Evaluations & Next Steps

[invisibleink]

Good Morning!

I have to say that this group has been an amazing resource over the past year, and thank you all for your time in guiding so many other parents.  

My son is a bright kid that struggles in school and is currently in 5th grade.  He usually gets good grades, but has to work SO hard to keep up!  His primary issues are with written expression (spacing / sizing of letters, takes a long time to write neatly, writes as little as possible), work stamina and processing speed.  He is having increasing problems with accurately copying a definition from a book, math problems--including poor copy legibility and omissions / substitutions of letters and words (IE writes a g instead of a).  He does also have organizational / planning issues and can get off task frequently.

He has been diagnosed with ADHD and "writing weaknesses" after a neuropsychological evaluation and educational evaluation a few months ago, and currently has a 504 (he did not qualify for special education because he is making "effective progress").  I have held off on medicating him because of what I felt was a strong pattern of visual weaknesses on his evaluation results.  

As a result, I had him evaluated by an optometrist who found convergence / accommodative insufficiency and mild-moderate oculomotor problems.  One of the tests asked my son to visually trace a line and find the endpoint.  He could not do this test, even after when tracing with a marker.  His DEM test showed him well below age level (I calculated it at around the 5%) largely due to automaticity.  To be honest, I don't think her evaluation went far enough into visual processing (figure ground / closure etc), and in the end I think we've just begun to understand the vision issues.  (He has 20/20 acuity).

However, the occupational therapy evaluation from the school stated that his convergence and tracking skills are intact.  The report says he only had trouble on the Perception portion of the VMI test with matching figures as they became more complex, and drawing a 5 pointed star.  They said his handwriting samples were inconsistent, but that he shows the "ability" to put spaces between words and write legibly.

I'm getting a growing sense that the school is hesitant to put the vision diagnosis on the 504 record.  I had to push back on the initial 504 for them to specifically mention the visual weaknesses shown on the neuropsychological evaluation.  They seem to merge together the evaluation results to say he is "average", when he is probably more like a 2e kid when you consider the discrepancies.  They do not consider a 504 meeting to be needed to discuss the new vision diagnosis, or to add it to the 504.  When I asked what they can do to accommodate scantron sheets on state testing they said he will be fine with just using paper as a guide, and that he doesn't have a diagnosis that qualifies him for a large print scantron sheet.

I feel that I am in a tough place.  I don't mind medicating my child for ADHD if that is actually what is causing his symptoms, but I do not want to medicate "ADHD-like" symptoms in a kid with a vision / processing problem. 

I guess I'm left with these questions, and would appreciate your advice on next steps:
1.  Do you see vision related weaknesses in the evaluation results, or does anything else jump out at you?
2.  Where do I go to get a complete visual perception / processing assessment?  We meet with a pediatric ophthalmologist in a few weeks.
3.  What are helpful next steps with the school?  It has been mostly cordial and collaborative so far, but I really don't like that the vision diagnosis is not formally acknowledged, even in the comments of his 504.  Even though the actual accommodations are similar, the context is very different.
4.  What is your experience with vision therapy?  A 3 month vision therapy program was recommended.

NEUROPSYCHOLOGICAL EVALUATION

WISC-V Index Scores
Verbal Comprehension:124 (95%)
Visual Spatial: 97 (42%)
Fluid Reasoning: 94 (34%)
Working Memory: 107 (68%)
Processing Speed: 92 (30%)

Full Scale IQ : 105 (uninterpretable due to discrepancies)

WISC-V Scaled Scores

Similarities 14 (91%)
Vocabulary 15 (95%)

Block Design 8 (25%)
Visual Puzzles 11 (63%)

Matrix Reasoning 7 (15%)
Figure Weights 11 (63%)

Digit Span 12 (75%)
Picture Span 10 (50%)

Coding 8 (25%)
Symbol Search 9 (37%)

ATTENTION, PROCESSING SPEED, EXECUTIVE FUNCTIONING

WISC-V Digit Span
Longest DS Forward=6 61%
Longest DS Backward=3 21%
Longest DS Sequencing=5 53%

DKEFS Twenty Questions
Initial Abstraction 37%
Total Questions 50%
Total Weighted 63%

DKEFS Tower Test
Total Achievement 37%

NEPSY II
Auditory Attention 50%

NEPSY II Inhibition
Naming Time=48" 50%
Naming Total Errors: 2 11-25%
Combined 16%

