Case Study School Aged Child Assessment Report
The following assessment case study describes a 7 year-old girl in the second grade presenting with academic difficulties.
Reason for Referral
Amy, was referred by her mother, Stella, for a cognitive and educational assessment. Stella referred her in the context of Amy appearing to learn at a slower pace than her peers and her apparent word finding difficulties. An initial interview with Stella was carried out on 03/08/2015, and Amy was first seen on 05/08/2015 for assessment. Three forms of assessment were administered to Amy: Cognitive (Wechsler Intelligence Scale for Children: Fourth Edition; WISC-IV), educational (Wechsler Individual Achievement Test: Second Edition; WIAT-II), and memory and learning (Children’s Memory Scale; CMS). Amy was assessed over three sessions and a fourth session was organised with Amy’s parents to provide them with feedback regarding the assessments.
Presenting Problem
Based on information gathered from school reports, Stella, and Amy’s teacher, Amy appeared to display a slow work pace and distractibility. She is disorganised with her room, gets lost with instructions and often has difficulty finding the correct word to communicate what she would like to say. Amy is able to mask her word finding difficulties by stating a definition of the word or an alternative word. Since commencing schooling she has disliked it and struggled academically, evidenced by low marks received on report cards. The beginning of each year of schooling is a struggle for Amy as she is slow to warm up to new teachers and classrooms. She is reluctant to take risks and only attempts things if she is confident in her abilities. Amy sometimes expresses that she does not want to go to school because “she is stupid” or “can’t do the work” and appears to have to work hard to achieve at an average level.
Amy is a relatively well behaved, compassionate, and caring child with a somewhat fiery temperament at times. Amy tends to lose her temper in the classroom or at home when she is having difficulty with an activity. She becomes frustrated, emotionally unresponsive at times, and refuses to complete the activity. Amy stops exerting effort into her learning making it difficult for her to keep up with the expected level. She appeared to be struggling with reading, comprehension and math, and Amy’s teacher expressed concern about her slow work pace.
Upon first meeting Amy on the day of the first test administration, she appeared to be fit and healthy, joyful and excited to meet the examiner. Over the three assessment sessions, Amy was compliant, sociable, and spoke clearly using simple language. Although Amy was initially attentive and motivated, she became quite restless and distracted, as testing progressed, resulting in the need for frequent breaks. She appeared to understand instructions and try hard on all assessments. However, Amy could be reluctant to have a go at tasks she was not confident in responding correctly to. She constantly looked to the examiner for encouragement and reassurance. When presented with large amounts of text on a page, Amy appeared to become overwhelmed and shut down completely, refusing to complete the task. In this instance, Amy required encouragement or a break before she re-engaged in the task. It was notable that Amy would skip words she did not know when asked to read a sentence aloud. As evidenced by observations of Amy and reports from her mother and teacher, it is clear that Amy has experienced great frustration with her schoolwork, specifically her reading skills.
Background Information
Amy is from an intact family with an older sister, Alyssa, who is 10 years of age and a younger brother, Bradley, who is 4 years of age. Amy gets along well with her siblings. Amy’s parents are healthy with no history of any serious medical problems and are both self-employed. Stella is a clinical psychologist and Arthur, Amy’s father, works in telecommunications. Both parents progressed through school with no difficulties. Amy was the product of a planned pregnancy and was born full term at 40 weeks. Amy was delivered with the use of the suction cap and was apparently healthy. There were no signs of prenatal illness or stress and Stella did not smoke, drink alcohol, or take any drugs or medication during pregnancy.
Amy was described as being a very placid and easy to look-after infant, and was breast-fed till the age of 12 to 13 months. Stella’s only concern for Amy during infancy was that she had severe eczema and cradle cap. Amy met all developmental milestones at age appropriate levels. She was identified as being a typical toddler who tested the limits on occasion, but responded relatively well to discipline. Amy was toilet trained by the age of 3, but had, and continues to have problems with constipation. Amy has gone through phases of soiling and has seen a specialist regarding this. She has been on medication to assist with her continence difficulties since the age of 6 years. Apart from these continence difficulties, Amy has no noted serious medical history, no hearing problems or problems with eyesight.
Amy has exhibited a slow work pace and distractibility since prep, and this has been a relatively stable concern for Stella throughout Amy’s years of schooling to date. Amy was slow to warm up to reading and did not begin reading until the second semester of Prep.
At school, Amy’s teacher communicated that Amy is fairly well behaved in the classroom but inclined to get distracted. Amy often takes long trips to the bathroom and often needs to be reminded to stay on task. Amy appears to be making reasonable progress academically, but Amy’s teacher is concerned about her slow work pace, reading and mathematics skills, and apparent frustration with challenging tasks. Amy seems to be relatively sociable at school and is involved in some outside school activities including; musical theatre, swimming and oz-kick. Amy enjoys musical theatre and Stella expressed that observing her in these classes is the first time she has seen Amy passionate and confident.
