So, I finally got DS9's WISC 5 results this morning. The evaluation was requested because we wanted to evaluate for a specific learning disability in writing, which they told us only the psychologist could diagnose. However the psychologist's report only mentions evaluation for GT, which we already knew he qualified for. Our IEP evaluation meeting is supposed to be tomorrow morning.

Here are the results:

Block Design: 18
Matrix Reasoning: 11
Coding: 12
Figure Weights: 12
Picture Span: 19
Arithmetic: 19
Similarities: 17
Digit Span: 19
Vocabulary: 16
Visual Puzzles: 13
Symbol Search: 11

Verbal Composite: 136
Fluid Reasoning: 109
Processing Speed: 103
Visual-Spatial: 132
Working Memory: 155
Full Scale: 133

His recent KTEA results are:
ASB: 138
Reading Composite: 126
Math Composite: 158
Written Language Composite: 106

And the KTEA subscores are:
Letter and Word Recognition: 115
Reading Comprehension: 131
Math Concepts and Applications: 150
Math Computation: 160
Written Expression: 114
Spelling: 99
Phonological Processing: 108
Nonsense Word Decoding: 116
Silent Reading Fluency: 110
Word Recognition Fluency: 120
Reading Vocabulary: 133
Associational Fluency: 120
Object Naming Fluency: 91
Listening Comprehension: 143
Oral Expression: 140
Letter Naming Facility: 97
Writing Fluency: 74
Math Fluency: 103

Besides the fact that he has an incredible working memory, what can we learn from these WISC results? Which subtests would be affected by a fine motor weakness? Which would be affected by some sort of visual processing issue that could also be affecting his writing?

What specific questions do I need to ask at our meeting to actually get the answers we need?

On the cognitive side:

He has exceptional working memory, both visual and auditory, meaningful and rote, topping out the scale. Processing speed (which is the area most affected by fine motor) is his weakest area, in the Average range. He actually shows better language reasoning than non-language reasoning. His visual spatial skills are actually solid to exceptionally strong, which isn't consistent with a visual processing deficit.

What is more suggestive of writing concerns is what we see in his KTEA, which is extremely strong in all reasoning and application skills (with the exception of written expression, which is in the upper end of the Average range). The areas of personal or general weakness are all centered on fluency skills, with a consistent pattern of relative weakness (in the lower half of the Average range) in rapid naming skills, which contribute to automaticity skills. (Rapid naming is also one of the three pillars of effective phonetic reading development, but since his other two are solid (phonological processing) to exceptionally strong (auditory working memory), this relative weakness doesn't appear to have affected his reading decoding skills in any way. That doesn't stop it from affecting writing/encoding skills.) Since written expression requires a host of automatic skills (letter formation, spelling, capitalization, punctuation, grammar) before you can even get to generating organized and meaningful language, it is not surprising that he should have some challenges with writing.

The very high Block Design score suggests that it is not visual processing that is the obstacle, but more likely automaticity, probably for skills like spelling and letter formation, at a guess. His untimed spelling is Average, which is functional, but far below his verbal cognition. Then you see writing fluency, which is Below Average (and this isn't even scored for accuracy--purely for the number of words generated), and also far below his written expression. His other pencil-and-paper fluency score (math) is much lower than his untimed basic skill score. See also the sizable gap between written and oral expression, which tells you that it's not language that's the issue (not that we thought it was, with those verbal cognitive scores), but the process of putting it to paper.

Has he been looked at by an OT? That's who you need to actually rule in/out fine motor issues.

I'd also be interested in some error analysis. Was his Writing Fluency score slow because of his actual rate of physically writing words, or because he kept stopping to correct spelling, or because he was slow to generate sentences, or because he got distracted, or something else? What kinds of errors did he make on Written Expression? Were they predominantly mechanical errors, or evenly distributed across grammatical, structural, and mechanical errors, or some other distribution? (Because if they were mostly mechanical (spelling, punctuation, capitalization, etc.), that would tend to support the idea that it's automatic skills that are his area of struggle in writing.) How is his writing if you have him try typing/keyboarding or speech-to-text?

