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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.

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All right, everybody. Welcome back to The Testing Psychologist podcast. And welcome to a business episode where we’re going to talk all about Form Publisher with Dr. Rebecca Murray-Metzger. So you have likely seen Rebecca in the Facebook group. She’s a longtime member of The Testing Psychologist [00:01:00] Community. But if not, that’s okay. You will learn a lot about how she uses Form Publisher in her practice and how it can help us as clinicians here today.

So let me tell you just a little bit about Rebecca.

Rebecca is a mother of three children, a licensed psychologist, and owner of Mind Matters, a group testing practice in San Francisco, California. She also owns and operates the Right Door, which is a shared office space for mental health and wellness professionals. She specializes in psychoeducational and neuropsychological evaluations for children, teens, and young adults with the goal of helping parents better understand their kids and helping school teams to better support their students.

As the owner of two businesses, she’s constantly looking for shortcuts in Google workspace, what used to be known as G-Suite and beyond in the hopes of having more time for her family and her hobbies which used to include hiking, skiing, swing dancing, and [00:02:00] organizing community events.

So Rebecca, like many of us, is really focused on efficiency and like you heard, making time for things outside of work. And today, we are talking all about  Form Publisher, which is a fantastic tool that she has been honing over the years. And what Form Publisher does essentially is, it helps create a templated yet personal narrative from the history that we gather from clients. And there’s a lot more to say about it than that. That really doesn’t even do it justice. So I hope that you will stick around and listen as Rebecca dives deep into how she uses Form Publisher and how you might use  Form Publisher as well.

Now, if you’re an advanced practice owner or a practice owner who hopes to be advanced in the next year or so, I would [00:03:00] invite you to check out the next cohort of The Testing Psychologist Advanced Practice Mastermind Group. It’s a group coaching experience where you’ll join about five other psychologists as we just work on leveling up your practice. So it could be hiring, it could be streamlining, it could be additional streams of income, just getting more efficient, buying a building, any number of things.

If that sounds interesting to you, then you can get more information at thetestingpsychologist.com/advanced and schedule a pre-group call to see if it’s a good fit. We start on June 10th. So I know that seems like a long time away, but the spots are filling up and we’d love to have you be a part of the group if you are interested. So check that out and let me know if you would like to chat.

Okay. Let’s jump to the interview with Dr. Rebecca Murray-Metzger all about Form Publisher.

Dr. Sharp: [00:04:00] Hey, Rebecca. Welcome to the podcast.

Dr. Rebecca: Hi, Jeremy.  It’s so nice to be here.

Dr. Sharp: Yeah, thanks for coming on. I haven’t seen you in a little while. It’s good to see you.

Dr. Rebecca: Yeah.

Dr. Sharp: Thank you. I know that you have gained a little bit of notoriety in our Facebook community for this amazing tool that you have developed and figured out how to use for report writing. I’ve seen so many posts about it and I’ve seen people bombard you with email addresses to send to them. So I thought it would be great if we could just talk about it here on the podcast and maybe have just one single [00:05:00] link or something so that you don’t have to respond to all these different people.

Dr. Rebecca: Yeah, it’s actually really easy to respond because I have a Gmail template set up. And so when somebody emails me, I just send them the templates. It’s very easy to do.

Dr. Sharp: That’s great.

Dr. Rebecca: Yeah.

Dr. Sharp: That’s great. Okay. Well, we’re off to a good start. I’m super curious about this. I’ve heard so many people kind of mention it and talk to me about it. I want to know how it works. So let’s start at the beginning. So, a tool called Form Publisher, right?

Dr. Rebecca: Um-hum.

Dr. Sharp: I am curious how you even got the idea to pursue something like this. What was going on in your practice and what problem are you trying to solve?

Dr. Rebecca: So, I have used Form Publisher for a long time as a mom, right? Anytime I wanted to create a volunteer sign-up or [00:06:00] anything related to my kids’ school. So I was familiar with Google forms through that. And then I can’t even remember how I learned about Form Publisher. It is a blank spot in my memory. But I essentially was trying to save time. I mean, aren’t we all, right?

Dr. Sharp: Um-hum.

Dr. Rebecca: And I find there are certain aspects of writing reports that can be a little mind-numbing. Say the things you do over and over again, that you really don’t need a doctorate to do. And so, those kinds of things I’m always looking for ways to cut out the time I spend on them. So, that’s really what I was trying to do is save myself time on writing the history portion of the reports. And then by accident, it’s actually saved me [00:07:00] time during the interviews too. And I can talk more about how I use it in my practice but when I interview families, I find I’m able to talk about the meaningful pieces more in-depth and save time on some of the more demographic information.

Dr. Sharp: That’s interesting. Yeah. I want to dive deep into all of this. Before we totally go there, can you just back up a little bit, or we can back up a little bit, all backup, and explain what Form Publisher is? Like, what is it essentially doing?

Dr. Rebecca: Yeah, so I should back up even further than you suggested and say that these tools are used in Google Workspace or formerly known as G-Suite. They just changed the name. So for people interested in this, the very first step [00:08:00] is you need to sign up for Google workspace. Within Google workspace, you can create forms that people can fill out. And what the Form Publisher tool does is takes the information from the form and pushes it into a narrative that you’ve written.

So you have a personalized, it could be a letterhead, it could be the history section, it could be a progress note that you’ve written, and then it pushes the specific client information into that narrative. And then it emails the narrative to you. So you get a nice history section emailed directly to you after the client fills out the form.

DR. Sharp: Oh, that’s amazing. Okay. Now there is clearly some magic involved in the middle section there and I’m really interested in [00:09:00] that. Okay, just laying the groundwork though. Does it only work within G-Suite or Workspace?

Dr. Rebecca: Yes. Form Publisher and Google Form are unique to Google workspace. There is another option for people who don’t use G-Suite, which I’m happy to mention. Stephanie Nelson wrote a blog about it, TheFormTool.

Dr. Sharp: That’s right. TheFormTool?

Dr. Rebecca: Yeah.

Dr. Sharp: Okay. But Form Publisher is specific?

Dr. Rebecca: Yeah. So for people who hate Google, they should stop listening right now and go to Stephanie Nelson’s blog about TheFormTool.

Dr. Sharp: Great, I will link that in the show notes. That sounds good. So we’re going to focus on Google workspace and how to make this happen. So even more groundwork, when you say fill out a Google form, what is a Google form if anybody doesn’t know what that is?

Dr. Rebecca: [00:10:00] Yeah. So it is a form that I designed or you, anybody can design one, and it’s like a questionnaire. So it has questions and then the person who is completing it responds. You can set up questions to be short text responses, multiple-choice, check boxes so they can check multiple options, paragraphs. So, there’s quite a number of different question forms you can put on your form.

And then once you’ve designed the full form, you get a link. You can send that link to anybody by email, and they can just click on the link and the form will appear and they fill it out. Once they submit it, it goes to a Google sheet, which is Google’s version of Excel [00:11:00] in your G- Suite so you have all their responses. That’s the process of a Google form.

Dr. Sharp: Okay. Yeah, that’s fantastic. When we discovered Google forms, however, many years ago, it was really kind of an amazing moment because they are pretty powerful.

You can do a lot with Google forms. And I should mention too if people are using the workspace, it’s HIPAA compliant as well. So all this is secure as long as they’ve signed that BAA with Google.

Dr. Rebecca: Yes, you do need a paid version of Google workspace in order to sign a BAA, but the cheapest version is $6 a month which is totally worth it.

Dr. Sharp: It’s totally worth it.

Dr. Rebecca: That I can tell. Yeah.

Dr. Sharp: Yeah, it’s amazing. Okay. So we’ve got our Google Form. [00:12:00] We’ve got Form Publisher.  So tell me a little bit more about how these things work together.

Dr. Rebecca: All right. So what Form Publisher is doing is taking that information that the client has entered into your Google form and pushing it into a narrative that you’ve created.

So for example, most of us in our history section, have a usual format that we follow. We have typical information we like to include, right? So, basically you find the spot in that narrative that would be unique to each client and you create a question on the form about that spot. And then when the person fills out the form, Form Publisher will push that little bit of information into that spot on your narrative. So you get a narrative that’s basically written for [00:13:00] you by the client.

Dr. Sharp: That sounds incredible. How does that happen? Like when you describe it that way, I just see… Like you use this phrase “push to a narrative.” I’m not sure how questions from the form or responses on the form turn into a narrative versus just being a long list of answers. You know what I mean?

Dr. Rebecca: Yes. So, I think the best… So Form publisher has a feature where you create your intake form and then you provide it, basically give it to Form Publisher. And it will generate a list of data labels essentially, then you know that you need to find a place in your narrative for all of these data labels.

So, [00:14:00] to try to explain this clearly because I think it’s hard to verbalize without a visual. You have your history narratives and you create an intake form that asks questions with each piece of information that would go into those spots in the narrative. Form Publisher has a tool that will take your intake form and generate a list of data labels that you can just insert into your narrative to create a template.

And it sounds complicated. Once you get into it, there are a lot of nice demo features in Form Publisher where it becomes clear how to do it. But I know it can be really [00:15:00] overwhelming. So one of the things I’ve done is created samples for people. And this is what you’ve seen people emailing me about. And so I provide them with a sample. What does a form look like? What does the narrative look like that gets produced? And it gives you a better idea of how it works practically. It’s much easier to conceptualize this I think with the visual example.

Dr. Sharp: Yeah. I could see that. I’m trying to picture it in my mind and it’s a little challenging. So yeah, I think it’d be great to see some of those examples.

Dr. Rebecca: Yeah.

Dr. Sharp: But generally speaking, it sounds like… Well, so here’s a question. Does that Google form take the place of your ‘intake paperwork?”

Dr. Rebecca: Yeah.

Dr. Sharp: That’s your demographic form, basically?

Dr. Rebecca: Yeah. You know what? It might help if I just [00:16:00] explain my process with clients, explain it from the end of how does a client experience this and then, what do I end up with?

Dr. Sharp: Sure. That’d be great.

Dr. Rebecca: Okay. So, once a client is signed up for an evaluation with me, I send them a link, it’s in an email, and ask them, ” Could you please fill out this intake form?” And this I do before the intake meeting. I asked them to have the form completed within at least two days ahead of the intake. They fill out the form. Clients have told me it takes them between 10 and 30 minutes to fill out the form. It depends on the client and how detailed they are. They submit the form. Form Publisher does its magic in the background and I get an email with a narrative version [00:17:00] of all the history information that I want to know about a client. And it’s based on what the parents put into the form.

So what I do is I review that in the 10 to 15 minutes before the intake and I highlight things that I might want to ask more about, or if the family has entered information in a way where it’s a little confusing, I just use my yellow highlighter feature on my Google doc. And then when I meet with the family, I already know a lot about their questions and concerns, and I already have a lot of that detailed information, the birth and weight and all of that, that I don’t need to spend time asking them at all. And so, I always start [00:18:00] my intakes with a general opportunity to connect with them around their worries.

So we spend 10 or 15 minutes just talking before I turn to the form and ask for some specific information to fill it in, clarifying. And I’ll just type right into the history narrative. And then at the end of the intake, my history is essentially written. It does need clean-up because when you’re interviewing and typing, it’s never perfect, but I have an assistant who cleans it up for me in about 20 minutes. And then that portion of the reports written at the end of the intake.

Dr. Sharp: That sounds incredible. Is it just life-changing?

Dr. Rebecca: Yeah, it really, really helps. I feel more prepared for intakes. [00:19:00] I know more about the child we’re going to be talking about. It saves me time in the interview because I can focus on the big questions that they have. We can spend more time establishing rapport and connecting rather than just asking detailed yes and no data questions.

Dr. Sharp: Sure.

Dr. Rebecca: And then to have the history section pretty much written at the end of the intake is great.

Dr. Sharp: That’s great. If you had to ballpark it, how much of the history is kind of pre-written versus how much you fill in during the interview?

Dr. Rebecca: That’s a really good question. I would say, first of all, it depends on the client. So this is something I want to mention. I think [00:20:00] this approach is really useful with clients who are relatively used to using technology and filling out forms. It hasn’t worked as well. I have some clients whose most of their internet access is through their phone and that can be harder for them to really put time into the form.

So for those clients, I find the information I have is pretty sparse and I still have to get quite a bit in the interview. I still think it saves time. And it also reduces errors because they type in names and they type in some of the demographic information and I don’t have to worry about misspelling it as an issue.

But with most of my clients, I live in the Bay area right near Silicon Valley, most of them are really comfortable with technology. And they also [00:21:00]  tend to be pretty good reporters in terms of what they remember. So I find that during the interview, I add maybe a paragraph or two about the family’s questions and concerns, or maybe examples.

That’s something that I’m often asking for in the interview that I don’t get to the form. And I do find that I sometimes need to flesh out the academic section. So parents will report on the form, Oh, reading was fine, writing was fine. And sometimes when I dig into it, it turns out there were little red flags that they hadn’t thought about.

So, I’d say probably at least 75% written, but I definitely do need to add to it.

Dr. Sharp: It’s still impressive. [00:22:00] It makes me think about the form that people are filling out. And I have a lot of questions about that, but maybe the first one is, how detailed is that form? That’s a hard question to answer. But maybe a better question is, what sort of things are you asking on that form?

Dr. Rebecca: One of the things I send to people when they inquire about it is my forms so that they can see what questions are in there.

Dr. Sharp: Okay.

Dr. Rebecca: I ask a lot of factual background questions, you know, birth and weight and medical issues, those kinds of things, but also some more open-ended questions like, what’s the child’s greatest strengths and what are your questions you’d like the evaluation to [00:23:00] answer? So there’s a variety of types of information. Clients have told me it takes them between 15 or so and 30 minutes to fill out. I’ve had a few clients that said it took them an hour, but that’s more about them than my form.

So, it’s fairly detailed. And then my history section ends up being about a page and a half or two pages.

Dr. Sharp: Okay. I got you. It seems like this will be really easy to capture like factual information like you said. I am curious how you tackle the presenting concern section of a history where it’s for me, at least that’s pretty open-ended. So I’m curious how what that might look like.

Dr. Rebecca: Yeah, I think I ground that in [00:24:00] asking the parents, what questions are you hoping the evaluation will address? And they usually will list several questions. Usually, that prompts them to put it in a list form. And I started just… I write my reports in the pyramid style. And so I’ll actually take those questions and put them right after my introductory paragraph on the first page. And my history is now in an appendix. So most of the history is buried in the report.

So yeah, I find that the presenting concerns listed in a question format really help me writing the summary too. So I appreciate it.

Dr. Sharp: I can imagine. Very cool. So people fill out this form, they type in their answers to the questions that you’ve already [00:25:00] devised, that goes into the magic world of Form Publisher, which manipulates it and turns it into a narrative. And thinking about this outcome, when you say narrative, is it a narrative that we would… like, could you tell a difference between a Form Publisher written narrative and a handwritten narrative?

Dr. Rebecca: I think if I sunk a lot more time into tweaking my narrative and my questions to align them, it could be pretty seamless. But I decided, I wanted it close, that it was okay with me if I have to spend 10 or 15 minutes editing it a little bit. But I phrase and people can see if they look at the form, the way the questions are phrased, and the way the responses, [00:26:00] either using checkboxes or multiple-choice, the responses are written in such a way that it can be put right in a gap in a sentence to create a seamless phrase or sentence.

Dr. Sharp: Right.

Dr. Rebecca: So, it’s pretty personal. You can produce decent text through this. It doesn’t sound robotic most of the time.

Dr. Sharp: Okay. That’s the concern, I think is that it feels like one of those just like plug-and-play templated kind of things that feels less personal or something.

Dr. Rebecca: Yeah. I spend a little time, like I said, adding in some things. But it doesn’t take long. And in my history, there are sections and you can build right into the [00:27:00] narrative headings and prompts for yourself to write further information that isn’t coming from the form. So I have a section for prior evaluations. And the parents don’t fill out anything about that but there’s a prompt for me or my assistant to know we need to put in this information from the prior eval report. It’s pretty flexible.

Dr. Rebecca: It does sound flexible. Yeah. So how much time did it take you to set all this up?

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All right, let’s get back to the podcast.

Dr. Rebecca: Once I got familiar with the tool using their demos and just playing around a little, it took me about six hours to set up my intake form and the narrative template, and then install them on my G suite, my [00:29:00] Google workspace.

Dr. Sharp: Okay. Six hours. That sounds like a lot. And if you think how many intakes you’ve probably done since then, I’m guessing it saves you at least an hour of time for every intake.

Dr. Rebecca: Roughly.

Dr. Sharp: So it pays for itself “pretty quickly”.

Dr. Rebecca: Yeah. And I do offer to people if they want to buy my template, they can. Most people have told me that if they use my template, it takes them about an hour to set up. Unfortunately, I only have a template for a pediatric intake because we only see children, not adolescents and adults, but that is another way to save more time.

Dr. Sharp: Yeah, definitely. I’m [00:30:00] guessing that, gosh, theoretically, you could sell that for like $500 or more. And I’m guessing you’re not selling it for $500.

Dr. Rebecca: I don’t. I sell it for $100. I figure it’s nice for me, but it also saves people time. And one of the things I love about The Testing Psychologists Community is how much people help each other with ideas. So I also think of it as a way to just help other psychologists.

Dr. Sharp: Yeah.

Dr. Rebecca: I’m not trying to fund a trip to Tahiti off of it.

Dr. Sharp: Just very slowly. Maybe in 10 years.

Dr. Rebecca: Yeah.

Dr. Sharp: That’s really cool. What else about this tool would be worth us knowing? What have I not asked about it or [00:31:00] what are cool features or even challenges with it that would be good to know about?

Dr. Rebecca: Yeah. So, a couple of things. I do think there are many more uses for it. And one of the people who bought my templates and started using it, Chris Barnes, who you know, he’s using it for all kinds of things now. He uses it for progress notes and collecting information from collateral context. He did offer that he would share some of those templates with people too. And so anyone who emails me about this, I’ll connect them with what he has. But I really think for him it really has endless use uses.

Something that it does that I haven’t tapped into is you can actually have people sign the [00:32:00] forms. So there’s an e-signature option. So technically, you could use it for your consent forms. People could create consent forms for people. I can’t speak to how to do that personally just because I haven’t used it myself, but it does. You can also embed a video. So that is something I’ve thought about is having a video at the start of the form that coaches or coaxes parents to fill out in a way that’s going to be most useful for me, detailed but not too detailed basically is what I need.

So there’s a lot of potential I think with the Google form and Form Publisher.

Dr. Sharp: Yeah. It sounds like it. 

Dr. Rebecca:  I think another question I get a lot is about HIPAA compliance.

Dr. Sharp: Of course.

Dr. Rebecca: [00:33:00] Yeah, so I’m actually not… my business is not a HIPAA-covered entity because I don’t bill insurance. We’re all private pay. But I do, of course, try to follow those guidelines and certainly protect client confidentiality. So I know some information I can share about that. So Google form, if you’ve signed a BAA with Google workspace, Google form is HIPAA compliant.

Form Publisher follows the European standard. It was the GDPR, I think it says, which is even more protective and more restrictive than HIPAAs rules. So if it follows the [00:34:00] standards, you can be confident that it’s going to protect information to the degree that HIPAA does or HIPAA compliance tools do. I know that even with that though, somebody who is a HIPAA-covered entity would need a BAA which you can have with Form Publisher. And in my instructions, I tell people how to do that. So it is it’s certainly possible, but you do have to sign a second BAA with Form Publisher. 

The other thing to know people ask me, is this going to cost money to have Form Publisher? There is a free version of Form Publisher that lets you have up to 20 different people can complete any given form per month. For [00:35:00] me, that’s been fine. We don’t see more than 20 clients a month. But if you do have more than 20 clients a month filling out your intake form, then you would have to pay $79 a year to get the individual premium version of Form Publisher.

Dr. Sharp: Oh gosh. That’s nothing.

Dr. Rebecca: Yeah. So, we’re talking $79 a year for Form Publisher and $6 a month for Google workspace. And that would be your cost.

Dr. Sharp: It sounds like a pretty amazing tool that saves you a lot of time and has a lot of flexibility. What’s not to love?

Dr. Rebecca: You’ve summed it up. 

Dr. Sharp: That’s great. Well, it’s just, I love things like this that are, I don’t know about simple exactly. But these are things that are hidden in plain [00:36:00] sight that we may not be aware of but can do wonders in our practice. And it’s always nice to see psychologists finding ways to utilize these tools and improve our practices. Because like you said, a lot of these things, a lot of these tasks are just kind of rote tasks that we don’t need to be doing. And so if we can automate those things and have it still sound personable, that’s ideal.

Dr. Rebecca: Yeah. And I will say too, having families fill this format ahead of time, I think helps orient them to the conversation they’re going to have with me. And I think a regular paper intake form might do that as well, but I do find that [00:37:00] they tend to come in with a more clear idea of what their questions are. And it helps focus our conversation a little more effectively than I was finding before I started using the form.

Dr. Sharp: That’s an interesting observation. Yeah, I know there’s probably a term for that when people, you know, it’s like front-loading or something. They organize their thoughts ahead of time. But yeah, I could see that. So then you’re not springing that question on them in the interview, right?

Dr. Rebecca: Yeah. Although I must caveat that with the fact that usually, one parent fills up the form and the other one does not. And so, sometimes I have to do some looping in of the parent because I have all the information that one parent shared with me and I have to make sure I [00:38:00] get the perspective of the other parent in the history.

Dr. Sharp: Okay. I see. Well, this has been really helpful. I think you’re demystifying a process that can sound kind of mystical if we don’t know much about it. So, thanks for explaining all the details with it. And I’ll link to everything that you mentioned in the show notes. And if people do want to reach out and get any of these things that you’ve put together, what’s the best way to do that?

Dr. Rebecca: Sure. It’s probably easiest just to email me, rebecca@sfmindmatters.com but I will also give you something to put in the show notes that will link people to a Google doc so they can just access these free examples that I’ve told you [00:39:00] about. So that they can check that out. And then if it seems like it might be helpful in their practice and they want to look into buying templates to save themselves a little more time, then they can email me.

Dr. Sharp: Okay. Perfect. Well, this is great. Thank you so much for coming on. It’s nice to have you on the podcast. You, I think have the unofficial claim to, what would I call it? Like Best Podcast Guest Facilitator Award. You’ve hooked me up with numerous podcast guests that you just happen to know or know of, and they’ve come on the podcast.

So I’m glad to finally have you here and let you talk about something.

Dr. Rebecca: I love connecting people. That’s how I market. Actually., it’s just connecting people. So it brings me joy to do that. I’m glad it’s worked out.

Dr. Sharp: I’m very grateful. Yes. Well, thanks for sharing all of this. [00:40:00] I’ll make sure all the info’s in the show notes if people want to reach out and let me know if you find other tools that save us a lot of time, and you can come back on.

Dr. Rebecca: Thanks.

Dr. Sharp: Okay, y’all, thank you for checking out this episode. I hope you enjoyed it. I love technology and any tool that will help us practice more efficiently. Hopefully, you have got your wheels turning about how Form Publisher might work in your practice.

Now, quick note, if you do not use Google workspace or G-Suite, Form Publisher is specific to Google workspace. Like we mentioned in the podcast, Stephanie Nelson has a great article on how to use something called FormTool, which I think is just generally windows compatible. If that is more attractive to you, there is a link in the show notes to her article. So you can check that out as well.

