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Test Administration and Feedback:
A Dynamic Approach

Neuropsychological testing can be a significantly therapeutic intervention for everybody involved; the patient, the family as well as the professionals who work with the patient including educators, therapists and tutors. The intervention begins with the intake: getting the patient and his or her family to articulate their concerns and begin to unravel the pieces of the puzzle that have brought them to the testing. Perhaps the family and the patient have different concerns. It is extremely important to involve the patient in the testing process. As I test primarily children and adolescents‚ I have formulated intake‚ administration and feedback principles of this group.

Helping the patient‚ (even a small child) understand the reasons for the testing and how the testing will benefit them is an integral part of helping the person then understand and integrate the test results. That begins with the parents introduction to the child of why they are being tested. I often advise parents to explain to the child that I am a school doctor who will help figure out how to help them in school. Children are usually aware of their difficulties and it is reassuring to them that the adults are considering their needs and trying to help them. They will often verbalize that they are “not good” at a subject or “get into trouble”. I always focus on the positive as well‚ so I explain to the children and parents that the testing will reveal their strengths as well as their challenges and give practical suggestions for success.

I always focus on the positive as well‚ so I explain to the children and parents that the testing will reveal their strengths as well as their challenges and give practical suggestions for success.

I tend to use the test administrations as another way to help the child understand their learning style, demystify their difficulties and pave the way to further insight. To that end, the testing is conducted with humor and I allow plenty of time for rapport building. We give frequent breaks and try to give the child as much control over the process as possible. Thus‚ I might ask a child when they want to do something, i.e. reading or writing. I often sympathize with the difficult task and compliment them on their effort. Use of stickers‚ snacks‚ games‚ drawing etc. is essential to help the child gain trust and enjoy the testing sessions. In addition, I might ask the child about their struggles and brainstorm together regarding solutions. For example‚ “It’s hard for you to sit still for a long time‚ so how about we go for ten minutes and then we do some jumping jacks”. I use a timer which I show to the child so they know how long each work period is and have some control during the process.

Giving feedback is an art as well as a science and I would like to introduce some principles here that I have found helpful. First‚ I always demystify my role as the expert. In fact, I explain to the parents and child that they are the experts and I am only correct if they agree with me. I explain that I have a certain type of information but I need their help to figure out if I am right and if it works for them. Second‚ I pepper my feedback with references to information they have given me. For example, I may say,“your child has difficulty processing auditory information; that’s probably why you know you can only give him one thing at a time to do at home” Third, I focus on the positive with the child and gently introduce one or two areas of challenge. I understand that receiving feedback is a highly stressful event and I acknowledge the anxiety surrounding the situation.

I initially give feedback to the parents here I outline the child’s learning style their neurocogintive strengths and challenges and their social ⁄ emotional functioning. I always administer the projectives; personality piece of the testing as children and adults have emotional responses to their cognitive issues that always bear examination. After the parents understand the issues and are in accord with my recommendations‚ I have a separate feedback session with the child where I review the information but stress the positive. For example, “You're really smart but your eyes don’t move as quickly as your brain so you read slowly”. I then discuss the recommendations that may be helpful such as tutoring, therapy and medication. I then have a family session where the child tells the parents what I have told them and the family discusses the issues and recommendations together.

Following the family session‚ I often have a second meeting with the parents to process the results and review the recommendations. We have this meeting after they receive the written report and need clarification or explanation. It can be very different to hear information as compared with seeing scores in black and white. Upon that meeting, I disseminate the report to the professionals involved and may have a school meeting. The family sessions are often extremely revealing and therapeutic in nature. The parents get to see what the child is struggling with and hear from them in their own words show they understand their issues. This can lead to improved parent child relationships as the parents begin to understand the neurocognitive etiology of troublesome behaviors and its impact on the child. Often, the children are scapegoated in their families due to their issues and understanding them is the first step to becoming more productive with the child.

The parents get to see what the child is struggling with and hear from them in their own words show they understand their issues. This can lead to improved parent child relationships as the parents begin to understand the neurocognitive etiology of troublesome behaviors and its impact on the child.

Helping the parent understand what is really going on for the child can help diminish this issue. Often, there are terrible struggles particularly around homework and routines at home. Sometimes, the parent reduces their demands and expectations upon understanding her child’s challenges. In addition, practical suggestions that fine tune the environment in accord with the child’s learning style can make an enormous impact on their functioning.

For example, for a child with Auditory Processing Disorder, creating a checklist of the home routines can be invaluable. As they have a hard time processing multi–step directions, having a written or pictorial sequence of the routine increases compliance and decreases frustration for all involved. Similar strategies can be used with children with attentional and learning difficulties. Understanding the neurocognitive challenges presented by the environment can lead to tweaking the environment improving performance and diminishing the stress associated with these challenges. With these principles in mind I will now discuss diverse diagnostic categories and implications for treatment.

