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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. On June 3rd, PAR is holding the first-ever PAR talks. A one-day online event offering free NASP CPD credits. Learn more at partalks.parinc.com.

Welcome back, everybody. Glad to be with you again.

Today, I have a fantastic guest, Dr. Stephanie Meyer. Stephanie got her Ph.D. from the Institute of Child Development at the University of Minnesota.

Over the years, she’s conducted research at NIMH, Harvard Medical School, and UCLA. Since 2009, she’s been in private practice, specializing in comprehensive evaluations of young children. That [00:01:00] is exactly what we’re talking about today. So if you are a kid-person and are interested in the ins and outs of cognitive assessment with preschoolers, today is your day.

Stephanie and I tackle a number of topics in that realm. Some things that we talk about include: why she doesn’t charge for missed testing sessions in preschoolers, contextual factors that can impact testing results, why she loves the Feifer Assessment of Reading, and the earliest age that she might diagnose ADHD in a young child among many other things.

So, there’s a lot to take away from this episode. I hope that you will stay tuned and listen all the way to the end so that you don’t miss anything.

Now, at the time of this release, I believe we might have one spot left in the Advanced Practice Mastermind Group, [00:02:00] possibly, possibly not. If you are trying to sneak in at the last minute, the next cohort of the Advanced Practice Mastermind Group starts on June the 10th. This is a group coaching and accountability experience for psychologists who are trying to move beyond that beginner phase of practice. So, these are folks who really want to work on taking your practice to the next level either financially or by hiring folks or just by working less and getting your systems to a more efficient place, things like that. If that sounds interesting to you, you can get more information at thetestingpsychologist.com/advanced.

All right, let’s jump to my conversation with Dr. Stephanie Meyer.

[00:03:00] Hey, Stephanie, welcome to the podcast.

Dr. Stephanie: Thank you so much. I am incredibly honored to be here. I just want to say that I’m a super fan of the podcast. I think that it’s been such a gift to so many of us who are in private practice during the pandemic, just kind of a lifeline and guiding light. So, I’m very grateful and honored to be here.

Dr. Sharp: Likewise. I am so glad to have you here. And it is because of fantastic guests like yourself that I think this is helpful for people. So, thanks for being a part of that.

Dr. Stephanie: Absolutely.

Dr. Sharp: Yeah, I’m really thrilled to have this conversation with you. We haven’t really talked a lot about assessment with preschoolers here on the podcast. It’s funny stumbling into[00:04:00] these topics. I’m like, “I’ve done 200 episodes. How have I not talked about this very much?” So yeah, I think there’s a lot to say. I’m glad we’re going to cover some of these things.

Dr. Stephanie: Yeah.

Dr. Sharp: Traditional questions starting off. Just tell me why is this important? Why this area in our field out of everything?

Dr. Stephanie: I think there are three layers to how I landed in early childhood assessment psychology. The first layer is genetics. Psychology in general is probably in my genes. My dad is a psychiatrist. My mom is an occupational therapist, so I came by it naturally. And then the question of assessment versus therapy or research. I was a research psychologist for the beginning [00:05:00] of my career and definitely went to a research program at the University of Minnesota.

And I have that brain. I love data. I love detective work and the process of understanding how certain information maps onto the world of scientific knowledge and literature. I’m not good with gray areas. I always say, I’m not a good therapist but I love working with people and I love working with kids. This is just such a good fit for my brain.

And then in terms of early childhood, as a child development researcher, I always understood the importance of early intervention. But when I opened my practice in 2009, I didn’t have a specific age in mind. I just opened my doors.[00:06:00] And the first three kids who came to see me just happened to be preschool age. It was two boys. First was two boys and then a girl. And in each instance, somebody had wondered, does this child have autism? But none of them actually met the criteria for autism.

So just for clarity, I think autism is a very helpful diagnosis when it fits. I think it’s a legitimate diagnosis. And I certainly have kids that I see who have autism. But I became interested in the question of, who are these kids who can seem like they have autism during recess or during a pandemic or in the company of certain people because autism isn’t a sometimes diagnosis. It’s not a time-limited[00:07:00] diagnosis. It’s a pervasive developmental disorder.

I got really interested in that question of what’s contributing to this variability in presentation. And that question just really continues to compel me and has led me to really focus in my practice on young children.

And it’s been interesting because, in our field, not a lot of people focus on this age range. So parents, when they’re looking for guidance, there are definitely people and institutions who have a broad-strokes approach to like, does your child have autism or not but not many people are doing a deep dive into the nuances of that question.[00:08:00] And so parents are often told like, “Well, wait and see. Or he’ll probably grow out of it.” Or at the other extreme, it’s close enough to autism. Let’s just call it that and see where things are in a few years.

