Written by Charles Galyon, Ph.D. & Carolyn Blondin, Ph.D.
Following a psychoeducational evaluation, you should have a results session with your examiner to discuss the results and the meaning of the results. However, even an extended results session may leave you with unanswered questions. The time to discuss results is limited, your examiner will not be able to anticipate all of your questions, the amount of information you receive may feel overwhelming, and you likely will have many other questions come up after the results session. The information provided below is here to help you figure out what to do next after your results session and how you can get additional help and information when you need it.
What does a diagnosis mean?
First, remember that a diagnosis is only a “functional label.” By itself, a diagnosis is not helpful. The reason you might seek out a diagnosis is to get better ideas about what you can do to improve the problem. With a diagnosis, then you can get an idea of what may happen in the future, and what kinds of accommodations or treatments may be helpful. For example, when you know your child has a cold, then you can expect it will be unpleasant for a period of time, but that your child will get better without need for medical intervention. On the other hand, if your child has a severe case of the flu, then you can expect the child may need medical assistance, and that a pediatrician will have an idea of what treatment will prove most helpful.
How reliable and permanent is a diagnosis?
When making a diagnosis, the examiner is looking for a combination of symptoms and characteristics that tend to occur together, which may indicate some underlying condition (for example, a learning disability, an Autism Spectrum Disorder, or a developmental delay). The examiner is well-trained in a variety of disorders, their symptoms, and how to test for other characteristics that would be consistent with a disorder. However, it is ultimately “clinical judgment,” and some individuals simply do not show symptoms in the same way. Also, the examiner only sees you or your child for a limited period of time and typically only in one setting (such as a clinic). While the examiner is aware of these limitations and tries to take them into account, you may have important information that would affect the diagnosis. For that reason, be sure to share all information you believe may be important with your examiner.
Keep in mind that as you or your child grows, learns, and develops new skills, things may change with respect to the diagnosis. Many diagnoses are considered “permanent” (such as Autism Spectrum Disorder), meaning that if the diagnosis is received earlier in one's life, then it stays the same regardless of changes in the symptoms. However, the degree of impairment can change considerably, which is ultimately the goal of receiving a diagnosis and treatment.
Is there a cure?
Generally speaking, there are no “cures” for disorders; however, many disorders are better understood now and can be greatly helped with different treatments. For psychoeducational disorders, many of the treatments are called, “interventions.” Interventions may include skill training, behavior modification, or therapy. Medical treatment is also often used in conjunction with interventions to improve the effectiveness of interventions and reduce potentially more severe symptoms (which may interfere with the ability to benefit from interventions). Though your examiner may be able to discuss medical treatment to a limited degree, remember that they are not trained in medical practice. To gain more information regarding options for medical treatments, you should speak with your family physician.
What is involved with “training skills, modifying behavior, or receiving therapy”?
Skill training. Training skills is used for academic difficulties (improving math, reading, or writing skills), adaptive behavior (day-to-day activities), and to teach compensatory strategies (such as for problems with organization, memory, communication, or social skills). Skill training usually occurs periodically (such as once per week), involves assessing the current skill level, using a scientifically-validated training program, and measuring improvement in the skill to make sure the training is working. Skills training can be an invaluable approach to addressing disorders and may reduce problems associated with the disorder. It generally provides significant improvement, but does not completely eliminate the problem.
Behavior modification. Behaviors may become a regular habit over time, and often occur without thinking. Most behaviors are appropriate and desirable, but sometimes behaviors are not desirable (misbehavior) and need to be changed. Many problems may be effectively addressed by modifying behavior or replacing an undesirable behavior (for example, throwing toys), with a new desirable one (such as, expressing anger verbally). Behavior modification requires several steps, including identifying the “antecedent”, “target behavior”, and “consequences”. This process is known as “Functional Behavior Analysis” and is done before behavior modification begins. The “antecedent” is what occurs before the behavior and may act as a trigger. A simple example would be: when a traffic light turns green, the driver applies his/her foot to the gas pedal of the car. The “target behavior” is the behavior to be changed. The “consequences” are what occur after the behavior that increase or maintain the behavior. This is easy to understand if you consider how you might respond if you got $50 each time you said, “Hello” to someone (you would probably say, “Hello” a lot!). A major goal of behavior modification is promoting “successful behaviors” (behaviors that we desire and that result in good things) and making them more enjoyable than the previous, undesirable behavior (typically by using rewards for the good behavior).
