Language diversity is on the rise in U. S. schools. The U.S. Census Bureau reports that in 2019, nearly 68 million people in the U.S. spoke a language other than English at home. English learners (ELs) in U.S. schools speak over 400 different languages, according to the U.S. Department of Education. Now more than ever, speech-language pathologists (SLPs) are serving linguistically diverse children and families. 

Identifying speech and language disorders, learning disabilities, and other conditions can be challenging when more than one language is involved. Speech and language disorders occur at roughly the same rates in mono- and multilingual students. But over- and under-diagnosis can happen because of the time and skill it takes to distinguish between language differences and other conditions that can affect how people speak, read, write, and process language.   

The Diagnostic Role of the SLP   

SLPs are specially trained to distinguish between language differences that stem from linguistic or cultural factors and those that are linked to health conditions and speech-language disorders. Even so, an accurate diagnosis can be difficult to formulate. Here are just a few of the reasons why: 

• Developmental patterns differ from one language to another, making it harder to recognize when a delay is happening.   

• Lots of different factors (personal, cultural, and linguistic) can interact to delay the acquisition of language.  

• Communication difficulties such as speech sound disorders may be attributed to language learning difficulties.  

• Cultural beliefs may prevent parents or caregivers from seeking a diagnosis. 

• Parents and caregivers may not be aware of available resources and services. 

Despite the challenges, the Individuals with Disability Education Act (IDEA) requires that assessments be administered in a way that doesn’t discriminate based on racial or cultural factors. The IDEA also requires practitioners to administer valid, reliable assessments in a language and form most likely to yield accurate results. 

Researchers around the world have investigated which strategies help ensure that speech and language assessments for ELs are fair and accurate. Here’s an overview of research-supported best practices.  

Research-Based Best Practices  

The body of research on multilingual language development is always growing. The strategies described below can be used along with your own clinical judgment to create a fair and culturally sensitive assessment environment. 

Start with hearing and oral function tests.  

When a multilingual child is experiencing symptoms of a speech or language disorder, it’s important to confirm whether a medical or structural condition might be at the root of a speech sound difference. For many children, hearing screenings take place in infancy and health exams follow periodically. However, some children may not have had access to these services.  

Plan the evaluation using a “converging evidence” approach. 

A converging evidence model bases a diagnostic or eligibility decision on what most of the evidence indicates, rather than relying on a single measure. The practitioner gathers information from multiple sources, including: 

• Reports of parent, practitioner, and educator concerns 
• Descriptions of a student’s communication behaviors, including pre-linguistic skills such as taking turns and displaying joint attention 
• Detailed history of a student’s language development and experience 
• History of speech or language disorders in family members 
• Information on risk factors such as hearing loss or other health conditions 
• Analysis of single-word and narrative speech samples in both of the student’s languages 
• Validated speech and language assessments appropriate for English learners (in both languages if possible)  

This approach is likely to take longer and involve more collaboration than evaluations of single-language speakers. The extra time and effort may seem like a heavy lift if your caseload is already overwhelming. But a diagnosis based on multiple measures in multiple settings is more likely to be accurate. Investing time up front will yield better information later. 

Consider culture in your case history. 

Every student has a unique background to consider. If you’re working with an EL, it’s a good idea to build a clear picture of the child’s language exposure and culture. You can ask questions such as these: 

• When was the child first exposed to each language? 
• How much of each language does the child hear or use every day? 
• In what setting did the child learn each language? 
• Who speaks each language to or with the child? 
• Which language feels more comfortable to the child? 
• Which language is the child better at using? 

In addition to building a language profile, it’s important to learn as much as you can about the family’s values, concerns, and beliefs—especially as they relate to education and health. You can ask questions like these: 

• What beliefs does the family have about child-raising? 
• How does the family view disabilities, disorders, and learning differences? 
• How does faith factor into the family’s view of healthcare and education? 
• What issues is the family most concerned about? 
• What are their priorities when it comes to interventions or treatment? 

To make the evaluation process more uplifting and positive, you may want to explore and document a child’s strengths as well as needs. This approach allows the child and parents to share a child’s capabilities and gifts. Later, you’ll be able to tap those strengths as you design intervention plans. 

Incorporate academic artifacts.  

If you’re a school-based SLP, you may already have access to some very valuable information. You may want to take a look at the student’s academic writing. You may also want to observe how the student uses language in classroom, which can give you insight into a student’s    

•       verbal and non-verbal communication,
•       response to instructions,
•       ability to ask and answer questions,
•       self-advocacy communication skills, and
•       capacity for interacting with others.

Keep in mind that academic language and content-area language skills take much longer to develop than conversational skills. Some experts think it takes as long as seven years for most English learners—and that’s if direct, explicit instruction in academic language has taken place. 

Adopt a dynamic assessment model. 

Some researchers recommend a pretest-teach-retest strategy known as dynamic assessment (Castilla-Earls et al., 2020). This method allows you to set a baseline and track a student’s response to instruction (RTI).  

Evaluating the RTI can help you decide whether a student has a language difference or a language disorder. Dynamic assessment can also help you determine how much support a student needs to improve their skills. 

Consider including language sample analysis in the evaluation.

Language sample analysis may not be ideal in every evaluation, but it is considered by some researchers to be a “naturalistic and unbiased indicator of linguistic development in preschool-age bilingual children” (Gulberson, 2020).

Transcribing language samples and analyzing them can be time-consuming, and it’s best carried out by bilingual SLPs. Despite these obstacles, it can be a useful tool in a comprehensive evaluation. Many SLPs develop their own methods of gathering samples during their interactions with a child (Gulberson, 2020).

Some practitioners prefer to ask someone who knows the language to take the test. A recording of that individual’s test responses can be compared to the student’s test results (McLeod et al., 2017). A family member who speaks the child’s language might be a good option for this task. You can separately record both the child and family member producing single words, then compare the two productions. A family member may even be able to help you identify which of the child’s sound productions is correct.  

Boost your transcription skills.  

The International Expert Panel on Multilingual Children’s Speech recommends that SLPs participate in training in the International Phonetic Alphabet and its extensions. If you regularly work with multilingual students, you may already feel comfortable with phonetic and phonemic transcribing. If you’re building skill in this area, you may want to explore resources to help you extend your knowledge of the articulation of sounds in languages around the world.   

The International Phonetic Association has created charts that link speech sounds to symbols. The University of Glasgow’s Seeing Speech site offers animations that show exactly how sounds are produced.   

Choose assessments with age, grade, culture, and development in mind. 

Before you choose a test, review the vocabulary test items and images to be sure they are a good match for the experience level of the child you’re evaluating. If you’re not sure whether a test is appropriate, you may want to speak with one of the publisher’s Assessment Consultants, who can guide you to tools that suit the child’s needs.  

Many assessments have been accurately translated into languages other than English by trained assessment translators. It is not usually a good idea to try and adapt a test to another language on your own.  

Include non-word repetition tasks.  

Phonological processing can be tested with non-word repetition tasks. Asking students to repeat non-word sounds can be an effective way to distinguish between those who have speech or language conditions and those who are typically developing language learners, studies show (Schwob et al., 2020). Varying the complexity of the non-word sounds and including sound patterns that are not similar to words can be especially useful (Taha et al., 2021).  

Assess morphosyntax as an indicator. 

Some practitioners find a “disorder within diversity” approach useful in evaluating speech and language disorders among English language learners (Oetter, 2018). One of the promising methods often used with this framework is morphosyntax assessment. 

Studies suggest that morphological markers may differ in bilingual students with language disorders. Researchers have found that clitics and verbs are particularly useful in distinguishing between Spanish-speaking students with and without developmental language disorder (Castilla-Earls et al., 2020; Jacobson et al., 2019). Verb error patterns have also been linked to phonological impairment in dual language speakers (Hasselaar et al., 2020).  

Collaborate with an experienced interpreter.

A trained, experienced interpreter can assist objectively with an assessment, but it’s a good practice to train the interpreter before the test date. The interpreter should understand the goals and purpose of the assessment. They should also have a basic understanding of language development and language disorders, experts say (McLeod et al., 2017). 

One of the benefits of working with interpreters is that they may be able to provide cultural insights that help you better serve the student and family. An interpreter can also report on intelligibility and may be able to share how a student compares with other children the same age (Jasso & Potratz, 2020).  

Include validated, reliable standardized assessments appropriate for the child. 

Normed speech and language assessments can provide you with valuable insights about a student’s English proficiency, as well as their speech and language skills. They can illuminate a student’s strengths and areas where they need extra support. That information is vital when planning interventions, writing individual education plans (IEP), and monitoring progress.  

With ELs, standardized test scores should not be the sole factor you consider when making diagnostic decisions. Even so, test results can prompt important questions about where and why deficits exist. It's always up to you, as an SLP, to use your clinical skills and professional judgment as to which measures to use, how to adapt them, and how to interpret the scores.

WPS is pleased to offer trusted assessments to help you elevate your speech-language assessment of English learners.  

Tools and Resources  

Numerous online resources have been developed to help SLPs serve English learners and their families. Here are a few to consider. 

