Dr. Sharp: [00:00:00] Hey everyone. Welcome back to The Testing Psychologist podcast. This is your host, Dr. Jeremy Sharp. This is the podcast where we talk all about the business and practice of psychological and neuropsychological assessment.
Hey, hope you all are doing well. At the time of this recording, I am seeing some glimmers of hope in the news about the COVID-19 shutdown possibly relaxing over the coming weeks. Who knows what that will look like, and if those glimmers of hope might be a little premature. At this point, we have been home for going on a month and a half, two months, (6 to 8 weeks) with our kids, and the community is pretty quiet. So, any hope is very needed. So I hope you’re all taking care and staying healthy and that your practices are at least staying afloat in these [00:01:00] crazy times.
My interview today is another expert interview, non-COVID related, with Dr. Linda Daniel. Dr. Daniel is a licensed psychologist and pediatric neuropsychologist based in Southeastern Massachusetts. She has over 15 years of experience performing neuro-psychology evaluations, autism evaluations, and multi-disciplinary evaluations. She’s worked with schools in doing program observation, and clinical consultation. She has a lot of experience with inpatient and outpatient settings, schools, and private practices.
She primarily works with kids, but she has a big age range. She sees kids as young as 14 months old and goes all the way up to 22 years old. And a big part of her work has been collaborating with a multitude of professionals, including developmental pediatricians, neurologists, speech-language pathologists, educators, advocates, and special ed [00:02:00] attorneys.
A little bit about her education. She got her undergraduate at SUNY New Paltz and her Ph.D. from William James College. She did her pre-doc internship at Hudson River Psychiatric Center and then she did her post-doc. Well, she did two postdoc fellowships, one at Children’s Evaluation Center in Newton, Massachusetts, and one at Integrated Center for Child Development in Canton, Massachusetts.
Linda is talking with me all about really assessing toddlers, specifically looking through the lens of assessing toddlers for autism. So we cover a lot of ground here.
We do talk about a number of concerns, issues, and strategies that he might run into when you are assessing little kids, including just how to incorporate a number of caregivers [00:03:00] in the assessment process, how to manage your own emotions and perhaps fear when working with really little kids, some strategies to get familiar with toddlers and increase your comfort, how to engage toddlers and how to work with them when they are melting down, which we all know happens during the assessment process. We also touch, I think, fairly regularly on how these strategies apply when you are training others to work with toddlers. Linda has done a lot of training with postdocs and interns and shares those tips with us as well.
Without further ado, please enjoy my conversation with Dr. Linda Daniel.
Hey everyone. Welcome back to another episode of The [00:04:00] Testing Psychologist podcast. This is Dr. Jeremy Sharp. And like you heard in the intro, today I am talking with Dr. Linda Daniel. Linda welcome to the podcast.
Dr. Linda: Thank you for having me.
Dr. Sharp: Of course, yes. Thank you for being here. This is the first podcast that I have recorded during the COVID-19 craziness. So I’m just thankful to be able to get time with anyone given what it’s like, at least for me to work from home. I appreciate you being willing to be here.
Dr. Linda: The sentiment is entirely reciprocated. It was my three-four hours this week.
Dr. Sharp: Fantastic. Well, like I said, I’m honored to be a part of that. Oh my gosh. How precious time these days is for so many of us. So that’s what I think is apropos of our discussion today. We’re going to talk a lot about assessment with toddlers and just managing that situation, and the various challenges [00:05:00] that can produce. We’re also going to talk about assessment with toddlers in autism specifically. I know you have a post toddler at home, just a toddler and there’s a lot of managing toddlers at home.
Dr. Linda: Yes. I leave my professional hat at the door. I have to say. It helps me.
Dr. Sharp: You have to. Yes.
Dr. Linda: Exactly.
Dr. Sharp: I figured that out pretty quickly when we have kids.
Dr. Linda: My husband keeps me. He helps me with that. He’s like, you should be in the neuropsychologist at the office.
Dr. Sharp: Right. I need that balance. My wife has also a mental health professor. She’s a therapist. So we just get lost in the weeds […]
Dr. Linda: But at least you can understand the same language.
Dr. Sharp: This is true. There are pluses.
Dr. Linda: My husband is very right-brain. He’s a computer engineer. So it would be balanced each other out.
Dr. Sharp: Very cool. Nice. I see that combo [00:06:00] of engineers and psychologists a lot. We have two friends where that’s the situation. It seems like it works well.
Dr. Linda: Yes.
Dr. Sharp: I’m really glad to be talking with you. I thought maybe we’d just start like usual. I am curious just why you do this, why toddlers, why autism? Why is that important to you?
Dr. Linda: I was actually thinking about that after you said how this story started. When I was an undergrad, I thought I was going to go to dental school. And then at some point, I realized that I had racked up way too many psychology courses for it to be at least not a minor concentration. So that’s what I ended up doing.
And then when I was looking into grad school, I was thinking, okay, in general, therapy land, but pretty quickly after I started grad school, I was pretty young when I started grad school. I realized right in the middle of taking psychology assessment, I [00:07:00] realized that it’s like it has been waiting for me. I really enjoyed assessment. Just looking at datasheets and matching them with the child that I was testing.
So somewhat prematurely I would say, I landed in that position first year of a five-year program, and my very good advisor said, why don’t we try different things before we say, this is exactly what you want to do. And I did. I actually worked with adults for a little bit before I came back to assessment. But during the time when I was in grad school because my program was a PsyD program, we had to work in the field every year. So I worked at an elementary school and a middle school, and then in college, and then in a full-locked adult psychiatric ward for my APA internship, as well as an outpatient before doing a post-doc in pediatric neuropsychology with a subspecialty in autism.
And I have to say for all of the assessment experience I had up until that point in the school and actually in the hospital setting, I hadn’t seen a ton of autism. Now [00:08:00] this was back from 2001 to 2006. So when I started my postdoc, which was a very intensive postdoc at a private practice, our postdoc required 200 full neuro psychs. So 100 the first year, 100 the second year. And it was a very busy practice. So just by the virtue of being at that practice, I just ended up seeing a lot of children starting from…
At that time even seeing the babies was a specialty within that practice. So I tended to see children three and a half at that time, but more so 4years and 5years, because that was actually the average age of diagnosis at that practice. And that practice was known for working with children on the spectrum. So I thought I was seeing them pretty early, even at 4years and 5years.
