Summaries: the best scientific articles for clinical and health psychology summarized

In the current study the broaden-and-build theory of positive emotions is reviewed. This theory is based on the genesis of positive psychology. Empirical and theoretical advancements are made in the understanding of upward spirals that are associated with positive emotions. Furthermore, the upward spiral theory of lifestyle change is explained. Deeper end more rigorous tests should be done to see reciprocal and prospective relations with positive emotions. This research can help translating theory into applications to improve health and well-being.

What was the objective of the study?

The broaden-and-build theory of emotions describes that momentary experiences of everyday positive emotions extend people’s awareness so that they contribute to overall well-being. Positive emotions broaden the mind and feed the growing of resources. The long-term effects of mild -and everyday positive emotions was further investigated in the current study by reviewing the following hypothesis:

1. Positive affect will predict improvements in broad-minded coping with a strategy solely related to creative responding.

2. Positive (not negative) affect will be improved after broad-minded coping.

3. In five weeks, the primary positive affect will cause an increase in broad-minded coping.

4. Also, broad-minded coping will cause an increase of positive affect.

The last two hypothesis illustrate the dynamic and upward spiral.

What was found in the study?

There were 138 participants in the study who completed a survey. The data collection provided support for all hypothesis. Another study of 185 participants re-confirmed these findings. The goal was to replicate findings to support the broaden-and-build theory (Fredrickson & Joiner, 2002).  It was demonstrated that positive emotions initiate a spiral that has a positive impact on people’s future emotions. Further research found the effects of positive emotions training can increase over time, which is consistent with the dynamics of upward spirals.

How did research on positive psychology emerge?

The study of positive emotions is relatively new, as they only focused on the effects of negative emotions such as fear, sadness and anger in the past. For this reason, the broaden-and-build theory received a great amount of attention. The article by Fredrickson & Joiner has been cited many times, of which some turn out to be strong scientific contributions.

Some evidence for upward spiral dynamics was researched by Keyes (2005) and Krueger, Schkade, Schwarz and Stone (2004). They found that the presence of positive emotions, the lack of mental illness caused an increase in positive behaviours such as helping, playing and learning. It also predicted future increases in flourishing of positive emotions. Other research shows that emotion regulation strategies are affected by positive emotions. The team of Fredrickson also identified biological resources that influence or are influenced by positive emotions. The upward spiral theory of lifestyle change was tested as framework to understand the processes through which positive emotions influence health. Furthermore, the incentive salience theory of addiction shows that associations are formed between pleasantness and predictive cues of it called incentive salience.

How does the upward spiral model of positive emotions work?

The inner loop of the spiral model contains nonconscious motives that operate as a central mechanism for behaviour maintenance. Positive emotions affect health behaviours because of the salience of cues associated with these behaviours. Thus, a cascade of unconscious processes involved in producing positive emotions might orient individuals to redo previously enjoyed behaviours. The outer loop of the model represents the claim, based on the broaden-and-build theory that positive affect creates resources that moderate the inner loop processes. It means that vantage resources predict an increase in enjoyment of positive health behaviours.

What should be done in further research?

The reciprocal relations associated with positive emotions have been researched, but more development is needed. Causal pathways should be tested by controlled lab experiments and randomized controlled trials to find ways to create interventions to promote lifestyle changes. Larger samples and more frequent measures are now available and should be used to set motion in discovering resources people use in the upward spiral processes that improve health and well-being.

In 2014, 31% of working adults felt tension or stress, and 61% reported that they had enough resources to deal with this stress. A low salary and a lack of opportunities for growth were the most common sources of stress. Job insecurity is also in the top 5. Furthermore, uncertain job expectations and long working days were also in the top 5. With regard to interventions against work stress, the emphasis has probably been too much on 'red cape interventions' with the intention of stopping negative experiences, instead of on the 'green cape interventions', interventions with the aim of growing positive experiences. An example for the focus in this is increasing the employee resources. In this article, literature about stress management interventions is summarized, with an emphasis on green cape interventions.  

