SOCW 6111

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Chapter 3 Assessment of Adolescents

David W. Springer and Tara M. Powell

Purpose: This chapter provides an overview of assessment tools for adolescents, including methods of assessment, limitations of evidence-informed assessment tools, treatment goals, and implications for social work. Rationale: To educate students and practitioners about appropriate assessment strategies and tools for adolescents. How evidence-informed practice is presented: This chapter focuses on evi- dence used in assessments with adolescents, presenting options and strategies for choosing evidence-informed scales and assessment tools while considering such factors as a client’s background, the clinical utility of the assessment tool, and treatment goals. Overarching question: What is the acceptable protocol for choosing and implementing an assessment and treatment plan with adolescents?

‘‘They love too much and hate too much, and the same with everything else. They think they know everything; and are always quite sure about it; this, in fact, is why they overdo everything.’’ These words were written by Aristotle, the ancient Greek philosopher, more than 2,300 years ago (Rhetoric, Book II). Today’s scientific study of adolescence can be traced back to the work of G. Stanley Hall (1904), who wrote a two-volume work on adolescence in which he proposes that adolescence is a separate stage of development. Now, fast-forward 100 years.

As recently as 2005, the Journal of Clinical Child and Adoles- cent Psychology devoted a special section on developing guidelines for the evidence-based assessment of child and adolescent disorders, where evidence-based assessment (EBA) is ‘‘intended to develop, elaborate, and identify the measurement strategies and procedures that have empirical support in their behalf’’ (Kazdin, 2005, p. 548). In this special issue on EBA, Mash and Hunsley (2005) emphasize the great importance of assess- ment as part of intervention but acknowledge that the development of EBA has not kept up with the increased emphasis on evidence-based treatment. In fact, there is a significant disconnect between EBA and evidence-based treatment. This is no small problem for those in the field. Several studies spanning different geographical locations (such as the United States, Puerto Rico, Canada, and New Zealand) have produced consistent results on the prevalence of disorders among children and adolescents, with estimates

71 Holosko, M. J., Dulmus, C. N., Sowers, K. M., & Sowers, K. M. (2013). Social work practice with individuals and families : Evidence-informed assessments and interventions. John Wiley & Sons, Incorporated. Created from waldenu on 2021-11-02 18:23:38.

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indicating that 17% to 22% suffer significant developmental, emotional, or behavioral problems (U.S. Congress, 1991; World Health Organization [WHO], 2004; as cited in Kazdin & Weisz, 2003).

The developmental tasks associated with adolescence only serve to complicate matters, because the practitioner must take into account many interrelated domains of the adolescent’s life. Some behaviors may be con- sidered quite normal at one age but later cross a threshold that suggests mental illness or impairment in functioning. In addition to the importance placed on recognizing the developmental tasks of adolescence during the assessment process, this chapter adopts the assumptions about assessment presented by Jordan and Franklin (1995): ‘‘(1) assessment is empirically based, (2) assessment must be made from a systems perspective, (3) mea- surement is essential, (4) ethical practitioners evaluate their clinical work, and (5) well-qualified practitioners are knowledgeable about numerous assessment methods in developing assessments’’ (p. 3). These assump- tions serve as a guide for social workers when determining what type of assessment protocol to implement with adolescents (and their families).

Assessment is the first active phase of treatment (Springer, McNeece, & Arnold, 2003). Without a thorough and complete assessment, the social worker cannot develop a treatment plan that will serve the youth and his or her family. In this chapter, various methods of assessment, such as interviews and the use of standardized instruments that may be useful in assessment with adolescents, are reviewed. For a more comprehensive review of assessment methods and tools for youth, see other excel- lent sources, including a compilation of rapid-assessment instruments for children and families (K. Corcoran & Fischer, 2007), an overview of tools and methods for assessment with children and adolescents (Shaffer, Lucas, & Richters, 1999b), and a guide to empirically based measures of school behavior (Kelley, Reitman, & Noell, 2003; Roberts & Greene, 2009). The special section of Journal of Clinical Child and Adolescent Psychol- ogy referred to earlier is another excellent resource, as it examines the EBA of pediatric bipolar disorder (Youngstrom, Findling, Youngstrom, & Calabrese, 2005), anxiety disorders (Silverman & Ollendick, 2005), depres- sion (Klein, Dougherty, & Olino, 2005), Attention-Deficit/Hyperactivity Disorder (ADHD; Pelham, Fabiano, & Massetti, 2005), conduct problems (McMahon & Frick, 2005), learning disabilities (Fletcher, Francis, Morris, & Lyon, 2005), and autism-spectrum disorders (Ozonoff, Goodlin-Jones, & Solomon, 2005).

After reviewing each of the articles in the special issue mentioned earlier, Kazdin (2005, p. 549) provided a commentary where he identifies common themes in child and adolescent clinical assessment:

1. There is no gold standard to validate assessment.

2. Multiple measures need to be used to capture diverse facets of the clinical problem.

3. Multiple disorders or symptoms from different disorders ought to be measured because of high rates of comorbidity.

Holosko, M. J., Dulmus, C. N., Sowers, K. M., & Sowers, K. M. (2013). Social work practice with individuals and families : Evidence-informed assessments and interventions. John Wiley & Sons, Incorporated. Created from waldenu on 2021-11-02 18:23:38.

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Assessment of Adolescents 73

4. Multiple informants are needed to obtain information from different perspectives and from different contexts.

5. Adaptive functioning, impairment, or, more generally, how individ- uals are doing in their everyday lives are important to assess and are separate from symptoms and disorders.

6. Influences (or moderators) of performance need to be considered for interpreting the measures, including sex, age, developmental level, culture, and ethnicity, among others.

These themes are certainly critical to the assessment of adolescents and will be revisited throughout the remainder of the chapter.

Evidence-Based Assessment With Adolescents

There are various methods of assessment available to social work practi- tioners that can be used with adolescents. These include, but are not limited to, interviews, self-observation, observation by others, family sculpting, individualized rating scales, rapid-assessment instruments, and standard- ized assessment tools. The focus of this chapter is primarily on the use of standardized assessment tools and interviews with adolescents.