Test Administration
The WISC-IV, WIAT-II and CMS were administered to Amy to assist with understanding what her cognitive and academic abilities look like, as well as what her memory is like. Based on Amy’s presenting problem and background history, these assessments were chosen to clarify Amy’s skill level and underlying cause of her reported slow work pace and word finding difficulties.
The WISC-IV produced a Full Scale Intelligence Quotient (FSIQ) score (a single score representing Amy’s overall estimated intellectual functioning) that placed Amy in the Average range (27th percentile). However, Amy’s processing speed score was in the Low Average range (13th percentile), which may have something to do with her slow work pace. Amy’s results from the WIAT-II indicated she is in the Low Average range for Reading (18th percentile) and Mathematics (14th percentile), but in the Average range for Written Language (53rd percentile). It is notable also that in the Reading index Amy performed in the Average range during the word reading subtest (30th percentile) but in the Low Average range during the psuedoword decoding and reading comprehension subtests (14th percentile). Therefore Amy appears to have trouble with automaticity and fluency when reading sentences and unfamiliar words, and struggles to extract meaning from text. Lastly Amy’s CMS results indicated she has Average to High Average skills in immediate memory of visual information (84th percentile) and delayed memory of visual information (73rd percentile). Amy’s verbal immediate and delayed memory was placed in the Average range (42nd percentile and 58th percentile respectively). Additionally, Amy was found to have attention/concentration skills in the Low Average range (21st percentile) and her scores on the learning (66th percentile) and delayed recognition (34th percentile) subtests placed her in the Average range for these areas. Although Amy’s general memory score places her in the High Average range (75th percentile), this should be reported with caution due to her varied profile on the CMS.
Amy was talkative during all assessment administration, appeared to be in a positive mood, and calm throughout. Despite her somewhat diminishing motivation at times, Amy was able to focus when needed and still appeared to be thinking about her answers before providing them. Given the observations during administration of these three assessments, and their results, the WISC-IV, WIAT-II, and CMS are considered valid representations of Amy’s abilities.
Formulation
Predisposing factors. There appears to be a history of slow processing speed and academic difficulties as Amy has demonstrated a slow work pace from prep. Amy’s late interest in reading may have predisposed her current difficulties with reading. Amy has disliked school from the very beginning, and her negative view of schooling may have hindered her capacity to focus and exert effort into her learning. Therefore this may have also predisposed her current difficulties.
Precipitating factors. Amy’s slow processing speed may have triggered her distractibility and difficulties with reading and math. Amy is aware that she requires more time to complete tasks than her peers and gets frustrated. This may be precipitating her distractibility, causing her to disengage from the task, and affecting her learning.
Perpetuating factors. Amy’s reluctance to try unless she is confident in her abilities and her distractibility may be maintaining her difficulties in reading and math, as well as her slow work pace. Her awareness of her difficulties may also be a maintaining factor, as she disengages when she realises she cannot do a task or is taking too long to complete it.
Protective factors. Amy is in good health and has loving and caring parents. Amy’s teacher reported she has friends at school and her mother reported she has good social skills and is creative. Amy appears to be a happy, social and knowledgeable child with good memory skills. All these factors will assist Amy in improving academically with appropriate intervention.
Diagnosis
After considering the collected information it appeared that Amy was displaying symptoms consistent with Specific Learning Disorder with impairment in reading (315.00(F81.0)). The DSM-5 criterion A requires at least one symptom associated with difficulties learning and using academic skills to be present for at least 6 months, despite the provision of interventions that target the difficulties (American Psychiatric Association, 2013). In line with criterion A, Amy has been exhibiting academic difficulties throughout her schooling years to date. Results of the WIAT-II indicated Amy’s word reading pace is slow and effortful, as she tends to skip words she does not know and struggles to sound words out. Amy’s slow work pace may also be a product of her difficulties with reading. Amy further exhibited difficulty with extracting meaning from text as evidenced by her score on the reading comprehension subtest of the WIAT-II.
Criterion B states the academic difficulties must be substantially below the expected level for the individual’s age and significantly impede on academic performance. Assessment results indicated Amy is only slightly below the average level for her age. However, criterion C states that the learning difficulties start in school-age years but may not fully become apparent until demands for the affected skills exceed the individual’s limited capacities. Amy may be at the early stages of diagnosis in which academic demands have yet to exceed her capabilities.
Criterion D states the learning difficulties are not better explained by intellectual disabilities or other medical conditions, or inadequate educational instruction. Amy does not display any signs of an intellectual disability or memory deficits as evidenced by results of the WISC-IV and CMS, and she has no reported auditory, motor or eyesight problems. Amy is competent in the English language of instruction at her school, receives adequate educational opportunity and is exposed to the same instruction as her peers. Differential diagnoses of attention-deficit/hyperactivity disorder and psychotic disorder were also excluded because criteria for these disorders were not met. Despite Amy’s distractibility at times and reported disorganisation, this was not inconsistent with her developmental level.
