Fuss

Written by Dr. John Carosso
There has been lots of fuss about the DSM-V and the autism diagnosis; will it result in less children meeting diagnostic criteria and therefore less children getting the services they need? Is this concern legitimate? I’ve written about this in prior posts, but here I’ll provide further elaboration. (more…)

Subtle difference?

Well, it’s really not so subtle. It’s the difference between labeling your child, or simply describing an annoying and transient behavior. (more…)

At cpcwecare.com you can find a bunch of helpful parenting resources.

Here are a few:

Check out our TV programs from “CPC Presents” covering any number of topics including:

o Facts and fallacies about autism
o Teenage cutting
o Understanding fears and phobias
o Facts and fallacies about ADHD
o Trichotillomania
o Selective mutism
o Managing behavior problems
o Bipolar Disorder in Children
o Video game addiction
o Back to school anxiety
o ADHD and Learning Disabilities
o Child custody issues
o Childhood sleep disorders
o And more

· We have a link to the AppleTreeInstitute.com site that offers on-line step-by-step guidance on how to effectively manage children with autism and/or behavioral challenges. We also have a link to our dyslexiatreaters.com website. (more…)

1. The School District Does not have to evaluate your child just because you submit a signed request to evaluate.

When you submit a written and signed request for an evaluation, the school district has 15 days to meet as a team, discuss your child’s educational needs, and provide a written response with indication of a game-plan to meet your child’s needs. That “game-plan” does not necessarily need to include a referral to the school psychologist for an educational evaluation. It may, rather, include any number of other options including modifications to how the classwork is assigned. However, you can appeal their feedback and request due process in that regard.

2. To determine eligibility for special education services, most Districts still use the 15 point discrepancy rule

If your child is evaluated by the school psychologist, various tests are administered (IQ, Academic…). The scores are listed as “Standard Scores” with an average of 100 (average runs from 90 to 109). There generally needs to be a 15 point “discrepancy” or difference between the IQ score and the academic scores (reading, math…) for a child to be deemed eligible for special education (Specific Learning Disability). For example, if the child obtains an IQ of 100, then it’s expected the reading and math scores will also be about 100 (it’s expected that the child will achieve at the same level as their IQ). However, if the reading or math scores are 85, that’s a 15 point difference and would qualify the child for special education (under the classification of a Specific Learning Disability). Less than a 15 point difference would preclude qualification. Other factors are also considered including PSSA scores, grades, work effort, prior opportunity for being appropriately educated, and English language proficiency. However, the 15 point rule is often primary.

3. The 15 point discrepancy model is why many kids, who may need special education, don’t qualify

It can be quite challenging to obtain a 15 point discrepancy, especially in the lower grades, and even more-so if a child has a lower IQ, say in the low average range. For example, if a child has an IQ Standard Score of 82 (low in the low average range), then the reading and math standard scores would have to be as low as 67, which is quite deficient and unlikely except in the most severe of situations. So, kids who have a lower IQ, and who are often in most need for special education, are often excluded. Keep in mind that, in this scenario, a child with a Standard Score of 70 in Reading is clearly struggling, but does not qualify because there is less than a 15 point discrepancy. This is a situation that most school districts acknowledge as a problem and try to provide alternative options such as Title I and similar programs.

4. The benefit of using grade-equivalents in addition to standard scores

A child may have a Standard Score of 87 in reading comprehension, which is at the upper end of the “low average” range and, on the surface, does not appear significantly deficient and often would not lead to a child meeting criteria for special education (under the classification of a specific learning disability). However, despite the low average score, the grade-equivalent (the grade-level on which the child is working) for that child may be two grades behind, truly revealing the degree to which the child is struggling. Most often, grade-equivalents are not listed in the report, and their importance tends to be down-played for various reasons I won’t bore you with today. However, I’ve found that grade-equivalents are important and need to be reviewed, discussed, and taken seriously during team meetings.

5. A classification of “specific learning disability” or “learning disability”, used by the school district, is essentially synonymous with “dyslexia”

The terminology used by school districts (Specific Learning Disability, Other Health Impairment…) comes straight from the Pennsylvania Department of Education in Harrisburg. This Department tells the Districts what terms they must use to receive funding. Consequently, school districts use the term “specific learning disability (SLD)”. It’s important to know that well over 90% of all kids who fall under the classification of SLD, have dyslexia (or dysgraphia, or dyscalculia…). In that regard, the reason they have a specific learning disability is because they have dyslexia. I’ve written at length about dyslexia, so feel free to read my prior posts about that disorder on the cpcwecare.com blog.

What does this mean for you?

