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[00:00:00] Dr. Sharp: Hello, everyone. Welcome to The Testing Psychologist podcast, the podcast where we talk all about the business and practice of psychological and neuropsychological assessment. I’m your host, Dr. Jeremy Sharp, licensed psychologist, group practice owner, and private practice coach.

All right, y’all, welcome back to the last episode in the beginner practice launch series. As before, if you have not checked out the previous beginner practice launch episodes, definitely go check those out. I would say that the past 4 or 5 episodes are all geared toward folks in the beginning stages of practice because I am recruiting for the next cohort of the beginner practice mastermind group that starts in April/May. You can get more information at thetestingpsychologist.com/beginner.

Today’s episode is all about ways to collect payment in your testing practice. It might seem like a simple topic right off the bat, like, [00:01:00] hey, you just take payment, but there are many variations and ways that I’ve seen people do it. And I would like to talk through some of those so you can start to figure out what might be the best way for you.

So let’s go ahead and jump to the episode.

Okay, y’all. Again, here we are talking all about collecting payment. On the surface, you might think this is super easy. Jeremy, what are you talking about? Why is this a podcast episode? You simply provide your services and then you take payment for the services. Well, there are many ways to do this and some might work better for you.

Let’s start with the very simplest way to take payment. And that [00:02:00] way is to not accept insurance and have folks pay cash right up front for your testing services. Now, the likelihood that someone is doing this is pretty low. Actually, I haven’t run into any practices that only accept cash all upfront for their testing services, but it is certainly possible.

So this would save you the vast majority of administrative headache that comes in when we’re considering taking payment. You wouldn’t have to deal with credit card fees. You wouldn’t have to deal with installment payments or people not paying or checks bouncing. It’s pretty straightforward. Unfortunately, like I said, this does not happen very often, especially as the price for testing goes up.

So let’s assume that’s not going to be happening. Then where do you go from there? Well, if you are private pay, you have a [00:03:00] lot of flexibility about how you might want to accept payment in your practice. Insurance does limit some of these options and I’ll talk about that in a minute, but if you’re doing private pay, you have options.

The first question is, will you take credit cards? Big question. Anytime that you accept credit card payments, you will pay a processing fee of about 2.5% of the total transaction cost for the privilege to run a credit card. Some people say, oh, that’s not worth it to me. I’m just going to accept checks or cash. That’s totally fine. You do run the risk of checks bouncing, people not having checks, that sort of thing, but it is certainly doable to only accept checks or cash.

If you decide to take credit cards again, 2.5% fee, give or take, you can roll that fee into the cost of your [00:04:00] testing and simply up your price a little bit. It’s relatively minimal. Just to give you an example. For every $100 you’re charging, you would increase the cost by $2.50. So not too much. Overall for a $2,000 evaluation, this would add $50 to the cost of the evaluation. Totally fine.

So if you decide that you want to accept credit cards, which I think is a good choice, I think it’s convenient. I think it lets people pay for larger balances over time and not have that money immediately accessible in a checking account, which is helpful when we’re talking about a high-dollar service like testing. If you do decide to accept credit cards, then the question is, when do you charge those payments?

I work with a lot of practices and a lot of folks who choose to take a deposit right upfront. They [00:05:00] charge a non-refundable deposit to even book an appointment. I think that this is helpful and it does increase people’s buy-in to the testing process. It also makes it easier for you to manage your schedule because you’re not dealing with last-minute cancellations if folks get to be seen somewhere else a little bit quicker.

I think it’s a good move. It doesn’t have to be a crazy high amount. A lot of folks will just do, like, let’s say 10% of the total cost of an evaluation for a deposit. And you take that right on the phone when you book the appointment and you of course have to communicate to people that it is non-refundable, but that’s relatively easy.

If you don’t take a deposit, then what do you do? Well, depending on your testing flow, your testing model, or process, a lot of folks will take half of the payment for the evaluation at the intake appointment [00:06:00] and the other half of payment, either on the testing day or the feedback day.

You can structure that in any number of different ways. You can take a quarter of the payment on the intake day. You can take the other quarter on the testing day. You can take the remaining half on the feedback day. You can switch it up a little bit and not collect the final payment until the report is delivered. That’s totally fair as well.

There are a number of different ways to do this. I personally, just for cash flow sake, like to collect as much payment upfront as possible. We do take a lot of insurance in our practice. And again, I’ll talk through those options, but even in private pay, I think it makes sense to take a big chunk during intake because that’s going to account for the intake, planning the battery, and likely some collateral phone [00:07:00] calls, record review, things like that. So you’re going to spend a good amount of time upfront before the person comes in for testing and then a relatively large chunk during or on the testing day as well. So you’ve got the bulk of your payment collected before you do the feedback session.

Now feedback session, as we know, is going to entail feedback and report writing. So that is a good bit of work, but as much as you can collect the payment upfront, I think the better, because the longer the evaluation goes on the higher the likelihood that folks will drop out or have financial fatigue and not feel as compelled to pay or in the worst-case scenario, be unhappy with the evaluation results and think that they don’t have to pay because they don’t appreciate the results or agree with those results.

So you can switch it up. Private pay gives you a lot of flexibility. You can choose to do whatever [00:08:00] you want. Some folks collect the entire payment upfront and clients are okay with that. I think it’s all in the way that you communicate it and the expectations that you set. And then, of course, you have to deliver on those expectations.

If you take insurance, the picture is a little bit murkier because most of your insurance contracts, all of them, as far as I know, do not allow you to charge for services that weren’t rendered. So this makes it a little tougher to take a deposit. I think you do have some flexibility in being able to take a deposit. You just have to structure it in the right way and make it clear that they are not paying for services at this point. They are, again paying to hold the spot. And even that it’s a little bit murky. Certainly, consult with your insurance panels and perhaps even an [00:09:00] attorney to know if that’s doable.

What you can do is collect payment on the day of service. Plenty of medical practices, plenty of other entities operate this way where clients just have to pay for the services at the time they are rendered. So when they come in for the intake, they pay the copay or deductible amount for the intake. When they come in for testing, they pay for the estimated cost of testing.

Now you, of course, will not have the insurance claim processed and back to you by that time because it’s the day of service, but if you’re doing a good job ahead of time verifying benefits, then you should have a pretty good estimate of what it’s going to cost. So you can charge that first half of the testing payment on the testing day.

When they come back for the feedback session, most of us, I think at this point who take insurance [00:10:00] are billing the time for feedback and the time for report writing on the feedback day. So you can collect that second half on the feedback day and then submit the claim. And then it puts you in the position of maybe having to charge a little more or do a little bit of a refund or in some cases, do a big refund or charge a lot more if the insurance quote was incorrect.

Again, this all goes back to providing and getting an accurate quote in the beginning. So as long as you’re getting an accurate quote for coverage, which happens, I would say 98% of the time for us at this point, then that will help you be accurate as you’re collecting payment.

Now, some folks say, I don’t want to charge for writing the report because that’s going to take me a few weeks and I’m not going to get that to the clients. I don’t want them to pay for it. [00:11:00] That’s totally okay. And that’s the way that we do things here in our practice, at least at this moment. I think we are moving to more of a model of collecting payment on the day of feedback, but at the current time, that increases the risk that people are not going to pay when the insurance claim comes back and you need a method to control for that so that you don’t have cash flow issues.

One way to do that is to alert the client and make sure to put it in your informed consent that you will charge their card when that final insurance claim is processed. As long as you communicate that, and as long as you tell them a good estimate of what it’s going to be, then I think you’re in the clear.

So you can say at the feedback session, hopefully before that as well, that you’re going to submit the final insurance claim. It usually comes back within one to two weeks and you will charge their card for the [00:12:00] remaining balance at that time. As long as you inform people of that, I think it’s okay. I would not do that as a surprise.

The final option is that you can simply submit that final insurance claim from the feedback session or the last appointment, the last amount of report writing you did, wait for it to come back, and then send statements. We found in our practice that this is the least efficient way of collecting money. People do not respond to statements. They ignore them. They choose not to pay. They get upset. So, I think using any of the models that I’ve discussed prior to this is more valuable or more effective in collecting payment so that you’re not chasing money. That’s the last thing that you want to do.

One piece that I didn’t mention early on that I think is crucial is if you decide to take credit cards, I [00:13:00] would seriously consider requiring a credit card to make an appointment, whether it’s private pay or whether you’re going to be billing insurance, because in the vast majority of cases, even with insurance, you will be charging that card.

So, having that card on file from the very beginning is super helpful because again, it’s fine when it goes well, but if it doesn’t go well, you don’t want to be chasing credit cards and chasing payments from people. And that also gives you leverage to charge their card if their bill goes too long. If they just don’t respond for 60 or 90 or 120 days, then you can charge their card.

That’s my final piece of advice. No matter what you do, if you do take credit cards, make sure to require one on file before anyone makes any kind of appointment. Some of the EHRs out there will let you even run a test charge and validate the credit card [00:14:00] to make sure that it is real, which I think is super helpful.

All right y’all. That is it for the beginner practice launch series, an impromptu series that turned into quite a few episodes that were pretty fun to do. If you want to do a deeper dive into any of these things, there are plenty of previous episodes that you could check out. I’ve linked a lot of them in the show notes as the series has continued.

And of course, if you want to dive really deep and get a lot of support as you launch your practice, you could consider joining the beginner practice mastermind which is a group coaching experience where we’ll support you, provide guidance, accountability, homework, and cohesiveness with other professionals as you launch your practice. You can find that at thetestingpsychologist.com/beginner and schedule a pre-group called there.

Okay [00:15:00]y’all, pleasure as always. I look forward to talking to you next time as we move to some other topics. Take care.

The information contained in this podcast and on The Testing Psychologists website is intended for informational and educational purposes only. Nothing in this podcast or on the website is intended to be a substitute for professional, psychological, psychiatric, or medical advice, diagnosis, or treatment.

Please note that no doctor-patient relationship is formed here, and similarly, no supervisory or consultative relationship is formed between the host or guests of this podcast and listeners of this [00:16:00] podcast. If you need the qualified advice of any mental health practitioner or medical provider, please seek one in your area. Similarly, if you need supervision on clinical matters, please find a supervisor with expertise that fits your needs.

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Dr. Sharp: Hello, everyone. Welcome to The Testing Psychologist podcast, the podcast where we talk all about the business and practice of psychological and neuropsychological assessment. I’m your host, Dr. Jeremy Sharp, licensed psychologist, group practice owner, and private practice coach.

Hey everyone. Welcome back. I’ve got another return guest with me today, Dr. Jordan Wright. Jordan is here talking all about context-driven conceptualization in assessment. If you don’t know Jordan, he’s been on the podcast two times before, so go check those episodes out. Jordan was here talking about telehealth assessment and supervision of assessment, both great episodes linked in the show notes.

Today we’re talking about context-driven assessment. This is such an important topic. It really gets at the idea that not every diagnosis or every problem is firmly rooted solely in the individual as a personal fault, if you will, of that individual, but that contextual factors are incredibly important as we consider our conceptualization.

So we talk through the different types of contexts that might influence assessment. We talk about how to get at context a little bit better. We talk about the relationship between conceptualization versus diagnosis and how those play into one another and might be separate. We talk about lots of other things, but those are some of the main topics.

Let me tell you a little bit about Jordan before we get to the conversation. He is on faculty at New York University, where he is a Clinical Associate Professor, Director of Clinical Training for the Counseling Psychology PhD program, and Director of the Center for Counseling and Community Wellbeing.

Jordan is the author of multiple books on assessment, including Conducting Psychological Assessment: A Guide for Practitioners; the Handbook of Psychological Assessment; and Essentials of Psychological Tele-Assessment. He does a lot of research. He’s published in the areas of LGBTQIA+ psychology, social justice in psychology education, and integration of context and culture in psychological assessment.

He’s also a regular presenter speaker and CE workshop provider on a number of topics: data integration, report writing, and infusion of culture and context within assessment. He recently led a team of colleagues in the production of a new paper on the state of evidence-based psychological assessment which has been accepted and will be published in Professional Psychology: Research and Practice.

Jordan has his hands in a lot of things. I’m always so amazed at the quality of work that he’s doing given the number of things that he’s doing. So, we’re lucky to have him again and talking about one of those areas of expertise.

Without further ado, let’s get to my conversation with Dr. Jordan Wright.

Dr. Sharp: Hey Jordan, welcome back.

Dr. Jordan: Thanks for having me again.

Dr. Sharp: Absolutely. I think you’re in the three-timers club at this point, which means your jacket is in the mail. So look for that.

Dr. Jordan: Excellent. I look forward to it.

Dr. Sharp: I’m always glad to have you. It is so interesting to me. We’ve talked about this off-air that you seem to do many things well. We’ve had a different topic every time we have talked and they are very distinct. And today’s going to be distinct. I have a lot of admiration for how you seem to be able to be researching and practicing and all these different ways and doing these things well.

Dr. Jordan: It’s my ADHD. I get tunnel-focused on certain things, I get passionate about them and I go deep, deep, deep diving on them, they [00:04:00] become my focus for a good amount of time, and then I move on.

Dr. Sharp: Okay. Well, it seems to be working well professionally, at least. So I’m glad to be able to take advantage of some of that.

So, you are back today. We’re talking about context-driven assessment. We’re going to dive deep into that: what it is, why it’s important and different aspects of that. But I’m curious, just to lead off, as usual, particularly in the context of our beginning comments, why this? Why now? Why are you spending time on this of all the other things?

Dr. Jordan: I think there are big, good movements in our field more generally to understand people more contextually. Our history as a profession has very much localized psychopathology illness deficit within individuals. We’ve decided that ADHD is your brain working wrong. We have decided, unfortunately, that autism is your brain working wrong. That all of these things, even depression, anxiety are localized entirely within yourself and they are yours to deal with. You go to individual counseling. You deal with it yourself.

And I think that we haven’t given enough attention to all of the contextual factors that play a role in the development of these problems, in the maintenance of these problems, in coping as well. Certainly, contextual factors play a role in keeping us going, but there are so many contextual factors that play a role. Some of these are cultural contextual factors. Some are personal history contextual factors.

All of these things multiply determined when someone doesn’t function optimally. When somebody is in distress, is so multiply determined by an interaction between who they are, how their brains work, how their bodies work, how everything works, and all of the context around them.

And when I started looking at all the measures we use, when I started looking at very traditional psychological assessments, we just don’t give this the respect it deserves. We don’t collect data on context using our traditional methods very well. We get little snippets here and there of contextual issues, but not nearly enough to really understand a person as they interact with the world.

One of the things I’ll say really quickly is, there’s been more discussion recently in the literature. Bob Bernstein has done great work in this area. He just published a comment on this in the journal of personality assessment around how people behave differently in different contexts.

So, it’s not just the context that drives things that are pervasive and things that are problematic in our lives, but also we behave differently in different contexts. I know that seems basic, but when we write up our testing report, they assume that we are monoliths. We behave function exactly the same way throughout our lives, across different contexts across time.

And I think more and more, we need to respect the fact that our context, our culture, our society, our immediate context, our interpersonal relationships, all of these things are playing a role in how we function moment to moment throughout our lives.

Dr. Sharp: There’s a lot to unpack there. I totally agree with you. I think that’s something that I’ve been working on across my career is moving away from that idea that an assessment is the rule and a blanket sort of broad document that is meant to cover someone’s entire life basically. And this is just largely born from getting old enough at this point. I’ve evaluated kids multiple times from when they were like 3 to 10 to 17, and I’m like, these results are very different. What’s going on here? I thought I was right the first time.

Dr. Jordan: Absolutely. I think probably developmentally, we do a little bit better. We say let’s retest in three years. Let’s do a little remediation. Let’s do a little intervention.

I think we’re better at that than we are at adults where we slap on a diagnosis. I know we don’t mean to, but diagnoses carry so much power and so much weight and feel so finite. They feel determinant in some way, like, oh, you have a borderline personality disorder. That is who you are across every context, across time. Good luck with it. Get some treatment and maybe you’ll go into remission a little bit. Maybe you’ll be able to function one day. We don’t maybe mean to propose these things in this way, but I think the way diagnosis works implies that too much no matter how careful we are about it. 

Dr. Sharp: That’s true. I’m curious before we really dive into this, do you have a sense of where this practice came from to pen diagnosis, I don’t know if self-imposed is the right word, but do you get what I’m saying? Located within someone versus within our within context. Where’s that coming from?

Dr. Jordan: Sure. It comes straight from Freud, right? We’re talking interest psychic. Freud was brilliant in a lot of ways, gave us a lot, thought a lot about determinism. There’s a lot to take from that. He was also dead wrong about a bunch of stuff. He talked a lot about how things solidify within us from those early interactions from your parents from your mother, all that kind of stuff. But he located everything within the individual.

And even as we progressed, I think psychology became the study of the individual, not necessarily the study of the individual in context or the study of the individual in interaction with other stuff around them. So even the behaviorists, especially the cognitive psychologists are really locating everything within your brain.

When you look at a lot of social psychology research, it’s really looking at social cognition. It’s really thinking about how people are thinking about the social world around them. I am the protagonist. My world around me is just secondary to the way that my brain functions. So it’s been perpetuated, I think, throughout.

And I think there’s a lot of value to a lot of it. I don’t want to throw out everything we know about how brains work and how the mind works and all of that. But I do think we need to start respecting the interaction between us and our environment a little bit more. 

Dr. Sharp: That’s fair. I do want to ask you some questions around that like how do we have some nuance here and balance neurobiology, for example, and things like that, but I think this is a great place to start.

People may have an idea already, but I’d love to get a good working definition of context-driven assessment. What are we talking about with that phrase? And is there a better phrase? I just picked that. 

Dr. Jordan: Yeah. That’s not an exact phrase that I use when I publish in this. I really think about deliberate context-sensitive conceptualization.

So we’re not necessarily mitigating diagnosis. We’re not necessarily negating individual factors. The way that our brains work. We might be talking about brains that represent natural human diversity, right? Not everybody’s brain works the same.

What we’re talking about is when we think about contextualizing how an individual is functioning in their life, we are taking into account in a very methodical deliberate way, the potential role of contextual factors. We’re not saying that everything is contextually driven. We’re not saying that everything is 100% defined by context or defined by things that are outside of the individual brain or the individual mind, but we are saying, let’s at least consider it. Let’s be deliberate in thinking about what other factors are playing a role if you are not functioning perfectly in life. 

Dr. Sharp: Sure. Do you feel like psychotherapy has done a better job of this than assessment over the years? That’s my inclination, but I don’t know. Your face says maybe that’s not the way you think.

Dr. Jordan: That’s not fair. They can’t see my face. I think probably in general, psychotherapy has done a slightly better job. When we think about family systems therapy, when we think about other systemic therapies, they’ve probably done a better job.

However, we also know that the history of psychotherapy has been an individualized treatment. It has absolutely been, let’s make you fit into your context better. Let’s change you. Let’s not change the world around you. Let’s not adapt to your social environment. Let’s change you to pretend that your brain works the way that everyone else’s brain expects it to.

So, I’m actually not sure we’ve done a better job in psychotherapy on the whole. I think some people do a better job. I think there are people who are advocating for change. When I think of, for example, the subfield of counseling psychology, there’s a lot more advocacy that’s happening to change the world around us as opposed to historically I think clinical psychology, which has located most of the work in for psychically.

Dr. Sharp: That’s reasonable. Do you know much about how this shows up in other countries or other cultures assessment-wise? I think about it very simplistically, just like more collaborative cultures versus the US which is a little more individualistic. Do we know anything about what assessment looks like in 

other places?

Dr. Jordan: I would not dare to say that I know across the world and all that, I do know two other cultures which when it gets to the point of psychological assessment, they are necessarily thinking of it as a disease. They tend to actually be much more medically oriented when it comes to this.

I actually think that other disciplines are probably better at this than we are. I think social work is better at considering all of the factors around people when they are conceptualizing. Of course, they’re not doing comprehensive, formal, psychological assessments in the way that we are, but they’re collecting data about individuals. They are writing up little psycho-social reports that try and understand how people are functioning. I think public health does this better than we do because they are just outwardly focused in a way that we’ve become very inwardly focused.

Dr. Sharp: That makes sense. Even this far into the conversation, which is not very far, it’s just recognizing there is so much that we could look into with this. There’s a lot of work to do.

Dr. Jordan: Yeah. As if psych wasn’t complicated enough and brains weren’t complicated enough, now we’re adding 3 million other interactions that we need to respect and pay attention to. 

Dr. Sharp: Yeah. I asked this question when we were chatting about what we will talk about, but that interplay, and what does this do to the integrity of diagnosis, if that’s even reasonable. It’s sort of like foundation. I have this very concrete black and white, all or nothing brain sometimes, and I’m like, okay, if we’re not thinking diagnostically and we have to take all these contextual factors into account, what are we even assessing? And why is [00:16:00] this important? Do people get assessed every year or every six months? So these are all the questions that come up for me. You can take that wherever.

Dr. Jordan:  You said you have a black and white brain sometimes, you mean every time across every context across all of human history, right? You are black and white in everything.

Dr. Sharp: Yes.

Dr. Jordan: Even that is contextual. This is not meant to undermine diagnosis. Diagnosis is a shorthand that we use to communicate with other professionals. It’s a list of symptoms that are clustered together that most psychiatrists have decided to cluster together phenomenologically, and we use it as shorthand. We use it to research. We use it to talk to other professionals about what we’re treating and how we’re treating it. This is a shorthand, but it’s also meant to be contextual. It’s meant to be decontextualized where we’re writing a little checklist of symptoms that you are exhibiting and that’s diagnosis.

So it’s not meant to necessarily undermine that. It is meant to add nuance to it. So we’re talking about conceptualization not diagnosis, and they are of course, inextricably linked, but they are different things. When we talk about conceptualization, you’re talking about thinking about the person sitting in front of us and tying it to psychological feeling. That’s what we’re talking about when it comes to conceptualization. It’s the why is this happening? Not the, what is happening.

Diagnosis is what’s going on. This is all about why this is happening. What led to it? What caused it? What contributed to it? What is keeping it up? What is strengthening it? When is it better? When is it not? That’s all part of conceptualization and that’s what we’re talking about here. Not necessarily the integrity of diagnosis, which is super debatable and a totally different topic. 

Dr. Sharp: Absolutely. I like that distinction. And again, thinking about it in terms of, at least the reports that we write, there is a section where we’re symptom-driven and it’s like, okay, this is showing up. This is showing up. Here’s the diagnosis. But then there’s a whole other section that’s more or less real-world effects, or like, how does all this matter or something. We’re pulling in all this into like you said, the conceptualization, the why and how this actually shows up, and the nuance, I suppose.

Dr. Jordan: Yeah. Often when I’m doing, for example, ADHD evaluations, which are fairly straightforward and someone comes in and says, I want to know, do I have ADHD or not? I always steer them in a different direction and say that that’s not a great assessment question, because if the answer is, yes, that is helpful. If the answer is no. And I say, you don’t have ADHD, have a nice life, that is not helpful at all.

