Assignment 6

Essentials_of_Assessment_Report_Writing_----_Three_REFERRAL_AND_BACKGROUND_INFORMATION_.pdf

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T his chapter discusses the initial part of the assessment report: the iden tifying information, the referral questions, and background informa tion.

TITLE AND IDENTIFYING INFORMATION

Most reports begin with a title that is followed by important identifying informa tion. The title of the report is typically centered across the top of the first page (e.g., “Psychological Evaluation,” “Neuropsychological Evaluation,” “Psychoeducation al Assessment,” or “Speech and Language Evaluation”). At times, a disclaimer is included to protect the individual’s privacy, such as “for confidential use only.” Under the title, standard identifying information is recorded, typically including

• name of examinee • date(s) of testing • date of birth • date of report • chronological age • examiner’s name • grade (if testing a student) or • supervisor’s name (if relevant)

occupation (if relevant)

Depending on the setting and the purpose of the evaluation, other informa tion may be included, such as parents’ names, teacher’s name, or the name of the school.

REASON FOR REFERRAL

The next heading, Reason for Referral, sets the stage for the rest of the report. The reason for referral is your reason for testing. This section is usually no more than one or two paragraphs long, and its central purpose is to express concisely and clearly the questions and concerns of the person or people requesting the evaluation (the referral source). The referral section includes the names and po

Three

REFERRAL AND BACKGROUND INFORMATION

Lichtenberger, Elizabeth O., et al. <i>Essentials of Assessment Report Writing</i>, John Wiley & Sons, Incorporated, 2004. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/waldenu/detail.action?docID=361899. Created from waldenu on 2019-11-13 19:12:06.

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sitions (e.g., third grade teacher) of the referral source as well as the specific reasons for referral. If specific questions have not been posed, then contact the referral source to clarify the nature and scope of the concerns. The following il lustrates the reason for referral for Jonas, a fourth grade student:

The multidisciplinary team at his school referred Jonas for his three year review of special education services. For the past three years, he has been receiving occupational therapy and learning disability services in a resource setting. In addition, both his fourth grade teacher, Ms. Mantell, and his parents have expressed concern about his overall motor development, par ticularly his poor handwriting, and want to know ways to help Jonas.

For some evaluations, the referral question is not about problems. For example, a student may be referred to help determine eligibility for certain types of special programs, such as placement in a program for gifted and talented students. Or an adolescent may be referred with the purpose of providing ideas for vocational planning. Also, some school districts mandate periodic testing to ensure that a student’s services are appropriate or still needed. In general, however, unless you work at a specialized clinic or hospital, most referrals stem from concerns regard ing a client’s academic, linguistic, cognitive, behavioral, or social development.

Rapid Reference 3.1 presents several examples of questions that can help you formulate the referral section, and Rapid Reference 3.2 provides illustrations of

32 ESSENTIALS OF ASSESSMENT REPORT WRITING

DON’T FORGET

Important Information to Gather About the Referral Question

• When did the child’s problems start? • How old was she when the problems were noted? • How old was she when her parents first became concerned? • If person is a child, do the parents agree about the problem? Do others who

regularly see the child agree (e.g., grandparents, babysitters, teachers)? • How long have these concerns been present? • If concerns have existed for a while, why are the parents coming in now? • How frequent is the problem? • What is its duration? • How intense is it? • Ask: “What are some specific examples of the problem?” • Ask: “What do you hope to gain from this evaluation?”

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Sample Referral Questions

Psychoeducational/school psychology assessment: • Does Juanita have a reading disability? If so, what methods of instruction

would be most effective? • Is Graham socially and intellectually ready to begin kindergarten? • Does Gavin have a diagnosable disability that warrants having extra time to

take the SAT or other standardized tests? • Should Haley be retained in second grade? • Would Jenna benefit from participating in the school’s gifted and talented

program? • Do Sixto’s behavioral problems at home and at school warrant a diagnosis

(and, therefore, treatment) of Attention- Deficit/Hyperactivity Disorder? • Is Delia at risk for engaging in violent behavior at school? • What modifications need to be made to accommodate Lydia when she

returns to school after surgery? • Is Ana (a 15- year- old) at risk for dropping out of school? • Does Nicole (a kindergarten child) have a school phobia?

Vocational/developmental disabilities assessment: • Is Caroline capable of living independently? • Will Alan, who has developmental disabilities, be able to transition to a group

home or a supervised apartment setting rather than remaining at home? • Which areas of vocational study will Mr. Jackson be able to benefit from given

his interests and abilities? Neuropsychological functioning: • Is the memory impairment Elinor experiences indicative of early dementia

such as Alzheimer’s- Type Dementia? • Have Charles’s years of alcohol abuse caused any impairment in cognitive

functioning? • What are the neuropsychological effects of Bryan’s head injury? • Are attention or memory problems impacting Andrea’s school performance? • Has Lily’s high exposure to lead affected her cognitive abilities?

Assessment of emotional functioning: • Is Charlene suicidal? • Is Noel suffering from a mood or anxiety disorder? • Does Michael appear to have Post- Traumatic Stress Disorder (PTSD)?

Forensic assessment: • What will be the best custody arrangement for Todd? • Did Elmer meet the legal definition for insanity when he committed the murder? • Is Esther competent to stand trial?

