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Article

The Development of Ecologically Integrated and Culturally Informed ADHD and SLD Diagnostic Tools for Doctoral Assessment Training

by
Anna Cecilia McWhirter
1,*,† and
Karrie P. Walters
2,†
1
Prevention Science Institute, University of Oregon, 1600 Millrace Dr. Ste. 106, Eugene, OR 97403, USA
2
College of Education, University of Oregon, 377 HEDCO Education Building, Eugene, OR 97403, USA
*
Author to whom correspondence should be addressed.
†
These authors contributed equally to this work.
Disabilities 2024, 4(3), 583-615; https://doi.org/10.3390/disabilities4030037
Submission received: 24 July 2024 / Accepted: 9 August 2024 / Published: 20 August 2024
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Abstract

:
Psychological assessment is an integral aspect of training in graduate school. Developing ecologically integrated and culturally sensitive diagnostic tools to support case conceptualization and differential diagnosis is critical to improving assessment practices. Nevertheless, there is a dearth of research on diagnostic training practices, particularly when integrating the cultural context into an assessment. The current study addressed this gap by evaluating four novel diagnostic tools used to guide doctoral externs (n = 11), including case conceptualization and differential diagnostic tables, an attention-deficit/hyperactivity disorder (ADHD) matrix, and a specific learning disorder (SLD) in reading matrix. These tools were designed to integrate a range of clinical data from an ecological context. The current study (1) evaluated extern perspectives on the use and benefit of the diagnostic tools in their training and (2) discussed tool adaptation based on extern feedback. Data were analyzed via frequencies of extern responses to items. The results demonstrated high extern acceptability of the diagnostic tools and that the tools supported their ability to integrate the clients’ ecological context into the diagnostic process. Adaptations of the tools in response to extern feedback are discussed. These tools can support culturally and ecologically sensitive assessment practices.

1. Introduction

Diagnostic assessment has been a critical aspect of psychology doctoral training over the last few decades [1,2,3,4]. Yet, there is a dearth of research on training practices in assessment, with challenges in monitoring and understanding training methods due to differences in how training is tracked and evaluated [2,3]. Further, a focus on the cultural context in the diagnosis of mental health problems has been lacking [5,6]. Developing ecologically integrated and culturally sensitive tools to support case conceptualization (CC) and differential diagnosis (DD) in graduate training and the assessment of children, youth, and adults is critical to improving graduate trainee understanding, accuracy, and methodology in diagnosis.

1.1. Challenges in ADHD and SLD Diagnosis across the Lifespan

Learning disorders are quite common in the United States (U.S.), and about 15% of students in public schools received some form of special education services in 2022 [7]. Attention-deficit/hyperactivity disorder (ADHD) and specific learning disorders (SLDs) are highly common [8], accounting for many of these services, and the diagnoses are often comorbid [9]. Variability in symptom presentation [10], challenges in operationalizing diagnostic features, inconsistent assessment practices [8], and varying definitions of learning disability diagnoses all pose challenges to the accurate assessment of ADHD and SLDs [4,11,12]. These disorders continue and change across an individual’s development, which can differentially affect their long-term outcomes [13], and consistency in what constitutes evidence-based assessment practices has been lacking [14]. These challenges highlight the importance of developing and refining ecologically sensitive assessment tools geared toward doctoral student assessment training.
ADHD involves persistent difficulty with inattention and/or hyperactivity/impulsivity that interferes with an individual’s functioning and overall development [8,15]. It is estimated that anywhere from 2.7–17.8% of school-aged children and 4.4% of adults have ADHD within the U.S. [8,15,16,17]. Nationally, approximately one in nine children have ever received an ADHD diagnosis (11.4%), and among children currently diagnosed, 58.1% had moderate-to-severe ADHD, 77.9% had at least one co-occurring disorder, 53.6% were receiving medication, and 44.4% received behavioral treatment for ADHD in the past year [18]. Globally, the rate of adult ADHD is 6.76%, accounting for 366 million adults worldwide [19]. Differing estimates of ADHD prevalence over time or based on geographic location, however, are primarily due to differing methodological approaches in the research. Therefore, it is difficult to determine the true prevalence of the diagnosis [20]. Further, a primary characteristic of ADHD is its variability in presentation. An individual with ADHD can present with many symptoms in one context but with few symptoms in another, due to their interest level or the individual’s ability to compensate for attention challenges or restlessness [10]. Considering this variability, ADHD typically requires a multi-method approach to diagnose and treat and often requires parent and teacher reporting of challenging and cooperative behaviors [15].
SLD encompasses difficulties in one or more basic phonological processes affecting the ability to understand or use spoken language, which impacts the reading, writing, and math abilities required for learning [6,7,21]. Of the 15% of students who received special education services within the U.S., 32% of those students ages 3–21 were served under the Individuals with Disabilities Education Act (IDEA [21]) under the category of SLD in 2022 (5% of students overall) [7], and reading disability (e.g., dyslexia) is the most common, accounting for about 80% of all SLDs [22,23]. Despite the high prevalence, SLD assessment is challenging due to confusion and misinformation about the diagnosis [22], the absence of consensus on its definition, the lack of a “gold standard” for assessment and identification, and the relationship of SLDs to other academic, behavioral, and attention difficulties [9,24]. Historical challenges related to U.S. Department of Education positions on legal definitions and diagnostic approaches, ethical concerns around the most appropriate term for the disorder, the evolving definition of SLDs over time, and the lack of universal acceptance of a definition across professions have perpetuated these challenges for decades [14,25,26].

