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[00:00:00] Dr. Sharp: Hello everyone, welcome back to another episode of The Testing Psychologist podcast. This is episode 55.

Today, I’ll be talking with Dr. Robin Peterson. Robin is a pediatric neuropsychologist whose primary research interests center around dyslexia and related disorders. She also has research interests in the area of traumatic brain injury and spina bifida.

Robin trained through the Colorado Learning Disorders Resource Center since 2004. She’s a board-certified clinical neuropsychologist with the pediatric neuropsychology subspecialty. She’s also an Assistant Clinical Professor at Children’s Hospital Colorado in conjunction with the University of Colorado School of Medicine. She works full time at Children’s Colorado evaluating and treating children with a range of brain based disorders. Robin also participates in mentorship of graduate students, predoctoral interns, and postdoctoral fellows.

[00:01:00] She has an incredible wealth of knowledge around learning disorders and not included in that biography’s the fact that she co-authored many chapters in Bruce Pennington’s book, Diagnosing Learning Disorders, Second Edition and she has bumped up to be an official co-author for the third edition, which is coming out in January, 2019.

So we get into lots of discussion around dyslexia evaluation and the state of the research for that. She shares many nuggets of fantastic information that I think y’all will find helpful in the assessment of dyslexia.

Before we get to the interview, I want to give a shout out to our sponsor, Q-interactive. They’re on board for the last episode of the month as a sponsor. Q-interactive, if you have not heard, is Pearson’s digital test administration platform. You could administer and score and report on several [00:02:00] relevant measures for our field; intellectual measures, academic measures, language, memory and neuropsychological; all on the iPads.

This system has been super helpful. In our practice, we use it every day and kids love it. It helps with scoring time. It’s fantastic. So if you are interested in Q-interactive, you can check it out at helloq.com/home and figure out if it’s right for your practice. I think it’s great for those who are just starting out because it definitely lowers the cost of entry into assessment. You don’t have to spend thousands of dollars on an assessment battery. You can have access to many of the most popular tests just with a small yearly licensing fee. So helloq.com/home.

All right, let’s get to the discussion with Dr. Robin Peterson.

[00:03:00] Hey y’all, welcome back to another episode of The Testing Psychologist podcast. I’m Dr. Jeremy Sharp. Like I said in the introduction, I am here today with Dr. Robin Peterson, someone that I am thrilled to be speaking with. I’ve heard of Robin for many years now through my connection with Amy Connery, who was also on the podcast several episodes ago.

Robin and Amy are both pediatric neuropsychologists at Children’s Hospital of Colorado. Robin is also, she had a big role in Bruce Pennington’s book Diagnosing Learning Disorders from back in, was it 2010, you said, Robin?

Dr. Robin: That’s right. Yes.

Dr. Sharp: Yeah. I apologize, were you a co-author of the book? [00:04:00] I know your name was on several chapters.

Dr. Robin: Right. In the second edition, and hello everybody, and thanks for having me.

Dr. Sharp: Welcome, pardon.

Dr. Robin: Came out when I was a graduate student or we did the work on that when I was a graduate student. At that time, I was a co-author on most of the specific disorder chapters. We have a more recently revised book. It’s in its third edition now and it should be coming out from Guilford Press in January. On that new version Lauren McGrath, who’s now a colleague at the University of Denver and I are the second and third authors respectively.

Dr. Sharp: That’s fantastic. I’m excited for that book. That was news to me when we were chatting before the recording started. So that is really something to look forward to.

Dr. Robin: Good. We really enjoyed putting it together and a fair amount has happened in the field in the last nine years or so, it will end up being, and so there’s [00:05:00] some good new material in there.

Dr. Sharp: Oh, that’s great. I’m just going to go off script right away and since you say that, I’m curious, are there any little teasers or tidbits that you could throw out there that has changed, that feels like new material since the last one?

Dr. Robin: Sure. Yes. There are several new chapters. The DSM has been revised since the last edition. So there’s a new chapter on the shift in diagnosis for specific learning disability with the change from DSM-IV to DSM-5 and discussion of the strengths and weaknesses of that approach as we see it.

There is a new chapter on comorbidity since we know that comorbidity among learning disabilities and more broadly, neurodevelopmental disorders is the rule rather than the exception, but way back when Bruce was the single author and wrote [00:06:00] the first edition of that book, the field was still driven by a single deficit approach to learning disorders. So really looking for what is the core deficit that can explain dyslexia, we really thought at that time it was phonological awareness and what’s the core deficit that can explain autism or math disability.

Since that time, I think the field has evolved to this more of a multiple deficit model with the idea that there are many at the etiologic, brain, and cognitive level, there are many different risk and protective factors that interact to determine what diagnoses a child would have. Some of those risk factors tend to be shared across diagnoses, which helps account for comorbidity. So that’s become a focus of this, certainly was the second edition to some extent, but even more in the third edition.

Dr. Sharp: Sure.

Dr. Robin: There is a new chapter on understanding group [00:07:00] differences in achievement; things like gender differences and socioeconomic status and racial differences. I’m trying to see how that approach is complementary or distinct from an individual differences approach.

There’s a new chapter that’s focused on clinical applications, so explaining overall the assessment model that we advocate as well as common issues, confusions, things that might come up dealing with things like a broad approach to the recommended battery, those sorts of things.

And then all the disorder chapters are similar to the second edition, there’s a front matter that tackles these general issues. And then there are specific disorder chapters that cover dyslexia, math [00:08:00] disability, speech and language disorders, ADHD, intellectual disability, autism spectrum disorder.

There’s been certainly a lot of new science that has come out in the decades since the second edition was published. So the scientific parts of those chapters have all been thoroughly revised. Their case studies have been updated to be more consistent with DSM-5 versus DSM-IV.

Dr. Sharp: Oh, that sounds great. I’m super excited to see that. I’ve used that second edition, just referred back to it so many times for so many questions and bring it into supervision, and recommend it to all my graduate students. So it’s really cool to hear that y’all are updating it. I really anticipate that.

