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[00:00:00] Dr. Sharp: Hello, everyone. Welcome to The Testing Psychologist Podcast, the podcast where we talk all about the business and practice of psychological and neuropsychological assessment. I’m your host, Dr. Jeremy Sharp, licensed psychologist, group practice owner, and private practice coach.

This episode is brought to you by PAR. The BRIEF-2 ADHD Form uses BRIEF-2 scores to predict the likelihood of ADHD. It’s available on PARiConnect- PAR’s online assessment platform. Learn more at parinc.com

Welcome back everyone to another episode of the Testing Psychologist. Hey, we have a return guest today. Dr. Ellen Braaten is back talking about some of her latest research and a variety of other topics.

We dig into the recent article that she’s written that talks about the relationship between processing speed and a variety of psychiatric concerns, but we also get into a number of other topics like sluggish cognitive tempo, and its relationship to ADHD and processing speed. We talk about the impact that COVID-19 has had on learning and how it has been a different impact depending on what’s going on with the kid. And we touch a little bit on ADHD and the perception of time and some ideas to help gauge time effectively. So, this is a pretty wide range in conversation, and there’s a lot to take away from our talk. So hope you enjoy that.

Let me tell you a little bit about Ellen. If you didn’t catch her back on episode 50, that was a great one as well. She really dove into her book, Bright Kids Who Can’t Keep Up, and we spent a lot of time just talking about the nature of processing speed, what it is, and how to work with it. If you didn’t check that out, please go check that out.

Let me give you a little bio for Ellen in case you don’t know much about her. She is the associate director of The Clay Center for Young Healthy Minds at Massachusetts General Hospital (MGH). She is the director of the Learning and Emotional Assessment Program (LEAP) at MGH as well, and she’s also an associate professor of psychology at Harvard Medical School (HMS).

She is a psychologist, teacher, and researcher whose career has focused on the better understanding and treatment of children with learning and attention issues, especially ADHD, learning disabilities, dyslexia, and autism spectrum.

As she is a mother of two young adult children, as well as a psychologist, she is keenly interested in parenting issues, especially those relating to normal development, education, and parenting kids with behavior and learning differences.  In addition to the book that I mentioned earlier, Bright Kids Who Can’t Keep Up, she has written/co-authored Straight Talk about Psychological Testing for KidsHow to Find Mental Health Care for Your Child, and I know that we’ll talk about this in the episode that she is working on a sequel of sorts. I don’t know if sequels applied in the nonfiction world, but a follow-up to bright kids who can’t keep up, about kids who seem to have low motivation.

She’s also, as I said, a prolific researcher. Lots of publications, collaborations with psychologists and academics around the world. She has also written the book that’s now in its second edition called The Child Clinician’s Report Writing Handbook. So Ellen has done a lot and she continues to do quite a bit. I am very fortunate to have her back.

Before we jump to the episode, I want to invite any of you beginner practice owners out there to consider joining the Beginner Practice Mastermind for testing psychologists. This is a group coaching experience that is meant to increase accountability and help you launch your practice successfully.

This group is going to start in March of 2021. It’s a group of about 6 psychologists and they’ll all be in that beginning phase of practice, either about 6 months prior to launch or 6 to 12 months after launch. So we talk about things like how to set up your business, get office space, tax entities, set up your schedule, purchase your battery, marketing, and a variety of other things. So if that sounds interesting to you, I invite you to check it out. Get more details at thetestingpsychologist.com/beginner.

All right, let’s jump to my conversation with Dr. Ellen Braaten.

Hey, Ellen, welcome to the podcast.

Dr. Ellen: Hi, thanks for having me. It’s great to be back.

Dr.Sharp: That’s right. I should’ve said, welcome back to the podcast. Gosh, I was looking, and it was April 2018, which is nuts. I can’t believe it’s been that long.

Dr. Ellen: I can’t either. It seems like it was just yesterday, but this year worked our sense of time in a way but has passed fast too.

Dr. Sharp: Yeah, for sure. I know. I don’t know how else to put it, but it really is like a time warp. I feel like this year in some ways did not even happen and in other ways, it’s just has been the longest year ever.

Dr. Ellen: Yeah.

Dr. Sharp: Here we are. I’m glad that you’re back. I know that you’ve been busy since the last time that we talked. I’m excited to dive into all things with you. So maybe tell us, what have you been up to over the past two and a half years? What are the big things on your radar?

Dr. Ellen: Since I spoke with you in 2018, I worked as a visiting professor at Charleston University in their Medical School in Prague, Czech Republic was seven months. I was working with a number of ADHD researchers there who are also interested in some of the topics that I’m interested in, particularly Hine perception and ADHD, but I was able to see another medical and psychiatric system, and it was really wonderful. I did a lot of teaching. I’m still going back. I’ve got a five-year appointment there as a visiting professor, so I still have another three and a half years I think on it. And so I go back frequently or did it pre-COVID. So that’s been exciting.