Interviews

The assessment process typically starts with a face-to-face interview (e.g., psychosocial history) with the adolescent. The family should also be involved for at least part of this interview. The interview serves several purposes, such as an opportunity to establish rapport with the client and allow the client to tell his or her story. Recall that one key assumption of conducting a good assessment is to operate from a systems perspective. Involving the family during part of the interview may help meet this goal, because family members provide varying perspectives and are more often than not a key factor in an adolescent’s life.

Morrison and Anders (1999) have written a useful book on inter- viewing children and adolescents in which they advocate for a blended interviewing style that uses both directive and nondirective techniques:

In general, nondirective, open-ended style of questioning is important during the early stages of an initial interview, when you want to give the respondent greatest leeway to volunteer important observations concerning the child’s or adolescent’s behavior and emotional life. Later on, as you come to understand the scope of your respondent’s concerns, use questions that require short answers to increase the depth of your knowledge.

—(p. 20)

Consider the following case for illustration purposes. Ramon, a 16-year-old Hispanic male who has been diagnosed with ADHD and

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oppositional defiant disorder (ODD), is brought into an agency by his parents, because he is ‘‘failing 11th-grade Spanish and precalculus, and he won’t listen.’’ Ramon also has threatened to run away from home on more than one occasion. In addition to obtaining information from Ramon’s parents that is typically covered in a psychosocial history (e.g., medical, developmental, social, and family history), some areas that the social worker may cover with Ramon’s parents during an initial interview are as follows:

• Presenting problem and specific precipitating factor (e.g., Tell me in your own words what prompted you to bring Ramon in for help at this point in time?)

• Attempts to deal with the problem (e.g., What has your family done to try to deal with this problem(s)? What have you tried that has worked?)

• Hopes and expectations (e.g., What do you hope to get out of coming here for services? If you could change any one thing about how things are at home, what would it be?)

In addition to these areas (with variations of the corresponding sample questions), consider some topics that the social worker may ask Ramon about individually:

• Peer relationships (e.g., Tell me about your friends. What do you like to do together?)

• School (e.g., What are your favorite [and least favorite] classes at school? What about those classes do you like [not like]?)

• Suicide risk (e.g., When you feel down, do you ever have any thoughts of hurting/killing yourself? Do you ever wish you were dead? How would you end your life?)

• Substance use (e.g., What do you drink/use? When was the last time you had a drink/used? How much did you have? Have you ever unsuccessfully tried to reduce your substance use?)

• Targeted behavior/goal setting (e.g., If there was any thing that you could change about yourself/your life, what would it be? What do you like most about yourself?)

These questions are meant only to illustrate the range of ques- tions that a social worker might ask during an interview. A complete psychosocial history would need to be conducted with Ramon.

J. Corcoran and Springer (2005) emphasize a strengths-and-skills- based approach to engage the adolescent client in the treatment process. This approach pulls primarily from solution-focused therapy, motivational interviewing, and cognitive-behavioral therapy. Youths, especially those with externalizing behavioral disorders, like Ramon, have often expe- rienced a range of life stressors, such as poverty, overcrowded living

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conditions, parental divorce, incarceration of parents, community vio- lence, and parental substance use. The practitioner’s attempt to explore the adolescent’s feelings and thoughts around such issues is often met with resistance. Rather than getting into a struggle with adolescents or trying to push them in a certain direction, the strengths-and-skills-based approach underscores building on strengths and past successes rather than correcting past failures and mistakes. Accordingly, the interviewer focuses on positives and solutions over negative histories and problems. Consider some of the following interviewing tips provided by J. Corcoran and Springer (2005, p. 136).

They propose the following options for dealing with the ‘‘I don’t know’’ stance that adolescents take:

1. Allow silence (about 20–30 seconds).

2. Rephrase the question.

3. Ask a relationship question (adolescents sometimes feel put on the spot by having to answer questions about themselves but can take the perspective of others to view their behavior).

4. Say, ‘‘I know you don’t know, so just make it up,’’ which bypasses teens’ resistance or fear that they don’t know or don’t have the right answer. Or, using presuppositional language, say, ‘‘Suppose you did know. . . . ’’

5. Speak hypothetically about others: ‘‘What would (prosocial peers that teens respect) say they do to keep out of trouble (get passing grades or get along with their parents’)?’’

J. Corcoran and Springer (2005) go on to point out that asking evocative questions may help adolescent clients increase their readiness for change, and they provide a recommended line of questioning to explore the disadvantages of the status quo (e.g., ‘‘What difficulties or hassles have you had in relation to ________?’’ ‘‘What is there about _______ that you or other people might see as reasons for concern?’’) as well as the advantages of change (e.g., ‘‘What would you like your life to be like 5 years from now?’’ ‘‘If you could make this change immediately, by magic, how might things be better for you?’’ ‘‘What would be the advantages of making this change?’’).

Such social workers as Saleebey (1997), Clark (1998), and Lerner (2009) recommend that practitioners incorporate a strengths-based per- spective into their assessment approach with adolescents. Cowger (1997, pp. 69–71) proposes specific exemplars for assessment of client strengths in five areas:

1. Cognition (e.g., is open to different ways of thinking about things).

2. Emotion (e.g., is positive about life).

3. Motivation (e.g., wants to improve current and future situations).

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4. Coping (e.g., has dealt successfully with related problem in the past).

5. Interpersonal (e.g., makes sacrifices for friends, family members, and others).

For the complete list of exemplars, see Cowger (1997). Indeed, a thor- ough assessment includes a deliberate examination of the client’s unique strengths that in turn can be amplified over the course of treatment.

In addition to these interviewing strategies, more structured and systematic interview protocols for use with adolescents are also available to practitioners. The Diagnostic Interview Schedule for Children (DISC) is one such interview.

