Learning Disability Case Studies

CHILD LD EVALUATION

REFERRAL INFORMATION

Client was a 14 year old biracial male referred for attention concerns and reading difficulties that have affected work completion and reading comprehension.

Client maintains good familial relationships and enjoys video games and football.  He is very talkative and open socially but is occasionally labeled “annoying” by friends, has trouble initiating conversations, and feels self-conscious about speaking to others.  He has no history of special education services despite issues with reading, reading comprehension, and reading retention since 5th grade.  Client frequently misses letters and misspells words but provides correct responses when spelling aloud.  He often struggles to focus when reading and is easily distracted.  He prefers typing rather than writing for the additional grammar correction features but still struggles with note taking and organizing class notes.

Client has difficulty with sleep but no history of counseling or medication intervention.  Attention issues increased over the last year including issues with task completion, forgetfulness, and fidgeting.  His attention span was reportedly 10-15 minutes long and he often needed explicit instructions.  Client also struggled with blurting out responses, interrupting conversations, and disorganization.  He has trouble with irritability and low mood unless around others and experiences frequent anxiety and panic symptoms when completing schoolwork, providing incorrect responses, and speaking to others.  There are also sensory sensitivities and trouble making eye contact with strangers.

Behaviorally, he was anxious when reading aloud, easily distracted by the environment such that he missed instructions, very fidgety, and made more mistakes when working quickly.  He also needed to stand after one hour.

DIAGNOSES

• Specific Learning Disability with impairment in reading (also known as dyslexia)
• Other Specified Depressive & Anxiety Disorder

- Depressive and anxious episodes with insufficient symptoms (meaning there were not enough symptoms to meet criteria for general anxiety or a major depressive episode)

• Other Specified ADHD (secondary to dyslexia; absent clinical impairment)

- This means that attention and hyperactive deficits occur as a result of reading difficulties and there is no evidence of clinical impairment such as failing grades, poor behavior or home life performance.

• Rule out Autism Spectrum Disorder due to mild social difficulties, anxiety regarding speaking and interacting with others, and sensory concerns

WHAT ARE THE CLIENT’S STRENGTHS?

With some students, their strengths are that they are functioning adequately in some areas and this helps offset vulnerabilities in other areas.  In this client’s case, his verbal abilities are developing nicely.  This means that he will have no difficulties with language, understanding and expressing himself well across most situations.

His spelling and math skills are also evenly developed, which are both good considering how significant his difficulties are in reading.  Though he struggles in several areas of reading, Client’s basic reading, comprehension, and fluency (accuracy and pace) were all within normal limits, meaning they are developing well also.

Client was also described as hardworking and social, both of which can be personal strengths.  He may work harder to keep up and use comfortable social relationships and interactions to get what he needs in instances where he might be struggling or lost and need support.

WHAT ARE THE CLIENT’S VULNERABILITIES?

With this client, his vulnerabilities appear to outweigh the areas that are developing well, thus him having issues compensating or finding ways to manage.

• Nonverbal Skills

Client may have mild difficulty with processing and finding solutions to unfamiliar situations and problems.  This suggests that he may be struggling to find ways to problem-solve even with available and previously learned information.  This may impact finding patterns, understanding how problems may be broken into smaller, more manageable steps, and executing based on available information.

• Reading and Phonological Ability

Though his basic reading, comprehension, and fluency were within normal limits, this client struggled significantly with nonword reading and decoding.  We often use sounds and syllables to help us decode words we have never seen before, which impacts our overall ability to read.  For someone like this client who is good at basic reading but struggles at decoding, he may have a hard time understanding and reading new words.  There was also difficulty with awareness of sound structure in language, combining sounds to form words, and repeating nonwords he heard orally, which also impacts decoding abilities.

• Executive Functioning

Client has issues with sustaining attention and responding consistently over time.  This means that he varies in how and how quickly he responds to stimuli, which may be fast or slow depending on the medium in which it’s presented (orally or visually).  Parent rating forms indicated additional concerns regarding task initiation, remembering things, planning and organizing problem-solving approaches, checking for mistakes and monitoring performance, and keeping materials and belongings in order.  All of these things together may affect his ability to work quickly and efficiently, recognize when he is off task, has completed a task, or has more to do, keep things organized, and pay attention better when distracted.

• Social/Emotional Functioning

Rating forms indicated high levels of atypical behaviors, feeling out of control, social stress, anxiety, depression, physical complaints, difficult relationships with parents, interpersonal problems, anger control, and resilience.

HOW CAN THE CLIENT BEST BE SUPPORTED?

For client’s where their vulnerabilities outweigh their strength and well-developing areas, it is important to take a strength-based approach to treatment that helps them highlight and feel good about what they are good at while also realistically talking about where he continues to struggle.  Ways to do that include:

• Counseling, specifically cognitive behavioral therapy, to address ADHD and mood concerns.  Counseling should also allow the space and opportunity to process and work through his difficulties with learning and how they impact his mood and self-esteem
• Medication consultation for ADHD, anxiety, and depressive symptoms
• Academic accommodations including:

- Extended time and separate testing space

- Oral exam administration in addition to written form

- Reading accessibility tools

- Using a word processing program for writing

- Assistance for assignments including extended deadlines, substitute assignments, reviewing due dates and assignments in advance, and reduced homework as appropriate

- Course substitutions and note-taking assistance

- Frequent breaks

- Tutoring

• Social participation in a group or extracurricular activity
• Re-evaluation for full diagnosis of ADHD if attention issues persist after supports are put in place

ADULT LD EVALUATION

REFERRAL INFORMATION:

Client is a 36 year old female referred for problems with attention and learning.  She has had difficulties with reading, decoding, and reading fluency that has impacted comprehension and resulted in academic accommodations throughout school.  Client also has longstanding difficulties with attention and distractibility along with a family history for ADHD and dyslexia.