And then the more we started to do this, the more I started to see, especially the research, you could really make a difference the younger you got them. Slowly they age. And as the [00:09:00] awareness of the public and from research started to spread, there was a lot more awareness of even the milder forms of autism in the younger population, because back then it was age-old wisdom- well, you can’t really tell if it’s autism until a certain age, and then more and more we realized actually you can. So then we started to distill that knowledge into the younger and younger population until it predominantly became toddlers.
When I was at the last practice that I was at, I think I saw three toddlers a week for a few years. It was really because that practice also had easy access to early interventions in the area. So it was a major referral source. And in the beginning, we did have to do a lot of speaking with the early intervention providers about why early identification was important, and that sort of thing. This is back to now 2012, and 2013.
So there were still not [00:10:00] that many baby clinics around. You had a waitlist at children’s door in other major area hospitals. So we actually went around and spoke to early interventions about why it was important to have a diagnostic evaluation if you suspect. And most early intervention providers are very good with child development, and they usually have concerns that they may not feel necessarily okay sharing with parents.
So it required some strengthening of their competence. This is okay. You leave the hard job to us. You’re not telling them that their child is developmentally delayed or on the spectrum. You’re basically saying there are some red flags that maybe we should look at just to be sure.
And that was a hard conversation because I was also in the process of having my own children. I actually started to have a deep appreciation for how brave our [00:11:00] parents are in coming to our office with their tiny, precious toddlers and they are looking to us to basically guide them. And that was a huge responsibility, especially once I had my own children. So I really started to enjoy doing that.
I remember once upon a time doing feedback was a terror, especially if you thought you were going to diagnose something like autism. But the more and more I saw toddlers, the more I realized, I could be present for the start of this journey for these parents- empower them so they don’t feel like this is the end of life. This is the beginning of the rest of their lives, where they’re more informed and someone is giving them a guide for what to do from here on out.
It took many toddlers over many years, but I feel like you become a lot more comfortable as a clinician in [00:12:00] joining them and empowering them, and having them walk out of your office feeling like, okay, I feel like I know what to do. Not that it was not devastating if the diagnosis was autism, but I feel like just preparing them more and not focusing too much on the limitations, but more so much on let’s focus on just the next year of life and see. These are the discrete skills that we don’t have now, and this is what we are aiming for at the end of this year. Because sometimes, we’ll often, the question you have is can they go to college? Can they be married? This is an 18-month-old or a 2-year-old. So I feel like life changes quickly. So it’s important to focus on the short term before we start to go 10, 20, or 30 years.
And it’s only empowered me as a parent as well, just having that alignment with very brave parents. [00:13:00] And I follow them over many years. So my parents often come back to me. There are 2-year-olds that are now 15. So it’s good to see the journey of even how autism changes over time. And the research tells you one thing, and then anecdotally, you see how it evolves and everyone is unique.
Dr. Sharp: Yeah. I imagine we might dig into this as we go along a little bit, but I love that reframe of feedback and delivering the diagnosis really is an opportunity to empower parents and inform them and support them through a pretty tough time.
Dr. Linda: Right. So at this point, it’s an honor so I take it on. I want them to come to me. You’ve heard stories from 20 years ago where someone has told someone’s child, oh, [00:14:00] they will never do this. They will never do that. That parent never forgets that conversation. And I want those of us who do this with little ones to not have that be part of our profession. Even with significant limitations, there is still growth possible.
Dr. Sharp: I’m going to go off-script immediately. And since we’re stumbling into this, I would love to ask just how you balance being realistic with optimistic, I suppose if that’s a way to think of it. How do you help parents navigate those potentially scary futures but also instill some hope?
Dr. Linda: So there’s a very discreet tool that I’ve picked up over the years. One of the main ones is I never answer a question that I don’t have an answer to. So if someone is asking me, will my child go to [00:15:00] college? That’s just not a question that… You can pivot to, just because your child has the capability doesn’t mean that they want to go to college.
What after all brings personal satisfaction and happiness in life, that’s defined individually for each of us. So I usually reframe the question to once again, that next year of life. There are so many changes, even in typical development that happens between 18 months to 8 years that you really want to approach it step-by-step. What the child is possible between 4years and 5years is dictated by what happened between 3 and 4. And that is brain gated on what happened between 2 and 3. So let’s focus on 2 and 3. So all of the other years will be affected by the gates that are made this first year.
And it’s not taking away out. It really does depend on the data that you get over the [00:16:00] next 12 to 18 months. If they needed something like ABA, once the ABA has been in place, how much progress was a child able to make? That tells me something about how we should continue after this.
So I always say with expectations, at this point for most of the children, I should say, because how they present at 18 months, sometimes you don’t even know what is going to happen in 2/3years. There are clinical impressions that you can develop from what happened before, but there was that rare child who will surprise you and will completely go on a different path.
So I usually like to say, let’s gather some data; the number of services, and the rate of progress made before we make a determination about what’s possible for the year after, and then the year after rather than make long-term predictions. That is not going to bring any [00:17:00] reassurance to anyone because those are just not based on any truth hood.
Ability does not necessarily determine success. That just means you have a potential for success. Whether you achieve that is completely dependent on so many other variables. I want Johnny over here to be able to approximate more skills within the next year that would improve his chances of being able to access everything around him.
So I try to keep it a little bit more discreet so that it’s something that they can actually measure because fortunately, ABA is about measurement or any service, it has to bring about some functional qualitative improvement in life. And sometimes they may seem small to us, but for a parent, a child who can respond to a name is a miracle if they’ve never been able to do that.
So I like to focus on things like that. Wouldn’t you want? The next year when I see [00:18:00] him and I call him Johnny from here, I want him to be able to turn around and look at me. When you put it that way, it’s that moment that they’re waiting for. Whether they go to college, or whether they get married is no longer really relevant as much as my child should be able to look at me when I call him and return my hug or whatever, the things that make a huge difference.
