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This week’s blog was contributed by Carrie Champ Morera, PsyD, lead project and content director, and Theo Miron, PsyS, regional manager–educational assessments.

Why should psychologists and other clinicians assess for emotional disturbance (ED) in the school setting? Parents and caregivers of 8.3 million school-aged children (ages 4 to 17 years) have sought help from school staff or mental health professionals about their child’s emotional or behavioral difficulties. Approximately 7.5% of children ages 6 to 17 years used prescribed medication during the past 6 months for emotional or behavioral difficulties. Assessment of ED is necessary in the school setting to help children obtain the emotional and behavioral support services they need to be successful.

Over the past 20 years, the number of students served within special education has steadily increased, while the number of students being served under ED eligibilities has steadily decreased. For example, during the 2000–2001 school year, 6.29 million students received special education services with 7.6% of those students identified as having an ED. Although the population of students receiving special education services grew by almost one million children to 7.13 million over the next 18 years, only 5% were identified as having an ED during the 2018–2019 school year.

How can we improve ED identification and help children obtain the services they need to be successful in school? It is the school’s responsibility and a school psychologist’s professional role to find children who are struggling emotionally and behaviorally, identify them through the evaluation process, and then connect them with appropriate services and interventions so they can begin to heal and make educational, social, emotional, and behavioral progress. 

When completing assessments for ED, we need to carefully consider and adhere to specific eligibility criteria while distinguishing the difference between social maladjustment (SM) and ED. Practitioners also need to consider DSM-V-related diagnoses as well as the impact of trauma, adverse childhood experiences (ACES), and the pandemic on the child’s functioning. It is also imperative to be cognizant of racial disproportionality in determining eligibility for ED services (see NASP Position Statement: Racial and Ethnic Disproportionality in Education).

Assessments of ED need to be comprehensive and include multiple tests and information from a variety of sources. Clinical interviews with the student, caregivers, and teachers, as well as observations of the student in the natural environment are paramount. Trauma, ACES, and the pandemic also need to be considered in the assessment of ED. Childhood adversity is a broad term that refers to a wide range of circumstances or events that pose a serious threat to a child’s physical or psychological wellbeing, including child abuse, neglect, divorce, bullying, poverty, and community violence. Adverse experiences can have profound consequences, particularly when they occur early in life, are chronic, and accumulate over time. Trauma is an outcome of exposure to adversity while adversities are the cause of trauma. Trauma affects everyone differently, depending on individual, family, and environmental risk, as well as protective factors.

Repeated or prolonged trauma in addition to the effects of the pandemic can have a litany of adverse outcomes on our children in the areas of cognition, brain development, behavior, emotions, mental health, physical health, and relationships. These factors need to be considered in a comprehensive evaluation for ED.

Since the start of the pandemic, we have seen a significant increase in kids struggling with both emotional and behavioral difficulties. This increase may lead to an uptick in the number of ED-related assessment referrals that come across our desks and the number of students who require special education services. This leads us into how we assess children for an ED and the benefits of using the Emotional Disturbance Decision Tree (EDDT).

Dr. Bryan Euler, the author of the EDDT, has worked as a school counselor, diagnostician, lead school psychologist, and a clinical psychologist. While working in the Albuquerque public schools, Dr. Euler teamed up with PAR to create the EDDT to provide a standardized approach to the assessment of ED. It was designed to directly address the framework of the federal ED eligibility criteria; for every component of the federal ED criteria, there’s a corresponding EDDT scale or cluster. The scales within the assessment are written to address these broad domains thoroughly, then help school psychologists apply the specific criteria to make informed decisions on both eligibility and programming.

The EDDT includes all the relevant aspects of the federal ED criteria. It contains scales and clusters that address each of the specific ED criteria. The structure of the EDDT walks the practitioner through each area of the federal ED criteria.

  • Section 1 reviews the important exclusionary items to address “an inability to learn that can’t be explained by other factors.”
  • Section 2 Part A examines the 4 important characteristics we look for in ED (building/maintaining relationships, inappropriate behaviors/emotions, depression factors, and physical symptoms and fears).
  • Section 2 Part B serves as a screener for characteristics of both ADHD and schizophrenia/psychosis.
  • Section 3 assesses the characteristics of social maladjustment.
  • Section 4 measures the level of severity, where we examine the magnitude of the symptoms and characteristics the student is exhibiting. 
  • Section 5 helps determine the level of educational impact that these issues may be causing in school.

