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Effects upon Affect and Mood

Research studies and reviews of the pediatric literature demonstrate high rates of new psychiatric disorders following pediatric traumatic brain injury.80 ADHD and depressive disorders are the most common lifetime and new diagnoses in children following traumatic brain injury. When looking at depressive symptoms specifically, these seem mainly related to socioeconomic status. An inverse relationship exists between the frequency of depression in children and the level of socioeconomic prosperity.81 However, when one reviews the large groups of studies of head-injured children, there is a significant paucity of data about mood and depression in these children. Most of the data are concerned with cognitive function rather than mood function.82-85 Max and others8687 have documented the development of depression and other psychiatric disorders in children and adolescents following traumatic brain injury, and their findings are consistent with the findings of other researchers that have noted substantial behavioral disorders in brain-injured children.

Measuring Mood Changes in Children Adolescent Psychopathology Scale

The Adolescent Psychopathology Scale (APS) was developed and standardized for use in the clinical assessment of adolescents ages 12 to 19 years. The APS consists of 346 items and requires approximately 45 to 60 min to complete. A significantly impaired adolescent may take somewhat longer for completion. The standardization sample of this test instrument does not include individuals under the age of 12 years or over the age of 19 years. Therefore, this test should not be used for children or young adults outside those age ranges.88 Reading level requirements are at about the third-grade level. However, the test author advises that years of completed education is not a reliable indicator of reading ability, and it is recommended that the youngster be administered an appropriate reading test such as those described in Chapter 6.

This is a self-report measure of psychopathology, and the test instrument has been devised to comport with the majority of DSM-IV Axis I clinical disorders and five of the DSM-IV Axis II personality disorders. The APS was designed specifically for adolescents, and it is not a downward extension of adult scales from other test instruments. It assesses four broad content domains: (1) clinical disorders, (2) personality disorders, (3) psychosocial problems, and (4) response style indicators. The APS further provides the perspective of internalizing and externalizing domains, which are based on a factor analysis of the scales. Specific analytical procedures for performing this function are contained within the technical manual, and a well-trained psychologist experienced with this test instrument should have no difficulty with interpretation. The clinical disorder scales deal with 20 DSM-IV diagnoses: ADHD, conduct disorder, oppositional defiant disorder, adjustment disorder, substance abuse disorder, anorexia nervosa, bulimia nervosa, sleep disorders, somatization disorder, panic disorder, OCD, generalized anxiety disorder, social phobia, separation anxiety disorder, PTSD, major depression, dysthymic disorder, mania, depersonalization disorder, and schizophrenia. The personality disorder scales evaluate pervasive aspects of inner sense, feelings, affect, and thoughts, as well as behaviors that deviate significantly from normal characteristics of adolescence. The five personality disorder scales include avoidant personality disorder, obsessive-compulsive personality disorder, borderline personality disorder, schizotypal personality disorder, and paranoid personality disorder.

The psychosocial problem content scales function primarily as targets for intervention. These scales are categorized along the internalizing-externalizing dimension noted previously. The psychosocial problem content scales include self-concept, psychosocial substance use difficulties, introversion, alienation-boredom, anger, aggression, interpersonal problems, emotional lability, disorientation, suicide, and social adaptation. A number of these problems are important in the assessment of children following traumatic brain injury, and they would include the anger, aggression, emotional lability, and suicide scales.

The response style indicator scales are used for validity checks. They include four scales: (1) lie response, (2) consistency response, (3) infrequency response, and (4) critical item endorsement. The Lie Response Scale assesses the adolescent's openness and willingness to give honest answers. The Consistency Response Scale measures the youngster's understanding of item content and serves as a potential screener for random responding or inattention. Inattention could occur due to poor reading comprehension or serious brain injury, and that should be kept in mind. The Infrequency Response Scale contains items that generally are not endorsed by normal adolescents. They represent unusual and bizarre behaviors, affect, and cognition. The Critical Item Endorsement Scale consists of 63 of the 346 items on the APS. They are designated as critical items for their ability to differentiate clinical from nonclinical individuals.