That’s how I usually pivot to a question I can’t answer. That is my very discrete answer. But there are times when the situation is quite dire and if you see very significant global developmental delays, I think it’s preparing the parent for what is coming. And that’s a different kind of conversation. And that is not the traditional conversation I have with a child who is on the spectrum, but who has intact skills otherwise. But when I have seen children with [00:19:00] significant delays, that is certainly a different conversation. Because I want them to be empowered but prepared. It’s a rare occasion in which you have to. And in those cases, I feel like parents already know this is different, it’s broadly improving the quality of life.
Dr. Sharp: Right. I would like to get how you might handle that conversation, but I’ll give you just a second to think about that because I want to highlight something that you said that really made me think, it is very interesting that we have these conversations around will my kid go to college? Will my kid marry? Will my kid… That tends to come up in cases of autism or maybe intellectual disability, but rarely comes up when you diagnose a kid with ADHD or depression or bipolar [00:20:00] but the fact of the matter is that there are so many variables.
Dr. Linda: It’s just relevant, yes.
Dr. Sharp: Right.
Dr. Linda: Absolutely.
Dr. Sharp: Right. That you just have to consider all those variables. And it’s not specifically kids on the spectrum.
Dr. Linda: It’s true. Let me answer that question a little bit differently. See that skill that I just told you about. How often would I have that conversation with the parents of a toddler? Like I said, when the delays are significant enough for me to have that conversation, that occurs pretty rarely, but I can distinctly remember one particular child.
Fortunately, the caregivers, in this instance it was not parents, the caregivers were the adoptive mom had some knowledge of child development and could see what was happening. But in that regard, I could align with her and say, you’re understanding what the situation is. [00:21:00] I would agree with that. We have to prepare for how to improve her functional communication, and how to improve her ability to care for herself to the extent possible. I think at that point she was not even walking and she had no sound. She didn’t make any sounds. It’s a very little contact. It was more about giving those caregivers a guide forward. These are the agencies you need to contact. This is the care that is wanted at this point to proceed.
When I’m saying there’s an intellectual disability and it’s an older child, that tends to be the more difficult conversation. And there have been times when, more infrequent now than before, where the parent was, I don’t want to say entirely out of touch, but somewhat in denial of the capabilities that the child had in terms of [00:22:00] if you have an ID and you want your child who is an 8th grade to be mainstream for our classes, a1nd this particular role was hiding out in the bathroom half of every class. And it was communicating to the parents. She’s extremely anxious and she does not want to upset you, but it’s gotten to the point where she’s completely overwhelmed.
I find that it’s always helpful to align with something that the parents can agree with you on before making that transition to something that they may not be ready to hear. So it’s approaching it incrementally, and finding some common ground. And it’s not that they’re completely unaware of the truth. It’s just that they might not be there yet. And I usually don’t believe in pushing against resistance.
I heard someone once say, be like water, just go with the flow. It will [00:23:00] figure out how to flow around with things. And in those moments, it’s helpful to think about this as a parent and say, someone in this person’s position, a doctor is basically saying, you have to come to terms with reality, blah, blah, blah. Obviously in much nicer terms.
I think that’s not helpful for them because you might be the only point of contact that they have in being able to hear this. Maybe the school has tried and has not worked. Maybe other people have tried, but it has not worked. So I feel like giving the truth serum in a very harsh way is not necessarily all that helpful. But you also want them to be able to hear what is coming in the report. So I usually align with something that they can agree on. It may be that we can agree that she does seem a lot anxious to you. She does seem to miss quite a bit of class.
So we will start that conversation there and then [00:24:00] figure out where it can go from here so that her daily routine is not torture for her. Going to school is not torture for her. How can we move things forward? I think the first thing that parents said to me was that I want her to graduate high school in a normal way. So I had to shift that conversation entirely because I was not going to argue that point. She was still only in 8th grade. This was a conversation that was just starting. But you could see where this was going to end, but that doesn’t mean that she was ready, she was there with you.
There are times when parents sometimes surprise you. I had a boy that I followed from the time of his initial diagnosis to 11, and I thought parents and I were on the same page in terms of IQ. The relative standing of IQ is dropping. Every two years, you could see the decline. And still, when we finally had that conversation, that [00:25:00] around 11 years of age, she was still surprised, not in a bad way, but in a devastating way.
That she was devastated for her child. But at that point, I knew her well enough that we were in this together, and to acknowledge that at that point would allow her to prepare for the many years they were coming afterward before he would be out of high school.
But still sometimes even when you’ve worked with families for many years, I think sometimes we get into our profession so much and we are looking at data and numbers all the time that it’s different when it’s your child and when you see them every day and every new skill that they’re learning seems incredible to you. Even if it’s a few years behind chronological age.
Dr. Sharp: Yes, that’s such a good point.
Dr. Linda: That’s how I would sort of approach that. But I feel like [00:26:00] the resistance of what you have to say, whether it’s label or level of functioning, that’s not just with autism. Sometimes the pushback I’ve gotten from parents have surprised me because in my head, probably because I see some extreme cases, it might be for something well, yeah, there’s a reason why this evaluation was sought after in the first place because there was some difficulty, but I feel like sometimes your need for your child to do well is so strong that they could start to impact how you’re able to take the news.
So a lot of my learning over the years has been to be able to deliver news after I prepared them to take it. So there is just feedback. A lot of the work with toddlers is really just reading the room from the moment the parents come in. For me, one of the main referrals [00:27:00] concerns being heard just because our specialty has been autism, especially in toddlers. So is it a language delay or is it autism?
So just the fact that they used to get initial screenings by the EI providers before they even came to us, we had a pretty high rate of diagnosis of autism, especially the first two years when they only sent us cases in which there were many red flags. So at that point, it wasn’t pretty, so we could tell within the first 15 minutes when the child arrived if they had a spectrum disorder or not, and then the rest of the time was just figuring out how to prepare the parent. I didn’t really like to do the feedback just at the end. I wanted it to be a conversation. So when it’s the actual feedback time, it was just an extension of the conversation that we had been having until that point.
Dr. Sharp: Right. That’s such a good point that if the parent is totally blindsided at feedback, something got missed [00:28:00] along the way I think between the two of you.
Dr. Linda: Exactly.
