Cedar Tree Clinic

This blog is a little different than most in that it is based on research and my personal experiences working with adolescents and young adults diagnosed with autism. Adults with autism have impacted the way we think about autism, which is necessary if we are going to fully understand how to intervene as mental health professionals.

The brain of a person with autism is fascinating and uniquely different from the brain wiring of the “neurotypical” (individuals without autism/or other typical behaviors or thought patterns) population. However, we are just beginning to understand what this means for their functioning. We have learned that typically these individuals experience heighted emotional states, which can be due to sensory regulation (e.g., seeking or avoiding behaviors) and may lead to behavioral or emotional breakdowns. Although each person with autism has unique personality traits and presentations, many struggle with the awareness of interoception (e.g., feelings in the body or body sensations) and related emotional experiences. For example, if an individual is tired, his/her eyes may be heavy and muscles may be weak or if he/she is anxious, his/her heart may be beating fast, or he/she may have sweaty palms. Furthermore, they may have the need to engage in “stims’ (e.g., flapping hands, playing with fidgets), which are ways for them to regulate their internal states. As long as these behaviors are not self- or other harming, it may be beneficial to allow them to engage in these behaviors. The awareness of internal states can be a first step in helping with emotional and behavioral regulation

In addition, individuals with autism perceive the world differently. They tend to be immensely loyal to friends and family and have deeper connections to some people more than what was originally believed about autism. Consequently, when compared to a person without autism “neurotypical”, who may consider a small little slight (e.g., a friend not wanting to play with them, a parent taking away a toy they outgrew, or an employer asking them to stop fidgeting) as something to be brushed off or made to make you stronger, the highly sensitive autistic person may retreat into a “protected state” because it is too much for them to handle. At these times, their heighted emotional state makes it difficult if not impossible to process the situation. These situations may cause trauma and make it tough for them to talk about the situation because they tend to re-experience the emotion of the trauma all over again. Additionally, these experiences may result in fragmented relationships that deeply impact their future functioning. Preventative strategies may include following the child’s lead, understanding their highly sensitive states, and meeting their interoception needs. Interventions may include Occupational Therapy, Equine Therapy, grounding techniques, and/or calming strategies.

The social world can be confusing for people with autism. Consider a highly sensitive individual, who is already overwhelmed by internal or external factors, having to engage socially in a world designed by people without autism. Individuals with autism tend to use language literally and struggle with small talk (what is the purpose of talking about the weather, anyway?), humor, or figurative language (e.g., idioms such as “it’s raining cats and dogs”). Although typically, those without autism tend to have inferential social abilities, people with autism struggle to pick up on the nonverbal signals and nuances within the context of social interactions. Consider what you typically do when you engage in social exchanges: you watch what the other person is doing, you move closer to them to talk (but not in a creepy, on-looking way), and you talk to the person about their interests (which shows thinking about others’ thinking or perspective taking). If you have autism, you may not understand these “unwritten rules” of social interactions. Interventions may include teaching the unwritten rules literally (if they are willing or have the desire to learn), perspective taking, and/or finding other ways to connect. These strategies can provide a person with autism, confidence and necessary skills and facilitate meaningful social interactions.

At Cedar Tree Clinic, we are committed to helping families and the individual with understanding  to embrace the unique brain wirings. We “follow the client” and explore ways to improve everyday functioning.

Psychological evaluations are truly not a one-size-fits-all endeavor. Given the high cost of a quality evaluation, it’s important to understand who is conducting the evaluation, what types of tests will be included, the process and procedure for the testing, as well as the finished product. A high-quality complete comprehensive evaluation holds value in that it captures you or your child’s unique profile of strengths and challenges as well as recommendations for follow up. Typically, clients find that a well-done psychological evaluation provides a clearer path for supportive services, such as therapy to address direct life challenges, insight for medical professionals to know how to address specific needs, and differentiating between diagnoses. It represents a roadmap for you or your child’s future.

Who should conduct a high quality evaluation?

Evaluations should be conducted by a doctors-level psychologist or neuropsychologist, although a psychometrician can conduct assessments under the supervision of a psychologist. Also, masters level school psychologists are qualified to conduct school-based psychoeducational evaluations. When you are investigating who will be conducting the evaluation, make sure you ask questions about their specific qualifications. For example, ask what type of degree they have (master’s degree vs. doctoral degree), trainings they have completed, and the specific experience of the clinician who will be conducting the evaluation. The quality of the evaluation report will vary greatly depending upon the qualifications and skills of the evaluator. A psychologist or neuropsychologist typically has more training and an understanding of the brain processes and how it impacts a client’s functioning.