And my lab has published a number of great papers on processing speed which is one of my interests. And one of my books, The Child Clinician’s Report-Writing Handbook, I came out with a new edition of that, and I mentioned to you when we were chatting that I have a new book that is being written right now, frantically written, that the take-off on my book, Bright Kids Who Can’t Keep Up, which is Bright Kids Who Don’t Give a… We’re trying to come up with the right word that fits in there that doesn’t offend people.

It’s about kids who don’t really care and can’t get motivated, but it’s really more than just about motivation. So hopefully, in another year or so you might invite me back to talk about that, but for right now, it’s not finished yet, but it does take my research on processing speed to the next level, like who are these kids as they move on into adulthood. And I know it’s an epidemic that most of us who evaluate kids for a living are seeing, there are lots of kids or just not making it successfully into adulthood, and it’s about both kids.

Dr. Sharp: Sure. So is this overlapping with the failure to launch set? Is there something in there?

Dr. Ellen: Yes, although the book is really written for younger kids, not really for the adults, but to kind of say, if you’ve got a child who you think, even in second grade, isn’t really rolling with the punches and doesn’t seem to have much drive, what do you do at different ages of development? And so, a lot of it really is parents understanding what the motivating factors are, and also understanding through evaluating kids and knowing, I think so much power can come from having a good evaluation and understanding who your child is and what their capabilities and limitations are. I think that knowledge is power and it can be used as a real way of motivating kids to understand who they are.

Dr. Sharp: Sure. That’s interesting. I know this is just a little side path as we get started, but I dove into the literature around motivation, I don’t know, maybe 6 or 12 months ago for a little project I was working on. And tell me, my conception of all that is that the two factors that really make a big difference in motivation are meaning and agency like having it matter, but also having control over the thing you’re working on. I don’t know. Is that accurate or is that what y’all are finding?

Dr. Ellen: Yeah, it is. Although, what I’m finding is there are so many theories of motivation that it’s hard to pick just one. And maybe that’s part of it is that we think that motivation is a thing, but you’re right, those two things are clearly well studied, and they’re, in theory, important components of motivation. As part of that, I think that parents don’t always listen to what their child is telling them. We only have a sense of agency or things that we actually want to do.

And so, I find that a lot of things go off the rails for the parents that I evaluate early in their development because there are assumptions about what their child should do, particularly as it relates to college and it sets a trajectory, and that is sometimes destined for failure. And kids tell us a lot of times what they are capable of doing by not doing what we want them to do. And that’s not always because they just want to misbehave. A lot of times it’s because they’re incapable of it.

So in terms of motivation, that’s why we really have to find out, can they have a sense of agency over it? Are we asking them to do things that are not possible? And that destroys your motivation if you’re asked to do something you can’t do.

Dr. Sharp: Absolutely. There’s so much here, and I’m like, Oh My Gosh, we should be talking about this.

Dr. Ellen: I’ll be here, but it’s great, it’s really an interesting and complicated subject.

Dr. Sharp:  Yeah, absolutely. We’ve seen that just on our own. We have two kids, a 7-year-old and a 9-year-old. One of them is super motivated for homeschool, does all his work and is on top of it and reminds us of his meetings instead of the other way round, and then our little girl, she really couldn’t care less about school and she’s motivated for plenty of other things, but just not jumping onto those meetings and doing the schoolwork, and it’s been really eye-opening. My wife is also a therapist. So we’re pulling our hair out, what do we do?

Dr. Ellen: Nothing more humbling than being a psychologist or a therapist and having kids.

Dr. Sharp: Exactly.

Dr. Ellen: I have more than one undecided because my first was also like, she did everything then my son. I had two that were very different. And they both turned out to be great adults, but during the process, you realize that there’s so little we do that they come out who they are. The best we can do is just help them understand who they are so that they can figure out what they want, what they desire, and how they can most easily do that.

Dr. Sharp: I love that. Right, it’s like long-term vision or something. Delayed gratification. I don’t know, but it’s hard.

Dr. Ellen: Delayed gratification, yeah. 20 years. 25 years.

Dr. Sharp: That’s encouraging though. I just need to keep hearing that. They’re going to be successful adults and it’ll be fine.

I know that you’ve been doing a lot of work. We were talking before we started to record just about COVID. And I know that y’all have been doing a little bit of work just looking at the impact on kids from that. I wonder if we might just start there. I know that you have this recent article as well that I want to dive into about processing speed and its role in different pathologies, but the COVID thing is topical and it’s right in everybody’s face right now. So I’m curious about that. What have you all been finding with COVID and learning?

Dr. Ellen: Well, one of the things that we’re doing is a survey on kids and families and their stress levels during COVID, but we haven’t gotten any data yet. And one of the things that I think we’ll probably end up doing is looking at these kids longitudinally. But it’s interesting because last year we published a study on slow processing speed and Sluggish Cognitive Tempo. And one of the reasons why I got interested in that is because I was always asked about those two things, especially when I had a […] that I was giving to teachers.

