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Hey everyone. Hey, this is a little bit of a different episode today. Today, I’m going to play for you an excerpt from a presentation that I gave for the Group for Rural Internship Training or GRIT. Many of you, or maybe not many of you know that our practice is part of an internship consortium, an APEC internship consortium. And I [00:01:00] got connected with GRIT through our consortium and kind of that APEC world. And this was a presentation that I did for them a few weeks ago on pediatric assessment.
The portion that I’m going to play for you is specifically around the diagnostic interview. So I’ll just talk about my approach to the interview, what I’m asking, how I structure it, and those sorts of things. Usually, I like to leave the clinical information to the experts, but today I thought I would share a little bit of this presentation with you. Hope you enjoy it.
Before I get to the presentation, I, of course, would like to invite any advanced practice owners or soon-to-be advanced practice owners, or hopeful advanced practice owners to the Advanced Practice Mastermind which starts June 10th. It has a cohort model so you would join the group with five other psychologists and go through the group experience [00:02:00] together. And we like to work on all those issues that come up as you grow your practice: making that transition from a clinician to more of a leader or a CEO, streamlining your time and your approach, hiring, all those things. If that sounds interesting to you, you can get more information at thetestingpsychologists.com/advanced and schedule a pre-group call to see if it’s a good fit.
Okay, let’s jump to my thoughts on a diagnostic interview.
Amy: Let’s get 30 and over. Back to you, Dr. Sharp.
Dr. Sharp: Okay. Awesome. Thanks, y’all. I didn’t realize we’d have people that were so spread out across the country. This is kind of cool. [00:03:00] So, yeah, as we get started, I always like to tell people, I prefer to do as much of an interactive presentation as possible. So feel free to jump in whenever you want to with questions, thoughts, reactions. It sounds like we can drop those in the chat in both myself and Amy will try to monitor the chat for questions as they pop up. So don’t hesitate to do that. I’m not going to do a presentation and then a Q&A separately from one another. I’d much rather you just jump in whenever you want to with thoughts and questions and reactions as we go along.
Now, as we get started, I always like to hear what would be interesting for you all as we go through the presentation. So I have material that I will present and can present, of course, but I want to make it interesting. So could [00:04:00] you just put some information, you can put it right in the chat. That’s totally fine. Just give me one thing that you would want to take away from this presentation that would make it worthwhile where you would walk away thinking, “I’m glad I spent my time on that today.” So, give me just one thing related to pediatric assessment that I can make sure to talk about that would be interesting for you all.
Amy: Jeremy, I just have a general question. And maybe you can address this at the beginning or at the end. But one of the parts of our field that I felt like we have not had a lot of creativity or innovation in is around our testing and assessment capabilities tied to our degree. And while we talk about it as kind of a highlight of how our training is different, I haven’t seen a lot of group practices or specialty [00:05:00] practices that really focus there. And I just have… I think I’ve gotten the most questions in terms of referrals I’ve received over the last decade have been around kind of where and how do I start and how would I find a diagnostic evaluator or is that even separate from therapy?
And I just think it’s an important gap and a potential gap in our field that you’re filling. I’m curious about how you thought about building a practice? Just from a general perspective, I think we need more for people to know about them, especially for kids, but in the general assessment and diagnostic evaluation arena in general.
Dr. Sharp: Sure. Oh my gosh. I mean, we can totally pivot the presentation. That’s a whole can of worms to open, I think, but I totally agree. The reason I started the podcast really was because I feel like testing is such a [00:06:00] valuable service, but a lot of people get scared away from building a practice around it. For me, the quick answer, I guess, is just the intersection of what I was interested in and what there seems to be a demand for in our community. And luckily those things overlapped quite a bit way back then. And as the practice has grown, it just seems like there’s more and more demand, right? I keep thinking, if I just hire one more person, we’ll be able to shorten our way, it’s a snowball rolling downhill at this point. So I totally agree.
Amy: Nice. Thank you.
Dr. Sharp: Hey, thanks, Andrew. Yeah, great question. Culturally informed elements into assessment. I love that. I will touch on that for sure as we talk through the assessment process. What else?