Behavior Assessment System for Children

The Behavior Assessment System for Children (BASC) is a multimethod, multidimensional approach to evaluating the behavior and self-perceptions of children ages 21/2 to 18 years. The BASC has five components, which may be used individually or in any combination. These are (1) a self-report scale, in which the child can describe his or her emotions and self perceptions; two rating scales, (2) one for teachers and (3) one for parents, which gather descriptions of the child's observable behavior; (4) a structured developmental history; and (5) a form for recording and classifying directly observed classroom behavior.89

The author has used this instrument in his practice for a number of years, as he has most of the other instruments discussed in this text. Through trial and error, it has been learned that the teacher section of the BASC correlates poorly with measurements made in the doctor's office. It seems that teachers are significantly concerned about identifying a child with special needs, as that child will then require government-mandated programs. Therefore, the author has discovered that unless the child is so observably brain injured that no one can miss it, teachers are loathe to describe the child's behavior as being significantly different following a brain injury. Moreover, they see potential risk in that they might be pulled into a legal situation. Therefore, it is not recommended that the teacher forms be used with this test instrument in the assessment of traumatically brain-injured children, as the results may be spurious.

Norms are representative of the general population of children for that age and sex. There are separate-sex norms for males and females. The test authors point out, for example, that although raw score ratings on the Aggression Scale tend to be higher for males than females, use of separate-sex norms removes this difference and produces distributions of normative scores that are the same for both sexes. Whereas the Teacher Rating Scales should not be used generally for brain injury assessment, the Parent Rating Scales (PRSs) and the Self Report of Personality (SRP) are useful.

The SRP consists of statements that are responded to as true or false. It takes about 30 min to complete and has forms at two age levels: 8 to 11 years, and adolescents from 12 to 18 years. The child level has 12 scales and the adolescent level has 14 scales. Both levels have identical composite scores: school maladjustment, clinical maladjustment, and personal adjustment. An overall composite score, the Emotional Symptoms Index, is obtained.

The PRSs are a comprehensive measure of a child's adaptive and problem behaviors in the community and home settings. The PRSs use a four-choice response format and take 10 to 20 min for the parent to complete. There are three forms at three age levels: the preschool child, the child, and the adolescent. The PRSs produce a clinical profile that delineates the following behaviors: (1) hyperactivity, (2) aggression, (3) conduct problems, (4) anxiety, (5) depression, (6) somatization, (7) atypicality, and (8) withdrawal. Two composite scores are also generated that measure whether the child is externalizing or internalizing problems. Scales 1, 2, and 3 measure internalization of problems, and scales 4, 5, and 6 measure externalization of problems.

Since the BASC has the PRSs as well as the self-report from the child, interesting contrasts or difficulties within family structures due to the brain injury may often be determined. The weakness of this test is that currently the basic structure of clinical descriptors is based on the DSM-III-R rather than the more contemporary DSM-IV.

Minnesota Multiphasic Personality Inventory-Adolescent

The Minnesota Multiphasic Personality Inventory-Adolescent (MMPI-A) was developed because many studies of the MMPI test instruments have demonstrated the importance of using adolescent norms for young people. The use of adult norms applied to adolescents tends to overpathologize or make adolescents appear more disturbed than they actually are. Thus, the MMPI-A is an outgrowth of the MMPI Adolescent Project Committee of the University of Minnesota, which was specifically appointed to develop the MMPI-A.90

The MMPI-A contains 478 items. All the basic clinical scale items, as well as those that are unique to the adolescent form, appear among the first 350 questions. Thus, scores for F2, F, VRIN, TRIN, the content scales, and the supplementary scales are not obtainable in the first 350 items, but require complete administration of the test booklet. The clinical sample for the normative base included 420 boys and 293 girls, ages 14 to 18. It is recommended that the MMPI-A be used with 14- to 18-year-olds. The grade level of the clinical sample ranges from 7 to 12, and all normative subjects were enrolled in school, although some were attending school in a psychiatric treatment facility. When scored on the basis of the original MMPI norms, this clinical sample produced clinical scale profiles that were very similar to those of the previous clinical sample used by Marks et al.91 to develop the MMPI code-type data for adolescents.

