Psychodiagnostic Assessment

UNIT 6
Psychological report

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 The psychological report

The psychological report is one of the most important end

products of assessment:
▷ It constitutes an integration of the assessment data into a
functional whole so that the information can help to make
recommendations for future steps and/ or treatment (Growth-
Marnat & Wright, 2016).
▷ The central purpose of the report is to answer/address
the referral questions.
▷ The report is based on the case conceptualization

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Remember the questions that guide a case conceptualization:

▪ Has the person a significant clinical condition?

▪ What kind of clinical condition?

▪ What are the causes of the patient´s discomfort?

▪ How do the patient’s biology/physiology and social interactions (family, work)

contribute to the disorder?

▪ Is it an acute or a chronic clinical condition?

▪ How could the condition change in a short and/or long term? Under what
situations might these changes occur?

▪ What is the best therapy for this clinical condition?

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Psychodiagnostic reports according to class
Categorical (nomothetic or quantitative):
▷ Uses inclusion/exclusion criteria from specific categories (DSM, ICD-10).

Descriptive (idiographic or qualitative):

▷ Describes the elements and levels of cognitive, emotional and behavioral
performance of the patient.
▷ Assesses the discourse, symptoms, personal and family history, health record,
functional adaption, and personality characteristics.

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The psychological report
▷ The psychodiagnostic report allows to transmit, in
written form, to the patient, colleagues and
professionals, an objective scientific diagnostic
certification, which provides a comprehensive case
description, elaborated through diagnostic criteria
shared at a scientific and international level (DSM/
ICD).
▷ The language used, although technical, is based on
a terminology that is understandable by other
professionals and the client himself.
▷ The purpose of the report is also to keep a historical
record of the assessment, as well as all the data
related to the case.

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 Structure
▷ Most assessment reports are structured documents, with multiple levels of headings that
make it easy to find particular kinds of information quickly.
▷ A common practice is to write the report in roughly the same order in which the assessment
process occurred:

○ First, there was a referral.

○ Then an interview was conducted in which background information was obtained.
○ Then came the testing, with some behavioral observations along the way.
○ Then the observations and test data were interpreted.
○ Then the information was summarized, perhaps leading to a diagnosis.
○ Finally, recommendations are made.

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Structure Title or heading

The most common

components of a typical
report are:

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 1. Identifying information
▷ Basic demographic information about the individual and relevant current
circumstances.

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 2. Reason for referral
▷ The reason for referral should give an orientation to the types of issues that are
addressed.
▷ Begin this section with a brief description of the client and the nature of the problem
○ “Mr. Smith is a 35-year-old, European American, married male with a high school
education who presents with complaints of depression and anxiety”

▷ Provide a description of the general reason for conducting the evaluation (reason for
referral)

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▷ An effective reason for referral should accurately describe the client’s current
problems.
▷ After the reasons for referral have been clarified and outlined, they can be addressed
throughout the rest of the report.
▷ It is helpful to reiterate and summarize the answers to the referral questions
toward the end of the report → number each of the referral questions listed in the
Referral Question section of the report and follow this up with succinct answers to
each question in the Summary and Recommendations section.

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 Examples of possible reason for referrals (Schneider et al. (2018)

Noelle, a sophomore in pre‐medicine, referred herself for an evaluation because of difficulties with spelling.
Many of her teachers over the years have suggested that she be tested, but her parents never pursued an
evaluation. Recently, a college English professor spoke to her about her many mistakes in writing and
strongly recommended that she contact the university learning disabilities clinic for dyslexia testing. Noelle
would like a better understanding of why she has such difficulty spelling, as well as suggestions for how she
can improve her skill.

Jonas has been receiving occupational therapy and learning disability

services in a resource setting for the last 3 years. His fourth ‐grade teacher,
Ms. Mantell, and his parents have expressed concern about his overall
motor development, particularly his poor handwriting, and want to know
ways to help Jonas.
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Examples of possible referral
questions
(Schneider et al., 2018):

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 3. Background information (relevant history)
▷ Background information should include aspects of the person’s history that are
relevant to the problem the person is confronting and to the interpretation of the test
results.
▷ Relevant history, along with the referral question, should place the problem and the
test results into the proper context.
▷ What information to include?
○ Brief summary of the client’s general background, descriptions of family
background, personal history, medical history, history of the problem, and
current life situation.

