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Telehealth testing with children: Important factors to consider

Psychologists will need to make some adjustments to testing children during the
public health emergency.
By Gabrielle G. Banks, PhD, and Colleen Butcher, PhD Date created: April 17,
2020

The goal of psychological testing with children is to ensure that a child receives
services, supports and accommodations to help them maximize success in all
areas of functioning. During the public health emergency caused by the
coronavirus, psychologists have to consider whether and how testing can help
to achieve this goal.
Many children will not attend school in person for many months. Some students
may be receiving supports provided for in an Individualized Education Program
via telehealth, though many are not. Similarly, outpatient therapy supports may
or may not be available under the current Centers for Disease Control and
Prevention (CDC) guidelines.
As a result, when presented with a child who needs testing, psychologists
should weigh the benefits of completing testing via telehealth versus waiting
until in-person testing is available.
Here are the issues to consider when providing telehealth assessment to
children and adolescents during the pandemic.
What are the “best-fitting” cases?
Appropriate screening is required to determine the best-fitting cases for
telehealth assessment. In some cases, psychologists are encouraged to
postpone the assessment until testing can be administered traditionally. It may
benefit the child and family to wait until a more definitive diagnosis can be made
in person, but for some children, waiting to provide in-person testing can cost
them months of access to crucial supports.
When determining the best-fitting cases for telehealth testing, consider:
 Whether the tests indicated for use based on the referral concern can be
administered in a telehealth format without violating standards for validity and
ethical practice.
 Individual factors that significantly challenge engagement and accurate
assessment of ability (such as cognitive and developmental differences in
youth) that are mitigated with in-person test administration.
 Environmental factors such as the family’s ability to create and maintain an
optimal testing environment in their home (such as access to a web-camera and
access to a secure, high-speed internet connection).
Is the child prepared for testing?
Providers should take additional steps to guide parents in establishing the best
possible conditions for testing. Before the testing date, the psychologist should
inform parents that children should follow their typical school/learning day
morning routine on the day of testing.
For example, the child should wake up at least an hour before the testing, eat
breakfast and take prescribed medications. Parents can help create an
environment with as few distractions as possible — such as by removing toys,
books, unnecessary screens, electronic devices, games and pets — and
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providing a clear desk or table space. Parents can notify all members of the
household that the child will require privacy and a quiet environment during
testing.
Should the parent be present during teletesting?
Psychologists will want to weigh the benefits and limitations of having parents
present when trying to conduct assessments via telehealth.
Parents are usually asked to leave the room during in-person testing, for a
variety of reasons, including trying to follow the protocol used in standardization,
reducing potential performance anxiety in children, maintaining test security and
other factors. Providers should carefully consider if and how parents should be
asked to leave the space in their own homes, and how that may affect test
administration and interpretation.
In contrast, when testing younger children in a clinical setting, parents typically
remain in the room. This can help children remain more comfortable in the
presence of a stranger and help with managing challenging behaviors.
When testing in our usual workspaces, psychologists can often maintain some
sense of control in the room, even when parents are present. For example, they
can offer guidance about when a parent should or should not intervene or
where a parent should sit during the assessment.
This may be more challenging when parents are present in the room in their
own homes. Providers are encouraged to discuss the parent’s presence in the
room as part of their broader discussion of establishing the best possible
conditions for testing.
How has the family been affected by the pandemic?
In all testing circumstances, providers consider biopsychosocial factors affecting
test performance including fatigue, hunger, life experiences, anxiety and mood.
Conducting assessments in the context of a pandemic with physical distancing
and isolation requirements can present notable challenges to the child’s
presentation.
As such, the parent and child interview questions about psychosocial well-being
deserve heightened focus. Providers should ask about the child and family’s
experiences of stress or agitation related to COVID-19 as this information is
integral to the child’s presentation.
For example, solely participating in shelter-in-place as a preventative measure,
self-quarantining due to illness or enduring the recent loss of a loved one to
COVID-19 can differentially influence their presentation.
Information regarding changes in the child’s sleep schedule and appetite as well
as increases in worry or deterioration in mood should be noted. Providers
should also note any changes in motivation for academic achievement given
that the child is not currently in school.
How does testing data align with other behavioral observations?
There are significant limitations in interpretation of data in conducting
assessments via telehealth at this time. Testing is not being conducted in
standardized administrations by which the measures are normed, and many
children and families are experiencing extreme stress and disruption of typical
routines. So results should be interpreted with great caution.
It will be more important now to contextualize any information obtained during
testing by considering how this information aligns with information provided by
caregivers and educators, a review of records, and behavioral observations.
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Similarly, psychologists must be extremely mindful in how we document our

evaluation process and ultimate conclusions. Providers should recognize the
limitations faced in trying to conduct testing via telehealth, while fully detailing
our use of clinical judgment in determining potential diagnoses.
In many cases, we may have to offer provisional diagnoses and gather
additional information when in-person testing becomes available again.
Nonetheless, when a psychologist can be reasonably certain of a diagnosis, it is
still appropriate to provide it for the child and family.
Another consideration is how other entities (schools, insurance companies, etc.)
will accept diagnoses made by assessment conducted via telehealth. For this
reason, psychologists will need to document findings as clearly as possible, but
advise children and families that additional testing may be necessary in the
future.
It is assumed that all psychologists will adhere to respective federal and state
rules and regulations, the American Psychological Association’s Ethical
Guidelines, and the Standards for Educational and Psychological Testing. This
guidance does not imply that these professional services will be reimbursed.
Psychologists should check with payers to confirm billing, coding and
reimbursement policies.