I take a really different approach than that approach. And I just love the opportunity to be the first point of contact and to be on this journey with kids and families who are seeking these more nuanced answers, and approach to understanding.

Dr. Sharp: Yeah. Gosh, you said so much good stuff just in that little introduction. So, I’m just going to go with the flow here and leap on that question of your approach to assessing autism and little kids right off the bat since that is a complex area. I’m curious. When you say you take a different approach than [00:09:00] some of the ones you’ve mentioned, what do you mean by that?

Dr. Stephanie: I use the same gold standard measures. I do the ADOS™-2 and I do the ADI-R. I do it in a very standardized manner. But I’m not just looking at that question of, yes, no. I’m looking at the way that this child responding, because with the ADOS™-2, just for people who aren’t familiar with it, it’s a series of activities and scenarios where there are expected ways in which a child is going to respond and then there are less effective ways. And so I’m rating how this child is responding to bubbles and things like that.

[00:10:00] I can give an example. Years ago, I worked with a little guy who was two years old. He was 2 years and 11 months old. And he had just come from a major Institution in our area and actually the parents hadn’t told me that he was coming to me with a diagnosis of autism. But they told me later on that they were fine with the diagnosis, but it didn’t feel right. And they just wanted a second opinion with fresh eyes.

So as I was doing the ADOS-2 with him, what struck me was that it was almost like when you’re watching a movie and the audio and the visual are on different tracks, they’re not quite aligned. And so like I would do the bubbles or I would do the various scenarios and he would have the appropriate response[00:11:00] 30 seconds later than unexpected.

So, I’m looking at not just yes/no, but how is this child responding? And I said to the parents afterward. I said, “Technically, he’s going to get a certain score on this but I really want you to go get his hearing checked because something is going on where he is having the expected response. It’s just delayed.”

And so they went, there’s a specialty clinic here for little kids who need a hearing check and he failed the test, and then he had to do a test under general anesthesia. It turned out he was missing all the sounds in the upper ranges. He got a hearing aid and things dramatically changed for him. So, that’s kind of an example of like really looking at the child’s behavior[00:12:00] not just, what’s the number?

Dr. Sharp: Sure. I see what you mean. So when you talk about taking a little bit of a different approach, it’s not just like, Hey, I’m going to administer the ASDS and the ADOS-2 and maybe a checklist or two, and look at the scores and then black or white, yes or no. It’s a little bit more of a nuanced deep dive and thinking about other factors that may be. Sure.

Dr. Stephanie: Yeah. It is a similar approach but a different conclusion. The tests are the same. I actually think the ADOS-2 is a really interesting task. I enjoy giving it. I think I get a lot of information from it. It gives me a lot of information about a child’s social and emotional development more broadly than the question of autism, yes or no.

Dr. Sharp: Well, I appreciate you talking about that. I know that we didn’t necessarily plan to dive straight into autism assessment, but since you brought it up, I know a lot of people [00:13:00] are really curious about that process. I do want to talk about though just generally the idea of assessing preschoolers. So, maybe we could start with just why. Why in general is it helpful to even test down young. And I’m guessing we’re talking like maybe 2 to 5years old. Is that what you’d consider?

Dr. Stephanie: Well, I might have tested some… my youngest I think was 14 months. An amazing broad dark girl.

Dr. Sharp: When we’re testing that young, there are so many factors like, is it even going to be stable or is this going to give us any useful information? So, I’m curious from your perspective, what is the value or utility in assessing kids that young, let’s say outside the question of autism,[00:14:00] because that I think is pretty clear. Early identification. We’re always trying to do that. But if there’s not a question of autism, what’s the purpose here of testing young kids?

Dr. Stephanie: So I always think that the purpose of doing an evaluation of any kind at any age is twofold. One, the preservation of self-esteem in the child. And two, peace of mind for parents. With those goals in mind, the earlier you can get started on that journey, the better. So that’s where I see a great deal of value. We know the power of early intervention and I see it in my daily life just how much change you can see when a child is[00:15:00] 0 to5 and 6 to 7, and beyond. But you really see the pace of change is tremendous at the younger ages.

And we also know that in keeping with this idea of preserving self-esteem, a child’s reputation among their peers and their teachers begins the first moments of kindergarten. So, if we can identify any asynchronous patterns of cognitive development early on before they start to cause problems, then that is a huge reason to start early.

And there’s also just the logistics of [00:16:00] in that period that leads up to kindergarten. It’s just a really… sometimes I get calls from parents second half of  Pre-K or even at the beginning of Pre-K and I just love that period of time, those months leading up to kindergarten because we have this wonderful opportunity to look under the hood, understand what’s going on, and set this child up for success so they can hit the ground running and not just cross our fingers and hope, but actually take proactive steps.