Rapid Reference 3.1

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34 ESSENTIALS OF ASSESSMENT REPORT WRITING

Sample Reason for Referral Sections

• His foster parents, Jim and Arlene Mueller, and the teachers at Project First Step, a special needs preschool program, referred Tariq. Tariq’s foster parents are pursuing adoption and wanted information on cognitive development as relative to his age- peers. The Muellers also wondered if Tariq has Fetal Alcohol Syndrome.

• Her mother, Ms. Jaffe, a kindergarten teacher, referred Anna, a 4- year- old pre- school student. Ms. Jaffe expressed concerns in regard to Anna’s social, emotion- al, and linguistic development. She described Anna as not showing much interest in people but showing considerable interest in the wheels on toy cars. She also noted that Anna rarely makes eye contact, engages in imaginative play, or talks. She wondered if Anna would benefit from occupational therapy, speech therapy, family counseling, or some type of social skills training.

• Rebecca was referred for an evaluation by her social worker at the Depart- ment of Economic Security, Amelia Forrester. Ms. Forrester reported that Rebecca’s preschool teacher felt she was immature and slow in developing pre- academic skills. Ms. Forrester requested a brief assessment to help establish appropriate pre- academic educational goals for Rebecca.

• Her father, Pierre Whitman, referred Maria. Mr. Whitman wondered if Maria has a learning disability that is impeding her math development. Specifi- cally, he noted that Maria appears to be far behind her classmates in math despite several years of tutoring. In contrast, she has had little difficulty learning other school- related subjects.

• Michael was referred for evaluation to see if learning disabilities, in addition to his psychiatric diagnoses, are contributing factors in his difficulty learn- ing and retaining academic skills. Additionally, the results of this evaluation are expected to provide information to aid in determining effective instruc- tional techniques, as well as the best educational placement for Michael in his next Individualized Educational Plan meeting.

• Amy Reid was seen for a neuropsychological evaluation at the request of her parents, Michael and Nancy Reid, who were concerned about her lack of progress in school. Mrs. Reid stated, “Amy cannot read, does not know her numbers, and takes lots of time to recall the letters.” Amy’s parents requested the evaluation to help determine the cause of her learning dif- ficulties and to determine appropriate instructional strategies.

• His itinerant teacher of the Hearing Impaired, Pat Adler, referred Tony to this clinic. Ms. Adler expressed concerns regarding his ongoing difficulties in written language, which is affecting his success in middle school. She requested more information about the reasons for these difficulties as well as specific recommendations for intervention.

• Although he is an intellectually capable student, Paul currently is failing several classes at Westchester Preparatory Academy. His father and stepmother re-

Rapid Reference 3.2

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REFERRAL AND BACKGROUND INFORMATION 35

quested this evaluation. Teachers from Westminster Preparatory reported that Paul’s father and stepmother are concerned about his weak academic perfor- mance and question whether there is a “processing deficit” of some kind. Paul’s stepmother specifically mentioned the possibility of a weakness in memory. Paul’s cognitive profile, general adjustment, and academic skills will be inves- tigated as one source of information for educational planning in conjunction with teacher and parent observations, educational history, and present levels of academic performance.

• The purpose of the present evaluation was to determine Jen’s eligibility for a gifted and talented education program and, depending on the outcome, to consider ways to adapt and enrich the curriculum to challenge her.

• His grandmother, Mrs. Gwen Stevens, referred Tyler to this academic tutor- ing center for an evaluation. Mrs. Stevens was concerned about Tyler’s poor school grades and lack of motivation. Tyler has just failed most of his seventh- grade classes, and retention has been recommended. Mrs. Stevens wanted an estimate of how far behind Tyler was in school, an opinion regarding whether he should be referred for a comprehensive evaluation in his school, and an opinion regarding the advantages and disadvantages of his repeating seventh grade.

• Tania Martin, his sixth- grade teacher, referred Gregory for evaluation due to his poor attention in class and extreme difficulty getting along with peers. She further noted that he talks nonstop during class and often interrupts con- versations to say something completely unrelated. Ms. Martin wondered if Attention- Deficit /Hyperactivity Disorder is the cause of Gregory’s behavioral and social difficulties.

• Donald is currently incarcerated in a maximum- security setting for juvenile of- fenders. Eleanor Earle, his case manager, referred him for an evaluation. Results from the assessment will be used to develop goals and objectives for his new Individualized Education Program as part of the Kilmore County Jail’s Education Assessment program.

• Noelle, a sophomore in pre- medicine, referred herself for an evaluation because of difficulties with spelling. Many of her teachers over the years have suggested that she be tested, but she never pursued an evaluation. Recently, a college English professor spoke to her about her many mistakes in writing and strongly recommended that she contact the University Learning Disabilities clinic for dyslexia testing. Noelle would like a better understanding of why she has such difficulty spelling, as well as suggestions for how she can improve her skill.

• Gavin was referred by his parents for an evaluation because of concerns regarding his present performance in law school. Although he understands the concepts of the presented material, he finds that he often does not have enough time to complete examinations. Consequently, he is unable to demonstrate his mastery of the information. He also finds that he spends an inordinate amount of time completing assigned readings. The purposes of the present evaluation were to determine Gavin’s present levels of performance, consider eligibility and need for services, and propose appropriate accommo- dations.

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how the “Reason for Referral” section may appear when written in a report. The Don’t Forget box lists types of questions to ask the referral source that can help clarify the purpose of the evaluation and the nature of the problem. In the report, in addition to stating the referral questions succinctly and directly, you may also include in this section a short summary of the specific behaviors or symptoms that led to the referral. You may provide examples and brief anecdotes to illus trate the reasons for concern.