Teachers hear this term sluggish cognitive tempo an awful lot. And so, they’re curious about it. I’ll just say that. And I really didn’t have a good understanding of what the difference was. And so, we looked at these two areas in our data set, which we have a large data set that we’re following kids longitudinally over time, and basically, we found that in kids with ADHD, that Sluggish Cognitive Tempo and processing speed are both closely related to ADHD, but they’re not the same.

Sluggish cognitive tempo is a cognitive-emotional phenotype, that’s daydreaming, confusion, kids are staring blankly up the window, they’re kind of sluggish and unmotivated. Teachers described them as sleepy and drowsy, but just sort of underactive. And about 60% of kids with sluggish cognitive tempo will have comorbid ADHD. So that’s a big percentage.

In our study, about 40% of youth with ADHD had comorbid Sluggish Cognitive Tempo. So you’re looking at this either way, but we wanted to know whether Sluggish Cognitive Tempo and processing speed were the same thing. I’ll kind of cut to the chase because the reason I bring this up in relation to COVID is that there are some things that we can take away from our study on this.

We’ve found that there was a significant negative correlation between Sluggish Cognitive Tempo and processing speed. The higher the Sluggish Cognitive Tempo cyst of symptoms, the slower processing speed, but it was a low correlation of like .14. So, we’re not talking about the same thing. Basically, what we found was, we looked at both adaptive symptoms and academic achievement as well as ADHD, and what we found is that there wasn’t a lot of association between the Sluggish Cognitive Tempo and academic skills.

So when you think about Sluggish Cognitive Tempo, those slow-moving kids still perform well academically in general. Not the same thing for kids with slow processing speed. We know that they’re affected by academic skills. And in fact, the study that, we’ll hopefully talk about later, we got into that even more. But processing speed wasn’t associated with adaptive skills.

So what we’ve found is that there’s this double dissociation that there is a separate measurement of both processing speed and sluggish cognitive tempo and ADHD samples is warranted, that kids with this sluggish cognitive tempo had problems with adaptive skills and processing speed is associated with academic skills. Now there are students who have both, but when we’re thinking about what this means, these kids who have slow processing speed need more academic support, more focused on accommodations, but kids with sluggish cognitive tempo need more adaptive functioning daily living skills.

So, what does that mean for COVID? It really means that the kids who are at home who have sluggish cognitive tempo are probably having even more difficulties now during COVID because they’ve got these poor academic or poor adaptive functions. And so that means that they’re home, they’re having to do a lot of things around the house, and they’re also having to adapt to one week on one week off or Mondays and Wednesdays at school all of that. So they’re probably having more difficulties right now.

Kids with slow processing speed are probably more at risk for their academic skills falling through the cracks. And I am worried about kids right now because I’m not sure they’re getting as much of the basics as they need to. So kids with slow processing speed are at risk in that regard. So if you’ve got your kids who are either one, they probably are having unique challenges right now.

Dr. Sharp: That’s fascinating that they are so unique. I would have assumed that there was a lot more overlap between those two, but this distinct difference, adaptive versus academic is super interesting.

Dr. Ellen: Well, I think too. And I should have said this at the beginning is when we’re talking about the Sluggish Cognitive Tempo, we’re really talking about something that someone reports on. Parents are reporting the child seems sluggish because it’s more of a tempo, whereas processing speed, we’re measuring it as a neuropsychological trait. So they’re really are two different things. And like I said, there’s an overlap between the two, but they’re not identical. And I think that maybe the tie in here might be inattention, but we can talk about that when we get to the other study.

Dr. Sharp: Yeah. That might be a good segue because it just got me thinking about… When you describe sluggish cognitive tempo, honestly, in many ways it kind of mirrors the inattentive symptoms of ADHD. If you’re talking about just describing or reporting behaviors, that seems like there’s a lot of overlap there. Is that fair?

Dr. Ellen: Yeah, definitely. But when we have to time someone in something like coding or symbol search or word generation, that’s not necessarily the same as sort of this long behavior trait that you see hour after hour but if those sorts of skills are very important in terms of completing a math worksheet, those sorts of things.

Dr. Sharp: Yeah. So when you say inattention, can you define that for us a little bit?

Dr. Ellen: Yeah, so when we’re measuring it, we’re really looking at the actual inattentive symptoms of ADHD. We’re really talking about that actual criterion. In our research, when we’re measuring attentional skills, usually, the measure that we’re looking at is, some of the factors from the CPT is really just visual attention skills, when I’m talking and the data that we generally analyze, we’re looking at just those attentive skills in the ADHD diagnosis.

Dr. Sharp: I got you. So what did y’all find? I know, again, before we were recording, this dimension of inattention was common across several diagnoses, but maybe getting into the weeds. Could we maybe back up. You just talk through the basics of this most recent article that we’ve referenced and what that was all about, and then we’ll dive into some details?

