Update to DD's Dev Ped Appt

[dashofreality]

Recap - DD, 4, had significant selective mutism and some other flags, but has recently made big improvements. No ASD dx, but a selective mutism dx. Unfortunately, this wasn't great news to me, which reinforced that I truly believe there are some concerns. I do appreciate the stories from you ladies regarding the difficulties in getting a dx, especially at a young age, for a high functioning girl.

Looking back I probably should've asked additional questions. DD loves going to the doctor (yay Doc McStuffins) and was excited to go, played, cooperated, and was very engaged with doctor. He did IQ tests - she was high in verbal >the normal range and at the very bottom of the normal range for spatial. He did the BASC-2. Which is where I am most confused. I don't have the report yet, but he showed me a graph and the majority were in the dark gray with some in the light gray which is the concern area, and one fell in the white/no concern. He went through the ASD criteria and she had 3 of 3 in the one category, but only 1 of 4 (when you need 2 of 4) in the other category. 

A local therapy center here has a music and movement class, that I think I'm going to enroll her in, and I will do my best to help her at home. And I can only hope that the doctor/testing is correct. 

[hopecounts]

That is frustrating.
What therapy is she going to be getting for her selective mutism, selective mutism occurs in higher frequency in girls on the spectrum so I agree with you that it's not a R/O for ASD, particularly in a girl.

Given that she is young pursue the SM therapy and revisit, you can always have her reevaluated in a year or if things pop up that indicate something more is going on.
((hugs))

[cam]

Sorry you are left feeling like things are incomplete. Make notes and just keep doing what you can, then hopefully things will be clearer in one direction or the other when she can be evaluated again. Good luck!

[bubbalicious]

I am wondering if Neuropsych when she is about 6 could help tweak this out.

[mrsbuttinski]

I'm sorry you came away feeling you didn't have definitive answers. It can happen.

Perhaps time will flesh this out; fours are a quirky bunch. In that context, it might be difficult to flesh out what's a stage and what's symptomatic of something bigger. I'm not sure DS could have been dxd at as a young four. Things looked very different at six.

Or it could be she's one of those kids who has some traits associated with ASD but not enough to rise to the level of a dx. I know a few kids like that. One is a scout who group up with DS. He eventually got an OCD and GAD dx; there's some debate on whether he is bipolar or was activated by an SSRI he took for the OCD/anxiety. We had a boy on spectrum who had a para at all times because he was aggressive. I shared with the para that we had another scout in the troop with that dx. The para who spent a week with the boys had picked up on the quirks and tic of the scout with OCD/GAD and guessed it was him rather than DS.The thing is, anxious as this kid was, he had the "with-it-ness" most on spectrum lack at that age.

You said:

Looking back I probably should've asked additional questions. DD loves going to the doctor (yay Doc McStuffins) and was excited to go, played, cooperated, and was very engaged with doctor. He did IQ tests - she was high in verbal >the normal range and at the very bottom of the normal range for spatial. He did the BASC-2. Which is where I am most confused. I don't have the report yet, but he showed me a graph and the majority were in the dark gray with some in the light gray which is the concern area, and one fell in the white/no concern. He went through the ASD criteria and she had 3 of 3 in the one category, but only 1 of 4 (when you need 2 of 4) in the other category.

I always think of questions I should have asked on the way home. My DS's dev pedi is great about phone calls and emails. The written report you get should have more information as well. There have been times when something was indicated in the report without having been mentioned in the appointment. DS's ADHD when he was initially dxd at 7 by the dev pedi and his GAD by his adult psychiatrist.

As bubbalicious mentioned, a neuropsych closer to 6-7 might be useful if you are still concerned. At 6, there's a student form associated with BASC-2 for her input. How many BASCs went out? You and ? I find preschool general education teachers are not always as tuned into their students as elementary teachers are- they tend to spend less time with them, there's a shorter "academic day" where the child might be challenged, in a DCC setting the instructors tend to be considerably less qualified than their elementary counterparts.

In addition to participating in BASC, at 6 a child is old enough for TOPL-2 which looks at language pragmatics and social communication. This is a good age to add a full Vineland which can tease out adaptive and executive function differences and the immaturity that an ASD brings to the party even for bright kids. At 7, she could do a WISC which can be suggestive of ASD when the subset scores are compared. In kids with what was formerly known as Aspergers, the VIQ should be higher than the PIQ.

