Diagnosing Children with Special Educational Needs in Kazakhstan

Faculty Development Competitive Research Grant Program 2019-2021

This is a proposal for a 2 year project which explores understandings and processes of diagnosing children with special educational needs in Kazakhstan. It involves a survey and interviews with professionals involved in the diagnostic process and observations of Commissions who carry out assessments. The project is a partnership between Nazarbayev University Graduate School of Education (NUGSE), Nazarbayev University School of Medicine (NUSOM) and Astana Medical University (AMU).

The objective of this study is to explore the processes and mechanisms involved in the diagnosis of children with special educational needs, in particular Autism and intellectual impairment, in order to gain understanding of these processes and practices within this context. The focus on Autism and intellectual impairment has been chosen as non-normative (subjective) categories which do not possess objective assessment measures. Hence, there are potential challenges relating to diagnosis as discussed in this proposal, which will be explored through this research. The results of this study can also inform the development of the diagnosis and education/rehabilitation of other groups of students with special educational needs. The aim of his study will be to ultimately provide recommendations to the Ministry of Education and Ministry of Health, to strengthen and improve diagnostic systems and processes in place.

Participant profiles

A total of 26 specialists involved in the diagnosis and assessment of children with ASD and intellectual impairment, were interviewed, as well as the manager of an NGO working with children with ASD. The interviewees consist of 9 pediatric neurologists, 10 child psychiatrists, 2 clinical psychologists, 4 defectologists and 1 special pedagogue. Most of them conduct a diagnostic assessment for ASD or ID one or two times per week. Most work at medical institutions like hospitals and others like defectologists, pedagogue and psychologists work at private educational centers. Most participants had no special training for diagnosing children with intellectual impairment and autism, but claimed they gained their knowledge through “self-learning”, “participation at short term seminars”, “working experience”, and “knowledge through general neurological specialization or psychiatry educational program”. There were no specific educational seminars on “how to diagnose ASD or ID, what and how diagnostic tools need to be implemented “.

Understandings
Understandings of Autism

Survey
Data responses from the open ended question that asked participants about their understanding of ASD were exported into the qualitative data analysis tool – ATLAS.ti Cloud. Responses from participants (Figure 1) are shown as codes by frequency count and indicate that the majority of respondents believe that communication, behaviour, and social problems are the most common characteristics related to the disorder. Other common responses included emotional issues, mental disorder (potentially schizophrenia), withdrawal (lives in own world), and developmental delay. These data reflect a broad understanding of observable challenges that professionals may see in the diagnostic process. These data also indicate the beliefs that associate ASD with having a mental disorder and as ‘mental retardation’ (developmental delay) or cognitive ability. These codes were grouped into categories that come under the following broader themes:
1. Communication - problems with communication, issues, deficits, and impairment. This also included statements such as ‘lives in own world’.
2. Social - social problems, emotional dimension problems, and disruption in social, family, and educational spheres.
3. Behaviour - behavioural problems, sensory processing, disturbance of basic instincts, phobias, sleep, eating disorders, tantrums and will issues.
4. Cognition - developmental delay, cognitive ability, special case of mental development, consciousness disorder, neurological development, and mental retardation.
5. Schizophrenia - mental disorder, psychological, schizophrenia.
6. Heterogeneous - disorder, variety of states, disease, special children, heterogeneous states.
7. Genetic.

Figure 1 - Understanding of Autism





The following section of the survey (Figure 2) asked participants to indicate how they had come to their understanding of ASD. Of the total responses, most participants indicated their knowledge came from literature they had read, through their work and study, others mentioned their own observations and based on symptoms and practice, and some conferences and seminars. Only two participants indicated that their knowledge came from the ICD10 which is adopted by the Ministry of Health in Kazakhstan to provide diagnostic criteria.

Figure 2. How have you arrived at this understanding?


























