Let’s start with a case. Consider Damon, an eighth grader whose English teacher reported overhearing “nearly constant talk” about guns plus witnessing “several graphic drawings of dead, bullet-riddled bodies.” More alarming, after issuing Damon a discipline referral for roughhousing during class, his teacher, Ms. Sarum, found a drawing of a pistol left conspicuously on her desk. She assumed Damon placed it there, in part because the artwork matches a drawing style that she has seen him use. When she asked him about the drawing, Damon reportedly smiled, chuckled to himself, and walked away without actually responding to his teacher. Ms. Sarum recounted all of this to the building principal. The principal calls Emma Garcia (the building’s school psychologist) into her office and requests her “to take a look at Damon.” She happily agreed and set out to conduct her assessment.

Here is the problem. Emma is assessing to what end? The referral agent (the individual initiating a referral) is the principal. But what does her principal mean by “take a look?” When Emma reported back a few days later, the messiness of her predicament becomes all too apparent. Emma’s interview revealed that Damon denied leaving a drawing on his teacher’s desk. She found out that he is indeed angry and resentful toward Ms. Sarum, an attitude he blamed on her unfair treatment. When Emma shared her impressions, sympathetically but somewhat disappointedly, her principal said, “What did you expect he might say? I actually wanted your professional opinion about whether he has a mental disorder, is dangerous and whether he might be better off in our self-contained ED classroom. So….what do you think?”

What when wrong here and how can a repetition of this problem be avoided? Damon’s case illustrates a classic mismatch between a referral agent’s intentions and a diagnostician’s execution. Specifically, it appears that the principal’s referral questions were understood to be something like “how does this student perceive his teacher, and does he admit to placing an inappropriate drawing on her desk?” Logically then, Emma set out to answer these questions. After the fact, however, it seems obvious that the real referral questions (at least in the mind of the referral agent) were more like these:

1. Is this student a threat?
2. Is he experiencing a diagnosable mental disorder (e.g., a DSM-5 condition)?
3. Could he satisfy criteria for emotional disturbance and if he does, then would placement in our school’s self-contained classroom be indicated?

In retrospect, how to avoid this problem seems easy. What was needed is a mutually-agreed referral question(s) before the school psychologist acts. And it is the diagnostician’s (school psychologist’s) responsibility to assure such a question is formulated, understood by stakeholders, and written down for reference in the event of future confusion or disagreement. Don’t count on referral agents to understand that assessments need to start with a crystallized question. To be clear, it is you (the school psychologist) who must query, discuss, clarify, and ultimately corroborate with a referral agent the scope of what you do. This requires patience, capacity and inclination for collaboration, listening and re-framing skills, and attention to detail. Illustration 3.1 provides a hypothetical replay of the school psychologist-principal interaction in the botched case of Damon.

Advantages of Clear Referral Questions

You may have sensed that several advantages come along for the ride when referral questions are correctly formulated. These may be apparent in the second principal interview (Illustration 3.1.) A few of these benefits are presented below.

First, formulating a referral question(s) is much like creating a contract. That is, it constitutes an agreement about what you (acting as a diagnostician) will and will not do. In fact, linking referral questions with answers to those questions is a key aspect of effective assessment practice (Wiener & Costaris, 2012). This remains true whether you answer referral questions in a written or an oral format, as seen in Chapter 13. Consider again the case of Damon. The Emma Garcia’s exchange with her principal in that case creates clear boundaries regarding her mission. During this exchange, Emma confirmed that she will answer three questions for her principal, the case’s referral agent. Favorably, these are made quite explicit. Ms. Garcia would not be expected to address anything beyond these three questions. Additionally, she need not guess halfway through the assessment process about what to do. Recall the principal’s inexact request to “take a look at” in the first depiction of Damon’s case. It’s anybody’s guess about what “take a look at” means. Tolerating vagueness like this is no way to establish an agreement.

Second, a properly devised referral question adds focus (Dombrowski, 2020). In the case of Damon, for example, the concern is not about gathering information as a prelude to treatment. Consequently, nuanced questions about perceptions, family and interpersonal dynamics, transient life stresses, motivations for change and aspirations for the future may not fit this referral question. These types of idiographic concerns may be crucial when consulted by a colleague about a counseling case, the kind of referrals that school psychologists seem to receive sometimes, although not often (Choi, Whitney, Korcusha & Proctor, 2008). In Damon’s case, however, concern with these types of nuances, internal feelings and one-of-a-kind life stresses may prove secondary. Review of the types of social-emotional evaluations completed in school can be informative (Table 3.1). Different roles and different assessment lenses follow logically from different questions. As you can see, the three questions in this case, more or less, call for a nomothetic lens. They concern whether Damon fits into one or more categories that have already been studied at the group level. Critically, one of the principal’s referral questions provokes concerns about the topic is special education eligibility or Section 504 designations (so called entitlements). This topic, as it pertains to referral questions, is revisited later in this chapter.

