Author Archives: jengle

Let’s talk about challenging feedback

When I first started doing assessments, it was not unusual for parents to cry when I shared a diagnosis of intellectual disability. I was glad to be there with parents to process this new information and plan next steps. Now, I rarely have parents cry during a feedback session (though it’s perfectly OK if they do!). Today, I walk to the conclusion with families, so there are no big surprises at the end. When I anticipate a particularly challenging feedback session, I find Steve Finn’s (2007) three levels of feedback helpful.

Level 1 findings

Level 1 findings are consistent with how a parent already views their child. This information is typically readily accepted.

“As you told me, Frank is a very smart kid. The assessment shows that he is indeed gifted.”

“You’ve always wondered if you have ADHD. I would agree, you do meet the criteria for ADHD.”

Level 2 findings

Level 2 findings are mildly discrepant from the way a parent views their child. Findings often modify or deepen a parent’s existing perceptions rather than contradicting them outright. They are generally not experienced as threatening to a parent’s sense of their child or their narrative about their child.

“Frank is very smart. He also has a lot of difficulty with reading, despite trying hard and getting a lot of help. We call this a specific learning disorder in reading. Let’s talk about ways we can help him.”

“You noticed that Said’s reading skills are behind his classmates and he seems frustrated with school. His reading skills are a bit behind, but the biggest difficulty seems to be in his focus and concentration. He is also really active and has trouble sitting for long. I think he has ADHD and I suggest considering treatment for that first, before starting a new reading intervention.”

Level 3 findings

Level 3 findings differ markedly from how a parent currently understands their child and can be anxiety-provoking or destabilizing. Without preparation and careful framing, a parent may struggle to integrate or may dismiss level 3 information.

“You were wondering why Katy has trouble making friends and seems behind the other kids at school. Based on this assessment, she meets criteria for Autism. Let’s talk about what that means.”

“I heard from you that although you know Dave has always needed more time to learn than his siblings, you believe he will catch up. The assessment shows that Dave has an intellectual developmental disorder which means he will always need support.”

Setting the stage for feedback

The process of preparing families to accept level 3 information starts from the beginning of an assessment.

  • Invite parents to work collaboratively with you to identify the questions you will be answering.
  • Gather specific, concrete examples and quotes that you can return to in the feedback session.
  • Be open about what diagnostic questions you are considering (“Given your concern about X, one of the things we will look at is Y”).
  • It is also helpful to listen for what Stephanie Nelson describes as “secret questions.” According to Dr. Nelson, secret questions are “those questions you listen for in the intake with your inner ear. The questions that tell you the parent’s hopes, dreams, wishes, and fears. The questions that wake them up at 3 AM. The questions they don’t really want to say out loud if they don’t have to.” Don’t miss reading the first and second parts of Dr. Nelson’s series on secret questions.

More than once, after hearing parents describe characteristics that sound consistent with Autism in an intake, I’ve asked “have you ever wondered if your child might have Autism?” This opened them up to talk about previously feeling dismissed for considering that, or “secretly wondering.”

More tips

Finn recommends presenting feedback in order of levels, starting with level 1, with most information landing at level 2. When you are presenting level 3 findings, it’s worth stepping back to consider how you can “walk there together” with the family. Perhaps you need another meeting to gather information and consider additional questions together with the family. It’s also important that if you hear information from parents that doesn’t fit with what you are presenting, take time to listen and consider your own biases. We are all wrong sometimes.

When receiving level 3 information, parents may be grappling with feelings of grief or loss for expectations they once held. Rita Eichenstein’s book Not What I Expected: Help and Hope for Parents of Atypical Children (2015) offers a thoughtful exploration of these normal experiences. She helps parents understand their own emotional experience, nurture themselves in addition to their kids, and embrace their child with acceptance, compassion and joy.

Conclusion

Feedback to parents is a relational process that shapes how families come to understand their child and, by extension, how children come to understand themselves. When we listen carefully to understand a parent’s perspective, it helps us align with them and walk together toward a shared understanding.

References

Eichenstein, R. (2015). Not what I expected: Help and hope for parents of atypical children. Fair Winds Press.

