Parent- and Adolescent-reported Executive Functioning in the Context of Randomized Controlled Trials of Online Family Problem-Solving Therapy.

OBJECTIVE: We examined parent- and adolescent-reported executive functioning (EF) behaviors following pediatric traumatic brain injury (TBI) in the context of Online Family Problem-Solving Therapy (OFPST) and moderators of change in EF behaviors. METHOD: In total, 274 families were randomized to OFPST or an internet resource comparison group. Parents and adolescents completed the Behavior Rating Inventory of Executive Function at four time points. Mixed models were used to examine EF behaviors, assessing the effects of visit, treatment group, rater, TBI severity, age, socioeconomic status, and family functioning. RESULTS: Parents rated their adolescents' EF as poorer (F(3,1156) = 220.15, p < .001; M = 58.11, SE = 0.73) than adolescents rated themselves (M = 51.81, SE = 0.73). Across raters, EF behaviors were poorer for adolescents whose parents had less education (F(3,1156) = 8.60, p = .003; M = 56.76, SE = 0.98) than for those with more education (M = 53.16, SE = 0.88). Age at baseline interacted with visit (F(3,1156) = 5.05, p = .002), such that families of older adolescents reported improvement in EF behaviors over time. Family functioning also interacted with visit (F(3, 1156) = 2.61, p = .049), indicating more improvement in EF behaviors over time in higher functioning families. There were no effects of treatment or TBI severity. CONCLUSION: We identified a discrepancy between parent- and adolescent-reported EF, suggesting reduced awareness of deficits in adolescents with TBI. We also found that poorer family functioning and younger age were associated with poorer recovery after TBI, whereas adolescents of parents with less education were reported as having greater EF deficits across time points.

Changes in child functioning pre-to post-neuropsychological evaluation.

Although a key goal of neuropsychological evaluation is to improve patient outcomes, research regarding changes in child functioning following neuropsychological evaluation is very limited. This project examined changes from before neuropsychological evaluation to several months afterward in parent report of their child's functioning and ability to participate across home, school, and community settings. Fifty-one parents of children and adolescents receiving their first outpatient neuropsychological evaluation completed questionnaires prior to initial parent interview and following the final report (of n = 162 who were mailed the follow-up questionnaire). Parents rated their perception of the severity of their child's problems, their child's ability to participate, and satisfaction with the child's ability to participate across school, home, and community domains. Analysis utilized MANOVA with bootstrapping to obtain standard errors and false discovery rate to control Type-1 errors. Parents reported a significant decrease in the severity of problems related to academic progress (p = .034) and overall severity of problems (p = .028) at follow-up. There was no significant change in the rated severity of the child's problems with peers or family. Parents reported significant increases in their child's ability to participate, and parent satisfaction with child participation, in school (ps<.001), at home (ps<.01), and in the community (ps<.001). Although this observational study cannot definitively show cause-and-effect, findings support the utility of pediatric neuropsychological evaluations in facilitating child functioning. These findings dovetail with prior work suggesting that such evaluations can increase parents' understanding of their child, awareness of care options, and efficacy in pursuing those options.

Evolution of parental knowledge and efficacy across the pediatric neuropsychological evaluation process.

OBJECTIVE: The handful of studies examining parent satisfaction after pediatric neuropsychological evaluations have focused on post-evaluation appraisals. By examining parent experiences across the course of their child's evaluation, this study aimed to provide important insights into how and when parents experience changes in knowledge, understanding of care options, and efficacy during evaluation process. METHOD: Parents of youth receiving neuropsychological evaluation completed questionnaires at four time points (prior to evaluation [n = 363], day of testing [n = 300], prior to feedback [n = 250], and post-report [n = 99]). Parents rated aspects of their knowledge and efficacy regarding their child's functioning. Parents also rated their perception of the neuropsychologist, medical provider, and school along the same domains. The resulting longitudinal data were analyzed using structural equation modeling and ANCOVA. Although primary analyses focused on the entire sample, differences between first-time evaluations and re-evaluations were also examined. RESULTS: Families receiving an initial evaluation showed lower ratings in knowledge, awareness of options, and efficacy at the beginning of the evaluation and a significant increase in ratings by the end of the evaluation. Families returning for re-evaluation showed higher initial ratings that changed comparatively little during the evaluation. Parents receiving initial evaluations also perceived increased knowledge of their child by medical providers and school. CONCLUSION: The study supports the clinical assumption that parents gain knowledge about their child and treatment options during a neuropsychological evaluation. The difference between initial and re-evaluation warrants further study. Studying the process and experience of neuropsychological evaluation may provide more nuanced findings than post hoc satisfaction measures.

The Parent Experience of Assessment Scale (PEAS): Development and Relation to Parent Satisfaction.

This study outlines the development of the Parent Experience of Assessment Scale (PEAS), which is based on principles of Therapeutic Assessment. The study includes pilot testing of a 64-item questionnaire across 134 participants, with psychometric analyses utilizing confirmatory factor analysis. The revised version consists of 24 items across five subscales with appropriate internal consistency reliability (alphas from .76 to .88). The PEAS demonstrates statistically significant relations with general parent satisfaction, with two subscales indicating significant direct effects via structural equation modeling. The PEAS has the potential utility to provide more nuanced clinical and investigative feedback regarding the parent process during child psychological assessment.

