Clinical Reasoning in School Psychology

To think well is one of the most important keys for being successful in life. Thinking well allows us to be inquisitive, fair-minded, and open-minded. Thinking well guides us toward being skeptical of quick solutions and motivates us to put forth an effort to know more rather than less before making a decision. Thinking well will temper us and lead us to be less impulsive, listen more carefully to others, appreciate points of view different from our own, find out what we do not know or understand, and compensate more effectively with respect to our limitations. If nothing else, we owe it to others to know what it means to think well.

This special edition of the Canadian Journal of School Psychology titled “Clinical Reasoning in School Psychology: From Assessment to Intervention” is about school psychologists “thinking well” across the full range of services they deliver including assessment, program planning, intervention, and consultation. In this regard, clinical reasoning, psychological and psycho-educational assessment, and intervention planning and implementation are complex and sometimes idiosyncratic processes. Clinical reasoning is the ability to accurately diagnose a child or youth and develop an appropriate intervention for him or her with respect to the presenting problem(s), and it is far from uniform across and within practicing psychologists, as many factors influence clinical decision making at each step from assessment through to intervention. For professional accountability, school psychologists should be able to describe the basis for their complex assessment and intervention decisions within a well-defined clinical/theoretical framework. At the focal point of psychologists’ assessment decisions is clinical judgment, which is often based on among other things, one’s training and clinical experience, as well as on one’s knowledge of human behavior and development, of theory and empirical evidence, of techniques and procedures, and of personal/professional models of clinical practice. Intervention planning and implementation like assessment is complex and is often a collaborative and consultative process. In this regard, school psychologists should be knowledgeable of and be able to recommend and be involved with evidence-based interventions for children and youth they assess and for whom intervention is required. Moreover, they should be able to tailor interventions to better fit the particular assessed needs of the child or youth. This process requires both an understanding of the child, the environment, and systems that interactively influence intervention development, implementation, and evaluation. Similar to assessment, clinical judgment about the nature and use of interventions develops from a practitioner’s training and experience as well from his or her reasoning abilities.

Not everything we think is true; not everything we feel is real; and not everything we do are who we are. The people with personal insight about themselves and others and who can make wise judgments about themselves and others know the difference.

Clinical reasoning serves to bridge the gap between one’s experience and knowledge base and the strategies used to solve real-life problems. It involves observation, reflection, judgment, inference, and problem-solving abilities as well as an appraisal of factors related to client status and change. It is generally well known in psychology that the way people think, feel, and behave can be problematic at times. For example, how we interpret the world around us, what we think and feel about ourselves and others, and how we act within and across situational contexts are influenced by, for example, our attributional styles and biases, our cognitive appraisals, our deliberate and logical thinking as well as our distortions or misguided thinking, our emotionality and regulation of emotions, as well as our genetic, neurobiological, and neurophysiological entity and mechanisms. One of our roles as psychologists is to make judgments about how and why children and youth think, feel, and act as they do particularly when their thinking, feeling, and behavior distress them, cause harm to themselves or others, and impair important areas of their functioning. In this regard, it is important for psychologists to not only consider the multifaceted reasons for a possible psychopathology within a child or youth but to also determine the primary reasons why someone is having difficulty adapting to his or her life situation.

Children and youth with disorders are not disordered in all areas; they have both strengths and weaknesses within and across a variety of personal, academic, and social areas, and they can fluctuate in and out of healthy or unhealthy states throughout their development. Moreover, although some disorders can continue into adulthood, some others can be effectively treated while in childhood and adolescence and not persist into adulthood as a result of such things as intellectual ability, social ability, coping ability, and the personal support of parents, peers, and others in their home and school environment. (Andrews, 2012)