A section of the survey provided a list of n=16 statements concerning children with ASD and autism in general. These statements were adapted from an instrument by Stone (1987) used to compare the attitudes and beliefs of health care professionals in the United States (US) with those of acknowledged experts in autism. The original instrument was based on criteria from the DSM-III-R (APA, 1987) and consisted of two parts; the first was designed to assess 23 beliefs regarding the social/emotional, cognitive, and treatment/prognosis of autism. Statements included those that arose from common beliefs or misconceptions concerning autism. The second part addressed participants’ knowledge of the DSM-III-R assessment criteria. An adaptation of the first part of this instrument was incorporated within the survey on beliefs and attitudes about ASD and to medical professionals in Kazakhstan. Some statements were considered not relevant and other statements were modified in content for use in the current Kazakhstani context.

After analysis of these data (see Appendix 1), most notable among the responses were the percentage or number of medical professionals that were unsure of certain statements. For example, question 16.14 states that ‘with the proper treatment, most children with autism will outgrow autism.’ There 31% of participants that agreed with this statement which consisted of several neurologists (n=6) psychiatrists (n=6), and a psychologist (n=1) with another 45% (n=19) that were unsure. These statistics represent together, about 86% of the responses. It is well known that autism is a lifelong disorder and not a disease that can be outgrown or cured. Similarly, the responses to the statement ‘Autism is preventable’ indicate that 19% of the respondents agreed with the statement These included neurologists (n=3), psychiatrists (n=4), and a psychologist (n=1) and another 50% were unsure. One statement related to parents of children with autism and immoral behaviour written as ‘Autism in children is attributed to immoral parental behaviour.’ Even though the overwhelming number of participants 86% disagreed or strongly disagreed, a small number of psychiatrists (n=5) were not sure, and one pediatric neurologist agreed with the statement. This is not necessarily surprising given the stigma associated with a diagnosis of autism and that was clear from responses to question 16.7 which states ‘Children with autism usually grow up to be schizophrenic adults. Participants’ responses highlight the challenges that underpin the stigmas associated with a diagnosis where 17% agreed with this statement and 29% were unsure representing almost 50% of the total response.

Interview Data Autism - Results

Each participant’s response to the questions in the interview were translated from notes and transferred into a spreadsheet. In total there were 26 interview responses analysed. These consisted of:
8 Psychiatrists
10 Pediatric Neurologists
3 Educational Psychologists
2 Clinical Psychologists
3 Defectologists

The codes and their related categories were first grouped by profession. From these groups it was evident that there were some similar and different patterns between professions in the way in which they explained their understandings. For example, psychiatrists could describe autism as a disorder or a disease with clear variations that then fit with a specific diagnosis such as Kanner’s, atypical autism, or Aspergers. These categories are also mentioned in the responses of clinical psychologists. Only one pediatric neurologist (A#4) said “There is a lot of difference in etiology.” The responses from the remaining pediatric neurologists and the educational psychologists indicated similar differences in understandings which could be described as broader in scope and less specific. For example, pediatric neurologists and educational psychologists’ responses indicated their understandings were based more on a single diagnosis of autism. One defectolgist explained autism specifically as Kanner symptoms.

“It is a complex systemic disorder that covers almost all spheres of the child. Cognitive and communication impairment with specific language impairment. These are all the Kanner symptoms.” D#1 Defectologist

“A psychiatric disorder, a disturbance of interaction and behavior and emotion.” A#3 Educational Psychologist

“Intellectual impairment and memory impairment and speech delay and psychomotor delay and stereotypic movement and may have aggressive behavior.” A#5 Pediatric Neurologist

Even as there were differences in the way groups of professions explained their understandings almost all responses consisted of descriptions of observable behaviours related mostly to developmental delays across several domains. These delays were perceived as global in areas of communication, behavior, and intelligence rather than clear variations within domains that related to specific diagnostic criteria. Psychiatrists highlighted their understanding of the variability of diagnoses and did clinical psychologists, educational psychologists, and defectologists.

