Evidence-based assessment/Vignettes/Ty

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Ty

What is going on with Ty?

Clinical description

Ty Lee is a 12 year old Korean American male who lives with his mother and older sister. He is in regular middle school education classes, and had been an A/B student until this year. His mother scheduled the appointment because of concerns about his “bad temper, lack of effort on homework, and slipping grades.”

History of presenting problem

According to Ty’s intake form, he is 12 years old and lives with his mom and older sister. His mom reports “bad temper, lack of effort on homework, and slipping grades” as the reasons for seeking treatment. Pre-intake assessment indicates elevated internalizing symptoms, mild externalizing symptoms, onset of symptoms in past year.

During intake interview, mom reports that she has been having increasing problems with Ty’s attitude and behavior since she and her husband separated about a year ago. Ty sees his dad on weekends. According to mom, Ty’s older sister is a “straight-A student” and has “never had any problems” like what she is seeing in Ty. She feels frustrated by his behavior and is very worried that he is putting his future in jeopardy due to his slipping academic performance.

In your conversation with Ty, he is quiet and reports experiencing a lot of academic pressure. He is also worried about being the “man of the house” now that his dad is not there. He reports getting criticized a lot, and you do not get the sense that he is also praised for what he does well. He says he has “a few friends,” but is not currently involved in any after-school activities with his peers. In the past, he played soccer, but had to quit because his mom is not able to pick him up after practice. He likes video games and reluctantly plays the piano. You administer the Mood and Feelings Questionnaire (MFQ) and the parent and child report of the Screen for Child Anxiety Related Disorders (SCARED), along with the Mini International Neuropsychiatric Interview (MINI) focusing on mood and anxiety modules. Ty meets criteria for depression and rules out the diagnosis of Generalized Anxiety Disorder (GAD).

Conceptualization

Ty has increasing pressure in school heading into eighth grade when he will take tests determining where he gets to go to high school. His dad’s absence and perception of older sister as “perfect” have put extra pressure on him. Culturally, as a second generation Korean American, there is also an expectation that he do well in school. His mother and sister are close, which makes him especially aware of dad’s absence. He misses seeing his friends and connecting with them through soccer. He spends a lot of time alone now that he comes home right after school and is there by himself until his mom gets home from work. Mom has limited time and is stressed by her new role as a (mostly) single parent. She feels Ty’s problems might be her fault and is frustrated that her efforts to force him to do homework and to improve his grades have been unsuccessful and have lead to significant conflict between the two of them.

Initial treatment plan

Cognitive Behavioral Therapy (CBT) to help Ty challenge his negative cognitions and to increase his positive activities. Family therapy to improve communication, reduce conflict, and help mom feel more supported in her parenting practices.

Assessment findings

Checklist scores

Ty, his mother, and his Math teacher all completed the Achenbach System of Empirically Based Assessment (ASEBA) checklists. Here are the results, reported as T scores (M = 50, standard deviation (SD) = 10, compared to other males between 11 and 18 years of age).

ASEBA Scores

Scale	Mom (CBC)	Ty (YSR)	Teacher (TRF)
Externalizing	77	42	57
Internalizing	72	44	50
Anxious/Depressed	63	50	51
Withdrawn	56	51	53
Somatic Complaints	78	52	57
Attention Problems	80	51	62
Social Problems	52	51	50
Thought Problems	70	58	50
Delinquent/Rule-Breaking	71	50	50
Aggressive Behavior	70	50	58

Mom is clearly the most worried, which is common in outpatient clinics. It is usually the mother who makes the referral and sets up the appointment.

The teacher notes some problems, but nothing that rises to the level of a serious concern. The teacher might comment on Ty sometimes having trouble paying attention or seeming moody in the quarterly progress notes, but he is not getting detention or sent to the principal's office.

Ty is reporting no concerns, to the point that some of his scores are the lowest possible. On the 8 clinical syndrome scales, a raw score of zero (not reporting any problems) gets a T score of 50. The scores for Internalizing and Externalizing are below average levels of concern.

Select more specialized scales to refine probabilities

Ty and his mom disagree about whether or not he has any concerns. This is fairly common; on average parents and youths only agree moderately, with typical correlations of r = .2 to .3. These would be considered small to medium effect sizes for psychology research, but they are very low if considered a measure of inter-rater agreement. There also is a wide range of agreement across parent-youth dyads: Some have very similar perspectives, some show little consistency, and occasionally they systematically disagree!

