Chapter 5

Comprehensive Screening and Assessment 151
Chapter 5
Comprehensive Screening and Assessment
Jane Summers, Chrissoula Stavrakaki, Dorothy M. Griffiths,

and Thomas Cheetham
Learning Objectives
Readers will be able to:
1. Identify two reasons why assessment and screening

are important
2. Provide an example of an instrument that is used with
persons with developmental disabilities in each of the
following areas: diagnostic and health care screening,
biomedical assessment, psychological assessment and
social-ecological assessment
3. Understand how the range of assessments assist in de-
velopment of a comprehensive biopsychosocial profile
Introduction
Why are screening and assessment important?
This chapter contains a review of different instruments that are

used during the biopsychosocial assessment of mental health
problems in persons with developmental disabilities. Some of
these instruments have been developed for “screening” pur-
poses – that is, to identify those individuals who are likely to
152 Mental Health Needs of Persons with Developmental Disabilities
require more in-depth assessment or particular types of ser-

vice. Screening tools can be used on an individual basis, or on
a larger scale with groups of people. They are helpful in the
clinical decision-making process about whether to proceed to
the next level of assessment. They are useful for detecting po-
tential problems that may not have been recognised, or for for-
mulating a tentative diagnosis. In doing so, they can lead to
faster and more specific treatments, and can minimise the time
and cost involved with unnecessary assessment.
The dominant theme throughout the book is the biopsychoso-

cial approach to assessing and understanding mental health
problems in persons with developmental disabilities. Often,
mental health problems present as non-specific behavioural
challenges. Griffiths (2001) noted the need for differential di-
agnosis for behavioural challenges in order to determine the
underlying factor or factors. For instance, a behaviour can be
or do any of the following:
• reactive to biomedical influences or traumatic events

• responsive to ecological events, interactions or conditioned
stimuli
• function to enhance stimulation or reinforcement, to avoid
discomfort or unpleasant events
• provide communication.
In order to diagnose the different factors that may be working

alone or together to produce the behaviour, a comprehensive
screening and assessment process must be conducted at multi-
ple levels. Box 1 illustrates how a single behaviour such as
aggression may be associated with numerous factors or condi-
tions. Without a thorough biopsychosocial assessment, it is im-
possible to make a differential diagnosis. Moreover, without a
well-conceived hypothesis (or hypotheses), the selection of an

appropriate treatment is like shooting in the dark.
BOX 1 - Ten Factors to Consider in the Differential Diag-

nosis of Aggression (Lowry & Sovner, 1991)
1. Medical illness
2. Medication side-effects
3. Pre-seizure irritability
4. Irritability secondary to mania, depression, or
organic mental syndrome
5. Rage attacks
6. Task-related anxiety
7. Schizophrenia-related paranoid delusion
8. Inability to express needs
9. Means to gain positive reinforcement
10. Means to avoid or escape an unpleasant event.
A comprehensive assessment process involves gathering the

existing data and background information, interviewing the in-
dividual and relevant others, making observations in the natu-
ral environments, and synthesising the information into work-
ing theories that make sense to explain why the person may be
behaving in this way. Often, further tests or measures are
needed to confirm or eliminate hypotheses. However, the as-
sessment is a scientific process of elimination and confirma-
tion of potential influences, based on all available data, and
taking a broad-based perspective.
No one person or member of one particular professional disci-

pline can possess the breadth of knowledge and skills that are
needed to perform such a comprehensive assessment. For in-
stance, the expertise and scope of practice for a behaviour ana-
lyst is quite different from that of a medical doctor. That is

why an interdisciplinary approach, that involves a synthesis of
input from professionals from several different disciplines, is
considered to be “best practice” when assessing and treating
individuals with developmental disabilities and mental health
problems (see Chapter 10: The Interdisciplinary Mental Health
Team for more detail). But, it is not professional input alone
that is taken into consideration during a comprehensive assess-
ment. Information from the individual, his or her family, and
caregivers is a critical part of the process.
Isn’t dual diagnosis just another label?
A comprehensive biopsychosocial assessment provides you

much more than a label, although sometimes a new label or di-
agnosis may emerge. For instance, the person may be given a
psychiatric label, such as depression, mania, or post-traumatic
stress disorder. The reason for the label is twofold:
• It provides understanding. It is descriptive to other people

working with the individual so that they can respond ap-
propriately, and with full knowledge of the challenges the
person faces.
• It is also key to treatment. Persons who are deemed to
have clinically significant depression are often, based on
that diagnosis, prescribed a path of chemical intervention
and cognitive therapy to alter the mood state. Thus, the la-
bel helps to guide appropriate treatment.
At times, the assessment may uncover a genetic disorder that

can give rise to a characteristic pattern of behaviour (a behav-
ioural phenotype). The diagnostic label can be helpful in put-
ting the individual’s behaviour in context. For example, as we
learned in Chapter 3– The Integrated Biopsychosocial Ap-

proach to Challenging Behaviour, individuals with a diagnosis
of fragile x syndrome can be expected to share certain features
and vulnerabilities. Knowledge of the underlying syndrome
can lead to more focused assessment and treatment (see Ap-
pendix A for a list of common genetic syndromes and their as-
sociated features). The outcome of assessment is not just a di-
agnostic label, but a profile of the person’s biomedical, psy-
chological and social conditions as they influence the behav-
iour. This assessment then, is the foundation on which treat-
ment and intervention are built.
Type of Assessments:
What does it mean to do a comprehensive biopsychosocial as-

sessment? Does it mean completing a comprehensive biomedi-
cal work-up, performing psychological evaluations, and con-
ducting a social or contextual analysis? The answer is maybe
and maybe not. The assessment flows from the nature of the
background information and observations made by the team
members.
A. Biomedical Factors
Challenging behaviours can be influenced, directly or indi-

