Psychological Evaluation of Parental Fitness: Information for Allied Professionals

1. Psychological Evaluation of Parental Fitness: Information for Allied Professionals Clifton R. Hudson, Ph.D. Licensed Psychologist (304) 415-2299

2. Special thanks to... • Department of Veterans’ Affairs Medical Center, Huntington, WV. • Process Strategies, Charleston, WV. • NASW - WV Chapter

3. Clinical Assessment Focus on helping the client. Forensic Assessment Focus on helping or educating the courtor other entity, without regard to the potential benefit to the examinee. Clinical vs. Forensic Assessment1

4. Clinical Assessment Diagnosis (DSM-IV-TR) is central to treatment strategy, insurance coverage, etc. Forensic Assessment Diagnosis is usually less critical and not always even required. Statutorily-defined behaviors of interest to the court have a central role. Clinical vs. Forensic Assessment

5. Clinical Assessment Recognizes that almost all human behavior falls on a continuum, or normal curve. Forensic Assessment Serves legal and administrative systems that recognize discrete categories which are often dichotomous (i.e., all or nothing). Clinical vs. Forensic Assessment

6. Clinical Assessment Reports focus upon explaining the patient’s behavior. Forensic Assessment Reports focus upon the provision of information relevant to specific legal questions. Explanations may or may not be relevant. Clinical vs. Forensic Assessment

7. Clinical Assessment Implicit belief in the truthfulness of the patient’s report in interview and testing. Inaccuracy is viewed as arising from lack of insight or personality characteristics. Forensic Assessment Explicit questioning of the truthfulness of the client’s report. Awareness of potential ulterior motives. Tests of response bias. Use of collateral sources for confirmation. Clinical vs. Forensic Assessment

8. Clinical Assessment Present-oriented focus. Forensic Assessment May have some emphasis on the present, but often focuses partially or exclusively on the past or the future. Clinical vs. Forensic Assessment

9. Clinical Assessment The science of psychology recognizes a .05 level of statistical significance. Forensic Assessment Required standards of proof vary, as does placement of the burden for that proof. Experts are expected to make opinions “to a reasonable degree of professional certainty.” Clinical vs. Forensic Assessment

10. Clinical Assessment Professionals are accountable to organizations like APA and to licensure boards, but generally receive little scrutiny in individual cases. Forensic Assessment Professionals and their work are routinely scrutinized by judges, attorneys, other practitioners, etc. Accountability to all parties involved in the legal system, as well as to traditional institutions. Clinical vs. Forensic Assessment

11. Clinical Assessment The recipient of services is the client. Privilege, duty, etc. belong to that individual. Forensic Assessment Clients include retaining attorneys, judges, juries, even society as a whole. The goal is objective assessment, regardless of who made the referral or what the outcome will be for the examinee. Clinical vs. Forensic Assessment

12. Clinical Assessment Emphasizes support and empathy. Relatively unstructured. Forensic Assessment Strives for detachment, neutrality, and objectivity. Considerably more structure. Clinical vs. Forensic Assessment

13. Legal Context of Parent Evaluations2 “Parents enjoy important civil and constitutional rights regarding the care for their children. A child has a fundamental interest in being protected from abuse and neglect. Child protection laws attempt to strike a balance between these interests. Under the concept of parens patriae, all states have the right to intervene in cases where a child is at risk for harm.” -APA Guidelines

14. Legal Context of Parent Evaluations • Chapter 49 of the West Virginia Code • Per DHHR summary: “Generally speaking, child abuse involves a parent, guardian, or custodian who knowingly or intentionally inflicts an injury upon a child. Neglect involves the failure or the inability to provide a child with necessary food clothing, shelter, or other items. Sexual abuse includes, but is not limited to: Sexual intercourse, sexual intrusion, and sexual contact.”

