Guidelines for Reviewing Standard Parent Intake report

Introduction

The following steps are extracted from "Interpreting the Brief Child and Family Phone Interview" in the BCFPI Interviewing manual. It includes information about the limitations of the BCFPI interview, and interpretation of its standardized T scores. It also includes detail re the areas covered by the interview, including child mental health, child functioning, caregiver mood, family adjustment, family functioning, and other risk and protective factors (including barriers, readiness, abuse and family demographics).

The steps listed below guide a user through a report, to obtain and assess case information, designed to support the user's triaging and case management decisions. The references are available in the appendix to the interview manual.

Steps to Review a BCFPI Intake report

STEP 1: CONSIDER LIMITS TO THE INTERVIEW

It is important to remind yourself of the limits of this brief interview. As noted above, the BCFPI does not constitute a comprehensive assessment, does not yield diagnoses, reflects the perspective of a single informant, and inevitably yields a certain percentage of false positive and false negative results. Parents, for example, may have more difficulty judging the severity of a child's anxiety or mood disorders and may be unaware of antisocial behaviour such as theft or substance abuse. Other problems, such as Attention Deficit Hyperactivity Disorder, are often most evident in classroom settings. Parental mood may influence child behaviour directly, or effect ratings indirectly by influencing parental perceptions of child problems (Boyle & Pickles, 1997a,b).

STEP 2: REVIEW NARRATIVE DESCRIPTION OF PRESENTING CONCERNS

Print /view the BCFPI's Standard Parent Report. Review the problems identified by the informant and accompanying narrative details recorded in the Comments section at the top of the BCFPI's Standard Parent Report. The Comments section should include important contextual information such as a recent divorce or custody dispute, additional concerns emerging during the interview, specific service requests, etc.

STEP 3: REVIEW BACKGROUND INFORMATION AND DEMOGRAPHIC DATA

Review the demographic information summarized in the BCFPI's Standard Parent Report. Demographic measures often act as general risk or protective factors. Limited education, economic disadvantage, and single parent status, for example, may increase child risk (Offord, Boyle, & Racine, 1990) and reduce the odds of service utilization (Cunningham, et al., 2000; Offord et al., 1987). Higher educational and economic levels, in contrast, may act as protective factors and may be linked to improved service utilization.

STEP 4: REVIEW THE COMPOSITE SCORES

Using the Standard Parent Report, review the BCFPI's composite 18 question Externalizing, 18 question Internalizing, and 36 Item Total Composite problem t-scores. Composite scores are more reliable measures of child functioning than individual subscales. They often constitute better estimates of overall risk, better measures of service outcome, and better predictors of the longer term course of child problems than individual subscales.

STEP 5: EXAMINE PATTERNS OF COMPOSITE SCALE SCORES

Examine the pattern of composite Externalizing and Internalizing child problem t-scores. Epidemiological research consistently yields three clusters of clinical problems: (1) High Externalizing problems and Low Internalizing problems, (2) High Internalizing problems and Low Externalizing problems, (3) a combination of High Externalizing and High Internalizing problems, or Low Externalizing and Low Internalizing. These clusters are important to the estimation of risk, design of service plans, the measurement of outcome, and the prediction of long-term outcome.

STEP 6: REVIEW INDIVIDUAL MENTAL HEALTH SUBSCALE SCORES

Review individual Mental Health subscale scores (e.g. Cooperativeness, Managing Anxiety, Managing Mood, etc.). T-scores of 70, higher than 98% of the norming population, are generally considered to be a significantly elevated score. A t-score of 65 (greater than 93% of the population) might be considered a borderline score.

STEP 7: EXAMINE PATTERNS OF SUBSCALE SCORES

Next, examine t-score patterns. Many children present with combinations of the BCFPI's subscale scores (Offord, et al., 1987). For example, approximately 40 to 50% of children who have difficulty regulating attention, impulsivity and activity level, also have difficulty establishing cooperative relationships with adults and peers (Szatmari, Boyle, & Offord, 1989). Children who have difficulty regulating attention, impulsivity and activity level often evidence problems managing their anxiety or moods (March, et al., 2000). Combinations of problems influence risk, treatment selection, response to treatment (March, et al., 2000), and long term outcome.

STEP 8: REVIEW ITEM BY ITEM RESPONSES

Examine responses to individual BCFPI questions and clusters of questions… What questions contributed to t-scores above 70? Which items accounted for borderline scores. Pay particular attention to high risk questions such as those on the Conduct, Self Harm, and abuse scales.

STEP 9: REVIEW CONTEXTUAL NARRATIVE

Read the contextual narrative comments recorded by the interviewer in the text box below each question. The contextual narrative of the BCFPI may suggest other problems which need to be explored in follow-up interviews, situational influences on child behaviour, precipitating factors, or clues regarding potentially useful interventions.

