Psychological Reports, 1975, 3 7 , 9 2 3 - 9 3 4 .
@ Psychological Reports 1975
A CLINICAL DECISION-MAKING MODEL FOR CHILD PSYCHIATRIC INTERVENTION SELECTION1 PETER B. HENDERSON University o f Pittsburgh, School of Medicine MAX G. MAGNUSSEN. BARBARA B. SNYDERMAN2 Pirdsburgh Child Guidance CenterJ JUERGEN HOMANN Eastern Maine Medical Center Summary.-This paper describes a four-component procedure of clinical decision-making, developed by a group of senior child clinicians in an urban child mental health center. The major goal of the paper is to give readers a basic understanding of the theory underlying the formulation of our dispositionoriented clinical decision-making system, chat can be eventually translated into questionnaire format, and made useful and usable in general clinical application. The four-component procedure is described in a step-wise fashion and then linked to clinical dispositional options to be chosen from the clinical services available in a clinic. A child mental health data system will ultimately be developed.
The diagnostic evaluation of referrals to child psychiatric clinics tends to be an extended process, involving the collection of a great deal of information about the referred child and his/her family. This collected information and the underlying theoretical assumptions are typically recorded in varying lengths of narrative style reports, which differ considerably from one clinician to another in content, quality, and clarity+ven within che same clinical setting. This situation has created a problem in the effective utilization of limited child psychiatric evaluation and treatment personnel. It has also rendered an unnecessarily costly service to individuals referred for such evaluation and possible on-going treatment, as well as for the communities that are attempting to support such care delivery agencies. The need to develop a standardized form for collecting child mental health and retardation evaluation data is now generally recognized. This standardized form would result in uniform, comparable, and retrievable data on all patients thereby providing information for many purposes, i.e., efficient service delivery, program evaluation, long-range planning, and clinical research. Furthermore, standardization of such record-keeping - - will ensure that all essential data would 'This project has been partially supported by a grant from the Buhl Foundation and by contributions through the Neighborhood Assistance Act. T h e authors wish gratefully to acknowledge the assistance of Norberto Rodriguez, M.D., Staff Child Psychiatrist, Pittsburgh Child Guidance Center. and Zaven Khachaturian, Ph.D., Research Assistant Professor of Psychiatry (Psychology), University of Pittsburgh School of Medicine. Both Dr. Rodriguez and Dr. Khachaturian have participated in the project on which this paper is based. . 'Pittsburgh Child Guidance Center, 2 0 1 DeSoto St., Pittsburgh, Pa. 15213.
92 4
P. B. HENDERSON, ET AL.
be collected by all clinicians, regardless of their training, theoretical preference, experience level, etc. Finally, an evaluation data system would tend to streamline the evaluation process, hopefully enabling more efficient use of professional time and skills. In deciding what information should be included in a clinical evaluation data system for a child mental health center, it is necessary to confront the purpose for which data are presently being collected in d~agnosticcenters for children and their families. The decision-making procedure described by the authors of this paper is based on the premise that the purpose of a child evaluation should be for the selection of the appropriate treatmenc plan(s) for the child and his/her family, a view chat is increasingly shared by a growing number of clinicians (Hadley, 1958; Wallen, 1966; Sundberg & Tyler, 1962; Cole & Magnussen, 1966; Sletten & Ulett, 1972). This premise may seem to conflict, and in many instances does, with evaluation systems that are primarily or exclusively aimed at arriving at diagnosis and diagnostic formulations. The authors believe that, except in infrequent cases, diagnostic formulations are only loosely related to treatment seleccion. Furthermore, there is ofcen little agreement regarding which diagnostic category best diagnosis fits a patient (Ash, 1949; Mehlrnan, 1952; Goldberg, 1968). There is a second critical issue to be considered in che evolving of a data syscem for chiId mental health evaluation-thac is, the amoilnt of data which should be collected. There is considerable evidence that, whether the predicted criterion is the seleccion of treatment or assignment of a diagnosis, certain information is critical, though this informa:ion need not be excessive (Oskamp, 1965; Schwartz, 1967; Webster, 1967; Taft, 1955, 1959; Gauton & Dickinson, 1966). Studies such as those referred to, suggest that increasing the amount of information, beyond a certain level, does not lead to an improved clinical decision. This paper describes the fundamentals and theoretical considerations of a model, derived from clinical practice, that forms the basis of a data system (presently being developed at the Pittsburgh Child Guidance Center) which relies on minimal and sufficient data to make incervencion decision(s) in a child psychiatric setting. A THEORETICAL DECISION-MAKING PROCEDURE DERIVED FROMCLINICALPRACTICE Whether a clinician is aware of the many variables impinging on the clinical decision-making process or not, there are mulciple factors and variables involved in selecting the appropriate intervention, and the relationship among these variables is complex. Any approach designed to identify essential variables in clinical decision-making must deal with a wide variety of informational items and theoretical frameworks, i.e., ego psychology, behavior and learning theory,
CLINICAL DECISION-MAKING MODEL FOR INTERVENTION
925
systems theory, etc. The authors believe that clinicians should make explicit the assumptions and theoretical beliefs which underlie their decision to include a given set of variables in ueatment considerations, and those which lead them to exclude others. General systems theory (Cronbach & Glaser, 1957; Leavitt & Bass, 1964; Johnson, Kast, & Rosenzweig, 1969) provides a framework for dealing with multiple variables and the relationships among them It is a derivative of systems theory that forms a basis of the four-component model that is described in this paper. Ordinarily, in child mental health settings, evaluation information is derived from a standard clinical format, such as the one outlined in Table 1. TABLE I STANDARD CLINICALI N P O R M A ~ NFORMAT : 1. Child psychiatrk referral and intake 2. Child psychiatric evaluation 3. Medical, neurological information 4. Social and family history 5. Longitudinal developmental history 6. Correlative history from community system ( s ) 7. Summary including, laboratory findings and results of other special studies, and diagnostic formulation 8. Recommendadon ( s ) for treatment
In the theoretical model described by this group of authors, a four-component system is recommended. Fig. 1 represents a schematic breakdown of the four-component approach. MODELAND COMPONENTS FURTHERDESCRIPTIONOF THEORETICAL Component A This component consists of the various clinical dispositions (treatment options) available to a particular clinical setting. At the Pittsburgh Child Guidance Center it includes the following options: Option 1. Family therapy, Option 2. Individual therapy, Option 3. Group therapy, Option 4. Pharmaco therapy, Option 5. Inpatient treatment, Option 6. Educational therapy, Option 7. Childcentered parent counseling, Option 8. N o treatment indicated, and Option 9. Other. The category "Other" is utilized for purposes of gathering additional treatment/intervention dispositions recommended by clinicians, for purposes of future development of the data system. The number of dispositional options has a direct bearing on the complexity of the evaluation process, and on the data system that must parallel that process. If a clinic utilizes only one treatment intervention modality, then differential decision-making is minimized, or excluded, i.e., the clinic that only offers family treatment is thereby making the statement that they believe that all clinical
