Essentials of Psychological Assessment Series

Series Editors, Alan S. Kaufman and Nadeen L. Kaufman

Essentials of WAIS®-III Assessment by Alan S. Kaufman and Elizabeth O. Lichtenberger

Essentials of CAS Assessment by Jack A. Naglieri

Essentials of Forensic Psychological Assessment by Marc J. Ackerman

Essentials of Bayley Scales of Infant Development–II Assessment by Maureen M. Black and Kathleen Matula

Essentials of Myers-Briggs Type Indicator® Assessment by Naomi Quenk

Essentials of WISC-III® and WPPSI-R ® Assessment by Alan S. Kaufman and Elizabeth O. Lichtenberger

Essentials of Rorschach® Assessment by Tara Rose, Nancy Kaser-Boyd, and Michael P. Maloney

Essentials of Career Interest Assessment by Jeffrey P. Prince and Lisa J. Heiser

Essentials of Cross-Battery Assessment by Dawn P. Flanagan and Samuel O. Ortiz

Essentials of Cognitive Assessment with KAIT and Other Kaufman Measures by Elizabeth O. Lichtenberger, Debra Broadbooks, and Alan S. Kaufman

Essentials of Nonverbal Assessment by Steve McCallum, Bruce Bracken, and John Wasserman

Essentials of MMPI-2™ Assessment by David S. Nichols

Essentials of NEPSY® Assessment by Sally L. Kemp, Ursula Kirk, and Marit Korkman

Essentials of Individual Achievement Assessment by Douglas K. Smith

Essentials of TAT and Other Storytelling Techniques Assessment by Hedwig Teglasi

Essentials of WJ III® Tests of Achievement Assessment by Nancy Mather, Barbara J. Wendling, and Richard W. Woodcock

Essentials of WJ III® Cognitive Abilities Assessment by Fredrick A. Schrank, Dawn P. Flanagan, Richard W. Woodcock, and Jennifer T. Mascolo

Essentials of WMS®-III Assessment by Elizabeth O. Lichtenberger, Alan S. Kaufman, and Zona C. Lai

Essentials of MMPI-A™ Assessment by Robert P. Archer and Radhika Krishnamurthy

Essentials of Neuropsychological Assessment by Nancy Hebben and William Milberg

Essentials of Behavioral Assessment by Michael C. Ramsay, Cecil R. Reynolds, and R. W. Kamphaus

Essentials of Millon Inventories Assessment, Second Edition by Stephen N. Strack

Essentials of PAI® Assessment by Leslie C. Morey

Essentials of 16 PF® Assessment by Heather E. P. Cattell and James M. Schuerger

Essentials of WPPSI™ -III Assessment by Elizabeth O. Lichtenberger and Alan S. Kaufman

Essentials of Assessment Report Writing by Elizabeth O. Lichtenberger, Nancy Mather, Nadeen L. Kaufman, and Alan S. Kaufman

Copyright © 2004 by John Wiley & Sons, Inc. All rights reserved.

Published by John Wiley & Sons, Inc., Hoboken, New Jersey.

Published simultaneously in Canada.

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Library of Congress Cataloging-in-Publication Data:

Essentials of assessment report writing / Elizabeth O. Lichtenberger . . . [et al.].

p. cm. — (Essentials of psychological assessment series)

Includes bibliographical references and index.

ISBN 0-471-39487-4 (pbk.)

1. Psychodiagnostics. 2. Report writing. 3. Clinical psychology—Authorship.

I. Lichtenberger, Elizabeth O. II. Series.

RC469.E875 2004

616.89′0075—dc22

2003066066

To Julie . . . Your passion for books and writing inspires me to keep writing. Your love of being a grandmother inspires me to be a good mother. Thank you for providing such loving inspiration.

E. O. L.

To Michael for listening and loving. . . To Ben and Dan and the joy and purpose you bring to my life . . . To the late Dr. Samuel Kirk, who taught me the importance of linking assessment results to practical interventions.

N. M.

To Mom and Dad—Hannah and Seymour Bengels—who have the courage to make it look easy to grow old. We love you both and appreciate your lifelong support of us as professionals and as your children.

N. L. K. and A. S. K.

SERIES PREFACE

In the Essentials of Psychological Assessment series, we have attempted to provide the reader with books that will deliver key practical information in the most efficient and accessible style. The series features instruments in a variety of domains, such as cognition, personality, education, and neuropsychology. For the experienced clinician, books in the series will offer a concise yet thorough way to master utilization of the continuously evolving supply of new and revised instruments, as well as a convenient method for keeping up-to-date on the tried-and-true measures. The novice will find here a prioritized assembly of all the information and techniques that must be at one’s fingertips to begin the complicated process of individual psychological diagnosis.