1.2. Contextual and Cultural Considerations in Disability Assessment

The assessment of ADHD and SLD requires the identification of both individual (e.g., age, sex) and contextual (e.g., environmental, cultural) factors that contribute to the client’s presentation. Environmental factors, such as lack of sleep [27], a chaotic home environment [28,29], parenting behaviors [29,30], or lack of resources, can contribute to difficulties in attention and executive functioning. Among low-income children, reading problems can be related to multiple factors, such as under-stimulation at home, inconsistent school attendance, and lack of appropriate instruction [31,32]. It is essential to identify these contextual characteristics, as they have implications for the clients’ diagnosis. For example, there is a strong relationship between ADHD and SLD in reading, as inattention in children is predictive of reading problems and not responding to effective reading interventions [31].
Further, it is crucial to recognize limitations and biases in diagnostic assessment. For example, boys are diagnosed with disabilities at higher rates than girls, and girls tend to be under-identified for ADHD due to a lack of awareness of how the disability presents in girls [7,33,34]. In women and girls with ADHD, inattentiveness is more prominent than hyperactivity/impulsivity, and therefore, the presentation of ADHD is often considered “subthreshold”. Comorbidities, such as anxiety and depression, can often lead to missed or misdiagnosis [35,36]. Further, women and girls may develop better coping strategies to mask symptoms compared to their male counterparts [35,36]. Growing research has additionally demonstrated that some racial and ethnic minority youth are more likely to receive a disruptive behavior diagnosis (e.g., conduct disorder) than a diagnosis of ADHD compared to non-Hispanic white youth [37,38]. This is further evidenced by disability under-identification of minoritized youth throughout the U.S. [39]. These biases may lead to judging or interpreting behaviors that are common across oppositional defiant disorder, conduct disorder, and ADHD differently based on racial or ethnic background, placing vulnerable populations at greater risk [38,40]. Therefore, when engaging in assessment practices, it is critical to develop a strong understanding of the client’s individual characteristics and culture, and awareness of personal bias in assessment to provide a comprehensive assessment and accurate diagnosis.
Integrating and considering all individual and contextual factors in training graduate students in the psychological assessment of ADHD and SLD is critical to understanding the role of presenting symptoms, the client referral question and context, and providing appropriate recommendations and resources to clients. While there is a clear connection between diagnosis, bias, and cultural context, the literature addressing the integration of these considerations into training and assessment procedures among doctoral students is scarce.

1.3. Ecological Models in Diagnostic Assessment Training

The study of graduate psychological assessment training practices in the U.S. is infrequent [41,42], and the coverage of multicultural issues in assessment training in the U.S. is lacking [42]. As such, there is a dearth of resources and research about tools to enhance ecological and culturally responsive differential diagnosis [5] and case conceptualization. Systemic contextual factors, such as those represented in Bronfenbrenner’s Ecological Model [43], have only recently been integrated into psychological assessment training tools. The DSM-5 Cultural Formulation Interview can support a clinician’s ability to gather culturally relevant information during the clinical interview [44]. However, it does not support a graduate trainee’s ability to apply and integrate the content into their case conceptualization. Further, most of the current models focus on the integration of ecological factors in the context of intervention case conceptualization, as opposed to diagnostic case conceptualization. Three such models include the Developmental/Ecological/Problem-Solving Model [45], Hays ADDRESSING Framework [46], and Bronfenbrenner’s Ecological Model [43].
The Developmental/Ecological/Problem-Solving Model [45] has been used in select school psychology internship settings and attends to development (i.e., assessment of intern’s current skills and needs across domains), ecological considerations (e.g., schools exist within community systems and family systems affect students), and problem-solving (i.e., core professional activity for school psychologists rooted in data-based decision making, applying to individual and contextual factors to find a solution, and progress monitoring [45]). While this model focuses on the ecological and systemic factors relevant to school psychology and has been used as a model to guide the supervisory relationship and student training [45], it has not been utilized for training in psychological diagnostic assessment.
The Hays ADDRESSING framework was developed to support therapists’ ability to work with diverse clients, considering multiple aspects of identity and context, and has been used to investigate the assessment of treatment and outcomes in a psychology training clinic [46,47]. The Hays ADDRESSING framework considers age and generational influences, developmental or other disabilities, religion and spirituality, ethnic and racial identity, socioeconomic status, sexual orientation, indigenous heritage, national origin, and gender in conceptualizing an individual [46]. This framework has been applied to clinical practice domains, such as assessment, diagnosis, and therapy [48]. However, research on its use within diagnostic assessment training (e.g., to support case conceptualization) among doctoral students is limited.
The Bronfenbrenner [49,50] Ecological Model depicts human development within multiple interconnected systems, including the microsystem, mesosystem, exosystem, macrosystem, and chronosystem [51]. The microsystem is centered on the individual and their personal characteristics (e.g., gender, socioeconomic status, and culture), and includes immediate settings (e.g., work, school, family, friends, and neighbors). The mesosystem involves the interaction between the microsystem and two or more additional systems. The exosystem includes local governments, parents’ friends, extended family, media, and other things that, while not always directly involving an individual, can still have an impact on that individual. The macrosystem is even broader and includes social norms, economic systems, political systems, and culture. Finally, the chronosystem includes time, in recognition of an individual’s place in the current time period as environments change over time [51]. This ecological model has been applied to various areas of psychological practice, such as psychology trainee development [52], adult therapy [53], mental health research in schools [54], community research [55], among parents and teachers in schools working with children with disabilities [56], and children with reading problems [57]. However, there is a dearth of research focusing on the integration of the ecological model in psychological assessment training practices. Considering the lack of integration of ecological and multicultural frameworks in graduate psychological assessment training and the complexity of diagnostic assessment for ADHD and SLD, the current study sought to address this gap by testing a set of diagnostic tools that integrates the bioecological model in assessment training among doctoral students.