And the other thing is that people will often call and say, I know you’re not supposed to do an IQ test until 6 or 7 years and that they’re not really stable, but my read on literature is that there is a great deal of stability [00:17:00] in IQ from early on, but that young children are more susceptible to contextual factors that can impact their performance.

So because the literature suggests that there is more variability in a child’s performance, therefore, you might see more instability in IQ over time, my goal as an early child testing person is to minimize any contextual factors that could impact a child’s performance. So, I have a policy that I don’t charge for missing sessions. I encourage parents to contact me up until the very last minute if their child has even a slight cold, a stomach ache, they didn’t get a good night’s sleep because what I see when a child has a slight cold[00:18:00] that has zero impact on the rest of their life, is that when we’re in the midst of an IQ test, what you see is that the things that come easily to that child are still going to come easily to them. But the things that are hard are going to be so much harder.

So you see, stamina is just really low. And so, there will be a bigger discrepancy between the strengths and weaknesses. And you get to do it once a year and I want to know what this child is capable of, not what they can do when they’re sick or feeling tired or cranky.

And then the other thing is that I only do preschool assessments in the morning. I don’t do afternoon assessments because kids are at their freshest,[00:19:00] most alert, first thing in the morning. And I don’t really want to bump up against lunch either. So usually my testing is like 8:00 to 10:00 or 10:00 AM to 12:00 PM. And so what’s been exciting to see actually is that when you do minimize contextual factors, the stability of IQ is striking.  I’m going to share my graphs because I’d like to share my graph with you.

Dr. Sharp: Yes, and just for the listener who can’t see the graphs, we will put copies of the graphs in the show notes so that you can download them and check them out on your own. But yeah, we talked before we started recording about your love of graphs. And so this will not be complete without looking at graphs.

Dr. Stephanie: Yes. [00:20:00] Can you see this?

Dr. Sharp: Oh, yes.

Dr. Stephanie: Okay. So this is a repeat IQ test for a girl who first came to see me when she was 3 years old and then came back when she was 6 years old. When she was 3 years old, I was still using the  WPPSI-III, not the WPPSI™-IV. And so this is actually a comparison of her performance on the WPPSI-III and the WISC-V. So that’s a lot of space between those two tests, right? So what made them more comparable is that she was three and the WPPSI-III performance IQ is only Visual-Spatial tasks.

So the comparison is much easier than if she were 4 years or 5 years between the tests. That’s a testing issue. But look at this. Look at the stability. And this is pretty typical. So what you can see[00:21:00] is that her verbal skills are like, there’s no space between the top graph and the ceiling. And then her visual-spatial skills are average to high average. And there are only a few points, maybe one or two points here, but in full-scale IQ or General Ability Index, depending on… so that I think it gets incredible.

And I try not to remind myself of what the previous scores were. So I’m not trying to get any kind of score. I don’t want to influence anything unconsciously. But what’s really interesting then is when you have minimized the impact of contextual factors, then when there are changes, they’re meaningful. So, I’m thinking of kids who have [00:22:00] a semi or partially-treated learning disability.

I don’t know if you’re familiar with it, I’m sure you are. What’s the term like Matthew effect? So if for kids who have an untreated or partially treated reading disability, what you would expect to see between kindergarten and 2nd grade is a decrease in their vocabulary score. And if there’s a math difference, what you’d expect to see potentially is a decrease in matrix reasoning and other fluid reasoning tasks.

So then it’s still meaningful because we have a valid preschool assessment. But it’s not a good business model. It’s a terrible business model only doing this testing in the mornings and not charging[00:23:00] for cancellations. I don’t mind it. For me, it’s so important that kids have the opportunity to do their best. So in that way, it is a good business model.

Dr. Sharp: Right. Let me ask a little bit more about this. So I love this idea. I love the way that you frame this, that if you’re limiting the impact of these contextual factors then IQ gets a lot more stable over time. What are some of those other contextual factors that we might want to be aware of that could impact a kid’s functioning?

Dr. Stephanie: So a big one is, are they comfortable with the tester? So sometimes people will say, “I took my child for IQ. It doesn’t feel right. The results don’t feel like the child I know.” And I say, “Well, were they excited for this? Did they vibe with the tester?” And they’ll say, “No,[00:24:00] she seemed like she was rushed. She seemed impatient or it was at 4:00 PM” Especially with kids who are young and very sensitive, I always say, you want to choose your assessment person the same way that you would think about a therapist. Is this person going to be a good fit for your child because you’re going to get really different results?

Sometimes parents will call and say, I want to understand my child’s potential, but know I’m going to bring him in and he’s going to refuse to answer any of your questions or he’s going to give you silly answers that are the wrong answers. I see that all the time. My job is to get past[00:25:00]  that. I can see those dynamics, I can document those dynamics, but I want to know what is beyond those dynamics. What’s really in there, not what he’s willing to give me when he feels scrutinized or tested. I want to know what his potential actually is.