rectly, by physical conditions, medications, and/or psychiatric
conditions. Some common medical conditions that have been
noted to relate to challenging behaviours are seizure disorders,
sleep apnea, otitis media, blocked shunt, migraine headaches,
and premenstrual problems. Hyper/hypo thyroidism, autoim-
mune disorders, upper respiratory tract conditions, eating dis-
orders, or heart conditions (e.g., mitral valve prolapse), can
present like depression, mania, or anxiety/panic disorder. Ryan
and Sunada (1997) noted that an overwhelming percentage of

clients who present with behavioural challenges actually have
undiagnosed medical conditions. These medical conditions
may be directly related to the behavioural challenge (e.g.,
headbanging to alleviate severe pain caused by a migraine
headache), or they may play a more indirect role (e.g., sleep
deprivation due to sleep apnea ⇒ irritability ⇒ aggression in
response to a minor provocation). A thorough assessment
should include a careful medical and medication history and
physical examination (Loschen & Osman, 1992). It may in-
volve a laboratory work-up, a mental status examination, neu-
rological testing, sleep studies and diagnostic imaging (x-rays
or MRI scans).
Specific observation charts have been developed to assist in

gathering biomedical data that can be used for diagnostic pur-
poses. As an example, sleep disturbance is an important factor
in multiple DSM-IV diagnoses, either as a criterion for a disor-
der, or as an associated feature of a disorder. Sleep data can
serve as a general index of psychological status, and should be
included as a routine component of any biomedical data col-
lection package (Carr, Neumann & Darnell, 1998). Sovner
and Hurley (1990) developed an overnight observation sleep
chart to record when a person actually sleeps (as opposed to
when the person goes to bed or gets up). This chart was modi-
fied slightly by Carr et al. (1998). See Figure 1.
Figure 1–Monthly Sleep Chart
Reprinted with permission from Psych-Media. Originally printed in article by Carr, E.G.,
Neumann, J.K., & Darnell, C.L. (1998, Apr-June). The clinical importance of sleep data
collection: A national survey and case reports. Mental Health Aspects in Developmental
Disabilities, 1(2).
Certain syndromes are associated with an increased risk of

medical or mental health conditions. Health care screening
guidelines have been developed for a number of these syn-
dromes. For adults with Down syndrome, for instance, some of
the following investigations are recommended by the Down
Syndrome Medical Interest Group (1999):
• annual thyroid screening

• auditory testing
• ophthalmologic evaluation
• cervical spine x-rays as needed for sports participation
• enquire about sleep apnea symptoms
• monitor for signs of skill loss or behavioural change
• anemia and liver screening
The timing and nature of the challenging behaviour can pro-

vide a valuable clue to potential medical and mental health is-
sues (i.e., cyclical behaviours may relate to allergies or menses
in women; to medication effects or side effects; to seasonal
changes caused by Seasonal Affective Disorder, or related to
Post Traumatic Events; to shifts between depressive behaviour
and mania as seen in Bipolar Disorder). The following chart
(Figure 2) developed by Sovner and Hurley (1990) is an excel-
lent example of how these cyclical shifts can be tracked.
Figure 2– Bipolar Mood Chart
Reprinted with permission from Psych-Media. Originally printed in article by Sovner , R. &
Des Noyers Hurley, A. (1990). Assessment tools which facilitate psychiatric evaluation and
treatment. Habilitative Mental Healthcare Newsletter, 9(11).
Certain medications can influence behavioural symptoms. For

example, the relationship of medication to drug-induced dis-
orders presenting with physical aggression has been shown in
numerous studies (e.g., propranolol induced psychosis; Ger-
shon et al., 1979) or vigabatrin induced mood disturbance
(Aldenkamp et al., 1994). Clinicians completing a compre-
hensive assessment for this population will need to rely on a
psychopharmacology reference guide to check potential ef-
fects and side-effects of the medications. Sovner and Hurley
(1992) developed a user-friendly worksheet that can be used
by caregivers to document the following types of information
to assist with a medication review:
• current medications, dosages and administration schedule

• discontinued medications
• current behavioural and psychosocial interventions
• physical signs and symptoms
• global impression of the individual’s behaviour problems
A tool that has been recently developed to assist clinicians in

identifying biomedical factors that may be influencing the
onset or aggravation of behavioural symptoms is the
Behavioral Diagnostic Guide for Developmental Disabilities
(Gedye, 1998). Gedye (1998) has compiled an exhaustive
guide of potential biomedical issues that may relate to
presentation of behaviours such as physical aggression, self-
injury, screaming, sleep disturbance, eating disturbances,
dementia and unwitnessed or unusual falls. She clearly
demonstrates that each non-specific behavioural symptom can
have a variety of potential factors that could be influencing
the behaviour.
Screening for genetic disorders
In recent years, significant progress has been made in

identifying the genetic factors that are involved in many
syndromes in which developmental disability is also present.
This information is important because individuals with a
specific genetic syndrome often have associated medical
conditions that require identification and treatment. As well,
they frequently show a characteristic pattern of behavioural
challenges. Thus, knowledge of an underlying syndrome is
useful from an assessment and treatment perspective (See
Appendix A). Since it is not feasible or advisable to perform
genetic testing for most people with a developmental
disability, it is important to be able to identify particular
individuals who may be at risk for a syndrome, and to refer
them for more thorough assessment. A screening tool can be
helpful in this regard. As an example, a checklist for screening
males with developmental disability for fragile x syndrome has
been developed (Butler, Mangrum, Bupta & Singh, 1991). A
rater determines whether each item on the checklist is present
or absent. Items on the checklist include:
• large ears and testes

