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Cognitive Behavior Therapy and Emotional Communication: A Necessary Marriage

While the prevailing evidence in the professional literature is that cognitive behavioral therapy is the gold standard in addressing problems like childhood anxiety disorders, the eminently reasonable principles of exposure and response prevention should be accompanied by what we know about emotional communication. That is, behavioral symptoms and the resistances to changing behaviors, even those that are not productive like compulsive actions or obsessive thinking, not only serve as the individual’s best attempt to cope, but also give us clues as to how to address them if only we take the time to decipher them.

For example, children who feel compelled to follow a ritual or have negative automatic thoughts that take a simple worry and transform them into huge fears, will be initially reluctant to give up these unproductive behaviors until they are convinced that they do not need them anymore. Meeting kids where they are-i.e. joining them-is the essential first step in rendering resistances to change no longer necessary. Here is an example in a case of selective mutism: the anxiety driving the resistance to not speaking must be respected by not pressuring the child to speak. Joining involves acting like the old sportscaster, Howard Cosell, and just broadcasting/describing what a child is doing with no questions asked. In this way, the child feels implicitly understood. The next step may be to ask forced choice questions that can be answered verbally by a yes or no or a nod of the head. In this way, we slowly scale the mountain of steps necessary to facilitate speaking. Joining or describing or mirroring are considered emotional communications-i.e. communications that help a child move progressively forward. Another important tool is object oriented talking. Here, we again take the focus off the ego (i.e. the child) by placing it elsewhere. This is an important emotional communication that can be powerful when applied correctly. For instance, if a child is not mastering an academic task at school, the emotionally responsive teacher may put the focus on herself/himself by asking about what he or she can do better to explain the work, assigning primary responsibility for the child’s lack of progress on the teacher.

The psychotherapy literature has long held that whatever approach is used, the relationship is the key. After all, why should anyone make themselves vulnerable by giving up a familiar albeit unproductive behavior if they do not feel that the person proposing such a change understands and listens to them? So when constructing a hierarchy of behavioral steps with the goal of extinguishing a behavior, it is important along the way to always be consulting with the child about the plan so it is a cooperative effort. I have found an important missing step is to inquire about how a proposed plan will fail before implementing it as this will yield important information before operationalizing a strategy. Making the child a partner, even if he or she is a reluctant partner, goes far in reaching the desired goals.

Training Teachers to Understand the Links between Cognitive Abilities and Learning Difficulties

            Teachers can greatly benefit from the advances in our knowledge about the connections between cognitive processing abilities and instructional strategies. Without this kind of framework to understand students’ learning problems, it is very difficult to craft an individualized learning strategy that targets the areas of deficit.

I have talked with many teachers who are working hard to understand why students in their classes are not learning. For example, many students experience problems in generating narratives. These difficulties can result from any one or more of a group of cognitive processing deficits. Specifically, students’ productivity can be affected by ability difficulties in generating adequate verbiage. This kind of problem is common in students who were not readers and did not accumulate a solid reservoir of vocabulary to use in oral or written language. However, producing narratives can be influenced by either difficulties in retrieving acquired/already learned information from long term memory or being unable to retrieve the information quickly enough. Either of these difficulties can result in the same productivity problem. Yet, in trying to fix the problem, you need to know which of these deficits are implicated and target your remediation efforts to the specific areas of deficit. Otherwise, you could be remediating the wrong area.

Similarly, I have talked about how a lack of knowledge about how to break down academic tasks into the cognitive processing skills that comprise them can lead to misdiagnosing the problem. For instance, a student who struggled to activate himself to produce a narrative was asked by the teacher to produce not only a greater quantity of verbiage, but also a qualitatively more sophisticated piece. The teacher did not realize that the student suffered from a shortage of adequate vocabulary because of reluctance to read over the years. The student also had a deficit in fluid reasoning, a skill that involves inferential thinking. Consequently, going beyond concrete writing was extremely difficult. Asking the student to produce in two ability areas in which he was deficient morphed into a behavioral problem.

Knowledge of the ability areas and the executive functioning skills that mediate the connection to these abilities can help teachers to understand and remediate learning difficulties and give them a framework that will inspire a sense of mastery and confidence in working with students with learning difficulties.

Living on the Edge: Emotional Attunement and Working with Kids

In the recent movie, “The Edge of Seventeen,” Woody Harrelson plays a teacher who, while eating lunch, finds himself face-to-face with one of his adolescent students who just wanted him to know that she planned to kill herself. Undaunted by this announcement, he states that he was just writing down a list of reasons about why he should do the same!