So the real question is what’s underlying your problems with attention, right? You’re coming in for a reason. You probably have some problems with attention or executive functioning or organization or planning or whatever. What’s underlying that?

And so, yes, diagnosis is going to be part of that, but I also need to tell a story of what’s going on for you. Is something exacerbating this? We can have ADHD and some depression or anxiety that is cyclical, right? We can absolutely worsen our anxiety with ADHD. We can absolutely worsen our attention with anxiety. This is a psychological theory that’s helping us be more comprehensive and narrative about what’s going on for a person sitting in front of us, rather than just giving them a big stamp of ADHD on their forehead. 

Dr. Sharp: Yeah. Right. Well, I know in some of your research, you talk about different examples of context, or things we might want to consider. Could we maybe talk about some of those examples?

Dr. Jordan: Sure, I’m happy to.

Dr. Sharp: Okay. Sweet. I was taking some notes while I was reading some of the research and one thing that came up right off the bat was what you call dominant culture mismatch. Can you speak to that? 

Dr. Jordan: Absolutely. I think that, in general, we tend to evaluate the people that we are testing, the people we’re working with, we tend to evaluate them through a white supremacist lens. We were brought up in that. We just can’t help it. We are biased in certain ways. We know from the research that we tend to over-pathologize communities of color, especially children of color are overrepresented in the discipline.

There’s some great research about the exact same behaviors by Latino girls and white girls are attributed as assertive versus aggressive. Latina girls are labeled as aggressive for the exact same behaviors that white girls are labeled as assertive for. There’s just so much to unpack here.

In my paper, I admit that this is not doing justice to the fact that our culture is racist. Our culture is sexist. Our culture is heteronormative. All sorts of isms. So when I talk about it as a mismatch, this is underplaying the real problems, the underlying problems.

But what I mean by it is, when there is a mismatch between how you, a client, behaves in the real world and what is expected by the dominant culture. Sometimes that is actually just us misinterpreting your cultural values. Sometimes it’s not. Sometimes it is a symptom. Sometimes it is problematic. But sometimes we need to take into account maybe our bias is getting in the way and making us interpret this child’s behavior, this adult’s behavior based on my white supremacist lens.

So this is a mismatch. This is a contextual mismatch, right? The way that you’re behaving, which may be absolutely [00:22:00] culturally sanctioned and culturally aligned with how you are brought up.

We know a lot about code-switching. Kids especially learn really early on to behave differently at home where they are within their own culture. If they then have to go to, for example, a white space, which is their school, or a heteronormative space, which is their school, they have to code-switch. They have to behave in different ways.

Some kids who do not code-switch very well are labeled as problems in the school and sent for evaluations. And it actually just has to do with a mismatch between what is culturally sanctioned, what is okay within their culture in terms of their behavior, and what is expected of them in these white supremacists, largely white, largely straight, largely SIS environments. So that is a mismatch.

Dr. Sharp: Yeah. And for anybody who might be interested in deeper discussion, particularly about [00:23:00] kids with color, the episode from a few months ago Beyond ODD and Conduct Disorder with Dr. Akeem Marsh and Dr. Lara Cox, we talk about that a lot.

Do you have examples of a dominant culture mismatch? Anything that comes to mind right off like behaviors or things that we might misinterpret?

Dr. Jordan: Yeah, absolutely. There’s plenty of research and I think the Latina girls’ research is there. I can give some clinical examples from my own practice. And I think that a lot of it has to do with people of color standing up for themselves. That is where I see it a lot. When adults of color in their workplace stand up for themselves, it is seen as aggressive. We for our white supremacist lens absolutely label people of color as some sort of danger.

For some reason, we have a shorter fuse for allowing them to be assertive. And it turns into, oh, you’re angry. You are being aggressive. In this moment, you need to reign it in. This is your problem. When in fact, actually this is absolutely well sanctioned within their culture, at home, they give back as much as they get.

For clients that I’ve seen, this is a fairly normal way of interacting with their families, with their friends. When they are talking they say, I don’t hear it as aggressive. My friends don’t hear it as aggressive. So we need to think about the fact that that is just a mismatch between what’s expected in that white space versus what is culturally sanctioned when they are in their predominantly a space of color, black space, Latino space, whatever it is.

Dr. Sharp: Right. So you also talk about, I think you call it developmental mismatch as well. What’s that all about?

[00:25:00] Dr. Jordan: Yeah. I write a lot about this in the conducting psychological assessment book and elsewhere. This is when an individual’s level of development is mismatched with what is required of them in their everyday life.

I can give two examples. One is probably the more straightforward example that we’re all used to. An adult who is emotionally dysregulated. An adult who emotionally is acting like an adolescent. I shouldn’t say that, but I have a pre-adolescent girl at home right now, so I know it well. I know that their emotions are all over the place at times. But that’s completely normal and adaptive.

It’s normative for a pre-adolescent adolescent to be overly emotional, maybe a little dysregulated emotionally.

But when we get into adulthood, that emotional dysregulation is no longer sanctioned. It’s no longer adaptive. It’s no longer normative. And it is a mismatch with what is expected of you at work, for example, right?

Our schools, especially middle schools may be more forgiving of this because they expect it. It is developmentally matched. We know, oh, okay. Pre-adolescence, adolescence. We expect it. But when we get into a professional space as an adult, there is now a mismatch between my developmental level of functioning and what is expected of me. Now that is a “psychopathology” example.

Another example is the other direction. When a very normally developing child is expected to function more as an adult is parentified, right? As an example, parents getting divorced and one of the parents needs a lot of emotional support from their child. The child is expected to be another surrogate parent. They’re expected to be the strong one, the rock because the parents are all over the place or really hurt, or emotional or whatever.

There is a developmental mismatch between what that child to completely normally developing child is able to handle emotionally, cognitively, socially in that moment and what is expected of them in their environment. That is a mismatch. These mismatches cause problems.

Dr. Sharp: Right. So in that case, it would be the parent bringing the child in for an eval and saying, I don’t know, my kid isn’t communicating like they should be, or my kid is avoidant or something like that, where they’re reacting to being parentified? 

Dr. Jordan: Or depressed.

Dr. Sharp: Or just depressed. Yeah.

Dr. Jordan: I had a client that this is exactly the dynamic that was going on. They went to school and looked depressed. We’re exhausted. We’re tired. They were kept up late at night caring for their parents and they went to school and they just looked withdrawn. They weren’t interested in school. The kid was depressed.

We could absolutely locate the entirety of the depression within this kid and medicate them, give them cognitive behavioral therapy. That is one way to go. But when you take a step back, there was this huge mismatch. There was a contextual factor that was playing a very driving role in what was going on emotionally for this kid.

Dr. Sharp: Absolutely. Let me ask an adjacent question. How might you handle delivering feedback to that parent, for example, in a case like that where I could see that being hard? I’m curious how you approach something like that.

Dr. Jordan: I usually just tell them they’re bad parents and move on.

Dr. Sharp: Great. Okay. Check.

Dr. Jordan: I shake my finger at them. No, I will tell you, since I’ve been really thinking about this contextual conceptualization model, it becomes so useful in feedback. People are so much more open when instead of saying you’re doing bad parenting stuff, we say, okay, there’s a mismatch between what this kid can handle and what is needed of them right now at home.

You have been through so much recently, and I see it. I see the pain that you’re going through. I see the needs that you have. I hope that you will take my recommendation and go and get some support yourself. I don’t say this, but outside of your child. But there is a mismatch. This child is a 9-year-old and is being asked to behave emotionally, behaviorally, socially, like an adult, and really support you.

And that’s great. I think families are there to support each other, but we also need to respect the fact that this kid needs to be a kid. Your son, your daughter, your child needs to be a child. So, even explaining it as a mismatch between this kid’s level of development and what is expected of them in the world, softens it for families. And they’ve been much more receptive in my experience to this kind of feedback than the alternatives.

Dr. Sharp: Right. Nobody likes to be confronted with perceived or intended shortcomings. I like that language. Mismatch is good. That’s going to stick with me, certainly. You also talk about, what is it, personal contextual mismatch. Am I getting that right?

Dr. Jordan: Yeah.

Dr. Sharp: What’s that?

Dr. Jordan: This is more of a catchall for the rest. And this is with reverence and respect to the neurodiversity movement and the neuro-diverse communities and my neuro-diverse colleagues. I have ADHD, but I don’t fully identify as neuro-diverse. So this is with a lot of respect to those communities. 

Dr. Sharp: Could you just do a little sidebar on the neuro-diversity community? For anybody who may not have a great conceptualization of that, what are you speaking about there?

Dr. Jordan: Sure. And you’re going to have to edit this because I’m going to be clumsy about it. I don’t mean to be clumsy about this.

This is a community of individuals whose brains work differently than what we consider allistic or neuro-typical brains. So autistic individuals, learning differences, ADHD. There is a big movement- the neurodiversity movement is pushing us as a field as I think we should to not necessarily think of these things as psychopathology, as abnormal psychology, as problems or disorders or disease, but actually very real representations of human diversity.

Neuro-diverse communities, especially come with so many strengths for us as a society. When it comes to ADHD, for example, there’s a ton of research about entrepreneurship and creativity in ADHD individuals. And if we stamp that out and medicate it out early on, then it’s bad for everybody, not just them.

There are strengths in autistic individuals. There are strengths in learning differences. There are strengths that we need to start respecting. And this is where the neurodiversity community and movement is starting to push us toward.

The personal contextual mismatch, this third bucket that you’re talking about, frankly, it’s just a mismatch between the way that a client’s brain works and what’s expected of them in their everyday life. I’ll give an example. Probably the most common example we see in clinical practice, well, depending on your practice, is our educational system has arbitrarily decided that the best way to learn is to sit with 30 other kids at a desk, listen to lectures, take notes, learn it, and then take tests to show you know it. We have just decided that that is the best way to learn and show knowledge and all this other stuff.

Now, kids with ADHD do not fare well in this. We, as a society has decided that this is a medical problem. This is a psychopathology that we need to Medicaid so that you can fit in better to these very typical Western classrooms that we’ve decided are the best way. But in actuality, maybe we need to be readjusting how we think about education, right? There is a mismatch between how this kid’s brain works and what is expected of them in terms of learning.

When we think of different learning models, for example, one-on-one education, there’s a growing movement for one-on-one education, not necessarily homeschooling, but even in school where you get a ton of individualized attention and it’s tailored to your strengths. And kids with ADHD fare extremely well. And then even test better. They do better on the SATs, which are problematic. And again, arbitrarily have decided this is a good way to show it.

So this is just a mismatch between the way that an individual’s brain works and what we have a society as a society have arbitrarily decided should be expected of everybody.

Dr. Sharp: Yeah. As someone who sent both of our kids to Montessori school for the first 4 or 5 years, I’m very much in favor of different non-traditional learning environments, at least. I totally get on board with that idea. And I think you probably, I’m just running with this example in particular, but you live in a place where I imagine there are so many choices of where kids can go to school if people have the means and the ability. Is that fair?

Dr. Jordan: That is fair. I live in New York City. I’m going to try not to break down crying because I am working on admissions to middle school for my daughter right now and it is horrible. We’re in the public school system. There are millions of choices. It’s a terrible process, but yes, there are many options if you have the means.

But I will say even there are problems in the public schools in New York City. To their credit, they do also have programs that are absolutely tailored to different types of learners. They at least put in some effort to think about kids with learning differences, different types of brains. There’s the NEST program which is a specific program for autistic kids with extremely high IQ. There’s the Horizon program for autistic kids who don’t have high IQs. They tailor the educational environment to the way that these kids’ brains learn best.

Dr. Sharp: That’s great. My reason for bringing that up, I think is that we live in a much smaller place, but we have an astounding amount of school choice here somehow. So I end up in a lot of conversations with parents around what environment might be best. And that’s a gift. That was my point with all this. It’s a gift to be able to have that conversation with some parents and know that we can do something to ameliorate that mismatch sometimes.

Dr. Jordan: That’s exactly it. We didn’t think of it in this way, but you’re doing exactly that. You’re talking about the contextual mismatch. How can we find a better match for the way that your kid works? That is honoring the context. That is thinking about it from a contextual mismatch model. 

Dr. Sharp: So this is where I ask a clunky question maybe. I’m just curious on your perspective of how to reconcile some of this with again, neuroanatomy or biology or whatever, things we know about autistic brains or ADHD brains being functionally different than other brains. How do these two things go together? That’s where I get hung up on the whole person-environment mismatch, and I’m like, oh, there’s some brain stuff going on here too. How do we deal with that? 

Dr. Jordan: I think the key is in the question. If brains are functionally different, that doesn’t mean one is better than the other.

Dr. Sharp: Yeah, that’s so true.

Dr. Jordan: We have placed value on neuro-typical brains. We as a society have placed a value on those who learn well in a general education environment. We’ve placed value on those kids who sit quietly. We know for example that a lot fewer kids are identified by teachers as potentially having ADHD if they are purely inattentive than if they are hyperactive, right? So if they’re hyperactive and out of their seat and disruptive, then absolutely they’re identified by teachers and sent to usually a pediatrician for medication.

Those kids who are anxious, those kids who are inattentive, those kids who are flying under the radar, we value that. And then the ones who are thriving, we value even more. So I don’t think these things are in competition. I think understanding that brains work differently is not saying that one brain is bad and one brain is good. It is saying just that, they work differently. One brain may be better suited to the environment of a traditional school and one brain may not be.

Dr. Sharp: Well said. Not bad, just different. I’ve used that many times. So let’s see. I had another question. Oh, I did want to ask you, you specifically mentioned this example of situating PTSD as a personal diagnosis versus more of a contextual diagnosis. Out of everything, that was pretty compelling to me. Could you talk about that for a little bit? 

Dr. Jordan: Yeah. And I think we as a field again, have underplayed the importance of trauma in a lot of problems. I’m not talking just about PTSD. PTSD is a cluster of very specific symptoms. And it is one small way that a very small proportion of people respond to trauma.

So, the idea and what I write about and what I think about when it comes to trauma is we, again, treat it as pathology and we think about individual treatment of PTSD symptoms and sending to EMDR or exposure or something like that, and how is it within the individual.

We’re a little bit better when it comes to PTSD at least honoring the fact that you’ve been through something terrible. You have had a trauma. You’ve had a capital T DSM-defined trauma. So we at least acknowledge that.

What I think we don’t acknowledge well enough is that trauma responses, how individuals respond to trauma, whether it’s PTSD or the development of what may later be labeled as personality pathology, or a personality disorder or something like that may be the way they survived, right? It may be the only way that they survived that trauma. And it may be a very natural and positive response to that trauma.

When we look at avoidance as a symptom, maybe avoidance is a good thing. Based on whatever that trauma was, maybe avoidance was the only thing that allowed this person to continue functioning in their life, in the years that followed this trauma. Maybe we don’t pathologize avoidance. Maybe we honor it and champion the fact that you survived this. You, your brain, your body has found a way to warn you.

We might think of it as an over-reactive startle reflex. When we hear a car backfire, someone with PTSD may completely freak out and that may actually be a fantastic adaptation. That may be a really good thing for thinking about how your body is warning you of danger because it knows the danger.

This is not to say we then don’t treat it or we don’t try and alleviate some symptoms that are uncomfortable. The idea is that we honor this a little bit more. When we’re conceptualizing, we really deliberately think about, okay, could this be the best way that their brain, their mind, their body could have adapted to this heinous horrible thing that happened to them, this horrible trauma that they went through, maybe this helped them survive even though it’s maybe not comfortable now and maybe not working so well right now.

Dr. Sharp: Sure. That makes sense. I think we’ve talked about a lot of examples, which is great. I also, of course, love to apply some of this. And so, I’m curious where we take this. How do we actually bring context into our assessment? I could go on. I’m going to stop there though. How do we bring context into our assessment process?

Dr. Jordan: One of the things I did was look at most of the major tools that we use: the PAI is the MMPI, the BASC, these sorts of things. I looked specifically for where context shows up on them. And it does show up here and there.

There are traumatic stress scales. There’s a stress scale. There are some family problems subscales here and there. There are interpersonal problems. There are school issues. There are little things here and there, but typically, we’re not very good at systematically collecting data around culture, around context, around adverse childhood experiences, around any of these things that play a role or potentially play a role in problems.

So I worked with a colleague to develop a measure, the WCSCI, and this is a shameless plug. But as I told you before, I’m okay, shamelessly plugging this because we developed it and it is completely free. If you Google WCSCI, it’s going to come up. I encourage people to look at it, use it, adapt it. We’ve started doing research on it and found some very positive benefits to using it in our evaluations.

What it is it’s, it’s the Wright-Constantine Structured Cultural Interview. So it is a structured interview organized around Pamela Hays’ ADDRESSING framework. If you’re familiar with it, great. If you’re not, I highly recommend you look it up, but it is specifically around culture and understanding culture.

Dr. Sharp: Sorry, can I jump in real quick? For anyone who might not be familiar, can you give a brief overview of the ADDRESSING framework?

Dr. Jordan: Sure. The ADDRESSING framework is an acronym. A-D-D-R-E-S-S-I-N-G. Each one of those is a cultural influence on an individual’s functioning. A is age and generational dynamics. D is experienced with disability either developmental or acquired. It goes through. There’s ethnicity. There’s a sexual orientation, gender identity, these other sorts of things. It’s an acronym that helps us understand cultural influences on an individual’s life and functioning.

What we did with the WCSCI was break it down into this, and there are some shortcomings, there are interactions between these when we think about intersectionality is not as prevalent, though it does come out. But we developed a structured interview that typically takes between 30 minutes and an hour depending on how many minoritized identities somebody has, traditionally marginalized minoritized identities, and asks very specific questions about not just how they identify, but what that means for them in their lived experience both historically, currently.

And we’ve built in quite a few of what we consider these contextual potential mismatches, not just pure culture, but also some of these other things. So, it’s just a systematic way of collecting data that can inform the potential contextual mismatches. And again, we’re just not good at this. We’re not good at collecting contextual data. Some people do it informally in their clinical interview, but typically not in a systematic way. 

Dr. Sharp: I love this. Can you give any kind of example of a, I’m not even sure, is it a question on this measure or however you gather this information?

Dr. Jordan: Yeah, absolutely. It’s a little bit of choosing your own adventure type of measure. You do you. There are questions for each of the addressing variables, each of those. The first question is always how you identify. So, you might start with how do you identify in terms of your sexual orientation? I’ll give that as an example. Then depending on the answer, there are different questions to ask for those who identify as heterosexual, those who identify as sexually minoritized individuals, and whatever words or terms they use queer or gay or whatever they term it in their own words.

We follow up with questions and the questions tend to focus on what has it meant being a, let’s say, a queer individual in your life? How has it affected you? How has it affected the way others interact with you? And it goes down. There are some, I’m going to put air quotes, “required questions”. Obviously, nothing’s required. But there are some strongly suggested questions. And then there are a bunch of follow-up questions that you can add to, or not ask depending on how vague it is or if it seems that to be a meatier topic.

We might think about, for example, sexual orientation needing to dig more deeply into the experience of being a queer individual within their family growing up. So there are questions about their identity within their family growing up only because that tends to be a very salient influence on the development of queer individuals. It goes further and further down each rabbit hole one by one some of which you don’t need to ask. Some of which, if it’s not salient, if it’s not important in the lived experience.

Obviously, we’re limited by insight. As any self-report measure is, any clinical interview is or structured interview, we are limited by who is reporting, but the idea is we are trying to honor their lived experience. We’re trying to get their context and their interaction with the world around them, in their own words, in their own experience. And this is how we collect the data that we can then think of when conceptualizing.

I often say this metaphor. I think of this as the pillow on which we lay the clinical presentation. So that whole context of the whole culture, the cultural context of the individual historical context is an understanding of an individual. And then we lay symptoms on top of it. How they’re functioning right now is understood with this foundation, this pillow of their lived experience within their context, within their culture.

Dr. Sharp: Yes. As you’re describing that, it just occurs to me that a huge variable in this process is the lens that we interpret the information through as clinicians. And that’s what power.

Dr. Jordan: Absolutely. I have a mentor who’s one of the smartest people I’ve ever met. And he, when training me and my colleagues, very often said, I have a blind spot for certain things. I have a blind spot for substance use. I just never really asked about it. Or I’d write it off. And he has a blind spot for money.

He had realized what his biases are, what his blind spots are. Most of us don’t right. Most of us know some of our blind spots, know some of our biases, but we don’t know what we don’t know necessarily. So going through systematically, which is the goal of the WCSCI, going through systematically one by one through the addressing variables to ask deliberately and pull these data at least covers some of those blind spots. At least it gives us a little safety net. 

Dr. Sharp: Yeah. That’s what I like about this is you’ve operationalized something that a lot of us maybe aspire to, or do somewhat haphazardly depending on the client. And now, it’s a little more structured approach, which is valuable. It’s very valuable.

Dr. Jordan: And my brain needs it in a linear fashion.

Dr. Sharp: Yes. I can get on board with that. Definitely. You mentioned other things. Are you, are you a fan of using something like the ACES in our assessment or any other measures that are floating around out there? Is there anything helpful?

Dr. Jordan: Yeah, honestly, I’m a big believer in more data, not necessarily let’s just collect every piece of data and make every type1 error we can. Well, when it comes to understanding lived experience, I’m a fan.

So things like the ACES, it’s a fine measure. It’s a research measure. It’s not really a clinical measure. And so it has limited utility yet until they research it more clinically, whoever is doing that, I don’t know if anyone’s researching it clinically. There are benefits to it. There are drawbacks to it. It is reductive.

But if we, for example, did a WCSCI and some really adverse childhood experiences came out, I might throw something in there to better understand it or to give me a more quantitative view to balance my purely qualitative idiographic view that an interview falls prey to.

Dr. Sharp: How does this translate to report writing?

Dr. Jordan: I tend to be conceptualization heavy in my reports. So when I look at the psychological functioning, when I look at the emotional and behavioral functioning, if it’s a kid or personality and emotional functioning, if it’s an adult or something like that, I tend to really care about psychological theory. I tend to really care about not just a list of symptoms or a list of findings and certainly not testify tests. I am a big believer in multi-method assessment and thinking through the WHY.

So when I go to conceptualize a case, when I write up a report, I’m going to have a paragraph that is more of a narrative paragraph that ties together all of the themes that emerged in an assessment. And one of those themes may be something like…

I had an assessment very recently where it just emerged how many invalidations this young adult, it was a young adult male, had had throughout his life. It was a pattern throughout his development of being invalidated. His parents invalidated him in his sexuality. He had had a sexual assault and a rape at one point and was told that his feelings were inaccurate about those. He had been so invalidated in his history that of course, he developed some symptoms of borderline personality disorder.

When you’re told your emotions are wrong, you learn not to trust your emotions and they get wild and erratic. When you’re told your identity is wrong, you start questioning your identity. When you’re told that your way of interacting with people is wrong, or when the people you love are treating you horribly, of course, you don’t trust them and interact with people all that well.

