Psychological Testing of Children

Symposium on Ambulatory Pediatrics

Psychological Testing of Children Review and Commentary

Bayard W. Allmond, Jr., M.D.*

The preceding article has essentially described some parameters of psychological tests frequently employed in the diagnostic evaluation of children. And the editor has asked me to follow with my comments, as a physician, regarding clinical psychological testing. My quarrel, if I have one with regard to psychological evaluation, is hardly with the tests themselves. Granted, some, particularly parts of both the Wechsler scale and the Stanford-Binet test, are beginning to creak with age and the bias of their original standardization populations (basically white middle class); and others, i.e., the Illinois Test of Psycholinguistic Ability, need to age into maturity somewhat more with continuing standardization studies. Still others, such as the Bender Visual Motor Gestalt Test, remain classic illustrations of well conceptualized yet simple invaluable measuring devices, weathering the vicissitudes of time and social change without so much as a rotation or angulation error. For the most part I view all the tests mentioned in the preceding article as useful, sometimes elegant but always imperfect, standardized measures for the assessment of children's abilities and behavior at a given point in time. I do, however, have decided concerns regarding the utilization of these tests by the medical profession when it comes to children. I am not speaking here of the actual administration of the test itself by a physician, although that, too, would concern me were it to occur; that just seems generally inappropriate and unethical, since most physicians have had little or no training in the administration and interpretation of psychological tests. My larger worry has to do specifically with what I see as a frequent misuse by medicine of the referral itself for psychological testing. I would therefore like to begin precisely where Dr. Weiner's article ends-with his final sentence: "Gradually a model seems to be developing within which psychological testing of children is undertaken more selectively, where results are presented with less emphasis on scores and *Assistant Professor of Pediatrics, University of California at San Francisco; Acting Director, Child Study Unit, University of California at San Francisco

Pediatric Clinics of North America- Vol. 21, No. 1, February 1974

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more on individual strengths and weaknesses." In that concluding sentence, "more selectively" is the phrase I'm after, since a physician's more selective use of psychological consultation would indeed be an encouraging development. It would first of all help to stem the impending data deluge. Waist deep in Wechsler's and badgered by Bender's is no way to run a pediatric practice. However, increasing thoughtfulness in the use of psychological services would offer not only the opportunity of cleaning up the office, but other much more important advantages as well: (1) genuine assistance for the child and/or family in question; (2) increased effectiveness and availability of the pediatric psychologist; (3) enhanced appreciation of the basically sound concepts underlying many of the measuring devices (psychological tests) currently available, and a better understanding of their limitations as well; and (4) increased satisfaction by the physician with his own skills and capabilities. It is this issue, the more effective use of a referral for psychological consultation, that I would like to be the substance of my writing. We physicians request diagnostic psychologic consultation for our pediatric patients for a variety of purposes, some reasonable, some questionable, and some horrendous. Together with my pediatric psychologist colleagues, I recently compiled a representative sampling of specific referral requests by physicians and found myself alternately encouraged, depressed, or appalled by what unfolded. Imagine yourself, if you will, a pediatric psychologist on the receiving end of these requests; they are listed in the left-hand column of Table 1. Since the reader is now wearing psychologist's shoes and since "testing" is central to the content of both Dr. Weiner's paper and this one, I request your continued indulgence. Again referring to Table 1, please match the numbered requests on the left with the appropriate lettered response offered on the right. A successful physician to psychologist transformation would be reflected by the following combinations: 7. A

I.E 2. I (A) 3. B 4. L 5. J

10. H 11. A (I)

13. 14. 15. 16. 17.

