Case Study: Hyperactivity, Aggression and Auditory Processing Difficulties

Associate’s Name & Discipline:
Lynn Schoeneck , OTR/L

Name of Organization:
Porter Academy

Presenting Problem:
Inattention, hyperactivity, aggression, poor peer interactions, auditory processing difficulties, making disruptive sounds or screaming during class

Background:  
Male, age 7 years, 8 months (pre-test Jan 2010); 9 years, 0 months (post-test May 2011)
Diagnosed with Asperger’s, ADHD, Anxiety during transitions

Therapeutic Goals:
Improve auditory processing, improve attention, decrease hyperactivity and aggression, improve self-regulation, improve bilateral coordination and balance

iLs Program Used:
Spring 2010: Sensory Motor – 50 hours of Sensory Motor Program
Fall 2010 and Spring 2011 – 60 hours of Sensory Motor Program

Other Interventions used:
Received occupational and speech therapy within a group setting as part of the curriculum at Porter Academy.

Conclusions and Recommendations:
The improvements that made the biggest difference for this boy were in auditory processing, attention, and self-regulation.  His auditory processing improved from “disordered” to “normal” in every category and overall auditory processing composite improved from 0.1% to 81%.  While he was previously unable to sit for 15 minutes straight and attend to an academic task, he now has no trouble attending to task, even during independent centers.

His improved ability to self-regulate has also had a great impact on his functioning.  He used to be aggressive (punching/throwing pillows, screaming in people’s faces); this has completely stopped.  He can still get overly excited at times, but his ability to bring himself back to a “just right level” has improved dramatically (he can do this on his own and in a timely manner).  His overall academic and social functioning has made an impressive turn, and he is a much happier child.

COMMENTARY BY RON MINSON, MD, iLs Clinical Advisor and Advanced Trainer:

This very interesting case illustrates a number of features worth noting. As he gained control of his externalizing behaviors – aggression, hyperactivity and conduct- his anxiety may have temporarily increased.  It isn’t clear since the original teacher rated him as having more anxiety but a new teacher after the summer break rated this as typical. Nevertheless, let’s assume he is more anxious. How can we account for this? His increase in self-control has to come from increased self-awareness in order to alter the behavior through increased self-control.

With this increased self-awareness comes a sense of insecurity which I like to call “stage fright.” With all the changes, he might be feeling, “I don’t know how to act.” He is in a new body, so to speak, uncertain how to act if not doing the old acting out behaviors. Yet, in spite of this anxiety, he has shown an increase in leadership, thus, increased responsibility, uncertainty and anxiety.  The increase in somatization, although scoring typical (the scores are at the extremes of typical), is understandable given his increase in self-awareness. Before, I doubt if he had much awareness of himself; his behaviors suggest he impulsively expressed whatever he felt toward the world. Hopefully, with time and more listening he will continue to improve his social skills, gain confidence and reduce his anxiety. I think the higher frequencies from the next program will help in this regard.

Summary of Changes: (tests, observations, feedback, etc.)

Auditory Processing as measured by the SCAN 3: C – January 2010 and August 2011

Summary: Improved in every category of the SCAN-3:C diagnostic tests from disordered to normal. Auditory Processing Composite improved from 0.1% to 81% over a time span of 1 ½ years.

	Raw score	Scaled score	Percentile	Descriptive Category
Auditory Figure Ground +8 – January 2010	0	1	0.1%	Disordered
Auditory Figure Ground +8 – August 2011	40	14	91%	Normal
Filtered Words  – January 2010	14	5	5	Borderline
Filtered Words  – August 2011	29	10	50	Normal
Competing Words – Directed Ear – January 2010	10	1	0.1%	Disordered
Competing Words – Directed Ear – August 2011	43	11	63%	Normal
Competing Sentences – January 2010	24	4	2%	Disordered
Competing Sentences – August 2011	68	12	75%	Normal
Auditory Processing Composite – January 2010		51	0.1%	Disordered
Auditory Processing Composite – August 2011		113	81%	Normal

Gross Motor Skills as measured by the Bruininks-Oseretsky Test of Motor Proficiency, Second Edition

Summary: His motor skills improved by over one standard deviation in the area of bilateral coordination and over two standard deviations in the area of balance.

