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 In Case Studies, Learning Difficulties

Author:
Jill Sengbusch, MA/CCC-SLP, Speech-Language Pathologist, Parkdale Elementary School, NY

Clinician Bio:
Jill is a New York state licensed, ASHA certified Speech-Language Pathologist, with over ten years of experience. She has served the pediatric population in clinic, hospital and school settings.

Abstract:
Many school-age children demonstrate significant difficulties in the classroom, in multiple, related areas. This case study employed a single-subject design in which iLs was implemented in conjunction with other school-based interventions. The subject, a first-grade student, presented with general gross-motor incoordination, academic and social difficulties and anxiety. After completing an individualized iLs program, the client saw significant gains in academics, social interactions, confidence and emotional regulation. The increases in auditory and language skills (including a 510-point gain on the Phonological Awareness Test) positively impacted his academics, particularly decoding and early literacy skills.His reduced anxiety is apparent in a newfound ability to accept changes to routine and schedule. Socially, G shows confidence when working with peers during academic tasks. He presents as a generally happy child who is now excited to learn and be in school.

Client:
“G”, a 7-year-old male

Background:
G is a first-grade student who demonstrated significant difficulty in early literacy skills and auditory processing. G was diagnosed with a Central Auditory Processing Disorder by an Audiologist at the Buffalo Hearing and Speech Center. G’s teacher reported his skills were significantly below grade-level in phonological awareness, decoding, writing and listening/language skills. G’s independent writing in the fall was just random letters. He was not able to segment a simple word to write the sounds he heard without assistance. G was receiving Academic Intervention Support services in reading and math (three 30-minute group sessions per week in each subject), as well as speech/language (three 30-minute sessions per week: two individual and one group) in school.

G’s mother reported that he would often leave out articles when speaking and often confuse the order of words in sentences. Her concerns were that G “is below level in reading and math and has trouble with comprehension.” Mom also stated, “G is easily frustrated, anxious and very emotional – lots of tantrums”.

G has a history of high-anxiety. He had had difficulty with change and demonstrated a low frustration-tolerance, particularly when engaging in academic or motor-related tasks. He cried easily and perseverated on topics (for example, if he knew there would be a substitute teacher that day). G responded well to structure, but again, struggled when there is a change to routine.

Presenting Problems & Findings:

  • General gross-motor incoordination
  • Anxiety surrounding school and homework
  • Academic difficulties, particularly in reading and writing
  • Auditory Integration deficit and a classic right ear advantage (left ear weakness)
  • Auditory processing difficulties – particularly in decoding and tolerance fading memory

Therapeutic Goals:

  • Increase his ability to independently decode words during structured reading tasks at his instructional level.
  • Increase his ability to retain and recall auditory information (sounds, words) in sequence to a minimum of three items of information with minimal assistance.

Parent Goals:

  • Improve self-esteem and decrease negative self-thoughts regarding his ability to learn.
  • Improve physical coordination to feel more comfortable and confident playing sports.
  • Listen to and comprehend directions or task requested of him with the ability to filter out surrounding sounds.

iLs Program Used:

  • G listened to a customized 23-program (each 80-minutes long) on the iLs Pro over 3 ½ months. Each session was broken into 40-min sessions, Monday through Friday. G also used the Interactive Language Program (ILP) every other day during the Transition and Activation phases.
  • The initial 15-20 min of each listening session was spent using iLs Playbook activities (a combination of visual, balance and coordination activities). The remaining time was used to participate in more traditional speech therapy activities with the last 5-7 minutes of each session saved for the G’s choice of activity. G typically chose a building, craft or drawing activity.
  • * R/L balance was left at 0 throughout the program in response to the noted left ear weakness.

Summary of Changes:

Overall, G demonstrates significant changes in his overall self-esteem and emotional regulation. He is demonstrating decreased anxiety and is readily accepting changes to routine and schedule as well as attempting new tasks throughout his school day. G is taking risks in the classroom, and participating in classroom discussions and activities independently, without physical signs of anxiety. Socially, G shows confidence when working with peers during academic tasks. He presents as a generally happy child who is now excited to learn and be in school.

