(content warning: disablism, possible racism)
If you are in the Greater Boston area and are trying to get a neuropsychological evaluation, do not go to Dr Tyler Zink at Beth Israel if you can possibly avoid it. I had a horrible experience with him in late 2017. My psychiatrist referred me to Beth Israel’s neuropsychology department to look into some attention-span and executive-functioning issues I’d been struggling with. I don’t typically engage in callout posts or name-and-shame campaigns, but this experience was bad enough that I feel the need to warn the community about Dr Zink as a public service.
During the October 2017 intake appointment, Dr Zink repeatedly tried to elicit stereotypically autistic answers out of me. He was priming me to give him the right answers. For example, when I was talking to him about my interests, he seemed to be trying to push me into saying I had restricted interests when I had told him I had a broad range of topics I found fascinating. I clarified this by saying that I was interested in particular sub-topics within those disciplines. If I were in an environment in which I felt I could be autistic and have multiple interests, I wouldn’t have responded that way. It was clear that he had a specific model of what an autistic person looked like in his head, and he was determined to fit me into it regardless of what I actually told him.
A graduate student, Melanie (I don’t think I got her surname) actually administered the tests in November 2017, though Dr Zink was responsible for choosing the set of tests she used to examine me. Part of the diagnostic battery for autism he used included questionnaires by Simon Baron-Cohen, he of the ‘empathising and systemising’ and ‘extreme male brain’ hypotheses. I felt as though, yet again, I were being primed to give autistic-sounding answers. In this case, I was filling them in silently, but the nature of the environment seemed to have that effect on me.
I received my final report in December 2017. Some of it was helpful, like its identification of my fine-motor and executive-functioning difficulties. These brief moments of lucidity were marred by stereotyping and mechanistic approaches to the interpretation of my results. The two particular conclusions I took the most issue with involved intelligence and empathy.
Dr Zink tried to tell my intellectual functioning was between ‘high average and superior’ (roughly IQ 115-120, I think). I was horrified, because being within that range would represent a twenty- to thirty-point decline in intellectual functioning compared to the Wechsler tests I had to take to receive special-education services. (Never mind the fact that ‘superior’ just reeks of eugenics; some practitioners are shifting towards ‘advanced’, but he didn’t get that memo.) I remember seeing one of my IQ scores, and was told about others later on. He was trying to butter me up, telling me that I was ‘so smart’ and was in the ‘top 10%’. I scored in the 99th percentile in the past. For example, when I was 11, I qualified for gifted education in a district that had a strict IQ cutoff of 130. I was identified as gifted extremely early. I told him I’d scored higher when I was younger, and he said that ‘things may have changed from when you were a kiddo’, and proceeded to mansplain to me about how he took into account age and other factors. Yes, he said ‘kiddo’. I’m 31 years old, for god’s sake. He implied that I should be totally fine with a twenty- to thirty-point decline in intellectual functioning. Also, I know damn well that modern IQ tests are based on rankings within a given age band. A twenty- to thirty-point drop is severe, though. This is like telling someone who earned an IQ score of 100 – average intelligence – at the beginning of secondary school that it’s acceptable for them to now have scores that reflect a mild intellectual disability or borderline intellectual disability. Also, why are we talking about ‘premorbid intellectual functioning’ when I’m being assessed for lifelong conditions? It turns out that he derived this IQ range from a quick-and-dirty IQ test called the Wechsler Test of Adult Reading, or WTAR. It can’t even get you a score of 120, but he didn’t tell me that. He just ‘splained to me and gave me false reassurance. Nor did he explain the other limitations of the testing. I was supposed to just accept what he said as given. Of course, I think there are flaws with intelligence testing and don’t think that IQ tests always work well in neurodivergent people in the first place. But his dismissal was ridiculous and not in keeping with researchers’ findings on the consistency of intelligence-test scores throughout the lifespan. Intelligence tests can be compared across different life stages; a British/Australian longitudinal study by Howlin et al (2013) compared autistic people’s childhood Wechsler Intelligence Scale for Children (WISC) scores with Wechsler Adult Intelligence Scale (WAIS) tests. Most of the studies I’ve seen about changes in IQ scores in autistic people across the lifespan involve increases, not decreases. Of course, there are exceptions, but when there are exceptions, then clinicians should understand their patients’ concerns. I suspect that his dismissiveness may have stemmed from unconscious racism and disablism. Who am I, a Black disabled person, to question his judgement of my intelligence? I imagine that if I were white, he would have been more receptive to the idea that either his testing methodology was questionable or that I had experienced a decline that merited addressing. Intelligence tests are ostensibly objective, but examiners have an incredible amount of leeway in interpreting those tests. He chose to believe I was of slightly above-average intelligence; if I hadn’t told him I was a grad student, I suspect he may have claimed that I was of average or below-average intelligence. These complaints aren’t a means for me to go, ‘why, look how intelligent I am!’ as much as they are to point out exactly how dismissive and condescending Dr Zink was.