Bryan Euler, PhD, describes the benefits of the EDDT and the importance of multiple informants, including the student’s perspective, here.

There are several best practices to keep in mind with the EDDT: Include the viewpoint of multiple raters (teacher, parent, and/or self) from different settings (school, home, and community). Use the EDDT as part of a comprehensive evaluation to determine ED eligibility. In addition to the EDDT, be sure to include qualitative information such as interviews (from the student, parents, and/or teachers) and observations across school settings to supplement the data received on the EDDT.

Carrie Champ Morera, PsyD and Theo Miron, PsyS will present on the EDDT at the National Association of School Psychologists (NASP) annual convention in February. In their presentation, Assessing Emotional Disturbance in Schools Using the Emotional Disturbance Decision Tree (EDDT), they will explore the features and trends in ED and investigate the structure and use of the EDDT. If you attend NASP, feel free to stop by the PAR booth to learn more about how PAR can meet your assessment needs.

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This week’s blog was contributed by Jeremy Sharp, PhD, licensed psychologist and clinical director at the Colorado Center for Assessment & Counseling and the host of the Testing Psychologist Podcast. Dr. Sharp earned his undergraduate degree in experimental psychology from the University of South Carolina and earned his master’s degree and doctorate in counseling psychology from Colorado State University. He specializes in psychological and neuropsychological evaluation of children and adolescents and provides private practice consulting for psychologists and other mental health professionals who want to start or grow psychological testing services in their practices. He lives in Fort Collins, Colorado with his wife (also a therapist) and two kids. 

Upon returning to school in fall 2021, my 8-year-old daughter started showing signs of separation anxiety almost immediately. She would not go into the classroom on her own and developed a compulsive habit of checking the weather before school each day to see if it was going to rain. Over the course of a couple of weeks, we spent hours on the playground before (and during) school, attempting to cajole her into feeling safe. We eventually enlisted the help of the fantastic school psychologist who helped our daughter get over her fears and go in on her own within another two to three weeks. 

Though her separation anxiety seemed to come out of nowhere, hindsight would say otherwise. The biggest clue was that she started a new, much bigger school this year. She was also having trouble making friends, which was different for her. The final piece of the puzzle was learning that a classmate had shared information about a flood warning with my daughter, and she became scared that there might be a flood while she was at school—hence the checking of the weather every morning.  

Related post: Jeremy Sharp on trauma-informed assessment 

My daughter is not alone. Depending on what you read, estimates on prevalence of anxiety disorders in kids ages 3–17 range from about 2% to more than 30%, with a recent meta-analysis settling on about 7%. That’s two kids in your average classroom who are experiencing clinical anxiety, with even more who have subthreshold anxiety.  

There are many reasons that kids might feel anxious at school, but let’s break it down into three areas for the sake of simplicity. Those areas are: 

  • Separation from caregivers 

  • Social interaction 

  • Academic demands 

Separation anxiety is the most common form of anxiety in kids under 12. The core theme of separation anxiety is “excessive distress” when separated from or thinking about separating from a primary attachment figure or caregiver. At school, this looks like unwillingness to get out of the car, clinging to a parent’s leg, not leaving the caregiver to go into the classroom, and other similar situations. As in my daughter’s case, it can also show up as a fear of an event that would cause separation from the primary attachment figure. Separation anxiety often ramps up after breaks, like when returning to school after the holidays or summer vacation. Even a typical Monday can increase anxiety, as kids have gotten used to being with caregivers over the weekend. 

Social interaction is another area of potential distress in kids. The clinical diagnosis of social anxiety disorder is estimated to occur in about 9% of adolescents (ages 13–18 years). Social anxiety is characterized by the fear of being judged by others paired with avoidance of certain situations that cause anxiety. An example is eating lunch alone due to a fear of saying something “dumb” while sitting with peers. 

Lastly, academic demands can lead to anxiety in kids. Research suggests that around 20% of students experience test anxiety overall, though it differs depending on several demographic factors. For instance, female-identifying students and ethnic minority students are more likely to experience test anxiety. Regarding personality factors, there is a consistent negative relationship between self-esteem/self-concept and test anxiety. Students with disabilities (i.e., ADHD) are more likely to experience test anxiety than students without an identified disability. Additionally, test anxiety’s negative impact on performance is highest in middle school and decreases in high school. It’s important to note that text anxiety is not the only form of performance anxiety in school, however. Some students feel a variation of social anxiety or fear of being called on in class as well. 

