Archives: BCAAN Resource Files

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

Composite score extremity effect: An explanation

CDBC/BCAAN Education Bite – originally emailed April 12, 2024

I hope this could be helpful for trainees, or those who like a review of statistical concepts. 

It seems counter-intuitive when index scores of 70, 71, and 72 lead to an overall composite score of 67. This has been called the composite score extremity effect. This effect accounts for the fact that imperfectly correlated scores are always more extreme (further from the population mean) than if you were to simply average the scores. As explained in Schneider (2016) –

Composite scores are more extreme when:

  1. The composite is made up of a higher number of individual scores
  2. The individual scores have a lower correlation with each other
  3. The individual scores are farther away from the mean

Schneider explains this in simple terms: “though it is unusual to have a particular deficit, it is even more unusual to have that deficit and several more. A composite score that summarizes all of these deficits would have to take this comparative rarity into account. It is for this reason that a composite score that consists of many low scores is lower than the average of those scores” (p. 8)

An important concept in this is regression to the mean. For a composite comprised of two similar subtests, where there is a low score on subtest A (70), the predicted score for subtest B might 78, due to regression to the mean. If the person scored 70 on both A and B, the composite would be under 70, as it is unusual for people to be equally extreme on both subtests. The technical/mathematical explanation can be found here starting on page 10.

References

Barnett, A.G., van der Pols, J.C., & Dobson, A.J. (2005). Regression to the mean: what it is and how to deal with it, International Journal of Epidemiology, 34(1), 215–220. https://doi.org/10.1093/ije/dyh299

Schneider, W. J. (2016). Why Are WJ IV Cluster Scores More Extreme Than the Average of Their Parts? A Gentle Explanation of the Composite Score Extremity Effect (Woodcock-Johnson IV Assessment Service Bulletin No. 7). Itasca, IL: Houghton Mifflin Harcourt.

IQ Stability – Research review

CDBC/BCAAN Research Bite: Originally emailed December 15, 2023

Understanding long-term stability of IQ scores is essential, especially when we are making decisions about diagnoses expected to be stable over time (into adulthood).  Watkins et al., (2022) found that with an approximately 2 ½ year interval, only the VCI, VSI and FSIQ were stable enough for normative comparisons, while unusual differences between subtests or index scores were unlikely to be repeated at retest. Previous research has shown stability in IQ scores for those with intellectual disabilities (Whitaker et al., 2008). Eichelberger and colleagues (2023) showed that those with lower-end IQ scores (below 100) were less likely to be stable over time. This suggests we need to be particularly cautious about diagnosing intellectual developmental disorder in preschool children with “borderline” type profiles. There is also evidence that IQ scores are more dynamic in individuals with autism (Prigge et al., 2022).

References

Watkins, M. W., Canivez, G. L., Dombrowski, S. C., McGill, R. J., Pritchard, A. E., Holingue, C. B., & Jacobson, L. A. (2022). Long-term stability of Wechsler Intelligence Scale for Children-fifth edition scores in a clinical sample. Applied neuropsychology. Child, 11(3), 422–428. 

https://doi.org/10.1080/21622965.2021.1875827

Whitaker, S. (2008). The Stability of IQ in People With Low Intellectual Ability : An Analysis of the Literature. Intellectual and Developmental Disabilities, 46(2), 120–128. http://eprints.hud.ac.uk/id/eprint/4283/1/stability_of_IQ_%282008%29.pdf

Eichelberger, D. A., Latal, B., Kakebeeke, T. H., Caflisch, J. A., Jenni, O. G., & Wehrle, F. M. (2023). The influence of preschool IQ on the individual-order stability of intelligence into adulthood. Acta Paediatrica, 112(10), 2161–2163. https://doi.org/10.1111/apa.16925

Prigge, M. B. D., Bigler, E. D., Lange, N., Morgan, J., Froehlich, A., Freeman, A., Kellett, K., Kane, K. L., King, C. K., Taylor, J., Dean, D. C., King, J. B., Anderson, J. S., Zielinski, B. A., Alexander, A. L., & Lainhart, J. E. (2022). Longitudinal Stability of Intellectual Functioning in Autism Spectrum Disorder: From Age 3 Through Mid-adulthood. Journal of Autism and Developmental Disorders, 52(10), 4490–4504. https://doi.org/10.1007/s10803-021-05227-x

 

 

Executive functioning intervention – Research review

CDBC/BCAAN Research Bite: Originally emailed March 8, 2024

Adele Diamond’s group published a systematic mega-review of 179 studies up to 2015 (Diamond & Ling 2019) on intervention to improve EFs. Importantly, this paper required each study to have at least one behavioural measure, include a measure of generalization, include a control group, and not be purely correlational.

