Download Final Exam CES 728 Advanced Assessment Summer 2010 John

Final Exam
Summer 2010
CES 728 Advanced Assessment
John King and Reg Watson
To most effectively answer the questions for our final exam we have attempted to
merge question 1): list the broad areas of testing, with question 2): justify our selection of
these measures including our reasons for selecting these specific measures as each pertain
to the case study. What follows is a list of the instruments/tests we feel would be helpful
in assessing Peter as well as our rationale for each measure used. We believe the
following assessment tools will provide a thorough evaluation of Peter’s issues and
provide insight into how we might best help him.
Clinical Interview
A clinical interview is an important diagnostic tool to help evaluate the client’s issues and
needs. Since our introduction to Peter includes a violent suicide attempt, a comprehensive
clinical interview will help us ascertain the following:
 The seriousness of the suicide attempt and the sense of hopelessness that he feels.
 Peter’s criminal record, or at least a report of the times and reasons he has been in
trouble with the law.
 His perceptions of schoolwork and an objective look at the history of his grade
reports from his school.
 His thoughts and feelings about his family of origin. Additionally we will want to
gather information regarding his first adoptive family as well as his current
adoptive family. This will include his parent’s separation and divorce, as well as
the abuse that he suffered at the hands of his former adoptive parents.
 The exact timetable of significant events in his family of origin and how those
correlate with his failing grades, getting in trouble with the law, and his being
expelled from military school.
 Peter’s perceptions of his minority status in the U.S., how he classifies himself,
and the ethnic group with which he most readily identifies.
 His social interactions with others and how he endears himself to peers.
 The extent of his of his drug use and addictive behavior.
We will obtain this information from Peter, his adoptive mother and father, his school
counselor, teachers and hospital staff. The clinical interview will give us significant
information and thus enable us to better understand timelines for the events in Peter’s
life, as well as his current life situation.
Achievement
Wide Range Achievement Test – 4 (WRAT-4)
We will have Peter take the Wide Range Achievement Test – revision 4. The
WRAT-4 is a norm-referenced measure used to measure the basic academic skills of
reading, sentence completion, spelling and math. The information we gather from the
WRAT-4 will help us determine his level of academic placement and possible
intervention strategies.
Final Exam
Summer 2010
CES 728 Advanced Assessment
John King and Reg Watson
Cognitive
The Shipley Institute of Living Scale (SILS)
The SILS is designed to assess general intellectual functioning in adults and
adolescents. The Shipley includes two subsets: Part 1 (Vocabulary) and Part 2
(Abstract). We propose giving the Shipley to Peter because of the ease of administration
and the very high correlation (.85) to the Wechsler Adult Intelligence Scale (WAIS)
Intelligence Quotient. The Shipley is designed for teenagers starting at age 14, but it is
normed for ages 16 through 64. Our goal is to give this assessment at the beginning of
the evaluation process, and then score and interpret it while Peter is taking another longer
assessment (viz. the MMPI-A). With the SILS our goal will be to evaluate Peter’s
cognitive abilities, and whether or not Peter’s corresponding score is above or below two
standard deviations (T-Score below 30 or above 70). From the results of the Shipley we
will use Peter’s T-scores to determine his IQ based on the WAIS. We may also elect to
have Peter take the Wechsler Abbreviated Scale of Intelligence or WASI.
Optional Cognitive Assessment
Wechsler Abbreviated Scale of Intelligence (WASI)
The WASI is an abbreviated version of the Wechsler Adult Intelligence Scale
(WAIS) and is designed to provide a full-scale IQ score in about thirty minutes. Similar
to the WAIS, the WASI uses vocabulary, similarities, block design, and matrix reasoning
subtests. Because of the use of both the Shipley and the WASI, we feel confident in
obtaining a reasonably accurate IQ score for the sake of our assessment needs.
Weschsler Intelligence Scale for Children (WISC)
If we were to assess Peter for an Individualized Educational Program in his school
setting, however, we would likely forego both the Shipley and the WASI and use a fullscale test of intelligence. Since the Wechsler Intelligence Scale for Children (WISC) is
designed for children and teens ages 6 to 16, and since the WAIS is designed for adults
ages 16 to 90, we would make the determination about which IQ test to use (WISC or
WAIS) based on our observations during the clinical interview with Peter. If we sensed
average to above average intelligence and cognitive ability, we would choose the WAIS,
and if we sensed below average intelligence, we would chose the WISC.