This information confirms what we already intuitively know: as “front line” workers in pediatric mental health, school staff plays a very important role in kids’ social and emotional wellbeing. Indeed, the research is clear that kids learn better when they also have skills to manage their emotions. But it’s not always easy to know which students need help! Anxiety is an internalizing disorder, meaning that kids tend to feel it in their minds or bodies without necessarily expressing it overtly to others. What we do know is that kids from lower income homes and ethnic minority kids are at greater risk of “flying under the radar” and not receiving the support that other kids get. We also know that school is a great place to implement interventions given that so many barriers to accessing treatment are removed when kids are already there. 

So, what school-based interventions actually work? A recent meta-analysis of prevention programs showed that cognitive-behavioral strategies make up the vast majority of interventions in the academic environment. The effect sizes across all forms of intervention were small but statistically significant, indicating that prevention programs are certainly helpful in addressing anxiety. The study looked deeper into whether the type of program (universal vs. targeted) made a difference and found that it did not. Similarly, it didn’t matter whether school staff (i.e., teachers, school counselors) or an external mental health professional delivered the intervention. The research suggests, however, that intervention be delivered as early as possible, in a preventative context, given the relatively early age of onset of anxiety.  

To summarize, a substantial minority of kids will experience some form of anxiety at school before finishing high school, but there are ways to help. School counselors and teachers are in a great place to do so. Being mindful of anxiety as an internalizing disorder and paying attention to kids who tend to fly under the radar are excellent places to start. Knowing the different types of anxiety and the places they show up are valuable as well. On a broader scale, prevention programs are helpful and effective, especially when delivered earlier rather than later.  

Catch up with the Testing Psychologist podcast on their website, via Apple Podcasts, Google Podcasts, or on Spotify. 

 

Related: School resources to help you address trauma, anxiety, and more. 

 

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This week’s blog was contributed by Jeremy Sharp, PhD, licensed psychologist and clinical director at the Colorado Center for Assessment & Counseling and the host of the Testing Psychologist Podcast. Dr. Sharp earned his undergraduate degree in experimental psychology from the University of South Carolina and earned his master’s degree and doctorate in counseling psychology from Colorado State University. He specializes in psychological and neuropsychological evaluation of children and adolescents and provides private practice consulting for psychologists and other mental health professionals who want to start or grow psychological testing services in their practices. He lives in Fort Collins, Colorado with his wife (also a therapist) and two kids. 

Have you seen that social media meme on “The last normal school year” that’s been going around? It has one column listing kindergarten through Grade 7 (students’ current year) and another column showing their last “normal” school year, which was, at this point, THREE GRADES AGO. Essentially, a kid who is now in seventh grade hasn’t had a typical school year since they were a fourth grader. The math makes sense, but it truly blew my mind. That means that current kindergarteners, first graders, and second graders have never experienced a typical school year. Eighth graders are just now getting a real sense of what middle school is like (for better or worse). Though the pandemic is far from over, psychologists and other mental health folks have several considerations to keep in mind as students encounter their third school year of the pandemic. 

First, the impact of the pandemic cannot be underestimated.  At baseline, children are generally more vulnerable to the stress of a pandemic because they have more difficulty understanding the scope and circumstances of a global event than adults. Studies around the world are consistently documenting the negative effects on kids. A variety of personal and environmental issues have been proposed as contributing factors. For example, authors cite increased parental stress, increased risk of abuse and domestic violence, and increased exposure to social media as potential reasons for elevated mental health symptoms. Physiologically, there is some evidence to suggest that kids and adolescents are experiencing higher levels of cortisol, eating poorer diets (or experiencing notable food insecurity), and missing out on the brain development that comes from participating in novel social and academic situations. And children have varying responses to the pandemic. Variables that contribute to a child’s response include prior exposure to traumatic events, socioeconomic status (SES), and disability status. Regarding specific mental health symptoms, research shows that anxiety, loneliness, and depression are the most common mental health concerns to arise from the last several months. Others have described increased clinginess, distraction, irritability, and fear for family members’ safety. I’ve experienced this firsthand, as my eight-year-old daughter developed significant and acute separation anxiety upon going back to school this fall. 