There are many ways to collect information from a referral source. You may have contact primarily over the phone, in person, or from a written form. Figures 3.1 and 3.2 provide samples of forms for collecting information about the refer ral questions. The type of referral information requested on a written form will vary according to the setting. For example, a medical setting such as a hospital will probably request more information about specific medically related issues, whereas a form used in a school setting will request information that pertains mainly to academic issues and behavior. If you choose to use written forms for gathering referral information, tailor them to make them most useful for your specific situation.

BACKGROUND INFORMATION

Sources for information for the background section include the person, a parent, a teacher, a boss, a supervisor, a physician, a therapist, or other specialists. You may also obtain information from anyone who has regular contact with the per son, such as a coach, babysitter, primary day care provider, or nurse. In addition, it is good practice to gather information from previously written records, such as psychological and educational evaluations, medical records, and academic re cords based upon the nature of the referral. As an example, Jonas was referred for an evaluation in regard to concerns about motor development. His relevant background information is presented in Rapid Reference 3.3.

As illustrated in Rapid Reference 3.3, the background section contains infor mation that is pertinent to test interpretation or to issues related to the referral concern. Often you will collect more information than you will actually report. Do not include information that is personal in nature and not pertinent to the evaluation itself (Kamphaus & Frick, 1996). For example, Ted was referred for an evaluation because concerns were noted in regard to his math computational skills. During the course of the evaluation, you learned that Ted’s mother is re covering from bulimia. Because this finding does not appear to be related to the

36 ESSENTIALS OF ASSESSMENT REPORT WRITING

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REFERRAL AND BACKGROUND INFORMATION 37

Figure 3.1 Sample Referral Request used by Personnel in a Medical Setting

Source: Adapted from Tallent (1993). Note. Although an initial request may be made from a physician with such a written form, you must fol- low up the written request by gathering more detailed information from the referral source.

MEDICAL PROFESSIONAL’S REQUEST FOR PSYCHOLOGICAL EVALUATION

To: ____________________________________________________________ Name of patient: __________________________________________________ Date of birth: _____________________________ Age: __________________ Diagnosis (if one has been made): ______________________________________ Medical problems: _________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ Reason for referral: ________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ Behaviors or symptoms that led to this referral: ___________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________

Special Testing Concerns: Y / N Limitation of movement that might interfere with testing Y / N Hearing Loss (specify severity and if corrected __________________

______________________________________________________) Y / N Poor Vision (specify severity and if corrected ___________________

______________________________________________________) Y / N Speech impediment Y / N English is second language (how English proficient is client? _______

______________________________________________________) Y / N Poor understanding of language Y / N Poor cooperation Y / N Medication Name _________________________ Dose __________________ Side effects _____________________________________________

______________________________________________________

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Figure 3.2 Sample Referral Form Used by Schools

Source: Adapted from Kamphaus and Frick (1996).

Student’s name ______________________________________ Date of referral _________ Referring person _____________________________________________________________ Age _____ Grade _____ Grades repeated _____

Communication Problems Never Sometimes Often

Expressive language (problems in grammar, limited vocabulary) Receptive language (difficulty with comprehension, not following directions)

Classroom Behavior Never Sometimes Often

Overly energetic, talks out, out of seat Very quiet, uncommunicative Acting out (aggressive, hostile, rebellious, destructive, cries easily) Inattentive (short attention span, poor on task behavior) Doesn’t appear to notice what is happening in the immediate environment Poor peer relationships (few friends, rejected, ignored/abused by peers)

Academic Problems Never Sometimes Often

Reading (poor word attack, comprehension) Writing (illegible, reverses letters, doesn’t write) Spelling (cannot spell phonetically, omits or adds letters) Mathematics (poor computation, concepts, application) Social sciences, science (doesn’t handle concepts, doesn’t under stand relationships, poor understanding of cause and effect)

Physical Problems Never Sometimes Often

Gross motor coordination (poor eye- hand, manual dexterity) Visual (cannot see blackboard, squints, rubs eyes, holds book too close) Hearing (unable to discriminate sounds, asks to have instructions repeated, turns ear to speaker, often has earaches) Health (example: epilepsy, respiratory problems, etc.)

Treatment Currently Received No Yes Frequency

Speech therapy Physical therapy Psychological therapy Occupational therapy Medications (if yes, list type)

Other problems: _____________________________________________________________ How have you tried to solve the problem? _________________________________________ Signature and position of referring person: ________________________________________

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REFERRAL AND BACKGROUND INFORMATION 39

referral concern, you would not mention it. As a general rule, only include infor- mation that relates to the interpretation of the person’s scores or test behaviors or is relevant to the referral questions.

To collect information from sources other than the person, you must have a signed release of information form. If the person is a child, then the parents should sign this form. Permission forms are necessary to obtain written informa tion (previous reports or medical records) and even to collect information over the telephone.

When collecting information from various sources, be sure to protect the con fidentiality of the person. Confidentiality refers to the ethical obligation never to reveal information obtained through a professional relationship without consent. The Ethical Standards of the American Psychological Association (APA, 2002) provide guidelines related to the issues of confidentiality, privacy, and disclo sure. Specifically, these APA guidelines note that a psychologist must protect the confidentiality of the information obtained during the evaluation. In graduate training, the supervisor has responsibility for assuring that all trainees maintain confidentiality. The only exceptions to confidentiality are (1) when the person (or guardian) gives consent to release the information; (2) when the examiner is working with other professionals within a school, clinic, or agency; or (3) when failure to release information would violate the law.

