The “youth top problems” measure: Identifying and keeping track of youths’ needs

Weisz, J. R., Chorpita, B. F., Frye, A., Ng, M. Y., Lau, N., Bearman, S. K., Ugueto, A. M., Langer, A., Hoagwood, K. E., & The Research Network on Youth Mental Health. (2011). Youth top problems: Using idiographic, consumer-guided assessment to identify treatment needs and to track change during psychotherapy. Journal of Consulting and Clinical Psychology, 79(3), 369–380.

Summarized by Ariel Ervin 

Notes of Interest: 

  • It’s common for clinicians to inquire about the issues that concern their clients the most and what they would like them to talk about in treatment at the beginning of youth psychotherapy.
  • Although this common practice can help build rapport, establish therapy goals, and create a working alliance between clinicians and clients, it’s difficult to track progress over time.
  • This study suggests that having youth pinpoint their top problems can create a youth-guided and psychometrically-sound strategy for approaching a helping relationship.
  • Findings indicate that the top problems measure is a youth-guided and psychometrically sound approach that simultaneously aligns with standardized assessments.
  • Using this measure with youth  can help focus attention and treatment planning on the problems that are most important for youth and their caregivers. This measure can also provide insights into how these identified problems change throughout psychotherapy sessions.

Abstract (Reprinted from the article)

To complement standardized measurement of symptoms, we developed and tested an efficient strategy for identifying (before treatment) and repeatedly assessing (during treatment) the problems identified as most important by caregivers and youths in psychotherapy. Method: A total of 178 outpatient-referred youths, 7–13 years of age, and their caregivers separately identified the 3 problems of greatest concern to them at pretreatment and then rated the severity of those problems weekly during treatment. The Top Problems measure thus formed was evaluated for (a) whether it added to the information obtained through empirically derived standardized measures (e.g., the Child Behavior Checklist [CBCL; Achenbach & Rescorla, 2001] and the Youth Self-Report [YSR; Achenbach & Rescorla, 2001]) and (b) whether it met conventional psychometric standards. Results: The problems identified were significant and clinically relevant; most matched CBCL/YSR items while adding specificity. The top problems also complemented the information yield of the CBCL/YSR; for example, for 41% of caregivers and 79% of youths, the identified top problems did not correspond to any items of any narrowband scales in the clinical range. Evidence on test–retest reliability, convergent and discriminant validity, sensitivity to change, slope reliability, and the association of Top Problems slopes with standardized measure slopes supported the psychometric strength of the measure. Conclusions: The Top Problems measure appears to be a psychometrically sound, client-guided approach that complements empirically derived standardized assessment; the approach can help focus attention and treatment planning on the problems that youths and caregivers consider most important and can generate evidence on trajectories of change in those problems during treatment.

Implications (Reprinted from the Discussion)

Leaders in treatment research have often called for assessments that rely on the perspective of clients, and some have documented clinician concerns about the utility or sufficiency of the standard-ized outcome measures often used in research (e.g., Bickman et al.,2000; Garland, Kruse, & Aarons, 2003); clinician suggestions about how to improve the utility of assessment tools have stressed the need for brevity and simplicity of measurement (see, e.g.,Garland et al., 2003). The present study explored whether a type of client-guided assessment that is widely used in clinical practice might be structured to form a brief, simple, psychometrically sound idiographic complement to standardized assessment of mental health symptoms. The findings suggest that the resulting approach—having clients identify and repeatedly rate the severity of their top problems—may contribute to both clinical practice and treatment research in a number of ways. The problems identified by youths and caregivers were clinically significant concerns; more than 95% of both youth and caregiver problems were reliably coded as matches to CBCL and YSR items. To assess the potential contribution of top problem assessment, we investigated (a) whether the top problems identified by youths and caregivers add to the information standardized measures provide and (b) whether the TO measure provides psychometrically sound assessment.

As to the first question, the specificity of youth and caregiver top problems complemented the more general information provided by standardized measures. The CBCL/YSR provided a rich array of valuable data, in the form of 0–1–2 ratings on problem items, and scores on narrowband and DSM scales, with scale scores in the clinical range warranting clinical attention. Such Information provides an excellent index of severity relative to normative samples, and multiple scales that can be rank-ordered in terms of their statistical deviance; however, that information is not designed to reveal which specific problems represent the highest priority treatment targets for caregiver or youth. TP assessment complements the CBCL and YSR by providing that information onclient problem priorities. TP assessment also adds useful specific-ity to CBCL and YSR information, as when Item 112 on the CBCL or YSR shows that a youth “worries,” but top problem identifica-tion shows what the youth worries about (e.g., in our sample,“dying,” “falling into a septic tank,” “losing my house and family,”and “something bad happening to Mom”).

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