P. B. HENDERSON, ET AL.
1 COMPONENT A 1 COMPONENT B
-
I=='
COMPONENT D
1COMPONENT C I
FIG 1. Component A represents the treatment option considered. This component may combine with other components, suggesting multiple treatment options for clinical recommendation. Component B represents clinical variables that qualify, or expand upon, the theoretical assumptions of Component C. Component C represents the explicitly outlined assumptions related to theory pertinent to each disposition component. Component D represents accual clinical data irems that are utilized to substantiate the number of relevant variables qualifying each treatment disposition.
problems for children and families can be/should be managed in a model of family therapy. If, conversely, a clinic offers a variety of treatment modalities, the system and the evaluation process become increasingly more detailed.
Component B This component consists of clinical variables in the presenting problem that are necessary to select the treacment option available. The variables in this component follow directly from theoretical assumptions that will be described below in Component C. For example, the decision to treat a "hyperactive" pre-school youngster with amphetamine medication, rather than recommending individual play therapy (considering both options are available) would be dependent on a belief system that central nervous system dysfunction is a primary etiologic factor in the child's behavior problem. This relates, as indicated below, to a theoretical assumption that a major cause of hyperactivicy in children is central nervous system dysfunction. W e might consider another example to elucidate the variables in the system. The decision to treat the mother of a school age child who is reluctant to go to school, rather than see the child individually, relates to a clinical variable pertaining to mother/child relationships and the ramifications of that, uncovered in a clinical evaluation. This relates to a theoretical assumption (Component C) that the etiology and development of the child's maladaptive behavior are related to maternal influence in the mother/child pair. Component C This component accommodates to, and makes explicit, the belief system of theoretical preference of an individual clinician, or a total clinical setting. As set forth in Component B, the assumptions determine the variables that are to be included in the Component B section of the theoretical model. An example here would be that of a clinic in which individual, psycho-
CLINICAL DECISION-MAKING MODEL FOR INTERVENTION
927
dynamic treatment is a ueatment option. For deciding on this option, the variable studied for the intervention decision will include a careful understanding of intrapsychic/internal dynamics of the "identified patient." A study of these variables, in the clinical situation, enables the clinician(s) to select between the equally available treatment modality of individual and family therapy. Component C, therefore, in the theoretical model relates to the careful externalization and clear explication of the clinician (s) ' theoretical assumptions. Frequently decisions, even while nominally relating to the same "school of thought" (as in the example above regarding internal dynamics), are still highly idiosyncratic and vary by differing individual interpretations of the same theory. This Component C, therefore, forces individual clinicians (or the clinic as a whole) to make explicit basic assumptions about each of the treatment modalities thac are currently being provided and are presently available.
Component D This component includes the actual clinical information items that will go into the construction of the evaluation data system, derived from the theoretical model being described. The D items are derived from tho variables (Component B ) that are studied and evaluated in the clinical assessment. In the example given of the "hyperactive" child (under Component B) one of the variables was central nervous system function/dysfunction. The D items should provide information that would allow for a clinical judgment as to whether CNS dysfunction is present, or not. These D (data) items should include: coordination attainments and difficulties, lzteralization accomplishments, perceptual motor function/dysfunction, past history of a CNS insult, etc. It is important, from a reading of the above detailed explanation of the theoretical model, to understand that in making qualifying and descriptive statements about clinical variables (Component B ) it is assured thac each D (data) item is related to the process of sorting out decisions among the given treatment options in a given clinical setting. These clinical data, if the above described four-component model is utilized and applied, should lead to collecting minimal and szbfficieltt data in the final decision-making process. Such a model could then be applied to each aspect of the clinical process, that is, case assignment, evaluation, intervention and ueatment review, progress reporting, termination, and later follow-up. For each step just mentioned, it would be necessary to identify the types of decisions that need to be made at each of those steps. Such decisions would then be composed to constitute Component A. The process of developing th: Components B, C, and D would then become the process of making explicit the assumptions related to that point, variables that could be studied in the clinical situation, and the "hard data items" that would be minimally and sufficiently necessary to reach the appropriate decision. In the table that follows, the four-component model is further illustrated by
TABLE 2 VARIABLES, ASSUMPTTONS AND INFORMATIONAL ITEMS I N TREATMENTS
Component C (Assumptions)
Component B (Variables)
Component A: Family Therapy family members' maladaptive behaviors will be more easily changed through a family approach in those cases in which the behaviors are intertwined with family interaction.
1. Relationship between family interaction and non-adaptive responses (symptoms) of one or more family members.
1. Individual
2. Family's abiliry to change.
2. The flexibility of family members' interactions will determine the potential for change i n the family unit and for each member.