Inhibition Time=69" 50%
Inhibition Total Erros:10 <2%
Combined 5%

VISUOSPATIAL / VISUOCONSTRUCTIVE

NEPSY II
Arrows 25%

Rey-O Complex Figure
Copy:21 19%

LANGUAGE & AUDITORY SKILLS

NEPSY II
Word Gen (Semantic) 63%
Word Gen (Phonemic) 50%
Comprehension Ins. 63%

KABC 2
Expressive Vocabulary 84%

WJ IV Cognitive
Sound Blending 95%

PPVT 4
Standard Score: 126 96%

LEARNING & MEMORY FUNCTIONS

Rey-O Complex Figure
Immediate Recall: 12 5%
Delayed Recall: 10 5%

RAVLT
Trial 1: 6 39%
Trials 1-5: 52 63%
Short Delay Recall: 14 86%
Long Delay Recall: 10 25%

WRAML 2 Story Memory
Immediate Recall 95%
Delayed Recall 75%

WRAML 2
Design Memory 9%
Design Memory Recognition 37%

WIAT-III (School evaluation)

Word Reading: 112 (79%)
Reading Comprehension 101 (53%)
Pseudoword Decoding 109 (73%)
Oral Reading Fluency 115 (84%)
Spelling 111 (77%)
Essay Composition 102 (55%)
Sentence Composition 108 (70%)
Written Expression 108 (70%)

Math Problem Solving 112 (79%)
Numerical Operations 86 (18%)
Math Fluency Addition 103 (58%)
Math Fluency Subtraction 97 (42%)
Math Fluency Multiplication 99 (47%)

Oral Expression 114 (82%)

OCCUPATIONAL EVALUATION

Beery VMI
Visual Motor Integration: 105 (63%)
Visual Perception: 86 (18%)
Motor Coordination: 106 (65%)

BOT 2
Fine Motor Precision 23
Fine Motor Integration 9
Fine Manual Control 51%

[bros]

If it brings you any comfort, those Beery scores are better than I did (I took the Beery when I was 16) - the highest percentile I got was 0.1%

Honestly, you need to push for an IEP at this point - get the school to let him use a computer for everything - that will help with a lot of things, typing is less.. involved than writing, so none of the letter sizing, spacing, and collision issues. Have they checked him for dysgraphia? Ask him if he has pain when he writes and when he starts to have pain. People with dysgraphia can get it much quicker than others. I thought it was normal for my hand to hurt when writing - because every other kid would go "ohhhhhh why do we have to write so much, my hand huuuurts" so I thought it was normal to hurt after writing for a minute.

Contest their OT eval, get an IEE from an OT and try to get an IEE from a behavioral optometrist - www.covd.org/

[invisibleink]

Hi bros,

Thanks so much for sharing your suggestions and your own struggles with writing--it must have been very difficult for you!

The school has done a very good job of writing accommodations, including typing longer assignments. As far as an IEP, his lows weren't "low enough" to be eligible, and he gets good grades (but gets pretty worn out and work often takes twice as long).

I am not sure who would run the tests or diagnose dysgraphia, and I've wondered many times if this is what he has. The school believes that ADHD is why he has a hard time writing (can't slow his thoughts down to get it on paper). He started saying in 2nd grade that his hand hurt when writing vocabulary words 3x each. He still complains of pain, tries to avoid writing (even putting his name on papers), and he tells everyone he hates writing. He seems to bomb out after a sentence or two, and it takes him a very long time to write neatly (though he CAN have "nice" handwriting if he really works hard.) It's bad enough that he's been teased about it in the past.

I have already signed off on the school's evaluation, but that was before finding the vision issues. Would an IEE from an OT be able to assess both the vision and writing in more detail, and is this better than going for a private OT evaluation?

The optometrist we went to was from an office on the covd.org website. They did go beyond a typical eye exam, but they didn't evaluate things like figure /ground, closure, sequencing. How would an IEE from a behavioral optometrist be different than what we had done privately?

Thanks for the suggestions!

[bros]

Feb 19, 2017 15:07:13 GMT -5 invisibleink said:

Hi bros,

Thanks so much for sharing your suggestions and your own struggles with writing--it must have been very difficult for you!

The school has done a very good job of writing accommodations, including typing longer assignments. As far as an IEP, his lows weren't "low enough" to be eligible, and he gets good grades (but gets pretty worn out and work often takes twice as long).