Phonemic Inventories

To understand how the speech sounds inherent in one language can influence the way sounds are produced in another language, you may want to learn more about the phonemic system of your student’s first language. ASHA’s phonemic inventories can be a good starting place.  

These inventories can help you identify sounds unique to each language, along with those that are common to both languages. This database also provides insights into cultural considerations for speakers of each language.  

Intelligibility in Context Scale

The International Expert Panel on Multilingual Children’s Speech provides an easy-to-complete family questionnaire that measures a child’s intelligibility in the home language. It can be used to gather information about speech sound disorders and childhood apraxia of speech. 

The Intelligibility in Context Scale is available in many languages and has both monolingual and bilingual formats.  

Cross-Linguistic Phonology Project

The University of British Columbia’s School of Audiology and Speech Sciences offers a variety of phonological development tools in its Cross-Linguistic Phonology Project. Transcription resources are available in English, French, Spanish, and Mandarin. The site also offers word lists and phonology tests in 14 languages.  

WPS Assessment Consultants

Choosing the right tests for English learners can be a challenge. WPS Assessment Consultants are experienced speech-language pathologists, school psychologists, occupational therapists, and educators who understand the complexities of assessment. We stand ready to help you evaluate your options and choose the best assessment for the child in your care—and we’re available to train and support you as you move through the assessment process. 

Key Messages  

Each English learner is unique—with particular physical and mental characteristics, a distinctive language history, and a singular pattern of speech and language capabilities. Speech-language pathologists are specially positioned to diagnose and plan interventions for English learners with differences, delays, or disorders. 

To do so effectively, SLPs must maintain cultural sensitivity, assess in multiple languages when possible, collaborate with native speakers, and base decisions on a wide variety of information sources.  

Further Reading: 

•  The WPS In-Depth Guide to Reading Assessment 

• WPS Dyslexia Assessment Tool Kit

• Infographic: Types of Phonological Processes 

Videos:

• Unraveling the Complexities of Pragmatics 
• Evaluating Spoken Language Skills with CASL®-2 
• Unlocking Potential: WPS & SLPs 

Assessing Dyslexia: The Importance of Testing Executive Functioning Skills

Executive function and dyslexia may be as intertwined as Scarborough’s celebrated reading rope. While not every student with dyslexia has executive dysfunction, some studies suggest the two co-occur 40% to 50% of the time. Understanding how executive dysfunction affects students with dyslexia can help you target instruction and interventions where they’ll do the most good.  

How Does Executive Function Enable Reading?  

Executive function is a cluster of cognitive skills that, together, enable people to monitor and control their attention and behavior as they work toward goals. Researchers usually include these skills when they’re discussing executive function: 

• visual and verbal working memory (storing and processing the information you need to complete a task) 
• set shifting (moving flexibly from task to task) 
• response inhibition (starting and stopping activities) 

When young children are learning to read, working memory helps them store, process, and update phonological information. Working memory is active as students map each grapheme to a phoneme. It helps them to hold onto each sound as the next is processed and added. As children become more automatic readers, working memory can be tapped for higher-level reading comprehension tasks (Morris et al., 2022). 

Set shifting plays a role in decoding as students move their attention from one sound unit or word part to the next to make sense of a word. Similarly, set-shifting allows students to move from one word to the next in a sentence—and ultimately from one idea to the next, building meaning. 

Students use response inhibition skills to direct their attention to the visual information that matters, disregarding information that doesn’t. Response inhibition helps them to focus on pairing letters and sounds and to resist the urge to guess when words or letters look alike. Students also need to resist the urge to guess based on context (De Rom et al., 2023). Inhibition skills are, for that reason, involved in reading accurately. 

These executive functions work together. As one study described it, “successful word recognition results from the ability to process, integrate, and inhibit multiple features of words during word reading” (Spencer & Cutting, 2020). 

How Does Executive Dysfunction Affect Reading for Students With Dyslexia?   

Dyslexia can interfere with all of these executive functions. When executive function skills are delayed, it can create difficulties with every aspect of reading, from language processing to decoding to comprehension.  

Here’s a quick look at how executive dysfunction can affect reading in people with dyslexia: 

Word Reading  

Several studies have linked executive dysfunction to word-reading difficulties (Halverson et al., 2021). Working memory deficits can make it harder for struggling readers to remember phonemes in complicated or irregular words. Set-shifting and inhibition deficits can also hinder a reader’s ability to ignore distractions and irrelevant information, whether in their surroundings or in texts. 

Fluency and Automaticity 

In a 2022 study, researchers measured executive function and reading abilities in students with dyslexia, some of whom also had ADHD. On tests that involved timed measures of reading and naming fluency, lower executive function scores were linked to lower scores on reading fluency. Reading accuracy didn’t seem to be affected by executive dysfunction (Al Dahhan et al., 2022). 

Comprehension 

When reading doesn’t become automatic, students may have to focus more of their executive function resources on decoding words. Some researchers think that could leave fewer resources for more demanding processes like comprehension. In other words, students may be so absorbed in reading words that they are less attuned to the meaning of texts. They may also be less focused on strategies to improve comprehension, such as reading titles or summarizing. 

What Could This Mean for Interventions?  

For children with dyslexia, the chief intervention is systematic, explicit reading instruction. Still, there is some evidence that training executive function may have an indirect impact on reading skills.  

Research suggests that it’s more effective to teach reading skills while supporting students’ executive functioning (Cirino et al., 2019). In one study, researchers emphasized the priority of evidence-based reading instruction, saying “children first need to form a solid basis in decoding in order to free up cognitive resources needed for executive functioning” (Nouwens et al., 2021).  

There are many activities that can support executive function: 

• Use reading exercises that involve orthographic neighbors (words that look alike) to encourage students to slow down for more accurate decoding (DeRom et al., 2023). 
• Teach analytical decoding skills to reduce guessing errors (DeRom et al., 2023). 
• Simplify instructions in teaching materials to lower the load on working memory. 
• Break learning goals and projects into smaller steps. 
• Help students predict obstacles that could keep them from completing projects, and plan ways to deal with obstacles (International Dyslexia Association, 2018). 
• Develop personalized checklists to aid self-monitoring during academic tasks (International Dyslexia Association, 2018). 
• Teach specific strategies to strengthen memory and improve comprehension, such as rehearsing information out loud (Peng & Fuchs, 2017). 
• Provide action video games that have been shown to improve attention control and enhance phonological processing speed in students with dyslexia (Bertoni et al., 2021). 

Key Messages  

There’s solid evidence that assessing executive function can help you predict which students are likely to develop reading problems down the road (Halverson et al., 2021). Because executive dysfunction can interfere with word reading, fluency, and comprehension, it may also be helpful to add executive function supports to supplement evidence-based reading instruction for students with dyslexia. 

Learn more: The WPS In-Depth Guide to Dyslexia Assessment 

Helpful Assessments: 

• Tests of Dyslexia (TOD®) 

Further Reading: 

• The WPS In-Depth Guide to Reading Assessments 
• Dyslexia Symptoms to Look for When Testing at Different Stages 
• Strategies to Improve Word Reading Skill in Struggling Readers 

For the first time, recent data from the Centers for Disease Control and Prevention (CDC) show autism in girls at a prevalence rate higher than 1%. While the CDC says autism is around 4 times as common in boys as in girls, many researchers think the diagnostic gap between the sexes is wider than it should be. The gap suggests that many girls and women don’t get the support they need to navigate the world. 

A 2021 research review identified several factors that present challenges in evaluating girls and women for autism (Estrin et al., 2021). As you review the findings, it’s important to note that 

• findings sometimes conflicted across studies; 
• the samples in many of the studies involved a greater number of boys than girls; and 
• more research needs to be done to clarify understanding. 

Here’s what research tells us about the barriers to timely, accurate diagnosis. 

“Gendered symptoms” make it harder to identify autism in girls.

Researchers point out that, for autism to be identified, girls often need to experience more pronounced autistic traits, another disorder or health condition, or greater difficulties with language.    

Behavior Difficulties  

In studies, girls who had been diagnosed with autism often also had conditions like these: 

• staring or seizure-like symptoms 
• hyperactivity 
• low IQ or intellectual disability 
• toileting or temper difficulties 
• eating difficulties  

Researchers said an autism diagnosis was more likely in cases where girls had a co-occurring behavioral condition.  

Social Communication Patterns 

Social communication has many facets. In autistic and in neurotypical people, trouble with one area doesn’t necessarily mean trouble in others. Generally, this skill set includes a person’s ability to  

• explain what an emotion feels like physically and mentally; 
• talk about times when they feel a certain emotion; 
• identify when someone is feeling a particular emotion, even if it doesn’t show in facial expressions; and 
• predict the impact someone’s emotions might have on other people or on their actions. 

Every autistic girl has a unique array of abilities. Some autistic girls may seem to have ample emotional and social skills. When researchers observed playground social settings, for example, they noted that autistic girls socialized in groups—while autistic boys played alone or were engaged in “structured activities.” On closer study, however, researchers noticed that autistic girls were often “fringe members of female social groups.” The social situations may have given girls a chance to study interactions for the purpose of camouflaging (Mattern et al., 2023).  