For example, you may suspect during an evaluation that a child is being physi cally abused by a family member. To protect the child, you would want to have these allegations confirmed or rejected by others with specialized expertise in abuse issues to ensure adequate safety for the child. Familiarize yourself with your state laws for guidance about confidentiality and the reasons for breaking confidentiality that are considered to be justified.

How to Collect Background Information

Once the initial contact with the person or parents has been made, the process of collecting data begins. Usually face to face interviews are better than interviews over the telephone because you are able to see subtle nonverbal cues that may be relevant to the case. If parents are divorced or separated, you may be able to see only one of them in person. Attempt, however, to interview both parents (and stepparents), even if contact can only be made by telephone.

Several styles of interviews are appropriate for gathering background infor mation; what works best for one examiner may not work well for another. You may obtain background information through unstructured, semistructured, or

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Sample of Background Information from Child’s Report

Jonas is an only child who currently resides with his parents, Dr. Arthur Haggerty, a dentist, and Dr. Margaret Rawson, a college professor. Both parents work full time. The Rawsons adopted Jonas at birth. His biological mother was 14 years old and reported that she smoked cigarettes throughout the pregnancy. Although little is known about prenatal care, concerns have been raised about possible drug and/or alcohol use during pregnancy.

Dr. Haggerty reported that Jonas attended preschool for two years and then entered Ashton Cove Elementary School for kindergarten. Based upon both parental and teacher concerns regarding motor development, he was referred for an occupational therapy evaluation in first grade. Results from the Peabody Developmental Motor Scale indicated delays of up to 17 months in fine- motor development and up to 26 months in gross- motor develop- ment. He demonstrated weakness in his flexor muscles, particularly abdomi- nals and hip flexors; toe walking; and weaknesses in visual- motor planning. Jonas was unable to hop on one foot without losing his balance. On the Gardner Test of Visual- Perceptual Skills (nonmotor), Jonas obtained average scores on measures of visual discrimination and visual- spatial relations, and a below average score in visual memory. Recommendations were made for occupational therapy with the goals of improving fine- and gross- motor skills, visual- perceptual motor planning, and muscle weaknesses. In addition, Jonas began to receive resource support for reading, writing, and math.

Dr. Rawson reported that although Jonas has tried to participate in team sports (both soccer and baseball), the experiences were not positive. During baseball games, Jonas would often sit down in the outfield. On the soccer field, Jonas tried to stay away from the ball. His mother reported that on several occasions, when she picked Jonas up from practice, he would be crying. Presently, Jonas is enrolled in a karate program that he attends once a week. Because of problems with balance, he has been unable to advance to the next belt level.

Now that Jonas is in fourth grade, delays are still apparent in his gross- motor development. At the age of 9, Jonas is unable to ride a bike or tie his shoes with ease. He walks with an awkward gait and often trips. Because of continued toe walking, Jonas is currently wearing casts on both legs to stretch his heel cords and position his feet flat on the ground. When the casts are removed, Jonas is sched- uled for physical therapy to help strengthen his legs. Recent results from a brain magnetic resonance imaging (MRI) indicated subtle cortical dysplasia involving the cerebellar hemispheres (the area of the brain involving motor development and balance). These findings are supported by clinical observations.

For the past three years, Jonas has received special education services in a resource setting under the category of Specific Learning Disability. He has also received half- hour weekly Occupational Therapy services. He currently uses an Alpha Smart, a small computer with a screen and a keyboard, in his classroom to assist with lengthy writing assignments. Jonas reports that he wants to quit his karate class and that his favorite activities are playing with his Game Boy, watching television, and eating candy.

Despite his difficulties, Jonas’s parents note that he is creative and articulate and has a good sense of humor. When asked to write what he likes to do on the week- ends, Jonas wrote, “Watch TV, play Nintendo, and fall down the stairs.”

Rapid Reference 3.3

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structured interviews. No specific guidelines exist in regard to how long an inter view should take, but the following general recommendations can help orches trate the process.

Structure of an Interview The length of an interview depends on how talkative the person is and how struc tured an interview you conduct. Some examiners prefer to gather information from a questionnaire completed before the interview and then spend less time on the actual one on one interview. The completed questionnaire can be brought to the interview and the person’s or parent’s responses can be used as a starting point for asking follow up questions. You may want to review the questionnaire prior to the interview so you have time to think about specific topics that you want to discuss. The process of completing a questionnaire may help prepare the person or parent for the types of questions you will be asking.

Even if a questionnaire is completed ahead of time, many people reveal ad ditional details when they speak with you. In addition, a frequent complaint that parents have (especially in custody evaluations) is that they did not have enough time to “tell their story” (Ackerman, 1995). Thus, sufficient face- to- face time helps to ensure that the people you are working with feel validated, under stood, and pleased with the assessment process. To further ensure satisfaction, make sure that the referral persons are happy with how you have perceived and interpreted their referral questions. Always check to confirm that you understand exactly what is being asked of you so that you are clear about the purposes of the evaluation.