1. The presence of specific non-adaptive responses to generally facilitating environment.
2. Willingness of child to relate t o an adult therapist.
3. Willingness of parents to support therapy program.
Component A : Individual Therapy for Child 1. A child's symptoms are indicators of the child's efforts to resolve individual conflict ( s ) . These may be resolved by a facilitating relationship with a clinician. 2. The interpersonal transactions between child and therapist are the main ingredients for change toward more adaptive behavior responses. 3. In an on-going therapy program for child(ren), the parents' understanding and support of the child's therapy is very important for the success of the effort(s).
Component D (Informational Items) 1. Characteristics of family interaction: a. communication b. conflict c. openness of system d. family roles and relationships. 2. Problems of family members. 3. Relarionship between problems and characteristics of family interaction. 4. Family members open to change: ( a ) willing to be involved, ( b ) open to intervention in the system. 5. Family's potential for change.
1. Disturbances in affective behavior. 2. Disturbances in impulse control. 3. Disturbances in thought processes. 4. Disturbances in cognitive functions. 5. Disturbances in social behavior. 6. Disturbances in bodily function. 7. Functional relationships with another supporting adult in community (including clinic during evaluation).
8. Parents' demonstration of understanding that child needs therapy.
9. Parents' activity that assists therapist's efforrs.
Component A : Group Therapy for Individual Family Members 1. Certain selective non-adaptive responses 1. Symptoms are indicators of idiosyncratic 1. Disturbance i n affective behavior. to a generally facilitating environment. conflicts. These may be resolved via a 2. Disturbance i n impulse control. therapeutic group process, i.e., a multiThese responses are more apparent in a 3. Disturbance i n soc:al relationships. plicity of peer interactions and a more group. 4. Disrurbance in bodily function. diluted relationship with adult authority. 2. Interpersonal transactions among group 2. A capacity and willingness to relate to 5. Functional relationship with a s u p members and adult therapist are main peers and adults. portive adult i n family o r communingredients of change toward behavior ity (clinic included). responses. 6. Peer group experiences. 3. In an on-going therapy program for a 7. Parenrs' demonstration of understand3. Willingness of parents to support treatchild(ren) the parents understanding ment program. ing that child needs trearment. and support of the child's therapy is very 8. Parents' activity that nssists therapist's important for the success of the effort(s). efforts.
1. Cognitive dysfunction.
2. Significant educational underachievement.
3. Child's capacity to profit from educational therapy.
Component A : Educational Therapy at Clinic 1. Certain cognirive and/or perceptual problems may result in interference with the learning process.
2. Academic deficiencies even though resulting from non-academic problems, should be remcdied. 3. A child may not be ready to use educational help.
4. Community (school) resources.
4. Educational therapy should be done at
5. Parental supporr.
the child's school where possible; recommended elsewhere only if not available. 5 . Parents' undersranding and support is a necessary ingredient in on-going work with their child. (Continued on next page)
1. Historical irems relate t o development of minimal brain dysfunction. 2. Hyperactivity. 3. Distractibilirv. 4. Sensory and Lnsoty-motor functioning. 5 . Medical neurological data. 6. Intellectual functioning. 7. Academic achievement.
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8. Ability t o concentrate on learning tasks. 9. Motivation. 10. Response to teaching during evaluation.
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11. School's resources for educational theraPY. 12. Parental understanding of learning prob!em. 13. Parents' potential ro sustain awareness over extended period. 14. Parents' willingness to involve child effectively.
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TABLE 2 ( C o n i d ) VARIABLES,ASSUMPTIONSAND INFORMAT~ONAL ITEMS IN TREATMENTS Component B (Variables)
Component C (Assumptions )
Component D (Informational Items)
Component A: Residential Treatment (Inpatient Psychiatric Hospital) 1. Child's self-care behavior severely dis1. The greater the severity and the dura1. Multiple and severe non-adaptive behavcurbed over long duration of time. tion of the child's maladaptive behavior, ior patterns existing over longer periods a. Parental and relevant social systems the more likely will there be further nonof time. (This may or may not be within the context of disordered family units.) facilitating responses from the child's management ineffective or insufficient. 2. Severe and longstanding communicapresent home, school and community. tion disturbance in child. a. Parental and relevant social systems management ineffective o r insufficient. 3. Serious and long-term interpersonal disturbance. a. Parental and relevant social systems management ineffective or insufficient. 4. Severe difficulties in thinking of extended duration. a. Parental and relevant social systems management ineffective or insufficient. 5. Severe difficulties in impulse control for long duration of time. a. Parental and relevant social systems management ineffective or insufficient. Component A : PsychopharmacologicaI Treatment 1. CNS functions.
2. Affective responses and states.
1. The so-called "minimal" brain dysfunctions are related to observable behavior and can be ameliorated frequently by cerrain drugs. 2. Certain affective states are maladaptive in that they can produce further nonfacilitating responses in the environment. These may be reduced by certain drugs.
1. Distractibility. 2. Hyperactivity. 3. Hisrorical data. 4. Medical neurology data. 5. Anxiety. 6. Depressive moods. 7. Suicidal tendencies.
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3. Disturbance of cognitive and thought processes.
3. Certain cognitive and thought process disturbances have a high potential for non-facilitating responses from the environment. These may be reduced by certain drugs.
8. Perceptual abberations and thought process disturbance.
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2
Component A: Child-centered Parent Counseling (Focus of counselling confined to referred child)
1. Parents' understanding of child. 2. Parents' management of t h e child.
3. Parents' communicetion t o child and m each other about child.
4. Parents' attachment to child. 5. Parental capacity to modify perception and/or management of child.
1. Parental understanding of a child in a developmental context facilitates good child management. 2. Parental management is a crucial variable in child development. 3 Good communication m and about the child is necessary for good child management. 4. An appropriate degree of parental atrachment to child is necessary to facilitare healthy development. 5. Parental experience of evaluation period is one indication of ability t o profit from counselling.