In summary, there are lots of accommodation options besides directly referring to the school psychologist for an evaluation. In fact, you may find the process faster and smoother to receive feedback from the team regarding simple and efficient things they can do, now, in the classroom to help your child, and things you can do at home rather than waiting 60 days for the school psychologist to complete and present evaluation results. This is especially true given that a 15 point discrepancy is often needed for eligibility to receive special education services, and the chances are not great your child will have that discrepancy; especially in the lower grades. A 504 Plan may be more than sufficient and is much faster to develop. A 504 Plan is used for children who have a diagnosis for which various modifications can be used to ensure they have the same opportunity for an appropriate education as everyone else. It’s often used, for example, with kids who are diagnosed with ADHD. Ultimately, however, it’s vital to obtain information about what you can do at home to help your child learn. Again, see my prior posts about dyslexia (learning disabilities) for specific tips and suggestions.

Also, feel free to email me at jcarosso@cpcwecare.com

Dr. John Carosso

We are delighted to announce:

Apple Tree Institute

AppleTreeInstitute.com is an Online Training program offering videos and webinars to help parents of children with autism and/or with behavioral problems.

Our goal is to make the site as helpful, user-friendlyand cost-effective as possible.

We would be indebted if you would view the Web site at AppleTreeInstitute.com, and share your thoughts with us about other topics that you'd like covered, and any suggestions to improve the Web site?

Please forward your thoughts to Dr. Robert Lowenstein, M.D. at r4lowe@gmail.com and Dr. John Carosso at jcarosso@cpcwecare.com.

Thank you again - your feedback is vital and appreciated.

Dr. John Carosso

Pathologizing?

There is wide-spread belief that children are over-diagnosed and over-prescribed, which implies that some kids are ‘just being kids’ and we’re pathologizing them, i.e. giving them a diagnosis, counseling, and medication when we should, rather, be sensitive and accommodating to the wide-spectrum in children’s activity-level and ability to attend. Is this an accurate perspective?

Just the facts Mam’

First, lets look at the stats: Rates of children, ages 4-17, diagnosed with ADHD are at about 7.8% (according to a recent National Health and Nutrition Examination Survey), which is not especially high, and stimulant prescription rates range between 4.3% and 4.4%, which you can see is substantially lower than 7.8%. Also, in that same survey, it was found that only 48% of the ADHD sample had received any mental health care over the prior 12 months, which would suggest children are, actually, being under-treated.

How is the diagnosis made?

To make the point further, if a clinician uses a strict clinical protocol, false-positives (inaccurate diagnosis) should be kept to a minimum. I provide a thorough explanation of the evaluation process in my video on the ‘evaluation process’

But here is a quick overview of specifically what is needed for an ADHD diagnosis: Click Here to Watch YouTube Video

-The child must have a long-history of demonstrating the core ADHD symptoms of inattention, impulsitivity, and hyperactivity. ADHD does not suddenly ‘spring-up’ one day after years of attentiveness. It’s usually something teachers and parents see from as early as the pre-school years.

-The signs are seen in multiple locations (school, home, community…).

-The problem is really getting in the way of the child’s functioning.

-Someone else in the family also has a similar problem with inattention, impulsivity… (ADHD tends to run in the family).

The problem cannot be explained better by some other malady. For example, if the child is distressed, depressed, anxious, or has learning issues, that may explain the symptoms better than ‘ADHD’. In that regard, if a child is experiencing some sort of stress or serious problem, it’s likely he or she will be preoccupied and subsequently have trouble concentrating.

So you can see…

If this protocol is followed, it’s far more likely that there will be an accurate diagnosis, and an effective treatment plan can then be established. I’ve written at length about proper strategies to address ADHD (please see my prior blog posts) that include a consistent and predictable routine, visual reminders, an organized environment, extra attention and assistance, counseling to improve insight and coping strategies and, in some cases, a medication consultation.

Questions?

If you have questions about this process or your child’s diagnosis, email me at jcarosso@cpcwecare.com or call the office. I’d be happy to answer your concerns.

Dr. John Carosso

Without further ado, here they are:

1. ASSUME CONTROL
Control based in Action/Relationship
Don’t entertain explanations
Project self-confidence
Business-like
Give direction, don’t make requests

2. AVOID ARGUMENTS AND EMOTION
Cut-off communication if child becomes belligerent
Avoid reasoning with child
Give direction and walk away
Communicate: It’s your problem, not mine
1-2-3 Magic

3. PLAN FOR NEXT TIME
Discuss ahead of time what will happen if noncompliant
Also discuss between parents – PLAN AHEAD and BE ON THE SAME PAGE
Predetermined expectations and consequences (behavior charts…)
Most problem behavior is predictable and patterned
Be consistent
Don’t give a direction if not ready to back-it-up (each time you do that, you lose some control)

4. DON’T LECTURE
Brief and to the point
Humor
No emotion (be the James Bond of parents)
Don’t explain or lecture
1-2-3 Magic