Importantly, as psychologists, we need to keep “in mind” that we all think, feel, and behave in adaptive and maladaptive ways. In other words, normality and abnormality are part of a developmental continuum and are determined by, for example, the frequency, intensity, and chronicity of our adaptive or maladaptive thoughts, feelings, and behaviors relative to varying contextual and cultural factors, and one’s age, gender, and ability or disability to accept or resist change. In addition, we should dually consider both the unhealthy states of an individual (i.e., deficit model) and healthy states of an individual (i.e., strengths-based model) when undertaking both assessment and intervention so that our diagnoses as well as our plans for remediation and/or compensation for an individual’s areas of weaknesses are addressed along with and through the individual’s strengths. Hence, a primary role of psychologists is to distinguish between what a child can do and not do for himself or herself, why this may be so, and determine the best way or ways that a person can be helped to better adapt to his or her life situation and positively influence his or her thinking, feeling, and behavior. Some have argued that the best way to maximize the development of and use of enabling skills and insights of psychologists in training and in practice is by being mentored by those who have excellent clinical reasoning skills and by having them “think aloud” and explain their thinking to us as they progress through their clinical assessment and intervention planning and implementation (e.g., Pinnock & Welch, 2014). In this regard, all of the authors of this special edition have embedded within their articles their clinical reasoning from assessment to intervention to demonstrate the complexity of clinical decision making, and reveal how different ideas, hypotheses, and decisions are considered, developed, evaluated, re-evaluated, and confirmed, and how it evolves into a coherent picture through the stages of assessment and intervention planning. Revealing psychologists’ clinical thinking and reasoning with respect to their assessment and intervention planning and implementation processes and decisions is considered to be beneficial for training and clinical practice. Comparing the clinical reasoning of psychologists can provide insight regarding what information they attend to, what questions are asked, how decisions are made, and what checks and balances are undertaken to ensure their accountability regarding clinical diagnosis and intervention as little is known about individual differences among clinicians (Garb, 2005).

Our thinking is very often evaluated by others relative to the decisions we make and how we account for our decisions. Generally, our thinking is often directly or indirectly evaluated by our friends, family, and peers and we often anticipate that our judgments will be questioned by them. However, as psychologists, we typically expect that our judgments will be accepted by our clients and colleagues due to an implicit expectation that our judgments will be deemed accountable due to our accreditation by way of our degrees, training, licensure as practicing psychologists, and our clinical experience. However, how sure are we of our judgments? In all of our training and experience, how much course work, supervision, and mentorship have we received with respect to our clinical reasoning? How familiar are we with the judgment literature? How often and how well has our thinking been formally and critically evaluated and systematically developed and enhanced? If we were given the same client referral as others, would we refer to similar theoretical and clinical frameworks to orient our thinking about the case? Would our case conceptualization follow the same processes and procedures as others? Would we choose the same approaches and tests to investigate the referral problem(s)? Would we evaluate and re-evaluate our hypotheses and decisions the same way as others with respect to how we consider our assessment findings, hypotheses, and formulate our judgments? Would we come to the same conclusions about the nature and scope of the referral problem(s) as others do with the same information presented? Would we consider and develop similar intervention plans and resources? How sure are we that how we arrive at our decisions relative to assessment and intervention are what others would have decided given the same evidence? It seems that we as school psychologists would benefit from knowing and understanding the approaches and decisions of other psychologists relative to their cases of child and youth psychopathology and to be continually engaged in developing how we think, how we can tap into the benefits of our colleagues’ thinking and how we can be enlightened by this shared experience.

Although there has been some discussion and study of the judgment process itself (Barnett, 1988; Dawes, Faust, & Meehl, 1989; Fagley, 1988; Fantino, 1998; Garb, 2005; Kahneman, 2011; Tversky & Kahneman, 1974) as well as clinical judgment in clinical practice (Faust, 1986; Gambrill, 2005; Ruscio, 2003), diagnostic decision making (de Mesquita, 1992; Macmann & Barnett, 1999; Watkins, 2009), and adaptive intervention design (Bierman, Nix, Murphy, & Maples, 2006), there has been very limited empirical literature with respect to the assessment and intervention practices and clinical reasoning of school psychologists. Trainers of psychologists point to supervised field experience as providing the essential opportunity to learn clinical judgment. However, even if excellent, site supervisors typically present their particular view of assessment, interpretation, and intervention, which may not be sufficiently detailed and comprehensive in addressing the multiple perspectives and models of practice that are available. Hence, opportunities for psychologists in training and in practice to have a broader range of clinical insight relative to childhood psychopathology and the clinical reasoning of other psychologists with respect to their diagnostic and interventionist decisions particularly relative to childhood disorders would seem to be professionally beneficial and fill a gap within the discipline of school psychology.

