Dance with the Tiger.

Twice this week, I embarrassed myself by making an obscure reference to an obscure part in an obscure film to make a point. Has anyone else besides me and my husband seen Cedar Rapids, starring John C. Reilly and Ed Helms? No? Well then you would have looked at me with the same look these two groups of people did. But I like the analogy, so here you go.

In the soon-to-be-classic film, Cedar Rapids, starring John C. Reilly and Ed Helms, the main characters are insurance agents attending a conference to battle for the prestigious “Two Diamonds” award for excellence. In one scene, John C. Reilly’s character gives Ed Helms’s character advice: that in order to meet his goals, he can either “fight the tiger” or “daaaaaaance with the tiger.” In the context of the movie, it is basically a decision to fight the guy in the jacked up insurance system or work the guy and the system to your advantage.* And it’s funny because John C. Reilly he does so in his underwear and does a tiger dance.



In one case where I embarrassed myself this week, the school staff and district muckidy mucks (sp?) were having a strategy meeting before a highly contentious parent meeting. The parent has had her child assessed three times over the course of the kid’s school history, and each time, the child came up in the intellectually disabled range cognitively (formally known as mentally retarded). She claims that the school district each time has not assessed him properly and further, that she is entitled to a hojillion dollars in compensatory education at the district’s expense for failing to bring him up to state academic standards. Oh, and the child is autistic as well. Like, biting other people autistic. Low and behold, the last assessment also came up with low cognitive scores as well. As the conversation turned to how to fight this mom and her denial, I told the staff, “I think on this one we should daaaaaance with the tiger” and I made a dancing gesture not unlike the one John C. Reilly does.

[Crickets chirp]

So I went on to explain the movie, and then suggested that we might partially validate mom’s concern, without totally caving in. I get denial. Dealing with the truth is painful. Externalizing blame happens. I can’t claim that if I had a severely disabled kiddo that I wouldn’t be a fighting tiger for his or her rights. I’ve never been in that situation, and can empathize with the grief and anger of having an out of control child. I know that some districts do not provide a very good education for some groups of kids. We're not perfect, and we have no money to create perfect programs. But if I were in the parent's situation, I would like to think I would not sue poor urban school districts for a squillion dollars in compensatory education and blame the teachers for my child's disability. One never knows though.

Anyhoo, the mom’s big thing was that her child had untapped potential. And maybe there is untapped potential we can’t see because the kid is off biting and punching people in class. In my post-doc years, I learned a great way to describe the concept of untapped potential in kids with Autism. I had the great fortune to train with the amazing Bryna Siegel, autism guru, and author of The World of the Autistic Child and many others. She explained it something like this:

Each child’s cognitive potential is like a bowl. Some bowls are deeper than others. We can measure cognition in kids without Autism, because they comply with “on demand tasks” (as in, put these blocks together, answer this question right now, finish this puzzle this fast). Kids with Autism (or behavior problems, for that matter) have saran wrap over their bowls. We don’t know how deep the bowl is, because they have trouble performing on demand. The bowls could be very deep and untapped potential is in there, or the bowl could be shallow. We don’t know until we peel the saran wrap off. We peel the saran wrap off by working on the behaviors that are interfering with joint attention.

I proposed that we use the analogy with this mom. That way, we are acknowledging there could be untapped potential, but in order to fully see it, we have to address the behavior and work on “peeling the saran wrap” off. Instead of arguing about how “deep” his cognitive bowl is, we can shift the conversation to helping this kid connect to others and be safe. I am sure this is a mutual goal of the mom. Let’s just hope after the meeting, it looks a little something like this….



Wish me luck. I do want to have a productive and positive meeting. No one likes getting swiped in the face by a tiger mom.

Special Education, IEPs, and Due Process, Oh My.

For those of you who missed it, here's my appearance on Learning and Laughter with Louise on the topic of special education. I did this radio appearance at 6:00 am on my summer break, since Louise is on east coast time. That means I had to get up at 5:30 to make a coffee the size of my head to be somewhat normal by 6am. I did it for the children.

We talked about a variety of topics, from the basics of Individual Education Plans (IEPs) to warning signs for Autism. At the end, there is a Q and A with parents who want to know if their child's behavior is typical, or a sign of a disability.