We started this whole journey with an SLP and OT evaluation at the end of second grade (when he was 7 1/2) due to speech and handwriting concerns. At that point, they gave him the Goldman-Fristoe Test of Articulation, which he scored <.1 %-ile on, and the Beery VMI Test, with results of VMI: 93 %-ile, VP: 99.9 %-ile, MC: 30 %-ile. The OT noted bilateral small motor weakness, causing decreased fine motor skills. They also gave him a KTEA, with similar results to the more recent ones above.

We put him on an IEP for speech/articulation, which included OT for hand strengthening and handwriting and access to a Chromebook for typing as desired. In the same meeting as the IEP, we decided to do a full grade acceleration at the recommendation of his 2nd grade teacher. So he skipped third grade.

He received speech and OT somewhat sporadically through his fourth grade year. Every time we brought up concerns about it, they starting doing it again for a couple of months and then it kind of faded out again. His speech improved some; however, his handwriting showed no notable improvement.

At the end of that year, they gave him the GFTA test again and said his articulation was now within normal limits, so he no longer qualified for the IEP. (I honestly do not believe his articulation was ever as poor as their test implied, nor do I believe it improved as much as their test implies. He still has a lot of trouble using voice-to-text, for example.)

He had also started complaining about words disappearing when he reads, particularly on a computer screen, which is where the concerns about visual processing came in. His basic letter formation is still so poor that it seemed like a possibility they were related.

We've seen 4 pediatric ophthalmologists in 3 states since he started wearing glasses when he was 2, and they all swear that his vision shouldn't be affecting reading or writing.

I asked the IEP team to consider his eligibility for a specific learning disability in writing, because his writing hadn't improved. The OT then came to the next meeting and requested that we see a neurologist to evaluate for a possible neurological cause of the fine motor/small muscle weakness--particularly because he also has vision issues, along with the articulation. We set up a 504 with accommodations for writing. When I pushed the issue of IEP eligibility for a SLD in writing or for orthopedic impairment in writing, they indicated that only the psychologist could give either of those diagnoses. At that point, I requested a new IEP evaluation to look for those issues. Those papers were signed 4 days before the end of the school year last May.

Over the summer, we saw a pediatric neurologist, who also noted bilateral hand weakness, hypermobility, and limited web space. She didn't think it was necessary to do imaging to look for a possible brain lesion because his strength is symmetric and there's no focal area of weakness. Essentially, she thinks it's just a structural issue with his hands, with possible genetic causes.

They administered the KTEA again this fall as well as this WISC.
The report from the psychologist that I just got this morning says nothing about any of his fine motor issues or the visual processing concerns. Just that he qualifies as gifted and talented, which was never in question.

In the meantime, he remains at the top of his class (as a just-turned-9-years-old 5th grader) in every area except writing. He's learning algebra 1, got a score of 248 on the 6+ Math MAP, and reads at a high school level. I hope this doesn't come across as me just being arrogant, but I don't think a FSIQ of 133 accurately reflects his cognitive abilities.

However, the writing is still a huge issue. His homework a couple weeks ago involved writing declarative and interrogative sentences from a set of words, like: newspaper astronaut was the an in. He was supposed to write "An astronaut was in the newspaper." and "Was an astronaut in the newspaper?" That sentence alone took him almost an hour to write both ways. We suggested he type it instead (which isn't really better for him, but it's a different option), but he didn't want to. Voice-to-text is usually more frustration than it's worth as well. He seems to spend so much of his cognition to even be able to form semi-legible letters that spelling, punctuation, spacing between words, etc. is too much for him to focus on. Even after 1 1/2 years of focused handwriting practice and OT, there's been very little improvement. His letters in print are large, misformed, and very difficult to read. He does somewhat better in cursive, but it takes him even longer. They had a cursive worksheet in class a few days ago. He said everyone else in his class finished it in 10 minutes or less. He worked on it for nearly an hour at school (his estimate), and then brought it home and worked on it for another hour, to get the 50% done that he's required to do per his 504. And that was just rote copywork. If he had had to create and punctutate sentences by himself, it would have been even more of an impossibility for him to complete.

So I'm at a loss at what we can do besides continue with the accommodations on the 504. I may push for scribing and oral assessment to be added. But mainly I'm frustrated that because he performs at such a high level, it's a fight to get them to acknowledge this as an issue at all.

Does it mean anything that his processing speed and working memory are so different? It seems like they're grouped together in a lot of places, like when discussing GAI vs. FSIQ.

Do both of the processing speed subtests require writing?