So the idea is when I conceptualize this within a broader contextual framework of here’s why, here’s here is a theoretical, and psychology is all about theory. We’re different than other disciplines because we work in theory. And so, we take this theory of a history of invalidation and its role in the development of symptoms of borderline personality disorder. And we take that seriously.

And when we write it up, when we present that in feedback, again, if I couch it in this history of invalidation, it is so much easier for this guy to hear than if I just listed, oh, you have problems with your identity. Oh, your emotions are erratic. Oh, your interpersonal relationships are problematic. I could just list these symptoms that emerged.

What happened, in this case, is when I gave feedback, starting with the profound history of invalidation, he started tearing up. He said for the first time he felt seen and heard and understood, and that opened him up to all the other findings. And he was like, yeah, my emotions are a mess. I know my interpersonal relationships are a mess and I just can’t help it. But framing it within this contextual framework and taking the blame, some of the blame, at least off of him as an individual, that’s where this lives in reports and in feedback.

Thinking about this just like that parent and explaining it as a contextual mismatch or a developmental mismatch where we’re not placing the blame entirely within an individual for the symptoms they have. We are tying it to a mismatch with what’s going on. We’re tying it to some contextual factors that absolutely explain why you’ve developed the way you’ve developed.

Dr. Sharp: Yes. Well, to circle back to something we chatted about in the beginning, I’m guessing, tell me if I’m wrong, that you didn’t diagnose borderline personality disorder, but it was the explanation that came along with it that just made us so much richer and more nuanced. 

Dr. Jordan: Absolutely. He met the criteria. That’s not going to change. Whether I write about or know about his history of invalidation, he still has emotional dysregulation and problems with interpersonal relationships, the problem problems with identity, with association, he still had them. He met the criteria for BPD. I gave him the diagnosis of BPD. This is just a way for him to create a narrative that doesn’t blame himself entirely.

Dr. Sharp: It makes a lot of sense. And the way you describe it is very powerful. I felt like I was in the room there with him feeling differently for the first time.

This has been a fantastic conversation as always. I love the mix of theory and practice and making it real as much as we can. Gosh, what else are you up to? You seem to always be doing something interesting. Do you have anything interesting coming up here in the future?

Dr. Jordan: Yeah, I’m doing a few CE workshops at the society for personality assessment and through the APA and maybe convention and stuff like that. There are certainly workshops with some of this now intertwined within it. A lot of culture workshops in assessment and social justice workshops to think about anti-oppressive practices in psychological assessment which historically is built around a white supremacist model of pathology, and problems with tests and all that sort of stuff. I’ve got that.

I’m actively working on the next edition of the handbook of psychological assessment. So look for that in, I don’t know, 15 or 20 years or whatever. It may take me a little while. We’re working on that. And just again, I tend to get on my soapbox and I try not to preach too much, but this paper, the deliberate context conceptualization paper is really a call to action.

The take-home message is, it’s really a plea to us as psychologists, those of us who do psychological assessments, to be deliberate in at least entertaining the possibility of context driving some problems, maintaining some problems. It’s just a call for us to respect and honor context a little bit as we’re doing our work to really try and think about taking some of that onus off of the single person sitting in front of you.

Dr. Sharp: I think that is a fantastic note to end on. A good call to action. I love a good call to action. So let’s stick with that. Well, as always, thanks for the time. This was fabulous. I look forward to the next time that we get to chat.

Dr. Jordan: Thanks for having me.

Dr. Sharp: Okay, y’all, thank you so much for tuning into this episode. I hope that you learned a lot. Got some things to think about. And as always, the resources are in the show notes, lots are listed in the show notes today to check out.

Let’s see. I think all of my mastermind groups are full at this point. We just launched new cohorts on a number of levels, the beginner, the intermediate, and the advanced. So starting back over with rolling admission to each of those levels. So if you are looking for group coaching and accountability as you build your testing practice or build a group practice with testing as a component, I would love to help you out. You can get more information that thetestingpsychologist.com/consulting, schedule a pre-group call, and see if it’s a good fit.

All right. That’s all for next time. I will be back with you soon.

The information contained in this podcast and on The Testing Psychologist website is intended for informational and educational purposes only. Nothing in this podcast or on the website is intended to be a substitute for professional, psychological, psychiatric, or medical advice, diagnosis, or treatment.

Please note that no doctor-patient relationship is formed here. And similarly, no supervisory or consultative relationship is formed between the host or guests of this podcast and listeners of this podcast. If you need the qualified advice of any mental health practitioner or medical provider, please seek one in your area. Similarly, if you need supervision on clinical matters, please find a supervisor with expertise that fits your needs.

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[00:00:00] Dr. Sharp: Hello, everyone. Welcome to The Testing Psychologist podcast, the podcast where we talk all about the business and practice of psychological and neuropsychological assessment. I’m your host, Dr. Jeremy Sharp, licensed psychologist, group practice owner, and private practice coach.

All right, y’all, hey, welcome back. Today’s episode is another in the beginner practice launch series, which just keeps going. It’s fun just to keep adding episodes to the series as topics come up. If you haven’t listened to the previous few episodes, I’d say the last 3 or 4, maybe 5 have all been related to launching your testing practice. We’ve covered a variety of topics in that realm, and there’s plenty to take from them. So go back and check those out if you would like.

Today, I’m talking about marketing when you start your testing practice. This is a question that I get a lot, and I would love to dig into a couple of ways that you can approach [00:01:00] marketing as you start your practice, when those might be appropriate, and how to implement.

If you are a beginner practice owner or a hopeful beginner practice owner, check out thetestingpsychologist.com/beginner to get some information about my beginner practice mastermind starting in April or May, and you can schedule a pre-group call and see if it’d be a good fit.

All right, let’s go ahead and dive into this conversation about marketing in the beginning.

Spoiler y’all, marketing, in the beginning, is actually very similar to marketing later in your practice as well. There are essentially two [00:02:00] ways to think about marketing in your practice or two methods to think about marketing. One is in-person or warm marketing options. The other is digital or cold marketing options. Now those are umbrella terms. There are many different ways to engage in each of those approaches. I’ll talk through some of that here in the episode today.

As is the case with many of these beginner practice launch episodes, today is meant to be more of a big picture overview than anything. And there are plenty of links in the show notes to the deep dive episodes that I’ve done on each of these topics in the past.

Let’s start with warm or in-person marketing options. When I say in-person or warm, I essentially mean marketing options that involve interacting with another person. It might not be face-to-face. It could be over [00:03:00] email, it could be with a phone call, but it involves a human-to-human direct connection or interaction.

I personally think that sustainability in a practice is driven by warm marketing or building strong relationships. In the beginning, this can be a challenging thing to do. So if you did not go to grad school, or if you’re not opening a practice in an area where you’ve already been for a fair amount of time, this can be tough because it feels like cold calling. It doesn’t feel warm at all. It actually feels quite challenging, a little bit clinical, a little bit salesy, and maybe a little bit slimy or sleazy.

So, what I’m hoping to do is chat with you about how to shift that frame just a bit into more thinking of this not [00:04:00] as selling yourself necessarily, but just as building relationships. And that’s what in-person or warm marketing is all about.

So you have a few options here. I always think about, first of all, making connections that are truly warm. When I say warm connections, I mean, those that already have some energy flowing between you and the other person. At best, it would be practitioners or connections that you already know, that you’ve had a relationship with and you’re just amping up that relationship. You’re just putting more energy into that relationship as you launch your practice.

These could be clinicians or practitioners that you have known by being in town for a while and working wherever you worked before you started your practice. These could be family members. It could be friends. It’s anyone that you already know who already has [00:05:00] some idea of what you do. That’s the best place to start. I think of this process as a series of concentric circles with you being the bullseye, and then this is the first circle out. So this is the warmest of warm marketing. People you already know and relationships you’re just going to nurture more than the start if that makes sense.

The next layer out is folks that you may not know personally, but are 2nd-degree connections from your warmer connections. These are folks who may be in the community who you know of and maybe share a mutual friend with, that’s the hope, or a mutual connection with. You can leverage your mutual connection to make an introduction and give you a little bit of an in with these individuals. That’s the hope [00:06:00] because it is still warm if you get a warm handoff. We’ve heard that term clinically primarily, but you can get a warm handoff to a referral source as well. I would certainly encourage you to try to take advantage of any warm handoffs in the referral realm as well.

The next layer out are folks that you don’t know and you don’t have a connection to through someone else. This is the coldest of warm marketing. These are the folks that you are emailing or phone calling, or otherwise reaching out to perhaps with a mailer of some sort to make a connection with.

I did an entire episode on how to reach out to referral sources a few months ago and gave some email scripts and some phone calls [00:07:00] scripts in that episode. So, I’m not going to go into detail on that here, but I will say that this happens a lot. There is a little bit of an art to it but most people, well, I take that back. Most people likely will not respond to cold emails, but those that do can truly turn into some of your best referral sources or connections. So I don’t think there’s anything wrong with a cold email or phone call to folks that you think would be good to connect with.

I’ve also talked in the past about my four-quadrant approach to the people to reach out to. You want to reach out to those who are seeing your clients, so the places your clients hang out, the other practitioners your clients are seeing. You want to reach out to those [00:08:00] who you might send your clients to after the evaluation is over. So folks that would be a good referral source for you. You want to reach out to people in town who are doing exactly what you do because they are likely full and might want to collaborate. And then lastly, you might want to reach out to individuals in town who just have a great reputation. People you just want to know just for the sake of knowing. That can give you a solid base when you’re trying to figure out who do I reach out to with some of these cold or even warmer efforts.

The other overarching theme with warm marketing is that you want to start a spreadsheet from the very beginning that will talk about, that will not talking about, I’m sorry, y’all. The spreadsheet will not talk about anything. The spreadsheet will keep track of all the referral sources that you’ve reached out to in terms of dates that you reached out, their response, your feelings about the meeting with them, [00:09:00] follow up reach-out dates, and then eventually it’ll turn into a referral tracker where you can keep track of who sends you referrals.

And then that will help to build a library of referral sources. You’ll see that folks start to rise to the top and it’s likely going to follow the 80/20 rule where you’re getting 80% of your referrals from 20% of your referral sources. And you want to really nurture that 20% of referral sources.

Okay. Let’s transition over to the digital or truly cold marketing options. Digital options basically include, at the lowest level, it’s just online presence. So making sure you have a website, making sure you have a Google My Business listing, maybe a Psychology Today profile, maybe a Facebook page just increasing your digital presence so that when people look for you, they can find you. [00:10:00] That is marketing in a certain way.

It steps up to the next level, which is I think search engine optimization, making sure that your website copy is working for you and that all those behind the scenes settings on your website are engineered so that people can find you when they’re trying to search for you and search for those key terms that map onto the services that you offer in your practice.

There are plenty of experts out there who will be happy to help you with search engine optimization. It is a bit of a science, so just know that you could pay for this as you get started, but that’s the next level that you want to consider in making sure that your website is really dialed in with search engine optimization so that people can find you when they’re searching on Google.

Notice that all of the options so far are free. You don’t have to pay for any of these except for Psychology Today and of course, website hosting and the fee to get your website [00:11:00] going. There are no ongoing fees with any of the options I’ve discussed so far.

The last thing that you might consider in the digital or cold marketing realm is actually paying for digital ads. These would be like Google ads, in some cases, Facebook ads, maybe Instagram ads. I don’t know the science or the ROI on that so far. I don’t think therapists really use Instagram ads, at least at this point in early 2022, but Facebook ads, Google ads. Those are the top two methods of getting clients through paid advertising.

I think that Google ads are really helpful of those two because people are naturally searching on Google for the services that you provide. And that’s when your ads pop up. It’s not like you’re just serving ads to people who aren’t interested in your clinical services. People are already searching and then Google [00:12:00] provides them with ads that match their search terms. So in a way, this is the warmest of digital marketing because someone is already searching for that service, and Google’s just helping find the person who might fit.

Facebook ads are a little colder because people don’t tend to search for therapists or psychologists or testing on Facebook. So you’re just serving cold ads to people who aren’t already interested.

So you might be asking, okay, when is each of these appropriate? When do I do warm? When do I do cold? And in my mind, honestly, there is always a place for warm marketing. Building strong relationships goes a long way toward a practice’s sustainability. It is easier when you are opening a practice in a place that you’re already practicing, or if you are moving to an area or engaging in practice somewhere that you know, [00:13:00] people, but if you’re good at connecting with people, this is certainly doable when you move to a new place. It’s certainly doable, but for some of us, that feels like a lot of work.

So in those cases, if you’re moving to a new place, you don’t want to put yourself out there, which is totally fine, you don’t want to engage in a lot of effort around in-person marketing and you’re willing to pay for it, digital marketing can go a long way, especially in smaller cities where there’s less competition for ad space on Google searches, you can get a lot of bang for your buck out of Google ads. And it’s a good way to jumpstart your practice and get some referrals coming in the door which can then facilitate connections with other providers because those clients are going to come in with clinicians they’re working with, with a primary care provider and they will serve as a conduit of sorts to these other referral sources that you can then reach out to.

So Google ads can be worth it, I think right [00:14:00] from the beginning if you’re starting in a place where you don’t know many people, there’s less competition for ad space and you just want to get folks in the door relatively quickly without taking the time or the energy to build in-person connections.

So there’s a little bit to chew on there. I think a combination is always nice. You might run some Google ads to get started, turn them off as you build relationships, turn them back on as you need more referrals. So it’s relatively flexible, but those are just two approaches to consider when you’re trying to build your practice.

I hope that this was helpful. Marketing and getting referrals is a big part of launching and it can feel overwhelming, but there are certainly methods to help you out. I hope that you are able to implement some of the tools that we talked about today.

Like I said at the beginning, [00:15:00] if you’re a beginner practice owner and you’d love to get some group support and talk through some of these things and have some accountability as you launch your practice, you can go to thetestingpsychologist.com/beginner, schedule a pre-group call and see if a mastermind group might be helpful for you.

Okay, everyone. I think we’re going to continue at the beginner of practice launch series for one more episode and then transition to some other topics. So stay tuned and happy testing.

The information contained in this podcast and on The Testing Psychologists website is intended for informational and educational purposes only. Nothing in this podcast or on the website is intended to be a substitute for professional, psychological, psychiatric, or medical advice, diagnosis, or treatment.

Please note that no doctor-patient relationship is formed here, and similarly, no supervisory or consultative relationship is formed between the host or guests of this podcast and listeners of this podcast. If you need the qualified advice of any mental health practitioner or medical provider, please seek one in your area. Similarly, if you need supervision on clinical matters, please find a supervisor with expertise that fits your needs.

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Dr. Sharp: [00:00:00] Hello, everyone. Welcome to The Testing Psychologist podcast, the podcast where we talk all about the business and practice of psychological and neuropsychological assessment. I’m your host, Dr. Jeremy Sharp, licensed psychologist, group practice owner, and private practice coach.

Hey everyone. Welcome back. I am so happy to have a return guest on the podcast today, Dr. Liz Angoff. Liz was on about a year ago talking about her approach to giving feedback with children and her project, The Brain Building Book, which has since taken off and become quite popular in The Testing Psychologist Community.

She’s back today to talk about her newest project, which is really an evolution of that model. We’re talking today about feedback with adolescents specifically. We talk about how adolescents are different from children. We talk about the importance of shared language with [00:01:00] adolescents and getting them on board if they are resistant to evaluation. We talk about how she structures the feedback with adolescents. And we just talk about the continued development of this model- what it entails and how it’s come together over the past year. So plenty to take away. As usual, Liz is a fantastic guest, easy to talk to, and super informative.

If you don’t know who Liz is, I would encourage you to go back and listen to the podcast that she did about a year ago. You can also go to the resources in the show notes. Liz maintains a blog that is chock-full of excellent information, free information that is very valuable. It’s completely undervalued that she’s given it away for free, but those [00:02:00] links are in the show notes. And of course, you can find The Brain Building Book and anything that we discuss today on the website as well, which is in the show notes.

Here’s a little bit about Liz. She is a Licensed Educational Psychologist with a Diplomate in School Neuropsychology. She provides assessment and consultation services to kids and their families in the Bay Area in California.

Liz began her career as a family advocate and educator. She helped the Oakland Unified School District establish some of its first family resource centers. Then in 2016, she became a school psychologist, specializing in response to intervention, crisis response, and helping teachers implement Ross Greene’s Collaborative & Proactive Solutions in the classroom. She opened her private practice in 2014 where she focuses on neuropsychological testing and parents’ support.

As I mentioned, she’s the author of The Brain Building Book which is a tool to engage children in [00:03:00] understanding their learning and developmental differences as part of the assessment process.

So, stay tuned. This is a great episode and plenty of resources in the show notes. Without further ado, Dr. Liz Angoff.

Dr. Sharp: Hey, Liz. Welcome back.

Dr. Liz: Hey Jeremy, it’s awesome to be here. Thanks for having me.

Dr. Sharp: Oh yeah, definitely. I’m always excited when people want to come back. I’m like, “Oh great. I didn’t drive them away the first time. It wasn’t that bad.” So, I’m honored to have you again and just excited to share some more awesome [00:04:00] information with folks. So, if people aren’t familiar, you were on, gosh, I don’t even know, a year ago, maybe two years ago?

Dr. Liz: It’s been a year. Almost exactly.

Dr. Sharp: Oh, wow. Yeah. So you were on about a year ago talking about your approach to feedback with kids and the book that you developed. And now we’re back, there’s an adolescent version now, which I think people are probably really excited to hear about. All that as a means to say, welcome back. I’m excited about our talk. 

Dr. Liz: Thanks.

Dr. Sharp: For folks who may not be familiar with your work or your previous interview here, can you just tell me a little bit about this approach that you’ve got going on and how it’s even evolved since the last time that you were here on the show?

Dr. Liz: Sure. This all came from just being asked to [00:05:00] by parents. I worked in the schools for a long time, and then when I… We don’t really have the time in schools to sit down with kids after an evaluation and go through it with them. I went into private practice and parents started asking, will you talk to my kid?

I had one amazing session with a kid where it was just transformational, and then I tried to do it again with the next kid and it just fell flat. So, I started asking around, how do you talk to kids? And it turned out nobody knew anything more than I did. And people would talk vaguely about how they approached it, but there just wasn’t a lot. And so, it went to the sideline.

The thing that really made me turn back to it is that as I started to assess more adults and listened to their stories, they come in for re-evaluation and then I would ask them, can you tell me a little bit about your history with learning and your learning disability or [00:06:00] what was hard for you, and they didn’t know. They would say, “I wasn’t really made for school or I was a dumb kid. I was really lazy. I’m not sure.” And then we would go through the evaluation and it would be a total rewrite of their life narrative.

So, we talk through. This is dyslexia. This is what this means for you. And things would start to fall into place like, oh my goodness. I’m not dumb. Wow, my teachers really missed that. Or I didn’t realize that’s why I had such difficulty with this or why it showed up in my personal life that way. And then the other side of it, like, wow, I didn’t realize dyslexia included that ability to connect with people or the way I see the big picture or some of that out-of-the-box thinking. I’m getting a lot of positive feedback at work [00:07:00] that that’s part of my learning disability too.

Watching people put all those things into place and rewrite the narrative of their entire life, and then thinking, oh my God, how many decades has this person had this negative narrative about themselves? We have to do this. And when I keep saying this, it’s not optional because kids are creating a narrative. Whether we talk to them or not, they know something’s different and they’re starting to create those narratives.

So I went back to the drawing board and started experimenting with a lot of different ways to talk to kids about these things. And just going back into some of the research that helps us to understand how to talk to kids and then how to deliver feedback. There’s not a ton of overlap between those two [00:08:00] things, but it’s there and it’s evolving.

I have a lot of training in collaborative practice solutions, which is Ross Greene’s work. The piece that I really like about it is that there’s so much respect given to kids and their experiences in their language. And so, trying to understand, what’s their perspective and how are they seeing this? That’s the way that we solve problems.

A referral question is just a problem that somebody wants to solve. Parents come in with a referral question. It’s the problem that they see that they want to solve. Teachers have a referral question. It’s their problem? So, what’s the problem that the kid wants to solve? How do we figure that out so that they can be along with us for the journey and understand?

I’m wanting to couch all that within the growth mindset framework. And so, really having language that was positive and [00:09:00] forward-moving that even though there are real things that are hard and the kids know that they’re hard, there are no rose-colored glasses to give to a kid. If they leave the assessment and we tell them, we found out that you have all of these strengths and there, they know something is missing. And so, how do we talk to them about the things that are challenging in a way that is positive and leaves them feeling empowered to really engage in their intervention and make changes?

Therapeutic assessment is this whole branch of assessment that is using assessment as a therapeutic tool. And so, there’s just a lot about the way that you present feedback so that somebody can hear it. And there are these different levels. When you’ve interviewed a number of people from that community, one of the big things is the [00:10:00] levels of information.

So thinking about, when I’m talking to a kid, what’s level one information for this kid? What’s consistent with the way that they think about themselves? What’s level two information for this kid? What’s something that’s just going to be a slight reframing for them? And then what’s something that’s super inconsistent with their narrative? So they’re not going to be able to hear it right now.

I think the piece that I was thinking about in developing the model that I use is if we can’t talk to them about it right now because they’re not ready, how do we prepare parents and teachers to be able to continue that conversation ongoing so that it doesn’t stop at our office or pause at our office and just wait for the re-evaluation, that there’s an ongoing conversation in parents or teachers are prepared to have that with them?

So, bringing all of these things together, the model that emerged has four pieces. [00:11:00] The first piece is that feedback starts before intake. And it’s just a way of saying that we’re starting this feedback process in the very first moment of testing. And that first moment is actually before the child comes into my office for the first time. The first moment is when their parents or teachers say, Hey, you’re going to go work with Dr. Liz.

So how do they present the assessment in a way that’s going to set the child up to engage in this collaborative, exploratory process as opposed to like, go play games with Dr. Liz, which is not going to end well because if they think they were playing games, we can have a fun time. I can give them lots of prizes and we can really jam, but if then they come back in and I’m like, let’s talk about your brain and what we learned, they’re going to feel like they got hit with a Mack truck. [00:12:00] The metaphor is not coming, but they’re just going to feel like I did a bait and switch on them. I thought I was playing games.

Dr. Sharp: Right. That’s great. So part one, it starts very early.

Dr. Liz: Yes, and it’s integrated throughout. Feedback is not a single event. It’s a journey throughout. So how do we integrate that?

The second piece of the model is actually the integration. How do we build the shared language throughout the assessment so that we’re on the same page? If you look into the literature on feedback, the main thing that comes up over and over again is using language that the patient understands. And for kids, that language might not be even developed yet. 

[00:13:00] I realize in the assessment process, I can actually introduce some new language to the kid as well as use different prompts and conversations to elicit their language. And now, we’re building up that language. So we have a lot to draw from, by the time we get to the feedback session, that’s all really familiar.