Comparing the CBCL and YSR scores sets up some different hypotheses:

Ty might be minimizing or denying problems that really are there, or his mom might be more concerned than she needs to be. A third possibility is that that the problems are worse at home, or it might be that the main issue is conflict between Ty and his mom. The TRF scores are not considered clinically elevated, but the teacher is noting some attention problems and oppositional behavior, suggesting that Ty might be minimizing his behavior problems, or perhaps he just does not have insight into them.

We decide to ask both mom and Ty to fill out some more scales that go into more depth about attention problems, mood, and anxiety. These may help clarify what is going on. More focused scales also may give more information about the severity of the problem, and they can be helpful in tracking progress over the course of treatment. We meet with Ty for a few minutes to talk with him and give him some context. We want to establish good rapport, explain that he is not in trouble, and we want to understand how things look to him so that we can help things get better.

We decide to use the SCARED and Mood and Feelings Questionnaire as two free instruments with good evidence of validity across a range of samples. The SCARED goes into more depth about anxiety, and the MFQ covers depression. Both have easy reading levels and were built for use with children and teens, with self-report and parent-rated versions.

Ty's SCARED scores are low, with a raw total of 12, and 6 points on the GAD subscale, and 4 points on the Social Phobia scale. All of the scores are below the published thresholds. Mom's ratings on the SCARED are even lower, with a total raw score of 3, and all three points being on the GAD scale.

Mom's MFQ comes back with a raw score of 19. Ty's comes back a 28 -- clearly he has changed his approach to the rating scales based on our conversation! Both of these are above the published cut scores that discriminate between groups of youths with versus without depression (refs). Does this mean that Ty has clinical depression? Not necessarily. But the combination of the SCARED scores being low and the MFQ being high definitely are making the anxiety disorder hypothesis less likely, and the mood disorder problem more likely.

Updating probabilities

The Achenbach scales have likelihood ratios published for anxiety (Van Meter), depression (various? Or #666?), and ADHD (Raiker) diagnoses. We already used these to update the probabilities of each based on the intake packet of scores.

We now have scores that we could use from "best of the free" alternatives.

SCARED (both mom and Ty), MFQ (both mom and Ty), Vanderbilt (mom only). Add Vanderbilt from teacher later.

Vanderbilt high; MFQ high; Ty's higher after talking with psychologist and establishing some rapport. SCARED lowers prob of Anxiety, and MINI Kid rules out.

Illustrate replacing rather than adding for same informant.

Critical items

Another good habit to build is knowing whether the scales have any "critical items" on them. These are things that a clinician would want to know about and pay attention to, even if they do not figure into an elevated score. Examples include items asking about self harm and suicidal ideas or behaviors, threats to other people, fire setting, or physical or sexual abuse. Anything that indicates that the person may be a danger to themselves is crucial to know about and address with the treatment plan. If we ask the question, we definitely want to check the answer. Using a questionnaire that asks about suicidal ideation creates a "hot potato" where we are obligated to check and act on the information. Threats against other people may create a "duty to warn" situation. Information about abuse or neglect may trigger mandatory reporting to the Division of Child and Family Services or other authorities, depending on state regulations.

On the Achenbach....

The SCARED does not have any items that would be considered "critical items" in this sense. The MFQ does, however.

It is important to note that even though Ty's mother did not check any of the hopeless and passive ideation items, Ty checked "Sometimes" for three of these questions.

Diagnostic interview findings

Because of the information from the results of the previous assessments (MFQ, SCARED, Vanderbilt, Diagnostic and Statistical Manual of Mental Disorders Cultural Formulation Interview, Caregiver Strain Questionnaire- Short Form 7, ACSQ, and EASI-A), the MINI-KID anxiety, mood disorders, and ADHD sections were administered to both Ty and his mother. Given the mother’s view that the presenting problem was oppositional behavior and the mild elevations in externalizing symptoms in the pre-intake instruments, the oppositional defiant disorder section of the MINI-KID was given to help rule out externalizing problems.

