Telehealth testing with children: Important factors to consider

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.

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).

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 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.

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.

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.

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.

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.