1.4. Graduate Trainee Perspectives on Assessment Training

The lack of research on assessment training practices in graduate school is evident. Further, in the work that does exist, there is limited research investigating these practices from the perspective of graduate-student trainees [58,59]. In this limited work, researchers have found that graduate-student perspectives on the training environment can affect their learning experience in graduate school [60] and that trainee perspectives on their supervisory relationships are highly important for effective training [61]. Prior work has additionally demonstrated that graduate trainees reported a lack of focus on cultural competency in supervision and practicum settings and a need for stronger multicultural training [61]. Therefore, eliciting trainee perspectives and experiences in the assessment process, particularly when focused on supporting the trainee’s ability to understand and integrate the clients’ ecological and cultural context, is critical to the initial development of assessment tools aimed at enhancing trainee case conceptualization and differential diagnosis skills.

1.5. Current Study

The diagnostic process is complicated, and there is a need for tools that can support a graduate trainee’s ability to carefully conceptualize and engage in effective differential diagnosis considerations within an ecological framework. In response to this challenge, the second author developed a series of diagnostic support tools focused on enhancing doctoral psychology trainees’ ability to effectively integrate and organize a range of data to support their case conceptualization and differential diagnostic processes, with a specific focus on ADHD and SLD in reading. The goal of these tools was to engage trainees to think ecologically (e.g., clients’ culture and context) and interactively about client symptoms (rather than checking off a symptom checklist), and to provide a structured mechanism in which trainees could learn how to effectively develop and integrate clients’ contextual factors into their case conceptualization and differential diagnoses. The aims of the current study were to (1) describe the initial diagnostic tools; (2) elicit doctoral trainee feedback on the use and benefit of these tools in their training and implementation with clients in a diagnostic setting and assess whether trainees perceived these tools to improve their ability to integrate clients’ ecological and contextual factors; and (3) demonstrate the revised version of these clinical tools based on trainee feedback to facilitate improved skills in case conceptualization and differential diagnosis considerations among doctoral trainees. Our future work will include additional revisions based on feedback from faculty and staff involved in graduate assessment training to assess trainee diagnostic accuracy when using these tools.

2. Materials and Methods

2.1. Participants and Procedures

Participants included advanced doctoral student trainees in clinical, counseling, and school psychology (n = 11) who were training at an ADHD and SLD diagnostic community clinic in a Pacific Northwestern state. The trainees had all completed coursework in cognitive testing. Some had completed coursework in achievement testing, and all had passed the competency requirements for assessment administration. The trainees provided written consent to complete a questionnaire about their use of diagnostic tools and have their responses used for research. Demographics such as age, gender, and race/ethnicity were not obtained due to the small sample size, as well as to protect the anonymity of the trainee responses. All study procedures were approved by the IRB. The trainees were trained in clinical assessment procedures and were evaluated for competency to administer the cognitive, achievement, and behavioral measures required for differential diagnosis as part of the trainee practicum requirements. Trainees worked in a clinic serving children (age 7 and older), youth, and adults across the lifespan. Diagnostic procedures included an intake, client self-report, and/or parent report measures (e.g., the Behavior Assessment System for Children, 3rd Ed (BASC-3; [62])), cognitive and achievement testing (e.g., Wechsler Intelligence Scale for Children, 5th Ed (WISC-V; [63]) or Wechsler Adult Intelligence Scale, 4th Ed (WAIS-IV; [64]) and the Wechsler Individual Achievement Test, 4th Ed (WIAT-4; [65])), a clinical interview, and a feedback session to provide the client with a diagnosis, recommendations, and resources. The trainees attended regular group and individual supervision to promote an understanding of the assessment and the diagnostic criteria.
Over the course of 18 months, the trainees piloted four tools: (1) a case conceptualization table with integrated ecological framework, (2) a differential diagnosis table, and diagnostic matrices for (3) ADHD and (4) SLD in reading (see Figure 1, Figure 2 and Figure 3). These tables and matrices were utilized throughout the entire diagnostic process, and information was integrated after each step of testing procedures. The trainees then completed an online Qualtrics survey containing quantitative (n = 28) questions about the benefits and areas for improvement regarding the use of the diagnostic matrices, as well as some supplemental qualitative (n = 11) items to provide additional context for the quantitative data. Responses were collected in the spring of 2021 and 2022 (see Table 1). Finally, the tables and matrices were revised based on trainee feedback to enhance their utility for graduate training.

