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Neuropsychological Testing:
The Perils and Possibilities of Assessment Feedback

Abstract:

This paper addresses the delivery and usefulness of feedback of neuropsychological test results to parents, children, teachers as well as other professionals. How can a tester ensure an optimal experience for the parents and children during this stressful situation? The multiple dimensions and implications of giving feedback are presented. Clinical considerations including transference and countertransference are addressed along with suggestions for future training.

Neuropsychological assessments are widely used to diagnose and provide recommendations for how best to intervene with children with learning, attention, and psychiatric difficulties This process is anything but academic. It's intensely anxiety producing, stressful, potentially shaming and can leave both parents and child feeling acutely exposed. The challenge is how to engage parents in a collaborative investigation into their child's struggles that avoids alienating parents or rigidifying their perspective. It is equally important to create a collaborative relationship between child and tester. Rather than viewing testing as something that is done to the child, my aim is to find ways to reduce the asymmetry between tester and parent. Engaging parents as collaborators is the underlying principle guiding the concrete suggestions to follow.

Providing assessment feedback to children and their families has received short shrift in the literature (Tharinger et al, 2008). Despite its popularity and value(Meyer et al, 2001), the assessment process can be a source of significant frustration and anxiety for families (Westervelt et al, 2007). One common finding is that neuropsychological results are too often poorly communicated by professionals and misunderstood by parents and children (Donofrio et al, 1999). Seventy one percent of neuropsychologists in clinical practice conduct testing feedback sessions with patients (Pegg et al, 2008). Despite the centrality of feedback, this part of the testing process is under taught and underrepresented in the literature (Jacobson et al, 2015). We run the risk of leaving parents and children feeling bad about themselves and their diagnoses.

In successful feedback sessions, the psychologist explains how psychological and neurological factors contribute to a child's academic, social, and emotional difficulties. This information is intended to guide patients and families in pursuing treatment and accessing academic resources. In this paper I will discuss how to avoid common pitfalls and ensure that the test results will be positively received by parents and children.

As a beginning neuropsychologist (over 25 years ago) I vividly recall a formative incident with a father. I had assessed his son and diagnosed the boy with Attention Deficit Disorder (ADD). My perspective on this diagnosis was that this was good news as the son could get treatment and receive accommodations to enhance his academic success. During the feedback session, however, the father became increasingly agitated and insisted that his son did not have ADD. I find myself embroiled in a power struggle with the father that resulted in his departure from my office with angry feelings and left me with an unpaid bill. I came to realize that I had skipped over the father's anxiety about his son's deficits. In insisting on a diagnosis instead of attending to this man's anxiety, a good testing experience resulted in a bad clinical outcome. This experience, among others, motivated me to reflect on how to better conduct my feedback sessions in such a way as to lessen stress and enhance collaboration with the families and children. The poor training and dearth of literature in this area inspired me to write about this topic.

Intake:

The testing experience begins with an initial phone call. Typically, a parent calls asking to set up an intake appointment for his or her child. The parent is often ill informed about the process and feels confused, overwhelmed, and distressed. The parent may be wondering; "What's wrong with my child? Is it my fault? Will my child be asked to leave his school? Will she ever be able to function in a normal environment?" The first phone call can help the parent understand the complexity of the testing process and help the tester understand the parent's concerns. It is useful to find out who referred the parent and to explain the framework of the testing.

The intake session with the parent or parents can be a powerful point of entry into the testing process. The tester asks the parent about the child's developmental history along with information regarding the parents' fears, fantasies, and concerns about the child. As parents describe concerns, the tester can focus on how the testing information can be used to address the expressed issues. In doing so, the tester becomes a supportive ally who provides information and resources.

A self described "driven" father recently came to consult with me about his son who was "floundering" in a competitive academic school. The father was able to share his frustration about parenting his son, who was very different temperamentally. He was more "relaxed" than the father. As the intake unfolded, this father shared concerns about his own life and the effect that his busy work schedule and drive might be having on his relationship with his son. He was also concerned about his son's depression and possible substance abuse. I presented the testing as a potential means to understand the son's academic and emotional struggles; and suggested that his understanding could be a bridge to improve the father-son relationship. Had the father not been invited to share his concerns, he might have responded to the testing by labeling/condemning his son in ways that would have undermined rather than improved their relationship.

The intake session provides an opportunity for the parent to present useful information that might otherwise not be obtained, intake sessions provide the same sort of opportunities for the child. Additionally, intake sessions with the child build feelings of trust and comfort with testing. Sessions can be used to build rapport and to help them move from being passive subjects to active inquirers. They set the stage for the feedback process by clarifying concerns about academic or social issues that can be addressed when discussing the test results.

