Dr. Sharp: Hello, everyone. Welcome to The Testing Psychologist podcast, the podcast where we talk all about the business and practice of psychological and neuropsychological assessment. I’m your host, Dr. Jeremy Sharp, licensed psychologist, group practice owner, and private practice coach.
This episode is brought to you by PAR. PAR has recently released the Feifer Assessment of Childhood Trauma or the FACT, the first and only comprehensive instrument measuring how stress and trauma can impact children in a school-based setting. You can learn more or purchase the FACT teacher form by visiting parinc.com\fact_teacher.
All right, y’all, welcome back. Glad to be here. And I’m glad to have my guest today who is a return guest. Dr. Celine Saulnier is a licensed clinical psychologist that specializes in diagnostic evaluations of autism spectrum and related disorders across the lifespan. She spent the first 20 years of her career in academia conducting research on early detection of autism and adaptive behavior profiles at the Yale Child Study Center and Emory University School of Medicine. In 2018, she opened her own practice, Neurodevelopmental Assessment & Consulting Services in Decatur, Georgia where she has a private practice and continues to consult on research projects and works with individuals in her private practice. She has published numerous papers, written two books, and is an author on the Vineland Adaptive Behaviour Scales third edition.
We talk a lot about adaptive functioning today. That is our topic. Celine and I get into a number of topics related to adaptive functioning. We talk about the history of adaptive functioning assessment. We talk about different means of assessing adaptive functioning in terms of the interview versus questionnaire, why she prefers the interview. We talk about reconciling discrepancies between IQ and adaptive functioning and numerous other topics that I think will be interesting and applicable to your practice.
Speaking of your practice, the next cohort of the Advanced Practice Mastermind is almost full. It will be starting in mid-January. I think at this point we have 4 or 5 out of 6 spots taken. So, if you’re an advanced practice owner, that means you are a group practice, you have employees or contractors, you are looking to grow, you’re trying to manage your folks, trying to step back from your own clinical work, establish better systems, that sort of thing, this could be a good group for you. You can learn more at thetestingpsychologist.com/advanced and schedule a pre-group call to see if it’s a good fit. I’d love to have you.
All right. Let’s get to my conversation with Dr. Celine Saulnier.
Hey, Celine, welcome back to the podcast.
Dr. Celine: Thanks so much. I’m so happy to be here.
Dr. Sharp: I’m happy to have you. I’m always amazed when people come back a second time and it’s like, oh, I guess the first time wasn’t that bad. That’s great.
Dr. Celine: I love it. There’s just so much to talk about and it’s just so easy to chat with you.
Dr. Sharp: Well, thanks. Likewise. You have your hands in so many things I feel like in our field, but the two main areas, the first one you talked about autism when you were on two years ago, I think, and now we’re dipping into this other area that you have spent a lot of time and energy on, which is adaptive functioning. So, I am curious as always, of all the things that you could be doing and spending time on within our field, why do you focus all this time and energy on adaptive functioning, in particular?
Dr. Celine: I sort of fell into it. In grad school, my dissertation required me to do probably 300 Vineland Adaptive Behavior Scales. So I got to know the measure very well. And then, following my graduate degree, I went to the Yale Child Study Center as my post-doc. So it was literally coming off my dissertation. I enter where Sarah Sparrow, author of the Vineland is working.
My mentor at the time, Ami Klin was like, you’re now an adaptive behavior maven. I’m going to connect you with Sarah Sparrow and her husband Domenic Cicchetti who’s a biostatistician. They were both at Yale. And that’s how it began. We started doing some studies together. Working with them was an absolutely incredible experience.
Dr. Sharp: Can you think back to that time when you say it was an incredible experience? I think a lot of us, well, we have varying experiences with mentors and advisors and PIs, and so forth. So, what was so incredible about working with them?
Dr. Celine: So, Dom and Sarah never had children of their own. So I imagine that they just took on their students and mentees like their adopted children. And so, all I remember is their love for wine more than anything. So going to an APA conference in Hawaii, literally they’re like, okay, we’re going to have a chat about a child behavior in this project in our hotel room.
So I go over to their hotel rooms, sprawled out on a bed was a suitcase just with their wine. And they had glassware everything, and they would only travel with wines they chose because they were such exquisite wines. So you were probably thinking, I was going to tell you something about adaptive behavior and academics, but you know what was so incredible about them was just how personable they were. And that’s an example of it.
And then Sarah would throw annual Thanksgiving parties and parties for her psychology students that I heard about in the past. So just things like that.
Dr. Sharp: That’s great. I mean, we can talk about the academic rigor and any number of things in that vein, but it’s the humanizing that really makes a difference. I don’t know, for me, at least. There’s that relationship and like you said, personability.
Dr. Celine: Yeah, she was wonderful. And just things about in my training, the way she would go about talking about adaptive behavior just always stuck with me. She developed it as an interview. And it should always be conducted as an interview when you’re assessing adaptive behavior. And how you do these interactions with caregivers so that you’re getting the best amount of information that you can. So just even that type of mentorship has stuck with me.
Dr. Sharp: Sure. Well, I think we’re going to get into some of those topics here during our conversation. Certainly ,the interview versus questionnaire format is a big one that I would love to talk about.