2.2. Analytic Plan

The survey included quantitative and qualitative questions about each given area, as described below. Data were analyzed using SPSS version 28.0 [66] via investigation of frequencies of trainee responses to items. Qualitative items were included to allow trainees to give additional context to their qualitative responses.

2.3. Measures

2.3.1. Supervision Needs

Trainees rated how much supervision and skills building they needed at the beginning of the assessment practicum across 9 areas, including building rapport, structuring a clinical interview, administering cognitive and achievement testing, data interpretation, knowledge of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) [67,68] diagnostic criteria, developing an integrated and ecologically based case conceptualization, differential diagnosis using a range of data, report writing, and giving feedback. Trainees rank ordered areas in which they needed the most supervision on a 9-point Likert-type scale (9 items, 1 = needed the most supervision to 9 = needed the least supervision).

2.3.2. Case-Conceptualization (CC) Table with Ecological Framework

The CC table (Figure 1) was completed by trainees throughout the assessment process. The table included areas for trainees to provide information about the referral question, salient background and cultural information, developmental considerations, strengths/challenges using Bronfenbrenner’s Ecological Model [49,50], data from the self-reports, the clinical interview, testing, current hypotheses and evidence for specific diagnoses, and any symptoms not accounted for by the hypothesized diagnosis(es). Trainees responded to 5 items related to the benefits of the CC table that included the ecological framework in supporting them with a variety of areas (e.g., “How beneficial has the above case conceptualization/ecological table been in helping you consider and integrate macrosystemic factors into your case conceptualization?”). Items were answered on a 5-point Likert-type scale, ranging from 0 = not at all beneficial to 5 = extremely beneficial. Four qualitative items were then completed for this section (e.g., “How has using this case conceptualization/ecological table been useful in differential diagnosis and case conceptualization?”).

2.3.3. Differential Diagnosis Table

The DD table included the diagnosis and necessary symptoms, examples of symptom presentation, an area to indicate whether the client’s symptom was significant, and whether the symptom may be explained by a different diagnosis (the original DD table did not include symptom examples). Throughout the assessment, trainees added information to the DD table and indicated their source of the information (e.g., teacher report, clinical interview). Trainees answered 4 items related to the benefits of the DD table on a 5-point Likert-type scale, ranging from 0 = not at all beneficial to 5 = extremely beneficial (e.g., “How beneficial have the differential diagnosis tables been in building skills in differential diagnosis?”). Two qualitative items followed (i.e., “How could these diagnosis tables be improved to be even more beneficial?” and “How has using these diagnosis tables been useful in differential diagnosis and case conceptualization?”).

2.3.4. ADHD Matrix

The ADHD matrix (Figure 2) consisted of how diagnostic criteria for inattention and hyperactivity/impulsivity may appear on various assessments and measures (e.g., clinically significant inattention on BASC-3). The matrix additionally included a section for contextual information (e.g., family conflict, school history), as well as confounding factors (e.g., inadequate sleep, chaotic home environment). Trainees answered 5 items related to the benefits of the ADHD matrix on a 5-point Likert-type scale, ranging from 0 = not at all beneficial to 5 = extremely beneficial (e.g., “How beneficial has the above ADHD matrix been in helping you accurately diagnose clients?”). Two qualitative items followed (i.e., “If you noted this matrix has been beneficial, please comment on specifically how using this table been beneficial in differential diagnosis and case conceptualization (reflecting on specifically the above factors as well as additional benefits)” and “How could this matrix be improved to be even more beneficial?”).

2.3.5. SLD-Reading Matrix

The SLD-reading matrix (Figure 3) consisted of how diagnostic criteria may appear on various assessments and measures (e.g., appear as weakness on WISC-V or WIAT-IV), relevant historical information (e.g., family history of learning challenges), current functioning (e.g., word substitutions, difficulty keeping up with reading assignments), and environmental factors (e.g., receipt of adequate instruction). In the current study, trainees answered 5 quantitative items related to the benefits of the ADHD matrix on a 5-point Likert-type scale, ranging from 0 = not at all beneficial to 5 = extremely beneficial (e.g., “How beneficial has the above SLD-Reading matrix been in helping you integrate a range of data into diagnosis (testing, self-report, interview)?”). Two qualitative items followed (i.e., “If you noted this matrix has been beneficial, please comment on specifically how using this table been beneficial in differential diagnosis and case conceptualization” and “How could this matrix be improved to be even more beneficial?”).
One final qualitative item prompted trainees to include any ideas about additional structures or procedures that could be beneficial for structuring the diagnostic process, building skills around case conceptualization and differential diagnosis, and integrating exosystemic and macrosystemic factors into the diagnostic process.

3. Results

3.1. Supervision Needs

The results of the rank-ordering of supervision needs indicated trainee knowledge of DSM-5 diagnoses, developing an integrated and ecologically based case conceptualization, and differential diagnosis using a range of data were the top three reported supervision needs. The least needed areas of supervision were building rapport with clients, structuring the clinical interview, and administering cognitive and academic testing.