But [00:41:00] there’s plenty of information in the show notes. If you want to get in touch with Rebecca or access any of the information she talked about or templates or tools or support documents, or even talk with her directly. She’s fantastic.

Like I said at the beginning, if you’re an advanced practice owner or a soon-to-be advanced practice owner, I would invite you to check out the Advanced Practice Mastermind Group that’s coming up here in June. It’s a group coaching experience where we’ll try to hold each other accountable while we reach those goals that may have been elusive thus far and provide support and guidance and hopefully gets you to where you want to go with your practice, whatever that next level might be. So you can get more information at thetestingpsychologist.com/advanced and schedule a pre-group call.

Okay, thanks for listening. Hope you all are doing well. And we’ll talk to you next week.

[00:42:00] 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 [00:43:00] clinical matters, please find a supervisor with expertise that fits your needs.

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[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.

The BRIEF®2 ADHD form uses bBRIEF2 scores to predict the likelihood of ADHD. It is available on PARiConnect, PAR’s online assessment platform. Learn more at parinc.com.

Hey everyone. Hey, this is a little bit of a different episode today. Today, I’m going to play for you an excerpt from a presentation that I gave for the Group for Rural Internship Training or GRIT.  Many of you, or maybe not many of you know that our practice is part of an internship consortium, an APEC internship consortium. And I [00:01:00] got connected with GRIT through our consortium and kind of that APEC world. And this was a presentation that I did for them a few weeks ago on pediatric assessment.

The portion that I’m going to play for you is specifically around the diagnostic interview. So I’ll just talk about my approach to the interview, what I’m asking, how I structure it, and those sorts of things. Usually, I like to leave the clinical information to the experts, but today I thought I would share a little bit of this presentation with you. Hope you enjoy it.

Before I get to the presentation, I, of course, would like to invite any advanced practice owners or soon-to-be advanced practice owners, or hopeful advanced practice owners to the Advanced Practice Mastermind which starts June 10th. It has a cohort model so you would join the group with five other psychologists and go through the group experience [00:02:00] together. And we like to work on all those issues that come up as you grow your practice: making that transition from a clinician to more of a leader or a CEO, streamlining your time and your approach, hiring, all those things. If that sounds interesting to you, you can get more information at thetestingpsychologists.com/advanced and schedule a pre-group call to see if it’s a good fit.

Okay, let’s jump to my thoughts on a diagnostic interview.

Amy: Let’s get 30 and over. Back to you, Dr. Sharp.

Dr. Sharp: Okay. Awesome. Thanks, y’all. I didn’t realize we’d have people that were so spread out across the country. This is kind of cool. [00:03:00] So, yeah, as we get started, I always like to tell people, I prefer to do as much of an interactive presentation as possible. So feel free to jump in whenever you want to with questions, thoughts, reactions. It sounds like we can drop those in the chat in both myself and Amy will try to monitor the chat for questions as they pop up. So don’t hesitate to do that. I’m not going to do a presentation and then a Q&A separately from one another. I’d much rather you just jump in whenever you want to with thoughts and questions and reactions as we go along.

Now, as we get started, I always like to hear what would be interesting for you all as we go through the presentation. So I have material that I will present and can present, of course, but I want to make it interesting. So could [00:04:00] you just put some information, you can put it right in the chat. That’s totally fine. Just give me one thing that you would want to take away from this presentation that would make it worthwhile where you would walk away thinking, “I’m glad I spent my time on that today.” So, give me just one thing related to pediatric assessment that I can make sure to talk about that would be interesting for you all.

Amy: Jeremy, I just have a general question. And maybe you can address this at the beginning or at the end. But one of the parts of our field that I felt like we have not had a lot of creativity or innovation in is around our testing and assessment capabilities tied to our degree. And while we talk about it as kind of a highlight of how our training is different, I haven’t seen a lot of group practices or specialty [00:05:00] practices that really focus there. And I just have… I think I’ve gotten the most questions in terms of referrals I’ve received over the last decade have been around kind of where and how do I start and how would I find a diagnostic evaluator or is that even separate from therapy?

And I just think it’s an important gap and a potential gap in our field that you’re filling. I’m curious about how you thought about building a practice? Just from a general perspective, I think we need more for people to know about them, especially for kids, but in the general assessment and diagnostic evaluation arena in general.

Dr. Sharp: Sure. Oh my gosh. I mean, we can totally pivot the presentation. That’s a whole can of worms to open, I think, but I totally agree. The reason I started the podcast really was because I feel like testing is such a [00:06:00] valuable service, but a lot of people get scared away from building a practice around it. For me, the quick answer, I guess, is just the intersection of what I was interested in and what there seems to be a demand for in our community. And luckily those things overlapped quite a bit way back then. And as the practice has grown, it just seems like there’s more and more demand, right? I keep thinking, if I just hire one more person, we’ll be able to shorten our way, it’s a snowball rolling downhill at this point. So I totally agree.

Amy: Nice. Thank you.

Dr. Sharp: Hey, thanks, Andrew. Yeah, great question. Culturally informed elements into assessment. I love that. I will touch on that for sure as we talk through the assessment process. What else?

Speaker 1: I have a question.

Dr. Sharp: Yes.

Speaker 1: I think because of moving to a rural area for the first time, kind of just realizing like [00:07:00] 1) lack of resources and maybe the inability to purchase the tests that we would really want if we could cater. And so I don’t know if that’s like a specific question to answer, but maybe just your thoughts on the efficacy of that and kind of the… the only word that’s coming to my mind is conundrum, for what that means for us when we are wanting to provide resources but maybe don’t have all of the testing material and are kind of make making due with what we have. So broad topic.

Dr. Sharp. Yeah. I can see that fitting into talking about battery selection, which is kind of like the middle part of what I was thinking of talking about. So yeah, if I don’t address that specifically for some reason, make sure to jump back in and give me a little prompt. But that’s important, especially in rural areas.

Yeah, [00:08:00] other things would be helpful to take away?

Speaker 2: I guess one thing that comes to mind for me is that for pediatric populations, we rely so heavily on reporting from parents, teachers, caregivers. And I’m curious about the assessment process when perhaps those aren’t the most reliable be it, you know, for any number of reasons why it might not be the most reliable and how we can get more information perhaps from the child themselves as it relates to the assessment.

Dr. Sharp. Yes. Great question. So I will definitely talk about that. I call it like the four-legged stool of data integration. And I think that probably plays into that really nicely. Sweet. Anything else you want to throw out there before I get going?

Okay. So, like I said, as we talk through things, just drop your questions [00:09:00] in there and l will try to address them as they come up. So, I’m generally going to talk about the whole pediatric assessment process. So to me, that breaks down into the clinical interview, the battery selection/ testing process, the feedback appointment, and report writing.

Now, I will probably spend a lot of time on report writing because I am on a little bit of a crusade right now to keep us from writing long reports that nobody reads. So, I’ll likely spend a lot more time on report writing than some of the other sections, but we’ll see how the pacing turns out. But that’s to give you a little bit of a framework of what we’re going to talk about here today.

So let’s see. Just to get going, let’s talk about the interview. [00:10:00] So this is where we start, obviously. So when I think about the interview, I think, what is the purpose of a diagnostic interview, right? And it might seem fairly straightforward. So you want to get some information and use that to make hypotheses about your testing process, right?

But I like to define it as much as possible and just say that this is our opportunity to really determine what questions the client or parent or caregiver has about their family member or themselves and what questions we need to answer through the assessment process to be most helpful, okay? So, putting everything else aside., I think that’s our job in the diagnostic interview is to figure out how can we make this assessment be helpful? How do we gauge our audience? [00:11:00] How do we determine what they want to know?

So using that framework, I can talk through my strategy and how I structure our diagnostic interviews and we’ll see where it takes us.

Now, granted this is my approach, I think it’s based on others’ thoughts and strategies, but maybe there are some nuances that you haven’t run across before. We will see. But I think it’s pretty effective. I’ve been using it in our practice for I think over 10 years now. And it seems to do a decent job.

So for me, the first thing right off the bat, and I recognize that this might be a luxury for a lot of you, is that I always try to do two-hour interviews. So we always scheduled two hours for that initial appointment. Yeah. Magenta you’re like, “What?” So [00:12:00] here’s why I do that. I know that in other settings, Gary, I know has been in children’s hospital settings. I’m guessing in schools, in other settings that might not be doable, but this is my rationale for doing a two-hour interview.

What I found when I started out is that I cannot get the information I need within an hour. And here’s why. Because by the time the client arrives and you get them, if they’re on time, you’re back in the office maybe three, four, five minutes after the hour, right? So you’ve already burned five minutes. For me personally, I like to do a lot of rapport building in the beginning because we’re about to dive into a pretty vulnerable process for parents or kids, teenagers. So I spend at least five minutes just kind of talking with them about what’s going on and how they’re doing and whatever seems relevant. It’s truly just like shooting the [00:13:00] breeze and trying to make some connection with them. So then you burn 10 minutes, right?

Then we’re talking through some of the logistics. So it’s questions with paperwork, confidentiality, informed consent, all that kind of stuff. So now we burn another five minutes, basically. So 15 minutes are already gone. So now we go to the back end and I know I’m going to spend at least 10 minutes talking with them about scheduling the next appointment, paperwork, questionnaires, what HAP, releases, all that kind of stuff. So 25 minutes out of that hour is gone already.

Okay, so, some of you may be able to do that more efficiently. That is amazing. I could not do it more efficiently and maintain the relationship and the rapport that I was going for. So that really only left me with like 25 to 30 minutes to do the intake. And that was nuts to me. [00:14:00] I could not get any amount of important information in that time without seeming like a complete jerk and cutting them off too early when they were talking. So I do two-hour interviews. That’s the rationale for them.

I gave you a little bit of the layout for the interview. So, beginning and the end. I gave you the structure of what we’re doing at the beginning and the end, but within the hour and a half that we have left, here’s what I end up spending a lot of the time on. I think that my approach to the interview and others’ approach is to take kind of a bio-psycho-social view of what’s going on with folks. How you get that information can vary. And this is just the order that I go in. But I like to start with family [00:15:00] information. So after we go over paperwork, everything like that, logistics, I’ll just jump right in. And I’ll say something along the lines of, “Tell me your story or tell me what’s going on in your family right now.” Something like that.

So, it’s very deliberate to not say something along the lines of like, I don’t know, what brought you in or how can I help or something like that. Like I said, I like the phrase, “Tell me your story or tell me about your family.” It’s really open-ended and my hope is that that’s going to build a little bit of a closer relationship with some of these families and parents and put them a little bit more at ease, right? We’re not just immediately jumping into what’s wrong basically. So we talk about family first and kind of get the [00:16:00] family vibe.

All right. So I’m a big believer in context and environment in the assessment process. And this is totally wrapped up in a context environment and asking about the family information and family story. So I always just ask about where the kid was born, if they’ve moved, what the siblings look like, what their relationship is like with their siblings, relationship with parents. I always ask them to describe their home environment as well. People kind of balk at this sometimes. They don’t really know how to answer the question. So I’ll say, is it loud? Is it quiet? Is it structured? Is it chaotic? Is it predictable? Is it spontaneous? So kind of feed them a little bit of language just to describe their home. Is it clean? Is it messy? All those kinds of things just to try to get some sense of what’s going on in their home.

And so [00:17:00] that is one point just right off the bat. I’m kind of getting to Andrew’s question about the cultural elements. I’m trying to lay the groundwork even there for them to describe any of those cultural components or identity components that might be important for their family, right? So this is where I might ask about extended family and others involved in the child’s care or church or spirituality, any number of other factors that might be important for a family.

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All right, let’s get back to the podcast.

So I spend a little bit of time getting the family story and seeing what’s happening there. That can be super complex or super simple. It just depends. But I like to start there.  From there, I personally will switch and go into more of the medical history. And I’m just very explicit. And I just say like, “Hey, we’re going to switch gears just for a minute because I need [00:19:00] to talk about medical history real quick.”

For me, I do that right at the beginning after the family story because the way that I approached assessment and just kind of my mindset is maybe more of that neuro-psych approach where I feel like the medical history plays a really big role in what might be going on for kids. And if there’s anything significant in the medical history, I want to know that right from the get-go because that sort of colors how I see everything from that point forward. Behaviors, relationships, and so forth.

So within the medical history, I go way back always, pregnancy, delivery, all those pieces, ask about significant medical events. There’s a big list in our demographic form that we might talk about with that.

This is where I ask about sleep. I get really detailed with sleep. I ask them about trouble falling asleep, trouble staying asleep, sleep history- were they ever a bad [00:20:00] sleeper? Tons of questions about sleep because we know that it can affect so many aspects of kids’ behavior and functioning. I ask, “Does it seem like they feel rested each day?” And it’s interesting sometimes parents will describe like no sleep problems, but then they’ll say, “Actually, he seems tired most of the time.” Then we got to kind of dig into that.

So I’m asking about sleep. I’m asking about diet. This is where I might get information about kids being really picky eaters or not. I always ask about sugar. This is another one of my little soapboxes, I guess, that I’m interested in. And sugar being like basically a poison to everybody. So I ask about sugar and what that looks like for kids.

Let’s see, I am asking about screen time in medical history, which sounds weird maybe but honestly, I just couldn’t really [00:21:00] figure out a better place to put it in the interview. And it seems to fit well with sleep and diet and the other components of medical history. So I’m always asking about screen time and what that looks like. Not just quantity, but I ask about quality as well. So for me, it’s very different if the kid is spending five hours a day on YouTube versus five hours a day on, I don’t know, Photoshop, for example. Creating versus consuming is very different for me. So I try to ask specific questions around what they’re doing with the screen and how they’re spending the time there and the parents know how they’re spending their time.

If they’re playing video games, I always ask what, which video games. One that will give me something to connect with the kid on. I like video games and I’m happy to test them out so that I have something to talk with kids about. So always I’m asking what video games they play. Well, it’s also informative for me in terms of what kind of content they’re [00:22:00] allowed to access on their tablets.

I’m also asking about exercise in medical history, both current and history and of course medication. And like I said, medical events, illnesses, things like that.

So after the medical history, I kind of move into developmental history. So I’m asking about developmental milestones and what those look like.

And then after that, that is when I finally get to the presenting concern. And at that point, this is where I will say something like, “Tell me what you’re most interested in. Tell me what you’re most concerned about. Tell me what you want to learn about your child.” Some variation on one of those three questions. And that usually gets the [00:23:00] ball rolling.

So, I always try to get the information from the parent in their own words, of course and get some idea just as a general overview of the things that they’re concerned about. And depending on how they approach this, I try to corral parents a little bit and say if there are multiple areas that we’re concerned about, try to give me those areas right off the bat, and then we’ll dive deep into each one as we go along. So I’m trying to get a running list of what the parents are concerned about so we can tackle each of those in sequence.

Just very practically, I have a document that I use to kind of guide my interviews that has all these areas broken down. I type my interview notes. That makes it a lot easier. It’s very easy to do during COVID with everybody on screens, but even in person, I’ve adopted the typing [00:24:00] approach which has helped a lot.

So, as we dive into the presenting problem, that’s where things really get fluid for me. I have a number of areas that I want to make sure to ask about.

And my approach there, again, this might differ depending on your setting, but for me, I don’t want parents to walk away from their evaluation in our practice feeling that something was missed, right? So our kind of a calling card I think of our practices is that we do pretty comprehensive evaluations. So I’m going to screen for pretty much everything even if the parents don’t mention those areas as areas of concern.

Of course, I start with the things that they’re most concerned about. And for me, this ends up being a little bit kind of like a choose your own adventure or a decision tree kind of thing [00:25:00] where it’s like, if parent mentions attention, trigger ADHD path and then it goes down all the ADHD questions. Or if a parent mentioned social problems, trigger autism path and then I go down the autism path and have all sorts of questions there. And that’s kinda how I break it down according to these different areas. So there’s executive functioning, social and mood are my big umbrella headings within the intake interview with a lot of different paths underneath them.

So always, like I said, trying to dig deep into each of these concerns for parents and get a sense of what they’re seeing. When I do that though, I try to structure it as much as possible. Anything that they’re concerned about or [00:26:00] any significant symptom they’re bringing up or behavior, I’m always running through a set of questions to get those factors kind of fleshed out as much as possible.

So some of those things that I’m asking about are, of course, what it is. But then I’m always asking about the onset. So has it always been present or is it more recent? If it’s more recent, was there a precipitating event of some sort? I can’t count the number of times I’ve gone back and just not asked about a precipitating event. So, I always try to ask about that. Was it sudden? Was it agile? Those kinds of things with the onset.

I’m always asking about frequency. So if we’re talking about, say tantrums or outbursts, is this happening every day? Is it happening twice a day? Is it happening once a week? [00:27:00] Is it once a month? I always try to get parents to quantify these behaviors as much as they can. I also ask about intensity.

And Magenta, I just saw your question about trauma experience. The short answer is, yes. I’ll talk about that here in just a second.

So, with the intensity, I always just have them rated on a scale of 1 to 10. Like what does this look like and how intense is it? I’ll ask how long the behaviors last if we’re talking about like again tantrums or something that can be measured in a duration like that. Let’s see. I ask about just history. So, does it come and go, or rather cycling probably is a good way to put that. So does it come and go or is it consistent? Does he have good months or bad months? Is it better at home? Better at school? So just looking for [00:28:00] patterns and let’s see, I can’t think of the right word right now. Patterns is probably the best way to put it for these behaviors. And then of course I touched on the setting. Is it happening at home? Is it happening at school? Is it worse than one of those places? Does it happen at extracurriculars?

So really trying to, and you can tell, we’re kind of digging into this for each of the areas of concern and each of the significant symptoms. So that I think gives you some idea why we’re doing two-hour interviews. This is what I was saying. It’s hard to get all that information from multiple presenting concerns which happens a lot. There are a lot of kids with suspicion of ADHD and autism or a learning disorder and depression. So we’re gathering a lot of information in these interviews.

And yeah, so I do screen for trauma. [00:29:00] So trauma is on our demographic form. I just ask, has your child experienced anything that you would call traumatic over the course of their life? So I’m always looking at that question. It’s interesting to see how people categorize trauma and what qualifies or not. So I always try to ask again in the interview just to make sure we’re not missing anything. And that’s where I might give them some examples as well of what counts as “Trauma.” The way that I’ll phrase that too is, I may not say trauma. I might say, “Have there been any significant events that you think have shaped your child’s life?” And that kind of opens it up a little bit more. And people who might not otherwise respond to have they experienced trauma, they may say, oh, well, yeah, there was that incident, you know, that car accident then it seemed like we had trouble after that or something along those lines. [00:30:00] That also captures positive events as well which I think are equally important.

So again, I’m just trying to dive into each of these symptom areas as much as I can. Let’s see. And then, as we move through all those areas, I will also ask about education. I screen education and subject-specific strengths or challenges. And then at the end, before I totally wrap up the assessment or the interview rather, I’ll always ask about strengths. So, we try to be a “strengths-based practice” with our assessments. That’ll come up again when I talk about writing reports and feedback. But in the interview, [00:31:00] I like to kind of wrap up and just say like, what do you love about your kid? Like, what are they really awesome at? What are they interested in? Where do they shine basically? There’s a spot for that information on our demographic form as well. So I like to kind of end on a positive note.

Related to that, something I didn’t mention, when I’m digging into symptoms, I will often ask, are there any exceptions to this behavior or to this problem that you’re having?

Like, what are the exceptions to the rule? Where are they really amazing or where does this not happen? That can give some good information sometimes. And I will also ask parents in a very gentle way, ” What role might you be playing in these things that you’re describing?” And I just tend to personality-wise… I’m just kind of direct about it.

And I’ll say like, this could be a really hard question, so [00:32:00] you can get mad at me if you want, but I need to know, can you just tell me, ” If you had to guess, are you playing any roles in your child’s behavior? What are you doing or not doing that might make this more of a problem in your home?”

It gets some really interesting answers. So this is where I’ve had things from all the way from like, I drank six beers every night and I’m totally absent in my kid’s life verses, we’re worried we didn’t read to them enough when my wife was pregnant or something like that. Like it kind of runs the gamut. It’s really interesting to see how parents interpret this. But I think that in a lot of ways, parents or caregivers come into these assessments with the kind of secret fear that it’s going to be all their fault. And in a weird way, this gives an outlet for that beer that they can just like, put it on the table and [00:33:00] it’s like, well, now it’s out there. And at least somebody knows and it gives them a way to kind of keep themselves accountable. I could be making that up. Maybe I’m projecting as a parent myself, but I think that it’s helpful.

Let me see. Robin asked about how do you ask about head injury? Yeah, that’s a great question. I’ve seen it go both directions of where parents will report every bump on the head as a “head injury” and then some who totally downplay what appear to be pretty significant concussions or even more severe injuries. So we ask about it on the demographic form. It’s part of the medical questionnaire, medical symptom history that we get. And then I always just ask again in the interview just to make sure that we’re on the same page with that.

Speaker 3: That helpful. Yeah. Sometimes you’ll say, Any [00:34:00] head injuries? Nope. And then again, and it’ll be like, Oh, well there a time they fell out of a car or you know, Okay.

Dr. Sharp: Yeah, for sure. I think that’s a key with a lot of this is just phrasing things in different ways. If it’s not a head injury, maybe it’s a concussion or maybe they passed out or got knocked out that one time or whatever it might be. People use different language for different things. These are great questions.

Andrew, that is a fantastic question. So Andrew asks, is the child present for the interview or not? And I know people do this differently. I just interview parents first. The rationale with that is that I want parents to be able to speak pretty freely about their concerns and I don’t have to worry about the kid listening in or having to wait in the waiting area, especially if they’re younger. With adolescents or older [00:35:00] kids, I will split the initial interview time. So it doesn’t feel like they’re left. Particularly with adolescents, we’ll spend most of the time with parents, and then I’ll do maybe like a half-hour with the kid just to make contact and build some rapport. But with younger kids, I always interview the kid during the testing day when they come back and are doing their testing here in our practice. It’s a great question.

All right. Other questions or thoughts or anything before moving on?

So the last thing that I ask or discuss with the parents in the interview is, I just always ask explicitly, what do you want to take away from this evaluation? What do you want to learn from this? What do you want to gain from what we’re doing here? And this [00:36:00] is I think, borrowed from that therapeutic assessment approach literature and it’s a very, very therapeutic assessment question. Like, what do you want the outcome to be here? What are you trying to learn about your family or your child? And I really encourage them to give me as many as they want.

This is also where I think it’s part of our job to read between the lines a little bit and try to get at those unspoken questions that parents might be asking. My friend and colleague, Stephanie Nelson, who’s a neuropsychologist in Seattle says, she calls them secret questions. But it’s like those questions parents or caregivers come with but they won’t ask explicitly. And so, a lot of parents, I’d say the most common answer I get to this is we just want to know how to help her or we just want to know how best to support our kid. And the hidden question or the [00:37:00] secret question of that might be, we need to know that we’re doing our best as parents. Like we’re not dropping the ball or something along those lines. Like we need to know that there’s nothing wrong with our kid, or we need to know if there’s something wrong with our kid. There are any number of secret questions that parents might be wanting to know. And so I always try to keep that in the back of my mind and kind of bookmark it for the feedback session.