“Disease in children, impairment in social interactions, speech delay and cognitive delay.” A#8 Pediatric Neurologist

“A lot of these things are in the social domain, disturbances of social communication. Aspergers is autism but the intellectual development differs from Kanner’s.” C#2 Psychiatrist

Communication, Social Interactions and Behaviours

Every profession mentioned that diagnosis involved impairment in the category of communication and more specifically in a delay in speech. Codes such as speech is not developed, atypical speech, difficulties with speech and verbal communication were common across all fields. This is also consistent with ICD10 (reference) and DSM-IV (APA, 2000) criteria.

“Skills are not developing, communicative skills suffer, speech is not developed, atypical. Stereotypical forms of behavior – rituals. Behaviour disturbance, aggression, auto-aggression, tantrums.” B#4 Clinical Psychologist

Similarly every profession mentioned impairments or delay in communication, social interaction, social understanding, social problems, and social adaptation. Less common under the category of social interaction was the mention of eye contact made by one pediatric neurologist and one educational psychologist.

“When the children have no eye contact, children make strange noises, child not communicative, not playing games or with toys…” A#1 Educational Psychologist

Most psychiatrists mentioned emotional difficulties such as “Autism is children who are closed and won’t interact with the world” C#7 Psychiatrist. Similar remarks were made by pediatric neurologists and educational psychologists.

“A child living in their own world, no emotions, cannot feel happiness, doesn’t react to their name … child has poor emotions such as when he sees his mother he does not really react” A#11 Pediatric Neurologist

“No empathy, the child cannot understand the feelings of others.” A#2 Educational Psychologist

All professions could describe behaviours such as fixated with toy, rituals, not playing games with toys, stereotypic, stereotypical behaviours, stereotypic movement, and repetitive. However, clinical psychologists and pediatric neurologists were the only professionals who described aggressive forms of behaviours. These included the words aggression, auto-aggression, aggressive, and tantrums. Stereotypic behaviours were often mentioned together with descriptions such as disturbances of social interaction, social problems, social adaptation, and impairment in social interaction. These descriptions came most notably from pediatric neurologists, clinical psychologists, and defectologists.

“Impairment of communication and social interaction with stereotypical behaviours. All-sided mental disorder.” B#5 Defectologist

“Patients that have difficulties with social interaction and contact with others such as being touched. Also difficulties with speech and verbal communication.” A#6 Pediatric Neurologist

Cognition

Codes that related to cognition were prevalent across all professions. For example; delay, without delay, lost knowledge, intellectual impairment, memory impairment, brain pathology, cognitive delay, colossal memory, math skills, and academic skills can be normal to high. Several psychiatrists described differences in intellectual ability, and related this to a specific diagnostic category such as atypical autism, Asperger’s, or Kanner’s. Variations in intelligence were also mentioned by educational psychologists and clinical psychologists, however, only clinical psychologists and psychiatrists attributed these differences to a specific diagnostic category of Aspergers, Kanners, or atypical autism.

“Autism is also about Kanner’s syndrome, had children with Aspergers. Children with Asperger may have colossal memory, math skills…” B#4 Clinical Psychologist

“Autism is a disintegrative disorder of mental processes which doesn’t always have a total decline as in mental retardation … there are many forms” B#2 Psychiatrist

“Intellectual impairment and memory impairment and speech delay and psychomotor delay and stereotypic movement and may have aggressive behavior.” A#5 Pediatric Neurologist

Pediatric neurologists did not mention variations in intelligence at all. When explaining their understanding they referred only to deficits such as intellectual impairment, memory impairment, or cognitive delay. This differed from the responses from defectologists and educational psychologists who demonstrated an understanding of the variable or heterogeneous nature of the diagnosis.

“The main sign of Autism is impairment of social understanding and social interaction. Some children also have signs of intellectual impairment.” C#3 Defectologist

“Academic skills can be normal to high but emotional difficulty.”A#2 Educational Psychologist

Schizophrenia

Two groups of professions mentioned an association of autism with schizophrenia. This association was specifically made in relation to Kanner’s autism and schizophrenia and only appeared in the data and codes from psychiatrists and pediatric neurologists. Some comments also mentioned a stigma associated with a diagnosis of autism.