Dr. Robin: Well, thank you. That’s really wonderful to hear.

Dr. Sharp: Of course. It’s good stuff. Gosh, let me back up and do a formal welcome. Thank you so much for coming on the podcast. This is awesome to have you here in person.

Dr. Robin: It’s [00:09:00] my pleasure to be here. Thank you for inviting me.

Dr. Sharp: Of course. I wanted to maybe start talking a little bit about your background and how you got where you are today and what today looks like in terms of clinical versus research versus anything else that you’re doing.

Dr. Robin: Absolutely. Well, if you don’t mind, I might go way back just because I took a little bit of a winding path to get where I am. When I’m talking to trainees or young people trying to figure out their way, I always think it’s helpful to know, I think some people know right away; I want to be a psychologist or a clinical psychologist or a neuropsychologist and get there at a very direct route which can be wonderful but I did not. And so I always like to be able to share that side of the story as well.

I discovered [00:10:00] child psychology, developmental psychology, cognitive psychology as an undergraduate. I went to college thinking that I wanted to be maybe a math major, computer science major but then I got there and decided, maybe not. And so I started shopping around in the spring of my freshman year. I was at Harvard at the time. I took a class in child development and I was fascinated by it and loved it, so decided this was where I wanted to focus my efforts.

Harvard was just starting, at the time, a brand new cognitive neuroscience initiative for undergraduates. So I did that, which really meant a major in psychology and a minor in biology. And so I did that for the rest of my time there and was lucky to be able to work in some really good research labs. I worked with [00:11:00] Alfonso Caramazza, who’s a psycholinguist and cognitive scientist, and learned a tremendous amount from him. I also worked in an Infant Cognition Lab where I learned a lot and also met my husband, and that was wonderful too.

And then I thought, well, this is really cool and I love this research and I love this work but I had had almost no exposure at that point to clinical psychology. At the time, Havard didn’t have a clinical psychology program, now they do. So I didn’t meet anybody who had done that and I thought, well, I like this stuff in the lab but I actually want to work with kids so I don’t think I want to go to graduate school in psychology. And so I decided to become an elementary school teacher.

So right after college, I got a Master’s in Education. I did an in-service [00:12:00] teacher training program where we were placed as student teachers in classrooms during the day and then took courses in the evening. And then I went off and I taught for about five years. I taught kindergarten and 1st grade.

I loved aspects of the work. I loved getting to know the kids and trying to understand things from their perspective. I did not gravitate quite as much towards curriculum development and behavior management for large groups of children at once. And so I knew I wasn’t going to do that forever but I was trying to figure out my next steps and in the process of that, I ended up consulting with a clinical neuropsychologist about one of my students who was having difficulties with aspects of early academic development. [00:13:00] I was just so amazed and impressed that in the context of maybe meeting with this child over the course of a day or two days, she got all this rich information that felt so relevant to me and so helpful. I thought that that seemed like a really cool thing and maybe that’s the direction that I want to go in.

Also while teaching 1st grade, I got really fascinated with the kids who seemed to be having difficulty learning to read. There were a lot of different kids who seemed to have that difficulty and they presented in different ways; some seemed to be struggling pretty broadly, and others had a very interesting pattern of strengths and weaknesses. I was just struck by both kinds of kids.

So I ended up applying to graduate school and was fortunate to be able to go back to work with Bruce Pennington, which was just an [00:14:00] absolutely perfect fit for me because I was able to focus and learn a lot about dyslexia and language and reading disorders, and also get good broad training in clinical psychology and developmental cognitive neuroscience.

So I did graduate school here in Denver with him. And then I finished my clinical training in pediatric neuropsychology mainly at Children’s Hospital Colorado. I did my internship there, and then I did a postdoctoral fellowship that was combined between some work in Bruce’s clinic at the University of Denver and also with Michael Kirkwood who’s a pediatric neuropsychologist at Children’s Hospital.

Dr. Sharp: Mm-hmm. Talk about landing in the right place for what you’re interested in, right?

Dr. Robin: Absolutely. Yes.

Dr. Sharp: Wow.

Dr. Robin: I was very fortunate in that way.

Dr. Sharp: Yeah, for sure. Tell me [00:15:00] a little bit about what you do now day to day.

Dr. Robin: For almost five years, I’ve been a full time pediatric neuropsychologist in the Department of Rehabilitation at Children’s Hospital Colorado. My position is primarily a clinical position, although I try to keep my hand in the research and scholarship world as much as possible. We have a big training program there and we train externs and interns and fellows, and I’m quite involved with that as well.

And then as far as the clinical work itself, the majority of my clinical caseload are kids who are coming in through our concussion program. Most kids, if they get a concussion, they recover pretty quickly and well, but a minority of kids have problems that go on for a longer period of time and those are the kids that I typically see.

[00:16:00] On the neuropsychology side, we use an abbreviated evaluation model, which is designed to identify both injury-related and also non-injury factors that may be contributing to their slower recovery or ongoing problems, and then to design an appropriate treatment plan.

Interestingly, although most of those kids are not referred explicitly for a learning disability evaluation, I do end up still diagnosing and managing specific learning disabilities in a good number of kids in that context because one thing that sometimes can happen is that a child may have an undiagnosed learning disability which has been contributing to making school much harder for them. And then if they get the concussion, they maybe fall behind and it’s hard to catch up if they’re not getting appropriate supports or sometimes a learning disability might be misattributed to a concussion, [00:17:00] those kinds of things.

So that’s the biggest part of my clinical caseload. And then I also do see kids who have a variety of medical diagnoses and might have a medical home within the rehabilitation department, who might need a comprehensive neuropsychological evaluation. So I see a good number of kids with spina bifida, also more significant brain injury, so like moderate to severe traumatic brain injury, prematurity, anoxic brain injury, those sorts of things.

