Commentary

Functional dynamic assessment in evaluating childhood mental disorders

Motivation of the patient can have an effect on accurate evaluation and determination of a childhood mental disorder.

By Ennio Cipani, PhD

Is it a Disorder, or is it a Motivational Problem?

Imagine this hypothetical scenario. You have 10 people in a summer swimming clinic for health and fitness. They join your clinic to improve their performance and overall fitness. You want to place them in two groups for practice sessions: proficient swimmers and less proficient swimmers. You give them the following instruction. “I will give you three tries to swim 200 yards in under 2 1/2 minutes.” You record their time for each attempt to swim 200 yards in 2 1/2 minutes or less with a stopwatch. They have the option of attempting to meet that criterion for a maximum of three opportunities that day. Based on this day’s recordings, you note that only three of the ten are able to perform under 2 1/2 minutes. You conclude that those three are to be placed in the proficient swimmer group. The other seven belong in the second group of less proficient swimmers. With three attempts to meet this criterion, one would surmise that those that did not reach it are probably less proficient swimmers (according to this criterion).

On the next day you decide to give them the same opportunity to meet the swimming proficiency criterion again. However, this time you provide the following incentive; “For anyone who can achieve the proficiency criterion for the 200 yards swim, I will rebate 50 percent of their registration fee for the clinic.” On day two, the following results were obtained. The three persons who were judged proficient swimmers on day one meet the criterion again. But the surprise finding was in the other group. Of those seven people, four of them meet the proficiency criterion on this day.

What is the importance of day two testing? On day one, a decision about each person's skill with respect to their proficiency in swimming 200 yards was made. Based on that data, anyone would have concluded that seven people fit in the less proficient group. But day two illustrates that such a judgment would've been wrong for four of those seven people. When motivation was maximized by providing a partial rebate of their registration fee1, you found that the judgment about them being less-proficient swimmers was only correct for three of them.

What is the parallel to evaluating childhood mental disorders? With the consternation about the upcoming changes in the DSM V slated for next year, it is important to consider why such a system may be flawed in deciding who has a disorder. Here's a clinical example of the same phenomena. Let’s say 12 children are independently evaluated at a public school to determine if they meet the criteria for 314.00 Attention- Deficit/Hyperactivity Disorder, Predominantly Inattentive Type.2 The data collection for such an evaluation involves multiple measures and is collected across a two-week period. The measurements include observational data collected in the school program, in addition to rating scale data and reports from significant others. Based on this data, the decision is made that eight of these individuals demonstrate enough symptoms (at least six in the inattentive category) to warrant such a diagnosis. Further, such inattention is observed and reported across home and school settings.

Subsequent to this evaluation and determination of a childhood mental disorder, let's say that an expert in ABA becomes involved with the school district as a behavioral consultant for these children. She collects baseline measures of their performance during lessons and seat work. She then asks the teachers of these eight students to implement various contingencies during class lessons and seatwork. One of the plans to improve performance and completion of seatwork tasks is the beeper system (Cipani & Schock, 2011, p. 73). As a result of the beeper system in place, five of these eight children demonstrate rates of on-task behavior and attending during seat work that approximate or equal their non-disabled classmates. Further, this change in attention to task is achieved within one or two days of implementation of the contingencies and remains for the entire period of implementation. With other contingencies, other behavioral patterns change as well; to the point where one would not notice much of a difference between these five “diagnosed” children and other children sans the mental disorder diagnosis. At least with respect to the school setting, these five children are now appearing as “ADHD-free.” What is apparent is that changing the contingencies to favor performance resulted in a noticeable change in inattentive symptoms. Additionally, such a noticeable change occurred in a relatively quick time period (for more information on this functional dynamic approach, see the podcast entitled, “The DSM and comorbidity.

The problem with traditional psychological measurements that attempt to determine if a childhood mental disorder is present is their reliance on a static approach to measurement. In a static approach, a given child’s motivation to engage in his or her optimal performance and display a desired performance or behavior at some designated acceptable level is not experimentally manipulated. I believe that such static measures can produce a serious error in judgment. Professionals who rely exclusively on static measures often assume that an individual who does not perform a given behavior (with respect to negative symptoms3), or does not perform a behavior at an acceptable level or rate, truly cannot do so. They may wrongly conclude that the individual has an inherent skill deficit. Their assumption that motivation has already been maximized might be erroneous. Even if the performance skill or behavior is not evidenced across multiple settings, one should not assume that such contextual diversity would create contingencies that maximize motivation in at least one of the settings.

What would verify the existence of sufficient motivation to perform the desired behavior if it is in the repertoire of the individual? What is needed is a dynamic form of assessment. A dynamic form of assessment would supplement the current baseline measures of performance with a test condition that manipulates contingency variables. Such a test condition would involve the conduct of powerful reinforcement contingencies placed on the occurrence of that behavior. In the above swimming example, would you want to make your decision about swimming proficiency based on day one data? Or would the second day (of course supplemented with the first day) provide more convincing evidence in which to make a valid judgment about swimming prowess. Using the second day’s information, we would arrive at the following: three swimmers who failed to reach criterion on day two are probably not proficient swimmers. However the four swimmers who improve their performance on day two to meet criteria should be in the proficient swimmers group. With a static measure, this information on this latter group would have been missed.