6. Parental attitude towards treatment is also a n indication of ability t o profit from counselling.
6. Parental style.
7. Family style may be such that concrete child-focussed counselling is the treatment of choice. (Continued on next page)
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1 . Parental lack of understanding of child
in context of its developmental process.
2. Present management ineffective.
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3. Poor communication to child and to each other about child.
4. Inappropriate degree of parental attachment to child.
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0 5 . Parenrs experience evaluation as meaningful. 6. Parents responded well to suggestion during evaluation. 7. Parents feel child can be helped by treatment. 8. Parents believe child can change at leasr partly i n response t o change in themselves. 9. Parents willing ro involve themselves in some form of treatment. 10. Parents not open to intervention in the family system. I I . Parental style is concrete.
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Component B (Variables)
TABLE 2 (Cont'd) VARIABLES,ASSUMFTIONS AND INFORMATIONAL ITHMS IN TRBATMENTS Component C Component D ( Assumations) (Informational Items)
1. Parents' management of child.
Component A: N o Intervention with Parents 1. Environmental input sufficiently facilirates child's development to require no intervention with parents.
3. Parents' attachment with the child. 4. Parents' provision of developmental opportunities for child in environment (school, peers).
5. Parents' willingness to utilize clinic o r other helping resources.
1. Interpersonal relationships.
2. Psycho-sexual development.
3. Biological development.
4. Cognitive functions.
2. Intervention is not possible if parents unwilling to involve themselves with helping agencies. Component A : N o Intervention With Child 1. Facilitating relationships are one set of variables indicating mastery of developmental processes.
2. Psycho-sexual development is one important indicator of age adequate development. 3. Certain biological functions are essential for adequate mastery of developmental tasks. 4. Age adequate cognitive functions are essential for effective mastery of developmental processes.
N
1. Parental management is effective.
2. Parents communicate appropriately with child and with each other in relationship to child. 3. Appropriate degree of positive facilitatlng parental attachment to t h e child. 4. Parents provide child with appropriate school o r learning experience. 5. Parents provide child with sufficient peer opportunities. 6. Parents unwilling to utilize services.
2. Parents' communication with child.
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1. Re!ationship with mother. 2. Relationship with father. 3. Relationship with sibling. 4. Relationship with extended family. 5. Relationship with peers. 6. Relationship with other adults. 7. Impulse integration. 8. Phantasy (content and type). 9. Self-percept. 10. Motor function. I I . Language and speech. 12. Sensory function and integration. 13. Thought processes. 14. Academic skills.
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CLINICAL DECISION-MAKING MODEL FOR INTERVENTION
933
listing the variables, assumptions, and informational items developed by the authors for selection of each treatment modality. It is important to stress thac there is an "in-tandem process" during the collection of information to complete the decision-making tables on each intervention modality. That is, information is simultaneously and naturally collected for the syscems dealing with all intervention modalities that are available at this clinic. There may be duplications and overlaps, in that certain clinical variables may be common to one or more intervention modalities, and it is (in fact) quite possible that a given child and his/her family require two or more modalities for immediate, or eventual, resolution of the clinical problem(s) for which referral was recommended. The clinician assigned to a given case, however, is not restricted to only collect information needed to complete the decision-making instrument but is expected to at least collect the minimal necessary information needed to complete the questionnaire that is developed from the tables presented for each modality. A treatment decision would be reached on the basis of the clinical data collected by means of this questionnaire, using the decision-making rules specified in the tables.
SUMMARY
AND
CONCLUSIONS
The focus of this paper has been to describe a four-component theoretical model of clinical decision-making, that attempts to make overt the assumptions and clinical variables involved in choosing appropriate intervention modalities. The clinician(s) utilizing such a system should effectively be able to bring to focus an organized, systematic, and predictable framework for doing his/her dinical work. The attempt of the authors has been to move from the more traditional diagnostic categorization of clinical syndromes, which are often highly uncoordinated with final intervention choice(s), to a position of a more direct relationship between minimal and sufficient clinical data and intervention choices available in a given setting. Tables outlining the work-sheet proceedings for the construction of a questionnaire, related to the theoretical foundation of the fourcomponent model, are included. It is the belief of the authors thac utilizing such a model as a foundation, and developing clinical data systems for evaluation, assessment, treatment, and followup, will standardize record-keeping, lend itself to eventual automated record-keeping, and bring a standard of high quality to an ever-widening system of mental health care delivery for children and their families. REFERENCES
ASH,P. The reliabiliry of psychiatric diagnoses. Journal o f Abnormal and Social Psychology, 1949,44, 272-276. BANNISTER,D., SALMON, P., LEIBERMAN, D. M. Diagnosis-treatment relationships in psychiatry: a statistical analysis. British Journal o/ Psychiatry, 1964, 110, 726-732. COLE,J. K., & MAGNUSSEN, M. G. Where the action is. Journal o f Consulting Psychology, 1966, 30, 539, 543.