What should a highly skilled evaluator communicate to you?

It’s important from the very beginning of the pursuit of an evaluation (typically the first point of contact or intake interview) that the psychologist is listening to and answering questions that you want answered as well as describing the exact process and procedure for the evaluation. The psychologist may charge an hourly rate or flat fee for the assessment services, so be sure to ask what is included in the process. For example, typically evaluations require an 1) intake interview with the client, parents, and/or the child to gain background and developmental information 2) 4-6 hours of direct testing 3) multiple ratings (i.e. rating scales for social emotional, behavioral, personality, executive functioning, or attention) from multiple sources (parent, teacher, client, significant other) 4) data analysis and synthesizing of the data 5) written report 6) feedback session. A high quality evaluation process can take the psychologist 12-25 hours depending upon the selected battery of tests.

What is the typical process a skilled evaluator takes?  

Most scientist-practitioners (psychologists/neuropsychologists) have a working knowledge of forming various hypotheses based on the questions posed by parents/clients and based on the psychologists own questions (i.e., “rule outs” of other causes or diagnoses). The “referral question (s)” drives the choice of assessments, which are designed to answer the specific question(s).  For example, the referral question might be, “does the child have dyslexia?” If this is the referral question, a highly skilled evaluator will conduct direct testing of the area of concern (i.e., academic testing in reading comprehension, reading rate, and phonological processing), direct testing of potential underlying processes (i.e., cognitive assessments, neuropsychological assessments), and indirect testing which may be contributing factors to the reading difficulties (i.e.,rating scales for behavior, mood, etc. and observations).

What are essential components of a high-quality evaluation?

Essential components of a high-quality psychological evaluation, which will get you the most value for your investment, should include: 1) a full battery of tests that “rule in” or “rule out” diagnoses and answer specific referral questions 2) data that shows specific strengths and challenges of the client based on the data. (not just reporting the scores or what the test is measuring), 3) thorough analysis and synthesis of the data to create a holistic profile 4) specific recommendations based on the results of the data – recommendations should be linked to the unique testing result 5) A usable roadmap to help other practitioners and related service providers develop appropriate interventions, supports, therapies, medicine, or school-based assistance.

As a client, it is important to fully understand the psychological evaluation process and potential outcomes before engaging the process.

When your child struggles to fit into the social world of others, seems to “march to a different drummer”, or has difficulty with everyday functioning, you, as a parent, may be overwhelmed finding the right help for your child. You may feel like you are an island trying the navigate the incoming storm and waves of change. You are not alone. Many parents have been in your shoes and have found support in the storm, although the path to getting help was daunting.

As a psychologist, I have seen how a diagnosis, specific interventions, and community supports have helped with a families understanding of autism, ways to interact with their child, and how to optimize the child’s functioning across multiple settings. While in the midst of the storm, know that your best days are ahead when you have others to walk with you through the seemingly overwhelming circumstances.

How common is autism?

The prevalence of autism has risen sharply over the past 40 years. In 1980, the prevalence of autism in the population was 4 in 10,000. Currently (2020), the prevalence of autism has increased to 1 in 54 (Center for Disease Control and Prevention- Autism and Developmental Disabilities Monitoring Network). According to the CDC, more boys are diagnosed with autism than girls. However, in general, girls tends to be more communicative and social, compared to boys, which may contribute to girls not being diagnosed or being misdiagnosed.

How do you know if your child is exhibiting characteristics consistent with autism?

First of all, it is important to remember each child has his/her own unique personality, so symptoms of autism are typically expressed within a child’s unique personality traits or expressed interests. However, the following characteristics may be considered as indicative of an Autism Spectrum Disorder (ASD) diagnosis:*

• tends to avoid eye contact
• shows little interest in caregivers
• withdraws from social exchanges with same-aged peers
• struggles with peer relationships
• seems to be in his her own little world
• seems immature for his/her age
• prefers adults over children
• gets upset with minor changes in his/her schedule
• shows rigidity in routine or thinking 
• sometimes called quirky or a “little professor”  (knowing everything correcting others)
• struggles with language expression or interpreting language (especially social language or pragmatic language)
• talks “at you”, but not “with you”
• expresses very few words for his/her developmental age
• shows language regression (typically between18-20 months)
• flat affect or intonation
• Behavioral concerns (inattention, unware of personal space, struggles with his/her body in space)
• does not like the consistency of certain foods
• bright lights/sounds seems to get him/her upset
• repeats phrases or behaviors
• unusual sensory experiences
• indifferent to pain or extreme adverse reaction to pain

*It is important to remember that not all of these characteristics will be displayed with each child. The above characteristics are presented as guidelines for some typical presentations of ASD.