Okay, y’all, thank you so much for listening, tuning in to that first part. So this is a two-hour presentation and the audio there as I transitioned to the next section was a little abrupt.

I’m sure you notice that, but yeah, this was the first part of a 3-part presentation on pediatric assessment. And again, just my approach to doing a pediatric interview. I hope that you enjoyed it. Hope that you took away a tip or two or something that you might be able to [00:38:00] implement into your own practice.

If you disagree with anything that I may have thrown out there, I would love to hear. I’d love to hear a different approach. You can always email me, jeremy@thetestingpsychologists.com.

So, thanks for listening. Let’s see. Next time, we’ll be back with you on Thursday with another business episode. So if you haven’t subscribed to the podcast, I would love for you to do that. That’s really easy in Apple Podcasts and Spotify and really anywhere else. And if you find it in your heart to rate the podcast, that would be great as well. We are well over a hundred ratings now in Apple podcasts, which is amazing. So thank you all. And yeah, the podcast continues to grow. I am always on the hunt for fantastic guests. So you can trust that I will keep bringing great content.

All right, everybody, take care [00:39:00] and I will talk to you next time.

The information contained in this podcast and on The Testing Psychologists 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 [00:40:00] 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] 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.

The PASS™-12 is a new entirely digital tool that will help you discover whether students’ struggles are related to the pandemic. You can learn more at parinc.com\pass-12.

All right, folks. Welcome back to another episode of The Testing Psychologist podcast.

Hey, glad to have you. Hope you’re all doing well. I’m excited to talk about our topic for today. This is something that I’ve been looking into and studying in various ways over the last year or so. I’ve really been on a little bit of a deep dive around productivity and focus and time management. And this is just [00:01:00] one piece to come out of that research, which is ongoing.

Today, I’m going to be talking about journaling for productivity. I’m going to leave it at that. I’m not going to give you too much information here before we get started because I want to save most of the important information for the episode. But suffice it to say, I’m going to talk about why journaling is important for productivity. I’m going to talk about the specific journaling system that I use, how I implement it in my daily life, and ways that I have used it to really supercharge my business. So, if that sounds interesting to you, please stick around. This will be a good one, I think.

Before we get to the episode, I want to invite any of you advanced practice owners to consider joining the Advanced Practice Mastermind. This will be starting in June, I think June 10th as the next cohort. And it’s a group coaching experience for those advanced practice owners who are looking to level up their practice, looking [00:02:00] to hire, or maybe you have a group practice and want to streamline things, stop trading time for money, that sort of thing. If that sounds interesting to you, you can get more information at thetestingpsychologist.com/advanced and you can schedule a pre-group call there to check out the fit.

All right, let’s get to it and talk about journaling for productivity.

Okay, everybody. Let’s just dive right into it here. Like I said, I have really been loving the idea of productivity and focus and harnessing our cognitive energy. I’ve been looking into this pretty deeply over the last year or so, and have read so many books on [00:03:00] different topics. So it is fascinating to dive into productivity and motivation and so forth. But one aspect of productivity that I’ve really gotten into over the last few months is journaling for productivity.

So, let me start at the beginning and tell you what this is all about. So here’s the thing. I, I think like a lot of us had a completely insane 2020. It felt like it was survival mode for much of the year. And at the end of the year coming into January, I was just feeling honestly overwhelmed and aimless in my businesses. And I just knew that I needed more deliberate reflection that exceeded what I typically do with my quarterly retreats, which I’ve talked about here on the podcast. So I do the quarterly retreats where I [00:04:00] get away for a few days. And those are amazing, but I recognize that I need a little bit more.

And what I found myself looking into was journaling or some form of deliberate reflection that would happen basically on a daily basis. Now, you might be saying, well, Jeremy, why don’t you just do coaching or use a coach to clarify some of these ideas. And I did do that as well. I’m kind of always in coaching in some form or another. And that was happening concurrently, but I was just feeling this deep need to be more deliberate in my businesses and my life as well. But this is about business, right?

So I was feeling this need to be more deliberate in my businesses. And so I took a pretty extensive look at the world of planners, journals, [00:05:00] all those sorts of products to see if that might be able to fill the need. And the good news is that it does. And I’m going to talk with you about that today. So if any of those feelings resonate with you. If you’re feeling overwhelmed, lost, like you’re juggling too many things, like you’re just putting out fires, those are the feelings I was experiencing and the feelings that I was looking to deal with through journaling.

So here’s what I did. I looked into so many journals and planners. And right off the bat, let me just…

I want to talk a little bit about why journaling and what that even means. So, journaling takes many forms. There are so many ways to do it ranging from just sitting down and writing just freehand-stream of [00:06:00] consciousness kind of writing, there is more structured journaling, there’s something called Morning Pages, there are 5-year journals where you just write two or three lines each day, there are planners, there are productivity products. So there are a lot of pieces out there. A lot of options out there that would all fall under the umbrella of journaling. But generally speaking, however you do it…

And I know there’s good research out there on journaling and like what specific types will help you in which ways. So, just know I’m acknowledging that. I’m not saying that like any journaling is going to be amazing. There are definitely ways to structure it that are more helpful for certain outcomes.

But generally speaking, journaling has good research behind improving your mental health, your physical health. It helps give you a sense of [00:07:00] control over your life when you write things down. It helps you remember important things. It increases the likelihood that you’ll achieve your goals. It’s kind of similar to the research saying that if you just put something on your calendar, you’re 40% more likely to do it just because it’s on your schedule. So this idea that if you write something down it’s more likely that you’re going to accomplish it. And it also just helps you feel less overwhelmed. It kind of clears out all the things that are running around your mind, which for me has been super helpful just as a business owner with multiple businesses. It feels like there’s always something running around and that’s not to say anything about family, right?

So journaling in general is a helpful thing. It has a lot of positive benefits and can make a big difference in your life. [00:08:00] So one thing though that I found is that a lot of the research that I was reading says that handwriting is more effective. I don’t know if effective is the right word, but handwriting versus typing is a better way to journal. It’s going to help you a little bit more in terms of accessing and processing some of the information. Not to say that typing is not okay. I’d say just do what works for you. But there is something about handwriting that at least for me generates a little bit more deliberate processing and thinking through what I’m writing.

So journaling is good. Now, the way that I chose to implement it or what I knew I was looking for is, I wasn’t looking for a journal like a diary, like sit down and write about [00:09:00] your feelings, fill up the page or two pages each day. I was not looking for something like that. I was looking for more of a productivity product that really had some focused components that would point me in the right direction when I was journaling. So, as I dove into this world, I found that there is such a thing as a productivity planner. So I found that that was the term that I ended up Googling most often, the one that got closest to what I was looking for.

I was looking for something that definitely pointed me more in what I would call the life coaching kind of direction. I’ve done a lot of coaching and I enjoy self-reflection and questions that make me think about important things. So I knew that I was looking for something [00:10:00] like that. Not just a blank open page where I could write whatever I wanted without any direction.

And the good news is that there are a lot of products out there that have that element, that kind of life coaching element. So I knew that I wanted, here are some things that I wanted. And when I say this, know that it took me a lot of research and comparing different planners to really figure out which pieces were important to me. So, you can do your own research, of course, and figure out if these things are important to you or not. But these are the things that I knew I was looking for. And after I share these components, I will tell you which journal I ended up settling on. And there’s a link to it in the show notes as well if you want to check it out.

But here are the things [00:11:00] that I knew I wanted. So I wanted something that would kind of marry the emotional reflection with more business-oriented planning and big picture visioning. So as I looked around, I found that there are a number of products out there that offer pages in the journal that take you through kind of a quarterly planning process at the beginning of the journal. So, just as an aside, I will say it was really hard to find a year-long journal that would capture all these elements. Most of the ones that I ended up considering as a final option are based quarterly. And it’s still a pretty thick book.

I knew that I wanted one that would offer quarterly planning where at the beginning of the journal, it forces me to [00:12:00] sit and really think about what I would like to accomplish and what directions, what goals, what ideas are important at the beginning of the quarter and really set that intention to accomplish those things or work on those things over the next three months. So I knew I wanted one with quarterly planning.

I also knew that I wanted one that offered a weekly review. So, many of these journals that are out there or productivity planners give you the opportunity both at the beginning and end of the week to do a weekly planning session and weekly review respectively. And I knew that I wanted that. So again, this is all in the name of being deliberate because that’s what I was missing. I was not being deliberate with my planning. I was just running from thing to thing. So I wanted as much deliberate reflection as possible. And so, the weekly review was helpful in that process.

At the beginning of the week, [00:13:00] I sit down, I write out the goals that I have for that week, the projects that I want to accomplish or get done or work on, it also forces me to think through what I would like to improve on and how I would like to change my mindset in one particular area or a couple of areas. So that’s super helpful. And then on the back end, the weekly review forces you to look back and say, did you accomplish your goals? If not, why not? What would you like to change going forward? And a series of questions that again, just forces you to check-in and kind of be honest with yourself about how you structured your time over the week.

Now I also knew that I wanted something that offered daily reflection. And this was super important. So this was [00:14:00] probably the component that took me the longest to really nail down in terms of features because what I found is that a lot of journals or planners dedicate a lot of space for a schedule. You’ve seen these like in Day-Timer or other planners. There’s like a daily schedule with 8:00 AM, 9:00 AM, all the way down to the evening time where you’re supposed to write out your appointments. I don’t need that at all. That’s not important to me whatsoever. I have an electronic calendar and that’s not helpful. So it took me a long time to find a journal that did not dedicate a huge portion of the page to the daily schedule. I knew that’s something I did not want.

Now, what did I want? I wanted a daily reflection that:

1) Included gratitude. There’s some good research out there linking gratitude with [00:15:00] happiness and being grateful just being good for your wellbeing and the wellbeing of others. So I knew I wanted a gratitude reflection.

2) I knew I wanted some open space to be able to write my to-do list for that day or random thoughts or ideas.

3) I knew that I wanted to be able to track certain habits or develop certain habits. So, a checkbox or a dot system or something that would allow me to track habits.

So those were the important things that I was looking for. And again, if you dig in and do your own research, you’ll find there are all sorts of things that these planners offer. But these were the components that were important to me.

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All right, let’s get back to the podcast.

Now, after doing all the research, the one that I finally settled on is something called the Dailygreatness journal. So, the Dailygreatness journal fit all of these criteria and it had [00:17:00] a couple of bonus features that I really enjoyed. One of those is that it makes you define your daily priorities. And the way that it does that is interesting. It gives space for you to write a to-do list, but it separates your to do list from what I call an inspiration list. That to me was really important. And as I got into this process, I realized that I’m really, really good at making to-do lists, not so good at tapping into what I’m inspired to do. And in fact, as I got started, that was a really interesting concept for me to wrap my mind around like being inspired to do activities on a daily basis. So I’ve really enjoyed that. 

But then the Dailygreatness journal also provides I think really [00:18:00] nice prompts just as bonus questions each day in it. And it kind of switches up the phrasing. It’s the same idea each day but it changes the phrasing just a bit to where you know that you are writing about something slightly differently. So those questions might be something like, what was interesting about today or what habit would I like to develop after today? What beliefs would I like to upgrade? What was today’s lesson? What strengths did I use today? What did I succeed at? What was fun about today? What new behavior can I adopt into my life?

So these are, like I said, just random questions that occur each day. There’s like one or two of each of those on each daily page. And I found that I really liked this. It was [00:19:00] surprisingly powerful for me to reflect on questions like how did I show leadership today? What was I most proud of today? What did I do well today? I think, maybe like a lot of us, those are questions that I tend to avoid or brush off or kind of ignore in favor of all the things that I could have done better or went wrong or anything in that realm. So those questions were quite powerful for me and have really helped me, I think reflect on strengths and challenges.

So I don’t want to give the impression that it’s all Rose-colored glasses. I mean, it definitely asks you to reflect on the things that could be better as well and places you can grow.

So, like I said, I ended up settling on the Dailygreatness journal. There’s a link in the [00:20:00] show notes if you want to go check it out. But I love it. It’s a quarterly journal. It forces me to reflect quarterly, weekly, and daily and has these nice kind of bonus questions. I just liked the way that it lays everything out.

So the way that I use journaling is, and this is very practical. The way that the journal is set up is that there questions that you’re meant to reflect on at the beginning of the day, and then questions that you are meant to reflect on at the end of the day. You don’t have to do it that way but I’ve just found that that system works well for me. And that sort of naturally breaks down into those two time periods. So I do it in the morning and in the evening.

I use some of the principles from atomic habits. If you’ve read that book, he talks a lot about [00:21:00] chaining behaviors together to create habits. And so, I have sort of created the habit of, first thing when I get to the office, I sit down, I meditate for a bit, and then I write in my journal. So those three actions are linked. Arriving at the office, meditating, journaling. And then I jump into my day. And what I like about that is I get to do the morning portion and do some of that deliberate reflection and really define two or three tasks that I know I want to get done that day.

And this is just one more weapon in your arsenal against email, chat, other people’s to-do lists, voicemails, stuff like that. So it creates just a little bit more of a barrier where you get to say, “Hey, this is what’s important to me.” And the idea then is that you go straight from that list to your work that day without [00:22:00] getting interrupted with some of these other activities.

So I do that in the morning. I found that it helps me be much more focused. It forces me to think again about what I’m truly inspired to do. And what’s been interesting is I find that what I’m inspired to do often does not match my to-do list. So it has led me to be kind of constantly evaluating my priorities in the business and the work that I’m doing and helped with delegating and offloading tasks or eliminating tasks that just are not inspiring.

It’s also helped me engage in more downtime and just enjoyable time. I found that more often than not one of the inspired action items is to do something fun. And I don’t know about y’all, but I [00:23:00] don’t do a lot of fun things just on my own day-to-day. I don’t think to like build-in fun. I mean, life is fun, right? Like it’s fun to laugh with coworkers and joke around with my kids and kind of be silly and that sort of thing, but in terms of deliberate fun time or self-care time or whatever you want to call it, that has been really interesting that finding that I’m inspired to take more downtime has been really nice and has helped me create some of that.

So then at the end of the day, like I said, I’ll again chain these behaviors. So my trigger is putting the kids to bed and walking down the stairs. So, when I get home in the evening, I take the journal out of my backpack [00:24:00] and I put it at the specific spot in our living room where I know that I will see it right when I come down downstairs from putting the kids to bed. And that’s just the first thing that I do when I’ve got a little time at night. And all told, journaling each day maybe takes 10 minutes total. So we’re not talking about a lot of time. So then like I said, I circle back in the evening and reflect on the day. That’s when I usually do my gratitude and reflect on what went well or what I could improve on and just revisit the list and see how I did.

So, yeah, it’s been really, really nice for me just to be more deliberate. I’ve also enjoyed it. I’m about to finish the first quarter. So I started this in January.

So, I’m getting geared up to do kind of my retroactive quarterly review. [00:25:00] Generally speaking, I can say that it has really helped me focus on goals, be more deliberate about big picture projects, not get lost in the day-to-day minutiae, have a little bit more fun, and recognize things that I’m grateful for.

And it’s nice because it prompts you to do gratitude every single day. So, I get bored. I don’t want to write the same thing every day. So it’s a nice exercise to make me really think about what are the little things that I’m grateful for and think about the nuances of life that bring me joy and gratitude.

So that is my experience thus far with journaling for productivity. Now, like I said, there are a lot of options out there. But if you want to try out the Dailygreatness journal, you can search for it or just click on the show [00:26:00] notes. It’ll take you to the one that I use. And you can check it out. There’s a lot of information on the internet about this, but that was just one kind of habit that I’ve really enjoyed building over the last few months. And one that has seen a noticeable impact on my life and my business.

And like I said at the beginning, speaking about being more deliberate. If you’re a group practice owner or advanced practice owner rather, you’ve gotten past that beginning stage and maybe you’ve hired, maybe you want to hire more, maybe you find yourself overwhelmed and need a little bit more direction. I’d invite you to check out the Advanced Practice Mastermind. So you can learn more at thetestingpsychologist.com/advanced and just see what it’s all about. It’s a group coaching experience. We work a lot on streamlining and efficiency and being a good leader and [00:27:00] making sure that you’re spending your time the way that you want to spend it, and being deliberate as you grow your practice. So you can again go to thetesting psychologist.com/advanced and schedule a pre-group call to see if it’d be a good fit. It starts on June 10th. Two spots are filled already. So, make sure to jump in if you think that would be interesting for you.

As always, thank you all for listening. Let me know via email or really any feedback. You can find me in the Facebook group or on the blog, anywhere. Let me know how you’re enjoying these episodes, if you want to hear anything new or different. And in the meantime, take care. And I will see you next week.

[00:28:00] 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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[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.

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Hey everyone, welcome back. Glad you’re here as always.

Today’s episode is another fantastic replay of a highly downloaded episode from 2019. This was one of the top five episodes from that year. It’s my interview with Dr. Aimee Kotrba, all about selective mutism. So we really dig into the details about assessment and treatment of  selective mutism and separating selective mutism from other anxiety disorders, autism and so forth. 

Aimee is a true expert in this area, which I think will come across very quickly. For her full bio, you can check the show notes. But I will say she’s a licensed clinical psychologist. She’s a group practice owner in Brighton, Michigan. She does a lot of consulting, diagnosis and treatment of selective mutism and other anxiety disorders. She has also written a book on selective mutism, which is linked in the show notes. So a lot to offer.

This is one of those episodes where I think you’ll definitely want to take notes if you can. If you caught it the first time around, that’s great. There’s  more  to check out this time and I think you’ll take quite a bit away from it again. And if you didn’t catch it the first time around, then today’s your lucky day.

All right, before I get to the interview, I want to invite any advanced practice owners to check out the advanced practice mastermind. The next cohort will be starting June 10th. And this is a group coaching experience for advanced practice owners looking to take your practice to the next level.

So, if you are kind of looking toward the summertime where you might have a little downtime to reflect, vision, plan and take your practice to that next place, this could be for you. You can get more details and schedule a pre-group call at thetestingpsychologists.com/advanced.

Okay, without further ado, here’s my interview with Dr. Aimee Kotrba 

I’m excited to be here talking to you, Aimee. Welcome. 

Dr. Aimee. Thanks so much. I’m excited to come in at a good time for you, a patient in your practice.  

Dr. Sharp: Yeah, right. I’m being honest. That’s how I try to schedule these podcasts interviews, so a clinical consultation from Aimee. So, thanks for helping me with that. 

I did have a kid last week, actually. Maybe I’ll ask some questions about that. But I think this is, like I said, very relevant for a lot of folks particularly just differential diagnostic kinds of stuff, how do we look for selective mutism and just the ins and outs. So, I’m really grateful that you’re willing to sit down and chat with me for a little bit.

Dr. Aimee: Yeah, I’m excited. 

Dr. Sharp: Easy questions to start off. How did you get where you are right now? What does your life look like day to day from a clinical standpoint? 

Dr. Aimee: Yeah, absolutely. So I went to Wayne State University here in Michigan. During my graduate work, I never heard the words selective mutism. It was never brought up. It was never something that we were trained on. And then I did a post-doc near here, and while I was on post-doc, a kid came into the clinic needing treatment and he had pretty severe selective mutism. He had never spoken to anyone in school, never spoken to anyone in public, and about a year prior to coming into our clinic, he had stopped speaking to his parents. It’s a pretty severe presentation, more severe than we typically see with kids with SM. But in treating him, I was really interested and really engaged in trying to find out what the evidence-based interventions were and how I can best work with this family?

And it just didn’t seem like there was a wealth of information on evidence-based intervention at the time. And so I had to do a lot of literature reviews and go to conferences and talk to the well-known people in the field. Through all of that and just my enjoyment in treating this kid, I kind of accidentally fell into specializing in selective mutism. So that was about… I’m aging myself. That was about 12 years ago.

And now at this point, I own two clinics, and our specialty, not the only thing that we do, but our specialty is seeing kids with selective mutism. So we do diagnostic evaluations. We do the treatment as usual. We provide intensive options where families will come in and do an entire week of intensive treatment with us, exposure-based interventions. I run a camp for kids with selective mutism during the summer, and it’s actually coming up in 10 days. So the stress is on right now.

Dr. Sharp: Maybe we could take a little bit before we totally dive into selective mutism just to talk about this somewhat unique practice model you have with the intensive treatment. Would that be all right? 

Dr. Aimee: Sure.

Dr. Sharp: Let’s talk about that.

Dr. Aimee: We offer a few different kinds of intensive treatment. And I think of them as being in-clinic intensive treatment, on-location intensive treatment, and then a group intensive treatment, which we call camping. It sort of functions like a camp.

So the camp is a group intensive treatment where the kids come for one week. It’s not a stay-away camp. They attend from 9:00 AM to 3:00 PM. We try to make it like a classroom experience for them. We always do it the first week of August. So, we’re hoping to catch kids right before they go back to school so we can provide this sort of pretend or exposure-based intervention where it feels like a regular classroom setting. We go on field trips, we do classroom activities, but they’re all paired with a therapist for support.

And I do in-clinic and on-location intensive. So, that basically looks like 30 hours of exposure where we work with kids to help them be verbal first with us through behavioral interventions, and then we start practicing with other people, in public scenarios, and we do this in schools- that’s what I would consider to be on-location. I’ll actually go to the child’s school and spend a week in the school. And we train the parents also as a part of that week- these sort of paraprofessionals so that they can walk away from the week knowing how to both advocate for their child in school but also how to help their child be brave in public and family situations.

Dr. Sharp: It sounds really powerful. I’m assuming there’s some literature support for this kind of treatment model. Is that right? 

Dr. Aimee: There is. It’s just now coming out because it’s sort of a new way of treating kids with selective mutism. But there’s a lot of evidence that suggests that it’s more effective than treatment as usual and certainly faster than treatment as usual. I think it’s so much fun too. It’s my favorite thing.

Dr. Sharp: Oh, that’s wild. Let me ask a few logistical questions. I guess you have several therapists. So, are you able to see multiple kids per week on this intensive model?

Dr Aimee: We can. We typically just do 1-2 a week because I feel like otherwise, it would be a little bit of an overload for our clinic, but we couldn’t see more than that. Yeah.

Dr. Sharp: Got you. And how do you bill for it? Are you just private pay or is there insurance?

Dr. Aimee: We do take insurance. We only take Blue Cross Blue Shield, but we do take insurance. It is a mix of private pay and billable hours. So, a typical day would be billed as one parent training session because that’s always a part of it. So, one family without a patient present session, and then the rest of them are client elective services. 

Dr. Sharp: Okay. This is fascinating. This is really cool. And it’s clear that you have a lot of energy around it. I think this is something that I struggle with. I think others probably do too, where you would like to be able to just dig in there and work with a family but there’s some hurdles to putting that kind of model in place. So, I’m impressed to see that you’ve done it. 

Dr. Aimee: There’s a lot of hurdles to putting in place. Once you master those hurdles, it’s fantastic.

Dr. Sharp: Sure. I don’t want to dive too deep on that. I know that you’re recently on The Group Practice Exchange Podcast, I think talking all about this intensive model that you run. If people are really interested in that, I’ll link to that in the show notes. That’s Maureen Werrbach Group Practice Exchange podcast. For us though, we get to talk more about selective mutism today.

So you said that you just sort of fell into this area. I mean, in retrospect, can you identify anything that really has called you to this population that is personal or is it just, “Hey, this is an area that needs service and I’m going to go that direction”?