“Very difficult, cannot answer in one word. Autism is equivalent to schizophrenia in children.” A#4 Pedicatric Neurologist

“There is no full picture of autism but there are autistic disturbances which match with others such as schizophrenia…as a specialist I believe it is better for children to have a diagnosis of intellectual impairment than autism.” C#2 Psychiatrist

Understanding of autism

When participants were asked how they arrived at their understanding of autism psychiatrists , pediatric neurologists, and clinical psychologists mentioned that this was part of their training at university and practical experience. One psychiatrist (B#1) said “Practical experience, no one was teaching.” Some specialists mentioned reading books but most said they had received no specific training. For example, a pediatric neurologist (A#7) said“During practical assessments but no specific training” and psychiatrist (B#2), “Major source practical experience. Reading as well.”

“I understand this during basic medical training and specialization in psychiatry when learning about schizophrenia. Reading a lot of books, conferences and seminars.” C#8 Psychiatrist

Many comments from educational psychologists (A#3) and defectologists (D#1) respectively also mentioned reading from Russian authors such “Research literature books such as Libederskiya” and “From books of Lebedinskaya and Nikolskaya.” However, for these two professions as well as clinical psychologists, it appears that only a few have received specific training or attended seminars in diagnosis of autism and this has come predominantly from NGO’s or Akimat (mayoral office).

“In 2016 an autism centre opened in Kyzlordya and training was held by Marina Izenova from USA. After training my understanding was change. It is a group of different pathologies and there is a wide diversity.” C#3 Defectologist

“Attended seminars and Asyl Miras, international specialists eg., Dr Peterson, conference, special literature.” C#4 Clinical Psychologist

Understanding of Intellectual Impairment
Figure 3: Understanding of Intellectual Impairment

Figure 3 above reflects the variety of meanings of intellectual impairment held by participants.

The majority of responses across both the survey and interviews (34, 22%) claimed that intellectual impairment referred to a delay or impairment in cognitive development, functioning and abilities. In this regard, children would lack the ability to understand the connection between phenomena is reduced and critically examine statements. As a result of cognitive impairment, the child lacks ability to learn new knowledge and skills and has difficulty in the formation of writing, counting and reading skills. An educational psychologist from Aktau claimed that the child will have ‘limitation in some domains, Younger children may have lighter limitation but becomes more obvious when child goes to school. Often there are cognitive difficulties with reading comprehension’. A paediatric neurologist from the same region suggested this may lead to low academic achievement. He/she has reduced ability to think logically and thought processes are immature. A pediatric psychiatrist claimed this may be congenital like Down Syndrome or epilepsy.

Thirty three participants suggested it is an impairment in the mental capacity which could be caused by mental lesions. One of them claimed this could be due to ‘damage to the cortical substance of the brain which is congential and develops up to 3 years.’ Eight others suggested this could be a result of mental lesions. A psychologist suggested that is a ‘total disturbance of all mental activities’ and a psychiatrist termed this ‘mental retardation’ and a ‘mental somatic disorder.’ It is identified as a disorder of intellectual development and all cognitive functions including problems with memory, visual and verbal perception and understanding of tasks as noted by a paediatric psychiatrist. Six participants suggested that children with intellectual impairment had difficulty thinking.

17% said it related to development delays in all areas of functioning. Eleven participants identified intellectual impairment as a deviation from normal functioning for children in the same age group. Two paediatric psychiatrists suggested this was possible to measure when assessed against the classification codes of ICD 10. An educational psychologist identified the developmental delay by using a table based on Piaget’s stages of development. According to a defectologist from Astana, understanding of instructions does not correspond with other children of the same age group. Functioning is lower.