A 10-year-old boy came for testing due to parental concerns with maladaptive social behavior. Teachers and parents described him as inattentive to limits, socially oblivious, and disruptive at home and with friends. The boy reported that his main problem was with the bullies in his class. Upon questioning he revealed that he had difficulty with math and felt extremely distressed about his perceived incompetence in this area. He felt he was "stupid" and friendless. I suggested we use the test results to help him understand his challenges with math and friends. His face lit up. He was enthusiastic about the possibility that the testing might help him have an easier time socially as well as academically.

Preparing The Child For Testing

Complying with the demands of tasks that are difficult and take multiple hours can be frustrating and fatiguing. There are diverse techniques a tester can employ to reduce the stress of the process and help children enjoy it. The tester can open the intake session with a brief explanation about how the test results can be useful. The tester reviews the components of the test and how long they may take. Children should be encouraged to weigh in on the schedule and the tester can clarify that children's needs in this regard are the priority. The tester should ask the child what tasks she would like to start with and invite her to participate as the testing unfolds. Humor, frequent breaks, snacks, and empathy build rapport and help children become active participants in the process.

Information Gathering

Preparing for providing feedback involves integrating test results with information gathered in school and from other professionals involved with the child. Children's teachers, tutors, therapists, and other professionals are valuable sources of information and should be consulted by testers. Connections with the school and other professionals pave the way for a successful feedback experience with the family as the tester can weave in anecdotal information from these sources about the child to help the parents understand the test results. A classroom observation can round out the picture and illuminate specifics of the child's behavior. It is valuable to observe children during a structured academic task as well as during unstructured times such as recess or lunch. These situations provide valuable information regarding the child's areas of strength as well as challenges.

An assessment of a preschool boyrevealed a bright, verbal child with significant distractibility and short attention span. When I observed him in the classroom, I noted his engagement with his peers, his love of building, and his motivation to please his teachers. During conversations with the teachers and parents I related my observation that he was one of the first children to comply with the direction to stop playing and go to the rug for circle time. He sat on the rug and assumed a yoga pose, apparently attempting to regulate and focus. Although he was only able to sit in the circle and attend to the teacher for the first 10 minutes of the lesson, his motivation to please and to cooperate was impressive. The teachers and parents enjoyed the anecdote and told me that he was a "good boy" despite his difficulty complying with classroom routines and expectations. My observations about their son's behavior at circle time made these parents feel I understood and was sympathetic toward their son. This greatly aided in their capacity to accept the test results.

School observations bring to light the child's strengths and weaknesses and pave the way to understanding the test results in a child's real-life setting. The examiner can use the observations to connect the dots for the parents and teachers and relate how the child's learning style and neurocognitive functioning impacts her behavior and productivity in the classroom. Observations conducted during recess and lunchtime highlight the child's social emotional functioning and often point to a need for intervention in those areas.

Impact of Feedback on Parents

Feedback may have therapeutic effects on both parents and children (Finn and Tonsager (1997); Gorske, 2008; Hamilton et al, 2009). Human and Teglasi (1993) reported favorable changes in parents' self-reports following feedback, including an improved understanding of their child and improved parent-child relationships. How might testers leverage the positive effects of feedback? The information testers need to impart exposes the child's difficulties and elicits diverse responses. The parent's anxiety about the child's future is often triggered and his or her wishes regarding the child may make it difficult to hear the feedback. As the parents are able to voice their concerns, they can better understand their children's challenges.

A high-powered lawyer brought in her 4-year-old daughter for testing due to concern with the child's language development. In the intake, the mother cried as she described her wish for her daughter to succeed academically and to attend a competitive private school. During an extended consultation period the mother was able to accept the diagnosis of auditory processing disorder (APD) and to support realistic potential placements where her daughter would be more likely to flourish academically.

Parents may feel angry and hurt by the exposure of their child's challenges. They may also be overwhelmed by the steps required to address the issues. They may feel guilty that they did not have this information before the testing occurred. Parents often express anger regarding prior consults that did not reveal their children's academic and psychological challenges and limitations.

A verbal 8-year-old girl was diagnosed with dyslexia, and specific reading support services were recommended by the tester. The mother was angry that the school and pediatrician did not previously uncover her daughter's challenges when the mother had discussed her concerns with the professionals and that she had "wasted time" with ineffective reading techniques.

Shame is a particularly potent and often unexpressed emotion that parents can feel during the testing process. It can be experienced as a narcissistic injury to learn that one's child has neurocognitive and/or psychiatric difficulties (Fajardo, 1983). Concomitant with new understandings, parents often blame themselves and feel guilty about how they may have mistreated their children prior to neuropsychological testing, since they did not yet understand their children's challenges.

For many parents, diagnosis comes as a relief. On more than one occasion I have heard a parent exclaim, "I knew there was something wrong but nobody would tell me what it was." Parents often experience challenging years prior to testing without understanding their children's difficulties and thus feel supported and empowered when they finally receive the correct diagnosis. Being able to make good decisions regarding interventions, schools, and services for children allows parents to feel hope and even excitement for the future. The parents can finally understand and empathize with the children's learning and/or emotional issues.