Theoretical framework

The authors use the job demands-resources (JD-R) model, a dual process model. This model reflects two mechanisms through which job demands and resources can lead to tension or motivation that subsequently influences organizational and individual outcomes. The first process is a health limiting process in which poorly designed jobs and chronic demands lead to poorer outcomes for employees and companies by exhausting the mental and physical resources of the employee. The second process, a motivational process, assumes that sources (for example, control, autonomy and feedback) can be motivators because they can help to achieve work goals or stimulate growth and development. This motivational process is especially important for health promotion and positive interventions. In particular, the mediating effect of burnout and work engagement between job demands and resources on the one hand, and well-being on the other, is supported by literature.      

Stress management interventions

Stress management interventions in 2008

The authors have categorized the different interventions into three categories: primary interventions are proactive and aimed at prevention and focuses on all employees, secondary interventions focus on employees at risk, and tertiary interventions focus on employees who need stress experienced guidance to to recover from this. Primary interventions are seen as the most effective, followed by secondary interventions and finally the tertiary interventions. Three meta-analyzes showed that stress management interventions are effective, but this seems to depend on the outcome being measured. Relaxation interventions are less effective than cognitive behavioral interventions. This is perhaps because relaxation is not aimed at changing cognitions but at letting go. CBT interventions are proactive. Moreover, a multimodal approach combining different types of interventions is no more effective than a unimodal approach, because it requires much more from the participant's resources. A system approach, in which both individual and organizational interventions are combined, is more effective because it does not necessarily exhaust the resources of the individual. The organization-oriented interventions are primary interventions and are the least researched. Whether these interventions are effective on their own is not yet clear.          

Recent developments

Mindfulness based interventions

In recent years there has been an increase in the number of interventions that use mindfulness techniques. The definition of mindfulness is "a state of giving attention to and awareness of what is taking place in the present." It could reduce employee stress by accepting an event and not judging it. The mindfulness-based interventions that are now being discussed are primary: aimed at all employees. According to a study by Wolver and colleagues, workers in the mindfulness and yoga condition experienced significantly a reduction of stress and improvement of sleep quality. There were also differences in heart rate variability and breathing, but no differences in blood pressure and work productivity. The intervention was just as effective when it was offered online as when it was done in real life. Research by Hülsheger and colleagues focused on the Mindfulness-Based Stress Reduction Program and Mindfulness-Based Cognitive Therapy. There was a significant decrease in emotional exhaustion and an increase in job satisfaction. Michel and colleagues (2014) found that participants who took a mindfulness intervention could psychologically detach themselves better from their work and experience less work-family conflict and were more satisfied with their work. Loving-kindness meditation also led to more positive affect, self-efficacy and job satisfaction and less psychological stress.           

Recovery interventions

Another intervention type focuses on facilitating experiences and improving processes that can reduce the negative effects of work stress. Hahn and colleagues (2011) studied the effectiveness of a recovery program consisting of four modules: psychological detachment from work, mastery, relaxation, and a check during leisure time. It consisted of two sessions of 4 to 5 hours. Improvement in all four areas was observed, as well as a decrease in stress and negative affect and a significant increase in self-efficacy. Siu and colleagues (2014) also showed positive results: higher scores on positive emotions and mastery and lower on emotional exhaustion and physical and psychological symptoms. However, the results were not statistically significant. Finally, there was an intervention that was tertiary and lasted 12 months. However, there was no standardization and no control group, so this means that no conclusions can be drawn.     

Multimodal interventions

Multimodal interventions consist of elements from different types of interventions, and are primary: available for all employees. Eisen and colleagues (2008) studied an intervention consisting of general stress education, stress reduction techniques, and progressive relaxation. They compared a group intervention with a computer-based intervention. In both groups there was a decrease in stress after each intervention module. However, there was no global decrease in stress after the intervention or a month later. The authors blame this on the fact that employees have not applied the skills learned in their daily lives. There were also a lot of dropouts in the computer group. Bourbonnais et al. (2011) investigated an intervention aimed at improvement in various psychosocial work factors. Three years after the intervention there was a significant improvement in almost all factors that were part of the study. Moreover, there was a decrease in work-related stress and burnout. The effectiveness of this intervention is probably due to the risk assessment that led to the development of the intervention. Cifre et al. (2011) did an intervention focused on the JD-R model. First they mapped out the psychosocial risk factors: few resources in the job (e.g. autonomy), innovation climate and perceived quality of training. Based on this analysis, they did a team redesign consisting of job redesign and training. This was a secondary intervention. The intervention led to increased self-efficacy and competence, perception of innovation climate and work involvement. Another intervention, Workplace Triple P (WPTP) is specially designed for parents with a job with the aim of building personal resources and coping behavior. It reduces dysfunctional parenting which in turn reduces general stress levels. This in turn led to a reduction in work-related stress.              