Speaker 1: I have a question.
Dr. Sharp: Yes.
Speaker 1: I think because of moving to a rural area for the first time, kind of just realizing like [00:07:00] 1) lack of resources and maybe the inability to purchase the tests that we would really want if we could cater. And so I don’t know if that’s like a specific question to answer, but maybe just your thoughts on the efficacy of that and kind of the… the only word that’s coming to my mind is conundrum, for what that means for us when we are wanting to provide resources but maybe don’t have all of the testing material and are kind of make making due with what we have. So broad topic.
Dr. Sharp. Yeah. I can see that fitting into talking about battery selection, which is kind of like the middle part of what I was thinking of talking about. So yeah, if I don’t address that specifically for some reason, make sure to jump back in and give me a little prompt. But that’s important, especially in rural areas.
Yeah, [00:08:00] other things would be helpful to take away?
Speaker 2: I guess one thing that comes to mind for me is that for pediatric populations, we rely so heavily on reporting from parents, teachers, caregivers. And I’m curious about the assessment process when perhaps those aren’t the most reliable be it, you know, for any number of reasons why it might not be the most reliable and how we can get more information perhaps from the child themselves as it relates to the assessment.
Dr. Sharp. Yes. Great question. So I will definitely talk about that. I call it like the four-legged stool of data integration. And I think that probably plays into that really nicely. Sweet. Anything else you want to throw out there before I get going?
Okay. So, like I said, as we talk through things, just drop your questions [00:09:00] in there and l will try to address them as they come up. So, I’m generally going to talk about the whole pediatric assessment process. So to me, that breaks down into the clinical interview, the battery selection/ testing process, the feedback appointment, and report writing.
Now, I will probably spend a lot of time on report writing because I am on a little bit of a crusade right now to keep us from writing long reports that nobody reads. So, I’ll likely spend a lot more time on report writing than some of the other sections, but we’ll see how the pacing turns out. But that’s to give you a little bit of a framework of what we’re going to talk about here today.
So let’s see. Just to get going, let’s talk about the interview. [00:10:00] So this is where we start, obviously. So when I think about the interview, I think, what is the purpose of a diagnostic interview, right? And it might seem fairly straightforward. So you want to get some information and use that to make hypotheses about your testing process, right?
But I like to define it as much as possible and just say that this is our opportunity to really determine what questions the client or parent or caregiver has about their family member or themselves and what questions we need to answer through the assessment process to be most helpful, okay? So, putting everything else aside., I think that’s our job in the diagnostic interview is to figure out how can we make this assessment be helpful? How do we gauge our audience? [00:11:00] How do we determine what they want to know?
So using that framework, I can talk through my strategy and how I structure our diagnostic interviews and we’ll see where it takes us.
Now, granted this is my approach, I think it’s based on others’ thoughts and strategies, but maybe there are some nuances that you haven’t run across before. We will see. But I think it’s pretty effective. I’ve been using it in our practice for I think over 10 years now. And it seems to do a decent job.
So for me, the first thing right off the bat, and I recognize that this might be a luxury for a lot of you, is that I always try to do two-hour interviews. So we always scheduled two hours for that initial appointment. Yeah. Magenta you’re like, “What?” So [00:12:00] here’s why I do that. I know that in other settings, Gary, I know has been in children’s hospital settings. I’m guessing in schools, in other settings that might not be doable, but this is my rationale for doing a two-hour interview.
What I found when I started out is that I cannot get the information I need within an hour. And here’s why. Because by the time the client arrives and you get them, if they’re on time, you’re back in the office maybe three, four, five minutes after the hour, right? So you’ve already burned five minutes. For me personally, I like to do a lot of rapport building in the beginning because we’re about to dive into a pretty vulnerable process for parents or kids, teenagers. So I spend at least five minutes just kind of talking with them about what’s going on and how they’re doing and whatever seems relevant. It’s truly just like shooting the [00:13:00] breeze and trying to make some connection with them. So then you burn 10 minutes, right?