Finn, S.E. (2007). In our clients’ shoes: Theory and techniques of Therapeutic Assessment. Mahwah, NJ: Erlbaum

 

 

 

Using Generative AI at PHSA: What we need to know

Overview

PHSA has approved the use of Microsoft Copilot for generative AI (GenAI) tasks. You can access Copilot via https://m365.cloud.microsoft or directly within Microsoft Word, PowerPoint, and Outlook (look for the Copilot icon).

Important: Only use the PHSA-approved Copilot on the PHSA network. Do not use public versions of Copilot or other GenAI tools (e.g., ChatGPT, Bard) while signed into PHSA systems. When using Copilot, sign in with your health authority account. This activates Enterprise Data Protection (EDP). You will see a green shield icon in the top-right corner, confirming your session is secure.

Why PHSA-approved Copilot is safer

  • Data is not used to train AI models.
  • Information remains within PHSA’s secure environment.
  • Security tools are in place to protect sensitive data.

Human oversight is essential

GenAI tools can assist with brainstorming and summarizing, but they do not replace clinical judgment. Always critically evaluate AI-generated content before using it in any professional context.

Confidentiality and privacy

Do not input identifiable personal information into GenAI tools even if it’s de-identified. This includes:

  • Patient names
  • Medical records or health history
  • Education records or history
  • Diagnoses
  • Treatment plans

Multiple pieces of information, even if each by themselves are non-identifying, together might make the person identifiable. Therefore, PHSA recommends that you do not use GenAI to write or edit clinical reports or chart notes. Some physicians are using Heidi, an AI medical scribe for patient care, as approved by PHSA.

Tips for using Copilot effectively and responsibly

  • Upload reference files using the “Add content” feature. These files are stored in your OneDrive, allowing Copilot to reference them securely.
  • Review sources Copilot provides. Click the links to verify accuracy.
  • Start a new chat for each task to avoid confusion (use the “New chat” button).
  • Images generated by Copilot are copyright-free and can be used freely.
  • If clinicians use GenAI to assist with non-clinical work (e.g., presentations), they might consider adding a note like: “This content was generated with support from Microsoft Copilot and reviewed by a clinician.”

For lots of great tips, please see Dr. Liz Angoff’s AI Resources.

Examples of appropriate uses

  • Brainstorming ideas such as: “What are some evidence-based recommendations for a teenager with dyslexia?” or “How can I explain autism to a young child using a video game metaphor?”
  • Drafting educational materials for patients or families.
  • Summarizing recent research articles.
  • Creating outlines for presentations or workshops.

Trainees: please discuss use of GenAI with your supervisors.

Official guidance and more information

PHSA’s hub for AI information and interim guidance on GenAI support responsible adoption of AI in healthcare. PHSA also provides guidance on using GenAI in research. Guidance is expected to evolve with regulatory and technological changes.

Please also see interim guidance on AI from the College of Health and Care Professionals of BC and the College of Physicians and Surgeons of BC. Both highlight that patient consent is required to transfer patient data through AI and the CPSBC specifically notes that patient informed consent is required to use AI Scribe programs.

 

Disclosure: Copilot was used to edit this document for clarity

Intellectual Developmental Disorder (IDD) diagnosis when IQ > 70

CDBC/BCAAN Education Bite, Originally emailed October 2, 2205

The DSM-5 allows for the diagnosis of intellectual developmental disorder (IDD) under certain circumstances when an individual has substantial intellectual deficits but an IQ score above 70. These situations are uncommon and often complicated, so psychologists should rely on careful clinical judgment and review multiple sources of information before deciding whether a diagnosis of IDD is appropriate. 

Diagnosis of IDD requires standardized testing, with IQ at least approximately 2 standard deviations below the mean 

IDD requires deficits in “intellectual functions…confirmed by both clinical assessment and individualized, standardized intelligence testing” (p.33, Criteria A). In the Diagnostic Features section, the DSM goes on to clarify that individuals with IDD have scores of “approximately two standard deviations or more below the population mean, including a margin for measurement error (generally +/- 5 points, p.37).” 