Some clinicians prefer a loosely structured interview that moves freely from one topic to another; others prefer to ask questions one by one from a highly detailed questionnaire. Several structured interviews are available for gathering developmental histories. Sample history forms include the Structured Devel opmental History of the Behavior Assessment System for Children (BASC; Reynolds & Kamphaus, 1992) and the Checklist for Referral and Background Information form of the Kaufman WISC III Integrated Interpretive System (K WIIS; Kaufman, Kaufman, Dougherty, & Tuttle, 1994). (See Figures 3.3 and 3.4 for excerpts from these forms.)

Some examiners prefer to gather information on personal history from birth to the present. Others prefer to focus the interview on areas that are specifi cally relevant to the referral question, while including only introductory ques tions about development or other areas (Ackerman, 1995). You may use what is known as a branching procedure to pursue topics that are of particular relevance

REFERRAL AND BACKGROUND INFORMATION 41

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42 ESSENTIALS OF ASSESSMENT REPORT WRITING

Figure 3.3 Excerpts of K- WIIS Checklist for Referral and Background Infor- mation

Source: Adapted from Kaufman, Kaufman, Dougherty, and Tuttle (1994).

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REFERRAL AND BACKGROUND INFORMATION 43

Figure 3.4 Excerpts of BASC Structured Developmental History

Source: Adapted from Reynolds and Kamphaus (1992).

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to the referral question. When interviewing someone (the person, parents, or teachers), you may find it helpful to change your line of questioning if something of particular relevance is revealed. For example, if you find out that the child missed 30 days of school because of a hospital stay after a head injury, branch off into a line of questioning about the head injury. This branching procedure keeps flexibility in an interview and allows you to pursue relevant topics in more depth.

Content of the Background Section Like the structure of the interview, the content of the information collected for the background section of the report will vary from case to case. Certain general topics, however, are often addressed. Rapid References 3.4 through 3.7 provide a detailed outline of information that may be collected during an interview with a person or with parents. If the informant is a medical doctor, the questions would revolve around the medical history. If the informant is a teacher, then the information would revolve around academic history and present classroom performance.

Organize the background section in a logical progression from topic to topic. The lists of topics in Rapid References 3.4 through 3.7 provide a useful way to structure the report itself. Typically, you will have separate paragraphs on early development, school history, medical history, and so on. Try to keep the content of each paragraph on one distinct topic. If you have little to say about a topic (e.g., Jose’s medical history was unremarkable, with no major illnesses or inju ries), then integrate that information with another related topic, such as results from vision or hearing screenings.

The following example, adapted from Mather and Jaffe (2002), illustrates a sample paragraph that focuses on ocular albinism and the conditions affecting a child’s vision:

Gregory Blackhawk is a 7- year- old second- grade boy who has been di agnosed with ocular albinism, the result of which is impaired acuity and moderate horizontal nystagmus. Results of a functional vision evaluation last year completed by Dr. Martin, an ophthalmologist, indicated near acuity approximating 20/160 and distance acuity of 20/100. In addition, he has astigmatism, mild myopia in the right eye, and a left eye muscle imbalance. Gregory has binocular vision at a distance of up to two feet; at greater distances, he uses only his right eye. He also has the pigmentation of albinism, with pale skin, light blond hair, and blue eyes.

44 ESSENTIALS OF ASSESSMENT REPORT WRITING

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REFERRAL AND BACKGROUND INFORMATION 45

Sample Topics for Developmental History of Children

Mother’s pregnancy • Was the mother under a physician’s care? • Any problems or complications? • Any prescribed medications or nonprescription drugs taken? • Alcohol consumed? Amount? • Cigarettes smoked? Amount? • Illegal drugs such as marijuana used? Amount? • Weeks of gestation (37–40 weeks is considered full- term)? • prematurity (fewer than 37 weeks gestation)?

Delivery • Type of delivery? • Any fetal distress during delivery? • Anything that caused disruption of oxygen?

After birth • Weight and length at birth? • APGAR scores? 5 min. and 10 min. scores are not predictive, but low (below

7) are suggestive of potential fetal distress. • Any special care or medical tests needed? • How long were mother and child in the hospital? • Was the baby’s schedule predictable? (helps to determine temperament)

—eating —sleeping —frequency and intensity of crying

Developmental milestones • sitting • crawling • walking • first words • short phrases • toilet training

Rapid Reference 3.4

You will often want to organize parts of this section in chronological order, progressing from the earliest incidents up to the present situation. Rapid Refer ence 3.8 provides an example of a boy’s educational history.

Recency of Information A review of history can help you determine how long a problem has existed. When adults state why they are coming in for an assessment, they usually list the

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46 ESSENTIALS OF ASSESSMENT REPORT WRITING

Sample Topics for Educational and Occupational History

Acquire Information About All Levels of Schooling That Apply: • day care and preschool (for children) • kindergarten and grade school (for children/adolescents) • high school (for adults/adolescents) • college (for adults) • technical/vocational training (for adults)

Educational Considerations: • type of school attended (e.g., public, private, home- school) • bilingual teacher or class • separation from parents (in earliest school years) • peer relationships • type of grades earned • scores on standardized tests (group tests from school record) • attendance record • grades skipped/repeated • change in schools • problems/successes • relationships with teachers • attitude toward school • problems with homework • interests, activities outside of school • educational interventions (speech therapy, special education, etc.; what

types of interventions have worked?)