In this cinematic moment, Harrelson was actually demonstrating several fundamental principles of working with children and adolescents. First, he controlled his own emotional responsiveness to this student’s announcement instead of panicking, and second, he joined with her (and actually heightened the absurdity of the situation) to give her the impression that he was more like her. Both actions (not recommended for the pale at heart) resulted in taking the wind out of the student’s sails, and she acknowledged that she really wanted some attention and someone with whom to speak. Granted, his behavior was risky; however, he knew the student’s penchant for drama, and decided to exercise emotional attunement as a way of addressing her needs.

Children and adolescents, in particular, often present their parents, teachers, and therapists, with outrageous statements and behaviors meant to induce in them feelings to help them understand how they are feeling, and, in some instances, to test them to see if they can tolerate their emotional state. While all statements from kids need to be taken seriously, the key to working with them is to first be able to tolerate the emotions they are communicating long enough to understand them without having these propel you into actions that merely diminish your own discomfort while doing little for the kids who were making their best effort to communicate with you. This is not an easy task. It is similar to being a boxer who is challenged by a fierce heavyweight and needing to find a way not to go down after the first punch.

In this age of direct and faster therapeutic approaches, it must be remembered that the professional literature is in agreement that the most important ingredient of successful therapy is the establishment of a therapeutic alliance. Without it, there is no leverage-i.e. no reason for  child patients to allow themselves to be constructively influenced by you. The same process holds true for parents who are feeling frustrated by their kids. Unless kids feel that someone else is willing to hear their story, tolerate the emotions conveyed, and understand how to be accurately emotionally responsive (i.e. to determine what specific response is needed), they are unlikely to feel that the parent or therapist or teacher is the “right” one to be trusted with their innermost secrets.

Although it is certainly easier to do this in a movie when nothing is at stake, when it is your child or student, the stakes are higher. Learning how to be emotionally attuned and to be accurately emotionally responsive can be learned and a good therapist can teach it. Practicing these principles is like planting the seed that can grow into future successful encounters with your kids.

Screening for Dyslexia: What Dyslexia is and How to Assess It

86713_5_80x100            One of the most frequent questions I am asked is, “Can you perform a dyslexia screening?” While I evaluate children, adolescents, and even adults for the presence of dyslexia, it is important to be clear on the definitions of both dyslexia and screening.  Screening implies a brief assessment; however, dyslexia is a complex disorder comprised of ability and executive functioning deficits and any effective evaluation must test for each of these domains.

First, let’s define dyslexia. Dyslexia is a developmental disorder that is characterized by deficits in the cognitive processing areas of crystallized ability and auditory processing. These deficits are manifested by slow and labored reading, difficulty retaining letter-sound associations and decoding words, problems with spelling, trouble recognizing the shape and contours of letters and words, poor memory for and retrieval of learned words, low motivation for reading. Although some dyslexic individuals can understand what was read by using compensatory strategies like context clues, reading comprehension can be impacted because so much energy is devoted to decoding and storing words that processing is slowed and the main ideas are lost. Those individuals who have the added burden of a deficit in another ability area called fluid reasoning have more problems with comprehension because they do not have the capacity for higher order critical thinking. Executive functioning weaknesses manifested in dyslexia may include problems with verbal fluency (i.e. generating words), visual search and scan skills, short and long term memory, poor planning and organization (i.e. in written expression), and trouble with task completion.

Second, screening, according to Dr. Steven Feiffer, one of the leading authorities on dyslexia, recommends that screening should include testing for each of the deficit areas. He suggests a 90 minute screening that involves testing for: intelligence, phonemic awareness, rapid naming, verbal memory , reading fluency, orthographics, attention, executive functioning, and family history. It is important not to omit testing for any of these areas because there are different types of dyslexia. While many people think of dyslexia as a decoding problem (i.e. dysphonetic dyslexia), some individuals can effectively decode, but are unable to recognize by sight the way letters and words look (i.e. surface dyslexia). Moreover, others have both problems (i.e. mixed dyslexia).

Accurate assessment of the deficit areas is essential because instructional strategies must be targeted to these problems. That is, if an individual’s weakness is in orthographics, the visual recognition of letters and words, remediation that focuses on phonemic awareness will miss the mark. This is why screening should not be short sighted. It must touch on each of the above areas.