Chronological o thematic sequencing?

Start with a chronological history of the relevant concerns that prompted the referral, and
organize the remaining material thematically where possible.

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 Relevant History: Family information
▷ Family information helps to determine causal factors, what variables might help
maintain relevant behaviors, and the extent to which the family should be used as
either a focus of systemic intervention or as social support
▷ This may include.
○ Parents are separated/divorced
○ Socioeconomic level, cultural background, health status
○ Emotional medical backgrounds of close relatives
○ General atmosphere of the family
○ Common family activities, urban/rural environment

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 Relevant History: personal history
▷ Information from infancy, early childhood, adolescence, adulthood.
▷ Early medical history
▷ Development of peer relationships and school adjustment
▷ School grads, best or worst subjects, repeated grades
▷ Relationship with parents
▷ Romantic and sexual relationships
▷ Substance abuse
▷ Employment/occupational adjustment
▷ Career goals
▷ Hobbies, leisure time

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 Relevant History: history of problems
▷ Initial onset and nature of symptoms
▷ Changes in frequency, intensity or expression
▷ Previous attempts at treatment, outcomes
▷ Precipitating and reinforcing causes

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 Example background information from a child´s report
Jonas is an only child who currently resides with his parents, Dr. Arthur Haggerty, a dentist, and Dr. Margaret
Rawson, a college professor. Both parents work full time. The Rawsons adopted Jonas at birth. His biological
mother was 14 years old when Jonas was born.
According to the adoption agency, his biological mother smoked cigarettes throughout the pregnancy and concerns
were raised about possible drug and alcohol use during pregnancy. It is impossible to know what role, if any, his
biological mother’s substance use played in Jonas’s developmental problems. Although smoking and substance use
during pregnancy do not usually result in developmental problems such as Jonas’s, they are known to increase the
risk of such problems.
Jonas attended preschool for 2 years and then entered Ashton Cove Elementary School for kindergarten. Although
his motor development delays were noted by his parents and monitored by his pediatrician throughout his preschool
years, a comprehensive occupational therapy evaluation was not conducted until he was in first grade. The primary
findings from that assessment were that Jonas’s fine ‐motor development was almost a year and half behind children
his age and his gross‐motor development was over 2 years behind. He demonstrated weakness in his abdominal
muscles and hip flexor muscles, which are important for proper posture and efficient walking and running. Jonas
was observed to walk primarily on his toes, as is common among children under 3. Jonas was unable to hop on one
foot without losing his balance.

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 Example background information from a child´s report
Now that Jonas is 9 years old and in fourth grade, delays are still apparent in his gross ‐motor development. Jonas is
unable to ride a bicycle or tie his shoes with ease. He walks with an awkward gait and often trips. Because of
continued toe walking, Jonas is currently wearing casts on both legs to stretch his heel cords and position his feet
flat on the ground. When the casts are removed, Jonas is scheduled for physical therapy to help strengthen his legs.
Recent results from a brain magnetic resonance imaging (MRI) indicated subtle cortical dysplasia involving the
cerebellar hemispheres (the area of the brain involving motor development and balance). These findings are
supported by clinical observations.
For the past 3 years, Jonas has received special education services in a resource setting under the category of
Specific Learning Disability. He has also received half ‐hour weekly occupational therapy services. He currently
uses an Alpha Smart, a small computer with a screen and a keyboard, in his classroom to assist with lengthy writing
assignments. Jonas reports that he wants to quit his karate class and that his favorite activities are playing video
games, watching old television shows on his iPad, texting with friends, and eating candy.
Despite his difficulties, Jonas’s parents note that he is creative and articulate and has a good sense of humor. He
collects action figures and posts entertaining video reviews of his purchases on social media. When asked to write
what he likes to do on the weekends, Jonas wrote, “Watch YouTube, play Xbox, and fall down the stairs.”