I am curious. I would love to lay a little bit of groundwork. And speaking of someone who’s not an expert in this area by any means, I wonder if you could just give us a little bit of background on the study of adaptive functioning and why… Why is this important is the question because in my mind, and I’m just going to be transparent here, it’s like adaptive functioning measures these behaviors that sort of fade into the background or maybe they are subsumed in other questionnaires. They’re just these behaviors that it’s easy to overlook and it seems like those are just what we do from day to day. It’s not symptomatic necessarily. So anyway, that’s a long rambling.
Dr. Celine: Well, you know, that’s exactly it. They are everyday practical behaviors. And that’s why they fall into the background. It’s we take them for granted because we just are applying them every day. They are literally defined as self-sufficient skills. So the difference is, even though they overlap with, let’s say, developmental cognitive speech and language skills, it’s not your capacity of them. It’s not that you have the ability to perform the behavior. It’s that you actually do perform the behavior. So that’s a subtle difference in typical development, but in these different neurodevelopmental disorders, it’s a big difference.
For autism, for example, you can have the capacity to speak and have hundreds of words in your repertoire, but you can’t put even two words together functionally or meaningfully to say, hi, how are you? Nice to meet you. Or mom, I love you. So that’s the functional application. So it’s the difference.
And the way Sarah Sparrow taught it to me was cognition is the can do, adaptive behavior is the does do. We know does do means without any prompts, supports, reminders or help, It’s complete independence and self-sufficiency
Dr. Sharp: Right. I like that distinction. That’s very simple and very easy to understand, but very descriptive. Can you speak to when this started to become a thing that we were concerned about in our field. Has it always been present as a part of evaluations or?
Dr. Celine: If we open the history books of cognition and intelligence testing, dating back to the early 1900s, everything was focused on IQ. And it was Edgar Dahl that actually developed one of the first measures of adaptive behavior. And it was in Vineland, New Jersey called the Vineland Social Maturity Scale. And that would evolve into the Vineland Adaptive Behavior Scales with Sara Sparrow.
But in the early 1900, when you think of all of our diagnostic systems, the DSM, but then there is what’s now AAIDD which used to be the American Association for Mental Deficiency and then Mental Retardation, everything was defined by what was intellectual disability, the deficiency of time, mental retardation at the time. There were two areas of deficit, cognition and these real-life practical skills called adaptive behavior.
So no matter where you look, those are the two criteria. So we needed standardized assessments for both. It’s just that we have always had these IQ tests as long as we can remember, from the early 1900s and even before. It’s just there weren’t as many adaptive behavior measures. And so, the Vineland, the one that Sara and Dom revised, and it was published in 1984, when you think of it, 1984 is really late when you think about the early cognitive measures, but I would say the Vineland is probably the most widely used measure worldwide in the Adaptive Behavior Assessment System, the ABAS.
Dr. Sharp: Right. And now, I don’t know if we… Well, we haven’t talked about this so far, but I’m sure it’s in the introduction, but then you have jumped in and played a big role in the newest version, right?
Dr. Celine: So that their addition to the Vineland, I should actually have made that disclosure when I’m talking about it being the most widely used measure, I do have to disclose that I’m an author on it and receive royalties from it. But that happened because I was working with Sarah and Dom at Yale and I was at Yale for nine years. In 2010, my mentor, Ami Klin was in discussion with people in Atlanta to relocate to Emory University. And that’s how I got to Atlanta.
So around 2010 when we were discussing this, just completely unexpectedly, Sara Sparrow passed away. She had a heart issue. And she passed away very suddenly. And because Ami Klin was so close to her and her family, he was with her in the hospital. And unbeknownst to me, she said to him, I want Celine to carry on the Vineland after I’m gone. That blew me away. I was not expecting that at all. And it just so happened that 2010 was when Sara and Dom had just started discussions with Pearson about the revision into the third edition. So I started with the revision from the beginning on and then Domenic Cicchetti got pretty sick after his wife died. And then he ended up passing away in 2018 or 2019.
So now I’m the only living author of the Vineland, which is a huge honor yet in a way, a burden to carry on a legacy. It’s a good burden, but…
Dr. Sharp: But a burden on the last. That seems like a lot of responsibility for lack of a better word to describe that. Anyway, that’s a whole other set of questions and what happens in the future and what the direction might be. Maybe we’ll save that for a little bit later.
I would love to dig into adaptive functioning a little bit more though and what this looks like. We gave a little bit of a definition earlier in terms of these day-to-day behaviors and what you can or could do versus can-do. Anything else that you would add to just a working definition of adaptive functioning that we should know about?
Dr. Celine: Yeah. So when you were thinking these, they’re such broad skills, right? So most adaptive measures have a conceptual. The Vineland has communication. The ABAS has conceptual. These are the closest coming to academic or cognitive, right? You’re receptive and expressive language. You’ve written communication skills, numerical skills, but then you have your motor skills. Then you have your daily living skills, your personal care. How do I dress, bathe, toileting, all of that, and your domestic- how do I do chores and cooking and cleaning and how do I go out in the community? And then you have your socialization and interaction skills. So these are so broad, right?