Excluding block design and matrix reasoning (which are oddly switched), he has a score less than 14 on every timed subtest and a score higher than 15 on every nontimed subtest.

In fact I'm really puzzled by that block design score knowing that it's both timed and fine-motor dependent. Hmm..

It's all coming back now...I do remember you describing this history!

With the marginal articulation, he would have to use human scribing, and, preferably, oral assessment. I would affirm that recommendation. The key really is the huge difference between his written and oral output. The exercise you described ("astronaut", etc.) is exactly like one of the tasks on the CELF-5, which is one of the core language assessments given by SLPs. If he did well on that task (which he should have, and which the absence of language therapy Rx suggests), but struggled with the written version of it for multiple hours, that is a really stark difference between oral and written language skills. If it is not the case that his ability to complete this task orally is substantially better than his ability to complete it in writing (which would be evident on a CELF-5), then that may suggest an actual language expression disorder, which would indicate speech/language therapy, not just for articulation.

And of course, I'm not a neurologist nor an occupational therapist, but given his history of both severe speech articulation and handwriting weaknesses, I'm a little surprised there was no further investigation regarding motor planning skills, as that is one of the deficits that would be involved in both of those presentations.

Processing speed and working memory really aren't all that related to each other per se. They're grouped together because they both primarily affect efficiency (hence output), rather than abstract reasoning. Also, they are both sensitive to a number of other common concerns, such as challenges with attention, emotional interference, low motivation, fatigue, etc.

Both processing speed subtests do involve pencil work, but one of them is just slashes, while the other is letter-like forms. Notice he did equally Average on both. But the letter-like forms are unfamiliar to all students (hypothetically), so no one really gets to use automaticity skills on them, with the exception of the minority who memorize them in the brief timespan of the subtest. His original VMI scores were extremely high in visual perception, still quite high in integration, and on the lower end of Average in coordination. These were, of course, untimed scores.

His BD score probably reflects his visual perceptual/spatial reasoning more than his speed or fine-motor performance, mainly due to his age. His chronological peers aren't getting enough items correct to separate by speed (three years from now, this score may begin to reflect effects of speed more than accuracy, as the number of items correct obtained by the median student rises), so the fact that he correctly completed many designs, albeit slowly, is more important than the lack of bonus points for speed.

Though I too am a little puzzled by the lower Visual Puzzle score. It does have time limits, though. Also, not true that every timed subtest is below 14. Arithmetic is timed, as are Word Recognition Fluency and Associational Fluency, which are the equivalent of 14s.

Not as puzzled by Matrix Reasoning, as it is very close to Figure Weights. I'm more interested in how he is this strong in math, when his most math-associated cognitive tasks are just average/high average (other than the actual math task, Arithmetic).

Thank you, aeh. Besides scribing and oral assessment is there anything specific you'd ask for in the meeting tomorrow? I'm pretty sure they're not going to count him as eligible for an IEP, so we'll just be adding things to his 504.

I wasn't looking at the KTEA scores when I was talking about the timed tests, just the WISC.

And he's probably so good at math because we have a very math-centric house. DH teaches college math full time, I teach college math part-time and the gifted math at their elementary school part-time, including his algebra 1 class this year. He has also always been extremely interested in math, from toddlerhood.

The one remaining unknown (unless you have CELF results from the previous eval; I can't quite tell, as you only listed artic assessment, but that might not have been the whole of it) is whether there are genuine expressive language challenges too. I wouldn't think so, given his KTEA-3 OE score, but the CELF is a bit more in-depth, so it's possible there are subtle deficits or relative weaknesses that would show up there, but not on achievement testing. I would say that that is the one remaining area that one might consider looking at, if one were going to do any more testing. I'm not advocating strongly for this one, but fwiw.

Graphic organizers: also called mindmaps, idea maps, etc. Some are even more specific, and can be converted directly into a paragraph or multiparagraph product, either by hand copying or clicking. It's unclear how much of a factor organization and planning is in his writing (not much paragraph-level writing is in the KTEA), but certainly, if one has to devote a lot of mental energy to the physical and technical mechanics of writing, not much working memory is left for holding one's ideas and writing structure. Externalizing that into a graphic organizer might help. I'd consider both paper and electronic graphic organizers (he can try them and see which ones work better for him).