Although Amy’s difficulties have been present for some time, a diagnosis of specific learning disorder with impairment in reading was not made due to the inability to conclude whether these difficulties persist following targeted intervention. An intervention plan needed to be put in place before a formal diagnosis could be made.
Relevant Evidence-Based Theories
Tests of Amy’s cognitive abilities show that she has the ability to perform at grade level, and does so in some areas, but struggles to do so in others. This may be due to a number of things. One hypothesis was that Amy might have poor processing speed that is affecting her learning, as evidenced by her slow work pace, distractibility and WISC-IV results. Amy may also be in the early stages of developing a specific learning disorder. She is performing at the expected academic level for her age in most areas but struggles with reading and math. Another hypothesis was that Amy’s learning style might not match her teacher’s instruction style. Research has shown that a student’s learning capacity and learning outcomes can be impacted upon by the compatibility of his or her learning style and the instructor’s teaching style (Ford & Chen, 2001). After observing Amy during assessment sessions, it was clear that she lacks confidence in her academic abilities. A study by Yip (2012) found that self-efficacy, or an individual’s perception of whether they can achieve something, has an affect on academic performance. Therefore Amy might be inclined to disengage from tasks quicker because she is aware she takes longer than her peers or she believes she cannot complete it.
Possible Course of Future Intervention Plans and Delivery Goals for future intervention included Amy being able to read accurately and fluently at a quicker pace, being able to extract meaning from text with less effort, improving her math abilities and increasing her confidence and self-efficacy. Suggested intervention consisted of organising a tutor to work with Amy once a week on Saturday mornings. Based on Amy’s indicated areas of academic weakness, this tutor would focus on practice with reading fluency and reading comprehension, and improving her skills in math. In addition to this, Amy was to practice reading every night with her parents to improve her reading fluency speed. Research suggests that, repeatedly practicing oral reading of appropriate grade level text, supports growth in oral reading fluency and comprehension (Wendling & Mather, 2008).
Positive reinforcement and encouragement appeared to be very important for Amy, as she seemed to lack confidence in her abilities, preventing her from attempting unfamiliar tasks. It was suggested that a reward system put in place at home and in the classroom might prove useful for Amy, where the emphasis is more on trying than achievement. Providing Amy with encouragement, praise and motivation will build her self-esteem, self-efficacy, and confidence (Robins, 2012). It was also suggested that work requirements at school be modified for Amy. A reduction in the volume of class work and an increase in time to complete tasks was recommended. Instructions given by Amy’s teacher were to be kept basic and easy to understand, and provided to Amy orally and/or visually. This was recommended because Amy experiences difficulty focusing, which might be because she has difficulty understanding directions. Research has shown that understanding depends on the interaction between features of the information, and that diagrams can reduce cognitive load, increasing understanding (Marcus, 1996).
It was recommended that Amy be re-administered the WIAT-II in one year to explore if her difficulties have persisted despite intervention, and if there is reason for concern around a specific learning disorder.
Evaluation and Reflection This was a demanding yet positive training case. Amy’s parents were provided with possible interventions that could be implemented for her, however I would not know the outcome of these. Although the feedback session with Amy’s parents ran smoothly, it was a struggle for me to come to terms with the idea that I would not know if Amy’s difficulties improved or remained. Nonetheless, Amy’s parents appeared to be pleased that Amy did not seem to fit the criteria for any learning disabilities, but required some intervention to support her learning and build her confidence.
I struggled with learning how to administer each of the assessments appropriately and taking notes in session while still remaining present with the client. I learnt a lot about myself, about ethical consideration and the complexity of assessments with children at times. In future, I need to be more present with the client and not constantly thinking about what needs to be done or said next. This will clearly improve with practice. Although there are many things that still need improvement, I believe that I handled this case to the best of my capabilities at this early stage of my psychology career.

References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: American Psychiatric Association.
Ford, N., & Chen, S. Y. (2001). Matching/mismatching revisited: An empirical study of learning and teaching styles. British Journal of Educational Technology, 32(1), 5-22.
Marcus, N., Cooper, M., & Sweller, J. (1996). Understanding instructions. Journal of
Educational Psychology, 88(1), 49.
Robins, G. (2012). Praise, motivation, and the child. Routledge.
Wendling, B. J., & Mather, N. (2008). Essentials of evidence-based academic interventions
(Vol. 74). John Wiley & Sons.
Yip, M. C. (2012). Learning strategies and self-efficacy as predictors of academic performance: A preliminary study. Quality in Higher Education, 18(1), 23-34.