And the thing that’s nice about adaptive skills is they’re very discrete behaviors. So if you don’t have one and you need it, you can be taught it to your mental capacity to be taught it and then you have it. So adaptive behavior can change quickly over time for better, for worse. Intervention can make it improve. Lack of intervention can make a decrease. That’s why these measures are very useful as outcome measures in clinical trials. Patient is relatively stable. He won’t probably see movement in like a 12-week trial, but you could see movement in adaptive behavior over that short amount of time.
Dr. Sharp: Right. I guess I didn’t think about that application, but that makes a lot of sense that they would use adaptive functioning as an outcome measure. Yeah, certainly.
Let’s see. We can dive into the different areas, but I’m honestly curious about the role in different diagnoses and certainly in intellectual disability and the change from DSM-IV to DSM-V to put a pretty heavy emphasis on adaptive functioning. Maybe we go that direction. I’m not sure what the question in there is. It’s more just the reflection that we did move to this model where adaptive functioning is more prominent, right?
Dr. Celine: I’m so glad they did because it just makes it so much more applicable to treatment and translating to how much support does this individual needs because of their disability and that’s adaptive behavior, right? Self-sufficiency and independence. And everyone has their own personal level of what that self-sufficiency will be.
In autism, for example, there are profiles of adaptive behavior where understandably socialization skills are the lowest because it’s a social disability and that adaptive skills tend to fall far below IQ or cognitive expectations, let alone age expectations. And that’s because of this sort of, for whatever reason, individuals across the spectrum have difficulty intrinsically knowing how to apply their skills functionally. And so, that’s something that helps in the diagnostic process. So now it’s standard practice to include assessment of adaptive behavior in an evaluation for autism.
And then you can see profiles like that in ADHD and genetic disorders. Whereas an intellectual disability, by definition, you have delays in both cognition and adaptive behavior, but you would expect those two to be on par with one another. So if someone is 10 years old and they’re functioning at a 7-year mental age because of their cognitive delays, then you would expect that their adaptive skills are also delayed, but also at about a7 year mental age, whereas in autism, if you have a 10-year-old with the same cognitive delay mentally at about a 7 year level, their socialization skills are going to be far lower, like at a 2 or 3-year level. And that’s how we diagnose. We start to piece things together.
And so, when I go to make recommendations, I would much rather have the benchmarks be about specific areas of need rather than an IQ number. So moderate intellectual disability means they need this amount of support and conceptual development and practical skills in socialization rather than it’s an IQ of 47. You’ll figure it out.
Mark Tassé has an amazing paper that he literally goes through all the benchmarks and gives you explicit criteria across conceptual daily living skills and socialization, mild, moderate, severe, and profound ID, and actually gives examples of what amount of support you would need based on that. So, that kind of depth should actually be included in our diagnostic systems to help us as clinicians, right?
Dr. Sharp: Yeah. What was his name again?
Dr. Celine: Mark Tassé, and it’s T-A-S-S-E with the
Dr. Sharp: thing?
Dr. Celine: French.
Dr. Sharp: Yeah, the accent
Dr. Celine: You’re testing my vocabulary here.
Dr. Sharp: Oh gosh. Yeah, mine too. I feel like I’m losing more and more of my vocabulary as I get older. I just want to put that in the show notes so people can come and look at it.
Dr. Celine: I’ll email you the article so you have it. In that way, people have the reference.
Dr. Sharp: Great, thank you. Well, you brought up two things within that that I would love to ask about. I think they both revolve around discrepancy between IQ and adaptive scores in both directions. I feel like we have… I’ve seen a lot of clients where IQ is relatively low, and certainly falls in the range for ID, but adaptive scores are relatively high. They’re low average, maybe average. So that’s one example. And then the other example is the one you mentioned for IQ might be relatively high, but adaptive functioning is relatively low.
I’m curious how you clinically conceptualize both of those, but then how you might explain those situations to parents as well, or caregivers who are curious about that discrepancy. So there’s a lot wrapped up in that question.
Dr. Celine: Yeah. I’ll start with what I prefer to see. I prefer to see adaptive skills higher than mental age. That’s because you know that person is exceeding their capacity. So think about whenever you go to the grocery store or Starbucks, anywhere out in the community and you see someone with a disability, Down Syndrome, whatever, and they have some form of cognitive delay, but they are working, they’re living independently, they’re getting married, they’re having children and families and they’re just fine. That’s what we want. That’s what’s optimal outcome, right? That’s all adaptive behavior.
Whereas on the flip side, you have in the autism field, the vast majority of autistic individuals, autistic adults have no cognitive impairment and no language impairment yet they are failing to achieve levels of independence. They’re not holding down jobs. They’re not living independently and they’re not sustaining successful relationships. And that’s because of their poor adaptive functioning.
So, it’s so critical to me as an outcome measure of both, whether or not a clinical trial is effective, but if life is successful and meaningful. So that was the whole premise going back to early 1900 of Edgar Dahl’s research was, the importance of self-sufficiency and why the social competence or competence in general, is so meaningful to one’s contribution to society.
Dr. Sharp: Yes. So, a dumb question from that.
Dr. Celine: There are no dumb questions.
Dr. Sharp: Thank you. We’ll see after I ask the question. So, what can account for that? How is that possible that someone can overperform their “IQ”? And this is honestly a purposefully naive question, but I want to make it explicit. How can someone outperform their IQ and conversely not perform up to their IQ? Yes, I’ll just leave it there and let you take it wherever you’d like to take it.