Then we’re talking through some of the logistics. So it’s questions with paperwork, confidentiality, informed consent, all that kind of stuff. So now we burn another five minutes, basically. So 15 minutes are already gone. So now we go to the back end and I know I’m going to spend at least 10 minutes talking with them about scheduling the next appointment, paperwork, questionnaires, what HAP, releases, all that kind of stuff. So 25 minutes out of that hour is gone already.
Okay, so, some of you may be able to do that more efficiently. That is amazing. I could not do it more efficiently and maintain the relationship and the rapport that I was going for. So that really only left me with like 25 to 30 minutes to do the intake. And that was nuts to me. [00:14:00] I could not get any amount of important information in that time without seeming like a complete jerk and cutting them off too early when they were talking. So I do two-hour interviews. That’s the rationale for them.
I gave you a little bit of the layout for the interview. So, beginning and the end. I gave you the structure of what we’re doing at the beginning and the end, but within the hour and a half that we have left, here’s what I end up spending a lot of the time on. I think that my approach to the interview and others’ approach is to take kind of a bio-psycho-social view of what’s going on with folks. How you get that information can vary. And this is just the order that I go in. But I like to start with family [00:15:00] information. So after we go over paperwork, everything like that, logistics, I’ll just jump right in. And I’ll say something along the lines of, “Tell me your story or tell me what’s going on in your family right now.” Something like that.
So, it’s very deliberate to not say something along the lines of like, I don’t know, what brought you in or how can I help or something like that. Like I said, I like the phrase, “Tell me your story or tell me about your family.” It’s really open-ended and my hope is that that’s going to build a little bit of a closer relationship with some of these families and parents and put them a little bit more at ease, right? We’re not just immediately jumping into what’s wrong basically. So we talk about family first and kind of get the [00:16:00] family vibe.
All right. So I’m a big believer in context and environment in the assessment process. And this is totally wrapped up in a context environment and asking about the family information and family story. So I always just ask about where the kid was born, if they’ve moved, what the siblings look like, what their relationship is like with their siblings, relationship with parents. I always ask them to describe their home environment as well. People kind of balk at this sometimes. They don’t really know how to answer the question. So I’ll say, is it loud? Is it quiet? Is it structured? Is it chaotic? Is it predictable? Is it spontaneous? So kind of feed them a little bit of language just to describe their home. Is it clean? Is it messy? All those kinds of things just to try to get some sense of what’s going on in their home.
And so [00:17:00] that is one point just right off the bat. I’m kind of getting to Andrew’s question about the cultural elements. I’m trying to lay the groundwork even there for them to describe any of those cultural components or identity components that might be important for their family, right? So this is where I might ask about extended family and others involved in the child’s care or church or spirituality, any number of other factors that might be important for a family.
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All right, let’s get back to the podcast.
So I spend a little bit of time getting the family story and seeing what’s happening there. That can be super complex or super simple. It just depends. But I like to start there. From there, I personally will switch and go into more of the medical history. And I’m just very explicit. And I just say like, “Hey, we’re going to switch gears just for a minute because I need [00:19:00] to talk about medical history real quick.”
For me, I do that right at the beginning after the family story because the way that I approached assessment and just kind of my mindset is maybe more of that neuro-psych approach where I feel like the medical history plays a really big role in what might be going on for kids. And if there’s anything significant in the medical history, I want to know that right from the get-go because that sort of colors how I see everything from that point forward. Behaviors, relationships, and so forth.
So within the medical history, I go way back always, pregnancy, delivery, all those pieces, ask about significant medical events. There’s a big list in our demographic form that we might talk about with that.
This is where I ask about sleep. I get really detailed with sleep. I ask them about trouble falling asleep, trouble staying asleep, sleep history- were they ever a bad [00:20:00] sleeper? Tons of questions about sleep because we know that it can affect so many aspects of kids’ behavior and functioning. I ask, “Does it seem like they feel rested each day?” And it’s interesting sometimes parents will describe like no sleep problems, but then they’ll say, “Actually, he seems tired most of the time.” Then we got to kind of dig into that.
So I’m asking about sleep. I’m asking about diet. This is where I might get information about kids being really picky eaters or not. I always ask about sugar. This is another one of my little soapboxes, I guess, that I’m interested in. And sugar being like basically a poison to everybody. So I ask about sugar and what that looks like for kids.
