Speech Update: Four Years, Three Months

I received the written report from his most recent speech evaluation. (A post on last year's evaluation here.)

Bad News First: Overall, his expressive communication was pegged at two years nine months. Over the twelve months from May 2009, he only progressed five months. He scored a 63 on the expressive language portion of the Reynell Developmental Language Scale, a test in which the mean for his age is 100 plus or minus 15. So that's discouraging.

His deficits appear to stem from four types of issues: verbal/visual association errors, paragraph comprehension, semantic errors and rigidity. The examiner also observed "as expressive language tasks became more complicated and Brad was ask to describe pictures or re-tell narratives, he began to resist." Go figure. He's four years old!

Excerpted from the report, for your information and amusement:

Although Brad responded accurately with regard to production of grammatical skills, errors were noted in semantic abilities. For example, when asked to label an illustration of a group of men, Brad responded, "children." When shown a picture of several people trying to escape the rain and asked, "What's happening," Brad responded, "It's not raining." The examiner continued "It is raining. And the people are getting ____" and Brad responded, "frozen." He provided definitions for concrete or abstract concepts with inconsistent accuracy. When asked, "what's an apple - what do you do with an apple?" Brad responded correctly by showing the examiner eating. Error responses were predominantly reiterations of the targeted concept. For example when asked, "What does cold mean, "Brad responded, "I'm cold." Brad's motivation waned when asked to describe a group of illustrations depicting a family engaged in various tasks. He fell out of his chair and told the examiner that the task was "so so hard. It might take a very long time." With encouragement, Brad provided short sentences that in general described the pictures. For example, in response to a picture of a family washing the dishes, Brad responded, "She's making a recipe." In response to a picture of the same family setting the table, Brad provided, "He's making dinner." Brad substituted "he" and "she" pronouns thoughout.

The picture card sequence probe outlined in the language comprehension section of this report was used to assess Brad's formulation skills for sequenced activities. Brad experienced difficulty on this task. He repeatedly pointed out numbers on the cards that existed outside the illustrations. He appeared to focus on pictured details and neglected salient features of the illustrations. For example in the sequence that depicted a girl making her bed, the line that the sheet's border had created intrigued Brad. He ran his finger along this line and asked the examiner about the "rope."

That's Brad in a nutshell. Marching to the beat of his own drum. Falling behind in communication but getting ahead in numeracy.

As a parent reading the report, it was hard for me to figure out how much was attributable visual/verbal association problems versus semantics versus he's four years old and the exam was taxing on his attention.

The good news: The perpetual tough grader wrote:

In contrast to previous testing, Brad made several improvements in nonverbal and verbal pragmatic skills. During current assessment, Brad followed the examiner's gaze and engaged in joint attention.

He also did very well with object identification, sentence completion, syntax construction and pragmatic judgment, scoring within the average range for each of those assessments.

Annual Physical.

Like most kids, Brad gets an annual check up around his birthday, which is in January. Two notable aspects of his most recent appointment:

• He failed the depth perception test. He passed the eye exam, meaning his eyesight, in the conventional sense, is fine. The nurse practioner administers a test with multi-directional Es and special glasses aimed testing depth perception, and he failed. Which means he wasn't trying, he didn't understand or, what I suspect, he has issues with ocular musle control and visual perception that interfere with depth perception.
  
• I unbundled one of his vaxes. Since, for better or worse, there is a "vaccine debate" (although I don't think the debate is debatable, meaning, I think it's well-settled that vaccines don't cause autism), I thought I'd share my views. Although I don't buy into the vax-autism link and I'm very pro-vax, I don't have a problem with a modified schedule, so I unbundled varicella from the other shots he received at his 4 year appointment. I don't follow the Dr. Sears modified schedule; I just follow my intuition, but in any event, I make sure he is fully vaxed - it just takes an extra appointment. I'm happy with my decision.

Why am I posting now? Because Brad goes for his varicella shot this upcoming week, and I'm going to have him re-tested for depth perception. I'll post the results. Wish him luck!