STEP 10. CONSIDER CHILD FUNCTIONING SCORES

Review the Global Child Functioning score. This score provides an overall estimate of the impact of the problems discussed in the BCFPI interview on the child's extracurricular, social, and academic functioning. Higher t-scores reflect higher overall levels of functional impairment. These scores provide an important check on the severity of the problems noted in the BCFPI's behavioural and emotional subscales.

The levels of impairment associated with different problems varies considerably. For example, high t-scores on the BCFPI Mood Management subscale are typically associated with higher levels of impairment than high scores on the Managing Anxiety subscale. Next, examine individual Social Participation, Social Relationship, and School Participation subscale scores. High t-scores on child functioning subscales may suggest important targets for intervention. A child whose social participation has been limited as a result of difficulties managing mood or anxiety, for example, may benefit from an intervention designed to increase participation in enjoyable extracurricular activities and establish new friendships.

Low t-scores on Child Functioning scores may reflect child strengths. For example, a child whose School Participation and Achievement does not appear to have been affected by difficulties in other areas has assets that can be capitalized upon when planning interventions.

STEP 11: EXAMINE IMPACT ON FAMILY SCALES

Review the Global Family Situation Score. This score provides an overall estimate of the impact of the problems discussed in the BCFPI interview on family functioning. Higher t-scores reflect higher overall levels of functional impairment and risk. This score is, again, important in understanding contextual factors that may influence service planning and outcome.

Next, examine the Impact on Family subscales: Family Activities and Family Comfort. These subscales describe the extent to which problems may be associated with a breakdown in family networks, conflict between partners, or overall distress regarding the child. These scores provide clues regarding issues which need to be addressed in follow-up assessments, potential targets for intervention, and family strengths. For example, if the child's behaviour has become a source of conflict between partners, interventions (readings, books, videos, or workshops) designed to improve problem solving and conflict resolution skills may be helpful.

STEP 12: CHECK FOR ABUSE

Examine the 4 BCFPI questions devoted to emotional abuse, physical abuse, sexual abuse, and exposure to domestic violence. Positive responses to these questions require narrative follow-up and may necessitate a report to child protective services.

STEP 13: EXAMINE INFORMANT MOOD

Examine Informant Mood t-scores. Note that high t-scores on this scale are associated with more depressed mood.

STEP 14: EXAMINE FAMILY FUNCTIONING

Examine t-score for Family Functioning. Note that the positively worded items on this subscale are reversed when the BCFPI software computes t-scores. High t-scores on this scale are associated with more dysfunctional family relationships.

STEP 15: OTHER ITEMS AVAILABLE FOR INQUIRY

Review responses to the 'Other Items Available for Inquiry' questions. Determine whether other issues emerging during the interview must be followed up with more detailed clinical assessments. For example, in a proportion of children with difficulties managing anxiety, concerns regarding obsessions or compulsive behavior may be noted. Others report very specific fears or phobias. Some children who have difficulty regulating attention, impulsivity and activity level, may evidence learning problems or in some cases movement problems such as tics or vocalizations.

STEP 16: READINESS FOR SERVICE

Using the Standard Parent Report, examine response to questions on the BCFPI Readiness subscale. The client's responses to these questions will provide suggestions regarding potential interim service recommendations (e.g. books, videos, or parenting workshops) and information regarding service delivery preferences. Most parents are interested in reading about or watching a videotape about their concerns and a considerable majority are interested in skill building groups. A growing body of evidence suggests that these resources have a significant clinical impact (Montgomery, 2002).

STEP 17: BARRIERS TO SERVICE UTILIZATION

Using the Standard Parent Report, review client responses to the BCFPI's Barriers subscale. Determine whether transportation difficulties, the location and time of your services, family work schedules, child care demands, and other logistical factors might prevent or limit utilization of your services. Note that barriers are often higher in cases with other demographic risk factors such as economic disadvantage or limited parental education. Formulating individual service plans or developing organizational service delivery models that reduce barriers will improve the utilization and effectiveness of your services.

STEP 18: CONSIDER SERVICE PRIORITIES

The BCFPI does not yield a simple formula for determining service priorities. However, a clinician with the training and experience needed to interpret the BCFPI can utilize BCFPI scores, in combination with available narrative information, to consider service priorities. Several factors should be taken into account when considering service priorities.