Did he do a WPPSI? It's interesting that she was in the lower range of average for spatial; for many on spectrum that's a strength. But for some with NLD spatial can be an area of relative weakness. Straight up NLD can overlap ASD in symptoms. Back when DS was dxd 15 years ago, boys often got Aspergers and girls got NLD in part because they are a bit more skilled socially. NLD is considered a learning "style" so schools don't tend to address it. It's possible to have NLD and ASD, or either as a stand alone.

You might want to poke around this site and see if anything feels familiar. At four, a lot of this won't apply yet, but it's still might be useful-

www.ldonline.org/indepth/nonverbal

When you say the doc went through the criteria. Do you mean he pulled out the DSM-5 and said she's got this, this and this, but doesn't make the cut in section B? Did he not do ADOS with her? What about ARI, CARS, GADS? Both DS's dev pedi and Psychologist did both the ADOS and at least one other scale before dxing him. Dev Pedi did ADOS, GADS and ARI. Psych did ADOS and Soh.n Gr.ayson Scale for Aspergers.

What concerns do you hope to address through movement therapy?

[KC thepouchh8r]

Maybe auntie can chime in but when kids are right on the cusp why don't they do an ADOS? With dd all the other a screenings came back not autistic but right on the cusp. On the ados she again scored on the cusp but just enough for a dx. Can you request it?

[mrsbuttinski]

KC thepouchh8r

Hard to say.

Unless a diagnostician can observe a child with peers in an unstructured setting, IMHO, they can't R/O ASD without ADOS.

But it's time consuming- up to an hour to work through the required modules, time to score the results and add it to the written report. It's not like a parent questionnaire that scores easily. In a lot of developmental pediatric practices, the dev pedi will have a psychologist do this portion of the assessment.

And it's expensive, the latest version with software to score it is just over $2K. You'd be surprised how often school districts avoid certain scales based on the purchase price. The Vineland, for instance is about $1200 to get started, plus $800 for scoring software and additional money for interview forms in languages other than English.

[macchiatto]

I'm sorry you came away feeling like you didn't have all the answers. I have felt the same after several of Leo's developmental pedi appts, especially the first few. He does seem to be one of those kids who has a number of ASD traits but not quite enough for a Dx, which is confusing territory when you're wondering if they'll kind of grow into or out of those traits. (He's currently considered "at risk for autism." We'll see the DP again in June.) I like the BASC-2 but it does just give the parent report and has to be balanced again observations and evaluations of the child. FWIW, Leo met criteria for ASD on the ADI-R and a lot of areas of concern were noted on our BASC-2 but on his ADOS at the DP's, he only scored a 5 and the cutoff was 7.

[mrsbuttinski]

Feb 15, 2015 15:46:10 GMT -5 macchiatto said:

I like the BASC-2 but it does just give the parent report and has to be balanced again observations and evaluations of the child. FWIW, Leo met criteria for ASD on the ADI-R and a lot of areas of concern were noted on our BASC-2 but on his ADOS at the DP's, he only scored a 5 and the cutoff was 7.

I like Vineland better.

At 6, BASC-2 includes a Student Report. A teacher/caregiver should be asked to complete BASC as well. Last time we did it, DS was transitioning to middle school- his teacher and I reported almost identically. But DS reported some stuff we didn't see.

[dashofreality]

Thank you all for the responses - this is definitely a world that I have very little knowledge. And I thought the government was bad with the acronyms:) After looking into this further after having some more information, I'm even less sure on her dx now.


Or it could be she's one of those kids who has some traits associated with ASD but not enough to rise to the level of a dx. I know a few kids like that. One is a scout who group up with DS. He eventually got an OCD and GAD dx; there's some debate on whether he is bipolar or was activated by an SSRI he took for the OCD/anxiety. We had a boy on spectrum who had a para at all times because he was aggressive. I shared with the para that we had another scout in the troop with that dx. The para who spent a week with the boys had picked up on the quirks and tic of the scout with OCD/GAD and guessed it was him rather than DS.The thing is, anxious as this kid was, he had the "with-it-ness" most on spectrum lack at that age.

My DS's dev pedi is great about phone calls and emails. The written report you get should have more information as well.

I should have the report tomorrow, so that will be interesting.

As bubbalicious mentioned, a neuropsych closer to 6-7 might be useful if you are still concerned. At 6, there's a student form associated with BASC-2 for her input. How many BASCs went out? You and ?