When Mattern et al. compared autistic boys to autistic girls, they noted that girls scored significantly higher on two specific social skills: social cognition and understanding social causality. Social cognition refers to a set of abilities that allow us to detect, interpret, mirror, and respond to emotional signals from people around us. In this study, social causality referred to the ability to describe emotional reactions to past events and explain how behaviors affected other people.  

In studies that analyzed brain images in a resting state, researchers found some differences in brain networks between autistic and neurotypical girls. The brain networks that were reliably different were those related to emotion regulation and anxiety.

When imaging studies showed differences between autistic and neurotypical boys, on the other hand, the differences were related to person perception and social perception. Those traits look more like the diagnostic criteria for autism. Researchers suggested that since the brain networks underlying symptoms may differ between sexes, interventions for girls might be more beneficial if they focused on emotion regulation and anxiety (Pelphrey et al., 2017).

Language Development 

Overall, studies show that autistic girls without intellectual disability often have better-developed vocabulary and core language skills than autistic boys of similar age. Since delayed language development can prompt parents to seek an autism evaluation, some researchers worry that more advanced language skills could delay diagnosis (Ratto et al., 2018). 

Girls diagnosed with autism at an early age tend to have lower scores on measures of cognitive language ability, studies show. When autistic girls have higher language skills, they are often diagnosed with autism at a later age (Estrin et al., 2021). 

Researchers say these findings seem to support the idea that girls are more likely to receive an autism diagnosis if there is a co-occurring problem. 

Circumscribed Interests and Repetitive Behaviors 

These traits are important for meeting the threshold for an autism diagnosis. Yet the patterns of interests and repetitive behaviors sometimes differs across sexes. Several studies have concluded that autistic girls have fewer circumscribed interests and repetitive behaviors than autistic boys typically do.  

Some researchers have suggested that the difference may be owing to different phenotypes in boys and girls. Others say that girls’ interests may not be as apparent because they may look more like the interests of typically developing girls, such as animals, celebrities, or popular bands (Tillmann et al., 2018). The difference may not be what interests an autistic girl, but the intensity of that interest.

Parents may be more concerned about repetitive behaviors in boys than they are in girls (Estrin et al., 2021). When that is the case, autism diagnoses may be delayed. 

Camouflage and other factors also expand the gap.

Compensatory behaviors, bias, and the lack of information about autism in girls and women may also be widening the diagnostic gap between sexes.

Compensatory Behaviors   

People of all backgrounds adapt their behavior to different social situations. For autistic people, the practice of hiding autistic traits and mirroring neurotypical behaviors takes enormous energy. And when compensatory strategies are skillful, they may interfere with an accurate diagnosis. They can also make it appear that girls are less impaired or need less support.  

There’s some evidence that autistic girls may be more inclined than autistic boys to use compensatory behaviors. For example, girls in one study used gestures energetically during an autism assessment. Using fewer gestures, especially gestures to signal joint attention, is considered an autistic trait, and some autism assessments measure gesture use. For that reason, the study’s authors worried that the girls’ emphatic use of gestures might lead to a lower score and less chance of a diagnosis (Estrin et al., 2021). 

There’s also evidence that camouflaging works well in childhood, but not as well in teen years. When social communication becomes more nuanced in the teen years, compensatory strategies might not keep up with new demands. One autistic adult, looking back on her transition to secondary school, said, “Suddenly, they all just seemed weird…just a whole different set of…principles, standards or morals” (Kanfiszer et al., 2017).   

One parent observed, “We noticed the divergence between friendship at primary…to secondary…it was like her typically developing peers blossomed…. And girls’ behavior becomes very nuanced, doesn’t it? It can be just a look…and she can’t read that” (Halsall et al., 2021).   

“A Boy’s Disorder”     

People’s perceptions influence referrals, evaluations, and diagnoses. Some parents, educators, and practitioners still consider autism a male condition. This perception may be based on research that proposed a “female protective effect”—the idea that simply being female lessens the risk of developing autism. Some studies do suggest that it may take a greater number of risk factors for a girl to develop autism, but the evidence is mixed and doesn’t fully explain the diagnostic gap (Doughtery et al., 2022).

If parents think of autism as “a boy’s disorder,” they may be less likely to pick up on autistic traits. In a 2017 study, one parent said, “I didn’t listen to her. She would just say how she hated school and how she hated visiting my parents and how loud everything is.…I forced her to do all those things. I arranged play dates for her and forced her to go and of course it just made things worse. It was a total failure” (Navot et al., 2017).

When parents do seek evaluations, clinicians may take a “wait and see” approach that can delay identification for years. One parent reported, “I kept asking to have her evaluated, but with her being a girl, it was even less likely that the pediatrician would refer us. I remember her saying that this is usually a boys’ thing, and she is only a little different” (Navot et al., 2017). 

Competing Diagnoses     

Autistic girls and women often have other health conditions that can complicate the identification process. Studies show that the chances of having a co-occurring condition are higher for girls—and that co-occurring conditions affect the age at which autism will be identified. Researchers think having a co-occurring condition improves the odds that a girl will receive an autism diagnosis (Rødgaard et al., 2021).  

Some of the more common co-occurring conditions are  

• ADHD 
• mood disorders such as depression 
• anxiety disorders 
• conduct disorder 
• eating disorders 
• sleep disorders 
• intellectual disability 
• obsessive-compulsive disorder 

It’s often the case that the co-occurring condition is diagnosed first, followed by a later autism identification. 

Learn more: Lived Experiences—Autistic Girls & Women

Key Messages   

Autism in girls and women is often overlooked or misdiagnosed. That may be because another condition is easier to recognize, or because autistic traits can look different in girls and women. Compensatory behaviors, bias, and misinformation can also shape the diagnostic process.  

It’s important to be aware of these barriers because early identification and support are critical for the long-term health and well-being of autistic girls and women. Everything we know about intervention indicates that outcomes are better for everyone the earlier they begin.  

If you’d like to learn more about assessments and interventions for autism, WPS Assessment Consultants are available to support you.  

Further Reading on Autism     

• The WPS In-Depth Guide to Autism and ADHD   
• How Does Autism Present Across the Lifespan? 
• Understanding the Complicated Interplay of Autism and ADHD  
• How Autism and ADHD Can Disrupt Interoception  
• How to Choose the Best Autism Assessment for Your Client  
• Best Practices in Autism Assessment  
• Autism Conversations: Individualizing Educational Interventions with the MIGDAS-2 Evaluation Process  

Videos and Webinars on Autism    

• How Cyberbullying Impacts Students On and Off the Autism Spectrum  
• Conversation Over Labels: A Better Way to Understand Autism  
• Autism Spectrum Brains 'Get Energy' from These Things

Despite the clarity of diagnostic criteria, identifying depression in teens isn’t always straightforward. At every age, depression can look different from person to person, with some people experiencing emotional symptoms and others having more physical ones.  

As an added complication, depression can interfere with people’s thinking, so they may not be fully aware of their symptoms or may have trouble finding the right words to describe them.  

For lots of adolescents, there is yet another layer.  Many have a hard time trusting adults with their thoughts and feelings. For some, the desire for privacy involves actively hiding what they’re going through.  

Melody M. Ott, LCSW and her colleagues at Wellbeing Counseling & Wellness are skilled in interpreting the signs of depression in teens and young adults. Here are a few of their top recommendations. 

Look Past the Cheery Exterior 

“We often see kids that look as happy as can be on the outside, especially when they’re with their friends,” Ott explains. “But deep down, it’s a totally different story. We see this pattern a lot with high achievers—the kids who have good grades and are in five clubs and play sports. On the outside, things look great. But they tell you, ‘I think about killing myself every day.’” 

Anxiety often rides along with this kind of depression, Ott says. It’s not uncommon to see substance use, too, because teens may be trying to relieve the anxiety by self-medicating. It can be tricky to diagnose without knowing which questions to ask, or without an instrument that guides you through the right questions. 

Pay Attention to the Doom-Colored Glasses

“Another thing we notice is kids who see the whole world through a pretty hopeless lens,” she says.  

Negative interpretation biases, as these thought patterns are sometimes called, can create a self-reinforcing cycle in teens with depression. In a 2020 study involving 122 children and teens ages 9 to 14, researchers presented a series of 10 situations which could be interpreted positively or negatively. Young people diagnosed with major depression disorder interpreted the events in a more negative way than those who did not have depression (Sfärlea et al., 2020).  

“Kids with depression can have a hyperfocus on things that are negative, almost as though they have a metal detector on the beach that only finds the rusty nail, and not the ring,” Ott points out. The tendency toward negative interpretations can amplify sadness and a sense of hopelessness, which may deepen the depression over time. 

Check on Teens with Big Feelings 

Persistent sadness, hopelessness, and guilt are aspects of the diagnostic criteria for depression. But powerful emotions of all types can be an indication of vulnerability to depression. Ott describes teens like these as “the big feelers.” Their acute sensitivity can often be at odds with family dynamics, especially when caregivers, parents, and educators emphasize emotional control or repression.  

“Some kids are highly sensitive to criticism, rejection, and failure—and that can drive depression,” she notes. “Another thing we see is really big mood swings. This can be confusing to parents, who may be worrying that their child could have bipolar disorder, which isn’t usually the case.” 

