Life Beginning Again: Limited Assessment Protocol

Dr. Craig Childress: Attachment Based "Parental Alienation" (AB-PA)

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A Limited Scope Assessment Protocol

I am a clinical psychologist. As a clinical psychologist, I am trained and professionally knowledgeable in the construction, administration, scoring, and interpretation of assessment instruments and procedures. I have constructed assessment protocols in the past.

In this companion blog to Comment of Child Custody Evaluations, I am going to describe the six-session treatment focused assessment protocol. But before beginning, I want to set the context for the level of the discussion. This is not my first time developing a structured assessment protocol for a category of pathology. I have done so with juvenile firesetting behavior for FEMA and the Department of Justice, and I have done so with early childhood pathology for a multi-university collaboration in the assessment and treatment of childhood trauma pathologies.

Before beginning my description of the six-session treatment focused assessment protocol for attachment-related family pathology surrounding divorce, I am going to describe the two prior assessment protocols I developed for other pathology types, and provide the direct protocols for these assessments. My goal is to set the standard of professional expectation for discussion of pathology assessment protocols, and the psychometric properties of protocol development.

Juvenile Firesetting

I served as the Clinical Director for a FEMA/Department of Justice project to develop a mental health assessment protocol for juvenile firesetting behavior. I worked with Dr. Kenneth Fineman on this project, he is a Board Certified forensic psychologist and an internationally recognized expert on juvenile firesetting behavior. He provided the professional expertise in juvenile firesetting behavior, I provided the professional expertise on the design and construction of pathology assessment protocols.

Of note regarding this prior project on assessing juvenile firesetting behavior and my current involvement in the assessment of court-involved family conflict, is that juvenile firesetting behavior is also a domain of court-involved pathology. The assessment protocol we developed for juvenile firesetting behavior addressed both the court-involved juvenile justice component and the mental health component of the behavior.

Child custody family pathology is not my first encounter as a clinical psychologist with world of court-involved forensic psychology . I understand the requirements of the court and legal system, and I have integrated this knowledge into the structure of the treatment-focused assessment protocol.

The juvenile firesetting assessment protocol we developed for FEMA and the Department of Justice involved several layers. The initial protocol was a screening assessment performed in the field by the contact fire fighter who responded to the juvenile firesetting incident. This screening instrument triaged the firesetting behavior into one of three categories (Simple curiosity firesetting; Complex firesetting behavior requiring additional mental health assessment; Emergent firesetting behavior of high concern and immediate risk). The categorization of firesetting behavior into Simple, Complex, or Emergent types was based three factors, 1) the type of fire set, 2) what the juvenile intended to set on fire, and 3) the outcome of the firesetting behavior.

Based on the initial triage screening, three levels of intervention followed. For simple child curiosity firesetting behavior, the child received a full-day fire safety education class from the fire agency. For Complex firesetting behavior, an additional comprehensive mental health assessment of the firesetting behavior was conducted. For Emergent firesetting behavior, a juvenile justice response and immediate risk management steps were initiated.

In addition to the initial screening of the firesetting behavior, we also wanted a triage screening instrument for possible emotional, psychological, and family problems, independent from the direct assessment of the firesetting behavior. This mental health screening instrument needed to identify a full range of potential psychological issues, it had to have solid psychometric properties, and it needed to be sufficiently simple to be administered by a non-professional (the fire fighter in the field). After a review of the structural and psychometric properties of possible instruments, we selected the Pediatric Symptom Checklist as the mental health triage screening instrument.

At the second level of assessment is the mental health assessment protocol for the juvenile firesetting behavior. At this level, we developed a structured clinical interview assessment instrument for the parent and a separate structured clinical interview for the child that systematically reviewed a set of features associated with juvenile firesetting behavior. For the child, this included a behavior-chain interview regarding the firesetting incident designed to identify triggers to the behavior.

Firesetting Assessment: Structured Child Interview Protocol

The interpretation of the data from this comprehensive mental health assessment protocol for juvenile firesetting behavior was summarized on a form:

Firesetting Reinforcement Summary

This description of the assessment protocol we developed for juvenile firesetting behavior is provided as an indication that the current six-session treatment focused assessment protocol for attachment-related family pathology surrounding divorce is not my first project in developing an assessment protocol for a court-involved pathology.

If the assessment of court-involved attachment related pathology surrounding divorce required an assessment protocol at a higher level of specificity, I could develop it. I know how to do that. I’m a clinical psychologist. Developing assessment instruments and assessment protocols is within the specialty scope of practice for clinical psychologists.

But the assessment of attachment-related family pathology surrounding divorce does not require such an extensive assessment protocol. What it does require is the diagnostic foundation for the pathology in order to identify a parsimonious set of symptom features that are characteristic of only this form of pathology (AB-PA). Each assessment protocol for pathology presents its own unique set of challenges and solutions.

