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 In Case Studies, Learning Difficulties

Abstract:
H, an 11-year-old girl with a history of medically treated AD/HD since kindergarten, had an 18-point full scale IQ increase after approximately four months of iLs. The gains were primarily due to a 25-point improvement in her non-verbal index. Both her therapist and teachers reported improved attention and ability to process verbal information, and test scores in those areas supported their observations.

Authors:
Mark L. Prohaska, Ph.D., Licensed Clinical Psychologist, Clinical Neuropsychologist, Clinic Director), Heather C. Miller, B.Slinic Coordinator, Michelle Campbell, B.A.

Name of Organization:
Neuropsychology Clinic, P.C.

Client:
“H”, an 11 year-old girl

Background:
H has a history of AD/HD, treated with medication since Kindergarten. Overall, H was observed to be easily distracted and to take a much longer time to get tasks accomplished than she should. She gets along well with her peers and participates in a Girl Scout troop.

Presenting Problem:
H has required two increases in her AD/HD medication dosage over the previous year. Her inability to complete tasks during the school day was making the homework load at night overwhelming, and her family was considering homeschooling.

H’s performance on formal cognitive testing revealed that she was performing below her potential in several aspects of cognitive functioning, most notably in the areas of attention and response control (auditory skills testing lower than visual skills). Her mother also commented several times on H’s clumsiness and tendency to sporadically fall into stationary objects. Upon initial observation, it was noted that H exhibited extremely poor vestibular and proprioceptive abilities as well as poor coordination and somewhat awkward gross and fine motor movements.

Therapeutic Goals:

  • Sensory-motor integration
  • Visuo-motor coordination
  • Higher order attention
  • Working memory
  • Executive tasks

iLs Program Used:
iLs Concentration & Attention Program (40 one-hour sessions), three times per week in clinic.

Other Interventions used:
Cognitive-Behavioral interventions

Post-treatment evaluation:
At baseline, H obtained an estimated Full Scale IQ of 85 (low average range). An analysis of her index scores revealed slightly better developed verbal vs. nonverbal abilities (Verbal = 92, average range; Nonverbal = 83; low average range; all based on mean=100; SD =15), a statistically significant though not uncommon difference that was seen in 25% of the standardization sample. H’s post-treatment performance on this measure yielded a Full Scale Estimate of 103 (average range), representing an 18-point increase over her baseline performance. This increase was largely due to a 25-point improvement in her nonverbal index, which reversed the verbal-nonverbal discrepancy that was present at her baseline testing.

WASI – II
Subtest Raw T-score Scale Sum of T-scores CompositeScore %ileRank Confidence Interval (95%)
Block Design (17)30 (40)50 Verbal (90)97 (92)98 30(45) (86-99) 91-105
Vocabulary (25)30 (44)51 Nonverbal (79)110 (83)108 13(70) (77-92) 100-115
Matrix Reasoning (12)22 (39)60 Full Scale (169)207 (85)103 16(58) (80-91) 97-109
Similarities (22)23 (46)46
Confidence Level (IQ =(103 ) Difference Raw Significance Base Rate
90% 68% VCI>PRI 10 .15 20%
(85-87) 103-104 (85-86) 103-104 VCI<PRI

*pre-treatment scores are in parentheses

June October
IQ 85 (low average) 103 (average)

With the exception of psychomotor speed, H’s post-treatment performance on cognitive measures reflected an improvement to the average range of functioning in all cognitive domains, which correlates with the improvement of her estimated overall level of ability from the low average to the average range.

X = Post-Treatment; O = Pre-treatment

Patient Profile Percentile Range > 74 25 – 74 9 – 24 2 – 8 < 2
Standard Score Range > 109 90 – 109 80 – 89 70 – 79 < 70
Domain Scores Subject Score Standard Score Percentile ValidScore Above Average Low
Average
Low Very
Low
Neurocognitive Index (NCI) N/A 37 Yes X O
Composite Memory 100 47 Yes XO
Verbal Memory 51 32 Yes X O
Visual Memory 49 63 Yes XO
Psychomotor Speed 133 19 Yes O X
Reaction Time 677 55 Yes X O
Complex Attention 22 30 Yes X O
Cognitive Flexibility 25 40 Yes X O
Processing Speed 38 19 Yes X O
Executive Function 33 55 Yes XO

In the area of attention, H’s baseline performance revealed significant deficits in auditory (though not visual) response control and low average abilities to sustain her attention over extended periods of time for both auditory and visual information. H’s post-treatment performance in this arena revealed a significant improvement in auditory response control as well as in both auditory and visual sustained attention, both of which improved to the average range.

