Academic Progress

¶ … 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 no history of any developmental delay in either Jailah or in her siblings.

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 questions are answered on a Likert scale format where A corresponds to almost every day, B corresponds to once or twice a week, C corresponds to once or twice a month, D corresponds to a few times a year, and E. corresponds to never or hardly ever. Jailah's responses fell in the BCD section. In the second part of this survey questions regarding reading were asked.

The Likert scale for this section is A almost always, B more than half the time, C about half the time, D less than half the time, capital he never or hardly ever. Jailah's responses on this section fell into the ABC range. Phonics Survey Letter Identification In this section the student was asked to name random upper and lowercase letters. Jailah was able to correctly name 21 capital consonants but missed all five of the capital vowels.

When presented with 21 lowercase random letters she was able to correctly identify 19 of the letters, but again she missed two vowels. Letter Sounds / Consonants When asked to sound out 21 consonants she scored 21/21. Jailah was then asked to describe the sound of five consonant digraphs. She received a score of 4/5 missing the CK sound. Letter Sounds/Vowels Jailah scored 0/5 on her attempts to reproduce the sounds of vowels.

When she was asked to reproduce the sounds of the vowels in this section Jailah verbally identified the letter as opposed to reproducing the sound of the letter (e.g., she responded "e" when presented with the letter e). She continued to name the letter even if the examiner prompted her to reproduce the sound of the vowel. Reading Real and Nonsense Words Jailah was asked to read a short list of real words and nonsense words that emphasized very short vowel sounds.

She scored 5/5 on the real words and 3/5 on the nonsense words. Jailah scored 5/5 when asked to read real words that were combination of short vowel sounds with consonant digraphs. She also scored 5/5 on a set of nonsense words with short vowel sounds and consonant digraphs. Jailah scored a 5/5 when she was instructed to read real and nonsense words consisting of short vowel sounds and consonant blends. When requested to read nonsense words Jailah was unable to read any of the nonsense words with short vowel sounds and consonant blends.

She continued to display significant difficulty when attempting to decide the sounds that correspond to the vowels were. Jailah was able to read real and nonsense words consisting of vowel diphthongs and digraphs without significant difficulty and scoring 20/20. When she was asked to read real and nonsense words that were R -- controlled words she scored 5/5. She worries also able to score 5/5 when asked to read real and nonsense L -- controlled words. Jailah was able to read prefixes with all difficulty (scored 5/5) and suffixes without difficulty (5/5).

When asked to read multisyllabic words Jailah scored a perfect score of 6/6. Overall the results of the phonics survey indicated that Jailah has mastered eight of the 14 areas that she was examined on. She was able to reproduce the sounds of consonants; however she displayed difficulty in her understanding of vowel sounds. This difficulty was evident throughout the phonics assessment. The Yopp-Singer test of Phoneme Segmentation Jailah was given a list of words to the sect based on their phoneme representation.

She was presented with a list of 22 words and scored 18 correctly. The words we missed included: 1. Keep given as k/eep 2. Wave given as w/a/ve 3. Grew the selected as gr/ew 4. Lay given as l/ay. Again Jailah's difficulty in determining the sounds of vowels as compared to consonants was evident here. On a spelling test Jailah spelled 25 words correctly receiving a total score of 83 points on the spelling test. Caption Reading Jailah was presented with a page that contained pictures with captions.

She was asked to look at the pictures in numerical order and asked to read the captions out loud. She demonstrated a correct left the right reading style and began at the top of the page and continued in this manner until she reached the bottom of the page. There were no reading errors observed in this test. Second Testing Session: Friday, February 20, 2015 During this second assessment session Jailah was tested on her ability to read word list and to understand passages.

The Word Lists and Graded Reading Passages For Form L. And Form M. Jailah was asked to read a list of words. Because she is in the third grade the standardized starting point for her would be to begin with the words from the second grade level; however, Jailah did not want to start there. It appeared as if Jailah was slightly intimidated by the list of words. However, it could also be that she wanted to impress this examiner by reading the entire list of words.