And so, prior to the pandemic, I had an office. During the pandemic, I’ve actually been doing in-home testing. But prior to the pandemic, I had an office that I had intentionally set up. My first criteria was, I don’t want anything in this office that is precious or breakable or that I even in any way feel nervous about anyone touching. I want there to be no zones that are off-limits. And I want it to be just incredibly[00:26:00] compelling, but not distracting.

I find that when kids… Well, let me backup for a second. The way that I encourage parents to say, because parents will say, “How do I explain what we’re doing?” I encourage parents to be honest about why they’re bringing their child for testing, but at the same time, present it in the most compelling way possible, because I want kids to not feel that they have to come to these sessions but that they get to come to these sessions. But these are like a special occasion that they are excited and their siblings are a little bit jealous that they get to come for the session.

Dr. Sharp: I love that. How do you do that?

Dr. Stephanie: So [00:27:00] this is the best feedback that I can get ever. I’m still glowing for this feedback. A mom who had brought 3 of her sons to see me said that whenever they talk about Stephanie Meyer, it’s like they’re talking about Disneyland. We did IQ testing and they’re brilliant boys. But I think a big part of it is… what is it? I think that a lot of the kids that I see in my practice are, it may sound silly but even if they’re 4 years old, they don’t suffer fools very well. Like they’re onto you.[00:28:00] And if they feel that there’s even a little bit of hypocrisy going on or somebody has a therapist voice or something that feels false, they will shut down.

I really enjoy working with young kids. And the way that I just naturally am with young kids is that I don’t think of them as young kids. I mean, this is who I’m hanging out with this morning and it’s standardized. Like, I don’t want to create the impression that in some way that it’s not standardized. It’s absolutely. I’m a stickler for things being standardized. But at the same time, I think that the kids feel really respected and there’s even something, I always[00:29:00] start with the IQ test because it feels to me like a great icebreaker because it’s closed-ended rather than like a verbal fluency task, which is like every child that I see, it’s their Achilles heel to say, like how the animals you can think of in one minute. The close endedness of the IQ test is very comforting, I think.

Well, I guess the other thing is that I was told in grad school, and this was not a compliment, this was a critique, was that I have a really expressive face and that maybe I need to tone it down. And I think that there might be something about that just makes me a good tester for young kids.

Dr. Sharp: I’ve been told the same thing, Stephanie. So this is very validating. And I think that is really helpful with kids when you can just be how you are and a little more, I don’t know if animated[00:30:00] is the right word, but that goes a long way.

Dr. Stephanie: Yes. I like to have little… one, I do have a candy shelf that you’re going to earn something really great at the end. So that’s one thing. It could all be that. And I could be deluding myself that there’s anything special about me. It could be the candy shelf.

Dr. Sharp: It could be.

Dr. Stephanie: Yeah. But I’m always thinking… I have these huge bean bags in my office that are like you can just dive into them, be piled into them, planted in them. And I had a, I call it like my wiggle machine where if you need to get wiggles out, I have this wiggle machine and I have erasable Magic Art Markers and just fun things that we can do when we’re taking our breaks.

[00:31:00] Dr. Sharp: Well, that gets to one of the other questions that I don’t know if you have more to say about this, but you used the phrase compelling but not distracting in describing your office setup. Is there anything else in that realm that you might share with folks who are looking to create a similar space in their own offices?

Dr. Stephanie: Yeah. A lot of the kids that I see really love to move. The movement is really big. So all of the furniture in my office moves in a really interesting way. So, I have two leather chairs that are fine for adults or kids and they spin. There’s not anything flashy about that. [00:32:00] And after IQ tests, parents are often mortified because their child is spinning or running or jumping because the reverberations of an IQ test are pretty profound.

And I have a convertible couch so that it also turns into a flatbed. And I had a table kind of like a Lazy Susan, but it was also called an infinity table. So when it was fully open, they would come in and I’d be like, “Okay, I’m going to give you a tour of my office. This is the area where we take breaks.” And I have games. I don’t have a huge shelf of games where it’s something they’re all in a cabinet, but I also love the furniture. I have a really modern sensibility in terms of how I like to decorate. So my office is modern and so I love being there.

[00:33:00] And then I think that translates. It was also huge and had a big window. I’d say, this is the area where we take breaks and there are games over here. And then this is the area where we can sit and chat. Look at this table, it actually opens up into an infinity sign. And this is the most important. This is a candy area. This is what you get to…for kids who come and play learning games with me, you get to pick something out from there.