Dr. Sharp: Well, that may be a nice segue to back out a little bit and take a little bit of a broader view on the assessment process. So let’s talk just generally about working with toddlers, and assessment with toddlers. What are some considerations that we need to have in mind when we’re working with those younger little ones, even in terms of setting up the assessment, the room, the layout, and the parents being there or not? It’s a lot to tackle here.
Dr. Linda: It is. I’m going to speak from the perspective of just having worked with many interns and post-docs over the years because I feel like you see yourself in them. Every time you get a new batch, you remember when you started. I remember when I started my postdoc, given that I had worked with children, I [00:29:00] had just never worked with children that young. So elementary school, middle school life, and beyond I could handle, but the little ones and the little ones who had quite a bit of needs or had externalizing behaviors.
I just remember that I must’ve looked petrified because I remember my supervisor at that point could read my body language and would say, my hands are fisted. He would give me a little tap and say, unfurl your hands. And it would probably be because I was so nervous.
These are the things that you learn to look for in all the individuals in the room when a child is there for an evaluation, not just in the child because our non-verbal kids often show you their anxiety through many other means rather than just telling you, but how the parent is sitting, how the other people who’ve come into the room are. Not just that, but how your intern and your postdoc is because I’ve had some interns who had very little experience [00:30:00] working with… I mean, a lot of interns just don’t have experience working with toddlers unless this is your specialty, you just don’t get a lot of experience in that.
So I think you have to build up that comfort level with working with children that young. Obviously, it helps if you have your own children, just because you’ve interacted with toddlers on a regular basis and they don’t scare you, but toddlers scare a lot of people.
Dr. Sharp: Right. They are so unpredictable.
Dr. Linda: And parents can pick up on it. One of the things is that the clinic that I worked at, we were all women with, I think there were 7 or 8 kids between all of us. So we had tons of kids. So I think that probably helped in our approach to assessing the babies. But when we had interns or post-docs, they often did not have children. And you had to allow them to be kind towards themselves. We don’t expect you to have the scale overnight. This [00:31:00] is a hard one on our part as mothers, it took some time.
And some interns I had to say, it took them almost eight months to gain comfort. You could still see. If the child did something that was a little bit off, you could see the fear. And that is because toddler evaluations by nature have spectators. I think this is what you were referring to before. Children below the age of 3, we always assess in the presence of their parents. And usually, it’s not just parents, it’s usually parents or there’s usually an EI provider because we always encourage EI providers to come. Sometimes they’re say, support person. Sometimes there’s an interpreter.
One of the first things I taught my interns and post-docs is to always be ready for a full house. The office was long, but it was always filled with people. So there were always these moving targets that you had to watch out for. I’ll [00:32:00] touch on those briefly, but I know that this is one of those things where there was standardization and evaluating children, and then there is evaluating children. And I think you try to keep to the first as much as possible. But I think if it’s occurring at the cost of breaking rapport with the family or with the child, you have to think on your feet at the moment. So this is one of those things where I think certainly experience helps.
We usually told our interns and post-docs, just hang out with family members who have little kids or if you have access to like a playground, go watch how, don’t be creepy, but go watch how children play because sometimes those are just things that you just don’t get a chance to observe until you are like at the setting. And it’s not as natural as you would think. Even if you interacted with children, maybe you have just not interacted with them for a prolonged period of time [00:33:00]. So:
a) Be ready for a full house.
b) I visually told them, “If they get nervous, you need to give me a nonverbal signal so I know.”
I usually picked up on it before but my interns would always look at me if they were starting to feel like this is getting a little too much so I could step in, but also as a supervisor, I think in the beginning when I was starting to get my interns and post-docs, I would try to cover that up very quickly, but now I think if you are in control of the situation, it doesn’t bother you that you have to step in even if it’s obvious to the parents. You’re not trying to hide it from the parents. And parents really appreciate it. I usually say, this to my student and sometimes I will step in and I’ll take over. And that is not a reflection on how they’re doing. Sometimes I just want to see how the child will interact with me.
I feel like a lot of my evaluation is [00:34:00] about making the parents feel like they are in good hands. They are with someone who understands their children and who can manage the room. Because if you start to become overwhelmed, you are a lot more transparent than you think, and the people sitting there with you will start to pick up on it.
I think some of this is also just developing tools for how to take a step back if something is becoming overwhelming. And just because there are so many people around, there will be times where we have a set battery that we will think to administer. And then if the child is having a 30-minute tantrum, you have to do some quick math about what is essential and what are the things that you can leave for acquiring by observation or my collateral report.
There are times when you just have to figure out how to write this up in a way that is doing service to the child, but at the same time, leaving some room for [00:35:00] interpretation given what is happening, but that is often the case, they are not perfect test candidates by how they are made. So I think being flexible is extremely important in being able to assess a child. They often don’t sit at the table. That’s completely fine. You can follow them around.
I have done my assessments in the waiting room. I’ll come back into the sitting room. Usually, I’m on the floor with them. But I will at least attempt to do it in the way that we do in a standardized way. I will attempt to get them back to the table. And then you modify it based on what is happening while at the same time, always being aware of how the parents are because I think that is key. The child generally does not necessarily care, except if they’re completely distressed in your office. They’re not necessarily caring about how you’re responding to them or what you’re saying, but the parents are the ones who are, what does this mean? She’s asking him to blow bubbles. What does that mean? [00:36:00] She is covering up the toy that he wants, obviously, that’s frustrating to him.
So I usually walk my way through everything I’m doing. So when I’m doing the ADOS-2, I’m usually explaining to them what I’m doing, especially toy blocking. I’ll usually tell them if I had to block his way. I just wanted to see his response. And I feel like that just makes them feel a little bit more like, okay, this is not just meant to frustrate my child. This is assessing a specific skill that he should be doing. And generally speaking, when there is an absence of skill in the office, it’s also a skill that’s absent at home. So I usually ask, if you were to do this at home, how would little Johnny react? So there’s always that tie-in so that if the diagnosis is forming, it’s not solely based on how the child did in the office. There are always real-life examples that have been tied into what has been happening in the office.