Dr. Sharp: Oh, yeah. It’s funny when you talk about, you mentioned that brief model that y’all use. I remember talking to Amy, I don’t know when this was, maybe a year ago, and she outlined, she called it the one-hour concussion battery. I don’t know if that’s literal or not but it was pretty close to an hour to get a pretty decent sense of how a kid’s doing.

Dr. Robin: For many kids that does, [00:18:00] that can be sufficient for this population and the referral questions but it’s been such a great experience for me more broadly because it has taught me how a very focused battery, very efficient approach for many questions or if at least for certain questions can give quite rich and detailed information. Certainly, I don’t do one hour of testing with many of my patients but it’s helped me learn efficiencies in other places too.

Dr. Sharp: Yeah, for sure. I think that’s a common thread and discussion around on the podcast and elsewhere. I talked to Jacobus Donders who wrote that book, Neuropsychological Report Writing. When he came on, he blew a lot of folks’ minds when he was saying that he wrote his reports in about 20 minutes after thinking [00:19:00] through it and conceptualizing. So this is the testing battery equivalent of that. It’s like how do we pair this battery down to do only as much as we need to.

Dr. Robin: Right. And to be clinically relevant. I think that’s been his argument with reports too, is that, you can write a 20-page report but who’s going to read it? And so how useful is that going to be?

Dr. Sharp: I’m going to go off the path a little bit, but since it’s come up for us, I know people are probably out there like, what is the one-hour battery? Would you be willing to just briefly run down the brief battery that y’all use in the concussion clinic?

Dr. Robin: Sure. I think this could be extended to many kids where the real question is a straight up reasonably specific learning disability that you get a ton of information from them [00:20:00] a well-organized clinical interview and review of records. So those pieces don’t count towards the time of the testing battery but are important to include.

And then in the context of Concussion Clinic, in addition to interview, certainly as far as performance-based tests, we tend to do a two-subtest WASI, just to get a general sense of overall cognitive or intellectual ability. We typically do an untimed word reading measure, we have three, is one most of us are using right now and that’s useful because it’s something that we know is pretty insensitive to brain injury, including more severe brain injury so it should give a pretty reasonable sense of where the child was likely functioning prior to the injury, except of course, in the case of dyslexia, then it wouldn’t be so good for that.

We do some [00:21:00] measures of cognitive efficiency, so typically like a Wechsler Digit Span and processing speed measure. Many of these kids have complaints about memory and so to better understand those, we give formal learning memory tests. So either California Verbal Learning Test or in some cases, maybe verbal learning from the WRAML or the ChAMP, something like that.

Sometimes we’ll include, especially if the nature of the injury and the time since injury are such that it would be more likely that we could capture ongoing injury effect on performance-based testing, we might include things like D-KEFS, Trail Making and verbal fluency. We almost always give Structured Social and Emotional Questionnaire so often something like a MSCEIT to the parent and child, often an anxiety depression measure; we like the RCADS.

[00:22:00] For many of our kids, post-traumatic stress symptoms are of some relevance so we like Edna Foa’s measure, which is the Child PTSD Symptom Scale for that. If we’re concerned about a preexisting ADHD or learning disability, we might give the parent questionnaires around those things like a Vanderbilt, or there’s the Colorado Learning Difficulties Questionnaire

And then, because we have found that approximately maybe 15% of the kids who are referred for concerns following concussion present in with what we would call noncredible efforts, so there’s evidence essentially, not doing their best on some of the tests, we think formal validity testing is extremely important with this population so that we might use the Medical Symptom Validity Test, sometimes the TOMM, the Test of [00:23:00] Memory Malingering. In younger kids, there’s a newer test out called the Memory Validity Profile, which is pretty good.

Dr. Sharp: Cool.

Dr. Robin: I guess I should just say, the Test of Word Reading Efficiency, the TOWRE, is a great screener, a quick measure for dyslexia concerns. So if you have concerns about that, we’ll throw that in as well.

Dr. Sharp: Got you. That’s great. Thanks for taking that little deviation. Like I said, I know people were probably like, tell me the battery. So that’s super.

Dr. Robin: That’s flexible, of course. Add things as needed, depending on the question.

Dr. Sharp: Sure. Very nice. Let’s dive in, you do a lot of research and have done a lot of research around learning disorders and I would love to talk with you about that. There’s a lot of discussion about what is a learning disorder. How do you diagnose it? How do you measure it? [00:24:00] What’s the battery? All of those pieces.

Dr. Robin: Sure. I like the term learning disorders. I think Bruce somewhat helped pioneer that with his first edition of the book and at least the way I think of it is that it is a broader term than just learning disability or specific learning disability and maybe we can talk about that; how specific are learning disabilities, I think is a really important question, clinically and from a research standpoint that I hope we can talk about.

So when I think about learning disorders, I think broadly of many of the neurodevelopmental disorders, so things like certainly dyslexia or reading disability, math disability but also ADHD and language impairment, intellectual disability, those sorts of things. The majority of my research work has been more focused on that subset within [00:25:00], which is, the specific learning disabilities. I’ve done some work on speech and language disorders, and then because of the very high comorbidities with ADHD, that needs to be considered as well.

The research that I’ve done has generally been, I’ve been fortunate to train and now collaborate with the Colorado Learning Disabilities Research Center, which is an NIH-funded multi-site center. It has been around in some form for other years. Currently, it’s a collaboration between many different institutions. Erik Willcutt at CU Boulder is the overall center PI. The goal is to better understand the etiology of different learning disabilities as well as their [00:26:00] relationships to one another.

Dr. Sharp: That’s wonderful.

Dr. Robin: There are two other LDRCs around the country. Currently, there’s one in Texas and one in Florida. I know at one point you had asked about resources and so all three of those LDRCs have web pages with varying amounts of links to different resources. I know that Texas LDRC, for example, has things like lesson plans for teachers. I think the Florida one has a lot of resources for parents. So I think all three are worth checking out.

Dr. Sharp: Oh, that’s great. I’ll link to those in the show notes so that folks can jump on those websites.