What To Expect Age 4, PDD Edition: Sensory-Motor

As promised, a WTE segment on Brad's sensory and motor profile. But first, a "happy birthday" to Brad and a thanks to his well-wishers. He had a nice day.

And now he is four.

We've seen his motor coordination skills improve significantly over the last year. His OT thinks he may be "caught up" on the fine motor side, based in part on his grasp and his pedaling.

There's still something wonky going on though. The "ho-hum" profile still describes him well; the low tone is still there. In the Out of Sync Child, Carol Stock Kranowitz refers to this as the "gravity monster." Well, Brad is four and he's still fighting the gravity monster. Here's another clip we made recently, which illustrates his tendency to lean or flop.



(As an aside, I know, I need to quit my ill-fated attempts at making conversation while holding the camera; Brad is not the only one who has trouble multi-tasking.)

We still do "wheelbarrow" exercises on a regular basis to build up trunk strength. We make it a game: Brad hides his favorite ball, and he leads me to it with a wheelbarrow walk. Not to be outdone, Jeremy plays too.

On the sensory front, the sensory-seeking behaviors at this stage appear to be mostly limited to face-touching. Emotional regulation appears good; he's still our chill little guy; we bring him to restaurants, etc. all the time.

What To Expect (Almost) Age4, PDD Edition: Communication

As promised, a WTE post on speech and communication.

His most recent speech stats are here, but that doesn't really tell the whole story.

I'm proud to report...drumroll please...Brad is talking. Well that isn't exactly news, but it is a fair description of his ability. His progress on the speech front has been slow and steady. When exactly his speech took off is hard to pinpoint. At this juncture, he can express his needs and even his emotions, and his conversation skills are budding. Exhibit A:



And if it isn't obvious, the more he talks, the more he charms us with his sweet nature.

Not to take away from his progress, but there are still many challenges ahead. He's still scripting. Or something. For example, often our exchanges will go like this:

Me: "How was school?"
Brad: "The name of the day is Friday. Friday is a tuna fish day."

That having been said, on the whole, we're very pleased, and proud of his progress.

What To Expect (Almost) Age 4, PDD Edition: Introduction

I've long complained that there isn't a What To Expect (WTE) book for PDD. So every now and then, I blog about milestones and such in an attempt to distill Brad's experience WTE style.

Which brings me to my next series of posts. With Brad's birthday approaching (he turns 4 on January 22), I'll be writing about Brad's progress in the following areas: speech, motor, social and feeding. This is Brad's PDD trajectory; it may or may not be representative of any other child PDD or otherwise.

What to Expect (Almost) Age 4, PDD Edition: Engagement

In the coming weeks, I will be blogging about Brad's progress, but this week, I'm blogging about that which has been constant: his engagement.

Engagement is a difficult thing to describe.

I believe that Brad is easy to engage. In fact, several of his examiners (including his developmental pediatrician, his teachers and his speech language pathologist) have commended him on his ability to attend.

But the quality of engagement. It's different. It's not sharp, focused and sustained, like a typical child. You can see it in the videos.

This is the way it's been since he was a baby. I would never say "he's in his own world." But he's not always in my world either. He's somewhere in between, absorbing some pieces of his environs but disregarding others. I think this is part of what's vexing about A Little Bit Autistic. It's in between, neither here nor there.

One is Silver and the Other Gold

This is the third installment in a series on interventions. Installments one and two can be found here, here, here and here.

***

Part of PDD/SPD/A Little Bit Autistic, what have you, is a deficit in socialization. In my view, what to do about social impairment draws on medical science, treatment philosophy, but also norms, in the general sense. From a normative perspective, I'm of the mindset that it's okay to not be social. If Brad likes solitude, then I don't want to project my preconceived notion of happiness (having a lot of friends) on him. Also, if Brad is quirky, I have no interest in de-quirkifying him. Normal is overrated.

That having been said, I want Brad to be happy, and if Brad wants friends but doesn't know how to make friends, then I want him to have the facility to make friends and if school can further that goal, then I welcome the help. My goal then for Brad is the facility to make friends.