In some cases, the child's diagnosis resonates with the parent who expresses a wish to be evaluated. A common parental reaction is, "I bet if you tested me you would find the same thing!" Occasionally I test a parent and often find that the parents demonstrate similar neurocognitive and psychiatric difficulties to their children.

A mother was concerned about her son's consistent reluctance to try new foods and activities and to tolerate breaks in routine. The test results indicated that her son met diagnostic criteria for autistic spectrum disorder (ASD) and he approached the world with an overly rigid approach to situations, concrete understanding of language, and poor ability to negotiate change. When I explained the etiology of his refusal to try new activities, the mother was able to work more effectively with her son to prepare him for change and to regulate her reactions when he had difficulty with transitions. Knowing that her son had neurocognitive impairments helped her move away from feeling that he was simply a "brat." She was able to empathize with him and intervene more effectively when he was having trouble.

Impact on the Child

Children may find receiving test feedback quite painful. Siegel (1987) suggested that children may dread the exposure of their weaknesses in the testing situation. They may feel caught because they thought they were fooling everybody about their challenges and now need to "fess up." Many bright children with learning/attentional difficulties are aware of their limitations and have been consciously disguising them for fear of exposure and embarrassment. They can be resistant to addressing areas of weakness and feel overwhelmed by the services recommended. Children often come up with their own explanations for their difficulties or internalize the way caregivers have seen them. They are convinced that "I'm stupid, I can't do it" and so on. They may feel committed to these self-perceptions and reluctant to embrace other ways of understanding challenges.

Alternatively, children may feel relieved that the adults are collaborating on a plan to address their difficulties. They may feel understood for the first time around academic, social, and emotional difficulties. Self-esteem may improve as they let go of toxic ideas, replacing them with more helpful models of understanding how their minds work.

A bright, engaging 8-year-old boy at a competitive school was struggling with reading and attention difficulties. Upon receiving a diagnosis of dyslexia, he happily announced his diagnosis to his class. He created a signup sheet for his peers to ask him questions about his diagnosis. When confronted with a word problem in math, he stated, "I have dyslexia so I may need help with reading the problem." He then proceeded to do the problem independently and confidently. Receiving the diagnosis and understanding his problems helped him advocate for himself successfully.

What to do when the child has low scores as a result of intellectual disabilities? Often children are referred due to significant neurocognitive deficits. If that is the case, it is very important not to share the scores with the child. Always focus on the areas of strength and encourage the child to feel positively about his or her skills. Often, coming up with an appropriate school placement is essential in these cases to provide support for the child.

An engaging nine year old was referred due to significant academic difficulties. Testing revealed deficient language skills with low average to average visual spatial skills. As a result, academic skills were significantly below grade level. The boy had been previously assessed by the Board of Education with minimal services recommended to him. The parents had been very distressed regarding his low scores. I explained the etiology of his low scores and guided them in obtaining a special education placement for their son. The family expressed relief regarding the results and recommendations.

Dispelling Misconceptions

Dispelling misconceptions surrounding children's problems is one of the most challenging but rewarding aspects of testing. Helping the children and their families understand that the child is not "stupid, lazy or bad" is complicated and requires time (Kelly and Ramundo, 2014). Untangling the neurocognitive and psychiatric underpinnings of children's underperformance and maladaptive behavior at home and in school provides clarity and understanding. With feedback, parents can understand that Attention Deficit Disorder with Hyperactivity ( ADHD) can cause children to space out and not hear teachers or parents. This does not mean that they are oppositional. An anxious/avoidant response to learning difficulties can look like procrastination or poor motivation.

Parents are sometimes suspicious of the diagnoses and the recommended services. They may fear that the diagnosis itself and the recommended supports will become crutches that will further limit or even disable their children. Parents may say, "Oh he just needs discipline. If we tell him he has ADHD, he will use it as an excuse to not do his homework." They may be concerned that tutoring or medication will take away the child's independence, because taking advantage of these types of support will mean that he will not be "doing the work himself." Analogies such as an "invisible wheelchair " and "eyeglasses" stress that the child is receiving needed services and that the focus should be on how to facilitate success while acknowledging the child's limitations. The tester develops realistic goals and expectations using the test results to explain the child's areas of strength as well as the challenges.

Rejection of the Test Results

What may seem crystal clear to the clinician is often misunderstood by the family. At times it may seem like the clinician and family are speaking two different languages. What does the tester do when the feedback is perceived as negative or when patients and families disagree or reject the diagnosis and/or recommendations? This issue is rarely discussed in the literature but often comes up in the consulting room. Most often the negativity reflects anxiety and a wish to avoid bad news. The tester can interrupt this negative cycle by allying with the parents. The tester can say, "We don't need to put a label on your child. We just need to understand what's going on and figure out how to help." What is aimed for is a meeting of minds with a focus on problem solving.

