Index Response Pattern Consistency L Index V Index Acceptable MOMENTUM Acceptable NSM15 Acceptable Acceptable Acceptable T Score Percentile Rank School Problems Internalizing Problems 70** 95 Inattention/Hyperactivity Emotional Symptoms Index 81** 99 Personal Adjustment 23** 1 Stephen s SRP T Score Percentile Rank Attitude to School Attitude to Teachers Sensation Seeking 35 5 Atypicality Locus of Control Social Stress 80** 99 Anxiety 65* 90 Depression 89** 99 Sense of Inadequacy 71* 96 Somatization 63* 87 Attention Problems 64* 90 Hyperactivity 36 2 Relations with Parents Interpersonal Relations 10** 1 Self-Esteem 27* 4 Self-Reliance 33* 5 TPA

12 Stephen s SRP Content Scales T Score Percentile Rank Test Anxiety Anger Control Mania 36 5 Ego Strength 14* 1 67 DSM-5 DIAGNOSTIC CRITERIA Listed below are DSM-5 Diagnostic Criteria based on the ratings obtained from on the SRP-A rating form. Each section first presents a list of symptoms of the disorder, along with SRP-A items that correspond to these symptoms. Then related DSM-5 criteria and codes are presented. While information from SRP-A items will likely be helpful for making a diagnosis, clinicians are strongly encouraged to use additional information that is gathered outside of the BASC-3 SRP-A form (e.g., observations of behavior, clinical interviews) when making a formal diagnosis. Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (Copyright 2013). 69 TPA

13 BASC-3 SRP-A INTERVENTION RECOMMENDATIONS Primary Improvement Areas - Depression - Interpersonal Relations (Social Skills) - Self-Esteem - Sense of Inadequacy - Social Stress Secondary Improvement Areas - Self-Reliance -Anxiety - Attention Problems - Somatization Adaptive Skill Strengths - None Stephen's scores on Interpersonal Relations (Social Skills) and Depression fall in the clinically significant range and probably should be considered among the first behavioral issues to resolve. His score on Anxiety is also elevated and may warrant targeted interventions and/or further monitoring to ensure it doesn't worsen. Note that Stephen has scores on Social Stress, Self- Esteem, Sense of Inadequacy, Self-Reliance, Attention Problems, and Somatization that are areas of concern. Interventions for these areas are not provided in this report. However, these areas may require additional follow up. 74 Primary Improvement Area: Interpersonal Relations (Social Skills) The essential elements of Social Skills Training include the following: 1. Identify the target social skills to develop. 2. Teach the skills and talk about why each is useful or important. 3. Model the skills through active demonstration. 4. Help the child practice the skills in a controlled environment while receiving feedback. 5. Assist the child in generalizing the skills by practicing them in new environments. The procedural steps for incorporating social skills training into the treatment of social skills deficits are summarized below. See the BASC-3 Behavior Intervention Guide for a detailed discussion of this topic. Primary Improvement Area: Depression There are two groups of intervention strategies that have been shown to effectively remediate problems associated with depression, including: Cognitive-Behavioral Therapy (which typically includes one or more of the strategies below) Psychoeducation Problem-Solving Skills Training Cognitive Restructuring Pleasant-Activity Planning Relaxation Training Self-Management Training Family Involvement Interpersonal Psychotherapy A detailed summary of Relaxation Training and Problem-Solving Skills Training intervention is provided below. See the BASC-3 Behavior Intervention Guide for additional details about these interventions, along with the other intervention strategies listed above. Depression Problems Intervention Option 1: Relaxation Training Relaxation training teaches children to relax by monitoring muscle tension created by stressful situations and events. Tension-related physical discomfort can exacerbate common depressive symptoms and cause a child to feel even worse about him- or herself and the situation. Improvements in the child's physical well-being can influence his or her thoughts and emotions and lead to a reduction in depressive symptomatology. The goal of relaxation training is to help the child learn to use physiological changes in his or her body to relieve depressive symptoms. The essential elements of Relaxation Training include the following: 1. Identify emotional triggers and their corresponding physical symptoms. 2. Teach the child the selected relaxation techniques. The procedural steps for incorporating Relaxation Training into the treatment of depression are summarized below. See the BASC-3 Behavior Intervention Guide for a detailed discussion of this topic. Depression Problems Intervention Option 2: Problem- Solving Skills Training Problem solving enables a child to identify negative thinking that occurs in a specific situation, recognize how those thoughts can lead to depression, and replace those thoughts and subsequent feelings with healthier ones. The goal of problem-solving skills training is to help a child to view situational depression (caused by a lack of positive reinforcement) as a dilemma to be resolved rather than as a hopeless situation or an incurable disease. The essential elements of Problem-Solving Training include the following: 1. Define the problem (e.g., thinking patterns, loss of appetite, decreased interest, agitation) as actionable. 2. Generate potential actions or solutions. 3. Evaluate these options. 4. Select the option that is the best fit and try it out. 5. Evaluate and revise as desired. The procedural steps for incorporating problem-solving skills training into the treatment of depression are summarized below. See the BASC-3 Behavior Intervention Guide for a detailed discussion of this topic. TPA

14 Problem-Solving Skills Training Implemented for target behaviors Worrying Feeling anxious Feeling lonely BASC-3 Flex Monitor, Standard, internalizing Stephen was seen for weekly therapy sessions. Stephen completed the BASC-3 Standard Flex Self, Adolescent, Internalizing (10 items) once per month 80 Flex Monitor Progress Report QUESTIONS? Anise Flowers, Ph.D. Assessment Consultant South Texas TPA