THE BEHAVIORAL ASSESSMENT THROUGH INTERVIEWS, INVENTORIES AND CHECK LISTS

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Clinical Psychology (PSY401)

LESSON 22

THE BEHAVIORAL ASSESSMENT THROUGH INTERVIEWS, INVENTORIES AND

CHECK LISTS

BEHAVIORAL ASSESSMENT

Careful assessment lies at the heart of all clinical interventions. Same is the case, when using the

behavioral theoretical model in therapy. The emphasis on making a careful assessment of the patient and

his life circumstances before, during, and following treatment is one of the most distinguishing features

of the various clinical procedures.

DEFINITION OF BEHAVIOR

There are two broad categories of behavior which have been recognized by most behavior therapists.

These categories are respondents and operants.

Respondents are the antecedent-controlled behaviors which function in a reflexive manner. They are

the most stereotyped kinds of behaviors, having relatively fixed patterns across populations as well as

within individuals. Respondents include

Somatic reflexes

Emotional reactions and other responses of the smooth muscles, glands, and heart, and

Sensations

Each sub-type of respondent may be elicited by appropriate unconditioned stimuli. For example, a

sudden, unexpected noise may cause a person to hear the noise (an auditory sensation), to jump (a

somatic reflex), and to be afraid momentarily (an emotional reaction). Such unconditioned responses

may be conditioned to occur in response to previously neutral stimuli.

Operants include

Actions

Instrumental responses of the smooth muscles, glands, heart and

Cognitions

Whereas respondents are antecedent-controlled behaviors, operants are consequence-controlled. In case

of respondent behavior, the environment produces changes in the patient's behavior; but in the case of

operant behavior, the patient's behavior produces changes in his world.

ASSESSMENT TASKS

The basic tasks of the behavior therapist in performing an assessment are to identify, classify, prophesy

(predict), specify and evaluate. The specific tasks under each of these general tasks and the procedures

needed to perform them are described below.

Identify

The behavior therapist needs to identify all of the antecedents which are affecting the patient's target

behaviors; the respondents which are of concern to the patient; the operants which are of concern to the

patient; the consequences which currently follow the designated operants; and those consequences

which could be programmed into the therapy plan to benefit the patient. The therapist also needs to

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identify the setting events which are influencing the patient's behavior to obtain a full overview of the

biological, physiological, and anatomical concomitants of the patient's clinical picture

Classify

Once this information has been obtained, it needs to be classified. A useful classification procedure is to

group behaviors according to those which need to be weakened or removed (i.e. behavioral excesses),

those which need to be strengthened or added (i.e. behavioral deficits), and those which are inherently

inappropriate (i.e. behavioral anomalies). Then there are those behaviors which are valued by the patient

and/or which are valued by others with whom the patient lives and which are presently in his or her

repertoire (i.e. behavioral assets), as these are crucial in planning treatment.

Prophesy (prediction)

Although prophesying is not an activity which would seem to attract most behavior therapists, most

engage in some form of prediction. Prediction seems to account for much less of behavior therapist's

assessment activities, however, than is true for therapists of many other theoretical orientations. To the

extent that behavior therapists o engage in prediction regarding individual cases, they tend to use

actuarial data as a basis for their predictions. Moreover commonly, however, they simply attempt to

control therapeutically the present target behaviors, rather than attempting to make predictions about the

way a given patient might react to a hypothetical situation some time in the future.

Specify

Specifying precise goals, methods of intervention, and therapeutic agents is an important part of the

behavioral assessment process. The specification of goals, methods of intervention and therapeutic

agents corresponds basically to the "recommendations" section of the traditional psychological

evaluation. There is a general tendency for behavioral therapists to try to specify clearly enough so that

any informed clinician could carry out the prescribed procedures.