Clean copy of notes: he's a bit young, so notes probably don't come up much now, but as he goes into middle school, this will likely become a problem. With his slow, illegible handwriting, and rudimentary typing, having complete notes provided by the teacher after class, and skeleton notes during class, will be important. He has a really good memory, but everyone has limits.

I'm assuming he already has extended time, and you've already mentioned reduced work load. I might clarify that to:

Starred items only, sufficient to demonstrate mastery, no more than 50% of workload. Meaning that (like the existing 504) he doesn't have to do more than 50%, but he can stop when he's demonstrated mastery of the skill/concept. I prefer that the teacher star the specific items that will allow her/him to assess mastery of the learning standard. On a page of 25 items, one can usually narrow it down to five that will demonstrate mastery. The remaining are for practice and reinforcement. I typically tell students that they'll get a handful of starred items, which they should do first, and then if they have time, they should go back and do as many of the other ones as is reasonable, but not if it interferes with other important life functions (like eating, sleeping, having a life outside of homework). The extra items will give them more practice, and act as backup, in case they got one of the the starred items wrong.

Word prediction: I know he doesn't type well, or like typing, but adding word prediction might help, as he reads well, so he'll know if the word prediction is on target or not.

Spellcheck/thesaurus: So I know he has a deep vocabulary, and he spells adequately, but his spelling isn't keeping up with his vocabulary, which is why using the two in conjunction might help make his writing reflect his oral language a teeny bit better. I usually have students use the words they can spell (or get close enough that the spellcheck recognizes them!), and then use the thesaurus function to locate the more nuanced word in their existing vocabulary that they would have preferred to use, if they could have spelled it. Even though his spelling is not atrocious in isolation, it sounds like it kind of falls apart when he has to do anything else at the same time (which is typical for certain types of dysgraphics).

Well, the cognitive skill he has that is both strong and strongly associated with math is his working memory, so that part of the equation adds up. And BD, which is visual spatial, has some connection to geometric and logical thinking too, depending on how people solve the puzzles.

Also, on both the WISC and KTEA, the timed tasks that scored well are all oral only. So it's probably not processing speed per se that's the issue, but only certain types of speed (fine motor, rapid naming).

The rapid naming is visual identification, right? So these results indicate that basically anything that he has to process visually or with writing is notably slower than the tasks he can complete using only his aural-oral connection?

Which feels like it puts us back in the visual processing realm.

How would a dyspraxia/motor planning diagnosis affect his visual processing? Would this be an expected consequence of that type of diagnosis?

And yes, his spelling utterly falls apart when he has to use it in context. Even if he spells the word correctly orally before he writes it or has it written in front of him, he still frequently writes it wrong and erases multiple times. He even forgets spaces between words still.

I don't think they've done CELF. It was mentioned a few times, but I don't think it was ever actually done.

They did tell us once his expressive language was poor and he needed a special group to learn how to express himself with his peers. But I think that was based on a less formal assessment, and when we pressed, the SLP said the only thing he was low on was code switching from formal to casual speech--he used formal speech too much, which really didn't seem an issue to me.

Just to note that DD did pull off a 98th percentile on block design (old WISC, so no other VS scores to compare) with some significant visual processing deficits. In his initial testing, optometrist did note that he had never before witnessed a child who could successfully "unsee" double vision by a sheer act of will. It was fascinating - and a tad unnerving - to watch her do it. It has been suggested (often by complete strangers in public places) that DD is a.... determined child.

On an unrelated note, with respect to "I don't think a FSIQ of 133 accurately reflects his cognitive abilities", don't underestimate the impact of his extraordinary working memory, especially in younger grades. WM has enormous benefits in school.

I have a DS with quite a few similarities to yours, including hypermobility and fine motor issues (and high WM/ low PS). I too was surprised at how high his early block design scores were - but have seen them drop over subsequent assessments. In retrospect, I think his VS skills are so strong that when young, sheer ability put him way over average despite his slowness. As he got older and the testing more complex, the timing had more impact compared to age peers. In his most recent testing (at 14), VS was his lowest index despite being his greatest IRL strength; the psych said that was a purely timed issue. Ah, I see further down that aeh predicts exactly this.

