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22 Assessment of Childhood Disruptive Behavior Disorders

and Attention-Deficit/Hyperactivity Disorder


The focus of this chapter is to provide an updated presen- crucial for diagnostic decisions and case conceptualiza-
tation of current evidence-based practices in the assess- tion (Barry, Golmaryami et al., 2013); (3) in addition to
ment of attention-deficit/hyperactivity disorder (ADHD) core features of ADHD and DBDs, assessments should
and disruptive behavior disorders (i.e., oppositional defi- evaluate for the presence of co-occurring or comorbid
ant disorder [ODD] and conduct disorder [CD]) in children difficulties; (4) assessment batteries should include tools
and adolescents. In this chapter, the terms “disruptive that add incremental validity to the understanding of
behavior disorders” (DBDs) and “conduct problems” will a child/adolescent’s presentation (see Johnston &
be used interchangeably and are meant to reflect the array Murray, 2003); (5) the clinician should gather information
of behaviors associated with ODD and CD. Approaches to connecting the child/adolescent’s behavioral problems to
comprehensive, multi-informant, multimodal evaluations academic, emotional, legal, or social impairment (Power
will be discussed, and some of the particular challenges in et al., 2017); and (6) evidence-based assessment inherently
these evaluations and limitations of existing methods will involves a scientific approach whereby the accumulation
also be described. We will first provide a current overview of evidence about a case and relevant research inform the
of principles of evidence-based assessment of ADHD, answer to the referral question and the resulting recom-
ODD, and CD. Issues to be addressed include assessment mendations. Underlying each of these issues are consid-
tools, informants, construct-relevant content, technologi- erations of which assessment tools to use, the sources
cal advances, and cultural factors. Finally, we will discuss from which to gather information, and the appropriate-
directions for future research in this area as well as some ness of interpretations generated from the results of the
of the practical implications of the issues presented in the assessment, all within ethical guidelines and potential
chapter. practical constraints of the setting in which assessments
are conducted.
As noted, one of the principal issues in the assessment of
PRINCIPLES OF EVIDENCE-BASED ASSESSMENT ADHD and conduct problems in youth is the need to assess
OF ADHD AND CONDUCT PROBLEMS for a wide array of symptoms and behaviors such that
At its core, evidence-based assessment is that which evaluations account for the heterogeneity of these con-
accounts for research on developmental psychopathology, structs (Barry, Golmaryami et al., 2013; McMahon &
including differences in manifestations of behavioral pro- Frick, 2005; Pelham et al., 2005). To do so, not only is
blems across childhood and adolescence, as well as issues knowledge of ADHD, ODD, and CD symptoms necessary
involved in multimodal assessments that account for chil- but the clinician must also be aware of developmental
dren’s behavioral functioning in multiple settings (Mash & influences on the manifestations of these symptoms and
Hunsley, 2005). Furthermore, these assessments should areas in which related impairment may be most pro-
provide a road map for intervention by accounting for nounced. A crucial aspect of assessing ADHD and conduct
a child’s specific presentation of ADHD and/or conduct problems both for diagnostic and for case conceptualiza-
problems (Barry, Golmaryami et al., 2013). This discus- tion purposes is determining the age of onset of the symp-
sion will center around the following principles: (1) the toms. For ADHD, onset of symptoms before age twelve is
need to assess for the presence of a variety of symptoms/ necessary under the DSM-5 diagnostic criteria (American
behaviors within the broad construct of externalizing Psychiatric Association, 2013), whereas, for conduct pro-
behaviors to account for heterogeneous manifestations blems, including diagnoses of ODD and CD, a wealth of
of ADHD, ODD, and CD (McMahon & Frick, 2005; evidence supports different etiological and prognostic
Pelham, Fabiano, & Massetti, 2005); (2) the developmental implications for childhood onset vs. adolescent onset of
context (e.g., onset, course, severity) of symptoms are problems (Frick & Viding, 2009; Moffitt, 1993).