6. I

12. A

18. D

8. K

9. A

G F

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I (A) E

I say successful, but must qualify: though the transformation itself would be successful, such a transformed psychologist would undoubtedly be seeking new employment both for his skills and for his chutzpah. I recognize, and assume the reader will also, that the preceding exercise is absurdly overdrawn (some of the stated misunderstandings are in reality often resolved by mutual clarification and personal communication between physician and psychologist). Nonetheless, my point stands: we physicians often do a grave disservice to our patients, our psychologist colleagues, and to the practice of medicine with cavalier and occasionally infuriating requests for psychological assistance for our patients. Many of the specific requests mentioned above suggest a

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PSYCHOLOGIST'S RESPONSE

PHYSICIAN'S REFERRAL REQUEST

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1. I need a baseline as part of a complete work-up. 2. School and parents do not agree about the abilities of this child. Can you profile her strengths and weaknesses? 3. Is this child brain-damaged? 4. Is his problem organic or emotional? 5. Can you give me a diagnosis of his personality? 6. Is the child mentally retarded? 7. Why is the child not talking? 8. She has chronic headaches. All hospital studies are negative, and I have done everything else I can think of. 9. She has chronic headaches. I am wondering about a psychosomatic cause. All hospital studies are negative. I need your assessment of her cognitive abilities and your observations of her behavior, coping, and personality style. 10. What is this child's intellectual prognosis? 11. Does he have a specific learning disability of some sort? 12. Her behavior is so unusual. Is she severely disturbed, perhaps autistic? 13. Is mixed brain dominance a problem? 14. I do not have the time to tackle the problem-obviously complicated-in 15 minutes. Will you see him? 15. Is her mother/father the cause of her problem? 16. This child is very clumsy. Is that a reflection of more generalized psychomotor retardation? 17. I want you to do a Rorschach. 18. How should this child be taught with her learning difficulties?

A. I can do part of the evaluation; but you may require other disciplines as well for a comprehensive study. B. Try a neurologist. C. Refer her/him for a psychiatric evaluation. Better yet, send the whole family to a competent family therapist.

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F. Most good medicine-immunization aside-requires more than 15 minutes. I would prefer that you face that fact, G. Only for you, thanks to the confusions of the medical literature. H. Try Madame Arcati, not a psychologist. I.

A decent question and one which psychologists generally feel comfortable answering. I'll be happy to see.

J. Since when was personality a disease? K. This is not the Christian Science Reading Room.

L. Heads or tails?

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disquieting underlying reason: physicians often do not seem to know quite what they are asking for when they request diagnostic consultation from a pediatric psychologist. The "how to" of a successful referral thus becomes a rather important concept to be considered. More effective referral for psychological study is not only desirable; it is essential to the practice of good medicine. And fortunately it is also quite possible. If, faced with the possibility of psychological consultation, a physician would briefly consider a yes or no answer to each of five specific questions, he would find much of his ambiguity and confusion lifted, and the appropriateness/inappropriateness of his referral might become largely self-evident. The questions: 1. Is my referral for specific information (and what, specifically, do I want)? 2. Is psychological testing likely to provide that information? 3. Will obtaining that information help the child, his family, me? 4. Does the value of this study outweigh disadvantages to the patient, if the consultation is made? 5. Do I still want the consultation, taking all the previous into account?

The clarification which utilization of these questions can provide may most directly be illustrated by applying them to the specific requests mentioned in the bogus matching test above. See Table 2. Some general comments regarding Table 2 seem warranted. First, the reader will note that the questions tend to favor specificity and to discourage generality. Secondly, a single no to any of questions 1, 2, 3, or 4 seems to invalidate the referral as stated and should suggest a rethinking of the need or at least a restatement of the request, more appropriately worded. At the same time clear yes responses (or a combination of yes and perhaps) indicate that the referral is appropriate and one likely to be undertaken. Question 4 (Does the value of the study outweigh the disadvantages to the patient if the consultation is made?) does not receive a single yes answer among the 18 referral requests but has been responded to with either a question mark or a no. This was by design, since every request for diagnostic psychological consultation invites certain risks or disadvantages, and these must be considered each time. For instance: 1. The study may levy a significant financial burden on the family. 2. The child may have unspoken misconceptions, worries, fears, and hopes about the testing which, if unresolved, may have a decided impact on his subsequent behavior and function. 3. Likewise the family may have similar or differing unspoken worries and misconceptions which, if undetected, may have similar consequences for family members. 4. A study, even expertly done, still represents in part an assault on the child by outsiders. For he essentially has no part in deciding whether or not the consultation will take place- yet it will be done with him and to him. 5. The study may not provide the answers needed. Whether or not these risks take precedence over the study must be determined separately each time with each referral, for each child, by each physician. There can be no categorical affirmatives to this question. Conversely, some categorical negative responses are listed by the author,

Table 2

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QUESTION QUESTION

REFERRAL REQUEST

I

Is my referral for specific information (and what, specifically, do I want)?