Why is diagnosis important?

Although studies have continually shown that early diagnosis and intervention are key for optimal outcomes, in my experience many times children are misdiagnosed or go undiagnosed well into adulthood. In addition, I have talked to many parents who have been frustrated by the process of finding a diagnosis (e.g., long waiting lists, less-informed doctors, etc.). Given the critical timing of a correct diagnosis, a complete psychological evaluation is recommended to uncover the unique presentation of symptoms a child is displaying and the most effective ways to intervene to help the child. Early intervention may include:

• behavioral strategies
• speech and language therapy
• occupational therapy
• sensory strategies
• school interventions and accommodations
• social skills training
• social thinking strategies
• executive functioning strategies
• emotional regulation treatment
• daily living skills support

Outcomes for ASD increase greatly with targeted early intervention and appropriate support strategies.

Have you noticed your child has difficulty sitting still, doesn’t seem to be paying attention when you are talking, stares out the window or “daydreams”, gets distracted easily, or becomes frustrated when completing tasks? Does your child struggle with time management, planning ahead, organization, initiation of new tasks, emotional control, or remembering things like completing homework? If this sounds familiar, it may be that your child has Attention-Deficit/Hyperactivity Disorder (ADHD) as well as the typical executive skill difficulties associated with ADHD.

ADHD is one of the most prevalent neurodevelopmental disorders diagnosed in children. In 2016, according to a national parent survey conducted by Centers for Disease Control and Prevention (CDC) the estimated number of children ever diagnosed with ADHD is 9.4% or 6.1 million, with boys more likely being diagnosed than girls. Although ADHD has been associated with difficulties paying attention or inhibiting impulses, it is also related to less-developed executive functioning skills.

Based on my experiences working in the schools and with parents, children/adolescents with less-developed executive functioning skills have been described “lazy” or “unmotivated”. As Peg Dawson, the author of the book, “Smart, but Scattered” would say, “What is the intervention for lazy?” Also, if the child/adolescent is lazy are we suggesting that he/she can actually help it? Or, maybe it’s the parents fault? Perhaps the parents aren’t providing enough structure in the home. I would whole-heartily disagree with this line of thinking with these children/adolescents!! fMRI studies have repeatedly shown statistically significant differences in the brain functioning of those with ADHD compared to those individuals without ADHD (Kooij, S.J., Bejerot, S., Blackwell, A. et al. [2010];  Depue et. al [2010]).  In fact, brain-based research has found that the pre-frontal cortex, which is related to executive functioning, does not fully develop until someone is in their mid-20s. The pre-frontal cortex for children/adolescents with ADHD or executive functioning deficits take even longer to develop!!

So what are executive functioning skills? Although research has uncovered over 40 different executive skills, recent studies have pinpointed specific skills related to executive functioning.  Executive skills include thinking skills (cognition) and doing (behavior) skills, although they may be labeled differently depending on the researcher. The thinking skills include working memory, planning/prioritization, organization, time management, and meta-cognition. The doing skills include response inhibition, emotional control, sustained attention, task initiation, goal-directed persistence, and flexibility.

Why is ADHD and executive functioning testing important? Children/Adolescents who have executive skill difficulties are more likely to struggle in school, have low self-esteem, become depressed, and may lack future independence (i.e., securing and keeping a job, staying in a relationship). A comprehensive testing evaluation to determine how the child/adolescent is functioning across multiple settings helps to clarify specific skill deficits, which can be targeted for intervention.

What types of accommodations and interventions are research-based to help build executive functioning skills? First of all, it’s important to understand that changing behaviors takes time, practice, and patience. Executive skills are considered “habits of the mind” and take a long time to develop and change. These skills take continual practice every day until they become automatic. So, now back to answering the question. Accommodations are environmental changes or modifications that can be made (i.e., schedules, cues, prompts, computer apps, seating arrangements), whereas an intervention consists of specific, measureable, appropriate, time-sensitive (typically 8-10 weeks) strategies, which target each specific goal in a hierarchal way. Typically, these interventions need to change if they are not working or if the child/adolescent is making progress and needs a new goal.