So, I give them a tour but I don’t have a lot of things on my wall. The only things on my wall are drawings that kids have done. And then I had a really just like a perfect photograph that my mom had taken[00:34:00] of purple flowers. And parents would often look at it and go, I don’t know, there’s something so calming about that photograph. I can’t stop looking at it. And honestly, I don’t personally have a good sense of […]. It’s just not in me. I’m not a good three-dimensional planner, but I had my cousin and my cousin’s wife come and set it up.

And I was terrified that I was going to break… that I would need to replace a piece of furniture because honestly, I didn’t know how to do it if it wasn’t exactly the way they had set it up. So for like seven years, my office did not change. And even when I did have to replace pieces of furniture, I got the exact same one.

Dr. Sharp: That’s great. I’m guessing I’m not the only one hearing you describe this who wants to see this furniture? Maybe if[00:35:00] we can, I don’t know if there’s a way to send me the links to this furniture. I can put them in the show notes for anybody who might want to check it out because that sounds very unique.

Dr. Stephanie: Well, and I got really lucky because somebody, a set designer, was having a big home sale and I somehow came across it on Craigslist. So I just benefited from his amazing taste. But yeah, I will definitely.

Dr. Sharp: Maybe we could talk about some practicalities here. Do you have a standard or semi-standard battery that you’re thinking of with most preschoolers who come into your office? And if so, what’s included in that?

Let’s take a quick break to hear from our featured partner.

I’d like to take a moment to let our listeners know about an upcoming event that I am pretty excited about. [00:36:00] On June 3rd, our good friends at PAR are holding the first-ever PAR talks- a one-day online event focused on helping you prepare for in-person schooling with three free sessions offering NASP CPD credits.

One session features Steve Feifer, author of the Feifer family of assessment tools who will present the neuropsychology of stress and trauma. How to develop a trauma-informed assessment. He will explore the neural underpinnings of stress, trauma, and emotional dysfunction in children and their impact on learning. Register or learn more at partalks.parinc.com.

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

Dr. Stephanie: Yeah, so I would say that I have a pretty standard battery and then I bring in some other things. I start with an IQ test and then I do the NEPSY-II select[00:37:00] subtests from the NEPSY-II.

Dr. Sharp: Can I jump in real quick, just with the IQ. Are we talking WPPSI-IV?

Dr. Stephanie: Yeah, so I do the WPPSI-IV and then I do the NEPSY-II. When kids are in Pre-K, 4years and above, I do pre-academic testing. And so I’ll do the Woodcock-Johnson and then the FAR. And I really like the auditory processing test that is designed for young kids called the ASA. I really like that. So, if I’m suspecting something in the auditory where I am, I will because I don’t feel qualified to do [00:38:00] the other. This one is just really simple. It doesn’t feel like I need to calibrate anything. It gives me just a sense of there’s something there.

Dr. Sharp: What is the full name of the ASA?

Dr. Stephanie: The auditory I looked it up actually, what is it? The auditory assessment.

Dr. Sharp: I’m going to guess auditory skills assessment. I just don’t know if that’s the one.

Dr. Stephanie: Yeah, that’s what it is.

Dr. Sharp: Is that really it?

Dr. Stephanie: yeah.

Dr. Sharp: Great, okay. That really was a guess.

Dr. Stephanie: Yeah. I get into the abbreviations. We had talked a little bit before about favorite tests. I love the tests I get. I love[00:39:00] the FAR- the Feifer assessment reading. Doing the FAR with 4-year-olds is one of the great joys. I love everything about it. I love the color of it. I love that it’s given me a tool that is so precise and so clear that I’m able to pinpoint things at a level that I wasn’t ever able to before, and I can conceptualize what’s going on. So can I show you a graph?

Dr. Sharp: Of course.

Dr. Stephanie: Okay.

Dr. Sharp: And I’ll do a little description once it pops up here. I’ll try to describe for our listeners what’s going on here. While you’re pulling that up, I know people are probably curious too about how you make these graphs because[00:40:00] they look really nice. I’m curious how this is happening?

Dr. Stephanie: Yeah. So, I use numbers, which is one of the apple programs and it’s super easy. And I will just take… once I figured out a great template for a graph, I just save it for the next child and then just plug in the numbers in. But so I’m now showing Jeremy a graph of the FAR profile of sub-test scores. And I honestly feel like this is the closest thing we have to an x-ray. So in this instance, what you can see is, let me backup, these are the index scores for this child.

[00:41:00] So you wouldn’t be in any way alarmed by this because it’s like, oh, they’re right. Where they should be everything. And then you look here and it’s like a missing tooth in certain places. And so this was actually for a girl in 3rd grade, just a little bit older. But what you see here is that phonemic awareness, strong; fluency, there are these gaps in rapid naming, visual perception, and irregular word reading.