Dr. Sharp: Yeah. I just want to emphasize too that we’re not talking about adults but I think, you tell me if you agree or not, that a lot of us don’t even use language that adults would prefer or are familiar with. So to step it down to kids is a whole other process that we have to be extra deliberate about. 

Dr. Liz: I have been just bowled over by the effect that this really dialing into what kids understand has improved my feedback sessions with parents. And it wasn’t my intention to. I [00:14:00] thought it was doing pretty good with parents. I don’t know I was doing as well as I thought because I have had so many parents that at their child’s feedback session go, oh, that’s what you meant.

I have a little handout that is now on the brainbuildingbook.com website. It’s very simple. It’s just four boxes.

And it says highways, which are your strengths; construction zones, which are the things you’re building, not weaknesses, but things you’re building; special words, which is just how we’re explaining the diagnosis to the kid and then the tools that you’re going to use to build. So that’s your recommendation.

I started using it just to plan my feedback session so I had that kid language, but parents started asking for copies of it. And so now it’s a document that I [00:15:00] produce formally and I use it during zoom IEP meetings because that’s all we have anymore. And so, instead of putting the report up on the screen, which is ridiculous, just put this four-part thing which is a lot easier for people to see, and that’s the document that everybody wants. Nobody actually cares about my report it turns out. They just want these four things. And it’s helping it to make sense to parents and teachers in a way that’s just like oh, here’s the elevator speech on my kid. And this, I can wrap my head around. It’s not to say the rest of it isn’t important. I’m being a little flippant, but it really brings things home in a way that was unexpected to me.

Dr. Sharp: I hear that. I have the benefit of hindsight, of course, and like the big picture view, but that totally makes sense. People want simple and digestible [00:16:00] and what’s the easy way to take this in. Anyway, we could go down the rabbit hole as far as to report effectiveness and how we write reports and all that, but we’re not going to do that. We’re going to stick with the feedback session and just acknowledge simple is better.

Dr. Liz: Right. So that shared language. The key part of this model is really spending the time to get the kid’s language and to introduce different concepts throughout the assessment.

I do a lot of trying things on for size with kids. Like today I had a kid in my office who’s talking about how he loves to write but he has a hard time with punctuation and things like that. A middle-school [00:17:00] kid. I said, “Okay, so the things you’ve been talking about, it seems like you really like the big ideas but like little details can escape you. Does that feel right?” And he says, “Well, no, not really.” And then he corrects me and he’s like, “I can’t catch my own errors, but I can catch it. If I have to correct my friends’ paper, I’m all over it. I can find every little detail.”

And so now, things have gotten interesting because now I’ve tried a general theory out on a kid, and now he’s had a chance to take my language and then correct it back. Now we have something that’s getting more complex, which I don’t know where this evaluation is going yet. I know the referral question, but I don’t know where we’re going to end up, but I do know that we’ve just started to have a really in-depth conversation about how his brain works and the fact that sometimes his attention can be turned [00:18:00] totally on for details and sometimes it’s totally for details. And I can’t help but think that that’s going to be really helpful on the other end to talk about some of the things that are challenging without saying this is all challenging all the time. We’ve already started to unpack that.

Dr. Sharp: Yeah, that’s great. I like that illustration as well. I know we’re going to dive more into each of these areas or some of them at least, but I’m curious, can you give us steps three and four to wrap up the overview, and then we’ll dive deeper?

Dr. Liz: Step three is no surprises. I think that every time a feedback session has not gone well, I can trace it back to missing this step. And it’s really trying to make sure that whatever I am presenting at the feedback session is not a surprise. It’s not brand new information. We’re building off of things we’ve already been talking about. [00:19:00] Again, it’s true for parents too.

If I am looking at the feedback session and I’m now seeing something that I wasn’t expecting, I get a call with the parents to plant the seeds for that first so that I’m not throwing them a curveball at the feedback session because there’s no way to process those things.

And so for kids, that’s really important because as we’re building that shared language and I’m hearing from them how they’re understanding things and the questions that they’re asking, which is a big thing, like how do you get a kid to ask their own questions? Whatever we’ve talked about, I know that we can continue that conversation.

If it hasn’t come up at all, or if they flat out rejected it, as we talk about adolescents, a lot of times I’ll say, your parents say that sometimes you seem anxious and they’re like, no, I don’t get anxious.[00:20:00] Not at all. And it’s like, okay, so let’s put that to the side and we’re going to figure out something else. There’s no way I’m going to convince a kid that they have anxiety if that’s not how they’re thinking about it.

This no surprises helps me in preparing for the feedback session. I think about, what have we talked about? What’s the child’s current narrative and then what have we already introduced so we can shift that a little bit? And then, what’s off the table because we haven’t gotten there yet and help parents to understand that too, that we’re just not here yet.

The fourth piece is for kids especially, setting up the adults to be able to continue the conversation because it’s overwhelming for adults to hear all of this. For a child, they can nod their head and be in agreement and even tell me I get it in the feedback session, but that doesn’t mean they’re going to be able to generalize to the next time they hit a [00:21:00] roadblock. The next time something hard, it’s like, oh, I’m so dumb. I can’t get that. The frustration takes over or they’re not making the connection. So, I want to make sure that the adults are really set up to be able to keep this conversation going and really help the kid make the next step.

Dr. Sharp: That’s so important. We talked at other times about the follow-up for evaluations and what that might look like. Well, we don’t talk a whole lot about setting parents up to continue the conversation, right? I think a lot of us assume that we have to be a part of that process- a part of the continuation of their support, but in the vast majority of cases, that’s not happening. People don’t return to our office necessarily. So I love [00:22:00] that fourth point that that’s a pretty important part of this.

Thanks for talking through the overview. I know folks probably have a million questions from getting the teaser for each of those parts of the model. And so, I would love to go a little deeper with a few of them. I’m generally curious, I’m not sure actually where this fits into the model that you described, but I’m generally curious, how you are finding this process is different with adolescents compared to kids. Can you speak to that a little bit?

Dr. Liz: Yeah. I think the thing that strikes me over and over with adolescents is that they, especially adolescents seem to have a very different conceptualization of what’s going on than their parents. And so, really understanding their language is really [00:23:00] important because when you have a kid who’s in the stage of their life where their biological imperative is to define themselves independent of their family, even if they come back to the same conceptualization that their parents have, they’re driven to see it differently.

And so, just validating that the way that they understand their experience is going to be different and giving them the space to articulate that, it comes back to really having a space to really show the kid, I respect your opinion. I’m going to weigh it with all this other input that I’m getting because we can observe you, but you’re the expert on your experience.

And it’s a huge piece that comes up all over the collaborative assessment literature. We are experts in assessments, we’re experts in psychology, [00:24:00] we’re experts in education, we’re experts in all the things we’re experts in, but the patient is an expert in the patient’s experience. And this is true for kids also.

And so I think, especially in adolescents because they are in a process of defining themselves and figuring out their identity in this way, that we actually have the opportunity to use the assessment as a way for them to explore that a little bit. So helping them come up with their language and really hearing how they’re describing their experiences.

A really simple one that happened recently is, I have a child who’s super anxious. His final diagnosis is anxiety, but the way he describes it is really around stress and overwhelm. The word anxiety is loaded for him in such another way [00:25:00] that the wording becomes really important. And the specificity of what we’re talking about becomes really important so that we can, like I mentioned before, figure out what his problem is that he wants to solve so we can help him solve that problem.

We’re actually working on the bigger issues that we might be able to see as adults by helping him to address that problem. I mean, obviously working on stress management and the executive skills involved in homework, that’s going to help the bigger picture, but that’s where he’s at right now. And putting weight there means that he’s going to be more involved in the intervention as well because he gets it. It’s solving a problem for him.

I found that younger kids, sometimes they’re going to see a piece, but they might be more willing to go with the flow. You’re going to go work with Mr. Smith to help you with school.[00:26:00] We can get away with those things. I get away with the wrong framing, but I think there’s a little more trust in like, we’re going to set this up for you and it’s going to help. But with adolescents, it just feels like I’m doing a little more work and making sure there’s a real connection between the thing that they’re interested in making better and the thing that we’re going to do to help.

Dr. Sharp: Yeah. Can you give some examples of how you do that? How do you make that connection?

Dr. Liz: Sure. Where do I start? There are two different ways that I go about trying to help the kid ask their own referral question, their own assessment question. I [00:27:00] use The Brain Building Book. The new book for adolescents is called Brain Building 101. The prompts in there are designed to set us up for asking questions.

So, I start with just introducing the brain similar to how I do it with the younger kids but I use more sophisticated vocabulary. We talk about the different lobes and take something that they just like doing. Today, I had a kid who really likes rapping. And so, we talked about what it takes to design his rap lyrics. Often a sport is one of the things that kids really like. We’ll talk about how their brain is involved in helping them to do that sport.

And it just gets us talking about how the brain works together and these different systems go. And it’s just designed to get them curious about the science behind what we’re doing because it’s fascinating. The brain is just [00:28:00] interesting and it’s not you. Let’s evaluate you as a person. We’re going to see how your brain works. It takes it one step removed. So it’s a little easier to talk about. And it just takes down that emotional wall a step, because it’s easier to ask just a question about the brain than it is like, oh, let me tell you about my most vulnerable, deepest, darkest, secret, wondering within the first five minutes of meeting you. So, just getting them curious about the process.

And then after we’ve gotten into our groove and we’re at another interview break, I don’t know how everybody does it, but I integrate my clinical interview throughout the process at different breakpoints. So we talk about what are some things that you feel come easily to you? I do a lot of educational evaluation, so like things around school or [00:29:00] things extra, like things that you do outside of school, things you feel talented at, or sports, art, some other robotics club you might be part of, what are the things that you really enjoy doing?

And then what are some of your construction projects? So these might be things that you are working on that are just new. It’s the next frontier. It could be something that’s trickier for you or something you just don’t like. I don’t like history class. And so, we can put that under like, okay, that’s something that’s not flowing as easily as your math class, which is one of your highways.

Once we have this, we start making comparisons. I might model something like, you said that you really like math but you don’t like history. What’s that about? Can you tell me a little bit more? And a lot of times that compare and contrast can help us come [00:30:00] up with a question.

And I’ve told kids at the beginning that we’re here to ask questions. I want to find some questions that are interesting to you. So to model that I might say, I wonder if it’s interesting to figure out why you’re always bored by history, but you seem to like your math classes. Does that feel like a question that’s worth asking? And so, that’s another way to start to generate the kinds of questions that you might ask.

Oh, I love this club I do after school because I have so many friends there. And then you find out that it’s harder for them to make friends at school or they don’t like group work. I’m like, I wonder why it’s so easy for you to work in groups in your afterschool program but not during your English class. What’s going on there?

Being able to set up the comparison [00:31:00] contrast, I’m able to see what’s interesting to them. I’m also able to test the waters on some things. There’s a social question in the parents’ referral questions. I can start asking about these things to see if that’s a question that the kid might want to answer too.

There are so many ways to do this when we do some more of the social, emotional questions, things that you wish were different, things that you’d like to change. How do I change that? How do I make that difference becomes a really great question?

And then for some kids who are more resistant, thinking about the next construction project can be really helpful, even if it seems unrelated to their “academic” problems or their “social-emotional” issues or problems that are coming up. 

I have an example. Recently, a kid who was really hesitant to talk about anything, I’m fine. I’m fine. [00:32:00] But when we did this, what are you working on next? She really likes photography. And I was like, where’s it going to take you next? And she’s like, “Actually, I want to really get good at art.” Okay, well, what’s that going to take? She’s like, well, I don’t know, because in the class I want to take, you have to display your work at the end. And I just don’t like showing my work at all. I don’t want to do that. And so I was like, okay, well, let’s figure out how we’re going to help you get better at drawing.

And through that, we were able to tackle the anxiety piece which is a big part of her profile. Part of why she was so resistant to talking, but we could talk about like, okay, if you want to get better at this thing, it’s going to involve getting your work evaluated, let’s stay within here. And it was a really great way to attack the anxiety in a way that was safe for her and solved a problem for her [00:33:00] that was still in line and really respecting where she was coming from. And then she wasn’t ready to talk about what we think we see as adults quite yet.

Am I answering your question? I feel like I might be rambling a little bit. 

Dr. Sharp: You’re doing great. Yeah, this is good. I’m thinking through this lens or looking through this lens of shared language, right? So we started in this place of how is this different with adolescents compared to kids, but I like how it’s evolved into this component of language. Adolescents have a lot more awareness of themselves. They have presumably a bigger vocabulary and different ways to describe what’s going on for them. They’re typically resistant. So we’re touching on all these components.

Dr. Liz: Yeah. And I think being able to write those things down and do the comparison has been really helpful for me. I don’t do well on the fly. I definitely need a process. [00:34:00] Having those steps has been just really helpful for me. The book’s really helpful because it’s right there. It’s like the next page, like, oh, oh yeah. Okay. Let’s talk about things you like to do, the things that you feel like you’re good at. And then we can really concretely look at like, okay, you said this on this page and this on this page, let’s talk about how those two things go together.

If you’ve heard me talk about the way I end up defining a diagnosis at the end, it’s often putting those things together. Your brain is built in a way that gives you this highway and makes this hard. And that pattern is what we see in a lot of people who are dyslexic or a lot of people with ADHD or a lot of autistic people. These are the patterns that we see these strengths and challenges that go together and just the way that your brain happens to be built.

And so building up all that language over time, that we can then really concretely come back to and say, look what you wrote. I think this is the pattern I’m looking at, and this is what that means. [00:35:00] This is what we call it.

Dr. Sharp: Yeah, I think it just goes back to what you said. I think it was the third piece, no surprises, right? You’re building this shared experience throughout the assessment using their language. It all ties together. It’s like it’s a coherent model or something. 

Dr. Liz: If it were, it surprised me when it formed that way. Here we are.

Dr. Sharp: Right. Let me see. I want to focus on the language component a little bit more particularly around how you are doing this during the assessment process because it’s not built into our standardization to talk with kids about how they’re doing during the process, right? That’s not in the manual, but yet I know that you consider that to be pretty important in [00:36:00] building the shared experience. So how do you approach that?

Dr. Liz: Yeah, I will pose it that is definitely a paradigm shift to think about talking to kids about their results at all, never mind thinking about how you integrate that into the whole process, but there is precedent for it. There’s a lot. And so, thinking about different approaches, I know that for me, I’m not going to be able to cite them all, but for me, the Boston process approach does a little bit of this breaking a task down and individualizing the different pieces within the assessment process.

In some of the things that I’ve been reading, even tracing back to Lauria, he had a model of presenting feedback in a way that checked in with the patient, like, [00:37:00] is this making sense? Do we have examples of this? Can we connect it back? And then, the therapeutic assessment does a lot of this too. Let’s look at what we did here, and let’s look at your response. 

There’s a tiny bit of literature on collaborative neuropsychological assessment and asking patients, how do you think you did on that? And then getting their response and then comparing that to what actually happened and having this back and forth. So, there’s a lot of precedent for this. And with a kid, they’re not going to remember. So integrating it within becomes actually really important. So the experience is fresh because it’s hard to take them back.

And so, what I’ve been doing is, the first thing that I do is in that whole introductory process of showing them their brain and [00:38:00] and orienting them to, this is a discovery process format to the assessment, as opposed to, let’s see why things are hard for you. It’s like, no, we’re going to discover how your brain works. I’m setting it up and I’m telling them, I want you to let me know. If something is particularly fun for your brain, let me know. If something is particularly challenging, let me know that too because I’m not always going to be able to see it or know. So, if we get to the end of something and you’re like, oh my God, I am so exhausted after that, tell me. I want to know.

So before we even start, I invite them to let me know about their experience. And then a lot of times after I’ve completed a section, so after the WISC or after we’ve completed a memory battery, after the WRAML, after these big sections, I’ll ask a general question like, what did you enjoy the most? What was hardest for [00:39:00] you? Can you just tell me a little bit? And a lot of times they’re sharing.

One kid recently he’s like, I love digits. He said, “I love the numbers thing. I love digit span.” And I was like, really, that was fascinating?

Dr. Sharp: Said no one ever.

Dr. Liz: But it became really important because I ended up diagnosing him with ADHD, with a working memory score that’s off the charts and it’s because he loves numbers and actually got a kick out of trying to memorize these things. He was so into it, but his functional working memory on a day-to-day basis was really challenged.

So it was actually really important information to know that he got such a kick out of that task and he felt like it was such a challenge because it made it make more sense, right? Just asking for simple things like that.

I love asking about the WRAML because, and I’m not [00:40:00] trying to push any tests, but any memory battery is actually awesome to ask about because you’re looking at visual memory, auditory memory, story memory, all these different, you’re kind of breaking it down. I get a ton of information just by asking, what was easier, what was harder, what did you like, what didn’t you like, about how they’re approaching different tasks, and what they’re doing in that.

If I see that a kid had a really negative reaction, and this happens a lot with writing for whatever reason, it’s just like, oh, or sometimes tears, I mean sometimes head on the desk and tears. It’s not uncommon. And when I see those big reactions, I will stop and do a little Collaborative & Proactive Solutions style emergency plan B intervention, like, wow, [00:41:00] I am noticing you’re having a really hard time. What’s up? And we break it down. And those kinds of conversations have been so critical to analysis because you really get insight into what’s going on with the kid in that moment.

Dr. Sharp: Yeah. I love that. This is so validating. You’re describing a lot of things that I like to do, but never really put it all together necessarily. I love that. I love asking kids, what was really fun for you during the process? What was hard? How does that map on to your life? All that kind of stuff.

Dr. Liz: Yeah. How does it map on to your life? Do you have an example of where that shows up, is a good one too because sometimes it’s immediate? They’re like, oh yeah. And a lot of times I get, oh yeah, I think, and with adolescents, this is cool because they’re old enough to start making these connections on their own.

And a lot of times asking about a memory battery, they’d be like, [00:42:00] do you think that’s why I hate history so much? Because she just talks on and on. I didn’t like the stories and those were so long. Do you think that might be something? I’m like, “We should put that as one of your questions. Why is it hard to remember a lot of talking? That’s a great question.

I’ve had that experience a lot that can start to make those connections, or I can prompt it, like, do you think this has anything to do with what you told me earlier about not liking this class or why you really like this teacher? Is that a connection? And they can start to make those and they become really important insights.

And then I get to tell parents, your child had this amazing insight, which is just like really, really cool to shift the parents’ narrative of like, oh, my kid really understands themselves and bring them in. 

Dr. Sharp: Yeah. That’s wonderful to be able to share that information for the love of doing that. [00:43:00] Before we transition to the actual feedback session, I’m curious about what you do with kids or teens if you see these teens who are just super reticent. My parents dragged me in here. I don’t care. I don’t have any questions. I’m working on getting better at this video game or whatever. Do those cases ever pop up for you? And do you have any…

Dr. Liz: I am not special in that way. The first thing is that I think that this approach in really thinking about what’s the problem the kid wants to solve has been a big help with those cases because it really shifts us away from, I think most often it shifts us away from diagnostic categories and [00:44:00] into just like what’s the kids’ daily experience.

Instead of focusing so much on them, is it like, what are the hardest parts of the day for you? What’s going well? What’s not going well? Because often there’s some point of conflict or something that like, my teachers are against me or my parents are against me or they just give me too much homework or I’ve got it. And so, starting from those places where there’s something there that could get better.

And a lot of times, for those kids, I’m not writing things down. I might not be using the feedback workbook at that moment, but more trying to figure out what’s going to move the needle just a degree here to really help them start to [00:45:00] engage? I think it’s really important to recognize where a kid is at, and describe that accurately to a family. This is what this child is working on right now.

A lot of times with adolescents, there’s such a strong desire to be normal, whatever that means, and to be part of the group that any recognition that anything is hard is like, I’m opening myself up to Pandora’s box of you’re going to tell me there’s something wrong with me and I need special help, and I need all these things. And so, it’s really important to recognize when kids are in that place and to see what one degree of moving we can make.

For a kid who is on my mind right now who really came in with that, the only question we can come up with was why are my parents making me do this? Which is actually not an invalid question. One of the things I [00:46:00] say a lot is, I don’t care what question. Ask me any questions because we can do something with it.

One of the conversations we had with the school team for him is, how do we normalize the struggles of adolescents? Let’s just start there. That adolescence is hard. You don’t have to be special in any way to have a hard time between 12 and 16. So, let’s figure out how we can start normalizing these things and intervening on some of the common things. And this is going to help move the needle just a bit to open this child up to help moving things.

And I think for where that kid is at, and then having stuff documented so parents can help move him those steps without having to wait until their next appointment with me or their next evaluation becomes really important so that we have some movement that makes sense for the child.

[00:47:00] Dr. Sharp: I like that. And just validating that if a teenager has the question of why do I have to do this? That is a question. Or why are my parents making me do this?

Dr. Liz: I feel like then you can come back and be like, well, your parents are concerned about your Ds.

That’s why you’re here. Like, why are my parents making me do this? I have an answer to that. And I like to check in with the parents. Can I share your referral questions? Can I share this referral question? To be honest, your parents are concerned about the Ds. Let’s talk about them.

I’m going to really validate that respect for the child. You’re telling me nothing is wrong. Help me understand the Ds in the perspective of nothing is wrong. Actually, that can often help shift parents away from I’m so scared for my child’s future to, oh, this is a hard time. And we can [00:48:00] move them to the middle.

I don’t want to go too far off, but I can think of a number of times that parents who are just looking at how much trouble their kids are having at school at this adolescent age, and wanting them to be in either a specialized program for learning or behavioral challenges or a smaller school depending either within a district or moving them to private school because the learning needs are so high.

And what we find out from the child is actually my biggest problem is the social piece. I feel in one child in my head, we did this CPS- the Ross Greene intervention with him, and just learning, geez, it happened today too. This happens a lot. Learning at this age, how important the social support piece [00:49:00] is, and hearing out the child. The kid’s fear is that you put me in a school and I’m going to be so isolated. My life is going to be awful. It doesn’t matter if I’m getting all the support that I need.

So helping parents figure out how to weigh, this stage of his life or the stage of her life is as much about building those social connections as it is about the learning piece. How do we come to the middle to find that balance? And I found a lot that when we start to validate that, the kids start to soften.

I’ve had very few cases, I have a lot of cases that start with, I don’t need to be here and end with, okay, if we can just make this one thing better, that would be good. Or if you can make sure that my parents don’t send me to that school, we will be on a good page. And that just opens up the conversation for let’s figure out what [00:50:00] everybody’s needs are here, and then we can come to a solution that’s going to work for everybody and validate the child.

Dr. Sharp: I love that. Well, let’s talk about the actual feedback session. How do you structure feedback with adolescents?

Dr. Liz: So with young kids, it’s a family affair. I’ll come in, I’ll talk together. It’s great for parents to be able to hear all that language. For older kids, I see them alone first.