Summary and future research

There have been a number of new interventions since the meta-analysis by Richardson and Rtohstein (2008), namely mindfulness focused interventions, recovery interventions and multimodal interventions. Some studies had poor methodology, and most were primary and focused on individual outcomes. In addition, the measurements mainly consisted of self-reports. It must become more clear a) which outcomes are influenced by which types of interventions / activities, b) for whom an intervention type or specific intervention is most effective, c) the specific causal mechanisms.    

Health promotion and workplace welfare programs   

Stress management programs are generally red cape programs. Health promotion and well-being programs, on the other hand, are usually green cape programs because they focus on improving and promoting health. Madsen (2003) reported that welfare programs increase the emotional, intellectual, physical, social and spiritual well-being of employees, where well-being is defined as functioning at the highest possible level of yourself. Well-being programs in the workplace can focus on communication and awareness, or screening and assessment. A third category focuses on lifestyle and education programs. The latter category focuses on behavioral change and support. Previous research has shown that these programs have positive results for organizations, but there is not yet a lot of research into changes in employee behavior. Parks and Steelman (2008) found that it reduces absence and increases satisfaction.        

System approaches

Byrne et al. (2011) investigated annual assessments over a period of 7 years. It was a primary intervention focused on health risk assessment and educational video to raise employee awareness. It also included a lifestyle management tool to encourage employees to set specific goals to reduce their health risk and maintain their health. They found that most risk factors improved over time, but the biggest difference was between the first and second year of the intervention. There was clear evidence of lasting improvements in terms of increased physical activity, improved nutrition, less smoking, and an increase in the use of a seat belt. The implementation of health promotion programs in the workplace started in 1970, and about 70% of large and more than 50% of medium-sized organizations have such a program. Lincoln Industries is a small company that has implemented such a program. The primary purpose of this welfare program is to improve physical fitness and nutrition and increase employee satisfaction. It consists of health screenings and three activities in which employees can participate. Merrill et al. (2011) observed significant improvements in body fat, blood pressure and employee flexibility, with the greatest results among older employees and those with the highest risk factors. There was also an overall improvement in physical and mental health. One of the factors that contributed to this success is the culture of health created by Lincoln Industries' senior staff. Most health promotion programs take a medical perspective and focus on behaviors that are risky to health. Little work is done with positive psychology.    

Positive psychology interventions

Positive psychology interventions focus on increasing positive aspects of well-being and therefore not only on negative outcomes. An advantage is that individuals can often do this themselves. Only a few studies have looked at positive psychology in the workplace. Writing down things that you are grateful for at work leads to an increase in gratitude and work-related well-being. Writing down three positive things per working day also leads to less stress, fewer mental and physical health problems and being able to distance yourself better from work. It also reduces the negative effects of work-family conflict.   

Directions for future research

This article has shown that there is evidence that stress management interventions and workplace health promotion and that well-being programs can be effective. The authors indicate that prior to further research better theoretical models have to be developed to provide an integrative structure to interventions that indicate the specific effects of an intervention on organizational and individual level to explore causal mechanisms of intervention. There must also be a more integrated system perspective to understand the experiences of employees inside and outside the working environment, as well as the effects of these experiences on employees, families and organizations. Ideally, longitudinal studies should be carried out to serve as a barometer for the health of their employees and the working environment. Research has also shown that there may be important moderators of the effects, so more research needs to be done on this. This can be, for example, national or organizational culture. There must be more cross-cultural investigations to clarify similarities and differences . The quality of intervention studies is slowly improving. There should also be more studies with a control group. Literature suggests that interventions with a system approach and both an individual and organizational component are the most effective. Based on this article, the JD-R model is a useful framework. Recognizing multiple domains and resources is a useful extension, especially for the understanding of employee well-being.   