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Furthermore, these assessments should include informa- intervention is needed as well as potential specific inter-
tion on important aspects of a child’s psychosocial context, ventions (e.g., effective command delivery if the child is
as situational or setting-specific factors may point to pro- persistently noncompliant with parent or teacher
tective factors in a child’s environments, issues that serve instructions). It should also be noted that a child or
to maintain or exacerbate the child’s functioning, and adolescent does not necessarily need diagnosis of
important targets for intervention. ADHD or DBDs to benefit from available interventions,
Beyond assessing core symptomatology and contextual supports, or accommodations. As such, impairments in
factors related to ADHD and DBDs, clinicians should be a child’s daily life are still important to evaluate even if
prepared to assess for the presence of a wide array of the child does not meet a diagnostic threshold for the
problems, including internalizing problems, as comorbid- number, frequency, or persistence of symptoms.
ity in clinical child and adolescent populations is the rule Lastly, an important element of evidence-based assess-
rather than the exception (Frick, Barry, & Kamphaus, ment is that, as more information regarding the depth and
2010). Indeed, the co-occurrence between symptoms of breadth of a client’s symptomatology is gathered, the clin-
ADHD, ODD, and CD can be observed as early as the pre- ician should engage in a process of hypothesis testing,
school years (Bendiksen et al., 2017). Moreover, the pre- whereby all data from all sources are treated as informa-
sence of additional problems has direct intervention tion that helps to confirm or disconfirm hypotheses that
implications. Research on the developmental psycho- address the referral question, including but not limited to
pathology of ADHD and disruptive behaviors points to diagnostic decisions (Barry, Frick, & Kamphaus, 2013). In
additional constructs that should be evaluated for this way, evidence-based assessment has been likened to
a comprehensive picture of impairment. For example, the process of completing a scientific study in that hypoth-
ADHD has been associated with broad, pervasive execu- eses are developed based on background information, data
tive functioning deficits that are connected with specific are collected and interpreted, and conclusions are reached
impairments at home and at school (Barkley, 2013). In the with an emphasis on the next steps to further address the
case of conduct problems, the presence of callous- problem (i.e., informing intervention; Frick et al., 2010).
unemotional (CU) traits, which are analogous to the char- A central aspect of evidence-based assessment, though, is
acteristics of the Limited Prosocial Emotions Specifier in a careful consideration of the methods and informants
the DSM-5 criteria for CD (American Psychiatric used to gain a comprehensive view of the child’s externa-
Association, 2013), emerged as predicting the most severe lizing symptoms.
and persistent behavioral problems in youth (see Frick
et al., 2014).
Particularly from a cost-effectiveness standpoint, clini-
cians should strive to design assessment batteries wherein
General Issues in Selecting Measures
each component has incremental validity. That is, there
should be limited redundancy in the assessment of symp- There is no evidence supporting a single measure or set of
toms and each assessment tool (e.g., interviews, beha- measures as the definitive approach to assessing ADHD or
vioral observations, rating scales, neuropsychological conduct problems. As noted, it is incumbent on a clinician
testing) should provide unique information toward the to conduct an evaluation that will assess for a wide variety
answer of diagnostic or referral questions and for generat- of behavioral issues associated with these constructs as
ing treatment recommendations. The concept of incre- well as potential comorbidities. To that end, clinical inter-
mental validity as an additional consideration beyond views, behavioral observations, and behavior rating scales
traditional psychometric attributes of assessment mea- may represent a parsimonious battery. Importantly, each
sures is discussed further in the “General Issues in of these methods provides incremental validity toward
Selecting Measures” section. answering a referral question while still leaving an oppor-
If the result of a multimethod, multi-informant, evi- tunity to use more specific tools if necessary.
dence-based assessment suggests that a child or adoles- Aside from selecting measures/methods that assess het-
cent has significant problems with inattention, erogeneous presentations of ADHD or conduct problems,
impulsivity/hyperactivity, oppositionality, and/or con- it is also important for measures to appropriately reflect
duct problems, a diagnosis of ADHD, ODD, or CD may developmental context. For example, evaluations of pre-
still not be appropriate. The clinician must first deter- school-age children should place more emphasis on asses-
mine if the symptoms are atypical in their frequency or sing behavioral dysregulation (e.g., temper tantrums),
severity for the child’s developmental level, as well as whereas, for adolescents, conduct problems that reflect
consider whether there are better, alternative explana- covert conduct problems (i.e., acts of opportunity) should
tions for the symptoms. At that point, the connection be more central (Maughan et al., 2004; Ramtekkar et al.,
between apparent difficulties and functional impair- 2010). In the case of rating scales, there must be appro-
ment (e.g., academics, relationships) is needed to priate norms on which to base conclusions about the typi-
make a diagnosis. Perhaps more importantly, the evi- cality/atypicality of a child’s behavioral problems (Frick
dent impairments would highlight areas in which et al., 2010).

