The information in this document is intended to support practitioners in making informed, well-reasoned decisions around remote assessment.
This information is not intended to be comprehensive regarding all considerations for assessment via telehealth. It should not be interpreted as a requirement or recommendation to conduct an assessment via telehealth. Practitioners should remain mindful to:
- follow professional best practice recommendations and respective ethical codes
- follow telehealth regulations and legal requirements from local authorities, licensing boards, and professional liability insurance providers
- develop competence with assessment via telehealth through activities such as practising, studying, consulting with other professionals, and engaging in professional development.
Practitioners should use their clinical judgment to determine if assessment via telehealth is appropriate for a particular examinee, referral question, and situation. There are circumstances where assessment via telehealth is not feasible and/or is contraindicated. Documentation of all considerations, procedures, and conclusions remains a professional responsibility.
The Pyramids and Palm Trees Test (1992) can be administered in a telehealth context by using digital tools from Q-global®, Pearson’s secure online testing and scoring platform.
Q-global digital assets (e.g. stimulus books) can be shown to the examinee in another location via the screen-sharing features of teleconference platforms. Details regarding Q-global and how it is used are provided on the Q-global product page.
A spectrum of options is available for administering the Pyramids and Palm Trees Test via telehealth; however, it is important to consider the fact that the normative data were collected via face-to-face assessment. Telehealth is a deviation from the standardized administration, and the methods and approaches to administering it via telehealth should be supported by research and practice guidelines when appropriate.
Providers engaging in telehealth assessment may train facilitators to work with them on a regular basis in order to provide greater coverage to underserved populations (e.g. only two providers within a 75-mile radius, shortage of school practitioners within a city/county council). If such a facilitator is well trained and in a professional role (i.e. a professional facilitator), they can present stimulus books as well as adjust audiovisual equipment.This approach yields the Pyramids and Palm Trees Test scores that are available in face-to face assessment mode.
In times when social distancing is necessary (such as the COVID-19 pandemic), using a professional facilitator may not be safe or feasible. If testing must occur under these conditions, it is possible that the examinee may participate without the help of an onsite facilitator. If the examiner determines that no facilitator is required, the examinee can assist with technological and administrative tasks during testing, and should be oriented to these responsibilities prior to the testing session, and again at the beginning of the session.
An initial virtual meeting should occur in advance of the testing session to address numerous issues specific to testing via telehealth. This initial virtual meeting is described in the administrative and technological tasks portion of the Examiner Considerations section and referred to in various sections of this document. The examiner should consider best practice guidelines, the referral question, and the patient’s condition, as well as telehealth equivalence study conditions to determine if this is possible and appropriate. Independent examinee participation may not be possible or appropriate, for example, for examinees with low cognitive ability, traumatic injury or with low levels of technological literacy and experience.
If the examiner determines that the examinee cannot participate independently, and testing must occur under social distancing constraints, the only facilitator available may be someone in the examinee’s home (e.g. a parent, guardian, or caretaker). If the onsite facilitator is not in a professional role (i.e. non-professional facilitator), they can assist with technological and administrative tasks during testing and should be oriented to these responsibilities in the initial virtual meeting, and again at the beginning of the session.
Professional and non-professional facilitators typically do not remain in the room with the examinee throughout the testing session. The examiner should plan to minimise (as much aspossible) the need for the facilitator to remain in the room. In rare cases when the facilitator must remain in the room, they should do so passively and unobtrusively, and merely monitor and address the examinee’s practical needs, as well as any technological or administrative issues as necessary. The facilitator’s role should be defined clearly by the examiner, and they should only perform those functions the examiner approves and deems necessary.If a facilitator is necessary, it is preferred that the facilitator remain accessible.
Conducting Telehealth Assessments
Conducting a valid assessment in a telehealth service delivery model requires an understanding of the interplay of a number of complex issues.
In addition to the general information on Pearson’s telehealth homepage, examiners should address the following five factors when planning to administer and score assessments via telehealth.
1. Telehealth Environment and Equipment
Computers and connectivity
Two computers with audio and video capability and stable interne tconnectivity – one for the examiner and one for the examinee – are required.
A web camera, microphone, and speakers or headphones are required for both the examiner and the examinee. A second computer screen or split-screen format on a large computer monitor for the examiner is helpful to allow a view ofthe digital manual.
When items with visual stimuli are presented, the digital image of the visual stimuli on the examinee’s screen should be at least 9.7” (24.63 cm) measured diagonally. Some teleconferencing platforms shrink the size of images, so the facilitator should verify the image size in the initial virtual meeting. It is recommended that computer screens used for teleconference assessment be at least 15” (38 cm) measured diagonally. Smaller screens, such as those of iPad minis, small tablet PCs, and smartphones, are not allowed for examinee-facing content, as these have not been examined empirically and may affect stimulus presentation, examinee response, and validity of the test results.