 

The Importance of Seeking a Neuropsychological Evaluation Using the Pattern of Strengths and Weaknesses Model (PSW)

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While few would disagree with the fact that neuropsychological evaluations offer the most comprehensive information about students’ learning and performance issues, it is equally important to seek out an evaluator who utilizes the PSW model in constructing the test battery, interpret the findings, and translate the data into practical instructional strategies.

This is because the PSW model posits that academic subjects like reading, math, and writing are really byproducts of a group of neuropsychological processes that are necessary to perform successfully in a particular subject area. The PSW approach drills down to find the specific broad and narrow abilities that are contributing to students’ school problems better than any other existing assessment model.

A skilled evaluator will conduct a PSW based neuropsychological in the same way you would peel back the layers of an onion. You start by looking at the outer layers-the broad abilities. However, it is important not to stop there. Each broad ability is comprised of a number of narrow abilities that may determine what is causing the learning problem. For example, it is not enough to say that a student has a reading problem. You must go further and identify if this problem is caused by a deficit in phonological awareness (i.e. decoding) or orthographic processing (i.e. difficulty storing and retrieving the visual images of letters and words) or both. It is only then that an instructional plan tailored to each student can be effectively constructed.

A failure in doing the necessary PSW analysis can lead to plans that do not specifically meet a students’ individual needs, leading to continued frustration and feelings of failure.

 

The Importance of Seeking a Neuropsychological Evaluation that is Educationally Informed

86713_5_80x100 When individuals are experiencing learning and performance difficulties, there is a high probability that cognitive ability, neuropsychological processing, and/or executive functioning deficits are at fault. The job of the evaluator is to first take a thorough history (i.e. academic; developmental; medical), generate hypotheses about which of the above areas may be implicated, and then construct a test battery that will target the domains in question.

It is not enough, however, to just review test findings. They must be linked in a meaningful way to instructional strategies, accommodations, and modifications that address the areas of deficit. This is because academic subjects are really byproducts of these processes. Moreover, recommendations based upon the test data must be practical and realistic. That is, the evaluator must have knowledge and experience about how schools work, the kinds of recommendations that can be reasonably accepted by a child study team and implemented by teachers. Reports that are computer driven and yield reams of unreasonable and impractical recommendations are frowned upon by child study teams and not taken seriously. Even when a reasonable strategy is generated it may not be implemented due to unavailability of either school personnel who can implement it or equipment. In these instances, it is important to be able to create alternate instructional recommendations that are doable for a particular school or child study team.

This kind of educationally informed neuropsychological evaluation takes into consideration what is possible within the confines of a specific school. It is of equal importance to be knowledgeable about how child study teams work, how they view outside evaluations, and how to consult the team in a way that is not threatening and is collaborative rather than adversarial in nature. The best plans can get stuck in the “institutional mud” if they are not presented in a manner that brings everyone involved-student, parents, teachers, and child study team-on board and in agreement with the common goal of helping a student progress.

Since schools typically offer psycho-educational rather than neuropsychological evaluations, it is of paramount importance to write reports that can be easily understood by the audience of professional that will read it and written with an inclusive tone rather than one that makes school teams feel threatened or defensive as they must implement the recommendations.

Serving as a private evaluator and a member of child study teams has given me a view from both sides of the fence that allows me to navigate the school system and avert an adversarial stance. Similarly, when doing evaluations for the purpose of requesting accommodations on college admissions exams, I have extensive knowledge of how the reports are reviewed and am skilled at writing appeals when requests are declined.

 

Diagnosing Orthographic Dyslexia

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Orthographic or surface dyslexia is a form of reading disorder characterized by deficits in visual processing of and visual memory for symbols. It is less well known than dysphonetic dyslexia and often overlooked.

In orthographic dyslexia, individuals have difficulty with: the rapid recognition of sight words; memory for specific spelling patterns; and encoding and retrieving shapes and contours of letters and words. Consequently, there is an over reliance on phonics which diminishes fluency, poor spelling, letter reversals and problems in quickly recognizing letters and words.

Instruments like the rapid naming subtests on the new WISC-V or the CTOPPS can be helpful as well as visual memory tasks. Individuals with visual processing deficits like visual scanning can also have difficulties with reading fluency because they frequently skip words or even lines.

It is important when assessing the presence of dyslexia to measure orthographic processing as well as phonological processing. Without this kind of comprehensive evaluation, a prescription of a phonics program for individuals with surface dyslexia can be incorrectly recommended and they will may little progress.