¶ … Therapist Name: Case Name/#: Reason for Referral:

The client is an eight-year-old female who may not have be making adequate academic progress consistent with her age and grade level. She is currently in the third grade. The client was assessed over two sessions.

Presenting Problems:

Clinical concerns: Difficulty in school/with academic progress.

Clinical concerns: Possible learning disability.

Clinical concerns: Reading difficulties.

Clinical concerns: Client potentially not motivated to perform in class.

Clinical concerns: Rule out depression and/or anxiety.

Family

Jailah was born on September 11, 2007. Jailah is the third child and a sibship of five. According to her mother Jailah is of Hispanic and African-American descent. Her native language is English.

With respect to her family Jailah has three sisters ages 16 years old, 14 years old, and five years old. She also has a younger brother age seven years old. The children the family have three different fathers. Her 16-year-old sister has a different father from the rest of the children, her seven-year-old sister and younger brother have the same father (but a different father from the rest of the children), and Jailah and her 14-year-old sister have the same father (but again a different father from the other children in the family). According to her mother, Jailah has no contact with her birth father. At this time it is unclear if Jailah identifies with her father or if she identifies with one of the fathers of her other brothers and sisters. There was no mention of any close ties to any other family members apart from Jailah's immediate family. According to her mother Jailah gets along well with her siblings.

Current Living Situation

Currently Jailah lives with her mother and her siblings in a shelter. The domestic situation of the family appears to be relatively unstable. Jailah's mother reported that the family has moved several times and lived stayed in several different shelters over the last three years; however, her mother refused to further discuss the reasons for the moves.

Family Dynamics

Jailah lives with her mother and siblings. Her mother is the clear head of the household and Jailah does respect the authority of her mother and of her older siblings. Jailah has no contact with her birth father and it appears that she does not have a significant father -- type figure in her life. The hierarchy of order in the immediate family begins with the mother and that appears to extend chronologically down the line between the siblings based on age with the eldest sibling have the next amount of authority in the line and so forth. Jailah reportedly gets along fairly well with her siblings except for the usual and expected spats that occur between siblings who live together.

Education/School History

Jailah is currently in the third grade. According to her mother she has no history of problems in school and Jailah has no previous history of consultations or referrals for learning problems, issues with attention, behavioral issues, and she has no previous diagnosis of any developmental disorders such as ADHD, and no previous history of any other issues in school.

Jailah and her three younger siblings have also attended three different public schools. Her older sister has remained in the same school throughout her education. Jailah's mother again refused to discuss the reason for Jailah and her younger siblings' frequent school changes; however, Jailah's mother did report that despite these transfers into different public schools all of the children have had no learning issues and have continued to perform a well in each of the schools they attended.

Medical History

Jailah has been diagnosed with insulin-dependent diabetes for which she receives regular insulin shots. Jailah also has asthma. According to her mother Jailah uses an inhaler for her asthma and at times uses a nebulizer for asthma in the home. Jailah takes no other medications regularly and has no history of using tobacco products, alcohol, or these of illicit drugs of any type.

Family medical history appears to be significant for asthma in her two younger siblings, and asthma and diabetes and her mother. There was no information of any significant medical conditions of Jailah's birth father or of his family available at the time of this assessment. According to her mother there is no history of alcohol or illicit drug use in the immediate family that she was aware of at the time of this evaluation.

Physical Development

According to Jailah's mother Jailah met all of her developmental milestones on time and there is...

Jailah began to ambulate with in her second year and Jailah began to produce verbal language within the expected time frame. Aside from speaking with a lisp there are no overt difficulties with expressive or receptive language noted in her history and her mother reported that she has never been diagnosed with any hearing problems. There is no history of Jailah ever being involved in speech therapy for her lisp.
Social/Emotional Development

Jailah's mother reported that Jailah has no significant issues with anger management;

however, she is very independent and strong-willed. When Jailah decides that she wants to do something or that she does not want to do something it is very difficult to convince her to change her mind. Her mother also reported that she gets along reasonably well with her siblings although there are occasional arguments and disagreements. There appears to be no significant history of depression, anxiety, or other serious emotional conditions and according to her mother Jailah is generally pretty easy-going and makes friends relatively easily although she tends to spend most of the time in the shelter with her brother and sisters. According to the results of the interview with her mother Jailah does not exhibit any types of behaviors or restrictive motions that would suggest the presence of a pervasive developmental disorder, conduct disorder, oppositional defiant disorder, or some other childhood emotional disorder.

Based on the information provided by the school does not appear that Jailah has any significant issues regarding making friends, socializing with other children, or any significant truancy or behavioral issues with her teachers. She was described as being generally cooperative, happy, and generally easy-going. However, according to her teachers at times she does appear to get frustrated with reading and with some aspects of her schoolwork and at times appears to give up easy on assignments that are challenging to her. There was also some indication that when she is challenged at times she may not put for the extra effort that may be needed for her to master some of the basic tasks in her classes.

III. Behavioral Observations

Jailah was assessed over two different days into different assessment periods. The first assessment occurred on Thursday, February 19, 2015 at 10 AM and the second a valuation occurred on Friday, February 20, 2015 at 9 AM.

During the first assessment day Jailah appeared to be happy and was smiling and laughing when she was approached. She was dressed in a pink T-shirt with the popular "Hello Kitty" logo/patch on the front of the shirt. She also wore blue jeans and white sneakers. Her hair was made up in very long loose braids with clips on the end.

During the second assessment period Jailah was again cheerful and laughing, but this time she was much more talkative when she interacted with the assessor. She appeared to have a lot to share regarding her day and previous evaluation with the tester during the second assessment. On the second assessment day she wore a beige skirt with a uniform shirt, black shoes, and black leggings. Her hair was pulled back into a single pony tail that was tied with a beige bow on the top of the ponytail.

Jailah was well behaved during both assessments. She appeared to be quite comfortable with the assessor from the very beginning and interacted very well with the tester during both assessments. However, at times when Jailah was pressed to extend herself during the assessment she would simply give up and refused to continue. She did not get angry during these times, but it was clear that she was frustrated and did not wish to appear to be unable to perform the task at hand. Thus, by refusing to continue or to extend herself she was able to maintain a sense that she was not failing.

Jailah did speak with the notable lisp during both sessions; however, this did not significantly interfere with her ability to verbally communicate with the examiner during this assessment.

IV. Test Results

First Assessment Session: Friday February 19, 2015

The first assessment concentrated on Jailah's attitude towards reading, her letter identification, and her decoding skills.

Denver Reading Attitude Survey

In this test Jailah was asked "How often do you do each of the following things?" There were seven questions referring to several different activities that she responded to such as how often do you like to read something interesting, how often do you read the newspaper, how often you read outside of school, tell about the types of things you read to someone else, coffee read more than one book. The…