CLINICAL REPORT Name: Joseph Patrick Date of Birth: 6/20/04 Chronological Age: 7 Grade: 2nd Date of Evaluation: December 14, 2011 Referral Question: Does the child meet criteria for Autism or ADHD, and based on testing results, are there recommendations for school and home that can help the child? Relevant Developmental History Medical History Joey was born prematurely at 28 weeks gestation, weighing only 3 pounds, 4 ounces. During her pregnancy, his mother experienced bleeding in the first trimester. She took prenatal vitamins and did not smoke or drink.
She ceased taking her migraine medication while she was pregnant. After his birth, Joey spent three days on mechanical ventilation. At 30 days, Joey was diagnosed with periventricular leukomalacia. He spent a total of seven weeks in the hospital before he was released. Joey developed spastic hemiplegia on his left side and was diagnosed with cerebral palsy at 8 months of age. Joey has undergone many surgical procedures, including, strabismus in his eyes and tendon releases. He also experienced severe reflux and received nutrition through a gastric tube.
Related to his spastic hemiplegia, Joey had a Baclofen pump implanted, which, from parent reports, has greatly decreased his spasticity. Around his fifth birthday, Joey began to have seizures. According to his mother, Joey has had 12-15 significant seizures, but none within the last year. He currently takes Trileptal to control his seizure activity. Family History Joey’s immediate family consists of his father, mother, older brother, Tanner, and younger sister, Marie. His family is Caucasian and only speak English in the home. Tanner is 13-years-old and has been treated for ADHD since his diagnosis in 2008.
He receives services through his IEP; accommodations include occupational therapy for handwriting once a week, daily math instruction in a resource room, and may resume speech therapy. Marie is 5-years-old and was also born prematurely at 30 weeks gestation. Marie had expressive speech and language delays, but is now declassified. She is currently not receiving any services. Both of Joey’s parents are healthy, though his mother had a history of migraines that ceased five years ago. On his mother’s side, he as one first cousin with a learning disability and one cousin on his father’s side with Down Syndrome. School History
Joey attends Northpoint Elementary School in Granger, IN. He is currently in a mainstream classroom and receives both physical and occupational therapy for 30 minutes, once a week, as stated by his IEP. Recently, both his mother and teacher have reported he has become more distractible during certain activities, especially spelling. They also note that Joey becomes frustrated easily with reading and spelling and will attempt to avoid these subjects. Joey has received grades of ‘needs work’ in reading for the first and second quarter and in spelling for the second quarter. In all other subjects, he received ‘progressing’ or ‘good’ marks.
His teacher reports that she believes Joey is a ‘natural’ in his math abilities, but does not apply the same focus with other subjects. She has noticed that Joey is inattentive and attempts to avoid subjects such as reading and spelling, but also notes this inattention happens inconsistently. She has noticed this behavior more in the last month, but does not consider Joey’s behavior to be disruptive to the rest of the class. Joey’s handwriting is also a concern, possibly due to physical limitations. His teacher indicates that Joey can be a very enthusiastic participant during class, especially during group activities.
Recently, Joey has been ‘zoning out’ during school and has been struggling with his schoolwork, particularly reading and spelling. Personal History Joey is very interested in the movie Cars, and often quotes lines from the movie. In school, he often wants to discuss the movie, but his teacher reports he can be redirected easily. He has two classmates that he will talk to about Cars and the related toys. During recess, Joey plays with the girls in his class (his teacher believes his physical limitations prevent him from playing sports with the other boys).
Joey has one female friend, who his teacher believes looks out for him. Joey enjoys playing on the computer and doing math. Previous Psychological Testing Joey has received one psychological evaluation before the current evaluation. On October 30, 2009, when Joey was 6 years and 5 months old, the Weschler Preschool and Primary Scale (3rd edition) was administered. Joey’s full scale intelligence score was within one standard deviation of the mean (Full scale IQ=105). His verbal abilities were lower, but still within normal range (verbal IQ=92).