Evaluation

The final assessment task, evaluation, can be broken down into three subcategories: process evaluation,

outcome evaluation, and follow-up evaluation. An adequate behavioral assessment will initially

prescribe and then carry out procedures to identify what changes are occurring in behavior during the

course of treatment; where the patient is at the termination of formal treatment; and where the patient is

after some specified period or periods following the termination of treatment.

THE BEHAVIORAL TRADITION

Before we examine specific methods of behavioral assessment, let us consider three broad ways in

which it differs from traditional assessment.

SAMPLE VERSUS SIGN

When test responses are viewed as a sample, one assumes that they parallel the way in which a person is

likely to behave in a nontest situation. Thus, if a person responds aggressively on a test, one assumes

that this aggression also occurs in other situations as well. When test responses are viewed as signs, an

inference is made that the performance is an indirect or symbolic manifestation of some other

characteristic (Goldfried, 1976)

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A description of the situation is much less important than the identification of the more enduring

personality characteristics. In behavioral assessment, the paramount issue is how well the assessment

device samples the behaviors and situations in which the clinician is interested. For the most part,

traditional assessment has employed a sign as opposed to sample approach to test interpretation. In the

case of behavioral assessment only the sample approach makes sense.

Functional Analysis: Another central feature of behavioral assessment is traceable to Skinner's (1953)

notion of functional analysis. This means that exact analyses are made of the stimuli that precede a

behavior and the consequences that follow it. Behaviors are learned and maintained because of

consequences that follow them. Thus, to change an undesirable behavior, the clinician must

1) Identify the stimulus conditions that precipitate it and

2) Determine the reinforcements that follow.

Once these two sets of factors are assessed, the clinician is in a position to modify the behavior by

manipulating the stimuli and/or reinforcements involved.

Besides there are certain other considerations of behavior assessors:

The behavior of concern must be described in observable, measurable terms so that its rate of

occurrence can be recorded reliably. Both antecedent conditions and consequence events are

thus carefully elaborated.

A behavioral assessment ignores such hypothesized internal determinants as "needs" and focus

instead on the target--behavior of concern.

A functional analysis reveals that stimulus is followed by behavior which in turn is followed by

consequence.

Most behavioral therapists have broadened the method of functional analysis to include

"organismic" variables as well. Organismic variables include physical, physiological, or

cognitive characteristics of the individual that are important for both the conceptualization of

the client's problem and the ultimate treatment that is administered. For example, it may be

important to assess attitudes and beliefs that are characteristic of individuals who are prone to

experience depressive episodes because of their purported relationship to depression as well as

their suitability as target for intervention.

SORC MODEL

A useful model for conceptualizing a clinical problem from a behavioral perspective is the SORC

model.

S = stimulus or antecedent conditions that bring on the problematic

behavior

O = organismic variables related to the problematic behavior

R = response or problematic behavior

C = consequences of the problematic behavior

Behavioral clinicians use this model to guide and inform them regarding the information needed to fully

describe the problem and, ultimately, the interventions that may be prescribed.

BEHAVIORAL ASSESSMENT AS AN ONGOING PROCESS

Peterson and Sobell (1994) pointed out, that behavioral assessment in a clinical context is not a one-

shot evaluation performed before treatment is initiated. In fact, it is an ongoing process that occurs

before, during, and after treatment. Behavioral assessment is important because it informs the initial

selection of treatment strategies, provides a means of feedback regarding the efficacy of the treatment

strategies employed as they are enacted in the treatment process, allows evaluation of the overall

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effectiveness of treatment once completed, and highlights situational factors that may lead to recurrence

of the problematic behavior(s)

METHODS OF BEHAVIORAL ASSESSMENT

A wide range of methods has been developed for use in behavioral assessment. These methods and

measures can be implemented across the age range from children to adults and can be used to examine

different areas of functioning (e.g. classroom performance, marital communication, psychopathology,

social skills, Psycho physiological functioning).assessment information can be drawn from different

sources, including observation by clinicians or other trained observers, reports by the clients themselves,

and rating by significant others (e.g. Parents, Teachers, Spouses). Information can also be obtained

about behavior in different settings (e.g. Home, School, Work, Community), regardless of the specific

method or measure that is used, however or the particular area of functioning that is assesses, a critical

distinguishing feature of this approach is on the emphasis of behaviors (or cognitions or physiology)

that occur in specific situations. In the following sections we will describe three broad classes of

behavioral assessment methods: behavioral interviewing, and self-report inventories.