Let’s see, I am asking about screen time in medical history, which sounds weird maybe but honestly, I just couldn’t really [00:21:00] figure out a better place to put it in the interview. And it seems to fit well with sleep and diet and the other components of medical history. So I’m always asking about screen time and what that looks like. Not just quantity, but I ask about quality as well. So for me, it’s very different if the kid is spending five hours a day on YouTube versus five hours a day on, I don’t know, Photoshop, for example. Creating versus consuming is very different for me. So I try to ask specific questions around what they’re doing with the screen and how they’re spending the time there and the parents know how they’re spending their time.
If they’re playing video games, I always ask what, which video games. One that will give me something to connect with the kid on. I like video games and I’m happy to test them out so that I have something to talk with kids about. So always I’m asking what video games they play. Well, it’s also informative for me in terms of what kind of content they’re [00:22:00] allowed to access on their tablets.
I’m also asking about exercise in medical history, both current and history and of course medication. And like I said, medical events, illnesses, things like that.
So after the medical history, I kind of move into developmental history. So I’m asking about developmental milestones and what those look like.
And then after that, that is when I finally get to the presenting concern. And at that point, this is where I will say something like, “Tell me what you’re most interested in. Tell me what you’re most concerned about. Tell me what you want to learn about your child.” Some variation on one of those three questions. And that usually gets the [00:23:00] ball rolling.
So, I always try to get the information from the parent in their own words, of course and get some idea just as a general overview of the things that they’re concerned about. And depending on how they approach this, I try to corral parents a little bit and say if there are multiple areas that we’re concerned about, try to give me those areas right off the bat, and then we’ll dive deep into each one as we go along. So I’m trying to get a running list of what the parents are concerned about so we can tackle each of those in sequence.
Just very practically, I have a document that I use to kind of guide my interviews that has all these areas broken down. I type my interview notes. That makes it a lot easier. It’s very easy to do during COVID with everybody on screens, but even in person, I’ve adopted the typing [00:24:00] approach which has helped a lot.
So, as we dive into the presenting problem, that’s where things really get fluid for me. I have a number of areas that I want to make sure to ask about.
And my approach there, again, this might differ depending on your setting, but for me, I don’t want parents to walk away from their evaluation in our practice feeling that something was missed, right? So our kind of a calling card I think of our practices is that we do pretty comprehensive evaluations. So I’m going to screen for pretty much everything even if the parents don’t mention those areas as areas of concern.
Of course, I start with the things that they’re most concerned about. And for me, this ends up being a little bit kind of like a choose your own adventure or a decision tree kind of thing [00:25:00] where it’s like, if parent mentions attention, trigger ADHD path and then it goes down all the ADHD questions. Or if a parent mentioned social problems, trigger autism path and then I go down the autism path and have all sorts of questions there. And that’s kinda how I break it down according to these different areas. So there’s executive functioning, social and mood are my big umbrella headings within the intake interview with a lot of different paths underneath them.
So always, like I said, trying to dig deep into each of these concerns for parents and get a sense of what they’re seeing. When I do that though, I try to structure it as much as possible. Anything that they’re concerned about or [00:26:00] any significant symptom they’re bringing up or behavior, I’m always running through a set of questions to get those factors kind of fleshed out as much as possible.
So some of those things that I’m asking about are, of course, what it is. But then I’m always asking about the onset. So has it always been present or is it more recent? If it’s more recent, was there a precipitating event of some sort? I can’t count the number of times I’ve gone back and just not asked about a precipitating event. So, I always try to ask about that. Was it sudden? Was it agile? Those kinds of things with the onset.
I’m always asking about frequency. So if we’re talking about, say tantrums or outbursts, is this happening every day? Is it happening twice a day? Is it happening once a week? [00:27:00] Is it once a month? I always try to get parents to quantify these behaviors as much as they can. I also ask about intensity.
And Magenta, I just saw your question about trauma experience. The short answer is, yes. I’ll talk about that here in just a second.