BOT-2 (scale score: mean = 15, SD=5)	Bilateral Coordination	Balance
January 2010	10	7
May 2011	16	19

Behavior Assessment System for Children, 2^nd edition (BASC-2: parent rating scale)

Summary

• Externalizing Problems: In January, he ranked as having more problems than 75% of the population (at risk) in the category of externalizing problems (hyperactivity, aggression, conduct problems).  By May 2011, the same teacher ranked him has having more problems than 52% of the population (typical).
• Internalizing Problems: While his depression ranking improved, his anxiety and somatization got worse over this time period.  From talking with his teacher, this may be associated with increased social interaction (and the stresses involved with managing friendships) and a more difficult work load.  His 2011-2012 teacher ranked his anxiety back down to 52% (“typical”).
• Behavioral Symptoms Index: Overall improvement in this area went from having more difficulties than 86% of the population (at risk) to having more difficulties than 66% of the population (typical).  This section includes ratings on atypical behavior (86% to 65%), withdrawal (95% to 91%), and attention problems (80% to 58%).
• Adaptive Skills: Overall improvement from 23% to 30% (higher scores better on this section).  The specific areas in which he displayed the most improvement include leadership and functional communication.

Externalizing Problems: Teacher Rating higher scores indicate more problems	T score	Percentile Rank	Descriptive Classification
Externalizing Problems composite – January 2010	55	75%	At Risk
Externalizing Problems composite – May 2011	48	52%	Typical
Hyperactivity – January 2010	65	91%	At Risk
Hyperactivity – May 2011	52	69%	Typical
Aggression – January 2010	50	64%	Typical
Aggression- May 2011	46	45%	Typical
Conduct Problems – January 2010	49	55%	Typical
Conduct Problems – May 2011	47	51%	Typical

Internalizing Problems: Teacher Rating higher scores indicate more problems	T score	Percentile Rank	Descriptive Classification
Internalizing Problems composite – January 2010	49	51%	Typical
Internalizing Problems composite– May 2011	61	88%	At Risk
Anxiety– January 2010	58	81	Typical
Anxiety – May 2011	82	99%	Clinically Significant
Anxiety – October 2011 (different teacher rater)*	48	52%	Typical
Depression– January 2010	47	51%	Typical
Depression – May 2011	45	38%	Typical
Somatization– January 2010	42	19%	Typical
Somatization – May 2011	50	66%	Typical

* I compared January 2010 to May 2011 so the ratings were completed by the same teacher.  However, looking at the Fall 2011 ratings, his anxiety was rated much lower.

Behavioral Symptoms Index: Teacher Rating higher scores indicate more problems	T score	Percentile Rank	Descriptive Classification
Behavioral Symptoms Index composite– January 2010	61	86%	At Risk
Behavioral Symptoms Index composite – May 2011	52	66%	Typical
Atypicality– January 2010	59	86%	At Risk
Atypicality – May 2011	50	65%	Typical
Withdrawal – January 2010	69	95%	At Risk
Withdrawal – May 2011	66	91%	At Risk
Attention Problems – January 2010	60	80%	At Risk
Attention Problems – May 2011	51	58%	Typical

Adaptive Skills: Teacher Rating lower scores indicate more problems	T score	Percentile Rank	Descriptive Classification
Adaptive Skills – January 2010	43	23%	Typical
Adaptive Skills – May 2011	45	30%	Typical
Adaptability – January 2010	51	50%	Typical
Adaptability – May 2011	45	30%	Typical
Social Skills – January 2010	51	53%	Typical
Social Skills – May 2011	47	40%	Typical
Leadership – January 2010	38	12%	At Risk
Leadership – May 2011	44	31%	Typical
Study Skills – January 2010	44	29%	Typical
Study Skills – May 2011	42	23%	Typical
Functional Communication – January 2010	34	8%	At Risk
Functional Communication – May 2011	46	30%	Typical

The BASC-2 teacher rating scales provided additional information about improvements in attention, leadership, and functional communication.  When asked in person how this child has changed since January 2010, the teachers reported that he can now work independently, he now has healthy peer relationships, his ability to maintain a calm alert state has improved dramatically (from less than fifteen minute stretches to up to an hour), and, when his arousal level does escalate, his recovery time has decreased dramatically.