And so what was happening that nobody picks up, and I think of it as like the princess and the pea, like there’s something that’s under 12 mattresses but nobody picks up on this until there’s an issue with comprehension. [00:42:00] So the other areas of comprehension are strong, but the compensation that’s happening over here is depleting the brain resources that would allow you to actually understand what you’re reading. So nobody picks up on it until 3rd or 4th grade when you have to start really comprehending at a high level. So this is where graphs just are so helpful.

Dr. Sharp: Yeah. I love this. I love the visuals. And there’s so much… I was actually talking with somebody just yesterday about the research around the visual presentation of information. People love that. It really helps understand information. So yeah, the graphs are awesome. Is this just a matter of course with all of your evaluations that you are plugging the scores in and generating these graphs?

Dr. Stephanie: Yes, every report I[00:43:00] do. So here is IQ. This one I just think is so beautiful. What you can see is that pretty much every domain, the full-scale IQ, all the domain scores are at the ceiling. And then you’ve got processing speed, which is average but it’s clearly… and this is okay, so I think what’s so beautiful about this is like…

We talked about perfectionism, and people think that parents cause perfectionism, right? This kind of profile is what causes perfectionism. I always think about like, if all of these scores are up here and then I’m looking down on this processing speed score going, like, what the heck are the hands doing? How is that happening? They can see how they want their handwriting[00:44:00] to look but they can’t make their hand do it. And it’s where it’s going. It’s not automatic or it’s slower.

So this just creates a visual I think that is so powerful. I’m such a visual person. When I see something like this, I’m like, “It’s right there. It’s so exciting.” And then here this little dye, so the question of the common wisdom that you should wait until the child is 7 years old before you do a dyslexia assessment, right? So here’s a little guy in kindergarten where parents were told his reading and writing is right where they should be. We don’t have any worries. But he does get distracted and silly when he has to read out loud but[00:45:00] otherwise nothing.

So we take a look at his… It was actually hard to get him to do much in the way of reading because he was self-protective. But look, his phonemic awareness is at the ceiling and then we’ve got rapid naming and visual perception way down here.

Dr. Sharp: And just for people listening, his percentile rank for phonemic awareness looks at 99.9, and then rapid automatic naming and visual perception are down below 10. Both are below 10.

Dr. Stephanie: Yeah. It’s so exciting to catch this before there’s a problem, right? And by the way, he was really excited to hear that. And his mom is just[00:46:00] incredible because I told her what I was finding and she was able to convey the information to him in such a way that… usually, I do that. She just somehow knew how to do it. I have stealth dyslexia. I said stealth dyslexia because nobody has picked up on it. He’s young. It’s hidden.

And stealth dyslexia for people who don’t know, if you have a very bright child who has maybe average reading skills, and if you look under the surface of how they’re reading, the patterns are similar to somebody with dyslexia, you call it stealth dyslexia because they’re putting in so much effort and so much deflection and compensation that people don’t pick up on it.

So he was so excited by the idea that he had stealth dyslexia. He was telling everyone. So[00:47:00] we were able to intervene, right? So these are his fluency scores before and after. His parents just got right on it. You can barely see the original scores. So this was August 2020,  now March 2021.

Dr. Sharp: So, less than a year of intervention.

Dr. Stephanie: Less than a year. And so I just actually did a follow-up reading just to see where is his reading? So his reading went from… this was during the pandemics when I first tested him. …his reading skills had literally stopped at kindergarten 6, which is when the pandemic hit. Now his reading is at a 6th-grade level actually. And so he[00:48:00] was applying to go to a new school and he had this interview and he said, they said, is there anything we should know about you? He said, I have stealth dyslexia but I overcame it. It’s so exciting and…

Dr. Sharp: That’s a great story. Let me ask you. This is a little bit of a departure I think from generally what we’re talking about, but since it’s coming up, I know there’s a lot of debate or discussion around the concept of stealth dyslexia. And I think this example you’re giving is a fantastic one to talk about this just for a bit because in his story he said, and I overcame it and we’re looking at these scores, right? And it’s like, they went up from almost 0 up to at least average or above. So I’m curious how you[00:49:00] reconcile that. I have two questions. Did you originally make a diagnosis of dyslexia? Or was it more just, Hey, these readings are really weak. We need to watch this and get an intervention. So that’s the first question. What are your thoughts?

Dr. Stephanie: The diagnosis of dyslexia requires that a child has had 6 months of some reading instruction remediation. So, when I see scores like this in his original Feifer scores, when I see them at 4 years old in Pre-K, what I say is they don’t meet the duration criteria but what we’re seeing places them at very high risk if [00:50:00] these patterns continue.