Personality
Minnesota Multiphasic Personality Inventory – Adolescent (MMPI-A)
The validity and reliability of the MMPI-A is highly researched and is an excellent
choice for assessing dimensions of personality, psychopathology, and deficits in Peter’s
situation. Our primary interest in this test is to understand the reasons behind Peter’s
failed suicide attempt beyond the personal reasons he would give us in the clinical
interview. Based upon the information given in the description of Peter, we will be
looking specifically at the following scales:
 Scale 2 – Depression. Given Peter’s violent suicide attempt, we want to see how
this score coincides to Peter’s overt behavior and reason hospitalization.
Final Exam
Summer 2010
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CES 728 Advanced Assessment
John King and Reg Watson
Scale 4 – Psychopathology Deviate. Because of Peter’s trouble with police,
truancy from school, and history of conflict and lack of respect for house rules,
we suspect that this scale will be elevated.
Scale 6 – Paranoia. Given Peter’s history of abandonment, we suspect Peter’s
level of trust is low and his suspiciousness of others is significant.
Scale 8 – Schizophrenia. With Peter’s suicide attempt and subsequent description
of the attempt, we are interested if this scale will show any psychopathology.
Scale 9 – Hypomania. This may be a stretch, but we are very interested in the
reasoning process Peter used in the failed suicide attempt, and since we are
entrusted with this assessment, we do not want to miss anything. If he does suffer
from some depressive symptoms, he might also exhibit some manic
symptomatology that could result in future attempts.
The results of the MMPI-A should be able to provide a comprehensive picture and
objective measure of Peter’s situation. The MMPI-A will therefore be an excellent choice
as a evaluative instrument to use with Peter. Nevertheless, we will take all the
information from Peter’s assessments into account, but the MMPI-A will undoubtedly
provide much important information.
Additional Personality Assessments: Projectives
Sentence Completion Adolescent
To give us a well-rounded assessment for Peter, we propose giving him the
sentence completion test for adolescents. The information we receive from the SCA will
be very helpful for us, especially if Peter is less communicative during the clinical
interview. We are particularly interested in his perceptions of his past history of
abandonment and how that affects his current interpersonal functioning now. We will
likely use some of these statements from him to further validate the more objective
measures, such as the MMPI-A.
While a sentence completion test may reveal some of Peter’s underlying issues,
we realize that a sentence completion inventory may be limited in that Peter may be
resistant to completing the sentences according to what he really thinks/feels. He may
therefore attempt to provide the answers for which he thinks we are looking. To break
through some of these defenses, another projective test we may consider giving Peter is
the Thematic Apperception Test.
Optional - Thematic Apperception Test (TAT)
One of the benefits of using the TAT with Peter is that this type of test is more
open ended—there are no “right” or “wrong” answers—consequently, his responses to
the pictures may provide more comprehensive insight into Peter’s thinking about himself,
others and his unconscious motivations. Another benefit of using the Thematic
Apperception Test with Peter is that it will allow us, the examiners, to mannerisms, vocal
tone, posturing and other more subtle signs of emotional response to the pictures he
describes.
Final Exam
Summer 2010
CES 728 Advanced Assessment
John King and Reg Watson
Behavioral
Behavioral Assessment System for Children (BASC-2)
The BASC-2 offers several important features that would be helpful in accessing
many of Peter’s issues. For example, the BASC-2 evaluates/rates both the behavioral and
emotional functioning of the individual. It is also a comprehensive instrument with
several multiple observational layers, e.g. a student self report measure, a parent rating
scale, a teacher rating scale as well as a Student Observation System (SOS) and
Structured Developmental History (SDH). The combination of these completed forms
will allow for the assessment of a wide variety of behaviors that indicate problems and
strengths as well as externalizing and internalizing issues including academic concerns
and adaptive skills. The measures of the BASC-2 accurately rate a broad range of
behavioral, emotional and academic problems including attitude at school, attitude
toward teachers, atypicality (e.g., bizarre or odd thoughts and/or behavior), social stress,
anxiety, depression, interpersonal relations, locus of control, sensation seeking, social
stress, somatization, hyperactivity, relations with parents, self-esteem and self-reliance.
Since the BASC-2 is a such a comprehensive instrument, we believe the BASC-2 to be an
essential protocol for Peter to complete in order for us to ascertain the most complete
picture possible.