With the kids that I work with, we’ve been using the feedback workbook to document all this stuff. So when they come in for the first half just on their own and we recap what we’ve done and what we’ve already learned and seen what’s happened since that. If they’ve had any other experiences, any other thoughts about things.

I often start just with a [00:51:00] game. If we’ve played cards or something, we’ll play that again and just catch up on what’s been going on and remind ourselves of what we did and what we’re discovering. And then we start to bring these things together. So we look at the highways that we found and sometimes I’ll add one or two more if there’s something that when I brought all the data together, I learned.

When I’m sharing things, people often ask, “Well, do you share test scores with kids?” I’m never sharing test scores and very infrequently will share you did “well or poorly” on something. Obviously, if a kid refused to do something or wrote two words for an essay, you might say like, gee, what’s going on? They already know. I’m not sharing those things. And if I’m not sure that I’m seeing a pattern, if I’m not sure [00:52:00] of something, I’m also not going to share it at the moment with the kid.

And so a lot of times at the feedback, I’m like, I looked at everything that we did and it’s like, wow, whenever I gave you something that had a story behind it, your brain really turned on. And these are the things that you actually did better than most kids your age on. So I want to add those to your highways.

And then we look at the construction projects that we had come up with and I might add one thing. If it’s something we haven’t already reviewed, then that’s going with those levels of information. I don’t want to add on like, and then we found these five things that you can’t do.

So, we’ve already talked about some of the things and I might say, I found more evidence that this thing… I have more examples of this thing that you pointed out that you’re working on is showing up. I [00:53:00] think we can connect that to different things, but I’m not going to introduce something new, maybe one new thing.

So really careful about introducing new information. The thing that I say is, this pattern is common and you’re not alone. We have a way of describing this. One example would be this pattern is called ADHD. And for you, it means your brain finds it easy to come up with big ideas and even quick creative ideas, but it can be challenging to pay attention to little details unless it’s your friend’s paper, whatever comes in. But we have that information. We’re looking for patterns. This is the pattern we found. And when we bring your highways and your construction zones together, we have a name for it.

And that name can be an official diagnosis, or sometimes it’s not for whatever reason. Either [00:54:00] we don’t want to share it with a child for some reason, or we’re not sure because sometimes we’re not sure what’s going on. For a child who’s in this stage of life where everything’s in flux, there can be a number of reasons why we may not share a specific technical term, but we can always show things like, we call the kinds of construction projects you have going on executive functioning skills. And so, those are the things we’re going to work on. Or the patterns that we see, these are big feelings and those big feelings give you those big passionate ideas and they also can give you that anger that you’re feeling, that frustration that you’re feeling when your mom is telling you, you have to do more work when you just spend an hour or whatever the situation is.

We can come up with other terms to tie it together that’s like, this is a pattern that’s familiar.[00:55:00] And then we write that definition down and that’s documented so that it’s on our office, but then that’s there for parents to use and for teachers to use moving on to build on. So we all have that common language to talk about.

A lot of times I’ll ask the kid, how would you describe it? And they’ll come up with new things. There’s one example I use that I told a kid when you talked about that sometimes people don’t understand your jokes or you might feel like you have the wrong timing on when you comment on something, we call that difficulty with pragmatics. And this is a kid who was on the border. We were considering autism as a possible diagnosis. We didn’t have enough of this during COVID. We didn’t have enough data. And so it’s something we talked about as a family, but we wanted to do some [00:56:00] intervention with this kid.

We needed to help him understand the pragmatic piece, and he had talked about I laughed at all his jokes but nobody else did. And you mentioned that I was like, oh, that’s an interesting question. And he goes, oh, I get it. My jokes take off, but they don’t always land. I was like, great, that’s a great way to understand pragmatic. So we wrote that down and that was his definition. And we went to his IEP meeting and he attended and he’s little for attending, but he attended and he’s like, I was like, oh, do you want to share what you learned? And that’s what he shared. It was pretty cool to get his little take on how he would do it.

And then the last thing, I invite the parents in and we share what we discussed. So it gives the kid another time to process. And we only share what they give me permission to share. Some of our conversations with adolescents sometimes are just between us. But we [00:57:00] talk about what we want to write down in the book and what we want to share out. And then they have a chance to teach their parent about their brain which is just a whole different experience and you get their language and then I help them out. I tell them, it’s not a quiz, I’ll help you. And I fill in the blanks.

And then we usually watch a video or a comic or look at a bio of a famous person who might have a similar profile if that’s available. And we do that as a family because a lot of times when we watch these videos, families will be like, that’s totally you, or I noticed that about you or do you think… So that can lead to a lot of great conversation. It is an awesome way to end altogether.

Dr. Sharp: Yeah. This is very granular, but how long would these typically last, and do you ever do separate feedback just with parents?

Dr. Liz: I always do a separate feedback just with parents.

Dr. Sharp: Okay. Good to know.

Dr. Liz: The first feedback [00:58:00] is with parents only, and that’s important because it gives them time to process. I want to make sure that they’ve had time to process and I want to make sure that I let them know that this is the piece I want to share with your child for them to be okay with that, and sometimes parents aren’t. And so then we have to… And really having respect for the parents processing whatever we’ve done is a really important piece of this. And so that feels like a whole nother area to go into that could take a while, but yeah, I want to make sure the parents and I are on the same page about what we’re going to share with the child.

And they know from the beginning that the intent is to share with the child something. We want the child to leave with an understanding of how their brain works, whether that’s a formal diagnostic term or just a way of explaining, [00:59:00] it’s important to me that kids are getting something out of this, that they feel like they, I mean, they’re the ones putting in all the effort to do all of this. If they leave with something that feels like, okay, I learned something here, I got something out of this, I think that that’s really important. 

Dr. Sharp: How do you evaluate what the kid is taking away?

Dr. Liz: I ask the kid if somebody is like, “Hey, what’d you do a Dr. Liz, what would you say?” Or if somebody said, “Dyslexia, what is that? What would you say?” And often at that point, parents are there, so they can hear what the kid got and what they didn’t.

And that’s part of the reason for the workbooks honestly, is that it’s all written down because sometimes kids are there with me, [01:00:00] but to rely on a one hour, with a kid it’s an hour at most, and to rely on that one hour to be this magical moment where the kid suddenly understands everything that we did is ridiculous. It is an unreasonable expectation. It relies on so many factors including how the kid shows up and how I show up that day. If we’re resonating, it’s a lot.

And so, being able to write it down and have a way to document that is the piece that makes sure that they do leave with an understanding of how their brain works, because that can then be communicated to a parent, a teacher, whatever intervention they’re going to, so that it’s like, you know what, they came in, I started to explain and they just shut down. I tripped over something that shut them down, but this is where we got [01:01:00] to, and now I’m going to pass this physically onto you, therapist, or on to you resource specialists to continue that conversation. And here’s how we started it so that it’s not dependent on one magical moment every time because some kids, it’s just a very hard thing to come. It’s scary to come in for a kid even when we do everything to build it up. It’s a tough session.

Dr. Sharp: Sure. Well, and there’s research right around just messaging and how many times it takes to have a message sink in and have it stick with someone, things like that, just from a general information presentation standpoint that, something’s going to stick, there are probably going to be some flashbulb moments or whatever, but some won’t. It takes all well.

Dr. Liz: Yeah. I have many more magical moments now. [01:02:00] The more I think about feedback as a process that’s integrated throughout the entirety of assessment, the more magical moments there are because even if it doesn’t happen at the feedback session, it’s already happened or we’re building on something. Those things are there and we’re on a trajectory. And so it definitely helps.

I think one of your guests a little while ago said something like parents hear five minutes of what you’ve said. So make that five minutes count. It’s like, well, okay, I bet a kid here is one minute of this whole session. And so, we got to make that minute count.

And I think my answer to that is, I can’t rely on being magical for that to show up at that minute exactly the way the kid needs me every single 100% of the time. So, I need lots of minutes. I don’t know. I’m a person who needs a lot of do-overs in life. And so, I figured might as well work those into everything that I do.

And so having lots of [01:03:00] moments with this kid to try things out and what are we discovering, and that’s a cool thing and light like, hey, this was just a testing session, but we just discovered that you really learn in groups better than on your own. That feels really important. Let’s share that with your parent is just like something that we learned today and we’ll figure out what that means later. We just discovered something, so why wait until this one session to share everything instead of making it this whole process with a kid that could be really exciting and get them really engaged?

Dr. Sharp: Yeah. Gosh, I feel like we could talk for a long time. It always goes by fast. The part we didn’t really get to is the supporting parents after the evaluation and how to send them away successfully and continue that conversation. So maybe since you’re willing to come back a second time, maybe there’s a third time. Maybe I haven’t driven you away after the second [01:04:00] time.  We’ll see. I want to make sure I know.

Dr. Liz: It’ll be amazing.

Dr. Sharp: Yeah, I would love for you to talk about the project you got going on though. That’s a huge deal. So, what’s happening and is related to how the audience can actually access some of this material.

Dr. Liz: Last year I was on talking about The Brain Building Book, which is a book for elementary students. It was amazing. It was just a cool tool I wanted to share and it caught fire. So many people are using it now. I’m sure people are using it in ways that I never even imagined because I’m just getting a lot of feedback that it’s being used in the hospitals and therapy practices and different types of assessment in schools. I think people didn’t have a way to talk about these things. And so, any [01:05:00] way to involve the kid, I think it’s something that a lot of people really want to do.

Now we have an adolescent version. So this version is called Brain Building 101. It follows a super similar format to The Brain Building Book but the language is a lot more sophisticated. The drawings are comic book like as opposed to The Brain Building Book junior is very colorful and playful and the older book just has a different style of drawings and much more space for kids to contribute and for kids to write, or for me to write to document what we’re discovering.

And that is up on Kickstarter right now. I used Kickstarter to launch the other book and use this book because it just gives me a sense of whether this is [01:06:00] important to the community, whether it’s something that would be helpful for older kids. I’m super stoked to say that we met the goal. We met it, so that means that the book will be printed, but you can still pre-order books through Kickstarter and get some of the Kickstarter discounts until February, 18th- just a few more days. And then the book will not be available for a little bit while I get the final copy printed and work out all of the details.

It’s been really fun to use the prototypes in my office. I really like this book. It’s just really helped to bring out for those resistant adolescents or really bring all that out, and have a process for doing it. So, it’s been really cool. And I hope other people also like it and it brings that same thing to their work.

Dr. Sharp: Yeah, absolutely.

Dr. Liz: And you can find it on [01:07:00] brainbuildingbook.com. You should probably know where to go.

Dr. Sharp: That was a great pitch. Here it is. And we’ll have a link to that in the show notes, of course. I’ve seen, I guess, an advanced copy of that. That sounds very official. I feel important. And it’s great. The first one was great. It’s not like it’s unexpected, but it’s super cool to see this continue to evolve. And I know that folks really appreciate it and they found that super helpful. 

Dr. Liz: And then I’m going to send you a discount code for the younger version too. It’s available just available for purchase on the brainbuildingbook.com website. So, I’ll throw that out to you for the show notes.

Dr. Sharp: Well, thanks, Liz. Thanks for coming back. It’s always a pleasure. This was really fun and informative at the same time, which is a good interview in my book.

Dr. Liz: Aww, thanks, Jeremy. It’s really fun to be on here and talk to you. 

[01:08:00] Dr. Sharp: All right. Take care until next time.

Dr. Liz: Okay. Bye.

Dr. Sharp: Okay y’all, thank you for checking out this episode. I hope that you found it helpful. Like I said, there are plenty of resources in the show notes, both free and for purchase that will aid you in your assessment and feedback process. If you didn’t check out the first episode with Liz, it is great as well. So you can run back and check that out.

All right. I think that is it for today. As usual, if you were at any stage of your practice, beginner, intermediate, or advanced, and would love some group support and coaching and accountability, I have rolling admission for mastermind groups, The Testing Psychologist Mastermind groups, and you can get more information and schedule a group call at thetestingpsychologist.com/consulting.

All right, y’all, take care. I will catch you next time.

The information contained in this podcast and on The Testing Psychologist website is intended for informational and educational purposes only. Nothing in this podcast or on the website is intended to be a substitute for professional, psychological, psychiatric, or medical advice, diagnosis, or treatment. Please note that no doctor-patient relationship is formed here, and similarly, no supervisory or consultative relationship is formed between the host or guests of this podcast and listeners of this podcast. If you need the qualified advice of any mental health practitioner or medical provider, please seek one in your area. [01:10:00] Similarly, if you need supervision on clinical matters, please find a supervisor with expertise that fits your needs.

Click here to listen instead!

[00:00:00] Dr. Sharp: Hello, everyone. Welcome to The Testing Psychologist podcast, the podcast where we talk all about the business and practice of psychological and neuropsychological assessment. I’m your host, Dr. Jeremy Sharp, licensed psychologist, group practice owner, and private practice coach.

Okay, y’all, I’m back with another beginner practice launch episode. This loosely titled series marches on. Today’s episode is all about hiring admin help, and more specifically when you might want to hire admin. If you haven’t listened to the previous few episodes in the beginner practice launch series, the previous three episodes, I believe, have been dedicated to this topic. So certainly, I encourage you to go check those out.

As we get started today, I will invite any of you in this beginner time period to check out the Beginner Practice Mastermind at thetestingpsychologist.com/beginner. The next cohort is enrolling in April or May. I’d love to chat with you to see if it’d be a good fit.

Okay. Let’s get to this brief discussion about hiring admin help as you launch your practice.

All right, everyone. We are back. I think today’s episode is going to be relatively short simply because my stance on when to hire admin help is quite clear, and the answer is very early. The title of this episode is, is it too early to hire admin help? My answer unequivocally is no. The only argument I can make for waiting a bit to hire admin help is to give yourself some time to understand your own processes and establish your own processes so that you can teach those to someone else in a relatively clear and concise manner.

I’ve said many times on the podcast before that I waited way too long to hire admin help. It was probably 3 to 4 years into launching my practice back in 2009 before I decided to bring someone on to help, the reason being, we do this for a lot of reasons, but I think one of the main reasons is that we feel that we are the only ones who can do a task the way that we would like it to be done. Maybe there’s some truth to that. Maybe the reality is that you are the only one who can do the task 100% the way you want it done. But what I found is that the incremental improvement between 98% and 100% is not worth the time that it takes for you to do all these tasks yourself.

So that was my reason for a long time. I didn’t feel that someone could answer the phone, that I could trust someone with emails, that I could trust someone to schedule or do billing. The fact of the matter is that many of these skills are quite teachable. And as long as you put in the time and the effort to teach someone how to do them well, it can be very, very helpful in your practice.

Now that I’ve answered that question, is it too early to hire admin help? The answer is likely no, definitely not. I would be thinking about bringing on an admin support person, even for just two hours a week from the very beginning of your practice. And be thinking through that lens or looking through that lens as you develop your practice materials because you want to be writing out standard operating procedures from the very beginning with the intent or with the idea, with the goal of knowing that you’re going to try to communicate those standard operating procedures to someone else relatively soon in your practice journey.

What are some of the things that you might look to outsource from the beginning? Well, an easy one is sending questionnaires for evaluations. This is a very easily taught task. It’s a pretty rote task. It’s something that could be accomplished with a simple shared checklist where you can communicate which questionnaires to send out electronically to your reporters for your evaluations. So that’s one thing to think about. It’s an easy way to weigh into having an assistant.

If you want to step up your game a little bit, you can bring someone on to collect payment, do your billing, to process insurance claims. Those are relatively easy steps that you can teach someone. And if you want to go a step further, you can even bring someone on to answer your phones and do your scheduling. These are probably the top three tasks that I see folks using virtual assistance for. When I say virtual assistant, I just mean remote assistant. If you want someone in the office, that’s totally fine too, but with the work-from-home culture these days, we’ll see whether that changes or not, virtual assistants can be very helpful.

So, those are just three things to think about when you’re thinking about outsourcing. Now, I’ve done more in-depth episodes in the past around tasks that you can outsource to a virtual assistant. There are tons of things that you can outsource in your testing practice, but these three are, I think, easy things to wrap your mind around and just simple, straightforward tasks that you should not be doing in your practice.

And again, the rationale for this is that your expertise lies in the clinical realm, and you get paid really, really well to do what you’re trained to do, to do these clinical tasks. So anytime that you’re engaging in administrative tasks or anything outside of clinical work, you are essentially paying yourself your clinical rate or losing that money that you would be paying yourself for doing clinical work, which makes you the highest-paid assistant that you would ever hire.

So if you’re doing administrative tasks, I just want to let that sink in, if you’re doing admin tasks, you’re essentially paying yourself your hourly rate for clinical work to do that task. No administrative assistant is making $100 an hour, $150 an hour, $200 an hour, or even higher. So don’t waste money. Don’t waste time. Think about it from the very beginning how you might bring someone on to support you in your practice.

There’s a lot more to say around this, but I will keep it short and sweet. Again, this is just for those who are launching. I recognize that it could be a lot to think about bringing on someone in your practice right off the bat. So I just want to plant that seed, get you thinking about it, get you checking out some of the other episodes where I’ve talked about hiring admin support, and just start to wrap your mind around it.

If you’d like more intensive support, you can check out thetestingpsychologist.com/beginner and schedule a pre-group call to see if a mastermind group would be a good fit for you. The next group is starting in April or May, and we would love to have you.

All right, I’ll keep it short for today. I look forward to talking to you next time.

The information contained in this podcast and on The Testing Psychologists website is intended for informational and educational purposes only. Nothing in this podcast or on the website is intended to be a substitute for professional, psychological, psychiatric, or medical advice, diagnosis, or treatment.

Please note that no doctor-patient relationship is formed here, and similarly, no supervisory or consultative relationship is formed between the host or guests of this podcast and listeners of this podcast. If you need the qualified advice of any mental health practitioner or medical provider, please seek one in your area. Similarly, if you need supervision on clinical matters, please find a supervisor with expertise that fits your needs.

Click here to listen instead!

[00:00:00] Dr. Sharp: Hello everyone. Welcome to The Testing Psychologist podcast, the podcast where we talk all about the business and practice of psychological and neuropsychological assessment. I’m your host, Dr. Jeremy Sharp, licensed psychologist, group practice owner, and private practice coach.

Hey everyone. Welcome back to The Testing Psychologist. Today is a masterclass episode. If you haven’t caught the previous masterclasses, these episodes are a little bit different than the typical interview. On masterclass episodes, an expert in our field comes on to do a case presentation in a particular subject area. Today, I have Dr. Donna Henderson, presenting a case of an autistic adolescent girl.

Donna was a previous guest from episode 119, which was the second most downloaded podcast episode ever. She has a lot to share with us about this [00:01:00] particular subject area of autism in girls and women.

So let me tell you a little bit about Donna. Donna is a clinical psychologist. She earned her doctoral degree from the School of Professional Psychology at Wright State University. She then worked as a staff neuropsychologist and then director of an acquired brain injury clinic at The Gaylord Hospital in Connecticut.

After staying home with her three kids for a while, she joined a private practice, The Stixrud Group, in 2011. She currently specializes in neuropsychological evaluations for individuals with cognitive, academic, social, and/or emotional challenges, with a particular specialty in autism, of course.

Dr. Henderson is a frequent lecturer on the less obvious presentations of autism on autistic girls and women and on parenting children with complex profiles. She provides case consultation, particularly for mental health professionals who’d like to learn more [00:02:00] about autism.

A little shout-out, if you are interested in case consultation, you can reach out to Donna and find her contact information on her website, drdonnahenderson.com. Donna is likewise publishing a book later this year. If you’d like to get updates and announcements on the book availability, you can do so at her website as well.

A little bit of a disclaimer before I transition to the episode, Donna and I chatted after we ended the recording. This will make sense as you listen to the episode, but as we ended our masterclass, we want to make sure that it comes across and it’s very clear that not all of the problems were solved by this individual, this teenager, [00:03:00] receiving her diagnosis.

We want to make sure that everyone is well aware that getting a diagnosis does not solve all the problems and that this was just a piece in the process and hopefully a step in the right direction for this girl and her family but just to be clear that we don’t mean to present it like getting the diagnosis is a tying bow on the story and everyone rides off into the sunset.

Hopefully, I didn’t mix too many metaphors there and you get the picture, but there is a lot of great information to take from our discussion.

I will transition to this masterclass with Dr. Donna Henderson.

[00:04:00] Hey Donna. Welcome back to the podcast.

Dr. Donna: Hi, Jeremy. Nice to be back.

Dr. Sharp: Good to have you. I feel so fortunate that you agreed to come back and present some information in this format. Very grateful for your time and energy. I know people are excited to hear from you, your first episode was, it’s still the second most downloaded podcast episode ever.

Dr. Donna: What!

Dr. Sharp: Yeah, totally. So you are …

Dr. Donna: That’s crazy.

Dr. Sharp: I know, it’s wild. Honestly, it’s only behind the one that Susie Raiford did on remote administration of the WISC right at the beginning of the pandemic. So I almost feel like that was a very unique time-specific episode. I don’t know, you could [00:05:00] make an argument that you have the most popular episode on The Testing Psychologist. So we’re lucky to have you back.

Dr. Donna: Wow. I feel really lucky to be here. Thank you.

Dr. Sharp: Sure. So you’re going to be here in a little bit of a different format this time. Last time we did more of the typical interview style around autism in female-presenting individuals but this time we’re here for more of a masterclass format. We’re going to return to the original masterclass format from Stephanie Nelson from a year or two ago where it’s more of a case presentation that you’re going to share with us.

I’ll, of course, jump in here and there and ask clarifying questions and whatnot. I’m excited to hear about this case you have prepared for us and see where we end up. So I’ll turn it over to you to start wherever you would like to start.

Dr. Donna: All right. Thank you. I guess I’d want to start by saying that I’m in no way suggesting that my way of doing this is the only [00:06:00] way or the best way. It’s simply a way that has worked for me and the people I’ve trained. I’ll also tell you it was absolute torture picking a case because everybody’s so different. I had to think about what kinds of things I wanted to highlight and obviously, I’ve completely, de-identified the data to protect the client.

I’ll also say as part of that, even though I live in Maryland and I work in the DC area, this client happened to travel to see me. So they’re not from this area, just to further de-identify them.

So I’m going to call her Annie Jones. Annie was in 12th grade when I saw her last year. Usually when you present a case for case consultation, ideally you integrate the data first, but for this format, I think it makes more sense for me to provide the information in the [00:07:00] order that I received it. So I can talk about what I was thinking and doing it at each point in time. So I’m resisting the urge to just integrate it all. Don’t worry, I’m going to talk about how to organize it and integrate it at the end.

Dr. Sharp: Great.

Dr. Donna: Okay. The first contact was the initial phone call, which came in from Annie’s mother. She described Annie as a kind and friendly person who’s motivated and has a fantastic work ethic. So right off the bat, that’s all, just wonderful to hear.

Annie’s always been a great student, although an incredibly slow worker. The reason Mrs. Jones was calling now was that Annie was struggling with remote learning during the pandemic. I’m sure you got a lot of those calls.