But I think you also have to get comfortable [00:37:00] basically if an evaluation is going in a way in which the child is just not having a good day. Sometimes my parents are coming from 2 or 2.5hours away. They’ve been on the waitlist for six months. I am not about to bring them back to do any evaluation just to make it meet standardization. I’m going to have to, at that moment, think in my head, what do I need to know about this child? What is the central diagnostic question? Is it about autism? Is a clinical picture emerging that shows that the child does have autism, but he’s crying for this amount of time, and there’s only limited participation in this and this?
That is in itself a diagnostic. That itself is telling you something about how the child is doing, but at the same time, you may not get this done as administration of a Bayley. You may have to omit some of the things from the ADOS just because there was no opportunity to do that. But that does not take away from the diagnostic picture.
So I’m not relying on the test to tell them solely whether I have arrived at the diagnosis. I’m using the test to support my clinical hypothesis as [00:38:00] well as the collateral information that is coming already from the parents, as well as the EI provider. So it’s a joint picture. But I think you just have to start to get comfortable reorganizing things in your head. These are the things I wanted to do, three of them have fallen away, and this is what we’re left with.
Dr. Sharp: Well, I just wanted to underscore two themes from all of this that we’re talking about. One is setting expectations is huge when you’re assessing toddlers, mainly for parents, right? I’ve been in the room with so many parents who end up, like, they just don’t know what to do if we don’t tell them. And so they ended up directing or talking throng time or saying, or there’s any kind or just getting anxious. There are any number of things that they could do if they weren’t sure what to do.
I totally agree with that process or maybe that feeling of not wanting to [00:39:00] seem incompetent maybe. And you got to throw that out the window. Like if you’re in the room and we just say like, okay, we’re going to do things a little bit differently, or like you said, this is my student. I might step in and then just make it normal. I think that eases parents’ anxiety so much.
Dr. Linda: Right. If you remain calm, they will be calm. And there is a little bit of a learning curve into that. I think that’s the hardest part about assessing toddlers because you just don’t know what you’re not going to get and things will change. And I think that is an anxiety that you just have to get comfortable with. And at some point, it won’t be anxiety-provoking, but my most important consideration is the child and the parents in combination.
Dr. Sharp: Have you found anything just in working with so many trainees, is there anything beyond just experience that can help build that tolerance and that ability to be flexible, or are there specific methods or strategies that [00:40:00] you actually teach them to try to increase those skills?
Dr. Linda: My inclination is to say, we see so many cases that you can tell most of the interns and the trainees will start to round a corner at some point between 3 and 4 months. I think that the first month is very anxiety-provoking. I usually lead all the assessments for the first two months. But there’ve been times when I have the assessments with all toddlers for 8 months because that particular intern just had some difficulty getting over. And she very candidly told me that toddlers are probably not the population that she would choose to work with primarily, but she was great with the older children. I could see her strengths were somewhat different.
But for most trainees, I think there is a very steep learning curve, at least at the practice that I was at within that first two to three months. And then you could see the comfort. [00:41:00] There’s not the deer caught in headlights look. And I think they just look too…
Our training model was an apprenticeship model, even when they started to do the assessment. We were always in the room with them. They always watched us the entire time. They never did feedback. We always did the feedback. So there’s a ton of opportunity to just watch and learn. I feel like that was really important. That’s how I was trained. So that was really important in struggling with that anxiety and getting over in the moment, and just doing it again and again until they started to develop familiarity.
The other interesting observation that all of the neuropsychologists that I worked with had was, we called it reorganization of what was typical because they didn’t have a lot of experience around a lot of children who were typically developing, they after the first 2 to 3 months started to [00:42:00] think that the kids that we were seeing in the office somehow that was a typical path of development.
So it was very good to say remind them at some point because they wouldn’t be some Bayley item that a typical two-year-old would pass and most of our kids just didn’t pass. And then when you got that one child who could do, it’s like, oh my God, he’s a genius. So it was good to say, yes, but this is something our kids inherently struggle with. If you are actually just looking at typical development at this age, this would be a skill that would’ve come 2 to 3 months ago. So that was good to have that. I often found that they really started to enjoy the work once they became comfortable. And just interacting with toddlers and letting them lead you.
And then sometimes you had to bring them back to standardization. Don’t go so far with that. Now the ADOS is no longer valid. But at the same time, it’s a balance you need [00:43:00] to know. We had regular training in the ADOS and we trained on every module for sometimes several weeks. And we did every year. Even for postdocs, I had to go through the same training the year after. And that’s really so you understand how does a standardize and how you have to administer it and you have to stick to it as close as possible so that when you’re taking a deviation, because if you start to administer in the way that it’s not standardized, and then the more and more you do it, the more you think that’s how I’ve always done it, even though that’s
So it’s good for even the supervisors to get a refresher. That is the standardization. It is good for us. This is sometimes the way in which we will work around it if it’s just not possible. And case in point, there’s oftentimes when we substituted the bedtime routine for the birthday party routine for a child who’s not been to a birthday party. That’s something that it’s like, well, if you don’t have sufficient experience going to birthday parties, that’s not going to tell me much [00:44:00] about how you participate in a birthday party. That’s just going to show your unfamiliarity.
Those are the things that you need to know how it’s done first before you start to take some deviations. I’m sure that there are very discrete steps that I probably did just because of the behavioral nature of the company that I worked at. You’ve been in doubt through this, and this. But I think it’s overall what I think worked for them, at least from the exit interviews that we did is having us in the room all the time. I think that calms the anxiety more than anything else. Your supervisor never left you alone was something that was a draw off the practice as well as something that reassured them.
The other thing I wanted to briefly touch on is when you have parents who are not on the same page. Now, there’s only so much you can manage. And that happens more often than you’d think. And I usually once again, on the path of least [00:45:00] resistance, I try not to go into the areas in which they’re going to completely disagree, and we just focus on what we need to do now to move forward for the child. Because there are some times, one parent will be completely resistant to the label and will say…
Dr. Sharp: How do you even handle that? I’m very curious about that.
Dr. Linda: Some of this may have to do with my personal belief rather than my professional belief. I am not a huge stickler for trying to get someone to swallow a label. I will sometimes say if… I have had parents say, someone told me that he could have the A word. And so that tells me a lot about where that parent is in relation to autism. And so I will say, okay, well then let’s not talk about the A-word. Let’s talk about his difficulties in this domain, this domain, and this domain and what we need to do to be able to get him to improve in those domains.