QUESTION QUESTION

2

Is psychological testing likely to provide that information?

3

Will obtaining the consultation help the child, his family, me?

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4

Does the value of the study outweigh the disadvantages to the patient if the consultation is made?

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5

Do I still want the consultation, taking all the previous into account?

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no

no

no

no

4

yes

no

no

no

no

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5

yes

no

no

no

no

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6

yes

yes

yes

?

yes yes

7

yes

perhaps

perhaps

?

8

no

?

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no

9

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yes

perhaps

?

yes

10

yes

no

no

no

no

11

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yes

yes

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yes

12

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perhaps

perhaps

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yes

13

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yes

no

no

no no

14

no

?

no

no

15

yes

no

no

no

no

16

yes

yes

yes

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17

yes

yes

yes

?

no

18

yes

no

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no

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192

BAYARD

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ALLMOND, ]R.

and I am assuming that they will become self-evident in the context and situation applied. With regard to the specific referral requests and the five clarifying questions: 1. I need a baseline as part of a complete work-up. This request, though decidedly popular with physicians, is not very specific (a baseline what?); nor does it promise much in the way of specific help for either the child, his family, or the doctor (hence, no to questions 1 and 3). It is more often than not a reflection of the "test everything in sight" attitude, and as such is not an appropriate request. It receives a no answer to question 5. 2. School and parents do not agree about the abilities of this child. Can you profile her strengths and weaknesses? This represents a frequent and reasonable dilemma for physicians. A psychological evaluation may be invaluable in providing additional critical information for its resolution. Yes to question 5, if question 4 seems in line. 3. Is this child brain-damaged? The question of brain damage, though very specific, cannot generally be answered by the services of a pediatric psychologist (no to question 2). Nor, does the author feel, is it generally helpful to have that question answered, particularly in reference to a ·youngster with learning difficulties, the context in which it is most often raised. Answering the question affirmatively in such a situation stigmatizes the child, frightens the parents, stymies the school, and is probably inaccurate. Another no for question 5. 4. Is his problem organic or emotional? Again this request passes with regard to specificity but merits a no with question 2: psychologic information simply cannot in the majority of cases make such a clear distinction. The error lies in the simplistic formulation of the question to begin with. Children's developmental, behavior, and emotional difficulties frequently have a way of being both emotional and organic at the same time. Asking for an either-or answer is to overlook the fundamental notion of multi-causality and to erroneously simplify the complexities of development and illness. No to question 5. 5. Can you give me a diagnosis of his personality? A large segment of pediatric psychology is becoming less and less comfortable with the role of hanging a label on a child. To "diagnose" his personality is to do just that. It is probably not only not helpful for the child (question 3) but potentially damaging. A study undertaken for this reason is generally inappropriate. 6. Is the child mentally retarded? This very frequent concern of both parents and physicians is very appropriately brought to the psychologist's door. Yes on all accounts, again taking the specifics of question 4 into account. 7. Why is this child not talking? This is a most worrisome dilemma, about which I wish more physicians would ask. Children with delayed language development have a way of being overlooked by the medical profession. It is certainly appropriate to ask a psychologist for diagnostic help with this symptom, but the doctor must be prepared for only partial help from such a diagnostic assessment. The evaluation may also require

