Let's Talk Sped Law

Season 3, Episode 3: Comprehensive Evaluations In Light of the COVID Pandemic with Guest Speaker Dr. Elizabeth Kryszak

February 16, 2021 Let's Talk Sped Law by Special Education Attorney, Jeffrey L. Forte, Esq. Season 3 Episode 3
Let's Talk Sped Law
Season 3, Episode 3: Comprehensive Evaluations In Light of the COVID Pandemic with Guest Speaker Dr. Elizabeth Kryszak
Show Notes Transcript

In this episode leading clinical expert Dr. Elizabeth M. Krysak discussed conducting comprehensive remote evaluations during the COVID pandemic. Liz Kryszak, PhD, is a psychologist at the Nationwide Children’s Hospital Child Development Center (CDC) and a Clinical Assistant Professor at the Ohio State University. Liz’s clinical and research work focuses on the evaluation and assessment of children with neurodevelopmental disabilities including Autism, with a particular focus on assessment of very young children and creating system changes to improve access to services for families. During the COVID-19 Pandemic, she led her clinic’s transition to assessment through telehealth, developing an observation protocol that allowed clinicians to partner with parents to assess for symptoms of autism in a home environment. To learn more about Dr. Krysak visit, https://www.nationwidechildrens.org/find-a-doctor/profiles/elizabeth-m-kryszak

Speaker 1:

Welcome to the podcast. Let's talk sped law, a podcast dedicated to discussing special education rights of children with disabilities. I'm your host and special education attorney. Jeff forte. Now let's talk sped law.

Speaker 2:

Hi everyone. And welcome to another episode of let's talk sped law. I'm Jeff forte, your host and special education lawyer. And today we're going to be talking about comprehensive evaluations in light of the COVID pandemic. I'm so delighted to have on our show today, Dr. Elizabeth cries, Zack, Dr. Krizek is a psychologist at the nationwide child's hospital development center and a clinical assistant professor at the Ohio state university Liz's clinical and research work focuses on the evaluation and assessment of children with neurodevelopmental disabilities, including autism, which is something that we're going to definitely be talking about today, as well as the particular focus on the assessment of very young children and creating system changes to improve access for all families during the COVID-19 pandemic. Dr. Krizek has led her clinic's transition team to assess through tele-health, which is something that we're also going to be talking about and the development of observation protocols. That's allowing clinicians to partner with parents to assess children in the home environment. So, Dr.[inaudible] welcome. And thank you so much for being on the show today. Well, thank you for having me. I'm excited. So, so talk to me first a bit about the important role that nationwide children's hospital is playing

Speaker 3:

As far as within the pandemic.

Speaker 2:

Yes. As far as within the pandemic goes, um, how are you handling a lot of the, uh, evaluations that you're doing through the tele-health program that you've, that you've helped to build and create?

Speaker 3:

That is a great question. So we have been lucky to have a lot of support from our hospital at the time that, uh, COVID restrictions were first put in place. We were doing 0% of our evaluations by tele-health and we are currently, um, at, well at the height of the pandemic, we were doing a hundred percent of our evaluations by tele-health and we were actually able to transition pretty quickly to a full tele-health models. So we are very lucky to have a very, um, flexible and creative team that was willing to jump in and try some new things. Um, and we're as well as the hospital that was able to give us some great support. So we have the software and, um, capability to actually do the tele-health in a HIPAA compliant way. So that way everyone's confidentiality was protected, but we were still able to do that. Does assessment measures? Yeah,

Speaker 2:

Well, you know, you've mentioned the technology component of it, and so obviously that's a big part when entering into tele-health and switching over night, practically, it sounds like a nationwide children's hospital already had a lot of that technology software and equipment in place. Is that, is that fair to say

Speaker 3:

We were working on developing a tele-health program. I think the plan was in about two years, we would have that program up and going. So luckily they had already started getting, um, working with zoom in particular to get work with their, um, they have a hospital platform that's specific for working within hospital and medical centers. And so they luckily on the software side, they were already working with them to get all of that set up. Um, but then the rest of the planning for the actual how to do those evaluations got sped up exponentially and where we were able to get that up and going much faster than we had planned.

Speaker 2:

Yeah, I'd say it was almost put into a pressure cooker, but that's remarkable. I mean, congratulations, first off on that, I mean, just a two year plan to migrate, to have telehealth that you had to implement within just a couple of weeks, if not months, it's just truly remarkable. So congratulations on that feat alone. I mean, that's, that's huge. We can talk about that just in this podcast, the world,

Speaker 3:

But you appreciate that. Thank you.