IVA Continuous Performance Test
Response Control Attention
  Baseline Post Rx   Baseline Post-iLs Rx
Full Scale Quotient 73 88 Full Scale Quotient 90 105
Auditory 55 75 Auditory 92 106
Visual 93 99 Visual 88 103

Lower scores reflect greater deficits

H’s mother’s baseline observations on the Conners-3 Parent Report resulted in significant elevations on the Inattention and Hyperactivity/Impulsivity content scales; the Learning Problems and Executive Functioning sales were also elevated, though to a lesser degree, while the Defiance/Aggression and Peer Relations scales were in the average range. An analysis of the DSM-IV-TR Symptom Scales revealed an endorsement of symptoms that meets criteria for a diagnosis of ADD, Predominantly Inattentive Type, with her endorsement of symptoms resulting in a 97% probability that the condition exists (based on the Conners-3 ADHD Index); however, she endorsed a very high number of hyperactive/impulsive symptoms as well that fell only one symptom short of meeting diagnostic criteria for AD/HD of the combined type. Her mother’s post-treatment observations on the Conners-3 resulted in no significant changes of the clinical or DSM-IV-R symptoms scales.

Conners Parent Rating Scales (t-scores)
Content Scales DSM-IV-TR Symptom Scales
  Baseline Post Rx   Baseline Post-iLs Rx
Inattention 78 88 Inattentive AD/HD 76 81
Hyperactivity/Impulsivity 85 83 Hyper/Impulsive AD/HD 80 77
Learning Problems 63 72 Conduct Disorder 44 44
Executive Functioning 67 65 Oppositional Defiant Disorder 49 49
Defiance/Aggression 51 47
Peer Relations 48 58

Lower t-scores reflect great level of impairment

At baseline, H’s parent’s ratings of her executive abilities on the Comprehension Executive Functioning Inventory (CEFI) resulted in an overall classification that fell in the low average range with lower scores in the area of initiation and significant relative weaknesses in attention (2nd percentile) and working memory (2nd percentile). Post-treatment, H’s full scale score significantly improved from the low average to average range with statistically significant improvements being seen in the areas of attention, emotional regulation, flexibility, and working memory.

Comprehensive Executive Function Inventory (CEFI)
  Baseline Post Rx Significance
Full Scale 83 96 Significant
Attention 70 93 Significant
Emotional Regulation 80 95 Significant
Flexibility 106 124 Significant
Inhibitory Control 102 109 No Change
Initiation 78 90 No Change
Organization 80 85 No Change
Planning 98 105 No Change
Self-Monitoring 93 93 No Change
Working Memory 68 84 Significant

Lower scores reflect greater deficits

Summary of Changes:
H’s full scale IQ estimate increased by 18 points (from the low average to the average range), mostly due to a significant 25-point improvement in her nonverbal index, which reversed the verbal-nonverbal discrepancy that was present at her baseline testing. H’s performance on screening measures of academic achievement revealed no significant differences between baseline and post-treatment assessment, with her results being most notable for an unusual decline in word reading performance that is of uncertain etiology or significance.

H’s performance on formal cognitive testing revealed significant improvements on measures of complex attention, reaction time, cognitive flexibility, and processing speed, as well as significant improvements in auditory response control and both auditory and visual sustained attention. Although her parent’s rating on measures of executive functioning suggested significant improvement in attention, emotional regulation, flexibility, and working memory, a comparison of baseline to post-treatment rating on other behavioral measures completed by H’s parents revealed no significant differences in symptom ratings that correlated with the improvements seen on formal cognitive testing and their functional ratings on the CEFI.

Personal Comments by Heather Miller, Clinician:
H began our program very shy and extremely uncoordinated. Her gross motor movements were very awkward and she was unable to stay in time with her therapists.. She was socially inappropriate often and seemed to speak exactly what was on her mind at all times. She took jokes so literally that our sessions became very bland and monotonous for her. About halfway through, she began making her own jokes and laughing much more often. Her gross motor movements were much more fine-tuned and rhythmic and her coordination was impeccable. She quickly became a social butterfly, initiating and leading conversations just about every session.

Comments from iLs Clinical Director, Ron Minson, MD:
When seeing improvements in IQ following an iLs program it is tempting to say that iLs increases IQ. However, it is more likely that iLs has improved brain function and removed obstacles to a student’s achieving their potential. The result – IQ scores go up. This is certainly true when inattention, poor working memory, distractibility, disorganization and auditory processing issues are present. Any one of these conditions is enough to lower performance in general as well as on an IQ test.

It is interesting to note that the 18-point increase in IQ resulted mostly from the 25-point improvement in her non-verbal index – a right brain function. Attention pathways are also allocated primarily to the right brain, particularly the right fronto-temporal lobes. Thus we see a correlation between attention and non-verbal skills. The significant improvements in auditory response control and in auditory and visual sustained attention are quite relevant here.

Improved body organization is a prerequisite for cognitive functions such as attention, freedom from distractibility and emotional regulation among others. Remember that cortical or cognitive function is highly dependent upon good subcortical organization as reflected in the degree of body organization. The following comment from her therapist is apropos in this regard: “Her gross motor movements were much more fine-tuned and rhythmic and her coordination was impeccable.” Now we see that her higher cognitive functions are freed up to do what they were designed to do rather than manage a poorly integrated body.

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