Author Archives: jengle

Attention-deficit/hyperactivity (ADHD) in the news

CDBC/BCAAN Education Bite, Originally emailed May 9, 2025

An April 2025 New York Times article has been making news: Have We Been Thinking About A.D.H.D. All Wrong?  This article highlights fluctuations in ADHD symptoms, the continuous (not dichotomous) nature of ADHD, and mixed evidence for the long-term benefit of medication for ADHD. Clinicians may want to review this article since it’s making the rounds and you may get questions about it.

From the article – “The failure to find a clear biomarker doesn’t mean that there is no biological basis for A.D.H.D.; most scientists I spoke to agreed that the condition is produced by some combination of biological and environmental forces, though there is little consensus about the relative importance of each. But it does have certain implications for the field, including for the question of medication. If we’re no longer confident that A.D.H.D. has a purely biological basis, does it make sense that our go-to treatment is still rooted in biology?”

The Testing Psychologist podcast discussed this article and gave some specific suggestions for clinicians. It’s worth a listen. Reading the NYT article brought me to a recent update to the  Multimodal Treatment of ADHD (MTA) study which I’ll highlight here.

 Characteristics and Predictors of Fluctuating Attention-Deficit/Hyperactivity Disorder in the Multimodal Treatment of ADHD (MTA) Study (Sibley, et al., 2024)

This study provides detailed comparison of the MTA’s fluctuating ADHD subgroup to the stable ADHD and remission subgroups. This study included 83% of the original sample who had at least one follow up over 18 years old. Unfortunately, this is not an open-access article. I’ve highlighted a few key points here:

In this MTA long-term follow-up study, fluctuating ADHD occurred in 63.8% of the sample, characterized by alternating periods of remission and recurrence. “The high prevalence and moderate severity of fluctuating ADHD indicates that it may be the standard clinical course of ADHD—not a rare variant. Stable persistence appears to be a less common variant of ADHD (10.8% of sample) characterized by early and lasting risk for comorbid mood problems, elevated substance use, stable impairments, and low medication utilization relative to severity. The recovery (9.1%) and stable partial remission subgroups (15.6%) may be rare variants marked by milder ADHD and protective factors such as low parental psychopathology or elevated comorbid anxiety”

 “Among fluctuators, periods of remission (particularly full remission) were associated with higher environmental demands, particularly at younger ages [young adult]…Though fluctuations in demands and remission appear to coincide (particularly at younger ages), it remains unclear whether remission promotes entry into more demanding environments or greater demands facilitate symptom/impairment management…Clinicians should emphasize that ADHD often fluctuates over time and patient monitoring of symptoms is imperative to trigger as-needed return to care.”

 

References

 Sibley, M. H., Kennedy, T. M., Swanson, J. M., Arnold, L. E., Jensen, P. S., Hechtman, L. T., Molina, B. S. G., Howard, A., Greenhill, L., Chronis-Tuscano, A., Mitchell, J. T., Newcorn, J. H., Rohde, L. A., & Hinshaw, S. P. (2024). Characteristics and predictors of fluctuating attention-Deficit/Hyperactivity disorder in the multimodal treatment of ADHD (MTA) study. The Journal of Clinical Psychiatry, 85(4)https://doi.org/10.4088/JCP.24m15395