Dr. Ellen: Yeah, sure. So we want it to look separately from these others cognitive tempo and the processing speed, but really looks like, take a deep dive into what does processing speed mean, psychiatric symptoms or academic and adaptive symptoms. So what we looked at was how processing speed and different psychiatric disorders were linked. And we predicted the odds of having impaired processing speed for different diagnoses compared to kids in our clinic with no psychiatric diagnosis.

For example, we looked at psychosis, autism spectrum, mood disorders, ADHD, and anxiety disorders. And we put this in as a stepwise regression. If you have psychosis, that’s the most significant psychiatric disorder followed by the autism spectrum, mood disorders, ADHD, and anxiety. So, it’s a hierarchical model. So the odds ratios are over and above what would be predicted by age and sex. And we put all of these diagnoses in the model so that they’re essentially accounting for comorbidity. I hope all this makes sense. Interrupt me if you need a little more explanation on the spectrum.

What’s interesting is that even though impaired processing speed is so much associated with ADHD in the literature, I found it’s not the only diagnosis that’s associated with impaired processing speed. The other areas, in addition to ADHD that were associated with impaired processing speed were psychosis, autism spectrum, and anxiety disorders. That was really interesting in and of itself.

We asked them though, what about inattention? All right, so we know those 4 diagnoses are highly associated with processing speed deficits, but we also know that it’s important to consider psychopathology as a dimension, not just these diagnoses. We did the same analysis, but this time we looked at symptoms.

Let’s get back to what you are asking about. How do we measure attention? We measure them as clusters of symptoms. And we didn’t just look at inattention. We looked at regression, depression, hyperactivity, inhibition, anxiety, social responsiveness, mania. We looked at all of those things, and the only one of all of those things that were associated with impaired processing speed was inattention. And so, it’s interesting to think that inattention is that pure attention is something that’s really important in terms of understanding the connection to a lot of different disorders, and processing speed is one way that we can measure that beyond just how well a child attempts on a CPT, for example.

Dr. Sharp: Right. Well, there are so many questions from all of that. Let me sort through and see if I can make this make sense. One seemingly random question, but something that hopefully will tie in is, I noticed in the article you defined lower processing speed as I think sub 85, is that right? Below 85?

Dr. Ellen: Yes.

Dr. Sharp: And was that just one the PSI from the WISC-V or was that from a different one?

Dr. Ellen: Yes, it was from the processing speed index from the WISC-V. And we have really struggled with this. We really struggled with how to define what processing speed weaknesses are. That’s stuff that we’re doing right now, where we’re really trying to figure out how to analyze this is to look at whether or not processing speed is something that is a distinct cutoff, that’s normatively based like an 80, one standard deviation below the mean, or if it’s important for some kids to have a processing speed of maybe 92 but have a verbal comprehension index of 115. And I’m positive, you haven’t seen kids like this. Those are the real puzzles. It’s the difference between processing speed and other factors of intelligence what trips some kids up. And I definitely think so. We are just having trouble trying to figure out how to analyze that.

Dr. Sharp: Right. I talk with parents a lot about just anecdotally sort of this gap that you’re talking about or that discrepancy, whether it’s 80 to 100 or 95 to 125, but just that kind of internal felt sense for a kid of being slower or some things being harder than others, just the idea of their inconsistencies and performance and what that must mean internally for a kid. I don’t know if anybody’s ever actually measured that or looked at that or quantified it somehow, but it seems like it’s a thing.

Dr. Ellen: It definitely does. Anybody who tests kids knows exactly what we’re talking about. It’s hard because I have seen kids who have an IQ or verbal comprehension of 140 and a processing speed of 80. Those kids are at huge risk. And those are a lot of those who I find wind up being the subject of other books that I was telling you about that there’s no motivation in that because you’ve got this incredible intellect, but no ability to actually get your thoughts on paper or do any of the tasks that you need to do to be an efficient learner. But then there are also those kids, like you said, who has a 120 and a 98, what does it mean for them?

But development likes consistency, and personalities like to be consistent, our world likes to be consistent. And when you’ve got an inconsistent profile, it’s going to come with a challenge, and some of those might be in this range that I’ve just talked to you about that deal with psychiatric kinds of issues.

One thing to think about is if it’s inattention that runs through all of these diagnoses, not that might be where we want to start in terms of intervention. And so, maybe medication at an earlier age is important or accommodations that decrease inattention, I should say.

Dr. Sharp: Right. Just for explanation’s sake, could you talk a little bit more about just the relationship between processing speed and inattention? Is processing speed the underlying piece of inattention that’s driving that or vice versa? Are there other components that are involved in inattention? I really want to suss out the relationship between those two a little bit, if we can.

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All right, let’s get back to the podcast.

Dr. Ellen: That’s such a great question. I wish I had a really great answer, but I do know they’re both multi-determined. And the way we measure them as neuropsychologists it’s pulling in a lot of different aspects of attention. So for most of the tasks we use, we have to have visual attention and auditory attention to some extent, and also motor attention and also processing speed. So we’ve gotta be able to process information visually, sometimes verbally, sometimes meteorically.