Speaker 2:

So really just kudos. It's, it's amazing work for you and your team. Um, but let's kind of peel that back a bit because there's been, there's been talk within the clinical communities about best practices with how to evaluate in a remote way, um, that, you know, performs and provides with information. That's going to be sound that a school team can use and you know, the clinical appropriateness of that. So can you talk with me and our listeners about how you've actually been able to get various assessment tools and evaluation measures to the point where we can rely on them clinically in a virtual, uh, remote tele-health, um, procedure?

Speaker 3:

Um, that's a great question. So I think the important thing to keep in mind is that while the large use or the large scale use of tele-health is relatively new tele-health itself has been in development for the several decades. So this is not a new question. Um, in particular, the, before the pandemic, I think we were really considering tele-health as a way to help reach families who weren't going to be able to access services other ways. So either due to transportation barriers or geographical barriers. So the development of tele-health testing or tele-health assessment has been in development for, as I said several decades. So there's been some lovely research that's already been done looking at comparing, um, measures that are done both by telehealth and in-person together to see, you know, are we seeing significant differences if we do these one way or another? And so there's a few different cognitive measures and academic measures that have been assessed this way and have been shown to have pretty good reliability by tele-health. Um, so certainly that's going to vary a lot depending on the child that we're testing. Um, so I think most of these assessments are being done with slightly older kids, kids that can pay attention a little bit better, where you don't have to have that in-person behavior management to keep them focused and on task. Um, but for many kids, this is a viable way of looking at those thinking and learning skills, um, similar to how we would do them in the clinic, uh, as well as looking at some, uh, diagnostics as well. So, I mean, as you mentioned, I specialize in autism. So a big part of our tele-health transition was developing an observational measure that we could use by tele-health to look at those symptoms related to autism.

Speaker 2:

And what, what measures are you using? You know, let's get into autism evaluations, right. So what measures are you using? What assessment tools are you using and what, um, have you found those to be, um, um, you know, welcomed in the, in the remote world, um, by other clinicians or is it being met with controversy? Um, can you talk about that?

Speaker 3:

I can, yes. So, so when we were transitioning, we had to think about, you know, what's going to transition very easily to a telehealth modality and what are we going to have to do a little finagling with to get it, to fit into that modality a little bit better? And so traditionally we do a standardized measures called the Adolfs or the autism diagnostic observation scales. This is one of the measures that's used all over and pretty well recognized as a gold standard measure for looking at those symptoms of autism, but it requires you to be in-person face-to-face with the child, ask them to do lots of different tasks and a coding system was developed. And really what that's looking is how can we quantify the observations that we're seeing and say, is this child having a lot of those symptoms or less of those symptoms? So we, you know, we don't have a blood test. We don't have a way of saying definitely yes or no for autism. So we're looking for patterns of behavior, but this measure in particular allowed us to really quantify those observations in a way that was more standardized. And so we're not going to have that. Um, so what we were looking for is other ways of doing that. So one other measure that's available is the, um, autism diagnostic interview, uh, which is a standardized interview measure that does, uh, uh, similar or work similarly in that it allows us to code, um, all the different answers that parents give to a range of different questions about symptoms related to autism. And again, gives us a number that basically says, is this child more like those with autism or less like those with autism? And so that interview measure in particular has been a nice way of giving us another standardized way of looking at some of these symptoms, but we still want to be able to see the child and be able to, um, get to see them doing different social skills and co um, or, um, social skills and different behavior, how they're playing with toys, how they're interacting with others, just because we have different perspectives. So even though I'm getting an interview from parents, they may be looking at their child differently than I might, if I got to see them in person. And so we've developed an observational protocol. That's similar to what we would have looked at with that Aidan measure, but instead of using the same scoring method that was used for the offs, we use a measure called the cars, um, which is the childhood autism rating scale, um, which is another measure that we can use to quantify those symptoms. Um, it's, uh, requires a little less standardization to be able to use. Um, but using that in combination with that ADR, we think is a pretty good combination along with trying to get some parent measures, um, and teacher measures, and basically get as many views of this child or perspectives of this child as possible to be able to look at those patterns or be seeing this pattern of symptoms related to autism across all those different environments and measures. And so really the, the measure we've added is that our own observational measure, um, which we're calling via Volvo, um, which is the adapted virtual autism behavioral observation. Um, so a long name, but it's a similar type of observation measure where it allows us to put the work with parents, um, to look at a lot of these different symptoms in a home environment.