Diversity is a good thing. People can improve their racial attitudes, leadership skills and their thinking about the social world. Still, there are many people who feel uncomfortable with diversity and want to live in a non-diverse area. Some people might even find interracial contact stressful and try to avoid this. However, it is almost impossible to avoid interracial contact. In this study the consequences of White individuals’ concerns about appearing prejudiced are examined.

People are sometimes afraid to show prejudiced behaviour, because they think that they are going to be rejected. It is not that they don’t want to be prejudiced, it’s that they don’t want to be viewed negatively. So interracial prejudice might be really stressful for people who are high in external motivation to respond without prejudice. Sometimes anxious people also react weird towards other groups when they are distressed. They get stressed because they don’t want to react prejudiced, but when they are stressed they may react really prejudiced towards Blacks. This research focuses on how appearing prejudiced creates stress responses to interracial contact and this will focus on external motivation to respond unprejudiced. The researchers think that people high on EM (external motivation) will experience more stress during interracial contact than people low on EM. This will be evident in behaviour and psychological responses. They also think that high-EM individuals will experience more stress over time the more interracial contact they have.

The researchers examined stress by looking at the body posture, facial expressions, blinking, adverted eye gaze and other nonverbal cues. They also measured physiological reactivity. The external motivation to respond unprejudiced was measured with a scale: the Motivation to Respond without Prejudice Scale. Participants had to react with a research assistant and the research assistant could be either white or black. He or she asked the participant some questions. This is the interaction. The whole study was filmed, so researchers could look at the nonverbal behaviour of participants. The hypothesis was supported: the higher people were on EM, the bigger stress responses they showed. They also showed more physiological stress responses.

The second study looked whether these results could be found in natural settings and over a large time period. Researchers decided to study college students, because they have more interracial contact. They did this over a time span of a year and the students needed to keep an online diary in which they had to answer what their mood was, how many hours they have slept, whether they took some caffeine and other things. They also had to list five people they had the most meaningful interactions that day. They also had to provide some information about the interracial partner. They also had to provide some saliva a couple of times. This was to measure their stress levels. These results also supported the hypothesis. Students, who were higher in EM, were more likely to have chronic stress.

Psychological interventions in chronic diseases

The article shows a model in which an attempt is made to structurally represent the variety of psychological interventions in the case of chronic illness. We look at differences in terms of:

• Intervention goals.
• Intervention level.
• Intervention channel.

The intervention goals: the quality of life and self-management

Every psychological intervention is aimed at improving the quality of life and/or self-management. Interventions with a primary focus on quality of life aim to increase physical, psychological or social well-being. The goal here is to minimize the negative impact of the chronic disease. However, the effects on the quality of life are limited and temporary.

Interventions with a primary focus on stress management include relaxation techniques and work with cognitive restructuring. The effectiveness of these types of interventions has been demonstrated for patients with coronary heart disease and patients with cancer. Accurate stress management programs can affect both the quality of life and the progression of the chronic disease. Mortality in cancer and coronary heart disease can also be influenced by stress management interventions.

With hypertension, relaxation is seen as an effective intervention. It is not yet known why this is so effective. The psychological and physical effects of stress on the immune system have recently been the subject of research.

Social skills training and/or assertiveness training aim to reduce social anxiety. People are also taught to replace dysfunctional reactions in situations that provoke social anxiety.

There are also palliative interventions. These interventions are aimed at improving the quality of life through emotional support. The goal is to reduce stress and speed up acceptance of the disease. These types of interventions are particularly effective just after diagnosis or when the patient is terminal.

Previous intervention types relate to improving the quality of life. In addition, there are also interventions that focus in particular on improving self-management in patients with a chronic disease. Living with a chronic disease often requires a change in lifestyle. In addition, the patient must follow medical advice to reduce disease progression (secondary prevention) and also to reduce the consequences and complications (tertiary prevention).

Approximately half of the patients with a chronic illness do not follow medical advice properly. Whether or not to follow medical advice is not related to personal characteristics or disease characteristics. Whether people follow medical advice is related to the nature of the advice, social support, illness perception, understanding of the advice and treatment plan and characteristics of the relationship between the professional and the patient.

Different techniques are applied in interventions related to self-management:

• Self-monitoring and self-observation.
• Setting goals.
• Drawing up a contract.
• Shaping (the goal is divided into small steps).
• Self reward.
• Stimulus-control.
• Modeling and observational learning.