Dr. Sharp: That sounds familiar.

Dr. Donna: Yeah, just a little. Specifically, Annie got overwhelmed by information. She was perfectionistic and she could be rigid at times [00:08:00] thinking there was only one right way to do things. None of these problems were new but they were more problematic than they had been in the past.

Annie had already been identified as having anxiety, ADHD, and probably depression. She had tried a fair amount of therapy and medication but nothing was helping. So they really wanted to get an evaluation to see what’s really getting in her way.

Mrs. Jones brought up a few other things during the interview but she didn’t bring them up on her own. These were in response to direct questions and she mentioned that there were chronic GI issues, and problems with sleep. There was a history of occupational therapy for sensory integration and some speech therapy at one point.

And then Mrs. Jones also mentioned that Annie generally got along well with others but she’s not particularly socially savvy and she’s had friends but not particularly [00:09:00] close friends, but again, none of this was the stated reason for the evaluation. It only came up with questioning.

So the next thing we do is send out a pediatric questionnaire. I like to have this completed in advance before I meet the client or the parents, in part because I don’t want to spend time in the interview on details like what school they went to or what medications they’ve tried. I want to save the interview time for the good stuff.

Dr. Sharp: So this is pre-intake.

Dr. Donna: Pre-intake, yeah, we call intake the initial phone call to set up the appointments. So the parent interview pre-meeting the client.

Dr. Sharp: Sure. Okay. Thanks.

Dr. Donna: The other reason I like to give this questionnaire in writing in advance is a lot of autistic adults in particular, [00:10:00] really like the opportunity to put their thoughts in writing, to put it all there, to take their time. They can write a lot of really rich information that would not necessarily come up during an oral interview. So that’s been a little side benefit for me of doing this in advance.

Dr. Sharp: Certainly noticed that as well.

Dr. Donna: Have you?

Dr. Sharp: Yeah.

Dr. Donna: It actually came up from research for the book. We’re just incorporating a ton of input from a lot of autistic adults for the book. That was one thing that came up a few times, it’s so hard for me in oral interviews to efficiently say what I’m thinking and talk about my experience, and to have the opportunity to do it in writing makes a world of difference for me.

Dr. Sharp: Sure.

Dr. Donna: So from the questionnaire, I had some very basic information. I knew that Annie lives with her parents and younger brother, pregnancy and birth were basically unremarkable except for some advanced paternal age. I think dad was maybe in his mid-40s when [00:11:00] she was born. Annie was homeschooled until high school and then she went to public school. It did sound like the community they live in has a lot of homeschooling families and that the mother did a really good job of providing both structured activities and unstructured opportunities for socializing.

I knew there was prior testing from 5th grade with a diagnosis of ADHD and that Annie was taking Strattera and Adderall. Emotionally, I knew that Annie had longstanding and persistent anxiety and then some increasing episodes of paralysis which were new, where she just struggled to get out of bed even to use the bathroom. She was isolating herself and she was on Wellbutrin. She had tried a few SSRIs in the past.

Socially, Mrs. Jones endorsed difficulty reading social cues on [00:12:00] my original questionnaire. She wrote in the comment section that Annie is not always aware of social cues and she has to tell Annie to read the room but she also made it clear that that’s not a major area of concern.

So at the same time that I sent out the pediatric questionnaire, I also sent out rating scales. I like to get those in advance too, so that I have time to review the items. I usually just go through with a yellow highlighter and highlight a few to ask the parents about at the interview.

Dr. Sharp: Can I ask you a question about that?

Dr. Donna: Sure.

Dr. Sharp: How do you know which rating scales to send out before you meet the person or parent.

Dr. Donna: There’s not a ton of variability for me. I’m always going to send the BASC, CBCL is another option there. I happen to like the BASC. I pretty much always send a BRIEF. If there’s any possibility that there might be some social concerns, I send an SRS. Those are my big three.

Dr. Sharp: [00:13:00] Okay. That’s fair.

Dr. Donna: So with Annie, the parent BASC was significant for hyperactivity, attention, anxiety, and actually was waterline for social skills. The parent BRIEF was elevated across the board. Just tons of concerns about behavioral, emotional, and cognitive regulation. The parent SRS was only a little bit significant. The T-score for social awareness was 65 and for repetitive and restricted with 60. So a little bit of elevation but nothing really extreme there.

I didn’t have teacher scales. This was one of the hardest parts of the pandemic, the teachers had only seen Annie remotely and so scales wouldn’t be valid.

Dr. Sharp: Yeah. It’s been so tough without teacher input or thorough teacher input maybe.

Dr. Donna: Right. I’ve been resorting to calling teachers that knew kids before the pandemic, [00:14:00] which is also not ideal. And that’s what I did for Annie. So I’ll talk about that interview later but I don’t have the teacher’s scales.

Dr. Sharp: Okay.

Dr. Donna: So what did I know so far after that initial phone call, the questionnaire and the rating scales? I knew that there was, it seemed like there was anxiety, depression and ADHD, and it was possible that that’s all there was to the picture. I knew that there were some social concerns but they weren’t front and center.

Autism did cross my mind at this point, not because of any one piece of information but because when I step back and look at the big picture, it felt like there might be a lot going on here from a young age. There was the persistent anxiety that didn’t respond to treatment and there was perfectionism, OT and speech and sleep and GI, and these are all things that can [00:15:00] co-occur with autism. And then the advanced paternal age was a risk factor as well. So it wasn’t on center in my mind but it was flipping around there.

I think what else crossed my mind was OCD possibly, because of the slow working tempo and the perfectionism, although Mrs. Jones hadn’t endorsed anything like compulsive behaviors on the rating scales. I think I wondered about a language disorder because Annie was stressed out by writing and Mrs. Jones had mentioned something about difficulty telling a narrative. So these were the things floating through my mind.

Dr. Sharp: Okay. Can I ask you a question about advanced paternal age? You mentioned 45. It’s been a long time, honestly, since I looked at this, but I feel like I remember “advanced paternal age” falling a little higher than that but I could be totally wrong. What’s the cutoff, so to speak, for advanced paternal age as a [00:16:00] risk factor for autism these days?

Dr. Donna: I don’t think of it as a cutoff. In my mind I have it, somebody is in their mid-40s or over, it’s a good question. I don’t know if there is a certain age that you have to think about it, but I think if either parent is at least in their mid-40s, it’s just something to note that it can raise the possibility of something going on there.

Dr. Sharp: Right. Cool.

Dr. Donna: I then did the parent interview. Unless it’s a very simple straightforward case where I’m not expecting anything complex, my parent interviews are two hours.

Dr. Sharp: Yeah.

Dr. Donna: You too?

Dr. Sharp: I love that. We share that. I do two-hour interviews and honestly cannot understand how anyone does less than a two-hour interview. It’s hard, especially those that stick to a strict hour because by the time you do pleasantries and paperwork and [00:17:00] policies, and then at the end, you’re wrapping up and scheduling and doing all that. You only end up with like 30 or 40 minutes of actual interview time. So I don’t know how an hour works.

Dr. Donna: I don’t know either. I don’t even do any of those. I do the social pleasantries. I don’t do any of the paperwork or scheduling at the interview. It’s just for the interview. If it’s a complex case, you need the parents to have time to sink into it and time to explore all the different possibilities that come up.

Dr. Sharp: Sure.

Dr. Donna: But I also appreciate that not everybody has that luxury, I’m in private practice and I’m very fortunate.

Dr. Sharp: Right. We’re fortunate.

Dr. Donna: So this parent interview was done on Zoom, which obviously less than ideal. Mrs. Jones came across as a valid reporter. She seemed to be very intelligent, very attentive to her children. They’re very detail-oriented. She seemed like a good historian.

Mr. Jones was sitting next to Mrs. [00:18:00] Jones but he never once looked at me. I think at the end of the two hours, if I asked him what color my hair was, he wouldn’t have known. He seemed to be doing something else and he mostly seemed oblivious to the conversation but he occasionally chimed in. So I knew he was paying attention because he would pop in once in a while with a comment or two.

I wasn’t sure what to make of that. It could just be a super busy day at work and he was trying to multitask. I found it interesting that he didn’t look at me at the beginning and say, hey, I’m so sorry. I’m multitasking right now. Nice to meet you. There was none of that sort of thing.

Dr. Sharp: Interesting observation. I’m always observing parents’ behavior just as much as what they are reporting or telling me about the kid.

Dr. Donna: Of course, it’s one of the reasons we love that longer parent interview because you’re getting to know who they are as people and what they’re bringing [00:19:00] both positive and maybe not as positive to the situation and where you might be able to affect some change, right?

Dr. Sharp: Sure. Okay.

Dr. Donna: So my parent interviews are divided into two parts. The first thing I do is simply have them tell me the story. I have them start at the very beginning of the child’s life and just walk me through and tell me what was going on at each stage. I interject with questions or to keep them on track, but mostly I’m just trying to get them into storytelling mood.

I find that this is a positive experience for them. It can be very cathartic. It can build rapport. It gives them that opportunity to go through it. I think it also raises their insight because it’s easy to forget things about our children’s early years and when you take your time and go through it, you start remembering more and more.

Dr. Sharp: Let me ask a really granular question. [00:20:00] How do you get them started with that?

Dr. Donna: Literally almost what I just said to you, I say, I just want you to start at the very beginning of Annie’s life and walk me through it. Tell me what was going on at each stage. You can talk about what was happening academically, socially, emotionally, funny stories, anything that you remember. Don’t worry about staying on track. If I feel like you’re off track, I will let you know. I always assure them of that. I’m trying to relax them and have them relax into the story.

And then we’re going to end up with why you’re here today. I’m going to have all of that context to really understand what’s going on today and then we’ll talk about that. People seem to like it.

Dr. Sharp: Yeah, I get that sense a lot. The parents are, whether they consciously say it or not, they have a great desire to [00:21:00] tell their story and know that someone has the full picture. That seems to be a fear a lot of the time, you weren’t going to know my kid as well as you need to, or as well as I do, or other providers haven’t asked those quite or taken the time, those themes come up a lot.

Dr. Donna: It’s a great point. And so when we come to a conclusion, whether it’s a diagnosis or a recommendation or whatever, I think they’re more likely to trust us because they saw that we did get the whole picture and we took our time and care about it.

Dr. Sharp: Sure. Great.

Dr. Donna: I just love hearing the story, getting the chronology. Having it told to me in that way, it brings it all to life for me.

So here’s Annie’s story. Here’s the story I heard from Mrs. Jones. Early motor milestones were fine but there was later OT for some vestibular and proprioceptive issues. Early [00:22:00] language milestones were advanced but Annie always had difficulty organizing language. So telling a story, getting to the point, her vocabulary was good but she would often start with the details and never get to the gist of a story.

The toddler years were noticeable for sleep issues. It sounded like there was good sleep hygiene but Annie took hours to transition from wakefulness to sleeping and then from sleeping to waking. It was significant enough that she had a sleep study at age five, which found delayed sleep onset and Annie benefited from melatonin ever since.

So then we get to the preschool and early elementary school years, a lot of parents rush through those years if there weren’t glaring issues, they want to jump ahead to when they perceive that the problem started. I often have to slow them down and encourage them to spend [00:23:00] more time on those years. And that was definitely true for Mrs. Jones. She was vulnerable to rushing through it because Annie had done well academically and behaviorally when she was young.

The short version was that Annie was this shy but happy kid who did well in school but the more we talked about it, the more I got a little bit of a different picture. Annie did go to a preschool, that was before she was homeschooled and the preschool experience was generally unremarkable, but Mrs. Jones did recall the preschool teacher saying that Annie didn’t know how to engage and play well with other kids and that Annie required a little bit more scaffolding than most kids did at that age.

Mrs. Jones also recalls that Annie complained about noise a lot and liked to spin sometimes when she was about four or five years old. She hadn’t marked any history of repetitive behavior on the rating scale. As we chatted more about it, this was a [00:24:00] memory that bubbled up, was to me, a good example of getting them into storytelling mood.

We talked about the early OT for sensory integration and the speech and Mrs. Jones didn’t remember a ton of details about those and that’s not uncommon but I did ask her for the documentation. I told her just anything you’ve got, any papers from those therapists, send to me and I’ll discuss those shortly.

Socially, Annie did engage in imaginative play by herself and with other children but she also tended to get lost in her own thoughts and just disengage from play at times. From kindergarten on, Annie had already started having anxiety, mostly around decision-making and performance. She also had a lot of phobias; elevators, escalators, heights, inclines, needles. There were just a lot of phobias and they were significant enough that Annie went for some [00:25:00] CBT.

When I heard that list, a few of them jumped out at me like escalators, heights, inclines. I wonder about the sensory piece, the balance piece, the ability to know where your body is in space. I wondered about the connection there.

Dr. Sharp: That’s interesting.

Dr. Donna: The other thing that came out about the early years was that Annie had chronic constipation and stomach aches, and that’s significant to me, maybe just anxiety but it’s also true that autistic kids are vulnerable to having early and persistent GI issues.

Dr. Sharp: And is that related to interoceptive weaknesses or unawareness or is there some more…?

Dr. Donna: I do think there is some research saying that autistics have a sensitive gut. Some of it might be related to [00:26:00] when people have limited diets. Although that wasn’t the case with Annie, she had a good diet. I personally think that autistic kids go into fight or flight frequently and they stay there for long periods of time because the world is so stressful for them.

And when you’re in fight or flight, your digestive system pretty much stops working temporarily. So if you’re constantly going into that state where your digestive system stops working, it makes sense to me that you’d be constipated and have stomach aches.

Dr. Sharp: Yeah, it makes sense.

Dr. Donna: I don’t know that I’ve ever read that anywhere. I think it’s just a Donna thing.

Dr. Sharp: We’ll take it.

Dr. Donna: Okay. Elementary and middle school, Annie really thrived with homeschooling. They didn’t homeschool for any particular need; it wasn’t Annie couldn’t handle school so we homeschooled. It was just a family decision and they did it for her younger brother as well.

There were a few concerns about inattention, excessive movement. Mrs. Johnson noticed that [00:27:00] Annie was a strong reader but she had some difficulty pulling out the main ideas and also that Annie seemed to really need explicit instructions.

So because of those concerns, in 5th grade, Mrs. Jones brought Annie for an evaluation and she was diagnosed with ADHD. I of course said, you’re going to send me that report. So I’ll talk about that report in a minute.

Socially, during the elementary and middle school years, Annie always had friends. So if I just said, she always had friends, yes. Nice friends, yes. Long-lasting friends, yes but she didn’t make friends easily and none of them were particularly close friends. She never actually had a best friend as far as Mrs. Jones could identify it. I always ask as we go through the chronology, who is her best friend and who is she close with them?

So Annie transferred to the local public high school for high school, and that was by [00:28:00] mutual agreement. I think Mrs. Jones was ready to stop homeschooling, Annie was ready to branch out a little bit. The school sounds like, I’m not familiar with it but it sounds like it wasn’t a pressure cooker school. It wasn’t a huge school and Annie was quite comfortable with that decision.

And right away, in 9th grade, she got into debate club and a competitive trivia club, and she made friends there. From 9th-11th grade, she earned strong grades. She seemed pretty happy but she was still incredibly slow and perfectionistic. She was in therapy on and off for anxiety.

And then in March of 2020 with the pandemic is when she seemed to become depressed. That was new. She had never been depressed before, she became really withdrawn. She cried, her working tempo got even slower. She spent more and more time in bed crying and isolating herself.

One day Mrs. Jones found Annie sandwiched in between her mattresses, [00:29:00] which is alarming to Mrs. Jones. To me, I hear sensory when I hear that. Mrs. Jones said that as, this set off alarms for me, that is weird, who sandwiches themselves in between her mattresses?

So at that point, Annie went back to therapy and the therapist wondered if her ADHD was getting in her way, she had never had tried medication for it. So her therapist referred her for medication and he saw a psychiatrist who agreed with the prior ADHD diagnosis and started Annie on Adderall.

I should say at this point, that during a parent interview, I take notes just in the order of the conversation but I also categorize my notes on the side. So I have a little side piece of paper or document, if I’m typing, that just has the [00:30:00] diagnostic criteria for autism, it’s mostly white space.

So it just says, interactions with space, then relationships with space, then non-verbals with space. When I hear something that might fall into one of those categories, I just jot it quickly there. So when I heard the thing about the mattresses, I just jotted mattresses in the sensory. It’s just a way for me to organize and keep track as we’re going along like, is autism something I need to consider here?

If I end the interview with a whole lot of notes on that page, then yeah, maybe I need to. If I end the interview with almost nothing on that page, then I probably don’t need to think about autism. With Annie, in the middle of the parent interview, it wasn’t screaming autism at me at all. Social skills were not a primary concern. Rating scales weren’t dramatically significant, no repetitive or idiosyncratic behavior had come up, no intense or unusual interests had come up. It wasn’t [00:31:00] off my list entirely but if you had asked me at that moment, I wouldn’t have placed it as likely.

Dr. Sharp: Sure.

Dr. Donna: But I wasn’t ready to rule it out because there were so many red flags in the early history. Actually, there was a fantastic article in The Clinical Neuropsychologist last year. I think the primary author was either Susanne Duvall or Kira Armstrong. I can definitely get you the citation if not the article itself.

They talked about this concept of pink flags. So if you think of red flags as something that clearly you would link to autism, like somebody who’s flapping or obsessed with train schedules, pink flags are things that are less obvious but still potentially significant indicators of autism like having passionate interests or having trouble keeping a conversation going or having alexithymia. So using their language, I was seeing a lot of pink flags. So I really wanted to do [00:32:00] my due diligence.

This is the second half of the parent interview, which is where I’m asking more pointed questions. I did this in the order of the diagnostic criteria for autism, at this point. I did other things as well but for the purpose of this interview.

When I asked about interactions, Mrs. Jones reported that Annie has always better with the adults, that she’s never initiated interactions with peers and didn’t quite know how to play with kids. So for example, when they would go to homeschooling groups and there’d be a bunch of moms and a bunch of kids, Annie was more likely to hang out with the moms than the kids. When her mother said, go hang out with the kids, she did but it wasn’t her natural inclination.

She did actively play with other kids but she also spent more time than her mother expected in parallel play. When Annie joins a conversation, she needs to hear every [00:33:00] detail that she missed and she gets really agitated if she misses something. So that’s something we’re going to circle back to in a little bit.

Mrs. Jones said, Annie, doesn’t pay a whole lot of attention to what other people might be thinking. She doesn’t feel a lot of peer pressure and that Annie seemed to enjoy being with people and socializing but then she’d be exhausted and wouldn’t do anything for days. So I would call that low social energy informally. So it seemed a lot for interactions.

When I asked about relationships, we already talked about the fact that Annie never had a close friend before 9th grade. And again, I felt like she had had ample access to other bright kids with similar interests. I didn’t think it was a lack of access situation. Mrs. Jones herself was surprised at Annie’s lack of close friends.

Annie also seemed to have low social motivation. She was always comfortable with the limited [00:34:00] social life. She never seemed to get lonely. She just didn’t have a lot of needs.

And then when I asked about nonverbal, sorry, were you can ask a question?

Dr. Sharp: No.

Dr. Donna: When I asked about nonverbal communication, Mrs. Jones said that sometimes Annie doesn’t notice that she loses her listener and that her mother frequently had to tell her to read the room. And so while we were talking about this whole social-emotional piece, Mrs. Jones mentioned that Annie has poor emotional vocabulary, that she’s never been able to talk about how she was feeling, and that this was in contrast to generally a very mature vocabulary. So this is possible alexithymia, which is not specific to autism but is definitely a big pink flag.

Dr. Sharp: Yeah, could you give a quick definition of alexithymia in case anyone out there is wondering what that is.

Dr. Donna: Sure. It’s when somebody has difficulty talking about their emotions, [00:35:00] putting a label on them and describing them. And to my mind, the physiology that underlies alexithymia is interoception. I wonder if we should spend a minute talking about interoception.

Dr. Sharp: Sure, if that fits for you.

Dr. Donna: I think it does because it’s so important. Most people think we have five senses and we have eight, of course, and those other three are proprioception, vestibular, and interoception. I think interoception is unbelievably important for us to know about, particularly but not exclusively for autism.

So interoception has to do with our ability to notice signals from inside our bodies rather than out there in the environment, and also to contextualize and assign meaning to those bodily signals. So interoceptive awareness is highly individualized, so what you experience as anxiety is different from what [00:36:00] I’ve experienced as anxiety. We all have unique interoception. There’s no right or wrong interoception but it is important for each person to understand their own interoceptive experiences.

We all have a range of interoceptive awareness but some people can be at the extremes of this range, so they can have body signals that are too big. I call it the volumes too loud sometimes. So they might be over-responsive to some signals and maybe there’s very sensitive to pain or heat or cold. The body signals can be too small, maybe they don’t notice signals of hunger or anxiety until they’re huge or body signals can be distorted; so not specific or clear enough, so they might feel off or icky but not know if they’re tired or hungry or sad, right?

Dr. Sharp: Yes.

Dr. Donna: I should say that when we talk [00:37:00] about the emotions for interoceptive awareness, I would divide them into two categories. We have affective emotions like anger and joy and anxiety and all of that, but also homeostatic emotions like hunger and thirst and pain and all of that. So interoceptive awareness is huge because it’s the basis for self-care like eating when you’re hungry and going to the bathroom when you need to or responding to illness. Like these kids who pee in their pants way longer than expected, I always wonder, do they not feel the urge? Do they not feel the wetness going on there?

Interoception is related to emotional regulation and I wonder if it’s the missing link to those kids who don’t do well with CBT, because if you don’t know you’re anxious, you don’t know to use all those fancy CBT skills you learned in therapy, right?

Dr. Sharp: Sure.

Dr. Donna: It’s definitely a basis for social connection because if I don’t know what frustration feels like for [00:38:00] me, how could I imagine what it might feel like for you to be frustrated? I’ve always wondered if interoception is a basis for empathy in that way.

Dr. Sharp: Yeah. It plays a powerful role in life in general.

Dr. Donna: Absolutely and definitely motivation too. When I have a kid who’s got low motivation, obviously, I wonder about other things too. I’ll think about depression, are they smoking a lot of weed? What’s going on there, but having low interoceptive awareness, because motivation is a feeling so it’s definitely in there.

So definitely I noted possible poor interoceptive awareness under the sensory category of my little cheat sheet when Mrs. Jones said that Annie had never been able to talk about how she was feeling. There were no repetitive behaviors. Mrs. [00:39:00] Jones felt there were no intense or unusual interests.

Flexibility, Mrs. Jones had written the word rigid in the comment section of the BASC. So I asked her why she had written that. So when a parent or teacher draws a conclusion like that, I always ask for examples because I need to know what made them use that word, because what they’re calling rigid or anxious or shy or rude or whatever they say, I might interpret differently.