Dr. Celine: Oh boy! Don’t I wish I had the answers to both those questions, right? So starting with the ones who outperform their IQ. Maybe that’s a testament to the faultiness in our IQ measures. Maybe we’re not really getting at the true capacity of some individuals. It might be the clinicians. Maybe there was something in their assessment that didn’t get the true capacity or the environmental factors. It was noisy, it was hot, they were tired, whatever.
But at the same time, some of these skills, like my IQ is 60, but how does that play into the fact that I can or can’t brush my teeth? How those interplay, I just really don’t know. And so, if you teach someone by breaking it down like this is how you do it and then someone can do it, I think those teaching methods can work at many levels. Even for some people who are severely and profoundly affected, they can still learn. If we break things down so concretely, we can teach them at their ability to understand what we’re teaching them.
On the flip side, in autism, there are so many factors and more likely unknown factors that are contributing to why there are those discrepancies. Executive functioning is probably a huge factor that everything about executing something in life is all about planning, organization, understanding what’s meaningful versus less salient, holistic processing, working memory, all of that kind of stuff is executive functioning, which are also incredibly impaired in autism.
So Lauren Kenworthy at National Children’s, she’s the one who does all the research on executive functioning and adaptive behavior deficits across disabilities. So that interplay, I think, plays a really significant role.
Dr. Sharp: Absolutely. Yeah, it’s a complicated question. I was hoping that you might have the answer.
Dr. Celine: I’m sorry.
Dr. Sharp: No, it’s totally okay. It is complicated. But it’s one of those things in our field I think that we just continue to wrestle with. And it circles back to my question of how to explain some of these differences to different stakeholders in the evaluation process, whether it’s parents or for us, it’s a lot of community center board, applications for services where community center boards may say, well, their IQ is really high, so they don’t qualify for services, and we’re like, but the adaptive is very low.
Dr. Celine: Every time I give a presentation. The week before Thanksgiving, I was giving a two-day talk in Lancaster, I mispronounce it, Lancaster, Pennsylvania, and said this exact same thing. I don’t make friends when I promote this into school systems or with parents but do away with the focus on academics in a way like in the field of autism, my focus is, is this person going to live up to their potential?
Academically they’re likely doing fine. So I’m not going to focus on their academics. I’m going to inundate them with adaptive skills, social skills, functional real-life skills, their whole time in the educational system when they have an IEP, because that’s the only time. When they transition into adulthood, it’s a big, giant black hole.
And so, we need to really lean on IDEA because if you read the law, it says that it’s beyond academic. It’s being able to have adaptive and social functioning as well to meet the needs of society. So we just have to focus on that aspect of the law and say that these educational curricula need to be more flexible, that you have to have the life skills track that is usually for the low performing grade-wise students, unfortunately, and then you have your AP and IB tracks and everyone for the academically inclined. And these two are parallel. They don’t intertwine.
We need to allow the autistic individuals that are in the AP classes and the IB classes to take the life skills program and vice versa. Our school systems don’t work like that. They’re rigid. They’re like, Nope, it has to be one or the other and families are like, Nope, I want my kid to go to college and they won’t get into college if they’re taking Home-Ec. Well, they’re not going to get the answer they want to hear from me.
Dr. Sharp: Right. Where else do these skills come from if it’s not coming from school?
Dr. Celine: Then families are paying out of pocket unless you happen to have community programming that offers these services for free, which are few and far between where they’re going to do life, coaching, job coaching, social skills instruction, all of that kind of stuff. It’s not going to happen. Families who have means can go and pay for all of those private services, but most families can’t.
Dr. Sharp: Right. So then we’re back to this question of how you talk with different entities about the results from the adaptive functioning assessment and parents who might say, well, his IQ is so high, why is this adaptive functioning so low or a similar situation?
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All right, let’s get back to the podcast.
Dr. Celine: Every time I write my report, it’s exhaustive when you read my adaptive write-up because I’ll say, despite the fact that so-and-so’s cognition is this high, the fact that their adaptive skills are falling so below their age and cognitive expectations is the focus of what we need to have as our priority. And this is common in autism.
And I’ll even if I have to cite references of all the poor outcomes and adulthood, like this is the path that we’re on unless you start closing this gap. And the only way to close this gap is to foster the adaptive skills and stop focusing on the cognition because the cognition’s going on an upward incline, standard scores are commensurate with chronological development. So, they’re doing just fine, whereas adaptive skills because they’re not focused on, the listeners can’t see my hands, but the adaptive widens with age. And that’s just the common path. Not only in autism. ADHD has that common path. Some genetic disorders have that common path.
So I think the more and more we as clinicians can emphasize that in our reports and our write-ups and make our recommendations about what’s functional and adaptive, it’s our job to educate and inform. Then we can make a difference in that way.
Dr. Sharp: Certainly. Maybe we dig into that for just a bit in how recommendations might be tailored to match adaptive functioning assessment. I know it’s putting the cart before the horse a little bit, but it’s right here in front of us. So, can we go in that direction? So what do you mean when you say that when we try to tailor recommendations to the adaptive functioning level?
Dr. Celine: If I have, let’s say a teenager who’s in high school and already by the law, we’re supposed to be focusing on transition. Everything that I’m recommending is about life skills, life coaching, job coaching, vocational training, whatever that person’s path is. Are they going to post-secondary education, then we’re going to inundate them with those supports, but they’re going to be living on a college campus, or are they going to be having to function independently to some degree?