Therapy can take many forms, but when applied to psychoeducational disorders, it often focuses on desensitization, counter-conditioning, restructuring thoughts, and other anxiety reduction strategies. Therapy should be “solution-focused”, meaning it identifies a specific problem, creates a plan to reduce the problem, and evaluates progress throughout therapy. Therapy in this context is typically relatively short (for example, 7 to 12 sessions over a period of 2 to 3 months).
Now I've got a diagnosis, what should I do next?
There are a variety of steps that you may take next. Some disorders may benefit from medical treatment, such as Attention Deficit/Hyperactivity Disorder or severe Anxiety Disorders. In such cases you should meet with your physician to discuss your concerns and bring your evaluation report with you. You may want to request a letter for your physician from your psychoeducational examiner. The letter is a helpful way for the examiner to briefly state the evaluation procedure, results, and provide contact information for the physician.
It is also appropriate to begin treatment planning following the diagnosis. Treatment planning can include a variety of steps, such as those mentioned above, as well as identifying additional resources that may be helpful (such as local support groups, clinics, or material resources). If the disorder has an educational impact, then it is appropriate to begin the process of requesting accommodations from the school. An educational impact generally means the disorder interferes with the ability to succeed in academic work, or that the disorder produces behaviors or stressors that interfere with the ability to function in an academic setting (which may include social difficulties).
Though your examiner has provided a brief description of the diagnosed disorder in the evaluation report, it is usually helpful spend some time learning more about the disorder yourself. Your examiner is one useful source of information and should be consulted if you have additional questions, but there are also a variety of helpful resources that can be located elsewhere, including books, support groups, and internet resources. You should be careful to evaluate the credibility of these sources, though, because not all sources are factually accurate or well-researched. Your examiner may also be able to provide some suggestions for resources that are reader-friendly and scientifically valid related to the diagnosis.
I didn't get the diagnosis I came in for, now what?
Possibly one of the most frustrating experiences is to come in for evaluation due to problems, but not get a diagnosis to confirm or explain the problems. Just like getting a diagnosis does not solve the problem, problems can exist even if a clinical diagnosis is not made. Sometimes problems are “sub-clinical”, meaning that a problem is evident, but the degree of severity of impairment is not enough to warrant a diagnosis. Your examiner may still provide recommendations related to the problems you are experiencing, and these recommended solutions can still be beneficial. It is also possible that a problem may change over time and become more or less severe, which would change the eligibility for diagnosis. If you feel a problem has persisted or becomes worse over time, then consider requesting a re-evaluation.
Why does my child struggle despite not having a diagnosis?
This is a common question and point of frustration for parents, particularly when a child is struggling in school, but there is no apparent explanation. There is not a simple answer, but there are a number of possibilities that may make it easier to understand (though not necessarily easier to deal with). When making a diagnosis, there are two primary questions that must be asked: 1) does the child exhibit the symptoms consistent with a disorder, and 2) is the impairment significant enough that it affects daily functioning? Most often, when a child does not receive a diagnosis, it is the second question that comes back with the answer, “No.”
To help improve the reliability of diagnoses (so that different examiners will reach the same conclusion), certain scores must be reached to indicate significant impairment. A child may struggle, but their scores could be right on the edge, meaning they will not get a diagnosis. However, it is possible that if the problems continue, the child will qualify in the future. Therefore, if you do not receive a diagnosis initially and the problem is still present (or worse), then it is often a good idea to ask for a re-evaluation.
Why won't the school help my child?
Rest assured, the school wants to see your child succeed and is not intending to frustrate you. Similar to the previous question, schools are required to use certain criteria in deciding if a child will receive services. Because schools have limited funds, they often must be cautious with regard to identifying children for services. As a result, there are a limited range of disabilities and disorders for which children may receive services in a school setting.
Unfortunately, if a child struggles academically because of a cognitive processing deficit (for example, poor short-term memory, low processing speed, or difficulty with recalling information), then they may not qualify for services because these are not recognized “disability categories” within education. These difficulties are still very real and can cause a great deal of frustration for the child. In such cases, it is strongly encouraged that you try to work with your child's teachers to see if some reasonable accommodations can be made (such as extra time on assignments or tests or allowing the use of scrap paper for jotting down notes during tests). Keeping communication open with teachers about behavior, progress, and/or concerns can be very helpful. Many teachers are willing to work with students and parents to help the child succeed.