When teens are used to big emotions, they may start to confuse contentment and numbness. “They’re so used to highs and lows that contentment looks like a little blip on the radar,” she says. “They’re not used to a normal range of emotion.” 

Ask About Anger and Control    

For some teens, a lack of agency can lead to depression. “So many feel like they don’t have any control over any part of their lives. These kids can easily become combative with their families,” Ott says. “It’s kind of like they’re desperately grasping for any kind of control. The message is, ‘I’m hurting.’ So they light their emergency flare.” 

Researchers have identified conflicted anger as a central part of adolescent depression. They describe it as “anger, blame, and envy directed toward others that lead to disruptions in interpersonal relationships, confusion over responsibility, and self-directed anger…and depressive affects” (Henriksen et al., 2021).  

For that reason, when an angry teen walks through the door, Ott says it’s time to start checking for depression.  

Find Out About Academic Ups and Downs  

“A lot of the time, what brings kids to us is that they start doing really poorly in school. Maybe they’ve always had a little trouble with their grades, so the change is small. But more often, there’s a big change. And big changes get more attention,” explains Ott.  

Parents often notice a change in motivation, which can look like laziness or boredom. Underlying that loss of motivation, other symptoms of depression may be hard at work.  

“Not only can kids stop caring about school, they don’t care about the effects of bad grades,” she says. For that reason, disciplinary measures such as “grounding” students or taking away privileges and possessions may not inspire change or correct depression-related behaviors. “By the time I see some kids, they have nothing left but a mattress on the floor because they’re being punished for something they really cannot control.”

Notice When Someone Is Suddenly Solo     

Researchers have identified social isolation as a factor in the development and persistence of depression among adolescents.  

In a 2022 review of 12 studies, researchers found a strong association between depression, anxiety, and social isolation in children and teens. Depression was also linked to lower scores on tests involving verbal comprehension, poorer school performance, and decreased ability to learn new skills such as reading and writing (Almeida et al., 2022). 

“Isolating can look like a kid playing a lot of video games or becoming addicted to their various social media platforms,” Ott says. “They’re not really getting the kind of social connection they need in those settings, even though it might look like they are.” 

Key Messages    

Rates of depression are growing among adolescents. This trend can be frightening for teens and parents—and overwhelming for clinicians and educators responsible for evaluating the condition in teens. Knowing how depression shows up day to day can help practitioners evaluate with greater confidence and target interventions to individual areas of need.  

Look for signs like these when you’re assessing for depression: 

• superficial happiness with hidden sadness  
• perfectionism 
• hyperfocus on negativity 
• conflicted anger 
• emotional peaks and valleys 
• academic fluctuations 
• lack of agency and motivation 
• social isolation  

Speaking to clinicians and educators, Ott offers one other piece of advice: “We all need to be talking to each other about what we’re seeing out there,” she urges. “Nothing gets better until we all share what we know.” 

If you’d like to speak with a WPS Assessment Consultant about mental health, achievement, and adaptive functioning assessments, we’re here for you. Or if you’d like to share your expertise with WPS, reach out to our Marketing team about opportunities to contribute to the WPS Blog.  

Every person’s development unfolds in a unique way. In autistic people, some aspects of development differ from neurotypical patterns—but the differences vary from person to person. Some of those differences remain constant across the life span. Others change. 

Researchers at the University of California, Davis looked at how the brain changes in autistic individuals over the course of a lifetime. They identified close to 200 gene differences between autistic and neurotypical individuals. Some of those genes were linked to differences in the brain’s immune response, inflammation, and neural connectivity—all of which can affect how a person changes with age (Zhang et al., 2023). 

Here's a brief look at how autism traits can evolve as people mature. 

How Autism Can Look and Feel in Early Childhood 

As clinicians and educators, you are likely familiar with the diagnostic criteria for autism. The Centers for Disease Control and Prevention (CDC) notes that delays or differences in developmental milestones may be present in autistic infants and toddlers. Here are some indicators:  

• avoids eye contact 
• doesn’t respond to name or show emotion in facial expressions (by 9 months) 
• doesn’t play interactive games or use a variety of gestures (by 1 year) 
• doesn’t share interests or attention with others (by 15 months) 
• doesn’t seem to notice when someone else is hurt or upset (by 2 years) 
• doesn’t seem to notice or want to interact with other children (by 3 years) 
• doesn’t use imaginative or imitative play (by 4 years) 
• has strongly preferred interests  
• repeats certain words or phrases (a behavior sometimes called echolalia) 
• prefers a predictable order for events, activities, and objects 
• prefers to follow routines exactly or carefully 
• moves in ways that are not neurotypical (spinning, stimming, hand flapping) 
• responds to sensory stimulation in ways that are neurodiverse 

Every autistic child won’t have all these characteristics (CDC, 2022). How autism presents can also be shaped by co-occurring language differences and intellectual disabilities. 

Download the infographic: Early Childhood Development and Beyond 

Other Considerations for Young Children 

As you evaluate each child, it’s important to keep these factors in mind.  

“Motherese” as a Clue 

A study published in 2023 found that autistic toddlers between the ages of 1 and 2 years were less attentive than neurotypical toddlers to “motherese”—a voice tone mothers often use with very young children. Researchers tracked eye movements to measure children’s attention. Autistic toddlers who focused more on motherese tended to have more developed social and language abilities, researchers said (Pierce et al., 2023).  

Age at Identification 

Universal autism screening aims to identify autism in infants and toddlers so behavioral interventions can begin at a young age. Early interventions have been linked to better outcomes. In at least one study, researchers found that toddlers diagnosed between 25 and 41 months had greater developmental delays in several key areas than those diagnosed between 12 and 18 months (Miller et al., 2021).  

Learn more about the autism assessment called "the gold standard." 

How Autism Can Look and Feel in Childhood  

Traits that emerge in the toddler years may continue during later childhood. For some people, new behaviors, experiences, or co-occurring conditions may develop as school interactions present new challenges. For example, autistic students may 

• have a hard time interpreting social cues with friends, 
• take the lead in determining what to talk about in conversation, 
• speak in literal or concrete terms and have trouble understanding figurative language, 
• have some trouble with complex sets of instructions, and 
• become overwhelmed with the stimuli and social demands in classroom settings. 

Learn more about assessing social communication and pragmatic language. 

Data shows the following: 

• Nearly 40% of autistic children have an anxiety disorder which may be related to autism characteristics or to another co-occurring health condition (Lai et al., 2022). 
• Close to 35% also have attention-deficit/hyperactivity disorder (ADHD; Brown et al., 2021). 
• Approximately 27% have sleep disorders (Mutluer et al., 2022). 

• Gastrointestinal problems such as diarrhea, constipation, and feeding problems are much more common among autistic children than in the wider population (Krigsman & Walker, 2021) 

Read about the complex interplay between autism and ADHD. 

How Autism Can Look and Feel in Adolescence   

The core features of autism are the same in teens as they are in children. Even so, as social relationships become more important and puberty places new demands on the mind and body, core features may intensify. Experts say autistic teens may 

• have fewer of the challenging behaviors common among young children;  
• be more likely to have depression than typically developing teens, which can erode self-care, intensify inflexibility, and affect preferred interests (Pezzimenti et al., 2020); 
• behave in ways that put their health at risk (including violence, unprotected sex, self-injury, and unhealthy eating or exercise habits) especially when they feel uncomfortable or unhappy at school or they’re experiencing depression (Sun et al., 2021); and 
• be more likely to experience gender dysphoria or to be gender diverse or transgender (Cooper et al., 2022). 

Challenges to Understand 

As you work with autistic teens, be aware of these potential challenges: 

• When an autistic teen also has intellectual disability, it can increase the likelihood of aggression, weight changes, bathroom accidents, and self-injury (Pezzimenti et al., 2020). 
• Depression symptoms and certain autism traits can overlap. Both can increase irritability, withdrawal, and negative rumination. Both are linked to less emotional facial expression and to executive dysfunction. 
• There’s some evidence that eating disorders such as anorexia and binge eating are more common among autistic individuals (Numata et al., 2021). 

• Some autistic students reported that the biggest challenges of university included the constant pressure to socialize, the tendency to study one subject to the exclusion of others, understanding academic expectations, and sensory overload (Gurbuz et al., 2019).  

Discover assessments to help you identify depression and anxiety in children and teens. 

How Autism Can Look and Feel in Adulthood    

Increasingly, autism is being identified in adults. Whether it’s identified in childhood or in adulthood, autism can present new physical, adaptive, and mental health challenges as people work and live in neurotypically oriented environments.  

The CDC reports that the adult years often carry these additional concerns for autistic people: 

• unemployment or underemployment 
• limited post high school education 
• continued living with family members 
• less opportunity to spend time with friends or in social/community engagement 

When autistic adults have difficulty with employment, it may be related to problems managing, interpreting, or responding to emotions and social situations. These difficulties can also make personal relationships more challenging. Difficulties may exist, in part, because it can be so hard for autistic adults to access mental health services, allied health services, and healthcare transition services (Maddox et al., 2021). 

