Assessment of Children and Adolescents
When we speak about deficits in assessment, I’d like to remind you that these deficits are not exclusive to adults. Most things that we cover in this course are equally relevant to our work with children. In fact, I find that there are even greater degrees of assessment deficit when therapists work with children. For a variety of reasons, assessment of children seems to be often focused on superficial presentations like behavioural observations or 3rd party reports (for example reports by parents, caregivers, school and so on). So the child is not asked directly about their emotions, their thoughts, their motives or their experiences. Children can report these from very early stages of their development, almost as early as they can speak with some degree of coherence. Again, this reminds me of the analogy of throwing darts around in a dark room, when we can just turn on the light! We can go to the source and ask the child important questions such as “why?” and try to gain a greater understanding of their experience.
So why is it that so often the child’s input is not sought when therapists assess their cases? I find that there are two main biases towards children and adolescents that account for these observed deficits in assessment.
Bias #1: at times therapists are concerned that the child doesn’t have enough insight into their own thoughts, emotions or motives to be able to infer their own reasons for their behaviour. So they consider the exercise of asking the child directly as somewhat futile. However, assessment of insight is an important step towards a therapist forming a therapeutic judgement. Regardless of what age group we are working with, if there is a deficit in insight, it becomes one of the jobs of therapy to assist the client form that insight. Reduced insight could results from various factors. For example, certain developmental stages are associated with reduced insight (e.g. during puberty) and mental health issues could disrupt a client’s awareness of their thoughts, emotions and motives. But regardless of whether you are speaking to a 5 year old or a 50 year old, if you ask them “why did you act in a certain way” and their response was “I don’t know”, your next step as a therapist would be to guide them to understand their own thoughts and emotions better. This means that poor insight should never be a reason for us skipping direct work with a client (an exception to this rule may be in cases where mental disorders have so severely disrupted client insight that a period of pharmacotherapy may need to happen before client is ready for in-depth psychotherapy. But, of course, in order to arrive at the decision that a client is not ready to engage in in-depth therapeutic work, we still need to first ask important questions such as “why” or “how do you feel” to assess the client’s insight).
Bias #2: a culture of mistrust around the honesty and integrity of children and adolescents. Children and youth are at times viewed as conniving, invested in getting away with mischief, attracting favours or privileges and so on. Their misbehavior is interpreted as deliberate and planned deception as opposed to a byproduct of psychological struggles and pain. In the words of Chaffin et al. (2006) ‘intervention models that portray young children in negative ways, including describing certain groups of young children as pervasively manipulative, cunning, or deceitful, are not conducive to good treatment and may promote abusive practices. In general, child maltreatment professionals should be skeptical of treatments that describe children in pejorative terms.”
It’s worth noting that there may be times when the honesty of a child can be legitimately questioned by the therapist. This includes cases where a child might display pathological lying, conduct disorder or other defiant behaviour. Although in these circumstances your assessment could be partly informed by reports from parents, school etc., it should never be the case that assessment stops there. Regardless of whether you are working with an adult or a child, where honesty becomes questioned in the context of therapy, it is important that eventually you connect with the client and attract their cooperation in order to unpack their thoughts and beliefs and develop an effective treatment plan. In order to develop such a connection with the child, it’s important that we still give them benefit of the doubt and ask them directly about their own perception of their motives, thoughts and emotions.
An issue that frequently arises in the work of therapists with children and adolescents is counter-transference. In this case, therapists may:
Go into 'parent' mode
Reenact personal experiences of dealing with children or adolescents
Experience personal emotions such as anger, frustration, feeling rejected, or disapproval towards children or adolescent misconduct
As a result of these emotions the therapist may overlook the vulnerabilities of the client, resorting to methods of behavioral control or siding with adult caregivers. Of course, such dynamics would be unhelpful to therapeutic alliance and the child’s willingness to connect with the therapist. Interestingly, these dynamics could result in the child demonstrating defiant or avoidant behavior, which would confirm the two biases we just looked at. A defiant child could strengthen the misconception that they are dishonest or lack integrity (meaning bias #2). An avoidant child may be reluctant to respond to questions about their thoughts, emotions or motives, and answer with “I don’t know” more often. So they would give the illusion that they lack insight into their own inner processes (meaning bias #1). In module 2 we will explore some strategies to help therapists identify and process their own emotions in order to minimise counter-transference. So it’s important that we view the child as a whole human being and use similar mechanisms of assessment as adults, although we may use different tools such as play therapy etc. If you work with children, as you complete this course, contemplate how the assessment and treatment measures that you learn here can be adapted to that age group.