What about the impact on academic skills during the last 18 months? Data is still emerging, but some have attempted to estimate the decline in achievement. Researchers suggest that kids, on average, may have acquired about 65% of the reading skills and 37–50% of the math skills they would have gained in a typical school year. Studies that look at the influence of missing instructional days have shown that crystallized intelligence decreases by 1% of a standard deviation for every 10 days of missed learning. These numbers are simply estimates, however, as many highlighted the fact that kids didn’t only miss out on instruction, they also missed out on timely assessment and the resulting feedback or adaptation to their learning that comes from knowing their level of achievement in real time. But again, individual and environmental characteristics matter. Learners with a growth mindset adapted more quickly to online learning compared to those with a fixed mindset approach. Motivated learners and those from higher socioeconomic backgrounds experienced less decline or even made gains in some cases (i.e., reading skills in higher-SES kids).  

Given these concerns, how can we adjust our expectations for this school year? First, we must keep in mind that kids will be coming into this school year with widely varying degrees of achievement and learning from the past year. This exaggerated version of the typical “summer setback” will likely show wider gaps between the kids with access to food, internet, financial stability, and parental stability and those without. Kids with identified learning or mental health concerns are also likely to be further behind. Social–emotional needs may be higher across the board.  

As mental health folks, we need to recognize that our assessments and interventions for the next 6–12 months have a huge asterisk beside them. We should be less confident identifying learning and behavior disorders, knowing that kids are in an ongoing period of adjustment (at best) or trauma (at worst). We can test academic and social–emotional functioning more frequently to keep a handle on kids’ evolving needs. Children will likely need more instruction and more review. Providing stability and predictability will be important. Giving kids the benefit of the doubt and being deliberate as we consider more externalizing disorders (i.e., oppositional defiant disorder) is also crucial. Our report recommendations may shift from providing numerous, long-term recommendations to making sure we are only recommending what kids and families need right now. Relatedly, we can assure families that our findings may not be permanent, and that we can help them navigate the next several months by providing updated, brief evaluations throughout the school year. 

RELATED POST: Dr. Sharp discusses trauma-informed assessment 

Finally, a brief word on assessment using personal protective equipment (PPE). We don’t know much about whether or how the use of PPE affects assessment results. Limited research with adults (using the Neuropsychological Assessment Battery [NAB]) showed lower scores on the Language Index but no other differences. If you’re still testing with PPE, like many of us are, try to choose the option(s) that provide the most protection for you and the client with the least amount of deviation from standardization. 

Ultimately, kids going back to school is a positive step for the vast majority of us. As assessment clinicians, this is just another time for us to practice flexibility and think outside the box with our jobs. It won’t do for us to administer tests and interventions robotically—we need to be cognizant of kids’ individual needs as we do our best to support them. 

RELATED POST: Assess trauma symptoms exhibited at school 

 

Catch up with the Testing Psychologist podcast on their website, via Apple Podcasts, Google Podcasts, or on Spotify. 

 

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This week’s blog was contributed by Kathryn Stubleski, LMFT. Kathryn is a licensed marriage and family therapist and senior research assistant on the data collection team at PAR. 

On the heels of the COVID-19 pandemic, school professionals’ burnout is at an all-time high, shedding light on a problem that has existed for some time. Even without the extenuating circumstance of a global pandemic, nearly half of K-12 teachers (46%) reported high daily stress during the school year, tying nurses as having the highest stress levels among all occupational groups surveyed. Three out of four former teachers said that work was “often” or “always” stressful in the most recent year in which they taught in a public school. Teachers are not alone. There was a critical shortage of school psychologists prior to the pandemic. The U.S. Department of Education released data that the average school psychologist maintains a caseload of double the National Association of School Psychologists’ recommended amount, with many states reporting an even higher average. People in caregiving settings such as schools are at a higher risk for burnout than noncaregiving professions, and there is a necessity to focus on self-care to preserve personal and professional effectiveness.  

What do we mean by self-care? 

According to the National Institute of Mental Illness, there are six elements to self-care. These six elements influence our overall wellbeing, and it is helpful to be aware of which areas in your life might need more attention. Brainstorm ways to stay healthy in these categories: Physical, psychological, emotional, spiritual, social, and professional. 