So I’m not sure which drives which. I think that’s something that’s completely open for debate. They’re probably somewhat directional, but I think if you don’t have good attention skills to begin with, it’s going to slow down your ability to process that information. And then if you’ve got slower processing speed, it’s harder for you to hold on to attention as you’re doing a task.

So, we don’t really know which comes first. We just know that there’s a relationship between the two, to be honest. Not everybody with attention problems has slow processing speed and not everybody with slow processing speed has attention problems. So, there’s an overlap, but it’s…

Dr. Sharp: Complicated.

Dr. Ellen: […] very well.

Dr. Sharp: That’s okay. That’s validating. That’s something that I’m always wrestling with and to hear that there’s not a great answer makes me feel better. So selfishly, I feel that was a great answer.

Dr. Ellen: Yeah. One of the things we can do as testing psychologists is that we can really get a good sense of where the attention is most vulnerable and where the processing speed is most vulnerable. So if kids do poorly on word retrieval, for example, or hoarding, that gives us different data points. So they have a problem with quickly retrieving words, so that’s going to be an issue or problems quickly processing information verbally versus visually. So, it can give us a sense of where it’s breaking down for a particular child.

Dr. Sharp: Yeah, I got you. So tell me, with this research, with this article that y’all pulled together, how do these results strike you? Were you surprised to find that inattention was the more common dimension across diagnoses or not so much?

Dr.Ellen: I think I would have expected given the fact that the other diagnoses were so significant that it would be more than just inattention that would be important. So it did surprise me a little bit, but also shows the question that you just asked. It’s just how much important it is that we get a good handle on what is attention and what is inattention?

The other thing too that we found in this study is that I don’t know if this is a good time to bring it into play, but we also looked at academic functioning because we wanted to get more, beyond just psychiatric functioning. How does processing speed impact academic functioning? And we want to notice if it interferes with their overall approach to their work? Is it a study skills thing? And I bring this up because I think inattention does come into play here. So we looked at where their processing speed has a general impact on academic functioning broadly, or given that processing speed influences things like study skills, and would that be occurring through inattention?

So what we found were two different things. There was a wrong association between study skills and its relationship to processing speed, and that attention was an important part of that. So processing speed has a direct effect on study skills as well as an indirect impact on inattention. And so that may be why treating attention doesn’t fully resolve the burden of the slow processing speed has on academic difficulties. Do you know what I mean?

So, if you’ll hear kids whose attention is better because they’re on medication but they’re still not getting the work done, and that’s because attention, we can treat that but it doesn’t treat issues with processing speed.  But then we looked at if reading and math are related to processing speed as well, but with reading, it is mostly mediated by working memory in general cognitive ability, but for math, there is a direct effect of processing speed on math.

If I was back a little bit, processing speed has a direct impact on reading but when we look at the cognitive ability and working memory, no, it really doesn’t. But math has some direct effect on… processing speed has some direct effect on math. And that’s why I think we see sometimes these kids with slow processing speed, who aren’t doing that well in math and they don’t really have dyscalculia. They just don’t seem to hold it together. And I think that might be because math demands a lot more attention to detail.

Dr. Sharp: That’s fascinating. I’m fresh off of the second edition of Overcoming Dyslexia. It just came out. I guess what I took from that though, is there still that dual deficit model of dyslexia with processing speed playing a big role. I may be overreaching here, but are you saying that what y’all found was not necessarily true?

Dr. Ellen: So we were looking at just decoding skills. And we were really just looking at the effect of processing speed on reading decoding.I go as far as to say that… I don’t think it goes against anything that is presented in the research on dyslexia.

Dr. Sharp: Okay.

Dr. Ellen: In fact, we’re looking at… I mean, processing speed is still a big factor in dyslexia. And we’re not, I guess maybe this might be one difference here, we’re not just looking at kids with dyslexia on this study, we’re looking at all kids. And I think that’s where when we look just overall does processing speed have an effect on reading regardless, no diagnosis or not, some kids with dyslexia in the mix, no, but it does have an impact just on general mathematical ability.

Dr. Sharp: That’s wild. Can I dial it back just a bit and ask you to clarify something? When you say that processing speed had an impact on study skills, what do you mean by study skills?

Dr. Ellen: Our measure for study skills is we had teachers fill out the BASC Study Skills on the BASC. And on the BASC, there is a study skills scale which reflects those skills that are conducive to a strong academic performance including organizational skills and study habits. It’s got some internal consistency and reliability to it. We use the teacher ratings because they’re independent of the parent-rated inattention symptoms that we were used in the analysis to look at inattention. And we hope the teachers have a unique insight into that construct. So that’s how we were measuring study skills. So it’s really talking about the association, but the teacher evaluated the study skill scale and their academic functioning in general. Does that answer your question?