To add insult to injury, the report also claimed that I had ‘reduced empathy’, based on the ridiculous Simon Baron-Cohen questionnaires I took during the evaluation. I didn’t internalise it as badly as I did the intelligence assessment, but I felt that it was distorted and not in keeping with who I actually am as a person. I actually do feel empathy very strongly, but I sometimes have a harder time expressing it. Honestly, I lean more towards the ‘intense world’ interpretation of autism, in which I feel so overwhelmed by stimuli that I have to shut down or disengage to protect myself from dealing with all the intensity. It’s not a matter of ‘reduced empathy’. Baron-Cohen, and by extension Dr Zink, have conflated a superficial external expression with an internal reality; it’s like the difference between an extension and an intension in the philosophy of mind. To see the complexity of one’s thinking collapsed into horrific, dehumanising stereotypes is a painful experience I wouldn’t wish on anyone. This was a common theme throughout my interactions with Dr Zink and within the report: a routine tendency to flatten, minimise and pathologise.
The report contained blatant errors and distortions of things I had told both Dr Zink and Melanie. The clinical recommendations also seemed to be based on stereotypes, rather than anything I had actually talked about having trouble with in my intake. Dr Zink suggested joining local social skills groups run by the Autism Asperger Network. I do not need social skills groups. When I showed my therapist the report, she thought that suggestion was ridiculous. I have a decent network of local friends that I’ve met through various sources. When I do attend groups facilitated by non-autistic people for autistic people, I tend to feel out of place. I’ve never attended any AANE groups, but I did go to some similar groups back in San Francisco and didn’t get much out of them. Dr Zink was operating on the premise that autism is primarily a disability affecting social skills when my primary complaints were about executive functioning. I left him a phone message to see if I could talk to him further about my report, but he never returned my call. Clearly he expected me to get my report and get on with my life and not question it. He was so enamoured of the idea of my being limited that he didn’t recognise his own limitations.
What happened was not a case of what the intelligence researcher Alan Kaufman calls ‘intelligent testing’, in which clinical judgement takes precedence over mechanistically interpreting scores. This was thoughtless testing that didn’t take into account qualitative factors, self-reported case histories, or any other factors that might have affected my outcomes.
The worst part about the experience was how it warped my sense of self and reality. I wondered whether I had made up or imagined all my memories. I even wondered if I actually existed at some of my worst points after receiving the report. It also dredged up a number of childhood triggers that had lain dormant for years. It took me several months to recover from this experience. You’d think I’d have decent defences against this sort of thing, but it’s difficult when a supposed expert is telling me things about myself that don’t match my internal experiences or what people have said about me. It bordered on gaslighting, though I don’t think it was a deliberate attempt to fuck with my sense of reality. Rather, I think it was Dr Zink’s rigid adherence to stereotypes and his mechanistic interpretation of my results that caused him to treat me the way he did. I understand why he did it, but that doesn’t excuse his behaviour or his methodology. Nor does this mean that I have to forgive him. His intransigence and refusal to recognise that there may be flaws or exceptions to his methodology make me worry that he will continue to upset and traumatise autistic and other neurodivergent patients who come in to be evaluated.