Third, clarity about the referral question often assists in time management. Once Emma understood what was expected regarding Damon, she could anticipate how much time to set aside. Equally important in this case, the question about danger to others (clarified during the alternative interview) would be considered high priority; threat assessments warrant quick execution. Questions about placement and about special education eligibility, however, would probably be judged to be lower priority (but note that administrative/legal timelines exist regarding special education evaluations). Supported by this degree of clarity, Emma might juggle her schedule to perform an immediate threat assessment (plus she would need to allocate time for involvement of other team members; see Chapter 9 for more information on threat assessments).

Fourth, a sound referral sometimes helps kick off the problem-solving process because it often hints at explanatory hypotheses. In the case of Damon, for example, questions about impulse control on the one hand and peculiar (perhaps obsessive) ideation on the other hand seem like credible working hypotheses. Thinking back to the case of Angela (Chapter 1), the referral questions itself determined that one hypothesis concerned social skills deficits. In fact, the assessment process with Angela is all about social skills problems because the teacher (and parents) handed the hypothesis to the school psychologist whole cloth. What prompted a referral can begin to guide diagnostic formulation, but also to misguide.  For example, in one research study the mere mention of a problematic behavior (rather than an academic concern) prompted over-identification of ED cases (false positives) among school psychologists (Ward, Ward & Clark, 1991). Taming irrationality, such as by use of the HR Worksheet (as you learned in Chapter 2) can help. As you learned Chapter 1—the assessment process should never remain identical from case to case. Even a few cases reveal that the assessment process is, or ought to be, dynamic, unfolding, and reliant upon the critical thinking of the school psychologist who is orchestrating it.

Diverse Questions, Diverse Approaches

You already know that social-emotional evaluations are not uniform, nor are the questions that prompt them. Table 3.1 lists just some of the potential referral questions that might exist in schools. Interestingly, these may never be said aloud; they may not even be fully grasp by the person launching them. Questions 1 through 4 seem like they might fit in a clinic as well as (perhaps better than) in a school. They have nothing to do with special education nor with gatekeeping. Each of these particular questions prompts the school psychologist to think psychologically and to select task-congruent assessment tools. When determining why a student might be distressed or suffering a deteriorating attitude, clinical interviews and open-minded review of school records would seem to be especially important. Rating scales may be of little value. Questions 1 – 4 are probably largely idiographic, calling for a tailored explanation (not a classification) in each instance.

In contrast, Questions 5 and 6 concern (non-special education) classification. Accordingly, they are well suited to standardized behavior rating scales (e.g., BASC-3; Conners CBRS) or variants of them that concern screening (BESS-3). Question 5 is also a good match for interviews that address diagnoses. Both of these questions prompt the school psychologist toward a nomothetic approach (and to consider clinical, not administrative, categories). Like Questions 1-4, however, techniques like the HR Worksheet, can help prompt use of the Reflective System.

Question 7 represents an important set of concerns because it involves safety (of the school community as a whole or of an individual student [in the case of potential suicide]). Emma Garcia detected that there was an implicit question about Damon harming others, and she was wise to make the question about this entirely explicit. Emma (probably working with a team) would use interviewing, and potentially self-report rating scales, to determine if Damon represented dangerousness to others. There are fixed techniques to address this concern that may keep the building-level school psychologist involved or alternatively prompt a referral onward for a more specialized assessment. The same is true for suicide risk. Chapter 9 (Student Interviewing) will provide you more information.

Questions 8 (concerning progress) and 9 (immediate environmental causes of behavior) can not be answered by routine social-emotional tools. Regarding Question 8, there are tailored techniques to permit school psychologists to objectively track student progress, such as might be needed to evaluate an IEP. Chapter 14 reveals how to do this. Question 9 is especially important. It concerns applied behavior analysis to first conceptualize and then to correct a student’s problem behavior. This often involves a procedure entitled Functional Behavior Analysis (FBA). FBAs, however, are beyond the scope of this book. And, as argued in Chapter 1, FBAs are not typically required to answer the other referral questions listed in Table 3.1. Many school psychology training programs devote an entire course to applied behavior analysis and FBA. For others, several books might be helpful (e.g., Matson, 2012; Steege, Pratt, Wickerd, Guare & Watson, 2019).