• Higher t-scores generally suggest a higher level of risk than lower t-scores.
• With some notable exceptions, children with high t-scores on several BCFPI subscales may be at higher risk than those with a single problem. For example, children with high t-scores on both the Regulation of Attention, Impulsivity, and Activity level and Cooperativeness subscales may be at higher risk than those with either problem alone.
• Children with higher t-scores on the BCFPI's Child Functioning Scales are at higher risk than those with lower scores. Within these scales, poor social relationships may be a particularly significant predictor of longer term difficulties (Offord et al., 1990; Offord, et al., 1992). Note that some of the BCFPI's subscales are correlated with higher functional impairment than others. Table 18 in Chapter 9, for example, shows that, in clinic samples, Managing Mood, Cooperativeness, and Regulating Attention, Impulsivity and Activity Level are more closely linked to Child Functioning scores than Separation from Parents or Managing Anxiety,
• Children with higher Global Family Situation scores scores may be at greater risk than those with lower scores (Offord, et al., 1990; Offord, et al., 1992). Table 19 in Chapter 9 shows that Externalizing problems seem to be associated with higher Global Family Situation scores (more family impairment) than Internalizing problems. Among Internalizing problems, Managing Mood is associated with higher Global Family Situation scores than Separation from Parents or Managing Anxiety.
• Certain demographic factors may be associated with an elevation of childhood risk. For example, economic disadvantage, limited education, or single parent status, appear to be associated with higher risk and poorer outcomes (Offord, Boyle, & Racine, 1990; Offord, et al, 1992) and a lower probability of service utilization (Cunningham, et al.,1995; 2000).
• Other variables may act as protective factors. For example, while economic disadvantage or limited education may constitute risk factors, higher income and education may represent protective factors. Similarly, while poor peer relationships are a significant risk factor, good peer relationships appear to act as a preventive factor (Offord, et al., 1990). Other evidence suggests that participation in sports and extracurricular activities, optional questions on the BCFPI, may act as protective factors.

STEP 19: PLAN FOLLOW-UP ASSESSMENTS

Reviewing the BCFPI data for an individual client prior to conducting clinical assessments allows interviewers to plan questions or select assessment tools that pursue concerns identified during the phone interview. This contributes to a cohesive service delivery process and uses valuable clinical time efficiently. For example, narrative comments, individual subscale t-scores, and combinations of scores may suggest problems that should be pursued in more detailed differential diagnostic assessments. The possibility of a depressive disorder, for example, should be considered when parents report high t-scores on the BCFPI's Managing Mood or Self Harm subscales.

STEP 20: CONSIDER CORRELATED PROBLEMS

Given a knowledge of the literature on childhood behavioral and emotional problems, the BCFPI may suggest comorbid difficulties which are not addressed in this brief interview but should be considered when planning follow-up assessments. For example, children with high t-scores on the BCFPI's Regulating Attention, Impulsivity and Activity Level subscale may be at increased risk of obsessive compulsive disorder or Tourettes syndrome. Interviewers should be alert to the possibility of these correlated difficulties and should record them in the BCFPI's Other Items Available for Inquiry checklist.

The BCFPI's individual subtest scores may also suggest correlated family problems that need to be pursued in follow-up assessments. The types of oppositional behaviours measured in the BCFPI's Cooperativeness subscale, and the antisocial behaviours reflected in the BCFPI's Conduct subscale, for example, may be associated with ineffective discipline, marital conflict, domestic violence, or parental depression. One question regarding quarreling between partners in the BCFPI's Family Comfort subscale may provide clues regarding difficulties in this area. The Family Functioning scale provides additional information regarding family functioning. While the BCFPI's Risk and Protective Factor subsections screen for these difficulties, concerns in these areas should be pursued with more detailed clinical assessments and considered in the development of service plans.

STEP 21: CONSIDER INTERIM SERVICE PLANS

In many cases, clients must wait for more comprehensive assessments and services. In the interim, however, the BCFPI Readiness subscale may suggest resources which parents can use while waiting. These might include books on child development, videotapes on child management, community based parenting groups (Cunningham, Bremner, & Boyle, 1995), local parent support groups, or websites. Accumulating evidence suggests that these types of resources can make a meaningful contribution to client change (Andrews, Swank, Foorman, & Fletcher, 1995). Developing interim service plans capitalizes on the readiness for change and momentum that is often present when families initiate service contacts.

STEP 22: CONSIDER OPTIONAL SERVICE PLANS

The BCFPI may also suggest different interventions which might be considered when developing more detailed assessment and service plans. Much of the literature on evidenced-based treatments is linked to the effectiveness of interventions for specific groups of children and their families (Kazdin & Weisz, 1998). Many of the most promising evidenced-based interventions are manualized for specific problem clusters included in the BCFPI (Chambless & Hollon, 1998). Clinical trials, for example, suggest that different cognitive-behavioural, family, and pharmacological interventions are helpful for children with attention deficit disorder (MTA Cooperative Group, 1999), conduct disorder, anxiety disorders (Labellarte, et al., 1999; Silverman, et al., 1999), and mood disorders (Kolko, Bren, Baugher, Bridge, & Birmaher, 2000).