Mood
Beck Depression Inventory-2 (BDI-II)
Because of Peter’s suicide attempt, it is imperative that we discover Peter’s
current level of depression and suicidality. The Beck Depression Inventory is a 21
question instrument that can be completed by the patient in about 15 minutes. Answers
are measured from “minimal” to “severe.” Once the test is completed, scores are
tabulated and the client is given a depression rating of either “mild,” “moderate,” or
“severe.” The BDI-II can be used with children 13 years of age and older. The BDI-II is a
standard measure for depression and can be used to assess the presence and severity of
symptoms consistent with the DSM-IV criteria. Since questions on the BDI-II address
depressive symptoms (e.g., mood, hopelessness, sense of failure, self-dissatisfaction,
guilt, punishment, self-dislike, self-accusation, suicidal ideation, crying, irritability, social
withdrawal, body image, work difficulties, insomnia, fatigue , appetite, weight loss,
bodily preoccupation, and loss of libido) we believe this will be the best instrument to
evaluate Peter’s level of depression.
Trauma Assessment
Trauma Symptom Checklist for Children (TSCC)
Another assessment instrument we would use with Peter is the Trauma Symptom
Checklist for Children. Given Peter’s history of abuse we want to measure its affects on
his current level of functioning, depression, hopelessness, despair and suicidality. The
TSCC measures for posttraumatic stress in children and adolescents from ages 8-16 with
normative adjustments for 17 year olds. The TSCC measures for the overall effects of
child abuse including: sexual, physical and psychological. The TSCC also evaluates
issues such as interpersonal violence and witnessing trauma experienced by others. This
Final Exam
CES 728 Advanced Assessment
Summer 2010
John King and Reg Watson
54 item instrument will be especially helpful with Peter since it measures on the
following six clinical scales: anxiety, depression, posttraumatic stress, sexual concerns,
dissociation, and anger. We believe this instrument will provide us with the insight we
need to address the traumatic events Peter has experienced.
Social Support
Multi-Dimensional Scale of Social Support (MDSSS)
The MDSSS is a simple Likert scale assessment that gives clinicians information
about the social networks of support a client has. Given the history of multiple instances
of abandonment, our sense is that Peter probably has no close family relationships, and
that his sense of camaraderie comes from his peers, particularly the ones whom he uses
drugs. This assessment would probably come towards the beginning of the evaluation
process, and we would use this information in the clinical interview to have him describe
his close relationships, if any. The MDSSS also has some significant questions about
family support, so it is important for us to ascertain his perceptions of them.
Substance Assessment
Substance Abuse Subtle Screening Inventory – Adolescent-2 (SASSI-A2)
The SASSI-A2 is a screening instrument used to determine the probability of a
subject having a substance abuse disorder: substance dependence, or substance abuse.
The inventory identifies individuals with a substance use disorder with a 94% degree of
accuracy. The SASSI-A2 has a 5% false negative rate and a 11% false positive rate.
We chose this inventory because of the heavier drug use information that we
have: LSD, mescaline, glue, and marijuana. We anticipate this inventory will confirm
that Peter has a significant substance use disorder, which we believe will confirm the
information we receive from the clinical interview.
DSM-IV Multi-Axial Diagnosis
Axis I
Dysthymic disorder 300.04 Early on-set (Rule out)
Acute stress disorder 308.3
Conduct disorder 312.8
Substance induced mood disorder:
Alcohol 305.00; Hallucinogens 305.30; Inhalants 305.90; Cannabis 305.20
Axis II
V71.09
Personality Disorder NOS (Rule Out)
Axis III
Lacerations to wrists; eating/appetite
Axis IV
Parent-child relational problems v61.20
Physical abuse of child 995.5 (victim)
Axis V
GAF: 40
Final Exam
Summer 2010
CES 728 Advanced Assessment
John King and Reg Watson
Justification of Peter’s diagnosis
AXIS I
 Dysthymic disorder 300.04 - Early on-set (Rule out)
We chose this diagnosis because Peter fits the diagnostic criterion for this
disorder. From the description we have of Peter, we do not know if he has had a major
depressive episode, so because of that lack of knowledge we believe that Dysthymia is
the most accurate diagnosis, although we have provided a rule out status until this
possible diagnosis becomes clearer based on the results from our assessments.
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Acute stress disorder 308.3
We chose this diagnosis because of the effects of the physical abuse he
experienced in the first adoptive home. The DSM-IV-TR lists the criteria for this
diagnosis: (1) the person witnessed traumatic events that involved actual or threatened
death or serious injury, and (2) either while or after witnessing the event(s), the individual
has three or more of the following dissociative symptoms: a subjective sense of numbing
or absence of emotional response, a reduction of awareness of his or her surroundings,
derealization, depersonalization, and dissociative amnesia. While not completely sure of
all of these symptoms, we are fairly certain that Peter has at least three of the symptoms
expressed in point 2. Therefore, he fits the criteria, and thus we gave him this diagnosis.
