CA: 5-6 XACKGROUND: X’s birth is characterized by induced vaginal delivery and variable heart rate during delivery. He was subsequently identified with torticollis, a focal distonia affecting neck positioning. This was accompanied by and may have been influential in delaying eye contact until physical therapy was provided. Eye contact is reported to have improved by 4 or 5 months of age. Severe reflux with projective vomiting resolved at around 7 months. Delayed language seems to have prompted a referral to a birth to three program which provided OT and speech/language therapies. There is some conflicting information regarding speech. Private evaluations have found articulation errors in the form of sound substitutions and omissions as well as the tendency to use jargon in more complex linguistic constructions. Further suggestion of phonological deficits is found in X’s difficulty with function words (Z evaluation) as well as in his below expected use of morphemes (MLU at age 4-9, 2.93; mean 5.32, standard deviation 1.12). The Stamford speech and language evaluation (2/02) lists articulation and oral motor skills as strengths. Occupational therapy has supported “sensory processing”, self care, fine motor and visual motor skills especially as they relate to writing. Despite identified hypersensitivities (touch, sound), X is described otherwise as easy going and affectionate. Tantrums (3/01 progress report) were thought to be a means of escape presumably from over stimulation. Mrs. Y notes that he has over come a good deal of his hypersensitivity but will still occasionally simply sink to the floor in situations that are large, bright, and noisy. He is capable of enjoying engagement with other children (classroom observation), his test examiners (1/02 X center evaluation) and enjoys being praised. He nevertheless carries an identification of PDD with primary concern about delayed language development including expressive, receptive language and pragmatic communication. Pragmatic difficulties seem to center around sustained conversational turn taking, proper use of pronouns as well as, to a lesser degree, eye contact. Nonverbal tasks are managed better than verbal ones as is reflected in X’s Stanford-Xinet Intelligence Scale scores (12/01): verbal reasoning 82 abstract reasoning 95 quantitative reasoning 94 short term memory 80 Vocabulary recognition is among X’s strengths (Receptive One-Word Picture Vocabulary Test, 94). Nonverbal abilities appear to be compromised in the context of graphomotor demands (VMI 83). Novel linguistic utterances such as would be found in specific test directions or items have been difficult for X and can require prompts and/or demonstrations. He is reported to do better with familiar formulations and requests (1/02 Z center evaluation). X currently attends a special education preschool class following an ABA intervention model. He is accompanied by an ABA teacher into an integrated preschool program for half of the day. The Z center additionally has recommended an extended program including parent training in ABA techniques as well as running 12 months of the year. The current IEP goals/objectives (12/01) seem to reflect the general curriculum in the preschool class: fine motor development (writing, self care), sight words and letter sounds, retelling of stories, learning classroom directions and routines, receptive and expressive language, pragmatic communication, peer interaction, self care and reduction of noncompliance (noncompliance does not surface or get described in the rest of X’s record). Intelligible articulation is stated as a goal but it is not specified in the record made available for review what the articulation issues might be. Further by the age 4 evaluation done by the Stamford schools, articulation was reported as a strength. A recent progress report from the W Center for Child Development, where X attends, reports considerable development in language and communication. He is described as using up to 8 words and involving others in conversation. He is having difficulty learning the sounds of letters. Language comprehension difficulties (focus on irrelevant details, seeing relationships) appear to place reading comprehension at risk. He likes listening to stories and :shows strength” in matching printed words and objects. X can write his name. Otherwise letter formation and spelling are difficult for him. His school describes him as doing best with direct instruction, repeated practice, predictability and visual supports. Consistent repetition and predictability are thought to be important to him. TESTS ADMINISTERED: Woodcock-Johnson - III Raven Colour Matrices Developmental Neuropsychological Assessment (NEPSY) TEST OXSERVATIONS: X came bounding into the testing room interested and unintimidated by the new setting. He resisted being called to the testing table to settle in to do some work but came readily when invited to do a drawing. There is a clear distinction between those activities that engage X and those which he tries to resist. At this testing he would have drawn for a very long time, did not like to be interrupted for discussions about what he was doing, and protested that he was not finished when asked to shift attention to something else. He was also drawn to some of the Raven problems and quite engaged in the Tower task on the NEPSY. All of these share a nonverbal and visuospatial component. Much of what he engaged with was complex and challenging for X’s age. When he