So that's a high level description of our goals, from a parenting perspective.

As for interventions, at school Brad's speech language pathologist joins Brad in class (including on the playground) and focuses on social pragmatics. In english, this means she facilitates play, including greetings, turn taking, sharing, and the like. Sample progress note, from his SLP:

Bradley did a GREAT job today on the playground! I was on the playground and I didn't even have a chance to go up to him to ask him if he wants to play hide-and-seek or tag. He came right up to me and said, "I want to play tag!". There were already two boys playing tag, so I told him to join them, and he just ran right up and joined in the game. He played for a few minutes and only needed a couple of prompts from me to keep going. Then, the boys started playing with a kickball, so I prompted him to keep after the ball in the group. The group then went over to play basketball and he needed prompts to keep up with the ball (someone throws the ball and all the kids run after it -- he just needed prompts to be more assertive and stay with the ball). He was actively engaged in games all of recess and feeling connected with the other kids. When you play tag at home, try having him chase you, and then teach him to run up to you and say in a nice loud voice, "Now you chase me!". After playing tag for a few minutes where he was chasing other kids, he wanted someone to chase him, and we practiced going up to a friend and saying, "Chase me!".

And this:

When I was in class today, I sat with Bradley and made bat, cat, and pumpkins with him out of play dough. We used the language for rolling, pulling, pushing down, etc. Then, I prompted him to show friends what he made, which he did when I prompted him to do so. I prompted him to use a louder voice when talking to friends. He also told his friend that he liked his cowboy costume!

To me, this seems like a nice, safe way to introduce Brad to social situations. I don't see any downside.

That having been said, there are a two social interventions which I disapprove of for Brad, from a normative perspective, and my disapproval is actually in Brad's IEP: (1) no "look me in the eye"; and (2) no social scripting.

Regarding "look me in the eye", at issue I believe is working memory. If you asked me to do long division in my head, either I wouldn't be able to do it, or I'd have to close my eyes or look away while I think about it. This is a normal response. For children who have a weak working memory, a lot of ordinary interactions tax them from a sensory perspective like long division taxes me. That's the way I see it. Also, I've read enough first hand accounts of autistic adults who recall being forced to look so-and-so in the eye, and it's a source of anxiety and instills a sense of failure. When Brad was two and a half, the specialty provider who came to administer Floortime starting doing the face touch, where the therapist gently touched Brad's face under the chin when he wouldn't make eye contact. I told her to stop.

As for social scripting, I just don't like it, and I don't think it's necessary for Brad. Social scripting refers to teaching a child to say, for example, "do you want to hold my hand and walk with me?" the idea being that typical children know to do this naturally and atypical children need to be taught. My thought is that holding another child's hand should come from a place of joy and affection, and not from a place of "if I do X, I'll get external reward Y." But, again, this is normative, in part, so I say live and let live. If another parent prefers that their child learn social scripts, that's fine. For me, I don't want that for Brad. As for prevalence, I don't know about other school districts, but I know that a few children in my district are taught social scripts (and it shows).

Life is a Highway: Part I

This is the second installment in a series of posts on interventions. Last week, I explored a speech therapy exercise that Brad has tried. This week, I muse about something we haven't tried. This installment is divided into two parts.

* * *

"[I]t is remarkable that an intervention that is easily defined and implemented can have important lasting benefits at least to the end of middle school for all students."

To what is the quote referring? Floortime? Occupational therapy? Behaviorial therapy? Diet? A supplement?

Answer: None of the above.

The excerpt is referring to an intervention that is elegant in its simplicity: classroom size. Science Daily reports:

Small classes in early grades improve test scores in later grades for students of all achievement levels, but low achievers get an extra boost. That's the finding of a study on the long-term effects of class size in the November issue of the American Journal of Education.

The study followed 11,000 students and found that:

...small classes—13 to 17 students—are most effective when they are consistent from kindergarten through third grade. Students in consistently small early classes had substantially higher test scores in grades four through eight than students who had been in larger classes. Students at all achievement levels benefited, but low achievers showed stronger benefits in reading and science.