3.2. Reported Benefits of the Tables and Matrices

Most trainees indicated that the use of the CC and DD tables were very beneficial and extremely beneficial, respectively, and that both the ADHD and SLD-reading matrices were extremely beneficial (see Table 1). The DD table had the highest endorsed benefits, while the CC table had relatively lower endorsed benefits compared to the other tools (though still primarily in the very beneficial range).
For the CC table, trainees were mixed on responses to the item related to whether the table supported the trainee’s ability to “include a range of ecological factors into [their] clinical interview”, with over half the trainees noting this table was only slightly or moderately beneficial in this area. Further, half the trainees reported that the table was slightly or moderately beneficial for supporting their ability to consider macrosystemic factors in their clients’ case conceptualization.
The trainees predominantly rated the DD table as being extremely beneficial, or very beneficial. Thus, few changes were made. The ADHD and SLD-reading matrices were additionally highly rated, with most trainees rating aspects of their content as extremely or very beneficial for understanding the diagnosis and integrating the ecological factors into their case conceptualization. For both the ADHD and SLD matrices, trainees’ responses were most varied for the item related to how much the matrix helped them “Consider exosystemic and macrosystemic factors into your diagnosis”.

4. Discussion

The current study sought to conduct an initial evaluation of a series of diagnostic tools with an integrated ecological model, as there is currently a dearth in the literature on graduate training practices in assessment that include a focus on client ecological and cultural context. Our first aim was to describe the original diagnostic tools. Our second aim was to elicit doctoral trainee feedback on the use and benefit of these support tools in their training and implementation with clients and to assess whether trainees felt the tools improved their ability to think conceptually about ecological and contextual client factors. Our third aim was to demonstrate the adaptation of the clinical tools based on trainee feedback, as described below. Future work will include eliciting faculty and staff feedback about trainee diagnostic accuracy when using these tools.
Overall, the CC and DD tables and ADHD and SLD-reading matrices that were developed to assist trainees in building psychological assessment skills were highly valued by the trainees. The DD table, ADHD matrix, and SLD-reading matrix were predominantly described as extremely beneficial, and the CC table was described as very beneficial among the trainees, particularly related to building their knowledge of diagnostic criteria and supporting their ability to integrate a bioecological framework into diagnostic considerations. These results are important not only for demonstrating comprehensive training of assessment procedures but also because increased knowledge and practice of assessment can support trainee confidence in assessment skills [2]. As graduate trainee study participants represented three different disciplines (clinical, counseling, and school psychology), these results further highlight the usefulness of these diagnostic tools across fields with differences in approach to diagnostic assessment.

4.1. Modification of Diagnostic Tools

Consistent with the third aim of the present study, the diagnostic tools were modified based on trainee responses to questionnaires. Additional modifications were made to the tools based on supervisor observation of the trainees’ use of these tools and other training needs. Finally, as the DSM-5-TR [68] was released in the spring of 2022 after data were collected from the trainees, modifications to the tables and matrices integrated information from this revision.
The qualitative data were reviewed, as it provided context for trainee quantitative responses. Overall, the trainees found the tables and matrices especially useful in helping them organize data, engage in effective differential diagnosis, integrate a range of data into their diagnosis, and reduce bias [61]. Trainee-suggested areas for improvement fell into two main categories, namely (1) integrating more in-depth training and clarity on the use of these tools, along with specific diagnostic examples and (2) although the case-conceptualization table with the ecological framework helped them include exosystemic and macrosystem data into their initial case conceptualizations, the remaining table and matrices would benefit from the additional targeted inclusion of the systemic factors influencing diagnosis. Based on trainee responses and feedback, as well as supervisor observations of the use of the diagnostic tools, the tables and matrices were edited and enhanced. Next is a description of the modifications made and the final versions of these tools (see Figure 4, Figure 5, Figure 6 and Figure 7).