After a few days of fighting off depression, I went through the report again to see the sources for his ‘intellectual functioning’ claims, since I’d only read it cursorily beforehand. I knew he hadn’t given me the full WAIS, only a few subtests from which a clinician can’t derive a full-scale IQ, so there was no way he could have derived a score from it. The WTAR on its own can only produce scores between 70 and 119, meaning that it may underestimate the abilities of people who historically scored higher on IQ tests (Macniven, 2016). The test designers themselves indicate that it was designed to measure people’s intellectual ability before an acquired condition like a traumatic brain injury, dementia, Alzheimer’s or Parkinson’s. My reason for seeing Dr Zink had nothing to do with acquired conditions. Yesterday, I also found out that not only was this test inappropriate for what I was being examined for, it had also been discontinued nine years ago. The WTAR is no longer available for sale on Pearson’s website; the Test of Premorbid Functioning (TOPF) is the current version of the test. The TOPF was released in 2009. Considering that Dr Zink only started practising in 2013, there’s no excuse for his using such an old test.
In January 2018, I wrote a lengthy negative review on Yelp about my experience with Dr Zink. I focussed specifically on the intelligence issue because I had more concrete evidence that the methodology was questionable; I reasoned that it would be more difficult to argue my case about the SBC questionnaires. A patient relations representative contacted me about it a few months later. I called their hotline and they passed along my complaint to the neuropsychology department. I received a letter yesterday afternoon from a different patient relations representative, telling me that Dr Zink was a board-certified clinical neuropsychologist with extensive experience working with people with neurodevelopmental disabilities. There was no admission of wrongdoing whatsoever; all they did was reiterate that he was The Expert. Keep in mind that I didn’t question his credentials. I questioned his methodology. When I wrote my Yelp review, I specifically said that he was the wrong clinician for me, not that he was a bad clinician generally. I called the patient relations rep who wrote to me and she reiterated what the department told her, said she didn’t have any expertise to evaluate what I said, and said that the department ‘respectfully disagreed’ with me. They completely dismissed the fact that I based my conclusions on research on books from reputable academic publishers and peer-reviewed scholarly articles. She gave me the impression that her hands were tied. I don’t think, though, that the department’s judgement was respectful. I think it was degrading and invalidating. If what they said were true, my life would make no sense. There would be no explanation for some of the things I can do and have done. Qualitatively it doesn’t fit. It doesn’t fit previous quantitative assessments, either.
Because of this experience, I never want to have one of these evaluations ever again. One of my favourite quotes – a line from Tony Kushner’s Angels in America – comes to mind: ‘That it should be the questions and shape of a life, its total complexity gathered, arranged, and considered, which matters in the end, not some stamp of salvation or damnation that disperses all the complexity into some unsatisfying little decision.’
Again, if you are autistic, wonder if you’re autistic or are otherwise neurodivergent, I would strongly recommend against seeing Dr Zink or any other clinician who thinks similarly about autistic people. The damage has already been done with me, but I don’t want to see other people go through what I’ve gone through with him. The one positive thing I can say about this nightmarish experience is that I used the existential crisis I went through to help rebuild my self-concept and reject useless and facile interpretations of who I am and how I learn. Fortunately, neither my therapist nor my psychiatrist, both of whom have been working with me for the past two years, agreed with the worst aspects of this report.
Howlin et al (2014). Cognitive and language skills in adults with autism: a 40-year follow-up. Journal of Child Psychology and Psychiatry, 55:1, pp 49–58.
Macniven, J (2016). Neuropsychological Formulation: A Clinical Casebook. Berlin, Germany: Springer.
Moisse, K (13 May 2017). Many children with autism get significantly smarter over time. Spectrum News. Retrieved from https://www.spectrumnews.org/news/many-children-autism-get-significantly-smarter-time/