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 4. Test administered and procedure
▷ Lists the tests and other evaluation procedures (previous records and relevant
reports, etc.) used but do not include the actual test results.
▷ Use full test names along with their abbreviations then you can later in the report use
only the abbreviations. E.g. Trail Making Test (TMT)
▷ Number of assessment sessions and summary of content, e.g.:
 First contact: phone call from the sister
 First session: interview with Andres and his mother
 Second session: cognitive assessment and interview with the mother
 Third session: personality assessment and interview with the mother
 Fourth session: devolution interview

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 5. Behavioral Observations
▷ A description of the client’s behaviors can provide insight into his or her problem and may be
a significant source of data to evaluate test validity and confirm, modify, or question the test-
related interpretations:
○ Appearance (facial expressions, clothes, mannerisms, and movements, etc)
○ Behavior toward the psychologist
○ Degree of cooperativeness
○ Psychologist -client interaction

▷ Observations should be tied to behaviours:

“her speech was slow, and she frequently made self-critical

“depressed”
statements, such as ‘I’m not smart enough to get that one right.’”

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 Describing interpretations of behaviours
Behaviors Interpretation Description in report
Foot tapping, Anxiety Eduardo found it stressful to be tested, and he coped with his nervous
fidgety hands, energy by letting his body move—tapping his feet, fidgeting with his
twirling hair pencil, and twirling his hair. As with many people who have frequent
panic attacks, Eduardo experiences strong urges to flee the room
when stressed, and fidgeting helps him to control those urges.
Slouching in Resistance Michelle resented her parents’ suggestion during the interview that
chair, averted there might be something wrong with her and thus resisted
gaze, silence being assessed. She would not risk being openly defiant to her
parents (or to me), but communicated her resentment by slouching
low in her chair, avoiding eye contact, and stonewalling when asked
questions. To a degree that is unusual for an 11‐year‐old, Michelle
has a strong sense of privacy and dignity, and in her quiet way, will go
to great lengths to preserve it.

(adapted from Schneider et al. 2018)

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 Activity
▷ Provide example descriptions of Andrew´s behavior.

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 6. Results and interpretation
▷ Main body of the report and all inferences must be based on an integration of the test data,
behavioral observations, and relevant history.

1. Cognitive abilities
2. Academic achievement
3. Adaptive behavior
4. Personality
5. Mental health
6. Social functioning
7. Vocational interests
8. Occupational functioning
(adapted from Schneider et al. 2018)

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 6. Results and interpretation
▷ Use a clear, direct, simple language, avoiding professional jargon.
▷ Better “person-focused” than “test-focused”:
 Present results from tests thematically, rather than test-by-test
 Present results in terms of abilities or traits, rather than in terms of tests
themselves
 When results are presented by test or method, include a comprehensive,
integrative summary that describes what the data mean, taken together, for
the specific individual being evaluated

Maries PSCI scores (82nd percentile) were higher than her VCI scores (62nd percentile),
indicating that her processing speed is better developed than her verbal abilities.

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▷ A useful tool for organizing
the assessment data is a
grid with the topics for
consideration in the left
column the assessment
results in the rows.

Don´t use raw scores (“he

correctly answered 15 of 35
questions”). Always use
standard scores and
percentile ranks
(Growth-Marnat & Wright, 2016)

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 Intelligence/cognition

▷ A client’s intellectual abilities often provide a general frame of reference for a variety
of personality variables. For this reason, a discussion of the client’s intellectual abilities
usually occurs first:
▷ The description of intelligence (IQ scores and specific abilities) should be followed by a
discussion of the client’s intellectual strengths and weaknesses:
○ Elaboration on the meaning of the difference between index scores or describing
subtests
○ Comparison of the client’s potential level of functioning with his or her actual
performance.

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Results should be written in a narrative way

▷ Instead of writing: “On the Processing Speed test, Jaime´s score was 117, a score in
the 87th percentile compared to same-age peers.”, write:

▷ Regarding the processing speed of visual information, Jaime showed skills above the
average for his age, as his score of 117 fell in the 87 th percentile, meaning that 87%
of his age group normally score lower than him. Processing speed is a measure of
the velocity at which simple tasks are performed and is related to the monitoring,
and filtering of visual task-relevant information.

