One thing I have grappled with over the years is how to best organize the information in the summary section of the report.
How do you organize everything you want to say about a child in a way that is comprehensive, but readable? What parts do you cover in depth, and what parts do you spend less time on? If the evaluation looked at both strengths and weaknesses, do you start with the "good news" or the "bad news"? Is there a format you can use that makes reports easier to write?
In looking at my own and others' reports over the years, here are a couple of frameworks I see most often: 1. The Three Interacting Problems method: In this framework, the test results are synthesized into 3 (plus or minus 1) problems that seem to interact to contribute to the child's difficulties. Brief example:
Johnny's test results show three major areas of concern. First, he problems with paying attention. Second, he also is behind academically in reading due to difficulties with phonological processing. Third, Johnny is also more anxious than most boys his age. These problems are interacting [describe interaction - e.g., inattention also affects reading; reading problems cause him to tune out more during school; anxiety affects attention and reading confidence; academic and attention problems increase anxiety], resulting in increased difficulties. Johnny needs comprehensive support that addresses all 3 difficulties at the same time.
2. The Referral Question method: In this framework, the summary answers the specific referral question(s). These questions may have been provided by the professional who referred the child. Alternatively, these questions may have been generated with the parents and child, using techniques from Therapeutic Assessment. Often, these questions are directly stated in the text and then answered, like a Q & A. Brief Example:
Why is Julie Struggling to Focus in Class? Julie is having trouble focusing because she has ADHD. [Description of ADHD and supportive test results.] Does Julie Have a Learning Disability? Yes. Julie is more than 2 years behind in reading. She has trouble with the basic processes that support reading, including phonological processing and rapid naming. [Describe with supportive test results.] She has the learning disorder Dyslexia. Is Julie Anxious? How is her Self-Confidence? Julie's attention problems and reading difficulties are making her anxious and affecting her self-esteem. In turn, her anxiety is making her less able to focus and more likely to give up when reading. She meets criteria for an anxiety disorder [Describe with supportive test results.]
3. The Strengths and Weaknesses model: In this framework, the test results are organized by the child's relative strength and relative weakness (3 categories can also be used, e.g., strengths, emerging skills, weaknesses). This is the model I generally use. My summary almost always goes: Strengths, Vulnerabilities, Impact of Profile, How to Best Support Child. I also tend to borrow from the two frameworks noted above, as you can see in this brief example:
What Are Jamie's Strengths? Jamie's problem-solving skills are right "on target" for his age. He also has good X, Y, and Z skills. Jamie is also socially-skilled, well-behaved, and creative, with a wide range of interests including A, B, and C. What Are Jamie's Vulnerabilities? Jamie is struggling with his attention. He is also behind in his reading. Jamie is also more anxious than most boys his age. Impact of Profile: In the classroom, Jamie's vulnerable skills may lead to [Describe]. At home, his challenges could cause [Describe]. How Can Jamie Best Be Supported? Jamie will benefit from support that addresses his 3 vulnerable skills at the same time.
However, these are certainly not the only (or necessarily best!) ways to organize test results. Recently, I came across an article by Gary Blake on how to organize any type of information. [The article is posted at the website of the International Risk Management Institute, which I assume is not what I was reading when I came across this article, but I can't remember where that was now.]
Each of these ways could be applied to organizing test results in a summary: Order of location. In his article, Blake gives the example of how a "memo on the status of your company's offices could be organized by state or by region". At first, the connection to test results for this format was not obvious to me. However, then I remembered that many neuropsychologists think about test results by brain region, and probably even organize their test results in this way. Test results could certainly be organized in this way in a summary. This may be especially helpful in reports related to medical issues.
Chronological order. Per Blake, "this format presents the facts in the order in which they happened" and is how many case histories are presented. This format might be especially appropriate to medico-legal evaluations, like a report monitoring recovery after a head injury. However, that is not the only application.