The programs combine these and other techniques into an intervention. Such interventions exist for various chronic diseases such as hypertension, coronary heart disease and asthma. These types of programs seem to be more effective than traditional health programs.

Arborelius (1996) has drawn up a model that focuses on individual health support for lifestyle issues. She set up seven principles, which are successful in this:

1. Patient centered instead of patient oriented.
2. Reflection on the patient's own behavior.
3. Finding out the readiness to change of the patient.
4. Provide neutral knowledge instead of judgment.
5. The focus is on behavior rather than providing information.
6. The health ideas of the patient are emphasized.
7. The pros and cons are discussed.

The intervention level: individual patient, group or environment

Professionals are often trained with the idea that interventions aimed at the individual are the best. In The Netherlands, however, one professional is available for every five thousand chronically ill people. In most other countries, one professional has even more chronically ill people under his or her care. It is therefore important to pay attention to more indirect forms of intervention aimed at groups or the larger environment.

Most interventions are based on cognitive behavioral therapy or social learning theory. They use the previously discussed techniques. An example of such an intervention is the 'Heart and Health' program, aimed at patients with coronary heart disease. This intervention is given to groups of 8 patients with partner. A specific topic is discussed during each session based on the needs of the patients. The program has positive effects on patient satisfaction, smoking, eating habits and the use of medical means. Interventions at the environmental level are regularly underestimated. Nevertheless, psychological help is also very important with interventions of this kind.

The intervention channel: direct and indirect interventions

Many psychologists prefer direct interventions (psychological interventions performed by a psychologist). However, this type of intervention is not cost-effective. In addition, not all patients require intensive direct interventions. Besides, direct interventions are not always better than indirect interventions. In addition, indirect interventions have the advantage that they can also be carried out by other professionals, who are often closer to the patient.

An example of a successful indirect intervention is 'weight watchers'. Most of these programs are initially designed by a psychologist. Then others were trained to be able to carry out the intervention. This does not seem to affect the effectiveness of the intervention.

Conclusion and discussion

The first conclusion is that intervention programs can clearly have many positive effects, especially combined programs.

Secondly, it can be concluded that it is important to pay attention to the different levels of a patient. Psychological interventions now focus primarily on the individual level and ignore the rest. This must be taken into account in the development of new intervention programs. Furthermore, it should be noted that there is often a theoretical base missing, not only for the intervention itself, but also for the measuring instruments used. Secondly, methodological shortcomings in current evaluation studies are often problematic.

General conclusions and discussion

The question that is often asked is: is this intervention effective? While it would be better to ask: for which subgroup is this intervention effective and under which conditions and in relation to what?

Intervention developers must be informed of developments in health psychology and health psychologists must be willing to share this knowledge with many. A collaboration with the World Health Organization to bring health psychology knowledge to the world would be a possible solution to get health psychology on the map worldwide. Unfortunately, there is no interest in this from the field. As a result, the cost effectiveness of many intervention programs is certainly not optimal.

The influence of the social context is often not well represented in most models. A subsequent problem of this is: minority groups that often could benefit the most from interventions are often not reached.

People who are more at risk are becoming a bigger problem to handle. Due to medical developments there are more possibilities to identify risk groups (for example the presence of breast cancer genes). Health psychologists can play an important role in the development of screening procedures for such risks.

Finally, it is noted that the psychological and medical basis should go more together. Both disciplines should be trained in important aspects of each other's disciplines.

What is this article about?

Before one can decide on diagnosis and interventions, accurate assessment is necessary. Assessment is defined as a process of hypothesis testing, which is designed to answer the questions that clients have, and to solve their problems. This is an important process, so it is better if this process happens in a systematic, objective, and consistent way. The process should also be transparent to colleagues and clients.

In this paper, an assessment model for the special educational needs of children is described. This is the Assessment for Intervention (AFI) model. This model has the goal of providing recommendations which are science-based and which are feasible for the child, the parents, and the teachers. The model will be described, and the outcomes of an evaluation study will also be described.