Dr. Aimee: I think it was a little bit of both. I do think that when I found a lack of information on treatment options for these kids, that did pull me in. They’re my favorite population to work with for a few reasons.

1) I feel like the treatment can be incredibly effective. And it’s very systematic, the kind of treatment that you do. I wouldn’t say that it’s manualized necessarily. There are caveats and there’s, of course, an art to it like any kind of therapy, but it feels very specific and solid to me which I like. It’s just the kind of treatment that I enjoy doing. I also enjoy that the gains that are made are so obvious. Unlike depression where it’s just sort of like, is it getting better? It’s hard to tell. Let’s do these questionnaires. When you’re treating a kid with selective mutism, you can identify, okay, now the kids are talking to extended family. Now they’re ordering in restaurants. Now they’re talking to their teacher. They started talking to the kids in their classroom and it’s very specific the gains that are being made. And so for me, it’s a great feeling. I enjoy that. And I like the specificity of it.

Dr. Sharp:  I can totally see that. As someone who gravitates toward testing, maybe others are the same, there’s that concrete element to it. This is what we’re doing. This is what you get from it. Very cool.

Well, so can you just give us some basic information? What is selective mutism? When does it tend to manifest? Is it more boys or girls? Just some basic info about it. 

Dr. Aimee: Sure. So at its’ core, selective mutism is a lack of speech in social and school settings where speech is expected. These kids can speak just fine. Typically just fine when they’re comfortable. Usually, in the home setting, they speak very comfortably to their parents but when they get anxious, so that’s usually in more social situations, they speak less or stop speaking altogether.

We know statistically that boys are less likely to be diagnosed than girls are. So girls are two times more likely to be diagnosed with selective mutism. Just from my practice, so take this with a grain of salt, we tend to see more boys. And it seems like when we see boys, lots of times the severity is greater. I have a few hypotheses about that. I wonder if maybe boys don’t get diagnosed until a little bit later because speech isn’t so much a part of play or social interactions for boys when they’re young, and so by the time they make a task, they’re a little bit older and a little bit more challenging to treat, but take that with a grain of salt. No doubt about it then.

Dr. Sharp: It’s worth considering.

Dr. Aimee: Right.

Kids can be diagnosed after six months of not speaking in a new situation. So for instance, the beginning of the first year of school or one month into not speaking after that in school situations. But a lot of these kids get diagnosed in preschool or in daycare because they go for an entire year in a Preschool setting, let’s say without speaking to preschool teachers. So, they can be diagnosed as young as 3 years old, but more frequently kids come into the clinic to get treatment more around, I would say 6 to 8 years old because they’ve entered school at that point. They’re not able to be evaluated by the school academically because they’re not speaking or not speaking much. And so then the school is alerting parents that this is an issue.

Dr. Sharp: That makes sense. That’s interesting. I had very limited experience, but the kids I’ve worked with who had selective mutism seemed like they were very young. It emerged pretty early which made it hard. There was some difficulty there just with normal development of language and like what’s going on here.

Dr. Aimee: Well, and I think a lot of times parents don’t catch it even though it does emerge young. A lot of these parents will say, I knew something was different from the start. And there’s kind of common characteristics that happen with this population like they tend to be more difficult to soothe than as a baby. They tend to have separation anxiety when they’re young. And then they don’t speak in these social situations. But when they’re 2 or 3 or 4, you don’t expect those kids to order at a restaurant. And so it’s not really identified as a problem until later on. The issue is that like most childhood disorders, the earlier the intervention happens, the easier it is, the better it is, the less it messes with developmental milestones. So, we try to get kids in as early as possible for a diagnosis.

Dr. Sharp: That makes sense. Are there any other signs that folks might lookout for early on that can help pick up on early identification?

Dr. Amelia: The biggest sign is just that a kid goes without speaking for a significant amount of time to school or school-like activities or in social situations. I always encourage parents to take it seriously and not just pass it off as shyness. And there’s a lot of kids who are shy, but those kids tend to warm up after a short period of time. And they tend to sort of be the same across situations. So, shy kids tend to be kind of inhibited in social situations, kind of inhibited at home, sometimes inhibited at school, inhibited at church, inhibited in the store.

Kids with selective mutism are almost like two different kids. The kid at home who’s loud and outgoing and talkative, and then you’ve got the kid who’s in social situations and they might look frozen and make poor eye contact. And sometimes they might even look angry or wear things in front of their face to protect them from being seen or engaging with other people. If you’ve got that kind of kid, I always encourage people to just go ahead and come in for an evaluation because I would rather identify it early and do the behavioral intervention, which wouldn’t be harmful to anybody, and in fact, I would argue, it’s fun and engaging, versus waiting too long and then having the treatment be so much.

Dr. Sharp: Yeah, that totally makes sense. It’s hard to go wrong with early intervention.

Dr. Aimee: I agree.

Dr. Sharp: Maybe we can just agree on that. All sounds good. Got you and you said that kids will show perhaps some separation anxiety as well, and just that sensitive kind of reactive temperament. Is that among the symptoms? 

Dr. Aimee: Exactly. And it’s interesting because historically there’s been this idea that selective mutism comes from a trauma in the background.

And so I think a lot of parents, when they start noticing this, try to think back to, did something happen to my child? Was there some sort of trauma they experienced? But we just don’t find that in research. We don’t find that those are linked or correlated, selective mutism with trauma in history. It’s not that it can’t happen, but we don’t believe that some come from trauma.

We really have a lot of evidence that suggests it’s partly genetic, probably. Apple and tree. I see a lot in my clinic when we’re doing the diagnostic evaluations. Partly it might come from modeling. I think a lot of it comes from accidental reinforcement of avoidance by parents or caregivers. So caregivers are accommodating the child’s avoidance because of maybe their own anxiety, but we don’t find that trauma is correlated. 

Dr. Sharp: I see. Are there other primary etiologies that you know of aside from genetic components?

Dr. Aimee: No, we don’t have any evidence that it’s highly linked to medical conditions or birth trauma or anything like that. So we think that it’s sort of that nature versus nurture mix that we see.

Dr. Sharp: Yeah, like 99% of everything. Does the research reflect anything about the trajectory of kids with selective mutism, like what kind of adults they turn out to be?

Dr. Aimee: Yeah, and it’s hard to say. I would say that there are two trajectories. So trajectory number one is kids who have SM as youngsters but maybe because of caregivers who sort of naturally understand what needs to happen or maybe because of kids who are internally motivated to be brave and talk or engage with other people, sometimes kids, I don’t like to say grow out of it, but even without treatment might progressively get better and become adults that maybe are inhibited a little bit or shy, but certainly don’t have any significant daily life functioning kind of problems.

Trajectory number two is kids who are not created with excellent treatment will end up becoming more and more inhibited, tend to have anxiety and depression in their teenage and adult years, have a greater likelihood of substance abuse probably to deal with the mood issues that they’re experiencing, have lower rates of marriage, lower rates of finding work as adults.

What I usually tell people is it’s like their world gets smaller and smaller because they tend to react to anxiety-provoking situations with avoidance. Which is just an anxiety disorder. And so then it becomes not just these speaking situations that they avoid, but the engagement situations, or the going to the doctor or attending school or getting a job or driving. And so the world is going to become smaller and smaller as they avoid all these potentially anxiety-provoking situations.

And then in adulthood, usually we don’t diagnose with selective mutism per se. So, they might be diagnosed with severe social anxiety, maybe some kind of personality disorder, like an avoidant personality disorder. But the pathology, I guess I would say, grows over time in that population. So, I wish I could tell you at 3 or 4 which trajectory a child was going to take but we really don’t have a way to tell. And so to me, I feel like let’s treat what’s going on so that hopefully we can push all of the kids into that first trajectory of successful adult life.

Dr. Sharp: Yeah, of course. I think that’s true with most of the things that we’re working with, but it’s also one of those major questions parents always want to know. What is this going to look like down the road? And that’s a really hard question. I wish we could figure that out.

So, let’s talk a little bit about the evaluation process. We sort of touched on the two ways to approach this. There’s the side of how do you modify a traditional evaluation for a kid who is selectively mute? And then there’s the actual evaluating of the mutism. Which one do you want to tackle first? 

Dr. Aimee: Let’s start with the diagnostic evaluation. Is this selective mutism? I think that will shed some light on how we do a psychoeducational evaluation for a kid with SM.

So, when a kid comes into our clinic for a diagnostic evaluation, we have a few different components that we always include, I guess I would say above and beyond what is typical for a diagnostic evaluation in our clinic. We always start with parents only doing an interview with them. Our beginning intake interview is 1.5 hours long. So, we’re doing all of the normal diagnostic intake questions, background history, educational history, medical history, family history, things like that.

But they’re things that we particularly include in kids who may have selective mutism. We’re asking a lot of questions about communication behavior. So, who does the child communicate with? And we try to get a very extensive list. So, I don’t just ask that as an open-ended question to parents. I’ll usually start with that and then I’ll really go through specifically, do they talk to teachers? Do they talk to staff at school? Do they talk to peers? Does it matter if it’s a man versus a woman? Will they talk to people in public situations? Will they talk to parents in public situations when other people can overhear them?

So, I’m finding out a long exhaustive list of who they talk to. Then I want to find out how they communicate with those people? Sometimes communication might just look like non-verbals like nodding or shaking their head or shrugging or pointing to things. Communication might be whispering. It might be something that we call an altered voice. So some kids with selective mutism, when they do talk, it doesn’t sound like their typical voice. Whispering is actually an alternative voice, but some kids will talk out of the sight of their mouth instead. Some kids will talk out of their teeth- they’ll keep their teeth closed and speak through their teeth. Sometimes kids will talk in a robotic voice or a voice that’s not theirs.

Then you want to find out about things like responding versus initiating. Will the child respond to a direct question but maybe not initiate it to a person? And find out where the child’s back? There review, who does the child talk to? How does the child talk? I1n what situations does the child speak? So physically and environmentally. Does the child talk at home? Does the child talk in school? Does the child talk in the playground? They talk at the store. So I’m finding out a lot about their speaking behavior.

And then I’m finding out a lot about parent accommodation and the lack of speech. And I try to normalize these parents because I think that parents can feel very pathologized when their child has selective mutism like they did something, especially that sort of from a piece that’s out there in the public but isn’t accurate. Did the parents traumatize the child? So, they very much normalize it. 

Parents accommodate kids because they want to protect them because they feel anxious about their child’s anxiety because they love their child, but asking mom and dad, like when do you find yourself answering for your child? Or when do you find yourself avoiding or having other people avoid talking to or asking your child questions? Because the parents play such a huge role in the treatment of selective mutism that I need to know where we’re starting.

Dr. Sharp: Of course. Well, and that’s that black box. I feel like with any of the evaluations that we’re doing is really getting a sense of what parent behavior is like and what things are like outside the office, and it’s challenging. I mean, do you find that parents are fairly forthcoming or do you have to dig a little bit? Because I can imagine there being some shame around this once they sort of get the clue that they might be reinforcing some of the mutism. Does that make sense?

Dr. Aimee: It does. I don’t find that parents tend to be in denial of their accommodation of their child. Most of them will say upfront, Oh yeah, I answer for them all the time. I find that parents fall into two categories though after that. “I’m totally willing to do it a different way. Please show me how to help. Versus I can’t manage my child being anxious, and so I don’t want to stop accommodating them.” Not so much in those words, but  I don’t have a good enough distress tolerance myself to watch my child be uncomfortable. So I can’t go there. If that makes sense.

Dr. Sharp: It does. What do you do with that? 

Dr. Aimee: I think it takes a lot more psycho-education for the parents. Sometimes honestly we’re recommending that they consider going into individual treatment for their own anxiety as well at the same time. And I think that it sort of slows down treatment in the sense that now we have to move almost at the parents’ pace as opposed to the child’s pace for distress tolerance. So, it can be a problem. And sometimes that’s when parents drop out of treatment.

Dr. Sharp: I can see. Do you run into folks who no matter what you say you are still thinking, oh,  I can’t expose my child to these anxiety-provoking scenarios, that’s going to hurt them worse because it’s so distressing? Is that something that comes up? 

Dr. Aimee: It does. And those are frustrating because maybe selfishly as a clinician, I feel like, Oh, but I can help your child if you would be okay with them being uncomfortable. So it can be frustrating but it does happen.

Dr. Sharp: I think just about parenting in general, it’s hard to see your kids in distress.

Dr. Aimee: Absolutely.

Dr. Sharp: About the evaluation process, so you’re digging in just really a deep dive into all things communication and what the kid is doing or saying different scenarios?

Dr. Aimee: Exactly. 

Dr. Sharp: You mentioned the alternative voices. Does baby talk fall into that? 

Dr. Aimee: It does. Good job. I missed that, but it does. Absolutely.

Dr. Sharp: I’m just curious again, thinking about kids that have come through our practice recently.

Dr. Aimee: Yeah, it can definitely happen.

So after we do that initial evaluation meeting, then we’re trying to get other pieces of evidence or other pieces of data from the parents. At our clinic, we give them the BASC-3 looking at just general behavioral issues. We do the SCARED questionnaire, but you could also do the MASC or just a different anxiety questionnaire.

The only question specific to selective mutism is called the Selective Mutism Questionnaire or the SMQ, which is okay.  It’s a good pre-post questionnaire or a good way of comparing a child with selective mutism speaking behavior to typically developing peers. It’s not incredibly sensitive so you can’t give it on a frequent basis. It’s not going to give you a sort of progression of treatment data, but it’s helpful in the diagnostic process.

We like to get a lot of multiple sources. So we talk to teachers, we call up schools, sometimes extracurricular coaches, things like that, or grandparents to find out how the child does in different situations. Not infrequently. We’re referring for speech evaluation if a child hasn’t had one because about 50% of kids with selective mutism will have a fundamental speech impairment or issue.

There are complexities to doing a speech evaluation for a kid with SM as well, but if you have a skilled speech therapist who could do that, that’s helpful. Or minimally, I like to see videos of the kids speaking comfortably at home so that minimally I’ll have an idea of the speech issues that may or may not exist. And also just sort of a good idea of where we’re going in treatment. Like, okay, well there’s the child at home speaking comfortably. That’s the kid that I want to see in the clinic, in public, in school. But that’s part that’s really helpful for me is seeing the kid comfortably speaking. 

Dr. Sharp: That’s really interesting. I like that. Yeah, so you have something to shoot for. That’s cool.

Just touching on the speech piece, what concerns do you see most common with kids with selective mutism and from a speech perspective?

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Dr. Aimee: It really runs the gamut, but the vast majority of the kids have expressive language delays. So sentence structuring delays, or word-formation issues. We don’t know how […] might end up having selective mutism because they understand that to some degree they’re not fluent and maybe they’re getting some responses from people that their speech is not fluent. So it could be that. The other possibility is it could be that kids who don’t speak a lot and don’t have a lot of experience in getting corrected for their speech end up developing speech delays down the road. So, it’s interesting this idea of what caused what. 

Dr. Sharp:  Yeah, absolutely. At least from my side, our audio is sort of glitching a little bit. And it sounded like you were just saying it’s hard. It’s kind of a chicken or the egg issue, like how do you know what’s driving what?

Dr. Aimee: Exactly.

Dr. Sharp: That totally makes sense. I can see that being really challenging. 

Okay. So then just to sort of land the plane on your evaluation process, at that point, are you doing any cognitive assessment or anything like that or is this just specific to the speech and the emotional functioning and behavioral function?

Dr. Aimee: We typically don’t do more testing unless it’s warranted, which we’ll talk about the psychoeducational evaluation in just a minute. I guess, one more additional component that we do at our clinic to help with the differential diagnosis is we do something we call a direct clinical observation. So I think that this is helpful for differential diagnostic purposes to determine the severity of the selective mutism and to see sort of where we’re starting in treatment.

The way that we do this is kind of like a hierarchical exposure happening really quickly and observing what happens with the child. So we have the child and the parent in a playroom by themselves. We have cameras in our playroom, but some people don’t have cameras naturally set up in their playroom. When I first started doing this, I would literally set up my phone to videotape somewhere in a corner and I’d watch it later, but we have a camera set up in our playrooms.

So the child and parent go into the playroom and basically, the spiel that we give them is thanks so much for coming. We can’t wait to play with you. Actually, I have a little bit of work left to do today, and I just want you to kind of get comfortable here and see the toys that we have. So I’m going to leave you and mom and here, you guys can play anything that you want. I might be in to clean up in a little while because it’s looking kind of messy in here, but I’ll just see you in a little while. And I’ll leave the room. And then from my office, I watch speaking or communication behavior between the child and the parent when no one is in the room. So, that’s step 1. 

Step 2, I enter the room but I pay no attention to the parent or the child. I put no demands on them. I just want to see how the child does when there’s a potential audience member listening to them speak. Does that change whether or not they’re willing to talk to their parents? Then I go over and I join in the game. Oh, you guys are playing Chutes and Ladders. I love this game. I’m going to play too. I’m going to be this character. And I go ahead and I start playing with them. So, now I’m paying attention and I’m seeing if the child will still continue talking to their parents in my presence while I’m paying attention. Then I start asking questions.

There are three kinds of questions that we use with kids with selective mutism communication. Yes/No questions, which we try not to use in treatment at all because it perpetuates a non-verbal response, like a nod or shake of the head. But here I start with those. Those are the easiest. So I’ll ask them some, yes/no questions and see if they respond. Then I ask them forced-choice questions or multiple-choice questions. Are you the blue or the pink player? Or, Oh my gosh, did you just get to move 10 spaces or two spaces? To see if they can respond to those.

Then I ask them more open-ended questions. So, who won that last game? Or what’s your favorite color? And I progressed through those, whether the child is responding to me or not. And then after all of that, I have the parents leave the room. So, I usually say something to mom like, “Oh mom, there are a few forms upfront that I need you to fill out. Could you go to the front and fill out those forms and we’ll be up in just a minute?” And I have the parents leave the room. And then I ask the child a few more questions to see if the child can speak to me without their parent in the room because sometimes that can influence whether or not they speak.

So after all of that, I’m looking at the video. I’m seeing how the child did in all of those situations. And it’s really helpful because if a child can tolerate me hearing his voice as I come into the room, that’s a much milder presentation in my mind than a kid who, for instance, doesn’t even talk from the moment they enter the playroom even with the door closed. That’s a much more severe presentation. And it also tells me maybe this kid is already able to respond non verbally or maybe they’ll already whisper some answers to me. And I’m starting at a different point in my exposure hierarchy with treatment than I would be for a kid who never spoke in the playroom at all even when I wasn’t in there. 

We also get some indication of autism sometimes in these situations. And that’s also helpful to see. So, autism is a big differential diagnosis when we’re thinking about kids with selective mutism because these kids can look autistic in the school setting. They look frozen. They have flat facial expressions. They’re not speaking or if they speak, they’re speaking in a strange voice. A lot of parents wonder if this is autism, but through that diagnostic interview, getting the history thing, seeing the video of a kid speaking comfortably at home, and in this direct clinical observation, usually we start to get a flavor of, is an autism evaluation component something that we need to pursue or is this a ‘typical’ kid with selective mutism?

Dr. Sharp: Right. I love that evaluation process or the observation process rather.

Dr. Aimee: It’s really helpful. 

Dr. Sharp: Yeah. Do you have that scripted out or is that a standard protocol that you got from somewhere or what?

Dr. Aimee: I do have it scripted out. I have a book that I wrote. So I plug from the book that I wrote for professionals. It has that script. And the whole process of evaluation is part of that book.

Dr. Sharp: Oh, very cool. Tell me the title of the book. I’d love to put it in the show notes.

Dr. Aimee: Sure. It’s called Selective Mutism: An Assessment and Intervention Guide for Therapists, Educators & Parents. So if you just look up selective mutism and my name on Amazon, it’s there.

Dr. Sharp: Perfect. I’ll put that in the show notes.

Dr. Aimee: Thanks. 

Dr. Sharp: Nice. That seems super helpful just to get some real-world “data” from how they interact with a stranger basically.

Dr. Aimee: Right. So that’s our diagnostic process. I feel like after kids come out of that, we have a good idea of affirming a diagnosis or switching gears and maybe testing for something else. And we have a good idea of where to start with treatment. And after we do that, we write up a short report. I want to say it’s usually like three pages of a little diagnostic report to give to parents and to give the schools that the parents relate to.

Dr. Sharp: I got you. Very cool. So, then maybe we could pivot just a little bit and talk about how to modify a more traditional neuropsychology evaluation for a kid who’s selectively mute.

Dr. Aimee: Yeah, absolutely. I would start with a few caveats. And my first caveat to this is, if you’re doing a psychoeducational evaluation for a kid with selective mutism, thinking about what is the purpose, will we get valid results even in the best-case scenario? I mean, I’ve tested hundreds of kids with selective mutism and  I don’t know that I can tell you that I always get a valid result from psychoeducational testing because of the anxiety component that’s there.

If the school is wanting services, could we explain to the school about the potential lack of validity of testing results and still get services instead? So can we kind of skirt around this without doing a full battery if it’s possible? And if the answer’s no, if we want to go ahead and do the evaluation, that’s fine. There are just some things to keep in mind. One of them is probably not going to be the most valid result, right? It’s just probably going to be slightly skewed.

And we’re probably going to have to go about testing in a way that may be slightly outside of the standard testing procedure because of what we’re dealing with. So for instance, some of the caveats or different things about testing these kids are, this is one case where I will test a longstanding therapy patient instead of referring out. And I know that that’s not usually mandated, but I feel like if I have a comfortable communication line with a child through therapy, I might get the most valid results at testing versus referring them to somebody that they have no experience in speaking to.

Dr. Sharp: That makes sense.

Dr. Aimee: We also would probably set up a few sessions prior to the actual testing where we’re building rapport with the child. So we usually will code those as therapy sessions to build rapport prior to testing because I feel like if you can get a child speaking to me in those sessions, then the testing is probably going to start a lot more valid than it otherwise would.

And then we kind of honestly switch a little bit of the testing procedures. So some of the examples of that would be things like I would allow whispering, I might not look at the child at all during testing because we know that for kids with selective mutism having somebody make a lot of eye contact with them can be very anxiety-provoking. So I might not look at them during testing. That might even be me sitting next to them instead of across from them even though that’s the standard testing procedure.

I might have parents in the room and tell the kids, you can tell your parents the answer so I can at least hear what they’re saying. I might prompt them to say, I don’t know even though that’s not standard protocol, or I might give them a little sign next to them that says pass or I don’t know that they can point to non-verbally so I can at least get some kind of response from them. I might change the order of testing starting with the non-verbals first so that they’re more comfortable by the time that we get to the verbal testing. I might fill out extra time for a verbal response. I’m noting all of these changes in a report. To me, this would at least increase the validity perhaps of the scores that I got from testing.

Dr. Sharp: Yeah, that all makes sense. And it’s validating as well. I’m thinking about our little guy last week and a lot of these things we ended up doing just to try to get some information, but it’s really challenging.

Dr. Aimee: It’s really challenging. I would say that psychoeducational testing for a kid with selective mutism, we end up scheduling much shorter chunks than we typically would with a lot of rapport building and kind of calming downtime. Testing just generally takes longer.

Dr. Sharp:  Sure. Are there any measures in particular that you would say are better geared for a kid with selective mutism?