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Substance induced mood disorder: Alcohol 305.00; Hallucinogens 305.30;
Inhalants 305.90; Cannabis 305.20
We see in Peter’s case a persistent disturbance of mood that may be related to his
drug use, including alcohol, hallucinogens, inhalants, and cannabis. At this point, it is
difficult to determine which mood disorder is most prominent: dysthymia or substance
induced mood disorder. Thus, we include this diagnosis because of the suicide attempt
which may have been influenced by Peter’s drug use. It should be noted however, that
following a treatment program some of Peter’s diagnostic criteria may change, but we
will not know this until he has been detoxed.
AXIS II
 V71.09
 Personality Disorder NOS (Rule Out)
We do not see any cause for classifying Peter with a personality disorder; however,
we are curious to see if a personality disorder manifests upon his completion of a drug
and alcohol detoxification program. There appear to be no mental retardation issues.
AXIS III
 Lacerations to wrists, and potential appetite issues
We describe the potential for appetite issues because he appears small and waiflike,
which may be either related to his drug use and/or poor appetite. Another possibility is
that his small and waiflike stature may be related to his drug use. We expect that since he
is hospitalized that he will undergo a full medical evaluation. Since eating disorders are
Final Exam
Summer 2010
CES 728 Advanced Assessment
John King and Reg Watson
much more prevalent in women, young men are often missed. We must pay attention to
the potential of an eating disorder if it is warranted.
AXIS IV
 Parent-child relational problems v61.20
Given Peter’s description, he has had significant problems with his second set of
adoptive parents.
 Physical abuse of child 995.5 (victim)
From the information we are given, Peter was physically abused, beaten, and burned
by his first set of adoptive parents.
AXIS V
 GAF: 40 (current)
We give Peter a GAF score of 40 because we feel that he fits in the DSM-IV GAF
description of “serious symptoms.” Peter’s failed suicide attempt, his drug use and
trouble with the law, problems in school, and his nihilistic outlook contribute to this
rating. In addition, he is currently hospitalized in an inpatient psychiatric unit.
Conclusions and Recommendations for Client
It is clear from the description that Peter is in serious trouble on many fronts in his
life: with the law, with his family, with his physical health, with his emotional health, and
with his education. It seems that because of Peter’s multiple traumatic events, primarily
his abandonment experience and physical abuse, he has reacted in some sad and selfdestructive ways.
Peter has endured trauma at the hands of his adoptive parents. Although we do not
know much about his family of origin, we do know that at age 2 Peter may have
developed attachment issues as a result of the separation from his biological mother and
the abuse he experienced in the first adoptive family. And since his current parents have
separated, this undoubtedly has resulted in another experience of abandonment from his
mother and siblings. We wonder whether his choice to stay with his father has anything
to do with his birth mother releasing him for adoption. To summarize, Peter has
experienced significant losses in life: his biological mother at age 2, his first set of
adoptive parents at roughly age 6, and his second adoptive mother and siblings at age 14.
The only parent that has stayed with him is his second adoptive father of whom he has a
poor relationship. Not only has he experienced these multiple losses, but he has also
endured prolonged physical abuse from his first set of adoptive parents.
Because of his diagnoses of Dysthymia, Acute Stress Disorder, and Substance
Induced Mood Disorder, we recommend the following for Peter as part of his treatment
plan:
 A full medical evaluation if that has not already been done yet, including a
psychiatric consultation.
 Individual and group therapy while in the psychiatric unit.
Final Exam
Summer 2010
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CES 728 Advanced Assessment
John King and Reg Watson
A referral to a drug treatment facility, potentially a longer-term facility where he
can more fully understand some of his drug use behaviors.
Regular attendance at Narcotics Anonymous or another Twelve-Step program.
Ongoing individual family counseling with as many of the family members as
possible, especially with the custodial father.
Consultation with the school psychologist and administrative team as support and
to devise a plan to help Peter complete his education.
Referral to a mentoring program, e.g., “Big Brothers,” summer camps, etc.
If Peter does not receive significant intervention during this time, we are
concerned that his antisocial behavior will persist and that he will: (1) develop a more
significant drug abuse problem, (2) eventually become incarcerated, (3) repeat his suicide
attempt, or (3) a combination of any/all these. It is critical that Peter receive this support
from a network of professionals: psychiatrist, psychologist, counselor, school support,
teachers, and parent(s). If we fail Peter, Peter is likely to fail himself.