What is in a Neuropsychological Report?
The typical neuropsychological evaluation involves three steps: intake, assessment, and feedback. Depending on the individual’s situation, these steps may take place in one session, or they may be broken up into separate sessions. The final “product” of the evaluation is the written report. You should expect to receive a written report from the clinician within two weeks of the assessment portion.
The written report is a comprehensive document that contains the results of the assessments and, most importantly, guidance for intervention, treatment, and support going forward. The clinician’s job is to write a report that is both informative and easy to read. While psychologists and other clinicians tailor their reports to their own standards, a comprehensive report should include the following components.
Reason for Referral
This is a brief statement of why the individual was recommended for testing and by whom. Often times the reason for referral is simply to update a previous evaluation (they are typically valid for three years). Sometimes it is on the advice of a school counselor or teacher.
Relevant Background
Relevant background includes any information leading up to the reason for referral. Relevant background information may date all the way back to birth, or it may be relatively recent. I like to include teacher and parent input (which is obtained during the in-take interview) and sometimes clinical input if there was a previous evaluation. The relevant background information lays the ground work for the narrative throughout the rest of the report.
Brief Developmental/Medical Background
Developmental and medical background can play an important part in an individual’s diagnosis. Many disorders such as ADHD, dyslexia, and anxiety have a hereditary component. Often times if mom has dyslexia, so does the child. Understanding how a student developed and knowing any past medical issues can lend important insight into any current problems.
Behavioral Observations
It is important to know how an individual is functioning on the actual day of the assessments. Is she sleepy, energetic, disengaged, or hungry? These characteristics can impact the results of the evaluation, so it is important to keep track of how the individual is behaving and functioning throughout the day. This is a big reason why I try to limit the amount of time a client is in my office; after three hours or so an individual simply cannot perform his or her best, and results of the evaluation may become questionable.
Cognitive Assessment
Perhaps the most important part of the report is the individual’s cognitive exam. Most clinicians administer either the Wechsler or Woodcock-Johnson assessments to determine the base-level intelligence quotient. Determining a valid cognitive score lets the clinician know what the individual is cognitively capable of in various domains. The findings from the entire evaluation pretty much begin with the cognitive score.
Academic Evaluation
Most individuals that I work with are referred because they are struggling in school. So logically it makes sense to assess their overall academic skills. Again, the Wechsler and Woodcock-Johnson assessments are the most widely used scales to determine a student’s academic skill level. Both tests evaluate pretty much the same domains, but I typically include math, reading, and writing. There are many other specialized assessments of academic skills, and I may or may not use those, depending on the reason for referral.
Attention/Focus
ADHD can be hard to diagnose since there is no definitive test for it. Rather, there are a set of criteria an individual must meet to qualify for a diagnosis. In order to determine if an individual meets this criteria, the clinician will get input from parents, teachers, doctors, and others who have insight into the individual’s attention and response control. Additionally, most clinicians will administer a computerized test to help confirm or rule out a diagnosis of ADHD such as the IVA-2. The most thorough evaluations will include the computerized component.
Social and Emotional Functioning
There are many ways to assess social and emotional characteristics of an individual. But the most frequently used are surveys that parents, teachers, caretakers, and the individual him or herself complete. There are many different survey available, and clinicians usually have their favorites. They can range from short (35 questions or so) to really long (over 300 questions). You will most likely be asked to fill those out at home and bring them back the day of the testing. Sometimes you may need to sit in the waiting room and fill them out.
Behavioral Functioning
Similar to the social and emotional evaluation, behavioral evaluation is mainly determined with the use of surveys. These are usually bundled with the social and emotional surveys so that they can all be filled out together in one sitting. Many times the social and emotional part of the report will be combined with the behavioral part, since there is so much cross over between the two.
Summary
As I mentioned, the purpose of a neuropsychological and/or psycheducational report is to build a narrative to offer insight into the individual’s strengths and weaknesses. When conducting the evaluation and writing the report, the clinician is trying to piece the puzzle together and gain a comprehensive understanding of what the individual is struggling with and why. Similar to an essay we all wrote back in high school, there should be an introduction, main body, and conclusion. The summary section gives the overview and offers succinct view on the overall problem and findings from the evaluation.
Diagnosis
Once the narrative is established, then the clinician can assign a diagnosis if one is warranted. A diagnosis should make sense given everything taken together in context. The best reports leave no doubt as to why a diagnosis is assigned. In the instance when no diagnosis is warranted, the report should also inform the reader why. The diagnosis is typically made with guidance from the Diagnostic and Statistical Manual of Mental Disorders (DSM-V).
Recommendations
Perhaps the most important part of the report is the recommendation section, which lists appropriate support, intervention, and resources for the individual. The list can be short or long, but it should give a bulleted list of services that are appropriate based on findings from the evaluation. Many of the recommendations listed are also used when putting together an IEP for a child’s 504 or Special Education plan. Also, when considering accommodations for the ACT and SAT, those organizations will want to see the list of recommendations.
Writing reports is a skill and good reports provide invaluable information when creating a treatment plan. If you are considering an evaluation, make sure you ask the clinician if all these components are included in the report. Some clinicians may even provide a sample report with redacted information so that you can see for yourself.