Dr. Aimee: The ones that offer a non-verbal response are probably going to be easier for them. So evaluations that allow them to point or write their response are going to be easier than the verbal response piece. We actually don’t typically give non-verbal IQ tests to our kids with selective mutism.  What I found is that schools don’t particularly feel like that’s a great indicator of their cognitive ability. And so what I would rather do is spend more time getting them comfortable in building rapport and then be able to do something like a WISC instead even though I know that things like comprehension are going to be complicated or vocabulary because they require such a longer response than information or similarities would. 

Dr. Sharp: Yeah. Do you have kind of your standard line in the report about,…. this may be not being valid. I mean, how do you phrase it in the report? 

Dr. Aimee: Well, I don’t have a report in front of me so you’re catching me a little bit off guard, but we’ll say something like “Due to modifications from the standard testing procedure as well as over anxiety observed in the testing secondary to a diagnosis of selective mutism, these scores may not provide the best or most valid indicator of child’s ability” something like that.

Dr. Sharp: Hey, that was pretty good. That totally makes sense. I’m just again thinking about the kids that we’ve worked with. And I think this is a theme that has come up in different ways across the podcast with different guests. There’s like an undertone of you just got to be okay with what you get. It’s not going to be the best estimate and that’s just what we’ve got. You get the data you can, you work with that and do your best, right?

Dr. Aimee: Absolutely. I mean, even for “typically developing kids”, you can have a bad day or be angry. So, so you get what you got. 

Dr. Sharp: Exactly. Got you. So are there ever any times when you would just scrap the evaluation completely and say, this is not good, we can’t do this? And then what do you do if they need academic data? How does that play out?

Dr. Aimee: There have been a few where I felt like the information that we were getting wasn’t even in the remote vicinity of valid or reliable or helpful indicators of a child’s ability in any way. And in fact, I felt like, should I continue down this road of the evaluation, the school might misinterpret the results. No matter what kind of caveat I wrote into the report or disclaimer, they might misinterpret the results and it might hurt the child. So they might disturb my guest score in an impaired range that I don’t feel is a good representation of their ability. The school might move them into a contained classroom that would be harmful to them.

So I have a few times in the past scrapped testing and basically said, now is not the time. The kid is going to need some treatment before we’re going to be able to do a valid testing measure. In the meantime, what can we do to sort of put together a plan at least for school services because that’s usually what we’re talking about is how do we help this kid at school? How do we get them some school services? So kind of going, what else can we do? Let’s think creatively about a way to get this kid services and not totally write off testing, but put it off until we can make some movement with behavioral intervention for this kid. 

Dr. Sharp: Got you. I would like to talk with you about intervention and treatment a little bit. If possible, before we jump into that, could you talk any more about differential diagnoses to be aware of for selective mutism and how to separate it from say, autism or just generalized anxiety or social anxiety? How do we sort through those?

Dr. Aimee: Sure. I think of selective mutism as being, it’s almost like a specific phobia of communicating or speaking. And so, a lot of these kids do have generalized anxiety, but the nearest speaking tends to be above and beyond, sort of sticks out as the biggest of daily functioning issues. 90% of kids who have selective mutism do have social anxiety. So in 90% of the cases of kids that I’m evaluating, they have a secondary diagnosis of social anxiety.

The 10% that don’t, you can kind of tell because they’re not hiding. They look very much like they want to engage. They just don’t seem to be able to engage verbally. They’re playing with you from the very start. They like being the center of attention. They’re on stage during their classroom musicals. They’re not talking but they’re dancing out there in the middle. They might sometimes get attention from peers in school via other ways, like making noises, not verbal noises but pounding on their desk, tapping other kids. But the vast majority of kids do have social anxiety in selective mutism.

And then for autism spectrum disorders,  what I’m typically looking for is when the child is comfortable, are they able to speak in those situations, you know, speak typically? And do they seem to have appropriate social skills in those situations? It’s hard because these kids don’t oftentimes interact with peers at all. And so asking parents what their social skills are like when interacting with peers, most parents can’t even report on that because they’ve not seen it. And so sometimes we do have to see how the child interacts as treatment gets started. As you know, working with kids with autism or on the autism spectrum, you can start seeing signs and signals of it fairly early on when you’re interacting with them.

Some things that you would expect to see with a kid with selective mutism are, you would expect to see them not necessarily responding to you, or a long latency to respond, or flat affect, or a lack of eye contact. But I wouldn’t expect him to have difficulty with, let’s say, following an eye gaze or a finger pointed at something like, “Oh, look at that” The kids are going to turn and look at it. Or having parents or peers talk to them about experiences, these kids would be able to report really well on their experiences or feelings about things. 

Usually, they wouldn’t have repetitive behaviors or repetitive interests. So, if you see any of those kinds of things, then I do have my antenna up for this may be autism or autism in addition to selective mutism because those two things in my mind can co-exist. The DSM says that other things have been ruled out like autism, but what clinically we see is we see kids who have autism or autism-like characteristics and have selective mutism because they speak comfortably in the home setting.

Now, maybe pragmatic speech isn’t fantastic or feelings, identification, or things like that, but they speak very comfortably at home. And then out in public, they don’t speak. So those kids, I think they have both. I think that there’s a co-occurrence.

Dr. Sharp: Sure. That answered one of my big questions. Thank you. And that makes sense. I can understand that.

Can you talk a little bit about treatment and how we might help these kiddos particularly after we’ve completed an eval and what we might recommend outside the home. And it sounds like a number of treatment approaches, but I’m thinking about, how do we talk to teachers in schools and what would be helpful there?

Dr. Aimee: Yeah, absolutely. I think treatment is a really long conversation. So, I’ll give you kind of the quick and dirty version of what we would be looking for in a good treatment plan. We know that exposure-based behavioral treatment is the gold standard for kids with selective mutism. So, you know, our treatment on a very basic level looks like starting with psycho-education for both the parent and for the kid and then moving into an exposure-based behavioral treatment.

So, we talked to the kid about practicing being brave, and then we as the therapist set up a hierarchy of increasing the number of people and places the child can talk to. Like any hierarchy, we do that slowly and systematically, and we usually add a reward system to that in order to increase motivation. Our treatment, it’s practicing first having the child speak to us in the clinic and then adding in new people probably in the clinic setting.

My poor receptionist didn’t know that when she got hired, she was going to be a part of many, many therapy sessions.

Dr. Sharp: Oh, my goodness.

Dr. Aimee: And then we’ll practice at the hall of the clinic. We’ll practice in the waiting room. Then we start going out into public and we’re practicing speaking, ordering at the ice cream store, and going Bowling so that we can order our shoes and get a soda while we’re there and going to Home Depot and doing scavenger hunts asking the employees where things are located. And the whole time, the parents are really involved in the treatment because it’s not sufficient for the child to be able to talk to me. That’s great. It makes me feel good, but it’s not sufficient. And so my goal is to teach the parent how to elicit speech in all of these settings as well.

In relation to that, I would say that this diagnosis is one that requires the most case management, probably similar to a score refusal treatment that you really have to be working with the school too because most of these kids experience the highest anxiety and the worst selective mutism symptoms in the school setting. And so, I’m working with the school to get IEP plans set up for the child, treatment plans put in you know, determining who’s going to be working with them in the school setting on an individual basis, and then continuing facilitating and consulting with the school at that point. 

Dr. Sharp: I see. That totally resonates. I can understand that. From a practice management standpoint again, how are you billing for all of that time involved in coordinating with the school?

Dr. Aimee: Yeah, that is out of pocket. We have not yet found a billing code that the insurance is going to pay for school consultation. So, unless I’m going into the school and doing an intervention, and in that case, I can code for treatment but just with a different modifier for location, I’m consulting with the school. That is out of pocket.

What I have found though is that if I can explain it to parents, they do understand the need for me to consult. I’m not consulting every week. I try to spread it out after that initial education for the school, but if a child’s not getting intervention within a school setting, we’re really limiting the generalization of these new skills that they’re developing.

Dr. Sharp: Absolutely. Like you said, that’s a primary spot where selective autism is happening. So you got to go to target that somehow.

Dr. Aimee: Absolutely.

Dr. Sharp: Well, I know that was a very quick overview of treatment. And that’s something that apparently you can write an entire book on. So we’re summarizing that very quickly. But if you want to find out more, they can check out which will be in the show notes.

Let’s see. I feel like we’ve covered a lot of ground. Are there any things that are still kind of hanging out there that you want to touch on or highlight before we wrap up? 

Dr. Aimee: I think I would just encourage people to be willing to treat selective mutism. Interestingly, I love it. It’s my favorite thing to treat, but I found a lot of psychologists find it intimidating perhaps, or feel stuck with it. And I would just encourage people to get good training in this exposure-based behavioral model to treat SM because it’s really enjoyable to treat. And it’s in my opinion, very rewarding.

There is good training out there. There are other books that are written that are fantastic on the subject. Our office provides clinical professional training if people are interested in where people come out and they visit us for several days in a row and they come a long way with the kid doing an intensive intervention. At the same time, they are taught how to do the treatment for selective mutism. So that’s a cool opportunity if professionals are really interested in getting their feet wet and learning treatment for selective mutism. 

Dr. Sharp: Absolutely. And it’s the best way to find… are those just on your practice’s website or is there a different resource to find those?

Dr. Aimee: No, it’s right for my practice’s website.

Dr. Sharp: Fantastic. Yeah, I’ll put that in the show notes as well. This was one of those little niches that I don’t know that PESI is going to offer training on selective mutism that is any good. 

Dr. Aimee: Well, and now Jeremy, I used to do training for PESI on foot.

Dr. Sharp: Of course you did. Okay, in that case, fair enough. That’s great. But if you want the real deal, do this.

Dr. Aimee: Do you want the real deal? There is also a selective mutism association, which is selectivemutism.org. They’re a non-profit organization that provides all kinds of fantastic information about selective mutism. And once a year, they have a conference. This year in Vegas in October. And it’s fantastic as a good training opportunity for professionals looking for more information

Dr. Sharp: Nice. I’ll put all these things again in the show notes so that folks can check it out if they’re interested. If people want to get in touch with you, what is the best way to do that? 

Dr. Aimee: They can either go to my website, which is thrivingmindsbehavioralhealth.com or they can email me. Direct email is probably the best way to contact me. And that’s akotrba@thrivingminds.info.

Dr. Sharp: Great. I would imagine you might get some questions after this.

Dr. Aimee: Sure.

Dr. Sharp: Well, this was great. I really appreciate your time and your knowledge. I mean, you clearly have your mind wrapped around this whole topic, and you’ve done a lot of work and you’ve written a book, that’s pretty cool. I’m just so grateful to be able to chat with you. And I would definitely learn some things and I hope that listeners have too. 

Dr. Aimee: Thank you so much for having me. I appreciate it.

Dr. Sharp:  Of Course. And I’ll have to look you up next time I’m in Michigan together and see your clinic.

Dr. Aimee: That’s great. Fantastic. 

Dr. Sharp: All right, well thanks, Aimee. Take care. 

Dr. Aimee: Thank you. 

Dr. Sharp: Okay, y’all, thanks as always for listening. I really appreciate it. Hope you enjoyed the last two clinical episodes which were replays of really popular episodes from two years ago. I’m just lining up my content calendar and some interviews for the coming weeks. So, we’ll be back with fresh interviews and a masterclass over the next month or two. 

If you’re an advanced practice owner and you are looking for a group coaching experience to have some accountability and help take your practice to the next level, check out the advanced practice mastermind that starting June 10th is the next cohort. And you can get more information and schedule a pre-group call at thetestingpsychologists.com/advanced. I would love to see you there. And it’s already starting to fill up. I’ve already got 2 folks on the waiting list. So, there are six spots total. If you want to jump in, go for it, make that happen.

All right, everybody, take care. I will get back with you on Thursday.

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.

Introducing ChecKIT, a one-stop-shop for Testing Psychologists that puts common mental health checklists in one place, saving you time and simplifying your assessment process. You can learn more at parinc.com/checkit.

All right, everybody. Welcome back. I’m so glad to have you. Hey, today is the last day in our Practice of the Practice February takeover. I’m talking with Alison Pidgeon today all about systems and processes in our practices.

Let me tell you a little bit about Alison. Alison is the [00:01:00] CEO of a large group practice called Move Forward Counseling in Lancaster, Pennsylvania. She also works as a business consultant for Practice of the Practice, and she is the owner of a virtual assistant company called Move Forward Virtual Assistance. Allison is also a mom to three boys and she proudly drives a minivan. It takes a lot to proudly drive a minivan, but Alison is the one to do it. She, as you can tell, has made a career out of developing and teaching others systems and processes. And I am really excited and lucky to have her on the podcast here.

So we talk about all things systems. And what this means, if you don’t even know what a system is,  that’s totally okay. We define systems versus processes. We talk about what kind of numbers and data you might want to track in your practice and how to do that. We do a brief dip into Facebook ads and how they can be helpful for your practice. [00:02:00] And we also talk about what it might look like to hire a Chief Operating Officer or a COO in your practice.

So we really kind of run the game from beginner practice tips and easy things that you want to think about as you’re just getting started. But then we take it all the way up to delegating on a large scale for bigger group practices. So I think there’s probably something for everyone in this episode.

Now if you are a beginner practice testing psychologist and you would like some support launching your testing practice here in 2021, I would love to have you consider the Beginner Practice Mastermind Group. So this is a group coaching experience where we will hold you accountable and give you support as you launch your practice or try to refine your practice if you’ve launched it recently. You can get more information at testingpsychologists.com/beginner. And as of recording, I think we have two spots [00:03:00] left. I’ve been lazy. I have not sent it out to my email list. I’m just putting it on the podcast. So Jump in while there are a couple of spots left if you’re interested. So you can schedule a pre-group call and see if it’s a good fit there at testingpsychologist.com/beginner.

Okay. Let’s jump to my conversation all about systems and processes with Alison Pidgeon.

Hey, Allison, welcome to the podcast.

Alison: Hi, Jeremy. Thanks so much for having me. 

Dr. Sharp: Yes, thanks for being here. You are, I think Practice of the Practice expert number three this month in the series.

Alison: Oh, nice.

Dr. Sharp: Yes. So I talked to Joe, I talked to Whitney. Oh no, you’re number four.  Latoya, I [00:04:00] think we released before you. So yeah, you’re closing out Practice of the Practice. You’re the last

Alison: Very cool.

Dr. Sharp: Bring it home strong. So as we said before we started to record, I don’t know that we have actually talked one-on-one, but I know we’ve been in the same zoom rooms at different events. And I have sent so many of my testing consulting clients to your VA company. So I’m excited to be talking with you all about systems today.

Alison: Yeah, me too. It’s one of my favorite things to talk about.

Dr. Sharp: Yeah. Well, let’s just jump right into it. I want to know when you say systems or anybody says systems, what does that even mean in the context of a mental health practice?

Alison: Yeah, that’s a great question. So I think sometimes people use this in different ways, but how I see it is that a system is something that is like the main vehicle that you use. So for example, an electronic health record, a phone system, an email system, [00:05:00] and then I often use the term processes to describe the little tasks that happened in those systems.

Dr. Sharp: I like that distinction. I think I’ve been using those mostly interchangeably, but that is a very nice distinction. So yeah, I mean, my hope is that we can talk about systems and processes. So talk to me about… let’s go back. Can you even think back to the beginning when you realized like one, I need better systems and, or two, I need better processes in my practice. What was that moment like or what was happening at that point that led you in that direction?

Alison: Yeah, I think it was really in the beginning when I started the group practice, of course. I was trying to do everything myself and then I realized, “Oh wow!, I shouldn’t be doing all these things. I really need an assistant.” And then teaching the assistant how to do what I was doing and then realizing, Oh wait, there’s probably a much more automated way of doing this. Like, why am I doing all of this manually when there’s probably a software tool or [00:06:00] something already built into the EHR that could do this for us. And so it was really just like looking at the whole…

A process can be quite long. If you think about the process of scheduling a new client, especially if you’re an insurance-based practice, that’s many, many steps. And then you can see how a weak link in that process can really mess up a lot of things down the line. And so in my brain, I’m looking at the whole process and trying to figure out, “Okay, where is the weak link or what is something that could be more efficient?” Because I know this thing takes up like an inordinate amount of time and there has to be a better way or a quicker way to do this thing. And I just kept working on how to improve it either by automating it, delegating it to somebody else. There are lots of different ways that you can approach it, but that was kind of how I started.

Dr. Sharp: One thing that I hear from my coaching clients a lot is they love the idea of automating and systems and processes, but the next question is always, how do I have [00:07:00] time to do that? How do I even find the time when I’m already working 60, 70 whatever hours a week and not seeing my kids and family, how do I make the time? Do you run into that or have you thought through that at all?

Alison: Oh yeah, that is a very common problem. And I feel like practice owners tend to start out just doing everything themselves and then they realized way too late that they’re drowning in all this administrative work. And then we’re like, ” You need an assistant.” And they’re like, “I don’t even have time to eat lunch. How do I have time to train an assistant?” You know what I mean? And so we always tell people like hire an assistant way before you think you need it. Because if you wait until you actually realize you need it, it’s too late. You’re like drowning in work at that point. And you don’t even have the bandwidth to train somebody or the time.

Dr. Sharp: Yeah, absolutely. 

Alison: So I would say if you have to hire out to get that done, I think a lot of times when people hire an assistant, they think like they have to have this like beautiful binder full of like, this is how I do all [00:08:00] the things and the practice. And that’s not necessarily the case. You could bring on an assistant and say, I need you as I’m training you to document how to do these things. So that way when you’re on vacation, or if you ever leave there’s something here that I can use to train the next person. And so you don’t necessarily have to be the one doing all that work. That’s what I did with my first assistant. I was like, I’m going to tell you everything that’s in my head and you’re going to take notes and then you’re going to put it in a Google doc. And that’s what we did.

Dr. Sharp: That’s amazing. I think I’ve in the past made that mistake of thinking that you do need a solid operations manual before you can bring someone on, you know, in the interest of not bringing them on and then confusing them or looking disorganized or whatever it might be. But I don’t know, I think there’s definitely some value in just having them write it at the moment while you’re doing the training. Right?

Alison:  Right.

Dr. Sharp: Yeah. How do you, I’m just asking hard questions right off the bat, but how do you find the time to train them? [00:09:00] Because that to me it was like, okay,  so I take a week off of work, I take two weeks off and just sit with this person. How does that even work when you’re a busy practice owner?

Alison: In the VA company, we call it progressive delegation. So if you brought on an assistant and you basically told them every single task that they’re ever going to do in their job the first week they were there, they would be so overwhelmed. You know what I mean?

Dr. Sharp: Sure:

Alison: So we go by what we call progressive delegation, which means you give them the most important tasks first that you want to get off your plate. So for me, when I first brought on my assistant and I was like, I don’t want to answer the phone anymore and do the scheduling. I’m going to teach you how to do this. So for the first two weeks, that’s all we did. We did this initial training for two hours. This is how you do the scheduling. And then we met at regular intervals just as difficult questions came up. And then I was like, okay, now you have the hang of this. Let’s now add this next task. So it was like, pieces of training broken down into smaller chunks. So it was easier for me [00:10:00] to train her, but then it was also easier for her to grasp everything that she was doing because she was just doing it one phase at a time.

Dr. Sharp: That makes a lot more sense to keep your assistant sane, I think. Keep them from running out the door screaming.

Alison: Yeah. 

Dr. Sharp: Sure. How do you identify those tasks that are most important to delegate first?

Alison: I think what we find typically is that scheduling and answering the phones and answering emails for new clients is usually at the top of the list for most people because they know they need to stay on top of that to bring new clients into the practice because obviously, that’s where your revenue is coming from. And if they’ve been in sessions all day and can’t get back to people for 24, 48 hours, they’re losing clients and they know it. So I would say that is usually the biggest thing that we get asked to take care of first because there’s an obvious financial implication to that.

[00:11:00] Dr. Sharp: Absolutely. I know people with me will often say I cannot delegate answering the phone. Nobody can answer the phone like I can. And this seems maybe a little more prominent in private-pay practices. I don’t know if you found that, but there’s this whole I am the magic and that’s part of the high touch, private pay boutique kind of thing that I do. What have you found in that regard?

Alison: That is so hard. And I hear that so often from people. And it’s so hard to change their mindset around like, you do not need to be the one answering the phone. You are the most overpaid scheduler that ever was because you’re the owner of the practice. I think it’s really about hiring the person who is the right fit for your practice and who can be open to learning how you do it.  You’re just going to become this huge bottleneck if you’re the one answering the phone. It’s actually not uncommon. I’ve had clients who have [00:12:00] million dollar practices and the owner is still answering the phone. They just cannot let it go.

Dr. Sharp: That’s crazy to me. 

Alison: Yeah, I know. But it happens. And I think actually they don’t think that maybe somebody could do it better than you could. What I often recommend is all pay practices as they have the assistant schedule like a pre consulting call with the therapist that they think is the best match for that client.

And then they can then have that high touch more therapeutically oriented conversation about, are we a good fit for therapy and all of that stuff, but there’s no reason why you have to be like sitting at a desk all day answering the phone if you’re the owner of the practice. There are other ways of going about it. That’s just not a good use of your time.

Dr. Sharp: I like that. I forgot about that option that you can have your assistant just do a little screening almost, or not even a screening, but put that person into spots on your calendar so that you’re not just waiting by the phone or feel like you always have to return messages or whatever you can [00:13:00] have dedicated spots on your calendar if you want to do that.

That’s great. So we’ve just sort of dived right into it, but let me back up. That’s so exciting to talk through systems. What are some of the main systems that you think are crucial for practices these days?

Alison: Yeah, definitely an EHR, obviously a phone system especially if you have a group practice having a phone system with extensions.

Dr. Sharp: Yeah. Which one do you use?

Alison: I use All Call Technologies which doesn’t have an app, which is the big hangup that a lot of people have, but I like it. I think they have great customer service. and the system works well.

Dr. Sharp: That sounds good. Are there others that you might recommend?

Alison: People obviously have different experiences with different systems, but really common HIPAA compliant ones are like Phone.com, RingRx, there’s one called 8X8, Spruce Health is another one that has a really good reputation.

Dr. Sharp: Great, [00:14:00] people are always asking what phone system. We moved to Google voice maybe six months ago and it has worked well for us. We have about 20 people in our practice and it has been pretty good. The only thing I don’t love about it is that you can’t record a human voice for the greeting. It’s like a robot greeting. That’s my main complaint about it. But otherwise, we like it, it integrates with G-Suite really well and otherwise works pretty well. But I interrupted you. So EHR, phone system.

Alison: Yeah. I mean, especially if you work with insurances, you’ll need some kind of fax which nowadays they have online fax systems which are really nice. So you don’t have to have a physical fax machine anymore. HIPAA compliant email obviously, especially now it’s some HIPAA compliant Telehealth platform.

Dr. Sharp: Yes. Good question there too. Which Telehealth platform are y’all using?

Alison: We actually switched to zoom a few months [00:15:00] ago and it’s actually been great in terms of reliability of the connection. So I think it’s been good. We obviously pay for the HIPAA compliant version. So it’s like $20 per therapist, but to have it work and know that it’s HIPAA compliant is well worth it.

Dr. Sharp: Got you. Yeah. We also use zoom and seem to love it, but TherapyNotes added Telehealth recently and that’s hard to switch. Nice so yeah, those are the major systems. Any other systems that you’ve got working in your practice then?