was not interested in the test designated task, X was quite eager to escape and find something that did interest him. Several breaks were taken during which he had no trouble amusing himself with stuffed animals. If he was not allowed to escape and asked instead to prolong his involvement in nonpreferred activities, X built up considerable agitation which got released in the forms of controlled hitting, slapping the table or very tight, constricted laughing. He brought with him two favorite dinosaurs which he had named X and Isabelle (his school friend). His mother indicated that his attraction to tails explained his interest in dinosaurs. Although he did include tails in his drawings, there were many other elements as well. In fact, his drawing was dynamic, filled with colors and contrasting lines and shapes, with a well formed structure. There is a good deal of intentionality about what X does. He certainly has distinct preferences (i.e., those things which engage him and those that don’t). He has a plan when he sits down to draw and returns to it when interrupted. He wanted to draw a second set of feet on his creature and spent some time assessing the body that he had rendered to determine the best positioning. He has a clear organization (see tower results as well) and returns to it when interrupted by needing to pick up a dropped object for example. Although his conversation is sparse, X can speak in complete sentences and thoughts: I forgot his tongue. (pronounced wung) You gotta go right over here. The map is going right over here. Even when he has a good deal to say and has learned a considerable amount from listening to a story, X will rely on questions to help him organize his verbal expression. In summary of the story read to him as part of the NEPSY narrative memory test, the following dialogue/retelling ensured: X: Pepper M: anything else? X: Jim the boy M: what happened? X: and he’s sad M: How come, What made him sad? X: because he’s up in the tree M: why does that make him sad? X: because he stuck in the tree, because he fall. He can avoid the need for lengthy explications by using very effective imagery. For example, X had drawn a volcano. I drew one too, only upside down, i.e., wide base at the top, vertex pointing down, fire/lava coming out at the bottom of the drawing. His response to my “error” was to say, “mine is a mountain volcano”, capturing in one word what was at the essence of the distortion. He was able to give me directions for drawing a picture of a dragon fly, one step at a time, accompanied by gesture. There are numerous articulation errors that appear to be phonologically based and that interfere considerably with intelligibility. These are discussed more fully in the phonological processing section of the results section of this report. X is well aware of emotions. He recognizes his own frustration and anger and tries to contain it, sometimes finding outlets like using a shrill voice, hitting, laughing. He was quick to pick up on the emotional content in the oral narrative (Jim was sad because he was stuck and might fall). He recognized the facial affect on the bunny’s faces in the comprehension of instructions test (see language section below). TEST RESULTS: Phonological Processing and Reading Readiness. Standard Score Equivalents* NEPSY Phonological Processing 75(5) Repetition of Nonsense Words 70(4) Woodcock-Johnson Letter-Word Recognition 104 *standard scores are reported with a mean of 100, standard deviation of 15. Scores in parentheses are equivalent, expressed in their original metric with a mean of 10, standard deviation 3 Phonological processing problems are apparent in difficulties with both speech perception and and articulation. On the phonological processing test, X needed a number of repetitions and had to struggle quite hard to piece phonological information together in order to earn the minimal amount of credit he did for combining syllable sounds in order to select the correct picture (bi-ke, ki-tchen). When an initial sound was omitted, X was not able to determine which picture was indicated (indow for window, ake for rake). Nor could X tell me what the first sound in a word was (/f/ in fly or /d/ in dragon, in relation to a picture of a dragon fly). He was unable to use the phonological information in letter names to invent spellings. For example, when asked to use what he knew about letters to write his mother a note that said, I love you, X was interested, engaged and spent some time trying to figure it out. He wrote, INU (N for love). He was motivated to spell the names of pictures drawn for him (cat, snake, frog) but had very little idea of how to go about it. Cat was spelled CDN, snake DX, frog I. X did not seem to appreciate the idea of a rhyme (isolate and change the initial phoneme level sound, maintain the remaining sounds). We made up a song about a dragon fly, words rhyming with fly. After we sang it two or three times, X could not fill in the missing rhyming word and supply another one. He seemed to like to hear about a dragon fly but when the emphasis was placed on rhyming words per se, he detached from the whole activity. There is a considerable contrast between X’s facility in learning letter names (letter-word identification, solidly average score; was able to label every letter in the alphabet) and his difficulty in letter sounds (current school progress report). His mother reports that X has known letter names and has had little difficulty with the labeling