I will definitely keep the neuropsych in mind. Her preschool teachers filled out a questionnaire, it didn't directly correspond to the BASC, but did have various rankings. While I like her teachers, I believe that they overlook a lot because they really like her and she is 'easy'. Every time I drop her off she stands uncomfortably off to the side, usually pulling her arms into her sleeves. Her teachers are good about acknowledging her and getting her involved, but without that she doesn't initiate. Also every time I pick her up she is either right next to the teacher or on her own. The only thing her teachers commented on was some anxiety and inability to initiate with peers.

In addition to participating in BASC, at 6 a child is old enough for TOPL-2 which looks at language pragmatics and social communication. This is a good age to add a full Vineland which can tease out adaptive and executive function differences and the immaturity that an ASD brings to the party even for bright kids. At 7, she could do a WISC which can be suggestive of ASD when the subset scores are compared. In kids with what was formerly known as Aspergers, the VIQ should be higher than the PIQ.

Good knowledge to have.

Did he do a WPPSI? It's interesting that she was in the lower range of average for spatial; for many on spectrum that's a strength. But for some with NLD spatial can be an area of relative weakness. Straight up NLD can overlap ASD in symptoms. Back when DS was dxd 15 years ago, boys often got Aspergers and girls got NLD in part because they are a bit more skilled socially. NLD is considered a learning "style" so schools don't tend to address it. It's possible to have NLD and ASD, or either as a stand alone.

Yes, he did the WPPSI. I did find it interesting that she missed a lot of questions that I know she knows the answer to. She did great on the questions that only required her to point to an answer (except she missed all of the emotion questions) but questions where she had to provide a more detailed verbal response she would say she didn't know. The spatial was odd, mainly because she did so well last time on the WPPSI. She had 130 on spatial and this time was 72.


When you say the doc went through the criteria. Do you mean he pulled out the DSM-5 and said she's got this, this and this, but doesn't make the cut in section B?

Pretty much exactly. He had a sheet with the DSM-5 cats and bullets underneath. He said most times he has parents circle what they believe applies but we would talk through it. He asked very few questions. We didn't go through it point by point. At the time I didn't believe it was going to be a diagnostic tool.

Did he not do ADOS with her? What about ARI, CARS, GADS? Both DS's dev pedi and Psychologist did both the ADOS and at least one other scale before dxing him. Dev Pedi did ADOS, GADS and ARI. Psych did ADOS and Soh.n Gr.ayson Scale for Aspergers.

No ADOS. I do not believe any other formal test was used. He did have her do things and watched for the response (maybe along the CARS guidelines?). He set out some toys, blew bubbles, had her walk on her heals, toes, and run, and climb up onto his table. The entire appointment was an hour and 15 minutes. Recently, she has been doing very well one-on-one with adults. I feel like he evaluated her good eye contact, her being engaged and responsive to him and he 'felt' that she did not have Autism.



What concerns do you hope to address through movement therapy?

She is behind in gross motor, and does not like to do things where she is off-balance - riding a bike, climbing, won't walk on a balance beam etc. The class is also through an occupational therapy place, so I thought the teachers may be able to help her engage more in the class.

[mrsbuttinski]

Feb 16, 2015 10:46:20 GMT -5 dashofreality said:

Thank you all for the responses - this is definitely a world that I have very little knowledge. And I thought the government was bad with the acronyms:) After looking into this further after having some more information, I'm even less sure on her dx now.


Yeah, I know. It makes DH crazy.

I should have the report tomorrow, so that will be interesting.


If you have any questions, a few of us have been through these.

As bubbalicious mentioned, a neuropsych closer to 6-7 might be useful if you are still concerned. At 6, there's a student form associated with BASC-2 for her input. How many BASCs went out? You and ?

I will definitely keep the neuropsych in mind. Her preschool teachers filled out a questionnaire, it didn't directly correspond to the BASC, but did have various rankings.

That's odd. Teachers scores are important because teachers generally have the context of the child in relation to peers as well as the child away from their parents.

While I like her teachers, I believe that they overlook a lot because they really like her and she is 'easy'. Every time I drop her off she stands uncomfortably off to the side, usually pulling her arms into her sleeves. Her teachers are good about acknowledging her and getting her involved, but without that she doesn't initiate. Also every time I pick her up she is either right next to the teacher or on her own. The only thing her teachers commented on was some anxiety and inability to initiate with peers.