Ten participants claimed that children with intellectual impairment have restricted social communication skills. They lack capacity for social interaction as they find it difficult to comprehend others and have difficulty communicating. Nine participants suggested that they have speech difficulties.

According to six participants, children with intellectual impairment demonstrate behavioural disorders, deviations or ‘social disturbances’ from what is acceptable or normal for children in the same age group. Two participants suggest therefore that children with intellectual impairment have a co-morbidity with autism spectrum disorder (ASD). Four participants claimed that they also lagged behind with emotional development.

Four participants indicated that there is a delayed formation of ‘self-service skills’. ‘Self-help skills and tidiness skills are suffering, this leads to disability’ (Paediatric Psychiatrist).

Almost all participants said they derived their understanding about intellectual impairment from practical experience working as specialists in a medical setting or with children at schools and correctional centres. Some derived knowledge from specialisation training eg. neurology or psychiatry from university study, mainly in Russia. Participants also suggested they learnt from conferences, reading books and research articles, but again mainly from Russia.

Diagnosis and Tools

Diagnosis and tools used for Autism

We defined experience of diagnostic and assessment processes by asking about sources of info, input from other specialists, age of patients, amounts of sessions, average time and diagnostic process.

The majority of specialists used child observation and data from parents or caregivers for assessment and diagnostic processes. Other resources are different and broad and depend on the specialist's personal clinical and working styles. Psychologists who participated in the study use sources of info for the assessment of what is accepted in their centers. Educational psychologists who are working as ABA therapists use the ABA Process. 2 other psychologists use ADOS-2. Like psychologists, defectologists are following their recommended protocol and sources of information for example -Tomatis Method. Moreover, child neurologists with approximately similar medical training use different resources of information from direct child’s observation to combination of several screenings and of developmental history. One child neurologist explained the resources of info in these way:
Parents, family medical history, genetic history, history of child development from birth. Clinical assessment and refer to psychiatrist but here they do not make ASD diagnosis, Mainly long conversation with parents and also speaking with "M" here at the centre. Very rarely make a diagnosis of ASD and mostly make diagnosis of developmental delay. Will refer to Astana Mother and child hospital on suspicion of psychiatric disorder or behavioural disorder as they treat there.

Participants advised that the diagnosis of ASD is made only by the child psychiatrists. In addition to observation and data from parents they all use information from other specialists like clinical psychologist, pediatric neurologists and speech therapist, ICD 10 criteria.

Like pediatric psychologists they do only assessment in their centers, so they use only information from the parents and the only resources available to them are observation and conversation with parents.

Some screening tools as resources of information like ADOS, MCHAT, CARS used only by pediatric neurologists from one region and one psychiatrist mentioned about MCHAT. One of the two defectologists used MCAT and CARS. From the data we can see that screening tools not widely used in KZ.

Screening tools are not very popular among participated specialists. Classification systems Like ICD 10 are used by all psychiatrists, DSM 5 were mentioned by 2 psychiatrists and еру old-fashioned ICD -10 classification is also one of the consequences of contributing factors to diagnosis process problems.

When participants were asked what the procedures of diagnosis of autism were, it was dependent on the specialist's working styles and their needs. Child psychiatrist reported criteria and process for making diagnosis.

All psychiatrists when diagnosing ASD refer to ICD 10 classification with a list of symptoms for ASD and use clinical methods – a long observation to make the diagnosis. All of them mentioned about obtaining history and medical records, complaints, direct child observations, comprehensive history taking and testing child development with games and toys. Next steps were different and depend on inpatient or outpatient psychiatrist’s experience.