Wherever feasible, visual shortcuts to highlight key points are utilized alongside systematic, step-by-step guidelines. Chapters are focused and succinct. Topics are targeted for an easy understanding of the essentials of administration, scoring, interpretation, and clinical application. Theory and research are continually woven into the fabric of each book but always to enhance clinical inference, never to sidetrack or overwhelm. We have long been advocates of what has been called intelligent testing—the notion that a profile of test scores is meaningless unless it is brought to life by the clinical observations and astute detective work of knowledgeable examiners. Test profiles must be used to make a difference in the child’s or adult’s life, or why bother to test? We want this series to help our readers become the best intelligent testers they can be.

In Essentials of Assessment Report Writing, the authors provide readers with succinct, straightforward methods for writing case reports from beginning to end. Assessment reports are written in a variety of settings, and this book is designed to help a broad spectrum of clinicians, including school psychologists, clinical psychologists, neuropsychologists, forensic psychologists, diagnosticians, and speech/language pathologists. The basic guidelines and writing principles highlighted here will guide readers through writing each of the critical components of a report: reason for referral and background information, appearance and behavioral observations, test results and interpretation, summary and diagnostic impressions, and recommendations.

Alan S. Kaufman, PhD, and Nadeen L. Kaufman, EdD, Series Editors

Yale University School of Medicine

One

INTRODUCTION AND OVERVIEW

Comprehensive written reports are the summation and culmination of most psychological and psycho-educational evaluations. These reports summarize the data from test administration, integrate relevant qualitative information, and directly address the posed concerns. Because these documents inform decision making and remain for years in academic, as well as medical and psychological records, they must be well written. When well written, assessment reports can enhance treatment, guide and inform instruction, and provide critical information to the referral source and others. The findings and observations are presented clearly so that they are understandable to parents, teachers, clients, and other professionals. In contrast, when poorly written, assessment reports may be incomprehensible to parents and teachers and the recommendations impossible or unrealistic to implement (Salend & Salend, 1985). Because the results from a report can affect decisions and influence decision making for years beyond the initial evaluation, the creation of assessment reports requires special attention and care.

The purpose of this book is to review the essential elements and structure of well-written psychological and psycho-educational reports. This book is designed for novice report writers, students and interns in training, and professionals who are required to read and understand reports prepared by others. The book is also intended for professionals in the field who desire to improve their skills in preparing and writing assessment reports. As Salend and Salend (1985) asked: “What if professionals were given a letter grade on the educational assessment reports they write? Would you get an ‘A’ or an ‘F’ or merely an average ‘C?’ Yet we all recognize the importance of these reports which contain data used to formulate IEP goals and subsequent programming” (p. 277).

This text is designed to cover all aspects of preparing a written report as well as to provide illustrative samples of clear, informative reports. This first chapter provides an overview of the purposes of report writing as well as a brief discussion of the major sections of a report. The second chapter reviews many technical aspects of writing.

Each subsequent chapter focuses on the creation of a specific part of a report: the reason for referral and background information (Chapter 3), discussion of appearance and behavioral observations (Chapter 4), test results and interpretation (Chapter 5), summary and diagnostic impressions (Chapter 6), and recommendations (Chapter 8). The seventh chapter discusses personality assessment. The ninth chapter presents special issues related to reports, including feedback, follow-up, and the use of computer-generated reports. The tenth and final chapter presents several sample case reports. An Appendix at the end of the book provides information about tests cited throughout the text.

Assessment reports are written for a variety of audiences (e.g., parents, teachers, clients, physicians, attorneys) as well as to answer a variety of referral concerns (e.g., psychological, linguistic, behavioral, or academic). Reports are also written by a variety of professionals (e.g., school psychologists, clinical psychologists, neuropsychologists, diagnosticians, educational evaluators, and speech and language therapists). Although the roles of these professionals differ, they all prepare written assessment reports. Thus, the skills required to both understand and write clear, informative assessment reports are critical for a wide range of professionals in fields of psychology and education.