or memory demands of the task. In contrast, letter sounds, which make the same demands on memory, require a specific phonological component not at issue in letter naming. He did have intermittent delays in retrieving letter names, a further suggestion of difficulty with phonologically mediated word retrieval. X made consist consonant substitutions to replace liquid sounds ( tree/twee; last/wast; color/cudder, vanilla/vanidda). He had difficulty with motor shifts between consonants causing consonant omissions and assimilations (carrying the same consonant sound through a word where it doesn’t belong): repeating the nonsense word indobtreelob as in-doe-tree-do, tromble as frumble. As can be seen in the previous example, th/f confusion is an issue as is t/d (boddie for bottom). X has determined at least one critical feature of the code. He realizes that the order of letters is a critical determinant of a word. He could write his name correctly. When I used the same letters (each written on a separate slip of paper) and ordered them incorrectly , X knew that it was not his name and reordered the letters correctly. Although he seems to come by this awareness through sensitivity to visuospatial relations, it is an awareness that can be used as the basis for phonological analysis (see recommendations). Language Comprehension and Reading Readiness Standard Score Equivalents* NEPSY sentence repetition 75(5) comprehension of instructions 75(5) narrative memory 80(6) Woodcock-Johnson verbal comprehension unprompted 71 prompted 79 *standard scores are reported with a mean of 100, standard deviation of 15. Scores in parentheses are equivalent, expressed in their original metric with a mean of 10, standard deviation 3 Most of X’s difficulties with language comprehension appear to be based in phonological difficulties. Phonological deficits make it difficult to perceive unstressed forms of speech, i.e., function words (words high in syntactic, low in semantic value such as articles, auxiliary verbs, pronouns) and word endings (see errors in nonsense word repetition above, verb tense endings). These are the forms omitted or altered in sentence repetition (The children got in line for lunch repeated as Children got ate his lunch). His own utterances leave off word endings as well (he stuck, he fall). In the absence of key syntactic information, X relies heavily on his facility with semantic content. This takes the form of maintaining the key, root words when he expresses himself (he fall, he stuck) and allows him to retell the main points of a story despite the need to have help with the structure that syntax might otherwise have provided (depending on questions to unravel his retelling of the story on the narrative memory test, see observations section). Phonological deficits impede language comprehension in additional ways. It takes considerable effort for X to listen and to capture the stream of speech sounds. He works effortfully to capture long strings of speech information such as those commands on the comprehension of instructions test, show me a bunny that is big and blue and happy. He seems to be taking in and trying to deal with one attribute at a time. This results in selecting some incorrect pictures at first and with more time to process subsequent attributes, self correcting. If this is how he processes most language input, X is too slow to capture speech when it is delivered at its typical pace. He is left with partial or erroneous information. The same effect can be seen in relationship to sentence length. He can repeat The cat ate his dinner but not Xob ran all the way home (ran omitted) but not Some children have libraries in their school (nothing repeated). X’s way of coping with the confusion seems to be to escape. Sometimes he simply detaches, distinctly avoids eye contact at other times he makes a firmer stand by moving away. When he was asked to make eye contact in order to ensure that I had his full ability to receive linguistic information, X managed it for a short period of time and then looked away. It is possible that given his sensory integration problems, the degree of stimulation that comes with eye contact in combination with the intense demands made by listening to speech amount to a degree of arousal that he cannot sustain very long. Furthermore, phonological processing is a critical ingredient in using reauditorization, rehearsal to keep information activated in working memory, i.e., to hold on to information until it can be made sense out of or downloaded (as with the NEPSY comprehension of instructions). This contributes further to loss of information and avoidance of working memory tasks. At this testing, X simply would not engage in tasks asking him to memorize lists of names or faces (memory for faces, memory for names). His difficulty with phonologically driven working memory has to affect most symbol learning which depends on arbitrary associations that must be rehearsed and practiced using working memory resources. It is likely that any lag in vocabulary development that X might have (verbal comprehension requiring the labeling of pictures, below average) is due at least in part to his difficulties in perceiving the phonological information needed to learn the label. His ability to appreciate the semantic value to which a label would be attached, however, is impressively strong. On the verbal comprehension test, X could not retrieve or did not know the word, faucet but he accurately said that it was