Previous Psychoeducational Test Results • referral questions • test results • diagnoses • recommendations • follow- up

Occupational History (adults) • present and past employment, periods of unemployment • presence or lack of appropriate training for the job (formal schooling or

on- the- job) • satisfaction with job • relationship with work colleagues/supervisors • status of retirement, alternate activities, or volunteer work

Rapid Reference 3.5

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problems that led them to seek help. Sometimes, however, the duration of the problem is unclear. Did the problem begin in the past 12 months? Or in the past 2 weeks? If the problems have existed for the past 2 years, what led the person to come in now? Inquire about the duration and intensity of the problems. Some people reveal valuable new information when prompted with the question “Why did you seek an assessment right now? ”

Obtaining Information about Touchy Subjects Some topics are difficult to discuss. Examples include drug and alcohol abuse, sexual offenses, divorce, strained family relationships, and obesity. Often, taking a matter of fact approach is helpful (e.g., saying “these questions are a routine part of our evaluation”). You can acknowledge that some things you ask may be difficult to answer, but encourage people to respond to your questions openly and honestly. It is also helpful to alternate discussion of sensitive topics with straightforward, unemotional fact gathering.

REFERRAL AND BACKGROUND INFORMATION 47

Sample Topics for Medical and Psychological History

Medical History • vision • hearing • illnesses • injuries • hospitalizations • medications (current/past; name; dose; frequency) • drug/alcohol use (current/past) • cigarette use • caffeine use • eating habits • sleeping habits

Psychological History • current or previous diagnosis • individual, family, or group therapy (past/present) • drug or alcohol rehabilitation • efficacy of past treatments

Previous Psychological Test Results

Past Records of Juvenile Detention or Incarceration

Rapid Reference 3.6

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During the interview, take notes about what the person says, but also observe how the person responds nonverbally. For example, did he seem defensive when asked about alcohol and drug abuse? Did she become embarrassed and blush when asked about how she disciplines her child? Did he become tearful when asked how he was doing in his math class? These additional bits of qualitative

48 ESSENTIALS OF ASSESSMENT REPORT WRITING

Sample Topics for Family and Social History

Family History • race of each parent (e.g., Caucasian, African American) • languages spoken in home, by caretaker, in neighborhood, and by person • siblings/stepsiblings and birth order • marital status, past and present (if testing adult)

—current relationship —if divorced, how long was marriage and when was divorce? —children from present or past relationships

• marital status of parents (if testing child) —if divorced, age of child at divorce —child custody and visitation arrangement — related difficulties

• parents’ child- rearing practices • has the problem affected the family? • living situation

—who lives with the child? — how long have they lived in the current residence?

Social Relationships • quality of friendships • sibling relationships (including stepsiblings and half siblings) • other social supports

Family’s Psychological or Educational History • history of psychological problems in immediate family (e.g., mother diag-

nosed with depression) • history of learning problems in other family members (e.g., father diag-

nosed with dyslexia) • history of medically relevant problems in other family members (e.g., older

sibling diagnosed with ADHD)

Individual’s View of Self (or of child) • self- concept • strengths • weaknesses • hobbies and interests

Rapid Reference 3.7

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information can prove invaluable when you are interpreting all results. On oc casion, you may question the accuracy of the information provided during an interview. Usually, when you are unsure of the accuracy of an account, you can confirm the information by consulting another source.

Information from Different Sources Mothers and fathers and parents and teachers may provide different (and con flicting) information about the same person. In fact, informants often disagree in their views of a child (Kamphaus & Frick, 1996). Compare the information provided by diverse sources and note all contradictions. For example, a teacher may state that a child exhibits aggressive behavior in school, but the parents may not report this type of behavior in the home. In another instance, the mother may have a higher tolerance for noncompliance than a father, leading to divergent opinions about whether the child is cooperative. Different expectations, inter

REFERRAL AND BACKGROUND INFORMATION 49

Example of a Boy’s Educational History

Jason began kindergarten at Castle Hill School but remained there for only 2 weeks. Mrs. Jasper felt that the program was too structured for him, and so she moved him to Garden Park preschool. As a result of this change, his behavior improved, and he began to interact successfully with his peers. His preschool teacher noted that Jason spoke well and was good at drawing pictures. The following year he began kindergarten for the second time at Castle Hill School but stayed only from August to December. During this time, the kindergarten teacher raised concerns about his lack of attention. Mrs. Jasper then enrolled Jason in Harper Elementary School, be- lieving that his difficulties with attention were because of his unhappiness at Castle Hill School. Prior to leaving Castle Hill, Jason was evaluated for special education but was not eligible for services. At that time it was reported that he could recite most of the alphabet but lacked sound- symbol relationships; he knew his shapes and colors and could count to 36, but he recognized numbers only up to 15. He then completed first and second grade at Harper Elementary. Both teachers noted problems with his attention. During these 2 years, he participated in a program called Reading Pals that was designed to promote early literacy.

Jason is currently in third grade in Ms. Mantell’s class. In an interview, Ms. Mantell reported that he is easily distracted, even on academic tasks that are well within his capability. She noted that he rarely finishes assignments, and when he does complete a task, he has a tendency to rush through it and not notice his errors. Usually when she looks over at Jason, he is playing with a pencil or staring out the window. Ms. Mantell commented that Jason’s attention is better when academic tasks are interactive, physical, or hands- on in nature.