Standardized Assessments show increases in the following areas:

Clinical Evaluation of Language Fundamentals (CELF-4)
Pre-iLs Percentile Rank Post-iLs Percentile Rank
Concepts & Following Directions 16 37
Recalling Sentences 16 37
Word Classes 84 91
Receptive Language Core Score 34 63
Expressive Language Core Score 50 45*
Language Content Core Score 50 70
Language Structure Core Score 45 47
* G’s score in one subset went down slightly, causing the shift, and he also was scored in a new age bracket. His score remained in the average range.
Phonological Awareness Test (PAT)
Pre-iLs Standard Scores Post-iLs Standard Scores
Substitution 90 98
Blending 92 100
Graphemes
Long & Short Vowels 100 108
Consonant blends Unable to complete (0) 103
Consonant digraphs Unable to complete (0) 99
Vowel digraphs Unable to complete (0) 106
Dipthongs Unable to complete (0) 119
Decoding
VC words Unable to complete (0) 96
CVC words Unable to complete (0) 113
Consonant digraphs Unable to complete (0) 105
Consonant blends Unable to complete (0) 94
Decoding (Reading) Skills – Students are asked to read a grade-level passage for one minute
Pre-iLs Post-iLs
Words Read Correctly per Minute 7 15

Case Study: Learning Difficulties - Reading, Writing & Anxiety iLs checklist

His family has seen positive changes at home. Mom reports, “G was a very anxious child at the start of iLs. Transitions were very difficult for him and caused him much anxiety, often leading to headaches, behavioral outbursts and somatic complaints. Since the onset of therapy, G has drastically decreased his anxiety in the home. He is more willing to adapt to unexpected changes in routine and does not obsess or worry about what is going to occur the following day.” In addition to decreased anxiety, Mom reports “G has more stable moods. Initially, G would be happy and cheerful one minute, then angry and aggressive the following minute. G now has very few aggressive and angry moments; and when those moments do occur, they are a fraction of the time that they previously were. We see a happy and confident child a majority of the time.”

G has increased his ability to retain and recall auditory information. He is consistently able to recall thee-words independently. He is working toward four-word lists, where he is successful in recall given a second presentation of information. G is sequencing multi-syllabic words and blending sounds into words with much less support. G has shown improvements in all areas of language and auditory processing skills.

G has shown steady improvements in his motor planning and coordination skills, which has supported his ability to engage in different activities. Mom reports “a willing to engage in extracurricular sports, without prompting. He is excited to go [to baseball] and enjoys being part of the team. He is working to maintain eye contact with the ball and bat, as well as catching the ball during baseball. This is something he was not able to do before.”

G now completes his homework as soon as he gets off the school bus. In the evening, he is proud to sit and read to his younger brother as well as Mom and Dad. The bigger the audience, the happier G is to read!

Conclusions and Recommendations:

G has developed into a more confident and emotionally regulated child. Developments in these areas have allowed him to make gains in his academics and social interactions as well as in his risk taking and willingness to try new things. G has also shown increases in auditory and language skills, which has positively impacted his academics, particularly his decoding and early literacy skills.

Mom commented, “We cannot be more excited with the changes that we have seen in G. His willingness to make changes and the ability to persevere through difficult lessons has paid off in a big way!”

Pre/Post Videos

Pre-iLs – G in the red

Post-iLs

Comments by Ron Minson, MD, iLs Clinical Director

How would you label this case? Is this a problem with reading? With language? Is this a learning disability? Or is this an emotional dysregulation problem? One could say yes to all of these options. But what came first? And are they connected in any way?

Let’s take a developmental approach to this very interesting and well-presented case to understand how the pieces fit together. Two things stand out in my review of this case: his poor language skills – “he leaves out articles when speaking and often confuses order of words in sentences” – and his poor motor coordination as revealed in the video. His motor coordination and language problems are antecedents to his reading difficulties.

When I began working with children struggling to read, I was struck by the frequent association of motor problems with reading problems. It was as if they were “dyslexic in their bodies” as well as in reading and speaking. A lack of fluidity, timing, organization and sequencing were common to both. To abridge this commentary, I see the most salient feature in this case as the difficulty with motor coordination and planning. To address his cognitive difficulties of reading, math and language before addressing his gross motor challenges is an exercise in futility.

There is clearly an underlying problem in the sequencing and order of sounds in the auditory domain that further affects his acquisition of clear speech and language. So in summary I see the progression as follows: his gross motor incoordination -> speech- language disorder -> poor reading (dyslexia) and handwriting.

The anxiety and “emotional dysregulation” are secondary issues due to his awareness of his poor performance and the repeated failures he has experienced. Of course there would be a great deal of anxiety at going to school where he can be exposed for what he can’t do! Change is unsettling since there is very little in his world that he can control. iLs combined with the therapist’s skills simultaneously improved the underlying disturbances to his academic success and were supported by iLs’ direct effect on emotional regulation and anxiety.

Pre/Post Handwriting Samples

Case Study Learning Difficulties - Reading, Writing & Anxiety Handwriting Samples

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