Which is interesting because at least one noted blogger has hypothesized that "sensory processing disorders are probably among the most common reasons children underachieve in school."

Which is also interesting because my school district is amidst a budget crisis and a school crowding problem. The town I live in is having an override vote in December to fund some needed school repairs. If it doesn't pass, the children from the sick building may be forced to fan out into the already crowded grammar schools.

While I can't control how my town spends its money, I can control how I spend mine. Which is to say, I can send Brad to private school, if he can get over the admissions hump and can function without an aid.

I may look back at this very idea as crazy talk, but for now, it's something I'm at the very least considering down the road. Not for preschool, but for K-5 or K-8, when classroom size makes a preciptious jump in the public school setting. Private school offers small classroom size and appreciation of individual learning styles, and some "typical" private schools offer special ed-type services, including services for language and social pragmatics.

That having been said, my husband and I are both public school graduates and believers in the public school system. For most.

Syllogism-ism: Part I

As I blogged last week, lately I have been concerned about Brad's ability to make those higher order connections. Recall Brad's speech evaluation over the summer. I was a bit - shall we say - prickly in the immediate wake of the debrief with the speech language pathologist. As I blogged, she told me that Brad was rigid and lacked imagination.

So I was reactionary. That's my M.O. when some one tells me something I don't want to hear. But to give me credit, over time, I was able to be objective about the evaluation and appreciate what she was trying to tell me; my reactionary phase was short-lived. Herein lies what separates a denialist from a realist.

She also told me something I hadn't previously considered: he's impaired in verbal reasoning.

"What???" I asked. No, Brad has a communication impairment but his ability to reason is perfectly in tact, I thought. Reasoning and language are totally separate areas of the brain. I read that somewhere. He has a language impairment. And a sensory issue. And a social issue. And poor working memory. But reasoning is intact. It's that simple, I reassured myself.

I hate it when I'm wrong.

After originally dismissing the SLP, I have come to believe that she is correct: Brad does have an impairment in verbal reasoning. What that means (disorder versus delay) and how it will play out, I'm not sure. But that he has an impairment is pretty obvious now that it's been brought to my attention.

Syllogism-ism: Part II

Cue the syllogisms.

To "treat" his impairment in verbal reasoning, Brad's private speech language pathologist engages Brad using printouts like the one pictured above.

It starts with W questions, who, where and what.



Then it moves to "what happened".



And then what I call the syllogism prompt: "what will we do?"

Every week, they work on a new "story" that follows this basic interactive format. The column on the left (the W questions and the syllogism prompt) does not change. The SLP leaves me a printout so I can reinforce and practice in between sessions.

Goals, by their nature, should be something to strive for, not something already mastered, and that's why I really like this intervention. Currently, Brad doesn't really get it. He can't deduce, or problem solve yet. That last "what will we do?" question consistently trips him up. But he even though he can't formulate deductive reasoning, I think he is starting to comprehend these little syllogisms, perhaps in a passive way. But comprehension isn't for nothing. Little by little, I like to think that this type of intervention does exercise those tenuous "higher order" synapses, perhaps keeping them from dying off or causing them to flourish.

I will close with a proof point: I set the table the other day and forgot to set cups with the kids' drinks. Brad: "Mommy, you made a mistake!" (Ha! And it won't be the first, Brad.) Now that's deductive reasoning.

Added: The printouts pictured above were created with BoardMaker.

"Pruning"

When it comes to interventions, much is written about "rewiring" the brain - the theory (and, for some, hope) that intensive interventions can cause an atypical child to be more neurologically typical. Is rewiring possible? I don't think anyone knows for certain.

But it is well settled that you can work with the wires you already have. During childhood, the brain undergoes a pruning process, during which underused neurons and synapses simply die off. This is perhaps the best argument for early diagnosis and early intervention. With early intervention, perhaps we can prevent some of those tenuous synapses from dying off, and the sooner we start, the better the chance for a positive outcome.

With that in mind, in the coming weeks, I will blog about interventions that we have tried. In the upper right, I indicate that we use "moderate interventions." I'm going to try to give that vague statement a little more shape, speaking of course from a parenting/anecdotal POV.