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CRONBACH,J. L., & GLESER,G. C. Psyhological tests and personnel decisions. (2nd ed.) Urbana, 111.: Univer. of Illinois Press, 1765. DAILY,C. A. The practical utility of the clinical report. Journal o f Consulting Psychology, 1953, 17,297-302. GAURON,E. F., & DICKINSON,J. K. Diagnostic decision making in psychiatry: I. Information usage. Archives o f General Psychiatry, 1966, 14, 225-232. GOLDBERG,L. R. Simple models or simple processes? Some research on clinical judgments. American Psychologist, 1968, 23, 483-496. HADLEY,J. M. Clinical and counseling psychology. New York: Knopf, 1958. JOHNSON,R. A., KAST, R. E., & ROSENZWEIG,J. E. T h e theory and management o f systems. (2nd ed.) New York: McGraw-Hill, 1967. LEAVI'IT,H. J., & BASS, B. M. Organizational psychology. Annual Review o f PsychoG ony, -- 1964, 26, 371-398. MEHLMAN,B. The reliability of psychiatric diagnosis. Journal o f Abnormal and Social Psychology, 1952, 47, 577-578. OSKAMP,S. Overconfidence in case-study judgments. lournu1 o f Consulting P~ychology, 1965, 29, 261-265. SCHWARTZ,M. L. Validity and reliability in clinical judgments of C-V-S protocols as a function of amount of information and diagnostic category. Psychological Reports, 1967, 20, 767-774. SLETTEN,I. W.. & ULE'IT, G. A. The present starus of automation in a state psychiatric system. Psychiatric Annals, 1972, 2 , 42-57. SUNDBERG, N . D., & ? ~ L E R ,L. E Clinical psychology. New York: Appleton-CenturyCrofts, 1962. TAFT, R. The ability to judge people. Psychological Bulletin, 1955, 51, 1-23. TAPT, R. Multiple methods of personality assessment. Psychological Bulletin, 1959, 56, 333-352. WALLEN,R. W. Clinical psychology: the study o f persons. New York: McGraw-Hill, 1956. WEBSTER, E. C. Decision making in the employment interview. Montreal: McGill Univer., 1967.
Accepted August 8, 1975.
@ Psychological Reports 1975
A CLINICAL DECISION-MAKING MODEL FOR CHILD PSYCHIATRIC INTERVENTION SELECTION1 PETER B. HENDERSON University o f Pittsburgh, School of Medicine MAX G. MAGNUSSEN. BARBARA B. SNYDERMAN2 Pirdsburgh Child Guidance CenterJ JUERGEN HOMANN Eastern Maine Medical Center Summary.-This paper describes a four-component procedure of clinical decision-making, developed by a group of senior child clinicians in an urban child mental health center. The major goal of the paper is to give readers a basic understanding of the theory underlying the formulation of our dispositionoriented clinical decision-making system, chat can be eventually translated into questionnaire format, and made useful and usable in general clinical application. The four-component procedure is described in a step-wise fashion and then linked to clinical dispositional options to be chosen from the clinical services available in a clinic. A child mental health data system will ultimately be developed.
The diagnostic evaluation of referrals to child psychiatric clinics tends to be an extended process, involving the collection of a great deal of information about the referred child and his/her family. This collected information and the underlying theoretical assumptions are typically recorded in varying lengths of narrative style reports, which differ considerably from one clinician to another in content, quality, and clarity+ven within che same clinical setting. This situation has created a problem in the effective utilization of limited child psychiatric evaluation and treatment personnel. It has also rendered an unnecessarily costly service to individuals referred for such evaluation and possible on-going treatment, as well as for the communities that are attempting to support such care delivery agencies. The need to develop a standardized form for collecting child mental health and retardation evaluation data is now generally recognized. This standardized form would result in uniform, comparable, and retrievable data on all patients thereby providing information for many purposes, i.e., efficient service delivery, program evaluation, long-range planning, and clinical research. Furthermore, standardization of such record-keeping - - will ensure that all essential data would 'This project has been partially supported by a grant from the Buhl Foundation and by contributions through the Neighborhood Assistance Act. T h e authors wish gratefully to acknowledge the assistance of Norberto Rodriguez, M.D., Staff Child Psychiatrist, Pittsburgh Child Guidance Center. and Zaven Khachaturian, Ph.D., Research Assistant Professor of Psychiatry (Psychology), University of Pittsburgh School of Medicine. Both Dr. Rodriguez and Dr. Khachaturian have participated in the project on which this paper is based. . 'Pittsburgh Child Guidance Center, 2 0 1 DeSoto St., Pittsburgh, Pa. 15213.
92 4
P. B. HENDERSON, ET AL.
be collected by all clinicians, regardless of their training, theoretical preference, experience level, etc. Finally, an evaluation data system would tend to streamline the evaluation process, hopefully enabling more efficient use of professional time and skills. In deciding what information should be included in a clinical evaluation data system for a child mental health center, it is necessary to confront the purpose for which data are presently being collected in d~agnosticcenters for children and their families. The decision-making procedure described by the authors of this paper is based on the premise that the purpose of a child evaluation should be for the selection of the appropriate treatmenc plan(s) for the child and his/her family, a view chat is increasingly shared by a growing number of clinicians (Hadley, 1958; Wallen, 1966; Sundberg & Tyler, 1962; Cole & Magnussen, 1966; Sletten & Ulett, 1972). This premise may seem to conflict, and in many instances does, with evaluation systems that are primarily or exclusively aimed at arriving at diagnosis and diagnostic formulations. The authors believe that, except in infrequent cases, diagnostic formulations are only loosely related to treatment seleccion. Furthermore, there is ofcen little agreement regarding which diagnostic category best diagnosis fits a patient (Ash, 1949; Mehlrnan, 1952; Goldberg, 1968). There is a second critical issue to be considered in che evolving of a data syscem for chiId mental health evaluation-thac is, the amoilnt of data which should be collected. There is considerable evidence that, whether the predicted criterion is the seleccion of treatment or assignment of a diagnosis, certain information is critical, though this informa:ion need not be excessive (Oskamp, 1965; Schwartz, 1967; Webster, 1967; Taft, 1955, 1959; Gauton & Dickinson, 1966). Studies such as those referred to, suggest that increasing the amount of information, beyond a certain level, does not lead to an improved clinical decision. This paper describes the fundamentals and theoretical considerations of a model, derived from clinical practice, that forms the basis of a data system (presently being developed at the Pittsburgh Child Guidance Center) which relies on minimal and sufficient data to make incervencion decision(s) in a child psychiatric setting. A THEORETICAL DECISION-MAKING PROCEDURE DERIVED FROMCLINICALPRACTICE Whether a clinician is aware of the many variables impinging on the clinical decision-making process or not, there are mulciple factors and variables involved in selecting the appropriate intervention, and the relationship among these variables is complex. Any approach designed to identify essential variables in clinical decision-making must deal with a wide variety of informational items and theoretical frameworks, i.e., ego psychology, behavior and learning theory,