So, I’ll have those recommendations. Sometimes I’ll be recommending a transitional program that they’re not ready. No one has worked on these skills, so they can’t go to college. There’ll be another statistic of the person dropping out of college because they can’t navigate a college campus independently. So a transitional program where they go to 1 to 2 years where all of that stuff is done in house, the life, coaching, job coaching, et cetera.
For younger kids, I am literally taking the results of the adaptive assessment which are behaviors. Does not initiate conversations. It’s not uncommon in developmental disabilities to not be toilet trained, to not have any kind of dressing skills or the motor skills to fasten and fasteners, those types of skills.
I will take every single skill, every item on the test that the individual score is zero where they’re supposed to be at a 2 based on their mental age. I do it by mental age because I’m not going to go to chronological age if they have a cognitive delay. But I will list all of the items by area. I’ll say, here are all the communication behaviors. Here are all the daily living skills and personal care. And here are all the socialization. Here are the motor.
And it’s your job as the family and school to prioritize these behaviors and put them in the IEP, because I only have met this individual for like a day, whereas you know them day in, day out. So what’s the priority? A family could say toilet training’s at the top of my priority where another family could say, no, speaking is at the top of my hierarchy. So I can’t make that decision. That’s for the people who know this individual the most. So I’m literally focusing on just entering those behaviors and having everyone work on them to foster them, teach them explicitly and then foster them in real life.
And then one thing that you’re making me think of that we didn’t talk about are elevated adaptive scores. If I see a child who has extremely high adaptive skills, that raises a red flag for me too, because you don’t want an 8 year old, why should they have adaptive skills like that of an 18-year-old? They shouldn’t be out in the community by themselves alone. They shouldn’t be driving a car. A 5-year-old shouldn’t be cooking dinner. So these are behaviors that I think, are we looking at a parental child or did someone do the assessment the wrong way? Did whoever was the respondent not understand the nature of the test? So that alway raises a red flag for me as well.
Dr. Sharp: That’s such a good point. I would not have thought of those possibilities necessarily. When we see exaggerated, or maybe just high adaptive scores compared to what we think the kid might be capable of, we always have a conversation with the parents around, how did you answer these questions? Did you answer these questions based on what your kid can do with a little bit of help from you or totally independently? Because that’s a big difference. We find a lot of parents, they have an investment in their kids being able to do well and to be capable. And whether that’s conscious or unconscious, it can influence their answers sometimes.
Dr. Celine: Well, this is why the interview is so important because it’s to no fault of their own if you gave me a rating scale and just said, go home and answer these 300 questions about all of these skills and no matter what you do, think about what your child actually does with no support, not what they can do. Any parent, any human being is after page 5 and 175 items later will be like, oh, can my kid do this? Yeah, I think they can. And they just score it.
So if I am doing that on my, I always throw my daughter under the bus here because it’s true. If my 13-year-old daughter brush her teeth, like if I saw that item and say, oh can my 13-year-old daughter brush her teeth, of course, she can, I’m going to give full credit. But now, there’s a clinician sitting across from me and says, wait a minute, Celine, you just said that your daughter can brush her teeth. About what percentage of the time does she actually do that without any prompt, supports, reminders or help from you? And then I think of every single day when I’m chasing her around the house with the toothbrush and the toothpaste, until I physically get them both in her hands and then physically push her hands into her own mouth, her teeth are never getting brushed.
So just by the nature of someone, they are interviewing me to correct me, you’ve gotten the accurate response. So that’s why rating scales tend to be inflated by 5 to 10 points as compared to the interview.
Dr. Sharp: That’s interesting. I’ve not heard that statistic before. So is that specific to adaptive functioning measures or to the Vineland?
Dr. Celine: Yes. So, for example, if you look at the Vineland-3 standardization sample and you look at those who administered the interview and also the parent caregiver rating form, they did that validity test, the parent/caregiver rating form in some age levels and some clinical samples is higher.
Dr. Sharp: And that’s a significant difference, I would imagine. I mean, 5 to 10 points, especially…
Dr. Celine: Yeah. And the interview, if you actually do statistics using like Cronbach’s alpha, and this is all Domenic Cicchetti’s work and Pearson’s statistics work that the higher the statistic, the more the item differentiates the clinical group from the normative sample and the interviews, all their numbers are higher than the parent caregiver rating form. So the behaviors are better distinguishing between clinical groups if you’re doing the interview.
Dr. Sharp: Right. Let’s talk logistics then, because I would imagine a lot of people are saying like, oh my gosh, when can I fit this into my evaluation process? It’s another interview. How long does it take? What recommendations do you have for folks in terms of integrating the interview into the evaluation?
Dr. Celine: I’m not going to lie and say that it’s so easy to administer. The Vineland takes an hour to an hour and a half to administer. It will say 40 to 45 minutes, but that’s if you’re a really good administrator and you reign in chatty parents and you have a young kid or an individual that doesn’t have many skills.