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Psychometric features (e.g., reliability, validity, norm unstructured clinical interviews allow the clinician to
sample) are also important in selecting measures. gain information about the connection between the
However, because of the strengths of tools that are not child/adolescent’s symptomatology and functional impair-
norm-referenced (e.g., unstructured interviews, beha- ments in important domains. A number of the tools
vioral observations), there is no ground rule in the area described herein do not provide the flexibility needed to
of evidence-based assessment that states that a measure determine the extent to which problems with concentra-
must pass a specific standard for inclusion in an assess- tion, sustained attention or argumentativeness, for exam-
ment battery (Barry et al., 2013; Mash & Hunsley, 2005). ple, are related to academic or relational difficulties.
Importantly, tests are not inherently reliable or valid. That However, unstructured clinical interviews do not pro-
is, one must consider the appropriateness of the conclu- vide direct information about the extent to which the
sions drawn from a measure given its psychometric prop- child’s presentation is atypical for their age and the infor-
erties, content, and scope (Barry et al., 2013). For example, mation is filtered through an informant who may have
a rating scale that does not provide adequate coverage of their own biases as to the significance of the child’s symp-
symptoms of ADHD or DBDs (i.e., construct underrepre- toms. Importantly, there is no mechanism for unstruc-
sentation) should not be used as a basis for arriving at tured clinical interviews to provide information about
diagnostic decisions on these disorders. noncredible reporting, a limitation that is at least indir-
In addition to reliability and validity, Mash and Hunsley ectly addressed by some rating scales, as discussed in
(2005) emphasize clinical utility as another important “Behavior Rating Scales.” In addition, because of their
consideration in evidence-based assessment (see also client-specificity, unstructured clinical interviews are
Hunsley & Allen, Chapter 2, this volume). Measures or inherently unreliable; thus, clinicians may also opt for
methods with clinical utility “make a meaningful differ- structured diagnostic interviews to gain important infor-
ence in relation to diagnostic accuracy, case formulation mation about symptom presentation in a consistent, reli-
considerations, and treatment outcomes” (Mash & able manner.
Hunsley, 2005, p. 365). Furthermore, as noted, incremen- Structured interviews by nature are consistent and reli-
tal validity speaks to an assessment method’s clinical uti- able, as the clinician is provided with the sequence and
lity in that it indicates the unique information provided by wording of questions that are presumably based directly
the measure (Johnston & Murray, 2003), thus aiding in on diagnostic criteria or core features of behavioral pro-
decision-making and the design of interventions. In blems. In addition, there are clear procedures for scoring
a practical sense, the assessment of ADHD and DBDs such interviews (Barry et al., 2013). Not surprisingly,
should include methods that provide adequate content structured interviews have far superior reliability to
coverage of the primary symptoms of these disorders, unstructured interviews, and structured interviews, if
account for the symptoms across different settings, and selected properly, have clear content validity in that they
recognize developmental differences in how the symp- typically assess the diagnostic symptoms of interest
toms may manifest and link to impairment. To date, directly (Frick et al., 2010). However, for the purposes of
there remains limited data-driven consensus on the clin- assessing ADHD and DBDs, structured interviews have
ical utility of particular measures/methods. Therefore, limitations, including the amount of time required to con-
clinicians must be aware of the relative strengths and duct the interview, the potential for informants to present
limitations of methods such as interviews, behavioral an inaccurately favorable or unfavorable view of the child/
observations, and rating scales and they should be pre- adolescent’s behavior, and the lack of client-specific infor-
pared to design batteries that provide the most compre- mation that would lend itself to interventions (Frick et al.,
hensive and least redundant evaluation of a child’s 2010). Therefore, structured diagnostic interviews may be
attention problems, behavioral issues, and co-occurring most useful when clinicians are unable to make
difficulties. a diagnostic decision from information gleaned from the
other tools discussed here. In that case, the specific,
detailed assessment of diagnostic criteria offered by struc-
Clinical Interviews
tured interviews would have clear incremental validity in
Clinical interviews, particularly unstructured interviews assisting the clinician in answering a referral question
that are tailored to the client, are indispensable in clinical related to ADHD or DBDs.
assessment but are also inherently unreliable (Barry et al.,
2013; Mash & Hunsley, 2005), as they are idiosyncratic to
Behavioral Observations
the case, interviewer, informant, and setting. Interviews
provide important contextual information about the spe- Behavioral observations are unique in that they allow for
cific symptoms of ADHD and the disruptive behaviors direct data gathering of important behaviors of interest,
exhibited by the child, their onset, the degree to which often in a child’s natural setting such as the classroom
they are setting-specific, and numerous other risk and (Barry et al., 2013). Approaches to behavioral observations
protective factors that may inform diagnostic decisions can vary in their structure and targets (see Frick et al.,
and treatment recommendations. Importantly, 2010). A unique strength of behavioral observations is