DS has also always had math passion and ability many SDs beyond what his FRI would seem to predict (and language function way below what his VCI would predict). For lack of better explanation, I've assumed that his math skills came from the combo of extremely high VS and WM, despite much lower FRI (but his two WISC-IV assessments at ages 8 and 10 were also surprisingly inconsistent, and raised more questions than they answered). Interestingly, FRI scores are way higher on his most recent assessment with the WISC-V, for the first time looking more consistent with his real-life math achievement. Psych *still* (argh) did not find any data that supported - let alone helped explain - his enormous and obvious in-real-life writing deficits (the purpose of the last two assessments), but did eventually finally provide a formal diagnosis of language LD nonetheless, based on clinical observation and a whole lot of input from parent and teacher on what happens in the real world, regardless of all those high scores.

Thanks Platypus. Lots of good information there. How is your son doing in high school?

Our meeting this morning went fairly well. The psychologist said he had never before encountered a child that didn't miss any items in the entire digit span test. He probably could have gone further on that, PS, and arithmetic, but the psychologist doesn't know of any way to test past the ceiling of 19.

They agreed that because he's hitting ceilings in his strong areas, and his fine motor/processing speed issues are bringing down the weaker areas, the 133 is probably a low estimate of his ability.

I feel like the elementary school team is finally starting to "get" the severe discrepancy between his mental ability and his output--just in time to start these conversations over again when he moves into middle school.

It seems our issue with getting a specific learning disability in written expression diagnosis is that it says it can't be related to a health/motor problem, which is at least part of DS's difficulty. However, in the same breath, they say his health/motor issues aren't severe enough to warrant IEP eligibility for those. So we're still on the same 504 plan for now, awaiting yet another OT assessment--which will be his third since May 2017. They're also going to do a TOWL test to see if that brings anything new to light. We're meeting again at the end of November.

A TOWL would be good. That's probably the best measure of written expression currently available. I'm still a little curious about a real speech and language evaluation, but a genuine writing disability should show up on the TOWL, which is good enough. One of the handy aspects is that there are multiple subtests, breaking out various aspects of mechanics, sentence structure, and applied open-ended writing, so it should be possible to see if there are vulnerabilities in specific skills and/or when skills are combined.

Spent some time this afternoon looking into stealth dyslexia. The Davidson article here: (http://www.davidsongifted.org/Search-Database/entry/A10435) feels like it describes so much about DS. Would the TOWL test be able to parse out if he has some level of stealth dyslexia?

It's maybe not exactly visual processing. He also did well on the reading fluency measures, which require some visual processing, but are also language processing, and have minimal motor organization demands.

Rapid naming has to do largely with retrieval efficiency, which can affect reading (and hence dyslexia), but specifically doesn't appear to be affecting his reading skills at this point, just his spelling skills. So in that sense, it does relate to stealth dyslexia, but probably, at this point, more accurately, the other name for that, which is compensated dyslexia.

The rapid naming deficit relates to motor planning in that he is less efficient at motor tasks which are automatic for other people--such as letter formation, writing mechanics (spelling, punctuation, capitalization). He can spell in isolation because he can devote all of his cognition to it. In applied situations, his peers rely on automatically retrieving handwriting and spelling skills, while he is still using cognition for those basic skills, or inefficiently searching his memory stores for how to execute them, which occupies too much of even his prodigious working memory. Typical of dysgraphics: write, spell, or compose language--pick any one.

And the TOWL is really best for identifying dysgraphia--but that's really top of mind at the moment. Any dyslexic traits appear to be largely remediated at this point.

Thank you, aeh!

He said they pulled him out for the BOT-2 test--"Bot, like robot, mom!" He also told me "She kept saying I was doing really good, even when I wasn't. I wasn't good at catching her ball or dribbling it; and I was really, really bad at staying in between the lines in her mazes."

Here are his BOT-2 Results:
Fine Motor Precision: Scale Score 9
Fine Motor Integration: Scale Score 9
Fine Manual Control: Standard Score 38, 12%-ile
Manual Dexterity: Scale Score 13
Upper Limb Coordination: Scale Score 9
Manual Coordination: Standard Score 40, 16%-ile
Fine Motor Composite: Standard Score 36, 8%-ile.