• plantar crease
• family history of developmental disability or autism
• tactile defensiveness
• hyperextensible finger joints
The following case provides an excellent example of the need

for a full biomedical workup.
The Case of Johnny
Johnny is an 18-year-old male with Down syndrome who

lives at home with both parents and his two brothers. Un-
til recently, Johnny was always affectionate, pleasant, co-
operative and interested in his schoolwork and friends.
Sixteen months prior to his first assessment at a psychiat-

ric unit, Johnny’s behaviour became slowly but progres-
sively worse. He became unable to show any pleasure,
was uninterested in his environment, and withdrew more
and more to the point of losing all social skills. Johnny
also stopped using his limited vocabulary and showed
problems eating and sleeping. On interviewing his par-
ents, it became apparent that there were two significant
changes that coincided with Johnny’s behavioural and so-
cial changes:
i) Father, due to work obligations, had to be away from

home for lengthy periods of time (up to a month at a time)
repeatedly for the six months prior to Johnny’s noticeable
changes. It is worth noting that Johnny has always been
very close to his father.
ii) The family had to move across the country because of
father’s new employment. This move took place two
months prior to the onset of the most serious observed be-
haviours.
Parents, at that time, tried to cope with Johnny’s changes,

and did not seek any professional advice. Four months
following the social withdrawal and severe loss of social

skills, he became extremely preoccupied with construction
toys and trucks. Any intervention or attempt to disengage
Johnny from these activities would escalate into a major
tantrum with physical abuse and extreme protestation.
Simultaneously, he started wetting himself, checking doors
and whispering. At this time, his parents sought profes-
sional help. When seen by staff from a developmental
clinic, he was diagnosed as suffering from Childhood Dis-
integrative Disorder. Following a neurological evalua-
tion, a rare form of epilepsy was suggested but not sub-
stantiated by EEG and other tests (i.e., CAT scan, MRI).
At a final attempt to disentangle this problem, Johnny was

referred to a dual diagnosis clinic. By this time, he was
totally uncommunicative and withdrawn, but showed a
“peculiar” preoccupation for the construction toys pre-
sent in the clinic. On parents’ account, Johnny’s regres-
sion was “total”. They were devastated and fearful of fu-
ture consequences to Johnny and his family. Following
the initial interview and the use of questionnaires and
scales relevant to ADHD and OCD, it was felt that Johnny
had suffered from a trauma that initially resulted in an
episode of depression, and subsequently in the emergence
of an Obsessive-Compulsive Disorder. He was treated
with an SSRI (Fluoxetine) and Respiridone to which he
responded very favorably. Family support and special-
ised academic programmes were also offered. Nine
months later, Johnny feels, looks and behaves like his
“old self”. He is demonstrative, happy, pleasant, verbal
and able to follow his scholastic programmes and activi-
ties as prior to the devastating events.
B. Psychological Factors
Gathering a Psychological History
A history is important to evaluate the path of the individual’s

life in relation to social/emotional and medical life events. Of-
ten clinicians will engage in an analysis to show these events
in a temporal manner.
Important events might include:
• History of emotional/physical or sexual abuse

• Significant medical procedures (especially involving
hospitalisation or invasive procedures)
• Family disruption (violence/divorce/remarriage/birth of
siblings)
• Educational milestones
• Environmental changes (moves, significant changes in
living arrangements or socio economic status)
• Grief or loss [due to death, abandonment, or change
(i.e., change of a caregiver)]
• Change of jobs
Let’s take a look at the following example in Figure 3 of a

young man who has been accused of sexual interference with a
child, and see how his history may be helpful in understanding
his past.
Figure 3: An Historical Perspective of Challenging Behaviour
Observed death Parents Began Sexually Institutionalized Sexually Abused Placed in a

of brother separated school abused by by S ex Education community
in violent mother’s cousin Instructor/ no setting with
dispute counseling minimal
provided supervision
________/__________/___________/___________/_____________/_____________/________________/_________ _____/____
4 years 41/2 years 5 -6 years 5 -7 years 7-10 10 -15 years 17 years

Began to show Became First signs of Began to show Adjusted well; no Became sexually Anxiety
anxiety reactions withdrawn cognitive challenges aggression symptoms noted indiscriminate with reactions .
other children returned/
sexually abused
a child
165
Psychological Testing
This section will focus on psychological tests, their uses and

limitations. These tests are designed to measure various as-
pects of an individual’s psychological functioning, often
within the context of assessing learning, developmental, be-
havioural and/or emotional problems. By using them, psy-
chologists are able to arrive at a better understanding of an in-
dividual’s strengths and weaknesses, which aids in the diag-
nostic process and development of service plans.
Standardised psychological tests differ in several ways from

informal tests that are often used by non-psychologists. Stan-
dardised tests are carefully developed and systematically tested
before they can be made available for clinical use. They must
meet established standards regarding their psychometric char-
acteristics, such as their reliability (consistency and precision),
and validity (the extent to which they measure what they are
designed to measure). They must be administered and inter-
preted by individuals who are qualified to do so by virtue of
their educational background, training and experience. Often,
this is a person with a Master’s degree, or a Doctoral degree in
psychology.
Standardised tests are administered in a uniform manner and

are scored according to objective criteria. These procedures
help to minimise subjective bias and outside influences on the
test scores. Tests yield numerical scores that are not inherently
meaningful. In order for this to happen, the scores of the indi-
vidual being assessed need to be compared to scores that are
obtained by individuals in a norm group or standardisation
sample. This process results in “derived” scores (such as stan-
dard scores, age-equivalent scores and percentile ranks), which
indicate how well the individual being assessed performed in

relation to the individuals in the norm group. It is these de-
rived scores that are typically presented and interpreted in psy-
chological assessment reports.
Inventories or rating scales are often used to measure aspects

of an individual’s personality, emotional or behavioural func-
tioning, and can assist with identifying clinical disorders.
These measures rely on information that is provided by the in-
dividual (“self-report”), or another person who is knowledge-
able about him or her (“informant”).
Psychological tests have limitations as well as advantages.