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Focus on the underlying constructs a test measures

▷ The Bayley Scales of Infant and Toddler Development–III was administered to Greg
(age 38 months). His successes and failures ranged from 12 months to 17 months.
His performance on tasks that did not require language was more advanced than
his performance on those that measured receptive and expressive aspects of
language. On the Bayley‐III Behavior Rating Scale, Greg’s Orientation/Engagement
was in the average range for his ability level, whereas his Emotional Regulation was
below average. Motor Quality was nonoptimal, although he was able to pick up and
use the toys and objects given to him.

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Provide person-centered descriptions

Test-centered Person-centered
Ken’s score on the BASC‐3 Ken has felt depressed for the last 4 months since he
Depression was 78 but on moved away from home to attend college, explaining his
the Parent scale of the score of 78 on the BASC-3 Depression Scale. His private
same name his mother’s thoughts have been relentlessly self‐critical, and he has
ratings yielded a score of been isolating himself from his friends. However, when
only 58, which is family comes to visit, he does not show his low mood in
significantly lower. order to “not bother anyone with my problems.” Thus,
although Ken’s mother noticed that he has been isolating
himself from others, she is not aware of the full intensity of
his distress because he has successfully concealed it from
her, which explains why the mother estimates Ken´s mood
much more positively (score: 58) than he does.

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 Indicate the relative
magnitude of the
relevant scores
(“Very high,” “High,”
etc.) or clinically
meaningful cutoffs.

(Schneider et al. 2018) 30

Description of test score
types
(Schneider et al. 2018)

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Personality and psychopathology

▷ The written report should provide a comprehensive psychological profile or

character analysis of the person being evaluated.
▷ Good reports, create narratives that are based on carefully gathered information (e.g.,
history, demographics, intellectual profile, and test scores), while also organizing and
making sense of the facts of the case.
▷ Establishing whether a person suffers from bipolar illness, for example, includes
getting a thorough history of any manic and depressive episodes, a medical history
and recent examination, and a history of past and current drug use.

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 Personality and psychopathology
▷ Personality testing, does not significantly contribute to the information gathered
through interview, history‐taking, and record review for a diagnosis .
▷ However, an understanding of personality functioning complements and enriches a
DSM‐5 diagnosis:
 Severity of the disturbances.
 Under what conditions symptoms get worse?
 Are the symptoms chronic or a transient a reaction to current life stresses?
 Coping behaviours (adaptive/maladaptive)
 Ideation: persistent thoughts, delusions, hallucinations, loose associations, blocking
of ideas, perseveration, or illogical thoughts
 Judgment and degree of insight

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 Personality
▷ Difference between simple diagnosis and report:

DSM-5 diagnoses group descriptions of behavior into diagnostic

DSM-5 diagnoses categories based on their symptoms (mania, psychosis, binge eating,
etc.)

Interpretation of the underlying dynamic that organizes and

motivates manifest behavior, e.g.:
Personality report:  Unresolvable conflict between one´s self-concept and ideal self,
 Inability to read another´s nonverbal cues,
 Pessimistic view of the world that results in distortions of
perception and reasoning.

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Personality and psychopathology
Reports are often organized as a function of the level of personality.
The level of personality functioning characterizes a person´s capacity for perception,
affect regulation, information processing, and decision-making:
1. Neurotic → functioning remains relatively stable, except discrete conflicts (for
example, about gender identity)
2. Borderline → functioning fluctuates between neurotic and psychotic
3. Psychotic → confuses boundaries between self and others and between fantasy
and reality

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 6. Diagnostic impressions and summary
▷ Summary of the primary findings and formal diagnosis or diagnostic impressions.
▷ Summary and diagnosis can be under separate headings or integrated into a single section.

Diagnostic impressions = tentative diagnoses

Diagnostic impressions may suggest future performance, but
they do not rule out a different diagnosis at another time
pending new evidence.

