Case Study: Acute Lymphoblastic Leukemia (ALL) and associated challenges related to reading fluency

Authors: Jennifer Sumner, Ph.D.; Licensed Psychologist, Clinical Assistant Professor OU School of Community Medicine–Tulsa & Megan McKinney, P.T.

Case: “C” is a 7 year old female diagnosed with Acute Lymphoblastic Leukemia (ALL) and associated challenges related to reading fluency. “H” is a 7 year old male diagnosed with Acute Lymphoblastic Leukemia (ALL) and associated challenges related to reading fluency and fine motor skills. Neither “C” nor “H” were involved in any additional private therapeutic services.

Summary: Both “C” and “H” were diagnosed with ALL at the approximate age of five years old, had completed their initial treatment phase and were in the maintenance phase. Both began displaying academic struggles during 1st grade. Results of evaluation completed with “C” indicated the presence of learning disabilities in academic areas of reading (word recognition, reading comprehension, nonsense word decoding, reading fluency) and written expression. Results of evaluation completed with “H” indicated the presence of a learning disability in the area of reading (reading fluency, nonsense word decoding) as well as fine motor delays.

Intervention was developed to address these difficulties which included integrated Listening Systems (iLs). Both cases experienced academic gains as a result of the iLs program. Teacher and parent comments supported formal academic assessment of academic gains.

Pre/Post Assessment: Both “C” and “H” were administered a comprehensive psychological evaluation which included a combination of the following tests: Wechsler Intelligence Scale for Children-Fifth Edition (WPPSI-IV)/Wechsler Preschool and Primary Scale of Intelligence-Fourth Edition (WPPSI-IV); Wide Range Assessment of Memory and Learning-Second Edition (WRAML-2); The Beery VMI Developmental Test of Motor Coordination-Sixth Edition; Kaufman Test of Educational Achievement-Third Edition (KTEA-III: Forms A &B); Wechsler Individual Achievement Test-Third Edition (WIAT-III) reading fluency subtests; Behavioral Assessment System for Children–Third Edition (BASC-3) parent & teacher forms; The Aggregate Neurobehavioral Student Health & Educational Review (ANSER).

Background: “C” is a 7 year old girl of Caucasian race. She attends 1st grade at a private school. She was born at 42 weeks gestation. Developmental milestones were reportedly achieved within normal limits for all areas. Medical history was noted to include a diagnosis of Acute Lymphoblastic Leukemia in September 2015 with subsequent medical procedures and chemotherapy treatment started shortly thereafter. She was additionally noted to be at greater risk for negative effects of treatment due to receiving a higher dose of Methotrexate than most patients (she received four doses). She was in the maintenance phase of cancer treatment during the implementation of the iLs program.

“H” is a 7 year old boy of Caucasian race. He attends 1st grade at a public school. He was born at 40 weeks gestation. Developmental milestones were reported to follow a normal progression until fine motor delays were noted at age four. Medical history was noted to include a diagnosis of Acute Lymphoblastic Leukemia on April 7, 2015 with subsequent medical procedures and chemotherapy treatment started shortly thereafter. He was additionally noted to be at greater risk for negative effects of treatment due to receiving extra chemotherapy due to being male. “H” was in the maintenance phase of cancer treatment during the implementation of the iLs program.

Therapeutic Goals:  

Improve reading fluency skills specifically for both “C” and “H”.

Improve academic performance across all subjects for both “C” and “H”.

Improve fine motor skills for “H”.

iLs Programs Used:

Both “C” and “H” were administered ten sessions of the iLs Sensory Motor program followed by the complete Reading and Auditory processing program. The program was administered three times weekly for the full 60 minutes. One session per week was done under the supervision of the physical therapist while the two additional weekly sessions were completed at home by the parent.