But there is some tacit understanding that yes, [00:46:00] there’s going to be a diagnosis of autism on paper, but I am not spending my two hours in that office trying to make this parent swallow this label. I’m much more focused on how to align with this parent so they will now obtain the services that the child needs. And sometimes it’s just breaking down the once again discrete skills. You’ve been trying to potty train him for eight months. Wouldn’t you like this to be easier? Once the ABA people come in, they have a protocol, let’s hand it over to them.
I think it’s showing them a different picture of the things that they’ve been struggling with and feeling like they failed as a parent and turning around and saying, let someone help you. This does not come with that manual. Every child is different, but when a child has needs, that makes the situation a little bit more complex. And sometimes it’s helpful to say, if I were in your shoes, I’m a parent myself, that sort of thing.
I think one of the [00:47:00] luxuries that we have as testing psychologists or neuropsychologists is that be allowed a little bit more sharing of personal information. Say if you’re a therapist and I use that to my best advantage I can say, I appreciate the fact that you had this much fear and you were able to come see me.
I usually share that I am a lot similar in terms of when it comes to my own kids. I don’t like to take them to the hospital. I hate it actually. So I would share things like that just so they feel like, especially sometimes if there was a cultural element and if my patient is someone from a culture that gives almost inordinate importance to the word of a doctor, and even if they disagreed would not think to say anything, it’s helpful to make them understand that I am also a parent. I’m not just in this one position that you have to revere. It’s a little bit of a different framework. I think that’s helpful as well. [00:48:00] So you try to read them and be aligned with them as much as possible.
Dr. Sharp: Sure. That makes sense. I like that you touch on just the differences in how parents may approach it, and what they may need to hear from you. It’s like you meet them where they’re at.
Dr. Linda: Exactly. That’s the only way to get them to take home what I’m about to give them. The luxury that we have is that there was a written document that is supplementing our verbal conversation. So I feel like if there were gaps in the conversation or if the parent was not able to hear something at that moment, that doesn’t mean that that did not translate into service because there’s a documented form now that says this is what they need. So I feel like the audience still has access to another medium in which we are trying to convey the information rather than just the feedback from the parent.
Dr. Sharp: Of course. So I want to switch gears just a little bit and go back to the actual [00:49:00] administration. We talked a little bit about just strategies for engaging kids that little and I think that could be really valuable for folks because toddlers are prone to wandering, right? And they’re not always interested in our assessment process. So how do you navigate that?
Dr. Linda: So I will make it very concrete. I usually have the peg set up before they come into the office, the pegs from the Bayley. And then when they come in, I’ll just pick it up, and then most kids will now come over and then I’ll hand one bunch to them. I can usually get them to put them in.
There are children who are not interested in the pegs, but at least it’s usually a good gauge to start. It’s something kinesthetic. It’s something they can manipulate. And it brings them over to me because I’m now handing it to them. Sometimes, I will start with the inside puzzle. So I usually like to try all those things to see if they have any interest in them.
Now, there are [00:50:00] children who are not interested in anything related to other-directed activities, and it went in a pinch I will ring the bell. I don’t know if it’s in the new Bayley. The old Bayley had a bell. I will ring the bell. That usually does the trick that they’ll at least look at me. I always start with the Bayley because I feel like attention is best in the beginning parts of the assessment rather than the latter parts of the assessment. So what I’m able to do in general, this is the rule rather, and there are exceptions, certainly to this, what I’m able to do in the first 25 to 30 minutes is generally the best work.
So I try to get in engaging pieces of the Bayley during that initial time. I’ll sometimes take the little mirror from the Bayley and see if they’re interested in looking at the reflection. Some are, some aren’t. So just generally using the manipulatives. I don’t go in order. I go in basically in hierarchy regarding interests that I have gathered over the years. So what do I think will draw the child to me. And then I just know all the items I have to hit on the Bayley. [00:51:00] I would never start with the item in which I hide something under the towels. That’s the best way to lose them.
Dr. Sharp: Right. What am I interested in here?
Dr. Linda: Exactly. It’s something as simple as that. There are certain items that I know will draw them over. Now, there are times when Bayley is a complete failure. They do not want anything to do with it. And then I will immediately shift to the ADOS.
Now, the ADOS usually will have at least one toy. It used to be that. We used to have that pop-up toy that made a song. And we ran into two problems with that one. I would say that had about a 98% success rate in engaging children. Unfortunately, the children also got fixated on that toy. So it was very difficult to remove. It was a diagnostic tool as well in that if you attempted to take it away if they had a tantrum that was prolonged, it told us something, but when the replacement did not have noise and it was not nearly as appealing.
So then we had to find other things. [00:52:00] Bubbles are usually pretty good in gaining their interest. Even the child who was completely unmotivated or uninterested, bubbles will…
Dr. Sharp: Everybody loves bubbles.
Dr. Linda: Exactly. So there are certain things that I would do. My initial five minutes is to get them to attend to me, find something to like about me so they would be motivated to do work with me.
Dr. Sharp: Can I ask you a question real quick?
Dr. Linda: Yes.
Dr. Sharp: I’m curious just your thought process, why lead with the Bayley versus the ADOS?
Dr. Linda: Because once I do the ADOS and I am now approaching the half-hour mark, 40 minutes mark, the engagement with the Bayley, which is, I would say admittedly deviations from the standardization of Bayley is less tolerated than the ADOS, at least from my clinical opinion. And I find that you need a lot more sustained attention on the Bayley to complete those tasks than ADOS, which you could modify a little bit because it does after all look a lot like play. Whereas on the Bayley, there are [00:53:00] certain tasks in which they had to pay attention to what you’re doing, model, and imitate.
So I find that in general, like I said, there are exceptions to this, in general, if I don’t get the Bayley done in the beginning, it’s much harder to go to something more structured after they’ve been exposed to less structure. The ADOS allows them a little bit more freedom in what they want to do. And then it’s harder to reign them in after that. And they’re starting to get fatigued around the one-hour mark, especially if they’re 18 months to 2 years, they’re much more irritable at that point and that’s harder to do the Bayley.
