Since its inception in 1993, CRG (Children’s Resource Group) has been committed to providing comprehensive evaluations of our patients to provide guidance in medical, educational, and therapeutic treatment. A thorough assessment of each patient’s needs is critical to our care. When it became apparent that the COVID-19 crisis would limit our ability to provide services in-person, we began exploring the possibilities of providing evaluations/assessments through telehealth. We were fortunate that we had already started administering most of our parent, teacher, and self-rating scales through on-line platforms that allow us to send links to those questionnaires to those involved. In addition, we had converted to using Q-interactive, a 1:1 iPad testing system, in January 2019. These changes over the past few years have enhanced our ability to convert in-person testing to testing via telehealth over the past two months. With a few exceptions (most notably the Autism Diagnostic Observation Scale-2 and the Rorschach Test), we are able to administer comprehensive evaluations via telehealth.
Old Dog…New Tricks!!
During 35 years of work as a school psychologist, both in public schools and in private practice, I learned early on that there will always be something more I have to learn. Early in my career, this was an unexpected shock to my system since I had finally earned my third college degree, a Specialist in Education, and thought I learned all I needed to know. My schooling took longer than normal, due to the fact that I was attending evening classes as a mother of two, which quickly became four, with the birth of my twin daughters. It was in my first week as a school psychologist when I realized that learning truly is a lifelong process and I have learned to embrace that insight.
Over the years, I have seen many changes in how we conduct assessments, many of which are due to the increased presence of computer technology. One of the bigger changes occurred about a year and a half ago when we at CRG moved to the practice of using some of our major testing instruments on a digital platform. There was a bit of a learning curve, of course, but soon we were interacting with our students on iPads like champs. At first, I was skeptical and was afraid that I would lose the connections that develop between me and my students over the course of a face-to-face assessment, but fortunately those fears did not materialize.
Those fears resurfaced recently as we explored the possibility of remote digital testing in the wake of the pandemic which made in-person evaluations impossible. Once again, my fears were unfounded.
Normally, the school psychologists meet the student and their parents only one time, on the day of testing. In our current practice of remote testing, we now have the good fortune to have a brief 30-minute online session with the student and their parents approximately a week before the assessment. I have found this to be a welcome addition to our process since it has served as an initial opportunity to build rapport, explain the testing procedures in detail, and deal with any technological issues. Taking time to address these issues seems to alleviate any fears or anxieties the student and parents may be harboring. When we meet on the actual day of testing, it seems much more relaxed and the sessions have proceeded smoothly.
I have now successfully conducted remote testing sessions with people of all ages, from 7 to 31. As an aside, the teenagers I have worked with have especially loved the flexibility in the start times, and the opportunity to take brief or extended breaks when necessary.
The mother of a child in one of the first remote sessions I conducted sent me a note afterwards thanking me and said, “I hope others are inspired to take this route as well.” A couple others have written to say, “Thanks for making my son feel special” and “Thank you for being amazing with my daughter!” These comments confirm that good working relationships can be established, even when we are not in the same room!
Of course, working with technology comes with unexpected glitches at times. I have to say, however, that students have been so patient, helpful, and understanding when these situations arise. Being digital natives, they are used to technology and have always had it in their lives. I, on the other hand, am a digital immigrant but feel the old adage certainly applies – an old dog CAN learn new tricks!
Legal and Ethical Considerations
When completing assessments using telehealth, there are a number of legal and ethical issues that must be considered and discussed with clients. As a result, those who administer assessments at CRG have been tasked the responsibility to continuously monitor updates within our field. This vigilance allows us to ensure that we are administering the measures in a valid and reliable manner similar to our in-person assessments. To do this, we have attended webinars regarding risk management, stayed up-to-date on the psychological associations’ statements regarding assessment via telehealth, and remained in frequent communication with those who publish the tests to follow guidelines on remote administration. In addition, we ensure that the family is able to provide a testing setting similar to our offices, one that is quiet and free of distractions. With these measures in place, we have been able to successfully complete remote evaluations to allow individuals to receive necessary and appropriate services now rather than wait until the field of psychology begins to resume in-person testing.