The following child psychiatrist says about his\her view on the continuity of ASD diagnosis
1. Observe behavior in office (30 minutes), 2. Discussion with parents, family medical history from birth to present. 3. Does MCHAT with parents, doesn't always give to them to take and do by themselves, and mostly asks them the questions from MCHAT herself. 4. Second Day - observations with pedagogues and with doctor. Children are divided into two groups’ ages 4-7 years and 7-14 years. 5. Speech therapist and psychologist do assessment during day hospital. 6. Main person making diagnosis is pediatric psychiatrist with the pedagogues. 7. After the initial observation in the office, the pediatric psychiatrist only observes, has video recordings of play with other children and often goes in person to watch the way the child behaves with others. 8. Three weeks in day hospital and then a decision on diagnosis is made. 9. In almost all cases the specialist from the PMPC will refer the child for psychiatric assessment and the pediatric psychiatrist will recommend the type of school the child should attend, regular, correctional, or home schooling. When the pediatric psychiatrist gives diagnosis they do not provide a full description of the findings as the document is confidential. They only write the code of the diagnoses and maybe mild or severe. This is what the PMPC receive.

In the following quote, the psychiatrist explained the team’s multidisciplinary approach: After this will analyze all information and determine if suspicious of something. 4. Send for EEG then psychological assessment then refer to logopedist. 5 take all this information plus any genetic information and then come to suspicion. 6. At second visit if other specialists (mentioned before) also see a suspicion of Autism will refer to day hospital and then to PMPC to determine school. Observations after the medical social expert commission is under Ministry of social affairs to determine level of funding. This commission consists of expert Doctors who cover several areas.

This example illustrates the psychiatrist's understanding of the multidisciplinary approach required in the diagnostic process. Specialists refer the patients to each other and work separately. Child neurologists mostly do pre-diagnosis.

Unfortunately ASD is not confirmed with gold standard instruments and does not include team-based decisions of advanced training specialists. We noticed that some information was skipped and did not highlight the comprehensive physical examination and co-conditions; differential diagnosis also has been neglected as a stage in the diagnosis process.
Age of diagnosis

From these results it is clear that almost all participants started the assessment and diagnosis process of Autism from 3-4 years old. Usually by age 6-7 years old kids have been observed by psychiatrists and no clear information at what age kids usually have confirmed official diagnosis.

It was described by one psychiatrist as being more detailed:
“Mainly 4 years - 7 years sometimes up to 10 years. By the age of 15 are not making a diagnosis. At 15 trying to differentiate between schizophrenia and cognitive impairment. (This is because of ICD10 criteria and also because of funding allocated by the Ministry of social services as they do not accept Autism diagnosis in older children and will not fund unless the diagnosis is Intellectual impairment or schizophrenia)”.

The neurologists and educational psychologists start their assessment of children earlier, under the age of 2 years old, sometimes earlier. Meanwhile, to the speech pathologists, patients can access diagnosis, regardless of age. However both defectologists noted that parents in recent years began to seek help within the first 2 years of life. Psychiatrists also mentioned that the awareness among parents about ASD got increased. One of the psychiatrists maintained that: 3-18 years. Officially from 3 years although some children are referred with they are 1.5 years but the child is so small it is hard to diagnose.

Accordingly, the interviewed psychiatrists said that ASD is difficult to diagnose in young children and they understand ICD 10 that they have to change ASD to schizophrenia when patients reach age 18.

What is interesting about this is that psychiatrists explain the reason for changing the diagnosis from autism to schizophrenia by reaching adulthood (when patients reached 18 years old) and interpreting the ICD 10 classification without specifying accurate diagnostic criteria that allowed to change the diagnosis. .

Different specialties and psychiatrists use observation and ICD 10 for diagnosis. Only half of the participants mentioned about screening tools. The most common tools used by specialists for screening or diagnosis ASD are M-CHAT, ADOS-2 and CARS. All specialists start their diagnostic or evaluation process from observation, then the majority of pediatric neurologists and psychologists administer M-CHAT for screening, some specialists are familiar with MCHAT and CARS but do not use it as explained by one of the pediatric neurologists due to lack of time.

Educational psychologists do not use any screening tools, one out of 3 are familiar with M-CHAT but do not use it and find it more relevant for other specialists. For educational psychologists observation and assessment of child's play, motivation, assessment of level of motor development are very important. They believe that we have some problems with Kazakh translation and interpretation.