First, they can’t provide a definitive answer about the cause of
an individual’s learning, developmental, behavioural or emo-
tional problems. Second, their strength lies in assessing an in-
dividual’s current functioning rather than predicting his or her
future performance with complete accuracy. Third, many tests
are very specific and their findings may not be applicable to
different psychological functions. Nonetheless, psychological
tests yield information that is invaluable when deciding upon a
course of action to assist an individual with learning, develop-
mental, behavioural and/or emotional problems.
Psychological Tests
While the process of assessing the psychological functioning

of individuals with developmental disabilities will vary in ac-
cordance with factors such as the referral issues that need to be
addressed, the complexity of the case and/or the availability of
clinically relevant information, it is customary to start with an
assessment of the individual’s intellectual and adaptive func-
tioning. Additional tests may be used to assess his or her lan-
guage functioning, academic or vocational performance, and to

identify behavioural, emotional and personality problems.
Commonly used assessment instruments
Intelligence Tests: used to measure an individual’s thinking,

reasoning and problem-solving ability with verbal and/or non-
verbal material, as well as his or her perceptual and spa-
tial/mechanical ability
• Wechsler Adult Intelligence Scale – Third Edition (WAIS-

III) (Wechsler, 1997)
• Stanford Binet Intelligence Scale - Fourth Edition (SB-IV)
(Thorndike, Hagen & Sattler, 1986)
• Leiter International Performance Scale - Revised (Leiter-
R) (Roid & Miller, 1997)
• Test of Nonverbal Intelligence - Third Edition (TONI-3)
(Brown, Sherbenou & Johnsen, 1997)
The last two tests are used to assess an individual’s IQ in spe-

cial circumstances (e.g., when he or she comes from a non-
English speaking background, or has a hearing impairment, or
when there are social/cultural differences)
Hurley (1989) suggests that intelligence tests are an important

part of a clinical assessment for psychiatric purposes. She
notes that persons with schizophrenia, for instance, may show
a significant lowering of verbal IQ and other language related
functions, and may show bizarre responses to testing. Persons
with anxiety disorder may show disproportionately lower
scores on digit span subtests; persons who are depressed may
show overall lower scores on performance tests which require
quick eye-hand coordination and timing of responses (Hurley,
1989).
Measures of Adaptive Functioning: used to assess the degree

to which the individual is able to cope effectively with (i.e.,
has mastered) the demands of his or her environment. This
includes: communication, self-care, home and community
living, social skills, work and leisure, and functional
academics.
• AAMR Adaptive Behavior Scales- Residential and

Community (ABS-RC:2) (Nihira, Leland & Lambert,
1993)
• Scales of Independent Behavior-Revised (SIB-R)
(Bruininks, Woodcock, Weatherman & Hill, 1996)
• Vineland Adaptive Behavior Scales (VABS) (Sparrow,
Balla & Cicchetti, 1984)
Language Tests: can be used to supplement verbal tasks from

IQ tests
• Peabody Picture Vocabulary Test – Third Edition (PPVT-

III) (Dunn & Dunn, 1997)
• Expressive Vocabulary Test (EVT) (Williams, 1997)
Academic Achievement Tests: used to assess an individual’s

academic skills in the areas of reading, writing and arithmetic
• Peabody Individual Achievement Test - Revised (PIAT-R)

(Markwardt, 1998)
• Wide Range Achievement Test – Third Edition (WRAT-3)
(Wilkinson, 1993)
Instruments for Assessing Psychopathology and Behaviour

Problems:
In the past two decades, a number of caregiver and client-rated

inventories have been developed to assist in the assessment of
emotional and behavioural challenges in adults and children
with developmental diabilities. Hurley and Sovner (1992)
identified that these symptom inventories can be very
beneficial in: a) establishing a tentative or provisional
psychiatric diagnosis; b) verifying a diagnosis for mental
health services; c) assisting with placement decisions, d)
measuring responses to treatment; and/or e) establishing
competency.
In Table 1, the most common inventories have been de-

scribed. It should be noted that these instruments are not
meant to stand on their own, but are to be used in conjunction
with other tools and methods of gathering assessment informa-
tion.
Table 1: Inventories for Assessment of Emotional and Behavioural Challenges
Instrument Purpose Format Information it provides
Aberrant Behavior -evaluate impact of pharma- -58 item questionnaire, rating -scores on 5 factors – irritability, lethargy,
Checklist - Community cological interventions on behaviours on a scale of 0 (not a stereotypy, hyperactivity and inappropri-
(Aman & Singh, 1994) maladaptive behaviours problem) to 3 (severe problem) ate speech
-assess behaviour problems
in children, adolescents and
adults with mild to profound
developmental disabilities
Assessment for Dual -screen for psychopathology -79 item questionnaire, rating -scores on 13 subscales - mania, depres-
Diagnosis (Matson, in individuals with mild to behaviours on dimensions of fre- sion, anxiety, posttraumatic stress disor-
1997) moderate developmental dis- quency, severity and duration der, substance abuse, somatoform, demen-
ability -scale scores range from a low of tia, conduct disorder, pervasive develop-
0 to a high of 2 mental disorder, schizophrenia, personal-

-higher scores indicate greater ity disorders, eating disorders, sexual dis-
problem orders
Developmental Behav- -assess emotional and behav- 96 item questionnaire, rating be- scores on 6 subscales - disruptive, self-
iour Checklist - Parent/ ioural disorders in children haviours on a scale of 0 (item is absorbed, communication disturbance,
Carer or Teacher ver- and adolescents with devel- not true) to 2 (item is very true or anxiety, autistic relating & antisocial
sion (Einfeld & Tonge, opmental disabilities often true)
1994)
Diagnostic Assessment -screen for psychopathology -84 item questionnaire, rating -scores on 13 subscales – anxiety, mania,
for the Severely Handi- in individuals with severe to behaviours on dimensions of fre- depression, schizophrenia, stereotypies,
capped - II (Matson, profound developmental dis- quency, severity and duration self-injurious behaviour, PDD/autism,
1995) ability -scale scores range from a low of elimination disorders, eating disorders,
0 to a high of 2 sleep disorders, sexual disorders, organic
-higher scores indicate greater syndromes, impulse control and miscella-
171
problem neous problems