Speaker 2:

That's, that's great. That's really great. I mean, yeah, I have heard, and obviously, you know, it's, it's, it's, um, it's not disputed that, that, you know, you just can't do the aid office remotely. You just can't. And, you know, I have found clinicians and some reports, which they've attempted to do that and then linearity is questioned. So, um, that's a red flag to parents. If, if an evaluator is saying, yes, we can conduct the aid offs virtually or remotely, or tele-health wise, it's just not, it's not really tried and true. It's not clinically appropriate, right.

Speaker 3:

Not using it in the same way. So I would say that, could you do the eight OSS activities and use those as an observation for what you're doing? So certainly the measure that we created uses a lot of those same activities, but the scoring system is what's not validated to be used by tele-health. So it may be at some point, but right now, if they were to score up that measure and use it in the same way, that's what wouldn't be valid. Um, but you could still do a lot of the same activities, but you'd have to, when you're interpreting those observations, think about what might be different by tele-health. Um, so for example, trying to judge nonverbal behavior by tele-health is really difficult because I contact is completely different on different, um, platforms of the different platforms that you use to communicate by tele-health or even being able to look at facial expressions or, um, you know, gestures, you know, a lot of times you're only seeing people from a certain view, so they could be using gestures and you're just not seeing them. Um, so those are the kinds of critical thinking that has to be done with these assessment measures to think about what might be different, so we can still often use them, but the interpretation is going to be done

Speaker 2:

That that's, that's incredibly fascinating. Um, so let me ask you another question. Let me kind of steer it into another way. Oftentimes parents will say, you know, well, I'm going to try to get this psychoeducational evaluation or neuropsych evaluation covered by my health insurance, and then use this evaluation as a means to advocate for additional services within my child's IEP or education program. Um, can you kind of unbundle the, the, the questions about parents wanting to submit certain portions of the evaluation through insurance versus the educational component pieces of an evaluation that typically aren't covered in insurance and you know, how, how you go through evaluations that may have, you know, insurance components and non-insurance components?

Speaker 3:

Well, um, since I'm working at a children's hospital, so everything we're doing is going through insurance, I would say, I think insurance can be really tricky because it's gonna vary a lot by state. It's going to vary a lot, um, by company, whether it's Medicaid versus not Medicaid, as far as what's going to be covered and what isn't. Um, so I think that'll be one tricky piece to this as I can't answer everything because it's really going to be, um, specific to your insurance. And one thing that I would strongly recommend is that if you're considering doing an evaluation is to talk to your insurance company about, um, what types of services are covered through evaluations, um, because that can be very different, um, depending on. So I think that's important. Um, so for example, in our center, we do all, we do both cognitive and academic testing as part of our typical psych evals. And for the most part, Ohio Medicaid tends to cover those evaluations. Many of our patients that we see are covered by Medicaid, um, and even a lot of the private insurances in Ohio seem to cover a lot of those evaluations. I worked at other centers where they did no academic testing as part of their evaluations.

Speaker 2:

Yeah. That's like a big part, right? Or you can get the medical diagnosis and the medical assessments, but if the evaluator that's paid through by insurance, isn't conducting teacher interviews or observing the child in a classroom or school-based environment, they can get some pushback from the school team. If they then use this evaluation to say, and I want an IEP based on the results of this insurance-based evaluation, but it sounds like your team has already covering everything, which is remarkable

Speaker 3:

For the most part. We don't typically we don't typically do, um, is school-based observations. And they will say that the majority of the time we are encouraging parents to give schools, copies our, of our evaluations. But I would say for the most part, the school is then going to do their own separate evaluation. Now, many of times they use our testing. So the schools that certainly the ones that are within our area, um, no, our reports, um, they seem to trust our reports. So many of the schools will actually just use the cognitive and academic testing we've done, which can often help speed up and evaluation in school, um, which we are thankful for. Um, but they aren't required to. So I, and a psychological evaluation that a parent often starts with us is different than seeking a secondary evaluation. Um, through, for example, if they're going through advocacy through the school or, um, moderation through the school. So those, we occasionally get those requests, but that's not the majority of what we do. Um, and I will say that typically cognitive testing, so looking at those thinking and problem solving skills that will be covered by insurance because we do use that diagnostically. So for example, if we were looking at an intellectual disability or even looking at something like, Oh, it is, um, I very rarely would want to diagnose autism if I didn't know what a child's cognitive functioning is. Um, because that's going to be a big part to that differential diagnosis, or even looking at something like ADHD. Um, we really want to know that cognitive functioning so that you can usually get covered. It's some places may be more tricky with that academic testing. Right,