5. FOCUS ON THE PROBLEM BEHAVIOR; BE SPECIFIC
Be specific (what you want, and what you like)
No emotion, model self-confidence
Don’t focus on “attitude” – focus on behavior

6. AVOID DISTRACTIONS
Turn off TV, video games
Remove siblings
Remove siblings, friends
No distractions during confrontations and chores

7. USE POSITIVE PRAISE AND EMOTION
Catch them being good
Whisper (softer and closer)
You get what you praise
Attention-Tank (fill child’s attention tank with positive praise)

8. SELF-DISCLOSURE
Use judiciously and cautiously
I-Feel Statements (“I feel frustrated when you ignore me…”)
Tell them how you feel, don’t show them (control your emotional response)

9. ROLE MODEL APPROPRIATE PROBLEM-SOLVING
‘What you do speaks so loudly, I can’t hear what you say’
Words and emotion are your enemy (brief, no emotion)
Role model effective problem-solving

10. PICK YOUR BATTLES
Be flexible
Check-in later

Dr. John Carosso

Two years ago I wrote about the problems we face trusting research findings. To bring you up-to-date, here is my follow-up post. Unfortunately, the situation isn't much improved.

The information, or misinformation, we face daily

You may have read the recent study out of Warwick Medical School in the UK suggesting that kids from families that frequently moved when the child was young (resulting in child often-changing schools) have an increased risk of psychosis. I imagine there a bunch of parents feeling guilty that they may have “caused” their child’s mental health issues because they frequently moved years ago. This type of interpretation, or misinterpretation, is all too common. Hardly a day goes by when we don’t hear another such aspersion from the news media. Why might this be off-base? That is correlational and observational-type research (not randomized or double-blinded); it’s not cause-effect. It’s simply indicating an apparent association between these two things; moving, and later evidence of psychosis. There are ample alternative explanations; for example, given that schizophrenia is predominately genetically-based, and can lead to job and housing instability, it’s reasonable to assume that families with a higher schizophrenia-loading are more apt to move, and it’s more likely that one of the children will later show some signs of psychosis. One may not have “caused” the other as the news reports would have you believe.

What made all the difference?

How are we able to cease making such associations between likely unrelated events? Historically, such capacity is relatively recent; think about it, how did we come to stop using ‘bled-letting’ to “cure” illnesses? What made the medical community finally realize these approaches were ineffective, and how did we come to realize that subsequent medical treatments were effective beyond simply doing nothing (or draining the blood out of somebody)?

Randomization

Yes, that simple word, but not so simple a process, saved the day for medicine and all subsequent treatment approaches to this day. The concept is relatively recent; first hypothesized and documented in the 1930’s, but not used to assess surgical treatment until the 1960’s. In the absence of randomization and, even better, single or double-blind controls, there are all sorts of things that can make you think the treatment works, or doesn’t work, when it really does, or doesn’t. These things are called confounding variables, and they wreak havoc on a study’s or a “treatment’s” apparent result or effect. Keep in mind that blood-letting was the treatment of choice for 2000 years and continued into the late 19th century. So much for basing a treatment on one’s clinical observation.

How much havoc?

Well, here’s the sad truth; when it comes to the predictive value of studies, randomized trials have an 85% Positive Predictive Value (PPV) rate. However, once you leave the world of randomization, it gets really bleak, really fast, with PPV dropping to between 20% and .1% for nonrandomized epidemiological studies (you know the ones, announced daily on the news saying that if you eat something in particular you’re going to get some type of horrible malady; or if you move, your child may become psychotic). This led to the prominent researcher, Dr John Ioannidis, asserting that half of all research findings are false (even worse, he suggested that 90% of all medical research is inaccurate, and 50% of the research deemed ‘most reliable’, in the most reputable journals, is inaccurate). In that regard, it doesn't matter if the research is coming from the most reputable of journals; it was still found to be flawed (see hormone-replacement therapy, vitamin D for heart disease, and coronary stints, among countless of other research topics).

It's also common to find a self-serving statistical sloppiness. In a 2011 analysis, Dr. Wicherts and Marjan Bakker, at the University of Amsterdam, searched a random sample of 281 psychology papers for statistical errors. They found that about half of the papers in high-end journals contained some statistical error, and that about 15 percent of all papers had at least one error that changed a reported finding—almost always in opposition to the authors' hypothesis. These errors have far-reaching implications. For example, claims based on fMRI brain-scan studies are increasingly being allowed into court in both criminal and civil cases. However, study in 2009 found that about half of such studies published in prominent scientific journals were so "seriously defective" that they amounted to "voodoo science" and "should not be believed."

What to do?