Special Education-Related Referral Questions Can Prove Tricky

Having a specific referral question in hand may not help much if you are simply a special education gatekeeper. Some perspective may assist in our understanding. Since the 1970s, a host of federal laws have impacted school-based practice (e.g., the watershed PL 94-142, The Education of All Handicapped Children Act, 1975). These laws obliged school districts to identify and protect the rights of all students with disabilities (the “Child Find” requirement of the updated 94-142, now called the Individuals with Disabilities Education Act, IDEA). The special education identification duty was often delegated to school psychologists and their team members, those who worked as gatekeepers. To better manage their legal duties, many schools set up structured processes for triaging cases and ultimately deciding which students received special education eligibility evaluations. All this meant that by the 1980s school-based assessment practices (such as regarding referral questions) grew apart from those in clinics. In schools, the identity and authority of the referral agent was sometimes quite murky (Was a teacher the “referral agent?” Was it an entire team, not any one individual?). More troubling, the formulation of a referral question often grew sloppy and imprecise. For example, someone (perhaps the school psychologist) might simply select the disability category most representative of the case data and create a facsimile referral question. Thus, for an aloof first grader the following might appear, “Oliver was referred to the special education evaluation team for an assessment of possible autism.” A referral for a belligerent 8th grader might have the following appear in a written report under the heading Reason for Referral:  “Nathan was referred to the special education evaluation team for an assessment of possible emotional disturbance.” But—and this is the key point–schools are obligated to examine students in all areas of suspected disability, not just those selected at the time the assessment process starts. This seems to imply that uniquely when special education gatekeeping is involved that referral questions cannot be restricted to just one category; they must address all IDEA categories. The U.S. Supreme Court case of Forest Grove v. T.A. seems to exemplify what can go wrong when all conditions are not considered in a quasi-legal, special education evaluation (see Illustration 3.2).

Illustration 3.2 United States Supreme Court Case: Forest Grove School District v. T.A.

On its surface, this case might not seem consequential. In 2009, the U.S. Supreme Court held that IDEA requires reimbursement of private schools’ special education tuition costs if a public school fails to identify (and never serves) a student who is later found to have a disability. That is, a school district must pay even if the student in question never even had an IEP in his district before moving to a private school setting.

The details of this case, however, prove quite interesting. The parent-school district dispute spanned nine years and involved legal fees in the hundreds of thousands of dollars. It included a due process hearing and lower court decisions, before being heard by the United State Supreme Court. It is fascinating to read the words of Supreme Court Justices voicing fine points about a student’s IEP.

The student, T.A., was evaluated by a school psychologist who seemingly ignored background information suggestive of attention problems, instead addressing just potential SLD. It appears the school said no to special education because they detected no SLD. Critically, there seemed to be no consideration of either ED or ADHD. When T.A.’s problems intensified, his parents opted for a private setting and sought reimbursement for out-of-district costs.

The Court held that the school district ignored its obligation to consider all areas of special education eligibility (i.e., failed to fulfill the mandatory “Child Find” requirement). This implies that one-category-only referral questions (e.g., “Is this SLD?”) are probably unacceptable in light of the Child Find requirement. It also appears that T.A.’s school district neglected to considered ADHD, which might have opened the door to OHI services. Scholars debate the importance of this case to school psychology practice. Some (Dixon et al., 2011; Wright et al., 2013) argue that there are profound implications, which perhaps compel school psychologists to routinely perform detailed evaluations that include neurocognitive elements. Others (e.g., Zirkel, 2013) suggest more modest practice implications. Either way, there may be logical limits on acceptable referral questions anytime special education eligibility is one question. Details are available at the following link http://caselaw.findlaw.com/us-supreme-court/557/230.html

 

The above discussion suggests that school psychologists involved in special education decisions may be stuck with practices that don’t work well for clinical-style questions. In other words, for many Questions 1-9, school psychologists should seek an exact referral question, just like their clinic-based counterparts. But for Questions 10-13, they might actually need to do the opposite. For special education concerns, they may be left, sadly, with a referral question like, “Nathan was referred to the special education evaluation team for an assessment to establish the presence of any disability condition, with emotional disturbance initially considered most likely.”