The tester can check in with the parents to make sure that the information being provided makes sense to them, and request examples from them that either confirm or contradict the results. For example, children with ADHD often have trouble complying with household routines and chores. This can be a good jumping off point for a family to begin to discuss the impact of the child's issues on family life. A common complaint is that the child does everything slowly and is delayed in leaving the house. When parents understand that the slowed speed is neurocognitive, they can begin to brainstorm strategies that will facilitate transitions. For example, use of a whiteboard in the child's room with a check-off list of items can jog the child's memory and eliminate the nagging that previously accompanied each morning. This will lead to a more relaxed start of the day.

A mother of a 9-year-old boy received feedback that her son is highly intelligent, with ADHD and anxiety. To my surprise, the mother was highly resistant to this feedback and was distressed that her son was not diagnosed with Autistic Spectrum Disorder as he had been previously. I struggled to understand her concerns and realized that she was worried that her son would stop receiving the free services that the Board of education was providing for him. I set up another meeting with her to address her concerns; with the additional diagnosis of Auditory Processing Disorder confirmed by an audiologist to whom I referred her, the mother felt more confident that her son would continue receiving services.

It is not simple to help the family navigate the thicket of their emotional responses at the same time as their practical concerns. Parents are vulnerable to feeling inferior or judged by the examiner, and it is important for the tester to establish him or herself as a "like subject" i.e., someone to whom the parents can relate, in order both to build an alliance and reduce the asymmetry of the testing situation. Helping the family understand that they are not alone and that many other families struggle with similar issues can take the sting out of the data and replace some of these negative feelings with feelings of hope and optimism.

Self Disclosure

I often share information about my own learning disability with families when I am diagnosing learning issues in the child. This offers hope to the family and begins to take the sting out of the diagnosis. I may also share information based on my experiences, for example, with complex negotiations with the Board of Education. I offer both empathy and realistic advice around those situations that I have personally encountered as well as those I have heard about from my patients and friends.

A bright, verbal 11 year old girl was diagnosed with dyscalculia. She teared up as she recounted her struggles with math, feelings of frustration and concerns that she was "stupid." I empathetically resonated with her feelings and in that spirit, shared my own learning challenges with math. I reassured her that we could come up with strategies that would help her understand math better and that she would be able to succeed despite her disability. She brightened visibly as we talked and left the session feeling more confident about her academic future.

What does a tester do when the parent seems committed to the idea of the child being defective, lazy, or stupid rather than having neurocognitive or psychiatric issues? It can be frustrating and upsetting to the tester to hear parents blame the child and/or reject feedback that could be useful. Taking a long-term view of the situation can often be helpful to the tester. Understanding that this is a process and allowing the ideas to percolate with the family can help counter parents' resistance and give them room to assimilate test results gradually. If the tester can find a way to allow parents to express their concerns, this can diminish parental resistance to testing feedback. When this approach is not sufficient, I refer to an outside therapist to work with the family's entrenched ideas.

Upon consultation with a bright 19-year-old who had failed his first semester of college, the driven, high-achieving mother readily acknowledged that her son was diagnosed with ADHD from age 7 and required extensive intervention throughout school. Despite this insight, she expressed frustration with her son and described him as " parasitic and lazy." She expressed bewilderment regarding her son's lack of motivation and contrasted her own work ethic with his difficulty performing. Leveraging the test results, empathizing with the mother's feelings, and engaging in parent guidance sessions over a six-month period resulted in an improved parent-child relationship. Focusing on the mother's understanding the impact of her son's attention and learning difficulties was key to the treatment. Educating her on the neurocognitive challenges that her son faced helped her reframe his issues and come up with realistic educational and professional plans that her son was able to successfully implement.

Division within the Family

Often parents have different views about their child and this is frequently the case when they are separated or divorced. It is important for the tester to maintaining a neutral stance and support each parent. This is a balancing act that may involve separate sessions and a great deal of tact. There may be a power struggle between the parents regarding who is right and who sees the situation clearly. The tester needs to negotiate the conflict without leaving one parent feeling blamed or dismissed.

Consultation about a 25-year-old young woman who demonstrated serious issues with daily living skills revealed that the parents differed in their concerns. The mother discussed her concern that the daughter receive 'round-the-clock supervision, as she would easily get lost and appeared to be unaware of her surroundings. The father was concerned that the daughter was receiving too much support and using it as a crutch. He wanted the daughter to achieve independence. In my consultation I stressed that each parent had a valuable contribution and commitment to their daughter's success. I affirmed that the daughter's neurocognitive impairments created difficulties with time management, directions, and self-care, and did necessitate intensive supervision. Concomitantly, I commented on her intelligence and high academic aptitude, and affirmed her abilities in the areas of reading and writing. The parents began to collaborate more effectively as the mother felt supported in her advocating care for her daughter, and the father was able to absorb more information about the daughter's challenges when they were presented along with areas of strength.