BEHAVIORAL INTERVIEWING

We know the various approaches to interviewing, including the use of structured diagnostic interviews. In

contrast to many forms of interviewing in clinical psychology, behavioral interviewing is used to obtain

information that will be helpful in formulating a functional analysis of behavior (Haynes & O'Brien,

2000). That is behavioral interviews focus on describing and .understanding the relationships among ante-

cedents, behaviors, and consequences. Behavioral interviews tend to be more directive than

other.nonbehavioral interviews, allowing the interviewer to obtain detailed descriptions of the problem

behaviors and of the patient's current environment. Kratochwill (1985) suggests that behavioral

interviews follow a four-step problem-solving format.

1. Problem identification, in which a specific problem is identified and explored and procedures

are selected to measure target behaviors

2. Problem analysis, conducted by assessing the client's resources and the contexts in which the

behaviors are likely to occur

3. Assessment planning, in which the clinician and client establish an assessment plan to be

implemented, including ongoing procedures to collect data relevant to assessment and intervention

4. Treatment evaluation, in which strategies are outlined to assess the success of treatment,

including pre- and post assessment procedures.

Thus, behavioral: interviewing focuses not only on obtaining information within the interview session,

but also Oil making plans to obtain information on behavior outside the interview, in the environment in

which the behavior naturally occurs.

One important reason that behavioral interviews are more directive than most other kinds of interviews

is that clients will often describe their difficulties in trait terms. That is, they will speak of being

"anxious" or "depressed" or "angry" The behavioral clinician must then work with the client to

translate these broad terms into more specific and observable behaviors. For example, "being

anxious" may mean breathing rapidly, sweating profusely, experiencing an increase in heart rate,

having cognitions about danger and threat, and avoiding- specific types of situations. In the following

example, the interviewer helps quantify a client's difficulties in behavioral terms:

Interviewer: It sounds like you have been having difficulty in a number of areas, but your conflicts

with your roommate are the most trouble right now.

Client: Yes, he's inconsiderate and I can't stand being around him.

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Interviewer: I'd like to ask some more questions about what happens when you are the most

bothered about it. Can you pick a particular disagreement and tell me how you felt at the time?

Client: He really pissed me off when I came in last night and wanted to go to sleep. He wouldn't

turn the TV off, and I couldn't sleep with the light and the noise.

Interviewer: How angry were you? Can you rate it from I to 10, with 10 being the most angry you've

ever been?

Client: I guess about a 6. What does that matter?

Interviewer: Well, I'm wondering if you also felt anything else, like tension, nervousness, anxiety,

apprehension. If so, how much?

Client: I was tense, too. About a 6, 1 guess. We don't really talk much except about the V and

superficial things about school.

Interviewer: When do you feel the most angry, and also the most tense? For example. When you

were walking into the room. Before? After he didn't turn down the TV?

Client: I was getting tense coming into the room, thinking what a drag this roommate situation was,

and then when he kept watching TV, I was so angry I couldn't sleep. (Adapted from Sarwer & Sayers,

1998, p. 70)

As this example makes clear, the client and therapist will work together to describe and understand the

problem behaviors. Where and when they occur, and the impact they have on the client's relationships.

The information obtained in a behavioral interview should be helpful to the clinician both in

generating hypotheses about what specific behaviors or contextual factors to target in an intervention

and in developing further plans for additional behavioral assessment procedures, such as direct

observation or self monitoring.