a picture of a “turn water”. Similarly a stethoscope was “doctor, because people get sick”. His reliance on visual perceptual information can be seen in his description of the function of a tourniquet (“because he has boo-boo”), his perception of the map quality of a globe, his classification of a pyramid as a building (pronounced burning) and even in his erroneous labeling of a padlock as a bucket. Math standard score* Woodcock-Johnson Applied Problems 75 *mean 100, standard deviation 15 X demonstrates far better math ability spontaneously than in response to specific test demands. He easily rote counts at least to 10 but does not coordinate counting with pointing (one-to-one correspondence) so does not always determine the correct amount. His tracking errors were made primarily when objects were arranged in a circle and stopping/starting points were not easy to distinguish. X has the capacity for intuiting amounts at least up to 3 without counting. He did not seem to know how to handle the items on the applied problems test that asked him to look at a picture and take a specified amount away (3 soup cans, take 1 away). However, he had no difficulty mentally determining that if he had 3 pieces of cereal and ate 1 that there would be 2 left; eat 2, there would be 1 left. This he did without looking or counting. He is quite aware that his drawings of creatures would ordinarily have 4 or 2 legs and was careful to depict them in proper symmetry. He thought the dragon fly should have 4 arms and placed 2 on each side of the body. This reveals not only number concept but a sense of how numbers can be decomposed into equal amounts. His copy of designs (see cognition/perception section below) suggests that X has some intuition about number. Without attempting to count or use one-to-one correspondence, X copied 10 dots forming a line by producing a line formed of 8 dots. He sometimes gets taken over by perseveration, drawing multiple circles where 3 were indicated. Cognition and Perception RAVEN prompted unprompted raw score 19 13 percentile 75-90 25-50 standard score equivalent* 110-120 90-100 standard scores* NEPSY Tower 110(12) Visual Attention** 110(12) Design Copying 70(4) *standard scores are reported with a mean of 100, standard deviation of 15. Scores in parentheses are equivalent, expressed in their original metric with a mean of 10, standard deviation 3 **This score is based on the first task, selecting and marking cats from among other animals. X began responding randomly on the second task, discriminating faces based on fine detail. If his complete abandonment of the task is counted as 0, the standard score would be 75. The Tower test seemed to be of greatest interest to X. The task requires foresight, planning and patience to determine in advance how to make the minimum moves to rearrange beads on pegs to conform to a picture. This is like the more traditional Tower of Hanoi problem. He performed with remarkable assuredness and intense concentration. At one point he let out a sigh of pleasure as he considered a difficult problem, “oooooooh”. With slightly less enthusiasm, X worked through the complex, abstract patterns on the Raven test. He was relaxed, efficient and accurate as long as the patterns could be answered based on basic perceptual features (form, orientation). In fact, some errors reveal a keen insight into perceptual features without the control to come under the constraint of the precise testing format. For example, to complete a pattern that marked off three corners of an implied rectangle, X chose the rectangle rather than the fourth corner. When the Raven patterns required the tracking of a great deal of detail, X seemed to be overwhelmed and simply give in to responding in any way just to get through the task. His appreciation for form could be seen in his copying of designs as well. In rendering a picture of a triangle on top of a trapezoid (looking like a sail boat), X easily isolated the two key forms, rendered each as an integrated entity and placed them in the correct relationship with each other. When X conformed to the requirements of the design copying test, his work was at least appropriate for age. His score is brought down markedly by his tendency to perseverate (drew a circle and then kept drawing a circle in the spaces where new items should have been copied, kept drawing continuous spiraling circles where 3 intersecting ones were indicated). It seems that circle drawing was a distinct attractor. His approach to the visual attention task of scanning densely arranged pictures on two pages and selecting all of the cats was, like his approach to the towers test, very systematic. He worked from one side of the page to the next. He was occasionally diverted by his interest in the other pictures (especially of a dinosaur which he was compelled to mark) but soon got back on the track he had set for himself. As indicated in the score table above, X drew to a halt when his matching had to account for a great deal of detail and a much finely focussed search activity. This suggests an impatience with going beyond an appreciation for broad form and semantic value into more detail that does not add to semantic content. ANALYSIS Reading/Language X has significant phonological impairments (NEPSY phonological processing, 75; repetition of nonsense words,70) severe enough to affect speech perception, speech production and perception of those words and word forms (endings) that carry important syntactic