That would be DS. He liked his teachers and camp counselors more than unruly and unpredictable kids given a choice.


Did he do a WPPSI? It's interesting that she was in the lower range of average for spatial; for many on spectrum that's a strength. But for some with NLD spatial can be an area of relative weakness. Straight up NLD can overlap ASD in symptoms. Back when DS was dxd 15 years ago, boys often got Aspergers and girls got NLD in part because they are a bit more skilled socially. NLD is considered a learning "style" so schools don't tend to address it. It's possible to have NLD and ASD, or either as a stand alone.

Yes, he did the WPPSI. I did find it interesting that she missed a lot of questions that I know she knows the answer to. She did great on the questions that only required her to point to an answer (except she missed all of the emotion questions) but questions where she had to provide a more detailed verbal response she would say she didn't know. The spatial was odd, mainly because she did so well last time on the WPPSI. She had 130 on spatial and this time was 72.

Sometimes kids trend down because they level off a bit with age as the questions get harder.

The emotional questions are a concern. These generally reflect things like Theory of Mind and Empathy- skills that are difficult for those on spectrum.


When you say the doc went through the criteria. Do you mean he pulled out the DSM-5 and said she's got this, this and this, but doesn't make the cut in section B?

Pretty much exactly. He had a sheet with the DSM-5 cats and bullets underneath. He said most times he has parents circle what they believe applies but we would talk through it.


WTF? Most parents wouldn't get the subtleties of the language used in the criteria. Until you have a child with a dx words like stereotypy, affect, echolalia, reciprocity, perseverative don't mean much.

 He asked very few questions. We didn't go through it point by point. At the time I didn't believe it was going to be a diagnostic tool.

Did he not do ADOS with her? What about ARI, CARS, GADS? Both DS's dev pedi and Psychologist did both the ADOS and at least one other scale before dxing him. Dev Pedi did ADOS, GADS and ARI. Psych did ADOS and Soh.n Gr.ayson Scale for Aspergers.

No ADOS. I do not believe any other formal test was used. He did have her do things and watched for the response (maybe along the CARS guidelines?). He set out some toys, blew bubbles, had her walk on her heals, toes, and run, and climb up onto his table.

The ADOS sometimes features "bubble play", sometimes a doll or birthday party. It's not like an exam, per se. A lot of good dev pedis can do some of these scales in such a way that it feels almost like a conversation.

www.hogrefe.co.uk/autism-diagnostic-observation-schedule-ados.html

The other stuff could be about gross motor issues and crossing the midline.

The entire appointment was an hour and 15 minutes. Recently, she has been doing very well one-on-one with adults. I feel like he evaluated her good eye contact, her being engaged and responsive to him and he 'felt' that she did not have Autism.

A good dev pedi wouldn't be fooled by a kid who is engaged with adults- it's their interaction with peers that matters. DS was always great with adults. At least until he became one.



What concerns do you hope to address through movement therapy?

She is behind in gross motor, and does not like to do things where she is off-balance - riding a bike, climbing, won't walk on a balance beam etc. The class is also through an occupational therapy place, so I thought the teachers may be able to help her engage more in the class.

I wonder if the bike and climbing is a function of crossing the midline. Can she pedal a trike? Ride a scooter?

[dashofreality]

Feb 16, 2015 12:32:29 GMT -5 mrsbuttinski said:

Feb 16, 2015 10:46:20 GMT -5 dashofreality said:

WTF? Most parents wouldn't get the subtleties of the language used in the criteria. Until you have a child with a dx words like stereotypy, affect, echolalia, reciprocity, perseverative don't mean much.

Yeah he mentioned since I was an 'educated' parent he would do it this way. I am not a MD, my JD does not help me in this regard.

The ADOS sometimes features "bubble play", sometimes a doll or birthday party. It's not like an exam, per se. A lot of good dev pedis can do some of these scales in such a way that it feels almost like a conversation.

www.hogrefe.co.uk/autism-diagnostic-observation-schedule-ados.html

The other stuff could be about gross motor issues and crossing the midline.

Outside of the bubble play, there was very little that would fit into the modules. She would be between module 2/3. There was no encouragement of imaginative play, stories, demonstrations, and the only questions he asked her were her name and birthday. While I have no doubt that he observed her actions, it wasn't a comprehensive test.