The OT report states, "Decreased fine motor skills. Weakness in extremity and upper body. Visual perception/visual-motor deficits. [DS] demonstrates deficits in fine motor skills affecting performance in school activities. He demonstrates handwriting difficulties as he has problems with spacing and alignment when copying. He demonstrates problems with dissociating arm and hand movements, isolating finger movement, deficits in in-hand manipulation affecting handwriting, scissoring, and self-care tasks. He has weakness in trunk and upper extremity strength resulting in difficulty with sitting tolerance, difficulty remain in upright sitting position, handwriting problems."


Still waiting for TOWL results. Our meeting is scheduled for tomorrow before school.

TOWL-4 Results

Vocabulary: 9, 37%-ile (which is interesting because his WISC and KTEA Reading Vocabulary were both above average.)

Spelling: 10, 50%-ile

Punctuation: 9, 37%-ile

Logical Sentences: 16, 98%-ile

Sentence Combining: 14, 91%-ile

Contextual Conventions: 13, 84%-ile

Story Composition: 13, 84%-ile

Contrived Writing Composite: 113

Spontaneous Writing Composite: 121

Overall Writing Composite: 116

Interestingly, his manual dexterity is within normal limits, while otherwise fine motor skills and upper body coordination are below average.

And yes, the TOWL-4 vocabulary results are interesting. He can define words and comprehend them well, but doesn't use them as effectively, at least in writing. This is also the only truly open-response contrived writing task. Spelling and Punctuation are dictated, Logical Sentences is editing, and Sentence Combining starts with two or more stimulus sentences. Spelling and punctuation are as expected based on prior testing.

I'm more interested in the difference between his contrived conventions (Spelling and Punctuation) and his Contextual Conventions, which are in the aggregate above average/high average, which is the kind of distinction I often see in learners who have some awareness of their spelling relative deficits, and select only words they can spell for their spontaneous writing, which tends to artificially restrict their writing vocabulary. Actually, his overall spontaneous writing (self-selected extended narrative) is quite good, and generally commensurate with estimates of his cognition. Contrived writing not scored principally for conventions is also above average, especially Logical Sentences, which is the most conceptual of the writing tasks, and also requires the least original writing. He can generate complex/compound sentence structures.

Taken together, these results suggest to me that his written expression includes many intact elements, commensurate with cognition--with the exception of relative weaknesses in mechanics, and possibly some subtle expressive vocabulary vulnerabilities. And, of course, we already knew that his writing fluency was low.

This is looking more like the primary deficit is fine motor in nature, with secondary effects on mechanical/automatic writing skills (spelling, punctuation, handwriting speed, etc.). The only higher-level written expression task that wasn't up to his personal level was Vocabulary, which happens to be the task most like the homework assignment he had involving making multiple sentences from a collection of words (though this subtest allows him to add his own words, and only requires one stimulus word at a time).

Thank you so much for this detailed analysis. All I got from the SLP that did the testing was that "His writing is fine. He should probably learn more spelling and punctuation."

These results really surprised me. But I know he was pulled out three days for this test, so I'm guessing he just did it very slowly and carefully. Do you know how long it usually takes to do this test?

The idea of the restricted writing vocabulary makes *so* much sense. And now that you've said that, I think that's probably some of the reason he hates writing so much--because he wants to say so much more than he feels comfortable spelling. And his spelling is still relatively low because the letter formation is so difficult.

Do you have any reccomendations for working on the automaticity of skills like spacing and correct capitalization? His spontaneous/recreational writing still has lots of words with mixed cases and he still missed spaced between words even when he's working on class assignments. He knows the rules for those things, but it gets lost somewhere before he actually gets the letters on paper unless he's thinking about it with every word.



Another question that came up at our meeting is whether his fine motor skills are falling even further behind his age peers. He had the Berry VMI test in April 2017 with scores of VMI: 93%-ile, VP: 99%-ile, MC:30%-ile.

On his recent BOT-2, his fine motor composite was 8%-ile, and that OT (a different one than before) noted visual perception as a weakness. The OT wasn't at our meeting to consult with.

Do you think those two tests are comparable enough to be concerned about the drop?

To my eye, his handwriting hasn't changed much at all since he started forming letters at 3 and 4--it may have even been slightly better in kindergarten than it is now. I happened across one of his notebooks from when he was 4 the other day and his name looked almost identical to how he writes it now.

We decided to have him take the Beery VMI test again so we could make a direct comparison of the 2017 scores and now, and meet again in two weeks to discuss those results.