PURPOSES OF ASSESSMENT REPORTS

As we have noted, the general purposes of an assessment report are varied. Ownby (1997) suggested the following four desired outcomes:

1. Answering the referral questions as explicitly as possible

2. Providing the referral source with additional information when it is relevant

3. Creating a record of the assessment for future use

4. Recommending a specific course of action

Similarly, Sattler (2001) specified the following four purposes:

1. To provide accurate assessment-related information (e.g., developmental, medical, and educational history) as well as current interpersonal skills, intellectual and cognitive abilities, motor skills, and personality to the referral source and other concerned parties

2. To serve as a source of clinical hypotheses and appropriate interventions

3. To provide meaningful baseline information for evaluating progress after interventions have been implemented or time has passed

4. To serve as a legal document

Kaufman and Lichtenberger (2002) outlined several principles of intelligent testing. The report writer’s main roles are to (1) generate hypotheses about the person being assessed, (2) support or refute those hypotheses with qualitative information and test data, and (3) propose recommendations related to the initial referral. Regardless of the types of questions posed by the referral source, as Ownby, Sattler, and Kaufman and Lichtenberger suggest, the central objectives of assessment reports are to answer questions, describe the individual and his or her situation, interpret and integrate qualitative and quantitative data, and then recommend appropriate treatment, therapies, or interventions (see Don’t Forget).

DON’T FORGET

Objectives of Psychological Reports

answer the referral questions

describe the person

organize the data

recommend interventions

In a school setting, reports are the cornerstone for determining appropriate adjustments, supports, and accommodations; recommending behavioral interventions and instructional strategies; and considering eligibility and need for services. These types of reports inform the decision-making process by making a direct connection between the obtained assessment results and the most relevant types of interventions.

Although the general purposes of written reports are similar across specialty areas, some differences exist in the types of evaluation as well as the recipients. The focus in some evaluations is on the educational needs of an individual, whereas in others the focus is on behavioral or psychological concerns. For example, speech language therapists are most concerned with disorders in spoken and written language and a person’s general ability to communicate to others using speech and gestures. In some instances, a report is written for another professional (e.g., a neuropsychologist to a physician, a clinical psychologist to a psychiatrist, a school psychologist to a teacher, or a forensic psychologist to an attorney; Figure 1.1). In other instances, a report is prepared for the parents of a child in school or directly for the individual. Regardless of the recipient of the report, always assume that parents or the examinee will read it. Therefore, the language in the report must be readily understandable.

Figure 1.1 Assessment reports may be shared with many types of people.

School psychologists, speech and language therapists, diagnosticians, and educational evaluators most often assess children who are not functioning well in aspects of school due to cognitive, academic, developmental, linguistic, or emotional concerns. These assessments usually focus on determining an individual’s strengths and weaknesses, as well as specific educational needs. The results then inform the development of an educational program as well as the selection of methodologies. Evaluations are also conducted to identify gifted and talented children who would benefit from enrichment and accelerated curricula.

The roles of clinical psychologists and neuropsychologists are diverse, as are the reports they prepare. These professionals may work in hospitals, university counseling centers, community clinics, or private practices. Clinical psychologists commonly share their reports with psychiatrists, psychiatric nurses, psychiatric social workers, and other medical personnel. Most often they are concerned with the assessment and treatment of disorders in behavior, whereas neuropsychologists are more concerned with neurological functioning and how various abilities relate to learning and behavior. Because evaluators work in different settings and write reports for various professionals and purposes, the formats and language of these reports will vary. In addition, reports will vary based upon the types of tests selected as well as the theoretical orientations of evaluators.

In this book, our primary focus is upon the use and interpretation of psychological and educational tests in clinical and educational settings. We present tests and reports that illustrate samples from the domains of neuropsychology, clinical psychology, school psychology, and education. Although some details in formats of a report may vary, the majority of aspects of the reports are standard across domains.

One significant commonality of all assessment reports relates to content: The writer must focus upon the individual and the problem being assessed. The central goal of all reports is improved outcomes for the person being evaluated. Another common aspect of all assessment reports relates to writing style: The author must create the separate sections of the report but provide integration so that the report forms a cohesive whole. These two topics are discussed next.

FOCUS ON THE PERSON AND THE PROBLEM

Regardless of the type of report written, the focus is upon the person being evaluated and the problem or problems of concern. Because testing data are gathered during an assessment, some evaluators spend too much time writing about the obtained test scores rather than about what these scores mean. Novice report writers often find it challenging to maintain focus on the individual. Because the sheer amount of data can be overwhelming, it seems easier to describe the tests and obtained scores than to interpret what these results imply or mean (Figure 1.2). Unfortunately, when scores become the focal point of a report, the person being assessed seems to disappear in the array of numbers. Keep in mind that the referral source is not interested in the scores per se but in what these scores mean in regard to an individual’s intellectual or academic functioning. Although data are often discussed within a report, present the results in such a way that the reader does not lose sight of the individual. Explain how the person responded to specific tasks, rather than simply reporting and discussing a profile of test scores (Kaufman & Lichtenberger, 2002).