Communication is key: the utility of a revised neuropsychological report format.

OBJECTIVE: The neuropsychological report is a critical tool for communicating evaluation results to multiple audiences who have varying knowledge about neuropsychology and often have limited ability to review long, complex reports. Considerable time is spent writing these reports and challenges persist related to readability, length/complexity, and billable clinical time (which may be capped by third-party payors or families' ability to pay). METHODS: This quality improvement effort systematically evaluated the redesign of pediatric neuropsychological reports in an outpatient clinic serving primarily medical populations. RESULTS: Revised reports were shorter, with improved readability, structure, and effectiveness in communicating results and recommendations. Improved clinical efficiency was also observed. CONCLUSIONS: We suggest that adaptation to efficient, readable, and effective reports is possible within the practice of neuropsychology. Findings encourage replication in other settings. Through collaboration with key stakeholders, providers can identify their populations' and audience's unique needs and set report targets accordingly. To encourage that practice, we summarize our general process, provide a set of guidelines that can be adapted across multiple settings, and include an appended sample report.

Time to follow commands remains the most useful injury severity variable for predicting WeeFIM® scores 1 year after paediatric TBI.

OBJECTIVE: To investigate the relationship between injury severity variables, particularly time to follow commands (TFC) and long-term functional outcomes in paediatric traumatic brain injury (TBI). METHODS AND PROCEDURE: Participants included 40 children with moderate-to-severe TBI discharged from inpatient rehabilitation. Measures of severity were initial Glasgow Coma Scale score, TFC, duration of Post Traumatic Amnesia (PTA) and total duration of impaired consciousness (TFC + PTA). Functional outcome was measured by age-corrected Functional Independence Measure for Children (WeeFIM®) scores at 1-year after discharge. RESULTS: Correlations indicated that injury severity variables (TFC, PTA and TFC + PTA) were all associated with functional outcome. Regression analyses revealed that TFC and TFC + PTA similarly accounted for 49% or 47% of the variance, respectively, in total WeeFIM® score. Thirty-seven of 40 children had good outcome; of the three children with TFC >26 days, two had poor outcome. CONCLUSION: PTA and TFC + PTA do not provide a benefit over TFC alone for prediction of long-term outcome and TFC is identified earlier in the recovery course. TFC remains an important predictor of functional outcome 1-year after discharge from inpatient rehabilitation after paediatric TBI.

Therapeutic assessment with an adolescent: choosing connections over substances.

This case study provides an in-depth example of a comprehensive therapeutic assessment with an adolescent (TA-A) and his parents. The TA-A addressed parental concerns about their son's drug experimentation as well as the adolescent's own private questions about his distinctiveness from others, all set against a backdrop of ongoing parental conflict and poor communication. The TA-A process and how it is specifically tailored to balance the needs of adolescents and their parents is discussed. Subsequently, each step of TA-A is illustrated through the case study. Research findings at the conclusion of the assessment and at follow-up indicated significant decreases in internalizing symptomology and school problems, increases in self-esteem and self-reliance, and improved family functioning as reported by the adolescent. At follow-up, the father spoke of developing a more assertive parenting approach and successful follow-through on recommendations. This case study provides a template for clinicians interested in conducting TA-A.

"Why won't my parents help me?": Therapeutic assessment of a child and her family.

We present a case study of a child's psychological assessment using the methods of Therapeutic Assessment (TA). The case illustrates how TA can help assessors understand the process and structure of a family by highlighting how maladaptive family processes and interactions impact a child's development. It also illustrates how TA with a child can serve as a family intervention. In this case, it became apparent that the child's social difficulties were significant, not minor as initially reported by the parents, and were rooted in an insecure attachment, underlying depression, an idiosyncratic view of the world, and longing for attention, all of which were hidden or expressed in grandiose, expansive, and off-putting behaviors. In addition, the familial hierarchy was inverted; the parents felt ineffective and the child felt too powerful, leading to enhanced anxiety for the child. Intervention throughout, punctuated by the family session and feedback sessions, allowed the parents to develop a new "story" about their child and for the child to experience a new sense of safety. Following the TA, the parents and child indicated high satisfaction, enhanced family functioning, and decreased child symptomatology. Subsequent family therapy sessions allowed the family to further implement the interventions introduced in the TA.

Family sessions as part of child psychological assessment: goals, techniques, clinical utility, and therapeutic value.

Including a family session in a child assessment can significantly advance the assessor's and parents' understanding of the child's problems and enhance the likelihood that parents will follow through on recommendations after the assessment. A family session allows the assessor to observe the child in the family context, test systemic hypotheses, better understand the meaning of individual test results, and try out possible interventions. A family session may also help parents see systemic aspects of their child's problems, help the child feel less blamed, foster positive experiences among family members, and offer the family a glimpse of family therapy. We describe methods and techniques for structuring family sessions and offer guidance on preparing for and conducting such sessions depending on one's case conceptualization. Detailed case examples illustrate each technique and demonstrate the immediate and subsequent impact of family sessions as well as their therapeutic value. We also address common clinical and pragmatic issues.