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the opportunity to observe and record consistent antece- here but widely used rating scale systems, including the
dents (e.g., extended periods of independent work) and Achenbach System of Empirically Based Assessment
consequences (e.g., teacher redirection) of a target beha- (ASEBA; Achenbach & Rescorla, 2001), the BASC-3
vior (e.g., becoming off-task, leaving one’s seat). Indeed, (Reynolds & Kamphaus, 2015), and the Conners-3
objective behavioral observations of activity appear to out- (Conners, 2008), are summarized in Table 22.1.
perform laboratory tasks designed to assess processes Overall, omnibus rating scales, particularly those that
underlying ADHD in predictive validity (Hall et al., 2016). cover theoretically relevant domains and have good psy-
However, there is the potential for reactivity on the part of chometric properties, generally have the advantage of
the child being observed, and there are important charac- providing norm-referenced information in a reliable and
teristics or behaviors that may not be directly observable cost-effective manner (Frick et al., 2010). However, infor-
in the selected situation (e.g., trouble concentrating, cov- mation from rating scales is filtered through the
ert conduct problems). Despite these limitations, beha- perspective of an informant and they lack the depth of
vioral observations are necessary, though not sufficient, client-specific information necessary to ultimately arrive
for drawing conclusions concerning the presence of at an individualized case conceptualization. Knowledge of
ADHD and DBDs, as well as potential avenues for some of the potential pitfalls of using rating scales should
intervention. greatly assist the clinician in selecting rating scales and in
appropriately integrating their results with other available
findings. Single-domain rating scales, often utilized in
Behavior Rating Scales
research, are also available for the assessment of attention
Behavior rating scales and symptom checklists have or conduct problems, as well as related difficulties (e.g.,
become a central part of assessment for a variety of child/ executive dysfunction), and may be used to provide more
adolescent problems as well as adaptive domains. Such in-depth coverage of the constructs of interest and the
measures stand out in terms of their efficiency and the heterogeneity of symptom presentation but still present
availability of norm-referenced scores based on large, gen- the potential issue of noncredible or biased reporting.
erally representative standardization samples. There are However, to date, commonly used rating scales of these
legitimate concerns about the lack of client-specific con- constructs do not include validity scales to aid in interpre-
textual information (e.g., antecedents, consequences of tation of potentially noncredible reporting.
problem behaviors), as well as about potential noncredible In summary, it is important for a clinician to be familiar
reporting. The former points to the indispensability of with the uses, strengths, and weaknesses of a variety of
clinical interviews to gain more information about the assessment methods to provide the most comprehensive
manifestation and developmental trajectory of a child’s evaluation of a child’s problems. To do so, particularly in
behavioral problems. The latter is addressed, in part, by the assessment of children and adolescents, multiple
the inclusion of validity scales in some behavior rating sources or informants are routinely used. This multi-
scale systems, such as the Behavior Assessment System method, multi-informant approach has the unique advan-
for Children – Third Edition (BASC-3; Reynolds & tage of gaining information about an individual’s
Kamphaus, 2015) and Conners – Third Edition (Conners- functioning in a variety of settings on a number of con-
3; Conners, 2008). Validity scales are geared toward noting structs without relying on a single informant or method
a pattern of overly positive, overly negative, or inconsistent that may be unreliable. However, that also means that
response patterns (Frick et al., 2010). However, noncred- a clinician must engage in the difficult process of carefully
ible reports could also be an artifact of reluctance to share considering the use of different informants and deciding
information about negative behaviors, limited observation how to integrate data across different sources based on the
of a child by a particular informant, or alternatively available research (Achenbach, Ivanova, & Rescorla,
a generally negative attitude regarding the child/adoles- Chapter 11, this volume).
cent’s functioning that lends itself to negative reporting
across psychological domains (Barry et al., 2013). Thus,
knowledge of the relative strengths and weaknesses of
different informants for child assessment and specific
Parent Informants
awareness of an informant’s overall view of the child in
question are essential for interpreting rating scale data. For multiple reasons, parents/caregivers are considered
The state-of-the-art rating scales in clinical child and indispensable informants for assessments of children
adolescent assessments are broad-band (i.e., omnibus). and adolescents. For children prior to adolescence, par-
These scales are efficient in that they assess a variety of ents are thought to be the most useful informant (Frick
domains (e.g., inattention, aggression, depression, social et al., 2010). Parents are well-positioned to provide
skills) in a relatively short format, include versions for detailed developmental history and descriptions of beha-
different informants, and generally have strong, represen- viors for their children. Once the child reaches adoles-
tative samples that are the basis of norm-referenced cence, a parent still can provide useful information
scores. A detailed review of these scales is not possible regarding changes in functioning and, when combined

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Table 22.1 Common rating scales used to assess ADHD, ODD, and CD

Number of Relevant Subscales/ Validity

Measure Name Type of Measure Age Range Informants Items Symptom Count Scales Overall Conclusions

Behavior Assessment Omnibus Rating 2–5 (Preschool) Parent 132 (Preschool) Attention Problems, Yes Normed based on current US
System for Children – Third Scale 6–11 (Child) 175 (Child) Hyperactivity, Census population
Edition Parent Rating Scale 12–21 (Adolescent) 173 Aggression, Conduct characteristics; adequate
(BASC-PRS; Reynolds & (Adolescent) Problems* reliability and construct
Kamphaus, 2015) validity; assesses for comorbid
disorders/ concerns
Behavior Assessment Omnibus Rating 2–5 (Preschool) Teacher 105 (Preschool) Attention Problems, Yes Normed based on current US
System for Children – Third Scale 6–11 (Child) 156 (Child) Hyperactivity, Census population
Edition Teacher Rating 12–21 (Adolescent) 165 Aggression, Conduct characteristics; adequate
Scale (BASC-TRS; Reynolds (Adolescent) Problems* reliability and construct
& Kamphaus, 2015) validity; assesses for comorbid
disorders/ concerns
Behavior Assessment Omnibus Rating 8–11 (Child) Child 137 (Child) Attention Problems, Yes Normed based on current US
System for Children – Third Scale 12–21 (Adolescent) 189 Hyperactivity Census population
Edition Self Report of (Adolescent) characteristics; adequate
Personality (BASC; reliability and construct
Reynolds & Kamphaus, validity; assesses for comorbid
2015) disorders/ concerns
Child Behavior Checklist Omnibus Rating 1½ –5 (Preschool) Parent 100 (Preschool) Attention Problems, No Includes multicultural norms,
Parent Rating Scale (CBCL; Scale 6–18 (Child) 113 (Child) Aggressive Behavior, adequate reliability and
Achebach & Rescorla, 2001) construct validity; assesses for
comorbid disorders/ concerns
Child Behavior Checklist Omnibus Rating 6–18 Teacher 113 Attention Problems, No Includes multicultural norms,
Teacher Rating Form (CBCL- Scale Aggressive Behavior, adequate reliability and
TRF; Achenbach & Rescorla, Rule-Breaking construct validity; assesses for
2001) Behavior comorbid disorders/ concerns
Child Behavior Checklist Omnibus Rating 11–18 Child 112 Attention Problems, No Includes multicultural norms,
Youth Self Report (YSR; Scale Aggressive Behavior, adequate reliability and
Achenbach & Rescorla, Rule-Breaking construct validity; assesses for
2001) Behavior comorbid disorders/ concerns
Conners Rating Scales – 3 ADHD, ODD, CD 6–18 (Parent, Parent, 45 (Parent) Inattention, Yes Normed based on current US