15. There are no pathognomonic (distinctively characteristic) signs or syndromes associated with child maltreatment!

16. Impact of Physical Abuse3 • Developmental delay (slow weight gain, growth, or moral development). • Impaired cognitive or academic development (slow language acquisition, grade retention, lower IQ). • Distorted social response (anxious attachment to parents, more responsive to other adults, negative responses to everyone, poor peer relationships, poor social understanding, lack of reciprocity, inflexibility, lack of concern for others’ distress, avoidance of maltreating parent).

17. Impact of Physical Abuse • Withdrawal or apathy (avoidance of parents, solitariness, shyness, minimal communication and socialization). • Hyperarousal (crying or irritability, refusal to calm down, nervous habits, nightmares, compulsive compliance). • Depression and self-destructive behavior (infliction of pain to self, suicidal thoughts, over-eating or somatic disturbances in adolescence).

18. Impact of Physical Abuse • Low self-esteem (feeling unloved, unwanted, inferior, inadequate; feeling disconnected from social systems; distrustful of others; feeling deserving of maltreatment). • Aggression or other conduct problems (ready to hit back, overactive and non-compliant, provocative behavior, truancy or running away in adolescence, membership in antisocial groups, power struggles, counteracting peer aggression with aggression). • Substance abuse.

19. Impact of Sexual Abuse3 • Regressive behavior (clinging, bedwetting, encopresis, enuresis, excessive crying or tantrums). • Hyperarousal (sleep disturbance, nightmares, exaggerated fears, intrusive memories of abuse, increased symptoms with exposure to reminders). • Anxiety or fearfulness (phobic avoidance, chronic tension, anxiety attacks). • Avoidance and dissociation (hysterical symptoms, emotional numbness, out-of-body experiences).

20. Impact of Sexual Abuse • Depression/cognitive distortion/low self-esteem (feelings of alienation, isolation, stigmatization; negative self-image; feelings of being damaged or different; poor sense of self; overestimating danger or adversity; feeling betrayed; feeling shame, guilt, fear, helplessness).

21. Impact of Sexual Abuse • Disturbances in sexual behavior (sexual hyperarousal, sexual aggression, repetitions and re-enactments of victimization, compulsive masturbation, promiscuity, prostitution, inappropriate or precocious sexual behavior, indiscriminate sexual behavior, difficulty differentiating affection from sexual relationships, a high level of sexual play, impaired sexual impulse control, sexual inhibitions or phobic reactions).

22. Impact of Sexual Abuse • Tension-reducing behaviors (binging and purging, self-mutilation, running away). • Somatic complaints with no known physical cause (headaches, nausea, vomiting, etc.). • Aggression (hitting, oppositional-defiant behavior). • Substance abuse.

23. Impact of Neglect3 • Impaired attachment (dependency, reactive attachment disorder). • Impaired cognitive or academic development (low levels of enthusiasm, persistence, creativity in problem-solving; poor receptive language capability even compared to children subjected to other forms of maltreatment; low educational curiosity; low capability and achievement).

24. Impact of Neglect • Impaired social development (passive and withdrawn, anger and resistance in toddlerhood, insecure attachment). • Low self-esteem. • Psychological distress secondary to physical and medical problems (poor self-image associated with poor growth, fatigue and irritability secondary to poor diet and nutrition). • Aggressive behavior (higher levels of anger even compared to children otherwise maltreated).

25. Impact of Neglect • Risk of arrest for status offenses, delinquency, and violent crimes (gang involvement, risk-taking behavior, truancy). • Substance abuse.

26. Legal Context of Parent Evaluations • Three stages of intervention: • Report / investigation. • Findings of abuse  assumption of care and/or custody by state  implementation of rehabilitation plan for parents. • Failure of rehabilitation  termination of parental rights.

27. Legal Context of Parent Evaluations • Psychological evaluation may occur at any stage of the process. • Referrals usually come through DHHR via court order, but may come from other sources. • Emphasis on the best interest of the child.