CLINICAL DECISION-MAKING MODEL FOR INTERVENTION
925
systems theory, etc. The authors believe that clinicians should make explicit the assumptions and theoretical beliefs which underlie their decision to include a given set of variables in ueatment considerations, and those which lead them to exclude others. General systems theory (Cronbach & Glaser, 1957; Leavitt & Bass, 1964; Johnson, Kast, & Rosenzweig, 1969) provides a framework for dealing with multiple variables and the relationships among them It is a derivative of systems theory that forms a basis of the four-component model that is described in this paper. Ordinarily, in child mental health settings, evaluation information is derived from a standard clinical format, such as the one outlined in Table 1. TABLE I STANDARD CLINICALI N P O R M A ~ NFORMAT : 1. Child psychiatrk referral and intake 2. Child psychiatric evaluation 3. Medical, neurological information 4. Social and family history 5. Longitudinal developmental history 6. Correlative history from community system ( s ) 7. Summary including, laboratory findings and results of other special studies, and diagnostic formulation 8. Recommendadon ( s ) for treatment
In the theoretical model described by this group of authors, a four-component system is recommended. Fig. 1 represents a schematic breakdown of the four-component approach. MODELAND COMPONENTS FURTHERDESCRIPTIONOF THEORETICAL Component A This component consists of the various clinical dispositions (treatment options) available to a particular clinical setting. At the Pittsburgh Child Guidance Center it includes the following options: Option 1. Family therapy, Option 2. Individual therapy, Option 3. Group therapy, Option 4. Pharmaco therapy, Option 5. Inpatient treatment, Option 6. Educational therapy, Option 7. Childcentered parent counseling, Option 8. N o treatment indicated, and Option 9. Other. The category "Other" is utilized for purposes of gathering additional treatment/intervention dispositions recommended by clinicians, for purposes of future development of the data system. The number of dispositional options has a direct bearing on the complexity of the evaluation process, and on the data system that must parallel that process. If a clinic utilizes only one treatment intervention modality, then differential decision-making is minimized, or excluded, i.e., the clinic that only offers family treatment is thereby making the statement that they believe that all clinical
P. B. HENDERSON, ET AL.
1 COMPONENT A 1 COMPONENT B
-
I=='
COMPONENT D
1COMPONENT C I
FIG 1. Component A represents the treatment option considered. This component may combine with other components, suggesting multiple treatment options for clinical recommendation. Component B represents clinical variables that qualify, or expand upon, the theoretical assumptions of Component C. Component C represents the explicitly outlined assumptions related to theory pertinent to each disposition component. Component D represents accual clinical data irems that are utilized to substantiate the number of relevant variables qualifying each treatment disposition.
problems for children and families can be/should be managed in a model of family therapy. If, conversely, a clinic offers a variety of treatment modalities, the system and the evaluation process become increasingly more detailed.
Component B This component consists of clinical variables in the presenting problem that are necessary to select the treacment option available. The variables in this component follow directly from theoretical assumptions that will be described below in Component C. For example, the decision to treat a "hyperactive" pre-school youngster with amphetamine medication, rather than recommending individual play therapy (considering both options are available) would be dependent on a belief system that central nervous system dysfunction is a primary etiologic factor in the child's behavior problem. This relates, as indicated below, to a theoretical assumption that a major cause of hyperactivicy in children is central nervous system dysfunction. W e might consider another example to elucidate the variables in the system. The decision to treat the mother of a school age child who is reluctant to go to school, rather than see the child individually, relates to a clinical variable pertaining to mother/child relationships and the ramifications of that, uncovered in a clinical evaluation. This relates to a theoretical assumption (Component C) that the etiology and development of the child's maladaptive behavior are related to maternal influence in the mother/child pair. Component C This component accommodates to, and makes explicit, the belief system of theoretical preference of an individual clinician, or a total clinical setting. As set forth in Component B, the assumptions determine the variables that are to be included in the Component B section of the theoretical model. An example here would be that of a clinic in which individual, psycho-
CLINICAL DECISION-MAKING MODEL FOR INTERVENTION
927
dynamic treatment is a ueatment option. For deciding on this option, the variable studied for the intervention decision will include a careful understanding of intrapsychic/internal dynamics of the "identified patient." A study of these variables, in the clinical situation, enables the clinician(s) to select between the equally available treatment modality of individual and family therapy. Component C, therefore, in the theoretical model relates to the careful externalization and clear explication of the clinician (s) ' theoretical assumptions. Frequently decisions, even while nominally relating to the same "school of thought" (as in the example above regarding internal dynamics), are still highly idiosyncratic and vary by differing individual interpretations of the same theory. This Component C, therefore, forces individual clinicians (or the clinic as a whole) to make explicit basic assumptions about each of the treatment modalities thac are currently being provided and are presently available.