Dr. Robin: Perfect. So let’s see, we talk about some research stuff maybe first and then we could answer questions about diagnosis and battery and all of that.

Dr. Sharp: Oh, yeah.

Dr. Robin: Maybe a few projects that I’ve been [00:27:00] involved with recently through the CLDRC, one was a project trying to look at the relationship between literacy development and then some of the cognitive correlates of literacy, so things like rapid naming and phonological awareness. I think this actually is quite clinically relevant because most folks who work clinically in this area obviously know that many kids or most kids with dyslexia have weaknesses in phonological awareness and quite possibly rapid naming and so those can be good things to assess in the context of an evaluation.

I think often there’s an assumption that the cognitive, if you will, issues are causal, and those are the core underlying problems that then lead to the literacy problems. And in some cases, even that, it wouldn’t be appropriate to make a diagnosis unless you find evidence of [00:28:00] these cognitive issues. If a kid has reading problems but their phonological awareness is okay, and their rapid reading is okay, maybe a diagnosis of dyslexia would not be appropriate, which I think is a misconception and we can talk more about why.

The point of this paper, which has been available online for a little while at Developmental Science, and the print version just came out pretty recently, was to try to understand whether some of these relationships might be reciprocal or bidirectional. We’ve known for a long time that literacy and phonological awareness has a bidirectional relationship.

There was some seminal research that was done showing that if you looked at adult natural illiterates, adults who never learned to read but not because of any particular disability on their part, but just because they happen to live in a culture where they didn’t get formal instruction and literacy. [00:29:00] They tended not to have good metalinguistic awareness of individual phonemes. So they couldn’t really pass what we think of as classic phoneme awareness tasks but then after they got reading instruction and learned to read an alphabetic script where individual phonemes are represented with individual letters, they did then develop phoneme awareness.

So this suggests that when you and I are listening to people talk, we have this sense that all of these individual sounds are neatly lined up in their speech like beads on a string, but that’s really more of an illusion and it comes from our extensive experience with an alphabetic script.

Dr. Sharp: Awesome.

Dr. Robin: We see a similar pattern in kids learning to read which is that robust phoneme awareness, metalinguistic awareness of speech sounds at the level of the individual phoneme. [00:30:00] Doesn’t fully emerge until kids are underway with their literacy skills. They can have good awareness of rhyme and bigger chunks but not individual phonemes.

Dr. Sharp: Oh, that’s interesting. I’m immediately jumping to the impact on assessment then and timing of an assessment and then how.

Dr. Robin: Exactly. Just to finish this one research project, so that had already been pretty well established for phoneme awareness. And then more recently, researchers were starting to look at this for verbal working memory. There’s some evidence that indeed learning to read improves your verbal working memory as well. Doesn’t seem shocking but it had been looked at a little bit less for rapid naming and the results were a little bit more mixed.

We had access to a longitudinal database called the International Longitudinal Twin Sample, [00:31:00] which included kids from the United States, Australia, and Scandinavia. Dick Olson here at CU Boulder and then his colleagues, Stephan Samuelson and Brian Byrne were the PIs on that project and generously allowed me to have a crack at the data.

And they had repeated measurement of these twins essentially prior to entering kindergarten and then at the end of kindergarten and the 1st grade and the 2nd grade and it’s continued from there. What we were able to show was that in the very earliest stages of literacy acquisition, it looked like the kids who were learning their reading and writing skills more quickly later showed more growth in some of their rapid naming skills. So also at other points in time, rapid naming predicted later literacy.

Essentially, it looks like that this pattern is [00:32:00] similar across all of these reading-related cognitive skills. And that certainly, better phoneme awareness, better rapid naming, better verbal working memory predicts later literacy and probably helps support literacy development but also learning to read changes your brain. As you become literate, you also, as a consequence of that get better at some of these tasks.

And so I completely agree with you that that has implications for assessment in that when we’re assessing a child who’s seven and does poorly on some of these tasks and also is struggling to read, we have to appreciate that probably part of the reason they’re struggling with those tasks is more of a consequence of their reading difficulties and not just a course.

Dr. Sharp: Okay. That’s fascinating. How do you tease that out?

Dr. Robin: At the level of the individual child, you may [00:33:00] not be able to, and I think that that’s okay. I think that the point is to appreciate how interconnected all of these things are. From an intervention standpoint, what matters is helping them to get better at reading.

We know that for the youngest kids, a combined approach that does explicitly teach phoneme awareness in conjunction with direct literacy instruction appears to be very helpful but we don’t have good evidence that training phoneme awareness or rapid naming or verbal working memory or any of these things in isolation without including that direct literacy teaching, we don’t have good evidence that that works.

And so that the critical pillar for dyslexia, for diagnosis, the critical question is, are their basic reading skills; word [00:34:00] reading and non-word decoding and spelling and fluency, are those things weaker than they should be given their age and the amount of instruction that they’ve had? Can we rule out alternative explanations for that like inadequate instruction or being deaf or those kinds of things? If yes, if the child has that kind of difficulty, then the key treatment is explicit direct literacy instruction.

Dr. Sharp: Got you. And when you say, just to break it down simply, when you say direct literacy instruction, what do you mean by that?

Dr. Robin: Typically, it’s done in a small group or one-on-one setting for kids who have a disability or more difficulties than their peers. And that it’s about breaking the code so phonics-based instruction; teaching kids about how letters and sounds go together. This is more [00:35:00] than just letter B says buh and P says puh.

Certainly, English has complicated rules about how letters and sounds go together. I think one example that a reading instructor shared with me years ago is that the long a sound in English can be spelled eight different ways, perhaps, /aye/ /ai/ and /ay/ and /eigh/ and the list goes on.

Most kids who don’t have dyslexia don’t need to be explicitly taught that, their brain figures it out implicitly and they eventually learn all of those patterns and they can apply them in their spelling and in their reading but some kids need to be explicitly taught that and to be shown each pattern and to practice it over and over again in the context of reading and writing activities.