Should I get a re-evaluation? When?
Re-evaluation may be recommended under a few circumstances. If the previous evaluation did not produce a diagnosis, but the problems persist or have gotten worse, then re-evaluation may be helpful after some time has passed. Usually you should allow at least a year to prevent a “practice effect” (when a test scores artificially high because it has been seen before). You should also be sure to inform the examiner of any previous evaluations that were done, when they were done, and (if known) the tests used for evaluation. This helps the examiner select an appropriate test.
Re-evaluation is also necessary periodically to check progress and to figure out if a new plan should be developed. This kind of re-evaluation is typically conducted once every three to five years. Information from these evaluations can help determine if there is improvement, if there is a new need, or if a different approach to treatment would be better.
And finally, an evaluation may be periodically required for progress monitoring. Schools often require recent evaluations when determining if accommodations and services are necessary. Many colleges and universities also require recent evaluations for services. Though “recent” may have different meanings between schools, in general, evaluations should not be older than 3 to 5 years.
Should I get more evaluations from other professionals?
The initial psychoeducational evaluation may only be a starting point in terms of identifying needed services. Psychoeducational evaluations typically assess cognitive, academic, and psychological functioning. This means that other skills, such as motor skills and language skills, are not evaluated in depth. Though the psychoeducational evaluation may provide some information about language skills, it is not intended to be a thorough evaluation of language skill, which is more thoroughly examined by a speech-language pathologist. Motor skills are also not thoroughly evaluated as part of a psychoeducational evaluation, and are usually assessed by an occupational therapist.
Depending on the diagnosis, your examiner may recommend follow-up evaluations by other health professionals, including speech-language pathologists and occupational therapists. If unsure, ask your examiner if it would be appropriate to seek further evaluations.
Should I share this report with anyone?
You may share your report with anyone you desire (it is your report); however, it is typically helpful to share your report with your family physician, any counselors or social workers with whom you visit, and schools. Your family physician may need the information to begin a collaborative treatment plan (as is often the case with Attention-Deficit/Hyperactivity Disorder). Your counselor or social worker may need the information to better understand how to best help you. And schools may need the report to set up a program of services and accommodations for your child. For example, you may require services under an Individualized Education Plan (IEP) or Section 504 Plan. Ask your examiner for a further explanation of these programs and what is involved in them. Similarly, sometimes it is appropriate to share the results of the evaluation with your employer to secure workplace accommodations (as protected by the Americans with Disabilities Act).
Written by Dr. Charles Galyon
Part of raising a child means teaching them almost all of the skills that they will need to get by as an adult (schools and the community pick up some of the job too). This means lots of correcting misbehavior. However, for many parents (especially those who have more “spirited” children), it may feel like this begins to dominate their interactions with their child and leads to frustration on the part of the parent and the child. It may begin to strain their relationship. Nobody wants to have a relationship with their child that is dominated by yelling, scolding, or other punishment, but this pattern often develops naturally and for good reason.
Is My Child Always Misbehaving?
In truth, the answer is definitely, “No, they are not.” Why does it feel like you always have to get on their case and correct their behavior then? Let’s use one somewhat extreme example to explain this: Are you more likely to remember all of the people that waved at you and said, “Hi” or the people that slapped you in the face whenever you walked by? One of those is common and expected, the other is unusual and extremely offensive. As an adult responsible for the child’s behavior, you will naturally notice misbehavior very quickly. Misbehavior, by its nature, tends to be offensive (meaning it aggravates us), which means it will get your attention.
Why Does It Feel Like That’s All I See?
Some children are more prone to behaviors that are considered “wrong” than others for a variety of reasons (hyperactive, anxious, easily frustrated…). Some children may specifically engage in behaviors that are antagonistic (such as aggression, defiance, or non-compliance). Almost all children engage in a variety of common appropriate behaviors. Appropriate behavior can range from common (playing quietly, eating food…) to uncommon (helping someone, doing chores voluntarily…). Uncommon appropriate behavior is likely to be noticed, but common appropriate behavior is usually overlooked. Why is this?
Common appropriate behavior is generally what is expected (for example, “well, of course they should not hit their brother”) and much of it doesn’t draw attention to itself as a result. Uncommon appropriate behavior may draw attention to itself, but it is not frequent, therefore you will still feel like your child is “always misbehaving.” So if a child could receive attention for uncommon appropriate behavior, why don’t they always do that? Well, why don’t you (as an adult) stop and help every person you see every day? It would be exhausting and the opportunity doesn’t actually present itself that often. Children do not have that many opportunities to engage in uncommon appropriate behavior, and it’s a lot of work. It’s great when it happens, and we want to pay a lot of attention to it, but it’s rare.