Similarly, presenting stimuli on extremely large screens has not been examined, so the same precaution applies. At the beginning of the testing session, the examiner may ask the facilitator to aim a peripheral camera or device (as described on below) at the examinee’s screen to ensure that the examinee’s screen is displaying images in the correct aspect ratio and not stretching or obscuring the stimuli image.
A teleconference platform is required. Screen sharing capability is required if anything other than items with verbal stimuli and responses are administered.
High-quality video (HD preferred) is required during the administration. Make sure the full faces of the examiner and the examinee are seen using each respective web camera. The teleconference platform should allow all relevant visual stimuli to be fully visible to the examinee when providing instruction or completing items; the view of the examiner should not impede the examinee’s view of visual test stimuli.
Screensharing digital components
Digital components are shared within the teleconferencing software. There are two ways to view digital components in the Q-global Resource Library: through the pdf viewer in the browser window; or full screen in presentation mode. Always use full screen(i.e. presentation) mode for digital components viewed by the examinee. This provides the cleanest presentation of test content without onscreen distractions (e.g. extra toolbars).
Test item security in the audiovisual environment
The examiner is responsible for ensuring test item security is maintained, as outlined in the Terms and Conditions for test use. The examiner should address test security requirements with the examinee (and facilitator, if applicable) during the informed consent process. The examiner should make it clear that the video should not be captured, photos should not be taken, and stimuli should not be copied or recorded, as this is a copyright violation.
The examinee must agree that they will not record (audio or visual) or take photos or screenshots of any portion of the test materials or testing session, and will not permit anyone to observe the testing session or be in the testing room (except for a facilitator, when necessary).
Peripheral camera or device
A stand-alone peripheral camera that can be positioned to provide a view of the session from another angle or a live view of the examinee’s progress is helpful. Alternately,a separate device (e.g. a smartphone with a camera or another peripheral device) can be connected to the teleconference and set in a stable position to show the examinee’s non-verbal responses. The device’s audio should be silenced and the microphone should be muted to prevent feedback. The examiner should guide positioning of the peripheral camera/device before administering the test so that any of the examinee’s real-time pointing or gestured responses are captured.
In a typical telehealth session, it is more feasible to make a document or moveable camera available in the examinee’s location. However, while social distancing is necessary,the only camera available may be a stationary camera integrated into the examinee’s laptop or computer screen. It is unrealistic to expect examinees to have document cameras within their homes. It may be necessary for examiners to think creatively about how to use a smartphone in the examinee’s location to gain a view of the examinee pointing at a screen. Prior to attempting this with an examinee, the examiner should work to become fluid and competent at directing examinees in these methods, which can require extensive practice with varied individuals and types of smartphones. In addition,this requires planning and practice in the initial virtual meeting to prevent technical difficulties, and so the examinee feels confident doing this when it is time.
Online instructional videos (e.g. here) demonstrate how a smartphone may be used with common household objects (e.g. a tower or stack of books, paper weight, ruler, and elastic band or tape) to create an improvised camera and stand upon which to position the device to provide a second-angle view of the examinee pointing at the screen. Typically, devices provide the best view of the examinee’s screen and pointing responses when positioned in landscape format. While using a smartphone as the peripheral camera is not optimal or an optimal solution for telehealth, it can be functional if executed well.
When gesturing to the stimulus book is necessary, the examiner should display it as a digital asset on screen and point using the mouse cursor.
High-quality audio capabilities are required during the administration. An over-the-head, two-ear, stereo headset with attached boom microphone is recommended for both the examiner and examinee. Headphones with a microphone may be used if a headset is not available.
The examiner should test the audio for both the examiner and examinee in the initial virtual meeting and at the beginning of the testing session to ensure a high-quality audio environment is present. Testing the audio should include an informal conversation prior to the administration where the examiner is listening for any clicks, pops, or breaks in the audio signal that distorts or interrupts the voice of the examinee. The examiner should also ask if there are any interruptions or distortions in the audio signal on the examinee’s end. Any connectivity lapses, distractions, or intrusions that occurred during testing should be reported.