Also, may I note that I never want to hear myself laugh on the radio again, even if it is on a show called Learning and Laughter. I checked the url to make sure it was the right episode and I managed to skip right to the part where I laugh at my own joke. I die of embarrassment.

Enjoy!

Click here to download the episode onto iTunes. I tried for 2 days to embed a media player in this post so y'all could just listen here, but alas, FAIL. I guess if I were one of those fancy Web2.0 education people, I could do it. And if I even knew what Web 2.0 was, that would be even better.

Sensory-Integration Disorders

When I first started my clinical practice at a Children's Hospital, I got referrals left and right to assess children for "Sensory Integration" disorders. The classic referral was from parents who were concerned that their 2 year old was clumsy (aren't they all kind of clumsy?) or didn't like tags touching them (who does?). I thought maybe I missed that day in graduate school, because at the time, I had never heard of such a disorder. Sure, I had heard of children with Autism and ADHD who had sensory issues, but not a "Sensory Integration Disorder," per se. All I knew was that when I brought it up to other professionals, it was met with an eye roll 9 chances out of 10. Over the years, I have heard the term less and less, but for those wondering what the heck it is, and if it's even a real disorder, check out this posting on Quack Watch. I'd love to hear what others think on this issue.

OJ is Going to Jail

You are thinking: “How is OJ Simpson’s latest pending incarceration possibly related to educational psychology?”

WELL. This is a full-service blog, people!

As I picked up my morning paper today, I saw that OJ was going to jail for 9 years and I smiled, not because I particularly enjoy when ex-athletes get incarcerated, but because I have a fond memory of an autistic child I worked with who could not stop talking about OJ Simpson. It was one of his “things.” As many readers know, one of the characteristics that can be present in children with Autism is both restricted interests* and echolalia (repetition of words or phrases). This particular boy was into OJ. Now this was 2 full years after OJ’s acquittal, and he always repeated, in the same voice tone, “OJ’s going to jaaaaaaaaaaaaail!” As in:

Me: Hi, how are you today?
Him: OJ’s going to jaaaaaaaaaaaaail!
Me: Honey, OJ isn’t going to jail. They let him go.
Him: OJ’s going to jaaaaaaaaaaaaail!
Me: OJ is not going to jail.
Him: I want juice.

*ten seconds elapse*

Him (screaming and running up and down the stairs ): OJ’s going to jaaaaaaaaaaaaail! OJ’s going to jaaaaaaaaaaaaail! OJ’s going to jaaaaaaaaaaaaail!

I can’t help but wonder this morning if that kid feels totally vindicated today.

*Be careful before you self-diagnose your 8-year-old child or nephew as “Autistic” because he is really into trains, Bakugan Battle Toys, biking or PS2. Those are normal restricted interests. We’re talking about RESTRICTED interests that are waaaay beyond the scope and intensity of normal fads and hobbies.

Under the Microscope

While waiting at the airport the other day, I overheard a mother saying solemnly to her friend, “Dillon is such a picky eater. AND he doesn’t like the tags in his clothing. I hope he’s not autistic.” Friend said, “You should have him evaluated.” I looked over at young Dillon, probably age 3, and he was happily playing with his sister, smiling, talking up a storm and laughing. I know it takes a village to raise a child, but I managed to hold my tongue from saying, “Show me a 3 year old who likes tags itching him and every food you put in front of him and I’ll give you a million dollars.”

The problem with certain disability awareness campaigns is that it makes parents paranoid. Parents are scouring their children’s developmental checklists and if there is a slight lag in anything, then the fear of a disability can take over. I don’t blame parents for wanting reassurance that their child is on track developmentally. I do empathize with difficult balance of appropriate awareness and the call for microscopic examination of children that is pervasive in the media (and sadly, sometimes in our own field).

I am reminded of a college biology unit in which we studied microorganisms. We were asked to swab a surface of our classroom and put it in a Petri dish to examine later under a microscope. To this day, I wish I never had such an up close and personal relationship with bacteria that lives on doorknobs. *gags to self* How could I have been so oblivious to the perils of opening doors?!? Look at all those little evil microorganisms just waiting to infect me! I’ll never open a door without a Haz-Mat suit again!*

Truth is, most are harmless. But when you put things under a microscope, you see things you normally wouldn’t see.

And what I saw as I waited for my flight, was a happy little normal 3 year old boy named Dillon whose mom probably caught an episode of Oprah in which Jenny McCarthy told her to send him to the developmental pediatrician at the first sight of any “autistic-like behavior.”