Alison: Yeah, I can’t really think of anything else. Obviously, depending on whatever types of marketing you’re doing, you might have a system. And for that, if you’re sending out email newsletters or things of that nature, but I think that’s dependent on how you do your marketing. 

Dr. Sharp: Of course, that makes sense. And then how about processes? When you think about the major processes in a practice, what comes to mind or what are you working with people on?

Alison: Yeah. Like [00:16:00] I said before, I think one of the biggest ones is how do new people get into your system? How do they get scheduled? How does data get entered into the EHR? How do benefits get checked if you take insurance? How are clients filling out new client paperwork? That’s a whole thing. Other systems too that are really important is what do you have set up in terms of when do clients pay their bills? Are they paying it during the session? Are you charging the card after? Are you sending them an invoice and waiting for them to pay it? There are all those different choices that you could make. 

And there are all these typical things that happen in the course of therapy, right? Like you come in for your initial session, you pay, you reschedule the next appointment. There’s all these common out like, no matter what kind of practice you are, what kind of therapy you practice, we’re typically all doing those same types of processes.

Dr. Sharp: Right. And how do you… I mean, I imagine there’s some process [00:17:00] for defining these processes almost, right? I just think about a beginning practice owner who wants to get started on this journey and figure these things out and define these things. How do you recommend somebody even start with identifying what processes they need or even systems to put into place?

Alison: Yeah. I think one really good place to start would just be to think about what is the normal day-to-day stuff that the therapist has to do to do their job. And what is the kind of experience of the client interacting in your business? So if you’ve hopefully worked in mental health before, you know, right?. A client comes in and they need to sign some consent, they need to give you some information. You need to write the progress notes. So really just thinking through on a fine detail level, what are all those things that happen? And do I have something in place to be able to do that? 

Something that I found out when I first started bringing people on was that I [00:18:00] thought I had things set up really well. And then some of the first therapists that I brought on were like, what about this? Where does this go? And I was like, no, I didn’t think about that. If a client hands me a cheque, where do I put it? Oh, I don’t know.

Dr. Sharp: Great question. I know. I’ve had that experience.

Alison: Yeah, good question. I didn’t think about that. So it’s just like those things that can get very very detailed, but at the same level, like, especially with group practices, as I’m sure you know, once you start adding volume of therapists and clients, you really need to make sure those things are very buttoned up because otherwise, it can cause big problems.

Dr. Sharp: Yes, that’s happened so many times. It gets problematic really fast. It’s like exponential problems.

Alison: Yes, snowball down the hill, right?

Dr. Sharp: Yeah, absolutely. It is hard.  That leads me to think about after you get past that beginning stage, who is keeping track of all these things and making [00:19:00] updates too? And is there a manual somewhere? Where’s all this held for anybody who might need this information?

Alison: Yeah, I think what’s really challenging is that you start a practice and everybody picks different systems and then your systems kind of… whatever set of unique systems that you picked all work together a little bit differently. And so it’s really hard, even as somebody who does this all the time, to tell you exactly like, Oh, you have SimplePractice and Spruce. And so they are going to work together like this or not work together like this. And so you need to make sure you do X, Y, and Z because of the ins and outs of those particular systems.

So it just makes it really challenging to advise people on that fine detail level of what exactly they should be doing or where they should be looking. But I have put together, like for my consulting clients, what I’ll do is I have what’s called a group practice audit. So this is a very long Google form [00:20:00] that asks all these questions about how do these things happen? And what do you think is working well here? What do you think is broken over here? And it Goes through every different topic and every different piece of their business. So we can identify where those weak points are or if there are things that fell through the cracks. So that can be really helpful.

And then we will go through and just say, okay, this looks like a problem. How do you think you could fix this? And a lot of times what I find is that people aren’t using their system to its fullest capacity. So they won’t realize that their EHR can run a report to see if there are missing progress notes, or if there’s outstanding money that clients haven’t paid.

They just don’t know that stuff is there and then when I’m like, ” Wait, does your EHR run this report to see if this thing is running smoothly?” They’re like, “I have no idea.” And they go and look. And it’s like, “I can click this one button and see all this information.”

Dr. Sharp: It’s incredible.

Alison: Yeah, it’s amazing.

[00:21:00] Dr. Sharp: It’s funny. I had that experience probably three months ago with TherapyNotes. I’ve used TherapyNotes for 10 years, probably and maybe more than that. And I just discovered the activity log. I don’t know if you… are you familiar with TherapyNotes? Do you know TherapyNotes?

Alison: No we use TheraNest.

Dr. Sharp: Okay. So TherapyNotes, maybe TheranNest has a similar thing, but it has this section in the settings called the activity log and it records everything, literally everything in the system. You can search when credit cards were run and which ones declined and why they declined and any number of things, like everything. And it was a gold mine, I’m like, Oh, the cloud’s part of the group practice owners dream. That’s a great example of people under-utilizing their EHR.

Alison: Yeah. I think though, once I start to say this is something that you should be tracking, they figure out pretty quickly how to make that happen. Whether it’s just going to run a report or whether it’s, [00:22:00] Oh, I just need to set up the simple Google spreadsheet and have my assistant track this data or whatever. It’s pretty easily solvable, even if I am not familiar with all of the ins and outs of their particular systems. 

Dr. Sharp: Sure. Since you bring that up, I’m curious what you think practice owners should be tracking?

Alison: Yeah, we could probably do a whole podcast episode about that because there’s a lot of stuff. I’ll sort of hit the highlights. So definitely anything with like clinician documentation. You want to make sure your progress notes are completed in a timely manner, they’re being signed. Treatment plans are getting done. Is the billing happening in a timely manner? What’s the timeframe? Claims are getting submitted and regardless of whoever’s job that is to do that, what is the amount of money that is unpaid that should be paid so we can run what’s called an aging report so I can see any money that’s older than 30 days that [00:23:00] hasn’t been paid either by insurance or by clients.

And usually, after 30 days, it’s like, okay, there’s a problem. And now we need to follow up on what happened. And it’s amazing to me, how many practice owners don’t pay any attention to that, and then one day they look and realize there’s $30,000, $50,000 missing on there that they’re owed. And with insurance companies, after a certain amount of time, you can’t submit that claim anymore. So definitely staying on top of those things is so important. We’re able to keep our uncollected amount of money per year under 1%, which I think is great.

Dr. Sharp: That’s amazing. And you’re an insurance-based practice, right?

Alison: Yes.

Dr. Sharp: That’s amazing.

Alison: So because we have a good system and a good process in place to keep tabs on that and my assistant is regularly following up to collect unpaid claims and balances and that kind of thing.  We keep credit cards on file so that we can charge them if the [00:24:00] client disappears.  So these are all these things that you have to think about and be tracking on a regular basis because again if you can nip the small problem in the bud, especially with a group practice, you’re going to prevent the whole avalanche of problems down the line. Because like you said, the problem can escalate so quickly.

Dr. Sharp: Yeah, sure can. I’ve told the story I think on the podcast before and written about it a lot, but there was a moment where I discovered the aging report in TherapyNotes probably three or four years after starting my practice. And it was like $90,000. I can remember that moment very well. And, we’ll never let that happen again.

Alison: Yeah it’s not that common.

Dr. Sharp: Sure. I mean, I didn’t know it was there. I didn’t even know what it was or why it was important.

Alison: Something else that’s really important to track that’s really simple is having your assistant keep a call log and keeping track of who’s calling, how many calls did you get in a day? Did they get scheduled? If they didn’t get [00:25:00] scheduled, why not? And then at the end of the month adding up what’s your conversion rate? Meaning like out of the number of clients who called, how many people actually scheduled. And if you were self-pay that number should be between 30 to 50%. If you’re insurance-based, that should be more like 70 to 80%. So those are just good rules of thumb. If your numbers are off from there there’s definitely something again, in the process that’s broken and you can go back through and figure out what that is.

But it’s just those things that can be so helpful in terms of like, is my assistant doing her job as well as she could be. And that tells me so much about marketing. Like I can see every day in real-time, how many calls we have coming in and I can see like, Oh, Monday’s the busiest day Friday’s the slowest day. I can see when a Facebook ad stops running the number of calls go down those kinds of things.

Dr. Sharp: Yes. Oh my gosh. I have so many questions about what lasts like two minutes. [00:26:00] So let me go back a little bit and just ask, for those of us who are in insurance-based practices, are there any systems or processes, maybe more processes that you think are worth mentioning to really keep that collections number pretty high, that you don’t see people doing all the time?

Let’s take a quick break to hear from our featured partner. The ChecKIT is a one-stop-shop for Testing Psychologists that puts common mental health checklists in one place saving you time and simplifying your assessment process. ChecKIT products are all accessible through PARiConnect, the industry’s most reliable platform. Administration and scoring are sold in packages of five, which can include any combination of ChecKIT products. Reports include interpretive text that you can use for your own reports. And there’s a free technical paper for each product. The current product lineup includes. The PHQ-9, the GAD-7, and the LAM [00:27:00] and more products will be added through 2021 and into the future. Learn more at parinc.com/checkit.

 All right. Let’s get back to the podcast.

Alison: Yeah. So a big game-changer for us has been to get credit cards on file and we didn’t do it until they showed up for the first session. And then we actually changed it and we have them give us their credit card number in order to schedule their first appointment. And what’s interesting is that people who are not really sold on coming to therapy will make up some excuse about how they can’t give us their credit card right then and say, “I’ll call back later” and they never do. And then the people who do put it on file do show up then. Our no-show rate has improved since we started doing that. And then obviously too, like we have them sign a form that says these are the reasons we would charge your card. Like for a no-show fee or insurance didn’t pay [00:28:00] or whatever the situation. And that helps a ton.

And I have my therapist actually charged the card at the end of the session so that if for some reason the card didn’t go through, they can say right then, Oh, it looks like your HSA card ran out of funds. Do you have another card you can give me and they take care of it right there in the session because if you have to chase people down for money, likely you’re not going to see it.

Dr. Sharp: Right. That’s so true. Yeah. The credit card on file was a game-changer for us as well. Yeah, it’s huge. So then we move into the call tracking conversation. I’m curious how you track your calls. Is that like a Google form or?

Alison:  Yeah, Google spreadsheet. Nothing Fancy.

Dr. Sharp: That’s good. Yeah, keep it simple. So are you a -Suite user?

Alison: Yes, we definitely use lots of Google docs.

Dr. Sharp: Yeah, we love it. So tracking calls, I love being able to see … you kind of answered my question of what do you actually do with those numbers because people are like, why do we track the calls? What good is that going to do? And let me see, I had [00:29:00] one other question in there. Oh, Facebook ads, you run Facebook ads for your practice?

Alison:  Yeah.

Dr. Sharp: Tell me about the success or lack thereof that you’ve found with Facebook ads.

Alison: So I actually started doing them myself and just experimented with what was working and what wasn’t. And so what I found is any kind of blog post that was more timely related to something like current events that was happening. So like one year, right? Like the week before Thanksgiving, I ran an ad for a blog post I’d written about how to deal with your dysfunctional family at Thanksgiving dinner. It was very popular as opposed to something more generic, like how to set boundaries with your significant other, you know what I mean? Like that wouldn’t be as appealing, obviously as clicking on an article about Thanksgiving week of Thanksgiving. And then anytime Therapist join the practice, we run an ad saying help us welcome [00:30:00] so-and-so they’re taking this insurance. They see these types of clients. Those types of posts always do well.

Dr. Sharp: I love that. Yeah, I’ve always been down on Facebook ads. I don’t know why. I mean, it just seems, there’s a whole… people aren’t really looking for a therapist on Facebook that whole thing. So it’s cool to hear somebody having success with it. I know a lot of people are having success with it. I just don’t do it.

Alison: What I like about it is it’s relatively cheap. So you could spend like $50-$70 on a Facebook ad and that’s like, okay, if it didn’t work, no big deal. But then the other thing of it is that I think sometimes people think they don’t work because they don’t necessarily traceback that they heard about the practice from Facebook, they see the Facebook ad and I always have them click through to the website and they get to their website. And by the time they call and we say, how did you hear about us? They say, I found the website, but they don’t say, Oh, I found the Facebook ad first. But I know that the Facebook ads work because every time we run them, the [00:31:00] calls always increased pretty significantly, but hardly anybody says we heard about, or we saw this on Facebook.

Dr. Sharp: Got you. Yeah, that makes sense. We have some trouble with that too. It seems like everybody just finds the website. That’s always like 50 to 60% of our referrals is Google, but who knows what they were referred from somewhere else.

Nice. I think those are all my questions from that whole conversation that we’re having about call tracking and insurance and all of those things. I think way back we started with what should we be tracking in our practice? So are there any other things that we haven’t talked about?

Alison: Yeah. There are tons of things and actually what I recommend to people is that cause they often think they have to do it all themselves. And I would definitely recommend you delegate that, especially if you have a group practice, you delegate that out to other people in the practice, whether it’s like your clinical director, your office manager, and then you [00:32:00] could just have one place. You can have one Google spreadsheet where you can open it up and see all these data points.  And it can take you five minutes to look at, okay how’s the health of the practice, basically, as opposed to you thinking I have to be the one going into the EHR, running these reports, doing this, doing that.

And I think that you could go crazy tracking data. I don’t know if it’s necessary to track every single thing, but I think you have to decide what’s important to you. So for me, it’s  The aging report because I want to make sure we’re getting paid, what we’re owed and we did the work we should be getting paid.

I know some practice owners are really big on therapist retention of clients.  Usually what I find is that I can tell how a therapist is retaining clients if, after the normal period of time, their schedule should be full, it’s not full. And also usually client retention is one of the issues that they’re having like they’re having other issues besides client retention. So yeah, it’s pretty obvious [00:33:00] to me without really tracking it at a detailed level, but I guess you have to decide what are your priorities? You want to make sure, obviously, your progress notes are being done in case you’ve ever got audited and that type of thing.

But again, it doesn’t have to be you keeping track of all of that. And actually for a while, how I had it set up was I basically told my assistant, once a month, I want you to run these reports. And so for example, I’m missing progress in that report and if there are one or two missings, just send it to the therapist and say, Hey, you missed one or two human errors can you fix that? Get it done.  But I said if it is like four or five. Well, now that’s a problem. And that’s something different other than human error. And that is something you need to alert me to. So if everything is running fine and nobody’s reached that threshold, she doesn’t even tell me she just does it and I know nothing about it until there’s a problem.

Dr. Sharp: That’s great. I mean, that’s the way it should be. Yeah.

Alison: Yes.

[00:34:00] Dr. Sharp: Yes. Okay. There’s a lot to think about. This is good. There was one other thing I wanted to ask about, which is call answering. So it sounds like you have a group practice. Right? A lot of us do. And even those who don’t live answering is a problem. So I’m curious what your philosophy is on. I mean, do you try to live answer every incoming call or do you have some other system to handle the incoming calls?

Alison: Yeah, in my own practice, we try to alive answer the call. So we’re at a size now where it’s actually somebody whose’s full-time job to live answer the phone. And then how we have the phone system set up is if she’s already on the phone, it will ring the next administrative assistant so that they can live answer the phone if the first person can’t. It’s so important.

And I think that has been one of the big contributors to the success of the practice and our growth in the past few years because I hired an assistant pretty early on because I don’t like answering the phone, but also [00:35:00] because Joe told me too. He was like, you need an assistant. I was like, really? It’s just me working part-time. Do I really need it? He’s like, yeah, you need an assistant. And he was right. 

Dr. Sharp: Yep. I hear you. We struggle with that as we get bigger and bigger. Live answering just the demand on admin time is large. So I’m always looking for creative solutions to them.

Alison: Yeah. I mean, I know people who try to do answering services and things like that, or they’ll basically just answer the phone and pass the message along, which, maybe can be somewhat of a band-aid, but I don’t know if that’s really going to hook the person into because when they call, they want to schedule right then. And if you end up playing phone tag, then you’ve probably lost them.

Dr. Sharp: Agreed and always an ongoing thing to think about or maybe that’s just the place to invest administrative staff money especially in a private pay practice.

Alison: Yes. For sure.

Dr. Sharp: So I also wanted to talk with [00:36:00] you about the next level here. So this has been great, like tons of how to get started, what systems do you need processes, et cetera, but you’ve really taken it to the next level where you have actually hired COO’s in both of your businesses to handle operations. Right? So can you talk a little bit about those individuals for anybody who might not know what COO is and how they can even exist in mental health practice?

Alison: Yeah, that’s a great question. So yes, both in the virtual assistant company and in the mental health private practice, I have, what’s called a chief operations officer. And so they’re really overseeing the day to day operations of what happens in the practice. I was fulfilling that role up until they came along and I found that for me, I’m much more the CEO type I want to look at the big picture and focus on expansion and [00:37:00] thinking in those terms rather than like, Oh, now we have this insurance billing problem and this client’s complaining. That stuff gets very tedious for me. So it was interesting in both situations how you’re never really quite sure when you are ready to get to the next level. But sometimes just like a leap of faith.

So in the VA business, the person I had filling that role ended up leaving and getting a new job and I was six weeks away from having my third baby. And I was like, “I need somebody to run this business for me.” So that’s how James came along and he’s done an amazing job with taking what I started and really formalizing our structure and our systems. And he’s very good with processes and he’s done amazing things with the business and then my COO and the counseling practice, Valerie actually just started about a month ago. And we’re going through, looking at the structure [00:38:00] of the counseling practice because everything with the pandemic now we have a whole team of their business, basically, that just want to do a 100% Telehealth from home, which is cool.

But we have another team of therapists who want to be able to go back to the office when it’s safe to do so. We gave up some of our office space. We had three different spaces in the County. Now we just have one. So we gave up the places we were renting and the only space we have now is the building that I own for the practice. So just a lot of changes and just figuring out what makes the most sense now that we have the COO in place. So we’ve been talking about having a clinical supervisor or a manager over a team of therapists. So maybe like 12 to 15 therapists based on location. And then the COO is over top of those managers, so to speak. And so we could just keep replicating that structure and we could potentially have many teams of therapists with those [00:39:00] managers and then all the managers would report to the COO.

Dr. Sharp: Yeah. I love that. So tell me, I would love to delineate a little bit more, the difference between, like you said, you are a CEO kind of person versus the COO. Can you explain the difference there a little bit more, and even like in practical terms what that person, what a COO is doing day to day versus what you’re doing day-to-day.

Alison: Yeah, I think we’re still trying to figure that out. Really a lot of the stuff that I don’t like doing, I passed off to her. So for example, we needed to update some policies and procedures in our employee handbook. That stuff is very tedious to me and she loves doing that. So she’s like, I’ll do that.

We’re looking at expanding, she’s helping me with those. I’m giving her the ideas and she’s actually the one who’s making the calls and setting up marketing meetings and in the new location and any sort of like HR type things, she’s [00:40:00] really taking over. I’ll still be involved in terms of maybe doing the final interview with the candidate, but everything up to that point, she’s going to handle, so like doing the job postings, doing the screenings, doing the initial interviews.

And so that was really a big piece of the job that can get time-consuming that was bogging me down, especially because things were getting so busy, obviously fueled by the pandemic that we added eight therapists may be in the past six months.

Dr. Sharp:  Yeah, it’s been a crazy year.

Alison: Yeah. So in 2020, we doubled in size. We had 12 therapists at the beginning of the year. In the end, we had 24. So it’s a lot of HR tasks.

Dr. Sharp: That’s a lot. Yeah. That reminds me of the book Rocket Fuel. Have you read Rocket Fuel?

Alison: I have not.

Dr. Sharp: The way you describe it sounds very similar. They talk about I forget the exact terms, but it’s basically like in each company you need a visionary and an executor. Vision person, and then the person who makes it happen. And that pairing is really [00:41:00] synergistic in most companies. It sounds very similar to what you might be saying.

Alison: It sounds like I need to read that book.

Dr. Sharp: It’s a cool book. Yeah. I’ll recommend it. We’ll put it in the show notes for anybody who wants to check it out.

Alison: So in terms of answering your question about what I do, I focus on starting new things, expansion projects. I also do a lot with the finances, which is not my favorite thing to do, but I feel like that is something as the owner that should remain on my plate. So I still sign all the cheques and all that kind of stuff.

Dr. Sharp: Yeah, certainly. So some really granular questions with this whole COO concept. Who are these people? Are they within your practice or are they outside your practice? And if they came from outside your practice, are they mental health practitioners or are they, business people? What education and training do these people have?

Alison: Yeah, so my COO is a licensed clinical social worker. So she actually is going to have a small caseload of clients in the beginning. That’s actually what helped me to be able to bring her [00:42:00] on was because it wasn’t going to be a totally non-revenue producing position. She was still going to be producing some revenue that would go towards her salary.

And then she had had experience working in an agency and managing multiple programs. So she was doing a lot of the stuff that she’s doing now: managing staff and hiring and firing and marketing activities and things like that. So she definitely had a lot of those experiences already.

Dr. Sharp: I got you. And you mentioned the term salary was that literal?  Is she literally salary?

Alison: Yeah. So actually my therapists are all hourly. But she is the first salaried employee. Yes.

Dr. Sharp: I hear that. How did you arrive at a salary for her? And you can share as much or as little as you would like to about that.

Alison: So this is where I need to give major props to GreenOak accounting. So I started working with them about a year ago and I realized what was missing in my practice [00:43:00] was I needed somebody who had a CFO, like a chief financial officer type view who could look at my numbers and tell me what to do and how to make these financial decisions. So I said, I think I need to hire a COO can I afford to do that? And they actually ran all the numbers and figure it out. Obviously, it was collaborative like, well, what do you think people in your area get paid to do that and okay, this is how we can make this work. And so they figured that out all for me, it was amazing.

Dr. Sharp: That does sound amazing. Yes. I put them in the show notes as well. Yeah. It’s funny. I’ve just been emailing Julie over the last couple of weeks as well. 

Alison: Yeah, they have been so incredible, especially like I said, I started working with them right before the pandemic started and they helped me get the SBA loan and they were just amazing. And they have paid for themselves many times over.

Dr. Sharp: Love that. I think people are always looking for a good accountant and I know that it’s like accounting plus.

Alison: Yeah. It’s that CFO piece, which when you [00:44:00] start running, I realized at one point that this practice is going to make multiple hundreds of thousands of dollars in a year and I don’t know how to manage hundreds and thousands. I barely passed math in college.

Dr. Sharp: That’s amazing.

Alison: Yeah. Like this practice is going to… this past year we got close to grossing, a million dollars. I was like, I should not be managing this much money without somebody’s expert opinion.

Dr. Sharp: It’s such a good point. But it’s one of those I’m like boiling the frog situations, right. Where it slowly grows and grows and grows and then all of a sudden you’re like, Oh goodness. I think I’m in trouble here. So yeah, definitely happy to shout them out and put them in the show notes. I think that’s super helpful. And it’s one of those expenses that people are hesitant to take on but super helpful.

Alison: And I think that’s mindset around making those strategic investments in your business in order to get to the next level because, without the people that I’ve [00:45:00] hired and even not only my staff but also these other vendors that have helped me build my business, it would not be anywhere near where it is today because I only have so much knowledge. I’m not a CPA. I’m not a social media expert. So we have to make these investments in order to get to the next level.