Based on the results of the MINI****

Cognitive and achievement testing

(Not done as part of the evaluation; may be able to match up information later)

Prediction phase

Let's see how we would apply the EBA principles to Ty:

Shortlist of probable hypotheses

Based on Ty's age and the common clinical issues, here is a short list of contending hypotheses:

• Oppositional-defiant disorder is common in Ty's age range and would be consistent with mom's description of concerns.
• An adjustment disorder following his parents' separation is a leading hypothesis.
• A mood disorder would be another plausible hypothesis.
• Anxiety disorders would be a third hypothesis.
• Attention problems are worth evaluating based on prevalence and also Ty's problems completing schoolwork and with academic performance..
• The family conflict is also important to assess, as well as potential cultural issues (and differences of opinion between Ty and his parents that might be influenced by differing degrees of acculturation).
• A learning disorder would be another possibility. This would be diagnosed by excluding the other possibilities.

Risk and protective factors and moderators

Ty's gender and age decrease the probability of a mood disorder.

During the interview, mom reported that Ty's father has depression, and has probably had more than one episode. He had refused to seek help for it, which contributed to her decision to start a trial separation. She believes that the father may be getting treatment now.

Updating probability of diagnoses

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

Ty	Common Dx Hypotheses (A)	Starting Prob. (B)	Broad Measure (D)				Cross-informant (E)						Confirmation (G)	Treatment Phase (I), (J), (K)
	Base Rate from Rettew et al. (2009) Meta-Analyses		Scale & Score	DLR	Revised Prob.	EAY Check	Next Test score	DLR	Revised Prob.	Next Test score	DLR	Revised Prob.	K-SADS Interview
Any Anxiety	Specific Phobia	0.15											Anxiety NOS ()
	PTSD	0.09
	GAD	0.10	CBCL T Internalizing 72				Other measures are better than Achenbach, such as the SCARED (see below)
	Panic Disorder	0.11
	Social Phobia	.20
	Separation Anxiety	0.18
Any Impulse Control Disorder	ODD	0.38	CBCL T Aggressive 70				No data about TRF scales for aggressive						ODD (50%)
	CD	0.25	CBCL T Aggressive 70
	ADHD	0.38	CBCL T Attention 80				TRF T Attention 58						ADHD Inattentive (85%)
Any Mood Disorder	MDD	0.26	CBCL T Anx/Dep 63				Haven't found data about TRF for internalizing						MDD ()
	BP		CBCL T Externalizing 77				YSR T Externalizing 42			TRF T Externalizing 57			Bipolar I ()
	Dysthymia	0.08											Dysthymia ()
Any Substance Abuse Disorder		0.30	CBCL #2 CBCL #99 CBCL #105

Answers

Arlene Common Dx Hypotheses (A) Starting Prob. (B) Broad Measure (D) Cross-informant (E) Confirmation (G) Treatment Phase (I), (J), (K) Base Rate from Merikangas et al. (2010) NCS-A Scale & Score DLR Revised Prob. EAY Check Next Test score DLR Revised Prob. Next Test score DLR Revised Prob. K-SADS Interview Any Anxiety Specific Phobia 0.19 Anxiety NOS (65%) PTSD 0.05 GAD 0.02 CBCL T Internalizing 59 0.98 0.02 0.02 Other measures are better than Achenbach Panic Disorder 0.02 Social Phobia 0.09 Separation Anxiety 0.08 Any Impulse Control Disorder ODD 0.13 CBCL T Aggressive 69 4.18 0.38 0.38 No data about TRF scales for aggressive ODD (70%) CD 0.07 CBCL T Aggressive 69 4.18 0.24 0.24 ADHD 0.09 CBCL T Attention 62 6.92 0.41 0.41 TRF T Attention 58 0.73 0.34 ADHD inattentive (75%) Any Mood Disorder MDD 0.12 CBCL T Anx/Dep 57 0.39 0.05 0.05 Haven't found data about TRF for internalizing MDD (85%) BP 0.03 CBCL T Externalizing 67 1.26 0.04 0.04 YSR T Externalizing 73 2.32 0.09 TRF T Externalizing 68 2.03 0.17 Bipolar I (85%) Dysthymia Included above Dysthymia (85%) Any Substance Abuse Disorder 0.11 CBCL #2 CBCL #99 CBCL #105

Cross-informant perspectives

Mention that these have DLRs. Also unpack the implications of agreement and disagreement for the client (and add a section about treatment implications of disagreement on the Conceptual Model Pages)

One of the other measures that would provide more information on anxiety is the SCARED (Ty's mom could fill this out on paper)

HGAPS- Ty Lee's vignette SCARED assessment

The SNAP-IV 26 item measure would provide more information on ADHD. Ty's mom could fill this out online using the assessment center.