Speaker 2:

Right, right. So, you know, let, let's get into a bit of what encompasses a comprehensive evaluation. Um, you know, oftentimes parents lay parents will have a dispute or confusion about the result of a school-based evaluation, but they not know the clinical vernacular as to explain why the results are not comprehensive. Hence then they need to get perhaps some advocate or attorney intervention. Um, so can you kind of walk through when you're, uh, reviewing a child's file, um, and you're looking at evaluations, what red flags in your clinical opinion, uh, cause you pause to say, Hey, this is not this evaluation that was done on such and such a date with this child. This isn't, this isn't comprehend.

Speaker 3:

Well, I would certainly want to see cognitive testing and not only cognitive testing, but updated cognitive testing. So I think there's a false belief out there that cognitive testing is crystals. So your IQ is your IQ is your IQ, um, which is just not true, especially when that IQ is first done at a very young age. Um, so cognitive assessment or results on cognitive assessment can change over time. Um, the other thing I would want when explaining those cognitive results is at least some sort of, um, explanation of what the child's behavior was during that assessment. Because obviously if you have a child who's misbehaving or refusing to answer, or, you know, it's just not a good day, um, you're going to get different results than you might on a different day. So when I'm trying to, for example, if I was going to be looking at an ETR and thinking about how I could use the cognitive testing that was already done, that can be one of my biggest, I guess, pet peeves is when there's no observations. So I can't interpret these results in any sort of context. Um, so I would certainly want some description of how the child was during the testing to be able to understand the results that are presented. And so I would want a standardized cognitive measure. So we like the, the whisk. Um, so they often use the, let's say the KTA is a common one that schools use. Um, the Stanford Benet would be another one where you're basically with that cognitive measure, we're looking at cognitive skills in several different areas. Um, so that way we're not just getting a quick summary of the kids skills. We're getting to see lots of different areas of how this kid might be thinking and processing information. Um, and similarly I would want a standardized academic tests. And I should say when I'm saying standardized, really what I'm saying is that this is a measure that allows us to compare the child to other children their age, to say, where are their skills compared to where we'd like them to be or where we expect them to be for that age or that grade level, um, because that allows us to know where their gaps, um, so if I'm seeing a score that's significantly behind where I want a child could be, that tells me that's where I need some intervention. That's where we need some support.

Speaker 2:

We asked you on that because, you know, I often will talk with parents about the bell curve and psychometrics conversion tables, and they just kind of get lost. Right. Is it, is it a, is it a best practice in a evaluation report to include the, uh, the results of the scores for a parent to understand what the age equivalency of those scores?

Speaker 3:

Well, age equivalencies, they they're, they're a tricky beast. Um, because I think it's tricky. Yes. Um, well the benefit to age equivalents is you're right in that they're easier to understand. So a standard score of, you know, 70, um, or an age equivalent of, if I know my kid is 14, but they're functioning, you know, this age equivalence as they're functioning at a seven year old level, I kind of get that a little bit easier than just saying that their scores is 70. And I don't know what that 70 means. Um, as a parent, the tricky thing with age equivalents though, is they're not always the best estimates. Um, so, you know, they're very gross estimates as we can't say that every seven-year-old would score on this level. Um, it's also tricky to say that skills are at a seven-year-old level because the child may actually, we have a range of different skills, but then they got lots of things wrong in between. And so the whole number puts them at the seven-year-old level, but they may have skills that are at a much higher level or a much lower level, depending on kind of where we're looking. So I think age equivalence can be kind of a down and dirty way of kind of understanding a little bit of, you know, if we really wanted to think about, you know, what is the skill mean compared to where this kid is now, um, can be a way of looking at that similarly, great equivalents are the same thing is that it gives us kind of a rough estimate. Um, but they, they aren't as, um, I think as good of a predictor as the standard scores of being able to tell us a little bit more information. I think what we needed then is that a really good explanation of what standard scores mean? So that is one thing that I do struggle with a lot of times with school evaluations is they have a lot to do in those meetings where they're going over those results. Um, so they want to go through all the results. They want to go through all the goals and get all of that approved. Um, and so I understand that they oftentimes really can speed through the results. Um, and so if you're speeding through those results, a lot of times parents do come away not having any idea of what was said. Um, so I would say one of the things we often do in our evaluations is actually go through some of the school testing too, to explain like, this is what the school did, and this is what they found. Um, that's one of the benefits I think, to going through like a private, psychological evaluation is we oftentimes just have more time to just spend time going through those results. I'm in your