Mindful movement practices (e.g., taekwondo & t’ai chi) showed the strongest results for improving EFs. Mindful movement exercises did better than more sedentary mindful practices. 30-40 minute sessions were more helpful than those less than 30 minutes. School-based programs such as Promoting Alternative Thinking Strategies, the Chicago School Readiness Project, and Tools of the Mind came in second, and were particularly good for improving inhibitory control. Both types of approaches showed better results than computerized cognitive training (e.g., CogMed).

Some key principles the paper summarized:

  1. EF can be improved.
  2. Generalization to untrained tasks usually occurs for similar tasks, but rarely improves on unpracticed tasks. Broader transfer effects happen with practice of a wider range of skills.
  3. EF training must include continued challenge, where the task adapts to keep challenging the person.
  4. Effects can last over time, but generally grow smaller (use it or lose it).
  5. Those with more EF challenges benefit the most from intervention.
  6. More training is generally better, with the exception of aerobic exercises with no evidence of greater EF benefits from longer programs.
  7. For the most part, length of the sessions matters, with sessions > 30 minutes showing better results than those less than 30 minutes.
  8. Spaced (distributed) practice produces better long-term outcomes than massed practice.
  9. Benefits are mostly clearly seen on complex, multi-component EF tasks

In addition, there seems to be strong evidence for the role of physical activity in improving EF in individuals with ADHD. A PLoS One meta-analysis (Song et al., 2023)   found a significant impact of physical interventions on inhibitory control, working memory and cognitive flexibility in children and teens with ADHD. While there was a benefit to all kinds of physical activity, results were in line with the first paper above in that moderate exercise and those which require adaptive/flexible skills, and which endure over time show the most promise.

UPDATE: ‘debate and request for further dialogue’ for the research from a group of researchers https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6969305/

References

Diamond, A. & Ling, D. S. (2019). Review of the evidence on, and fundamental questions about, efforts to improve executive functions, including working memory. In J. Novick, M.F. Bunting, M.R. Dougherty & R. W. Engle (Eds.), Cognitive and working memory training: Perspectives from psychology, neuroscience, and human development, (pp.143-431). New York, NY: Oxford University Press. (pdf)

Song, Y., Fan, B., Wang, C., & Yu, H. (2023). Meta-analysis of the effects of physical activity on executive function in children and adolescents with attention deficit hyperactivity disorder. PloS one, 18(8), e0289732. https://doi.org/10.1371/journal.pone.0289732

 

DSM-5 Revisions to ASD definition

Two small wording changes for clarity have been made in the revision of the DSM-5 (DSM-5-TR) entry for ASD released March 2022.

Quoting from the spectrum news article from March 17, 2022 (https://www.spectrumnews.org/news/dsm-5-revision-tweaks-autism-entry-for-clarity/)

The DSM-5, released in 2013, indicated that an autism diagnosis requires “persistent deficits in social communication and social interaction across multiple contexts, as manifested by the following”: deficits in social-emotional reciprocity, in nonverbal communicative behaviors used for social interaction, and in developing, maintaining and understanding relationships. The first text revision in the new DSM-5-TR adds two words to that description: “as manifested by all of the following.”

The second change swaps out a single word describing the “specifiers” that can accompany an autism diagnosis. Whereas the DSM-5 wording instructs clinicians to specify if a person’s autism is “associated with another neurodevelopmental, mental or behavioral disorder,” the DSM-5-TR version reads: “associated with a neurodevelopmental, mental, or behavioral problem.” It still instructs clinicians to use additional diagnostic codes whenever appropriate, but it no longer requires specifiers to be diagnosable conditions.

Changes have also been made to Intellectual Disability. The new terminology is “intellectual developmental disorder (intellectual disability)”.

Please see the APA fact sheets for more information: https://www.psychiatry.org/psychiatrists/practice/dsm/educational-resources/dsm-5-fact-sheets