In practice, there is often a gap between diagnoses and recommendations. Therefore, the Assessment for Intervention (AFI) model tries to bridge this gap. This model was developed in the Netherlands. It is a model which prescribes a decision-making process for a school-psychologist. This psychologist systematically proceeds through the stages: first questions of the teacher, parent, and child are analysed. Then, these questions determine what the purpose of the assessment is, what decisions will be made and what questions will be answered. The AFI can be functional, because it can lead to a diagnosis, and it also provides recommendations (interventions) on how to deal with this diagnosis.

Assessment involves two topics: the assessment process and the assessment methods. The AFI differs from other assessment models, because it is science and practice-based. It offers guidelines for teachers, parents, and students. It also includes all topics that have been determined to be important on the assessment of students with special educational needs.

What are recent developments that are incorporated in the AFI-model?

The concept of assessment has changed considerable over the last decade. Now, it is more focused on the teacher’s role, such as teacher’s instruction. Assessment for Improvement or Functional assessment is used to improve the instructional environment. A recent development is that the needs of students are more relevant for their interventions, instead of their disorders. So, instead of looking for specific diagnosis such as ADHD, school psychologists now focus on student’s abilities, and try to determine what next steps are needed for a good development. Another development in the concept of assessment is that assessment is now more focused on empowerment of teachers, parents, and students. Also, it seems that interventions work better when the people involved are part of the assessment process, from the beginning. There is also a therapeutic value of assessment: during the process of assessment, clients’ awareness and understanding of the situation, and their motivation, changes. This makes assessment also functional.

Children are also allowed to state their opinion, and they should participate in the assessment. Another important aspect of assessment is that the assessment process should be evidence-based. It should include a case formulation of the student and his instructional and home environment. On the basis of this case formulation, goals are set and the best intervention is chosen. The school-psychologist who uses the AFI, applies successful practices based on science. Thus, the psychologist is a scientist-practitioner.

The AFI model focuses on the content of the steps within the cycle, the communication skills of the school psychologist, and the different roles of the teacher, parent, and child within this cycle. The assessment process is specific to each client. This helps to decrease the gap between assessment and intervention: it is easier to stick to an intervention that fits your situation best. The AFI is thus scientifically fully sound and can be used by school psychologists. They can also use this model to reflect, and ask themselves questions such as: ‘What are my targets for assessment for intervention (what are my goals)?’, and ‘Which elements of AFI am I already successfully implementing?’.

What are the seven principles of AFI?

Pameijer and Van Beukering, the creators of the AFI, came up with seven principles which are important for the quality of assessment, namely;

1. AFI is goal-directed, it is aimed at recommendations that are both meaningful and useful for clients and beneficial to the child;
2. AFI applies a transactional perspective on development and therefore not only focuses on child factors, but also on teachers’ strategies and parental support;
3. AFI focuses on educational needs: what does this child need to achieve a specific goal?;
4. AFI focuses on the needs of parents and teachers, because they are key factors in achieving educational goals, so the AFI looks at what they need to support the child’s educational development;
5. AFI focuses on risk as well as protective factors of the child, school, and parents;
6. The school psychologist collaborates with the teacher, child, and parents;
7. AFI follows a systematic and transparent stage-like process

Goal-directed and functional assessment

In this principle, it is stated that only necessary information should be gathered. So, only information that helps to solve the problem. Then, this information is used to come up with feasible interventions. These interventions should be not too difficult. The school-psychologist therefore tries to determine what kind of strategy fits into the daily work of the people involved. Therefore, assessment can be seen as a change-oriented cycle of investigation, case formulation, intervention, and evaluation. Using the AFI, the focus is on variables that can be translated into interventions.

Transactional perspective

This principle is based on the fact that children develop through a continuous interaction with their instructional and home environments. Thus, the context is very important in the AFI. These interactions are transactional: children’s behaviours evoke reactions from their teachers, peers, and parents. This is also related to risk factors. For example, the risk factor ‘aggressive behavior at an early age’ is not directly related to behavioural problems at a later age. But, when a teacher clashes with this students, and parents physically punish the child, this can lead to more behavioural problems later in life. There are also protective factors, which reduce the impact of risk factors. Therefore, the AFI also takes these protective factors into account, and determines which interactions are already favourable, and which are not.