Though a child may often demand your attention for their inappropriate behavior, this is not the only thing they do, it just feels like it. Many children will misbehave precisely because it has gotten parental attention before. However, it would not make any sense for a child to always engage in behaviors that will receive corrections and punishment. They would undoubtedly prefer enjoyable, high quality attention from you.
What Can I Do Then?
There is no simple, fast cure for misbehavior, but there are things you can do to begin improving it and at the same time strengthening your relationship with your child. This article is about one thing: Changing the attention you give to your child’s behavior.
You need to learn how to identify and give attention for the appropriate things your child does (the common and uncommon appropriate behaviors). It is extremely difficult and you will have to train yourself to do it. Think of it as building a new habit. Learn to look for things your child does right (even “playing quietly”) and give them attention for it. Your goal is to get in there and give your child attention for appropriate behavior before they demand your attention with inappropriate behavior. It’s almost a game, and a very tricky one because we’re not really well-practiced at it. It may help to set a timer for yourself to remind you approximately every 5 to 10 minutes until it gets easier for you. In addition, you have to learn how to ignore some of the small misbehaviors that don’t really need attention or things that we specifically want to avoid giving attention (such as whining). Some of these behaviors will worsen before they get better (particularly whining), but if you give your attention to them, they’re likely to become stronger and last even longer.
Addressing misbehavior can be a complicated and challenging process. The first part of improving your child’s behavior is re-training yourself to identify and give lots of positive, high-quality attention to common appropriate behaviors. Later, you start learning more effective ways of dealing with the misbehaviors (including selectively ignoring them). Though a challenging task, keep in mind that your child would almost certainly to have praise and positive attention. We want them to learn how to get that attention appropriately instead.
Blog article written by Dr. Charles Galyon
It can be helpful to think of the brain like a muscle: exercise makes it grow and improves its capabilities. There are plenty of commercial products that claim to improve brain power (memory, processing speed, attention...), but the actual evidence for these products indicates either no real benefit or a very specific benefit (that is, improvement in that specific task, but not other tasks). There are simply no shortcuts for a "supercharged brain." That does not mean that various brain challenges are without value though. For example, crossword puzzles appear to help maintain the strength of long-term memory later in life. This article discusses a little bit about early brain development and why diverse experiences are important for children's brains, and a few specific ideas to keep in mind when trying to help your child develop their abilities.
Immature and Slow to Develop
Humans have an unusually long period of development. Our children are largely helpless for a very long time and their brains will not "fully develop" until possibly early to mid-20's. However, you can clearly see a lot of differences in the abilities of very young children and adolescents, with adolescents capable of understanding more abstract concepts and engaging in more complex discussions (Piaget and his colleagues generally explored these ideas long ago). Because the period of development is so long, that leaves a lot of time to help build a child's abilities and improve on areas that they may be struggling in. Children's brains are also very adaptable (a concept called "plasticity"). One example of that is how young children are more able than adults to recover from brain trauma. On the other hand, some neurological differences do not appear likely to ever be fully addressed. It would be difficult to discuss all of the types of abilities and differences that are "plastic" and those that are not, but we can cover some important areas that parents can work on with their children.
Critical Periods/Sensitive Periods of Development
Sometimes you may hear the term "critical periods" of brain development. This concept means that certain abilities (such as the ability of the brain to process visual information) must develop within a certain time window or else it will never develop. It may be an overstatement for us to say with certainty that some abilities will never be able to develop, but there are certainly times during which it is easiest for a child to acquire a certain skill (such as language). These times during which it is easiest for the child to develop an ability or skill are often called, "sensitive periods" instead of critical periods to help emphasize that the window of opportunity is not necessarily completely shut. Usually these periods are for very specific abilities, such as the ability to process certain types of sensory information, or to develop motor skills or language skills. We are still learning more about human development, however, and there are many areas that are less clear (such as social skills).
