Dr. Lauren Breese on ‘How does diagnosis and formulation fit together – when do you choose which?’
Recorded lecture from our event ‘Assessment and diagnosis in children with neurodevelopmental problems’ on 7 October 2019.
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Dr. Lauren Breese is a Senior Clinical Psychologist experienced in assessment, formulation and evidence-based psychological intervention working one to one with children, adolescents and adults, as well as with families, organisations and systems. She is experienced in using CBT and systemic family therapy, as well as mindfulness, ACT, CFT and DBT. Lauren has specialist experience in working with children, adolescents and adults with a neurodevelopmental disorder (ASD, ADHD, ID) and co-morbid mental health problems and/ or behavioural disorder.
You can find more about Lauren at her website.
Hi, everyone. My name’s Lauren Breese and I’m a clinical psychologist, and throughout my experience so far I have worked with people with a neurodevelopmental condition. Initially my experience was working with young people and children and that’s in CAMHS through psychological theory for children with neurodevelopmental conditions but also in diagnosis. And next, now, I’m currently actually working with adults with a neurodevelopmental condition and through diagnosis but also in psychological therapy, so I’ve got a bit of a lifespan perspective.
But today I’m hoping to talk and think with you about formulation and where that might fit in our diagnosis and assessment of children and young people. But to begin today, I want to ask you a question. Okay, so could I have a show of hands? So the sky is blue? A show of hands for yes. That’s wrong. A show of hands for no. Okay, so if you have put your hand up for yes, I’m telling you, incorrect. Pause there. What does that feel like?
Yes, thank you. [Laughter]. Thank you for your [inaudible 00:01:45]. So confusing, yes. Anybody else feel brave? What did it feel like to be told incorrect?
Annoying, yes. So a belief that you’ve held for a long time, you’ve maybe spoken to other people about, you of all of a sudden come to this talk to be told that you’re wrong. Yes, confusing. That’s really annoying. I suppose I was just thinking about what that might be like for people to come for an assessment for something that they might have researched online or met other people with a diagnosis of something, and then to be told that the assessment actually that’s not the case. We don’t think you meet the criteria for a diagnosis of something. They might… that might be upsetting. You might want to seek another opinion. You might feel confused. There are difficulties there, but how might we explain them?
And I think this is happening increasingly, particularly for children with neurodevelopmental conditions, who’re often presenting with emotional and behavioural difficulties alongside a neurodevelopmental diagnosis or perhaps they’re presenting with neurodevelopmental… so difficulties that might not necessarily meet the criteria for a diagnosis. And so we’re seeing these young people in services and parents or teachers or other people who are involved with the child’s care, are concerned about a specific diagnosis, ADHD or autism, and they might be quite invested in that diagnosis and feel like it explains a lot. And they come to the appointment after probably what is a long period of waiting, which builds the anticipation, expecting an answer from the person that they’re coming to see.
And so we’ve talked a bit about diagnosis. Diagnoses are useful. They might define a problem in a certain way against a standardised set of criteria. It also then opens up the treatment, so what next? It’s a quick reference for understanding people. If somebody has a diagnosis, you might have an idea of what that might mean or what that might look like for the young person, and that’s useful. And also, a lot of the time a diagnosis or having a diagnosis of a neurodevelopmental condition might give you access to the system, so access to CAMHS or different services that provides treatment or help.
However, there are certain challenges with diagnosis. They aren’t providing information necessarily about that individual as a person, so one person with a diagnosis of autism is going to likely to be different from another person with a diagnosis, the same with ADHD or other neurodevelopmental conditions. They might not take into account the context… Well, they don’t take into account the context that that person developed in, so what are their social… What’s their social context? What’s their relationship context? What’s their cultural family context? And a diagnosis or a label doesn’t take that into account.
It doesn’t take into account how many diagnosis… what personal meaning those difficulties or differences have or what the impact is of those differences. And then what happens if difficulties are clearly present for that child, but perhaps they don’t reach the threshold? So they don’t necessarily meet a certain number of diagnostic criteria that are necessary to receive that diagnosis. What happens if the child needs more time to develop and you need to do some watching and waiting? What happens if there are separate difficulties? For example, environmental factors or external factors that are separate from the presentation. So maybe a diagnosis present, but what about all of these other things that are clearly having an impact and are really challenging for the child or the family that’s just not captured in a label or one certain black and white way of looking at things? Maybe the clinician is unsure, we need more time, we need extra information. Some of the challenges that Mark was thinking about in the challenges of diagnosing. And often people might be hoping for a clear-cut explanation, but that it might not necessarily be as black and white as it might hope.