Dr. Sharp: It does. Yes, thanks for clarifying. I’m guessing people are probably wondering what study skills we’re talking about here.

Dr. Ellen: Yeah. And even though parents report on studying study skills, they’re also reporting on inattention. So those two things are correlated and we wanted something that wasn’t already biased.

Dr. Sharp: That makes sense. So then you found, like you said, the processing speed has a direct effect on general math ability as well independent of working memory or overall cognitive ability?

Dr. Ellen: Exactly. That sort of surprised us. And I guess this is a long-winded answer to when you asked before whether there are some things that surprised you? That did surprise us. Math seems to have, now even untimed math. So this is using the numerical operations of tests from the WIAT. And even in that untimed test, that processing speed still had an effect on a child’s ability to be able to do that, because that was computational math.

Dr. Sharp: What do you make of that?

Dr. Ellen: I think that math requires a lot of different steps and it requires you to do steps quickly. If you’re doing a long division problem, you’ve got to remember where you are in the process. And when you slow down the process, you’re more apt to make mistakes. And then also you’re juggling a lot of things in your head at the same time. You’re juggling multiplication facts and additional facts and procedural sorts of things. We don’t really know, but that’s our hypothesis about that. We’re doing the same thing with reading. I’m curious as to whether reading comprehension is also affected in the same way. So we’ll see.

Dr. Sharp: Yeah, there’s so much to dig into here. I love that y’all are just zoning in on processing speed. It’s such an important piece of the assessment that we do. And it seems like it’s implicated in so many different things as well. Let’s see. What else from this article feels important to highlight? Eventually, I think we can move on to just, what do you do with this? how does this translate to intervention like you had mentioned, knowing where to intervene or what to do? So two questions wrapped up in there.

Dr. Ellen: The article was published in the European Child and Adolescent Psychiatry Journal. And they did an editorial on processing speed in general. It’s really this cross disorder phenomenon that has a lot of clinical value and we need to be looking at it much more. I find that clinically when I see a child with slow processing speed, my antennae are up because I know this is sort of a child.

If it’s a child with dyslexia and slow processing speed, I’m probably going to advocate for more Orton-Gillingham, for example, than less. And they are going to be the kinds of kids that are going to take longer to respond to the treatment. And the moment to moment, hour that that teacher has or tutor, but also over the course of a year or two, and that they are at risk for other psychiatric issues that need to be monitored.

I’ve been at this long enough where I have seen kids who presented to me at age 7 with very weak processing speed, who are now at 27, who just haven’t launched that well or who have had psychosis, and so I think our data backed up what I’ve been seeing in my clinical practice over the last 20 years, that when kids have this really weak processing speed, that they are at risk for some significant sorts of psychiatric and learning challenges that go beyond the diagnosis of dyslexia or ADHD.

Dr. Sharp: Right. Well, that makes me wonder, and I wanted to ask this question earlier. I’m glad it’s come back around. It’s just like we talked about with inattention, just the directionality here. Is it the “psychosis” that’s driving the low processing speed or is low processing speed somehow contributing to psychosis? That connection feels more tenuous to me,  but that’s the big question. Or is it anxiety driving low processing speed or vice versa?

Dr. Ellen: Yeah, that’s exactly right. We don’t know that. But is it slow processing speed a marker? The Real marker of psychosis is that we need to pay attention to that. Of course, the vast majority of people with slow processing speed do not go on to develop psychosis, but it’s highly related. And so, is it something that we need to pay attention to at an early age, and just are these the kids who need to be monitored more closely than we would have thought before?

15 years ago, we would have just said it is a slow processing speed. Yeah, he just doesn’t take notes very quickly, so fairly fine. I’ll get him a typewriter and get him teacher-made notes and he’ll be fine. And what we’ve found is that that’s not the case. It’s an important data point. And hopefully, we’ll be able to answer that question you just posed or somebody’s will.

Dr. Sharp: Right. So is it at the point yet where you would say, okay, so let’s say we evaluate a kid at 6 or 7 or 8 and they show up with pretty low processing speed, is it at the point yet where you would say, we have this ADHD thing, but let’s also look out down the road for anxiety or pay extra careful attention for a psychotic issue or something else, or is it not quite strong enough yet?

Dr. Ellen: I actually do. I guess it depends on the 6-year-old. Sometimes they do grow out of it. And we do find kids who are… And I think this is the case. For some kids with slow processing speed, they might just have a white matter growth in their brain that’s just very slow that catches up. And I think a lot of this might have to do with white matter. And so there are some kids like that. But I do tell parents that it doesn’t seem like very much, but it is something that holds kids back in school and can make a lot of the learning that we do or we ask kids to do these days, very difficult for them. And so, I kind of set parents up to know that we need to take care of this kid and this gives us a sense of that.