28. APA’s Guidelines for Psychological Evaluations in Child Protection Matters2 I. Orienting Guidelines • The primary purpose of the evaluation is to provide relevant, professionally sound results or opinions, in matters where a child’s health and welfare may have been or may in the future be harmed. • In child protection cases, the child’s interest and well-being are paramount.

29. APA’s Guidelines for Psychological Evaluations in Child Protection Matters I. Orienting Guidelines (continued) • The evaluation addresses the particular psychological and developmental needs of the child and/or parent(s) that are relevant to child protection issues such as physical abuse, sexual abuse, neglect, and/or serious emotional harm.

30. APA’s Guidelines for Psychological Evaluations in Child Protection Matters II. General Guidelines: Preparation • The role of psychologists conducting evaluations is that of professional expert who strives to maintain an unbiased, objective stance. • The serious consequences of psychological assessment in child protection matters place a heavy burden on psychologists. • Psychologists gain specialized competence.

31. APA’s Guidelines for Psychological Evaluations in Child Protection Matters II. General Guidelines (continued) • Psychologists are aware of personal and societal biases and engage in non-discriminatory practice. • Psychologists avoid multiple relationships.

32. APA’s Guidelines for Psychological Evaluations in Child Protection Matters III. Procedural Guidelines: Conducting Evaluations • Based on the nature of the referral questions, the scope of the evaluation is determined by the evaluator. • Psychologists performing psychological evaluations in child protection matters obtain appropriate informed consent from all adult participants, and, as appropriate, inform the child participant. Psychologists need to be particularly sensitive to informed consent issues.

33. APA’s Guidelines for Psychological Evaluations in Child Protection Matters III. Procedural Guidelines (continued) • Psychologists inform participants about the disclosure of information and the limits of confidentiality. • Psychologists use multiple methods of data gathering. • Psychologists neither over-interpret nor inappropriately interpret clinical or assessment data.

34. APA’s Guidelines for Psychological Evaluations in Child Protection Matters III. Procedural Guidelines (continued) • Psychologists conducting a psychological evaluation in child protection matters provide an opinion regarding the psychological functioning of an individual only after conducting an evaluation of the individual adequate to support their statements or conclusions.

35. APA’s Guidelines for Psychological Evaluations in Child Protection Matters III. Procedural Guidelines (continued) • Recommendations, if offered, are based on whether the child’s health and welfare have been and/or may be seriously harmed. • Psychologists clarify financial arrangements. • Psychologists maintain appropriate records.

36. Sources of Information • Clinical interviews • Direct observation • Collateral interviews • Review of collateral documents • Psychological testing

37. Clinical Interview • Usual psychiatric interview content areas: • Family of origin • Current marital and other relationships (i.e., social support) • Mental health & substance abuse histories (diagnoses, interventions, responses to treatment, aftercare, etc.) • Medical history • Educational and occupational histories • Legal / violence history • Self-reported & observed mental status

38. Clinical Interview • Special emphases: • Discussion of referral incidents • History of involvement with CPS • Risk factors / mitigating factors • Caregiver’s relationship with child • Caregiver’s relationship with helping resources • Self-report of readiness for reunification • Tendencies toward over- or under-reporting • Inconsistencies within the clinical interview and between interview and collateral information

39. Stress. Limited family resources. Poor social support. Private settings. Untreated major mood or thought disorder. Failure to acknowledge mental illness or need for treatment. History of violent outbursts of temper. Active alcohol or drug addiction. Childhood history of abuse. Other adverse childhood history (harsh and rejecting family, harsh or unfair discipline, foster care or institutional placement, parental discord). Few ties to neighbors or community agencies. Violent marital or dating relationships. Factors Associated With Physical Abuse3