PSYCHOLOGICAL TESTING OF CHILDREN

193

the services of, among others, a speech and audiology consultant and a psychiatrist as well. Nonetheless, yes to question 5. 8. She has chronic headaches. All hospital studies are negative, and I have done everything else I can think of. The doctor's desperation is clear. Specifically what he wants from a psychologist is not. Question 5 gets a no, but note the following request. 9. She has chronic headaches. I am wondering about a psychosomatic cause. All hospital studies are negative. I need your assessment of her cognitive abilities and your observations of her behavior, coping, and personality style. This seems to be a much more explicit version of the preceding request, and one which receives unanimous affirmatives to the 5 questions. 10. What is the child's intellectual prognosis? This request is sometimes frantically pursued by concerned parents of "slow" children, understandably so. It, too, is specific in its demand, but tragically it cannot be answered by a psychological study (no to question 2) for the reasons mentioned by Dr. Weiner in his discussion of the validity of psychological tests. Tea leaves and palmistry are no worse than a WISC for predicting the future. No for question 5. 11. Does he have a specific learning disability of some sort? This currently represents the most popular request posed by physicians to psychologists. Perhaps overasked, as a result of the tremendous fanfare ·which now accompanies the field of learning disabilities, the question is nonetheless an appropriate one and a decent reason for a psychological consultation. Once again, the psychologist may provide only some of the answers, and this same question should be asked of other professionals: an educator, a language consultant, a neurologist, for instance. 12. Her behavior is so unusual. Is she severely disturbed, perhaps autistic? The request is relatively specific; the answer may be provided by psychological information; and chances are good that the information will be useful for the parent, the child, and the physician. If the potential disadvantages are not too great (question 4) a consultation would seem justified. Other consultations (psychiatric) may also be required. 13. Is mixed brain dominance a problem? This represents a specific request for which there is even a specific test-the Harris Tests of Lateral Dominance. But the information provided is currently felt to be of no clinical significance whatsoever. And as such it is certainly not very helpful to anyone. No to question 3 and no to question 5. 14. I don't have the time to tackle the problem-obviously complicated- in 15 minutes. Will you see him? The initial statement is very accurate, very sad, and not a good reason for the question which follows. The latter asks for no specific information. A study performed under these circumstances will probably be of little help, since the same harassed physician will probably have no more than 15 minutes to deal with the complex information provided by the study, once it is completed. And that, too, will be insufficient. No for question 5. 15. Is her mother/father the cause of her problem? The request is specific enough, but will be hard for a psychologist to answer with a diagnostic evaluation of a child alone. It also sets the stage for a blame frame-

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work to be constructed around the parents. And if such actually occurs, then question 3 must be answered with a resounding no. Blaming seems helpful to no one. A knowledgeable appraisal of the family relationships and family system by a family psychotherapist would seem more to the point than a diagnostic psychologic assessment of the child. 16. This child is very clumsy. Is that a reflection of more generalized psychomotor retardation? This is a bonafide concern and certainly within the province of a pediatric psychologist. Such a referral would seem quite appropriate. Yes to question 5, if question 4 allows. 17. I want you to do a Rorschach. This demand is the one exception encountered in the entire list. It merits a yes answer to all of the first three questions, and yet a no to the last, since it casts the consulting psychologist in the role of a laboratory technician, with little more to offer than a psychological CBC. The physician making this demand shows little appreciation for the competence and skill of another professional. It is an inappropriate demand, hence no to question 5. 18. How should this child be taught with her learning difficulties? I mentioned earlier that it is most appropriate for a psychologist to participate in the evaluation of a learning-disabled child. But the specific question of how to teach is most effectively left to an educator. A diagnostic psychologic assessment simply does not provide the necessary information, and should not be undertaken for this purpose. No to question 5.

CONCLUSION In summary, then, I would invite the physician reader just before his next telephone call to a pediatric psychologist regarding the testing of a perplexing child to take a moment to ask himself: what do I want; can I get it; will it help; is it risky? In so doing, he may find himself with a rather logical and almost automatic answer to an original query- does the patient need psychological testing? That question, adequately and accurately answered, brings not only the promise of help for the child and a lasting friendship with the psychologist, but a sharpening for the doctor of his own practicing skills as a physician. Department of Pediatrics University of California Medical Center San Francisco, California 94122