Interventions for parents/school professionals may include:

• Identify one or more executive skills which are difficult for the child/adolescent
• Pick one executive skill to work on
• Collect data on the behavior of concern (1-2 weeks)
• Share the data with child/adolescent (discuss negative and positive outcomes which may happen because of this behavior/lack of behavior)
• Brainstorm strategies to try (make sure the child/adolescent has input and gain agreement from the child/adolescent)
• Let child/adolescent pick the strategy and talk about when and where the strategy will be used
• Work with the child/adolescent to identify a goal – make sure the goal is specific, reasonable, obtainable, and measurable
• Have child/adolescent observe other children/adolescents who use the strategy effectively
• Right before the targeted situation, remind the child/adolescent of agreed upon time/place to complete the strategy
• Provide positive specific feedback and debrief with the child/adolescent
• After a week meet with child/adolescent to see how it’s going (discuss negatives, positives, way to make it better)
• Continue until a habit is formed
• Address issues when they arise – if one strategy isn’t working try another one

Although this is a list that provides ways to help an adolescent with executive skills, specific strategies can include delayed gratification, organizational systems (e.g., checklists, computer apps for reminders/structure), helping a child/adolescent think through situations, and problem-solving to name a few. Also, behavioral contracts between parents and child/adolescent, communication strategies, and contingency management plans (e.g., child/adolescent completes ½ an hour of homework, he/she gets a 5 minute computer break) can be most effective.

Targeting these executive skills may seem daunting at times, but with practice, consistency, and support from professionals, these skills may become positive habits for the adolescent and set him/her up for future success.

References:

Center for Disease Control and Prevention. Data and Statistics about ADHD. Retrieved August 19^th, 2020 from https://www.cdc.gov/ncbddd/adhd/data.html

Dawson, Peg. (2018, February).  Executive Skills: State of the Art, Trends for the Future. Workshop presented at the annual convention of the National Association of School Psychologists (NASP), Chicago, IL. 

*Dawson, Peg & Guare, Richard First initial. (2009). Smart but Scattered: The Revolutionary “Executive Skills” Approach to Helping Adolescents Reach Their Potential. New York: Guildford Press.

Depue, B. E., Burgess, G. C., Willcutt, E. G., Ruzic, L., & Banich, M. T. (2010). Inhibitory control of memory retrieval and motor processing associated with the right lateral prefrontal cortex: evidence from deficits in individuals with ADHD. Neuropsychologia, 48(13), 3909–3917. https://doi.org/10.1016/j.neuropsychologia.2010.09.013

Jacob, R. & Parkinson, J. (2015). The potential for school-based interventions that target executive functioning to improve academic achievement: A review. Review of Educational Research, 20 (10), 1-41.

Kooij, S.J., Bejerot, S., Blackwell, A. et al. European consensus statement on diagnosis and treatment of adult ADHD: The European Network Adult ADHD. BMC Psychiatry 10, 67 (2010). https://doi.org/10.1186/1471-244X-10-67

Samuels, W.E, Tournaki, N., Blackman., S., & Zilinski, C. (2016). Executive skills predicts academic achievement in middle school: a four-year longitudinal study. Journal of Educational Research, 109, 478-490.

Since this is my first entry, I thought it would be helpful to introduce myself on a personal level. My future blogs will include resources or research that you can use for support on your journey.

My journey to private practice began after years of working with my own children, who have been diagnosed with ADHD and Autism. When I made the decision to pursue graduate school, I remember distinctly thinking that parents need a champion. They need someone to help with understanding how their child is wired, ways to help their child, and resources that may improve their child and their family’s functioning. At the time, I had just finished navigating through the public school system, community organizations, and several doctors’ visits (e.g. psychologists, psychiatrists, and medical professionals). I worked hard to provide the best for my own family and knew that I wanted to walk with others to support them on their journey.

Fast forward to today, I have gained expertise in the area of neurodevelopmental disorders (e.g. Autism, ADHD, Intellectual Disability, & Academic Disorders, etc.) and mood disorders and effective ways to assess and treat these difficulties. As an added benefit, I have become proficient in strategies to assist parents through their own “gremlins” who have made them feel like they are not enough to handle these challenges. I have worked with many clients and helped them build “strong roots” which has sustained them through difficult times. I am grateful for my personal and professional experiences and am honored to have helped so many others on their own journey.