Impulse Control and Emotional Regulation
The ability to inhibit a behavioral impulse or an emotional response is important for success in many areas of life (jobs, social interactions, relationships...). Our capacity to do this seems to reside heavily within the front part of the brain (the prefrontal cortex). Fortunately, this appears to be the last part of the brain to reach full maturity, which means there is a lot of time to exercise it. On the other hand, this also partly explains why children, adolescents, and even young adults can be extremely impulsive or make some very questionable decisions at times. The development of the prefrontal cortex also seems to coincide nicely with our "cognitive peak." You could say that we are, essentially, at our smartest in early adulthood (though the decline afterward is actually rather slow). This means that for children we should continually encourage them to practice impulse control and emotional regulation. We can do this most effectively by giving them mild "patience challenges" that push slightly at their limits and providing them with appropriate feedback, encouragement, and (if necessary) rewards for achieving their goals. I would not recommend doing this with an overly high frequency (such as multiple times per hour, every hour, every day) as it's likely to produce so much frustration that you'll get resistance from them in the future. However, if it can be made slightly playful, then the child is building an invaluable ability and also building confidence in their abilities.
An important thing to keep in mind is that emotional regulation and impulse control (or "behavioral regulation") appear to rely on basically the same neurology. To build greater emotional regulation, it is often helpful to teach the child to voluntarily withdraw from a situation when needed (by rewarding them for doing so if necessary). This can give their brain (prefrontal cortex actually) time to catch up and reassert its control over the situation. I've seen parents use many approaches to explaining this to their child, but I think my favorite has been the idea of an "overheating engine" that needs to cool off. Teaching the child how to recognize the signs of getting emotionally overwhelmed is a helpful (possibly critical) step in teaching them to self-regulate their emotions more effectively. A variety of physical cues can help, including their heart rate and breathing, as well as how impatient they're feeling.
Frustration Tolerance and Patience
Similar to building greater impulse control and emotional regulation, the capacity for frustration tolerance and greater patience are likely to be great contributors to a child's long-term success. Tolerance for frustration or setbacks increases the likelihood a child will persist at a challenging task and, as a result, learn more skills and ultimately enjoy more success. Explaining this to a child is not likely to convince them to keep working on a particularly frustrating homework assignment though. As the parent, you effectively coach your child by encouraging them to persist, giving them just enough help when they need it (called "scaffolding"), and showing them how their continued effort has paid off. Then celebrate their success with them! The more they do this (and enjoy the success that follows), the more likely they are to persist at challenging tasks again in the future.
Building patience may be more challenging because "having it now" is always more appealing than "having it later." Individuals who are unable to wait (called "delayed gratification") are less likely to enjoy bigger successes later in life. Those who are able to wait can develop more complex plans and enjoy bigger rewards as a result of their patience. One way to help is to require the child to do "just one more time" or wait "just one more minute" on a fairly frequent basis (ideally at least a few times per day if circumstances permit it). I would not recommend prompting them to do a second round (at least not at first), because they may just get too frustrated, doubt your sincerity in the future, and decide they'll just make it happen on their own (whether you agree or not). You can also offer them bigger rewards for their patience (though starting with praise and allowing them what they originally wanted is a good idea). For example, "Sure, I'll let you have a cookie, but if you can wait until we're done with this, I'll let you have two cookies instead."
Training with ADHD
All of this comes to one final point. While reading this far (good patience and persistence!), you may have thought several times that the skills discussed sounded kind of like what is lacking in a child with ADHD, and you would be right. The neurology of ADHD appears to primarily be underactivity of the area of the brain involved in impulse control, emotional regulation, frustration tolerance, and patience. These skills are important for helping a child to persist at challenging tasks, maintain focus on one thing for an extended time, develop a complex plan, and carry out that plan. They're also important for preventing the types of impulsive or hyperactive behaviors that often get kids in trouble when they have ADHD. Because of that, the exercises discussed here are especially important for children with ADHD (though helpful for all children). This doesn't mean that children with ADHD just needed to do these exercises more, or that their parents committed "bad parenting", which lead to the problems with ADHD (there is clearly a strong genetic component to neurological development and a difference in brain chemistry for individuals with ADHD). Many children with ADHD may have more difficulty with completing these exercises successfully as well, and therefore may need a combination of medication and behavior therapy (rather than just behavior therapy). Progress in developing these skills may also be very slow for a child with ADHD (which can frustrate the parent), but slow progress eventually produces significant progress, and the time is well-spent. Remember, the prefrontal cortex seems to be the last area of the brain to mature, which means that "exercising that muscle" may help to reduce the neurological difference by the time your child is much older.
Written by Dr. Charles Galyon