Component D This component includes the actual clinical information items that will go into the construction of the evaluation data system, derived from the theoretical model being described. The D items are derived from tho variables (Component B ) that are studied and evaluated in the clinical assessment. In the example given of the "hyperactive" child (under Component B) one of the variables was central nervous system function/dysfunction. The D items should provide information that would allow for a clinical judgment as to whether CNS dysfunction is present, or not. These D (data) items should include: coordination attainments and difficulties, lzteralization accomplishments, perceptual motor function/dysfunction, past history of a CNS insult, etc. It is important, from a reading of the above detailed explanation of the theoretical model, to understand that in making qualifying and descriptive statements about clinical variables (Component B ) it is assured thac each D (data) item is related to the process of sorting out decisions among the given treatment options in a given clinical setting. These clinical data, if the above described four-component model is utilized and applied, should lead to collecting minimal and szbfficieltt data in the final decision-making process. Such a model could then be applied to each aspect of the clinical process, that is, case assignment, evaluation, intervention and ueatment review, progress reporting, termination, and later follow-up. For each step just mentioned, it would be necessary to identify the types of decisions that need to be made at each of those steps. Such decisions would then be composed to constitute Component A. The process of developing th: Components B, C, and D would then become the process of making explicit the assumptions related to that point, variables that could be studied in the clinical situation, and the "hard data items" that would be minimally and sufficiently necessary to reach the appropriate decision. In the table that follows, the four-component model is further illustrated by
TABLE 2 VARIABLES, ASSUMPTTONS AND INFORMATIONAL ITEMS I N TREATMENTS
Component C (Assumptions)
Component B (Variables)
Component A: Family Therapy family members' maladaptive behaviors will be more easily changed through a family approach in those cases in which the behaviors are intertwined with family interaction.
1. Relationship between family interaction and non-adaptive responses (symptoms) of one or more family members.
1. Individual
2. Family's abiliry to change.
2. The flexibility of family members' interactions will determine the potential for change i n the family unit and for each member.
1. The presence of specific non-adaptive responses to generally facilitating environment.
2. Willingness of child to relate t o an adult therapist.
3. Willingness of parents to support therapy program.
Component A : Individual Therapy for Child 1. A child's symptoms are indicators of the child's efforts to resolve individual conflict ( s ) . These may be resolved by a facilitating relationship with a clinician. 2. The interpersonal transactions between child and therapist are the main ingredients for change toward more adaptive behavior responses. 3. In an on-going therapy program for child(ren), the parents' understanding and support of the child's therapy is very important for the success of the effort(s).
Component D (Informational Items) 1. Characteristics of family interaction: a. communication b. conflict c. openness of system d. family roles and relationships. 2. Problems of family members. 3. Relarionship between problems and characteristics of family interaction. 4. Family members open to change: ( a ) willing to be involved, ( b ) open to intervention in the system. 5. Family's potential for change.
1. Disturbances in affective behavior. 2. Disturbances in impulse control. 3. Disturbances in thought processes. 4. Disturbances in cognitive functions. 5. Disturbances in social behavior. 6. Disturbances in bodily function. 7. Functional relationships with another supporting adult in community (including clinic during evaluation).
8. Parents' demonstration of understanding that child needs therapy.
9. Parents' activity that assists therapist's efforrs.
Component A : Group Therapy for Individual Family Members 1. Certain selective non-adaptive responses 1. Symptoms are indicators of idiosyncratic 1. Disturbance i n affective behavior. to a generally facilitating environment. conflicts. These may be resolved via a 2. Disturbance i n impulse control. therapeutic group process, i.e., a multiThese responses are more apparent in a 3. Disturbance i n soc:al relationships. plicity of peer interactions and a more group. 4. Disrurbance in bodily function. diluted relationship with adult authority. 2. Interpersonal transactions among group 2. A capacity and willingness to relate to 5. Functional relationship with a s u p members and adult therapist are main peers and adults. portive adult i n family o r communingredients of change toward behavior ity (clinic included). responses. 6. Peer group experiences. 3. In an on-going therapy program for a 7. Parenrs' demonstration of understand3. Willingness of parents to support treatchild(ren) the parents understanding ment program. ing that child needs trearment. and support of the child's therapy is very 8. Parents' activity that nssists therapist's important for the success of the effort(s). efforts.
1. Cognitive dysfunction.
2. Significant educational underachievement.
3. Child's capacity to profit from educational therapy.
Component A : Educational Therapy at Clinic 1. Certain cognirive and/or perceptual problems may result in interference with the learning process.
2. Academic deficiencies even though resulting from non-academic problems, should be remcdied. 3. A child may not be ready to use educational help.
4. Community (school) resources.
4. Educational therapy should be done at
5. Parental supporr.
the child's school where possible; recommended elsewhere only if not available. 5 . Parents' undersranding and support is a necessary ingredient in on-going work with their child. (Continued on next page)
1. Historical irems relate t o development of minimal brain dysfunction. 2. Hyperactivity. 3. Distractibilirv. 4. Sensory and Lnsoty-motor functioning. 5 . Medical neurological data. 6. Intellectual functioning. 7. Academic achievement.
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8. Ability t o concentrate on learning tasks. 9. Motivation. 10. Response to teaching during evaluation.
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11. School's resources for educational theraPY. 12. Parental understanding of learning prob!em. 13. Parents' potential ro sustain awareness over extended period. 14. Parents' willingness to involve child effectively.
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TABLE 2 ( C o n i d ) VARIABLES,ASSUMPTIONSAND INFORMAT~ONAL ITEMS IN TREATMENTS Component B (Variables)
Component C (Assumptions )
Component D (Informational Items)
Component A: Residential Treatment (Inpatient Psychiatric Hospital) 1. Child's self-care behavior severely dis1. The greater the severity and the dura1. Multiple and severe non-adaptive behavcurbed over long duration of time. tion of the child's maladaptive behavior, ior patterns existing over longer periods a. Parental and relevant social systems the more likely will there be further nonof time. (This may or may not be within the context of disordered family units.) facilitating responses from the child's management ineffective or insufficient. 2. Severe and longstanding communicapresent home, school and community. tion disturbance in child. a. Parental and relevant social systems management ineffective o r insufficient. 3. Serious and long-term interpersonal disturbance. a. Parental and relevant social systems management ineffective or insufficient. 4. Severe difficulties in thinking of extended duration. a. Parental and relevant social systems management ineffective or insufficient. 5. Severe difficulties in impulse control for long duration of time. a. Parental and relevant social systems management ineffective or insufficient. Component A : PsychopharmacologicaI Treatment 1. CNS functions.