The Voice Diagnostic Interview Schedule for Children The Diagnostic Interview Schedule for Children (DISC) is a computerized respondent-based interview that assesses more than 30 common diagnoses found among children and adolescents, including anxiety disorders, eat- ing disorders, mood disorders, attention-deficit and disruptive behavior disorders, and substance-use disorders (Shaffer, Fisher, & Lucas, 1999a; Shaffer, Fisher, Lucas, Dulcan, & Schwab-Stone, 2000). It was developed to be compatible with the DSM-IV, DSM-III-R, and the International Classi- fication of Diseases (ICD-10) and is organized into six diagnostic modules that measure the major Axis I disorders and impairment. The DISC-IV includes assessment for three time frames—the present (past 4 weeks), the last year, and ever—with parallel versions existing for youth ages 9 to 17 (DISC-Y) and for parents or caretakers of youth ages 6 to 17 years (DISC-P). The present-state assessment is considered to be the most accurate, because it minimizes the risk of bias due to telescoping (Shaffer et al., 1999a). The DISC-IV is scored by algorithms that apply Boolean logic (i.e., ‘‘and’’ and ‘‘or’’) to combine answers to component questions and is ‘‘an ideal candidate for computerization, given the highly structured nature of the interview, the limited response options, the complicated branching and skipping instructions, and the need for the interviewer to keep close track of an informant’s answers to numerous symptoms in order to ask onset and impairment questions correctly’’ (Shaffer et al., 1999a, p. 23). A recent voice adaptation allows youth to hear the interview over head- phones (while also reading questions on the computer screen) and key in responses via computer.

The Center for the Promotion of Mental Health in Juvenile Justice at Columbia University is spearheading efforts to administer the voice version of the DISC-IV. It has already been tested in three states (Illinois, South Carolina, and New Jersey) with youth recently admitted to juvenile- correction institutions, with the primary aims to more accurately assess rates of mental-health disorders among incarcerated juveniles and to test the feasibility of using this type of structured, self-administered mental- health assessment with this population (Ko & Wasserman, 2002). The Voice DISC-IV provides a ‘‘provisional’’ diagnosis for youth assessed. Findings from initial feasibility studies indicate that the instrument is

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tolerated well by youth, parents, and agency staff and support its validity, revealing that information on psychiatric status matches existing justice- system information regarding current substance offenses (Wasserman, McReynolds, Lucas, Fisher, & Santos, 2002b). Adaptations for detention, correctional, and community juvenile-justice sites are ongoing in 10 other states. The DISC-IV has also been translated into a Spanish version (Bravo et al., 2001).

For sites that are willing and capable, the Center for the Promo- tion of Mental Health in Juvenile Justice will provide the Voice DISC-IV assessment software program, provide training for key personnel, offer ongoing technical support via phone and e-mail, assist with data inter- pretation and preparation of reports/presentations, and provide guidelines for appropriate mental-health referral. For more detailed information, see www.promotementalhealth.org/voicedisc.htm

Information gathered from the face-to-face interview can subse- quently be used to inform a more in-depth assessment in targeted areas, which, in turn, guides treatment planning. Rapid assessment instruments and other standardized assessment protocols may prove useful for this purpose.

Rapid-Assessment Instruments and Standardized Assessment Tools

Rapid-assessment instruments (RAIs; Levitt & Reid, 1981) are short-form, pencil-and-paper assessment tools that are used to assess and measure change for a broad spectrum of client problems (Bloom, Fischer, & Orme, 2006; K. Corcoran & Fischer, 2007; Hudson, 1982). RAIs are used as a method of empirical assessment, are easy to administer and score, are typically completed by the client, and can help monitor client functioning over time. Given the proliferation of RAIs and standardized tools in recent years that measure various areas of adolescent functioning, it can be an overwhelming task to select a tool for use with an individual client. Thus, some guidelines are provided next.

The social worker practitioner needs to take several factors into consideration when choosing an RAI or standardized protocol for use with clients, such as the tool’s reliability, validity, clinical utility, directness, availability, and so on (K. Corcoran & Fischer, 2007). To the extent that an RAI has sound psychometric properties, it helps practitioners measure a client’s problem consistently (reliability) and accurately (validity). Using reliable and valid tools becomes increasingly critical as one considers the complexities surrounding assessment with adolescents who (potentially) have comorbid disorders. A brief overview of reliability and validity is provided next; however, the reader is referred to the following sources for a more detailed exposition on these topics: K. Corcoran & Fischer, 2007; Crocker & Algina, 1986; Hudson, 1982; Nunnally & Bernstein, 1994; Springer, Abell, & Hudson, 2002a; Springer, Abell, & Nugent, 2002b; Abell, Springer, & Kamata 2009.

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78 Social Work Practice With Individuals and Families

Reliability

A measurement instrument is reliable to the extent that it consistently yields similar results over repeated and independent administrations. A tool’s reli- ability is represented through reliability coefficients, which range from 0.0 to 1.0. What constitutes a satisfactory level of reliability depends on how a measure is to be used. For use in research studies and scientific work, a reliability coefficient of 0.60 or greater is typically considered accept- able (Hudson, 1982). However, for use in guiding decision making with individual clients, a higher coefficient is needed. Springer et al. (2002b) provide the following guidelines for acceptability of reliability coefficients for use with individual clients to aid in clinical decision making:

<0.70 = Unacceptable 0.70 to 0.79 = Undesirable 0.80 to 0.84 = Minimally acceptable 0.85 to 0.89 = Respectable 0.90 to 0.95 = Very good

>0.95 = Excellent

The greater the seriousness of the problem being measured (e.g., suicidal risk) and the graver the risk of making a wrong decision about a client’s level of functioning, the higher the standard that should be adopted.

Validity

Where reliability represents an instrument’s degree of consistency, validity represents how accurately an instrument measures what it is supposed to measure. There are various ways to determine an instrument’s validity: content validity (which subsumes face validity), criterion-related valid- ity (concurrent and predictive), and construct validity (convergent and discriminant).