A review of the published literature over the past 15 years indicates that apart from few limited studies, research on clinical reasoning in school psychology has been largely neglected in the field (Lilienfeld, Ammirati, & David, 2012; Wilcox & Schroeder, 2015). Authors who have written about the clinical reasoning of school psychologists (e.g., Huber, 2007; Lilienfeld et al., 2012) have argued that clinical reasoning in the profession should be grounded in science and that school psychologists should safeguard against cognitive errors (e.g., premature closure, overreliance on heuristics, confirmatory bias, belief perseverance, base rate neglect) when making their clinical judgments. However, an empirical review by Lilienfeld et al. (2012) suggested that many school psychologists underuse science and scientific thinking in their clinical reasoning. For example, a survey completed by American school psychologists indicated that projective techniques are being used regularly by school psychologists although they lack validity (Hojnoski, Morrison, Brown, & Matthews, 2006) and empirical support for the assessment of psychopathology in children and youth (Wood, Nezworski, Lilienfeld, & Garb, 2003; Smith & Dumont, 1995). Moreover, Bramlett, Murphy, Johnson, Wallingsford, and Hall (2002) found that half of their sample of psychologists reported on their survey that they did not refer to research to inform their intervention practices. In addition, Nelson and Machek (2007) found from their survey of school psychologists that 56% of them felt their knowledge about evidence-based reading interventions is either “low” or “moderately low.” Moreover, a survey of a sample of mental health professionals listed in the National Register of Health Service Providers in Psychology (Rock, 1994) to examine attitudes with regard to the generalizability of findings from clinical judgment research, general beliefs and practices about clinical judgment, and knowledge of scholarly articles and books in the clinical judgment literature indicated that the respondents agreed that tasks used in studies of clinical judgment were not representative of the types of activities performed in their clinical practice and that although they believed that the study of clinical judgment was important and that research could have meaningful implications for their clinical practice, they reported low levels of familiarity with the judgment literature. Hence, more published exemplars of school psychologists’ use of science within their practice relative to assessment, intervention, and associated clinical reasoning might not only better represent how psychologists are enabled by science but also model an accountable and effective practice that appears somewhat absent or underrepresented within the published literature to date.

Even though clinical reasoning underlying assessment to intervention has generally been thought to be the cornerstone of professional practice in school psychology, there are no published sources of information that describes how clinical decisions are formed, implemented, analyzed, and evaluated by practicing school psychologists. Hence, there is a need for the field of school psychology to elucidate the nature and scope of clinical reasoning particularly with respect to the assessment and intervention processes in order to be more accountable for psychological and psycho-educational assessment and intervention decisions.

There are a number of books and journal articles that help psychology students as well as practicing psychologists become knowledgeable with respect to general testing approaches, specific administrative techniques, interpretation guidelines, and report writing relative to psychological and psycho-educational assessment as well as become knowledgeable about assessment procedures such as interviews, behavioral observations, intellectual tests, personality tests and checklists, and adaptive behavior scales (e.g., Sattler, 2014). There are also a number of books that are useful references for psychologists in training and in practice with respect to psychological tests to be used for cognitive, academic, and social, emotional, and behavioral assessment, as well as information relative to assessment theory, and psychometric considerations (e.g., Andrews, Saklofske, & Janzen, 2001; Flanagan & Harrison, 2012; Kranzler & Floyd, 2013; Lichtenberger & Breaux, 2010; Mather & Wendling, 2015; Merrell, 2008; Weiss, Saklofske, Holdnack, & Prifitera, 2016). In addition, there are texts that provide information relative to academic, behavioral, and clinical interventions (e.g., Kratochwill & Shernoff, 2003; McClure & Friedberg, 2015; Shinn & Walker, 2010; Walker & Gresham, 2014; Wendling & Mather, 2008). There are also some books and publications with respect to clinical judgment and decision making (e.g., Gambrill, 2005; Plous, 1993), clinical judgment and psychological assessment (e.g., Garb, 1998), and guides for evidence-based practice (e.g., Gibbs, 2003; U.S. Department of Education, 2003). However, there are no publications that examine how school psychologists conceptualize the psychological/psycho-educational assessment to intervention process, and account for the developmental and dynamic conception of clinical reasoning in their diagnostic decisions as well as how they decide on appropriate evidenced-based interventions, and modify these interventions for the child-situation contexts.

In essence, there is no publication that describes the clinical decision making among practicing school psychologists. Given that these decisions change on the basis of time, and in response to changing relationships among data, current information is needed to highlight the thinking processes during this ever-changing decision-making model. Hence, the goal of this special edition is to present information and insights with respect to the processes, procedures, and decisions associated with clinical reasoning in psychological/psycho-educational assessment and intervention that can be used to guide students in training to become more effective clinicians and to provide a reference source for practicing school psychologists as well as educators relative to their own professional development.