Areas for Ongoing Support 

Autistic adults may also need extra support in these areas: 

• In adulthood, many autistic people—especially those who don’t have intellectual or language disabilities—learn to suppress repetitive behaviors in social situations. Adapting to neurotypical expectations can cause extra anxiety and even exhaustion. On the plus side, many autistic adults can leverage their preferred interests in their education, hobby, and career choices (Goldstein, 2019).  

• For those assigned female at birth, autism has been linked to a greater risk of endocrine dysfunction, including conditions such as polycystic ovary syndrome, premenstrual syndrome, and some reproductive cancers (Simantov et al., 2022). 

• In early adulthood (20–39 years) and middle adulthood (40–59), sleep may continue to be a problem, especially for people who take certain medications or who have mental health conditions (Joveveska et al., 2020). 

The Role of Camouflage in How Autism Presents     

Camouflaging is a set of skills that enable autistic individuals to appear more neurotypical in social settings. Those skills are usually categorized as 

• assimilation (strategies that help people fit into social environments); 
• compensation (strategies that help people learn and use social behaviors); and 
• masking (strategies that help people hide traits or behaviors). 

People of all backgrounds and identities camouflage from time to time. In one 2022 study, however, researchers found that autistic females tended to score higher on self-report scales measuring all three camouflaging skills. In that study, gender diverse autistic people had higher scores on the compensation subtest. Those diagnosed with autism as adults showed more assimilation and compensation behaviors (McQuaid et al., 2022).  

While camouflaging has perceived benefits, it also has costs. Children, teens, and adults can experience autism burnout, fatigue, and other mental health consequences because of the pressure to adapt to neurotypical expectations in their environments. And camouflaging can be so skillful that it keeps autism from being identified.  

Explore autism assessment best practices here. 

Key Messages    

Autism characteristics and behaviors can change as people mature. While some or all core features of autism may remain present from early childhood onward, the degree of impairment or the outward appearance of some traits and behaviors may change. Understanding how and when these changes may occur can be helpful to those who support autistic individuals. 

AUTISM RESOURCES  

Further Reading on Autism 

• The WPS In-Depth Guide to Autism and ADHD  
• Why So Many Autistic Girls & Women Are Still Missing Out on Early Identification 
• Understanding the Complicated Interplay of Autism and ADHD 
• How Autism and ADHD Can Disrupt Interoception 
• How to Choose the Best Autism Assessment for Your Client 
• Best Practices in Autism Assessment 
• Autism Conversations: Individualizing Educational Interventions with the MIGDAS-2 Evaluation Process 

Videos and Webinars on Autism 

• How Cyberbullying Impacts Students On and Off the Autism Spectrum 
• Conversation Over Labels: A Better Way to Understand Autism 
• Autism Spectrum Brains 'Get Energy' from These Things 

Lived Experiences: How to Recognize ADHD in Girls and Women

The girl who daydreams. The one who can’t find her keys or her homework or her phone. The one who totals her car every 2 years. The one who burns through friends because she blurts out secrets and shows all the feelings. These people aren’t simply stereotypes. They could be girls and women with attention-deficit/hyperactivity disorder (ADHD)—flying under the diagnostic radar.   

Why ADHD in Girls and Women May Go Undiagnosed 

ADHD is complex, and its core symptoms are expressed in individual patterns. Here’s a brief look at why those patterns may be harder to recognize in women and girls.   

ADHD in Girls and Women Is Understudied 

For many years, including the years when diagnostic criteria were initially developed, what researchers knew about ADHD was based on studies involving boys, most of whom were White. Studies often involved populations already diagnosed with ADHD. Since so many more boys had been diagnosed, researchers were seeing how boys experienced the condition.  

More and more researchers are studying the symptoms and effects of ADHD in girls and women today. That means we are getting a clearer picture of what ADHD looks like across different populations. 

ADHD Symptoms Can Present Differently in Girls and Women  

Numerous studies have confirmed that girls and women are more likely to experience inattention than hyperactivity/impulsivity. Inattention may not be disruptive enough to prompt a referral for evaluation. In one recent study involving teachers in New South Wales, teachers had generally positive views of students with ADHD but found externalizing behaviors “irritating” (Mulholland et al., 2023).  

“Generally, if girls are hyperactive, they might not necessarily be tumbling around the room or fighting,” Dr. Rupert points out. “Impulsivity might show up as answering a question the teacher asked without raising their hand, or talking out of turn, or being impatient. These are not things that are going to get them sent to the office.” 

Symptoms like these can look like personality differences. For Black and Brown girls, symptoms are often misinterpreted as loudness, defiance, or a behavior disorder (Fadus et al., 2020).  

“When Black and Brown girls are having issues in school, people might think, ‘Oh, they’re from a broken home,’ or ‘Their parents don’t care about their grades,’” Dr. Rupert says. Assumptions and biases like these can lead to inequities in diagnosis. “Students may be seen for behavior issues, but people may not be looking for the reason behind the behavior,” she explains.  

How to Build Your Ability to Spot ADHD in Girls and Women   

As more research becomes available, practitioners are getting better at detecting the signs in girls and women. Here are a few expert recommendations to help sharpen your symptom-spotting skills. 

Look closely for clues in academic performance.   

Students with ADHD can have lower scores on reading and math achievement tests, lower overall grades, and higher chances of being placed in special education classes (Jangmo et al., 2020). Yet ADHD has a normal distribution pattern across a range of intellectual abilities.   

Fabio et al. (2022) think ADHD can affect learning in these ways: 

• Difficulties with self-control and inattention may keep students from building learning skills. 
• ADHD symptoms may interfere with a student’s ability to apply what they’ve learned. 
• ADHD symptoms may prevent students from using efficient test-taking skills.  

Executive function skills or even handwriting could be clues that ADHD is behind academic inconsistency (Eng et al., 2023).  

“I would get papers returned to me ungraded because a teacher couldn’t read my handwriting,” Dr. Rupert recalls. “Even when I had an A or B on a test, when I’d go back through and read the questions, I’d see that I missed questions I absolutely knew the answers to—but I hadn’t finished reading the question. So I would have had a higher grade had I been able to focus and pay attention.” 

Watch for changes during life transitions.    

ADHD symptoms don’t remain steady over the course of a lifetime. Many girls experience a big surge in symptoms as they enter adolescence.  

Learn more about ADHD symptoms across the lifespan. 

For some, the increase in symptoms comes at a time when supports are being withdrawn at school and at home. Families and educators encourage students to take more responsibility for their learning and behavior—just as girls are experiencing more symptoms. The result can be overwhelming.   

“A lot of times, girls and women can compensate until high school or college, when they’re having to juggle multiple classes,”  Dr. Rupert notes. “Some can compensate until they have to manage people other than themselves—for example, when they become a manager at work or become a parent.” 

Studies have shown that hormonal changes in puberty, pregnancy, and menopause can also worsen ADHD symptoms (Antoniou et al., 2021).  

Explore family and developmental histories.    

There’s a strong genetic component to ADHD. For that reason, experts recommend talking to caregivers and parents about anyone else in the family who experienced similar symptoms, even if they were never diagnosed with ADHD.  

It’s also important to look at when each type of symptom appeared. Were earlier symptoms there but overlooked? Have there been periods when symptoms worsened or seemed to improve? What other interventions have been tried? What were the outcomes? 

Knowing the answers to questions like these can help you plan more effectively for the girl or woman in your care (Murray et al., 2019). 

Consider the possibility of co-occurring conditions.    

“It’s rare that I work with a student who only has ADHD,” Dr. Rupert says. Some students may be contending with multiple conditions at the same time. According to Jogia et al. (2022), ADHD can overlap or co-occur with 

• autism 
• dyslexia and other learning disabilities 
• depression 
• anxiety 
• oppositional defiant disorder 
• epilepsy 
• sleep disturbance 
• developmental language disorder 
• motor disorder 
• intellectual disability 
• obsessive compulsive disorder 
• tic disorder   

It’s important to know that many girls are initially diagnosed with depression or anxiety before receiving an ADHD diagnosis later (Young et al., 2020). It’s also a good idea to ask whether another condition could be causing ADHD-like symptoms. Sleep disturbance, for example, can worsen executive-function difficulties.  

Ask questions that match the individual’s stage of life.      

ADHD symptoms can change as people mature. Dr. Rupert advises practitioners to adapt diagnostic questions to the individual. “The diagnostic criteria in the DSM-5 are written for kids, but we’re not going to ask an adult about their school assignments. We can ask about their job reviews at work, or whether they’re changing jobs often.” 

You might ask if a teenager loses their phone a lot. What does a bookbag, a locker, or a purse look like? What are the person’s driving habits?  

“If they’re not always looking for things, is it because they’ve compensated and come up with systems, finally, after years?” she asks. “Are systems there because the individual has such a problem with organization that they have to overdo it in order to be on time or know where things are? It’s important to ask those questions across the lifespan.” 

Consider how personal identities and experiences shape the process.  

Understanding how families and caregivers perceive ADHD and the diagnostic process can enable you to communicate in a helpful way. Not all families have the same expectations for children’s behavior. Some families may be sensitive to the stigma around ADHD. And some families have a skeptical view of psychological and medical processes.   