It is thought to be possible that bright, mature 12- or 13-year-old adolescents can comprehend and respond validly to the MMPI-A. However, ethically it must be reported by the examiner that these age levels are outside the normative database. Also, for adolescents age 19, the MMPI-2 should be used rather than the MMPI-A. For 18-year-olds, the maturity level allows the clinician to make some judgment about whether to use the MMPI-A or the MMPI-2 during examination.

An essential requirement is adequate English language reading comprehension. This could prove especially troublesome for a youngster who was learning disabled or had ADD prior to traumatic brain injury. Alternative test instruments may be required for this group of youngsters. Some brain-injured youngsters may be too easily distracted, hyperactive, or impulsive to complete 478 items in a single testing session. Thus, frequent breaks may be required. The majority of

MMPI-A items are at the fifth- to seventh-grade reading level. The author recommends that all adolescents be screened for reading skill prior to administration of the test instrument.

The validity indicators contain some differences from those of the MMPI-2. Those that are similar to the MMPI-2 are the Cannot Say, L, F, K, VRIN, and TRIN scales. Two new validity scales, F1 and F2, are unique to the MMPI-A. The Cannot Say measures the total number of items that the adolescent failed to answer true or false. The L scale may be used as a measure of naive defensiveness in adolescents. F, the Infrequency Scale, is divided into a 33-item F1 scale and a 33-item F2 scale. The F1 scale is a direct descendant of the traditional F scale from the original MMPI. The F2 scale consists of items that occur in the latter half of the test booklet. Thus, the F1 and F2 scales for the MMPI-A may be used in an interpretive strategy similar to the one recommended for the F and Fb scales in the MMPI-2. Because all the F1 scale items appear in the first 350 items of the MMPI-A booklet, this measure provides a method for evaluating the acceptability of the response pattern for the basic MMPI-A scales. The F2 scale operates like the Fb scale of the MMPI-2 in that it provides an index of the acceptability of the test record in relation to the MMPI-A content and supplementary scales. F1 will enable the psychologist to determine the likelihood of significant symptom magnification or even malingering of psychological problems.

The K scale is a basic validity indicator in the MMPI-A, but few descriptors are available from the normative samples. The test manufacturer recommends that interpretation of K profiles with elevated T-scores (> 65) include a cautionary statement about the possibility of a defensive test-taking attitude. The test authors recommend that TRIN should be used to clarify elevations on this scale and psychological consultation will be necessary to complete this analysis. The VRIN and TRIN scales are new validity scales developed with the second edition of the MMPI-2. They are quite different from the traditional L, F, and K scales. VRIN and TRIN scores indicate the tendency of a person to respond to items in ways that are inconsistent or contradictory. TRIN is made up exclusively of pairs that are opposite in content. Thus, this scale can be used to determine whether the adolescent is acquiescent or nonacquiescent to true or false responses. VRIN is useful to determine if the adolescent is answering the questions carelessly or is confused. Moreover, it can be useful for determining symptom magnification or malingering. A high F1 with a normal or low VRIN is consistent with the adolescent understanding the responses and deliberately skewing the responses of the test items to represent either symptom magnification or malingering. A high elevation on VRIN accompanied by a high elevation on F1 may be consistent with a disorganized or confused adolescent who cannot attend to the test items or comprehend the test items. Psychological consultation is required for the neuropsychiatric examiner to fully use the validity scales on the MMPI-A.

