Uncertainty & Preference

Adaptational difficulties that lead to referral frequently reflect developmentally and/or situationally inappropriate or exaggerated expressions of behavior that may at times also occur in children who are not referred (Achenbach & Edelbrock, 1981). As a result, decisions concerning the evaluation and treatment of any child are heavily embedded within the child’s social and cultural milieu, and are always the result of ongoing judgements that are either made or not made by significant individuals in the child’s environment, usually parents and teachers (Mash & Terdal, 1981, 1988).

The professionals who assess and serve children and their families come from a variety of disciplines and backgrounds. In addition, there is a default judgement in favor of problem identification when a child is referred; for why else would such a referral be made? Such variables in assessment are multiplied when a child’s difficulties are identified, leading to such questions as:

• Do the difficulties require intervention?

• What are the projected outcomes in the absence of intervention?

• What outcomes do we want to achieve?

• Whose outcomes do we want to achieve?

• What interventions are likely to be most effective in meeting intended outcomes?

• Are these interventions likely to be accepted by the child/family?

• Who is the best person to provide the services?

• Is this person likely to be accepted by the child/family?

• When should interventions be initiated and when terminated?

• Is the intervention having the desired impact?

Since the criteria for judging abnormality in children are to a large extent social in nature. What constitutes a problem and the likelihood of referral for treatment will depend greatly upon the norms and expectations of the individuals in the child’s environment (Mash, 1989). This factor leads to a secondary question of “whose problem is it?” – for often we find that the offending behavior is not universally offensive.

Such questions are not now well answered if the literature is correct.

It would appear that most children who are in need of psychological services do not receive them (Kazdin, 1988).

Estimates indicate that only 20% – 33% of children with clinically significant disturbances actually receive treatment (Knitzer, 1982), and that children with more severe dysfunctions may be slightly less likely to receive help (Sowder, 1975).

On the other hand, the transient nature of many types of psychological disturbances during childhood would suggest that not all children exhibiting disorders are best served through the provision of specialized psychological services (Mash, 1989).

As we review these perspectives regarding decision making in regard to intervention, we are left with a certain amount of uncertainty. Despite an extensive body of knowledge about human growth and development, our attempts to help may be fraught with the counterintuitive concerns articulated by Forrester – “our attention is drawn to the very place where intervention will make matters worse”.

Added to these difficulties, we are faced with the fact that such intervention is not a monolithic, single methodological approach but incorporates widely diverse methods and techniques with differential efficacy that has not consistently been documented with such data collection that would measure meaningful outcomes. The uncertainty is exponentially increased by the variation among individuals – both clients and helpers and the impact of context as it moderates the expression not only of behavior, but of cognition and affect as well (Mash, 1989).

Reduction of this uncertainty is a requirement of any system of social intervention. Minimum ethical standards must include determining whose objectives should the intervention aspire to reach and keeping records that document the effectiveness of treatment in achieving the selected goals.

The first of these ethical standards – determining whose objectives should determine the goal of treatment is being increasingly addressed by the introduction of self-determination. The strength of an individual’s motivation is based on several constructs:

Expectancy – what is the probability that I will get what I want?

Instrumentality – will the attainment of what I want satisfy one or more of my needs?

Valance – is it worth the effort?

Since motivation is the critical variable in the effectiveness of any intervention, it may be wise to following the admonishment of Eduard Deming of Total Quality Management prominence: it is the customer who defines quality. Thus an increasing requirement is to turn away from a discernment of need toward a discernment of preference. Needs are a determination made by “experts” which often lead to counterproductive behaviors such as resistance or defiance. Kanfer and Schefft (1998) have described resistance and treatment noncompliance as representing a discrepancy between the client’s behavior and the clinician’s expectations (Mash, 1989). We would describe it more as a discrepancy between the client’s goals and the clinicians’s intentions. Motivation is never an issue when we help people pursue their own preferential goals. Blechman (19850) may have stated it best – Children with behavior problems deserve more … than training to conform to the demands of poorly functioning homes and schools.