*I recently attended a Health and Safety seminar for my work and am now also paranoid of sneezes. They showed a sneeze up close in slow motion and it was disgusting. The national health standard for sneezing, just so you know, is to sneeze into your sleeve. Spread the word, not the germs.

Psychoeducational, not Psycho-Educational—Part III

This post could be an entire blog, book, or career. I will try to do it justice. The cognitive/intelligence portion of the pychoeducational assessment is the keystone to determining whether or not a student has a learning disability, understanding the potential for learning, and/or knowing how the student learns best.*

First, lets start with some definitions. Try this activity. I want you to think about the word “LOVE” and try to define it. Go ahead….do it in your head.

Now, quick quiz. What is LOVE?

a) Never having to say you’re sorry
b) A deep, tender, ineffable feeling of affection and solicitude toward a person, such as that arising from kinship, recognition of attractive qualities, or a sense of underlying oneness.
c) Something people whom play tennis do not like.
d) A variety of different feelings, states, and attitudes, ranging from generic pleasure to intense interpersonal attraction.
e) Blind
f) Determined at first sight

The answer is: g)Yes. “Love” is a psychological construct that can be defined in any number of ways, depending on the context, culture, and what aspect you want to measure. The same goes for “Intelligence.” It can be defined in any number of ways, depending on your theoretical orientation. Each intelligence test given by a psychologist has a slightly different way of defining and measuring the construct of “intelligence.” In general, school psychologists will look at two to four aspects of intelligence.**

1) Verbal Reasoning
2) Nonverbal (Visual-Spatial) Reasoning
3) Working Memory
4) Processing Speed

Each one of these deserves a new post. Each one of these areas can also be described as areas of “Processing.” A low score in any one of the categories can be called a “Processing Deficit.” To confuse matters, the above processing areas do not necessarily map onto what special education law calls “Processing Deficits,” the presence of which is one criteria for eligibility for a student with a “Learning Disability.” The law defines “Processing Deficits” as Auditory Processing, Visual Processing, Visual-Motor Processing, Attention Processing, Conceptualization/Association.*** Each of these loosely map on to dimensions of “Intelligence” as measured by IQ tests, and also have their very own test.

A school psychologist’s job is to carefully examine the results of the IQ test and do further testing in “processing” areas to confirm that low results on one type of learning are due to actual deficits in cognition, rather than any number of factors such as fatigue, low effort, poor attention, malingering, social-emotional distraction, test anxiety, depression, etc. One cannot look at an IQ test and determine anything without testing observations and the larger context.

One word of caution for parents about seeking an assessment for a Learning Disability: Make sure the person is qualified. There are a number of inadequately trained people diagnosing Learning Disabilities whom are not psychologists and do not have the larger picture. Some have only bachelor’s degrees and took a summer or two of courses and call themselves “therapists.” They give an IQ test and a test of academic achievement, and based on scores alone diagnose disabilities. I have seen gross misinterpretation of scores, such as clearly average scores being called “deficits” and normal variations in processing called “disabilities.” I have seen computer printouts of scores as a “report” and no other factor is taken into consideration. Meanwhile, the parent has forked over thousands of dollars for a potentially wrong diagnosis. Think of it this way. It would be like taking your kid to the hospital with a symptom of “fatigue” and having someone with a B.A. in Biology who has had a little extra training in one specific medical problem diagnose him/her. You might not get an accurate diagnosis, because the symptom of “fatigue” can be caused by any number of medical problems, but they only have training in one.

Be sure that the person who is assessing your child is at minimum a Licensed School Psychologist or (in California) a Licensed Educational Psychologist (not “Educational Therapist”). Clinical Psychologists are the “gold standard” of assessors if you are also concerned that your child has a potential psychiatric disorder in addition to learning challenges. I would argue that a School Psychologist or Educational Psychologist would be more school/context/practically oriented and a Clinical Psychologist might be more psychological/interpersonal focused, though there is overlap depending on the person’s training. This was a bit of a digression from defining “Intelligence” and how to assess it, but I believe a diagnosis is only as good as the assessor’s clinical skills to interpret the test results.

*Cognitive=intelligence=IQ=ability=potential depending on what test you give. Same idea, used interchangeably in most psychoeducational reports. In California, it is state law that IQ tests cannot be used with African American students, but I think that is wrong. That is another post.