During the period of my work on the FEMA/DOJ juvenile firesetting project, I was also on medical staff as a pediatric psychologist at Children’s Hospital of Orange County. Along with my role as an on-call psychologist with the various medical units of the hospital, my primary role was as the lead clinical psychologist from CHOC working with our collaborative partners at the University of California, Irvine Child Development Center (Dr. Jim Swanson). Dr. Swanson is one of the leading figures in ADHD. I left Children’s Hospital of Los Angeles and took the job at CHOC specifically to work with Dr. Swanson and the UCI Child Development Center. The project was a collaborative CHOC-UCI venture to identify (and resolve) ADHD in preschool-age children. While at CHOC, I also served as a clinical supervisor in their APA accredited internship program and with post-doctoral fellows recruited to the hospital for training in medically involved pediatric psychology.

The next phase in the unfolding of my professional experience in child and family pathology began when I left CHOC to serve as the Clinical Director for an early childhood assessment and treatment center operated under the auspices of Calif. State University, San Bernardino. The clinic was an integrated project with the County of San Bernardino department of mental health, county child protective services, CSUSB’s psychology program, Loma Linda University’s occupational therapy program, and the University of Redlands speech and language program. The primary population we served were children ages birth to five in the foster care system; prenatal exposure to drugs and alcohol, exposure to violence and child abuse, profound parental neglect, sexual abuse victimization, autism-spectrum and developmental issues, foster care placement and attachment pathology.

The clinic had professional staff from each of the universities at the clinic. I was CSUSB’s clinical psychology representative. Initially, the psychology team was split into an infant division (zero to two) and a preschool-age division (two to five years old). I was initially the Clinical Director for the preschool-age children division, and a clinical psychologist from Loma Linda was the director for the infant division. My professional background was with ADHD, which is an older child issue, and I came to early childhood through ADHD. Infant psychology from zero to two is a unique sphere of professional practice because of the child’s foundational psychological emergence and limited capacity for communication during infancy. Assessment is different in infancy, and treatment is different in infancy. About a year into the project, the infant program director from Loma Linda University left, and I assumed the Clinical Director responsibilities for both infant assessment and treatment and for preschool-age assessment and treatment.

Along with professional staff from each of the university partners, each university also placed student interns at the clinic. The clinic assessment protocol for children ages zero to five in the foster care system integrated assessments protcols from clinical psychology (CSUSB), occupational therapy (Loma Linda University), and speech and language (University of Redlands), administered through clinical interns from the respective university training programs. In my role as the Clinical Director, I supervised both a professional staff and a set of MFT interns and post-doctoral fellows regarding the assessment of early childhood pathology and its treatment.

Our funding was primarily through the county Department of Behavioral Health in collaboration with the Department of Children and Family Services (child protective services). County mental health services have a standard documentation protocol. However, as a triparate interdisciplinary collaboration of three university training programs, our clinic sought to provide the highest standard of professional practice in the assessment and treatment of early childhood pathology. As the Clinical Director for the program, I developed the early childhood intake assessment protocol to reflect the highest standards of professional practice for the clinical intake assessment of early childhood mental health pathology.

Early Childhood Assessment Protocol

Following the intake assessment, we then developed the specific assessment protocol for each child, integrating child-specific psychological testing and assessment with occupational therapy and speech and language assessments. In many cases, the child’s emotional and behavioral dysregulation created from childhood trauma would not permit the child to participate in traditional assessment procedures. To address this, we also developed the capacity for unstructured play-based assessment.

Play Based Assessment

A sexually abused two-year-old of a meth-addicted mother, who was prenatally exposed to drugs and alcohol, and who is in their third foster care placement, doesn’t always cooperate with standardized assessment procedures. But when we know what we’re looking for, we can develop in-vivo circumstances that allow the young child to display current and emerging cognitive and social capabilities.

In the assessment protocol for attachment-related family pathology surrounding divorce, the two parent-child sessions similarly represent in-vivo opportunities for the child to display their current cognitive beliefs and their emotional regulation capacities.

Treatment Focused Assessment

I left the clinic and entered private practice in 2008, anticipating that I would begin winding down my career into writing books about the neuro-development of ADHD and its association to the attachment system and intersubjectivity. It was through my private practice that I was contacted by a guardian ad litem who asked me to submit my vitae. I did, and this GAL selected me as the treating therapist. This client became my introduction to court-involved attachment-related family pathology surrounding divorce.