So, with the intensity, I always just have them rated on a scale of 1 to 10. Like what does this look like and how intense is it? I’ll ask how long the behaviors last if we’re talking about like again tantrums or something that can be measured in a duration like that. Let’s see. I ask about just history. So, does it come and go, or rather cycling probably is a good way to put that. So does it come and go or is it consistent? Does he have good months or bad months? Is it better at home? Better at school? So just looking for [00:28:00] patterns and let’s see, I can’t think of the right word right now. Patterns is probably the best way to put it for these behaviors. And then of course I touched on the setting. Is it happening at home? Is it happening at school? Is it worse than one of those places? Does it happen at extracurriculars?
So really trying to, and you can tell, we’re kind of digging into this for each of the areas of concern and each of the significant symptoms. So that I think gives you some idea why we’re doing two-hour interviews. This is what I was saying. It’s hard to get all that information from multiple presenting concerns which happens a lot. There are a lot of kids with suspicion of ADHD and autism or a learning disorder and depression. So we’re gathering a lot of information in these interviews.
And yeah, so I do screen for trauma. [00:29:00] So trauma is on our demographic form. I just ask, has your child experienced anything that you would call traumatic over the course of their life? So I’m always looking at that question. It’s interesting to see how people categorize trauma and what qualifies or not. So I always try to ask again in the interview just to make sure we’re not missing anything. And that’s where I might give them some examples as well of what counts as “Trauma.” The way that I’ll phrase that too is, I may not say trauma. I might say, “Have there been any significant events that you think have shaped your child’s life?” And that kind of opens it up a little bit more. And people who might not otherwise respond to have they experienced trauma, they may say, oh, well, yeah, there was that incident, you know, that car accident then it seemed like we had trouble after that or something along those lines. [00:30:00] That also captures positive events as well which I think are equally important.
So again, I’m just trying to dive into each of these symptom areas as much as I can. Let’s see. And then, as we move through all those areas, I will also ask about education. I screen education and subject-specific strengths or challenges. And then at the end, before I totally wrap up the assessment or the interview rather, I’ll always ask about strengths. So, we try to be a “strengths-based practice” with our assessments. That’ll come up again when I talk about writing reports and feedback. But in the interview, [00:31:00] I like to kind of wrap up and just say like, what do you love about your kid? Like, what are they really awesome at? What are they interested in? Where do they shine basically? There’s a spot for that information on our demographic form as well. So I like to kind of end on a positive note.
Related to that, something I didn’t mention, when I’m digging into symptoms, I will often ask, are there any exceptions to this behavior or to this problem that you’re having?
Like, what are the exceptions to the rule? Where are they really amazing or where does this not happen? That can give some good information sometimes. And I will also ask parents in a very gentle way, ” What role might you be playing in these things that you’re describing?” And I just tend to personality-wise… I’m just kind of direct about it.
And I’ll say like, this could be a really hard question, so [00:32:00] you can get mad at me if you want, but I need to know, can you just tell me, ” If you had to guess, are you playing any roles in your child’s behavior? What are you doing or not doing that might make this more of a problem in your home?”
It gets some really interesting answers. So this is where I’ve had things from all the way from like, I drank six beers every night and I’m totally absent in my kid’s life verses, we’re worried we didn’t read to them enough when my wife was pregnant or something like that. Like it kind of runs the gamut. It’s really interesting to see how parents interpret this. But I think that in a lot of ways, parents or caregivers come into these assessments with the kind of secret fear that it’s going to be all their fault. And in a weird way, this gives an outlet for that beer that they can just like, put it on the table and [00:33:00] it’s like, well, now it’s out there. And at least somebody knows and it gives them a way to kind of keep themselves accountable. I could be making that up. Maybe I’m projecting as a parent myself, but I think that it’s helpful.
Let me see. Robin asked about how do you ask about head injury? Yeah, that’s a great question. I’ve seen it go both directions of where parents will report every bump on the head as a “head injury” and then some who totally downplay what appear to be pretty significant concussions or even more severe injuries. So we ask about it on the demographic form. It’s part of the medical questionnaire, medical symptom history that we get. And then I always just ask again in the interview just to make sure that we’re on the same page with that.