Clinical analysis and reasoning about a child’s performance and psychological state require an understanding of how to use and integrate multiple sources of assessment information for decision making while recognizing the strengths and limitations of the assessment techniques, and gathering crucial treatment/intervention information. Moreover, the clinical reasoning of school psychologists needs to involve discernment of empirically based interventions inside and outside of the classroom (Cowan & Sheridan, 2009; Kratochwill et al., 2009) as well as data-based instructional decision making (Ysseldyke & Burns, 2009). Clinical reasoning also requires knowledge of normal and abnormal developmental pathways as well as information about a child’s academic, familial, medical, and social–cultural history along with the complex interactions of individuals and the environments in which they function (e.g., the school and classroom, home and community). In fact, it is this interaction (internal states and external environments) and the interaction between psychological/psycho-educational assessment and intervention data that form the fundamental basis of analysis for school psychologists (Gutkin, 2009). Hence, the authors of the articles in this special edition will share with the readers their clinical/theoretical frameworks and judgments from case studies that exemplify children’s histories as well as their levels of functioning from multiple sources of information. In addition, the authors will use a child–environment match for conceptualizing the student-related problems and planning for effective intervention.

There is a timely need for school psychologists to have current information with respect to the clinical reasoning relative to both assessment and intervention. Importantly, psychologists (in practice and training) should benefit from a resource that provides information about how findings from current cognitive, achievement, social-emotional, and behavior tests along with other sources of information can lead to effective clinical judgment relative to students’ profiles of strengths and weaknesses and with respect to diagnostic and intervention decision making, all of which must be taken within an environmental context. Moreover, it is critically important that school psychologists be able to shift from using data for diagnosis to then using these very data to further guide intervention if their findings are going to have ecological and treatment validity and utility.

A major goal of this special edition is to emphasize that the characteristics of children and youth (e.g., academic/social skills, mood, self-esteem, executive functioning) are an important piece of the puzzle for determining strategies for developmental enrichment but not the only piece. It is also important to determine the best intervention approach based on varying environmental variables such as the school and home context, and the interpersonal relationships between students, teachers, and parents (Andrews, 2004; Gutkin, 2009). In this regard, the articles in this special edition will focus on case-based evaluations where the authors will present their clinical decision making to arrive at a specific child diagnosis, but also consider individual-treatment fit. Hence, along with determining and reporting the nature and scope of learning/developmental problems of particular children/youth, the authors will reveal their planning for interventions for these individuals based on their developing case conceptualizations. In this regard, the authors also provide case studies and clinical reasoning frameworks with respect to the most prevalent disorders of children and youth (i.e., mood disorder [major depression], behavior disorder [attention deficit hyperactivity disorder, oppositional defiant disorder], and developmental and learning disorder [autism spectrum disorder, writing disorder, learning disability]) from assessment to intervention. Hence, the clinical insights and judgments offered by the authors of the articles in this special edition are most relevant to school psychologists in training and practice particularly within home and school contexts.

One’s clinical orientation is considered to be one of the most important determinants of assessment/intervention planning and decision making. Clinical judgment is based on one’s training relative to models of child development and clinical conditions of the kind articulated in Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5; American Psychiatric Association, 2013) and the clinical practices that are used to guide decisions, as well as one’s awareness of factors that influence decisions, and the effective processes and procedures with respect to doing psychological/psycho-educational assessment and intervention.

A focus of the first part of the articles in this special edition will be to present the author’s clinical judgment frameworks with respect to decision making in psychological/psycho-educational assessment and intervention. One of the first judgments a school psychologist needs to make in the assessment process is with respect to the nature of the problem for a particular client and the reason for assessment. In other words, the first task in the assessment process is to clearly understand the reason(s) a child or youth is referred for assessment and what questions need to be addressed. Once the problem is identified and the reason for assessment is determined, school psychologists must then decide what processes and procedures will be necessary to investigate and address the problem. Typically, the psychologist gathers historical information about the developmental, familial, medical, and educational background of the child and current information about the child from interviews with significant people in the child’s life, observations of the child in his or her environment, and formal and informal assessment procedures (e.g., the four pillars of assessment; Sattler, 2001). Once the information from these sources is gathered, the psychologist must compare and contrast the information as well as analyze and synthesize the information in a way that best defines and describes the nature and scope of the problem.

Over the past decade there has been more attention to the resources required by school psychologists for evaluating the mental health of children and youth and the frameworks that should be used for determining the factors associated with their range of differences. Children and youth who undergo assessment as well as their parents and teachers should expect school psychologists to use approaches that link assessment to intervention and that are supported by contemporary clinical practice, theory, and research. Moreover, they should expect that school psychologists have a reasonable basis for their judgments and decisions and that their recommendations and involvement towards maximizing the health and wellness of the children and youth they serve will be efficient and effective.