information (tense, possession, plurality). Since an even greater degree of phoneme awareness and phonological analysis is required to map letters to the speech sounds that they are meant to represent, X is at very high risk for having difficulty learning to read unless he has the appropriate support. How sounds are articulated, of course, determine how they’re perceived. In this way, articulation and speech perception difficulties are part of the same dynamic. X confuses consonant sounds that are produced similarly. He does not seem to appreciate where sounds remain the same and where there are individual shifts. At this testing, X did not seem to be aware of rhyming words. All of this indicates that he does not have yet the fundamental, readiness skills upon which to build knowledge of the code. Phoneme awareness, analysis and discrimination will need to be a major part of his instruction this year and possibly next. Phonological deficits create a context in which learning phoneme level sounds is highly demanding for X. This, in combination with his natural and intelligent tendency to select and focus on semantically loaded information makes letter sound learning not only noxious but irrelevant to anything that must seem meaningful to him. Add to this the phonological resources needed to rehearse things in working memory as well as the heightened phonological demands when it is phoneme level sounds that must be rehearsed and it seems that this is a situation designed as one from which X would most like/need to escape. Although X tries to listen to language, it takes considerable effort on his part. He needed either repetitions or a chance to repeat things for himself to manage all of the information in longer utterances (comprehension of instructions). He is tired and sometimes angry when this has gone on too long. X’s phonological difficulties in perceiving speech are quite apart from his strong visual perceptual and cognitive abilities that prepare him very well for appreciating the structure (basis for vocabulary learning as seen in response to the verbal comprehension test, design copying) and meaning (Raven, verbal comprehension) of things. Comprehension of language, then, seems far less a problem than simply capturing the speech signal. The one aspect of language that might be a problem of meaning per se is syntax, in so far as it would be affected by auditory, phonological breakdowns. Math X seems to have a natural, intuitive understanding of basic math concepts. He can perform the task of mentally manipulating numbers in a take away procedure. He recognizes amounts at least through 4 without counting. In fact, X applies his more than ample perceptual abilities to the understanding of number concept. He has used perception and symmetry in his awareness of number (creatures with 4 legs or arms, subdivided into sets of two symmetrically placed). As his general pattern, X relies far more on perceivable structure (form, symmetry, spatial relations as in maintaining the form of the diagonal line and approximating an amount of dots that generally depicted the indicated length of the line) than methodical counting. Further, X has an impressively strong capacity for anchoring his intentions to a goal and doing whatever mental manipulations are necessary to achieve the goal in minimal moves (NEPSY towers). This will serve him well in school math IF his intention is to achieve the goal set out by the calculation/problem. His difficulty with maintaining attention to and efficiency with spoken language input has widespread implications for all forms of instruction. It seems to have had some effect on the language of math (take away). It will certainly necessitate that math learning be accompanied by experience that demonstrates concepts rather than rely solely on verbal explanations and directions. General Development It is unlikely that this testing was able to reveal the full extent of X’s abilities. Nevertheless, even the under estimates of his ability at this testing place him at least in the high average range (Raven, NEPSY tower) especially in the areas of abstract, higher cognitive functions. X’s difficulty in demonstrating his full intelligence seems due in part to the fact that he was aroused, often over aroused by the novelty of the test situation. He has not yet learned to manage his arousal to help him refine his very strong intuitions toward more controlled analyses (Raven items, counting/number manipulation, visual attention face task). Nor has he learned to put aside his feelings of urgency in pursuing his interests (drawing, playing, towers test) in order to comply with the demands of a non preferred task. This has both a positive and negative value. It is positive to the extent that X does have strong interests, that he becomes absorbed in them and can find considerable pleasure as well as the context for learning in very constructive activities (drawing, solving complex visuospatial problems). As part of this, X appears to have strong visual preferences (certain perceptual features, dynamics, forms) and a fairly well developed sense of aesthetics. It is negative to the extent that school is essentially an issue of allocating attention toward what you are told, modulating more compelling interests and maintaining one’s composure in the process. X’s failure to develop appropriate levels of self regulation/control seem to be driven by a number of things: 1) his interests are strong and can compel him to engage in another