We’re bombarded daily with news of the ‘latest research’ asserting one thing or another. What can we believe? I wish I had an easy answer for you. All I can communicate, as emphatically as possible, is that if the research is not based in randomization, then it’s a crap-shoot. Moreover, factor the all-too-common politicization of research findings that further bias the results. Bottom-line: always be skeptical, always look below the surface, study the research design, do not take the news reports at face value, and don’t take the reseacher’s findings, as reported directly in the study, at face value. In that respect, lots of researchers will report findings that sound convincing (they want to get published, get tenure, and be seen on 60 Minutes) but are based in correlational or even purely observational designs, both of which are ripe for errors. To make the matter worse, even randomized designs can have problems and inaccurately skew the results in a favorable light (see “enriched” design).

Where do we go from here?

We have a few options:

1.) read and accept research results, as the mainstream press and journals would prefer,

2.) believe nothing and remain skeptical about everything you read and hear,

3.) learn how to effectively analyze research, or

4.) don’t read anything and turn off your TV.

Option 4 doesn’t sound so bad, but I suggest options 2 and 3. It’s not easy, but the alternative is, in my opinion, worse.

If you want some resources to learn about effectively interpreting research, email me at jcarosso@cpcwcare.com.

God bless you in your ongoing pursuit of the truth.

Dr. John Carosso

To tell or not to tell

I am often asked by parents whether or not they should tell their child the diagnosis? It’s a good question, and of course the answer is somewhat complex.

Focus on symptoms, not the diagnosis

I find that it’s rarely beneficial to place a ‘label’ on the symptoms, and subsequently on the child. Rather, I find it helpful to focus on the two or three primary issues or behaviors and explain to the child that you, your child, and the treatment team are going to work improving those issues, e.g. compliance, social skills, safety awareness… The more specific you can be in describing the targeted behavior(s), the better. So, rather than tell a child that he or she has “ADHD” or “autism” and you’re going to treat that “disorder”, I find it more helpful to explain to the child that they have challenges, for example, paying attention in class, or with standing too close to friends, and they’re going to be helped in that regard by specific strategies.

Why not explain the diagnosis?

Explaining the diagnosis can be counterproductive. The child can feel ‘stuck’ in their diagnosis, which often can be stigmatizing and have negative connotations, and people often come to identify with their diagnosis, ie. “I’m ADHD”, or “I’m autistic”, or “I’m Bipolar…”. No, your child is not ADHD, or autistic; rather, your child has a diagnosis of autism; or has a diagnosis of ADHD…; the diagnosis is not ‘them’ as a person but is only a small part of their many wonderful traits and characteristics. Also, sometimes kids will use the diagnosis as an excuse, “I did that because I’m ADHD…” that too is counterproductive.

When to explain the diagnosis?

I find that, as children mature, they become increasingly inquisitive and insightful. At some point, it’s not uncommon that a child begins to sense that something is ‘different’ about them compared to their peers. It’s not uncommon that, in those situations, the child may approach the parent and ask “what’s going on with me… why am I different… I’m not like other people….” In those instances, it’s likely time to explain the diagnosis while, at the same time, focusing on strengths, abilities, and that the child IS NOT their diagnosis, but that the diagnosis simply reflects a cluster of signs and symptoms with which the child and parent will continue to target in treatment.

It’s also important to emphasize that the symptoms can be improved, and you can site examples of your child having risen above the ‘diagnosis’ in any number of ways.

At times kids will find the information about their diagnosis to be a relief ("I always knew I was different, but never knew why") but others may feel quite distressed with the news. Use a reflective approach (see my earlier posts on that technique) and remain supportive and reassuring. It may help to allow them the opportunity to meet other kids with the same diagnosis (a support group can be quite helpful).

Sum it up

I find that, in general, it’s best to not focus on labels and diagnoses but, rather, describe signs and symptoms that are going to be targeted and overcome. This strategy is empowering, motivating, and directive. However, there are times to discuss the diagnosis, especially if the child is relatively mature, has good self-awareness and insight, and is asking questions about why he or she seems or behaves ‘differently’ from peers. There are a number of helpful books and resources to help with this process; feel free to email me if interested.

Hope that helps. Feel free to email any questions at jcarosso@cpcwecare.com

God Bless!

Dr. John Carosso

Which Wolf are you Feeding?
I don't usually post stories such as this, but this one is too good not to share:

One evening an old Cherokee told his grandson about a battle that goes on inside all people. He said, “My son, the battle is between two ‘wolves’ inside us all."

“One is Evil. It is anger, envy, jealousy, sorrow, regret, greed, arrogance, self-pity, guilt, resentment, inferiority, lies, false pride, superiority, and ego.”

“The other is Good. It is joy, peace, love, hope, serenity, humility, kindness, benevolence, empathy, generosity, truth, compassion and faith.”

The grandson thought about it for a minute and then asked his grandfather, “Which wolf wins?”

The old Cherokee simply replied, “The one you feed.”

There is debate over where this story originated and who wrote it. No matter, I hope you find it to be moving, motivating, and inspiring.

God bless.

Dr. John Carosso