PSYCHOSOCIAL EVALUATION

The assessment of psychosocial status has different conceptual bases, depending largely on the age of the child. A multimethod, multisource assessment is critical, as

TABLE 3.7 MEASURES OF ADAPTIVE FUNCTIONING

INSTRUMENT (REF.)

DESCRIPTION

COMMENTS

Vineland Adaptive Behavior Scales-II (99)

Age: Birth to 90 years. Measures four domains: communication, daily living skills, socialization, and motor. Also includes a maladaptive behavior scale.

Assessment of adaptive motor skills relevant for

a rehabilitation population.

Rating scale and interview formats available.

Adaptive Behavior Assessment System-II (ABAS-II) (83)

Age: Multiple scales covering birth to 89 years. Measures three domains: conceptual, social, and practical.

Composite areas specifically match AAMR guidelines.

Abbreviation: AAMR, American Association on Mental Retardation.

different sources are sensitive to different areas of functioning (100). Structured interview, observational methods, performance evaluation, and careful analysis of both medical data and psychosocial variables should be combined, and, where possible, multiple sources of information should be included, such as parents, teachers, and child self-report.

CAVEATS

One of the trickiest issues in psychosocial assessment in rehabilitation populations is the need to account for the biologic factors on assessment results. Most psychosocial assessment tools are not specifically designed for use with children with disabilities or chronic illness, making their interpretation of results questionable. There is to be expected a level of adjustment that exists in children with disabilities or chronic illness. While children with chronic physical conditions appear to be at increased risk for psychological adjustment problems, the majority of children in this population do not show evidence of maladjustment (100). Furthermore, assumptions based on group membership by disability or medical condition can be inaccurate. For example, intuitive reasoning would indicate that individuals with disfigurements, such as amputations or burns, would be particularly affected. Such is not the case, however, as demonstrated in research of these groups (99).

It is important to be aware that some items on psychosocial assessment scales can elicit medical as opposed to psychological distress. Particularly in children, "somatization"—or the tendency to express high levels of physical symptoms—is often assessed in scales measuring emotional functioning. A high level of somatization is considered indicative of internalizing problems such as depression and anxiety in general child populations, and high somatization scores can lead to high scores on composite scales meant to measure general internalizing problems. Obviously, in youth with chronic illness, the extreme physical symptoms relating to the medical condition may, even in the absence of other areas of significant symptomology, yield a score on the somatization subscale that is high enough to lead to elevated "total" emotional symptoms scores. It is incumbent on the professional to analyze the general profile and individual items in these cases. If there are low rates of other indicators of emotional distress besides those symptoms specific to the medical condition, it is important not to overinterpret the elevated scores. At the same time, high total scores should not be disregarded just because they are in part due to medical symptoms, as this population does frequently show elevated symptoms of distress, even when somatic items are not included in scoring (101). An intimate familiarity with the items making up the measure and the specific variables associated with the individual child's medical condition is required for psychosocial assessment in this population. Physicians should be wary of scores provided by school and community clinicians who are not specifically familiar with the challenges in the assessment for this population. Referral to clinicians who specialize in pediatric rehabilitation should be strongly considered when psychosocial concerns are an issue.

Unique to the arena of personality of psychosocial functioning is the empirically based or criterion-group strategy of assessment. This approach grew in response to the serious liabilities presented by self-report tests, which used items that had face validity. For example, an item that asks about arguing with others was a direct question, just as could be asked in a live interview. There are great liabilities to that approach; it assumes that subjects can evaluate their own behavior objectively, that they understand the item in the way it was intended, and that they chose to respond candidly. In a radical departure, the developers of what came to be known as the Minnesota Multiphasic Personality Inventory (MMPI; now in the second edition and restructured form— MMPI-2-RF) formulated the test with the main premise that nothing can be assumed about the meaning of a subject's response to a test item—the meaning can be discerned only through empirical research. Items are presented to criterion groups, such as depressed, schizophrenic, or passive-aggressive personality disorders, and control groups. By their answers as a diagnostic group, the items become indicative of a given disorder or personality outplay, regardless of what the content of the items was or an intuitive judgment of what it should indicate. This approach also allows for the determination of respondent's bias—whether an adolescent self-reporting, as in the case of the Minnesota Multiphasic Personality Inventory-Adolescent (MMPI-A), or parents filling out a behavioral checklist such as the Personality Inventory for Children-2.

In young children, temperament is a more cogent concept than that of personality. The dynamics of psychological functioning are the effect of innate temperament in interaction with parents and other caregivers within the basic sensorimotor exploratory nature of infancy and early childhood. If school is children's work, play is the work of this youngest group. What an interview or a self-report measure yields in older children, the observation of play provides in the preschooler. To quote Knoff (102), "This information reflects the preschooler's unique perceptions of his or her world, perceptions that are important in any comprehensive assessment of a referred child's problems." Projective techniques such as the Rorschach are not recommended in this population because of the need to interpret ambiguous visual stimuli. The active developmental maturation of visual-perceptual systems and the attendant normative variability mitigate against the appropriateness in preschoolers.

 
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