Manage audiovisual distractions
As with any testing session, the examiner should do everything possible to make sure the examinee’s environment is free from audio and visual distractions. If the examiner is unfamiliar with the examinee’s planned physical location, a visual tour of the intended testing room should be given during the initial virtual meeting. The examiner can then provide a list of issues to address to transform the environment into one suitable for testing. For example, remove distracting items, silence all electronics, and close doors.The examiner should confirm that these issues have been addressed at the time oftesting. If possible, the examinee should be positioned facing away from the door to ensure the examiner can verify through the examinee’s camera that the door remains shut and can monitor any interruptions. The examiner should confirm that all other applications on the computer, laptop, or peripheral device are closed, the keyboard is moved aside or covered after the session is connected, and alerts and notifications are silenced on the peripheral device. Radios, televisions, phones, fax machines, smartspeakers, printers, and equipment that emit noise must be silenced and/or removed from the room.
Good overhead and facial lighting should be established for the examiner and examinee. Blinds or shades should be closed to reduce sun glare on faces and the computer screens.
The examiner should record any and all atypical events that occur during the testing session. This may include delayed audio or video, disruptions to connectivity, the examinee being distracted by external stimuli, and any other anomalies. These should beconsidered during interpretation and described in the written report.
2. Assessment Procedures and Materials
Permission must be obtained for access to copyrighted materials (e.g. stimulus books,record forms) as appropriate. Pearson has provided a letter of No Objection (PDF| 77.5 KB) to permit use of copyrighted materials for telehealth via teleconferencing software and tools to assist in remote administration of assessment content during theCOVID-19 pandemic.
The examiner should practise using the digital assets until the use of the materials is as smooth as a face-to-face administration. It is not recommended that the examiner display items from paper stimulus books on a camera.
Input and output requirements and equivalence evidence
The examiner should consider the input and output requirements for each task, and the evidence available for telehealth equivalence for the specific task type.
Telehealth Versus Face-to-Face Administration
Preliminary research has compared results obtained in telehealth and face-to-face administration modes. Several tasks drawn from the Wechsler scales have produced evidence of equivalence in telehealth and face-to-face modes for examinees with avariety of clinical conditions.
While equivalence data on similar measures are relevant, practitioners should be mindful that more research is needed to establish equivalence in all ages and for all tasks onother tests. Additional caveats and cautions are described in Grosch et al. (2011).(ref 3)
Also, most telehealth-based studies were conducted with volunteer subjects in controlled environments. When social distancing is key (such as during the COVID-19 pandemic) some examinations may need to occur in patients’ homes, and it should be noted that very little research has been done about remote assessment in private homes. It is important to consider the conditions under which equivalence studies of telehealth and face-to-face assessment modes were conducted and attempt to reproduce theseas closely as possible if testing via telehealth. Typical telehealth studies that support telehealth and face-to-face equivalence involve the examiner becoming very familiar with the teleconference platform by using it for its intended purpose for several hours and administering tests (even those that are familiar in face-to-face mode) multiple times to ‘practice examinees.’ Some studies that have established telehealth and face-toface mode equivalence involve a professional facilitator. However, preliminary research conducted and described by Lana Harder with parents serving as in-home facilitators who managed audiovisual needs and response booklets found no significant differences across modes (ref 4).
Finally, the examinee is typically in an office- or school-based setting. Therefore, if in-home assessment is taking place, it is advisable to prepare a similar environment as much as possible as described in the Telehealth Environment and Equipment section.
Digital Versus Traditional Format
Telehealth involves the use of technology in assessment as well as viewing onscreen stimuli. For these reasons, studies that investigate assessment in digital versus traditional formats are also relevant. A number of US investigations of Pearson products have produced evidence of equivalence when administered and scored via digital or traditional formats to examinees without clinical conditions (ref 5). In addition, equivalence has been demonstrated for examinees with clinical conditions, such as intellectual giftedness or intellectual disability (ref 6), attentiondeficit/hyperactivity disorder (ref 7), or autism spectrum disorder or specific learning disordersin reading or mathematics (ref 8).
However, it is important to note that these studies were not conducted remotely or via video conference.
3. Examinee Considerations
The examiner should first ensure that a telehealth administration is appropriate for the examinee and for the purpose of the assessment. Clinical judgment, best practice guidance for telehealth (e.g. BPS, 20209; RCSLT, 202010), information from professional organizations and other professional entities (e.g. licensing boards, legal resources,professional liability insurance providers), consultation with other knowledgeable practitioners, existing research, and any available government regulations should be considered in the decision-making process. Consideration should be given to whether the necessary administrative and technological tasks involved in a telehealth session can be accomplished without influencing results.
Before initiating test administration, the examiner should ensure that the examinee is well-rested, able, prepared, and ready to appropriately and fully participate in the testing session.
If using a facilitator, the role of the facilitator must be explained to the examinee so participation and actions are understood.