direction; 2) more than ordinary effort is needed to cope with a speech environment so X is tired, tense and vulnerable to impatience and frustration and 3) he is prone to being over stimulated and overwhelmed especially when already exhausted from his efforts to cope with speech. When he has adopted a goal, he has impressive resources for engagement and goal attainment. The NEPSY towers test demonstrates vividly that X can consider how to reach a goal in advance, reject false moves and begin to act with an efficient approach already worked out (often referred to as executive function). Special Education Identification X’s difficulties with language, speech and sensory integration have been well documented in the record and continue to be dominant in his profile at this testing. In terms of school functioning, his phonologically based language deficits appear to be primary. They aggravate and are aggravated by sensory integration problems, i.e., the more exhausted he is from coping either with speech or with other sensory input, the less tolerant he is of subsequent sensory (auditory or otherwise) information. RECOMMENDATIONS 1. Reading should begin very slowly with very few letter sounds and very few decoding principles. X will need a highly structured reading program that reveals the regularities of the code, capitalizes on his ability to perceive visually integrated structures (spelling patterns in this case), supports his phonological deficits and is careful not to overwhelm him. Following would be the needed components: X should learn to read in the Let’s Read program (Educators’ Publishing Service, Cambridge, MA). It is highly systematic, introduces no exceptions or atypical constructions, progresses very slowly and works at a syllabic vs alphabetic level thereby placing the least stress on phonological processing. He should be asked to learn only those letter sounds that he needs for the first syllable type in Let’s Read, i.e., the -at family. At this testing, he had most consistent difficulty with liquid sounds (/l/, /r/) so these should be the last consonant sounds learned. To begin with he would need to learn the short a sound, the sound for t and that they combine to make AT. From this point forward he can learn one consonant sound at a time, each to mastery defined by giving the sound and using it as an initial, onset consonant in an -at construction, and then moving on. The first sound might be X, the first sound in his name. From that point forward, the sequence used in Let’s Read can be followed, being sure to hold off l and r until last. Learning letter sounds might be facilitated by having him use pictures including those he has drawn. To learn the sound of b, for example, he might have a photograph of himself labeled with the letter b. X would select his picture while saying “X-X-X-X”. This would be phased into X-X-X and eventually just /b/. The same could be done using, for example, the picture he drew at this testing. It could be copied and the pictures of dinosaur and tree could be cut out and glued to a hard backing. The letters d and t would be written on each. He would be asked to select the one that starts with /d/. X’s response would be as above. X may need help articulating a given consonant sound in isolation. If so, he can be shown how to make the sound, using a mirror. A speech therapist should be directly involved in delivering this part of his program. The LIPS program can be used as a teacher guideline but it is not recommended that the LIPS names or descriptors be used to support articulation since this amount of language serves only to confuse X. Words need to be attacked first as rime (vowel through the end of syllable, in this case AT) and then with the onset (initial consonant sound) added (AT-cAT). Since X is very responsive to visual structure, this could be exploited in emphasizing the rime vs onset. Words can be written over for X and he can write them himself in a different font and color for the rime vs the onset as below: CAT XAT SAT When it’s time for a new rime pattern, this can be presented in a different font and color: CAN XAN SAN Visuospatial awareness might be exploited by giving X moveable letter tiles/slips of paper which he uses to spell a word as he says each sound. The idea would be to provide X with the same number of sections on a mat/card as there are sounds in a word. He would move a letter tile into the appropriate section as he says each of the sounds in a slow pronunciation of the word. Once he has begun to read actual words, he must be able also to spell them before he can thought to have mastered that word or syllable type. 2. At the same time, X can be given some exposure to the phonological structure of words and phoneme manipulation by: playing rhyming games and singing rhyming songs reading story books with rhymes, i.e., Dr. Seuss, Henny-Penny The same story or rhyme or song would be repeated until X can anticipate the rhyming word. When singing/reading to or with him, there could be a pause before the rhyming word which he could supply on his own. Eventually the idea would be for him to be able to make up some rhyming words for stories or songs. 3. X will need a very thorough speech and language assessment of articulation and phonological processing. This would be done best through observations in his home or school setting. When he is developmentally ready, central auditory processing disorder evaluation is also indicated (ordinarily around age 7 or 8). 