Working with the School

As the overwhelming majority of assessments of children are directly related to school performance, effectively working with school personnel is imperative for successful testing outcomes. What happens when the parent is reluctant to share information with the school? Parents often feel wary about how the school will respond to the results. They feel concerned that the results might stigmatize their children. Parents sometimes worry that the school will expel the child. The tester may need to encourage the parent to share information, explaining that the results will help the child to be better understood by teachers and receive needed accommodations.

Once the parent agrees to share the results with the school, how do you decide how best to present the feedback to the school teachers and administration? A meeting with the tester, parents and school professionals can be extremely useful to help the school better understand the child and implement specific accommodations and interventions. The school psychologist, guidance counselor, learning specialist and other support staff are often key participants in these meetings. Should the child be invited to attend the feedback meeting with the school? Older adolescents often benefit from attending the school meetings as they can experience first hand the information that is presented to their teachers and can learn what they need to do to advocate for themselves. In many schools, adolescents are expected to arrange extended time on tests with their teachers. Clarifying the process with the student, parents and teachers ensures effective follow up by the student.

For the younger child, explaining the etiology of behaviors is often the most valuable piece of the meeting. Children often say "I won't" when they mean "I can't." They can get inexplicably upset, refuse to comply with rules or withdraw from tasks as a result of learning, attention and psychiatric challenges. Deciphering behaviors and learning styles can be enlightening for teachers and guide them in appropriate interventions with the children. A child who was refusing to complete math work was able to successfully respond to problems when the format of the worksheet was changed to accommodate his visual processing issues.

An assessment of a 10-year-old girl revealed significant learning issues, particularly in the area of reading. While she presented as a bright and verbal girl, teachers reported behavioral difficulties such as tearfulness, distractibility, and lack of compliance with directions. Her mother consulted with me regarding these observations. When I asked for more specifics about when these behaviors occurred, it became clear that they tended to happen during reading instruction. The girl would become distressed, stop attending in class, walk around the room and not be able to follow the curriculum presented in class. Her mother had not shared the test results with the school due to concern about the school labeling her daughter and attaching negative consequences to the information. She was worried her daughter would be asked to leave the school. I explained how the feedback would benefit the child by helping the teachers understand that she was distressed about her reading skills. When I conducted a phone feedback session with the school, the teachers began to accommodate the child's learning style by providing individualized instruction during that time and the child's behaviors significantly decreased.

Sometimes, however, it is the school administration or the teachers that have a rigid perspective on the child and have difficulty incorporating information from the testing about the child's learning style. The information may need to be conveyed over time and in as collaborative a manner as possible. The tester can work directly with school personnel to understand their concerns and then help guide the parents regarding the best course of action. If the child is disruptive in class there may be different behavioral strategies to suggest. If the child is not advancing academically, it's useful to clarify expectations and ensure that the child can meet those standards. There are times in that the child may require a different school placement. The tester can offer suggestions for a more appropriate school setting or refer the family to a school consultant.

Using the test results effectively in a school setting often requires parents and testers to be forceful and insistent in advocating successfully to obtain services for the child. One mother commented, "When you told me my child needed resource room services, the Board of Education said 'no.' I was so convinced that you knew what was right for my child that I told them I am not leaving until my child gets those services. I got her into the resource room and she flourished." For parents and testers, having the confidence and know-how to advocate for the children and get them the services and accommodations they need is imperative in facilitating academic success.

A 10-year-old boy frequently wandered out of his classroom to complain to the principal about somatic or emotional concerns. Testing revealed that the student was missing basic writing skills and was leaving the classroom to avoid these tasks. The principal referred to the behavior as "manipulative." I explained that the student becomes overloaded and disorganized when presented with challenging work due to his learning difficulties. Several strategies were recommended including use of an iPad, dictation, and teacher support to help the student with his writing issues and indirectly to help him control his disruptive behavior. The teacher incorporated these techniques in working with the child, and the wandering behaviors subsided.

Feedback to the school can be communicated in face-to-face meetings, phone consultations, and email. Each modality calls for different skills. The guiding principles are to address the questions and concerns professionals have about the student, explicate the test data, and provide clear recommendations for intervention. Always, the tester needs to be mindful that the other team members may have different perspectives on the student and needs to find a way to communicate the test results effectively and respectfully.

An assessment of a 9-year-old boy revealed impaired reading comprehension due to an overly concrete and rigid learning style. He also evidenced anxiety and attention difficulties. A team approach was suggested that included tutoring in reading with a specialist, therapy and medication with a psychiatrist, and small group instruction in school. At the end of the school year a meeting was called with the parents, teachers, and school administrators to discuss progress and recommendations for the fall. During the meeting, confusion was voiced about the boy's erratic behavior and reading skills. The teacher offered an observation: "He can't work independently, and he can only finish a project when I sit with him." She felt this behavior was "emotional" and "volitional." I agreed that the student was anxious and impulsive and complimented the teacher on her ability to be supportive and reassuring.