PAR reached out to school professionals for feedback on summer self-care to manage stress. Here are some helpful things we learned: 

Healthy self-talk 

“I don't think people realize how much emotional baggage comes with the position. I have had many a sleepless night worrying about my students, anticipating a new lesson or evaluation, or reliving a difficult interaction with the parent.”–Karisa Casey, reading and English teacher, 13 years of experience 

“The emotions involved in teaching run deep and forever. There is always a child who you cannot get off your mind.” –Sandra Korn, resource teacher in the exceptional learners department, 12 years of experience 

“I have a difficult time handling stress and getting enough sleep. I worry about certain kiddos’ home situations, learning difficulties, and behavior issues.” –Kelle Rowan, 27 years of experience 

One way to manage emotional and psychological self-care is to increase the use of healthy self-talk. Our thoughts dictate our mood and behavior, and what we say to ourselves can fuel or tame negative emotions. In the examples above, teachers reflect on common worries that impact their sleep. To engage in healthier self-talk, recognize what you are telling yourself, acknowledge the emotions associated with it, and attempt to replace this thought with a more neutral or positive thought.  

For example: 

“I’m feeling conflicting emotions of anger and guilt related to work today. I provided progress reports to my student and their parents throughout the semester. Despite this, the student chose not to complete missing assignments and asked me for extra credit at the end of the semester. It would be unfair for me to provide an extra credit opportunity to just one student. My emotions are valid, but I did everything I could for this student while maintaining my personal ethics. Going forward, I will emphasize my personal policy with students and parents at the beginning of the year.”  

Some people find it helpful to journal this process.  

Support system 

One of the most effective ways to buffer against stress and burnout is by having a solid support system including mentors, colleagues, and professional contacts. Nonwork support may take the form of family relationships, friendships, spiritual communities, pets, and mental health services.  

When feeling run-down professionally, it can also be helpful to build up aspects of identity that are not related to work.  Engaging in interests and hobbies, learning new skills, volunteering, and maintaining relationships within your community often can reduce symptoms of early burnout.  

Increased emphasis on physical health 

Summer break allows for increased ability to prioritize physical health. Now is the time to focus on basic needs: physical rest, maintaining a sleep schedule, getting exercise, and improved nutrition. There is a greater ability to control what and when you eat during time off from work. No more 20-minute lunch breaks! 

“Physically, I think rest is really important. I try to keep the same sleep schedule for the most part and I'm still consistent with my workouts, but a lot of the times at the end of the school year, I'll get sick because my body is just run down.” –Karisa Casey 

“I look forward to going to the bathroom when I want!” –Kelle Rowan 

“During the school year, I struggle to take a lunch break. I always work through my lunch break— answering phone calls, returning emails, paperwork, etc. At the beginning of the year, I try to remind myself how good it feels to take 30 minutes of uninterrupted lunch. It is a hard balance between taking a lunch or working later after school. I have two children who I am eager to rush home and see.” –Sandra Korn 

Incorporating a transition between professional life and personal life 

The school professionals we spoke to acknowledge a ritual of closing out the school year and beginning their break:  

“At the end of every school year I have cleaned my office, secured the test materials and files, and on my last day, or prior to, that is closure. Nothing goes into the summer that is work-related. Every school year begins with a clean slate. Having things in order and tied off is very helpful to me. Any lasting stress responses I might feel is given over to meditation. It works for me.” –Glenda Smith, school psychologist, 27 years of experience 

“The most difficult aspect of self-care is creating that separation when the workday is over. It is sometimes difficult not to check-in electronically with the job. There has been an unwritten rule that we had to be even more accessible outside of our contract hours during the pandemic. It made it very difficult to rest. I separate myself from the technology associated with my job during my summer routine. I actually deleted my work email from my phone as well as many of the apps that I would normally use to communicate with students or colleagues.” – Karisa Casey 

“I do my best not to think about any aspects of school for about 2 weeks after school is out.” –Kelle Rowan 

Reflect and look forward 

It may be helpful to reflect on the past year. Think about what went well and what could be improved. It may be beneficial to set one personal and one professional goal for the upcoming year.  

“There usually comes a point in the summer where I start to get excited about forming new relationships with students as well as continuing established relationships with past students. Teachers do look forward to a new school year. Professionally, I try to reflect on the past school year and evaluate what worked, what didn’t, and what I would like to improve on.” –Karisa Casey 

“I look at things that I would like to change from the previous school year. Maybe lessons that didn’t go well, behavior incentives that I would like to change, and the arrangement of the room. I also look at myself as a professional and find at least one way I can better myself.” –Kelle Rowan 

Finally, we asked what advice you would give a novice: 

“They need to remember that they will not get everything done! There is always going to be “stuff” to do. That is okay! Let it go! Also, if at all possible, leave schoolwork at school and don’t go in on the weekends.” –Kelle Rowan 

“At the beginning of each school year, make a goal to incorporate something into each day or week that makes you feel good about yourself, whether it’s as small as taking your lunch break, meeting a friend for dinner, listening to a podcast on the commute, or working out a few times a week.” –Sandra Korn 

“Ultimately, it's the life that you live outside of the profession that sustains you.” –Karisa Casey 

 

 

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Proper assessment—conducted with psychometrically strong, easy-to-use instruments designed to help you make critical decisions faster—enables you to develop effective treatment plans for your patients. It can also help mitigate the mental health impact of the pandemic, which has exacerbated symptoms in many areas, including anxiety, depression, and PTSD.