Your question before though, the chicken in the egg question, I do wonder in some ways whether or not our current academic environment leads kids with slow processing speed, maybe some that might even be genetically disposed to psychosis to go on to develop psychosis because they’ve been working at capacity stuff for like 15 years, struggling to keep up in an environment that is for a lot of kids, overly taxing. I wonder if that is just one of those you sort of the stress model. There are some kids that are just being stressed in that way. And we know that psychosis does have a pretty strong genetic component, but not everybody goes on to develop it. So, I need to think about it.

Dr. Sharp: That is fascinating. I just have to ask. Is that something that’s come up in the literature, or is this something that you’re thinking off the top of your head because that’s fascinating that our school system is stressing kids enough? If they have low processing speed that might somehow play into that.

Dr. Ellen: No, I don’t find that in the literature we ever really talk about what kids have to really do. We talk about them in terms of diagnoses and symptoms. And then it’s like, well, what about the homework that they were asked to do all last year in 5th grade that was really more appropriate for an 8th-grader? What does that have on them? And I’m not aware of any literature that looks at that because I think it takes us looking in the mirror, all of us in certain ways, parents, teachers, as developers, everything we’ve got to say, what are we doing? I’m not sure if we’re ready to do that, although COVID gives us sort of an opportunity to rethink these sorts of things.

Dr. Sharp: That’s true. Well, I wonder if we could talk a little bit about intervention or takeaways from the article, where you go with the knowledge that you gained from this research or things that we might be able to put into play as we’re working with kids or things to just keep in mind as we’re assessing kids.

Dr. Ellen: I think we talked about some of the more important ones that I think about, which are these kids are really in need of the maximum amount of services. There’s been another study in the last two years. I mentioned that I was in Prague and there is a group of researchers over there, it’s very interesting in time perception. And there’s been a lot of user data on how people with ADHD have trouble with time perception, meaning just perceiving how long time goes by, what do 5 minutes feel like versus 15 minutes? And here’s why processing speed particularly has trouble with time perception.

And so one of the things I think that we can do with these kids is giving them a better sense of time. We spend an awful lot of time getting them planners, organizational tools, calendars, but if you don’t know what time feels like you can’t do that. So it makes it really, really tough. So teaching them about time, having them wear an analog clock, having a clock on the wall that shows them how much time is going by, time a lot of things that they have to undertake. Here’s the stopwatch. Here’s my phone. Time how long it takes to brush your teeth and how long it takes us to get to school in the morning and different from in the afternoon. What do those things feel like?

Dr. Sharp: I love those ideas. And you specifically mentioned an analog watch. Is that purposeful so that they can have a visual cue of time passing with the set the hands on the watch?

Dr. Ellen: Yeah, because you see how long like a quarter of an hour. It’s multisensory in a way that a digital clock just isn’t. A digital clock is just numbers on a clock, but an analog clock really isn’t. And even to change your phone, if you told adolescents to just change their phone to that, instead of seeing it when their phone comes on to see that clock, and I’m amazed at how many kids just do not have that really good sense of time. Infusing that into a family’s life and into the curriculum is important. And then also doing things like teaching kids about their profile. What do they need to do to be successful? What do they need from the environment? And they’d be taught to help other people to slow down, or if you’re talking too fast or those things that are important.

Dr. Sharp: That self-advocacy piece seems important like you just said. So, how old do you think kids have to be to get to gain that capability, to have enough understanding, to be able to communicate that to people? Do you have a sense of that?

Dr. Ellen: I really think kids can start at a pretty young age, like 7-8 years old now, I am not a believer that kids need to be their biggest advocate because let’s face it, we have trouble as adults advocating for ourselves. We’re not getting whatever the grade, the pay raise we want, or whatever. The hardest thing that we have to do is to advocate for ourselves, yet we ask kids to do this all the time. I hear this all the time, especially from teachers.

But that being said, I think we need to think about advocacy from a child with a small a, which is like what feels right to me right now? Did I not hear that? It’s more about self-awareness. That’s the key. And you can instill that even in a 6 and a 7 and 8 years old to know that, hey, I didn’t hear what you just said. Can you repeat yourself? That’s how advocacy starts with those small bits of knowledge and awareness of what you’re feeling, and what’s going on around you.

Dr. Sharp: Sure. I love that. I love these actionable ideas. It’s always nice to take things away. So I’m curious, as we start to wrap up, where are you headed in the future? You’ve got this book that I’m guessing you’re going to be working on a large part of the time. What else are you working on?

Dr. Ellen: I think right now, getting this book done and also getting through COVID, to be honest. I am an associate director and we also have a wonderful director of the learning and emotional assessment program at Massachusetts General, but it’s been really tough to figure out where we’re all going to be at the end of COVID and with virtual testing. And I think right now my mind is really on the next 3 or 4 months. Let’s see how we can best evaluate kids during this time.