Client has no history of developmental delays and maintains good familial and marital relationships.  Her daughter was recently diagnosed with a significant health condition that has contributed to emotional dysregulation and increased overall stress.  However, she boasts an adequate social life and social supports.

Client was recently accepted into a nursing program and has been completing prerequisite requirements online so that she can devote more time and concentration to classes one at a time.  She has had difficulty reading assignments and keeping up with lectures when taking notes.  She also has to listen to pre-recorded lectures repeatedly in order to comprehend the materials.  Client completed a bachelor’s degree program and expressed similar concerns.  However, she was able to maintain good grades with accommodations.  She struggled with reading, decoding, comprehension, and phonetics as a child along with writing, mixing up numbers, and completing math word problems.  When timed, it often took her longer to read questions and answers, which resulted in frequent mistakes due to rushing and misinterpreting questions and instructions.  Client was easily distracted during tests and study times as well.  She was evaluated for and diagnosed with Dyslexia as a child and received an IEP throughout school along with tutoring.  She also participated in the gifted program during elementary and middle school.

Client is employed full time and struggles with attention when not actively participating in meetings.  She also has trouble with spelling, proofreading mistakes, and concentrating.  Medically, she is prescribed anti-anxiety medications but generally healthy.  Client has attended counseling for the past several years following her daughter’s health diagnosis.  She denied current issues with anxiety, depression, and mood, but experienced her daughter’s diagnosis as traumatic.  She also consumes 200mg of caffeine daily.  There were no behavioral observations related to inattention or concentration and she did not require repetitions.

DIAGNOSES

When making or ruling an ADHD diagnosis, available information must indicate the presence of symptoms during childhood (prior to age 12), in more than one environment, as well as clinical impairment.  Otherwise a diagnosis cannot be made.  For adults, it sometimes requires a more thorough clinical interview and asking questions about things beyond the criteria such as “what was completing homework like?” “How did you turn in your homework?” and “What is driving like for you?”  Through this, we can determine how impairment is manifesting and what symptoms may have presented differently in childhood. We must also determine and rule out whether attention deficit and/or executive dysfunction is being caused or influenced by emotional difficulties.

For learning disabilities, academic skills must be well below expectations for age, which may be indicated by low academic achievement or average achievement that is sustainable only by extraordinarily high levels of effort or support.  For adults, low academic skills interfere with occupational performance or everyday activities requiring those skills.  Learning concerns must also be readily apparent in the early school years in most individuals but may also manifest fully in later school years when learning demands have increased and exceed the individual’s limited capacities.

As such, the following diagnoses were provided:

• Specific Learning Disorder with impairment  in reading (also known as dyslexia)
• ADHD, predominantly inattentive presentation

WHAT ARE THE CLIENT’S STRENGTHS?

• Nonverbal Skills

Client has significant strengths in nonverbal skills, which indicates the ability to reason through available information to improve problems solving and to process visual information.

• Verbal Skills & Processing Speed

Her verbal skills and processing speed are developing well, showing no issues with understanding and using language or processing information quickly and efficiently.

• Academics Abilities

Client shows evenly developed skills in the areas of language, writing, which includes essay writing, spelling, and sentence composition, math, and math fluency.

WHAT ARE THE CLIENT’S VULNERABILITIES?

• Reading and Phonological Abilities

While Client’s overall reading skills were adequate, she showed some difficulty with oral reading fluency and accuracy.  She had significant difficulty recognizing familiar words and decoding efficiently under timed conditions.  

Her phonological abilities were fine, but she had a significant issue with rapid retrieval.  This is involved in quickly sifting through essential and nonessential information in memory and “retrieving” what is needed for a given task or question.  People who struggle in this area often need more time to read, answer questions, and perform quick math calculations when there are timed conditions.

• Attention & Executive Functioning

Client was shown to struggle adjusting between low and high demand conditions for both auditory and visual stimuli.  This means that she had trouble with response speed and consistency when there was a low need to pay attention and when paying attention was required.  Because of this, she is likely to tune out when there is little demand to perform or pay attention, be very easily distracted, and have problems with mental alertness.

Based on self ratings, moderate symptoms of inattention were currently present along with sluggish cognitive tempo (daydreaming, trouble staying alert or awake in boring situations, easily bored, spacey, lethargic, and does not seem to process information as quickly or as accurately as others).  Moderate symptoms of inattention were endorsed by an observer and borderline inattentive symptoms were present during childhood.

HOW CAN THE CLIENT BEST BE SUPPORTED?

This client has a history of academic accommodations that have helped her maintain performance and complete a degree program in the past.  Results suggest that she continues to need that.  Considering that she is now experiencing similar difficulties at work, the following recommendations are needed:

• Workplace accommodations including but not limited to: assistive technologies, providing materials for meetings or presentations ahead of time, taped versions of documents, extra time to finish projects, shorter versions of documents, spelling and grammar checking software , and making use of larger print, fonts, or different colored paper.
• Books and online resources for Dyslexia and ADHD
• Ongoing counseling, specifically cognitive behavioral therapy, to address attention concerns..  Counseling should also continue exploring and processing her reactions and emotional experiences related to her daughter’s health.
• Medication consultation for ADHD
• Academic accommodations including but not limited to: extended time on tests and assignments with substantial reading or writing components, distraction reduced testing environment, reading assistance during exams, reading accessibility tools for online instruction, assigned note-taker, recording lectures, and having lecture notes in advance.