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(Conners, 2008) Teacher) Teacher, 41 (Teacher) Hyperactivity/ Census population
8–18 (Child) Child Impulsivity, Defiance/ characteristics; adequate
41 (Child)
Aggression, ADHD, reliability and construct
ODD, CD Symptomsa validity; assesses for comorbid
disorders/ concerns
Conduct Problems subscale is not on the Preschool Version of the BASC-3.

with adolescent self-reports, parent informants may shed whether the particular child or adolescent was sufficiently
light on the extent to which the adolescent engages in motivated to participate, was able to comprehend the
behavioral problems outside of the parent’s awareness. assessment questions, and provided truthful information.
Some general principles regarding influences on parent
reports should be kept in mind, particularly as they relate
Peer Informants
to assessment of ADHD and DBDs. For instance, parental
psychopathology is associated with more negative views of Peer-referenced assessment is rarely used in routine
the child’s adjustment (see Frick et al., 2010), that is, par- assessments of ADHD and DBDs; yet, for some con-
ents experiencing their own distress may overreport their structs (e.g., aggression, hostility toward others, class-
child’s difficulties. De Los Reyes and Kazdin (2005) also room disruptions), peers may provide unique insights.
noted that parents who view the child’s problems as dis- In research contexts, classrooms have been one of the
positional rather than situational are more likely to rate more commonly used contexts in which to conduct
the child negatively. Such factors should be considered for peer-referenced assessments and a common approach
case conceptualization but should not lead a clinician to is to have children nominate a number of classmates on
eschew parental reports based on the central role parents characteristics of interest (e.g., “fights most,” “liked
play in a child’s development/adjustment and in potential most,” “is shy”) and to determine the rate at which
interventions. the child being assessed is nominated. Despite the
unique information afforded by peer-referenced assess-
ment, logistical and ethical concerns limit their use. If
Teacher Informants
peer informants are desired, a professional must take
By virtue of the amount of time that children spend in steps to ensure confidentiality of the child who is the
school, the opportunities available for socialization in focus of the assessment and to limit the time required
that setting, and the potential for ADHD and conduct for children to complete the process so as to not disrupt
problems to translate to academic impairments, teacher their typical routine (Barry et al., 2013).
informants play a valuable role in clinical assessments of
children. As with parent informants, there are limitations
School/Institutional Records
in teacher reports that a clinician must consider. Teachers
are thought to be particularly good at providing informa- Another source of relevant information for assessments of
tion on ADHD symptoms but they may not observe the full ADHD and DBDs include records from schools or other
array of a child’s problem behaviors (Barry et al., 2013). institutions (e.g., treatment facilities). Specifically, impor-
Furthermore, as the child gets older, teachers may be less tant information from these records may include aca-
useful, as an individual teacher likely spends less time with demic grades, disciplinary citations or infractions, or
individual students and may also see more students in positive achievements/awards. These records have the
a number of classes throughout the day. Thus, their famil- advantage of providing a more objective and ecologically
iarity with a student receiving assessment should be valid account of the child’s functioning. For example,
expected to be lower than for teachers of young children. instead of a parent simply reporting that a child is doing
A unique strength of teacher informants is that they have poorly in school, obtaining grades would aid the clinician
professional knowledge of typical child development, can in determining the degree of academic problems (if any)
base their ratings of a given child on their understanding the child is experiencing and whether such problems are
of behavioral expectations at a particular developmental global or confined to certain subject areas. Unfortunately,
level, and are also able to observe the child’s classroom there is no clear empirical evidence as to the validity or
social functioning (Frick et al., 2010). utility of such records or how these records should be
integrated with data obtained through other means. The
difficulty in arriving at clear guidelines for handling insti-
Child Informants
tutional records is based, at least in part, on the vast set-
Although prior to approximately age eight or nine children ting-specific ways in which child behavior and functioning
are not considered reliable informants of their own atten- are documented (Barry et al., 2013). At the very least, these
tional or behavioral difficulties, older children may be records could provide indications of a child’s impairments
quite useful for gaining information on factors such as in important settings and thus might contribute unique
difficulty concentrating, feeling restless, and covert beha- information to case conceptualization and intervention
vioral problems (Frick et al., 2010). It is reasonable to planning.
suggest that children or adolescents may underreport
their own symptoms but there is no clear evidence that
Integration across Informants
indicates a systematic tendency for youth informants to
over- or underreport relative to parents (De Los Reyes & Perhaps one of the most challenging aspects of conducting
Kazdin, 2005). Thus, the clinician should be prepared to assessments with children and adolescents is the integra-
utilize youth self-report but make a determination as to tion of information from multiple informants. Informant