So I usually leave the Vineland towards the end where then they can pick their own toy and play while we interview. So generally, the administration routine is the Bayley, the ADOS, and the Vineland, and we have time, the PLS, but that is a brave parent and child interaction that I would introduce the PLS-4.
[00:54:00] Dr. Sharp: And you said earlier that you, at this point have your go-to must-have Bayley tasks. Could you just name those quickly for folks who are interested in that?Dr. Linda: Well, must have Bayley’s tasks as in?
Dr. Sharp: Like if you had to be flexible and cut.
Dr. Linda: So the cutting is actually based on the starting point. So like the LMN, I’m basically looking at their age and the order in which they have to go. But if I think that the Bayley administration is not going to be very successful, I need to know where they’re at cognitively. I would always try the two washcloths in a basic way object permanence items. I usually do the inside puzzles and the pegs just to have something to engage them with.
What [00:55:00] else? Some of this is based on what age they are. If they’re 18 months versus 2 years, 6 months,2 years, 6 months, you can just go to, O, and the starting point is, O, and the first three items are pretty easy to get, and then you can see if they have more. So I want to know if they have an item to item matching or if that’s a skill they already have. If they’re past 2 years, 6 months, I would want to know that. If they have an item to item matching. Can they do the blue board? Can they do the pink board? Do they have to pretend play skills? Relation to playing skills?
And then if they’re starting to get the skillset of like, is this heavier, is this light, sort by color, then I would go for the WPPSI. I wouldn’t have been stuck with the Bayley at that point. So once they’re actually 2years, 6 months, I want to see if they can do the WPPSI. If they can, I would stick with that. If they can’t, I would fall back to the Bayley.
And the reason really is that for our kids who are not very verbal, the WPPSI [00:56:00] makes a huge difference in IQ score, whereas Bayley is mix. There’s a lot of Bayley’s performance that’s dictated by how interested they are in language, and sometimes that produces a score, let’s just say that’s not very palatable to the parents.
And frankly, at that point, I am not as focused on their IQ score. That is just giving me a frame of reference for understanding the rest of their skills. And I think sometimes it does more damage to give a parent a very low IQ score because their understanding of that is not going to be necessarily what you’re thinking about. And I wouldn’t want them to…
And I give a big spill about IQ will continue to change over time, and believe me I do this every day. This is a very moving target for a child who still doesn’t have a lot of language. So you will see this core continue to change. But there are times when the parents will ask me specifically, what’s the [00:57:00] IQ score. At that point, I’ll take some time to explain IQ scores in 2-year-olds.
But the Bayley administration allows me to know what conceptual skills they have at that point in terms of how well they’re going to take to some of the instruction of ABA. So they will have item to item matching. They’ll have sorting. They’ll have categorization. So sometimes it’s just watching this is where the child is at and you can move past that level. Also, it allows you to track it over time. The next year when they come back, have they learned a skill or don’t they have it.
Dr. Sharp: Before we maybe totally move on. Are there other strategies just for engaging kids that young that you tend to go to?
Dr. Linda: I usually ask parents’ permission before I do this, but if the child is not averse to physical affection if they like tickles, [00:58:00] there’s actually, something that I was taught when I was in grad school, where you take them by their fingers and just go like this, just like a little wave motion and then press their arms and their forearms like this. And I have yet to meet a child who does not respond to that. It’s not the same as tickling.
There is something about that deep pressure that they really enjoy. And for the child who’s completely self-directed and shows no awareness of you in their space, it’s like that one moment where they look at you. And even if you don’t get the eye contact but for that one moment, they saw you. So that’s something that I will usually try, but I usually ask parents’ permission before I do something like that, because some children, will say, no, he does not like to be touched or tickled or anything. But that is a little PTOT trick that I like to try, that I find very helpful.
Dr. Sharp: That’s great.
Dr. Linda: I also don’t force my attention on kids. [00:59:00] I’m just comparing our kids and our kids meaning our kids on the spectrum, just because I see them a lot. Two children who are typically developing, who are completely motivated by social praise, it’s not that they’re not motivated by social praise, but sometimes at that point, they’re really not. And you need to connect with them over an object. And that’s why I have objects that I think they would like so that there are some sort of association with this object as me as the one who proffered this object to them. And hopefully, by association, I would also be not aversive.
So I think you have to connect over an object at that time, especially if they’re not showing sufficient social motivation. You are just not going to be very interesting. And you have to forgive yourself for that and move on.
Dr. Sharp: That’s fair.
Dr. Linda: Yeah. This is just aside on the ADOS. I will prepare the parents before I do this. I will [01:00:00] call the child by the wrong name to see if they respond.
Sometimes when kids respond, they’re responding to sound and not name. So when you call them by their name and they look, and you can tell because other information or observations have led you to believe that they’re not responding to their name consistently enough, but now the parent is saying, well, no, he does at home. To see if it’s just their sound or just responding to sound, I had actually a sibling set where the brother responded to anything I called him and the sister only responded to her own name. And it was something that the parents just have not noticed before. But that’s only if I have some reason to doubt that. That’s not a standard procedure but it’s good to know. It’s good to know because sometimes moms’ voices can be very reinforcing and it’s not necessarily the name as much as her sound. [01:01:00]
Dr. Sharp: Right. Well, I think I would be totally remiss before our time runs out, not to ask about behavior management with toddlers. So what do you do when toddlers are just melting down, freaking out?
Dr. Linda: This is Toddler management 101, anyways. It doesn’t matter if you have it he’s sort of special needs or not. I think the best work we can do is to read the signs before it becomes a tantrum. I’ll sometimes ask parents, are there things that they will do that tell you they’re starting to become upset? And that’s usually helpful information, but I always back away from demands when I’m starting to see that. It’s not like older kids who have some frustration tolerance that they can sort of keep it together even if you push them a little bit. But little guys, they could go.
So now most children will rebound pretty quickly and some children [01:02:00] will not. Now have I had 45-minute tantrums in my office? Yes, absolutely. I have been in this field too long to not have those. The important thing once again is to not freak out. Sometimes it’s also reassuring to the parents. Even if the parent has seen this at home, the fact that it’s occurring in a different place sometimes becomes very distressing to them.