An excellent example of behavioral interviewing is found in the work of psychologist Russell Barkley

and his colleagues, who have developed extensive interview protocols for use in the behavioral

assessment of attention deficit/ hyperactivity disorder, or ADHD. One portion of the interview generates

information on the nature of specific parent-child interactions that are related to the defiant and

oppositional child behaviors often associated with ADHD. The interviewer reviews a series of

situations that are frequent sources of problems between children and parents and solicit detailed

information about those situations that are particularly problematic, For example, parents may report

that their child has temper tantrums, during which the child cries, whines, screams, hits, and kicks. A

behavioral interview will be used as a first step in determining precisely what these behaviors look like

when they occur, in which situations the behaviors occur (e.g., while the parent is on the telephone, in

public places, at bedtime), and in which situations they do not occur (e.g., when the child is playing alone,

playing with other children, at mealtimes). Additional information is then sought regarding the

sequence of events, including the behaviors of the parents and the child that unfold during a

tantrum. This type of situationally focused interview provides a detailed picture about how the parent

perceives the antecedents and consequences that surround the child's problematic behaviors.

In sum, behavioral interviewing is the first step in conducting a comprehensive behavioral

assessment of a problem behavior and the contextual variables that may be controlling the

behavior. A behavioral interview is more direct than are unstructured clinical interviews and focuses

explicitly on the occurrence (or nonoccurrence) of specific behaviors. It is important to point

out that, despite the relatively narrow focus of the behavioral interview, we know little about

its reliability and validity. In fact, there is evidence indicating that behavioral interviews are

only moderately reliable.

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INVENTORIES AND CHECKLISTS

Behavioral clinicians have used a variety of self report techniques to identity behaviors, emotional

responses, and perceptions of the environment. The fear Survey Schedule (Geer, 1965; Lang &

Lazovik, 1963) has been widely used. It consists of 51 potentially fear-arousing situations and requires

the patient to rate the degree of fear each situation arouses. Other frequently used self-report

inventories include the Rathus Assertiveness Schedule (Rathus, 1973), the Beck Depression

Inventory (Beck. 1972), the Youth Self Report (Achenbach, 1991), and the Marital Conflict Form

(Weiss & Margolin, 1977).

Notably absent from this brief and partial listing of inventories are instruments that have a

psychiatric diagnostic orientation. Historically, this has been a conscious omission on the part of

behavioral assessors, who generally found little merit in psychiatric classification (Follette &

Haves, 1992). Their tests were more oriented toward the assessment of specific behavioral

deficits, behavioral inappropriateness, and behavioral assets (Sundberg, 1977). The focus of

behavioral inventories is, in short, behavior. Clients are asked about specific actions, feelings, or

thoughts that minimize the necessity for them to make inferences about what their own behavior

really means.

Inventories have also been developed that assess the person's perception of the social environment

(Insel & Moos, 1974). The scales that Moos and his colleagues have developed attempt to assess

environments in terms of the opportunities they provide for relationships, personal growth, and

systems maintenance and change. There are separate scales for several environments, including

work, family, classrooms, wards, and others.

RATING SCALES

Clinical psychologists have developed a number of rating scales and behavior checklists. These

measures are intended to provide information on a wider range of an individual's behavior over a longer

period of time than is possible with direct observation.

Rating scales have been developed to assess problem behaviors in children, adolescents, and adults. The

importance of assessing the behavior of children and adolescents in their natural environments is widely

recognized. Children's behavior may differ in critical ways depending on whether they are at home,

at school, alone, or with peers, and it is important to obtain samples or reports of their behaviors in these

different settings. It is also important that ratings of children's behavior be obtained from different

people, or informants, in the children's lives, most typically from parents, teachers, and peers. In

fact, numerous studies have found only modest levels of agreement among different informants with

respect to ratings of the children's behavior, and only modest agreement between the informants and

the children themselves, for similar findings with adult psychiatric patients). These findings highlight the

importance of situational factors in rating children's behavior and underscore the need for assessments in

different contexts. The findings also indicate that different informants may offer unique

perspectives or judgments regarding children's behavior.