The social worker must make decisions about a measure’s validity in relationship to its intended use. In other words, the social worker must determine whether the measure is valid for that particular client in a particular setting at a given time. A measure may be valid for one client but not for another.

Additional Considerations in Selecting Scales

Age and Readability Practitioners must take into consideration the client’s age and reading ability when selecting a scale. Scales are developed, validated, and normed for an intended population and for specific uses. If a scale is developed for use with adult clients, and a practitioner administers the scale to a

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13-year-old client with a fifth-grade reading level, then this scale is not being administered properly, and the results obtained from the scale are potentially meaningless and clinically irrelevant.

Ethnic and Cultural Diversity A second consideration is to fully respect a client’s ethnic and cultural background when using scales in practice. Ethnicity and culture affect all aspects of an adolescent’s life, and acculturation experiences among minority youth can also have a significant impact on a youth’s development and functioning (Jordan & Hickerson, 2003).

For example, consider the following challenges associated with assessing substance-abusing adolescents. An increasingly important issue in adolescent substance-abuse treatment is ‘‘amenability to treatment,’’ which concerns the identification of subgroups of individuals in a target population who are likely to be the most amenable or responsive to a treatment (i.e., what interventions work for whom under what conditions; Kazdin, 1995). Family influences on substance use may be particularly profound for Latino and African American youth due to important ethnic variations in family rules and monitoring of children in relation to risk behaviors, such as substance use. In fact, some research suggests that these variations may decrease risk behaviors among Latino and African Ameri- can youth (Catalano, Hawkins, & Krenz, 1993; Li, Fiegelman, & Stanton, 2000; Vega & Gil, 1998). The Latino preference for close family proximity may result in vulnerability when emigration from the country of origin causes family disruption (Vega, 1990). Moreover, there is evidence that traditional familial values can serve as a protective factor mitigating against adolescent maladjustment (Vega, Gil, Warheit, Zimmerman, & Apospori, 1993). Gil, Wagner, and Vega (2000) have shown that the loss of famil- ism and parental respect that accompanies greater acculturation among Latino adolescents has negative impacts on predispositions toward deviant behaviors and alcohol use. So, although it seems clear that ethnicity and acculturation are likely to impact multiple aspects of the substance-abuse treatment process (Collins, 1993), there is a paucity of knowledge about the assessment (and subsequent treatment) of substance use among ethnic minorities (Cowan, 2009).

Additionally, standardized measurement instruments may be biased against certain ethnic and cultural groups. For example, Mercer (1979) has documented that African American children routinely scored 10 points lower than European American children on the Weschler Intelligence Scale for Children—Revised (WISC-R), indicating a cultural bias in the WISC-R when administering it to African-American children. Practitioners should exercise cultural sensitivity throughout the assessment and treatment process with clients.

Overall Clinical Utility In addition to these factors, the overall clinical utility of a scale refers to several factors. Is the scale sensitive to changes in client functioning over

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time? Are the items direct and easy to understand? Is the length of the scale appropriate given its intended use by the practitioner? Lengthy scales may not be appropriate to administer in crisis situations, for example. Is the scale accessible at a reasonable cost? In addition to examining a scale’s psychometric properties, these are all factors that must be considered when selecting a scale for use with a given population in a given setting.

The number of standardized tools developed specifically for use with adolescents has grown considerably in recent years, and it is impossible to review them all here. However, selected standardized tools that may be useful in assessing for comorbid disorders in adolescents are briefly reviewed next. Each tool reviewed has sound psychometric properties and can be used to help guide treatment planning and to monitor client progress over the course of treatment.

Problem Oriented Screening Instrument for Teenagers

The Problem Oriented Screening Instrument for Teenagers (POSIT) was developed by a panel of experts as part of the comprehensive Adoles- cent Assessment/Referral System (AARS) for use with 12- to 19-year-olds (Rahdert, 1991). The POSIT is a 139-item, self-administered tool. Items are measured on a dichotomous (yes/no) scale. The POSIT is intended to be used as a screening tool. It is not designed to measure treatment progress or outcomes. A more complete diagnostic evaluation requires that the practitioner implement another component of the AARS, called the Comprehensive Assessment Battery (CAB). The POSIT provides inde- pendent scores in 10 areas of functioning: substance use/abuse, physical health, mental health, family relations, peer relations, educational status, vocational status, social skills, leisure/recreation, and aggressive behav- ior and delinquency. The National Clearinghouse for Alcohol and Drug Information (NCADI) offers the AARS (National Institute on Drug Abuse [NIDA], 1991, DHHS Publication No. ADM 91–1735), which contains the POSIT, free of charge. (Contact NCADI, P.O. Box 2345, Rockville, MD 20847; 800-729-6686.)

Drug Use Screening Inventory–Revised

The Drug Use Screening Inventory—Revised (DUSI-R; Tarter & Hegedus, 1991) is a 159-item multidimensional pencil-and-paper instrument mea- sured on a dichotomous (yes/no) scale that has recently been created to assess the severity of problems of adolescents and adults. Like the Addic- tion Severity Index (ASI; McLellan et al., 1985) and the POSIT (Rahdert, 1991), this instrument addresses areas in addition to substance abuse. The 10 domains of the DUSI-R are drug and alcohol use, behavior patterns, health status, psychiatric disorders, social competence, family system, school performance/adjustment, work adjustment, peer relationships, and leisure/recreation. A ‘‘lie scale’’ documents reporting validity. The infor- mation obtained from the completed DUSI-R can be used to develop an

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individualized treatment plan; however, scores do not indicate specific types of treatment needed. That decision is left to the clinical judgment of the practitioner. The instrument’s developers report that it is able to identify adolescents (and adults) with DSM-IV substance-use disorders, including those with and without psychiatric disorders. In a sample of 191 adolescents with alcohol- and drug-abuse problems, internal reliability coefficients averaged 0.74 for males and 0.78 for females across the 10 life-problem areas. In a sample of polysubstance-abusing adolescents, the mean test-retest coefficients (1 week) were 0.95 for males and 0.88 for females (NIDA, 1994).