40. Gross misperceptions of the child, child development, or appropriate and useful discipline strategies. Unrealistic expectations of the child. Difficulty discerning and responding to cues from the child. Insecure parent-child attachment. Role reversals. Scapegoating the child. Extreme worry about the child’s well-being. High levels of parental stress or social isolation. Hazardous home environment. History of violence. Extent of deliberateness, harm, & frequency of any past child abuse. Factors Associated With Physical Abuse

41. Previous violence Young age at first violent incident Relationship instability Employment problems Substance use problems Major mental illness Psychopathy Early maladjustment Personality disorder Prior supervision failure Lack of insight Negative attitudes Active symptoms of major mental illness Impulsivity Unresponsive to treatment Plans lack feasibility Exposure to destabilizers Lack of personal support Non-compliance with remediation attempts Stress Violence Risk: The HCR-204

42. Sexual Abuse3 • Prominence of aberrations in sexual history in child sexual abuse (as opposed to the power and control dynamics of rape). • Erosion of appropriate family boundaries and individual autonomy. • Theoretical associations include arrested psychological development, regression under stress, low self-esteem, low efficacy, a sense of inadequacy and immaturity, shame and humiliation from childhood experiences, identification with the aggressor, symbolic mastery over childhood trauma, imprinting and conditioning from childhood sexual victimization, and socialization that values dominance and power.

43. Sexual Abuse • Stress and substance abuse predict disinhibition. • Treatment programs typically require admission of offense, then focus upon reducing compulsive thoughts and urges, correcting cognitive distortions, reducing other antisocial conduct, reducing deviant sexual fantasies (especially during masturbation), increasing arousal to non-deviant stimuli, assertiveness and social skills training, increasing sexual knowledge, increasing knowledge of sexual offense cycles, and cultivating the development of relapse prevention plans. • Dynamic risk factors appear to be quite important.

44. Candor Self-initiation of disclosure Recall of details Degree of aggression or overt violence in offenses Length and progression of history of sexual offending Offense characteristics other than sexual aggression Number of victims in relation to victim access Victim selection characteristics and preferred victim type Victim blame Appraisal of victim harm Personal responsibility for offending behavior Precipitating factors Degree of arousal and habituation Factors Relevant to Sexual Abuse Risk3

45. Other exploitative or addictive behavior Family system functioning Stability of school or employment Stability of social relationships Non-offending sexual history Past victimization External and internal motivation for rehab Response to confrontation Treatment history and response Criminal arrests and convictions Current access to victims Ability to form and maintain healthy relationships Capacity for intimacy Social competence Factors Relevant to Sexual Abuse Risk

46. Factors Relevant to Sexual Abuse Risk • Trauma history • Self concept • Capacity for empathy • Substance abuse history • Depression • Suicidal ideation • Family roles and structure • Intellectual capacities • Ability to express and manage anger and conflict

47. Young (18-25) Ever lived with an intimate partner – 2 years (no) Index non-sexual violence – any convictions (yes) Prior non-sexual violence – any convictions (yes) Prior sex offenses (# charges and convictions) Prior sentencing dates (4+) Any convictions for non-contact sex offenses (yes) Any unrelated victims (yes) Any stranger victims (yes) Any male victims (yes) Sexual Offense Risk: The Static-995

48. Neglect3 • Risk is extremely difficult to assess due to lack of homogeneity among neglectful families. • Often co-occurs with other forms of maltreatment.

49. Blunted affect Apathy in parent-child interactions Passive-dependent parent-child interactions Non-reciprocal relationships between family members Cycling between passive and aggressive behavior Chaos and poor planning Impulsive actions in parents Conflict-laden interactions between parents Social isolation / poor social support Rejection by the community Factors Relevant to Neglect3

50. Difficulty connecting to others emotionally Apathy and futility Disorganization Depression Hostility Poor socialization Hopelessness Criticalness Showing little positive attention Providing little stimulation and nurturance Being less responsive and sensitive Speaking less Using shorter and less complex sentences Issuing more demands Expressing less acceptance Factors Relevant to Neglect