Children with Attention Deficit Disorder demonstrate a host of neurocognitive challenges with associated emotional implications. Typically, they demonstrate executive functioning difficulties that manifest itself in difficulty sitting still, focusing, concentrating on work as well as complying with routines and rules. Their impulse control and frustration tolerance are typically variable and they generally respond well to structure and support. Test administration is a challenge due to the lengthy nature of some tasks and demand for focus. It is also a perfect opportunity to begin discussing with the children the nature of their difficulties and begin brainstorming different strategies to improve performance. Emotionally, these children suffer from compromised self esteem due to their difficulties as well as heightened anxiety and possible depression as a result to poor performance. Thus, the testing and feedback can be therapeutic in enlightening the child regarding the etiology of their difficulties and providing hope for alleviating them.

Children with Auditory Processing Disorder typically mishear information as they tend to hear fifty percent of what is said to them. They have a great deal of difficulty following complex directions. They typically have the most difficulty when their environment is noisy and may react by avoiding noisy situations such as parties or restaurants. They often have acute auditory sensitivity and complain about ordinary background noise. They require intervention at home and school to help them conform to routines and meet adult expectations. Children with Nonverbal Learning Disability demonstrate compromised visual sequencing and processing skills. As a result, their academic and social functioning are affected as they don't pick up on visual cues or interpersonal nuances. They may present as “rude” or “bratty” given their obliviousness to typical body language. Their rooms are often messy and they lack organizational skills which make it very difficult for them to complete homework assignments or execute any takes requiring sequencing and attention to details. Helping them conform to routines, manage their time appropriately and improve social functioning are major areas of intervention.

I often use the TAT stories as examples of illustrating the emotional life of children to their parents. The first card, a picture of a boy with a violin, typically elicits feelings regarding school performance. Often, the violin is broken, the boy is sad or bored and he is convinced he will never be able to play the violin. I read the child’s stories to the parent and explain how the child feels about school. The stories also indicate themes of performance anxiety and sometimes awareness that getting help can result in a positive outcome. I stress these themes to the parent to help them understand what it is like for the child to labor under the expectations of his or her environment.

The use of a term “invisible wheelchair” is a useful one to help the parent understand the handicapping nature of the child's neurocognitive challenges. Identification of the problem, acknowledgment of its true handicapping nature and its impact on the child is the first step to a solution. With the child, I explain their problem in terms of their brain’s functioning. For example, I might say that their brain has a secretary that often relays messages incorrectly to the boss. The children get this image and begin to smile in relief that they are understood. We then discuss how we can help the secretary relay messages more correctly. I address both the neurocognitive and emotional challenges with the child as well as the parent. I might recommend breathing techniques, yoga, psychopharmacological intervention as well as other therapeutic or academic intervention.

The other piece of the testing is interfacing with the professionals involved and providing an evocative summary of the child’s profile to them. I make sure I am in phone contact with all the professionals involved with the child at the outset of the testing to obtain information from them. Then, at the conclusion of the testing, I provide feedback to all the professionals and make sure that everybody has the information they need to be as helpful as possible to the child. School consultation is an essential part of testing to ensure application of the recommendations and accommodations in school. I often conduct a school observation at the outset of the testing to observe the child in his or environment and then will meet with the teachers and other specialist to provide feedback regarding the test results. These meetings inform the school about the child and help me craft useful suggestions for improving his or her school performance.

I make sure I am in phone contact with all the professionals involved with the child at the outset of the testing to obtain information from them. Then, at the conclusion of the testing, I provide feedback to all the professionals

Successful school based consultation is an extremely effective tool as once the teachers understand the nature of the child's issues they can respond much more effectively and can continue to help the child advocate for themselves in the learning environment. For example, a student with an Auditory Processing Disorder complained that she was asked to complete a quiz in the hallway a nosy environment. The learning specialist responded by offering her a partition to put around her desk to serve as a barrier thus keeping her in the room and reducing stimuli. Tweaking the environment, offering options to the child to help them compensate for their challenges and offering support as needed can make a huge difference to the student both academically and emotionally.

Similarly, parents of a boy with auditory processing issues complained that the claimed the house was too noisy when he was doing his homework. They asserted that the house was “silent”. when they understand the nature of his auditory difficulties, they moved into presenting him with different options in the home that then reduced the daily struggles around homework completion.

Understanding the child’s emotional responses and being able to deal with them sympathetically is another cornerstone for success. For example, explaining the nature of childhood depression as it manifest itself in irritability, tantrums and apathy to school work can help parents in their expectations for the child's reactions. Anxiety typically is demonstrated by avoidance, procrastination and withdraw and can be easily misunderstood as defiance and lack of motivation. Helping both parent and child understood the psychiatric etiology of these behavioral difficulties paves the way to intervention and success. For example, a parent can address the anxiety behind the child's' protestations and send a message of competence as the same time; "I know the math is frustrating to you, let's take it one step at a time, remember what we did yesterday." The tester can give examples from the testing when the child took a risk and succeeded to build self esteem and mastery of challenges.

Lastly, recommending appropriate outside services is extremely helpful to the child and the parent. Perhaps the child needs to work with a homework helper or organizational tutor. Maybe they need to consult with an audiologist to provide intervention and recommendation for the environment given their auditory processing difficulties. Obviously therapeutic and psychopharmacological intervention are hugely effective tools of intervention. Once, a correct diagnosis is made then intervention can be offered in an informed manner that benefits the patient and family.

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