Dr. Sharp: Yes. Absolutely. Well, Alison, this has been an amazing discussion. I feel like we have covered so much and hopefully given people a lot to think about in terms of systems and processes and how to put some of those things in place, or even take them to the next level.

So as we start to close one, are there any topics here in this area that we didn’t touch on that you definitely want to mention before we wrap up, and two how do people get in touch with you if they want to?

Alison: Yeah. That’s a good question. I’m trying to think if there’s anything I didn’t cover. I feel like it’s such a big topic that it’s hard to know if you touched on all the [00:46:00] facets, but it’s interesting because we were just talking in the virtual assistant company about making a service for people where they can get some help with their processes and their systems. What we find is that people reach out for a VA, but a lot of times they’re so disorganized or they have no systems and no processes that they can’t even bring on a VA because they don’t have anything in place to teach them.

Dr. Sharp: Right. I see that a lot, actually.

Alison: Yeah. That’s actually something we were just in the process of putting together as like figuring out, how do we teach this to therapists or practice owners? Because there is no one size fits all. But there definitely are ways to help people figure out how to make it make sense for themselves and the way they have their practice set up. So I guess I should just mention that as well, that’s in the infancy stage at this point, but if that’s something you’re interested in that is going to be a service that we’re going to [00:47:00] offer through the virtual assistant company.

So the URL for that is moveforwardvirtualassistance.com. If people want to get ahold of me the best way is to contact me through Practice of the Practice where I do business consulting. So it’s alison@practicesofthepractice.com. If you want to check out my counseling practice website, the URL for that is moveforward.lancaster.com. If you want to see what we have going on there. I think those are probably the best ways of getting hold of me.

Dr. Sharp: That sounds great. Awesome. This is good. I love when I walk away from podcast interviews, thinking about things for myself that I could do, or put in place in our practice. And this is definitely one of those times. So I’m glad that we were able to connect. This was really inspiring. Thank you.

Alison: Thank you so much.

Dr. Sharp: Thanks for listening everybody. I hope that that was useful for you. I loved it. I love talking about this stuff after we hung up the recording, so to speak. Didn’t really hang it up [00:48:00] exactly but I think, you know what I mean. We talked for at least 10 or 15 more minutes just about systems and processes and our practices and how we’re working on refining those things. So I love the stuff. Alison clearly has a lot of knowledge around this topic. And there are tons of links in the show notes, both for her practices her Move Forward Virtual Assistant company, and a bunch of other things that we referenced. So check those out. If you’re interested.

And like I said, at the beginning, if you’re a beginner practice owner and you would like some group coaching and support and accountability to help you launch your practice, you can check out the Testing Psychologist Beginner Practice Mastermind Group. It starts on March 11th. So we’re getting really close. And as of the recording, we have two spots left. So if you’re on the fence, doesn’t hurt to jump on a pre-group call and see if it would be a good fit. And you can sign up for that call and get more information at the [00:49:00] testing.psychologists.com/beginner.

Thanks as always for listening, y’all. I will be back next week with more clinical and business episodes. Take care in the meantime.

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 [00:50:00] 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.

The BRIEF-2 ADHD form uses BRIEF-2 scores to predict the likelihood of ADHD. It is available on PARiConnect-PAR’s online assessment platform. Learn more at parinc.com.

Hey, welcome back, everybody. Hope you are all doing well. We have hit March I think when this airs, which means that springtime is right around the corner. I am ready. It feels like it’s been a long winter here in Colorado. Lots of snow. It’s been really cold. I feel like we’ve had snow on our back here for months. So I’m looking forward to getting back to springtime and some warm weather. That is it for my weather update for this episode, but I hope you’re all doing well. I’m looking forward to some better weather and hopefully, a light at the end of the COVID tunnel.

All right. So today’s episode is a replay of one of the best episodes of 2018. One of the most downloaded episodes of 2018. And this is my interview with Dr. Maggie Sibley.

Maggie is a clinical psychologist and researcher at the University of Washington and Seattle Children’s Hospital. She also has an adjunct appointment at Florida International University. She studies executive functioning, motivation, and attention problems in adolescents and young adults. She has authored two books: Parenting Therapy for Executive Functioning Deficits and ADHD Building Skills and Motivation.

As you can tell from our interview, Maggie is a true expert in the area of ADHD assessment and treatment. And like I said, this was one of the most downloaded episodes from two years ago. So I am glad to bring it back to you. As a matter of fact, I was preparing for a presentation on adult ADHD and came back and listened to this episode again, and just found so many little nuggets in here. So, if you didn’t catch it the first time, hope you enjoy it. If you did catch it the first time, hope you take away some additional information this time around.

Before I jump to the episode, it is that time again to start recruiting for the next cohort of the Advanced Practice Mastermind. I know y’all are like, “Jeremy, oh my gosh, didn’t we just hear about the Beginner Practice Mastermind?” You did. That group is starting in a couple of days. We are all full. That was fantastic. But now it’s time for another cohort of the advanced practice mastermind. So, if you are an advanced practitioner and you’re looking to take your practice to the next level, our next cohort will be starting on June the 10th I believe. So, you can go to thetestingpsychologist.com/advanced, learn a little bit more and schedule a free-group call if you’re interested. I already have at least one member signed up for that cohort. So my thought is these spots are going to fill up fast. So if that sounds interesting, give me a shout.

All right, let’s jump to my interview with Dr. Maggie Sibley.

Hey, y’all welcome back to another episode of the Testing Psychologist Podcast. I’m Dr. Jeremy Sharp. I hope you all are doing well this morning or this afternoon, or this evening, whenever you might be listening. We have a fantastic guest with us today. One of the cool things about doing this podcast is like I’ve talked about before connecting with folks in our community and in this world, and then getting introduced to other pretty amazing folks. And this is one of those cases.

Maggie Sibley, we got an introduction through Dr. Joel Nigg who was on the podcast a few months ago. And I feel really fortunate to have her on the podcast today to talk about all kinds of things that I think are going to be super interesting for us.

Maggie, welcome to the podcast.

Dr. Sibley: Thanks for having me, Jeremy.

Dr. Sharp: Yeah. I’ve been looking forward to this one. Ever since Joe mentioned your name and we started to connect, I’ve really been looking forward to talking with you. So yeah, very grateful for the time and energy that you’ve got for us today.

So like usual, I’ll start off. I would love to hear a little bit about what you are doing day-to-day. I know in the intro, people heard that you do a lot of academic work and you’re an Associate Professor and you got a lot going on. So, can you tell us what you’re up to these days and how you got there?

Dr. Sibley: Sure. I am a person who specializes in treating and diagnosing ADHD in adolescents in young adulthood. My primary work is probably about 75% research in applied settings and maybe about 25% treating and supervising and participating in the assessment of actual people who are coming in to find out if they have ADHD or not, usually for the first time as a person who’s either a teenager or an adult. I work with schools. I work with community mental health agencies, private practices, and hospitals to help them often refine the way that they are working with teenagers and adults with ADHD. So, I do a lot of different things and I’m involved with working with a lot of different people in the common thread of this area of expertise that I have.

Dr. Sharp: Sure. Yeah, it sounds like you have your hands in a few different arenas, which is really cool. It keeps it interesting I would imagine. So, are you doing some consulting as well? Is that part of the picture with the schools and other agencies?

Dr. Sibley: A lot of what I do is working on grant-funded projects where folks bring me in to train their camp. Some of the projects that I have are actually federal grants that are designed to evaluate better ways of working with kids in those types of systems. So, we’re actually doing some research on how to implement effective programs and effective procedures for working with people with ADHD.

Dr. Sharp: That’s fantastic. I would love to get into that here as we go along. Could you maybe just talk a little bit about how you got here? That could be education training, all that stuff but I’m also just curious about why ADHD, why this arena for you?

Dr. Sibley: I love teenagers and young adults in that transition. I was always first and foremost, interested in studying mental health in that age group and understanding how mental health changes as people are aging. And I think I stumbled upon ADHD because some of my early mentors in graduate school were doing work in that area. And it turned out that a lot of the kids that I was interested in working with clinical, kids who are having trouble figuring out what they wanted to do in life, being motivated, people who were trying really hard in school and had a lot of potentials but weren’t quite living up to that potential, it turns out a lot of them met the criteria for ADHD.

So although I’ve never been super attached to the specific category, I found myself doing the kind of work I wanted to do with the population who is having the kind of difficulties I wanted to help by staying close to that diagnosis. So, I do work with kids who sometimes don’t meet the criteria for ADHD who are still struggling and still need the same help as well.

I’m really interested in taking family-based approaches. I think there’s so much value in supporting a child who’s struggling with families who do some of the right things. And on the other side of that coin, kids can really get held back and hurt by families that don’t know how to do some of the right things. So, that’s something that’s been really important to me.

Also, a lot of my work takes an autonomy support approach where the idea is to help people be able to stand on their own two feet and know what they need to do in their lives to make themselves successful rather than relying on professional day-to-day that kind of coach them through it. That’s from a theoretical perspective. That’s been important to me as well. Some of those professional values have led me in the direction that I’m in right now.

Dr. Sharp: I got you. That’s interesting. I’ve never heard that term. What did you say, autonomy support? I would love to get into that as well. So we’re good. Our agenda is filling up quickly here. That’s good.

So, tell me just a little bit before we totally dive in. What has your research looked like over the years in terms of major topics or focuses?

Dr. Sibley: Great question. I think the two areas that I’ve done a lot of work in are: what should the criteria for ADHD be in people who are over age 12? That’s one area. And then what steps the practitioners need to take to figure out who really has ADHD and who doesn’t in that age range. That’s one set of work I’ve done.

And then another set of work is related to, what are the ways that we can help this age group that doesn’t necessarily have an interest in coming to therapy or getting help for their own difficulties, but we still know they need a lot of help. What’s a way that we can find things that are engaging for them that they actually want to participate in that could be effective and help them. And how do we wrap those opportunities for help into the communities and the systems that these kids are already interacting in? So, those are some of the major topics that I’ve been doing work in.

Dr. Sharp: Okay. Both super crucial. So, what should ADHD look like in kids over 12? And how is that different from what we currently conceptualize it as?

Dr. Sibley: It’s a great question. A lot of people who are listening are going to be already familiar with what the DSM-V says are the main symptoms of ADHD. And there’s a list with two sections. Each section has nine symptoms on it. The first set is the inattentive symptoms. And the second set is the hyperactive-impulsive symptoms.

So, the history of those symptoms really dates back pretty far to observations that were made in the 1950s and 1960s with children who were being treated clinically for what we now call ADHD. And these were children who were in elementary school. So, those symptoms were derived by seeing what were the most common troubling behaviors that these elementary school children were displaying. And then the thought back then was if we could put them on a list, people who displayed a lot of those behaviors must have ADHD.

What has happened over the years since that list was first formulated is a growing recognition that ADHD exists in people who are not elementary school children. And there’s been a lot of excellent research that started to paint the picture of what people in adolescence and adulthood look like when they have ADHD. And at the same time, it’s really challenging for the people in charge of that list on the DSM committee to make revisions wholeheartedly when the science is still coming out and it’s not that we have a perfect list to replace our childhood list with yet.

So then you’ll see this evolution is slowly carving out more and more of what we’re sure of. If you look at the DSM-V list of symptoms that came out in 2013, there actually are new texts that have been added. The symptoms are the same, but now you’ll see parentheses after them that say what the disorder should look like in older individuals. And that’s a good step in the right direction.

And so if folks haven’t checked out that list, a lot of people didn’t realize that the symptoms had actually morphed a little bit. That’s a good place to start. But one of the things that we’re still struggling with as a field is that even though we’ve figured out the adult version of those childhood symptoms, there may actually be adult symptoms that children don’t even experience. And so, those symptoms aren’t even captured on the list yet. And we’re still trying to figure out how to grapple with that problem.

So you’ll see that there are still core features of inattention and hyperactivity-impulsivity in people who have ADHD that are over 12. But you’ll also see that the manifestation of those same difficulties has changed.

One of the key things you’ll see is that motor overactivity, that hyperactivity, that running around is dissipating pretty steadily from around the teenage years through adulthood. So, you won’t be likely to see people seeming physically hyperactive who have ADHD when they’re older. That group of symptoms really morphs into something that looks a little bit more like difficulties with self-control generally.

So, this could be decision-making, this could be verbal impulsivity, it could be difficulties with trying to get yourself motivated to do things because you have a hard time regulating your own behavior. And those are some of the things that people who are older with ADHD might struggle with on the impulsivity side.

On the inattention side, you’re still going to see those classic difficulties with executive functioning that you see, difficulties with organization and time management, with memory, with being able to do complex tasks and keep yourself focused. But of course, the demands of life are going to be asking us to do different tasks when we’re older. So you might see the symptoms come out in different ways. So, whether it be trouble with your driving record because you’re having trouble focusing or difficulty remembering to pay bills or being able to meet deadlines at work, or develop reciprocal interpersonal relationships that are both friendships and romantic relationships, those are some of the problem areas for individuals with ADHD when they get older.

Dr. Sharp: I got you. Yeah. And I think that these are all things that anecdotally we have seen and really struggled to reconcile with the diagnostic criteria when you’re trying to follow up a manual, which is challenging. S,  how do you take all of that and integrate it with an assessment when you’re trying to diagnose ADHD, let’s say, and the presentation is different than what shows up in the DSM?

Dr. Sibley: Yeah. So that’s a good question. Some of the work that my colleagues and I have done shows that even though we know that the DSM list isn’t perfect right now, it’s still the best thing we’ve got unfortunately because a lot of times people have come up with these lists of alternative symptoms, things you seem to see over and over again in adults with ADHD, things like  I have a really hard time getting myself to work on something if I’m not enjoying it.

And the trouble with those symptoms is even though a lot of older people, adolescents, adults with ADHD will say yes to those symptoms, a lot of people who don’t have ADHD will also say yes to those symptoms. So even though it might make you describe people with ADHD better than we were with just the DSM symptoms, then you get yourself into this really difficult gray area of having more mistaken diagnosis because you might accidentally start diagnosing people who don’t have ADHD.

So the criteria for ADHD have five parts. The A criteria, which is this list we’re talking about, is just the first part. So really the recommendations now are to follow those criteria for now because that’s what the field is recommending and that’s our manual but to be open-minded about the manifestations of those symptoms. Also, there’s a lot we can get into here about through A criteria, which we also have to follow, which are going to help us make good diagnoses.

The B criteria is making sure that people are impaired and that they’re not just mildly showing those symptoms. Those symptoms are actually causing problems in their life. We’re looking at criteria where we have to make sure that the symptoms are in more than one setting. We have to make sure that this is a chronic pattern in the person’s life and not just something that jumped up in their life during a really stressful time. We have to make sure that we can’t explain the symptoms from some other source. So we really have to be detectives in making sure that if people are meeting criteria on the list, that they also have this profile that would essentially help them meet criteria for a mental health disorder, generally that they’re severe enough.

Dr. Sharp: Yeah, that’s such a good point. I’m glad that you touched on that. I think with a lot of diagnoses, we do get wrapped up in the “A” criteria and just look at symptoms and then forget to scroll down the list and make sure that those other pieces are in place.

Dr. Sibley: Yeah, and there’s been a number of studies now. It’s not just one study or my work that has shown that the majority of people who have enough symptoms do not meet the criteria for ADHD because of the other B-E criteria. So that’s an important thing for people to know that you can’t just stop at the A criteria. You have to keep going.

Dr. Sharp: Yeah. I’m going to ask you to say that again, just to emphasize it a little bit.

Dr. Sibley: The majority of people who have enough symptoms on the A criteria checklist to meet criteria for ADHD do not actually meet the criteria for the full disorder once you take into account the other criteria, the impairment criteria, the fact that you need to have the symptoms in more than one setting, the fact that you need to show a stable pattern of the symptoms over time. And also one of the biggest things is ruling out other reasons why someone might be having potentially cognitive difficulties at a certain point in their life. And there’s a lot of other reasons that somebody could have trouble focusing, with their memory, trouble staying organized or getting motivated, than just ADHD.

Dr. Sharp: Absolutely. This might be getting too nuanced, but is there any one in particular of that B-E criteria that tends to “disqualify people”? Is it the chronic nature or the multiple settings, or is that too specific?

Dr. Sibley: I think the biggest chunk of them are eliminated from consideration once you consider the impairment criterion.

Dr. Sharp: Okay. I’m glad that you said that. That’s a nice coincidence because I took some notes when you were going through this. I said, how do we define impairment in adults or even maybe adolescents? So can we start maybe with adults? How would you tell if they are impaired?

Dr. Sibley: This is a really good question and one that I think doesn’t have a very clear answer. However, there are some things that I think we can all agree on. First of all, ADHD is supposed to be affecting about 5% of the population. So, that means that the person in front of you should be more impaired than 95% of the people that are part of that person’s peer group, right?

Dr. Sharp: Yeah.

Dr. Sibley: So think about that. That’s one thing.

A big thing that plays into impairment is what kind of environment you’re in. You could put the same 11th grader in really basic classes and give them no extracurricular activities, and they would probably get pretty good grades and not have a lot of problems. But if you took that same child and put them in very advanced classes and gave them a sport to play after school and put them as a president of a club and gave them a bunch of chores to do at home, that same child might not be meeting the expectations that are placed upon them. And therefore, people might be saying they’re having trouble with impairment in their daily life. So we really have to consider the environment the person is in as part of the picture as well.

And then the third piece of this is clear examples of impairment are not being able to get the best grades that you can considering your intelligence level. It might be not being able to keep relationships with people because of behaviors that you’re doing that are making it hard for people to interact with you. It might be not being able to keep steady jobs. So, we’re talking about things that are really impacting somebody’s ability to live a healthy productive life.

One thing that isn’t impairment is distress. Distress is something different. Sometimes people are distressed because they are living in a world where there’s a lot of expectations placed upon them for them to be excellent at a lot of things. And we’re not all excellent at all things. So sometimes when people feel like their cognitive resources aren’t allowing them to do something they want to do, a person can become distressed and they could seek answers for that or seek help for that. And it becomes the clinician’s job to decide whether a person who’s looking for an ADHD diagnosis and complaining about their ability to perform in their life is really a truly impaired person or just a person who’s dissatisfied with their own performance.

Dr. Sharp: That’s such a good point. And it makes me think about almost the philosophical question of, is our culture, for lack of a better word, sort of generating more ADHD like cases where people feel overwhelmed, in demand, not enough time, more homework, you could throw any number of things in there. And I don’t know if there’s a question wrapped in there necessarily or not, but just observation may be that you may have run across in your research as to how our culture, in general, is contributing to all of this.

Dr. Sibley: Yeah. You’re not the first person to raise that question. There’s an important cultural piece of ADHD that always has to be looked at when you’re making a diagnosis. What are the norms that the person is following? What kind of environment are they in? What are the expectations placed upon them? And some of that has to do with the community that they live in. It could have to do with their parent’s socioeconomic status. It has to do with the country they live in and what’s considered to be acceptable behavior in the country or in society more broadly.

So all of this is part of a diagnosis. It is really trying to understand the context in which a person is operating and trying to stick to some of our agreed-upon principles within that and about how severe they have to be, what would that person look like if they weren’t in this setting? Those all should be things that should be considered.

Dr. Sharp: Sure. I want to ask you some more about how all of this might translate to the actual assessment process, but before I go that direction, can you comment at all? I feel like there’s a lot, and admittedly I’m not an expert in this area by any means, but a lot out there in terms of lack of ADHD in other countries outside of the US and other cultures. Can you speak to that at all?

Dr. Sibley: If you look at studies that are population-based that are simply trying to understand if there are people in various countries that show the symptoms of ADHD or meet the criteria for ADHD, and these aren’t people who are in a clinic seeking a diagnosis, just people in the general population, you tend to see the same percentage of people who are showing those difficulties across nations.

So, the actual incidents are assumed to be equivalent across people of various different cultures. However, that doesn’t mean that the same number of people are being diagnosed in every country. So, a separate question is in which countries are more people coming to clinical attention? And it could be a good or a bad thing because you want the people who need help to be being identified and being linked to care, and on the other hand, you also have some countries where people might be concerned that too many people are coming to attention just because of the way the symptoms are being interpreted by people or the diagnostic standards which might be different in different countries as well.

Dr. Sharp: Yeah, that totally makes sense. So that’s an interesting piece of information just for me that the symptoms are there, it’s maybe just the diagnostic part and who’s presenting that changes. Just curious. So yeah, maybe jumping back a little bit, you started to open that door of the cultural component. And I use that word so broadly and probably inappropriately, but just everything in the world or in someone’s universe could contribute to these symptoms. How do you start to translate that to the assessment and figuring out what is “environmentally driven” versus true ADHD?

Dr. Sibley: Well, my approach I think to a good ADHD assessment especially in somebody who might be an adult is, first of all, you need to get information from multiple sources. So you have to step out of the person you’re assessing personal lenses and you need to get more information from people who knew them as a child. Usually, the parents are the gold standard second person to ask if they’re available. People who know the person currently and observe them in hopefully multiple settings, and anything objective that you can obtain to be able to verify especially looking back in childhood and people recalling, yeah, maybe the teachers said there were concerns back then.

Sometimes parents keep their kids’ report cards and there are actually notes on there from the teacher about how the kid is doing and there can be clues in there. So you’re really trying to create a timeline of this person’s functioning with respect to what we consider almost like a trait of ADHD over time. Because that’s how we view it as a chronic difficulty.

You’re asking multiple people, you’re trying to get objective information, and then you’re really trying to be a detective and try to understand, are there things that happened that correlate with when symptoms seem to get worse or when symptoms seem to get better or when they weren’t there at all or when they first became recognizable.

There’s a lot of people out there who struggle with ADHD symptoms but they have other things that have made those symptoms not cause problems for them. So they could be really smart. And they’re able to use their wit to get themselves out of situations or finish their homework real quickly before they get in trouble for it. There are also people who’ve been in really excellent settings that have given them what they needed to be successful in spite of their symptoms.

So when you look back and you can say, this is why this person didn’t come to attention until they were 17, 18, 19 years old, and you feel good about that narrative, that’s going to be a time where you feel more comfortable giving a diagnosis. If you’re just scratching your head about where this is coming from, then you’re going to need to ask more questions. There’s a number of alternative explanations you could also consider why the person is coming to you now with these concerns.

Dr. Sharp: Yeah, are there any right off the top of your head that you’ve found tend to masquerade as ADHD that we should really be considering?

Dr. Sibley: Just two categories. For one there are certain societal benefits to having an ADHD diagnosis. People listening I’m sure are very familiar with these especially at this age group that I’m talking about. So for one, you could get stimulant medication. Some people who want to enhance their cognitive performance, who want to go from being a person of normal cognition into a person of supernormal cognition might be interested in that medication.

Alternatively, some people who are living a lifestyle where they’re not sleeping much and they’re using a lot of substances and their goals are not to not rooted in academic or professional ambitions but rather may be more recreational or social goals have been known to use stimulant medication to make up for or regulate the downsides of that type of lifestyle as well. So there are people who are out there potentially seeking a diagnosis to obtain the medications.

You could get extra time on your standardized testing if you have an ADHD diagnosis or other support in school. And psychologically, some people just want the diagnosis as a way to make themselves feel like there’s a reason that they’re not doing as well in life as they want to be.

So those rewards may lead some people to it. It doesn’t mean that they’re necessarily intentionally being misleading. They may actually see their situation as one in which they may feel like they have ADHD, but those could be some underlying motivators for people to tell their story in a certain way to clinicians. So that’s one thing you have to be on the lookout for.