Joey’s two verbal subscales were just below the mean score (information subscale=9, vocabulary=9). Three subscale scores were low, but also still within one standard deviation of the mean (similarities subscale=7, word reasoning subscale=7, comprehension subscale=7). Joey’s performance IQ was higher (performance IQ=110). However, within his performance subscales, however, there was a large discrepancy between matrix reasoning (subscale=16) and block design (subscale=7) and object reasoning (subscale=7). Joey demonstrated a strength in matrix reasoning and a relative weakness in block design and object reasoning.
On the remaining subscales, Joey performed at the mean level (picture completion subscale=10, picture concept subscale=10). Current Psychological Testing Tests Administered: Kaufman Brief Intelligence Test, Second Edition (KBIT-2) Woodcock Johnson Tests of Achievement III Connor ADHD – Parent, Teacher, Physical and Occupational Therapist Rating Scale Autism Diagnostic Observation Schedule – Module 2 Social Communication Questionnaire – Lifetime (Parent Report) On the KBIT-2, Joey’s overall IQ composite score was within the normal range (IQ composite=91).
His verbal subscale was lower and fell in the borderline range (Verbal subscale=85). Joey’s performance on the nonverbal subscales was rated as higher (Nonverbal subscale=98), demonstrating Joey’s relative strength in his nonverbal abilities. On the Woodcock Johnson Tests of Achievement, Joey’s performance yielded wide discrepancies between the subscales. Joey scored highly on broad mathematical ability (score=105) and listening comprehension (score=95). Joey’s oral expression fell within 2 standard deviations below the mean (score=85). His performance on the three verbal subscales, however, was much lower.
These scores on the reading scales, (score=65), basic reading skills (score=63) and writing scale (score=55), indicate Joey’s difficulties in verbal skills. Joey’s parents, his teacher, his occupational therapist, and his physical therapist completed the Connor ADHD rating scale. Across all of these ratings, Joey’s behavior was judged higher on the inattentive subscale than the hyperactive scale (inattentive: parent=59, teacher=79, OT=55, PT=51; hyperactive: parent=49, teacher=50, OT=45, PT=50). Only the teacher’s rating of Joey’s inattentive and total ADHD behavior was high enough to indicate a potential diagnosis of ADHD.
The examiner also administered the ADOS, Module 2, during the most recent testing session. Joey scored well below the ASD and Asperger’s thresholds on the Social and Communication subscales (social score=2, communication score=1). Joey also did not display any stereotyped or repetitive behaviors. Joey’s parents completed the Social Communication Questionnaire, commenting on Joey’s communication abilities across his lifetime. A score greater than 13 indicates a diagnosis of ASD is likely; Joey’s score was well below this threshold at 5. Genetic testing of Joey, his father and his mother, yielded no results of interest.
Behavioral Observations During Testing The examiner recorded Joey’s behavior during the most recent testing session. Joey was noted as being polite and engaging during the examination. The examiner noticed that despite his spastic hemiplegia, Joey had a relatively good range of motion on his left side, though he completed most of his responses with his right hand. Joey was very concerned with giving the correct answers during the testing process and would ask the examiner if his answers were correct frequently. If he did not immediately know the answer, Joey would quickly respond “I don’t know” especially for verbal tasks.
Joey did talk about the movie Cars, but the examiner did not consider this behavior out of the normal range for his age group. Summary and Interpretation: Autism Diagnosis After examining Joey’s previous tests and behavioral evaluations, it can be determined that Joey does not present characteristics consistent with an Autism diagnosis. Autism disorder, according to DSM-IV is marked by impairments in social interaction and communication, in addition to the presence of restricted repetitive and stereotyped patterns in behavior, interests, and activities.
Joey’s score on the Autism Diagnostic Observation Schedule (ADOS)- Module 2, along with the observations from his parents and teachers, does not suggest that Joey has Autism. The first major symptom of Autism is impairment in social interaction. Joey’s score on the social portion of the ADOS was a 2, with the Autism cutoff being a 7. His score in this section is not high enough to provide support for an Autism diagnosis. The observer noted that Joey made appropriate eye contact and used effective social overtures, but his responses were sometimes awkward.