The older the individual, the broader the range of skills, the longer the interview is going to take. And now put in a […] and it can go on and on and on. So you need to be trained in how to conduct the interview. You don’t have to have a specific degree to conduct. Anyone can learn to conduct an interview. It’s just knowing how to do it. Do not ask leading Yes/ No questions. To be broad about what you’re asking. I always like to ask, about what percentage of the time? That’s open-ended.
Pearson has been great. They have recorded my webinars. So if you go to Vineland-3 page, you can look up the webinars and they’re already prerecorded like an overview of how to administer the Vineland-3. Vineland-3 on adaptive profiles and autism, and then adaptive profiles and neurodevelopmental disorders. They’re all there. And so, it’s not even like you would have to have formal training, but I that’s what I do in my consulting. I do Vineland training all the time, especially for clinical trials where the raters do need to be reliable with one another.
Dr. Sharp: Of course. Are you doing the Vineland right off the bat? Is it packaged along at the same time as the intake interview? Or is it a separate appointment? I’m always curious about the concrete practicalities of something like this.
Dr. Celine: It’s different. Pre-COVID, when I would invite families to my office just to do clinical interviews, which post COVID I’ll probably never do again, why do I need to have someone physically come to my office just to do an interview? I would do back-to-back my developmental and diagnostic history and my Vineland together. And that would be on a separate day than I did the direct testing.
When I was part of a multidisciplinary team, and for those of you who have that luxury, it would be the same day. While one clinician is testing the child, the other clinician is doing the developmental history and the Vineland with the parent.
Dr. Sharp: Yes, that’s fair. I think people are always interested in the timing and allocation of time and all that stuff.
Dr. Celine: Sometimes what I’ll do is, because I am so familiar with the Vineland and adaptive profiles and can literally look at a score sheet and then be able to relay the feedback right away, if I do my feedback session the day following my testing. I need that time to score the cognitive and all of the direct testing. That takes a long time.
But the Vineland, if I’m doing the interview online, like I’m sitting with my parents who I’m about to give feedback to, and I have my iPad and I do the interview with them, I literally hit score report and it’s there for me within five seconds. I have the printout. So sometimes I do that and then just go right into feedback because now that was the last piece of information I needed. I have the parent there for feedback without the child. And so I can just incorporate that right then and there. That’s another way to do it. It doesn’t add too much time to the feedback day.
Dr. Sharp: Sure. Are there any situations where you choose to administer the questionnaire versus the interview or would advise that people do a questionnaire versus an interview? Is that ever before preferable?
Dr. Celine: Of course. And now I have to say, Sarah, I’m so sorry because she’s rolling over in her grave. But yes, of course, especially during COVID. At the beginning of COVID, we all had to just shift and do whatever we could do to survive. But when I send my email to parents, Q-global generates its own stock email. I have a revised template that I have underlined, bold, “With complete independence, I want you to be thinking about every single behavior. Your child’ is not expected to be performing every single behavior asked this measure self-sufficiency. I really want you to be thinking about independence without supports, without reminders, prompts, help.”
And so, I inundating them with that information. And I feel when I’m getting the results, you know, as a clinician it’s like, oh, this doesn’t match everything else. I felt confident enough when I give that amount of instruction to the family. I’m getting better results, more accurate results.
Dr. Sharp: Sure. Yeah. So, it’s sort of like, okay, there are situations where this can be fine with the asterisks?
Dr. Celine: With the asterisks. Yeah. And I might even go over it with them. I see a lot of adults in my practice that don’t live with someone. So I have to give them the ABAS because the Vineland does not have a self-report. The ABAS does. So I’ll give the same instructions. I don’t give the instructions that come with WPS’s computer printout. I modify it.
And then sometimes I’ll sit with them and go through the items. Like, let’s talk about this. You said that you do this with complete independence. Sometimes it’s the complete opposite. You said that you don’t do this, but I’ve met you and I’ve seen you perform this behavior. So let’s talk about the frequency with which, or not with which you do this on a daily basis, because it just seems incongruent. In that way, you’d like to have the results ahead of time so you can eyeball them.
So if I am going to give the rating scale, give it ahead of time so that you have the time to eyeball it before you actually see the parent again to go over things or the individual.
Dr. Sharp: Yeah. I just want to use that opportunity to highlight how important that is. I think across the board with rating scales or questionnaires that… I mean, I know we do it. I know we all do it. You know, where you get the questionnaire back and you’re trying to scramble and get the results together, and you look at the scores and you’re like, okay, this looks good. But if you have the luxury to dig into those items and really look in detail, it can be so helpful to catch discrepancies or get more information. There’ve been so many times when I look at any number of questionnaires and just think, this does not make any sense. I need to get more information here.
So I want to give you a little opportunity to highlight the Vineland a little a bit. We’ve done the disclosure. You are an author. We know this. With that in mind, I also trust you to be as objective as possible. People often say, why would I choose the Vineland over the ABAS or vice versa? So in your mind, are there major differences? If so, what are they? Let’s start there.
Dr. Celine: Well, so the Vineland was considered the “gold standard”, and we can argue that term all we want, long before I was a part of it. It was being used worldwide and translated in who knows how many languages way before my involvement. And so, I just jumped on the Vineland train and it’s thankfully, still
I think regarded as one of the gold standards.
