Specal education

Background Information

Case Study I

Phil

1st grade male – Age 6

· Very small for his age, constantly in motion

· Usually looks very serious; when he is unhappy with something, he will scowl and make a high pitched and long lasting shriek; this happens 8-10 times every hour

· Asks a lot of questions (e.g., Why? Where did that come from? What’s this mean?)

· When engaged in something in which he has an interest, he becomes lively and animated and asks relevant questions as he is trying to figure out what is happening (lasts up to 7 minutes at a time).

· Enjoys trains and collecting coins; likes to build things with Legos or Lincoln Logs

· Knows everything about local public buildings (city hall, library, schools) - # of windows, # of doors, when built, building materials, # of bricks each contains

· Developed very particular likes and dislikes with food (e.g., he will only eat white or light colored foods, and nothing can be mixed together. Refuses to eat meat and many vegetables and fruits).

· Behavior problems surfaced around 15 months - easily frustrated, which resulted in throwing things, hitting, kicking, biting, and disrespect shown to parents, especially mother

· Mother has used timeout chair – can take from 5 minutes to 2 hours for him to regain control

· Parents report that they do not take him out into the community (e.g., grocery store, etc.) because of behavior. One parent stays home while the other goes out to do errands.

· Phil is extremely active. He stopped taking naps at the age of about 2 ½ and he cannot fall asleep until three or four hours after he is put to bed. He spends the time looking at books and playing with the toys in his room. As long as he stays in his room and is quiet, his parents leave a dim light on.

· Phil lives with his parents and older sister. The family goes on recreational outings together, including summer camping trips and weekend trips to visit family in another area of Pennsylvania.

· Parents describe Phil as “interesting.” They have worked through many issues with their daughter (diagnosed with ADHD and bi-polar disorder, but not in special education) and feel that Phil will develop appropriate behaviors as time goes by.

· Defiance is an issue – incidents 10-15 times per day of yelling, stomping his feet, throwing things if he doesn’t get his way

· Will wander away from the yard – has gone up to 6 blocks away, crossing busy streets. This happens 3-4 times per month

School History

· Mother requested district screening when Phil turned 3 because he refused to follow rules, and would tantrum when he couldn’t get his way. He also showed a lack of interest in activities like coloring or drawing with markers or crayons, cutting paper, and repeating nursery rhymes. He would refuse to do these tasks.

· Parents did not want to consider district early childhood programming and enrolled him at a structured preschool at age 4 – his day was subsequently shortened to 2 hours and his parents had to pick him up early 1-3 times per week because of behavior (yelling, screaming, refusing to follow directions; wouldn’t participate in any tasks that involved drawing, coloring or writing).

· Community summer programs tried but he was asked to leave because of behavior (ran out of the room, yelled, screamed, threw things).

· During the summer before he started Kindergarten, the parents did not enroll him in summer school. They planned many family activities but Phil was not in any kind of a structured program. They report that the number of tantrums decreased to 1-2 per day. However, the tantrums were more severe with longer recovery time.

· Placed in a blended Kindergarten (5 special education and 11 regular ed students with Kdgn. and EC:special ed. teacher team)

· Identified as EBD in Kindergarten

· During the special education evaluation process, he took a pair of scissors and stabbed the teacher in the arm. He was suspended for 3 days and parents took him to a psychiatrist who put him on medication.

Concerns/Reasons for Referral

· Aggressive and disruptive behavior. Phil kicks and hits staff along with outright refusal to follow directives with yelling and screaming and throwing himself on the floor. Phil throws books and chairs and narrowly missed hitting a peer with the chair. These behaviors occur 4-6 times daily within a two-hour period.

· Unwillingness to follow directions for social or play activities - says, “No,” or “I won’t” or refuses to speak and sits with arms crossed and head down with no movement toward doing what was asked, or runs and hides under a table.

· Refusal to do any activities with scissors, paper, pencil, crayons or markers.

· Isolates self in a corner or under a table.

