Case Study: Learning Difficulties – Reading, Writing & Anxiety

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.

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:

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!

Pre/Post Videos

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