2. Affective responses and states.
1. The so-called "minimal" brain dysfunctions are related to observable behavior and can be ameliorated frequently by cerrain drugs. 2. Certain affective states are maladaptive in that they can produce further nonfacilitating responses in the environment. These may be reduced by certain drugs.
1. Distractibility. 2. Hyperactivity. 3. Hisrorical data. 4. Medical neurology data. 5. Anxiety. 6. Depressive moods. 7. Suicidal tendencies.
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3. Disturbance of cognitive and thought processes.
3. Certain cognitive and thought process disturbances have a high potential for non-facilitating responses from the environment. These may be reduced by certain drugs.
8. Perceptual abberations and thought process disturbance.
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Component A: Child-centered Parent Counseling (Focus of counselling confined to referred child)
1. Parents' understanding of child. 2. Parents' management of t h e child.
3. Parents' communicetion t o child and m each other about child.
4. Parents' attachment to child. 5. Parental capacity to modify perception and/or management of child.
1. Parental understanding of a child in a developmental context facilitates good child management. 2. Parental management is a crucial variable in child development. 3 Good communication m and about the child is necessary for good child management. 4. An appropriate degree of parental atrachment to child is necessary to facilitare healthy development. 5. Parental experience of evaluation period is one indication of ability t o profit from counselling.
6. Parental attitude towards treatment is also a n indication of ability t o profit from counselling.
6. Parental style.
7. Family style may be such that concrete child-focussed counselling is the treatment of choice. (Continued on next page)
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1 . Parental lack of understanding of child
in context of its developmental process.
2. Present management ineffective.
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3. Poor communication to child and to each other about child.
4. Inappropriate degree of parental attachment to child.
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0 5 . Parenrs experience evaluation as meaningful. 6. Parents responded well to suggestion during evaluation. 7. Parents feel child can be helped by treatment. 8. Parents believe child can change at leasr partly i n response t o change in themselves. 9. Parents willing ro involve themselves in some form of treatment. 10. Parents not open to intervention in the family system. I I . Parental style is concrete.
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TABLE 2 (Cont'd) VARIABLES,ASSUMFTIONS AND INFORMATIONAL ITHMS IN TRBATMENTS Component C Component D ( Assumations) (Informational Items)
1. Parents' management of child.
Component A: N o Intervention with Parents 1. Environmental input sufficiently facilirates child's development to require no intervention with parents.
3. Parents' attachment with the child. 4. Parents' provision of developmental opportunities for child in environment (school, peers).
5. Parents' willingness to utilize clinic o r other helping resources.
1. Interpersonal relationships.
2. Psycho-sexual development.
3. Biological development.
4. Cognitive functions.
2. Intervention is not possible if parents unwilling to involve themselves with helping agencies. Component A : N o Intervention With Child 1. Facilitating relationships are one set of variables indicating mastery of developmental processes.
2. Psycho-sexual development is one important indicator of age adequate development. 3. Certain biological functions are essential for adequate mastery of developmental tasks. 4. Age adequate cognitive functions are essential for effective mastery of developmental processes.
N
1. Parental management is effective.
2. Parents communicate appropriately with child and with each other in relationship to child. 3. Appropriate degree of positive facilitatlng parental attachment to t h e child. 4. Parents provide child with appropriate school o r learning experience. 5. Parents provide child with sufficient peer opportunities. 6. Parents unwilling to utilize services.
2. Parents' communication with child.
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1. Re!ationship with mother. 2. Relationship with father. 3. Relationship with sibling. 4. Relationship with extended family. 5. Relationship with peers. 6. Relationship with other adults. 7. Impulse integration. 8. Phantasy (content and type). 9. Self-percept. 10. Motor function. I I . Language and speech. 12. Sensory function and integration. 13. Thought processes. 14. Academic skills.
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CLINICAL DECISION-MAKING MODEL FOR INTERVENTION
933
listing the variables, assumptions, and informational items developed by the authors for selection of each treatment modality. It is important to stress thac there is an "in-tandem process" during the collection of information to complete the decision-making tables on each intervention modality. That is, information is simultaneously and naturally collected for the syscems dealing with all intervention modalities that are available at this clinic. There may be duplications and overlaps, in that certain clinical variables may be common to one or more intervention modalities, and it is (in fact) quite possible that a given child and his/her family require two or more modalities for immediate, or eventual, resolution of the clinical problem(s) for which referral was recommended. The clinician assigned to a given case, however, is not restricted to only collect information needed to complete the decision-making instrument but is expected to at least collect the minimal necessary information needed to complete the questionnaire that is developed from the tables presented for each modality. A treatment decision would be reached on the basis of the clinical data collected by means of this questionnaire, using the decision-making rules specified in the tables.
SUMMARY
AND
CONCLUSIONS
The focus of this paper has been to describe a four-component theoretical model of clinical decision-making, that attempts to make overt the assumptions and clinical variables involved in choosing appropriate intervention modalities. The clinician(s) utilizing such a system should effectively be able to bring to focus an organized, systematic, and predictable framework for doing his/her dinical work. The attempt of the authors has been to move from the more traditional diagnostic categorization of clinical syndromes, which are often highly uncoordinated with final intervention choice(s), to a position of a more direct relationship between minimal and sufficient clinical data and intervention choices available in a given setting. Tables outlining the work-sheet proceedings for the construction of a questionnaire, related to the theoretical foundation of the fourcomponent model, are included. It is the belief of the authors thac utilizing such a model as a foundation, and developing clinical data systems for evaluation, assessment, treatment, and followup, will standardize record-keeping, lend itself to eventual automated record-keeping, and bring a standard of high quality to an ever-widening system of mental health care delivery for children and their families. REFERENCES
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934
P. B. HENDERSON, ET AL.
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Accepted August 8, 1975.