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 Diagnosis
▷ If previous sections of the report have clearly and thoroughly described the relevant
behaviors and symptoms, the diagnosis will not come as a surprise to any mental health
professional reading your report. In such a case, you may simply declare the diagnosis
without any elaboration. For example:
▷ DSM‐5 Diagnosis: 296.32 (F33.1) Major Depression, Moderate

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▷ When a diagnosis is based partly on specific test scores, they can be listed explicitly in
Diagnostic Impressions section. For example:

Thomas meets criteria for intellectual disability. His intellectual deficits in reasoning,
problem‐solving, planning, abstract thinking, judgment, academic learning, and learning
from experience have been evident since early childhood to his parents, teachers, and peers.
His performance on standardized tests of intellectual functioning (WISC ‐V Full Scale IQ =
66) is consistent with observed deficits in adaptive functioning (Vineland ‐3 Adaptive
Behavior Composite = 59).
DSM‐5 Diagnosis: 318.0 (F71) Intellectual Disability, Mild

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 Summary

▷ The general summary section of a report gives a concise overview of the case
conceptualization.

Adapted from Schneider et al. (2018)

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 How to integrate key points from the different sections into a summary:
Key points Summary
Reason for referral: difficulty learning and retaining mathJoy was referred for an evaluation by her
skills despite long‐term math tutoring; referred by parentsparents, who were concerned about her
difficulties learning and retaining math skills and
Background information: anxiety concerning math, school concepts despite long‐term tutorial support. In
phobia, tutoring twice a week for 2 years in math, and addition, Joy’s anxiety regarding math has
therapy for school phobia developed into school phobia. She frequently
Behavioral observations: advanced conversational refuses to go to school and has bouts of
proficiency, stated she couldn’t remember how to do despair. Currently she is receiving therapy to
certain math problems and hated anything involving help her cope with anxiety and fear of math
numbers activities in school. By contrast, Joy does quite
well in all other academic subjects. Results of
Interpretive results: Above Average performance this evaluation indicate a specific math disability.
in all other academic areas, Low performance in math; Joy requires educational programming in math
weaknesses apparent in memory, visualmotor facts, math concepts, and procedures.
coordination, visual‐spatial skills, and knowledge of math
concepts and procedures
Diagnostic
Adaptedimpressions: specific
from Schneider math disability
et al. (2018)

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 Principles for writing summaries

1. Keep it concise
2. Do not include new material
3. Avoid vague and ambiguous summaries
4. Describe the person´s strengths and abilities

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 7. Recomendations
▷ Recommendations on treatment or future actions are based on the functional analysis of the
problem and should:
 Flow directly and clearly from the data (test findings, client’s clinical presentation,
referral question, and history)
 Be easily understandable for the reader
 Include enough detail (e.g., not just recommending, “therapy,” but specifying a
specific type of therapy that is likely to be most helpful)
 Be reasonable given the patient´s circumstances

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 Types of treatment recommendations

(Growth-Marnat & Wright, 2016). 43

 Overall recomendations
▷ Use a clear, direct, simple language, avoiding professional jargon.
▷ Built a clear, coherent text organization.
▷ Integrate different portions of data into the topics of interest
▷ Describe the person rather than merely reporting test data

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 Translate technical concepts into basic English (Klopfer, 1960)

“the patient is so fearful and suspicious of people in positions of

“Hostility authority that he automatically assumes an aggressive attitude toward
toward the them, being sure that swift retaliations will follow. He doesn’t give such
father figure” people an opportunity to demonstrate their real characteristics since he
assumes they are all alike.”

“The patient “the patient has a tendency to attribute to other people feelings and
projects ideas originating within himself regardless of how these other people
extensively” might feel.”

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 Translate technical concepts into basic English (Klopfer, 1960)

“The defenses
“the methods characteristically employed by the patient for reducing
the patient
anxiety are…”
uses are…”

“the patient can understand and sympathize with the feelings of others,
“Empathy”
since she finds it relatively easy to put herself in their place.!

“The client is “when the client entered the room she stated, ‘My dad said I had to
hostile and come and that’s the only reason I’m here.” or “later on in the testing
resistant” she made several comments such as ‘This is a stupid question.”

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Devolution session
▷ The psychologist has to explain the
psychodiagnostics results using a language and
content adapted to the person who receives it.
▷ The feedback can be done in one or more
sessions, always keeping in mind the patient´s
ability of understanding and processing.
▷ After the devolution session, a follow-up
meeting can be scheduled to check how the
patient has used the information provided.

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