The increased emphasis on self-determination has naturally led to a change in the nature of preferred interventions. Self-management strategies which are directed at teaching such processes as setting goals, evaluating norms and standards, monitoring and evaluating problem situations, examining choices, anticipating outcomes, employing self-reward and understanding the relationship between cognitions, emotions and behavior are increasingly the interventions of choice.

The second ethical standard, ‘keeping records that document the effectiveness in reaching objectives’ is also impacted by both Forrester’s ‘uncertainty principle’ – that we may make matters worse and by the ‘preference principle’ that if what we do is not effective in meeting the customer’s expectations we are likely to discover a reduced motivation for participation and an increase in resistance, defiance and non-compliance.

No entity can become a learning organism without the time, energy and creative thinking required for collecting and rigorously analyzing data. Our uncertainty should lead us to a clear concept that the provision of services and supports is an experimental services and that the ethical principles involving human subjects [The Belmont Report] are appropriate guidelines. These guidelines articulate three basic ethical principles generally accepted by our cultural tradition as particularly relevant:

Respect for Persons - incorporates at least two ethical convictions: 1) that individuals should be treated as autonomous agents, and 2) that persons with diminished autonomy are entitled to protection. The principle of respect for persons thus divides into two separate moral requirements: the requirement to acknowledge autonomy and the requirement to protect.

An autonomous person is an individual capable of deliberation about personal goals and of acting under the direction of such deliberation. To respect autonomy is to give weight to autonomous persons’ considered opinions and choices while refraining from obstructing their actions unless they are clearly detrimental to others. To show lack of respect for an autonomous agent is to repudiate that person’s considered judgements, to deny an individual the freedom to act on those considered judgements, or to withhold information necessary to make a considered judgement.

Thus the construct of self-determination is supported through adherence to the preferences of the autonomous person. One cannot assume, however, that the need to protect overwhelms the need to respect autonomy. Many people with severe disabilities that require a degree protection are still quite capable of autonomous decisions. If in no other way than resistance, they tell us of their preferences and the expert helper is able to utilize this knowledge to build informed decisions.

Beneficence – Persons are treated in an ethical manner not only by respecting their decisions and protecting them from harm, but also by making efforts to secure their well-being. In this context, beneficence is understood as an obligation. Two general rules apply: 1) do no harm and 2) maximize possible benefits and minimize possible harms. The question of harm through lack of self-determination, failure of inclusion or focus on disability rather than competence are issues of concern to the helping process. Blocking personal goals and objectives can be as harmful as physical attack. One need not support the method of achieving goals; only the goal itself.

One cannot maximize possible benefits and minimize harm unless one measures the impact of the intervention upon the quality of life of the person being served. This requires that a documentation of outcome data be utilized, not only to determine whether the intervention worked, but whether it is working. Such formative data is required so that modification of the intervention can be made before harm is done.

Justice – An injustice occurs when some benefit to which a person is entitled is denied without good reason or when some burden is imposed unduly. The concept of justice regarding social services is a vital component of federal law of “least restrict environment” and the question of justice arises whenever a child is separated from a mainstream environment. One could surmise that an injustice is potentially occurring when a person is non-compliant for the discrepancy between the client and the helper allows for potential error on either side.

Clearly if there is no harm to others, we are on rather insupportable ground to imply that the client is wrong for as John Stuart Mill admonished – ‘The only purpose for which power can be rightfully exercised over any member of a civilized community, against his will, is to prevent harm to others. His own good, either physical or moral, is not a sufficient warrant. He cannot rightfully be compelled to do or forbear because it will be better for him, because in the opinions of others, to do so would be wise, or even right (On Liberty, 1859)’. [Italics added] Thus the helper, no matter how concerned for the consequences that may befall the client, has no right to coerce compliance. Such coercion is not only unethical, but it provides a model for the client that is inappropriate.

These principles clearly underline the necessity for human service interventions to operate on the preferences of their clients – except where harm to others or illegal activity is concerned – and the need to document the effectiveness of intervention activities. This requires a system of careful study and systematic evaluation and supervised practice.