The entire appointment was an hour and 15 minutes. Recently, she has been doing very well one-on-one with adults. I feel like he evaluated her good eye contact, her being engaged and responsive to him and he 'felt' that she did not have Autism.

A good dev pedi wouldn't be fooled by a kid who is engaged with adults- it's their interaction with peers that matters. DS was always great with adults. At least until he became one.

Thanks for the confirmation. My pedi told me that she engages with him so he doesn't believe there is anything to be concerned about and that 'there have to be some kids on the low end of normal'. I was a bit taken aback when the dev pedi seemed to have the same opinion. As I stated before, at some point I start to feel like the crazy mom. I guess this is why I didn't push or question too much in this appointment.

What concerns do you hope to address through movement therapy?

She is behind in gross motor, and does not like to do things where she is off-balance - riding a bike, climbing, won't walk on a balance beam etc. The class is also through an occupational therapy place, so I thought the teachers may be able to help her engage more in the class.

I wonder if the bike and climbing is a function of crossing the midline. Can she pedal a trike? Ride a scooter?

No she isn't very good at crossing her midline. She often switches hands. We've started playing crawling animal tag and I'm trying to encourage it more. I haven't looked into what not crossing the midline means in terms of a potential dx. I just knew that it was an important skill for reading/learning. She just recently started pedaling a trike (4 yo) and only the specific ones at her preschool. She won't ride a scooter, Y bike, or big wheel. She will bounce, or ride the rowdy horse.

[macchiatto]

I hate feeling like the crazy mom but I have a lot of experience with that. I feel you on that one. I think that tends to happen when you have a higher functioning or borderline kid? Mine also tends to do well with adults, especially 1:1 with an adult who's good with kids. Watching him with peers was a totally different story (though he's come a long way since starting social skills therapy in July).

[KC thepouchh8r]

Feb 15, 2015 7:40:45 GMT -5 mrsbuttinski said:

KC thepouchh8r

Hard to say.

Unless a diagnostician can observe a child with peers in an unstructured setting, IMHO, they can't R/O ASD without ADOS.

But it's time consuming- up to an hour to work through the required modules, time to score the results and add it to the written report. It's not like a parent questionnaire that scores easily. In a lot of developmental pediatric practices, the dev pedi will have a psychologist do this portion of the assessment.

And it's expensive, the latest version with software to score it is just over $2K. You'd be surprised how often school districts avoid certain scales based on the purchase price. The Vineland, for instance is about $1200 to get started, plus $800 for scoring software and additional money for interview forms in languages other than English.

Ah yes-it's always about the money. Our ADOS wasn't performed by our developmental pedi as well. I think that worked to her advantage because she likely would have been more cooperative with an adult she had seen for a year.

[mrsbuttinski]

dashofreality Avatar
20 hours ago dashofreality said:
WTF? Most parents wouldn't get the subtleties of the language used in the criteria. Until you have a child with a dx words like stereotypy, affect, echolalia, reciprocity, perseverative don't mean much.

Yeah he mentioned since I was an 'educated' parent he would do it this way. I am not a MD, my JD does not help me in this regard.

I don't care how well educated a parent is, when it's their child they're just a mom or dad who is scared for their child and needs it spelled out with examples.

The ADOS sometimes features "bubble play", sometimes a doll or birthday party. It's not like an exam, per se. A lot of good dev pedis can do some of these scales in such a way that it feels almost like a conversation.

www.hogrefe.co.uk/autism-diagnostic-observation-schedule-ados.html

The other stuff could be about gross motor issues and crossing the midline.

Outside of the bubble play, there was very little that would fit into the modules. She would be between module 2/3. There was no encouragement of imaginative play, stories, demonstrations, and the only questions he asked her were her name and birthday. While I have no doubt that he observed her actions, it wasn't a comprehensive test.

The entire appointment was an hour and 15 minutes. Recently, she has been doing very well one-on-one with adults. I feel like he evaluated her good eye contact, her being engaged and responsive to him and he 'felt' that she did not have Autism.

A good dev pedi wouldn't be fooled by a kid who is engaged with adults- it's their interaction with peers that matters. DS was always great with adults. At least until he became one.