Figure 1.2 Even though the amount of data may seem overwhelming, remember to write about the person and what the scores mean rather than just describing the tests and scores.

O’Neill (1995) noted that some reports provide little interpretation beyond the test scores, whereas others are based on a complex process of problem solving. She describes three diverse levels of clinical interpretation: (1) the concrete level, (2) the mechanical level, and (3) the individualized level. Reports written at the concrete level do not draw conclusions beyond scores. The emphasis is placed on describing the various obtained scores. Reports written at the mechanical level focus upon the differences among subtests and factor scores. Conclusions are drawn, but they are based only upon the differences among the obtained scores. Reports written at the individualized level draw conclusions that are based upon an integration of background information, behavior, and scores. They are explanatory and include qualitative information. O’Neill explains that these reports look at the scores through the person rather than looking at the person through the scores. The most useful reports are written at the individualized level.

COHESION AND ORGANIZATION OF THE REPORT

A typical report includes the sections listed in Rapid Reference 1.1. Although these sections are presented separately, to communicate effectively you should organize the assessment report so that it is integrated and forms a cohesive whole. Consider information in the background section when writing the test behaviors section. Integrate both background information and test behaviors with the test results and interpretation. Base the diagnostic impressions and recommendations on the referral question, background information, and observations, as well as the test results. This process of integration does not mean that the specific sections of the report lose their unique identities, but rather that one section relates to another.

Rapid Reference 1.1

Components of Typical Reports

title or heading

identifying information

reason for referral

background information

tests administered

behavioral observations

test results and interpretation

summary and diagnostic impressions

recommendations

psychometric summary of scores

Note. Some reports also contain an appendix that includes any additional handouts or readings that the evaluator wishes to share to help implement the recommendations, such as an informational sheet on pharmaceutical treatment of Attention-Deficit/Hyperactivity Disorder (ADHD) or a specific technique to use for spelling instruction.

To help with integration and organization, one rule of thumb is that findings from an earlier section of the report may be integrated when writing a later section, but not vice versa. A second rule of thumb is to attempt to answer the referral questions, even if the answers are tentative or speculative. It is preferable to write that the results are inconclusive than to ignore the questions. The reader will then be assured that the concerns were not overlooked but presented difficult challenges that are yet to be resolved. The accompanying Caution reviews these rules of thumb. The next section provides a brief discussion of how the various sections of a report relate to and build upon each other.

CAUTION

Rules of Thumb

Rule of Thumb | Example
Do not integrate findings from a later section into an earlier section of the report. | Do not describe test results in the section on test behaviors.
Never ignore referral questions. | It is better to write “The results are inconclusive” or “Cannot be determined” than to ignore the referral questions.

Reason for Referral

The reason for referral determines the focus of an evaluation and provides the rationale for the assessment. Write all other sections of the report with the referral question or questions in mind. The reason for referral also helps determine the types of assessment tools that will be selected to complete the evaluation. A referral regarding behavior may involve the use of checklists, rating scales, and classroom and playground observations; a referral regarding academic concerns may involve specific standardized measures of intelligence and achievement (e.g., a reading or math test) as well as informal classroom assessments and a review of recent homework papers.

Background Information

The background section serves the important function of placing the assessment results within a pertinent context that highlights personal history. This history is often summarized chronologically. This section may include developmental history, medical history, educational history, family constellation, employment history (if relevant), and the results of previous evaluations. In many cases, an evaluator can write this section before the evaluation is conducted, basing it on a careful review of available records and notes taken during interviews. After the evaluation, additional findings may be added based upon other factual information (such as hobbies, interests, attitudes toward school or work) that are discovered during the course of the evaluation. In general, describe past history that may be relevant to present situations (e.g., frequent school absences, motorcycle accident resulting in head injury). Do not include current test behaviors or test results in this section.

Behavioral Observations

The Behavioral Observations section covers pertinent observations related to establishing rapport as well as behaviors during the assessment, such as levels of attention, motivation, persistence, and frustration. This section is devoted primarily to behaviors observed during the testing session. If the individual was observed in another setting (e.g., in a classroom, in the waiting room, on the playground, at home), then those observations may also be included in this section. When nontest behaviors are incorporated into this section, state the specific context of the observation (e.g., classroom), describe the behaviors observed in the real-life context (e.g., cooperative), and explain whether these behaviors were consistent with those observed during testing. You may also compare behaviors observed in past assessments to the ones observed in the present assessment.