A clinical vignette's (Ty Lee) description was utilized to fill out the SNAP-IV.

Prescription phase

Mental status and clinical observations

He was quiet and reports experiencing a lot of academic pressure. He is also worried about being the “man of the house” now that his dad is not there. He reports getting criticized a lot, and you do not get the sense that he is also praised for what he does well. He says he has “a few friends,” but is not currently involved in any after-school activities with his peers. In the past, he played soccer, but had to quit because his mom is not able to pick him up after practice. He likes video games and reluctantly plays the piano.

Genogram and family functioning

Here is a genogram of Ty's family: All of the information comes from Ty's mother, who reports that she and his father separated 8 months ago. Privately, she reports that the father has been drinking alcohol a lot, seems stressed and irritable, and probably has depression. She believes that he has started getting individual counseling. She is waiting to see how that goes before deciding whether to reunify or divorce.

Ty and his mother both agree that there is a lot of conflict between them, and that it has gotten worse over the last half year or so.

Treatment selection

The results of the MINI-KID indicated that Ty met criteria for Major Depressive Disorder; however, he did not meet criteria for any anxiety disorders. The mood episode thoroughly explained the internalizing symptoms. This makes sense considering anxiety related episodes are likely to be longstanding and chronic. Taken together with other information gathered through the interview and the results of the rating scales, Ty was assigned a diagnosis of Major Depressive Disorder, Single Episode, Moderate, with anxious distress. He also met criteria for ADHD, inattentive type, but it was considered a provisional diagnosis because depression could be responsible for many of his symptoms Other reasons for the provisional diagnosis included, it was unknown if the inattentive symptoms predated the depression or if Ty's symptoms were unusual for a boy in his age group.

Treatment with behavioral activation, exposures, cognitive restructuring, and ways to help him navigate his new family situation and his acculturation differences with his mother were recommended given the conceptualization. In addition, conjoint sessions might focus on communication training for Ty and his mother, and parent training or individual adult therapy for Ty’s mother might also be helpful, Research on adolescent depression suggests cognitive-behavioral therapy (CBT) and interpersonal therapy (IPT). CBT was considered the best fit because it often includes behavioral activation, cognitive restructuring, exposure therapy that included anti-avoidance strategies. However, IPT was also considered given its focus on framing and addressing adolescent depression within the context of significant interpersonal transitions, like parental separation, and interpersonal conflicts. Attachment-based family therapy was also considered because of its focus on the parent-child relationship. Finally, It was recommended that treatment proceed with a CBT treatment focused on Ty’s irritable mood and anxiety.

Client preferences

Ty agreed to the recommendation of cognitive behavioral therapy (CBT) treatment focused on his irritable mood and anxiety, but his mother expressed concern that treatment wouldn’t immediately help with Ty’s school work. Ty and his mother discussed the pros and cons of focusing on irritability and anxiety rather than school work. After this discussion, Ty’s mother continued to have concerns about the plan, but agreed to try focusing on his mood while monitoring to see if his school work improved as a result.  

Process phase

Clinically significant change

Reliable change index

Ty's mom is most concerned about Attention Problems (T = 80). Based on the reliability of the scale, if the score changed by 8 points or more, we would be 95% confident that treatment was helping; 7 points would be enough for 90% confidence.

We would explain this by saying....

Pick a treatment target and specify what the Reliability Change Index (RCI) would be for it. Discuss how you would explain to Ty and his mother.

Nomothetic benchmarks

A, B, Cs of Jacobson definitions. General stuff about limitations would go on the main concept page. Here it is focused on the client -- what are the benchmarks they will focus on? How explained to them?

Minimum important difference (MID)

Note that this section is a dangler -- not originally called out in the 12 steps. Medium d as a rule of thumb from Streiner, Norman, & Cairney (2015). Could work from AUC to d to raw units as a way of estimating, since psychology hasn't done research on this yet. Might be able to back into it with studies that had CSQ and outcome data.

Client goals & tracking

These would be personal goals and idiographic measurement -- YTOPS, etc.

Process measures

This would be traces such as coming to sessions, doing homework assignments. (Not sure of other specifics involved in current IPT protocols?)

Progress measures

YTOPS again and goal setting.

Termination planning and maintenance

Revisit Jacobson benchmarks. Is there much chance of relapse? What things would the client need to pay attention to if they were going to nip that in the bud?