Gatekeeping errors seem even more probable when there are academic problems and SLD is the presumptive categorical match. Consider the following referral question: “Chase, who is a poor reader, was referred to determine if he has a specific learning disability.” School-based evaluations confined to just SLD are widespread, as anyone who has read more than a few school psychologists’ reports can readily attest. But, thinking logically, why should a school psychologist assume that Chase’s problem is either a specific learning disability or that he has no disability at all (basically why assume a question with a binary answer)? After all, Child Find mandates consideration of all disability categories. In contrast, why not start with speculation open to the notion that reading problems can also arise from emotional problems (i.e., including the special education ED category)? Maybe Chase reads so poorly because chronic depression has precluded him from actively engaging in the reading process. A sad, irritable, easily discouraged boy with a pessimistic outlook might never invest in learning to read. Or what about intellectual disability, not SLD, as a plausible root of poor reading (see Wodrich & Schmitt, 2006, regarding this very question)? For school psychologists this line of thinking suggests that they ought to, minimally, consider and (and rule out if necessary) SLD, intellectual disability, ED, and other health impairment (many OHI students qualify because they have ADHD) for students like Chase.

SLD identification is more fraught with unique potential problems. Poor reading, for example, often sets in motion an evaluation process related to one or more of the following SLD determination methods: (1.) response to intervention (RTI) in which diagnosticians might study nuanced graphs of DIBELS® scores to determine reading progress, (2.) ability-achievement discrepancy in which extensive IQ testing such as Wechsler Intelligence Scale for Children-5th Edition and achievement tests like the Kaufman Test of Educational Achievement-3rd Edition might be conducted, (3.) patterns of strength and weakness, in which cognitive/information processing profiles such as come from the Woodcock-Johnson Tests of Cognitive Abilities-4th Edition and Woodcock-Johnson Tests of Achievement-4th Edition may be scrutinized. As the highlighted text in Table 3.2 illustrates, however, this can sometimes prove incorrect. Ruling in SLD logically means ruling out ED (see the SLD definition in Table 3.2). But as you learned in Chapter 1, logic is the province of the Reflective System of thinking. School psychologists who fail to slow down and study the criteria of a disability category or trust their intuition to guide their decisions are apt to commit errors. ED and SLD cases are best managed by slowing down and attending to exact criteria found in a checklist.

These are a lot of details to digest. The bottom line, however, seems to be the following: the diversity of referral questions possible in schools, in tandem with the legal realities associated with special education evaluations, can make school psychology practice daunting. At times, a school psychologist must operate with clinical labels, at other times administrative ones. Depending on the nature of a referral question, either nomothetic or idiographic perspectives might be needed. Likewise, sometimes a dimensional conceptualization, such as considering a student’s relative strengths or weaknesses, is required, but at other times categorical judgments are requisite. Depending on a referral question, interviewing, observing, and testing might be demanded. Thoughtful, flexible school psychology assessment is not simple.

Several Referral Questions Best Avoided

As suggested by Damon’s case (and Emma’s interview of her principal), a mutually agreed upon referral question is analogous to a handshake agreement or an informal contract. But just like in real-world, two-party agreements, some offers are better declined. Seasoned school psychologists often sense which referral questions to avoid as they come to understand the edges of their professional boundaries. But the unfortunate truth is that their lessons were often learned the hard way, via unpleasant experience. In contrast, beginning school psychologists seem more easily entrapped by accepting questions that are outside of their scope of practice. Perhaps this is because early in one’s career there is an understandable desire to convey confidence and to tackle whatever tasks arise, sometimes blindly. In reality, however, knowing the boundaries of one’s competencies and scope of one’s duties–together with thinking circumspectly—can prevent a lot of heartache. Happily, always starting with an unambiguous referral question, plus making sure all parties acknowledge it, helps you steer clear of trouble. This is so because the more explicit the referral question, the easier it is to spot brewing difficulty. Table 3.3 lists referral questions often best rejected. A brief discussion follows.