Dr. Sharp: Sure. Got you. Thinking about the timing again, does that change at all the age at which you might make a [00:36:00] formal dyslexia diagnosis?

Dr. Robin: Oh, it’s so interesting. You should ask that because a colleague of mine just emailed with a really fascinating case. It was a five-year-old who was in pre K, but there were a lot of signs. And so she was saying, I don’t think I’ve ever rendered a formal diagnosis at this point before, but I don’t want to withhold something that could be helpful from the point of getting services. I know where this is going and it led to very interesting discussion.

For me, personally, I think because kids can change and can respond to intervention, I don’t think I’ve ever personally diagnosed a child younger than age six and at least partway through 1st grade. And even then, I proceed with some caution but I think if there’s a preponderance of evidence that that can be meaningful at that age. I do think we can [00:37:00] identify kids who are at considerable risk or appear to be very much on that path and recommend intervention is certainly younger than that.

Dr. Sharp: Sure. That makes sense. So then just continuing on this dyslexia train here, how does that translate to actual assessment? What measures are you looking at? What’s your, maybe, I don’t know if you call it ideal battery to assess dyslexia?

Dr. Robin: Sure. Yeah. In general, my approach to assessment is to try to be comprehensive and integrated. So I really rely on three main streams of information. I think the HOT mnemonic is very useful. So history, observations, and test results, and really rely on all three and integrating information across the three. [00:38:00] So a single test result does not a diagnosis make, of course.

And so for dyslexia, certainly school history is very important. There’s got to be a history of some difficulty acquiring basic literacy skills. Family history is typically very relevant because we know dyslexia is partly genetic and does run in families and often there is a known family history of dyslexia. If not, often in talking with families, there’s evidence of somebody who had similar difficulties even if they weren’t formally diagnosed. Early developmental history typically doesn’t have major red flags but there might have been a mild speech and language delay. It’s not uncommon to hear about.

So then in terms of observations in [00:39:00] the context of dyslexia, oftentimes the child may not like reading, may be visibly distressed if they’re asked to read out loud. Sometimes we see certain types of errors; what we might call whole word guesses when they’re reading so just taking one or two letters and substituting a word that really doesn’t quite sound anything like that but just has some of the same letters.

A similar type of error in non-word reading is what we call a lexicalization error, so the child takes a non-word and turns it into a real word, which shows that they’re really not applying either knowledge of phonics or letter-sound correspondences and they’re just trying to make a match to a word that they already have in their lexicon.

Both of those kinds of errors, I should say, happen to some extent in typically developing kids who are relatively early in their reading development. And so it’s not like, oh, the child made one whole word, yes, they must [00:40:00] have dyslexia. Those errors do become less common as kids get older and I think as you have, of course, more and more experience with this, you develop to some extent, some internal norms about what’s developmentally appropriate at what age.

And then as far as test results, there are test battery, I should say. I think it depends on the context and referral questions and the history will be helpful in terms of identifying possible comorbid conditions that also need to be assessed for. We know dyslexia very commonly co-occurs with ADHD, with math disability, with language impairment, and to some extent also with internalizing symptomatology. So I think those are all areas that are important to at least screen for and how much testing needs to be done will vary with the child.

I do find an IQ test helpful in most cases [00:41:00] in the context, if I have the time, a more comprehensive evaluation, I will do a full IQ test for a few reasons. One is just that I think it gives a good context for understanding the rest of the battery and for understanding what kind of other strengths and weaknesses the child is bringing to the school setting, for sure.

Also, I use the WISC, and so if you give the WISC, then you get a pretty decent estimate of language, you get a good estimate of working memory, and you get a good estimate of processing speed, and those are, as we know, some of the cognitive correlates of learning disability. So that’s useful to have as well.

In other cases, as I was saying in the context of the Concussion clinic, I’ve certainly rendered many diagnoses just using the two-step test WASI, not necessarily […]. Of [00:42:00] course, it’s important to objectively assess academic skills. And when we think about academic skills and the ones that we can measure pretty well while we have reading and within the context of reading, it’s important to have basic reading. So on-time single-word reading, non-word decoding, also reading fluency is very important and then a higher level reading like reading comprehension measures can be quite helpful as well.

Typically, I would at least do a brief math screen. Go ahead, did you want to jump in?

Dr. Sharp: Oh yeah. Good catch there on my intake of breath. I was curious about silent reading fluency versus oral reading fluency, is there any difference there in terms of clinical utility?

Dr. Robin: That’s a great question. I don’t as regularly assess silent reading fluency, although I have. The argument for that is [00:43:00] that’s more what kids are often asked to do in school. The problem is you don’t always know how well they’re doing it and you certainly lose the opportunity for some of those behavioral observations that we talked about, like what kinds of errors are they making. So I think for those reasons, I’ve drifted away from it.

Certainly, for like a reading comprehension measure, I think there would be an argument for it especially if you think you have a child who might be reluctant or anxious about reading aloud, you remove that added load from them.

Dr. Sharp: Would you give something like the GORT in addition to the WIAT to get at both of that?

Dr. Robin: Yes, I often do. The nice thing about the GORT is that you do get the paragraph level reading fluency, which for some kids looks different and is pretty highly correlated with something like the [00:44:00] TOWRE however you prefer to pronounce it but there are kids who often, perhaps because of some underlying language strengths or weaknesses, they might do relatively better on one than the other. So that can be useful to see.

The GORT, of course, also gives you a measure of reading comprehension. All measures of reading comprehension have their own issues and Jen Greenfield, University of Denver has done some good work showing that essentially, they assess different things. So some reading comprehension measures load much more highly with decoding whereas others load more highly with oral language and listening comprehension. So depending on which measure you give and the age of the child, you might say a child does or doesn’t have a reading comprehension problem.

The issue with the GORT comprehension currently, the way it’s set up, there’s two of issues. One is that [00:45:00] it’s only a fluency ceiling and so a child who has a fluency problem is going to be limited in how well they can do with their comprehension.