The DUSI-R is available from Ralph Tarter, Department of Pharma- ceutical Sciences, University of Pittsburgh, School of Pharmacy, 711 Salk Hall, Pittsburgh, PA 15261. The instrument is copyrighted and is available in two formats: (1) paper questionnaire for manual scoring ($3 each) and (2) computer administration and scoring system ($495).

Child and Adolescent Functional Assessment Scale

The Child and Adolescent Functional Assessment Scale (CAFAS; Hodges, 2000) is a popular standardized multidimensional assessment tool that is used to measure the extent to which a youth’s (ages 7–17) mental- health or substance-use disorder impairs functioning. It is completed by the practitioner and requires specialized training. Like the POSIT, a major benefit of the CAFAS in helping practitioners determine a youth’s overall level of functioning is that it covers eight areas: school/work, home, community, behavior toward others, moods/emotions, self-harmful behavior, substance use, and thinking. The youth’s level of functioning in each domain is then scored as severe, moderate, mild, or minimal. Additionally, an overall score can be computed. These scores can be graphically depicted on a one-page scoring sheet that provides a profile of the youth’s functioning. This makes it easy to track progress over the course of treatment. The CAFAS also contains optional strengths-based and goal-oriented items (e.g., good behavior in classroom, obeys curfew) that are not used in scoring but are helpful in guiding treatment planning.

The psychometric properties of the CAFAS have been demon- strated in numerous studies (Hodges & Cheong-Seok, 2000; Hodges & Wong, 1996). One study on the predictive validity of the CAFAS indi- cates that this scale is able to predict recidivism in juvenile delinquents (Hodges & Cheong-Seok, 2000). Higher scores on the CAFAS are asso- ciated with previous psychiatric hospitalization, serious psychiatric diag- noses, below-average school performance and attendance, and contact with law enforcement (Hodges, Doucette-Gates, & Oinghong, 1999). The CAFAS is available for purchase online at http://www.fasoutcomes.com/ Content.aspx?ContentID=19

The CAFAS would be a useful assessment tool to use with a client like Ramon, who presents with impaired functioning in multiple areas, to help monitor treatment progress.

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82 Social Work Practice With Individuals and Families

Table 3.1 Ramon’s CAFAS Scores: Intake and Termination CAFAS Domain Intake Termination

School/work 30 10 Home 30 10 Community 30 0 Behavior toward others 30 10 Moods/emotions 20 10 Self-harmful behavior 0 0 Substance use 30 10 Thinking 10 0 Overall functioning 180 50

Based on the scores for each domain (see Table 3.1), Ramon’s impairment in functioning could be interpreted as follows: severe (score of 30), moderate (score of 20), mild (score of 10), or minimal (score of 0). The overall scores can also be computed as severe (140 to 240), marked (100 to 130), moderate (50 to 90), mild (20 to 40), or minimal to no (0 to 10) impairment in functioning. Using these clinical cutting scores, the CAFAS results indicate that Ramon made clinically meaningful progress over the course of treatment, moving from ‘‘severe impairment in functioning’’ at intake to the low range of ‘‘moderate impairment in functioning’’ at termination.

The Substance Abuse Subtle Screening Inventory for Adolescents

The Substance Abuse Subtle Screening Inventory (SASSI; Miller, 1985; Miller, Miller, Roberts, Brooks, & Lazowski, 1997) is a 67-item pencil- and-paper instrument. There is also an updated adolescent version of the SASSI, referred to as the SASSI-A2, which is composed of 32 new items and 40 true/false items from the original adolescent version of the SASSI. The SASSI-A2 has been empirically validated as a screening tool for both substance dependence and substance abuse among adolescents, based on a sample of adolescents (n = 2,326) from treatment and criminal- justice programs. Like the SASSI, an appealing feature of the SASSI-A2 is that it contains both face-valid items that directly address alcohol and drug use and subtle true/false items that do not inquire directly about alcohol or drug use. Administering the subtle true/false items to an adolescent client before the more direct items related to alcohol and drug use may help minimize defensiveness and lead to more accurate responses. Research findings revealed that 95% of adolescents with a substance-use disorder were correctly identified with a ‘‘high probability’’ result in the SASSI-A2 decision rule, whereas 89% of adolescents without a substance- use disorder were correctly classified with a ‘‘low probability’’ decision rule. (All the SASSI instruments are available from the SASSI Institute at www.sassi.com or 800-726-0526.)

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Adolescent Concerns Evaluation

The Adolescent Concerns Evaluation (ACE; Springer, 1998), a 40-item, multidimensional rapid-assessment instrument, measures the degree to which a youth may be at risk of running away (see Table 3.2). Items are scored on a 5-point Likert scale, and there are four separate yet interdependent domains: family, which addresses the youth’s perception of relations and functioning of his or her family; school, which addresses the youth’s self-esteem as it relates to school; peer, which addresses the youth’s self-esteem as it relates to his or her peer relations; and individual, which addresses the youth’s level of depression. The relevant literature on runaway youth, the ecological perspective (Germain & Gitterman, 1980), and the domain sampling model of measurement (Nunnally & Bernstein, 1994) provided the theoretical framework for the development of the ACE.

Participants in the validation study consisted of a clinical (youth at a runaway shelter; n = 110) and a nonclinical (students in grades 6 through 12, n = 117) sample. Each domain has excellent alpha and SEM values—Family (alpha = 0.9497, SEM = 0.206); School (alpha = 0.8884, SEM = 0.265); Peer (alpha = 0.9048, SEM = 0.222); and Individual (alpha = 0.9491, SEM = 0.214)—indicating excellent internal consistency and low error for each domain. The ACE has excellent known-groups validity, discriminating significantly (a = 0.05) between members of the clinical and nonclinical samples (Family Eta = 0.656, School Eta = 0.630, Peer Eta = 0.528, Individual Eta = 0.610). There is evidence of factorial validity using the Multiple Groups Method (Nunnally & Bernstein, 1994) as well as convergent and discriminant construct validity. The ACE performed very well in a discriminant-function analysis, often (87% of the time) classifying subjects correctly. The ACE is available for use from the chapter author at no cost from [email protected]

The ACE is scored by summing the item scores in each domain and collectively. After the client has completed the ACE, the practitioner reverse scores the items listed at the bottom of the ACE (2, 3, 5, 8, 11, 12, 13, 17, 18, 22, 24, 27, 28, 34, 36, 37). For example, if Ramon rated item 2 (‘‘My mother and I get along well’’) with a score of 4 (agree), the practitioner would recode it as a 2 (disagree). Higher scores reflect a higher risk of running away. The possible range of scores for each domain on the ACE is listed in Table 3.3.

