Expert: James Michael Roan - 10/10/2008

Question
QUESTION: Hello Jim, currently our 4 year old son is being evaluated by the local EIS. He
clearly has speech delay for which he just started speech class (his granddad
and mom were also speech delayed/shy but turned out fine). They are also
doing the Wechsler tests; however we don’t agree with the way they are being
administered; i.e. a too narrow off an interpretation in a classroom full of
toys. We have been told by the IES School Psychologist that he will probably
be rated as retarded. Something we don’t agree with on the basis that our
son does show advanced behavior that doesn’t fit in the strict test (i.e. when
asked what an object is on a picture and he answered a Mercedes they are
counting this as wrong because he should have said car). For a diagnosis of
Mental Retardation also medical tests need to be performed; we think the EIS
is not professional here. Our son does talk with direct eye contact (but not as
much in the test room). Our son does display abilities that should be
considered advanced:
- he asks us to leave the bathroom when going on the potty;
- he can distinguish different car sounds between a Ferrari, Porsche etc
before he sees the car drive by;
- he is very social and does flirt actively if he likes a girl; mostly college age
girls; it’s like he thinks he is of college age and can date them; he always finds
a topic to discuss with this girl
- he does talk directly to people (children and adults) with eye contact and
notices well the changes in his environment. He has good imaginary play and
asks friends and family to play with him.

We took a look at the DSMIV criteria as well and think he doesn’t meet the 6
criteria needed (we think he is at 4). However he does have constipation and
does hand-flap when constipated or excited (has decreased).

Overall we have the impression that the EIS is confused by him; they don’t
give him credit for the behavior outside the test. We have been reading up
extensively and what we found is that the retardation qualification can not
just be Wechsler based; needs to be accompanied by other
evaluations/observations. Now we have read and do realize that after
diagnosis parents go through a mourning process that includes denial and
that it’s best to get your child early intervention services as soon as possible.
However we feel that the EIS will recommend a Special Needs Class Room
(incl. Speech); we are afraid that because of the Retardation label he will be
grouped with non-functioning children which will pull his development back.
He is currently in pre-school and enjoys that a lot and is developing quickly
(his speech really started to get going 3 months ago).

What is your experience/thoughts regarding the classification by IES which is
the same body that is providing services? They need a score to enable
services and can then improve but this feels like too much of a beat down.

Best regards and thanks for the advice,

Peter

ANSWER: Hi Peter;

The Mental Retardation (MR) label is a dangerous one. It should NOT be applied until later in life after his performance across all areas of functioning can be reliably evaluated. Inaccurate labels do harm, no doubt about it. In my view the WPPSI-III (Wechsler IQ test for under age 6) sucks.

The MR special education category label and the clinical label requires standard scores below 70 in three areas: cognitive, academic, and adaptive behavior. Anymore, MR is relatively uncommon. It's possible he could have a cognitive delay, and that's very common. A delay is just that: a delay. 99% of all children I have tested and served over the years with cognitive delay are just fine by the age of 9.

He's only 4. Make them give him a chance. We are who we believe ourselves to be, and what we believe ourselves to be is largely based on what others believe of us. If he is truly not MR, then a placement with very low functioning peers will impair his progress socially and communicatively. If they are in the U.S., they can use the Developmentally Delayed label for service.

If you like, tell me more about his problem solving and intellectual skills.

Kind regards,
James

---------- FOLLOW-UP ----------

QUESTION: James,

Thank you much for your direct answer. That helps. Regarding our son's
problem solving he is "inventive" and persistent if he wants something (and is
also curious). He will log a chair across the house to get to the pantry and
get to the cookies. He is getting good at building with Lego's. He figurs out
quickly if something in a room changed; if there is new furniture he is asking
if we went shopping. He is good at cleaning up toys, puzzles (loves them
lately; including the more difficult ones), persuading why he needs us to buy
him a particular toy.