4.2. Final Case Conceptualization Table

The final version of the CC table (see Figure 4) was split into two parts. Part one is to be used during supervision after the trainee completes the intake and testing with the client to prepare for the clinical interview. Part two is to be used for finalizing the diagnosis and to prepare for the feedback session. The referral question and presenting concern are presented at the top of part one. As the supervisors observed that the trainees could lose sight of the referral question and the clients’ primary concerns as they gathered data, adding this information was intended to support the trainee’s ability to remember the primary referral questions throughout the assessment.
The trainees had feedback about the CC table, including “In the beginning it was hard for me to properly identify specific factors and put them in the correct system. I believe it would be helpful to have an example for reference” and “I think this table has been helpful in remembering to attend to the exosystem and chronosystem in assessment work”. Based on feedback, the final version of the CC table now includes a section for trainees to explicitly integrate information about the clients’ ecological context by specifically describing various levels of the clients’ ecological system. This enhancement more directly supports the trainee’s ability to think through each ecological factor in the assessment process and increases their ability to consider the cultural factors influencing the client. Specifically, the table now includes examples for each of the systemic levels and a place for trainees to write down salient background information in the client’s history that is relevant to their presenting concerns, as well as a table with information about the bioecological model (i.e., microsystem, macrosystem) [43] and Hays ADDRESSING framework [69]. Here, trainees indicate aspects of the client’s context affecting the referral question, their current presentation, symptoms, the overall conceptualization of the case, and potential recommendations. The goal of this section is to ensure that trainees understand not only client diagnosis(es) but also how the interaction between the client’s context and symptoms leading to the diagnosis. This section supports the trainee’s ability to integrate various pieces of information about the client’s background that could otherwise be overlooked, thus enhancing their ability to consider the client within their ecological and cultural contexts and identify relevant protective and risk factors. The results of the questionnaire indicated that trainees felt that this section was particularly helpful in ensuring that they were considering all relevant contextual factors contributing to the clients’ presentation concerns. As one trainee noted, “[the table] has helped me to consider a range of contextual and developmental factors”. Further, there is a spot for current data, where trainees can add additional pieces of information gathered from self-report questionnaires, a collateral interview, background source reviews, etc., as well as a section where trainees can begin planning out a structure for the clinical interview.
The next section includes a table where trainees provide their hypotheses about the first diagnosis (i.e., the diagnosis they feel is most likely) and their second diagnosis (i.e., additional and/or alternative diagnosis). Trainee feedback for this section included “I would personally prefer a format more like: Data that supports this hypothesis (e.g., symptoms, history, previous records, testing data, self-report data, collateral data) [blank], Data that is not accounted for by this hypothesis [blank], Data that goes against this hypothesis [blank] (with each of those being a column, and then “data that is still needed to confirm/deny” and “I think some of the categories could be fleshed out a bit (e.g., history could be broken down to family history, educational history, psychological history, etc.). That would get clinicians thinking about each of those factors and how they impact the diagnosis”. This section was designed to support the trainees’ ability to integrate information about the interaction between the potential diagnosis and the client’s context to develop a theoretically based case conceptualization. It is additionally expected that trainees integrate theory into their explanation, e.g., the coercive cycle [70,71]. For each of these sections, trainees are now expected to include information about background information and gathered data, as well as list additional data needed to confirm or deny their hypothesis (e.g., data that do not fit with this hypothesis, differentials they are considering, and why). This supports the trainee’s ability to consider potential contextual influences affecting the client and their diagnosis (e.g., bias in diagnosis [38,61]). Trainees are expected to identify any missing information and formulate a plan for gathering additional evidence during the clinical interview. Trainees are required to consider alternative diagnoses as a protective factor against confirmation bias.
Finally, part two of the CC table is completed after the intake, testing, self-report measures, and clinical interview are completed and is used to prepare for the feedback session. Here, the trainees are expected to list confirmed diagnoses and describe how the diagnosis(es) interact with the client’s environment to lead to the client presenting concerns (diagnostic tables and testing results are expected to be included here). Next, trainees describe whether there are concerns or symptoms that either are not accounted for by the diagnosis or that are counter-indicative. This is designed to promote trainees’ ability to pause and think about any data that do not fit into their conceptualization and plan for the next steps. One trainee’s response to this section was “This is very helpful to differential diagnosis because it forces you to play “devil’s advocate” and come up with alternative hypotheses”. This table, therefore, supports accurate diagnosis and allows trainees to be prepared to recognize how symptoms or concerns affect the clients’ experience. Finally, trainees include a plan for gathering the additional information needed to confirm or deny their current hypotheses, as well as recommendations for the confirmed diagnosis(es).

4.3. Final Differential Diagnosis Table

The final DD table (Figure 5) was created for use during the clinical interview. Separate DD tables are used for any of the diagnoses the trainee is considering for their client; the example in this study focuses on ADHD. As trainees rated this table highly (i.e., extremely or very beneficial) few changes were made. However, based on the trainee’s qualitative responses, supervisors included examples of symptoms to support the trainee’s ability to understand how the symptoms may manifest for clients. For example, trainees stated that “Even more examples of symptoms could be useful” and “[the table] could highlight how aspects of anxiety might come up but will look different. For instance, it could note that distractions in ADHD are chronic and not situational, while distractions in anxiety will be related to the anxiety provoking situations”. Including this information provides greater clarity to trainees about how clients with ADHD might present, as some trainees had not done prior work with individuals with ADHD.
In addition to providing specific examples, trainees received training on how to complete the table. For example, in the Yes/No column, a “Yes” indicates that the symptom is present, clinically significant, and discrepant from same-age peers. This column requires trainees to make decisions about diagnostic symptoms, which can be challenging as new clinicians hesitate to make these decisions. As trainees complete this table during the clinical interview, it supports their ability to ensure the symptom is clinically significant or recognize when they need to ask clarifying questions. The Notes and Differential Diagnosis (“DD”) columns are both completed prior to the clinical interview. In the Notes column, trainees include information from intake paperwork, self-reports, and testing data to streamline data gathering during the interview itself. Notes from the clinical interview are also integrated into this section. In the DD section, trainees include alternative hypotheses for a client’s symptoms (e.g., inattention due to sleep or anxiety) to prompt them to ask relevant follow-up questions during the clinical interview. This DD table can be integrated into the CC table so trainees can keep information in one place and streamline data collection.