Ramon was potentially at risk of running away from home due to conflict with his parents and as indicated by his repeated verbal threats to run away. Accordingly, it would be appropriate for the social worker to administer the ACE to Ramon at the beginning of treatment to assess his risk of running away. Of course, the social worker would also want to administer the ACE to Ramon throughout the course of treatment to determine whether this risk increased, decreased, or stayed the same. Ramon’s scores on the ACE (see Table 3.4) reveal that, over the course of treatment, his risk of running away decreased considerably.

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Table 3.2 Adolescent Concerns Evaluation (ACE) Name: ____________________ Today’s Date: ___________________

This questionnaire is designed to measure how you see the world around you. Since these are your personal views, there are no right or wrong answers. Please answer as honestly as possible. Some items ask about relationships with parents. If you are not living with a parent, then for those items think about your primary adult caretaker(s).

Please rate how strongly you agree or disagree with each statement by placing a number beside each one as follows:

1 = strongly disagree 2 = disagree 3 = neither agree nor disagree 4 = agree 5 = strongly agree First, think about your family life. _____ I am not comfortable talking to my parents about my problems. _____ My mother and I get along well. _____ My father and I get along well. _____ My parents do not understand me. _____ I enjoy spending time with my family. _____ I do not feel safe at home. _____ I am not listened to in my family. _____ My feelings are respected in my family. _____ My parents demand too much from me. _____ The rules in my family are not fair. _____ I feel my parents trust me. _____ All in all, I like my family.

Now, think about your experiences with school. _____ I have good relationships with my teachers. _____ My teachers are hard on me. _____ I get into trouble at school. _____ School is easier for other people than it is for me. _____ Finishing high school is important to me. _____ School is helping me prepare for my future. _____ I am not usually happy with my grades. _____ My friends generally do not go to school. _____ I do not enjoy school.

Now, think about your experiences with your peers. _____ I am well liked by my peers. _____ I do not fit in with my peers. _____ My peers seem to respect me. _____ I do not feel like part of the group. _____ My parents do not approve of my peers. _____ My peers seem to care about me. _____ I have a lot of fun with my peers.

(continued)

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Table 3.2 (Continued) Finally, think about your feelings about your life. _____ I feel depressed a lot of the time. _____ I feel hopeless about my situation. _____ I think about suicide. _____ I feel worthless. _____ I can’t do anything right. _____ I handle my problems well. _____ I feel trapped. _____ I feel good about myself. _____ I deal well with stress. _____ I feel angry a lot of the time. _____ I do not feel like I have control over my life. _____ I feel that others would be glad if I wasn’t around.

Table 3.3 Scoring the ACE ACE Domain Range of Scores

Family domain 12 to 60 School domain 9 to 45 Peer domain 7 to 35 Individual domain 12 to 60

Overall score 40 to 200

Table 3.4 Ramon’s ACE Scores ACE Domain Intake Termination

Family domain 55 20 School domain 35 15 Peer domain 30 12 Individual domain 45 15 Overall score 165 62

Additional Rapid-Assessment Instruments

In addition to the standardized tools reviewed, there are numerous RAIs that can be used with adolescents to measure functioning across various areas, such as suicidal tendencies (e.g., Multi-Attitude Suicide Tendency Scale), conduct-problem behaviors (e.g., Eyeberg Child Behavior Check- list), family functioning (e.g., Family Assessment Device, Index of Family Relations), and peer relations (Index of Peer Relations), to name just a few (K. Corcoran & Fischer, 2007). There are also standardized general- behavior rating scales (e.g., Louisville Behavior Checklist, Child Behavior

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Checklist, and Conners Rating Scales) and tools that are useful for measur- ing the degree of functional impairment (e.g., Children’s Global Assessment Scale; Shaffer et al., 1999b).

Having provided an overview of standardized assessment tools, a word of caution is in order. Recall Kazdin’s (2005) common themes listed earlier in the chapter, where he underscores the notion that multiple mea- sures need to be used to capture diverse facets of the clinical problem and that multiple informants are needed to obtain information from different perspectives and different contexts. It is ill-advised for a practitioner to rely solely on self-report measures when determining diagnostic impressions and a course of treatment for youth. Youth can easily present themselves as they wish to be perceived by others on such measures. Thus, clinical decisions should be supplemented by a thorough psychosocial history (which should include information gathered from external sources, such as parents, physicians, and teachers when at all possible), a mental status exam (when appropriate), and direct observation of the client. Indeed, there exists no gold standard of assessment with adolescents.

Limitations of Evidence-Based Assessment With Adolescents

Mash and Hunsley (2005) note that most practitioners routinely use tradi- tional and accepted forms of assessment, even though very little evidence exists for the clinical utility of the measures. That is, although assessment measures are frequently evaluated for their psychometric criteria (reliable and valid), they are rarely examined for their applied value and accuracy in assessing the clinical populations they are intended to measure.