Respectful and ethical work with interpreters

PHSA has a Language Policy that outlines the appropriate use of language services to reduce or eliminate language barriers to optimize the delivery of safe and equitable care. A few key and interesting points from this document:
  1. Staff are to make “all reasonable efforts” to obtain the services of a Qualified Interpreter.
  2. For Indigenous languages, an Indigenous Patient Liaison or Elder may assist with consent in lieu of a Qualified Interpreter.
  3. The need for interpreter, language required, and any refusal of interpreter must be documented in the patient record, in addition to any other language resources used (e.g., family members).
  4. “Interpretation” refers to the spoken/sign format and “translation” refers to the written format. For documents of two pages or less, the document can be “sight translated” by a Qualified Interpreter. PLS has a paid service available to translate written documents.
  5. Machine translation should only be used for non-medical conversation due to the risk of breach of confidentiality or miscommunication, where no other resources are available.
Practical tips
  1. Most of the time, sitting in a triangle is the best format to be able to communicate via interpreter, but the interpreter may have specific suggestions in your particular setting. With an ASL interpreter, the interpreter will typically stand next to you so that the patient can look back and forth between you and the interpreter easily. There are also lighting considerations with ASL interpretation.
  2. Speak directly to the patient or family member, facing them and not the interpreter. Use words like “you” and “you’re” and avoid saying things like “ask the patient.”
  3. Speak at your normal pace and volume. Speak using 1-2 sentences at a time but avoid breaking up a thought. Avoid asking more than one question at a time.
  4. Clarify unique vocabulary. Avoid jargon, slang, idioms, and acronyms. Be thoughtful with the use of humor – what you may intend as humor may not be the same in the patient’s first language.
  5. Keep in mind that sometimes there is not a direct equivalent term in another language. The interpreter may request an explanation or require more time to convey an unfamiliar concept.
Provincial Language Services has educational Resources and Education. Some highlights:
  1. Making Sense of Language: The Communication Conundrum (video with focus on intercultural communication)

Dyslexia Intervention

CDBC/BCAAN Educational bite: Originally emailed March 13, 2024

Targeted reading interventions improve word reading and spelling: A recent meta-analysis of 53 reading interventions targeting foundational skills for children at risk or with dyslexia show a significant, positive effect on norm-referenced reading outcomes. Dosage (higher=slightly larger effect sizes) and outcome domain (spelling and word reading were more impacted than reading comprehension) were important moderators (Hall et al., 2023). “Mean effects of interventions delivered earlier (in Grades K-2) were not statistically significantly larger than effects of interventions delivered later (in Grades 3–5). Descriptively speaking, though, studies with students in Grades 3–5 were associated with smaller effects (g = 0.16) than studies with students in Grades K-2 (g = 0.36).”

Phonological awareness can be directly taught through instruction: As suggested in the National Panel on Reading (2020), phonological and phonemic awareness instruction are important components of preventing and treating dyslexia. This intervention continues to be well supported as being able to be trained through intervention (Rehfeld et al., 2022). Phonological awareness training must be paired with high quality targeted reading intervention.

Music training may play a role in helping those with dyslexia: A prospective study published in PLoS One (Flaugnacco et al., 2015) suggested that music training can improve phonological awareness and reading in children with dyslexia, presumably due to an underlying poor temporal perception which is improved through training.

Treatments without research support

Neurofeedback: There is not sufficient research to support EEG neurofeedback as an intervention for reading (Othman et al., 2020).

Vision therapy: According to a joint statement which included the American Academy of Pediatrics, section on Ophthalmology “Convergence insufficiency and poor accommodation, both of which are uncommon in children, can interfere with the physical act of reading but not with decoding. Thus, treatment of these disorders can make reading more comfortable and may allow reading for longer periods of time but does not directly improve decoding or comprehension.” Overall, while vision therapy can help individuals with convergence insufficiency, it is not accepted as an appropriate treatment to improve reading, either directly or indirectly (initially published in 2009, and re-affirmed in 2014).