I think from the point of view of the, giving the test and the child taking it, I understand why they made that change because it was just so painful to give the task to a child who had dyslexia and couldn’t read anything that was in front of them but was maybe verbally bright enough to get enough answers right. That you had to continue testing while beyond the fluency ceiling.

The other issue is that there are a fair number of questions that really require very specific, almost rote memory of items from the text and so they’re not really getting at higher level comprehension processes. But again, I don’t think there’s any perfect reading comprehension measure.

Sometimes, I think you could just rely on, give your decoding [00:46:00] measures, your fluency measures, and then give good language comprehension measures and you should get out of those two things. You ought to have a pretty good sense of what the child’s reading comprehension would be.

Dr. Sharp: Yeah, I could understand that. When you say good language comprehension measures, is that like the oral language tests on the WIAT or are you thinking of something else or?

Dr. Robin: I often use some things from, say, the CELF, the Clinical Evaluation of Language Fundamentals.

Dr. Sharp: Oh, sure.

Dr. Robin: There’s an Understanding Spoken Paragraph subtest on there that’s pretty much an oral language version of reading comprehension. I think even things like some of the story memory tests correlate pretty strongly with listening comprehension measures. Even something like WRAML stories, although it’s technically supposed to be a memory measure. I think both quantitatively and qualitatively will give you pretty good information about that.

Dr. Sharp: Cool. So once you do all this assessment and you’ve got your test [00:47:00] results, and actually before I totally transitioned, were there other measures that you would include in your ideal battery?

Dr. Robin: Yeah, so I would say, you saw my estimate of IQ, pretty good coverage of academics including both basic academic skills as well as higher-level skills. And then at a minimum, some kind of screening for language but that might just come out of your IQ and history but if you have concerns, then doing more detailed oral language testing. Typically, some kind of screening for ADHD-type symptomatology because of the high correlation.

I guess people would be wondering about phonology and the CTOPP or phonological awareness and RAN. And as we’ve already talked about, I don’t think you need those things to make a diagnosis but they can be helpful and sometimes for treatment planning as well. I would consider that under the broader umbrella of language. And then probably, some kind of screen for emotional and behavioral adjustment.

[00:48:00] Dr. Sharp: Got you. Do you feel like there’s much utility in something like D-KEFS Color Naming or letter sequencing or anything like that? I’m not super familiar with that literature; if there’s anything to support those in thinking about dyslexia.

Dr. Robin: Right. D-KEFS Color Word Interference subtest has several different conditions. One is essentially a reading test where you’re getting […], one is essentially a rapid naming test and then one is supposed to be getting executive function, which is cognitive inhibition through the Stroop effect.

So certainly we would expect effects of dyslexia on those baseline conditions but you’re probably giving other measures that are a better reading test and possibly a better rapid naming test. I don’t think that the Stroop is [00:49:00] important in diagnostically for dyslexia.

Some people like to do performance-based executive functioning testing and an ADHD battery. I think there could be some utility there but you have to remember, well, if the child has comorbid dyslexia, to what extent are the executive functioning tests impacted by dyslexia-related issues? I think for both letter sequencing and color-word interference; you would have to wonder about that.

Dr. Sharp: That makes sense. All right, that’s a solid battery, certainly. There aren’t a ton of surprises there. It’s nice to have you clarify maybe not needing the CTOPP necessarily, or maybe not needing the D-KEFS exactly if you’re just looking at the dyslexia piece. I’m curious then, and this is such a can of worms to open, but I’m just going to do it, then how do you [00:50:00] make the diagnosis and how do you distinguish what is actually a learning disorder from a score standpoint? Of course, we’re getting into discrepancy model versus PSW and that kind of stuff, I’m curious your stance on that.

Dr. Robin: Yeah, absolutely. For me, the first thing that’s so important to frame this discussion is to appreciate that dyslexia as well as every other neurodevelopmental disorder, as well as essentially every diagnosis in the DSM, really falls on a continuum. And so we think literacy development is normally distributed and at some point, we’re setting a cut point and saying, if you’re below this point, you have a disorder. But you could fall,

I use the blood pressure metaphor with parents all the time. This is not like cystic fibrosis where you have it or you don’t. This is like blood pressure, at a certain [00:51:00] number, your doctor is going to say your blood pressure is too high and I’m recommending medication but you could be one point below that cut-off and it’s not as though you have no blood pressure issues whatsoever.

And of course, our tests all have error. Kids can change from day to day. And so no matter where we set the cut-off, there are just always going to be kids who fall into a gray area and about whom I think reasonable professionals could disagree. And so I always like to tell students, if you’ve been in a case conference discussion about whether the child has a learning disability or not, I’m sure you’ve had a heated discussion about it because it’s just the nature of what happens when we try to impose these categories on something that’s essentially a continuum.

Dr. Sharp: Oh, yeah.

Dr. Robin: So that being said, for me, the question then becomes, well, what’s the point of diagnosis and is it clinically useful? So is it going to help people understand this child? Is it going to guide appropriate [00:52:00] intervention? Is it going to buy them access to services that they need and are not getting?

And so depending on the answers to that question, potentially we could have two kids who have pretty much identical scores but I might come down differently on the diagnosis question, depending on how clinically meaningful I thought it would be for that particular child.

Dr. Sharp: Can you give me an example of that?

Dr. Robin: Sure. For example, I see a lot of kids who have a medical diagnosis like spina bifida, and they typically are identified at birth or before birth and are getting services from before birth, and they usually have an IEP and it may identify them as a student with an orthopedic impairment or something. And then a lot of them also have cognitive and learning issues that go along with it.

In some cases, they might technically meet our criteria for a specific learning disability, [00:53:00] but if I think that they’re already getting the appropriate services at school, and the school understands the individual child’s profile pretty well, and the parent understands, and just adding another diagnosis wouldn’t really shift the clinical picture at this point, I might not do that but another child who didn’t have access to services, didn’t have a medical diagnosis, even if they had a similar profile, I might find it more useful in that kind of case to give a formal diagnosis.