Rapid Reference 3.8

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personal interactions, and situational factors can all lead to varied perceptions of the same person. Keep in mind that varied opinions about the same person do not mean that one person is right and the other is wrong. Differing perceptions often result because a certain behavior is only present in specific circumstances and because people vary in their perceptions of behavior.

You have to decide how to reconcile and report these differences when writing the results. In general, evaluators tend to weigh adult informants, such as parents and teachers, more heavily for observable behaviors (e.g., conduct problem be haviors) and tend to weigh child self report more heavily for emotional problems (e.g., depression, anxiety; Loeber, Green, & Lahey, 1990). Perhaps that fact is not surprising given that adults report more conduct problems than do children (Kashani, Orvaschel, Burk, & Reid, 1985) and children report more emotional problems than do parents or teachers (Bird, Gould, & Stagheeza, 1992).

If you are evaluating a child, then the age of the child may affect how heavily you rely on the child’s self report in comparison to the parents’. As a child enters adolescence, parents invariably have less knowledge of his or her emotions and be haviors than they did when the child was younger. Therefore, adolescents may be better informants than their parents about certain topics, such as their emotional well being, interests, fears, or feelings about school. Similarly, an elementary school teacher, who sees a child for many hours a day, will have more knowledge of cer tain behaviors than a child’s junior high or high school teachers, who typically see the student for one class a day. In addition, as children develop cognitively, they are more capable of describing abstract concepts such as feelings and thoughts. Logically, then, the importance of a child’s self report increases with age, and the importance of information reported by parents or teachers decreases (Kamphaus & Frick, 1996). This generalization does not apply to factual developmental history or to situations where the child is incapable of providing an accurate self report because of linguistic, emotional, or cognitive impairments.

When integrating information from diverse sources into your report, try to ac count for discrepant information and explain the reason for it. Rapid Reference 3.9 provides a father’s brief summary of the educational experiences of Paul, his adolescent son. Paul’s father believes that Paul could do the work if he wanted to, but Paul feels that he really needs more support if he is going to succeed at his school. Mr. Matthew attributes Paul’s failure to a lack of motivation, whereas Paul attributes his current difficulties to a lack of support.

One reason for this discrepancy may be that Mr. Matthews only sees Paul on the weekends. He is the noncustodial parent, and Paul stays with him every other weekend. Mr. Matthews does not observe the amount of help that Paul needs on a routine basis to organize his materials and complete his assignments for school.

50 ESSENTIALS OF ASSESSMENT REPORT WRITING

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REFERRAL AND BACKGROUND INFORMATION 51

Example of a Father and Son’s Discrepant Views

Paul was adopted when he was 2 days old. Mr. Matthews reported that as an infant he was extremely active. He spent an extra year in preschool because of difficulties sitting still and participating in groups. Paul has always gone to private schools that have a small student- teacher ratio and an advanced curriculum. His elementary school, Pine Ridge, provided small classes, individualized instruction, and close supervision. Paul was successful in elementary school, but in his first year at Westminster Preparatory Academy his grades have deteriorated consider- ably. Paul is currently failing all of his courses.

Mr. Matthews feels that the reason Paul is not doing well in school is because he is not prepared for his classes, which results in inadequate completion of home work assignments and poor test scores. He believes that if Paul would just try harder, he could perform well in all of his subjects without any extra help or tutoring.

In contrast, Paul reports that while he was at Pine Ridge he had tutoring three times a week. The teachers also made informal accommodations for him, such as letting him retake exams and working with him on a one- to- one basis. He believes that one main reason he is not doing well in his classes is that he needs extra time on all of his tests in school but is too embarrassed to ask for this ac- commodation. In the past when he was given more time, it was easier for him to focus his attention on the important aspects of the task. Paul believes that he needs a tutor or “homework coach” who can help him organize, prioritize, and complete his assignments. He also commented that the classes are too big at Westminster and the teachers don’t have time for one- to- one help.

Rapid Reference 3.9

Paul’s mother, Ms. Hoffman, corroborated Paul’s perceptions. She noted that Paul has always struggled in school and required substantial outside tutoring to perform as well as he did at Pine Ridge. He currently does not have a tutor, nor is he receiving any special accommodations in school.

If you provide logical explanations for discrepant information, then the report will provide a more balanced picture of the person’s functioning in the context of family and environment. Rapid Reference 3.10 provides a sample of the back ground section from Paul’s report that contains conflicting information from his father and mother about his adjustment.

Identifying the Source of Information When you write the background information, always reference the source of the information. If you write “Mrs. Jones reported that her husband is extremely de pressed,” such a statement may be interpreted quite differently by readers than if you write “Mr. Jones’s psychiatrist reported that his client suffers from severe

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Example of How to Present Conflicting Information

Parent rating scales. Paul’s father and mother, who have been divorced for five years, completed the Behavior Assessment System for Children (BASC): Adoles- cent form, Parent Rating Scales. On the BASC, Paul’s father, Mr. Matthews, rated the following behaviors as being significant concerns: lying to get out of trouble, rapidly changing moods, needing too much supervision, and tendency to act without thinking. However, his ratings also indicated that Paul has lots of ideas, compliments others, and has no trouble being social or making new friends. Nev- ertheless, the extent of his behavior problems at home resulted in a Behavioral Symptoms Index (BSI) that surpassed 91% of his peers; only 9% of adolescents in the United States were rated as high (negatively) in terms of their attention and adjustment problems by their parents. The BSI comprises the Hyperactivity, Ag- gression, Anxiety, Depression, Atypicality, and Attention Problems subscales.

