Case+Study

Case Study: Amy - 5th grade, 504 Plan, Type I Juvenile Diabetes, 11 years old, evaluated for Special Education in 3rd grade.

Modifications already in place by the 504 Plan: Reduced Spelling List Extended time and reteaching of information missed while checking her blood-glucose levels at the nurse or receiving injections consistent lunch schedule reminders to be on task throughout the day manipulatives for math upon Amy's request participation in small group for stress management supervision during field trips HW no more than 30 minutes option to come into school early for help study buddy to help with organization extended deadlines for hw to be completed over the weekend School counselor visits to help with organization behavioral chart Compass Math (computer tutorial) private math tutoring

Parent's Concerns: self esteem, paying attention in the classroom, poor organizational skills, poor grades, hw load Amy's symptoms directly related to blod-sugar levels: fatigue, lethargy, irritability, and confusion


 *  Cognitive (WISC-IV): **

​  Amy's scores in the WISC-IV were for the most part consistent. The WISC-IV addresses four areas of intellectual ability. Amy was in the average range for verbal comprehension; this portion addresses vocabulary, verbal concept and reasoning skills, and knowledge acquired from the environment. It also assesses perceptual reasoning where Amy's score was also in the average range, but it was a lower average. In particular, she scored well in many areas and then extremely low in one area of perceptual reasoning. This lower average score should not be an important factor in determining her intellectual abilities because it was very inconsistent with her other scores. Amy's performance on the working memory section demonstrated other weaknesses of hers. Her score in the portion of the assessment was below average. In the "processing speed" portion of the assessment Amy was in the average range. This area requires the child to correctly scan visual information and determine an answer while be timed. Overall Amy achieved an average score of 88 on the WISC-IV.

 In order to measure Amy's current level in academics we administered the Woodcock-Johnson III Tests of Achievement, Form A (WJ-III) This test is a comparison of Amy to her same aged peers. After the scores came in the results indicated: Amy is slightly below average in the category of Basic Reading Skills and Reading Comprehension. For Math Reasoning and Listening Comprehension she was a little further below average but still within the standard deviation. For instance, a score of 100 is average. Therefore, if a student scores within 15 points above or below the average (85-115) they are considered in the standard deviation; this is where the majority of students fall. In the categories of Math Calculation and Written Expression Amy scored low average.
 * Academic (Woodcock-Johnson III Tests of Achievement)**

The nurse approved Amy before each testing which suggests her diabetes did not play a part in the outcome of her scores. During all tests it was observed that Amy made educated guesses and used resources appropriately and she rarely said, "I don't know." After the results of the WJ-III, we would like to see her scores improve in certain areas and are working with the parents and educators in order to find the best route possible.


 * Adaptive Behavior**


 * a) (Vineland) **

Amy's adaptive behavior was evaluated through an interview-like format of the Vineland Adaptive Behavior Scales. Through this interview Amy's parents were asked to discuss her behavior in terms of communication, daily living, and socialization. It seems that through her parents' perceptions, Amy falls into the average to low average for her overall adaptive behavior. Descriptions are provided for each of the areas of focus. In terms of communication, Amy's parents feel that she communicates expressively and receptively at a typical skill level for her age. They find her to enjoy listening to information that is of interest for her. As far as daily living skills, Amy's parents feel that she is independent in many areas. She has the ability to do many chores around the home and take care of food for herself. Amy's parents did mention that they provide her insulin injections and keep her on schedule, so this area is less than independent. It seems that socially Amy has a great deal of friends and activities that she is involved in, but is limited due to her diabetes. She is unable to stay the night with friends' and must have an adult supervising at all times. This issue of social limitation is being looked into by her parents in hopes for a fix. 