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discrepancies should be expected based on factors such as assessment may present useful models or algorithms for
situational specificity (Konold, Walthall, & Pianta, 2004) prioritizing and conceptualizing information in
but also factors related to the informant and the measures a clinically meaningful way.
used. These factors include the demographics (e.g., age,
gender) of the child and attributions (e.g., purposeful,
beyond their control) that the informant makes about the TECHNOLOGICAL ADVANCES
child’s symptoms or behaviors (De Los Reyes & Kazdin, Laboratory tasks represent an approach to assessment of
2005). The clinician should be aware of these potential externalizing problems that may have some intuitive
reasons for informant discrepancies, as well as factors appeal but they have mixed support in terms of validity
that may be at play for a specific child. and clinical utility. More specifically, laboratory tasks
To integrate and interpret findings, a process has been (e.g., Stroop, Continuous Performance Tests [CPTs],
recommended in which all issues considered problematic Lexical Decision Tests, Implicit Attitudes Tests) are pre-
by any informant are initially considered (see Barry et al., sumed to tap into important processes that underlie the
2013; Frick et al., 2010). Areas of convergence (e.g., associated impairments of ADHD and conduct problems;
between parents and teachers) signal important concerns yet the extent to which they do so in a reliable manner and
given their apparent pervasiveness across settings, with incremental validity is uncertain. Advances in the
whereas informant discrepancies may point to important area of evidence-based assessment may eventually support
considerations for intervention or issues in the assessment the idea that a child’s performance on an analogue task
methods that warrant closer examination (see Kazak et al., mimics their behavior in difficult, real-world situations.
2010). From there, the clinician can conceptualize the Such tasks would enjoy the advantage of not depending on
primary and secondary concerns that need to be consid- the perspective of informant responses and may also have
ered diagnostically and for treatment planning. treatment implications (e.g., clear, consistent contingency
Pelham and colleagues (2005) discuss the concepts of management for children who demonstrate low respon-
positive predictive power and negative predictive power siveness to punishment cues on a performance-based
that may also prove useful in efficiently highlighting infor- task).
mation that is diagnostically relevant. In brief, symptoms Many of the well-known laboratory tasks have been in
with negative predictive power are generally the core existence for a relatively long time. Generally, however,
symptoms of a disorder (e.g., difficulty with sustained agreement between measures such as CPTs and informant
attention), the absence of which would help rule out the reports has been only moderate to low. Recent research on
presence of a disorder (e.g., ADHD). Positive predictive preschoolers indicates that aspects of performance (e.g.,
power involves the unique symptoms of a disorder (e.g., omission and commission errors) correlate differently at
fire setting for conduct disorder) that, if developmentally different points in the test with teacher-reported ADHD
atypical, would increase the likelihood that the disorder is symptoms, suggesting that performance on these tests is
present. In the case of ADHD, Rosales and colleagues complex and multiply determined (Allan & Lonigan,
(2015) noted that each of the eighteen symptoms contri- 2015). It should be noted that laboratory tasks may have
butes unique information to the classification of ADHD clinical utility for youth with behavioral problems insofar
but that symptoms involving losing or forgetting things, as task performance might highlight processes (e.g.,
perhaps signifying positive predictive power, were indica- reward dominance) connected to potential responsiveness
tive of the most severe presentations. Thus, if a clinician is to behavioral interventions (Frick & Loney, 2000; O’Brien
preparing to conduct a comprehensive, multi-informant, & Frick, 1996). Nevertheless, there remains limited evi-
multimethod assessment of ADHD and DBDs, an effective dence that such tools are necessary or sufficient to make
approach may be to first screen for core symptoms of the diagnostic and intervention decisions for youth with
disorders of focus. From there, the lack of core symptoms ADHD or DBDs.
would allow the clinician to focus on other issues, whereas An additional use of technology in assessment has
their presence would signal to the clinician to then more been the online administration of rating scales and
carefully assess for other unique symptoms and the sever- other measures, whereby the informant (and clinician)
ity level of a disorder. More work is needed to further can access assessment materials outside of the typical
refine models of negative and positive predictive power clinical appointment. Such an approach has the poten-
across a number of clinical problems and across develop- tial advantage of increasing efficiency in the use of face-
mental levels. to-face time between the clinician, parents, and child/
The discussion herein has focused largely on interview adolescent, as well as allow the clinician quicker access
and rating information obtained from informants such as to ratings for scoring and interpretation purposes.
parents, teachers, and children/adolescents. However, the Although there is limited evidence regarding the psy-
field of clinical assessment has attempted for several dec- chometric equivalence of online responses to standard
ades to also develop presumably more objective, standar- assessment tools, initial findings indicate no differences
dized tools that might provide important data on the in reliability in caregiver pencil-and-paper versus online
child’s functional impairments. Further advances in ratings (Pritchard et al., 2017). Therefore, as the