Psychologists, defectologists and some pediatric neurologist are using diagnostic tools like ADOS 2 and CARS. Some interviewees pledged that after implementing these tools they “are more sure about diagnosis” while one of the specialists mentioned about the limitations

“ADOS-2 didn't show autism for this child. ADOS-2 accurately shows whether it is autism or spectrum or it is an autistic symptom.

All participant psychiatrists who followed the protocol talked about diagnostic criteria from ICD 10 and 3 out of 8 claimed that the old protocol did not work.

Only 3 out of 8 psychiatrists mentioned about screening tools like M- CHAT and one of them found ADOS useful.
Another psychiatrist discussed the limitations of the screening tool:
“M-CHAT works with children who are 18-24 mosnths old. Certainly, children who come to us are older, but we still administer it, so parents can help us to reconstruct what was before at that age (18-24 months). All parents still complete M-CHAT but coupled with our additional questions”. Another child psychiatrist concurred with this claim and offered some tips:

‘We also have additional questions that should be asked. When a mother answers herself (M-CHAT) she may not always accurately assess her child, and that's why parents should be asked additional questions. Everything else is not translated, not adapted. And we can't do it ourselves as it is expensive and we are a government organization.’

Overall, results reveal that all specialist use observation of child’s behavior and conversation with family about child’s development and behavior, as primary methods of diagnosis.

Diagnosis and tools used for intellectual impairment
The most common tool used by specialists in diagnosing intellectual impairment is the IQ test, namely Wechsler. The merits of using Wechsler was described by one psychologist as being

‘more detailed, it gives a more detailed picture. What is good about Wechsler is that during talk with parents you can explain what kind of disorders of attention, memory, thinking the child has, what use to further correct, what to pay attention to.’

However, it is believed that it requires a good psychologist to administer. Another specialist supports this assertion, claiming that only a limited number of people can administer it systematically. The psychologist was however aware of the limitations of Wechsler in relation to contextual factors and suggests that an

‘IQ test is not effective. It is not always indicative of Intellectual Impairment. Wechsler is not effective at all for express diagnostics, very hard to administer. If there is enough time (on average 1.5 hours) and special conditions (child came in the morning, not tired, not hungry) then it is possible to do it. Sometimes it takes even more time and then the child becomes tired.’

Another limitation identified is the rigidity of questions which remain unchanged and do not take account of the social context and historical changes. For example,

‘there are some things which children do not know at all: picture where you need to find missing detail - girl talks by a landline telephone and there is no cable attached from housing to handset [some children have never seen it], rooster and his missing scallop [some kids have never been to village], or thermometer which children have never seen as well. Or test on vocabulary: what is nitroglycerine? what is turpentine? It also concerns concepts that are not adapted to the local context: if a child only speaks Kazakh then the translation of sayings is not always accurately understood by children.

The psychologist believes that sayings and concepts should not be translated into local meanings and needs to be updated to suit the current times. She elicited the help of a company called IMATON to initiate changes in her version of Weschler. Another specialist agrees with this perception that Wechsler is not modern enough and that outdated questions do not help to estimate the child’s intelligence. She goes on suggest that the internet has an effect on the testing:

‘Some children have abundant information on the internet to access, that's why some show higher results in Wechsler although they have mental retardation.’

This specialists’ claims that Wechsler was tested in 1986 on populations in Moscow and Saint-Petersburg and PMPC s in Kazakhstan still use it. Examples she adds to support the claim that the tests need to be revised are as follows:

‘some children do not know who is a "mower", what is the distance between two Russian cities? who is the first cosmonaut? Wechsler is terribly translated.’

Individual educational psychologists use other tests such as VB maps/Abels, Howst (from Moscow) and a paediatric psychiatrist uses Seguin Form Board Test. Another paediatric psychiatrist bases her diagnosis on observation against development milestones.