I then explained that the student was not deliberately causing trouble or being overly demanding. Instead, his behaviors were the result of his neurocognitive difficulties; he had great difficulty organizing his thoughts, extrapolating information, and making inferences. He worked better with the teacher as he was receiving cues from her that compensated for his areas of difficulty. I showed the teacher how she was scaffolding him, i.e., give him sequential cues as she sat with him, and how he benefited from this structure. These insights facilitated better understanding of his learning style and improved the teacher's ability to work effectively with him.

Test taking accommodations are often recommended by testers following test administration and diagnosis. Obtaining these accommodations involve interacting with several institutions including the College Board of Examiners. This process can be lengthy, frustrating and cumbersome. The tester needs to carefully assemble supporting documents, obtain a rich history of the student's learning style and need for accommodations and present the data in a compelling manner. In the case of older adolescents, the school and the college board may not agree to the request due to the timing and the parent may need to vigorously advocate for this accommodation. During late adolescence, test results can also be instrumental in college planning and obtaining academic services in college.

It should be noted that the accommodation of extended time on standardized tests is one of the most frequently sought after accommodation. This accommodation is controversial as parents with resources can afford to pay for the assessment required to document need for the accommodation whereas parents who lack these resources can not provide the necessary documentation for their children. A possible solution to this issue would be to make the accommodation available to anyone who wants it with the caveat that the colleges would know that the students received the accommodation on the standardized tests.

Providing Assessment Feedback

Interpreting Data to Parents and Children

Using numbers and data points to describe a child can be upsetting and overwhelming for parents. It is useful to encourage parents to listen to the interpretation of the results instead of focusing on the numbers. Scores should be presented with an explanation of ranges and the bell curve. Parents should be encouraged to focus on recommendations and summaries as the data can be misleading. Feedback to children should not include any numbers but focus on their strengths and challenges. The focus should be on strategies for them to help compensate for their areas of weakness. For example, for children who present with Auditory Processing Disorder, they can sit in front of the class, do homework in a quiet environment, and use earplugs when in noisy places.

Communicating with Children

A concrete way of giving children access to the tester in a form that is relatively nonthreatening is through the use of texting and email. This mode of communication is developmentally appropriate and opens up a channel of communication that allows them to express concerns that they often do not express when we meet in person.

The tester can email a summary of the test results to patients, and encourage them to keep in touch via email. The summary is written in bullet points and breaks down the results into strengths and challenges. This has been extremely productive—it allows them an opportunity to digest the results in private and then return to me with questions or concerns.

A shy 12-year-old girl who had been extremely guarded throughout the testing and feedback sessions wrote an eloquent response to my email. She described how she had incorporated my suggestions for studying such as breaking the material into chunks, using flashcards, and talking to herself as she studied.

It is not optimal to allow the children to read the entire report, as they often become overwhelmed with the information and feel criticized. If an adolescent or young adult insists on reading the entire report, reading the report with the tester present allows for elucidation of questions. The concerns are most often around low scores, which can be usually explained by helping the patient realize that the score reflects the impact of their difficulties on their performance and is not a reflection of their intelligence.

Transferential Responses to the Tester

Transferentially, the tester may be viewed in many ways: a judgmental or critical parent, a helpful mentor, a competitor, etc. The parents also may view the tester as a threat to their relationship with their children and reject the testing information or they may too readily agree with the tester's perspective. They may feel envious of the tester's information about the child. They may feel judged by the tester and dependent on the tester for help and support. Often parents who bring their children in for testing feel desperate, and testing feedback is viewed with intensity. I learned this the hard way when my comments were repeated to the referring therapist in a tone very different from what I had intended.

A review of the literature reflects the different transferential reactions to the testing and illustrates the need for clinical skills in order to contain the anxiety engendered by the process. Pollak (1988) warns of the parents tendency to feel blamed by the tester. Appelbaum( 1970) describes the need for candor and support while trying not to assume an oracular role, which can stimulate unrealistic expectations around the testing. The tester needs to balance his or her position of authority with the parents; on one hand, the test results need to be taken seriously in order to ensure compliance with the recommendations. On the other hand, the tester does not want the parent to feel demeaned or inferior, as that will lead to a negative experience of the testing.

Children also experience significant transferential feelings. The tester is in a position of power and thus stimulates anxiety, distress, as well as a pull to be nurtured and taken care of by the examiner. Meersand (2011) outlines diverse transferential responses that children exhibit, including seeing the testing as punishment for being bad, belief in the magical powers of the tester, and fear that the test will reveal hidden thoughts or damage. The child also may have benign views of the tester and often sees the tester as a helpful and supportive adult. Sandler (date) describes the testing situation as a "safe space" where the child feels encouraged and self-esteem improves upon receiving positive reinforcement and attention.