In any event, she wanted to start with the words from the first grade level. Jailah began reading it the first grade level and continued to read all the way to the seventh grade level. She made only three mistakes on the word list. Her reading level was identified as being independent, scoring 24/25 correctly from each list. Oral Reading Passage Jailah was asked to read a several passages. As she read she was observed by the examiner and any reading errors were recorded.

Following reading a passage she was asked questions regarding the passage and the best responses were recorded. Jailah was able to read up to the fourth grade level paragraphs, but then she began to become restless, move around, and was no longer interested in reading. V. Summary and Test Interpretation. Jailah is an eight-year-old female student who is currently in the third grade. She was referred for an assessment of her reading abilities as she may be falling behind in her academic work and school.

While Jailah has no reported history of depression or anxiety is important to note that her living situation is a bit hectic. Jailah has no contact with her birth father. She lives with her mother and four siblings in a shelter. The family has moved from several shelters recently, but Jailah's mother would not discuss the reasons for these moves with the examiner.

She was pleasant and cooperative during assessment; however, she did get frustrated during passage reading tests (even though she did well on them) and during the second assessment got quite fidgety and discontinued reading the passages. Thus, there is some evidence to indicate that when she becomes frustrated she does not put forth extra effort into her academic work. Nonetheless, the evaluation appears to be reliable and valid estimate of her reading capabilities.

Aside from the aforementioned issues with frustration tolerance Jailah appeared to be able to concentrate adequately during the evaluation. She did not appear to be distractible, unable to maintain her attention over most of the tasks she was assessed, and there was no significant evidence to suggest that she has issues with impulsiveness or hyperactivity. Consequently, for the time being, a consideration of a diagnosis of attention deficit hyperactivity disorder does not appear to be relevant at this time.

However, this evaluation did not seek to identify any subtle issues with attention that Jailah might have. It may be prudent to refer Jailah to the school psychologist or to a neuropsychologist in order to better determine if her academic difficulties are affected by a more subtle attention deficit problem that can be determined by the observations of this examiner. Jailah was quite cooperative and friendly during the evaluation. She was generally happy, talkative, and interacted well with the examiner.

Thus, there is no significant evidence gleaned from this evaluation suggests that Jailah suffers from a mood disorder such as clinical depression or childhood bipolar disorder. As she was cooperative and followed the examiner's directions without incident there is no basis for consideration of conduct disorder. Nevertheless, Jailah's home situation is a bit unstable.

There is no evidence that this time to suggest any form of abuse by either her mother or siblings; however, Jailah's family does appear to have an unstable living situation in that they have been moving from shelter to shelter. It might be prudent to discuss this situation with Jailah's mother and arrange for her to meet with the social worker to discuss alternatives to the family's current living situation and available financial supports that the family may qualify for.

Such a discussion should be done very carefully and undertaken with the utmost consideration for Jailah's mother's feelings. This should be presented as an attempt to provide social and financial support to the family in order to help them maintain a stable living situation. The results of the reading and academic evaluation suggests that Jailah generally demonstrates an interest in reading outside of the school that is slightly lower than expected given her age and grade level.

In a comprehensive evaluation of her letter identification skills, her understanding of phonetics and her letter/sound decoding skills Jailah demonstrated significant difficulty understanding vowel sounds. During assessments of her word reading skills it was clear that she was able to decode and read consonants much better than vowels. Overall her performance on a phonics survey indicated that she had mastered about 57% of the material she was tested on (she mastered 8/14 of the tasks). Tests of Jailah's reading skills indicated that her approach to reading was generally within expectations.

She attempts to read passages in the conventional left/right, top -- down manner. Jailah's overall reading level was identified as Independent. She was able to read well past her own grade level on a list of words and at the fourth grade level during a test of oral reading passages. A detailed analysis of Jailah's reading difficulties indicates that she is able to generally process phonics of consonants and is able to generally read and visualize consonants in irregular or nonsense words.

There appears to be no difficulty with visual processing, the sequencing of words or synthesizing words from memory, thus a Visual Dyslexia or Dyseidetic Dyslexia is ruled out here. Because her visual processing appears to be intact.