**Sorry, forget about “Multiple Intelligences” such as musical, interpersonal, kinesthetic, etc. Schools may give lip service to multiple intelligences, but the only ones that “count” grade-wise are basically Verbal and Visual reasoning, heavily emphasis on the Verbal learning. Sorry kids who think outside the box. Get your creative musical self back in that box if you want to graduate and go to college.

***If you find one school psychologist who knows what “Conceptualization/Association” is, I will give you a prize. It is barely used to qualify students as “Learning Disabled” because no one has really defined it well. That’s what you get when the law doesn’t match the research.

Alphabet Soup

I once worked with a 6-year old boy who was referred for a special education assessment following a report from a clinical psychologist that diagnosed him with Attention Deficit Hyperactivity Disorder (ADHD), Anxiety Disorder—Not otherwise Specified (NOS), Tic Disorder, Autism Spectrum Disorder (ASD) and a Speech and Language Disorder. He was also being seen by a neurologist for a sleep disorder. The summary page read a lot like, ASD, ADHD, ASD, LMNOP. XYZ. That is a lot of diagnoses for a 6 year old.

I expected this child to be falling apart in the classroom. After all, he was anxious, hyperactive, inattentive, autistic, couldn’t speak or understand language, was having tics, and was working on barely any sleep. What I found was a friendly little boy working in a small group of students on an art project. He was sharing his art supplies, taking turns with the green marker, and sitting in his chair. At one point, he went to the teacher and gave her a hug. He used a robot-like voice with her, saying "I sure am glad you are my teacher." During an academic setting, he struggled with math—he counted 1-2-5-7-8 on his fingers when working out if there were more red or green marbles. Reading appeared to be a strong skill for him. He read outloud fairly fluently when called on to read from a predictable rhyming book.

On the playground, I observed him playing ball with some other boys. He was bossy. He demanded that they all play kickball and ignored other suggestions. There was nothing outrageous about his behavior though. After double-checking that I was indeed observing the same child as the report, I was perplexed.

Did I catch this kid on the best day of his life? It was unclear where the symptoms of his hefty portion of alphabet soup o’ diagnoses had gone. What was clear is that I needed more information. The teacher and mom shared that the boy sometimes “misperceived social situations” or “got upset for no reason.” I asked the teacher and parent for examples. His teacher said that last week, he told the boy to “Put your eyes on your own paper!” and he screamed “No!!! Gross!!!” The week before, he started crying when the teacher asked him to “Give me your hand.” He yelled “No!!! It’s mine!” His mom said that one time he went up to a man on the street and asked him if he wanted to go to school with him. Now that’s kind of odd, you have to admit.

What disability results in these types of social difficulties? He had a hard time interpreting metaphors and abstract language. He was bossy with peers. He had major difficulties in math (and ultimately on all visual tasks I gave him). This was a student who on the first day of testing bounded over to me like Tigger and grabbed my hand to show me where the testing room was; the next day he gave me a huge “hi-five,” and then one second later asked point blank, “Wait. Do I know you?”

A number of hypotheses came to mind about what was going on for this little guy---and most of them fell somewhere along the Autism Spectrum. School psychologists could write multiple dissertations on the differential diagnoses of Autism from Aspergers, Nonverbal Learning Disabilities, ADHD, PDD, and all the other diagnoses this boy had from the clinical setting. And after we published said dissertations, we would still meet a kid the next day who didn’t quite fit in any of these diagnostic categories. We might say to a colleague, I’m working with this kid whose kind of “spectrumy.”

After obtaining all the information, this little guy was ultimately diagnosed with a Nonverbal Learning Disability (NLD)*, based upon his poor visual processing, difficulties with language pragmatics, and problems reading social cues. Making differential diagnoses is one of the most difficult parts of our jobs. Some have argued that these diagnoses are arbitrary, and that we should just give kids what they need. It is tempting, I must admit, to pour the alphabet soup o’ diagnoses down the proverbial drain. I am torn though, because a good diagnosis can provide information about how to intervene. I will take the middle road and say that a diagnosis is good to the degree that it provides access to services and appropriate intervention.

*The best book on NLD I’ve found is called (big surprise!) Nonverbal Learning Disabilities: A Clinical Perspective, by Joseph Palombo. It details the diagnosis, assessment, and intervention with this population of students.