So I truly believe having now done all the research and being immersed in the history of the Vineland and adaptive behavior, that it was truly a construct that was developed to be assessed by a third party respondent through an interview. Edgar Dahl felt that way and Sara Sparrow felt that way. And so, I try to stay true to that because when you’re doing the interview, I’m getting a lot more clinical information than just what I need for their adaptive functioning. When we think about the whole comprehensive evaluation for whatever we’re doing. So I just find that that’s really critically important.
Also, if you look at the standardization, the way Pearson has standardized the Vineland is very close to the US census, as far as race, race, ethnicity, socio-economic demographics, whereas the competitors don’t even come close. When you look at how does this match? It does not even come close. So in that regard, I would say it is above and beyond.
Dr. Sharp: That’s great. These are important factors as we know. So I appreciate you doing that. I know that’s a somewhat awkward place. You don’t want to talk about your own measure, but there are some things to highlight there.
What about things under the surface of the Vineland? I think we all know the basics and certainly the sub-scales and the composites and that sort of thing, but are there any hidden secrets of the Vineland, things that it can be super useful, or things we might miss without doing a real deep dive into it?
Dr. Celine: So right off the bat, I don’t think that they’re secret, but the reports that you can print out, you can get multi-rater reports. So you can compare across two raters. I’m hoping to change that with the Vineland-4 that there can be more than two raters. But then you can do progress reports across five-time points. So if you are in a school system and you have the same child year after year, but even multiple time points a year shows progress in their IEP. That’s data you can give. And then that’s how clinical trials can also track progress.
There is a score called the Growth Scale Value, a GSB score, that’s not specific to the Vineland. It’s just new to the Vineland-3. The Bayley has had a GSB score as well. It tells you across time points what growth is significant or not. So you can then again, then this must be meaningful change over time. Otherwise, it’s probably just a random change. And so, it’s based on raw scores and not standard scores.
And if you think about developmental disabilities, even after a year’s time, you might never see movement in the standards score because of the nature of the disability. Even if someone makes the exact same amount of growth as expected for their chronological age, their standard score is not going to change. The growth scale value shows you change based on raw score for movement, which is much more informative from an intervention perspective. So that’s just a click that you make in Q-global. I want the multi-rater report with the GSV score and there you have it.
There’s also an intervention guidance where you can see by every single behavior, every single item, how they cluster by topic area. So you can see that like in the written domain, it was all of his reading items that were low. So now we know we have a recommendation for reading. So it helps you out in that regard.
And let’s see what other gems. The Vineland-3 came out with a brief version called the domain level. And it’s literally that instead of the domain and then the 11 subdomains, it’s only the domains, communication, socialization, daily living skills, and motor. Motor is always optional. It’s much less items and it’s really used just for determining eligibility. So if you’re a psychologist that is doing all of these eligibility assessments and you just need to do something quick, like you’re doing a brief intelligence measure, you need a brief adaptive measure. This is how you pair it.
But again, BRIEF measures tend to inflate scores. So that would also be something to consider. Like if you have someone that you think is in the mild to borderline cognitive range, I would say give the comprehensive versus the domain level because you don’t want to overinflate something that shows their adaptive score to be 80, rather than 72, where you could make the argument that this is mild ID, right?
Dr. Sharp: Right. Those are great. Some of those I was not aware of. I appreciate that.
Let’s see. We’re bouncing around, but that’s okay. I’ll trust people to be able to follow all this info. Any tips for the interview that you have found over the years to help you gather the information that you need, keep it on track, handle delicate situations where caregivers might be upset or emotions come into the room?
Dr. Celine: Oh, definitely. I’ll start with that one first, always change the starting age to the mental age estimate because you can upset parents. It will always default in the computer to their chronological age. And if you have someone who’s very, very impaired mentally, non-verbal, every single question you’re asking them, they’re like, no, my kid doesn’t do that. No, my kid doesn’t do that. And then they start crying because they’re like, everything is negative. So start with the lower developmental items where their child does actually do it.
Then use words like, how about dressing? Let’s talk about dressing. Tell me about your child’s dressing rather than does your child dress themselves, because then you’re asking a yes or no question. And we’re always going to default to can. Can your child do this? So, avoid can. Just every time you hear yourself say can he know that you’re asking the wrong question? Even the does he is still a leading question because you want it to be open-ended, but does he is better than can he or she.
And then with reigning in parents, I’m going to get to that just a little bit. That’s such a good point. I’m going to get to. Even if you don’t get to it, there are so many other behaviors they’ll forget about. We’ll all forget about it after 15 more minutes. Just say, oh yeah, I’m going to ask you about that coming up just to reign parents.
And giving examples. We have provided examples for most items. Use them. That’s why they’re there. You don’t have to come up with your own, but then come up with your own and then ask respondents for examples. So tell me another example because you don’t want just one. That’s a great example. Tell me another one. Those examples really give you more of a breadth of what.
Dr. Sharp: Got you. Let’s see. I did want to talk about the standard of care. You mentioned way back in the beginning that administering an adaptive functioning measure is now standard of care in autism evaluations.
Can you briefly justify that or explain why that’s important?
And then, are there other situations where we should be thinking about adaptive functioning that might not be obvious? Are there situations where it’s a standard of care if you want to use that term to administer an adaptive functioning measure?