So this is where I’m introducing this idea of formulation, which might be familiar to some of you. And what is a formulation? I like to describe it a bit like a road map, so a road map of somebody’s difficulties of how they might have developed and how they might have come to be where they are currently, what roadblocks might they have overcome, what challenges or roundabouts might there be on that journey ahead of them. So a formulation is structured narrative, a story of making sense of some of these difficulties, how they developed in their context, taking into account social, cultural relationship factors, what might be keeping them going in the present moment, and what the family or the child is making… how they’re making sense of those difficulties or differences. And it uses psychological theory to understand aspects of the child’s presentation.
And formulation can be simple. And I’m going to be talking to you about a brief framework that we can use to formulate some difficulties. It can also be complex. There are other psychological theories around different types of formulations that psychologists might use. But something that’s really important about formulation is that it guides treatment, so it can help you to come up with a plan. In the same way as a diagnosis can it actually points out potential opportunities for differences to be made. And what I like about formulation, it thickens the narrative of a diagnosis. So it becomes a story that the parents and the children can really engage with to explain how their problems might have developed and how they’re keeping on going. And it brings together multiple perspectives, so it becomes less of a yes, no, either, or, the sky is blue, it’s not blue. It’s a yes, the sky might be blue sometimes, and also it can be different colours, and it’s developed often collaboratively with parents, so using their language, which can be really empowering. And it helps other people to understand the child more broadly. So in the same way a diagnosis might be a quick reference guide for understanding somebody the same as formulation, it can guide people’s understanding more broadly. And it’s taking into account biological aspects, psychological, social aspects, to create a shared understanding. Okay, more about formulation in a minute.
So it can highlight any gaps in knowledge. So if you’re… If you realise that, yes, you might want to be more curious about a certain area formulation can guide that. And it can be quite validating for parents to come away with an understanding about their child that either whether they receive a diagnosis or not, that somebody has heard them, heard what their difficulties are, and this is our understanding of where you currently are, and this is what the treatment plan might be. And in my opinion can be used alongside diagnosis. It can be used as a… You know, they really go well together. It doesn’t have to be an either, or.
Okay, so just introducing a simple framework to… What do I mean by formulation? This is a framework that lots of psychologists use called the 5Ps and I’ll go into each P, don’t worry. So the presenting, predisposing, precipitating, perpetuating, protective factors, and I like to add in an extra P because I like to come up with a plan. So this is just a brief diagram of how they might fit together. So what are the past issues? How might they be influencing the triggers? How might they be influencing the current issues? What’s keeping things stuck? What’s going really well and what the plan is, but we can come back to that.
Okay, so to make this a bit more real, I’m just going to be thinking about a quick case study. And imagine you were referred a six year old boy. Referral comes from school. Mum is reporting this child as having angry outbursts, challenging behaviours, such as spitting, kicking, hitting, and he has been diagnosed with a language delay. Mum comes into the appointment. She’s very, very stressed. She’s really understandably concerned, trying to manage the child’s behaviour, really struggling, and she has spoken to lots of people, researched online. She’s certain that the child has a diagnosis of autism, and just really wants some help. She describes him pushing and kicking other children, having no sense of danger, running out into the road, not discerning between strangers and friends, talking to everybody, and really very tearful, emotionally labile, struggling to follow instructions and problems sleeping, waking up a lot in the night, very tearful, really hard to comfort.
However, when you meet the child, very sociable, very, very personable and funny, show… although non… struggling with language, maybe showing you things, modulating the eye contact with you, pointing things out, playing imaginatively. So immediately you’re kind of wondering, maybe ruling out autism as a possible presenting difficulty. But clearly, there are challenges, so how to go about having this conversation with the parent. Well how to go about understanding some of these difficulties in more broader detail. So we might take the first P, presenting. What the current issues? How is the parent describing what’s going on? How is the child making sense of their difficulties? And what did you observe? And that can fall under these categories. So biologically, what are the presenting difficulties? Is there anything going on biologically? Is there a chromosomal disorder? Is there physical health difficulties? Socially what’s happening? What was their social context? Are there any cultural factors that you need to be aware of or that are influencing the presenting difficulties? What’s their mood like or the psychological… any psychological difficulties that are presenting? Are they tearful? Are they low in mood? What’s their cognition like? Are there any learning delays? And is there any difficulties in their behaviour? So are they presenting with challenging behaviour? And the key thing about this aspect or this P is to be quite detailed, so to go into detail. So rather than challenging behaviour, maybe thinking about they’re kicking three times, for example, at a specific time. So really nailing down the detail.