Sometimes, I talk through the test results in almost chronological order with parents during the feedback. Brief example:
Essentially, I say, "We were worried about attention, so the first thing I did is rule out some other things that can "look like" attention disorders. Here is how I was able to rule out A, B, and C. The next thing I did was look at attention and EF on attention/EF tests. Then we looked at your ratings of her attention/EF. Here is what those results look like. Once it was clear attention was a problem, I looked at the many ways attention can affect and interact with other things, like academic progress and emotional well-being." I've never thought of writing my summaries like this, but I think it could be really effective done right. I do feel like using this format in the feedback helps walk some parents through the evaluation process in a way that ensures them that the evaluation was thorough and comprehensive.
Problem/solution. According to Blake, this format "starts with "Here's what the problem was" and ends with "Here's how we solved it, and here are the results we achieved.""I use this format for my summary for re-evaluations when the recommendations have produced nice results and the child is on an encouragingly upward trajectory. I think this format would also be useful in rehabilitation contexts, or as a discharge summary report (e.g., if you write reports for children who are being discharged from your residential unit).
Inverted pyramid. Blake writes "This is the newspaper style ... in which the lead paragraph summarizes the story" and "the paragraphs following present the key facts in order of decreasing importance." I first came across this format in Dean Beebe's and colleagues' discussion of report formats.
This is now how I structure my whole report. I start with the most important information - the diagnostic conclusions (as bullet points), then the summary, then the recommendations. Then on subsequent pages, I discuss the background, the current info, the behavior observations, and then the specific test results at the end. This inverted pyramid format could also be used for a summary. Some reports I've read start with an "Executive Summary" that resembles the lead paragraph of a news article or the abstract of a research paper. The first paragraph of the summary could also serve this purpose. The inverted pyramid might be an especially helpful way to encourage trainees to write at first, so they get lots of opportunity to grapple with the question of "What really is the most important info?"
Deductive order. Blake notes in this framework, you "start with a generalization—a theme you want to support or a point you want to make—then support it with as many facts and observations as possible." This tends to be a very persuasive style. I think a lot of psychologists use this format in their feedback.
I heard Karen Postal, in an episode of The Testing Psychologist Podcast, phrase it as something like, "You wondered if this is something like ADHD, and I do think that's what it is. Let's spend the next hour talking about how I came to that conclusion and unpacking what it means." This could easily be translated to a summary. This could also be combined with other frameworks -- for example, each paragraph in the "3 Interacting Problems" framework could use deductive order.
Inductive order. Blake writes that in this framework, you "begin with specific instances and examples and then lead the reader to the idea or general principle the evidence supports or suggests." I use this for my feedbacks when I sense I will be making a diagnosis the parents are not expecting. For example:
If the parents came in thinking the problem is anxiety but the evaluation results point to autism, my approach is to talk about specific test results and examples they gave me, getting their understanding and "buy in" on each one (e.g., "yes, that sounds exactly like him"). Then once we see all the details of the profile, we move to "there's actually a name for this profile of very deep interests and a strong preference for routine that goes along with trouble seeing others' perspectives and difficulties being flexible." If this approach works well in the feedback, I could also see it working really well in the summary.
Priority sequence. Blake states that in this format, you "rank recommendations, problems, concerns, issues, or other items from the most important to the least important." He describes this as "an ideal format for writing a letter or memo recommending a series of steps or actions." I think many psychologists do this automatically for their recommendations section. However, the entire summary could be written using this principle. This seems like an especially helpful approach when there is a very clear and circumscribed referral question. It also seems ideal for brief reports.
I use this approach occasionally when one of the child's problems is of grave concern or an actual emergency. For example, I might just start right off by saying [abbreviated example]: "I am extremely concerned about Joe's emotional well-being. He is harming himself and has expressed suicidal ideation. He is at high risk of further self-harm and needs a higher level of care immediately." I also use this approach if I am writing a report/letter to a teen or adult with schizophrenia, using a very simplified style depending on how much confusion and disorganization they are experiencing (I have a sample you can see if you're interested - just shoot me an email). Briefly, I say something like: "You have these concerns: (1) hallucinations, (2) confused thinking, (3) trouble meeting your goals. You need to do A, B, and C."