PAR has developed a new resource that can help you filter through your assessment options and quickly choose the right products for your needs—tools that will help you make better, quicker decisions about what’s best for your patients’ mental health and wellbeing.

Related article: Check out PAR’s Spanish assessment solutions page

Quickly compare the benefits of recommended products in the areas of depression, anxiety, trauma, suicide, parenting, resilience, and executive function. You’ll see that many of our products are available for digital and/or remote use—so you can easily and safely test your clients when you’re not together in person. Plus, we’ve included listings for supplemental books that can help round out your knowledge in a particular construct area.

Visit our NEW mental health resources page to discover more.

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This week’s blog was contributed by Jeremy Sharp, PhD, licensed psychologist and clinical director at the Colorado Center for Assessment & Counseling and the host of the Testing Psychologist Podcast. Dr. Sharp earned his undergraduate degree in experimental psychology from the University of South Carolina and earned his master’s degree and doctorate in counseling psychology from Colorado State University. He specializes in psychological and neuropsychological evaluation of children and adolescents and provides private practice consulting for psychologists and other mental health professionals who want to start or grow psychological testing services in their practices. He lives in Fort Collins, Colorado with his wife (also a therapist) and two kids. 

The past 18 months have been a rollercoaster for all of us. It seems like a lifetime ago when we got the news that my then-seven and eight-year-old children would NOT be going back to school after spring break in March 2020. I remember thinking, “Okay, we can get through this for a couple of months...things will be back to normal in the fall.” But no! Things were definitely NOT back to normal in the fall for us or for most families in the U.S.  

There are many implications for kids being out of school or partially attending school for the better part of a year. I’d like to focus on the implications for practitioners who may be seeing increased referrals for issues like ADHD and learning issues. 

Although some data suggest that mental health utilization (both psychotherapy and assessment) went down during the pandemic, this frankly does not match the anecdotal evidence from around the country. It seems like every practitioner I talk to is completely full—with longer waitlists than ever. Our practice has seen a huge increase in referrals for assessment of ADHD and learning disorders, and I think there is a direct link to the pandemic. Here are a few reasons why: 

  1. Instability in the environment. Kids do well with stable, consistent environments. Speaking for myself, other parents, and practitioners around the country, there was very little stability or consistency over the past year. Here are just a few examples of environmental changes: kids transitioning from in-school to in-home learning, parents transitioning to working from home, parents transitioning to being an in-home teacher, and cancellation of after-school programs and activities. Many families experienced variation or reduction in income. Marginalized groups and lower-income families may have experienced food insecurity. The list goes on and on. Increased instability = increased anxiety, acting out, distraction, or withdrawal. 

  1. Parents getting a firsthand look at kids’ behavior and academic skills. During the pandemic, many parents transitioned into the role of in-home teacher or a facilitator of education. For those parents who previously relied primarily on teacher comments or conferences to gauge their kid’s academic performance, this was an eye-opening experience. Parents suddenly got to see just how distractible, unfocused, fidgety, and (sometimes) disruptive our kids could be throughout the school day. If any parents of kids with ADHD were in denial about their children’s symptoms, those symptoms quickly became clear. Were they likely worsened by the instability mentioned above? Definitely. But many parents acknowledged and sought support once their kids were home all day trying to learn. 

  1. Parents being more burned out than usual. Not only were kids under more stress, but parents were also struggling during the pandemic. As mentioned previously, the world was turned upside down for us, too! It was challenging to juggle work (if you were still employed), finances, kids being home, spouses suddenly being home together more than usual, and any number of other things. When parents get stressed, it’s easy to focus on the negative or undesirable aspects of your child’s behavior. These might include not sitting still, interrupting the teacher, not doing their work, blurting things out, and so forth. Even if these behaviors are occurring with typical frequency, a stressed-out parent may notice them more often and perceive them to be more severe. 