So, for this case example, so this person’s a six-year-old boy, presenting as tearful and anxious. School have reported him as being very challenging, hitting and pushing other children in terms of his behaviour. Mum reporting no sense of danger, waking up three or four times a night distressed. So just a descriptive narrative of the presenting difficulties encompassing some of those aspects that were bullet pointed. So far, so good. So next is thinking about the predisposing factors. So really that just means past events. So what are the historical setting events that might have contributed to some of these presenting difficulties? And that could be in their personal history. So, for example, whether there are neurodevelopmental difficulties in the family. Are there any mental health difficulties in the family? Are there any genetic difficulties in the family? So personal history wise but also in the context, so have there been any adverse childhood events? Are there any difficulties in the parent child relationship? Any difficulties in the wider family or their social circumstances? Perhaps they’d have to move house four or five times in the last year. So these past events, predisposing events or factors are anything in their history that may have contributed to making the difficulties at the moment more likely to be present.
So from this case, this child was born and was taken to live with his aunt in America, which was very unusual for their culture. And the aunt and the child had a really close relationship, and through unforeseen circumstances, the child moved back to the UK with his mother two years ago. And of course, as a historical predisposing factor that might have been a huge change for the child and the whole family. Second, the mother reported to be socially isolated. So she’s saying to you that she’s really struggling because she doesn’t have any additional people around her that might be able to support her or would be able to help. So why is that important? Well because her feelings of stress and feelings of not being heard are likely to be having an impact on the child’s presentation, so really important to include in the formulation, which would be not necessarily included in or encompassed in a diagnosis. For example, the language delay might be the sense of the [inaudible 00:16:19]. The child is struggling to understand verbal instructions. Then he might be displaying some of his feelings through his behaviour. So these kind of historical or background factors are important in understanding that child’s presentation.
The precipitating factor, so triggers. What particular triggers are there for the presenting difficulties? So you might be thinking, well when is this behaviour more or less likely to happen? So you might be considering the social factors. Who is there? What is the social context? Biological factors. Are they tired? Are they hungry? I know that can be a trigger for me. In the context what exactly is happening? So are they more likely to be challenging when they get back from school, for example? Or is it a certain lesson that they display challenging behaviour? So for this child, particularly when this child is asked particular instructions, that we’re seeing the challenging behaviour, and particularly in the night-time when he has woken up; he’s fallen asleep on the sofa but he wakes up in the bed; particularly mum is finding that very difficult to manage when the child is very tearful.
Okay, so maintenance factors. So I would say your triggers and maintenance factors are the key areas where you might be able to think about a plan for intervention. So perpetuating factors, what is keeping these difficulties going in this present moment? And that might be biological, psychological, things in the system, things in the parenting or inconsistencies, things in the social network or consequences for the behaviour. So what might be maintaining these presenting difficulties, making it more likely to happen? So for this case example, for example, when the child is asked to do something he doesn’t want to do he ends up not having to do it, and therefore that is reinforcing the challenging behaviour, so it’s making it more likely that he was going to use that strategy again to try to achieve the same outcome. Another maintenance factor might be the social isolation because if then, yes, it is a setting event, but also it might be keeping going mum’s stress levels, and therefore, this is something that we need to be thinking about managing or helping mum to manage because that’s going to be keeping some of the behaviour going in the present moment. And thinking about ways mum or dad might be responding to the behaviour, if it’s inconsistent, it might be inadvertently reinforcing it, making it more likely to happen.
Okay, and the fifth thing, but not the least thing, thinking about protective factors. So what are the family’s strengths? So in each family, everybody is going to have things that are going well and it’s important to ask about them and important to think about what is helping at the moment. And that might be personally, it might be at home, at school, that the parents are there in front of you trying to ask for help, that they have an engaged SENCO or they’re achieving well. So really important to think about the protective factors and what might be lessening the impact of the difficulties. So this child is attending school, highly motivated, mum’s engaged.
So the final thing, thinking about the plan, and as I said, the key areas are around maintenance factors or potential triggers. So for this person, consider minimising any triggers that are present. So discussing sleep routine with the parent, discussing their consistency of rewards or consequences or how they might be giving instructions, addressing any maintenance factors like mum’s isolation or mental health or addressing any of the presenting difficulties that may not have had intervention. So this is where the formulation is useful in highlighting any gaps. For example, the language delay might require referral to speech and language therapy. And it also might highlight a need for parenting intervention for the parent.
So really I suppose what I’m trying to say is formulation is helpful to thicken that narrative that the sky is blue, but there might also be other factors that are going on that are really important that we need to know about that can describe the child and to support that child. So formulation can help to understand the child in their context, uses psychological theory to understand what’s going on. It shares responsibility so it’s generally collaborative, so has an understanding of the child from the parent and the child’s perspective, and from your perspective. It’s not just something that is given to the child. It’s very much collaboratively developed and highlights any gaps in knowledge and guides treatment, so can be used alongside diagnosis. Okay, perfect.