It may not be appropriate or feasible for some examinees to use a headset due to behaviour, positioning, physical needs, or tactile sensitivities, or if a headset is not available. Clinical judgement on the appropriate use of a headset in these situations should be used. If a headset is not utilized, the examiner’s and examinee’s microphones and speakers should be turned up to a comfortable volume.
On some teleconference platforms, the examiner can pass control of the mouse to allow the examinee to point to indicate responses; this is an option if it is within the capabilities of the examinee. However, best practice guidelines provide cautions about this. For example, IOPC guidelines suggest examiners be alert throughout administration, return control of the screen once the task is finished, and never leave the computer unattended while the examinee has control over the examiner’s computer (ref 11)
4. Examiner Considerations
During the telehealth setup, and before administering to any actual examinee, the examiner should rehearse the mechanics and workflow of every item in the entire test using the selected teleconference platform so that the examiner is familiar with the administration procedures. For example, a colleague could be used as a practice examinee (ref 12).
The examiner must follow the administration procedures of face-to-face administration as much as possible. For example, if a spoken stimulus cannot be said more than once in face-to-face administration, the examiner must not say it more than once in a telehealth administration unless a technical difficulty precluded the examinee from hearing the stimulus.
Administrative and technological tasks
In order to conduct a smooth telehealth session, audiovisual needs and materials must be managed appropriately. The initial virtual meeting involves the examiner,examinee, and/or the facilitator (if used), and is the opportunity for the examiner to provide information about the audiovisual needs and materials. During the initial virtual meeting, the examiner should provide training in troubleshooting audiovisual needs that arise during the testing session, including camera angle, lighting, and audio checks.The examiner should provide verbal feedback to guide camera adjustment, checking the onscreen video shown by the peripheral camera/device to provide information about how to reposition it until the proper view is shown. If used, the facilitator is to assist with administrative and technological tasks and not to manage rapport, engagement, or attention during the testing session. The examiner should direct them not to interfere with the examinee’s performance or responses. Any other roles and responsibilities for which an examiner needs support, such as behaviour management, should be outlined and trained prior to the beginning of the testing session. The examiner is responsible for documenting all behaviours of the facilitator during test administration and taking these into consideration when reporting scores and performance.
5. Other Considerations
There are special considerations for written reports describing testing that takes place via telehealth.
The professional completing the written report should state in the report that the test was administered via telehealth, and briefly describe the method of telehealth used.
For example: “The Pyramids and Palm Trees Test was administered viaremote telehealth using digital stimulus materials on Pearson’s Q-globalsystem, and a facilitator monitored the administration onsite during the livevideo connection using the [name of telehealth system, e.g. Zoom] platform.”
The professional should also make a clinical judgment, similar to a face-to-face session,about whether or not the examiner was able to obtain the examinee’s best performance. Clinical decisions should be explained in the report, including comments on the factors that led to the decision to conduct testing via telehealth and to report all (or not to report suspect) scores. In addition, it is recommended that the report include a record of any and all atypical events during the testing session (e.g. delayed video or audio, disruptions to connectivity, extraneous noises such as a phone ringing or a dog barking, a person or animal unexpectedly walking into the room, or the examinee responding to other external stimuli).
Notes may be recorded about these issues on the back of the record form. List and describe these anomalies, as is typical for reporting behavioural observations in the written report, aswell as any observed or perceived impact on the testing sessions and/or results, and considerthese in the interpretation of results.
For example: “The remote testing environment appeared free of distractions, adequate rapport was established with the examinee via video/audio, and the examinee appeared appropriately engaged in the task throughout the session. No significant technological problems ordistractions were noted during administration. Modifications to the standardization procedure included: [list]. The WIAT subtests, or similar tasks, have received initial validation in several samples for remote Telehealth and digital format administration, and the results are considered a valid description of the examinee’s skills and abilities.”
The Pyramids and Palm Trees Test was not standardized in a telehealth mode, and this should be taken into consideration when utilizing this test via telehealth and interpreting results. For example, the examiner should consider relying on convergence of multiple data sources and/or being tentative about conclusions. Provided that the examiner has thoroughly considered and addressed the factors and the specific considerations as listed above, the examiner should be prepared to observe and comment about the reliable and valid delivery of the test via telehealth.
Materials may be used via telehealth without additional permission from Pearson in the following published contexts:
- Pyramids and Palm Trees Test manual and digital stimulus book via Q–globalTM
Any other use of the Pyramids and Palm Trees Test via telehealth requires prior permission from Pearson and is not currently recommended. This includes, but is not limited to, scanning the paper stimulus books, digitising the paper record forms, holding the materials physically up in the camera’s viewing area, or uploading a manual onto a shared drive or site.
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