First, a prefatory note about goals. Because, of course, as any special needs mom or dad with an IEP knows, you need to start with goals. About one year and nine months ago, if you had asked me about my goals for Brad, I might have replied that there is only one and that it is that he acquire speech. Flash forward about six months later, I started thinking more about social pragmatics and empathy. I added warmth and humor to the list of goals for Brad. Today, on a high level, my goals for Brad have shifted to intellectual capacity, i.e. making those higher order connections and doing whatever we can today to avoid intellectual disability down the road. Not that communication and warmth and humor aren't goals for Brad - they most certainly are. But I no longer fear that Brad won't acquire speech or develop empathy.

Prevalence of Prevalence Statistics

In the wake of the recently published autism prevalence statistics, comes Behind the Autism Statistics, by the producer of Autistic-Like: Graham's Story. Behind the Autism Statistics is an insightful editorial, and I could relate to chunks of it from a parenting perspective, particularly being pushed into ABA and feeling as though it were a bad fit.

What struck me as I was reading it was this little gem:

A central goal of the SPD Foundation is to ensure that the disorder [sensory processing disorder], now estimated to affect as many as 1 in 20 children, is included in the DSM-V, which would turn it into an official diagnosis that would come with much-needed help.

Irony alert! An editorial that criticizes the establishment for distorting autism prevalence, suggests that the SPD net may be cast at 1 in 20.

From a parenting perspective, I've arrived at a place where I am fully at peace with the blurriness of the lines. I believe that "autistic-like" SPD is distinguishable from autism, if at all, in degree-only. And degree is not for nothing. Degree can be the difference between talking and not talking, and dependence and independence. I don't minimize the significance of degree. I just question the need for a new, potentially ill-defined label.

If treatment is the issue, and I share this concern, then why not lobby to reform the prescription for treatment of autism?

Just Asking, Part II

What about sensory processing disorder (SPD)? Where are the SPD adults and SPD support (for those who have it and parenting support)?

For starters, there is the SPD Foundation, incorporated in 2005. I'm not sure how high its profile is at this juncture, however.

As for support, I see two obstacles. First, SPD is not formally recognized as a diagnosis. Second, those who do diagnose it (mainly occupational therapists) haven't been doing it for long, relatively speaking. As noted above, the SPD Foundation incorporated in 2005, whereas autism support has been around for much longer. SPD support simply isn't evolved in part because it hasn't been around that long.

As for the lack of adults with SPD, perhaps that's in part due to the novelty of the diagnosis and in part to the affect of maturation on SPD. By the time adulthood sets in, perhaps the condition has lessened or the person has learned to adapt? Just guesses. In the next ten years or so, perhaps adults might start identifying as having sensory processing disorder? But as of today, that doesn't appear to be the case.

Added: As Kris points out, SPDLife is a resource dedicated exclusively to adults with SPD.

Back To School

I'm writing to report that there's not a whole lot to report. Which is good, I suppose.

We're back to four days a week at integrated pre-school ("integrated" meaning special needs and typical peers). As I have blogged, Brad is in a great program with a rich curriculum, including motor group and one-on-one speech. It wasn't all good news last year though. In last year's class, he had difficulty keeping up and tended to withdraw.

Over the summer, Brad had a good teacher, who REALLY REALLY understood Brad and appreciated him. (Well, technically, I think the summer program is camp, but it was at the same place.) Anyway, according to her, Brad came out of his shell during the course of the summer. Brad showed her that fullness of expression that we see around the house. She loved him. Well maybe she loves all of her students, but still, I was enjoying her Brad appreciation.

Anyway, out with the old and in with the new. His teacher for this year (September through May) has yet to bond with him on that level. But I'm hopeful they'll get there. And the class mix seems to be better for Brad, in terms of age and temperament and whatnot.

One thing new on the roster: they might add a twist to Brad's one-on-one speech pullouts. They suggested one-on-two, meaning one speech therapist for two children. To facilitate a friendship and administer therapy at the same time. Call me crazy, but I like that idea a lot.