The Tester's Response to the Parent and Child

The tester brings countertransferential feelings to the testing experience that may distort his or her understanding of the child or how best to communicate the results. Countertransference reactions to children can include anxiety around introducing difficult tasks for the child, impatience and frustration when the child is impulsive or oppositional, and a strong desire to help and protect the child. Sugarman (1981) delineates diverse manifestations of countertransference in the testing situation. He advocates using the countertransference as another lens in understanding the child. If the tester is feeling frustrated by the child, these emotions can be indicative of the child's difficulty with aggression. Similarly, feelings of anxiety on the part of the tester can signal concordant anxiety of the child. Chused (1988) noted that children's helplessness may arouse guilt or regret within the clinician for presenting challenging tasks that cause the child to struggle. When children are impulsive and/or oppositional, the tester may feel fatigued and frustrated.

Just as the tester experiences countertransference feelings towards the child, the parent can also provoke these responses. The tester may feel intimidated by the parents and may perceive information about the child as potentially threatening to the parents. The tester may feel warmly towards the family and want to spare them "bad news" or soft pedal the results in a way that downplays the severity of the child's problems. Countertransference reactions on the tester's part can include anxiety regarding how the parents view the tester, frustration with the parents when they don't agree with the results, envy of the parents for their perceived status (financial and otherwise), and feeling intimidated by parents' intense emotions.

For the feedback to be successful, understanding these feelings and using them to help the parents is essential. One technique for alleviating the anxiety in the room is to articulate how stressful it is to get your child tested and commend the parent's courage in undertaking the process. Reviewing initial concerns can refocus the feedback on the child's problems and allow for successful flow of information.

Consultation with parents who do not accept the results is among the most challenging countertransferential situations. Parent's anxiety can often be transformed into frustration and anger at the examiner. When confronted, it can be difficult for the tester to remain calm and help the parent feel understood and supported.

As a tester, one may not be inclined to obtain supervision or therapy for professional growth. But identifying and containing your feelings is an important piece of a successful testing experience. Understanding how painful the testing can be for parents and children despite its helpful aspects facilitates empathy in the tester. To best achieve this, it's essential for the tester to be self-aware and work with his or her feelings so they do not compromise the feedback.

CULTURE AND RACE

There are many cultural factors that the tester needs to be sensitive to as she assesses the child. Socio economic considerations must also be taken into account while testing and recommending interventions. These topics deserve separate consideration and are not the focus of this paper. Yet, it should be emphasized that all interventions need to be managed within the lens of understanding the contributions of culture, race and socioeconomic status. Clearly, bilingualism can interfere with test results and it is preferable for children to be assessed in their first language. A recent survey of psychologists (2010) revealed that many lacked the cultural sensitivity and training that would be optimal to conduct assessment and feedback (Mindt etal))

Sensitivity to socio economic considerations include tailoring the recommendations to accommodate financial concerns. The tester needs to be mindful of the family's resources and provide information that is appropriate for the family. There are many private special education options that can be funded by the Board of Education. These placements should be offered to families that require financial assistance. Similarly, in network recommendations should be made when the family can only afford those options. Recommendations for educational lawyers and advocates to assist families are particularly useful for families that could not otherwise afford special education services for their children.

Cultural and bilingual concerns also impact the testing and recommendations. If a child is bilingual, it is important to assess the child in both languages in order to properly gauge their functioning. It is also imperative to understand different cultures regarding expectations for behavior and responses to tests. Certain test items are culturally biased and need to be interpreted in that light. The projective (personality) tests only feature white people. Tests that assess social judgment, fund of information and vocabulary are particularly skewed towards cultural and linguistic assumptions.

An assessment of a 7-year-old bilingual girl revealed learning and attention difficulties that were confirmed by teacher report and classroom observation. The verbal feedback to the parents went well and they seemed to agree with the results and recommendations. However, upon receipt of the report, the mother emailed a detailed letter contesting the results and questioning the rapport the child had with the tester. She commented that her daughter appeared cooperative and willing but was not performing optimally in school or during the test situation. She further contended that the testing and results were invalid based on the daughter's inadequate English-language skills.

Upon my second meeting with the parents, I acknowledged the mother's email and asked for feedback from the parents regarding the testing information. We reviewed the areas of discrepancy between the parents' perspectives and the test data. I offered to further assess the child's language skills, as the mother felt that the child's scores were deflated due to her child's bilingualism. The mother was enthusiastic about getting more information and was relieved that I took her comments seriously. It was clear that the child felt most comfortable in a bilingual environment and was underperforming in school and during the testing due to the different cultural and linguistic expectations.