School psychologists typically compare and contrast as well as analyze and synthesize information from various sources by using foundational frameworks that they have learned from the theoretical and empirical literature and from their clinical experiences with children and youth. For example, many school psychologists follow a scientist–practitioner model where by assessment and intervention planning is informed by research. In addition, case conceptualization is often guided by specific scientific/theoretical foundations. For example, some school psychologists are guided by a developmental and/or developmental psychopathology framework and make judgments about the child from his or her understanding of the role of developmental factors, the importance of context, the influence of multiple and interacting events in shaping the child’s development, and the processes by which thinking, feeling, and behavior (normative and atypical) arise and are maintained. In addition, school psychologists may also be oriented to a cognitive framework with specific consideration of an individual’s attention and memory, organization of information, motivation, and self-efficacy, and/or behavioral, biological/neuropsychological, and social psychology perspectives whereby a school psychologist respectively considers environmental influences (e.g., conditioning, reinforcement), biological/neuropsychological factors (e.g., brain structures, brain functioning, neural circuitry), and social factors (e.g., interpersonal relationships, intergroup relations, pro-social and anti-social behavior). Concomitantly, psychologists typically use categorical frameworks (e.g., the use of DSM 5, American Psychiatric Association, 2013) and an empirically based dimensional framework (derived from multivariate statistical techniques) to aid their diagnostic decisions about the type of behavior problems/symptoms the child or youth is exhibiting (for example, internalizing or externalizing problems) and the degree to which the behaviors are normally distributed across children of similar age and gender. However, assessment of children and youth and diagnostic decisions are just part of the clinical role of school psychologists. School psychologists are also involved with treatment/intervention for assessed children and youth, which requires clinical awareness, insight, and judgment. For example, as school psychologists undergo the assessment process, information will be gathered about the strengths and weaknesses of individual children and youth that alert the psychologist to possible connections to treatments/interventions (e.g., psycho-education, behavior management strategies, cognitive restructuring, schoolwork modifications, student/treatment fit, teacher-treatment fit, parent-treatment fit). Hence, throughout the assessment process, the school psychologist needs to develop, test, and evaluate hypotheses. The school psychologist must also be able to formulate recommendations for treatments/interventions that are aligned with and accommodate to the particular diagnostic profile of the individual child. This process requires careful self-reflection by the school psychologist regarding his or her own orientation and skills, and simultaneously how other multidisciplinary team members, parents, children, and the school/home climate are related to the decisions made.

Interpreting assessment data is a critical component of clinical reasoning. To make sense of assessment data and provide accurate and accountable judgments about the cognitive, academic, and/or social–emotional–behavioral performance of a client, the school psychologist must among many other things be aware of (a) the fact that different raters of behavioral performance (e.g., children/youth, teachers, and parents) may provide discrepant information on that performance, (b) the need to look for confirming and disconfirming evidence when making causal inferences, (c) the issues of stereotyping and prototyping of cases due to personal experience and how to overcome this, and (d) their own limitations in the assessment to intervention process and reliance on a scientific approach relative to both assessment and intervention (Andrews et al., 2001; Watkins, 2009).

In this special edition, each author will provide information regarding the referral problem, as well as present background information, behavioral observation information, and assessment results from, for example, cognitive, achievement, and social–emotional–behavioral tests. In addition, they will present and discuss aspects of their clinical reasoning relative to their assessment of a particular child/youth. In addition, the authors will, by and large, present their various approaches and decisions with respect to choosing and implementing a particular intervention. In other words, their thinking processes as they arrive at clinical decisions will be elucidated at each step of the way. In this regard, they will compare and contrast information presented from each source (e.g., background, observation, interview, tests), present hypotheses for what the presented information and test results suggest within and across all information sources, describe how hypotheses are evaluated and revised based on subsequent data collection, provide sources of information they used to make judgments about the cognitive, achievement, and emotional–behavioral performance of the children and youth, describe limitations regarding their interpretative judgments, explain the reasons for their diagnosis and profile interpretations with respect to their assessment, present their decisions regarding their intervention planning and implementation, and report and discuss the resources required for the intervention.

In summary, the authors will convey to the reader their clinical and/or theoretical framework, an overview of the general characteristics of the disorder of focus, how they make sense of all of the information presented toward their case conceptualization formulation, what information they consider to be clinically significant from each of the source of information (e.g., background, observation, interview, tests), what impressions about the child/youth they form as they go through their assessment, what hypotheses they make as they move through their report, what information from each source information seems to fit with each other and what does not, what questions they pose themselves as they analyze and synthesize the information, what patterns emerge, what findings are most salient, what decisions about the child can be made and why, and what information they consider relevant for deciding on a particular intervention for the child/youth.

From our shared thinking relative to applied psychological research, theory, and practice and our shared psychological clinical experience, we can be both validated and enriched relative to our developing wisdom and excellence with respect to our services to children and youth.