“Many families in communities of color have a valid distrust of medicine because of the horrific history of experiments on Black, indigenous, and Latino people,” Dr. Rupert says. “And psychiatry has a similar history with disabled and neurodiverse communities. For that reason, you may have parents who are concerned that their child is going to be ‘drugged up’ or labeled. There is a basis for those concerns.” 

Dr. Rupert recommends taking plenty of time to educate families. It can also help when families are able to work with practitioners who understand or share their backgrounds. 

Key Messages   

“Undiagnosed ADHD can cause so much stress and trauma,” Dr. Rupert notes. Girls and women with untreated ADHD are more likely to develop unhealthy substance use patterns, to have an unplanned pregnancy, and to have serious self-esteem problems (Young et al., 2020).  

More research and greater diagnostic accuracy are needed where girls and women are concerned. Still, Dr. Rupert is optimistic. When people have access to treatment, including medication, outcomes improve.   

“We need to use every tool we have available to us,” she says. “If medications are needed, we need to use them. But we also work on other skills—time management skills, interpersonal relationship skills, communication skills. Learning those skills, along with medication, is life changing.” 

Dr. Rupert says one of the most satisfying parts of being a psychiatrist is “seeing the trajectory of a kid’s life completely change.”  

“They’re doing great at school. They’re doing great at home. And it’s amazing to be part of that.” 

WPS Assessment Consultants can speak with you about assessments you can use in a comprehensive ADHD evaluation, such as:

• Conners 4th Edition™ (Conners 4®)
• Behavior Rating Inventory of Executive Function (BRIEF-2)
• Revised Children's Manifest Anxiety Scale, Second Edition (RCMAS™-2)
• Children’s Depression Inventory, Second Edition™ (CDI 2®). 

Articles Related to ADHD in Girls and Women: 

• Why It’s So Important to Test Executive Function in Children With ADHD
• Could VR Become Part of Your ADHD Evaluation/Assessment Toolbox?
• Lived Experiences: Autistic Girls and Women

The Centers for Disease Control and Prevention (CDC) has released the Data Summary & Trends Report for its 2011–2021 Youth Risk Behavior Survey (YRBS). The full data set is to be published in Spring 2023.  

The summary explains new findings and tracks 10-year trends in these focus areas:  

• sexual behavior 
• substance use 
• violent experiences 
• mental health/suicidality 
• new data variables 

Data is drawn from information provided every 2 years by a nationwide sample of high school students. Here are some of the key takeaways from the CDC’s report.  

• Mental health among young people is worsening.  
• Female students are experiencing worse outcomes across almost all of the survey’s focus areas.  
• Race, ethnicity, and sexual identities are still linked to disparities, but the data is inconsistent.   

While some trends are troubling, others are encouraging. For example, the report says that: 

• Substance use and sexual risk behaviors are declining. 
• The proportion of students bullied at school is decreasing (though more male students are experiencing online bullying than in previous years). 
• Most students felt their parents knew where they were and who they were with most of the time, which is considered a protective factor.   

Download the Report here. 

Sexual Behavior Data 

The survey gathers data on these behaviors because some sexual behaviors can lead to negative health outcomes such as unintended pregnancy and sexually transmitted infections.  

The YRBS Data Summary and Trends Report shows that from 2011–2021, fewer students were sexually active. That trend held across all racial and ethnic identity groups included in the study. Condom use, HIV testing, and STD testing also decreased during that 10-year period. In 2021, the report states, around 30% of high school students had ever had sex.  

Substance Use Data 

The CDC includes these products in its definition of substance use: 

• alcohol 
• marijuana 
• vapes and e-cigarettes 
• misused prescription opioids 
• illicit drugs (defined as cocaine, inhalants, heroin, meth, hallucinogens, or ecstasy) 

For most of these substances, the percentage of students using declined from 2011–2021, except that vape use and misuse of prescription opioid medications stayed the same. Female students, LGBQ+* students, and those with same-sex partners used substances more than others, the report says.  

*The most recent survey did not have a question asking students to specify gender identity, so this report does not provide separate data for transgender students. 

Violence Data  

While at-school bullying dropped, every other measure of violence increased from 2011–2021. In its survey, the CDC included these types of violence: 

• being threatened or injured with a weapon at school 
• staying out of school because of the threat of harm 
• experiencing electronic or in-person bullying 
• having been forced to have sex at any time 
• experiencing sexual violence 

Female students, LBGQ+ students, and those with same-sex partners were more likely to have experienced violence than other students. In 2021, around 7% of students were threatened or injured with a weapon, such as a gun or knife, at school. Close to 9% stayed out of school because they felt it was unsafe to be there or to get there. And 8% of students were forced to have sex. 

Mental Health/Suicidality Data  

The YRBS asks students a series of questions about their mental health, including whether they 

• had sadness or hopeless that wouldn’t go away; 
• had poor mental health; 
• had seriously considered suicide; 
• had made a suicide plan; 
• had attempted suicide; or 
• had to receive medical treatment for an injury they got while attempting suicide. 

Each indicator increased between 2011–2021, except that the percentage of injuries from suicide attempts remained the same. The report says almost 60% of female students and 70% of LGBQ+ students felt lasting sadness and hopelessness during that period. In 2021, roughly 42% of students said they felt so sad and hopeless that they stopped doing activities they once did. The increase remained steady across all racial and ethnic groups included in the survey.  

Perhaps most starkly, 18% said they had made a suicide plan and 10% attempted suicide in the last year.  

Learn more about the signs of post-pandemic depression in young people. 

New Considerations   

In this year’s report, the CDC tracked three new variables which it considers social determinants of health: 

• unstable housing 
• school connectedness 
• parental monitoring 

Nearly 3% of students experienced unstable housing during 2021. Around 61% of students felt that people at school cared about them and their well-being. And 86% thought their parents or caregivers were aware of where they were going and who they were with most of the time.  

Read more about why schools need strong social–emotional learning programs. 

Key Messages    

The report’s authors emphasized the role schools play in providing accurate, inclusive health education and connecting students with the services they need. The authors said, “These data make it clear that young people in the U.S. are collectively experiencing a level of distress that calls on us to act” (CDC, 2023). 

To learn more about what you can do to strengthen protective factors and reduce risk behaviors among young people, explore the CDC’s What Works in Schools program.  

Find out more about the assessments so many schools and clinics trust to identify mental health conditions in young people: Revised Children’s Manifest Anxiety Scale, Second Edition (RCMAS™-2) and Children’s Depression Inventory, Second Edition™ (CDI 2®).   

Or speak with a WPS Assessment Consultant about opportunities to foster school connectedness through social–emotional learning.  

Related Videos and Webinars: 

• How Schools Develop Comprehensive Behavior Supports Using the BIMAS-2 Assessment 
• How Cyberbullying Impacts Students On and Off the Autism Spectrum 
• Anxiety: Recognizing and Assessing for Intervention 
• Using Social and Emotional Competence Assessment to Support Teaching, Learning, and Student Success 
• SEL as a Foundation to Safe, Supportive, and Equitable Schools 

Researchers in Spain have taken a deeper look at some of the gender-based stereotypes that may be keeping clinicians from accurately identifying developmental language disorder (DLD) in girls. A study published in the Revista Chilena de Fonoaudiología explains that much of the research on language disorders has focused on boys, which means researchers don’t have as much information on how these conditions may present in girls. Gender norms and beliefs may also influence teachers, parents, and clinicians, preventing early referral, diagnosis, and intervention for some girls.  

Disparities in Diagnosis (and Why They Matter) 

Developmental language disorder affects people of all genders, but boys are thought to have a higher risk and are referred for services more often than are girls (Calder et al., 2022). Race, primary language, and family income can also create barriers to diagnosis and interventions, according to researchers (McGregor, 2020).  

DLD can lead to long-term difficulties with speaking, reading, writing, and solving math word problems. Children with DLD may also experience more behavioral, emotional, and social adaptation issues than do children with typical development. The good news is that when DLD is identified, evidence-based interventions can make a difference in many language skills (Rinaldi et al., 2021).  

Cultural Myths That May Influence Diagnosis of DLD in Girls  

Previous studies have documented subtle differences in the early development of language between sexes (Adani et al., 2019). Evidence has shown, however, that DLD occurs at roughly the same rate in boys and girls (Calder et al., 2022).   

Researchers at the Universitat Oberta de Catalunya and the University of Barcelona reviewed available DLD research and compiled a list of stereotypes they say may limit the diagnosis of DLD in girls. The study (Ahufinger et al., 2023) cited deeply rooted myths such as these: 

• Girls are naturally better at communicating and language skills than boys at every phase of development. 
• Boys tend to say what they know, whereas girls are more likely to say what other people want to hear. 
• Girls speak more in private, criticize others, and talk about topics related to their personal lives. Boys, on the other hand, speak publicly and about topics of general interest. 
• In public speech, girls should speak softly, pleasantly, and as little as possible. Boys, by contrast, should speak with confidence, forcefully, and at length.  
• Girls are less likely to use speech to give orders, shout, or interrupt others. Instead, they tend to ask questions, make suggestions, and avoid conflict. Boys are more likely to debate, interrupt, and argue, believing their knowledge to be superior to the knowledge of girls.  
• Girls’ communications are based on opinion or emotion; boys’ on reason and knowledge. 
• Girls communicate with sensitivity toward the feelings of others. Boys speak rationally, to advance their own goals and achievements.  