(table continues)
Emotional Problems -help identify psychopa- -self-report inventory is made up -self-report inventory – scores on 5 clini-
Scales - Self-Report thology and emotional prob-of 147 behavioural items that cal scales-- (thought/behavior disorder, 172
and Behavior Rating lems in individuals 14 years
require a yes or no response impulse control, anxiety, depression, low
Scales (Prout & Stroh- of age and older with a mild
-behavior rating scale is made up self-esteem
mer, 1991) developmental disability of 135 items; behaviors are -behavior rating scales – scores on 12
scored on a scale of 0 (almost clinical scales – thought/behavior disor-
never reported or observed) to 3 der, verbal aggression, physical aggres-
(often reported or observed) sion, sexual maladjustment, noncompli-
ance, distractibility, hyperactivity, somatic
concerns, anxiety, depression, withdrawal,
low self-esteem
Psychopathology In- -help identify psychopatho- -two forms - self-report and rat- -self-report and ratings-by-others – scores
strument for Mentally logical behaviours for treat- ings-by-others on 8 subscales – schizophrenia, affective
Retarded Adults ment in adults with mild- -items require a yes or no re- disorder, psychosexual disorder, adjust-
(Matson, 1988) moderate developmental dis- sponse ment disorder, anxiety disorder, somato-
ability form disorder, personality disorder, inap-
propriate adjustment
Reiss Scales for Chil- -screen for dual diagnosis in -60 item questionnaire, rating -scores on 10 subscales – anger/self-
dren’s Dual Diagnosis children aged 4-21 years withbehaviours on a scale of 0 (no control, anxiety, attention-deficit, PDD/
(Reiss & Valenti-Hein, mild - severe developmental problem) to 2 (major problem) autism, conduct disorder, depression, poor
1990) disability self-esteem, psychosis, somatoform, with-
drawn/isolated, as well as other significant
behaviours
Reiss Screen for Mal- -screen for dual diagnosis in -38 item questionnaire, rating -scores on 8 scales - aggression, autism,
adaptive Behavior individuals above the age of behaviours on a scale of 0 (no psychosis, paranoia, depression - behav-
(Reiss, 1988) 12 years with mild, moderate problem) to 2 (major problem) ioural signs and depression - physical
or severe developmental dis- signs, dependent and avoidant personality
ability disorder, as well as special maladaptive
Mental Health Needs of Persons with Developmental Disabilities
behaviour items
C. Social-Environmental Factors
Many psychiatric disorders present as non-specific behaviour

challenges (Gardner & Sovner, 1994). In Chapter 3 of this
book, we explained that a non-specific behaviour means there
is a symptom that we see (i.e., a behaviour challenge), but until
there is an assessment, we do not know why it occurs.
Behavioural Assessment:
The first step in a behavioural assessment is to clearly deter-

mine what is the behaviour of concern. It is important to deter-
mine a clear description of the challenging behaviour. Just
knowing that John is aggressive is not descriptive. Does he hit,
bite, punch, destroy property? How often does the behaviour
occur? How severe is the behaviour? Does the behaviour occur
randomly or certain times of the day, week, month or year?
Does it occur with certain people or in certain situations more
often than with others? Are there certain times and with certain
people where the behaviour never occurs? Does the behaviour
occur more likely when the person is alone or with others?
In behavioural assessment it is important to identify the

“FIDD” characteristics of the behaviour (Griffiths & Hings-
burger, 1991):
• Frequency- how often does the behaviour occur?

• Intensity- how severe or intensive is the behaviour?
• Duration- how long does the behaviour last?
• Discrimination- where, when and under what conditions
does the behaviour occur?
The most common behavioural strategy for evaluating the

FIDD characteristics of behaviour is to conduct a functional

assessment or analysis.
Functional or Motivational Assessment/Analysis
Functional assessment is a process of gathering information

about antecedents and consequences that are functionally re-
lated to the occurrence of a problem behaviour (Miltenberger,
1997).
There are three types of functional assessments: indirect as-

sessment, direct observation and functional analysis or ana-
logue assessment)
a) Indirect assessment (interviews and questionnaires)
There are a number of interview formats and questionnaires

available to conduct a functional assessment. For example the
Motivational Assessment Scale-MAS (Durand & Crimmins,
1992) is a 16 item other-report questionnaire, through which
the motivation of a specific behaviour is determined to be sen-
sory (i.e., to gain stimulation), escape (i.e., to avoid an un-
pleasant activity or interaction), attention (i.e., to gain interac-
tion), and tangible (i.e., to gain a desired item).
One of the most commonly used and commercially available

formats is the Functional Assessment Interview (FAI) devel-
oped by O’Neill, Horner, Albin, Storey, and Newton (1997).
This interview format provides an easy to conduct and quick
method of gathering behavioural data. The FAI is divided into
11 major sections:
1. Description of the behaviour

2. Potential ecological setting events

3. Immediate antecedents (predictors) for the occurrence or
nonoccurrence of the problem behaviour
4. Consequences for the problem behaviour
5. Efficiency of the problem behaviour
6. Existing functional alternative behaviours
7. Communication
8. Approaches that do and do not work
9. Things that are reinforcing
10. History of the undesirable behaviour and previous pro-
grammes
11. Summary of major predictors and consequences
b) Direct observation
A more accurate but more time consuming way of gathering

functional information is through direct observation.The ABC
observation, observation cards, scatterplot, and functional as-
sessment observation form are four methods of completing di-
rect functional assessments. Although the types of assessment
forms vary among behaviour analysts, they are universally de-
signed to gather information on the interaction between the be-
haviour and factors in the environment. From this, a working
hypothesis, on which intervention can be based, is developed.
The data method should provide information that allows the

clinician to (i) redesign the environment to reduce or eliminate
or alter antecedents to the problem behaviour, and to introduce
or increase antecedents for competing alternative behaviours;
(ii) identify behaviours that can be taught or increased which
could act as functional alternatives to the challenging behav-
iour; (iii) alter the consequences to provide the functionally-
related reinforcement for appropriate means of gaining the de-
sired outcome, and reducing the reinforcement for the chal-

lenging behaviour.
ABC plus chart: The ABC sheet is a standard recording tool

that is used for collecting data that are used for analysing the
contextual relationship of behaviour. A stands for Antecedent,
or the events that occur before the problem behaviour, and
which set occasion for the behaviour to occur. B is the behav-
iour, and C is the consequence that followed the behaviour.
A standard ABC chart looks like the following:

Staff: Alice Smith Date: July 20, 6:20 p.m. Client: Paul Brown
A=ANTECEDENT B=BEHAVIOUR C=CONSEQUENCE

(what happened (what happened) (what happened after)
before)
Jane, the new staff, Paul sat on the couch Jane came closer and
asked Paul to do and refused to move gave him a second in-
the dishes struction
Jane came closer Paul threw the ashtray at Jane told him to go to his
and gave a second the staff member room if he could not be-
instruction have; Jane did the dishes
These data tell a very clear story. Paul was able to avoid doing
the dishes by throwing an ashtray. However, sometimes the
data are not so clear for some of the following reasons:
• The behaviours may occur at a very high frequency such

that it is difficult to record each incident.
• The behaviours may occur for different reasons at different
times.
• There may be patterns to the behaviour that are difficult to
assess.
• The antecedents may be a stimulus complex, and as such
depend on a combination of certain triggering events, as

well as the presence of some other factors.
Hurley (1997) has developed a training guide for using the

ABC Sheet to collect and analyze data. She recommends an
expanded ABC chart that includes describing as antecedents
not just the event immediately preceding the behaviour, but
other setting events or contributing events that could be ob-
served. Additionally, she teaches staff to provide expanded
information on the behaviour and the consequences. For ex-
ample she suggests recording:
• Antecedents including where it was occurring, what was

occurring, what activity or interaction was present, who
was present, and were there any indications of body lan-
guage or of a physical state that could be observed.
• Behaviours including what happened, to whom, where,
for how long, and to what intensity or frequency.
• Consequences including who responded, and how
(verbally and nonverbally) and to what end (what
changed in the person or for the person).
Data Recording Card: Gardner and Sovner (1994) describe a

procedure for obtaining more systematic observational data.
A small index card is used by an observer to record each inci-
dent of the problem behaviour as it occurs, or shortly after it
occurs. The observer records the Date and Time of the occur-
rence, the Situation (e.g., lunch, gym), antecedent Triggering
Events (e.g., Tom asked Jane to pick up her coat), Challeng-
ing Behaviour (e.g., Jane began to yell), Consequences (e.g.,
Jane was ignored), and Possible Contributing Instigating In-
fluences (i.e., anxiety, eye rolling, rocking motion prior to in-
cident, room was extremely noisy)
Scatterplot: The scatterplot is a recording method developed

by Touchette, MacDonald and Langer (1985). Using this
sheet, someone in the person’s natural environment records
during predetermined intervals whether the behaviour oc-
curred during the previous interval (1/2 hour is a typical inter-
val). A single chart contains seven days of data. Severity and
frequency are delineated as solid blocks (severe or high fre-
quency) versus a stroke (mild or low frequency). The severity
and frequency are clearly defined. The block is left unmarked
if no behaviour occurred. After a week the data sheet can re-
veal patterns for the behaviour (i.e., time of day, days of the
week), which can lead to additional analysis of the factors that
may be influencing the behaviour.
Functional Assessment Observation Form: The Functional

Assessment Observation Form (i.e., O’Neill et al., 1997) has
become a standard data sheet for gathering multiple points of
information on a single data sheet. This sheet is used to col-
lect data in intervals. As such, the day is divided into daily in-
tervals along the left side of the page. Across the top, data are
gathered on the following: various behaviours, predictors
(demands/requests, difficult tasks, transitions, interruption,
alone), perceived functions to obtain or get (attention, desired
item or activity, self-stimulation, other), or to escape/avoid
(demands/requests, an activity or person), and the actual con-
sequences. Multiple behaviours and multiple incidents can be
recorded on a single sheet that can be analysed for frequency,
trends and functions.
c) Experimental manipulations/ Functional Analysis
The most controlled approach to functional assessment is ex-

perimental manipulation of the antecedents and consequences,
to isolate the antecedents, setting events and consequences

that influence the behaviour. This is called a Functional
Analysis. Traditionally, this method has been conducted
with carefully orchestrated repeated sessions (i.e., Iwata,
Duncan, Zarcone, Lerman & Shore, 1994). However, less
time consuming approaches have been described by Derby
et al. (1992), in which a single 90 minute evaluation session
is employed. Although a functional analysis is considered
more methodologically sound compared to the methods of
functional assessment described previously, research has
shown that a comparison of the two approaches in an ap-
plied setting (children in home setting) produced compara-
ble results (Amdorfer, Miltenberger, Woster, Rortvedt &
Gaffaney, 1994). This finding is important for clinicians
working within applied community settings where the use of
highly controlled analogue functional analysis would be dif-
ficult to implement.
d) Specialised screening and assessment
Sociosexual testing and assessment: One area of specialised

assessment that is often requested is a sociosexual assess-
ment. Several measures are available for sociosexual
evaluation. Three will be discussed below. The most com-
prehensive socio-sexual assessment is the Sociosexual
Knowledge and Attitude Test-SSKAT (Wish, McCombs, &
Edmonson, 1980). It has been criticised as being out-of-
date, value-laden, time consuming, requiring a high level of
skill to administer, overly complicated in parts and lacking
in detail in others. However, it appears to be still the most
widely used measure in this area. A revised Socio-sexual
Knowledge and Attitude Assessment Tool (SSKAAT-R)
(Griffiths & Lunsky, in press) is currently being field tested.
Less complicated questionnaires (i.e., Timmers, DuCharme &