Before the psychological evaluation is conducted, a 30-minute pre-testing appointment is scheduled between the family and the school psychologist conducting the assessment. During this appointment, the remote testing process and technology requirements are fully explained to the family. At first, the thought of remote testing might appear daunting. However, with clear steps in place, families have adjusted quickly to this new way of testing. Most families have been able to set up the remote testing environment in their home with relative ease. Some families have been very creative! This upfront work helps to ensure that their child has a positive testing experience. As most schools used some type of an e-learning platform for the final months of this past school year, the technology needed for remote testing is not new technology to most. In fact, many of the kids are already quite tech savvy and proficient with such technology. A wonderful side benefit of this pre-testing appointment is that it allows the family and child to meet the examiner prior to the day of testing and to begin to establish rapport. It is nice then to re-connect with the family on the day of testing.
Telehealth Testing Advantages
During this time of physical distancing and isolation, using a remote testing platform has been a way to meet the needs of children, adolescents, and adults. While it is important for clinical practitioners to be aware of what influences the testing constructs and to assure an optimal assessment, remote testing can be a valuable tool to determine the client’s needs. Over the past few months, I have had the opportunity to test clients ranging from age 11 to 24 with different diagnoses including anxiety, depression, Attention Deficit Hyperactivity Disorder, Autism Spectrum Disorder, and other mental health issues. While the testing process has been adapted to sending some protocols in the mail and involves more technology, testing remotely has many advantages. Testing from the home environment provides a sense of security and comfort. Having a pre-meeting to discuss the testing process has assisted with knowing what to expect the day of testing, which relieves anxiety. For the clients with autism, testing through telehealth eliminates transitioning to a new office environment; working in familiar surroundings is less stressful. Additionally, if the client is having an “off” day, the testing can be scheduled later without inconveniencing the parent to travel to the office repeatedly. Remote testing also provides flexibility with time, especially for the adolescent or depressed client who struggles to get out of bed in morning; testing can be scheduled later in the morning or afternoon. Also, for those clients who struggle to sustain their attention, they can take a two-hour break or complete testing over several days in short sessions without having to travel back and forth to an office. Last, developing a rapport while assessing remotely seems more fluid and casual as the environment is less clinical and more natural. In general, while determining the appropriateness for testing through telehealth is done on an individual basis, it can clearly be less stressful and more flexible for many who are experiencing mental health issues.
CRG Telehealth ASD Assessment
One of the tests that we are not able to administer remotely is the Autism Diagnostic Observation Schedule-2 (ADOS-2). As individuals who are seen at CRG are often presenting with the diagnostic question of Autism Spectrum Disorder, it was important that we develop a systematic approach to addressing this concern. Thus, Drs. Merrill and Burkhardt worked together to develop the CRG Telehealth ASD Assessment. This assessment combines the interviews and observations needed to diagnose Autism Spectrum Disorder (ASD) via teleconferencing. The assessment utilizes a mixture of surveys, questions and activities, designed to cover the DSM-5 diagnostic criteria associated with an ASD diagnosis. This typically will include time spent working with the individual being assessed as well as a structured interview with parents and/or caregivers. Administered by experienced clinicians who specialize in ASD diagnosis and intervention, the CRG Telehealth ASD Assessment is a useful tool for providing services when face-to-face meetings are not recommended.
We recognize that evaluations through school systems and many other clinics and practices has been very limited during this time. We are pleased to be able to provide comprehensive evaluations through telehealth to answer a full range of diagnostic questions. In addition, we are able to provide evaluations in the following areas of disability under Indiana Article 7:
- Cognitive Disability
- Developmental Delay
- Traumatic Brain Injury
- Specific Learning Disability
- Other Health Impairment, including ADHD
- Autism Spectrum Disorder*
- Emotional Disability
* With respect to Autism Spectrum Disorder, the ADOS-2 is not currently available for administration via teleconferencing. CRG has developed an assessment protocol suitable to telehealth administration for appropriate clients.