These myths do not directly reflect the diagnostic criteria for DLD. Still, they may influence how people think about what’s considered “normal” in the development and use of speech in girls and boys. They may also make it less likely for caregivers to seek treatment when they are concerned about a language delay. 

Learn more about early language processes in this infographic.  

Collaboration and Education to Counteract Bias  

To reduce bias in the identification of DLD, researchers recommended better training for clinical and educational professionals to recognize the signs of DLD in children.  They also recommended training on gender roles, norms, and expectations.  

Researchers encourage speech–language pathologists, medical professionals, and educators to collaborate more on the protocols for diagnosing and treating DLD in children (Ahufinger et al., 2023). The aim is to shrink the gaps in research, diagnosis, and treatment—so every child receives needed referrals and the right interventions.  

To learn more about assessment tools to help diagnose language delays and disorders, visit WPS. Or explore the OWLS®-II, CASL®-2, CAPs™, and Arizona™-4 language and speech assessments. 

Related Videos: 

• Evaluating Spoken Language Skills with CASL-2 
• CAPs Review: Highly Recommended for Assessing Pragmatic Language 
• Using the CAPs: Affective Expression Subtest Examples 
• What You Need to Know About the Arizona-4 

Let’s cut to the chase: Executive dysfunction looks a lot like attention-deficit/hyperactivity disorder (ADHD). Distractibility. Organizational challenges. Trouble managing big emotions. And academic ups and downs. Assessing executive function can give you a window into how a child functions every day and which skills to prioritize in an intervention plan.  

Early intervention is key because better executive function can mean fewer ADHD symptoms, fewer conduct and defiance symptoms, less substance use, and less depression in the long run (Yang et al., 2022).  

Here’s what researchers say you should look for when assessing executive function in an ADHD evaluation. 

The Relationship Between ADHD and Executive Function: Why It’s So Important to Test in Children

Which skills are part of executive function? 

Executive function is an umbrella term for a group of processes that help people manage how they think, feel, and behave. The processes that usually fall under the executive function umbrella include 

• visual (or nonverbal) working memory, which is the ability to “see” images while working on a task or goal (such as picturing an outcome or the steps in a process); 
• verbal working memory, which is a kind of internal voice that enables people to talk themselves through a task or problem; 
• inhibitory control, which is the ability to stop or change behaviors and to manage emotions; and 
• set shifting, which is the ability to direct your attention from one task or stimuli to another so you can accomplish something. 

In fact, some studies have shown that ADHD affects at least one aspect of executive function for around 89% of children with the condition. Working memory can be a problem for around 62% of children with ADHD. Roughly 38% have difficulty with set shifting, and 27% with inhibitory control (Kofler et al., 2019; Veloso et al., 2022). 

These skills don’t operate independently. They interact. Together, they enable people to 

• organize themselves,  
• solve problems,  
• cope with emotions, 
• respond flexibly to new situations, and  
• focus their attention.  

ADHD and Executive Function: Common Difficulties 

Not every person with delayed executive function development has the same concerns. That’s why it’s so important to assess each person’s executive function in an ADHD evaluation. 

Here are some factors to consider as you do.  

ADHD affects working memory. 

Working memory is a kind of brain-space where we hold the information we’re using to complete immediate cognitive tasks. We can think of working memory as a mental whiteboard on which we sketch pictures or jot words we need to access quickly (Emch et al., 2019). 

The capacity of a person’s working memory can determine  

• how fast they learn,  
• how well they comprehend what they read,  
• how effectively they solve problems using reason, and  
• how efficiently they acquire language.  

Studies suggest that visual working memory doesn’t develop as quickly in children with ADHD as it does in children with typical development. Researchers found that children with delayed visual working memory showed higher inattention symptoms. Visual working memory deficits may not have as much impact on hyperactivity and impulsivity symptoms (Karalunas et al., 2018). 

Other studies have linked working memory to 

• difficulty with applied math problems (Friedman et al., 2018); 
• organizational difficulties (Kofler et al., 2019); and 
• classroom functioning difficulties, including trouble taking notes, following instructions, and keeping up with materials (Kofler et al., 2019).  

Learn more about assessments that measure school motivation and learning strategies.  

ADHD may shape inhibitory control and set shifting. 

Inhibitory control is another umbrella term. It refers to a group of thinking processes that, together, enable people to restrain or stop what they’re doing. These abilities are often measured by “stop” and “go” tasks in assessments.  

When researchers study inhibitory control in children with ADHD, it isn’t always clear whether ADHD or another factor is at the root of a deficit. For example, a 2020 study found that sleep disturbance, rather than ADHD, led to inhibitory control problems (Wollf et al., 2021). So, while children with ADHD may have inhibitory control issues, you may have to take a closer look to pinpoint the source of the difficulty.   

Evidence is also mixed with respect to set-shifting abilities in children with ADHD. In some studies, children with ADHD can quickly move from one task to another. In others, children have slower shifting abilities. At least one study found that shifting speed was not different in children with ADHD, but that some accuracy could be sacrificed in the process. Researchers said less accuracy may point to problems with other aspects of executive function, not set shifting (Irwin et al., 2019).  

Learn more about the interaction of ADHD and other neurodevelopmental conditions.  

ADHD and executive function are linked to emotion regulation, too. 

Difficulty managing emotions isn’t one of the diagnostic criteria for ADHD. But the DSM-5-TR lists emotional dysregulation and emotional impulsivity as common features of the condition.  

The neural networks and brain structures involved with executive function overlap with those that process emotions. ADHD affects those brain areas in complex and highly individual patterns (Rubia, 2018). 

For example, studies show that people with ADHD can have trouble noticing their own physical and emotional states (Ide-Okochi et al., 2022). Other researchers found that working memory influences how well children with ADHD manage their feelings (Groves et al., 2022).  

Learn more about how you can help strengthen interoception, the awareness of inner states. 

Other factors can slow development of executive function. 

ADHD isn’t the only factor that can disrupt the development of executive function. You may need to consider what else could be contributing to executive dysfunction. Research shows that both childhood trauma and lower socioeconomic status can influence executive function in children, for example.  

When children experience serious hardships or trauma at a young age, the stress they feel can change how the brain develops. This is especially true when stress  

• lasts a long time; 
• is severe (as it is with abuse, exposure to violence, or long-term financial need); and 
• happens during a crucial developmental period.   

For example, researchers have linked serious adversity to smaller amounts of gray and white matter in areas of the brain related to executive function (Nelson et al., 2020).  

In the same way, when researchers analyzed records from the Harvard Early Learning Study, they found that children from the highest-income families showed better executive function and self-regulation than children from the lowest-income families. Those differences were present whether researchers looked at assessments, parent reports, or teacher reports (Cuartas et al., 2022).   

Key Message 

In an ADHD evaluation, assessing executive function can yield powerful insights into the specific difficulties each child has at school, at home, and in relationships. Executive functioning and ADHD overlap in unique patterns. Discovering each person’s abilities can help you pinpoint the interventions most likely to bring positive change to a child’s life.  

Learn more about the tests many researchers use to assess the characteristics of ADHD:  Behavior Rating Inventory of Executive Function (BRIEF-2) and (Conners 4®) Conners 4th Edition™, the leading ADHD assessment for young people ages 6–18 years. 

Post-Covid Depression Is Hitting Teens and Children Hard: Can You Spot the Signs?

Across the country, thousands of students are carrying something heavier than the books in their backpacks. Study after study has confirmed what school psychologists, teachers, and caregivers see firsthand: A growing number of young people have depression that began or worsened during the COVID-19 pandemic.  

When researchers looked at pooled estimates, they found roughly 1 in 4 young people across the globe experienced “clinically elevated depression symptoms” during the first year of the pandemic (Racine et al., 2021). That’s double pre-pandemic rates. And depression is still hitting harder than usual. One meta-analysis compared the prevalence of depression before and after the majority of pandemic restrictions were lifted. Depression levels were “significantly higher” afterward (Wang et al., 2022). 

In response, the U.S. Preventive Services Task Force has called for depression screening in all students ages 12 to 18.  If you’re considering universal depression screening or you’re working with individual students at risk, here’s what to know about post-covid depression in young people.  

Signs of Post-Covid Depression in Teens and Children 

Depression looks different from person to person, and some signs are easier to spot than others. For example, some people have more physical symptoms, such as body aches. Others have more emotional or motivational symptoms.   

The Diagnostic and Statistical Manual of Mental Disorders (5th ed., text revision; DSM-5-TR) describes these symptoms of major depressive disorder (MDD): 

• feeling sad, empty, hopeless, depressed, or irritable most of the time 
• losing pleasure in activities they once enjoyed 
• changing weight or appetite that is unrelated to dieting 
• sleeping too much or too little 
• feeling restless or sluggish most of the time 
• having very little energy most of the time 
• feeling worthless or feeling guilty most of the time 
• having trouble concentrating or making decisions 
• thinking about, planning, or attempting suicide 

To diagnose depression, five or more of these symptoms must be present during a 2-week period and must disrupt the person’s ability to function. The symptoms shouldn’t be related to some other cause, such as the recent loss of a loved one or a medication side effect.  