I am not sure who would run the tests or diagnose dysgraphia, and I've wondered many times if this is what he has. The school believes that ADHD is why he has a hard time writing (can't slow his thoughts down to get it on paper). He started saying in 2nd grade that his hand hurt when writing vocabulary words 3x each. He still complains of pain, tries to avoid writing (even putting his name on papers), and he tells everyone he hates writing. He seems to bomb out after a sentence or two, and it takes him a very long time to write neatly (though he CAN have "nice" handwriting if he really works hard.) It's bad enough that he's been teased about it in the past.

I have already signed off on the school's evaluation, but that was before finding the vision issues. Would an IEE from an OT be able to assess both the vision and writing in more detail, and is this better than going for a private OT evaluation?

The optometrist we went to was from an office on the covd.org website. They did go beyond a typical eye exam, but they didn't evaluate things like figure /ground, closure, sequencing. How would an IEE from a behavioral optometrist be different than what we had done privately?

Thanks for the suggestions!

For an IEP, low evaluations are not to be used as the sole qualifier for an IEP - an IEP is supposed to be given if the disability significantly impacts education - this does not mean that the grades have to be low.

Dysgraphia & ADHD are a very common pairing - I have Dysgraphia and ADHD-PI (it was hyperactive when I was young, though. That sounds like he has dysgraphia. A neurologist or a neuropsychologist could diagnose it - provided they have HEARD of it. Make sure the neurologist or neuropsychologist has extensive experience with LDs.

Taking a while to write neatly is what happens - every time I have had OT, they have had to re-teach me how to form letters.

You can get an IEE from multiple doctors.

The difference between an IEE and a private evaluation? The school actually has to consider the report. With a private evaluation, they can just shove it in a file somewhere.

You can disagree with the evaluation at any time, as long as it has been less than 12 months since the evaluation.

[healthy11]

Invisibleink, welcome to the "posting side" of our forum. Bros has already given you some great information. My son also was a bright student with ADHD (combined type), dysgraphia (schools call it disorder of written expression,) as well as dyslexia. The dyslexia and dysgraphia weren't acknowledged by the school system until he was in 7th or 8th grade, because they felt (as you're being told) that my son's difficulties were related to his ADHD and giftedness, with his mind racing faster than his hand could keep up. We did end up doing a medication trial when he was in 4th grade, and while it helped his focus, it didn't help his penmanship much. The more he was allowed to keyboard, the more he was able to express his ideas, but it still wasn't easy, and the length of his responses on paper are shorter than many of his peers, but they're far better than they were when he had to write by hand. I can't speak into vision issues personally, because my son wasn't ever diagnosed with them, but for more information regarding writing difficulties, you might look at sites like www.understood.org/en/learning-attention-issues/child-learning-disabilities/dysgraphia/understanding-dysgraphia

[invisibleink]

Thank you both for your suggestions!

healthy11, it's sad to hear that your son went all the way to junior high before being identified. I know how frustrating this is for my son, and he's so aware of how he compares to his peers. My co-worker looked at my son's writing sample and said his 5 year old writes about as good as my 10 year old!

They do allow him to type longer assignments and we all agree that this approach is very helpful for him.

I was happy with the 504 until the bubble sheets could not be accommodated--and I do think he will need an academic support period next year (grade 6, middle school) to find strategies to work around his weaknesses. They said this was not possible under 504 and he needed to qualify for special education.

If I request an IEE are there specific tests that I should request? Can an IEE actually provide a diagnosis? I feel that the written expression disorder will be so hard to establish since the WIAT Written Expression tests came back around the 50%. A portfolio of his work is VERY inconsistent though, and I don't think the WIAT represents what he can actually sustain in a classroom.

And of course the oculomotor and visual perception issues muddy everything!

Thanks again!

[bros]

There are accommodations for scantrons! They had me use them when typing was not an option (For some state tests and the SATs). They had large format sheets (like 1/2 inch by 1/2 inch boxes for each letter, could just put an X in each one), still hurt, but was *much* easier to do.

When you request an IEE, you do not need to request anything - just say that you disagree with their evaluations and are requesting an IEE at individuals of your choice. Then you can get doctors to evaluate him. An IEE can provide a diagnosis as you are going to a doctor for it.

Honestly, I am a weird case too - just look at my neuropsych scores from 2010 - millermom.proboards.com/post/116821/thread & millermom.proboards.com/post/119596/thread

Where are you from?

Oh, and make sure your son gets OT for that dysgraphia if someone says he needs it. My district lied to my parents and said I was getting it after they discontinued it. I have been told by OTs since that if I had been getting the OT, I probably would be in a better situation. Now, I cannot write my name unless I try really hard.