Thanks for the confirmation. My pedi told me that she engages with him so he doesn't believe there is anything to be concerned about and that 'there have to be some kids on the low end of normal'. I was a bit taken aback when the dev pedi seemed to have the same opinion. As I stated before, at some point I start to feel like the crazy mom. I guess this is why I didn't push or question too much in this appointment.

Trust your gut; you're not crazy. DS's PCP pedi swore to me that DS wasn't on spectrum when I asked for a referral to CHOP. He did give it to me, and he did apologize for not taking my concerns seriously.

Where did you find this person? If you decide to revisit this at some point, you might want to go elsewhere. Often pediatric teaching hospitals have comprehensive developmental clinics.

What concerns do you hope to address through movement therapy?

She is behind in gross motor, and does not like to do things where she is off-balance - riding a bike, climbing, won't walk on a balance beam etc. The class is also through an occupational therapy place, so I thought the teachers may be able to help her engage more in the class.

I wonder if the bike and climbing is a function of crossing the midline. Can she pedal a trike? Ride a scooter?

No she isn't very good at crossing her midline. She often switches hands. We've started playing crawling animal tag and I'm trying to encourage it more. I haven't looked into what not crossing the midline means in terms of a potential dx. I just knew that it was an important skill for reading/learning. She just recently started pedaling a trike (4 yo) and only the specific ones at her preschool. She won't ride a scooter, Y bike, or big wheel. She will bounce, or ride the rowdy horse.

This sounds familiar to my ear. DS was late to establish hand dominance and cross midline. He was still switching hands in first grade when tired. He'd write sometimes with his left hand on the left side of the page and then switch. He was also late to pedal a trike, about 4 1/2. Pedaling requires cross body coordination he didn't have at the same age his peers did. He also had trouble globalizing the pedal motion from a Big Wheel to the Preschool's traditional trikes which happened closer to 5.

When will your LO start kindie? You might consider asking the school district for a MFE in all areas of suspected disability in advance of that. The district will have 60 school days in which to evaluate, so it's something you'd want to be proactive around if she's starting in the fall.

[bubbalicious]

Anecdotal. DD has an excellent developmental pedi who we started with just shy of 3yo. She got her adhd dx right and gave her a developmental delay dx (in my ear) and stated dd if dd continued on this path she would have an intellectual disability (formerly known as mental retardation under the old dsm). Both the dev pedi and I agreed to pursue neuropsych testing at 4. The intellectual disability was removed from the potential diagnosis table as result. We repeated testing again at 6 and retweaked dd's medical diagnosis. DD is a presents very complex. Hard to put a label on her. We have also looked at neurogenetics to get an idea of a label that fits. (no luck there).

Where I am going...it can be difficult to get a diagnosis sometimes on the first try. I really like dd's dev pedi. She is a fantastic resource and has handled my dd's diagnosis and care with great care, consideration, thought, expertise, etc. It is more a continuum for some kids.

A great developmental pedi (mine has been invaluable) is essential. Testing is essential (data collection). Some may have a one and done as far as diagnosis and others will live in a continuum. DS is less complex but his ASD diagnosis is now up in the air. He is young and has a subtle presentation compared to dd.He may require more effort for me to advocate for educationally than dd.

You have have many areas to advocate within...Medical and Education are main areas during the early years.

[dashofreality]

Feb 17, 2015 7:19:39 GMT -5 mrsbuttinski said:

dashofreality Avatar
20 hours ago dashofreality said:


Where did you find this person? If you decide to revisit this at some point, you might want to go elsewhere. Often pediatric teaching hospitals have comprehensive developmental clinics.

Military... My husband is getting out this summer so we will have more options then.

This sounds familiar to my ear. DS was late to establish hand dominance and cross midline. He was still switching hands in first grade when tired. He'd write sometimes with his left hand on the left side of the page and then switch. He was also late to pedal a trike, about 4 1/2. Pedaling requires cross body coordination he didn't have at the same age his peers did. He also had trouble globalizing the pedal motion from a Big Wheel to the Preschool's traditional trikes which happened closer to 5.

Interesting. Very similar, except I haven't seen her write with her left hand.

When will your LO start kindie? You might consider asking the school district for a MFE in all areas of suspected disability in advance of that. The district will have 60 school days in which to evaluate, so it's something you'd want to be proactive around if she's starting in the fall.

She is a Nov. bday so she has another year until K, which I think will be a good thing for her. I will keep the MFE in mind though. You really should start charging for all of this great advice:) I really appreciate it!