My work with this pathology has grown, and I have been sought out by family law attorneys for expert consultation and testimony. In this capacity, I’ve had the opportunity to review many child custody evaluations. As a clinical psychologist, I am appalled at the absence of professional rigor and professional standards of practice consistently displayed in the child custody evaluations I have reviewed. Ethical violations by professional colleagues triggers Standards 1.04 and 1.05 of the APA ethics code directing my response. In order to address my professional concerns under the requirements of Standards 1.04 and 1.05 of the APA ethics code, I have undertaken a variety of initiatives – from posting YouTube videos, to writing a blog, to composing a Petition to the APA now signed by over 20,000 parents.

I also set about the process of developing a structured assessment protocol for court-involved attachment-related pathology surrounding divorce. In addition to providing a professional critique of the inadequacies of child custody evaluations, the treatment focused assessment protocol that I developed for attachment-related family pathology surrounding divorce provides a clear definition of an alternative assessment approach and protocol that is embedded in the standards of practice for clinical psychology. By developing this assessment protocol, I am anchoring the discussion of the clinical psychology assessment of pathology in a concrete example of what I would propose as a clinical psychologist experienced in protocol development for pathology.

The six-session treatment focused assessment protocol begins by limiting the scope of the referral question to one that can be answered by clinical psychology:

Referral Question: “Which parent is the source of pathogenic parenting creating the child’s attachment-related pathology, and what are the treatment implications?”

Attachment-related pathology is always caused by pathogenic parenting (patho=pathology; genic=genesis, creation). Pathogenic parenting is the creation of significant psychopathology in the child through aberrant and distorted parenting practices. Pathogenic parenting is an established construct in both developmental and clinical psychology, and is typically used with regard to attachment-related pathology since the attachment system never spontaneously dysfunctions, but only becomes dysfunctional in response to pathogenic parenting.

The differential diagnosis is to identify which parent is the source of pathogenic parenting creating the child’s attachment related pathology surrounding divorce. The assessment protocol is structured around two data documentation instruments, one documents the potential pathogenic parenting of the targeted parent through abusive parenting practices (Parenting Practices Rating Scale), and one documents the potential pathogenic parenting of the allied narcissistic-borderline parent who has formed a cross-generational coalition with the child against the targeted parent (Diagnostic Checklist for Pathogenic Parenting).

The information needed to complete these two data documentation instruments can typically be obtained in six semi-structured clinical interview sessions in three phases, with each session collecting a subset of relevant information.

The first phase of clinical interview sessions is to collect history and symptom information from each parent individually. In the second phase of clinical interviews, the child’s symptoms and the parenting of the targeted parent is directly evidenced in-vivo. In the third phase, the parents are presented with information about the outcome of the assessment, and the cognitive schemas of each parent for organizing this information is assessed.

A structured report is then prepared for the parents (and the court) that provides the data from the two data documentation instruments and discusses the treatment implications based on predefined patterns of child and family symptoms (operational definitions of the pathology).

As a clinical psychologist, it is my professional opinion that a six-session treatment focused assessment protocol by a knowledgeable psychologist (the attachment system, personality disorder pathology, family systems therapy, complex trauma) can answer the referral question of “Which parent is the source of pathogenic parenting causing the child’s attachment-related pathology?”

Professional standards of practice in assessment encourage that the assessment protocol be as limited as required to answer the referral question. This surrounds the issue of protecting the privacy of the family members. Child custody evaluations are a substantial (and unnecessary) intrusion and exposure of the family’s personal privacy surrounding the marriage and divorce. The referral question is not about the marriage and divorce, the referral question is about establishing a post-divorce child custody and visitation schedule (or about identifying the source of pathogenic parenting creating the child’s attachment-related pathology following the divorce).

The alternative referral question of identifying the source of pathogenic parenting creating the child’s attachment-related pathology provides a limited scope and focused assessment protocol and report to the court that substantially limits intrusion into the privacy of family members.

If additional standardized test data is sought, I would recommend 1) the Robert’s Apperception Test for Children– Second Edition (RATC-2) to assess the child’s emotional and psychological functioning directly from the child through standardized testing using projective techniques, and 2) the Personality Inventory for Children–Second Edition (PIC-2) to obtain parent-rated perceptions regarding the child’s personality and emotional characteristics. However, while the information from these two standardized assessment instruments would be interesting (particularly from the projective techniques of the RATC-2), the information seems of little assessment utility because it is unclear how the information would be weighted and used in answering the referral question.

What the discussion of possible additional test instruments highlights is that the six-session treatment focused assessment protocol serves as a core for a limited-scope treatment focused assessment of pathology. If information from additional procedures or instruments is deemed valuable, then these assessment procedures and instrumens can be added to the core protocol.

Life Beginning Again

Friday, August 03, 2018

Limited Assessment Protocol

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