The use of experimental manipulations to derive information about problem behavior’s function now has a three decade history (Iwata, Dorsey, Slifer, Bauman, & Richman, 1982). The dynamic approach advocated here is congruent with such experimental manipulations of controlling variables, but for negative symptoms. The implementation of this functional dynamic approach to assessment would be feasible in treatment settings such as schools, inpatient settings, and other similar facilities where professional staff could measure behavior in real contexts or in analogue settings.

Such a dynamic approach would require an alternate classification system that directly examines the issue of motivation. I have developed a function-based classification system for the analysis of negative symptoms (Cipani & Shock, 2011, see Appendix A, pp. 285-2954). This classification system involves the following three categories: (a) misdirected contingencies, (b) inept repertoire, and (c) faulty discriminations. For the purposes of this article, I will focus on the first two classifications. A misdirected contingency diagnosis indicates that the negative symptom is within the repertoire of the individual child. However its lack of occurrence is due to the lack of reinforcement contingencies for its display, and/or contingencies that are misdirected to an alternate, usually undesirable, behavior. As noted in the clinical example provided above, presenting sufficient reinforcement contingencies for performance and attending during seatwork resulted in five children who were previously thought to be incapable of sustained attention displaying normative levels of on-task performance. Such a demonstration indicates that the misdirected contingency diagnosis best suits these children. Additionally, the prior diagnosis of 314.00 Attention-Deficit/ Hyperactivity Disorder, Predominantly Inattentive Type3 is on shaky grounds for these children.

In contrast, the three children who fail to change even with powerful contingencies directed at the appropriate behavior would not be classified in this functionbased category. Rather, the lack of display of such performance seems to be more chronic, and not amenable to immediate changes. The functional diagnosis for these children would be inept repertoire. Such a classification category denotes the individual’s current inability to perform designated skill or behavior, either at the desired rate or level of fluency.

There are significant implications of this functional diagnostic classification model. If the absence of the behavior in one or more contexts is the result of insufficient motivation, intervention needs to be directed at restructuring the social contingencies in those environments. The diagnosis of misdirected contingency would involve professional efforts around training direct care staff, teachers, or parents to implement a set of contingencies that redirect reinforcement to the desired appropriate behavior. Hence, efforts in behavioral consultation with direct care staff and parents are clinically indicated and essential. In contrast, child-directed therapy is not indicated for this type of problem. As long as the contingencies for the appropriate behavior, i.e., negative symptom(s), continue to be misdirected, all the training and therapy directed to the child will probably be fruitless in changing behavior in target contexts.

However, if the result of the dynamic assessment is relatively little or no change in the display of negative symptoms, then child-directed intervention is needed. An inept repertoire diagnosis would indicate that the individual has a skill deficit relative to the negative symptom or symptoms. This finding requires intervention or therapy to involve more individualized child-directed instruction and teaching methods (e.g., shaping, prompting, modeling, progressively skill building, etc) to develop the skill to a fluid and criterion level performance. Of course, one would want to ensure that once the skill is developed to criterion, that reinforcement contingencies maintain such behavior in the natural contexts.

In summary, sole reliance on static measures may provide information that leads to invalid judgments about the individual’s skill capability. This may produce over-estimates of a prevalence of a disorder. Using a more dynamic measurement as a supplement will also allow treatment direction to be informed by such contextual factors. For those children who fail to display the desired behavior to the normative criterion level because of lack of motivation, then resources should be directed to training persons in the target environments to respond in a different regimen. If motivation of the child is not the factor, then child-directed methods should be pursued (if the contexts are indeed directing reinforcement to the criterion behavior). 

About the Author

Ennio Cipani, PhD is a licensed psychologist since 1983 in California and a full professor in the Department of Special Education at National University. He has published numerous articles, chapters, books and software in the areas of child behavior management and parent and teacher behavioral consultation. His most recent books are Children and Autism: Stories of Hope and Triumph (2011) and a book he co-authored with Keven Schock entitled Functional Behavioral Assessment, Diagnosis and Treatment: A Complete System for Education and Mental Health Settings (2011). He has given many workshops at state and national conventions, as well as continuing education courses for psychologists, social workers marriage and family therapists and others, focusing on the effective management of problem child behavior.

Dr. Cipani has been doing in-home and in-school behavioral consultation for families with problem behaviors since 1982. He has dealt with a variety of behavior problems, conducting assessment and intervention activities in natural environments (i.e., homes and classrooms) and then training direct line people to engage in a parenting or teaching management repertoire that produces changes in child behavior, including structured training programs. Read more about Dr. Cipani’s extensive clinical experience (PDF, 1.72MB) in people’s homes and schools and views on behavioral intervention.

References

Cipani, E. (2012, May 7). "The issue of co-morbidity in DSM-V Childhood Mental Disorders: A functional perspec- tive and proposed alternative diagnostic system." (audio podcast). Retrieved from http:// behaviortherapist.podbean.com/2012/05/06/the-dsm-and-co-morbidity

Cipani, E. & Schock, K. (2011). Functional behavioral assessment, diagnosis and treatment: A complete system for education and mental health settings. (2nd Edition) New York: Springer Publishing.

Iwata B.A, Dorsey M.F, Slifer K.J, Bauman K.E, & Rich- man G.S. (1982). Toward a functional analysis of self- injury. Analysis and Intervention in Developmental Disabilities, 2, 3–20.