IQ scores may not fully reflect an individual’s functioning
The DSM-5 states, “IQ scores are approximations of conceptual functioning but may be insufficient to assess reasoning in real-life situations and mastery of practical tasks. For example, a person with deficits in intellectual functioning whose IQ score is somewhat above 65-75 may nevertheless have such substantive adaptive behavior problems in social judgment or other areas of adaptive functioning that the person’s actual functioning is clinically comparable to that of individuals with a lower IQ score (p.42).” 

Substantial impairment in intellectual functioning is required 

The DSM-5-TR emphasizes that an IQ “somewhat” above the typical IDD range may still warrant consideration of a diagnosis of IDD, but only when significant evidence of intellectual impairment is present. 

By adding the word “somewhat,” the DSM-5-TR clarifies that this is not intended to bypass requiring the presence of substantial impairment in measured IQ. Low adaptive functioning is necessary but not sufficient for a diagnosis of IDD. 

Psychologists must use clinical judgment to consider the various factors that can explain low adaptive functioning 

Adaptive scores may be explained by factors other than intellectual functioning. Standardized measures of adaptive functioning provide valuable information about the level of support needed in daily living domains, but they do not identify the underlying reasons for the support needs. Clinicians must therefore carefully consider co-morbid conditions, cultural influences, learning opportunities, and contextual factors when interpreting results. 

When co-morbid conditions are present, it may be useful to focus on daily functioning tasks less directly impacted by the condition. Although disentangling the effects of a co-morbid condition can be difficult, clinicians should consider whether the individual demonstrates impairments beyond what would be expected for the co-morbid condition. 

Cultural and contextual factors also play a critical role. Adaptive functioning expectations are shaped by cultural norms and opportunities for independence. Clinicians should ask: 

  • Do socio-economic or cultural factors limit the validity of standardized assessment tools? 
  • Are adaptive deficits evident across multiple environments (home, school, work, community), or do they reflect situational influences? 

Psychologists must use clinical judgment in interpreting the results of IQ tests 

In addition to IQ scores, clinical judgment regarding intellectual functioning should be based on file review, interviews, and observations, and should consider quantitative and qualitative evidence, including:  

  1. Early developmental history (Criterion C requires onset within the developmental period) 
  2. Developmental trajectory, including score patterns across multiple assessments 
  3. Educational and vocational history 
  4. Underlying developmental, psychological, medical, or neurological conditions affecting development 
  5. Cultural and language bias in IQ testing and culturally appropriate developmental expectations 
  6. Motivation and performance validity 

 Summary 

Diagnosing IDD when IQ is above 70 (+/- 5) means moving beyond test scores and weighing the broader picture of an individual’s functioning. Psychologists should ask: Are the observed adaptive deficits consistent, pervasive, and greater than expected for co-morbidities or environmental factors? Do they reflect longstanding developmental limitations rather than acquired impairments? Grounding the decision in developmental history, cultural context, and multiple sources of evidence helps ensure that the diagnosis is applied accurately, allowing for access to appropriate supports and services. Clear documentation of the clinical reasoning process is essential so that stakeholders understand how the decision was made. 

Note

Community Living BC (CLBC) requires a registered psychologist (not a school psychologist) to make a diagnosis of IDD with FSIQ > 75 in order to access CLBC services.  

CDBC guidance document: Complex neurodevelopmental profile

“Complex neurodevelopmental profile” is a term CDBC recommends assessment professionals use to describe how multiple areas of functional impairment interact and lead to support needs.

The assessment evaluation must incorporate information (as available) from the child’s school, caregivers, and at least two specialists/clinicians. A complex neurodevelopmental profile should be identified when there is evidence for at least two non-overlapping areas of significant functional impairment in the following domains:

  1. Social-emotional functioning (including emotional regulation)
  2. Communication
  3. Physical functioning (gross or fine motor functioning)
  4. Self-determination/independence (adaptive functioning)
  5. Academic/intellectual functioning (cognition, academic achievement, memory, attention, executive functioning)

CDBC recognizes that not all assessing professionals will use the same terminology. When the above criteria are met, if different terminology is used (e.g., neurodevelopmental disorder, complex neurodevelopmental disorder), it should be considered equivalent. For more information, please see the document: CDBC recommendation – Complex Neurodevelopmental Profile