So I usually say it’s okay, let’s give him some time. I usually want parents to bring a stuffed animal or a blanket or Binky or something that is soothing to them. And you generally back away from all demands and give them their preferred items and just remain calm. So I usually try to engage the parent in a Vineland or other conversation when this is happening to take their minds off the fact that this is happening. It will eventually quiet down like all the tantrums will.
But generally speaking, my first point of intervention is to read the signs as they’re starting to get rubbed up to back away. Not that I won’t re-administer that item, I’ll just do it at a different time. Not at that moment. [01:03:00] If I get resistance 2 to 3 times, I’ll stop. I won’t do it anymore.
I usually tell the parents too. My aim is not to cause distress to their child while they’re in my office. It is to really just understand their functioning and how they relate to others. And if we can do it as painless as possible, that’s great. But some of these things by their nature are designed to possibly get at skills that the child may not have yet. That’s going to cause some distress. But like I said, I’ll usually back away, if it’s getting to a degree. And once it’s there, you just have to let her write it out.
Dr. Sharp: Right. Would you ever engage the parent to try to soothe the kid? Like if they have particular strategies?
Dr. Linda: Absolutely. That’s the first thing I would ask. If it goes beyond a few minutes, I would say, when Johnny does this at home, what would you typically do? Some parents are quick to offer and some parents are [01:04:00] so stricken by anxiety that they forget what they did. I think it’s really just having this happen in someone else’s office. And I think immediately they think this is somehow their fault. And I think you have to quickly reassure them that I see toddlers for a living. This is expected. This is just another day. And then I say, what can we do? What do you have that would make him feel better?
I also encourage a child if their crying goes on for more than a few minutes, I encourage the parents to take them out for a walk around the office. Sometimes just leaving the office is helpful to be like, okay, that’s gone. So anything at our disposal really. It’s not to see how long they can cry.
Dr. Sharp: Well, our time has flown by.
Dr. Linda: I know. I knew I’m a [01:05:00] chatterbox, but that was like what do you want to talk about?
Dr. Sharp: We figured it out. Before we started recording, there was some concern that we wouldn’t be able to fill the time. In my mind, I thought, I don’t think you’re going to have trouble, we’ll see. Yeah, it’s all good.
Well, as we wrap up, what resources are out there? Folks want to learn more about assessing toddlers, or even its wide-open autism in toddlers, things have been helpful for you or for your post-docs
Dr. Linda: I would say, and this is just from watching the field evolve over time. I would get some supervision when you’re starting to work with younger and younger children for some time. Ideally with either watching other professionals who work with toddlers. I’ve had professionals ask me if they can come to observe my sessions. Obviously, I would allow that if the parent allows that, [01:06:00]because I feel like you would have a limited frame of reference if you have not seen sufficient toddlers. And it’s not necessarily something you can just garner from a textbook in terms of what is typical and what is not typical. There are so many moving elements in managing that.
In the beginning, it’s going to be your own anxiety about being found out that this is not your expertise. And then it becomes what if it doesn’t go in the way that we are planning it? All of those things will happen. And it’s just a matter of getting over it. So I think at the beginning, it’s helpful to watch someone else do it, or ask another person who is doing it to give you supervision on how to do it. Because I feel like if you don’t have a sufficient frame of reference, you could very well misdiagnose or approach it with a lack of understanding.
And that I think is detrimental to the profession [01:07:00], especially your relationship with the parents. They are going to be responsible for this child from the time they leave the office. You only have 2 or 3 hours. And I think it’s making them understand why you think what you are thinking, what your clinical impression is, and why it is important to get the services that you need right now, rather than six months from now, or eight months from now, and not letting time pass to see if you’ll just grow into it. Those are all very important conversations.
So, because there are so many elements, not just in the test administration and evaluating a child that young who may be non-verbal, but it’s also figuring out how to do the feedback. That is not the standard feedback that you would give to parents of an older child. Not that that’s easy, but it’s so different because our feedback is set to be on the same day of testing. So there’s a lot that you’re doing in your head that that [01:08:00] sub-sufficient supervision, I think that can become really overwhelming.
Dr. Sharp: Sure. That’s such a good point.
Dr. Linda: That would be what I would say.
Dr. Sharp: Very cool. Well, thank you again for just taking the time out of your day. It sounds like maybe this was a little respite for you?
Dr. Linda: Yes. Well, thank you for having me on. I really appreciate it. And you have such a wonderful group of so many testing psychologists. I joined the Facebook group not that long ago, and it was wonderful to discover so many people from all around the US and maybe even beyond.
Dr. Sharp: Yes, there is quite a bit of international audience too.
Dr. Linda: Especially during times like this, it’s been very helpful to have a community to immediately turn to figure out what is everyone else doing? What is the standard?
Dr. Sharp: That’s the hope. Yes.
Dr. Linda: Thank you, Jeremy.
Dr. Sharp: Thank you for contributing to that body of knowledge that we were building. I appreciate it.
Dr. Linda: Oh sure, no problem.
Dr. Sharp: Okay, folks, there you [01:09:00] go. That is my interview with Dr. Linda Daniel all about assessing toddlers. I think she shared a lot of helpful tips around managing toddler behavior, managing the room and caregivers with toddlers, and even training others on how to do the same thing.
It’s really got me thinking about how I might incorporate some of these things with my own trainees. And it was also just validating to know that even experts in working with toddlers run into these concerns and there are some ways to get through it. I think we’ve all had that deer in the headlights look when kids start to meltdown during an assessment session. So hopefully this is helpful for you.
As I said, there are a number of links in the show notes for you to check out. Linda is very open to consulting or answering any questions about this material. So don’t hesitate to reach out to her.
Okay, everyone, that is it for today’s [01:10:00] episode. Again, I hope that you are all staying healthy, staying sane, and just looking toward the future for whatever that might hold. We can only hope at this point that things are starting to improve and we’ll all be able to get back to work as normal before too long. And maybe some of you have really gotten accustomed to working from home and employing some remote practice. And who knows, there may be transitions coming up for some of you. Either way, I hope you’re all doing well. I will see you next time. Take care.