Speaker 2:

Current clinical role at the hospital. Do you also, um, get invited to attend IEP meetings or

Speaker 3:

Not typically? Um, so we I've been to a couple, um, for families where I'm trying to help advocate a little bit more for certain things. Um, but not typically, um, unfortunately I just don't know where we'd have the time to go to Al.

Speaker 2:

Um, so while we're on the topic of assessments and, and psychometric, conversion tables, real dense stuff here that I love talking about, um, you know, oftentimes when a child's coming up for a triennial, let's say, and they're having a cycle wet done, and we're looking at full-scale IQ scores and, um, and a school psychologist let's say is implementing the whisk, right? And you're looking at whisk scores from three years ago, let's say when a traveler was seven and their scores are, you know, scattered, which we'll, we'll get to scattered scores in a minute, but let's say they're at a certain percentile rank. And now at 10 years old for the triennial evaluations, they're at a lower percentile rank. And to the lay parent, they're saying, well, wait a minute. When my child was seven, they had a whisk full-scale IQ score that put them in the, you know, let's say that, you know, the 83rd percentile rank and now at 10 they're at the 72nd percentile rank, my child has regressed what I get, but, you know, often will parents will say that, is that an accurate statement clinically?

Speaker 3:

It is not. So, yeah. So what the standard scores are, is the best way to think of it is we're always comparing you to the kids your age. So at that seven-year-old, um, example that we could think of that child as they were doing as well as, or better than 83% of the kids that are also seven years old and then at 10 years old. So they've, they're now we're comparing them to 10 years old or 10 year olds. Um, now they're doing as well as, or better than 70, I think he said 73 or 72% of those kids. Right. Um, and so basically they've gained skills because they're, now, we're now comparing them to ten-year-olds. Um, but now they're doing slightly less well compared to those ten-year-olds as they were, when they were, we were just comparing them to seven year olds. Um, so the, there luckily, or likely their skills have, um, increased, but we could probably a better way of thinking that is, is that their developmental trajectory or how fast they're gaining those skills is slowing down. So they're not able, they're not keeping up to the same level as they were when they were that younger age. Right,

Speaker 2:

Right, right. Yeah. I mean, I often, I love having this conversation because with clinicians, because, you know, you're exactly, I mean, there's, you're exactly right there. It's not, you can't compare the two, it's not comparing a granny Smith, Apple with a granny Smith, Apple, you're comparing a granny Smith Apple that was grown, uh, three years ago to the freshness of a granny Smith Apple that just was grown right now. And with, with regards to placing it into the whisk, um, you know, it, I often will tell parents that their, their skill acquisition rate is lower. So as more academic demands are being placed on a child, their ability to understand it, or their ability to acquire and implement it. They're not as high in the percentile rank as they were when they were younger. So as the academic demands increase year over year with grade, um, year over year with grade growth, uh, they may be falling behind, but it's not the same as regression.

Speaker 3:

Exactly. Yeah. So they're, they don't seem to be learning as quickly as they were before, but they're not losing the skills that they had before. Right. Um, for typically now, I mean, you could see cases of progression in there, and then we would actually want to ask, you know, are there skills that they used to have that they don't have anymore, especially if that, that gap was really big. Um, then certainly I'd want to ask some of those questions, but, um, just seeing a lower number doesn't mean that they've lost skills by any mean that would still be something I want to look at. So I mean, generally the reason that those standard scores exist is because we should be able to compare across years and that if your IQ was staying relatively stable, that IQ, or that percentile should be relatively the same, the older you get. So you should continue to learn at a similar rate. Um, I will say, as I was kind of saying in the beginning that those IQ scores get more predictive, the older we get, because they, you know, again, it's a lot easier to be flexible and learn new things when we're younger and our brains kind of get more set in their ways, the older we get. Um, so they tend to be more predictive if I saw like the difference between a 12 year old and an 18 year old, I might not expect as much difference as I might between like a six year old and a 12 year old. Um, I might expect some more difference in there. Um, but generally we would want to see cognitive skills that are staying relatively stable over time and a little bit of wiggle in those numbers. Isn't, um, too concerning. Um, that's just going to be some standard air and the measurements. So we're not always going to measure everything, you know, every cause again, there's stuff going on that sometimes, you know, that sometimes you don't depending on the day. Um, but if we're seeing big differences, then that is something to look at, but it doesn't necessarily always mean I've lost skills, but for some reason we're not learning them as quickly.