And then what I’m saying to parents is, this really… and it’s not just these graphs. We think about dyslexia as just being this isolated reading issue, but there are so many things that go along with dyslexia. There’s a multi-sensory imbalance that you see. There are challenges with procedural learning. There are sometimes articulation issues, Proprioceptive issues, motor issues. So there’s a lot that goes along with it.

And so I’m looking at a whole pattern. I’m not just looking at like, oh, I have these beautiful graphs. I’m looking for patterns. But I’ll say, look, this is looking very strong. This is what’s going on. But I don’t [00:51:00] call it dyslexia until a child has had those six months. So with this particular child who had been in kindergarten and had actually finished kindergarten, I did give him a diagnosis of stealth dyslexia. Where was I going with that?

Dr. Sharp: Well, maybe my second question will help guide us toward wherever you are going. Maybe it’s the same place. Which is, what happens now? Like when a kid gets this intervention and these scores leap so dramatically when they come back or if they come back, do you still say, yes, this was dyslexia. We just mediated it. Or was this maybe just lack of instruction or developmental variability. How do you conceptualize that?

Dr. Stephanie: So [00:52:00] what I find over and over again is that if you intervene early with dyslexia, reading is not a long-term problem. And I’m talking about kids, not kids who have phonemic awareness issues and orthographic because that’s going to take more, but when it’s one or the other, and what I often see is as a pattern like what you see in the graph where phonemic awareness in kids who are gifted, I see this unbelievable phonemic awareness but they rely so much on their phonemic awareness for reading. So they’re reading by ear, but they can’t just glance at a word that’s fairly new and just know what it is. They are having to[00:53:00] rely on context and their phonemic awareness. So, oh again, I forgot where I was going.

Dr. Sharp: That’s all right. There’s so much to sort through here.

Dr. Stephanie: I know.So I give the diagnosis. I’ll give an example. So a girl came to see me at 4.5 years old. She had a profoundly gifted IQ, just off the charts. She came back to see me at the end of kindergarten and she still had this IQ but she was not able to read at all. And so she was great at faking it, incredible at faking it, but she couldn’t read. So I sent her to… and I’m very impatient about this. I want to get it[00:54:00] done. I have seen it, you can get it done fast or you can get it done slowly. And if we’re still thinking about preservation of self-esteem, it makes all the sense in the world to get it done fast.

I am a super fan of Lindamood-Bell. We have some magical Lindamood-Bell here in Los Angeles in particular. I don’t know the quality of all Lindamood Bells, but these two in particular are just very special. And so this girl, I sent her to Lindamood-Bell for the summer after kindergarten. Her reading clicked. She became an avid reader and she never had to go back to do any other kind of anything.

She came back recently in 3rd grade because the other aspects [00:55:00] of dyslexia were tripping her up. So, math fact fluency and spelling were still. So it’s the automaticity of being able to just know your math facts and be able to apply the rules of spelling and punctuation and capitalization without thinking about it. Those aspects of dyslexia were still there, but I didn’t call it dyslexia anymore. And we don’t even need you because it’s just a specific learning disorder, and now it was a specific learning disorder with impairment in math, fact fluency and written language. So, I don’t feel the need to continue to call it dyslexia because that would imply that she and her reading is off the charts.

Dr. Sharp: Right.

[00:56:00] Dr. Stephanie: But what I find with young kids is that they are closer to the beginning of reading. They don’t have the compensatory strategies that are so entrenched and there’s just a greater willingness to do the intervention and there’s much less resistance. And the power of it is unbelievable because it’s gone.

Dr. Sharp: Right. Well, and we all know that reading is such a big part of elementary school and can really get wrapped up in a kid’s identity. So early intervention is great.

Dr. Stephanie: Early intervention is great. We think about the social and emotional aspects of dyslexia as being stemming from the fact that you’re [00:57:00] in the lowest reading group or you’re not, but the way that I see it is that the more that… What I see is that the cognitive support structures that underlie successful reading are the same cognitive support structures that underlie social-emotional development. And so if you intervene in terms of reading, you’re going to see a huge benefit in terms of social and emotional because it’s the mind’s eye. It’s strengthening the mind’s eye, which is what allows you to take perspective. It allows you to regulate your emotions.

And then actually, if we look here, particularly in girls, what I see is that girls and boys with dyslexia have difficulty with verbal fluency. So if I say, tell me as many[00:58:00] animals as you can think of in one minute they really struggle with that because they’re not relying on their mind’s eye to picture the ocean and picture a safari there. So, honestly, they’re looking around the room, going like, cup, couch, pillow, and they can’t access those visualizing strategies.