Special needs of the child

The AFI focuses on the student’s educational needs. So, it is not focused on coming up with a diagnosis. Instead, the focus is on what the student actually needs to develop and perform well. Questions are: which SMARTI goals are we pursuing? And, which approach does this student need to reach these goals? These questions help to change the focus from problem-oriented toward solution-focused acting. The school-psychologist also cooperates with all involved parties: the child, the teacher, and the parents. He or she discusses with them what they are already doing that is beneficial to the child (goodness of fit), and what is missing (poorness of fit).

Teacher’s impact

Teachers are important for the development of children, and especially for vulnerable students. Competent and effective teachers are able to prevent problems in learning and behaviour in their students. A positive teacher-student relationship is also very important: a warm relationship offers a student emotional support and security. This has a positive impact on his relationship with peers and on his learning behaviour in the classroom. Thus, it is important to try and create a positive teacher-student relationship. Therefore, the AFI also focuses on the student-teacher relationship.

Protective factors and strengths

All students show some positive behaviors, no matter how severe their problems are. Protective child factors are for example having an easy temperament, having good intellectual capabilities, having strong emotion-regulation, having an internal locus of control and strong coping skills. The social environment can also serve as a protective factor: a supportive school team and a family network. For example, children with attachment problems can really benefit from a warm relationship with their teacher. Having a good relationship with parents is also a protective factor. Therefore, the AFI also focuses on strengths. These positive aspects are included in the assessment report, and are used in the interventions. The school-psychologist tries to determine what are positive exceptions, so: when is the student able to display the desired behavior?, and also tries to determine the successful teaching approach: what does the teacher do in this situation? Balancing these risk and protective factors results in a case formulation. An important remark is that it is easier to boost positive factors, than to change risk factors.

Collaborative partnerships

The clients of an assessment are important. They have good insights into the possibilities for change. Therefore, the school-psychologist collaborates with the students, teachers, counsellors and parents. Thus, this principle is about talking with the student, and not talking to or about them. The AFI is really personal and focuses on what do the student, the teacher, and the parents need? Scientific information is translated and made understandable for all the parties. This makes it possible for them to understand the case formulation and recommendations. Thus, for the AFI, transparency is key.

A systematic and transparent assessment process

For assessment to be of good quality, it should follow a systematic, objective and consistent way. The process should also be transparent. The AFI is based on the empirical model of scientific thinking. It includes five stages and each stage has its own guidelines. These guidelines support clinical decision making, and protect the school-psychologist from common pitfalls in decision making, such as tunnel-vision, confirmation bias, and over-confidence.

What are the five stages of the AFI-model?

Each stage in the AFI is closely linked to the other stages. The stages may overlap, but each stage will be discussed separately.

Stage 1: Intake

This stage has the goal of collecting information. Based on this information, the school psychologist can determine what the strategy will be for the client. Another goal of the intake stage is to create a good relationship with the school, student, and parents. Questions, goals, expectations and requests will be discussed. For example: what is intended to accomplish? Why? How?

Stage 2: Strategy

The information gathered in the intake stage will be used to determine a strategy that fits the specific situation. Relevant information is organised in four sections: student, instructional environment, parental support of learning and relevant history. The psychologist tries to determine whether more information is needed. If this is the case, he or she proceeds on to Stage 3. If this is not the case, he or she proceeds on to Stage 4. Each question that is asked, is based on an if-then reasoning: if we know…, then we recommend…. Thus, no questions are asked that do not fit in this if-then reasoning: only necessary information is collected. Information gathering is thus goal-directed!

Stage 3: Investigation, answering the selected questions

In this stage, the hypotheses determine which information will be gathered. Thus, it is goal-directed. The content of information varies for each specific client. To get answers, tests, questionnaires, interviews, and observations can be carried out. For example, the classroom may also be studied to determine whether the teacher or child are acting in a negative way. Data collected in this context may have a higher ecological validity compared to data gathered out of this classroom. Also, interventions can be based on this context, making the interventions personalised.

Investigating the potential for change

To get more feasible interventions, the psychologist can explore the learning ability of students. For example, by manipulating one variable, it can be determined whether an expected positive change occurs. This can yield insights into the child’s changeability, and the teacher’s changeability. Provoking and reinforcing factors are also identified, by looking at what occurs prior (antecedents) to the student’s behaviour, and what occurs after (consequences). This is a functional analysis, and can be used to create interventions in the classroom. For example, if someone thinks that a child’s problem behaviour (making funny noises) is reinforced by classmates’ laughter and teacher’s correction, one might create an intervention in which both the child and his peers are rewarded when they show task-oriented behavior. This would be expected to lead in a reduction of disruptive behavior.

