Case Study #2
Christian is a 4-year, 3-month-old, African-American male seen for a psychological evaluation after his mother brought him in seeking guidance with behaviors that she felt were of concern, including: impaired concentration, aggression in the home with siblings, difficulty making friends, and the presence of “imaginary friends that he talks to about planets and science,” which leads him to withdraw from classroom peers. In addition, he reportedly has considerable difficulty identifying letters and numbers. According to his mother, these behaviors became more pronounced since he began Preschool in August.
Christian was the result of a full-term uncomplicated pregnancy and delivery. However, postnatal complications included kidney reflux (grade 3) and obstructed tear ducts, however he was placed on antibiotics and discharged from the hospital within 24 hours. Developmentally, motor milestones were met on time although his mother perceived them to be delayed. However she reported that he has always demonstrated difficulty coordinating both hands while carrying out activities such as playing with a toy, buttoning his shirt, or tying his shoes; typically he carries out these tasks with either his right or left hand but rarely simultaneously. Language milestones developed early. Specifically, Christian’s mother reported during the administration of the ADI-R that by 6 to 7 months, he was saying “mom” and “dad”, and using single words like: binky (pacifier), granny (grandmother), granpy (grandfather), and Tuti (his name for his aunt). By 8-9 months, he was reportedly saying phrases like: “yellow house,” “I love you” and “I miss you” and between 12 and 18 months, he was reportedly using additional short phrases meaningfully like: “let’s go home,” “I’m tired,” “nap time,” and “I want my binky.” Christian resides with his parents and 4 four siblings; he is the 2nd of 4 children. Christian demonstrates albino traits that predispose him to a sun allergy and an episode of Steven-Johnson Syndrome when he was 13 months old before his parents were aware of this allergy. In addition, he is also allergic to Ibuprofen, honey and cinnamon. Christian’s mother also reported that her son presents with emerging difficulties with vision and has noticed that he tends to look at things from close up. He is currently not taking any prescription medication.
Although Christian presented with behavioral difficulties during the evaluation, such as hitting his forehead with a closed fist when he did not know an answer, he was generally cooperative with the examiner. However, his attention, effort, and motivation were variable throughout testing and there are possible difficulties with vision that may have affected his ability to respond to the tasks presented. Therefore, the results of the current evaluation should be interpreted with caution because they may underestimate his true potential.
Based on the WPPSI-III, Christian’s overall level of intellectual functioning is estimated to fall within the Average range. There was a significant discrepancy noted between his verbal reasoning abilities and nonverbal reasoning skills, suggesting a significant weakness in his fluid reasoning. There was variability in his scores on the Performance domain; therefore his ability for fluid reasoning is best understood by his performance on the separate subtests. His processing speed was average. Overall, his Verbal IQ of 104 is considered to be a more accurate reflection of his true intellectual potential.
Christian’s academic achievement, as assessed using the KTEA-II, reflects significant discrepancies between his pre-reading skills and mathematics achievement and his average estimate of intellectual functioning. Specifically, this discrepancy reflects considerable difficulty with letter-word identification and mathematics computation that is significantly below his average estimate of intelligence and current grade.
In regards to executive functioning skills, a comparison of his mother and teacher’s reports on the BRIEF reveals similarities which indicate that Christian demonstrates difficulty with his ability to initiate problem-solving, sustain working memory, and organize his environment and materials at home and in the classroom. There are differences reported between settings in his ability to inhibit impulsive responses, modulate emotions, adjust to changes in routine, and organizing problem-solving approaches, with his mother reporting fewer difficulties in these areas at home. These differences may be a result of more rigorous expectations at school which may lead him to become overwhelmed and limit his problem-solving abilities. On the Affect Recognition and Theory of Mind subtests, there is a significant discrepancy in his performance on these two subtests which may indicate that Christian had difficulty identifying emotions conveyed solely through facial expressions and that he benefits from contextual cues in order to adequately determine what others may be thinking and/or feeling.
With regard to attention and concentration, the results of Christian’s scores on the K-CPT (V.5), indicate indicates that there is an equal chance that his profile comes from a group with attention problems or a group with attention problems. However, he required frequent prompting and explanation of the demands of the task as well as appeared to have difficulty comprehending the demands that he was being asked to complete. Therefore, the results of the K-CPT (V.5) should be interpreted with caution. On the Conners’ Parent and Teacher rating scales, Christian’s mother and teacher endorsed an array of symptoms consistent with Attention-Deficit/Hyperactivity Disorder, particularly symptoms associated with inattention and difficulty with cognition. These symptoms may also be related to his difficulties with executive functioning. He does not demonstrate difficulties with hyperactivity or oppositional behavior in either setting as evidenced by ratings provided by his mother and teacher. It is also important to note that both informants also reported direct links between his difficulties with cognition/inattention and academic challenges.
He evidenced gross motor difficulties, including trouble placing pegs in a board within an adequate time-limit, evidenced poor motor control that required tapping with one while keeping his wrist on a board, and difficulty imitating hand positions demonstrated by the examiner. These motor difficulties are consistent with his mother’s reports of clumsiness and poor hand coordination.
The results of an assessment of Christian’s language ability related to his lexical/semantic skills, syntactic, and pragmatic use of language indicate that Christian has had some difficulty generalizing language from the environment and developing these skills for effective communication. It appears that while his understanding of language and ability to express himself are adequate, Christian seems unaware of how to use his language appropriately in social situations.
Christian’s overall adaptive functioning is estimated to fall within the average range. However, these results must be interpreted with caution because there was variability between adaptive domains reported by his father. There was a significant difference between Christian’s level of functioning on the Practical domain and his performance on the Social and Conceptual domain. Nevertheless, his scores reflect adaptive functioning that is commensurate with his average range intellectual functioning, assessed by the current administration of the WPPSI-III. Overall, Christian’s adaptive skills are comparable to that of same-age peers, from his father’s perspective.
Christian’s social interactions with peers and adults are often inappropriate and/or socially disinhibited. His interactions with the examiner were spontaneous yet awkward at times. Independent play is reportedly limited to a select few activities, including play with action figures and playing on the computer. He reportedly lacks the ability to engage in group play with peers and does not have any friends. Also, when he approaches peers, he is often rejected by them because he engages in comments or conversations which seem odd or irrelevant. Christian responds to peer rejection with verbal or physical aggression or by isolating himself. However, he indicated a desire to establish friendships and while the client demonstrated a utilitarian understanding of social relationships, he did not seem to understand his role in relationships or appreciate their emotional significance.