4. Although it does not appear that hearing acuity is an issue, it would be worthwhile to rule out hearing loss, intermittent or otherwise, as a source of X’s difficulty with language comprehension and phonological processing. 5. In conjunction with a speech and language clinician (SLC), it will be important to develop activities to help X capture and understand function words and word endings. This might be built into a drawing or building activity in which X is asked to draw a picture of a dinosaur who is falling vs one who will fall vs one who fell. To encourage him to capture extended amounts of information, he might be asked to draw pictures like those on the comprehension of instructions test, draw a happy, green dinosaur with a long tail; sad, red dragon fly.... 6. X would benefit from a slow rate of speech delivery, periodic pauses to give him time to process what he has heard, opportunities to hear repetitions and for him to paraphrase. 7. X seems worn down by his efforts to cope with spoken input. It will be very important, therefore, that he have adequate reading skill. Reading will eventually provide him an efficient way to compensate for auditory processing problems of this kind. Of course this is somewhat of a catch-22 since phonological deficits also undermine learning to read. Nevertheless, there can be no compromise in developing an effective reading program. 8. Math instruction should exploit X’s strength in visual perception, his appreciation for structure and symmetry. At the same time, it will be important to provide consistent support for his difficulty with those working memory functions that ordinarily are used to memorize numeral names, math facts and later math algorithms. Following are some suggestions: X might represent the same number in various ways. For example an amount of 6 might be rearranged as xxx xxx or xx xx xx. These examples maintain symmetry and might be the ones chosen by X. Whatever he chooses he would then write out his work in numerals. In this example, the first arrangement would be labeled with a 6, then 3 and 3, then 2 and 2 and 2. This can be done by drawing pictures as well. It can be applied to his interest in drawing by asking him to draw a dinosaur with 6 ( or 8...) legs. As a challenge and way to help him make the transition to organizing information in a different way, he might then be asked to draw a creature with 3 (or 5 or 7) legs. How he manages this next level would provide the basis for what form instruction should then take. Embed number concept into daily activities. One-to-one correspondence can be supported through setting the table for the right amount of people, sharing snacks brought into school, deciding how many pieces of cereal he wants to eat and then counting them out for himself.... Once he is comfortable with this level of activity, challenges can be set for him. For example, if there are 10 classmates (including X), he might be given 11 snack items to share and let him decide what to do with the extra. Eventually, he could also be given 5 dividable items such as bananas and left to his own (in conjunction with his classmates’) devices to figure out what to do. When he is asked to do paper and pencil computations, X should be allowed and encouraged to use manipulatives to compute his answer. If numeral learning does not follow from bullet #1 above, any practice should involve motor activity as rehearsal and not just language. Matching an amount with a numeral could be done by selecting the right cards and pairing them. This of course can be made into a number of games, i.e., a memory game where only the backs of cards can be seen, they are randomly ordered, the position of turned over cards must be remembered so that the correct pairs can be formed and taken as points. 9. In general, instruction, change or transitions should be introduced slowly and give X an ample opportunity to adjust, manage novel sensory information and find a comfort level before moving on. 10. It would be best to motivate X by making his efforts functional rather than trying to make target behavior contingent on some nonrelated reinforcer. This diverts his attention from the task and encourages him to go through the motions without fully engaging. Further, it fails to exploit X’s potential for deep, intentional, meaningful involvement. 11. All instruction needs to ensure that spoken language is accompanied by information that can be understood through visual perception and action. 12. The cautious, recommended approach to programming for X would be to have him do another kindergarten year next year. The morning would have him in an integrated classroom accompanied by a special education teacher with the goal of helping X engage, not just go through the motions compliantly, in kindergarten activities while regulating arousal. This would require support from an occupational therapist possibly consultative as well as direct intervention. There might be techniques that X can use unobtrusively in the classroom to help him find sensory grounding (sitting at a desk with weight on his lap, finding highly stabilizing positions...). The afternoon would consist of one-to-one instruction in readiness skills in reading/spelling, language and math, following the recommendations suggested here. 13. There will need to be thorough re-evaluation at the end of this year in order to determine the exact level of instructional needs for the following year as well as the appropriate form of instruction.