Children with Autism often exhibit impairment of the use of social cues, including eye contact, facial expression, and body postures. Joey does not exhibit any of these characteristics and appears to use appropriate social cues in his interactions. Although the ADOS observer noted that some of Joey’s responses were awkward, there is not enough detail about these interactions to suggest that they are abnormal enough to consider an Autism diagnosis. Behavioral notes from Joey’s other tests indicate that Joey was very polite and engaging.
In the notes from Joey’s teacher, she mentions that he plays with a group of girls during recess, gets along with almost all the children at school, and is very enthusiastic during group activities. He also talks with 2 boys in his class at lunch about Cars. These behavioral observations indicate that Joey does not have an impairment of social interaction. Autism is also characterized by impairment in communication. Joey’s score on the communication section of the ADOS was a 1, with the Autism cutoff being a score of 3. His score for this section is not high enough to be evidence for an Autism diagnosis.
The observer noted that Joey’s communication was appropriate for his age level. He is able to initiate and carry on conversations with people, a characteristic that is often absent in children with Autism. There is no behavioral evidence to suggest that Joey has problems with spoken language or communication. Also, Joey’s score on the Social-Communication Questionnaire is a 5, where a score of above 13 indicates the possibility of an Autism diagnosis. Joey does not score high enough on this to determine that he has social or communication impairments strong enough to make an Autism diagnosis.
The presence of repetitive behaviors and stereotyped interests and activities are also necessary for a diagnosis of Autism. On the ADOS scale, Joey scored a 0 in this section because the evaluator did not witness any repetitive behaviors. Although Joey often talks about Cars and, according to his mother, has seen the movie 50-75 times, this behavior is not inappropriate for his age. His conversations sometimes go to talking about Cars, but this does not always happen, and Joey’s teacher said he is easily redirected.
It has been observed that Joey will repeatedly question things when they do not stay on schedule. However, this does not appear severe enough to inhibit his daily actions. Joey does not exhibit any repetitive motor mannerisms or a persistent preoccupation with parts of objects- things that are common in Autism and symptoms that would contribute to an Autism diagnosis, according to the DSM-IV. Therefore, Joey does not present any of the criteria present to say that he demonstrates repetitive behaviors or stereotyped interests, which is a symptom necessary for an Autism diagnosis.
Overall, Joey’s test results and his behavioral observations from parents, teachers, and evaluators demonstrate that Joey’s behaviors are not consistent with the characteristics of Autism and a diagnosis of Autism cannot be made. ADHD Diagnosis Not only does Joey not present the characteristics consistent with an Autism diagnosis, he seems to also fall short of the required criteria for an ADHD diagnosis. According to the DSM-IV, a child must exhibit 6 or more Inattention and Hyperactivity-Impulsivity symptoms in order to receive a diagnosis.
These symptoms must not only be present now, they must have occurred for at least 6 months prior to the diagnosis. Symptoms of Inattention include the following: lacking close attention to details, difficulty keeping attention on tasks or play activities, not listening when spoken to directly, failing to follow directions and complete schoolwork, chores or other duties, trouble organizing activities, avoiding disliked activities, losing things needed for tasks, is easily distracted, and/or forgetfulness in daily activities.
According to observations from his teacher, Joey has a difficult time keeping on task with reading and spelling activities. He does not, however, have any problem giving math assignments his full and undivided attention. Joey also enjoys playing with his peers during recess, and except for a physical limitation that restricts him from playing sports with some of the boys, he is able to focus when interacting with peers. Teacher reports have expressed concerns that Joey has recently become more distractible. His attention span, however, seems to be “inconsistent across tasks”.
During reading and spelling lessons, Joey is much more distractible, whereas during math he is able to focus and complete assignments without any problem. We believe the reason Joey zones out in certain subjects, while not in others, is because he is having difficulty with some subject matter. Because this is the case, we do not believe his inattention is a result of ADHD, but rather a result of a lack of understanding. Joey’s grades seem to further reflect a lack of understanding in certain subject areas. According to the grades given by his teacher, throughout both quarters of reading, Joey has received marks that say he “needs work”.