Understanding EBA for adolescents is especially daunting, given the multifaceted nature of assessment with youth, including developmental issues and the role of family and peer groups. Assessing adolescents with comorbid disorders only adds to these complexities, amplifying the concep- tual soup surrounding systematic assessment of youth with multifaceted presenting problems. The terms comorbid disorders and coexisting disor- ders are frequently used interchangeably to describe adolescents who have two or more coexisting diagnoses on Axis I or Axis II of the DSM-IV-TR (American Psychiatric Association, 2000), whereas the term dual diagnosis is often reserved to refer to clients with at least one Axis I diagnosis and a substance-abuse problem. Approximately half of all adolescents who receive mental-health services have coexisting substance-abuse problems; common coexisting disorders are depression, conduct disorder, and ADHD (McBride, VanderWaal, Terry, & VanBuren, 1999).

Given the prevalence of coexisting disorders in clinical settings and the seriousness of making false-positive or false-negative diagnoses, it is critical that social work practitioners assess for the presence of co- morbid disorders in a deliberate manner rather than making ‘‘on the spot’’ diagnoses. A social worker’s assessment often helps guide treatment

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planning. Misdiagnosing an adolescent as not having (or having) a certain set of problems (e.g., mistaking acting-out behaviors related to poverty as conduct disorder, confusing symptoms of ADHD with pediatric bipolar disorder) can pose serious consequences for the course of treatment (e.g., the wrong medications may be prescribed, adolescents and their families may be turned off to treatment because of repeated treatment ‘‘failures’’). Unfortunately, in many respects, our methods of assessment for youth with comorbid disorders are not as sophisticated as the adolescents that we’re treating.

More generally speaking, standardized assessment measures have many strengths: They are quick and efficient to use, they are easy to score and interpret, and they provide other sources of data than can be gained in a client interview in that they measure or screen for specific client problems or characteristics. Yet, these measures do have some practical weaknesses other than possible limitations in their psychometric properties. Springer and Franklin (2003) identify the following limitations.

First, standardized assessment measures are subject to demand char- acteristics or social desirability. Clients may answer the questions on the measure to cast themselves in a favorable or unfavorable light.

Second, most rapid-assessment instruments present a narrow band of information and are not able to assess the whole client picture. Critics believe the measures have limited usefulness, because they treat character- istics of clients as if they are static instead of forever changing in response to environmental contingencies.

Third, standardized measures have been criticized for focusing on client problems instead of strengths. In this regard, standardized methods are believed to pathologize clients without pointing to their unique moti- vations and capacities. Some assessment measures, however, have begun to include scales on coping abilities or problem solving. For example, the Behavioral and Emotional Rating Scale, second edition (BERS-2; Epstein, 2004), is a strength-based battery of three instruments that measures functioning in youth across five different areas: interpersonal strength, family involvement, intrapersonal strength, school functioning, and affec- tive strength. A key feature that distinguishes the BERS-2 from other standardized tools (e.g., Achenbach’s widely used Child Behavior Check- list [CBCL]) is that it is truly based on a strengths perspective (in contrast to a deficit model), and the wording of the items reflects this perspective. The Teacher Rating Scale (TRS) has 52 items and is one of the three measures in the BERS-2 package. Some sample items from the TRS are:

• Maintains positive family relationships.

• Accepts responsibility for own actions.

• Pays attention in class.

• Identifies own feelings.

This makes the BERS-2 package popular among practitioners operating from a strength-based perspective, as well as with parents and teachers.

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Finally, standardized assessment measures have been criticized for their inability to make direct linkages between client problems and interventions—that is, the measure does not prescribe a useful treatment plan, which is the main purpose of assessment.

Building on this last critique, there is also, too often, a discon- nect between screening, assessment, and treatment planning. This is a truism across outpatient, inpatient, school-based, and juvenile-justice set- tings. In response to this challenge, a recent meeting of juvenile-justice assessment experts, dubbed the ‘‘Consensus Conference,’’ produced rec- ommendations for screening and assessing mental-health needs in the juvenile-justice system (Wasserman et al., 2002a). The Consensus Con- ference attendees suggest that screening mental-health problems and identifying needs with an eye to long-term service planning should occur for all youth prior to court disposition (Potter & Jenson, 2007; www.promotementalhealth.org/practices.htm). Developing a treatment plan involves practitioners’ using information gathered from screening and assessment tools and, more importantly, from their own cognitive abilities to map out a set of tasks to undertake with the client. The section that follows addresses this task.

Treatment Goals

Treatment plans and treatment goals are established collaboratively between the social worker and the adolescent and help focus their work together. Goals specify what the adolescent wants to work on in treatment, and the treatment plan serves as a ‘‘game plan’’ for how these goals will be obtained. Treatment goals and treatment plans are critical components of effective social work practice, for without them, both social workers and clients run the risk of aimlessly ‘‘stumbling around in the dark’’ until they happen on a ‘‘problem’’ that needs to be addressed. As consumers of care, we expect our primary-care physicians to deliver services with some sense of purpose, direction, and expertise. We should expect no less from social workers and the care that they provide.

The first step in establishing treatment goals with any client is to conduct a thorough assessment, as has been discussed throughout this chapter. This entails allowing the client to tell his or her story, conducting a psychosocial history, and using standardized assessment tools and rapid-assessment instruments as needed. Clients may also need to be referred for medical and/or psychological testing. Following a thorough assessment, the social worker and client work together to establish goals for the client. In this sense, goals link the assessment and treatment process.

The following guidelines are helpful in establishing treatment goals. The goals should be (a) clearly defined and measurable; (b) feasible and realistic; (c) set collaboratively by the social worker and the client; (d) originated directly from the assessment process; and (e) stated in

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positive terms, focusing on client growth. Treatment goals ‘‘should specify who, will do what, to what extent and under what conditions’’ (Bloom et al., 2006, p. 104).

Treatment goals need to be defined clearly and stated in such a way that progress toward the goals can be measured. If goals are stated too ambiguously, clients may become discouraged or feel as if the goals are ‘‘out of reach.’’ For example, compare the ambiguous goal of ‘‘Improve family communication’’ with the more concrete goal of ‘‘Ramon will have at least two 10-minute positive conversations per day with his parents over the next 2 weeks.’’ The latter goal is more likely to be meaningful and obtainable to Ramon and his parents.