Insurance Update

We won our insurance appeal. It took five months and two levels of appeals, but we won. Brad will be starting occupational therapy again soon.

Go sox!

Here, in New England, we are said to be stoic relative to others in, say, the midwest or the south. We don't feign pleasantries. We're not warm and welcoming to people we don't know. We keep to ourselves. As a general matter.

Unless you're wearing a Red Sox tee shirt, in which case puritanical stoicism gives way to two other Massachusetts traits: meatheaded-ness* and sports fanaticism. For the uninitiated, Massachusetts happens to be some sort of meathead mecca, for reasons I don't fully understand. Anyway if you're wearing a Red Sox tee shirt and it's the day of a game, perfect strangers have license to make remarks and engage you in conversation.

Which is fine, unless you have have a speech delay. I have blogged of my time as what I dub a "smile bully"; when Brad was 3 months old, I wouldn't leave him alone until he smiled. Well, what we have here are conversation bullies. People who won't be satisfied until they have elicited some sort of remark from Brad, like his favorite player or the anthem "go sox." Brad, of course, wants nothing to do with these well-intended people, understandably.

So I have resorted to taking the Red Sox shirts out of his rotation during game day. It's all I can do. Do you or yours ever get assaulted by conversation bullies?

*Patent-pending.

Impervious No More?

I have long speculated that Brad is slightly impervious to pain. He just doesn't seem to react to tactile input the way a typical child does.

Until now?

The litmus test I use: taking a bath.

There are certain near-universal truths about typical children. One such truth is that toddlers become upset if they get soap in their eyes, even if it's "No More Tears." Not Brad. Since he was 18 months old, I've waited for him to express upset when I rinse his hair. Nothing. Just smiles and laughter. Sometimes I know soap is in his eyes. I look at him suspiciously. Just smiles.

And now, finally, it's happened: every time we rinse, he cries. Not that that's a good thing! Of course, I don't like to see Brad upset. But I can't help but wonder if one of those elusive neurological synapses is finally connecting. By my limited anecdotal experience, this usually happens closer to 18 months. Brad is three and a half. But this is me, not complaining. Better late than never.

The DSM-V Saga Continues

You can't make this stuff up.

To recap: Certain members of the American Psychiatric Association (the "APA") have proposed sweeping revisions to the DSM-IV, which is used to diagnose, among other things, autism. With respect to autism and other conditions, the proposed DSM-V will include "dimensional ratings" and "subclinical" designations. This is said to represent a paradigm shift. The chair of the DSM-IV task force, Allen Frances, sharply criticized the proposed revisions and the lack of transparency of the process. The APA came out swinging with its rebuttal, in which it accused Frances of bias and financial motivation: the DSM V revisions will render the DSM-IV handbook, which Frances authored, obsolete.

Update:

1. Predictably, Frances took umbrage. Those royalties he'll be forfeiting when DSM V is published? $10,000 per year. Which, for him, is probably nothing. He doesn't write that, because that would be crass, but that's the implication. Frances also challenges the APA to be tranparent and make public the exact wording of the proposed revisions, and the research in support thereof.
   
   
2. One of the members of the Workgroup on Disorders and Childhood and Adolescence has resigned in protest. This is the group that is deliberating over the inclusion of sensory processing disorder in the DSM V. She writes:
   
   "I am increasingly uncomfortable with the whole underlying principle of rewriting the entire psychiatric taxonomy at one time. I am not aware of any other branch of medicine that does anything like this....There seems to be no good scientific justification for doing this, and certainly none for doing it in 2012."
   
   So even if SPD were included in the DSM V, who is going to respect it? The process appears to have little integrity.

Related: Bitterness, Compulsive Shopping and Internet Addiction [via Slate]
Secrecy and Made Up Illness: The Latest Fight Over Psychiatric Illness [Via Doublex]

Another Esoteric Post About DSM-V

Remember those proposed revisions to the DSM?

Hold the phone. Apparently, a shitstorm is brewing.