The MMPI-A contains 10 clinical scales. These have the same names as the MMPI-2 or the original MMPI scales, and they include:

1 — Hs: hypochondriasis

4 — Pd: psychopathic deviate

5 — Mf: masculinity/femininity

0 — Si: social introversion

As is true for the interpretation of the MMPI and MMPI-2 with adults, the adolescent MMPI-A interpretation is often done by code type. The only published empirically developed code type for the MMPI-A was by Marks et al.91 Archer and Klinefelter published code-type frequency data for

1762 adolescent patients who received the original form of the MMPI and were scored using the Marks et al. norms and the MMPI-A norms.92

The scoring and interpretation of the MMPI-A have options specific for adolescents that are not present for the adult interpretive schemes. For instance, the potential for school problems can be determined by two of the MMPI-A content scales (A-SCH and A-LAS). Several other MMPI-A scales also include school problems (see the MMPI-A 1992 manual). Scale 0 (Si) and its subscales are helpful for describing problems of social relationships. These of course occur very frequently in adolescents following traumatic brain injury. Predictions about family problems can be made from the A-FAM scale. Alienation (A-ALN) and cynicism (A-CYN) are covered by the MMPI-A content scales. Negative peer group influences can be inferred from elevations on the PRO scale, given its item content. The IMM scale also provides information relating to interpersonal style and capacity to develop meaningful relationships. Elevations on the A-TRT scale can be interpreted as an indication of the presence of negative attitudes toward mental health treatment that may interfere with building a therapeutic relationship.90 As with the adult MMPI-2, psychological consultation is recommended when using the MMPI-A.

Multiscore Depression Inventory for Children

The Multiscore Depression Inventory for Children (MDI-C) is a 79-item questionnaire in the form of brief sentences presented in a true-false response format. The administration time is about 15 to 20 min. This test instrument is standardized for ages 8 to 17, and it allows children to indicate their own feelings and beliefs about themselves. It is an unusual test in that it is the first behaviorally oriented test for children that was written by children in their own words.93 The MDI-C is reportedly useful both as a screening instrument and to identify high-risk children within clinical assessments. It yields scores on eight scales, as well as a total score measuring the general severity of depression. It may be scored on a computer, by sending the score sheet by fax to the manufacturer, or by mailin scoring.

The MDI-C scales are anxiety, self-esteem, sad mood, instrumental helplessness, social introversion, low energy, pessimism, defiance, and total. The Anxiety Scale measures cognitive and somatic aspects of anxiety. The Self-Esteem Scale reflects children's perceptions of themselves. The Sad Mood Scale is basically what it says. The Instrumental Helplessness Scale measures children's perceptions of their abilities to manipulate social situations in order to receive ordinary benefits. The Social Introversion Scale reflects the tendency to withdraw from social situations and social contact. The Low Energy Scale measures cognitive intensity and somatic vigor. The Pessimism Scale gauges children's outlook to the future. The Defiance Scale measures irritability and other behavior problems. The Total Scale sums all 79 items, including a Suicide Risk Indicator, and is an overall measure of depression. The scale items have a third-grade reading level. Most children have few problems understanding the content, since children wrote it. There are scales to determine faking good and faking bad as response biases. Children are more likely to have a defensive response or a "faking good" response, as they may be worried how adults or professionals will react to their problems. Children with high scores on the Infrequency Index are either "faking bad" or suffering extreme forms of depression. This instrument includes scales that address features widely agreed to accompany depression or contribute to it. The scores are displayed as T-scores exactly analogous to the T-score presentation with the MMPI-A. On this test instrument, the most reliable and valid measure of depression in a child is the total score of the MDI-C. This score is a measure of severity of childhood depression. Children with total scores greater than 65T have sad or blue moods often. They may be irritable, helpless, hopeless, and lack energy. Vegetative signs of depression may be present. On the subscale for suicidal ideation, children with total scores above 65T should be carefully evaluated for suicidal behaviors and ideas. Item 45 from this test instrument contains a Suicide Risk Indicator ("I have a suicide plan."). Furthermore, the test manufacturer recommends evaluating the child's answers to item 5 ("I think about death a lot."),

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