This leads to the second element of establishing treatment goals, which is that they must be feasible and realistic. ‘‘Improving family communication’’ is not only vague but may not be feasible or realistic, because it potentially covers so much ground. Additionally, little discussion between the social worker and the adolescent is needed to create vague goals. By contrast, concrete goals require a serious dialogue to take place between the worker and the client so that conceptual ideas about client functioning can be ‘‘wrestled to the ground’’ in clear day-to-day terms.

To the extent that adolescent clients participate in this discussion, the more likely it is that they will feel a sense of ownership over the established goals, which in turn means that they are more likely to follow through with the treatment plan. Clients (especially adolescents) will experience less ‘‘buy-in’’ to the treatment process if a social worker or parent imposes goals on them. Thus, goal setting needs to be a truly collaborative process among the social worker, adolescent, and his or her parents (when appropriate).

Treatment goals need to stem directly from the assessment process. The assessment should be thorough, empirically based, and grounded in a systems perspective. This minimizes the likelihood that the worker is creating treatment goals based solely on gut feeling or an on-the-spot diagnosis.

Finally, treatment goals need to be stated in positive terms. In other words, the goal should state what the client will do rather than what the client will not do. For example, a client will be more motivated and goal directed by a goal that states, ‘‘Attend the entire school day every day for the next 2 weeks,’’ in comparison to a goal that states, ‘‘Stop skipping school.’’

Implications for Social Work

Adolescents present with multiple needs, and these needs must be ade- quately captured in the assessment process so that interventions are practical and relevant. Regardless of the method of assessment and intervention used, one truism rings loud and clear: The assessment and

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intervention process with youths must be conducted in a therapeutic rela- tionship that is driven by worker genuineness, warmth, empathy, and understanding. In other words, youth need to connect with a caring adult. Wolkind’s (1977) seminal study of 92 children in residential care supports this notion, where he finds that prolonged contact with the same housepar- ent was associated with lower rates of psychiatric disorders and acting-out behavior.

It is critical that researchers continue their efforts to sort out what methods of assessment are the most effective with adolescents and to subsequently relay any relevant findings to workers and policy makers in a meaningful and user-friendly manner. Mash and Hunsley (2005) propose that it might also be important for EBA to appraise therapeutic-relationship and client-satisfaction variables across specific disorders and assessment constructs. More systematic guidelines are needed to inform practitioners in their assessment with adolescents: ‘‘Ivory-tower pleas to use multiple perspectives from multiple contexts in the absence of specific guidelines for translating these recommendations into clinical practice are not close to the mark regarding what is needed or feasible based on the way current clinical practice is structured’’ (Kazdin, 2005, p. 556).

Conclusion

The field continues to make progress in developing user-friendly stan- dardized assessment tools with sound psychometric properties that can be used in assessment with adolescents. Although these tools should not take the place of a face-to-face psychosocial history, they should be used to complement the assessment process and to track progress in client functioning over the course of treatment. It is important to emphasize that a standardized tool does not take the place of a solid therapeutic helping relationship. A limitation of RAIs is that a client may answer items in a way that presents him- or herself in a certain light to the social worker. This risk is minimized to the extent that rapport has been established between the social worker and the adolescent and to the extent that the adolescent understands the importance of the assessment process and how it will be used to help him or her make desired changes.

Social workers have an ethical obligation to utilize empirical assess- ment protocols and standardized tools whenever possible rather than relying solely on gut feeling when conducting assessments with ado- lescents. The potential consequences of misdiagnosing a client, such as Ramon, described earlier, can be severe. Thus, social work practitioners are encouraged to utilize available empirically based assessment tools within a systems framework to guide treatment planning, to monitor client functioning, and to evaluate the effectiveness of their interventions. In sum, although the practice of EBA with youth is itself in its adolescence, the field is maturing.

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Key Terms

Evidence-based assessment

Strengths-based approach

Standardized assessment tools

Rapid-assessment instruments

Treatment goals

Review Questions for Critical Thinking

1. From the information provided on assessment tools in this chapter, how would you, as a practitioner, decide the most appropriate scale for your client to complete?

2. What are three important considerations to take into account when choosing an EBA instrument for your client?

3. What are the potential downsides to a practitioner’s relying solely on self-report measures?

4. Name three limitations to standardized assessment tools?

5. What are some considerations a practitioner must take into account when creating treatment goals?

Online Resources

http://archives.drugabuse.gov/pdf/monographs/156.pdf This site is sup- ported by the National Institute on Drug Abuse and provides detailed information on drug-abuse treatment and assessment instruments for adolescents.

http://humanservices.ucdavis.edu/Academy/pdf/104056-MentalHealthLR .pdf This website, which is supported by the California Department of Social Services, reviews 95 mental or social-emotional assessment tools available for children and adolescents.

http://www.aacap.org/cs/root/member_information/practice_information /practice_parameters/practice_parameters This website is supported by the American Academy of Child and Adolescent Psychiatry and provides a comprehensive set of clinical parameters for assessing and treating children and adolescents.

http://pubs.niaaa.nih.gov/publications/Assesing%20Alcohol/behaviors .htm This site is supported by the National Institute on Alcohol Abuse and Alcoholism and provides a comprehensive list of validated instruments that assess adolescent alcohol abuse.

http://www.nctsn.org/sites/default/files/assets/pdfs/satoolkit_4.pdf This website is supported by the National Child Traumatic Stress Network. It outlines a comprehensive list of validated assessment tools that target trauma and substance use.

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http://archives.drugabuse.gov/pdf/monographs/156.pdf

http://humanservices.ucdavis.edu/Academy/pdf/104056-MentalHealthLR.pdf

http://www.aacap.org/cs/root/member_information/practice_information

http://pubs.niaaa.nih.gov/publications/Assesing%20Alcohol/behaviors.htm

http://www.nctsn.org/sites/default/files/assets/pdfs/satoolkit_4.pdf

http://www.aacap.org/cs/root/member_information/practice_information/practice_parameters/practice_parameters

92 Social Work Practice With Individuals and Families

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