Causes of Post-Covid Depression 

Researchers are still unpacking all the reasons for the surge in depression. Many think the post-pandemic increase could be the result of 

• avoiding social situations because of the risk of illness, 
• staying at home for long periods, 
• spending less time in physical activity, 
• fearing that family members might become ill, 
• facing the economic fallout of the pandemic, 
• living with parents whose mental health was affected by the pandemic, or 
• experiencing child abuse (Wang et al., 2022). 

Environmental stressors like these can lead to inflammation in the brain and body. Inflammation has been linked to depression—and depression can make people more vulnerable to infections. Depression and inflammation are believed to travel on a two-way street (Beurel et al., 2020).  

In addition, scientists have found that the COVID-19 virus itself causes inflammation, changes in brain structures, and depression. Symptoms can last for months after the body clears the virus (Benedetti et al., 2021). By some estimates, around 35% of those who had COVID-19 also had depression symptoms up to 4 months later (Mazza et al., 2022).  

Risk Factors for Post-Covid Depression in Teens and Children 

It’s important to understand which teens and children may have a higher depression risk. In a 2022 review of survey studies, Theberath et al. described several basic risk factors associated with mental health difficulties during the pandemic. Depression risk was found to be higher for people who  

• were assigned female at birth 
• were in upper grade levels at school 
• needed more social and physical activity 
• used the Internet in an excessive way 
• experienced emotional reactivity 
• avoided new experiences 
• relied on unhealthy coping strategies such as denial or substance use 
• experienced financial loss or instability  

Depression can run in families: People with a family history of depression are more likely to experience depression early in life (van Sprang et al., 2022). Other studies found that attention-deficit/hyperactivity disorder (ADHD), a prior history of mental health difficulties, and emotional abuse all increased the risk for depression in children and teens during and after the pandemic (Bai et al., 2022; Lewis et al., 2022; Sciberras et al., 2022). 

Key Messages

The pandemic raised the risk of depression in teens and children. Changes to routines, isolation, family stress—or even COVID-19 itself—led to symptoms that, for many, still linger.  

When you know the signs and have a sense of who may be vulnerable to the condition, you can better assess depression in children and teens. No one can turn back the clock to pre-pandemic stress levels. But those with access to tools and training can help young people cope and recover today.   

For information about trusted measures of depression in young people, reach out to a WPS Assessment Consultant or explore the Children’s Depression Inventory, Second Edition™ (CDI 2®) online.  

Check out the WPS School Resource Guide to learn more about how we can help you make a difference for teens and children. 

Scientists in Finland have developed a virtual reality (VR) game to help detect attention-deficit/hyperactivity disorder (ADHD) characteristics in players (Seesjärvi et al., 2022). The game, called EPELI (Executive Performance in Everyday Living) asks players to complete 13 task sets mimicking real-life goal-directed behaviors such as getting ready for school. A dragon character gives instructions, and VR technology tracks players’ attention and executive function as reflected by their eye movements. 

The game also features a “Shoot the Target” task in which players attack targets by looking directly at them. Could digital tools like this become a standard part of ADHD assessments and evaluations? 

Eye Movement Differences With ADHD 

Previous research has shown that people with ADHD have differences in goal-directed eye movements. When people read, for example, their eyes make short, sharp movements to take in all the letters in words in sentences. These movements are known as saccades. People with ADHD often have trouble controlling saccades. They may be less able to suppress or slow them. They may also have trouble keeping their eyes focused on an object or directing their focus exactly where they want it (Bucci et al., 2017).   

In this study, researchers compared the task performance and eye movements of players with and without ADHD. Clear differences emerged. Players with ADHD navigated and performed tasks less efficiently. Their eye movements also differed, with shorter saccades and longer fixations. Researchers found that eye-movement differences accurately predicted whether a player was in the ADHD or control group (Merzon et al., 2022).  

A Complementary Measure 

Researchers say eye-tracking data from VR games could become an objective, complementary part of ADHD evaluations, alongside validated ADHD assessments, interviews, and clinical observations.  

To learn more about comprehensive ADHD assessments, executive function assessments, and more, speak with a WPS Assessment Consultant in your area. 

Further Reading:

• The WPS In-Depth Guide to ADHD Assessments
• Why It's So Important to Test Executive Function in Children with ADHD

As we enter another winter with health experts predicting a “triple-demic” of flu, COVID-19, and respiratory syncytial virus (RSV), researchers are learning more about how the pandemic has affected students around the world. Learning loss in reading and mathematics is well documented. But is pandemic fallout affecting your assessments in other ways? 

Here’s an overview of the changes many students are experiencing post-pandemic, and how they could still be affecting assessments and evaluations. 

Neurodevelopmental Differences

As the brain matures, its cortical thickness decreases. Researchers have recently found that getting older isn’t the only thing that thins the cortex. Adverse events such as family dysfunction and abuse can also trigger cortical thinning. 

New studies have looked at cortical thickness among teens who experienced the pandemic. Researchers are noticing the same neurodevelopmental changes in their brains as those that occur with early adversity. Studies show that the hippocampus and amygdala, two structures in the brain associated with memory and emotion regulation, also grew rapidly during the pandemic. In other words, the pandemic seems to have accelerated brain aging in teens.

It isn’t yet clear whether these changes will be long-lasting. It’s also not clear how—or if—these changes will impact assessments going forward. Researchers caution that “if these changes are found to be enduring, accounting for and interpreting data acquired during this period will require additional attention and consideration” (Gotlib et al., 2022). 

Social–Emotional Development

For many children, school provides more than academic education. It’s the place where they access 

• food programs,  
• emotional support and safety,  
• opportunities to build friendships, and  
• education focused on coping and stress-reduction skills. 

To find out whether the pandemic affected social–emotional learning (SEL), researchers at the University of Cambridge, UK, and Addis Ababa University, Ethiopia, asked students to rate how strongly they agreed or disagreed with these statements: 

• I feel confident talking to others.  
• Other people like me.  
• I like to share things with others.  
• I help others when they need help.  
• I make friends easily.  
• If I hurt someone, I say sorry.  
• I am polite towards others (e.g., greetings, saying thank you). 

Using data gathered before and after schools closed, researchers found that students scored themselves lower after the pandemic than they had the year before. The effects were worse for students in rural areas and better for those in wealthier families (Bayley et al., 2022).   

The findings are aligned with other studies, such as Harvard’s Early Learning Study. In that study, researchers reported that 61% of parents said their child’s social–emotional development was affected by the pandemic (Hanno et al., 2021). 

Social–emotional skills have been linked to better learning. For that reason, researchers think the lingering effects are likely to worsen educational inequities linked to gender, age, and income. 

SEL skills can affect assessments and evaluations in lots of ways, including these: 

• Social–emotional skills are included in the diagnostic criteria for some neurodevelopmental conditions such as autism and ADHD (CDC, 2022).

• When students experience difficulties in SEL, self-confidence and self-esteem can drop, which may affect student performance on a wide range of assessments.

• Poorer social–emotional development may affect academic learning and recovery, so performance on cognitive assessments may be affected (Bayley et al., 2022). 

Mental Health

Perhaps the most widely reported effect of the pandemic has been the marked rise in anxiety and depression among young people. A recent meta-analysis found that the rates of these internalizing symptoms have doubled since the early days of the pandemic (Racine et al., 2021). Older teens and people assigned female at birth are experiencing worse symptoms, researchers say. 

The sharp rise in the risk for mental health problems prompted the U.S. Preventive Services Task Force (USPSTF) to recommend that all teens ages 12–18 be screened for major depressive disorder. The USPSTF also recommended that children and teens ages 8–18 years be screened for anxiety (USPSTF, 2022).  

As you conduct assessments and evaluations, it’s important to know several things: 

• High anxiety can lower scores on cognitive and neurocognitive tests, including those used to identify concussion syndrome (Champigny et al., 2020) and learning disabilities (Schulze et al., 2022).
• Social anxiety, in particular, can disrupt the ability to concentrate and reduce academic achievement (Leigh et al., 2021).
• Anxiety can interfere with executive function, a group of skills that includes working memory; the ability to plan, organize, and shift efficiently from task to task; and emotion regulation (Ursache & Raver, 2014). People with ADHD and learning disabilities such as dyslexia often have differences in executive function (Crisci et al., 2021).
• Depression is associated with changes in some cognitive abilities, such as processing speed and concentration (Wang et al., 2019). Both abilities could impact a student’s performance on a range of assessments.
• Depression can also lower self-esteem and can lead students to think they have less cognitive ability than they actually do (Srisurapanont et al., 2017).  

As clinicians, educators, and families address learning loss, evaluate health conditions, and plan services for students, part of the work will be acknowledging the changes the pandemic has brought about for all of us. We’ll need more research, more awareness, and more compassion moving forward. 

Further Reading

• Post-Pandemic Depression is Hitting Kids and Teens Hard: Can You Spot the Signs?
• Day-to-Day Depression: What to Look For in Teens