Interventions

· In-class interventions to build cooperation and compliance (e.g., model expected behaviors, extra time for compliance, encouragement, buddy system, teacher proximity, picture schedule, modified activities and short time-out when positive interventions were not effective).

· Areas of improvement

· Decreased aggressive reactions (such as kicking, hitting, spitting) which now occur less than 5 times per day

· Decrease in outburst responses when frustrated/angry. Currently has the ability to talk through situations and respond to staff interventions. Phil now states that he is getting upset or frustrated and asks if he can go to his beanbag chair 50% of the occurrences in a day. The number of “frustration or anger” opportunities is 9.

· Sensory interventions/assistive technology:

- Weighted lap pad or pressure vest

- Fiddle toys

- Special bean bag chair for sensory calming, processing

· No identifiable events or patterns were identified for 70% of the disruptive (yelling and screaming with refusal to do what was asked) or violent outbursts (hitting or stabbing others with objects)

· Any task involving writing set the stage for frustration and writing tasks precipitated approximately 30% of the verbal or physical incidents. It appears that Phil was frustrated with his inability to complete a task perfectly.

· Phil really likes being in the regular education classroom.

· Began Kindergarten with 2 hours per day. This was gradually increased until he began attending full days in February. That continued for the rest of the school year.

· OT for two 30-minute sessions per week

Testing and other evaluation

1. Wechsler Intelligence Scale for Children-Fifth Edition (WISC-V)

This test measures current intellectual functioning. Overall cognitive ability in the average range (FSIQ = 103; 58th %tile). Nonverbal ability is significantly better developed (77th %tile; 111) than verbal ability (37th %tile; 95).

2. Visual Motor Integration Scale

47th %tile; Age equivalent = 5 yrs. 10 months

The types of tasks in this assessment test perceptual and motor skills which are precursors for writing letters. Phil has shown improvement since initial screening at 3 years, 8 months when he was at the 25%ile. Given the right circumstances during testing session (e.g., cooperation, time, interest, motivation) Phil can perform the assessment task at levels commensurate with age norms. Phil can replicate lines, shapes, designs and figures.

3. Behavior Assessment Scale for Children (BASC-2)

Clinically significant ratings in the areas of:

· Hyperactivity (excessive movement, acts without thinking, calls out in group activities, interrupts adults when wants something)

· Aggression (threatens to hurt others, hits others, breaks and wrecks things of others)

· Depression (e.g., moods change quickly, easily frustrated and upset, pouts, screams “That’s not fair”)

· Attention Problems (e.g., gives up easily, short attention span, easily distracted)

· Withdrawal (e.g., plays alone, refused to talk, avoids activities with others)

· Atypicality (stares blankly, seems out of touch with reality, repeats thoughts over and over, sings or hums to self, and hears or sees things that aren’t there)

4. Peabody Individual Achievement Test-R (PIAT-R/NU)

Sub Test Range

General Info Above Average

Reading Recognition Above Average

Read. Comp. Above Average

Mathematics Average

Spelling Above Average

Total Test Above Average

Conclusions

He has acquired basic pre-readiness skills in reading (he can identify all upper and lower case letters in the alphabet, can identify pictures for word beginning with a, b, c, d, f, g, h, l, m, n, s, t, can retell a three event story and answer a comprehension question after a passage is read). In the math area Phil can orally count to 30, identify all basic shapes, say the names of the days of the week, and answer addition and subtraction facts to five.

5. Work Samples: Writing

· Only 3 samples were available because Phil refuses to write. Writing is very immature with large, gangly stick figures, no proportions, and very light.

· Pencil grip is incorrect and awkward - refuses to hold pencil correctly - even with cushioned grippers.

· Refuses to write name, letters or numbers

6. Occupational Therapy Evaluation:

Fine Motor Skill Development:

Bruininks-Osteretsky Test of Motor Proficiency (a standardized battery of motor performance tests; used by OTs, PTs and sometimes P.E. teachers; assesses both gross and fine motor skills) 54th %ile

· Needed prompts and motivator to overcome refusal - did complete test.