Dr. Sharp: Yeah, I see what you’re saying. That’s a great illustration.

Dr. Robin: Okay. So we talked about this falls on a continuum. We talked about what the battery would be. We talked about the fact that you’re looking for convergence across history and observation and test results. So it’s not just a matter of, [00:54:00] did your score on the TOWRE fall at a certain percentile or below or not?

But all of that being said, I imagine that listeners or people still want to know, well, where is the right? From a research standpoint, a pretty commonly used one is around the 10th percentile or a standard score of 81, and that seems fairly reasonable to me. We’re just talking about age discrepancy here, not IQ discrepancy.

Some researchers who really need research participants might set it higher, it’s below what they would call the average range but below a standard score of 90. That just seems too liberal to me because it identifies 25% of kids. And then you could set something stricter like two standard deviations below, but I think you’re going to miss a lot of kids who have clinically impairing problems.

[00:55:00] Dr. Sharp: What do you make of this whole discussion around average abilities equvaling a learning disorder. So like in the case of a really bright kid who maybe scores in the low 90s but has an IQ of 125, let’s say. What do you do with that?

Dr. Robin: I think the old DSM model required you to be both age-discrepant and IQ-discrepant. Your reading score had to be below average for age and also for IQ. The problem with that approach was that there was a lot of research showing that there’s not really good external validity of the age and IQ distinction. And we know that kids who are below average for age but not below expectations for IQ still have clinical impairment, and they still seem to respond to the same kinds [00:56:00] of interventions on average and so we shouldn’t exclude them from services.

I do think the DSM-5 overcorrected a little bit in doing away with the IQ discrepancy entirely and it’s exactly because of these kinds of kids that you mentioned. Of course, just because, let’s say you have an IQ 125 and reading score of 95, I don’t know that that necessarily means you have a learning disability but it might, to me, depending on the clinical impairment question.

I do think that there are really bright kids who are not learning to read at the rate that we would expect and for whom that’s very frustrating and does prevent them from probably achieving their full potential in some sense of the word.

Ironically, we know that that type of dyslexia is probably more strongly [00:57:00] genetically influenced. There’s some evidence that games play a stronger role on average in kids with higher IQ than lower IQ and it probably just because if you have all of these cognitive advantages, if you’re not learning to read, there’s probably a pretty clear or specific underlying reason for that, if you will.

I do think if there’s evidence for clinical impairment and there’s impressive discrepancy between the measures of the child’s ability and then how well they’re reading at this point, that a diagnosis can be helpful. And really because those kids we would expect on average to respond fairly well to intervention and to be able to really benefit from accommodations like access to audio books because we would expect their listening comprehension to be pretty good.

Dr. Sharp: Right. [00:58:00] Well, thanks for offering some opinions on that. These are all things that have come up in the past on the podcast. It’s interesting to see where people come down on it.

Dr. Robin: Yes. I imagine maybe you’ve got some different perspectives.

Dr. Sharp: Yeah, the one that’s coming to mind right off the bat is I interviewed Ben Lovett, who wrote Testing Accommodations for Students with Disabilities, I think it was. And so we got into a discussion around this, particularly, like, what do you do with these bright students who want to take the MCAT but their reading is down in a 90-something? He was like, that’s not a disorder. I like having different perspectives and just get to put it all together and then decide.

Dr. Robin: Right. I think when you get into that world of accommodations too, there’s all of those layers about [00:59:00] well, what you’re talking about in the context of maybe a high school classroom versus; meaning what presumably would be a higher bar on some of these very regimented high stakes tasks.

It’s an interesting question for me to think through, like, well, do I think that student should qualify for accommodations on the MCAT? I’m not necessarily sure, but certainly, I think they should get good phonics based reading fluency intervention when they’re little and to try to improve that reading to be more commensurate with what we might expect them to be able to do.

Dr. Sharp: Sure. That’s a good point. Those are two different things also in some regard; accommodations versus intervention, they aren’t totally overlapping.

Well, let’s see. Gosh, our hour went by really quickly. I feel like we did a nice dive into dyslexia in particular. [01:00:00] Before we sign off, I’m curious, other things that that you might want people to keep in mind as they’re looking at dyslexia in particular from a diagnostic standpoint or …

Dr. Robin: Sure. You had mentioned discrepancy, we covered IQ discrepancy. You talked about patterns of strengths and weaknesses and I do think that’s relevant to this question of how specific are specific learning disabilities and something that I do feel somewhat strongly about.

I think historically, there’s been a lot of research and clinical attention to kids who have these extreme discrepancies in their profiles, going all the way back to the first case report of developmental dyslexia, which was published in the British Medical Journal in 1896. It was a 13-year-old who couldn’t read despite being smart and good at math and [01:01:00] from an educated family.

It makes sense that those kids would come to clinical attention first, just because they are so striking but I think more and more, we’re learning that they are the tip of the iceberg because we know that all of these skills are pretty highly correlated. We know that reading and math in the population are relatively strongly correlated and they both correlate with language and other measures of cognitive ability.

They’re not perfectly correlated and so there absolutely are these cases of very extreme, very specific profiles, but for every one of those kids, there’s probably more kids who struggle broadly across the board. The kid who, their reading and their math and their IQ and their language scores maybe are somewhere between 75 and 85, let’s say. I know a lot of people are not comfortable diagnosing a [01:02:00] specific learning disability in that case because it just doesn’t feel very specific.

This is a case where I feel like the name is somewhat misleading us and that all those kids do need supports and interventions, and we know that school is difficult for them, and it just seems illogical to me to deny intervention on the basis of the fact that they have more widespread difficulties than a child who more clearly qualifies for a specific learning disability diagnosis.

I think the Patterns of Strengths and Weaknesses approach really is problematic partly for that reason but then also just psychometrically, I think it’s problematic because we’ve already talked about reading faults on a continuum and so you’re setting this cut point and you have kids falling on either side of the cut point, the next day they might fall on the other side depending on your area and your test. [01:03:00] Essentially, patterns of strengths and weaknesses is having you set cut points on multiple measures, which multiplies that difficulty.