Dr. Allen Frances, who headed the DSM-IV task force, fired the opening salvo with this blistering criticism. He writes:

Undoubtedly, the most reckless suggestion for DSM‐V is that it include many new categories to capture the milder subthreshhold versions of the existing more severe official disorders. The beneficial intended purpose is to reduce the frequency of false negative missed cases thus improving early case finding and promoting preventive treatments. Unfortunately, however, the DSM‐V Task Force has failed to adequately consider the potentially disastrous unintended consequence that DSM‐V may flood the world with new false positives. The reported rates of DSM‐V mental disorders would skyrocket, especially since there are many more people at the boundary than those who present with the more severe and clearly "clinical" disorders. The result would be a wholesale imperial medicalization of normality that will trivialize mental disorder and lead to a deluge of unneeded medication treatments‐‐a bonanza for the pharmaceutical industry but at a huge cost to the new false positive "patients"caught in the excessively wide DSM‐V net. They will pay a high price in side effects, dollars, and stigma, not to mentions the unpredictable impact on insurability, disability, and forensics.

* * *

A third category of DSM‐V innovation would create a whole new series of so‐called "behavioral addictions" to shopping, sex, food, videogames, the Internet, and so on. Each of these proposals has received little research attention, and they all have the potential for dangerous unintended consequences, by inappropriately medicalizing behavioral problems, reducing individual responsibility, and complicating disability, insurance, and forensic evaluations. None of these suggestions are remotely ready for prime time as officially recognized mental disorders.

I do not have space to enumerate the dangers of all the other innovative suggestions for DSM‐V, but I will list just some of the riskiest that require the most careful review and caution: adult attention‐deficit/hyperactivity disorder (ADHD) and adult separation anxiety disorder; making it easier to diagnose bipolar disorder; pediatric bipolar, major depressive, and trauma disorders; autism spectrum disorders; new types of paraphilias and hypersexuality disorder; and the suggested rating list to evaluate suicidality. [Emphasis added.]

Nice, huh? Sensory processing disorder inspires skepticism, and its inclusion is predicated on copious research. But shopping addiction? That's pathological! Maybe we should dress our sons in Manalo Blahniks? Label that, doc!

You can read the American Psychiatric Association's rebuttal here. The rebuttal has been criticized for its uncivil tone, and lack of substance.

To learn more, read DSM V Badly Off Track.

Source: Michelle Dawson's Twitter account

Me to Brad's SLP: He's Just Not That Into You

Or your dolls.

Allow me to explain.

I had Brad evaluated last week for private speech therapy. She raised the usual litany of concerns. Expressive language delay. Receptive language delay. No surprise there. What surprised me was her observation that his play is rigid and rote, and he has no imagination.

Oh really? I see him play with his brother all the time, and personally, I see mostly natural, unscripted play, with a lot of laughter. Brad has a sense of humor, albeit an immature one. Beyond that, I see a budding imagination, particularly when we use pretend food or stuffed animals.

The basis for the SLP's observation: it's the dolls.

The SLP did what every examiner does - she reverted to her preconceived notion of what inspires imagination in a normal kid. But Brad does not have an emotional connection to dolls or plastic representations of people. Why would he? In the world according to Brad, babies poop, cry, grab his stuff and don't share. He's around a baby - a sibling of one of Jeremy's friends - a few times per week. When he sees the baby, Brad goes right into bunker mode, protecting his booty of toys from the perceived threat because that's all that a baby is to Brad at this age.

So he lacks the emotional connection but he knows from past experience what to do with dolls. He puts them to sleep and says "shhhhh." He has memorized the play script. And being the pleaser he is, he happily goes through the script on request.

Fine, maybe I'm rationalizing. But the way I see it, he's acting in a rigid manner because we've reduced freeplay to an instructer-led service delivery model. Call me crazy but maybe play isn't always best when it's administered by a trained professional.

Not to worry though. I'm not shunning speech therapy. Brad is starting during the second week of July, two fifty minute sessions per week, covered by insurance at least for now. I plan to have a little heart to heart with the SLP before she starts however.