If it does seem his motor skills are falling farther behind his age peers, despite the interventions we've already got in place, what do we do next?

We saw a neurologist last summer who didn't believe there was a neurological cause for his fine motor weakness. If his fine motor skills are indeed falling further behind, it's clear we need to investigate that further, but I don't know where else to look for answers.

The TOWL-4 usually takes about 60-90 minutes to complete all sections, so 3 sessions could have been within range, if they were each about 30 minutes.

He may find spacing and sizing easier to maintain if he writes on square (graph) paper. Pick a grid size that approximates a legible version of his normal letter size. Or you can try placing a sheet of dark-lined square paper behind his worksheets, to use as a visual guide. Or writing on the backside of one-sized square paper, so the grids are present, but not in the way of his actual writing. (You can make your own; there are many free printables available. Search "free printable square or graph paper". Here's one: https://mathbits.com/MathBits/StudentResources/GraphPaper/full%20page.pdf)

His fine motor may very well be lagging further behind, if he is not progressing, while his peers are advancing. Although the two tests are not directly comparable, I would agree that it is worth examining the drop in performance further, such as with the re-test you already have planned.

I would speak to the OT regarding interventions. Often they can teach him exercises for hand strength or upper body stabilization, which may help. If the school OT isn't helpful, you may be able to get a referral through your PCP. Just because the neurologist believes it is structural/anatomical, rather than neurological in origin, doesn't mean it can't be improved at all with correct practice. Long-term, of course, it will be more valuable for him to become a fluent typist. (One of my sibs, who also has some level of ligament laxity, still has handwriting that looks like that of a 3rd grader. My parents started that sib on the typewriter (!) at age eight, which, in retrospect, clearly makes more sense than Palmer in the STEM field in which said sib is employed. It took a certain level of relentlessly-polite-yet-stubbornly-assertive advocacy, especially in that pre-ADA era. Also radical acceleration shortly thereafter to university, which made the argument moot.)

We got the results of the Beery VMI retest today.

The old (March 2017) results were (Raw Score/Standard Score):
VMI: 23/127
Visual-Peceptual: 25/142
Motor Coordination: 15/90

The new scores are:
VMI: 21/94
Visual-Perceptual: 25/106
Motor Coordination: 26/108

Everyone on the 504 team (except me) says it looks good because everything is in the average range on the new testing, and when asked about the drop, the psychologist said he probably just scored it more harshly than the OT that did it before.

I left the meeting way more puzzled than I was when I went in.

Curious what you think.

Hm. It is possible that the scorer could affect results, but mainly on the VMI portion of it. Visual-perceptual is either right or not (minimal output demands by the child), so it's hard to see that enormous drop coming from scoring differences. Motor coordination has more possibility of scoring effects, but that's the one that went up a standard deviation (still in the average range). This does line up with your previous report that his manual dexterity is within normal limits. The drop in the VMI and VP scores, which actually are more accurately described as failure to maintain progress over the past 1.5 years, are more interesting. To be fair, the ages at which he was tested are such that a one raw score difference can swing the standard score by quite a bit (note that the identical raw score resulted in 36 points of standard score difference when separated by 20 months of age difference).

I'm still thinking about whether that drop in visual-perceptual is meaningful. The recent OT, who did the BOT-2, reported visual perceptual as a weakness. So that's three data points on visual perceptual (by three different examiners, two OTs and a school psych): one is extremely high (2017 Beery:VP), one is average (2018 Beery:VP), and one is "weak" (2018 BOT-2), with the last two occurring only a few weeks apart. That suggests that some factor besides his intrinsic visual-perceptual skills affects his performance. Perhaps fatigue? Size or contrast of visual materials? Lighting? This may be leading back to Portia's suggestion of developmental vision evaluation.

What kind of doctor do we need to see for a developmental vision evaluation?

He's been wearing glasses since he was two, and has some strabismus. We've been to five different pediatric opthmalogists in three states since then, and several other optometrists. We've gotten many different diagnoses (it seems he never fits in any of their boxes), but the overall impression is that his glasses are correcting his problems well enough that it shouldn't be affecting him functionally. I think he's just *really* good at compensating over short periods, and making the doctors think it's less of a problem than it is. So I'm not sure where else we would take him to get evaluated for that.

https://www.covd.org/