So if a teacher says a child is a leader, I’m going to ask for examples, like what did you observe that led you to that conclusion? So let’s say it’s a 5th grader, they might say, oh, well, every single recess the child spends all of their time with the 1st graders organizing games and helping students who have no friends. So yeah, there’s some leadership qualities there but boy, that tells me something about how they spend their unstructured time, [00:40:00] not with their peers.

So I never take what somebody says, and it’s not that I’m doubting them, I just want to understand what led them to that conclusion. I want to hear the behaviors they observed more than their conclusion about it. So when we interview parents and teachers, that’s a lot of what I try to do.

Dr. Sharp: Right. It’s amazing what labels or descriptors people can put to the same behavior. People interpret so many different ways.

Dr. Donna: Right. Absolutely. Especially if you’re talking to people who have different cultural backgrounds, absolutely. So Mrs. Jones wrote rigid and when I asked her about this, she said Annie thinks that there’s only one right answer to things. I asked her for examples and she said, one day, Annie left a towel and some clothes on the floor and she also left dishes in the sink. Mrs. Jones said, you need to pick all of that up this minute and in Annie’s mind, it all [00:41:00] had to be done within a minute. So like really rigid interpretation of language.

I asked for another example, Annie had just turned 18 and she had this rigid idea that now I’m an adult and I have to know everything that adults know. She started having a meltdown thinking, I don’t know about retirement funds. Aren’t I supposed to know about retirement funds?

I asked for another example, Annie was trying to pick a college and she was obsessively researching the meal plans thinking that she had to know about that. She didn’t have a particular diet and her parents kept telling her, we’re going to get you the unlimited plan no matter where you go, stop looking at that. She just couldn’t get past it.

And so when I heard these examples, I did hear some rigidity but I also heard context blindness. To me, context blindness is a huge pink flag for autism. I wonder if we need to spend a minute [00:42:00] explaining what that is.

Dr. Sharp: Yes. I was going to ask you to elaborate on that just a bit when you say context blindness.

Dr. Donna: So we’ll take a relevant detour here and talk about that.

Dr. Sharp: Great.

Dr. Donna: I’m going to try to do it justice in just a few minutes, but it’s such an important concept. If people are interested in autism, if they’re going to read one book this year, I would recommend Autism as Context Blindness by Peter Vermaelen. It’s a wonderful book. It’s an academic book but it’s so beautifully written. It reads almost like fiction.

So let me just talk about typical brain functioning first and then this unusual type of functioning. Our brains don’t process information in isolation, we process information in context, and this is essential because there’s nothing in the world that’s absolute. Everything is ambiguous. We constantly use context to [00:43:00] predict and understand the world. Everything we see, we hear, we read, we experience, we rely on context to understand it.

Let me give you some examples of how nothing is absolute. So what is red lighting?

Dr. Sharp: Stop.

Dr. Donna: What if you’re walking across the street and you’re halfway there and it turns red?

Dr. Sharp: Oh, you should keep going and finish crossing the street.

Dr. Donna: Right. Exactly. Nothing is absolute. If somebody holds up their hand to you, what does it mean?

Dr. Sharp: Stop, maybe. I don’t know or shake my hand.

Dr. Donna: Yes, hi-five, stop talking, hello, goodbye, five.

Dr. Sharp: All of a sudden, am I getting the right answer here?

Dr. Donna: Well, that’s the whole point. There is no right answer. What if I say, we’ll talk about this later? Does that mean five minutes, two hours? Does it mean never?

Dr. Sharp: Great question.

Dr. Donna: What does it mean if my heart is pounding? I don’t know. Am I about to do something exciting or [00:44:00] scary? Is it okay to lie? It depends. How close to someone should I stand? How much eye contact should I make? How should I greet someone? Do I capitalize the word, what? It just could go on and on. We use it constantly.

And then there’s layers upon layers of context. So if you see a drop of water, context instinctively automatically tells you, is it dew? Is it raining? Is it sweat? Is it a leaky faucet? Is it a teardrop?

Let’s say it’s a teardrop. Then context will tell you what type of teardrop, by the context of the conversation of what you know about that person, what you know about what makes you cry. So there are all these layers of context and your brain uses all of this very automatically and intuitively and subconsciously and quickly to make predictions and to cope with the [00:45:00] unbelievable amount of input that’s coming at us all the time.

So let’s call this top-down processing and it’s what most of us use to interact with the world. It’s a very efficient way to move through the world, but some people rely more on bottom-up processing. They are not as sensitive to context first. They are more detailed thinkers.

I should say, if a neuroscientist was listening to this, they’d probably be horrified and say that they’re way oversimplifying because it’s not as linear as I’m describing it. Of course, we all use top-down and bottom-up processing, but the top-down is faster for most of us and guides the bottom-up.

And so for the people who don’t do the top-down, who don’t see the context as easily, Peter Vermaelen calls this context, blindness. Of course, they’re not actually blind to context. They’re just not as sensitive to it. Also it’s not a [00:46:00] super neurodiversity affirmative term. I don’t like it from that point of view but I’m going to use the term for the remainder of this conversation because I don’t have anything better.

So if somebody has context blindness, they’re going to look like they’re a very slow processor. They may be a slow processor, but they’re also processing a lot more information than the rest of us are. So like right now I’m looking at you, mostly, I’m looking at your movement, you’re nodding your head and what your eyes are doing. I’m ignoring what your microphone looks like, what color your shirt is, what type of earbuds you have, what type of lighting, what slimeball color in the background. I’m ignoring easily 200 little details right now and my brain doesn’t have to spend any time or energy on those but if I was taking in all those details as so many autistic people do, it would just take me a lot more time to interpret what’s happening.

People with context blindness are [00:47:00] vulnerable to missing the chest and focusing on minor details, even irrelevant details. They have a lot of difficulty knowing when and how to generalize rules. So they might overgeneralize. The best example I ever saw of overgeneralizing was this young man I worked with who had been kicked out of basic training for a whole lot of insubordination.

One example was, they were walking in formation, I guess you call it and he broke formation to pick up a piece of litter on the ground. The drill sergeant was screaming at him and he said, yeah, but there’s litter on the ground. You’re supposed to pick up litter. It’s bad to litter, like overgeneralizing.

You can also under-generalize rules. Like if a kid does the same math problem or the same type of math problem, say they do four problems and they got the hang of it and then the next problem is also slightly different and [00:48:00] they’re stumped and they can’t do it because they didn’t generalize the rule. We use context for all of this.

So if you have context blindness, the world is definitely a harder place. It’s going to take a lot more time and energy to move through the world. I should say, there are advantages to this style of thinking. Those of us who are more context-sensitive don’t tend to notice details as much so people with context blindness are better often at detailed thinking.

So with Annie, I heard a lot of signs of context blindness. Mrs. Jones said it was hard for her to start with the big picture and she jumps right into the details. When she wants information, she needs it as detailed as possible and she gets agitated if she’s missing something. For instance, they were doing Annie’s taxes because she had a little part-time job and she felt to me to read [00:49:00] every word on the tax form and understand all of it. Even her father kept saying, adults don’t even do that. Nobody does that but Annie felt like she had to.

When Mrs. Jones taught Annie to say, thank you and she was younger, Annie thanked her for every tiny little thing; thank you for setting the table. Thank you for the chicken. Thank you for the rice. Thank you for the piece. Thank you for putting salt on the table. She could thank her mother 30 times in an hour, overgeneralizing the rule.

When I interviewed a teacher, she said everything is equally important to Annie. She can’t prioritize. A big essay is the same as a minor assignment. I have more examples but I think you get the idea. Just real difficulty getting the gist, getting the context, getting stuck on details, right?

Dr. Sharp: Yeah.

Dr. Donna: So context blindness is a good example of something that’s not part of the diagnostic criteria for autism but is often part of the picture. [00:50:00] Back to the parent interview, just to end it up, I asked about family history and about Annie’s strengths. Family history, mom’s brother has never been diagnosed with anything but is described as socially awkward. He doesn’t know how to relate to people, even family members and it takes him three hours to shower and get ready in the morning. So I have no clue what’s going on with mom’s brother but autism is possible, right?

Dr. Sharp: Right.

Dr. Donna: On dad’s side, there was a paternal cousin in her 20s who’s described as brilliant but unable to finish college and had tremendous social anxiety. So I don’t just ask about what’s been diagnosed. I have mom and dad each tell me about your family even your extended family, whether or not somebody was diagnosed, just anybody who’s quirky, who’s had struggles.

And dad himself is an IT guy who said he has a lot of sensory [00:51:00] sensitivities. He feels that he’s very similar to Annie. He needs encouragement to socialize and he had difficulty making friends when he was younger. So that one away; the social presentation and I certainly starting to wonder about the family connections there.

I asked about trauma history and family history of trauma. There was nothing. And then finally, we went through Annie’s strengths. I always like to end the interview on that positive note. I’ve been noting strengths as we go along but I like to explicitly ask about it. Annie had tons of strengths. She’s willing to try things in order to get better like therapy or medication. She’s an extremely hard worker, intellectually curious. She likes to be helpful. She’s good with younger kids. So there was a whole lot there.

So now that I had dug deeper into the parent interview, I definitely had more reason to wonder about autism, right?

Dr. Sharp: Yes.

Dr. Donna: So then I did the document review and [00:52:00] collateral interviews. Ordinarily, I tell parents to bring in every report card. I don’t care if it’s disorganized and you have one from this year and two from that year, just bring in anything you’ve got. It was limited because Annie had been homeschooled.

Ordinarily, I would go through all of those, also ordinarily, I talked to prior teachers. So for an 18-year-old, I still will try to talk to a 4th or 5th grade teacher. Teachers are amazing people. I have never once, not once had a teacher say, I don’t remember that kid.

Dr. Sharp: It’s wild.

Dr. Donna: Isn’t it?

Dr. Sharp: Yeah.

Dr. Donna: I barely remember yesterday, teachers amaze me.

Dr. Sharp: Yeah. Agreed.

Dr. Donna: The OT summary report, Annie had OT from ages 4-9. That’s a lot of OT. The OT reports that it was due to concerns about sensory processing which interfered with social interactions. At [00:53:00] the time, the parents reported, this is documented by the OT, that Annie would isolate herself even with playdates at home. And then Annie did not seem to realize when she was hungry, thirsty, tired, cold, or in pain and the OT ends and that’s interoception. The OT documented differences in auditory, vestibular, and tactile processing.

I also saw the speech therapy summary that at ages 7-9, Annie was described as engaged and animated. During the first session at age seven, Annie got stressed out and squatted on the floor and rocked in place. The speech therapist noted that Mrs. Jones reported this is typical behavior when Annie is stressed.

And what’s key about that is that mom said no to all my questions about repetitive behaviors and on the rating scales. This is why it’s so important for us to not rely on one rating scale or [00:54:00] one question but to gather information in lots of ways.

The speech therapist also wrote that Annie struggled with flexibility and that she had trouble with even slight variations in things and that the mother had also reported that this was an issue at home. The speech therapist wrote Annie had difficulty discerning information that is not relevant, for example, what the back of the bookcase looks like. And that context blindness again. I don’t know what context that came up but that was what the speech therapist wrote for her example.

The speech therapist wrote, Annie had some difficulty keeping a conversation going and responding to other people’s cues. And so that was something they worked on in therapy. Mrs. Jones didn’t remember any of that. She told me when I asked that the speech therapy was for the organization of language and nothing else. And I think she was a valid reporter. We just forget.

[00:55:00] Dr. Sharp: Sure.

Dr. Donna: Prior testing; Annie had testing in 5th grade because of mom’s concerns about attention and getting the gist when she was reading and needing explicit instructions. Remember, all Mrs. Jones remembered was the ADHD diagnosis. I don’t know if there’s ever been research but there are any graduate students out there looking for a dissertation topic, I think it would be fascinating to know what people remember about our reports about their children six months later, five years later.

Dr. Sharp: Yeah, that’s great. That’s such a great point. I don’t know of any research either that I can pull out that specifically addresses that. That’d be a great project to start.

Dr. Donna: Because parents often misremember things, diagnoses, recommendations, all of that. Anyway, this [00:56:00] report said during all three testing sessions, Annie had difficulty with boundaries, like trying to turn the examiners’ pages and she asked unusual questions about the test manual. By the third session, the examiner asked Annie to imagine that everyone has a bubble around him and we shouldn’t pop their bubble because that is intruding on their personal space.

Dr. Sharp: Okay.

Dr. Donna: This doctor wrote, and I’m going to quote, “It is my impression that she has difficulty with reading nonverbal cues, taking perspective of other people, and understanding and responding to the impact of her behavior on other people”. And there is no evidence at all that this person considered autism as possibility.

I don’t know about you, Jeremy, but I see that all the time, that there’s just no evidence that it even crossed someone’s mind. Sometimes I get a report that says, I thought about autism and I ruled it out because of A, B, and C, and then fine. Great. [00:57:00] But I think a major issue is that we’re not even considering it as a possibility.

Dr. Sharp: Right. People have their biases in their lenses that they looked through, for better, for worse. But yes, of course, looking back on all this data, it’s like, oh, there’s a lot of pink flags and some red flags.

Dr. Donna: Absolutely. I’ll be the first to say that if I read a report that I wrote 10 years ago, I’m sure I get horrified and I’m sure I’ve missed autism. I think we’ve all gotten better about it but it was pretty glaring there.

So I also interviewed one of Annie’s prior teachers who had seen her live and she said Annie was one of the most careful and conscientious students she’s ever had. Just an absolute pleasure. The only thing she said was that Annie doesn’t decide what is or isn’t important, that she includes every little detail in her notes to the point that you can’t see the big picture, there’s that context [00:58:00] blindness. And then I interviewed the therapist who did not see any evidence of OCD or trauma.

So now I’m definitely thinking more about autism and then I finally get to meet Annie. It’s like I know everything about her and I haven’t even met her yet. I got to see her in person, which was fantastic. She was so delightful. I liked her instantly. She was pretty and well-dressed, she was vivacious, warm, polite. I just liked her immediately.

Very intelligent right off the bat and this is such an important point. If I had met Annie socially, I would never ever have wondered about autism. I have to constantly check myself to rule out autism just because someone is warm and engaging. I have to remind myself not to be influenced by how [00:59:00] charming a person can be.

Dr. Sharp: So this to me raises that question; you know what question I’m going to ask, I’m sure. If someone can come across so charmingly and engaging and let’s say, neurotypically, maybe for lack of a better word. Is that truly possible, can someone be autistic and pass so well?

Dr. Donna: Yeah. Right now I’m literally imagining thousands of autistic adults, mostly women, screaming yes. Yes, we can and it’s costing us so much. Absolutely, 100%. I think the autistic community has been very vocal about this. Researchers are catching up. There’s a great article. I can send you the citation for it. This was a few years ago written by Meng-Chuan Lai [01:00:00] and Simon Baron-Cohen about the lost generation of autistic adults and how it can be very hard as somebody matures and gets better and better at camouflaging, to see the autism except that their anxiety and their depression just keeps growing.

Definitely, when you see Annie’s test results and her report of her subjective experience, that will also become very clear to you in this case. There is just such a huge difference between the external presentation and the internal experience. As psychologists, we have got to constantly fight against that instinct that I’ll just know if someone’s autistic. I fight against it all the time and just look at the data.

Dr. Sharp: Right. I think I appreciate you talking through that. I have to ask that question because I know people have that question. [01:01:00] It can be difficult to reconcile those things for us; these different presentations.

Dr. Donna: Yes. For me as well, even doing this all the time, it’s a constant thing I have to struggle against. Behavioral observations; the ticking of the clock was a distraction. I had to remove it from the office for her. Her language was super fluent, fantastic vocabulary but when I asked her to talk about emotions, she was way less fluent.

Her eye contact was really good. It felt natural. She was super animated. Lots of gestures. A few of her gestures were odd and I couldn’t put my finger on it. There were just a few moments where I was just like, what was that but most of them were perfectly natural.

Annie was really chatty. She missed cues at times when I was trying to interject. She was not [01:02:00] reciprocal when I tried to make it a conversation. She would pause. She would listen to me and give me great nonverbal cues that she was fascinated by what I was saying and then when I stopped talking, she would then continue to talk as if I hadn’t spoken at all. So if you were watching the conversation but not listening to it, you would think, well, there’s some good, turn-taking, there are some nice nonverbals happening, but we were not having a reciprocal conversation.

Annie did well on effort testing and she seemed to care a lot about performing well. She was not attached to any outcome, I should be clear, neither Annie nor her parents were thinking about autism as a possibility here.

What was most memorable about her was her incredibly slow working tempo, which was due to her tendency to get lost in all of these irrelevant details. So back to context blindness, I saw it everywhere. I saw it in Annie’s constantly [01:03:00] asking for more clarification than most students ask for. So when I asked and I’m changing, so psychologists who are listening to this, they’re going to say, wait, where are these questions from? I’m changing them to protect the privacy of the test, how are valley and a mountain alike. Annie wanted to know, well, how high is the mountain? Irrelevant, right?

When we did Matrix Reasoning, Annie asked, do the numbers below mean something? Are they part of the puzzles? Whereas most students instinctively know they aren’t.

Sentence fluency was brutal. She really struggled because getting through the demo items, an apple is blue. Well, you can make an apple blue. And so I told her very explicitly, no, we’re looking for the most typical occurrence, answer how a kindergartener would answer. It’s not trying to trick you. She persisted that there could be a blue [01:04:00] apple somewhere in the world.

And this kept happening. A man has two legs while a man can have one leg. A penny is round. Well, what does it mean by round? The sides are round but the top is flat. If a kid asks one of these questions, okay, whatever, but it was over and over again.

For similarities, I assume other people do what I do, which is I’ll ask the full question for the first new items, how are blank and a blank alike? But after doing that four or five times, I’ll just say the two things, I’ll just say, light and candle, and kids know what I’m asking. There was this long pause and Annie said, what about them?

Self-report measures were brutal for her. She asked clarifying questions about almost every item. I keep the light on at night; well, when I’m sleeping or when I’m awake. I worry about what other people think of me; does that [01:05:00] include at school? Is that at home? I feel sick to my stomach; does that include worrying or just when I’m actually sick?

Dr. Sharp: So many details there.

Dr. Donna: She never instinctively got the intent. She had to think her way through every possibility for each question, it was exhausting for her and frankly, for me as a tester. She also provided a lot more clarification than most students do. So on a writing prompt on the WJ, she was asked to write a main or topic sentence for a paragraph about sports and she wrote: Swimming, baseball, soccer and tennis are the most popular sports among elementary school kids. Great sentence but she wrote an asterisk at the end of that sentence and then at the bottom of the page wrote, data not confirmed. I made it up to fit the prompt.

Dr. Sharp: Just to be clear.

Dr. Donna: Just to be [01:06:00] clear.

Dr. Sharp: Yes.

Dr. Donna: All right. So you get the idea, lots of context blindness. Now I’m going to circle back to your question about if she doesn’t seem autistic, can she really be, and the internal experience. So when I asked Annie about her internal experience, these are some of the things that I heard; conversations are draining. My brain is working twice in the conversation, taking in and understanding and responding to what everyone is saying, but also thinking about what I said and how everyone reacted, and what I’ll say next and how is this the same or different from other conversations I’ve had. And if I have it again, how would it go? It’s a lot of work.

She even does this with family members at times. She’s always still out of step with others. I think that was from the SRS. So part of interviewing, of course, is asking people about their responses on reading scales.

Annie said when she was younger and had to be in social situations, I wanted to be as [01:07:00] far away as possible. Having to interact with other people, even people that I knew when I went to birthday parties, it was like, how am I supposed to talk to them? Starting a conversation, continuing it, does another person join? What do I do if another person joins? What if they lose interest? How does a conversation start? How does it end? It felt like everyone else knew how to do this but I didn’t.

Annie talked about being misunderstood at times. She said if she saw someone for the second time in a day, I’ve heard a few autistic kids talk about this, like if I see someone in the first period, and then I see them again in the third period, I don’t know if I’m supposed to say hello to them again or not. What’s the rule? And so she decided not to, and then people would get upset with her because they thought she was ignoring them.

Annie said, as far as friends, that she has friends now but she wasn’t good at making [01:08:00] friends when she was younger and that she found it all confusing. She said, my mother used to tell me to have an open face, but I would do that and still no one would talk to me. And so I felt like I should have made friends and I didn’t, she wasn’t upset by this. It was very cognitive.

Annie told me that she has rarely if ever felt lonely. Relationships felt effortful to her and not worth the effort. And not in a depressed I’d given up way, just like I don’t get lonely. I’m good. I like my own company. She’s had crushes but she’s never dated and doesn’t really have much interest in dating.

Dr. Sharp: Can I back up just a little bit and ask you a quick question, Donna? Just for the sake of discussion and sorting through the case, you mentioned a lot of things that I think could be construed or grouped under the umbrella of social anxiety. What are you hearing that distinguishes, and maybe I’m leaping ahead, if that’s the case we can leave it but [01:09:00] what’s jumping out to you that might be different than social anxiety or just anxieties?

Dr. Donna: A major difference, obviously, the overlap is anxiety in social situations. In social anxiety, that’s the core issue, in autism, the anxiety is a result of confusion or sensory issues or flexibility challenges or all of the above. And so understanding the entire person, if all those other things are there, then it’s not just social anxiety. And Annie was clearly expressing confusion.

Another thing I look at is just the pattern; socially anxious people are generally fine with their family. They’re not socially anxious with their siblings or with their parents. So if parents and siblings even close friends are potentially giving me feedback about their interaction or what it’s like for them, then I think that’s really significant.

[01:10:00] Another thing that might differentiate them is public speaking. People who are socially anxious often have a really hard time with public speaking, like giving a talk in front of a group of people. A lot of autistic people do really well with that, in theater or giving talks because you don’t have to be reciprocal and they’re not anxious when they don’t have to be reciprocal.

And then socially anxious people who are not autistic won’t meet the repetitive restricted criteria. So if you have a socially anxious person who meets the repetitive restricted criteria, you need to at least be thinking about autism.

Dr. Sharp: Yeah. Right. Thanks for talking through them.

Dr. Donna: I guess the only other thing about the social pieces that I asked Annie, as I always do, what’s eye contact like for you? Remember, her eye contact looked great to me. She said, I hate eye contact. I don’t know why, but it feels really uncomfortable for me. [01:11:00] I used to not look people in the eyes, but somewhere along the line, it was brought up to me that it’s rude not to look in their eyes. So now I have to remind myself so that I don’t look weird.

When we talked about emotions and I should say, Annie has a vocabulary at the 99.6 percentile. So no vocabulary problem there, her vocabulary is better than mine, for sure. She could not express how she experiences emotions in her body. So when I’m looking for interoception, I want to know from them, what things feel like in their body.

And so if they give an answer like, well, when I’m anxious, I start moving around a lot. That’s not what it feels like in your body. It’s what you do. So when I asked her, what does anger feel like to you? She said, that’s a very hard question to answer. I don’t know how to explain it with words. I feel it in this part of my body and she [01:12:00] pointed to her face. Like in that moment, she didn’t even say face.