On intellectual skills he figurs things out quickly; how to open doors,
cabinets, where our house is from many streets away, He can count however
is not into that by himself. He understands age appropriate TV PBS shows;
Little Einsteins, Handy Many, Blues Clues etc. (used to love Thomas but that
has decreased now). He always wants to know what his baby sister is doing,
where she is etc.. Our family lives out of State and abroad and he
conceptualizes that they need to go on an airplane to come see us; he knows
where they live etc. He does like books being read to him; "reads" by himself
on occasion and is starting to recognize letters better. He seems very eager to
proof himself to us, family or friends; like when he sees a house he likes he
says "I like that house", "It's red", "It's a big house but not my house" etc.; so
he is very descriptive and has an eagle's eye. He is getting more and more
inventive in interactive playing; we are playing Lego's a lot know and when we
build a bridge he builds a track underneath, or we build a house and we need
to install a gate around it and we play with different characters around it etc.
He is very explicit about what he wants (food, activity (play a puzzle,
swimming, go to the park etc) but also what he likes/dislikes; he tells his
mom if he doesn't like a particular outfit she is putting on and tells her to
change it. What we have also noticed (and that really is since he is one year
old) if we have a good looking college type baby sitter, waitress, or guest he
goes out off his way and flirts with her and gets her to play with him; read
him books for hours and hours etc. Not sure if that's a sign of intellectual
strength but it is noteworthy. He certainly knows how to influence others (at
times). On playgrounds it takes him a while to warm up (20 minutes) to new
kids and because of his speech delay has trouble striking up a conversation
with new kids. He always wants to play with kids when he sees them. He loves
to help out in the kitchen with cooking; emptying the dish washer, bringing
groceries from the car to the kitchen.

Why do you feel so strongly avout Wechsler? It seems to be a widely used
tool; interested to know if you think there is a better tool as well. Also;
couldn't tell from your profile directly but it looks like you are in the medical
field; can you please let me know what field/experience?

Besides the delayed speech (although he just had 3 speech classes and the
teacher is saying he is a quick learner) we are concerned about the
handflapping; he does that now only when excited or constipated. Is there
any research on what % of the population that hand flaps actually is on the
Autism Spectrum? One of my childhood friends also did hand flapping when
excited but was just fine growing up and finished his BA.

On speech he does lispel a bit; but when my parents were teaching him some
Dutch words he picked them up quickly and was able to pronounce them
fluently; that surprised me. We lived in Belgium for his first year but 90% plus
spoke English (I am dutch my wife is american).

Overall I think that the EIS are confused about him and trying to stick a label
on to ensure funding. Now our objective of course is getting him the services
he needs; so we certainly will get him speech class and ABA if they do offer
that.

We live in CA. I think we will ask for an independent diagnosis.

Best regards,

Peter

ANSWER: Hi Peter;

He does not sound MR to me. Children who function in the MR range are low across the board, that is, all their skills are depressed.

I don't know if the WPPSI-II has low reliability itself (although the technical characteristics report strength here), or cognitive ability is highly plastic under the age of 6. I have found that when a child comes to me from another school with a really low IQ that was assessed using the WPPSI-III, that when I retest, there is a huge discrepancy between the WPPSI-III and my score. This only happens with the WPPSI-III. I use the Stanford-Binet IV. It is reliable and provides more useful information.

As far as an outside assessment, although CA laws may be different, I believe you can ask formally for an Independent Evaluation by an independent psychologist at school district expense. First let EI test, then if you disagree with the results, send a registered letter to your school district's special education director requesting an Independent Evaluation.

Kind regards,
James

---------- FOLLOW-UP ----------

QUESTION: James,

Ok we will most likely do that. And then by Law if we disagree and formally
request an Independent Evaluation by an independent psychologist at school
district expense the school district is required to continue to offer Speech
class untill the conflict is ressolved? Our son really benefits from the specch
classes.

What is your specific opinion about handflapping? He does that now only
when excited or constipated. Is there any research on what % of the
population that hand flaps actually is on the Autism Spectrum? Or that
handflapping plus speech delay always mean Autism spectrum? One of my
childhood friends also did hand flapping when
excited but was just fine growing up and finished his BA.

Thanks again,

Peter

Answer
Hi Peter;

It's funny, but I just remembered that I forgot to answer that question on the way to my office. Recent research says as many as 20% of typically developing children show evidence of some form of stereotypy, with hand flapping being just one. I've seen many children do this with no other signs. It's a way of modulating arousal level, and will disappear with age in typically developing children.

No, the occurrence of hand flapping and speech delay together do not always indicate autism. Generally, speech delay is not a brain centered problem and generally has to do with oral motor, oral sensory problems, or apraxia/dyspraxia. I'm not a speech and language pathologist, but that has been my experience. Apraxia/dyspraxia refers to the difficulty with the fluid execution of a sequence of motor actions as is the case with walking up and down stairs, or throwing and catching a ball, and with speech.  Speech is often delayed in children with autism for the following reasons: Low social interest and thus low motivation; low imitation skills so they do not naturally copy sounds made by parents; and, because they have trouble with executive functions such as organizing, sequencing, and delivering a narrative.

Yes, the district is required to deliver his current IEP and can only cease services if he meets his IEP goals or if you request so in writing.

I hope this helps.

Kind regards,
Jim