Race and class differences can engender anxiety among parents and children and render the testing especially stressful for minority and low income families. When a child is uncomfortable the test results may be compromised and the tester needs to be sensitive to these issues. As a psychologist, working for the Board of Education in a poor, non-white neighborhood, I witnessed countless examples of disrespect and intimidation by the teachers and administration towards the children and their families. These encounters led the children to mistrust white authority figures and underperform when being evaluated.

Mindt et al (2010) recommend best practice for providing neuropsychological services for patients of a different race/ethnicity including using the best instruments available and acknowledging the limitations of the tests and norms in the findings, gathering as much sociocultural information as possible to best contextualize the results, referring to a neuropsychologist with expertise with these clients when possible and to be actively involved in professional activities to advance cultural competence.

Post Test Sessions:

Because assimilating new information is difficult and requires time, it is helpful to offer several extended consultation/feedback sessions to help the family unpack the results and ensure that they fully understand the feedback. A typical scenario is a feedback session for the parents, then for the child, and then follow-up with a family feedback session. This aims to create a situation which everyone is on the same page. Omitting the family feedback session can lead to conflicts within the family, as parents and child may insist that the tester offered different feedback. A family feedback session is crucial to ensure that parents and child hear the same information at the same time. The family session is also an opportunity to consolidate information, vent reactions to the testing and/or feedback, and provide practical suggestions and strategies.

In addition to verbal feedback, a written report should be provided to the parents with an email to the child with a summary of the results. Following the written feedback, another separate feedback session is offered with an optional family/child session as well. When families make use of proposed sessions they gain clarity on the steps following the evaluation. If there is a need to refer to other professionals, the tester can review with the parents what follow-up works for them.

For best results, the parents contact the tester for years after the evaluations if they have questions or concerns. The tester frequently conducts reassessments if there is need for follow-up. This allows the tester to establish a long-term connection with parents and children that can result in many years of contact and collaboration. Reassessment of the children every three to five years and consultation between testing sessions facilitates academic and social/emotional success for the children. Establishing and maintaining these connections are part and parcel of a successful feedback experience. When the tester lets the family know that he or she is available for long-term work, this commitment enhances the level of confidence and trust in the testing. The tester who accepts the role of family consultant and case manager will develop a long term, in depth perspective on the child and better integrate test results over multiple settings.

Once the parent and child understand a diagnosis, the tester is in a position to come up with recommendations that address the concerns. The tester encourages the family to approach the recommendations as suggestions and empower the family to pick and choose among those recommendations that make sense for them as a family. Families often need to make decisions that directly impact the child such as choosing a new school and professionals to work with the child.

Follow-up is the key to successful recommendations. The job of the tester is simply not to provide a list and then say goodbye, but to remain a support and help the family negotiate the complex systems often required to get the child the help needed. The tester can spell this out explicitly, letting the parent know that the psychologist's job is to interact with the school and the professionals, impart information, and ensure that they are satisfied with the recommended resources. The parents are encouraged to be in phone/email contact with the tester as they are interviewing professionals and implementing strategies to help their child.

When to Refer to a Therapist

The tester needs to decide when it is appropriate to provide clinical services to the family and the child and when an outside referral is preferable. Establishing the limits of what can be done in the feedback sessions is important, as parents and child may attempt to use the feedback session as a therapy session to address conflicts or other issues. "Scope of practice" must be kept in mind — the tester needs to establish boundaries and clarify her role. It may help to describe the role as "quarterback" or "coordinator" and distinguish it from that of a child or family therapist. The tester can welcome the family's responses and can act as a consultant, but should be quick to refer to outside professionals for the more in- depth work in individual and family therapy as well as for parent counselling in weighing next steps .

Working with Therapists

As referrals for testing often come from therapists currently working with the child, the tester needs to be able to collaborate with the therapist effectively. This collaboration can be complicated by many factors. Does the tester has a different theoretical orientation than the therapist? Does the therapist has a different view of the child than the tester? Further, the potential for splitting within the family requires sophisticated clinical management. The tester needs to be mindful that the therapist has ultimate clinical responsibility and all suggestions for treatment should be directed to the therapist. I often suggest a joint session with the parents and the therapist, particularly if there are complicated treatment decisions to make. Use of statements such as "we are all on the same team" and making it clear how much the tester respects the therapist is instrumental in maintaining a productive working relationship with all parties.

Conclusions

Understanding the complexities of giving feedback and negotiating the intense emotional responses engendered by test results is very demanding and stressful for the tester. At the same time, it can be exciting and moving to facilitate increased understanding of a child's difficulties and creatively pursue resources and strategies to improve his or her life. More training is needed to help testers transform the testing situation from a potentially negative, stressful one to a therapeutic one. Trainees would benefit from direct instruction, role-play and seminars to improve their effectiveness as testers. We need to understand that merely imparting a diagnosis is not enough and attend to the complexities of giving feedback to facilitate effective use of neuropsychological assessments by parents and professionals.

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