  1. Increased variability in learning. Again, structure is important. In addition to the big-picture environmental instability discussed earlier, the academic realm itself was quite variable for many kids. Teachers absolutely did their best to develop and implement remote learning options. And yet, many children ended up with multiple platforms or websites to navigate. Many did not have stable internet access, which disrupted video and audio delivery. The remote school day typically looked different than the in-person school day, with many kids completing their work more independently than before. For kids with attention concerns, this was a recipe for disaster. 

Related post: Jeremy Sharp on Trauma-Informed Assessment 

All of these factors created quite a dilemma. Yes, many clinicians have seen increased referrals for ADHD evaluations, but how does one evaluate ADHD with so many environmental influences? These are just a few strategies that we’ve employed: 

  1. Conduct a more thorough intake. Our intakes now include explicit questions to gauge the impact of the pandemic. We ask about changes to the family routine, including parent work schedules, parent involvement in learning, kids’ reactions to the pandemic in general, loss of sports or after-school activities, and the timeline of in-person vs. remote learning. 

  1. Pay more attention to history. With a neurodevelopmental disorder like ADHD, history is always important. It should not just emerge out of nowhere. But with many parents now seeing longstanding or acute symptoms of ADHD firsthand, this factor is more important. In the past, we may have gotten by with documenting symptoms within the last year and going on our way with a diagnosis. Now, we must look further back. Were these symptoms present prior to the pandemic? Are they only happening during academic times? Do they vary based on in-person vs. remote learning?  

  1. Be less confident. Principle 5 of the American Psychological Association’s guidance on psychological teleassessment during the COVID-19 crisis explicitly states that we should widen our confidence intervals when making conclusions and clinical decisions. This is incredibly important. Most evaluations over the past 18 months have a big, metaphorical asterisk beside the results that says, “We are not as confident in these results as we typically are. Here’s our best guess.” We’ve gotten over the fear of saying, “This is unclear right now,” and have no shame about asking families to come back in 6–12 months for a brief, updated assessment. 

In summary, there are many things for us to consider as we see increased referrals for ADHD testing. We must take environmental factors into account, acknowledge that parents and kids are more stressed out than usual, know that certain groups have less access to resources than others, and generally be more diligent and less confident in diagnostic results. It’s a thrilling time, as my colleague Dr. A. Jordan Wright says, to “be brave” with our work as we navigate challenging circumstances to do our best in helping these families. 

 

Catch up with the Testing Psychologist podcast online, via Apple Podcasts, Google Podcasts, or on Spotify. 

 

 

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Are you using a PAR product in your research? If you are a clinician, researcher, or other professional who would be interested in partnering with us to advance the scope of solutions we can provide, we would love to talk to you about it!

We are looking to gather additional data on our existing assessments with the goal of further validating our instruments, identifying and developing product enhancements, or adding features that allow our customers to better meet the needs of those they serve.

Learn more about the PAR Data Program and find out how you can take part!

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This week is Children’s Mental Health Awareness Week, a time to address the mental health needs of children and teach them to care for their own mental health as well as the mental health of those around them. 

It is never the wrong time to communicate the importance of prioritizing mental health and offering acceptance, support, and respect for those who are facing mental health challenges. 

Get involved 

  • Download materials from the National Federation of Families, which offers age-appropriate activities and worksheets for students from Pre-K through high school. 

  • Read a book about mental health topics to a child. The Federation of Families of South Carolina has put together a reading list focusing on a number of different mental health topics at various reading levels.  

  • Join “Flip the Script Live,” a free fireside chat with children’s mental health experts from around the country. 

  • Participate in a virtual event sponsored by the Youth Mental Health Project. With events ranging from glitter jar making to a live concert, there’s something for everyone. 

PAR offers many assessments geared specifically toward children’s mental health concerns. Learn more about some of our most popular products for school psychology

 

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Already the most reliable platform in the industry, PARiConnect continues to grow by adding features that complement your online practice. One of our newest additions to PARiConnect is the introduction of the interactive bell curve, where you can:

  • Personalize the interactive bell curve.
  • Input multiple scores.
  • Quickly assess and visually capture how a client scores in relation to others.
  • Easily explain assessment results to clients/parents.

The interactive bell curve can be accessed within the PARiConnect Quick Links section.

Don’t have a PARiConnect account? Register for free and get 3 free assessments and reports.