Results and Discussion:

Case “H”

“H” was re-administered selected assessment tasks to determine the impact of the Integrated Listening System (iLs) intervention program administered. Upon re-evaluation academic skills were assessed to fall within the average to above average ranges and within a level expected when compared to his predicted ability. Comparison of assessment completed in October 2017 to that completed in May 2018 indicated growth and improvement in fine motor coordination skills as well as across all academic areas, with the greatest improvement noted in academic areas of math reasoning, nonsense word decoding and reading fluency skills. Analysis of his informal writing sample also indicated increased ability to express his thoughts in written form; with improved spelling and an increased word count noted.  The ANSER was also completed again in April 2018 by “H”’s teacher to assess perceived growth and/or continued academic concerns. Comparison of the teacher’s ratings on the ANSER from October 2017 to April 2018 indicated improved performance in in the following areas: decoding unfamiliar words orally, reading aloud fast enough, reading aloud with accuracy, reading silently at an appropriate rate, reading silently at an appropriate rate, forming letters legibly/accurately, copying from the board/overhead accurately, writing in complete sentences, spelling within sentences/paragraphs and isolation, learning new spelling words and writing sufficient amounts.

WIAT-III Reading Fluency

Time/Passage                         Oct 2017                                 May 2018

Passage #1                               67 seconds                             15 seconds

Passage #2                              5 minutes 25 seconds          63 seconds

Case “C”

“C” was re-administered selected assessment tasks to determine the impact of the Integrated Listening System (iLs) intervention program administered. Academic skills were assessed to fall within the low average to above average ranges and below a level expected when compared to her predicted ability for the area of nonsense word decoding while letter and word recognition was noted to be one point away from being discrepant. Comparison of assessment completed in October 2017 to that completed in May 2018 indicated growth and improvement across all academic areas, with the greatest improvement noted in areas of reading comprehension, reading fluency and written expression. Analysis of her informal writing sample also indicated increased ability to express her thoughts in written form; with improved spelling, a higher word count and complete sentences noted. The ANSER was also completed again in April 2018 by “C”’s teacher (Ms. Lewis) to assess perceived growth and/or continued academic concerns. Comparison of the teacher’s ratings on the ANSER from October 2017 to April 2018 indicated improved performance in areas of writing, language and memory but continued concerns in the area of reading.

WIAT-III Reading Fluency

Time/Passage                         Oct 2017                                 May 2018

Passage #1                               53 seconds                             19 seconds

Passage #2                              6 minutes 43 seconds          65 seconds

Parental Observations and Comments:

From “H’s” mother:

“The iLs program was well-organized, easy to follow, and (mostly) fun for “H”. Throughout the course of the program, “H” seemed to improve in coordination, specifically bilateral coordination and crossing the midline. He also experienced a drastic improvement in his reading ability, though it is difficult to know whether that was attributable to iLs or to increasing his practice of reading at home and being in school full-time for the first time…He was improving before we began iLs, but it could have been the cumulative effect of everything we were doing that contributed to his success. It certainly didn’t hurt.” Where we had difficulties was with increased irritation and insomnia during iLs, although these were symptoms he already experienced on chemotherapy.”

From “C’s” mother:

“C” enjoyed the challenge of activities and games during iLs sessions, especially when in the group setting with “H” due to fun and competition. At times “C” was not eager to begin a session but would have fun once the session began. Improvements were especially noticed in reciprocal gross motor tasks with cognitive recall. Her teacher was impressed with her improvements in reading fluency and spelling accuracy and stated her progress was better than she had predicted.”

Summary of Changes, Conclusions and Recommendations:

Both “C” and “H” evidenced an increase in academic performance not only in areas assessed as meeting criteria for a learning disability but generally across all academic areas as a result of participating in the Reading and Auditory Processing program. Academic growth ranged from mild to significant when measured by standardized testing (e.g., standard scores and percentiles). In addition “H” evidenced gains in fine motor coordination skills. Findings indicated, for these two individuals, that involvement in the iLs program produced significant gains in reading fluency skills beyond those typically expected with normal developmental growth and school exposure.

Re-evaluation of reading based skills is scheduled for late November/early December 2018 to assess sustainability of skills.