Jacob, 1981; Ousley & Mesibov, 1991) have been developed,
but they lack psychometric evaluation. A more recent evalua-
tion is the Sexual Knowledge, Experience, Feelings and
Needs Scale (SexKen-ID) by McCabe (1999). This is not
commercially available, and has been criticised for use as an
assessment tool because it goes beyond knowledge and atti-
tudes into personal experiences.
Violence and Sexual Risk Assessments: An important chal-

lenge for mental health professionals is the assessment and
treatment of persons with intellectual disabilities who have
committed a sexual offense. The reader is referred to Chapter
13, Sexuality and Mental Health Issues for a description.
Issues in Assessment of Persons who are Nonverbal or

Profoundly Challenged
As covered in Chapter 17, Mental Health Issues in Clients

with Severe Communication Impairments, a number of formi-
dable challenges are encountered when assessing individuals
who do not communicate verbally. These challenges are due
to a number of factors, including:
• the lack of firsthand information from the individual and

the need to rely on information from other sources (e.g.,
interviewing others, direct observation of behaviour).
• the co-existence of medical or sensory conditions which
can further complicate the picture.
• the finding that psychiatric illness may manifest differ-
ently in these individuals and that diagnostic criteria for
specific disorders may need to be translated into
“developmental disability equivalents” (e.g., Pary, Levitas
& Hurley, 1999).
Putting it Together: The Comprehensive Biopsychosocial

Assessment
The following multi-factorial case illustrates the point that,

while it is not always possible to arrive at a definitive clinical
diagnosis, a biopsychosocial assessment results in a more thor-
ough understanding of the individual’s needs and provides a
solid basis upon which to make more reasoned decisions about
treatment.
The Case of Bill
Bill is a 21-year-old male who was diagnosed with autism at

the age of two years. He is non-verbal, but uses
augmentative forms of communication (signs, gestures,
vocalisations, pointing to picture communication symbols).
He rarely initiates activities or makes spontaneous requests,
but relies instead on staff to prompt him to do so. He does
not have any major health concerns, although there is a
family history of migraine headaches.
Bill moved from his family home into a group home one year
ago. He is the only non-verbal resident who lives there and
staff did not know initially how to use sign language. Many
of them have never worked with anyone with autism. Bill
graduated from a modified high school programme 6 months
ago. While attending the programme, Bill was involved in
several community work placements, and was described as a
model student.
Until 9 months ago, Bill’s behaviour was very stable. He

was gentle, cooperative and easy going. He had a long
history of compulsive or ritualistic behaviours, such as
putting things in order, or pushing in chairs. However, he
did not become upset when his rituals were interrupted
except when he was anxious. He would at times display
signs of anxiety or agitation in the form of pacing, loud
humming, and occasional head hitting. There was no
clear pattern associated with these periods of agitation,
and they would not last longer than a day or two.
Staff started to notice a major change in Bill’s behaviour

about 3 months ago. Whereas he was formerly happy and
eager to please, he started to display high levels of anxiety
and agitation. He also became aggressive toward a
particular roommate in his group home. There were no
changes in his appetite, energy level or sleep habits. He
appeared to be in pain occasionally, and pointed to his
head as if to indicate the presence of a headache. A
support plan was developed which focused on helping him
to communicate his needs and wants through the use of
picture communication symbols and training staff to use
sign language; reducing his level of stress by taking him
for a walk or to a quiet place; allowing him to complete
his rituals when he was anxious; avoiding crowded or
noisy settings; involving him in structured activities; and
preparing him for changes in his routines or activities
through the use of calendars and picture schedules. He
was also given medication for pain relief when he showed
signs of having a headache.
Bill’s behaviour improved considerably about 2 weeks

after the support plan was introduced, and was stable
until one month ago when he again started to display signs

of intense anxiety, and aggressed toward several staff and
roommates. Staff continued to follow his support plan, but
his anxiety did not lessen. Bill’s family physician
prescribed Ativan as a PRN, but this only made him more
anxious and ritualistic. Staff were forced to call an
ambulance one day when his behaviour went out of control.
Bill was taken to the local emergency room, and kept in 4-
point restraint for several hours. He was given Haldol and
Ativan, and was sent home with orders for Chlorpromazine,
Valium and Cogentin. These medications made him
extremely drowsy, but the anxiety and aggression continued.
Several days later, his family physician discontinued all his
other medication and started him on Risperidone twice
daily. His agitation disappeared within two days and only
recurred again periodically; when it did occur, it was short-
lived and usually related to physical ailments (e.g., GI
problems). Bill’s dosage of Risperidone was decreased in
response to concerns that he was sedated and “spaced out”.
For the first time in months, Bill is back to his formerly
happy and easy-going self. Staff continue to implement his
support plan, and he is being eased slowly into community
work placements.
Bill recently underwent an interdisciplinary assessment in

regard to his behavioural difficulties. The consensus of the
team was that Bill had reacted to the cumulative effects of a
number of stressors in his life, but they were unable to offer
a definitive diagnosis regarding the etiology of his anxiety
and aggression. They were encouraged by the improvement
in his behaviour, and urged staff to continue to implement
his support plan, and to maintain him on his current level of
medication.
Table 2: Summary of biopsychosocial factors that were

hypothesised to be operating in Bill’s case
Instigating Factors Vulnerabilities Reinforcing Conditions
Biomedical -anxiety in -autism Negative

response to series -family history of reinforcement –offered
of life stressors migraines medication for pain
-migraine -anxiety disorder(?) relief
headaches(?) -obsessive -reduction in anxiety
compulsive when allowed to
disorder(?) complete rituals
Psycholo- -frustration over -rarely initiates Negative