Speaker 2:

Right. Right. Um, so let's, let's get into when you're, when you're conducting an evaluation and some of the subtests scores or all over the place. Okay. Um, and what does that commonly refer to as a clinician and what does it mean and how does a parent understand all the various ups and downs in certain standard scores and percentile ranks within subtests?

Speaker 3:

How does a great question, um, and that should be something that the clinician who's describing those results to you is helping you with. So I would say that it can be tricky to try, especially. So we typically think about that as scatter. So meaning that, you know, typically we expect all of those different scores. We're getting to be around the same number when there's a lot of variation there. Then what that's telling us is that there's some skills that are stronger, some skills that are are weaker, and that can be really helpful to understand some of those strengths and weaknesses when we're thinking about what sort of supports might be needed. Um, and so we really do want to understand, especially if we have one or two skills that are very different from all the other skills, um, trying to understand what might be causing that as well as what might supports might we be able to put in place to help, um, get that to be more where we want it to be, or the other way we may have all of our scores in one place. And then a couple of things that are much stronger, um, that may tell us that, Oh, these are areas where this child seems to really Excel and maybe we can give them some extra, um, support in those areas, just so they're doing something that they really seem to enjoy, or like, um, so I would really want to, um, start to understand what those differences are. So for example, one of the most common things that we often see is a child whose general verbal comprehension and, um, fluid reasoning. So kind of how they think and solve problems. Those things are more than the average range, but their working memory and their processing speed is significantly below. And so what that's telling me is this is a child who has the potential to learn like everybody else and who remembers things and understands things like everybody else, but they might not do it as quickly. So in the moment, their ability to remember information that's being said to them, I'm like, I'm talking to you right now. So without any sort of like writing it down or practicing, they might not be able to retain that information as well. Um, or they're just not able to do things as quickly. So that processing speeds. So, you know, while everyone else is able to complete their math test in, you know, 30 minutes, this child might need an hour. And so they know all the same information, but it takes them an hour to get all of their information out where everybody else can do it in 30 minutes. And so that you can kind of hear, as I'm saying that that there's some interventions that we might be able to put in place so that this child, that seems to be understanding information, just like everybody else might be able to show it. If we have a little bit more time for this child, or a little bit more repetition, or, you know, maybe they need to do it in a room where there's not as much distractions. So that way they can show all those good skills that they know.

Speaker 2:

You know, I'm just, I'm, I'm smiling here because if only school teams would, uh, break it down as eloquently and simplistically as you would for parents, uh, because, you know, you can really talk this vernacularly with a lot of clinical jargon and really lose a lot of parents, but the way you're explaining it, um, is a way in which a school team should, frankly, to parents, because you can think automatically about, well, you know, we're going to need some accommodations and modifications to the child's school environment, uh, by providing them with some additional supports, uh, you know, maybe not time testing, for example, or, you know, ask that the student, uh, repeat the instructions back to the teacher, check for understanding, for example, um, you know, and that is where the, the results from a clinician's perspective, you can really make great recommendations in the outcomes of, of the scores that you're seeing. Yeah.

Speaker 3:

Yes. And actually one service that we've been working on developing here that I found to be pretty helpful is that a lot of times the school has done very similar testing to what we would do here and they've done it well. They just haven't explained it very well. And so we have a lot of parents that will come in for initial Dai thinking. They want a second evaluation when really what they need is just someone to go through the first evaluation with them and really explain what all of it meant. So we ended up doing some appointments, which are just kind of DEI, right? To another feedback where, you know, I just spend time explaining to the family what was done in that school evaluation. What did it all mean? And what are some additional things they might want to ask for based on, um, what those results were. Right.

Speaker 2:

Um, one thing that often is, is, is needed, and that's a, that's a program review and, uh, you know, parents don't necessarily realize that a program review is a form of an evaluation, um, in which, you know, I'm sure you're, you know, you're meeting with the family, you're interviewing the child and so forth, but you're not necessarily conducting a full, comprehensive battery assessments. Like you said, they've already been done. It's just, no, one's doing anything with them.