4.4. Final ADHD Matrix

The final ADHD matrix underwent multiple changes (Figure 6). The matrix is used by trainees evaluating for an ADHD diagnosis specifically. The matrix includes three columns for trainees to indicate evidence against ADHD, evidence that is neutral or placing the client at risk for ADHD, and evidence for ADHD, including clinically significant symptoms. Further, the matrix is separated into symptoms required for a diagnosis and additional supporting data that, while relevant, are not required for an ADHD diagnosis (i.e., common cognitive processes in an ADHD diagnosis). Symptoms of inattention and hyperactivity/impulsivity are separated to ensure that trainees are able to clearly connect the data with the appropriate categories.
Trainees are expected to include information from their behavioral observations, self-report, and cognitive testing data to determine what evidence supports or negates an ADHD diagnosis. Based on trainee feedback, one of the primary changes made with these matrices was a more explicit integration of ecological factors, as well as more training on how larger ecological factors influence and interplay with ADHD symptoms. For example, the matrix now prompts trainees to consider both required symptoms (i.e., five or more clinically significant symptoms in either or both categories for adults and six for children), as well as symptoms not required for diagnosis but that could provide supporting or negating evidence (e.g., lower scores in working memory). Next, the ADHD matrix includes a section for other required or supporting data relevant to an ADHD diagnosis. One trainee noted this section was “Very useful to capture the evidence both for and against a potential diagnosis of ADHD”. Specifically, it included information about the history and settings (e.g., symptoms present before age 12, symptoms present in at least two settings); whether symptoms interfere with functioning (e.g., home, relationships); and supplementary symptoms not explicitly required for diagnosis but consistent with an ADHD presentation (e.g., emotional regulation and inhibition difficulties, issue with speeding while driving). Here, the highlighted sections indicate the symptoms required for diagnosis. This was important to help trainees consider the timeline in which symptoms occurred, as well as integrate all pieces of evidence.
Finally, a section for the client’s ecological context and potentially confounding information is included. Here, more information about diagnostic features was integrated into the matrices to support the trainee’s ability to engage in effective differential diagnosis between ADHD symptoms and symptoms that present like ADHD but, in fact, have a different etiology. It includes differential diagnosis information, such as difficulties with sleep, evidence of mental health issues (e.g., anxiety, depression), trauma history, home environment, and other comorbid disorders (e.g., dyslexia). This ensures that trainees not only consider the presenting symptoms but also rule out other possible diagnoses based on the clients’ contextual factors. Finally, an ADHD symptoms table is included to integrate all the data together. Notably, items with an asterisk indicate symptoms that are highly suggestive of an ADHD diagnosis.

4.5. Final SLD-Reading Matrix

Based on trainee feedback, the final SLD-reading matrix (Figure 7) now includes a section focused on the clients’ ecological context, including history relevant to an SLD in reading diagnosis (e.g., history of reading and/or writing difficulties, evidence of dysfluency, or difficulty memorizing basic math facts) to guide the trainee during the clinical interview. For example, one trainee noted, “I think the consideration of exosystemic and macrosystemic factors in the table is strong, but these are still difficult determinations to make (e.g., whether difficulties are better explained by other factors)”. The training was further enhanced to promote an understanding of how ecological factors influence SLDs in reading. The next section integrates scores from the WIAT-IV (e.g., standard scores, whether the client scores one standard deviation or more below the mean, i.e., <85, percentile rank, and whether the score was a personal or normative weakness), as well as notes about what areas of academic deficits fall under different subtypes of dyslexia to further aid in the identification of the SLD in reading. Notes under these tables support the trainee’s ability to understand and target the most essential diagnostic information.
Next, this matrix includes cognitive testing information that, while not required for diagnosis, is correlated with SLD in reading (e.g., deficits in working memory [72]). This is included to support trainee understanding of an SLD in reading diagnosis. Once again, there is a section on relevant environmental factors to account for client context (e.g., receipt of adequate instruction, cultural or environmental factors impacting reading). Finally, information about the client’s pattern of strengths and weaknesses is included. While the DSM-5-TR does not use this for diagnosis, this method was added to deepen the trainees’ case conceptualization of an SLD in reading, as some work has found it to be helpful for identifying SLD in children with diverse cultural backgrounds [73], and to integrate information that could be beneficial for client recommendations.
Overall, these four novel diagnostic support tools were rated as being highly beneficial among graduate-student trainees, and the feedback provided supported the enhancement of these tools for continued use. Focusing on ecological and cultural factors for clients within the diagnostic process is essential for increasing diagnostic accuracy, better supporting clients in understanding how their symptoms and context interact, and promoting comprehensive recommendations for clients. Future modifications to these tools will continue to support the trainee’s ability to consider ecological and individual contextual factors contributing to client presentation.

4.6. Limitations and Future Directions

This study demonstrated a highly positive reception of the use of four diagnostic assessment tools to support a trainee’s understanding of diagnostic and bioecological frameworks in their assessment work with clients. A future direction for this work will be to test the updated tools with graduate-level trainees to evaluate how these changes may further enhance diagnostic assessment procedures. Limitations in the current study should be noted. First, the study included a small sample of graduate trainees in one clinic in the Pacific Northwest of the United States. Future research will focus on eliciting feedback from the faculty and staff involved in graduate-student assessment training to further enhance the tools and assess for diagnostic accuracy. Additionally, future work should expand the use of these diagnostic tools with a greater number of trainees, as a larger sample would allow for assessing whether the utility of these tools differs by specialty, training level, or demographic factors. Second, the current paper investigated SLD in reading only. Future work should expand the use of these tools to include developing and testing them with SLD in math and in writing.

5. Conclusions

Psychological assessment is an essential aspect of graduate training, yet there is a dearth of research on assessment practices integrating a client’s cultural and ecological context. The current study demonstrates the acceptability of four novel diagnostic support tools for use in assessment training that support a trainee’s ability to integrate clients’ symptoms within an ecological context to support comprehensive case conceptualization and differential diagnosis skills. The adaptations made in response to trainee feedback include additional symptom information and a more direct integration of ecological factors to support trainee understanding of integrated case conceptualization and the diagnostic process. Enhancing diagnostic tools to be more inclusive of clients’ ecological contexts will promote improved graduate-student training, lead to accurate diagnosis, and promote client wellbeing.