I think that Jack Fletcher’s group in Texas has done some good empirical work on this. They’ve been able to show that most kids who have clinically impairing reading problems don’t meet PSW criteria. And then also that a small change in criteria causes a pretty dramatic shift in who gets identified and who doesn’t. So I don’t love that model.

The Response to Intervention model is very widespread nowadays in the schools and that model is better and has a lot of strengths. The idea there is, you’re supposed to study everybody with good evidence based instruction and monitor everybody’s progress. And then if you see a child who is not making expected progress, you give them a first block of intervention which is typically provided by their classroom teacher and you don’t [01:04:00] necessarily trigger a more detailed evaluation yet until you may see how they respond to the intervention. It’s only when kids have had a more prolonged period of getting good intervention and not responding, that you would do a more detailed evaluation.

I think that approach can be appropriate, especially for kids who have a focused academic difficulty. I think the issues with that approach are that in practice, sometimes it leads to appropriate intervention being delayed, unfortunately, because if it’s something beyond what a classroom teacher would be trained to do, they’re not going to get it.

I think the other issue is that it works really well or reasonably well for something like dyslexia but it doesn’t necessarily work so well for something like intellectual disability or autism and or even ADHD. And so the screeners that schools may be using may [01:05:00] not be so good at picking those things up. And so I do think we have to think carefully about how do we screen for some of these comorbid conditions earlier and in what cases do kids need to see a professional with broader expertise sooner.

Dr. Sharp: Oh gosh, yeah. Talk about a can of worms. We could have a whole other conversation about that. I see a lot of kids who either, I see them on both sides where parents have maybe tried to get more intervention or assessment at school and didn’t and so they went privately, or they have had a fair amount of intervention but just weren’t improving. I catch them on the tail end where it’s naming it almost, like you said, a little after the fact.

Dr. Robin: Exactly.

Dr. Sharp: Yeah. If you get some good answers to that conundrum, please let me know how to get kids assessed and get some intervention [01:06:00] sooner in the process when they need it.

Dr. Robin: Fair enough.

Dr. Sharp: Aside from your books, which I’ll definitely have in the show notes, any other resources, trainings, things for people to check out if they want to learn more and get better at this?

Dr. Robin: Sure. There’s a book called Learning Disabilities: From Identification to Intervention. Jack Fletcher is the first author on that. There’s several other eminent learning disability researchers or co-authors that had a first edition, but the second edition is also coming out from Guilford later than our book. So that would be a good one to look at.

I already mentioned the websites for the NIH-funded LDRCs around the country. Those are great. The International Dyslexia Association is a great resource. Certainly, here in Colorado, we have a Rocky Mountain Branch [01:07:00] that does maintain lists of recommended providers for an evaluation and intervention perspective, and they do run some workshops and trainings, including things for adolescents themselves. I’m sure other chapters around the country and the world do some similar things. So those are the first that spring to mind.

Dr. Sharp: Sure. That’s a great list. I think people are always looking for those resources. I get a lot of those questions anyway.

Dr. Robin: Absolutely. Well, there’s a lot out there and some is good and some is less good. So it’s important.

Dr. Sharp: Sure. It’s nice to separate. That’s where your opinion, I think it’s really valuable so thank you. I really appreciate your time, Robin. This was illuminating and really interesting. In some ways, it was just the tip of the iceberg. If [01:08:00] you’re up for it, I would love to have you back when your book comes out and we can maybe even dive into some of these other areas that I know you’re pretty knowledgeable about.

Dr. Robin: I would love that. Thank you so much for having me on. I really enjoyed it.

Dr. Sharp: Oh, good. Well, until we talk next time, take care.

Dr. Robin: You too.

Dr. Sharp: Bye-bye. Hey, y’all, thanks again for listening to that interview with Dr. Robin Peterson. As you can tell, Robin has been steeped in this research for a long time and one of those folks who has literally written the book on the topic that they are discussing. As you heard, Robin gave us a lot of resources; books, websites, so forth, and all those will be in the show notes. Her book will be coming out in January, 2019, and I am really looking forward to that.

So thanks again for listening. As I’m recording this episode, there’ve been two [01:09:00] milestones in The Testing Psychologist world, one is that our Facebook group passed 1,000 members, which is just incredible to me to see all that knowledge and expertise being shared on a daily basis among all those members. It’s so cool. If you have not joined the Facebook group, I would love for you to jump in there. It’s called The Testing Psychologist community on Facebook.

The second milestone is that the podcast passed 25,000 downloads around the world. It’s amazing to see the folks listening in other countries. I love it. That’s pretty cool. I could never have imagined that we would get to 25,000 downloads. That’s a relatively small number granted compared to some of the hugely popular shows, but gosh, for this small little niche in the world, I think it is really awesome. So thank you all for continuing to listen and provide feedback and make comments and send me [01:10:00] ideas. It’s just been a really cool journey and process. So thanks for being part of that here with me.

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If you’re heading into summer thinking about doing some revamping or redoing, tweaking some aspects of your practice, or maybe thinking about building a practice, give me a shout. I would love to talk with you about whether coaching might be helpful for that. I love to coach folks along how to build a testing practice or refine and build that your current testing practice. So give me a shout if that’s interesting to you. I’ll do a complimentary [01:11:00] 20-minute pre-consulting call and we can figure out if coaching makes sense for you. You can check that out at thetestingpsychologist.com. There are several buttons and ways to schedule that pre-consulting call. Give me a shout if you’d like to.

Otherwise, y’all, have a great summer. We’re heading into June. It’s going to be awesome. I love the summer. The pool is going to be a big part of our summer, getting in some early morning runs. It’s nice and crisp. So I hope that y’all have some cool things planned for the summer, getting some vacations and whatnot, but I will be back and talking with you pretty soon. Until then, take care.

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