· Response speed equivalent is 5 yrs. 8 months.

· Visual motor control equivalent is 5yrs. 5 months.

· Upper limb speed and dexterity age equiv.-7 yrs. 2 mo.

· Right hand preference with irregular grasp and tight hold. Demonstrates diminished strength in shoulders and arms. Complains of fatigue after one minute.

Sensory Processing Skills:

Areas of definite difference when compared to peers

· Touch processing (tactile defensiveness, craves touch)

Areas of probable difference when compared to peers

· Sensory seeking behaviors

· Oral sensory processing

· Auditory processing

· Vestibular (related to balance, orientation of the head, etc.) processing

· Multi-sensory processing

Conclusions:

· Fine motor skills are at a functional level with the exception of strength and endurance.

· Sensory processing is a concern. Difficulties interfere with participation in classroom activities, interaction with peers and staff, emotional and behavioral control and attending skills.

7. Observations

Day 1 - 9:00-11:00 a.m.

Students were engaged in circle time activities such as calendar (day, date, weather, etc.) Phil was asked to draw the weather symbol on chart—he refused…Said “no.” Refused teacher’s offer of help and ran to the table and sat under it. Teacher asked him to come out and join group. Refused and stayed under table until circle time finished (20 minutes).

Students engaged in various center time activities (e.g., making shapes with clay, alphabet activities, etc.).

· Phil refused to join in any of the activities. His off-task behavior consisted of shouting, yelling, screaming that he wasn’t going to do something, throwing things, knocking his chair over, trying to leave the classroom, hiding in the classroom, going under the table.

· He refused to participate in anything the class did 70 minutes of the 1.5 hour observation. Initially teacher tried to “coax” Phil into joining an activity. Then she ignored his behaviors and interacted with the other students (e.g., asking them questions about their center activity, etc.)

· During the last 10 minutes of the observation Phil engaged in a self-selected activity. Phil went to the Lego table and began to build a Lego structure.

· Peer behaviors included 1 “tussle” (both boys tugging at the same truck during free choice activity) over a toy truck with one boy saying, “I had it first.”

Day 2 - 9:00-11:00

Schedule of activities was the same as Day 1.

· During calendar Phil sat outside the group but didn’t verbally yell or interrupt group.

· During center time Phil refused to join his assigned group for alphabet activity. When teacher tried to physically assist him to group Phil kicked and hit at the teacher when she approached him. Whenever the teacher tried to engage or assist Phil to join group (4 different times) he refused verbally with yelling (“I’m not going to!” or “No, no, no”) and threw himself on the floor and finally moved under the table.

· Peers followed teacher directions. No verbal or physical interactions (hitting, throwing, etc.) occurred with peers.

Day 3 - 9:00-11:00

Schedule of activities was the same as Day 1.

· During calendar Phil sat outside the group.

· Didn’t join in any center activities.

· 15 occurrences of verbal disruptions (e.g., shouting out, humming, yelling, ”I’m going to kill you”) during the 2-hour observation

· 1 occurrence of tantrum (i.e., threw himself on floor and continued to scream and shout) with duration of 5 minutes.

· 3 physical threats (i.e., threw chair at another student who wouldn’t give him the Legos; pushed child to get out the door, threatened teacher with scissors (pointed scissors at teacher and made a jabbing motion) when she reminded him to be careful.

· There were 5 verbal outbursts (yelling, screaming) and 2 physical outbursts each day. On Day 2 Phil threw a book at teacher and pushed another child out of his way. On Day 3 Phil threw clay at another student, barely missing him, and kicked the teacher when she came over to ask Phil a question.

Recess Observations: Data was collected over 7 days for one 15-minute period each day. (One recess supervisor was assigned to watch Phil at all times and make sure he returned to the building.) Behavior included watching others play, running alone, or sitting on the ground singing and humming. There were no interactions with other students and Phil did not respond to supervisor prompts to join in.