In contrast, Paul’s mother’s ratings differed in that Mrs. Hoffman did not observe any indications of inattention, such as trouble concentrating, or impulsivity. Un- like Paul’s father, she did not note concerns about lying or moodiness. She also did not feel that Paul required an inordinate amount of supervision. She described Paul as “sometimes” creative and “often” polite. His mother’s ratings resulted in a BSI surpassing 52% of his peers, suggesting typical adjustment. One reason for this discrepancy in ratings may be that Paul lives primarily with his mother and only stays with his father every other weekend. Paul commented that he does not enjoy going to his father’s house because the rules are too strict, there is no computer at the house, and he is not allowed to stay out later than 9 p.m.

Both Paul’s father and mother rated his leadership skills as low. His father respond- ed “never” and his mother “sometimes” regarding the following characteristics: good at getting people to work together, “self- starter,” usually chosen as a leader, energetic, and involved in organized social clubs or groups. For someone of Paul’s superior cognitive and academic skills, his ratings in leadership are highly atypical.

Teacher rating scales. To obtain a comprehensive measure of Paul’s school be- havior, his ninth- grade science and English teachers completed the BASC Teacher Rating Scale. The science teacher’s ratings supported the evaluator’s impression of an adolescent who is not depressed, overanxious, or demonstrating any significant learning problems. Conversely, he “often” is distractible, rushes through assigned work, is overactive, bothers other students, and demonstrates poor study skills. Paul’s BSI score surpassed 88% of adolescents his age nationally. This score falls within the “at- risk” range (85% and above), suggesting a significant overall behav- ioral problem in the classroom.

Paul’s English teacher also indicated that Paul shows no significant symptoms of depression or learning problems. In contrast, she rated Paul as “almost always” demonstrating behaviors that comprise the domains of attention problems, hyperactivity, and anxiety. These behaviors included bothering others who are working, frequently seeking attention, exhibiting difficulty in waiting his turn, insist- ing that he is not good at something, and often seeming nervous. Paul’s BSI score surpassed 95% of adolescents his age nationally, which falls within the “clinically significant” range (95% and above), suggesting a severe behavioral problem in the classroom. Ratings provided by Paul’s father, science teacher, and English teacher indicate that he has significant problems related to the behavioral symptoms of ADHD. In contrast, his mother’s ratings indicated that Paul’s adjustment is typical for adolescents of his age. Adapted from M. Gerner (2003). Unpublished case report.

Rapid Reference 3.10

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depression.” As another example, a mother may believe that her daughter is “just lazy” when the father interprets her behavior differently. To clarify each source’s perceptions, provide specific information: “According to Mrs. Gomez, her daugh ter’s refusal to clean her room stems from her laziness, whereas Mr. Gomez sees this behavior as an example of the power struggle between his wife and teen age daughter.” Also, information from school records (e.g., report cards or standard scores on tests) can provide a more accurate account than a parent’s or child’s ac count of “what kind of student is Martha?” Examples of statements that can be used to clarify the source of information are listed in the Don’t Forget box.

REFERRAL AND BACKGROUND INFORMATION 53

DON’T FORGET

Statements for Clarifying the Source of Information

According to. . . . Mrs. Hoffman said . . . Dr. Earle stated . . . Ms. Morgan, his second- grade teacher, revealed . . . Ms. Pereza’s opinion is . . . Mr. Mohammad reported . . .

The principal, Mr. Ortiz, acknowledged that . . . School records indicated . . . As mentioned by Dr. Zhu in a previ- ous case report . . . Her psychiatrist, Dr. McGrew, noted . . . Colleagues of Ms. Whitney have com- plained to their supervisor that . . .

TEST YOURSELF

1. Well- written reports need to

(a) present critical pieces of history throughout the report. (b) avoid information that is not documented as factual by multiple

sources. (c) obtain referral and background information from adults, not children. (d) answer the referral questions.

2. In addition to the reason a person is being referred for an assessment, there are many other important pieces of information to gather about the referral question. Which of the following is not necessary to gather about the referral?

(a) intensity, frequency, and duration of the problem (b) when the problem started (c) why the person picked you for an evaluation (d) why the person came in now

(continued )

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54 ESSENTIALS OF ASSESSMENT REPORT WRITING

3. Examples and brief anecdotes are a waste of time and space when writing the paragraph on reason for referral. True or False?

4. Generally, face- to- face interviews are better than interviews over the telephone when collecting information from teachers or parents. True or False?

5. Name several areas that can be included in the section on background information.

6. Because gathering information about touchy subjects may disrupt rapport, you should avoid asking questions about topics such as divorce and drug and alcohol history. True or False?

7. Which of the following is true when gathering information from a variety of sources?

(a) Information from parents, who live with the child, is believed over any information given to you by teachers.

(b) Do not trust information from adolescents. (c) The age and maturity level of the child may affect how heavily you rely

on the child’s self- report. (d) Information from teachers is more reliable than that from parents

because parents are more biased in their evaluations. 8. Phrases that clarify the source of information, such as, “According to . . .” “School

records indicate . . .” or “He acknowledged . . .” are needless wastes of words in a report. True or False?

Answers: 1. d; 2. c; 3. False; 4. True; 5. see Rapid References 3.3–3.6; 6. False; 7. c; 8. False

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