Let’s take, for example, a referral question about the prospect of abuse. A school psychologist sees a six-year-old first-grader, Noah, for a learning disabilities assessment. He notices bruise marks on the student’s arms coupled with a guarded, on-edge approach reminiscent of a nervous pet that has been mistreated by its master. The subjective sense that the student seems unreasonably apprehensive together with the obvious bruises prompts the school psychologist to speculate with his child study team colleagues about the prospect of physical abuse. Two team members acknowledge his thinking and suggest that he go forward with questioning about mistreatment in general plus inquiries about the origin of the bruises in particular. Without ever being voiced, implicit referral questions now exist (“Has Noah been abused, what is the nature of the abuse, and does he need to be protected?”) Accepting these referral questions, however, would be a mistake. All United States territories and states have reporting laws regarding abuse (United States Department of Health and Human Services, 2016). There are fixed mechanisms in place to handle such concerns. Included are experts cognizant of research showing that it is easy to elicit tainted or false testimony by clumsy interviewing, such as using repeated and suggestive prompts (Andrews & Lamb, 2014). Similarly, expert teams are prepared and capable to document fact-finding interviews for later forensic (legal) use. This is true for both physical and sexual abuse. For example, simply adopting one standard interview protocol versus another can result in significantly higher rates of sexual abuse allegations (e.g., see Hershkowitz, Lamb & Katz, 2014). Critically, however, these specialized interview techniques are almost universally unknown to school psychologists. More important, the responsibility for conducting them is not part of school psychology practice. Simply follow abuse reporting rules.

A second example involves a six-year-old kindergartener, Alicia Clark, referred for evaluation of suspected autism (or in DSM-5 terms, autism spectrum disorder [ASD]). Her pediatrician suggested this diagnostic possibility despite a history of success at a private preschool without need for special services or even supports. Once Alicia started public school, however, her parents and her pediatrician requested an evaluation to answer a question about special education eligibility. Alicia’s school psychologist, Helena Parker, set out to collect health and developmental data from Alicia’s mother, Yvette Clark. At a personal level, Yvette was pleased when she discovered a host of similarities that she shared with the school psychologist. Both Yvette and Helena were the same age, both hailed from the same New England state, both were enthusiastic distance runners. It was clear that Yvette felt kinship with Helena from their very first meeting. Feelings of connectedness only intensified during two follow-up conversations. Eventually, Yvette confided details of an unpleasant divorce and subsequent shared custody with her ex-husband, an individual she characterized as unstable and disinterested in parenting their only child, Alicia. As a case in point, Yvette told Helena that her ex-spouse allowed their daughter unlimited access to cable television and a video tablet during her regular weekend visits with him. Worse, Alicia reportedly took two or three days to settle after each visit. Yvette said her daughter often slept poorly and engaged in elevated rates of hand-flapping after visiting her father’s home. Helena was supportive and sympathetic as she listened to these anecdotes about Alicia’s post-visit behavior.

Eventually, Yvette mentioned to Helena hope that Alicia’s upcoming evaluation might include a detailed interview concerning the girl’s perceptions of her current family circumstances, with special attention to her comfort with and attachment to each of her parents. On the same theme, Yvette shared with Helena comments from her attorney who mentioned the chance of modifying Alicia’s visitation schedule with her father if there were supporting documentation from a professional that described him as a marginal caregiver. In light of these facts, Yvette expressed the hope that Helena would share any findings or opinions about parenting that might be “in the best interest of Alicia.”

This case, of course, exemplifies several inter-related and quite unacceptable referral questions. Furthermore, the potential problems are not lessened because the questions are vague or barely stated. One implied question (subtly introduced by Yvette) pertains to a request to have her ex-spouse’s parenting capability assessed as part of a special education evaluation. Another veiled request, also introduced by Yvette, pertains to custody and visitation vis-à-vis her ex-spouse. Once again, making referral questions explicit can help highlight impending trouble. For example, if Helena had voiced aloud and reflected on Yvette’s comments, then she might have sensed that things were amiss. Rather than the standard method during which the child study team drives the referral process and helps formulate questions about autism and special education, Yvette had come to act as if she were the referral agent. Although it is true that IDEA’s “Child Find” provision empowers parents to request evaluations regarding special education, it is false that parents are authorized to request assessments of extra-school concerns (i.e., custody, visitation, etc.). Helena would be advised to stand firm by stating that she cannot address intra-family dynamics, parental capability, and a student’s custody preferences. Talking over these things politely, but assertively, could probably help Helena quash Yvette’s over-reaching requests.

It’s easy to see that school psychologists can be nudged into tasks that are neither part of their job nor necessarily fair. Comments on teachers’ characteristics or their teaching capability certain exemplify this. This is sometimes asked by an administrator. So too, would be the characterization of a classmate of a student undergoing assessment. It may be, for example, tempting to describe the personality of a bully who has been victimizing a student that you are evaluating. Don’t do it.