[invisibleink]

Hi bros,

I took a look at your post from 2010 and there are a lot of similarities in your test results. It's really inspiring to read, actually! It looks like you've found ways to work with your strengths and survived navigating some bumps along the way. Did you end up moving forward with a different behavioral OD later on?

I asked about large print scantrons! I was told that he didn't have a diagnosis that qualifies him for that accommodation and that he would need to be using large format everything all year long to qualify. I thought it was weird because scantrons aren't really used anywhere outside of standardized testing. I realize that ADHD might be a stretch for large format, but the vision diagnosis should suffice.

I guess that report must have ended up "shoved in a file somewhere" like you mentioned earlier.

I'm in MA.

[bros]

Okay, i'm in NJ.

Never went to another behavioral OD - doctors decided that I wouldn't drive because of other things.

That is usually the case with standardized tests that the student has to be using it the entire year - or as long as they have been identified as being disabled that school year. There is also the option of a scribe for standardized testing - they did that for me. I had the large block answer sheet for the SATs, scribe or use of a computer for everything else.

Unless, of course, it is a test that requires you to physically write to test you, like a psychoeducational evaluation.

ADHD wouldn't suffice for large format - vision might - motor skill would work, since if a doctor can show he would have trouble filling out the bubble and large format is easier, hard to dispute that.

I got through it by using computers extensively. Finished my BA December 2013.

[healthy11]

We've got several members from MA, and while many of them have children who are older than yours, I'm hoping some will see your post and be able to recommend good providers to get an IEE from, as well as give you other specific recommendations. In any case, have you looked at the many resources available at www.concordspedpac.org/ ?

[jisp]

invisible ink, what part of MA are you from? There are some interesting alternative treatments you might want to consider for your son. Check out LydianCenter.com in Belmont. I know it sounds quacky but they are getting very good results. It would be out of pocket though. I have also heard very good things about a bio-feedback center in Readhing. For some disabilities these types of alternative treatments are actually making a difference. And this is not quackery. There are actual studies and data being gathered on these places by researchers at McLean.

Do you have an advocate? It sounds like you need one. You can contact the Federation for Children with Special Needs -FCSN and they can suggest an advocate depending on your town and your needs. Also I and another member on this board who live in the Boston area are advocates/

As for evaluations. In the eastern part of the state there are tons of excellent neuropsychs. If the child is complex I happen to be partial to the Children's Evaluation Unit at McLean Hospital. Although my own son was never evaluated there, a cognitive psychologist who was a resident there helped "unlock" learning for my son. It was miraculous. Our son went from failing across the board to excelling in school. He was also a very complex kid.

Good Luck

[mykids]

You need an advocate and you need to disagree with their last assessments and request an IEE at their expense.

You stated "They do not consider a 504 meeting to be needed to discuss the new vision diagnosis, or to add it to the 504. When I asked what they can do to accommodate scantron sheets on state testing they said he will be fine with just using paper as a guide, and that he doesn't have a diagnosis that qualifies him for a large print scantron sheet.”

They are not allowing your input, so request IEE or evaluations to be considered for IEP. Request this in writing. I would fight to get IEP and then if they dismiss you like they are doing now you have more legal protections with an IEP then you do on a 504.

Get an Advocate!

[invisibleink]

Thanks so much for all of your input! It seems like a lot has happened since last posting. Healthy11, I checked out the concordsepac site--what a wealth of information! Thank you!

Jisp, I am in central / western MA. I think those locations are too far away to be practical, but maybe something similar is nearby.

The ophthalmologist said there is nothing wrong with his eyes, and that the problem lies in the pathways in the brain. The neuropsychologist doesn't think there is a neurological issue. The optometrist says the problem is oculomotor and convergence, which can be helped with vision therapy (unless there are perceptual problems too). Nobody agrees on anything, and I am not sure who to believe at this point--except my son who clearly struggles in several areas related to visual perception / processing. Agh!

The neuropsychologist (retained by me) reiterated the need for a complete OT eval (including sensory), and gave me a good place to have this done. Otherwise, she felt that my son had been evaluated well enough in other areas. He has been through a lot of testing already, and I don't want to pursue more unless necessary. Can I do an IEE just for the OT evaluation performed by the school? The only other area that was a bit concerning to me was a discrepancy in his achievement in reading comprehension and writing when compared to his verbal IQ.

It does sounds like an advocate may be helpful at this point, especially with his transition to middle school next year. Right now my son does get good grades and KNOWS most of what is being taught, but it takes a lot of time, effort, support, and accommodations / workarounds for him to get actual work done.