In language arts he received marks that say he is “progressing”, but in math his teacher reported that “he is a natural” and he has received only “good” marks. Since Joey is able to concentrate and succeed in activities that he finds easy and enjoyable, we know that inattentiveness is not the problem. According to the results of the Connors ADHD test completed by a parent, teacher, occupational therapist and physical therapist, when measuring Joey’s Inattentiveness as defined by the DSM-IV, these individuals all reported that he was within one standard deviation of the mean.
While his parent, occupational therapist and physical therapist all felt he fell into this range, his teacher reported that he was almost 3 standard deviations above the mean. His teacher’s response presents an interesting contrast to the data collected from the other participants; whereas 1 standard deviation above could be seen as similar to neuro-typical children, 3 standard deviations definitely implies there is a problem.
Our team believes the teacher may not be providing results that depict the child’s overall inattentiveness throughout the entire school day, but rather giving too much weight to his inattentiveness during reading and spelling activities. Because we have data from three other individuals that state he is within one standard deviation, we are confident that his teacher’s report is not a representative view of his overall inattentiveness. In order for a child to be diagnosed with ADHD, it is also necessary that he/she exhibit 6 or more symptoms in Hyperactivity- Impulsivity.
Some of these include: fidgeting, inability to remain seated, difficulty enjoying leisure activities, talking excessively, blurting out, difficulty waiting for one’s turn, and/or interrupting. Joey’s mother reported that Joey enjoys watching the movie “Cars” and has seen in at least 50-75 times. Since he obviously enjoys watching this movie and also “loves to play on the computer”, Joey does not seem to have any difficulty enjoying leisure time. There were also no reports of Joey having any difficulty being quiet or remaining in his seat while at school or home.
His teacher actually specifically reported that he “is never disruptive”. Although the observations his teacher made about him imply that he does not reach the requirements of Hyperactivity, our team also analyzed the Connors ADHD test that was completed by his Occupational Therapist, Physical Therapist, Teacher, and Parent. All four participants reported that Joey falls within one standard deviation of the mean for Hyperactivity. In 2 of the cases, Joey was reported to be below the mean in hyperactive behaviors, while the other evaluations reported that his score was equal to the mean.
This suggests that Hyperactivity-Impulsivity is not a problem for Joey. In general, it seems as though Joey has difficulty remaining on task during activities that he finds difficult. Since he has no difficulty focusing during activities in which he excels, nor does he have any instances of Hyperactivity-Impulsivity, we are confident at this time that he does not fit the diagnosis for ADHD. Although he is able to remain on task during some activities, he seems to struggle with reading, spelling and language arts, which may imply there is an underlying problem within these subjects that needs to be addressed.
Other Possible Diagnoses Although a diagnosis on the basis of Autism or ADHD was not probable given his case, in an examination of Joey’s overall profile, there is a possibility that Joey could have a learning disability, and more specifically, Joey could have dyslexia and/or disorder of written expression. According to DSM IV, the characteristics involved with dyslexia include: problems in reading achievement, accuracy or comprehension that is not consistent with the child’s chronological age, age-appropriate schooling, or intellectual abilities.
Also, these reading difficulties significantly affect school performance or activities of daily life that require reading skills. Along the same lines, Disorder of Written Expression is characterized by significantly low writing skills for the child’s chronological age, intellectual ability, and age-appropriate education. This problem must significantly interfere with academic achievement or activities of daily living that require the composition of written texts. Dyslexia is an information processing disorder where an individual lacks phonological awareness, meaning they have a hard time mapping words to symbols.
Dyslexia does not interfere with an individual’s ability to think or understand complex problems, however it does lead to problems of reading fluency, reading comprehension, spelling and writing. Dyslexia is characterized by problems in reading achievement that is inconsistent with the child’s age, intellectual ability, and age-appropriate schooling. Joey’s intelligence score on the Wechsler Preschool and Primary Scale of intelligence 3rd edition (score=105, mean=100), and the Kaufman Brief Intelligence Test (score= 91, mean= 100) suggest that he has average intelligence for his age.
