Evidence-based assessment/Step 8: Assess for treatment plan and goal setting

=Prescription Phase: Treatment Plan and Goal Setting=

Overview
By this point, the clinician has one or more hypotheses that have accrued sufficient supporting evidence that they are in the treatment zone. The focus now shifts to gathering information that would change the way treatment is done. In research parlance, the variables of interest would be conceptualized as confounds or moderators. It also is crucial to negotiate treatment goals that the client finds important and motivating. Confounds would be alternate explanations for the apparent diagnosis, especially those that would warrant a different type of intervention. DSM-IV listed these on Axis III, such as conditions due a general medical condition. If the youth is taking prescription drugs, or street drugs, the substance could create symptoms that mimic other conditions. PANDAS and other autoimmune responses to strep and other infections also can produce irritability, obsessiveness, and mood swings. With DSM-5 eliminating the multi-axial structure, it is likely that clinicians will often forget to consider these possibilities systematically, because we now have one less external cue to remind us. It would be valuable to have a simple checklist to cover common concerns for the age groups with which we work, to systematically evaluate the possible confounds ahead of time, rather than revisiting the issue when our otherwise well-formulated intervention fails to get the traction anticipated. The moderators could be general factors changing likely outcomes across a broad swathe of interventions, or they might be more specific to our first choice treatment. Higher verbal ability makes it possible to use more cognitive interventions with a youth. Comorbid anxiety and conduct problems may have a different prognosis than either in isolation. Greater parental distress or impairment may make adherence more difficult and missed appointments or premature termination more likely. Greater family conflict may actually predict larger improvements in more family focused interventions. Good reviews of EST options and more recent randomized trials are likely to include discussion of moderators, helping clinicians see what things may alter the course of treatment. Goal setting also improves the efficacy of therapy. Good goals are shared by the therapist and client, communicated clearly, motivating to the client, and measurable. Framing matters: Consider the difference between “reduce youth irritability” versus “decrease conflict” or “get mom off your back” from the youth’s point of view. These goals might be functionally identical from the therapist’s point of view, all indicating that coping skills, communication strategies, and conflict resolution might be treatment components; but the youth’s willingness to try learning them is going to vary markedly depending on the frame. It also matters whether the goals are “approach” oriented, increasing positive behaviors or positive functioning, versus “avoidance” oriented, focusing on symptom reduction : approach goals may actually produce larger symptom reductions. Good goals also connect with strengths of the client or family.

===Assessing Functioning and Quality of Life ===

A variety of tools are suitable for measuring functioning and quality of life in youths. The Child and Adolescent Functional Assessment Survey (CAFAS) is a brief, structured interview that has shown good inter-rater reliability across a range of educational backgrounds as well as utility for predicting service utilization and aiding in treatment planning. There are also parent- and youth-completed checklists. Free options with promising psychometrics are the Vanderbilt Functioning Indexes (VFI), the Child and Family Quality of Life scales , the KINDL , and the KIDSCREEN. These are brief, do not require rater training, and show good internal consistency. The VFI scales predict service utilization as well or better than interview based measures, making them appealing from a systems level or program evaluation perspective. The KINDL shows criterion validity across a wide range of behavioral as well as somatic health conditions, and also includes multiple gradations of item content and format to maximize developmental appropriateness. It also has translated into more than two dozen languages. The KIDSCREEN is a newer project, with additional scales and content; it is rapidly being translated and validated rapidly in a variety of languages. The combination of brevity, utility, and low “friction” – summarizing cost, reading level, scoring – make these particularly appealing as ways of assessing positive aspects of functioning.

Tables and figures
This would be a good place to put the figures.