PS: I did eventually manage to secure an accommodation for the bubble sheets with the "responses in exam book" accommodation--likely because this qualified under ADHD. At least it's a workable solution.

Thanks so much for your responses!

[bros]

Yes, you can do an IEE under any evaluation the district performed. Might as well do it for the IQ, too, if you are concerned about the discrepancy between achievement and test scores. You can see a neuropsych for the IQ and an OT for the OT, you don't have to just go to one doctor for both.

Oh, and the district will give you a list of doctors that they recommend you go to for the IEE.

You do NOT have to go to any of those doctors - you can pick any doctor anywhere, as long as they have the same (or better) qualifications as the ones they prefer you to see.

[invisibleink]

Mar 7, 2017 20:55:20 GMT -5 jisp said:

invisible ink, what part of MA are you from? There are some interesting alternative treatments you might want to consider for your son. Check out LydianCenter.com in Belmont. I know it sounds quacky but they are getting very good results. It would be out of pocket though. I have also heard very good things about a bio-feedback center in Readhing. For some disabilities these types of alternative treatments are actually making a difference. And this is not quackery. There are actual studies and data being gathered on these places by researchers at McLean.

Do you have an advocate? It sounds like you need one. You can contact the Federation for Children with Special Needs -FCSN and they can suggest an advocate depending on your town and your needs. Also I and another member on this board who live in the Boston area are advocates/

As for evaluations. In the eastern part of the state there are tons of excellent neuropsychs. If the child is complex I happen to be partial to the Children's Evaluation Unit at McLean Hospital. Although my own son was never evaluated there, a cognitive psychologist who was a resident there helped "unlock" learning for my son. It was miraculous. Our son went from failing across the board to excelling in school. He was also a very complex kid.

Good Luck

Good Morning!  

I have moved forward with the advice you all have given regarding the IEE request.  I did get an approval, however I have no idea how to start finding a provider that accepts the state rate.  I'm in MA, and the evaluators for OT on the concordsepac site are pretty far from me.

Do you have suggestions on where I could begin to look?  The district says that they don't send a list of providers.

Thanks so much!

[healthy11]

One place to look is www.yellowpagesforkids.com/help/ma.htm , but you might still contact some of the other groups/resources recommended above for the Boston area, and ask if they can provide names of individuals closer to you. It's been my experience that medical and educational experts often meet and network together at professional conferences and seminars, and they might be willing to share contact information if their own location is inconvenient for you. On the other hand, don't rule out traveling a bit further if it means getting a more thorough assessment.

[invisibleink]

Thanks for this suggestion for yellowpagesforkids.com! I will start looking into this.

It is a tricky situation. The neuropsychologist recommended a certain provider due to their experience, but they don't take the state rate. I'm trying to figure out if I can simply pay the difference to get the provider that was recommended.

I believe that I will get a less thorough assessment from a provider that does accept the state rate. Unfortunately, MA places this rate restriction. It's around $52/hr for OT.

The district did not provide a list, and several google searches do not seem to bring up evaluators that accept the state rate.

[bros]

I don't know about the legality of setting a "state rate" - sounds fishy to me. I imagine the evaluator wouldn't be allowed to take your money after taking the district's money - the point of an IEE is that the district cannot have the parent spend anything on the evaluation

[michellea]

I'm an advocate and mom in eastern MA. I agree w Jisp- www.fcsn.org would be very helpful. They have lists of advocates and offer training- look for Basic Rogjts Workshop.

Briefly- the IEE constraints in MA are real and limiting. Beyond Boston Children's and Tufts Floating Hospital there are not many who would take the rate which is less than 80% of market value. The hospitals have waiting lists of 6-12 months. If you can swing it or get insurance to help, that is your best bet.

I

[invisibleink]

Thanks bros and Michella!

I was really surprised to hear about the MA rule too, bros. I'm surprised there hasn't been a class action suit brought against the state because it does seem to clearly violate the federal laws. The cost limiting goes far beyond "reasonable" and severely impacts a family's choice in evaluators and the timeliness of an evaluation. From what I see the IEE at public expense essentially doesn't exist in MA unless you spend thousands on attorneys or advocates--even when the district failed to evaluate an area requested.

All I care about at this point is that the school really has to consider the results of the evaluation and not just file it away somewhere. Thankfully I am able to cover the cost. I can't imagine how frustrating this is for families that can't and believe that the federal laws will protect them.