However, on the Woodcock Johnson Test of Achievement III, Joey’s reading and writing deficits are clearly highlighted. His Broad Mathematical score (105, mean=100) is above average while his scores for Broad Reading (score= 65), Basic Reading Skills (score= 63) and writing (score=55) are all two standard deviations below the mean, signifying he is in the bottom 5% of scores for children his age. A potential answer for why his IQ scores are normal despite his problem is 2-fold. First, because his math scores are so high, they will pull the average IQ score up when combined with the verbal section.
Second, in the Wechsler IQ tests, the verbal section consists of sections that do not include reading specific tasks but rather vocabulary and knowledge of general information that Joey is able to score high on because he is an overall intelligent child. In sections specifically focused on reading comprehension and reading accuracy, Joey struggles immensely, indicating he is having problems with the actual act of reading. Dyslexia leads to significant problems in school performance and life skills that involve reading. It’s clear from Joey’s grades that he struggles the most in reading and spelling.
Also, Joey’s problems with attention in school could be stemming from his dyslexia, which is causing him to have trouble reading. Joey only gets overwhelmed and frustrated when he reads, which would make sense if he cannot understand what he is reading. This leads to him be easily distractible as well as avoiding some activities, which is a natural response for children who do not understand and therefore cannot complete a task. When Joey becomes frustrated with reading and spelling, he loses focus and interest and may be the reason he is “zoning out” during certain activities.
Dyslexia often appears with writing development problems, as writing involves using symbols to convey meaning. Joey seems to be exhibiting symptoms of disorder of written expression. His penmanship is a concern and this could be related to either this writing disorder or potentially to his cerebral palsy. In summary, dyslexia and disorder of written expression could be issues that are adding to Joey’s difficulty in school performance. They also could be the root causes that are leading to his minor behavior problems he exhibits in school.
Further testing should be done to determine if Joey meet criteria for these diagnoses. Recommendations In light of the findings of the current evaluation, the following treatment and educational recommendations are suggested: 1. A psychiatric evaluation is recommended to confirm a diagnosis of a learning disability, specifically, dyslexia and/or disorder of written expression. a. Specifics tests to determine dyslexia may include: Comprehensive Test of Phonological Processing, Slingerland Screening Tests for Identifying Children with Specific Language Disabilities . If Joey receives a dyslexia diagnosis, it is recommended that: a. Joey’s IEP should be revised in order to reflect this additional diagnosis. A PPT meeting should be scheduled to develop an adequate education plan for Joey. i. Joey’s progress in mastering phonetic rules, and in applying these new skills when decoding and spelling should be monitored closely, at 1 to 2 month intervals. Regular team meetings with parents and the educational team should take place to assess Joey’s progress and modify his plan. b.
Joey should spend time with a reading tutor or special education teacher in order to help him develop his reading skills. We recommend that Joey meet with this specialist at least twice a week. The specialist should develop a structured reading scheme, which focuses on repetition and introduces new words slowly, in order to help Joey overcome his problems with reading. c. Joey’s teacher should try and teach spelling more structurally and systematically, focusing on the patterns and rules of the language. This will greatly benefit Joey and would also be beneficial to the rest of the class.
Instead of weekly spelling words being random or topic based, is better to group words based on their structure. d. Joey should proofread everything he writes, at home and at school. He may make many spelling mistakes while writing, but if he looks over his work when he is done, he may be able to catch his own errors, which would help him learn the words for the future. e. Joey should not be asked to read out loud in class at this time. Instead he should spend time one-on-one with the teacher working on his reading skills. 3. It is recommended that Joey receive increased OT to two 30-minute sessions weekly.