References

American Academy of Pediatrics, Section on Ophthalmology, Council on Children with Disabilities, American Academy of Ophthalmology, American Association for Pediatric Ophthalmology and Strabismus, & American Association of Certified Orthoptists (2009). Joint statement–Learning disabilities, dyslexia, and vision. Pediatrics, 124(2), 837–844. https://doi.org/10.1542/peds.2009-1445

Flaugnacco, E., Lopez, L., Terribili, C., Montico, M., Zoia, S., & Schön, D. (2015). Music Training Increases Phonological Awareness and Reading Skills in Developmental Dyslexia: A Randomized Control Trial. PloS one, 10(9), e0138715. https://doi.org/10.1371/journal.pone.0138715

Hall, C., Dahl‐Leonard, K., Cho, E., Solari, E. J., Capin, P., Conner, C. L., Henry, A. R., Cook, L., Hayes, L., Vargas, I., Richmond, C. L., & Kehoe, K. F. (2023). Forty years of reading intervention research for elementary students with or at risk for dyslexia: A systematic review and Meta‐Analysis. Reading Research Quarterly, 58(2), 285-312. https://doi.org/10.1002/rrq.477

Othman, E. S., Faye, I., Sundaram Muthuvalu, M., & Naufal Mohamad Saad, M. (2020). EEG neurofeedback for dyslexia treatment: Limitations and future directions. Journal of Physics. Conference Series, 1497(1), 12028. https://doi.org/10.1088/1742-6596/1497/1/012028

National Reading Panel (U.S.) & National Institute of Child Health and Human Development (U.S.). (2000). Report of the National Reading Panel: Teaching children to read : an evidence-based assessment of the scientific research literature on reading and its implications for reading instruction, https://www.nichd.nih.gov/sites/default/files/publications/pubs/nrp/Documents/report.pdf

Vimont, C. (2017). Vision Training Not Proven to Make Vision Sharper, American Academy of Ophthalmology, https://www.aao.org/eye-health/tips-prevention/vision-training-not-proven-to-make-vision-sharper

Intellectual developmental disorder (IDD) – terminology

CDBC/BCAAN Educational bite: Originally emailed July 18, 2024

Global developmental delay (GDD) is a provisional diagnosis in the DSM that should be used for infants and children 4 years of age and younger where children are not meeting expected developmental milestones in several areas of intellectual functioning. At this age, it is difficult for many children to participate in formal assessment. Test scores are less stable compared to scores for older children (please see the bonus educational bite below, and the previous Bite). Even if a diagnosis of intellectual developmental disorder can be established under age 5, it can be challenging to establish a level of disability. GDD can be diagnosed by a physician or psychologist. When given by an evaluating psychologist, a diagnosis of GDD can be used to apply for services through Children and Youth with Support Needs (CYSN), although a re-evaluation will be necessary to ensure continuity of services when the child is older. Of note, GDD is equivalent to the International Classification of Diseases’ (ICD) diagnosis “unspecified IDD.”

While there is typically good reason to wait to confirm a diagnosis of intellectual developmental disorder (IDD), a diagnosis can be made under age 5, typically when there is robust evidence for disability, and there is also a medical/genetic condition known to be highly co-morbid with IDD.

When the evaluating psychologist identifies an intellectual developmental disorder in a child 5 or older, but cannot reliably assess the degree of the impairment (mild, moderate, severe, profound), unspecified intellectual developmental disorder is the appropriate DSM diagnosis. Of note, with unspecified IDD, the diagnosis of IDD is made with full confidence, it is the degree of the disorder which is unclear. While the DSM notes that this category requires re-assessment “after a period of time,” if the diagnosis is made firmly for good reason, it should be accepted by CYSN and Community Living BC (CLBC). The psychologist’s report should clearly state the reason for the “unspecified” diagnosis. The unspecified category is rarely used, as the degree of the disorder should be diagnosed based on adaptive functioning. Unspecified IDD and GDD are mutually exclusive categories (GDD for under 5, unspecified IDD for 5 and older), and the DSM’s “unspecified IDD” aligns with the ICD’s “other IDD.”