Consider the referral question and information from the background section when describing observed behaviors during testing. For example, Ben, a fourth-grade student, was referred to the school psychologist for poor attention. Ben’s limited attention was described as a notable and pervasive problem. Similarly, both Ben’s mother and teacher described him as inattentive. When describing test behaviors, note Ben’s level of inattentiveness with specific examples observed during the testing session (e.g., Ben continually had to be redirected to tasks). In general, review the concern (inattention) and determine if the present behaviors are consistent or inconsistent with this concern. If consistent, note specific examples of inattention; if inconsistent, note the differences between the behaviors reported and those that were actually observed. As another illustration, if a teacher describes a child as unmotivated (background) but the child is seen as motivated during the evaluation (test behavior), discuss the differing perceptions. When you encounter contradictory perceptions, generate hypotheses that will be supported or rejected later.

Whereas previously mentioned background information can be discussed in the behaviors section, do not bring test results or performance on specific individual tests or subtests into the Behaviors section. These test results will be presented systematically and organized carefully in the Test Results and Interpretation section.

Test Results and Interpretation

In the Test Results and Interpretation section, some of Ben’s test scores would probably relate to level of attentiveness, such as performance on tests requiring listening, memory, or speed. For example, on timed tests, Ben looked up frequently and had to be prompted to keep working. Ben also had trouble on tests that required following lengthy oral directions and would often request repetitions. You would then want to integrate these findings with the other observed behaviors, such as the report by the school psychologist, which noted that the obtained low test scores seemed to reflect Ben’s inattention rather than his ability to perform speeded tasks per se. As another example, if low scores on English language tests are related to a child’s being raised in a monolingual Spanish-speaking family (background), reiterate this information in the test interpretation section.

Diagnostic Impressions and Recommendations

Further integration occurs when writing the Diagnostic Impressions and Recommendations sections. Relate the diagnostic impressions, as well as the recommendations, directly to the referral question(s). For example, if the referral questions were about how to improve a child’s basic reading and writing skills, focus the recommendations upon the instructional methods that would be most appropriate given the child’s background, age, and prior interventions, as well as the severity of the problem. A written summary is optional. If a summary is written, highlight the most crucial background information, behaviors, and test results.

TEST YOURSELF

1. The main purpose of an assessment report is to

(a) summarize the test data.

(b) convince the person that he or she needs psychological or educational services.

(c) answer the referral question.

(d) describe current behaviors.

2. Assessment reports are mainly used to communicate between professionals within the fields of psychology and education. True or False?

3. Reports are most useful when they are written at the ______ level.

(a) concrete

(b) mechanical

(c) individualized

(d) abstract

4. The test scores are the most valuable pieces of information gained from an assessment and should therefore be the main focus of all reports. True or False?

5. A well-written report will always include a summary of findings at the end. True or False?

6. A well-integrated and organized report will

(a) integrate findings presented early in the report (such as behavioral observations) with later findings (such as test results), but not vice versa.

(b) preview relevant findings from test results in an earlier section of the report (such as behavioral observations) when relevant.

(c) keep the various sections of the report distinct (i.e., background, behavioral observations, test results) and never integrate findings until the summary section.

7. It is acceptable to write tentative or speculative answers to referral questions if the assessment results are inconclusive. True or False?

Answers: 1. c; 2. False; 3. c; 4. False; 5. False; 6. a; 7. True.

Two

TECHNICAL ASPECTS OF WRITING

When you are first attempting to write assessment reports, the technical aspects of writing can be challenging. Even experienced report writers often find themselves mired in grammatical considerations, such as maintaining consistent verb tense and checking the accuracy of subject-verb agreement. Managing the subtle nuances of English grammar and style requires careful attention to detail. Errors in grammar, punctuation, and spelling detract from the quality of a report, and an assessment report riddled with errors loses credibility. If these technical aspects of your writing are not perfect, people reading your report will not only doubt your writing abilities but will also question your clinical and diagnostic skills.

In this chapter, we review the most common stylistic and grammatical problems found in assessment reports. We discuss the basic principles of writing that are most relevant for preparing grammatically correct, error-free reports. Some of the rules that we present are followed by examples to illustrate how to apply these writing principles and how to detect and correct common mistakes.

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