Dr. Celine: Sure. I think across any neurodevelopmental disorder, it should be standard of care whether you’re talking about autism language disorders, learning disabilities, ADHD, you name it. So starting with autism, but certainly in these other disabilities as well, the majority of individuals right now do not have cognitive impairment. They’re only 33% of autistic individuals based on CBC epidemiological studies will have a cognitive impairment, which means the other 77% won’t. Did I get that math wrong? 67%.
Dr. Sharp: There you go.
Dr. Celine: Who said there’ll be math and vocabulary?
Dr. Sharp: You brought that on yourself. That was you.
Dr. Celine: I’m going to give a Wechsler test. They’re going to have highish to superior scores. We’re going to give language assessments like a self. They’re going to have average high, average superior scores. We’re going to give, academic and achievement testing and they’re going to excel.
And so now what do I have to say? I did my diagnostic tests. I did an ADOS and I did my diagnostic history. And I say, yes, she has autism. Now, what recommendations am I making based on what information? That’s where the adaptive comes in. Where is their disability shown here? I can write up the ADOS and talk about the social disabilities, social communication impairments, but I have no scores behind me to back that up because the ADOS, even though there are algorithm scores, they’re not standard scores.
So I still need something that’s going to inform insurance companies and educational systems why this person is eligible for services. And so, there’s your adaptive behavior, right? Throw in an executive functioning measure and for your older individuals, anxiety, and depression because that will likely be co-occurring. So that’s why I would say advocate for it because the adaptive scores will show you the deficits and you’ll have that ammunition, for lack of a better word, to fight for the services.
Dr. Sharp: That’s such a great point. I’m glad that you made that very clear. I haven’t really thought of it in that way before, but we do need some quantitative data sometimes.
Well, I’ve asked you a lot of questions. We went from subject to subject and I think covered a lot. I know there’s a lot more that we could dig into, but before we start to wrap up, are there any resources, guides, anything for folks who want to learn more about adaptive functioning just as a construct and how to assess it appropriately?
Dr. Celine: Oh, so not to plug my own book, but I have an Essentials of Autism Spectrum Disorders Evaluation and Assessment, and the essential series by Wiley. So most psychologists know. They’re like cheat sheets, your go-to guides. And so, I and Cheryl Klaiman wrote one on adaptive behavior. So it’s Essentials of Adaptive Behavior Assessment of Neurodevelopmental Disorders. I don’t have it right in front of me. I think that’s the name of it. So that’s a good book.
In autism, anything by Peter Gerhart. There’s a book by Dan Crimmins and Peter Gerhart going back in the day, that’s on adaptive skills. Those are good to read. And if you really want to get into history, anything by Edgar Dahl.
Dr. Sharp: Sure. Yeah, I think there are some folks out there who would probably appreciate that kind of thing. Although I have to say, the history of psychology was probably one of my worst classes in grad school, but I think I’d have a better appreciation of it now if I could go back at the time.
Dr. Celine: I absolutely have a better appreciation of it now. I know. I wish I could go back and take some of those courses now.
Dr. Sharp: Sure. It’s funny to think about that. My gosh.
So before we totally wrap up, you are learning some new skills in your own life these days. Tell us about these new skills or skills that you’re revisiting, maybe as a better way to put it.
Dr. Celine: I am revisiting old skills or trying for lack of a better word. I grew up as a Figure skater, and that’s how I spend my time when I’m not working. My two daughters who are 13 and 14 have been skating ever since we moved to Atlanta. So since 2011. And I figured if I’m there, you know, if you think about Atlanta, there are no rinks anywhere close. So I have to drive to Duluth, which is like in Atlanta traffic, a good 45 minutes to an hour from where I live. And I figured if I’m driving my girls that far, I’m going to start skating again.
I had taken a 25-year hiatus. And so now all three of us skate and we all compete and we’re all on Theater on Ice teams. It’s a great recreational thing to do with my girls. Even having that time. They’re teenagers. They never talk to me, but when they’re forced in a car and they’re on a highway for an hour, sometimes there’s nothing to do but talk. It’s helpful there.
Dr. Sharp: Absolutely. Like I was saying before we started to record, that is so admirable to get into something like that and be willing to push your body a little bit because that gets tougher as we get older.
Dr. Celine: Oh, thank you. The first 20 years that I did it, I never broke a bone. In the past 10 years, I’ve broken a shoulder, a foot, pulled a hip socket, tendonitis, you name it. I’ve gotten it from skating. Yeah.
Dr. Sharp: Oh my gosh. Well, even with those things, I’m sure your score on the motor domain would be really high, and that counts for a lot.
Well, this has been great. It’s fun to talk to you always. And I appreciate you sharing all of your expertise with us yet again.
Dr. Celine: Likewise. Thank you, Jeremy. And thanks to everyone who is listening. I really appreciate it.
Dr. Sharp: Okay, y’all. Thanks so much for listening as always. I really appreciate it. I hope that the holiday season is going well for you, whatever that might look like.
And like I mentioned, if you are looking ahead to the new year and want to take some steps to level up your practice and hopefully be less overwhelmed, step back a little bit, manage your employees a little better, grow your practice, that sort of thing, you can check out The Testing Psychologist Advanced Practice Mastermind Group. There are two spots left the last time I looked. And it starts in mid-January. So you can get more info at thetestingpsychologist.com/advanced. I hope to talk to you soon.
All right. Take care in the meantime.
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