When I asked her how anxiety feels in her body, she said, these are specific physical feelings that I know but can’t describe or explain, it’s in this part of my body, pointing to her abdomen. When I asked her about hunger, she said, often I don’t realize that I’m hungry. I feel like my stomach needs food but the emotions that come with hunger, I tend to feel on my skin. So that’s a lot of interoception alexithymia stuff from a person with an amazing vocabulary.

Dr. Sharp: Yeah.

Dr. Donna: So sensory stuff; I don’t remember Mrs. Jones recording current sensory issues. And that’s not uncommon because as people age, they tend to show their sensory problems less and less to those around them and it becomes an internal experience. So it’s definitely something to explore with the client even when the parents don’t highlight it as a [01:13:00] current problem, and I’m not going to read everything Annie said, because we’ve talked for a long time about lots of sensory stuff, but she said, I need more pressure on my skin than I get. When I go to bed, I want something to squish me down. Sometimes I get between the two mattresses with my weighted blanket on top.

She described light sensitivity; often I squint a lot because it’s too bright. I work better in the darkness with this little light as possible. She talked about difficulty with textures and here’s the part I want you to hear. She said, in public, I just suck it up and feel uncomfortable and can’t really think about anything else.

So let’s talk a little bit about test results. My big four for an 18-year-old, as far as self-report measures for social stuff are the AQ, RAADS-R, the CAT-Q, and the SRS. So the AQ is the Autism [01:14:00] Spectrum Quotient, which was created by The Autism Research Center, Simon Baron-Cohen’s group. Annie got a score of 29, which is a significant score.

The RAADS-R, Annie also got a significant score. One thing I like about the RAADS-R, I like that most of the items aren’t outdated or judgemental, there are a few that I don’t love, but most of them are okay. I find it to be really sensitive and specific in terms of matching my clinical judgment. I like that it allows people to respond to each item like true now. And when I was young true, only when I was young, true, old or never, true, it gives some flexibility that way.

The CAT-Q, I think you and I talked about last time, again, is not a test for autism but it’s a test for camouflaging, which is very common with [01:15:00] autistics and Annie’s score was 139, which is definitely a significant score. That measure autistics average around 120 and non-autistic around 87. So 139 is a significant score.

So for testing, I didn’t do a ton of social cognition testing in part because we don’t have a ton of great social cognition tests and in part, because I already felt like I’ve got a lot here but I gave her Affect Naming from the Advanced Clinical Systems test. On that test, somebody just looks at photographs of people and has to say what that person’s feeling; they’re happy, they’re angry, they’re sad. It’s not very hard to do. She was at the 75th percentile.

The test I gave that I love, and if somebody is going to get one new test, I would recommend this one, is the Social Language Development Test. Do you know it? Do you [01:16:00] use it?

Dr. Sharp: No, we don’t use it. Let’s hear about it.

Dr. Donna: Okay, good. I really want you to use it. It’s a great test. There is two versions. There’s an elementary school and an adolescent version. The adolescent only goes up to age 17 and 11 months, but I do use it for adults. Obviously, I can’t score it, but I think it’s compelling if somebody gets 0 out of 12 correct on a sub-test. And there are age equivalents too, for the raw scores. I really need the people who made the Social Language Development Test to do an adult version.

Dr. Sharp: If you’re out there listening…

Dr. Donna: Please. Annie’s two months older than the highest normative group but I scored her anyway. On the Making Inferences subtest, which is a brilliant subtest, a client has to look at a picture of a photographed person and pretend [01:17:00] you are that person and say what you are thinking.

So it’s not as easy as saying they are angry. You have to get in their head and be in their head using the cues that you get. It is brilliant. You also have to identify what you see on their face or in their body language that told you what they were thinking. I find it to be very sensitive to people having difficulty getting in someone else’s head. I love it. Annie got 4 out of 12 correct, which would have placed her at the 16th percentile and her IQ is about 99th percentile so that is significant.

I also look at what somebody is like when they’re taking that test; if they’re slower, if they’re less confident, if they get frustrated, all those things. If you get it, give it to kids where there are no social concerns too, because it’s good to get that frame of reference.

Dr. Sharp: Sure. [01:18:00] I’m going to check that out. I think I’ve seen it like another, anyway, I don’t have to tell that story. I think I’ve seen it. We just don’t own it and use it.

Dr. Donna: It’s not that expensive and I met a group practice and we all absolutely fight over that test on a regular basis. Mostly the Making Inferences subtest. There are a few other subtests I like, but it’s that sub-test, I think it’s so brilliant. I love it.

I often give a few cards from the Roberts as well. Part of that is the interpretation of body language but part of it is getting at the good language sample and a good storytelling sample of somebody’s narrative and coping with a more ambiguous task. I didn’t do that with Annie. It took us a long time to get through the regular battery with Annie because of how slow she was so I started cutting things.

At the end of a clinical interview, I always say to clients, I’ve asked you all these personal [01:19:00] questions, I really appreciate you answering them and now I’d like to invite you to ask me a question about myself, which is from the meekness. I think it’s brilliant and it’s a lot of fun and lots of autistic clients might pause and say, no, I have no questions and have no interpersonal interest and not even think about, all right, I guess I’ll be socially appropriate and ask her something even though I don’t care or they might ask unusual questions. I had a girl last week pause and say, do you always wear shirts with flowers on them?

Annie asked me a fantastic question. She said, is your work rewarding but she only did this after first saying, oh, no, when I first posed the invitation and then there was a 23-second pause as she tried to figure out what to ask me.

Dr. Sharp: Oh, interesting. Okay. That’s fair.

Dr. Donna: [01:20:00] It’s a great question. I’m 99% sure, I got that from Meekness. Of course, I did some emotional screening stuff; I did the MASC and the CDI. I didn’t do an MMPI, which I often would do, but I thought that would send her over the edge since the BASC took her three hours.

Dr. Sharp: It would take forever.

Dr. Donna: Right. It came out, of course, she was anxious. She was depressed. I asked her about trauma and no history of trauma and just really briefly other test results. She did fine, on effort testing, her WAIS full scale IQ was really high. Her VCI was 141, PRI 136, working memory and processing speed were both 105, language testing was all rock-solid, no language problem. Memory testing was all super-duper high commensurate with her VCI. Her Rey was absolute [01:21:00] perfection, took her 24 minutes.

Dr. Sharp: To copy?

Dr. Donna: To copy, a lot too high.

Dr. Sharp: Oh goodness.

Dr. Donna: Yeah. I did, after the first 10 minutes, started to tell her, it’s okay. It doesn’t have to be that perfect but that’s… Her TOVA was terrible. Her academic testing was fine as long as I didn’t time her, once I timed her, her scores got slower, but otherwise, it was fine. There were no learning disabilities.

So at this point, I had ruled out a language disorder. There was no evidence of OCD. There was no evidence of trauma. So I’m left with two theories. It’s either anxiety, depression, ADHD with the stress of the pandemic or it’s that she’s autistic and she’s trying to cope in a non-autistic, which is driving anxiety and depression.

So what I do for every client when I’m considering a possible diagnosis of autism is what I call my worksheet, which is, [01:22:00] I’m happy to send you a copy but it is embarrassingly simple. I’m not a complex person. So it is simply one piece of paper where I now go through everything I know about the client from every source. I just categorize things under reciprocity, relationships, nonverbals, repetitive, flexibility, interests and sensory, and see what I’ve got in each category, regardless of where it came from.

I make myself go through that exercise for everybody where autism is a possibility because I really want to check myself either way whether I do or don’t diagnose. And with Annie, I can think about sending you a copy if people want to see what it looks like. I’m not going to go through it now but there were a ton under everything but interests. Every [01:23:00] category had so much.

So then what I do is just take a step back and think about the big picture and wonder, okay, are there any other explanations for what I’m seeing that I haven’t yet thought about? Does autism make sense? Do the prior diagnoses fully explain everything in a meaningful way or not completely?

For me, at this point, it’s less about the details and more about the big picture, because sometimes we can explain each symptom away, like, well, that could be due to ADHD and that could be due to anxiety, but once you integrate it, it’s more meaningful. And at this point, sometimes I’ll do CARS2 if I’m not 100% sure, but in this case, it wasn’t necessary. Not surprisingly, I decided that autism made sense for Annie.

Do you want to hear about that feedback session?

Dr. Sharp: Yeah. Let’s hear about that. [01:24:00] You mentioned that there’s some aftermath as well.

Dr. Donna: Oh yeah. Okay. I listened to your interview with Karen Postal about feedback sessions. I had read her book at one point too, which is wonderful. It was a wonderful interview and it was so validating, the whole time I was listening, I’m like, yes. It’s wonderful. And definitely, the more the merrier as Karen says.

So with Annie, she and both of her parents were there. Mr. Jones tried to get out of me in there as happened sometimes, he said that his work schedule didn’t allow it and I said, okay, I’ll meet with you on the weekends. I’ll meet with you on weeknights. I just feel like it’s so uber-important for both parents to be there.

I took his excuse away and he came. I never name tests at all. I almost never talk about scores. [01:25:00] If I talk about a score, it’s to make a point like I did with you with her vocabulary at the 99.6 percentile and yet she couldn’t explain emotions.

It’s my belief that people are generally pretty darn anxious when they come to the feedback session, they might be worried about what I will diagnose. They might be worried about what I won’t diagnose. I try to make it more predictable by giving them a quick overview. Like here’s what we’re going to do. First, we’re going to talk about the problems, the things that brought you in to see me, then we’re going to talk about all the strengths and then we’ll get the recommendations.

I also try to manage their anxiety by giving them some control and making it clear, this is collaborative. This is a conversation, not a lecture. I really want your input on all of this. If you disagree with me or if you’re not sure, put it out there, let’s talk about it. I’m okay with that.

I don’t want them to feel like I have all the power because I don’t see it that way. [01:26:00] But the biggest idea I have at the forefront of my mind in a feedback session like this is to have a neurodiversity mindset because we’re the ones who set the tone and are role models for how they are going to ultimately understand autism.

And so if you’re doing a feedback session and you’re going to diagnose autism and you find yourself thinking, oh no, I’m giving them bad news and you’re anxious about doing that, then I would encourage you to hit that pause button and rethink it, and maybe seek consultation from someone who has neurodiversity, affirmative approach. Do whatever you have to do to process your own feelings about autism because it shouldn’t feel like you’re giving bad news. It’s big news, it’s emotional, it’s serious, but it is not bad. It should feel like you’re giving clarity and hope.

And as part of this, I don’t ever refer to autism as a disorder. [01:27:00] I use identity-first language, not person-first language. If people ask me what autism is, my best definition is that being autistic is having a different brain than most people have, which makes you experience, understand, and interact with the world in a different way but it also means having to live in a world that is dominated by non-autistic people and having to cope with all the misunderstanding and bias and blame that just comes from being different. That’s my understanding of autism.

The other piece I would say about that is just be careful about the particular language you use, because if you say something like, your eye contact is poor versus eye contact is uncomfortable for you and you’ve had to work hard to meet other people’s need for eye contact and you get blamed when [01:28:00] you don’t meet their need for eye contact, do you hear the difference?

Dr. Sharp: Oh sure. Small but important. You’re saying the same thing; you’re describing the same behavior but a different lens makes a little difference.

Dr. Donna: A huge difference I think or your child is rigid versus your child’s brain does best with predictability in team because he finds them to be soothing and safe. You’ve get the idea.

Dr. Sharp: It’s great examples.

Dr. Donna: So as far as the format of Annie’s feedback session, as Karen Postal does, I raised the possibility of autism, right at the start, I dive right in there. I don’t build up to it. And then we take a lot of time to walk through the diagnostic criteria. I explain each criterion and what it means, and then how I think that individual meets that criteria and we talk about it. This helps them understand [01:29:00] what I even mean when I say autism, but it also helps them see that this is a data-based decision. It is not Donna’s gut feeling.

And that’s important because it convinces the doubters like parents who are starting out with you’re crazy, my kid’s not autistic. It walks them through it. It also can help with what I call autistic imposter syndrome that I think some really bright autistic people get, they have moments of, maybe they were all wrong. Maybe I’m not really autistic. I fake it so well. In a bad way, this is a bad experience I’ve heard from a number of autistic adults. So I want them to know, no, this was not a mistake. I would not diagnose this if I was not 100% sure and this was based on data.

So we go through the diagnostic criteria and then we get to the parts that are not part of the criteria but are related to [01:30:00] autism or frequently co-exist with this. So that’s when we would talk about context blindness, ADHD, which is not at all uncommon as a first diagnosis for autistics, so many of them get that first.

We talk about the sleep issues and the GI issues. I’m trying to pull all the pieces together for them. And this is not like some new diagnosis on top of everything else you’ve been through. This is the underlying common denominator that pulls the pieces together.

Dr. Sharp: I want to rule them all.

Dr. Donna: And then we finally get back to what really brought them in the first place was this persistent anxiety and depression. Finally, we’re able to understand all the pieces that are contributing to that but the stress of camouflaging, which is tremendous, the sensitive fight or flight response that so many autistic people have and the [01:31:00] connection to constipation that we talked about earlier, or at least Donna’s theory

Dr. Sharp: Donna’s ideas of the connection.

Dr. Donna: Donna’s creative working. We talk about black-and-white thinking and how that makes you vulnerable to depression. Let’s say I yell at one of my own children, which has never ever happened, Jeremy.

Dr. Sharp: Of course, not, me neither

Dr. Donna: Of course, I assume you’re a perfect parent. Yes. So let’s say I yell at one of my kids and afterward I’m going to feel crappy about it. I will acknowledge it. That was a bad mommy moment. I’m not happy with myself but at the same time, I feel that I’m a good parent and most of the time, I don’t yell at them and I do my best. So that’s great thinking. But if I was a black-and-white thinker and I yelled at my kids and then felt badly, I would be vulnerable to I’m the worst mom ever. I yell at my kids all the time. I’m going to screw [01:32:00] them up forever and that kind of thinking is obviously going to lead to depression.

We talk about alexithymia and interoceptive awareness and how that contributes to anxiety and depression and the difficulty making gains in therapy and why she couldn’t benefit from CBT so far. We talk about autistic burnout, which I think happened a lot to her, and it’s not just from all the camouflaging, it’s the exhaustion from the context blindness and the sensory overload all the time.

So then Annie is feeling so validated and understood at this point. And then we talk about her strengths. I like to end on a positive note and I won’t go through all of her strengths now in the interest of time, but it’s not just strengths from the battery, like your vocabulary and your reading and your writing and all that, I highlight things like her work ethic, her [01:33:00] motivation, her desire to be helpful to others. I highlight the fact that it is a complete myth that autistic individuals have no empathy. I talk about her openness, her patience, her insight, her resilience. I highlight the character strengths more than the strengths I found in the battery.

I was feeling good about this feedback session and then the next day I got an email from Mr. Jones and I saw it in my inbox and my heart started pounding because I have a lot of interoceptive awareness. I got a little anxious, I thought, he doesn’t agree with me. It’s going to be a thing, but okay, let me read it.

He wrote to me, and I should say he had been very quiet throughout the feedback session. I checked in with him a few times but he was hard to read and pretty quiet. So he wrote to me that that night he got online and he took the [01:34:00] AQ and got a very high score. And that as we talked about everything, it resonated with him and that he suspected he was on the spectrum but that it hadn’t cost him any problems. He was happily married. He had a great career. He didn’t see himself as anxious and we had a great conversation about the difference between being autistic and having autism spectrum disorder because I think there are people who have an autistic brain and they’ve built a life that works for them, whatever that looks like and they’re fine.

Dr. Sharp: Yeah. This is such an important distinction. I’m glad that you are touching on that. That’s such a hot topic these days. There is a lot of questions and discussions around that thing but the way you frame it makes sense, we can somehow separate an autistic brain as an adjective versus the noun of the [01:35:00] disorder, right?

Dr. Donna: Yeah, there’s some way to look at it.

Dr. Sharp: It makes sense because I think we all have seen those folks over the years. Not those autistic folks, but maybe other diagnoses as well, where they have the brain but it’s not causing significant impairment and that’s okay.

Dr. Donna: Absolutely.

Dr. Sharp: That’s an important distinction.

Dr. Donna: Yeah. To finish up, I can talk a little bit about recommendations if you want. I also feel like maybe we’ve gone on too long, but I want to end by telling you that I checked in with Annie and her parents two days ago, just in thinking about this podcast, I thought, oh, I wonder what they think now that it’s 6-12 months since the diagnosis. [01:36:00] So I’ll check in with you about time. I don’t know if you want me to just jump right to that so we can wrap up.

Dr. Sharp: Yeah. I would love to hear, say your top two recommendations, the things that you felt were most important, and yeah, we’d love to hear a little ending here, wrap up with Annie.

Dr. Donna: I would say, as a general rule, my recommendations are not geared toward making the autistic person look less autistic. So it is not automatic to me like go to a social skills group. I don’t make that recommendation all the time or even most of the time, it’s really trying to help this person be their authentic autistic self in a way that’s more functional for them, less stressful for them.

Some specifics for Annie was doing therapy with a therapist who actually gets autism so she can [01:37:00] reframe her internal narrative about everything. And then working on her interoceptive awareness either with that therapist or with an OT or Kelly Mahler has some great books that people can go through for interoceptive awareness and then making some changes in her life to allow for protecting her social energy, allowing for recovery times. It’s hard for me not to be like, and this and that but those are some of the top ones.

And then I had recommendations for Annie’s parents. A lot of which really revolved around teaching them new communication patterns and the unbelievable importance of validation because individuals who are autistic get inadvertently invalidated over and over again. And so really just starting with a solid base of validation is [01:38:00] huge and there’s a great book I often recommend to parents called The Power of Validation. It’s a small book and really helps. I think it’s been a long time since I read it, but I think it helps them understand the difference of validation versus encouragement versus problem-solving and just easy ways to do it.

Just to finish up, two days ago, I reached out on email to Mr. and Mrs. Jones and to Annie and said, as part of my research, they know I do these extracurricular activities like podcasts, was it helpful? And if so, how? Mr. Mrs. Jones wrote; it was hugely helpful. It allowed Annie to feel better about herself almost instantly. It’s like a burden had been lifted. It allowed them to find the right therapist for Annie and they stopped trying to fix her, is what they said.

They now can anticipate areas of difficulty and discuss them as [01:39:00] a family. They have more of a sense of ethicacy as parents and a lower level of stress in the home. I was thrilled to read that but even better, it was what Annie wrote and I’ve read it like eight times. I’m going to try to read you a few quotes without crying.

Dr. Sharp: Hey, crying is okay.

Dr. Donna: Oh my God. I don’t want to be the first one to cry out in your show. I think I was the first one to curse on your show.

Dr. Sharp: Those are two pretty solid titles.

Dr. Donna: Okay. I’m going to give you a few quotes from Annie and I’m going to do it without crying. Annie wrote to me, I’m a lot more aware of my own needs and how to address them now that I know that I’m autistic. I’m much more forgiving of myself now that I know that the things I had always blamed myself for and felt shame over not being able to control are not flaws but are a result of my neurodivergence, which is not [01:40:00] something that I should be ashamed of.

Before my diagnosis, I never ever allowed myself to unmask even when I was alone. Now I’m allowing myself to act on a lot more of my impulses, to do things like steam, talk to myself, turn off lights, adjust to my environment to fit my sensory needs, respond to what my body wants, read social situations to reset, not force myself to talk if I don’t want to.

She wrote a lot more detail here that I’m not going to read but she ended by saying, overall, my symptoms have gotten much more pronounced now that I’m allowing them to manifest externally but I am much more comfortable with the person that I am and the things that I do, I am much happier, much more aware of myself, my brain, my emotions, and my body, much more capable of taking care of myself and my needs and I like myself much more.

Dr. Sharp: How powerful. That’s amazing.

Dr. Donna: It’s amazing, right?

Dr. Sharp: When we think about the ideal outcome for our evaluations, I guess there are many ideal outcomes, but this is pretty hard to beat; self-acceptance, self-love, family support.

Dr. Donna: Sometimes people are wondering whether or not they should proceed with autism evaluation or a neuropsychology evaluation, and they say, how does it help to get an autism diagnosis and yeah, accommodations and all that but the real issue is, it changes the internal narrative of the person and everyone who loves them and is in their life. That’s the real benefit to me.

Dr. Sharp: It’s cases like this, the perfect example of [01:42:00] that. Oh my gosh.

Dr. Donna: Yeah. So I want to thank the real Annie for allowing me to share that.

Dr. Sharp: Of course. That’s so special. I think that’s probably a nice note to end on, right?

Dr. Donna: I think so.

Dr. Sharp: Sometimes happy endings are okay. We can go with that. It doesn’t always have to be hard.

Dr. Donna: Yes, absolutely. Thank you for making this easy, Jeremy. I felt a little vulnerable talking through how I do my job. It’s just a different kind of interview. You made it easy and it was fun and I really appreciate it.

I wanted to say also, thank you for creating such a community. I don’t get on Facebook very regularly, but when I do, I’m always amazed at how active that community is. I think if you created something really special there.

Dr. Sharp: well, I appreciate that. At this point, [01:43:00] it’s really self-sustaining and it’s the members. Everybody is pretty incredible for the most part. Likewise, I just feel so fortunate that you were willing to take the time and come back and be vulnerable in different ways. I think this is pretty wonderful and I think that people are going to take a lot away from this. So thank you so much.

Dr. Donna: My absolute pleasure, anytime.

Dr. Sharp: Okay, everyone. Thank you for tuning in to this masterclass episode. I really appreciate it. I hope that you found it helpful. Again, just to reiterate as we ended there on the feedback session, both Donna and I want to be clear that getting a diagnosis is not the solution to all of someone’s problems by any means. We did not mean to present it that way. It is just a hopefully helpful step along the way for this girl and her family.

And like I said at the beginning, if you’re [01:44:00] interested in hearing more about Donna’s book release or reaching out for case consultation, you can do that at her website, drdonnahenderson.com, lots of resources in the show notes as usual.

If you need support in your practice, there is a mastermind for that. The Testing Psychologist Mastermind groups are geared toward practitioners at all levels of practice for group coaching, accountability, support, and guidance as you build your practice. You can get more information at thetestingpsychologist.com/consulting, and reach out for pre-group calls. We’ll check it out and see if it’s a good fit, and if not, we’ll figure out something else that will help you.

Okay. Thanks for listening as always and I will catch you next time.

[01:45:00] The information contained in this podcast and on The Testing Psychologist website are intended for informational and educational purposes only. Nothing in this podcast or on the website is intended to be a substitute for professional, psychological, psychiatric, or medical advice, diagnosis, or treatment. Please note that no doctor-patient relationship is formed here, and similarly, no supervisory or consultative relationship is formed between the host or guests of this podcast and listeners of this podcast. If you need the qualified advice of any mental health practitioner or medical provider, please seek one in your area. Similarly, if you need supervision on clinical matters, please find a supervisor with expertise that fits your needs.

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