Another is there’s a number of disorders that share features with ADHD. And so differential diagnosis is really critical, especially because it’s different when they’re children. When they’re children and you’re hyperactive or impulsive or inattentive, there are only so many things at that point that could potentially be causing it. So it’s a lot easier to narrow it down to ADHD.

When you get older, you’ve had the opportunity to develop comorbidities that may not be common until you become an adolescent like substance use disorders, depressive episodes, anxiety. In addition, you have a lot of people who could have had negative things happen to them in their life either physically like head trauma or it could be something that’s like a psychological trauma that psychological trauma has been shown to have cognitive aftereffects. So there are all these other things that could now explain why somebody is potentially meeting the criteria for these symptoms.

So without a full assessment of all these other possible hypotheses about where these symptoms would come from, you wouldn’t probably have enough information to make a good diagnosis.

Dr. Sharp: I got you. So is it a leap to say that you’re a fan of the more comprehensive assessment model? Like if someone walks in with a question of ADHD, is it almost like the standard of care to look at these other possibilities?

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Dr. Sibley: Yeah, I think at this point, at least with this age group it’s necessary to do a full diagnostic assessment. And I like to use instruments that are somewhat structured because it just makes sure you ask all the right questions. And so I think that’s important. But then also being able to really deal with ADHD, more than ever develop your own hypothesis and act like a detective and start crossing things off the list to really try to figure out because a lot of ADHD is subjective and gray areas. So you do have to just try to uncode the puzzle.

Dr. Sharp: Right. What structured instruments do you like?

Dr. Sibley: Well, I think CARRS is pretty good for people who are under 18. And there’s now evidence that I think that that instrument could be extended upward to young adults. And I think in adulthood something like the SCID is certainly good in terms of just making sure you remember to go through this full breadth of all of the DSM disorders. But also health history is really important for people with ADHD. Getting a timeline of any negative life events that people have experienced, family, trauma, all of that really can play into the reason a person is sitting in front of you today.

Dr. Sharp: Sure. I know that we had talked before we got the interview scheduled just about topics and such. And something that we talked about was the comorbidity with trauma, or differential diagnosis with trauma, and some other things that can look like ADHD.

Dr. Sibley: That’s an area that I think we’re still trying to figure out how to do our best. However, I think one key thing is a timeline. So if you can understand what was the difference between the times when the person seemed to be functioning okay in their life and the times when the person was having troubles and you can find differences.

A lot of times you may end up understanding that the drug use preceded the symptoms. Or you may understand that these symptoms have never truly been documented in the absence of a depressive episode. Or you may see that these symptoms really started after this person experienced this traumatic experience. And so I think the assessment question is, and I really think a timeline of mapping out everything really helps, is can you see patterns between the onset of symptoms or the escalation of symptoms and these other factors?

Dr. Sharp: Yeah, it’s a complicated picture sometimes. I mean, I think about and this may be a little young for who you typically work with or do the research on, but I see a lot of maybe 6,7,8-year-olds who have had traumatic experiences of varying degrees. But there’s also a question of ADHD in there. And it’s challenging for parents to separate those out and challenging for me to separate out even with a timeline because the kids are young enough where the symptoms were co-occurring as they developed if that makes any sense.

Dr. Sibley: Yeah. And that’s true. And sometimes I think you may never be able to know to what extent these symptoms are environmental versus genetic. And I guess that’s ultimately what we’re asking with that type of question. And at some point, the most important thing is that the person gets the best treatment that they can get.

So I think at some point, either diagnosis or both diagnoses are okay as long as qualitatively in the report you explain that confusion in that inability to fully understand exactly the chicken and egg question so that whoever’s reading can also share that information and make their own conclusions so to speak.

Dr. Sharp: Yeah. I see what you’re saying with that. It is hard. 

Dr. Sibley: Yeah. It’s not like there’s a version of inattention that looks different if it was PTSD versus ADHD. It doesn’t look different. It’s more of a matter of figuring out the patterns of things coming on and going away.

Dr. Sharp: Yeah. I like how you said that. That’s the question that I was trying to ask without actually asking it. So yeah, that’s what we run into a lot. It seems like there are some habit tale but it really seems like it’s not. You just got to have maybe a good history and a wait-and-see approach to see once the trauma is hopefully resolved, then you see what’s left.

Dr. Sibley: Yeah, the wait-and-see approach is good. I’m glad you brought that up because I think people should feel comfortable giving provisional diagnoses, especially with some of these questions we’re bringing up because if you come across somebody who’s experiencing some internalizing and externalizing difficulties at the same time, and you’re wondering whether it’s really ADHD or just a part of the psychological difficulties they’re having and you want to recommend or treat the depression or the anxiety first and see if the ADHD persists or not, sometimes you have to not just look at the snapshot but actually become involved in following the person a little bit longer to see what happens. And that might give you diagnostic clarity in the long run.

Dr. Sharp: I’m so glad to hear you say that. I’m a big fan of provisional diagnoses and I feel like professionally when I got to a place that I made peace with saying, I don’t know for sure right now, that made my evaluations so much easier and maybe helpful even too. I wasn’t trying to zero in and say, yes, this is definitively what’s going on, and here’s what you do about it.

Dr. Sibley: Yeah, people are complicated. It’s okay to not know yet. And I think the best thing we can do is write reports where we’re just really good at explaining all of that and letting people know what’s going on and why they don’t fit into a box right now. And also saying, here’s the information we need to start figuring out in order to get to a place where we can make a diagnosis so that everyone can be working together to gain clarity.

Dr. Sharp: That’s so true. So I know that when we were talking again, as we were trying to schedule, we were talking about mood disorders as well. And that’s how your name got brought up when I was talking to Joel a few months ago. I was asking him about these kids with what we think might be bipolar or a disruptive mood, or even just ODD, and some of the kids that seem to go maybe beyond typical ADHD. How do you separate those from just the impulsivity and trouble with self-regulation that comes with ADHD? So I wonder if that’s something that you’d be willing to talk about?

Dr. Sibley: Yeah, I think that’s a bigger question for the field too. I don’t think the field has figured out how to slice that pizza because they think there’s a lot of overlap in the systems involved in those different sets of difficulties. And so it becomes really hard for all of us who are struggling with figuring out how to provide a diagnosis to an individual like that. How to do that person the best justice.

I mean, yes, there is an emotion regulation component of ADHD that comes from the poor executive control and self-regulation that these kids have that’s going to the extent of regulating all aspects of themselves, including their behavior, their thoughts, and cognition, their motivation, their emotion. Then there are other kids who are having those emotional problems because a different part of their brain is acting up, but it may look the same to us, right? So they may have trouble with actually the level of emotion that they’re experiencing because of the way the neurotransmitters in their brain work.

So sometimes kids look the same clinically, but if we only had the magic ability to go inside with an MRI and figure out what was going on, we would see that there are different explanations for this. Because the science isn’t there yet, the best thing we can do is I think stick to the DSM and just make sure that we can defend the diagnosis we make because we feel like the kids actually meet the criteria for the symptoms. And sometimes you may end up giving multiple diagnoses just because ADHD alone doesn’t explain the full spectrum, but if you took away the ADHD diagnosis and only left them with a bipolar or mood disorder that wouldn’t explain it either. But those complex kids are different from people who only have one of the issues but you’re just trying to tell which one it is if that makes sense.

So those are different difficulties for diagnosis. I think people who are complex versus people who just have to figure out what’s the reason that they’re having attention problems.

Dr. Sharp: For sure. What do you think of ODD as a standalone diagnosis?

Dr. Sibley: I think it’s a valid standalone diagnosis, but you don’t see a lot of people with ODD who don’t also have ADHD. So, you should just always be on the lookout if they have ODD. Part of the feature of ODD that is related to ADHD is this verbal impulsivity- this talking back without thinking about the consequences of what you’re about to say. And there are so many family processes involved in the onset of ODD as well, and parenting is such a big part of that, that a lot of times ODD is conceptualized as ADHD with dysfunctional parenting. Not always though.

There are some people who maybe their personality, the traits that they have, the temperament that they have just make them a difficult person regardless of the environment they’re in. And those people are I think fewer and far between the ADHD variant of ODD but I do think they exist. 

Dr. Sharp: Sure. I’ve got ODD on the brain. I’m interviewing Ross Green later today. So that’s where I’m trying to think through these kids a little bit and see how we conceptualize them. I feel like I run into a lot of kids who do not quite reach the criteria for a disruptive mood because they behave pretty well at school and outside the home, but then home, they’re kind of blown up and losing it. There’s an anxiety component it seems like or a rigidity, maybe that executive functioning component, and then there’s often some ADHD kind stuff mixed in there. And I feel like I get those types of kids very often, and they don’t fit neatly into anything. I’m always struggling with how to conceptualize that.

Dr. Sibley: That group of kids I agree with is the most difficult one because they are not necessarily conduct-disordered, but they seem to have difficulty with their anger. They’re very anger disordered, but we don’t seem to have this anger disorder diagnosis because ODD isn’t purely that anger. I think everyone in the field knows that our diagnostic system just has to keep evolving with science. And I think a lot of times the science is behind all of our day-to-day observations. We’re seeing things and we’re like, this is clearly off from the criteria, but the people who write the criteria need to see the science that confirms these assumptions we’re all making before anything will change. So, it’s frustrating for us to feel like the system is behind our ideas for how we can classify people better sometimes.

Dr. Sharp: Sure. Well, if nothing else, this is validating that I’m not the only one that’s wrestling with this. We’re just trying to catch up and figure out what’s going on for these kids.

Yeah, I know marijuana is part of the picture too. We had touched on that. And that’s something you brought up as certainly something to consider when you’re looking at ADHD. Could we dive into that for a bit?

Dr. Sibley: Yeah. One thing that makes this complicated is that people with ADHD tend to use marijuana at higher rates than people without ADHD. So, if someone’s a heavy marijuana user, to begin with, it’s not a crazy hypothesis to think maybe they could have ADHD. And that could be one of the reasons that they happen to be using marijuana. A lot of people who have ADHD report that they’re using marijuana because it’s helping them in some way. We’re not sure whether it’s just making them feel better or they’re actually experiencing some true benefit from it on their symptoms of ADHD.

Dr. Sharp: Can I stop you for a second? How would you separate those two things?

Dr. Sibley: Well, if you smoke marijuana and it creates a reduction in your ADHD severity, that would be therapeutic. But if you smoke marijuana and you like the way it makes you feel, but it doesn’t actually reduce the severity of your ADHD symptoms, it would probably be recreational.

Dr. Sharp: Okay, I see. 

Dr. Sibley: For example, I think one of the pieces here that are under the biggest debate is the marijuana removing the mental restlessness that people are experiencing and therefore they feel calmer or is it actually improving their cognition in some way?

And I guess that’s a gray area. And of course, because there are laws about research on marijuana in this country, there isn’t enough research on marijuana to answer these questions yet because there are so many challenges to even doing that research. S, we don’t have any information on this question from science. But we do have information that people with ADHD are at a much higher risk of using marijuana regularly as adolescents and young adults.

However, there are cognitive effects of using marijuana that mimic ADHD symptoms, especially with respect to working memory and your ability to solve complex problems. You even see in some research that heavy marijuana use can impact IQ scores. It may be temporary, but how people do on those tests because their IQ does happen to those executive functions. So that’s another tricky one. If a person who’s smoking marijuana heavily is coming to you and saying they have ADHD, they might but it’s really hard to confirm that unless you understand what the person is like when they’re not smoking marijuana.

Dr. Sharp: Yeah. Again, I’m just thinking about how would you start to assess that?  I think a lot of us probably evaluate adolescents who have been smoking relatively regularly up to the point of testing and then what do you do with that?

Dr. Sibley: If you’re lucky, you can get good reports from other people about that so you are aware of when the person started smoking regularly. So you can isolate that in time and try to understand that retrospectively by getting the input of people who know them or potentially looking at differences in school grades et cetera.

If you can’t gather that information and you don’t have confidence in the information that you have, then without the person having a wash-out period which may be completely impractical to get the person to do, unfortunately, you may not be able to find out what’s going on with enough confidence to be making a good diagnosis. You may have to wait.

Dr. Sharp: Yeah. Do you have a recommended wash-out period before testing somebody who’s been smoking relatively regularly?

Dr. Sibley:  I don’t know if I feel comfortable saying that because I’m not sure that I could definitely verify that with science, but I think that you’ll probably look that up. Basically, you want to figure out what the research says about the cognitive effects of marijuana because there are acute ones, which means the short-term effects and how long those last. And when you can isolate that time period, then that’s what you’re looking to assess as a person after enough time that those effects would no longer be expected.

Dr. Sharp: I got you. I joked with Joe, not totally joking. We both live in states where marijuana is legal now and it’s getting to be more and more of a concern and how to approach it. I think it’ll be important to learn more about that as we go along.

Dr. Sibley: Yeah, I hope that there’ll be more opportunities to do good research on that now that some of the laws are changing because there’s a lack of research. A lot of people’s impressions are based on hearsay or things people are saying online and we have to be careful about the quality of the information that we’re taking in.

Dr. Sharp: Absolutely. Well, I feel like I would be remiss not to spend at least some time before we’re done on the treatment part. And that’s the other side of what you do it sounds like.

Dr. Sibley: Yeah.

Dr. Sharp: What happens then after the assessment? What are you finding in terms of helping these kids and young adults?

Dr. Sibley: Well, there’s a number of approaches to treating ADHD that have evidence and work. So, we’re lucky that we can give people options. As I’m sure everyone knows, stimulant medication has historically been the first-line approach for treating ADHD especially in people who are older and it is effective acutely.

One of the limitations to be aware of with stimulant medication is that it has a bigger impact on the actual cognitive ability that somebody is displaying than the impact of that ability on their daily life. I’ll give you an example to make that easier to understand. A person with ADHD who takes stimulant medication pills will be able to be less impulsive, calmer, and potentially focus better, but it doesn’t necessarily have an effect on their daily skills. So, their ability to keep themselves organized and their ability to have good relationships with people.

The reason for that is that it takes more than just having good cognition to be successful in those areas. And people with ADHD have a long history of struggling in those areas. So they may not develop some of the same skills that their peers did. For example, if you think about a person who didn’t pay attention for most of elementary school, even if they start paying attention through medication a little bit better in high school, they still missed out on a lot of potential academic growth that they could have had if they were treated earlier.

In addition to medication, it’s often recommended that a skills-based therapy approach is also applied. And there’s a number of options for that. There are CBT approaches that are out there for adults now. There are also organization skills training approaches or family-based behavior therapy approaches for adolescents.

Some of the work that I do is related to that approach. So, basically trying to teach parents age-appropriate behavioral strategies for older kids and young adults. Things like making a contract with them about expectations and consequences for not meeting those expectations. Teaching people time management strategies. Teaching people ways to overcome procrastination. All those skills have been shown to be helpful to people. So, those are the two main approaches right now to helping people with ADHD- medication and skills-based therapy.

Dr. Sharp: Sure. And where does your work fit into that? You mentioned autonomy support and…

Dr. Sibley: I developed a program for teenagers that’s called STAND- Supporting Teens Autonomy Daily. This approach uses motivational interviewing and works with the parent and the teen together to help them identify what their common goals are, to help them understand what their family values are and the things that are most important to them because being a person with ADHD and parenting a person with ADHD is just a life full of dilemmas.You’re always having two things you care about come into conflict with each other. On one hand you want your kid to do their best in school, and on the other hand, you feel that you have to help them for 4 hours a night to get them to do their best in school. And maybe that’s not allowing them to become independent.

So, which is more important to you, their grades or their independence? And there’s no right answer to that. People have to look into their priorities and figure out their own personalized plan for navigating the adolescent years. So we spend a lot of time on that and let people figure out what skills they’re going to need to be successful and teach those skills to people. That approach is where a lot of my work has been.

Dr. Sharp: Got you. How is the research looking on that approach? Have you been able to conduct any quality research?

Dr. Sibley: Yeah, so my work has been funded by the National Institute of Mental Health on this treatment program which is actually in a book so people can read about it if they want to do it. And this program has been compared to normal treatment in the community which means if people are already taking medication, keep taking it. If people are already getting tutoring or help at school, keep getting it. And we showed pretty big changes over a year for the kids who did this 10-week therapy program with their parents versus the kids who didn’t.

And the big areas we saw changes to, in addition to just the severity of their ADHD symptoms, was their organization skills, how they’re getting along with their family members. And one of my favorites is that parents were way less stressed after participating in this program as well. So having an impact on the parent as well as the kid.

So we’ve done 3-NH studies on this. I think at this point we’ve had over probably 400 kids participate in this program in the clinic I’ve been working in. It’s been really successful.

Dr. Sharp: That’s fantastic. I am just sort of recognizing that out of all the folks I’ve interviewed who have written books, this is maybe the longest into the interview that we’ve gone without mentioning the book. I don’t know if that’s good or bad or what? Thank you for being humble maybe and bad for me for not asking earlier.

Dr. Sibley: No, it’s totally okay. The people who are hungry for this information tend to find it anyway. And the other model that I’m doing right now that is really getting a lot of traction.  I’ve been working with the US Department of Education on this one- teaching 11th and 12th grade honors students how to deliver ADHD organization and motivational interventions to 9th graders who are coming into high school and really struggling with that transition. And that’s been awesome because from a public health perspective, if we can train people to give interventions that don’t cost the school district a lot of money, we’re going to be more likely to sustain them.

So these are kids who want to put this on the college resume that they participate in something like this. They want the community service hours that they need for graduation. They’re motivated to be interventionists and they don’t cost anything to the school district. So that’s been a really fun program to develop as well.

Dr. Sharp: Oh yeah. I’m sure that’s an easy sell for the school districts to have if you can get them on board. That’s really cool. And I should say too, we’ll have links to all the things that you’re mentioning in the show notes so that people can check out your book, your website, and so forth and any other resources we might talk about.

Dr. Sibley: Sounds good.

Dr. Sharp: Yeah, this is great. I did want to ask, with that stand approach that you’re talking about, is that something that could happen in a group format or is that more of a one-on-one family meeting with the parent and the kid or what?

Dr. Sibley: We’ve done both models and we’ve even done a study comparing two models to see if they are different. So you have a good question there. It turns out for most people who walk through the door, it’s equally effective and you see the types of gains I mentioned two minutes ago. However, the individual dyadic approach, and this was always about an 8 to 10 week once a week come in the outpatient type of thing. So people can do it in private practice.

The people who do not do as well in the group and need to be in this more individualized model tend to be parents who have ADHD themselves. They tend to benefit from that one-on-one support from a therapist. Parents who have depression also. And when there’s really high conflict between the parent and the teen. And that makes a lot of sense because in the group, what we’re relying on for the skills to take off in folks is other parents sharing what’s worked for them and being able to give advice to each other.

There’s a clinician who teaches the skills and then the parents process it together. But if parents are having trouble paying attention in those meetings or parents need someone to actually walk them through how they’re going to do those skills in a step-by-step way when they get home because they have trouble with the organization themselves, that one-on-one support is really helpful to them. And if the parents and teens are arguing a lot inside the group, then that’s tricky because they don’t get anything done. So we totally buy into this finding. It makes perfect sense with what we see in daily life.

Dr. Sharp: That totally makes sense. Well, that’s super cool. I mean, we’re always thinking of ways to provide access to the kids we evaluate after the evaluation and something like that would be fantastic.

My gosh, I feel like we’ve packed a lot into an hour. I’m very grateful that you were willing to sit down and talk through all of this and bear with some probably dumb questions at times. But before we wrap up, anything to add, any capstones for some of the topics we’ve talked about for anybody who might be out there listening?

Dr. Sibley: Well, I think one thing you said earlier, something that I like to emphasize to people is that it’s okay to not be sure with these really challenging diagnoses. And I find one in doubt, the best thing to do is just consult with other colleagues and probably solve things together because ADHD is really hard to diagnose in adolescents and young adults for all the reasons we talked about.

ADHD is also really hard to treat in that age group as well. Sometimes you don’t see that the things you’re doing are working, but I always tell people, keep doing them anyway, because we know they will pay off. But sometimes things that you do today aren’t going to pay off for 4 years. That shouldn’t stop you from continuing to do them and helping people who have ADHD slowly build a foundation of success that they can build on long-term.

Dr. Sharp: Got you. That sounds good. I appreciate that.

So I’m going to throw a curveball at you here before we wrap up like I do with everybody I interview regarding ADHD stuff. What are your thoughts/where are we at with research on neurofeedback as an intervention for ADHD?

Dr. Sibley: Well, you see a lot of different conclusions being drawn with reviews of the literature on that. Here’s what I tell people who are patients. There’s not as much evidence that neurofeedback works compared to medication and these therapies I’m talking about. And neurofeedback costs more money. So, if you want to try it and you don’t mind spending the money, go for it. But just be aware that it’s less likely to pay off than some of the other things and it is going to be a cost. So, I think people should draw their own conclusions because it’s tricky because the literature is giving us mixed messages on that.

Dr. Sharp: Sure. I feel like that’s right where I’m landing and that’s validating and just good to know. With you all that is steeped in the literature, I just want to make sure I’m not missing anything. And that’s pretty much verbatim what I’ll tell people as well.

Dr. Sibley: Yeah, because one week a review comes out and says that it doesn’t work at all, and the next week a review comes out and it says it’s the most effective thing we’ve ever done and get into the minutia of the science, but instead of doing that, just make sure people aren’t telling their patients to definitely go do it especially because it costs a lot. And if your patients are going to have a huge financial strain to do something that has a good chance of not working, that’s something I can’t bring myself to do. I want to make sure people are making informed choices.

Dr. Sharp: That’s fair. Well, thanks again for the time. This has been awesome. If people want to reach out and ask questions or learn more or get in touch with you, what’s the best way to do that?

Dr. Sibley: They can email me. My email is available online by just typing my name into Google. It’ll come up all over the place. So I love connecting with people who are both in practice and people who themselves have ADHD and families of people with ADHD because those are the people who keep my work grounded. So, don’t hesitate. I’ll definitely respond to you if you do reach out.

Dr. Sharp: Okay, that’s great. Thank you so much. Maggie, thanks for the time. This has been super informative and a good time. I feel like we covered a lot of ground. I know that people are going to take a lot away. So thanks. I’m really grateful for you and your time.

Dr. Sibley: Yeah, I’m really grateful that you brought me on because this has been a really great time to reflect upon some of these ideas. So, thank you.

Dr. Sharp: Yeah, absolutely. Well, I hope our paths cross again sometime soon. Take care in the meantime.

Dr. Sibley: Yeah, same to you.

Dr. Sharp: Okay everybody, thank you as always for checking out the podcast. If you haven’t subscribed yet, I would love to have you subscribe. It’s an easy way to get notified when all the podcasts are released. I have some awesome content coming up in the next few weeks. So make sure to do that if you haven’t already.

And like I said, in the beginning, if you are an advanced practice owner and you’d like to step back and do some reflection and some planning and visioning over the summer, the next cohort of the Advanced Practice Mastermind Group was going to start on June the 10th. You can get more information and just schedule a pre-group call. You can do that at thetestingpsychologists.com/advanced.

All right, take care. Talk to you next time.

The information contained in this podcast and on The Testing Psychologists 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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