And then I think after that, we’re really interested in looking at this construct more broadly. And we mentioned this idea about kids who are just low, a certain cutoff, or kids who have a discrepancy within their profile, something that’s really interesting to me. And eventually, I would love to see treatments come into play. I wish that pharmaceutical companies were interested in studying this outside of ADHD. And maybe if we’re talking about a different type of attentional factor, that might respond to medication. I don’t really know. That’s not my area. But I would love for psycho pharm to get involved in this because these are not always the kids who respond very well to medication, to be honest.

Dr. Sharp: Right.  Well, at least if they got involved, there would be more money presumably dedicated to looking into this stuff. That’s so true. Let me ask. I don’t think I’ve talked with anyone like a large-scale hospital or training facility like y’all have, how are you handling assessment right now with COVID?

Dr. Ellen: The clinic has been mostly a hybrid of virtual and in-person testing. Just to keep the numbers down in the waiting room and the offices as empty as possible at least at the same time, we are shifting now to all virtual for January and February. So it’s really tough because it sounds like things are going to get worse before they get better, but it’s hard to plan.

In my private practice, I’ve been seeing just a few people individually in person, usually not a hybrid but because when you’re in individual practice, you can have things, you don’t have people in the waiting room or coming into a hospital setting where they’re being exposed even more, but even I think I’m just going to go all virtual or just tell people to wait till the spring.

Dr. Sharp: Well, let me ask you what might be a hard question, which is, as such a processing speed proponent and expert, how are you assessing processing speed remotely?

Dr. Ellen: This is such a good question. This is why I like to see my kids in person. We’ve done a few things where we’ve sent the WISC protocol to a tutor and then they’ve administered it with us watching, and then they put it right back in the envelope and sent it. We could also get some things from being able to look at word retrieval, verbal fluency. There are some other tasks that you do get even a sense of processing speed on things like we can’t do block design, but most other tests of non-verbal functioning on the WISC are timed. I’m not sure how valid they are given that it’s on the screen, but still, we are getting a little bit of a sense of that. My personal preference would be to just at this point now just wait and see kids in person.

Dr. Sharp: Yeah.

Dr. Ellen: Because there’s going to be the vaccine enrollment and get back to normal.

Dr. Sharp: Right, that’s exactly what’s going to happen.

Dr. Ellen: It’s a little bit like yes.

Dr. Sharp: Yes, Oh my Gosh. I think that’s where we’re all at.  There’s some hope. There’s a light at the end of a still pretty long tunnel, but I think it’s maybe there now.

Thanks for talking through all this. I think we touched on a lot of different things. We got to dive deeper into a couple of different pieces as well. And it’s just always a pleasure to hear what’s on your mind and what you’ve got going on. I know you’ve got a lot of irons in the fire, so thanks for coming and sharing those.

Dr. Ellen: Yeah, it’s been really good talking to you.

Dr. Sharp: Sure. For people who are interested, we mentioned a lot of resources, and I’ll link to all the articles and books that I can hear in the show notes. The one thing I don’t know that I grabbed was the group out of Prague that you’ve been working with who’s been doing this research on time and ADHD.

Dr. Ellen: I can get a few of their articles if you want them to link to them.

Dr. Sharp: Yeah, great.

Dr. Ellen: Yeah. They do publish in English, but they don’t have any books or anything like that in English.

Dr. Sharp: That’s fair. We’ll take it.

Well, thanks again, Ellen. And like you said at the beginning, if there’s a third time around when the next book comes out, I would be happy to have you back. So I really appreciate it.

Dr. Ellen: Thank you so much for having me.

Dr. Sharp: All right, y’all. Thank you as always for tuning in to my conversation with Dr.Ellen Braaten. I hope that you took some things away from that, as I did. I know that I’m excited for that book coming up on kids with low motivation. So we’ll keep an eye out for that. Maybe Ellen will come back to talk about it when it comes out. There are plenty of links in the show notes, including to Ellen’s existing books and most recent article, and a couple of other things, so check those out.

Like I said, in the beginning, if you are launching your practice or thinking about launching your practice, the Beginner Practice Mastermind group is starting up in March 2021. This is a group that is meant to give you some accountability and support as you go through those beginning phases of launching your practice. It’s a small group coaching experience and there will be no more than 6 psychologists in there to help you out, all at that beginner phase. You can get more information and schedule a pre-group call at thetestingpsychologist.com/beginner.

I will be back on Thursday with another EHR review. I think the one coming up this time is a Therapy Appointment. I think it was a good one just as a teaser. So, you want to tune into that one if you’re looking for a new EHR for your practice. In the meantime, take care. I will talk to you soon.

The information contained in this podcast and on The Testing Psychologist website is intended for informational and educational purposes only. Nothing in this podcast or on the website is intended to be a substitute for professional, psychological, psychiatric, or medical advice, diagnosis, or treatment.

Please note that no doctor-patient relationship is formed here, and similarly, no supervisory or consultative relationship is formed between the host or guests of this podcast and listeners of this podcast. If you need the qualified advice of any mental health practitioner or medical provider, please seek one in your area. Similarly, if you need supervision on clinical matters, please find a supervisor with expertise that fits your needs.

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