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This week’s blog was contributed by Jeremy Sharp, PhD, licensed psychologist and clinical director at the Colorado Center for Assessment & Counseling and the host of the Testing Psychologist Podcast. Dr. Sharp earned his undergraduate degree in experimental psychology from the University of South Carolina and earned his master’s degree and doctorate in counseling psychology from Colorado State University. He specializes in psychological and neuropsychological evaluation of children and adolescents and provides private practice consulting for psychologists and other mental health professionals who want to start or grow psychological testing services in their practices. He lives in Fort Collins, Colorado with his wife (also a therapist) and two kids.

First, what IS trauma? The DSM-5 definition is easy to find, but the very first requirement for a PTSD diagnosis (“Exposure to actual or threatened death, serious injury, or sexual violence…”) does not capture the broad range of experiences that may lead to a trauma response. Right away, we find the categorical nature of the DSM-5 may not adequately conceptualize or capture the huge continuum of traumatic experiences. I think we can all agree that not all “traumatic” experiences involve exposure to death, serious injury, or sexual violence. What about neglect? What about emotional or psychological abuse? It is necessary to further define trauma and the many ways it can occur. One way to break it down a little further is to distinguish between acute (“Big T”) trauma and developmental or complex (“little T”) trauma. 

Acute trauma refers to a discrete event that occurs at a single point in time. With acute trauma, one can generally identify a clear change in functioning from before the event to after the event. An acute trauma may be something like a sexual assault, a car accident, or being held up at gunpoint. Complex trauma is more complicated and refers to ongoing, recurrent traumatic experiences. When these recurrent traumatic experiences happen during childhood, the collective experience is called developmental trauma.


Related post: Assess the impact of the pandemic on kids—the PASS-12 is now available!

 

Why is this distinction relevant for us as clinicians? Because it affects how we assess and treat individuals. We know that individuals with acute trauma typically may have a quicker path to recovery, while individuals with complex trauma tend to show more chronic symptoms. Acute trauma is also easier to assess in the sense that we are only gathering information about one event, with a relatively clear before and after, while complex trauma tends to be multilayered.

Regarding the assessment process specifically, detailed questions about trauma should be included in nearly all diagnostic interviews. As mentioned earlier, many parents and individuals can overlook or downplay potentially traumatic experiences. Kids also may not share their traumatic experiences with their parents or others unless asked directly. There are a couple of ways to get at these concerns without coming across as too heavy-handed. One is to say something like, “Tell me about some of the most important events in your life” or “What are the top three hardest/worst things that you can remember?” or “Have you held any secrets for a long time that you’d like to share?” Note that forensic interviewing is a clear subspecialty in our field. Do NOT practice outside the scope of your expertise! Another way to explore these questions is to use a broadband questionnaire as a guide for topics/events to inquire about. If your client shares anything that warrants further exploration, you can integrate a narrower questionnaire to drill down on specific trauma symptoms.

Moving further down the path of the assessment process, it is important to think through the relationship between trauma and other mental health diagnoses. A question that comes up often is, how to separate trauma from ADHD/autism/anxiety, etc. As Dr. Maggie Sibley and Dr. Julia Strait noted on past Testing Psychologist podcast episodes, maybe we don’t. Maybe we need to stop thinking about how to separate these diagnoses, because it is nearly impossible to do so, particularly in the case of developmental trauma. Even going by the DSM-5 definition of PTSD or acute stress disorder, there are many PTSD symptoms that occur in other diagnoses. These symptoms include repetitive play (autism), intrusive memories/thoughts (OCD), distress when exposed to certain cues (specific phobia), poor memory (ADHD), and alterations in cognition (depression, anxiety, ADHD), just to name a few. Unless we have a clear picture of functioning before the trauma started, it is extremely challenging to know if these symptoms “belong” to the trauma or something else. In these (and all) cases, gathering an accurate history is crucial to establishing context to interpret an individual’s symptoms and assessment results. 

In cases when an accurate history is not available from the primary caregiver, clinicians may need to expand the scope of the evaluation and incorporate a broader record review or interviews with additional people in the client’s life. Even then, we sometimes must simply do our best with what we’ve got to come up with meaningful conceptualization and recommendations.

Ultimately, we want our assessment to guide treatment and provide helpful recommendations for our clients. By conducting a thorough clinical interview; utilizing well-standardized assessment instruments; and providing realistic, evidence-based recommendations, testing psychologists play a vital role in helping individuals identify and heal from their adverse experiences.

Catch up with the Testing Psychologist podcast on their website, via Apple Podcasts, Google Podcasts, or on Spotify.