And so you also see that in terms of, with girls, with dyslexia, this is what I worry about. They can’t access their own story when somebody else has a competing narrative. They can’t speak up for themselves or self-advocate. So I’ll say like, I worry about this girl who’s so empathic and just so giving falling in with the wrong crowd and somebody pointing to her and saying like, “She’s [00:59:00] the one who robbed the bank” and her not being able to say, “No, I didn’t. This is what happened.” Because of not being able to access the movie of her past. That makes sense.

Dr. Sharp: That’s fascinating. Yeah. I feel like we could have an entire discussion just about that concept.

Dr. Stephanie: That concept is just so important. And when you look at it, just to bring it back, can you see the graphs? Verbal fluency, this is a boy, but still in his case you see him now being able to speak up for himself in ways that he wasn’t before.

This is a girl who I saw at the end of 1st grade who did Lindamood-Bell [01:00:00] the summer after 1st grade, she came back to see me a month after finishing Lindamood-Bell, and her story recall and her verbal fluency had gone up so much and it was apparent in her everyday life. She was able to tell her story in the face of loud counter-narratives. So to me, I think of Lindamood-Bell as a social and emotional intervention more than anything, because that’s what they teach in Lindamood-Bell, that’s what they’re teaching. They are building the muscle that allows you to look inward at what you’re seeing.

Dr. Sharp: Yeah, this is amazing. They should be paying you to generate these graphs for them because they seem very compelling.

Dr. Stephanie: I know. And these are  100%.[01:01:00] This was from a few years ago, this graph. I sent it to my colleagues at Lindamood-Bell and I was just jumping up and down. For a little while I had it on my phone as my backdrop or whatever because it’s so important. It’s everything.

Dr. Sharp: That’s great. Well, I know that we’re getting close time-wise and I want to at least touch on the construct of ADHD assessment in little kids. We get a number of referrals. I think a lot of people get a number of referrals where there’s a question or a rule out of ADHD in a 3-year-old or a 4-year-old or a 5-year-old. And I am really curious how you approach that process with little kids.

Dr. Stephanie: Yeah. So this is one area where I do take a little bit more of a wait and see[01:02:00] because the AAP says you can diagnose as young as 4 years and ACAP also you can diagnose this thing as 4years old. But I’m in the camp of proceed with caution until 5 years old because when kids are little, things like jumping around, climbing on things can be so many different things. Having difficulty following directions can be stemmed from so many other things. As they start to stretch and grow, it becomes so much clearer where that’s coming from.

I am of the camp where I take a wait and see more cautious approach. I want to see, like if we address anxiety, is some of that heightened need for the movement going to [01:03:00] decrease? If we address the learning challenges, are we going to see a reduction in some of the avoidance or difficulty with attention?

But once a child turns 5 years, I have no problem making the diagnosis. But to me, I’m kind of a stickler for that. Again, similar to with dyslexia, I’ll say, look, I’m seeing a lot of risks here. And I think when he or she turns 5 years, I think we should do a mini just check in on attention or have parents and teachers every three months do rating scales. So we’re really closely tracking it. We’re not letting it go, but I also don’t want to call it too soon.

Dr. Sharp: Yeah. I think I take a similar approach.[01:04:00] There are some very rare cases when I might diagnose ADHD in a kid who’s younger than kindergarten. I mean, if there’s a very clear family history, if it’s happening all over the place, if there’s maybe a sibling. It’s going to be pretty unique. 

Dr. Stephanie: It’s got to be kind of classic. Yes. 

Dr. Sharp: No other risk factor. Diet and sleep are good. All those. But otherwise, I’m in the same boat. I like to at least wait until kids are in some formal schooling environment just to get some sense of how they compare to other kids among other things.

Dr. Stephanie: Yeah. Exactly. And you’re supposed to have that… It has to be in multiple settings. And if they’ve been in… a lot of times maybe it’s something seen in multiple settings of a child like in a play-based preschool. But there are certain instances where I will say,[01:05:00] I know that in six months, I’m probably going to be calling this ADHD, but I just would like to wait.

Dr. Sharp: Right. This hearkens back to… we’ve had a number of discussions on the podcast just about the willingness or ability of a clinician to say, I don’t know yet. And this is one of those cases, I think, where it’s super appropriate where you can say, hey, these signs point in this direction but let’s give it six months. Let’s wait a year. Let’s track that behavior.

Dr. Stephanie: Exactly. 

Dr. Sharp: Gosh, you’ve shared a lot of info and…

Dr. Stephanie: I needed people to talk to during the pandemic. Clearly, I have been socially deprived.

Dr. Sharp: Hey, likewise. This is like pretty much my only social outlet each week. So yeah, I’m right there with you.

This is a good discussion. I feel like we covered a lot of ground. [01:06:00] I think a lot of us probably dabble in early childhood assessment, but to be able to speak with you knowing that you’ve really specialized in this for a while, it’s so valuable. I just can’t thank you enough.

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