A number of different rating scales have been developed to assess problem behaviors in children and

adolescents (e.g., the Revised Behavior Problem Checklist, Quay, 1983. the Revised Conners Parent

Rating Scale, Conners, Sitarenios, Parker, & Epstein, 1998; the Conners/wells Adolescent Self-Report of

Symptoms, Conners et al., 1997; the Sutter-Eybcrg Student Behavior inventory, Rayfield. Eyberg

& Foote. 1998). the most widely used rating system for child and adolescent psychopathology, however,

are the checklists developed by Achenbach and his colleagues .This system empirically integrates data

obtained from parents (the Child Behavior Checklist or CBCL), teachers (the Teacher Report Form or

TRF). And adolescents (the Youth Self-Report ;). Achenbach has utilized data from these three groups of

informants in generating an empirically based taxonomy of child and adolescent psychopathology (e.g.,

Achenbach, 1995).

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Rating scales have also been developed to assess behavior problems in adults. Typically, ratings on

these scales are made on the basis of information collected during an interview with the client. While

some rating scales focus on a particular disorder (e.g., the Hamilton Rating Scale for Depression,

Hamilton, 1967; the YaleBrown Obsessive-Compulsive Scale, Goodman et al., 1989), other scales are

broader (e.g., the Brief Psychiatric Rating Scale, Overall & Gorham, 1962; the Global Assessment

Scale, Endicott, Spitzer, Fteiss, & Cohen, 1976). For example, interviewers using the Yale-Brown

Obsessive-Compulsive Scale (e.g., Halmi et al., 2000) are required to make a rating from 0 to 4,

indicating the client's level of distress or impairment around obsessions and compulsions. Similarly,

interviewers who rate clients on the Hamilton Rating Scale for Depression rate several depressive

symptoms, such as insomnia, depressed mood, and behavioral slowness, on 3- to 5-point scales. As

is the case with most rating scales, the total score of all items can be used as an index of the severity of

the particular disorder.

In part because they focus so explicitly on behaviors, all these rating scales have sound psychometric

properties. Both the child and the adult measures have good internal consistency and test-retest

reliability. As we noted earlier, there is not always perfect agreement among informants for the child

rating scales. Consequently, Achenbach and McConaughy (1997) have formulated a decision tree, or

flowchart, for assessors to follow based on the rating scale responses of different informants. Currently

these behavioral rating scales are used more frequently in clinical research than they are in clinical

practice (Silverman & Serafini, 1998), but as more data accrue, demonstrating the scales' utility in

formulating effective treatment plans, this situation should change.

TECHNOLOGICAL ADVANCEMENT IN BEHAVIOR ASSESSMENT

Haynes (1998) has recently outlined several ways in which technological advances have begun to

change the face of behavioral assessment methods that involve observation.

The availability of laptop and hand-held computers facilitates the coding of observational

data by assessors

Hand-held computers can be assigned to clients so that clients can provide real-time self-

monitoring data

Hand-held computers can be programmed to prompt clients to respond to queries at

specified times of the day or night

Data from either laptop or hand-held computers can be loaded onto other computers that

have greater processing and memory capacity so that observations can be aggregated,

scored and analyzed

Behavioral assessment differs from traditional assessment in several fundamental ways. Behavioral

assessment emphasizes direct assessments (naturalistic observations) of problematic behavior,

antecedent (situational) conditions, and consequences (reinforcement). It is also important to note that

behavioral assessment is an ongoing process, occurring at all points throughout treatment.

Some of the more common behavioral assessment methods include interviews, naturalistic and

controlled observation, checklists and role playing or behavioral rehearsal. The variety of factors can

affect the reliability and validity of observation which include the complexity of behavior, how

observers are trained and monitored, and the unit of analysis, reactivity and behavioral coding system.

Besides these technological advances are also being made in behavioral assessment.

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