Bonus Research Bite: Early developmental assessment (using the Bayley) and the prediction of later IQ scores

  • When comparing the Bayley-III score at age 2 to the WPPSI score at age 4, only 81% of preterm children retained the same developmental classification (Bode et al., 2014).
  • In preterm children, “Bayley-III cognitive and language scores correlate with later IQ, but may fail to predict delay or misclassify children who are not delayed at school age” (Lowe et al., 2023).
  • The Bayley-III at age 3 strongly correlated with WISC-IV FSIQ at age 6 in very low birthweight children. This study suggested that those with Bayley scores 85-95 did not all end up in the average range on the WISC (some were lower scoring on the WISC; Nishijima et al., 2022).
  • In typically developing children, the Bayley-III Cognitive scores were correlated with WISC-IV Full-Scale IQ (r = .41), and accounted for 24% of the total Full-Scale IQ variation. This study concluded that the Bayley was an insufficient predictor of later IQ (Månsson, et al., 2019).

References

Bode, M. M., DʼEugenio, D. B., Mettelman, B. B., & Gross, S. J. (2014). Predictive validity of the Bayley, Third Edition at 2 years for intelligence quotient at 4 years in preterm infants. Journal of developmental and behavioral pediatrics : JDBP, 35(9), 570–575. https://doi.org/10.1097/DBP.0000000000000110

Lowe, J., Bann, C. M., Dempsey, A. G., Fuller, J., Taylor, H. G., Gustafson, K. E., Watson, V. E., Vohr, B. R., Das, A., Shankaran, S., Yolton, K., Ball, M. B., Hintz, S. R., & Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network (2023). Do Bayley-III Composite Scores at 18-22 Months Corrected Age Predict Full-Scale IQ at 6-7 Years in Children Born Extremely Preterm?. The Journal of pediatrics, 263, 113700. https://doi.org/10.1016/j.jpeds.2023.113700

Månsson, J., Stjernqvist, K., Serenius, F., Ådén, U., & Källén, K. (2019). Agreement Between Bayley-III Measurements and WISC-IV Measurements in Typically Developing Children. Journal of Psychoeducational Assessment, 37(5), 603-616. https://doi.org/10.1177/0734282918781431

Nishijima, M., Yoshida, T., Matsumura, K., Inomata, S., Nagaoka, M., Tamura, K., Kawasaki, Y., & Makimoto, M. (2022). Correlation between the Bayley-III at 3 years and the Wechsler Intelligence Scale for Children, Fourth Edition, at 6 years. Pediatrics international : official journal of the Japan Pediatric Society, 64(1), e14872. https://doi.org/10.1111/ped.14872

Driving safety and neurodevelopmental conditions

CDBC/BCAAN Education Bite – originally emailed June 26, 2024

Have you ever had concerns about a teen’s ability to learn to drive? What guidance can you provide to teens and families about driving with a neurodevelopmental condition? What options are available to support these families?

Responsibility to report

Section 230 Motor Vehicle Act requires psychologists, optometrists, medical practitioner and nurse practitioners to report to RoadSafetyBC any patient who is 16 years of age or older who:

  • Has a medical condition that makes it dangerous for them to drive, and
  • Continues to drive after being warned of the danger

Information is available from the provincial government on reporting a patient who is unfit to drive. If you have to report, here is the form for making the report.

Talk to your patients about driving

This article from Brainstreams outlines the cognitive, behavioural, and emotional-control factors that are important for safe driving which can serve as a starting point for discussion. Medical doctors may be asked to do a driver medical examination.

From VCH’s presentation on driver readiness

The following are activities that require some of the same skills as driving, but are done at a slower speed. If you cannot do these activities independently*, you may not be ready to drive

  • Prepare a simple meal (e.g. lunch)
  • Shop for 3-4 items at the grocery store
  • Take public transportation, HandyDart or a taxi
  • Move in the community, including crossing a busy street

*If you cannot do these activities due to a physical or language barrier, but can direct someone through the steps, then you are considered independent for the purpose of driver readiness

Consider suggesting a Functional Driving Evaluation (FDE)

FDEs are completed by specially trained professionals, often occupational therapists. There is an in-clinic and on-road evaluation and adaptive equipment can be provided. This service is available for people with an injury or illness affecting their driving ability, or for new drivers with a disability who already have a Learner’s permit. Healthcare professionals can refer for a Driver Rehab Assessment at GF Strong through Vancouver Coastal Health. The assessment is private pay, but there are funding options available (see the VCH presentation above).