Stage 4: Integration, goals, and needs

In this stage is the bridge from the diagnoses to intervention. It is therefore also called the ‘pre-treatment-assessment’. All the information gathered is integrated, and it is determined: how can the situation be understood? Then, this is translated into goals for the student, teaching strategies, and parental support, educational needs of the student, and needs for the teacher and/or parents.

The case formulation thus also includes risk and protective factors. This formulation includes what needs to be changed, but not how this should be changed. Therefore, the psychologist determines on interventions which are tailored to the client. There can be several interventions, so a decision should be made.

Examples of effective interventions are for example self-reported learning, in which the student gives himself a grade in advance, predicted on past performance with an emphasis on high expectations, direct informative and positive reinforcing feedback during learning, direct instruction models and strong classroom management.

Stage 5: Recommendations, appointments, and feedback

In this last stage, the clients are informed about what the outcomes are of the assessment. It also involves answering the clients’ questions, objectifying goals, matching these goals to specific needs and supporting clients in choosing the best intervention. All involved parties will attend, and they will discuss with each other. The result of this stage is a tailored intervention, which is supported by all relevant parties. The school-psychologist also asks whether all parties are willing to ‘start tomorrow’.

Also, appointments to monitor and evaluate the intervention are also made: who is doing what, when, and how?

How is the AFI in practice?

The AFI was developed in 1997, and it has been evaluated in 2004 and 2015. It is now the standard model for assessment. However, the AFI has not been evaluated systematically. Therefore, an evaluation study was carried out in the Netherlands. The following questions were analyzed:

• Are the principles of the AFI implemented as intended?
• Are the aims of AFI achieved?
• Does assessment offer a better understanding of the student and the support he needs?
• Does assessment generate recommendations for teachers and parents?
• Are teachers able to apply the recommendations in their classroom?
• What method was used?

The assessors were school psychologists and external school-coaches. The study took place for two years. In the first two years, these psychologists and coaches were trained in using the AFI.

What are the results?

It seems that the principles of the AFI were implemented as intended. Most teachers and parents also reported a positive collaborative partnership with the assessor. However, the assessors collaborated less with children. 77% of children enjoyed the investigation stage. So, it would have been better if students were more involved in the process. Counsellors and parents reported that the assessment process evolved systematically and transparently, so that is great, because it’s one of the principles of the AFI.

Are the aims of AFI achieved?

If the aims of the AFI would have been achieved, this would mean that the assessment lead to a better understanding of the student, and that the teachers were able to apply the recommendations in their classroom. The teachers gained more insight into the child’s situation compared to before the assessment. For parents, this was less true, but this makes sense because parents knew their children well before the assessment, and assessors did not know the children at all.

Teachers also felt like they are more capable of teaching the child. For 80 percent of them, the cost-benefit analysis is balanced: the time and energy they invested in the assessment paid off. Two out of three teachers also stated that the recommendations based on the AFI were feasible in the classroom.

What were successes and limitations in the evaluation study?

There were different limitations. For instance, questionnaires were only send to valid email addresses. There was also a low response rate, especially from parents. Successes were:

• The stages of the AFI made the assessment process structured from the beginning to the end. It also made it easier for professionals to discuss things, because they all followed the same aim and language;
• All relevant parties ‘sat at the table’. They worked at a shared goal, namely an optimal development for the child;
• The assessment helped the parents and teachers in collaborating;
• Counsellors, teachers, and parents valued the partnership and communication with the assessors;
• Parents appreciated the AFI-model, they reported positive aspects of it in the open questions.

What could be improved?

In a subsequent study, SMARTI goals for all students should be formulated, and also for the instructional environment and parental support of learning;

There should be a greater focus on translating the case formulation into the teacher’s approach in the classroom;

The case formulation should be explained to parents in an understandable way. It should be meaningful for them. Parents should also be told how they can support their child’s learning at school. They should also be complimented about things that they are doing well.