A Closer Look

Science-Based Case Conceptualization

When we start working with a student, there are almost limitless factors that can be assessed and investigated. However, not all of these factors will be relevant or helpful for assessment or intervention—nor do we have the time and resources to evaluate every factor. To successfully navigate the overabundance of factors, strategic use of case conceptualization may help to guide the selection of the most salient factors for consideration.

Defining Case Conceptualization

Case conceptualization is the development and ongoing revision of a set of hypotheses about the causes, maintaining factors, and intervention considerations relevant to a student’s social, behavioral, emotional, or educational problems (see Thomassin & Hunsley, 2019). To develop and refine questions in this way, a psychologist’s understanding of the student, our awareness of their distal and immediate context, and our knowledge of developmental, educational, and clinical science must be brought to bear. This requires extensive work on the part of psychologists as it makes necessary continuing education on child development (e.g., expected milestones), clinical pathology (e.g., signs, symptoms, correlates, progression of various disorders), and evidence-based assessments and interventions. Because the literature supporting our practices is expansive across a multitude of disciplines, journals, and topic areas, case conceptualization may also serve as a compass to direct psychologists to relevant literature.

Case conceptualization, just like the use of a compass, is not a one-and-done activity. Instead, it’s an ongoing process of revision based on the evidence at hand. Just as we would look back at our compass to continuously make sure we are headed in the right direction, we should continually check our data and how well those data support our hypotheses, and continually readjust. Broadly speaking, case conceptualization can be thought of as four stages that are continually formulated and reevaluated based on new information: (a) Identify concerns and strengths; (b) assess and assign classifications; (c) develop an intervention plan; and (d) monitor outcomes.

With each stage, additional information is collected that refines our overall understanding of the student and introduces new questions to be answered. This process is informed by evidence-based assessment, which is the use of research-supported and theoretically sound instruments and practices for the collection and integration of information to arrive at educational decisions (see Hunsley & Mash, 2007). The first half of the sequence is focused on identifying strengths and weaknesses—and in most educational settings, identifying whether the child warrants a special education classification. In the latter half of the sequence, the focus is on selecting and monitoring interventions. While the first half serves a bureaucratic role in most settings, the latter portion of the sequences focuses on finding actionable and efficacious solutions to the problems experienced by the student. Throughout the process, each piece of information gained must fit together with the total picture, and the case conceptualization is modified to accommodate the new information—much like a crossword puzzle where a new answer corroborates or contradicts the answers it intersects. New answers may also reveal new clues to follow, such as when a student does not respond as expected to an intervention, and this prompts hypotheses regarding how to improve their response to intervention.

Consider the case of Jackson, who fidgets, talks out of turn, and leaves his desk during independent math instruction. Information collected during stage 1 may generate a number of hypotheses, such as “Jackson is escaping because the work is too hard for him;” “he is escaping because he experiences math anxiety;” or “he is seeking the attention of his peers or the teacher.” Your case conceptualization has evolved, and the assessment strategies needed to address these questions have also changed; a standard battery is not adequate to evaluate each of these hypotheses. After strategic screening and assessment, you identify that Jackson is not fluent at foundational math, even though he’s accurate, and that he may feel anxious about independent work. You may also see that he’s not engaging in this behavior during down times, so the attention hypothesis is not supported. This has modified your case conceptualization, and you are capable of making more informed treatment and progress monitoring decisions moving forward. In Jackson’s case, math fluency building, coping skills for anxiety, or a combination of both may be warranted.

What Is Good Enough?

Case conceptualization can function as a data reduction technique in the sense that it takes students as they are, but it facilitates homing in on the variables most relevant to the referral concerns. In an ideal world, we would evaluate every relevant piece of information, but this approach is time- and resource-prohibitive, and so case conceptualization may also function to help us identify the most salient factors for assessment and treatment. In this sense, we are aiming for a “good enough” understanding of the student that permits us to provide efficacious services. In the end, we want efficient and effective services by focusing on those factors—and those interventions—that will have an observable effect on the issues at hand.

References

Hunsley, J., & Mash, E. J. (2007). Evidence-based assessment. Annual Review of Clinical Psychology, 3, 29–51. https://doi.org/10.1146/annurev.clinpsy.3.022806.091419

Thomassin, K., & Hunsley, J. (2019). Case conceptualization. In M. J. Prinstein, E. A. Youngstrom, E. J. Mash, & R. A. Barkley (Eds.), Treatment of Disorders in Childhood and Adolescence (4th ed.). The Guilford Press. 8–26.

Related Webinar: Evidence-Based Assessment Meets Evidence-Based Treatment: Science Informed Case Conceptualization in School Psychology

About the Author

Dr. Zaheer & Dr. Ryan Farmer
Dr. Zaheer has extensive research and practical experience and expertise in the area of evidence-based practices in schools, which includes the case conceptualization process. In research, Dr. Zaheer has applied case conceptualization for clinical needs as part of large nation-wide randomized control trials along with evidence-based assessments and interventions. In his role as the director of the “Clinic for Evidence-based Practices in Schools” (CEPS) at Montclair State University, he also has provided past trainings on case conceptualization to school and clinical psychologists as well as other mental health professionals (i.e., social workers) and has also directly used science-informed case conceptualization for clients at the CEPS. Dr. Ryan Farmer is an assistant professor of school psychology at Oklahoma State University. He received his doctorate at The University of Memphis and completed predoctoral and postdoctoral training at Munroe Meyer Institute at the University of Nebraska Medical Center. Dr. Farmer is licensed as a psychologist in the Commonwealth of Kentucky and is a Board Certified Behavior Analyst. His research interests include the assessment process and meta-science in school psychology. His two primary projects at this time are an evaluation of adaptive behavior scales and an exploratory study of research trends, methods, and practices in school psychology.