Author Contributions

The authors contributed equally to this work. Conceptualization, K.P.W. and A.C.M.; methodology, K.P.W.; formal analysis, K.P.W. and A.C.M.; investigation, K.P.W. and A.C.M.; data curation, K.P.W.; writing—original draft preparation, A.C.M.; writing—review and editing, A.C.M. and K.P.W.; visualization, K.P.W. and A.C.M.; project administration, K.P.W. All authors have read and agreed to the published version of the manuscript.

Funding

This research received no external funding.

Institutional Review Board Statement

The study was conducted according to the guidelines of the Declaration of Helsinki and approved by the Institutional Review Board of the University of Oregon (Study ID STUDY00000023; date of approval 19 March 2021).

Informed Consent Statement

Informed consent was obtained from all subjects involved in the study.

Data Availability Statement

Data can be made available upon request to the second author.

Conflicts of Interest

The authors declare no conflicts of interest.

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Figure 1. Original case-conceptualization table.
Figure 1. Original case-conceptualization table.
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Figure 2. Original ADHD matrix.
Figure 2. Original ADHD matrix.
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Figure 3. Original SLD-reading matrix.
Figure 3. Original SLD-reading matrix.
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Figure 4. Final Case Conceptualization Table.
Figure 4. Final Case Conceptualization Table.
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Figure 5. Final Differential Diagnosis Table.
Figure 5. Final Differential Diagnosis Table.
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Figure 6. Final ADHD Matrix.
Figure 6. Final ADHD Matrix.
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Figure 7. Final SLD-Reading Matrix.
Figure 7. Final SLD-Reading Matrix.
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Table 1. Reported benefits of the case conceptualization and differential diagnosis tables and the ADHD and SLD-reading matrices.
Table 1. Reported benefits of the case conceptualization and differential diagnosis tables and the ADHD and SLD-reading matrices.
Extremely BeneficialVery BeneficialModerately BeneficialSlightly BeneficialNot at All Beneficial
% (n)% (n)% (n)% (n)% (n)
Case-Conceptualization (Ecological) Table
Think about ecological factors you might otherwise inadvertently not consider in your CC18.2 (2)54.5 (6)9.1 (1)18.2 (2)--
Include a range of ecological factors in your clinical interview9.1 (1)36.4 (4)18.2 (2)36.4 (4)--
Consider/integrate exosystemic factors into your CC72.7 (8)--18.2 (2)9.1 (1)--
Consider/integrate macrosystemic factors into your CC--54.5 (6)18.2 (3)27.3 (3)--
Consider/integrate chronosystemic factors into your CC--63.6 (7)27.3 (3)9.1 (1)--
Differential Diagnosis Table
Accurately diagnosing your client45.5 (5)36.4 (4)9.1 (1)----
Engage in DD45.5 (5)45.5 (5)------
Building knowledge specific to DSM-5 diagnosis54.5 (6)27.3 (3)----9.1 (1)
Building skills in DD45.5 (5)36.4 (4)9.1 (1)----
ADHD Matrix
Accurately diagnose clients27.3 (3)63.6 (7)------
Integrate a range of data into diagnosis54.5 (6)36.4 (4)------
Consider exosystemic and macrosystemic factors in your diagnosis27.3 (3)18.2 (2)27.3 (3)9.1 (1)9.1 (1)
Engage in DD45.5 (5)27.3 (3)18.2 (2)
Build your own knowledge and skills for ADHD diagnosis45.5 (5)36.4 (4)9.1 (1)
SLD-Reading Matrix
Accurately diagnose clients45.5 (5)36.4 (4)------
Integrate a range of data into diagnosis54.5 (6)27.3 (3)------
Consider exosystemic and macrosystemic factors in your diagnosis27.3 (3)27.3 (3)27.3 (3)----
Engage in DD36.4 (4)36.4 (4)9.1 (1)----
Build your own knowledge and skills for SLD-Reading diagnosis36.4 (4)27.3 (3)9.1 (1)9.1 (1)--
ADHD: attention-deficit/hyperactivity disorder; SLD: specific learning disorder; CC: case conceptualization; DD: differential diagnosis.
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McWhirter, A.C.; Walters, K.P. The Development of Ecologically Integrated and Culturally Informed ADHD and SLD Diagnostic Tools for Doctoral Assessment Training. Disabilities 2024, 4, 583-615. https://doi.org/10.3390/disabilities4030037

AMA Style

McWhirter AC, Walters KP. The Development of Ecologically Integrated and Culturally Informed ADHD and SLD Diagnostic Tools for Doctoral Assessment Training. Disabilities. 2024; 4(3):583-615. https://doi.org/10.3390/disabilities4030037

Chicago/Turabian Style

McWhirter, Anna Cecilia, and Karrie P. Walters. 2024. "The Development of Ecologically Integrated and Culturally Informed ADHD and SLD Diagnostic Tools for Doctoral Assessment Training" Disabilities 4, no. 3: 583-615. https://doi.org/10.3390/disabilities4030037

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