Speaker 3:

Right, right, right. Yeah. Great.

Speaker 2:

That you offer that service to your families and patients that's remarkable.

Speaker 3:

Yeah. No, I agree. I think that's going to be one of the difficulties and one of the loops that people can sometimes get stuck in is that it feels like when, when there's not the right services in place that we just need to do more testing and more testing, um, or we're just not calling it the right thing. But a lot of times that we can use the information that's there. That it's, it's really that we just don't have the right supports in place yet, or we're not using that data to the fullest, that we can use it to understand this child or understand what they might need. Right.

Speaker 2:

So let me ask you a question on how on, how you roll those services out, you know, um, how, how do you and your team help to more fully inform a child's educational programming when evaluations have already been done or with the evaluations that you're doing now?

Speaker 3:

Well, as I was saying, what we're trying to do is look at what is the information that we're learning in that assessment? What is it telling us about this child? So, you know, does it seem like there's an actual ability that's missing? Does it seem like learning is the problem, or does it seem like there's some sort of behavioral or emotional problem that's getting in the way of this child being able to learn effectively, um, to help us understand what supports are actually needed at this point? Um, and sometimes it can, oftentimes it's both at that. By the time we get to see the child, because a lot of times children who start where there's an emotional behavioral problem getting in the way, if it's been several years, there's likely now a learning problem there as well, because this child has missed so much education at this point that they're going to need both supports to help them be able to cope better within the educational environment plus, um, supports to catch up in different areas of learning to the best that they can. Um, so a lot of times it's thinking about how do we translate these results into meaningful recommendation

Speaker 2:

Right now? Um, you mentioned that you, um, particularly work with children that are on the spectrum and what services do you do you offer at, um, nationwide children's hospital for families that have children that are on a spectrum?

Speaker 3:

Um, as far as like our entire range of services. Yeah, that's an excellent question. Um, it's a big range, um, because children with autism can vary a lot. Um, so one child from another, as well as what they need across the age spectrum, I think can really vary. So for very young children, we offer, um, early intensive interventions. So early behavioral intensive intervention are oftentimes what's referred to as ABA or applied behavioral analysis where we're trying to help parents, um, and children learn a different way. So what we often find with autism is that our children aren't learning the same way as other kids. So, you know, those social skills, those skills, so it should be easy to learn. And when you're not learning them, that means we have to teach you differently in order for you to be able to get those skills. And so we find ABA to be one of the most effective ways of breaking down those more complex language and social skills into smaller steps, and being able to teach those in a much more direct way, just like we would teach math skills or reading skills, um, in order to be able to help you catch up when those things are deficits. So we, and we offer those skills in a range of different packages from what we think of as comprehensive, you know, 20 to 40 hour a week programs to parent education, um, where we're working with families once or twice a week on working on very specific skills to help, um, children learn better, or to be able to address a skill deficit that parents really want to work on teach toilet training, dressing yourselves as early adaptive skills, or just work on engagement. So being able to work on those early play skills, um, and then as children get older, we start to offer more services where we're working directly with children, doing things like social skills groups, or adaptive living skills training, um, behavioral management training. So a lot of times we're also working with parents on creative ways on how to manage behaviors, because that is often very different with a child with autism. Um, a lot of times they're using the same kinds of strategies, but we gotta tweak them a little bit to make them work effectively, um, for children with autism. Um, and then we also do, um, both community and school-based, um, just outreach. So, you know, helping those, working with families and children, um, understand those families and children, um, as to the best that we can. So teaching more generally about autism spectrum disorder and then, um, working even with some individual programs to help them, you know, create a behavior plan or, um, a program to help, um, with different skills, um, improve different skills in those areas.

Speaker 2:

Right, right. Um, you know, you mentioned behavior programs and I've got a sprinkled some law in this, in this podcast here for you. Um, uh, so functional behavioral assessments, behavioral assessments, there's a recent decision out of the second circuit court of appeals that indicates legally speaking that a functional behavior assessment is not an evaluation. Um, do you have any clinical opinion on that doctor?