Speaker 3: That helpful. Yeah. Sometimes you’ll say, Any [00:34:00] head injuries? Nope. And then again, and it’ll be like, Oh, well there a time they fell out of a car or you know, Okay.
Dr. Sharp: Yeah, for sure. I think that’s a key with a lot of this is just phrasing things in different ways. If it’s not a head injury, maybe it’s a concussion or maybe they passed out or got knocked out that one time or whatever it might be. People use different language for different things. These are great questions.
Andrew, that is a fantastic question. So Andrew asks, is the child present for the interview or not? And I know people do this differently. I just interview parents first. The rationale with that is that I want parents to be able to speak pretty freely about their concerns and I don’t have to worry about the kid listening in or having to wait in the waiting area, especially if they’re younger. With adolescents or older [00:35:00] kids, I will split the initial interview time. So it doesn’t feel like they’re left. Particularly with adolescents, we’ll spend most of the time with parents, and then I’ll do maybe like a half-hour with the kid just to make contact and build some rapport. But with younger kids, I always interview the kid during the testing day when they come back and are doing their testing here in our practice. It’s a great question.
All right. Other questions or thoughts or anything before moving on?
So the last thing that I ask or discuss with the parents in the interview is, I just always ask explicitly, what do you want to take away from this evaluation? What do you want to learn from this? What do you want to gain from what we’re doing here? And this [00:36:00] is I think, borrowed from that therapeutic assessment approach literature and it’s a very, very therapeutic assessment question. Like, what do you want the outcome to be here? What are you trying to learn about your family or your child? And I really encourage them to give me as many as they want.
This is also where I think it’s part of our job to read between the lines a little bit and try to get at those unspoken questions that parents might be asking. My friend and colleague, Stephanie Nelson, who’s a neuropsychologist in Seattle says, she calls them secret questions. But it’s like those questions parents or caregivers come with but they won’t ask explicitly. And so, a lot of parents, I’d say the most common answer I get to this is we just want to know how to help her or we just want to know how best to support our kid. And the hidden question or the [00:37:00] secret question of that might be, we need to know that we’re doing our best as parents. Like we’re not dropping the ball or something along those lines. Like we need to know that there’s nothing wrong with our kid, or we need to know if there’s something wrong with our kid. There are any number of secret questions that parents might be wanting to know. And so I always try to keep that in the back of my mind and kind of bookmark it for the feedback session.
Okay, y’all, thank you so much for listening, tuning in to that first part. So this is a two-hour presentation and the audio there as I transitioned to the next section was a little abrupt.
I’m sure you notice that, but yeah, this was the first part of a 3-part presentation on pediatric assessment. And again, just my approach to doing a pediatric interview. I hope that you enjoyed it. Hope that you took away a tip or two or something that you might be able to [00:38:00] implement into your own practice.
If you disagree with anything that I may have thrown out there, I would love to hear. I’d love to hear a different approach. You can always email me, firstname.lastname@example.org.
So, thanks for listening. Let’s see. Next time, we’ll be back with you on Thursday with another business episode. So if you haven’t subscribed to the podcast, I would love for you to do that. That’s really easy in Apple Podcasts and Spotify and really anywhere else. And if you find it in your heart to rate the podcast, that would be great as well. We are well over a hundred ratings now in Apple podcasts, which is amazing. So thank you all. And yeah, the podcast continues to grow. I am always on the hunt for fantastic guests. So you can trust that I will keep bringing great content.
All right, everybody, take care [00:39:00] and I will talk to you next time.
The information contained in this podcast and on The Testing Psychologists website are intended for informational and educational purposes only. Nothing in this podcast or on the website is intended to be a substitute for professional, psychological, psychiatric, or medical advice, diagnosis, or treatment. Please note that no doctor-patient relationship is formed here. And similarly, no supervisory or consultative relationship is formed between the host or guests of this podcast and listeners of this podcast. If you need the qualified advice of any mental health practitioner or medical [00:40:00] provider, please seek one in your area. Similarly, if you need supervision on clinical matters, please find a supervisor with expertise that fits your needs.