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availability of online assessment tools (and, presum- assessment of ADHD and conduct problems and in alter-
ably, confidence in their security) increase, more clin- native modalities of service delivery. For example, preli-
icians may wish to utilize this resource. minary evidence has suggested that assessments via
videoconferencing may be comparable to face-to-face ser-
vices (see Diamond & Bloch, 2010), and it is likely that
clinicians have used variations of this approach for some
There is no evidence that cultural factors should result in aspects of assessment (e.g., teacher telephone interviews)
qualitatively different approaches to assessment of ADHD for years. Nevertheless, such alternatives, particularly
and DBDs. However, aspects of evidence-based assess- insofar as they increase efficiency and increase availability
ment described above should take into account a client/ of services in rural areas, are in need of systematic empiri-
family’s cultural background. For example, a systematic cal examination.
literature review found that white children were more This discussion has attempted to briefly highlight
likely to be diagnosed with ADHD compared to nonwhite research-supported principles of evidence-based assess-
children and that nonwhite children were more likely to be ment of ADHD and DBDs in children and adolescents.
diagnosed with a DBD, suggesting that children’s emo- Foremost among these is a recognition of the heteroge-
tional and behavioral problems may be interpreted differ- neous ways in which youth may present with attention or
ently based on their racial/ethnic background and perhaps conduct problems and the need to systematically consider
leading to an overrepresentation of minority children in evidence gathered through developmentally sensitive and
diagnoses of DBDs (Liang, Matheson, & Douglas, 2016). incrementally valid tools that also document an individual
A clinician may also choose to investigate a measure’s child’s specific impairments and contextual influences on
psychometric properties relative to specific populations, their strengths and behavioral concerns. In this way, clin-
as some measures have demonstrated acceptable reliabil- ical assessment inherently uses population-based knowl-
ity and validity in minority samples (Schmidt et al., 2017). edge on developmental psychopathology to provide the
This research, however, is still in relative infancy. best child-specific explanations for any difficulties and
Emerging psychometric research generally supports that guidance as to the next steps for ameliorating those
the factor structures of ADHD- and DBD-related con- difficulties.
structs (e.g., sluggish cognitive tempo, both ADHD sub-
types, ODD) hold up in samples from Nepal (Khadka,
Burns, & Becker, 2016), Spain (Servera et al., 2016), and REFERENCES
Germany (Rodenacker et al., 2017). Other cultural issues, Achenbach, T. M., & Rescorla, L. A. (2001). Manual for the ASEBA.
including the selection of measures, interpretation of find- Burlington: University of Vermont, Department of Psychiatry.
ings, factors in how child behavior problems are viewed, Allan, D. M., & Lonigan, C. J. (2015). Relations between response
and acceptability of treatment options, are also important trajectories on the continuous performance test and teacher-rated
and warrant more study. problem behaviors in preschoolers. Psychological Assessment, 27,
American Psychiatric Association. (2013). Diagnostic and statistical
FUTURE DIRECTIONS AND PRACTICAL manual of mental disorders (5th ed.). Washington, DC: Author.
IMPLICATIONS Barkley, R. A. (2013). Distinguishing sluggish cognitive tempo
In addition to being guided by the prevailing empirical from ADHD in children adolescent: Executive functioning,
evidence on the developmental trajectories of ADHD impairment, and comorbidity. Journal of Clinical Child and
and conduct problems – and by sound assessment Adolescent Psychology, 42, 161–173.
Barry, C. T., Frick, P. J., & Kamphaus, R. W. (2013). Psychological
methods that adequately cover all relevant aspects of
assessment in child mental health settings. In K. F. Geisinger,
the constructs in question – it is also important that the
B. Bracken, J. Carlson, J. Hansen, N. Kucel, S. Reise, &
assessments of these problems be conducted in a cost- M. Rodrequez (Eds.), APA handbook of testing and assessment
effective manner. To be comprehensive means to in psychology (pp. 253–270). Washington, DC: American
account for heterogeneous presentations of ADHD and Psychological Association.
conduct problems, assess for co-occurring difficulties, Barry, C. T., Golmaryami, F. N., Rivera-Hudson, N. J., &
address relevant aspects of the child’s context for Frick, P. J. (2013). Evidence-based assessment of conduct dis-
understanding symptom manifestation and potential order: Current considerations and preparation for DSM-5.
approaches to intervention, and account for intraperso- Professional Psychology: Research and Practice, 44, 56–63.
nal and contextual factors that might serve a risk or Bendiksen, B., Svensson, E., Aase, H., Reichborn-Kjennerud, T.,
Friis, S., Myhre, A. M., & Zeiner, P. (2017). Co-occurrence of
a protective role for the child’s ongoing development.
ODD and CD in preschool children with symptoms of ADHD.
To be cost-effective includes efforts to address the cen-
Journal of Attention Disorders, 21, 741–752.
tral concern or referral question in a sound manner
Conners, C. K. (2008). Conners (3rd ed.). Toronto, ON: Multi-
while using a parsimonious battery (Barry et al., 2013). Health Systems.
Further research is needed to delineate factors involved De Los Reyes, A., & Kazdin, A. E. (2005). Informant discrepancies
in increasing efficiency and cost-effectiveness of in the assessment of childhood psychopathology: A critical

Downloaded from University of Western Ontario, on 13 Dec 2019 at 15:32:42, subject to the Cambridge Core terms of use, available at