Speaker 3:

Oh, goodness. Um, I mean, I would probably have to look through it to actually understand how they're thinking. It's not an assessment, but I guess, I mean, it doesn't, I guess maybe some of the differences between a functional behavior assessment and what we often think of as assessment measures is that there's not necessarily a score. Um, so we're typically, you know, there's not a standardized measure. That's allowing us to say, you know, this is where this child was behavior is compared to every other child's behavior. Cause we're functional behavior assessments really varies. We're looking at this individual's assessments. We don't expect to be able to compare it to another child's assessment. Um, because this really is an individualized assessment to understand why is this child engaging in whatever the behavior is that we're concerned about? So really what we're looking for is being able to understand, you know, behavior does not happen in a vacuum. There's always a reason. Sometimes we don't understand what that reason is. Um, and that's where the functional behavior assessment comes in is that we, we have to often understand what that reason is before we can really understand what's the best way to intervene because we have to know what is this behavior achieving for this child? Um, so, you know, is it allowing them to escape from something? Is it allowing them to get something they want? Is it providing some sort of stimulation that they, um, really seem to need or want? Um, and without understanding that function of the behavior, um, we oftentimes aren't able to intervene effectively, but it's not going to give us a standardized score, which may be why they're considering that it's not an assessment, I guess, in the way others assessment measures like those IQ tests and academic measures are.

Speaker 2:

Right. Right, right. So, uh, you know, kind of moving on to when a, you know, a child is about to exit out of special education services under the individuals with disabilities education act and is more transitioning into adulthood and is on the spectrum, right. Uh, do you get involved with determining what the outcomes should be? You know, what, what transition evaluation should be implemented, what life skills that the child has acquired throughout their educational, uh, tenure, what's kind of the next step into adulthood for the patients that you've, you've watched grow up.

Speaker 3:

That is a great question. And I would say that that's a service area that we're still developing. Um, so we have one or two psychologists now who really specialize in those transition evaluations. And I think it's autism services have been growing with our children. Um, and unfortunately, you know, we've, we've come a long way in the last couple of decades, but we definitely have taken a developmental approach where, you know, we started with developing really good services for very young children, then school, age children, and now we're finally hitting, um, later adolescence and adulthood and really starting to develop some good services there. So I would say transition age evaluations are something that are still in their infancy, but there's a lot of good research coming out. That's showing that these transition evaluations can really help families plan for what's needed. And when I say transition age, you know, I'm, we're thinking 18, but a lot of times the evaluation can be helpful with it comes a couple of years before that, because a lot of times it will be time to get children on different wait-lists for different adult programs. Um, but really with that transition evaluation, we're going to focus on what does this child do well, um, what do they need supports in, um, in translating that into what would that look like for a job or, you know, what kind of supports would they need to live independently? Um, and when those things are in an option, what might be other, um, avenues, like what types of housing would this child be most effectively supported in or, um, what types of more supportive jobs with the child, um, be effective in. Um, and so I think it's, it's a different type of evaluation, cause it's really more of a strength space evaluation where we're really trying to understand, um, where is this child functioning compared to other children their age? What kinds of things could they do independently? And then where are we really going to need support? So, you know, should we be applying for guardianship or should we be applying for, and that's guardianship has a lot of different levels. Um, as far as, you know, is this someone who just needs help with money management or do they need help with all medical decision-making? Um, but I will say it's something that seems to really sneak up on parents and suddenly they are going to medical appointments and they're saying that, Oh, your child needs to consent for their services. Um, and you have a child who's really not at the mental capacity to be able to consent, but if you haven't applied for guardianship, um, they, we have to get their consent before we do anything. Um, so it's, it's definitely an area that we need more services in, but those services luckily are being developed, um, and are expanding.

Speaker 2:

Good, good, well, Dr. Crisis, thank you so much for being on the show. Um, uh, now if people want to get in touch with you, how can we get in touch with you? Okay.

Speaker 3:

Um, I would say either, um, through email or they're welcome to call our office here. Um, do you want me to just give you my email or is that something

Speaker 2:

What I'm going to do is I'm going to put your email, um, in the show notes for the podcast, but I have it as Elizabeth dot Christ at nationwide children's dot org. Correct. And Christ is K R Y S Z a K for folks touch with Dr.[inaudible]. Well, thank you so much. Thank you for being on the show. We really covered a lot of information in a lot of times. So, um, thank you for all the work that you're doing for, for the kids that you're serving and especially for just growing this tele-health program at the child development center at nationwide children's hospital. So thanks.

Speaker 3:

Yeah, it was my pleasure. Thank you for having me.

Speaker 1:

Thank you for listening and stay tuned for another episode of dreadlocks.