One session may be a continuance of his current OT focus, but include an additional session specifically to work on handwriting. Therapy should help him gain both confidence and greater skill in handwriting. 4. The following recommendations are suggested for Joey’s classroom environment: a. Provide preferential seating close to his teacher to gently ensure he stays on task. b. In order to promote confidence for Joey in school, it is recommended that his teacher provide reassurance when Joey is feeling uncertain about his performance. Joey would benefit from increasing his awareness of his many areas of strength. . Because task comprehension has been a consistent difficulty, Joey would benefit from help with organizing and breaking down complex tasks into manageable parts. When Joey is presented with a task requiring multiple steps, it would be helpful to provide him with a simplified checklist of steps, whether written on the board or as a handout. The checklist will allow him to stay on task and to see his own progress, which will improve his confidence in his own capabilities and prevent feeling overwhelmed and frustrated. i. Offer Joey a private place to go calm down when he feels overwhelmed and frustrated. . Provide Joey with additional time for reading, writing, and spelling tasks. e. To avoid frustration, attempt to keep assignments and tasks short. 30 minutes per task is acceptable in preventing Joey from becoming overwhelmed. The key is to provide practice, but not over do it. f. Read or tape directions and long reading assignments, so that Joey may follow along. It might be necessary to have someone help with note taking. g. Allow Joey to respond orally, especially on written tests in the content areas to access knowledge not writing ability. His physical difficulties may make tasks discouraging. h.
It is important that Joey’s teacher understands his limited handwriting ability and takes it into consideration in evaluations. i. Further incorporate group activities in his learning, especially with reading, to increase his interest in the subject with his enjoyment of his peers in mind. For example, after reading stories, Joey and his classmates might perform a short recreation of the story to generate engagement and facilitate comprehension. 5. The following strategies are recommended for home: a. Joey should have opportunities at home for some alleviation of the stress and difficulties of learning in school.
Parents are encouraged to allow Joey time where he does not have to complete schoolwork. b. He should have the opportunity to engage in tasks that he enjoys and in which he has strengths. It is recommended that Joey’s interest in extracurricular activities be encouraged and that he be provided with ample opportunities to interact with friends outside the school environment. c. Parents should read aloud to Joey while encouraging him to read along in his own book, pointing to each word as it is read by his parent, and working through unfamiliar or difficult words d.
According to his level of interest, Joey is encouraged to listen to books on tape, following along in the printed book with his fingers while listening. e. Because Joey enjoys playing on the computer, it is recommended that he use the following games to get more practice with reading at home: i. Free phonics games (http://www. funfonix. com/games/) ii. Free audio books, with additional suggested activities for comprehension (http://www. storylineonline. net/) iii. Free reading games (http://www. roythezebra. com/reading-games-word-level. html; www. professorgarfield. rg; http://www. starfall. com/) iv. Fluency practice (http://www. lexialearning. com/) f. Joey and his brother, Tanner, should work together at home- helping and encouraging each other to make improvements. g. Joey can practice his reading by reading to his sister, Marie, at night before she goes to bed. This could build his confidence in a non-threatening environment. Recommended Resources For Parents and Professionals Books Brunswick, N. (2009). Dyslexia (beginner’s guide). Oneworld. Gehret, J. (1996). The Don’t-Give-Up-Kid: And Learning Differences.
Verbal Images Press. A good resources to explain reading difficulties and learning disabilities to the child, it is at a 6 year old reading level. Knoph, A. (2003). Overcoming dyslexia: a new and complete science-based program for reading problems at any level. Reed Business Information, Inc. Eide, B. (2006). The Mislabeled Child: How Understanding Your Child’s Unique Learning Style Can Open the Door to Success. Hyperion. Websites www. dyslexia-parent. com Contains information about the diagnosis and resources available to parents www. readingrockets. com
Information and resources for parents who are trying to help their children with reading. Includes helpful blog posts from other parents who have kids with reading problems. www. childrensdisabilities. info/learning_disabilities/ldbooks. html Has a list of great books about learning disabilities. www. diin. org/resources Dyslexia Institute of Indiana, offers monthly information sessions classes and provides information about local advocacy groups www. ldaofindiana. org/ Learning Disabilities Association of Indiana – hosts a conference every year in Carmel. http://www. insource. org/
IN*SOURCE, Indiana Resource Center, a parent group that provides training sessions for parents on how to read/understand Indiana State laws about learning disabilites. http://slingerland. org/parents/tutors. html Find reading tutors in your area that specialize in dyslexia Videos http://www. youtube. com/watch? v=EgLam9LM4f8 – What can a parent do to help with dyselxia? http://www. youtube. com/watch? v=buK3j-CAucI;feature=related – What’s the best way to help students with dyslexia? http://www. youtube. com/watch? v=IEpBujdee8M;feature=related – What is it like being dyslexic?