review, theoretical framework, and recommendations for McMahon, R. J., & Frick, P. J. (2005). Evidence-based assessment
further study. Psychological Bulletin, 131, 483–509. of conduct problems in children and adolescents. Journal of
Diamond, J. M., & Bloch, R. M. (2010). Telepsychiatry assess- Clinical Child and Adolescent Psychology, 34, 477–505.
ments of child or adolescent behavior disorders: A review of Moffitt, T. E. (1993). Adolescence-limited and life-course persis-
evidence and issues. Telemedicine and e-Health, 16, 712–716. tent anti-social behavior: A developmental taxonomy.
Frick, P. J., Barry, C. T., & Kamphaus, R. W. (2010). Clinical Psychological Reports, 100, 674–701.
assessment of child and adolescent personality and behavior O’Brien, B. S., & Frick, P. J. (1996). Reward dominance:
(3rd ed.). New York: Springer. Associations with anxiety, conduct problems, and psychopathy
Frick, P. J., & Loney, B. R. (2000). The use of laboratory and in children. Journal of Abnormal Child Psychology, 24, 223–240.
performance-based measures in the assessment of children Pelham, W. E., Fabiano, G. A., & Massetti, G. M. (2005). Evidence-
and adolescents with conduct disorders. Journal of Clinical based assessment of attention-deficit hyperactivity disorder in
Child Psychology, 29, 540–554. children and adolescents. Journal of Clinical Child and
Frick, P. J., Ray, J. V., Thornton, L. C., & Kahn, R. E. (2014). Can Adolescent Psychology, 34, 477–505.
callous-unemotional traits enhance the understanding, diagno- Power, T. J., Watkins, M. W., Anastopolous, A. D., Reid, R.,
sis, and treatment of serious conduct problems in children and Lambert, M. C., & DuPaul, G. J. (2017). Multi-informant assess-
adolescents? A comprehensive review. Psychological Bulletin, ment of ADHD symptom-related impairments among children
140, 1–57. and adolescents. Journal of Clinical Child & Adolescent
Frick, P. J., & Viding, E. (2009). Antisocial behavior from Psychology, 46, 661–674.
a developmental psychopathology perspective. Development Pritchard, A. E., Stephan, C. M., Zabel, T. A., & Jacobson, L. A.
and Psychopathology, 21, 1111–1131. (2017). Is this the wave of the future? Examining the psycho-
Hall, C. L., Valentine, A. Z., Groom, M. J., Walker, G. M., Sayal, K., metric properties of child behavior rating scales online.
Daley, D., & Hollis, C. (2016). The clinical utility of continuous Computers in Human Behavior, 70, 518–522.
performance tests and objective measures of activity for diag- Ramtekkar, U. P., Reiersen, A. M., Todorov, A. A., & Todd, R. D.
nosing and monitoring ADHD in children: A systematic review. (2010). Sex and age differences in attention-deficit/hyperactiv-
European Child and Adolescent Psychiatry, 25, 677–699. ity disorder symptoms and diagnoses: Implications for
Johnston, C., & Murray, C. (2003). Incremental validity in the DSM-V and ICD-11. Journal of the American Academy of Child
psychological assessment of children and adolescents. and Adolescent Psychiatry, 49, 217–228.
Psychological Assessment, 15, 496–507. Reynolds, C. R., & Kamphaus, R. W. (2015). Behavior assessment
Kazak, A. E., Hoagwood, K., Weisz, J. R., Hood, K., system for children, 3rd edition (BASC-3). Circle Pines, MN:
Kratochwill, T. R., Vargas, L. A., & Banez, G. A. (2010). A American Guidance Services.
meta-systems approach to evidence-based practice for children Rodenacker, K., Hautmann, C., Gortz-Dorten, A., & Dopfner, M.
and adolescents. American Psychologist, 65, 85–97. (2017). The factor structure of ADHD – Different models, ana-
Khadka, G., Burns, G. L., & Becker, S. P. (2016). Internal and lyses and informants in a bifactor framework – testing the con-
external validity of sluggish cognitive tempo and ADHD inatten- structs in a German sample. Journal of Psychopathology and
tion dimensions with teacher ratings of Nepali children. Journal Behavioral Assessment, 39, 92–102.
of Psychopathology and Behavioral Assessment, 38, 433–442. Rosales, A. G., Vitoratou, S., Banaschewski, T., Asherson, P.,
Konold, T. R., Walthall, J. C., & Pianta, R. C. (2004). The behavior Buitelaar, J., Oades, R. D., . . . & Chen, W. (2015). Are all the
of child ratings: Measurement structure of the child behavior 18 DSM-IV and DSM-5 criteria equally useful for diagnosing
checklist across time, informants, and child gender. Behavioral ADHD and predicting comorbid conduct problems? European
Disorders, 29, 372–383. Child and Adolescent Psychiatry, 24, 1325–1337.
Liang, J., Matheson, B. E., & Douglas, J. M. (2016). Mental health Schmidt, M., Reh, V., Hirsch, O., Rief, W., & Christiansen, H.
diagnostic considerations in racial/ethnic minority youth. (2017). Assessment of ADHD symptoms and the issue of cul-
Journal of Child and Family Studies, 25, 1926–1940. tural variation: Are Conners 3 rating scales applicable to chil-
Mash, E. J., & Hunsley, J. (2005). Evidence-based assessment of dren and parents with migration background? Journal of
child and adolescent disorders: Issues and challenges. Journal Attention Disorders, 21, 587–599.
of Clinical Child and Adolescent Psychology, 34, 362–379. Servera, M., Bernad, M. D., Carrillo, J. M., Collado, S., &
Maughan, B., Rowe, R., Messer, J., Goodman, R., & Meltzer, H. Burns, G. L. (2016). Longitudinal correlates of sluggish cogni-
(2004). Conduct disorder and oppositional defiant disorder in tive tempo and ADHD-inattention symptom dimensions with
a national sample: Developmental epidemiology. Journal of Spanish children. Journal of Clinical Child and Adolescent
Child Psychology and Psychiatry, 45, 609–621. Psychology, 45, 632–641.

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