 * b) (BASC-2) Behavioral Assessment System for Children-Second Edition.**

In order to further evaluate Amy's situation, she and her father, her 5th grade teacher and special education teacher completed a series of questions on the Behavioral Assessment System for Children - Second Edition. The purpose of the assessment was to measure Amy's school problems, behavioral problems, and internal- and externalizing problems. The results were similar between the scores given by her father and her teachers; however, Amy scored herself extremely low. The ratings by her father and teachers addressed school problems, such as difficulties with attention, comprehension, and completing schoolwork. Both parent and teachers rated Amy's school problems as "clinically significant" at nearly 2 standard deviations from the norm. Both teachers included ratings of Amy's health-related concerns being greater than students her age. In addition, her father rated Amy's anxiety as "clinically significant." It is important to notice the similarities between the scores of Amy's father and teachers because their scores were extremely higher than what Amy rated herself. When asked to rate herself, Amy scored nearly four standard deviations from the norm, way below the ratings given by her father and teachers. She rated herself as having extreme "internalizing problems:" having little control, feeling isolated, sad and misunderstood. She also reported feelings of anxiety with her school performance, such as keeping focus and sitting still. She feels her teachers are unfair and too demanding, and that she worries because she has little control of her grades, despite her effort. Overall, Amy rated her internalizing problems, school problems, and self-esteem as "clinically significant." The overall "clinically significant" score given by all parties is a strong indicator that current interventions are not sufficient for Amy's progress. The significant difference between Amy's scores and those of her adult peers is a clear indicator that current interventions are not sufficient. Amy's scores strongly suggest feelings of low self-esteem and determination in school. Feelings of isolation and anxiety for a child her age need to be taken seriously, and are not normal. Her scores very well could be a reflection of her Diabetes, and should be considered as well as the possibility of childhood depression. For this reason, the weight of her father and teachers' scores are more significant than her self-ratings because they are more consistent. However, all scores are within the "clinically significant" range, which means Amy's adaptive behavior is an area where intervention is needed.

 //Questions 1-3 addressed in the following summary.//
 * Summary:**

A holistic view of Amy's current level of functioning is in the low average range when compared with students her age. Nearly every behavioral and psychological assessment used to evaluate Amy placed her between 1 and 2 standard deviations below the norm. Regardless of whether she actually has a specific learning or behavioral disability, we are looking into more targeted interventions to increase her scores. In our opinion, it is too soon to assume that labeling Amy with a disability will help her be more successful in school. After receiving the assessment scores, it seems as though Amy's current level of functioning is strongly affected by her Type 1 Juvenile Diabetes. The symptoms of fatigue, lethargy, irritability, and confusion are direct symptoms of Diabetes and could be precursors to Amy's behaviors of anxiety, frustration, and disorganization in school. There is not enough evidence to suggest that Amy has a learning or behavior disability without ruling out her Diabetes. The severe fluctuation of her blood-glucose levels could be a trigger of many behaviors. Still, Amy's expressed feelings of low self-esteem and frustration are red flags that current interventions are not working. Amy's feelings of isolation, being misunderstood, and feeling helpless in school need to be taken seriously. These signs could be reflections of her Diabetes and only people with a specific health condition could possibly relate to what she is experiencing, more specifically a child living with a health condition. Although her feelings of isolation and low self-esteem could be directly related to her Diabetes, they are also signs of childhood depression and this should be addressed immediately. Whatever the cause of Amy's feelings, it is affecting her overall social development and academic performance negatively. We cannot recommend Amy for Special Education without first ruling out her Diabetes. A specific recommendation for special education isn't possible at this time; however, we feel the next steps for Amy should be behavioral objectives since her feelings seem to be the underlying root of her performance in school. We feel that there is a possibility for Amy to overcome her feelings of dependence and gain some sense of control of her life. We recommend working with the parents to create new behavioral goals and objectives that focus on independence. Her feelings of isolation can only be imagined. Perhaps including her in the making of her instructional goals and giving her an appropriate degree of choice will help alleviate those feelings. Since her feelings are of great concern and importance, we would also ask the parents if it is possible to collaborate with Amy's doctor at their convenience. We believe that with permission, collaboration with her parents and physician would generate more positive options for Amy personally and academically. An expert of Amy's Diabetes and health history would be a beneficial tool in order to suggest the least intrusive recommendation regarding her academic future. We recognize that Amy's struggles with school are very real and need to be addressed sensitively. Our final recommendation is to meet with the parents and discuss the results of Amy's evaluation and the next steps for intervention.