For more information about GF Strong’s Driver Rehabilitation program, please see this powerpoint.

Thank you to Lisa Kristalovich, Occupational Therapist at the Driver Rehab Service at GF Strong for the resources and editing support.

Disability and accommodations

CDBC/BCAAN Education Bite – originally emailed June 21, 2024

Purpose of accommodations in education

Accommodations enable the student to access the curriculum (including exams) without interference from the disability. Accommodations do not necessarily ensure success or the ability to perform to one’s potential (Lovett & Lewandowski, 2015). Schools have policies in place to make sure that students from all backgrounds have equal opportunities and access to education.

Disability diagnosis, accommodations, and the “seven sins of clinicians” (Harrison & Sparks, 2022)

  1. Bias and conflict of interest – Be aware of the tendency to search for and favour evidence to support prior hypotheses; there is a higher risk when you have a dual relationship (e.g., you are a treating psychologist doing an assessment).
  2. Naivety – Include objective review + self/collateral report, use performance validity testing and symptom validity testing.
  3. Base rate blindness – When a condition is rare, first consider more obvious possibilities.
  4. Cherry-picking – Do not choose to focus on one or more low subtest scores; variability is the norm. For those in the CDBC/BCAAN network, check out a webinar on this topic.
  5. Counting apples as oranges – Cognitive processing speed alone does not predict performance on academic tests. It is best to use performance on timed academic measures.
  6. Psychometric slight of hand – Average scores are not evidence of disability, even with superior abilities in other areas.
  7. Blissful ignorance – Be aware of the research, for example on when and how much extra time is reasonable.

Extra time – evidence based recommendations

Harrison, Pollock and Holmes (2022) reviewed the literature around evidence for extra time in the post-secondary setting and concluded that the evidence suggested extra time being appropriate for students with learning disabilities (with 25% typically sufficient to equalize access), while those with ADHD did not benefit from extra time. A “stop the clock” type of accommodation was thought to be more useful for those with ADHD. There was not sufficient research to make conclusions about extra time in students with Autism.

For students mental health conditions such as anxiety, the authors said, “there must be a clear link between the functional impairments that arise from the disorder and a need for additional time for tests and examinations. For example, is the student reporting a tendency to freeze and panic in test situations, which they claim is impairing their ability to complete the test in the typical time allocated? In such cases, might it make more sense to recommend stop-the-clock breaks to allow the student to implement anxiety reduction strategies rather than simply remaining longer in an anxiety-producing situation?”

Canadian/BC resources

Recommended listening

For a great podcast on biases and errors in decision making (including ways we can do better), check out Dr. Stephanie Nelson the Testing Psychologist Podcast.

References

Lovett, B. J., & Lewandowski, L. J. (2015). Testing accommodations for students with disabilities: Research-based practice. Washington, DC: American Psychological Association.

Harrison, A.G., Pollock, B., & Holmes, A. (2021). Provision of extended time in post-secondary settings: A review of the literature and proposed guidelines for practice. Psychological Injury and the Law, 15, 295-316. https://link.springer.com/article/10.1007/s12207-022-09451-3

Harrison, A.G., Pollock, B. & Holmes, A. (2022), Provision of Extended Assessment Time in Post-secondary Settings: A Review of the Literature and Proposed Guidelines for Practice. Psychological Injury and the Law, 15, 295–306. https://doi.org/10.1007/s12207-022-09451-3

Harrison, A.G. & Sparks, R. (2022). Disability diagnoses: Seven sins of clinicians. Psychological Injury and Law, 15, 268-286. https://doi.org/10.1007/s12207-022-09449-x