gical wanting/needing requests or reinforcement –
something and performs tasks reduction in frustration
having to wait for without prompting when he is able to
prompt from staff from staff perform a task or obtain
-frustration over -lacks verbal skills a desired object after a
staff inability to -need for routine prompt
understand his and structure Differential
augmentative reinforcement – when
communication staff understand his
forms signs or gestures and
-confusion or can meet his needs (in
distress over end of the absence
school placement of aggression)
and loss of long-
time friends
Social -crowded, noisy -over-stimulated by Negative

environments too much noise or reinforcement –
-programmes that too many people removed from noisy or
focus on sedentary -need for high crowded environments;
activities levels of physical taken for a walk; given
-programmes that activity small jobs to perform
do not have clearly -need for structured
defined tasks programmes
Summary
This chapter contains a review of instruments that are used

during the biopsychosocial assessment of mental health prob-
lems in individuals with developmental disabilities. Uses and
limitations of various assessment tools were discussed. Practi-
cal information regarding how to conduct an assessment was
provided along with specific examples to illustrate the content
and format of different assessment instruments. Differences
between screening and in-depth assessment were highlighted.
Finally, case examples were used to draw the points together.
Do You Know?
1. Why are screening and assessment so important in

understanding the presenting behaviours in a person
with developmental disabilities? Name two reasons.
2. What are the most common biomedical conditions
that influence such behaviours?
3. Name a few common psychological events that can
present with excessive behaviours.
4. How the psychological assessment/s contribute to
the screening process?
5. What FIDD stands for?
6. What are the most common elements of a behaviour
assessment?
7. What are some of the challenges in assessing and
treating persons with developmental disabilities that
have committed a sexual offence?
Resources
The following list can help the reader to obtain more informa-
tion regarding the psychological assessment instruments that
were identified in the chapter. Access to many of these instru-
ments is restricted to professionals with specific training and
expertise; details are available from the companies or test pub-
lishers.
PSYCAN, Unit 12, 120 West Beaver Creek Road, Richmond

Hill, ON L4B 1L2; Phone: 905 731-8795; Fax: 905 731-
5029; Email: [email protected]; Website: www.psycan.
com (EVT; PIAT-R, PPVT-III; TONI-3; VABS; WRAT-
3) .
Psychological Corporation, 55 Horner Avenue, Toronto, ON
M8Z 4X6; Phone: 800-387-7278 or 416 255-4491; Fax:
800 665-7307 or 416 255-6708; E- mail:
[email protected]; Website: www.hbtpc.com/
tpccanada (WAIS-III; WRAT-3)
Psychological Assessment Resources, Inc. P.O. Box 998,
Odessa, FL 33556; Phone: 800-331-8378; Fax: 800 727-
9329; E-mail: [email protected]; Website: www.
parinc.com (ABS-RC:2)
Riverside Publishing , 425 Spring Lake Drive, Itasca, IL
60143-9921; Phone: 800-323-9540; Fax: 630-467-7192;
Website: www.riverpub.com (SB-IV, SIB-R)
Stoelting Co., 620 Wheat Lane, Wood Dale, IL 60191; Phone:
630 860-9700; Fax: 630 860-9775; Website: www.
stoeltingco.com (Leiter-R)
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Comprehensive Screening and Assessment 151

Comprehensive Screening and Assessment

Jane Summers, Chrissoula Stavrakaki, Dorothy M. Griffiths,

Readers will be able to:

1. Identify two reasons why assessment and screening

Why are screening and assessment important?

This chapter contains a review of different instruments that are

require more in-depth assessment or particular types of ser-

The dominant theme throughout the book is the biopsychoso-

• reactive to biomedical influences or traumatic events

In order to diagnose the different factors that may be working

well-conceived hypothesis (or hypotheses), the selection of an

BOX 1 - Ten Factors to Consider in the Differential Diag-

A comprehensive assessment process involves gathering the

No one person or member of one particular professional disci-

lyst is quite different from that of a medical doctor. That is

Isn’t dual diagnosis just another label?

A comprehensive biopsychosocial assessment provides you

• It provides understanding. It is descriptive to other people

At times, the assessment may uncover a genetic disorder that

learned in Chapter 3– The Integrated Biopsychosocial Ap-

What does it mean to do a comprehensive biopsychosocial as-

Challenging behaviours can be influenced, directly or indi-

and Sunada (1997) noted that an overwhelming percentage of

Specific observation charts have been developed to assist in

Figure 1–Monthly Sleep Chart

Certain syndromes are associated with an increased risk of

• annual thyroid screening

The timing and nature of the challenging behaviour can pro-

Figure 2– Bipolar Mood Chart

Certain medications can influence behavioural symptoms. For

• current medications, dosages and administration schedule

A tool that has been recently developed to assist clinicians in

Screening for genetic disorders

In recent years, significant progress has been made in

• large ears and testes

The following case provides an excellent example of the need

The Case of Johnny

Johnny is an 18-year-old male with Down syndrome who

Sixteen months prior to his first assessment at a psychiat-

i) Father, due to work obligations, had to be away from

Parents, at that time, tried to cope with Johnny’s changes,

following the social withdrawal and severe loss of social

At a final attempt to disentangle this problem, Johnny was

Gathering a Psychological History

A history is important to evaluate the path of the individual’s

Important events might include:

• History of emotional/physical or sexual abuse

Let’s take a look at the following example in Figure 3 of a

Observed death Parents Began Sexually Institutionalized Sexually Abused Placed in a

4 years 41/2 years 5 -6 years 5 -7 years 7-10 10 -15 years 17 years

This section will focus on psychological tests, their uses and

Standardised psychological tests differ in several ways from

Standardised tests are administered in a uniform manner and

indicate how well the individual being assessed performed in

Inventories or rating scales are often used to measure aspects

Psychological tests have limitations as well as advantages.

While the process of assessing the psychological functioning

guage functioning, academic or vocational performance, and to