Sample Diagnostic Cognitive and Achievement Evaluation Presenting Problem: Reading Miriam Cherkes-Julkowski, Ph.D. www.educational-advisor.com 59 Philip Drive/Storrs, CT 02688 860 429-4894 30 Seaview Ave./Ocean Grove, NJ 07756 732 988-8432 1920 S. Plaza Dr. #43/Apache Junction, AZ 480 209-1968 Diagnostic Cognitive and Achievement Evaluation CA: 9 GR: 3 BACKGROUND: Despite agreement among teachers and tutors that X works very hard, her performance in school seems to have degraded since her very good beginning in kindergarten. Where she worked independently, with good work habits and had good oral communication in kindergarten, in grade 2, X relied on others to know what to do. Now in grade 3, work habits have become a source of concern including working independently and using time well. Where the grade 2 teacher commended X for her self control, in grade 3 self confidence and self control were listed as need areas. A PPT upon X’s entry into the YYYY school system listed only strengths with modest concern about fine motor development and no concern about the fact that she was “working on Rhyming. not able to Rhyme yet (sic).” By grade 1 she was being tutored in both reading and math. She has received Title I support for reading, was doing poorly with phonics in grade 2 and now is reported to be below grade level in reading despite good comprehension. Most recently, X has passed the math portion of the third grade version of the state mastery test but failed the DRP and writing goal. Math is strength. Her grade 3 teacher has commented on X’s “wonderful...application of math concepts.” The grade 3 reports have contained some contradictions. Relating to others is listed as a concern but at the same time, X is described by her teacher as friendly, outgoing, warm and kind. The rest of the record is consistent in describing X as loving, responsive, happy, having a good sense of humor. Her comprehension is described as good (third grade teacher) but Title I intervention provides support for both comprehension and decoding. Despite agreement that phonics is difficult for X, her program seems to continue to be based in a whole language approach that does not systematically teach phonics. In fact, there appears to be some confusion about what phonics might be (grade 2 report card: “X needs to focus on using learned phonemic (emphasis mine) (letters and letter sounds) to decode text.(sic)” Her early difficulty with rhyming (kindergarten PPT minutes) as well as the delay in language development (see below), including a prolonged period of “babbling” are suggestive of phonological deficits where phoneme awareness problems interfere with phonic knowledge of letter sounds. She is now slow and dysfluent when she reads. Fine motor difficulties continue to be an issue. Current language issues seem to be manifesting not only in poor development of reading skill but also as poor oral and written expression and difficulty with grammar (grade 3 report card). Slow rate of processing and reading dysfluency are also continued areas of concern. Review of School Work Samples. Some of X’s recent papers were reviewed. Spelling errors reveal problems with phoneme awareness as she omits phoneme level sounds (soud for sound, emty for empty, cack for crack, gree for green, potat for potato), introduces them where they are not indicated (turaning for training, has for as). There are those grammatical errors associated with phonological deficits in perceiving unstressed ending sounds where grammatical markers are often situated (“Scott and Tim has 7 dog. How many dog are there”). Math papers involving fairly advanced ideas (decimals, multiplication grids, problem solving) are done consistently well, usually with check plus. When X writes, she tends to leave a wide left hand margin. TESTS ADMINISTERED: Woodcock-Johnson - III Gray Oral Reading Test - 4 Raven Test of Progressive Matrices Test of Written Language - 2,3 (TOWL) Rey Osterrieth Complex Figure (ROCF) California Verbal Learning Test - Children (CVLT-C) Comprehensive Test of Phonological Processing (CTOPP) Phonological Awareness Test (PAT) Rime-Onset Instruction TEST OBSERVATIONS: X works hard and with deep concentration but not efficiently. This can be seen at many levels of a task. When she lays out marks to count up (in figuring 3 x 7, see calculation results), she counts some of the marks in one set but not all, some in the next set, returns to the first set and then back to the next. This introduces a tracking issue which makes the task far more complicated than it need be. She did manage a correct count. Similarly, she took a fairly random approach to managing the CVLT-C lists, making it necessary to take longer to meet success. She often makes a first, erroneous attempt and then goes back to correct it. X is careful to monitor what she does, to find her mistakes and to correct them. She is willing to follow instruction with dedication but is more reluctant to try to solve novel problems on her own. She can be lively, curious and enthusiastic, at testing especially when talking about Winnie the Pooh characters whom she understood very well. She was also fully engaged in writing a story and when learning how to multiply with a two digit number. When decoding words in isolation, although she never failed to try, X became fidgety, twisted at her shirt and told me when she was confused, “I get confused by my b’s and d’s”. She did not seem aware of it, but she is confused by f and l as well. X appears to have low oral motor tone and discoordination to the extent that it affects speech intelligibility, particularly when she speaks quickly. She does not achieve full lip closure so that saliva is often collecting at the front of her mouth, further interfering with intelligibility. There are misarticulations at the phoneme level (r/l and w/l confusions, v/b, a/e/ e/i) as well as at the syllabic level when she transposes the order of syllables. There are word finding delays and problems with multisyllable word articulation (pentamid for pyramid, hurdy for hurried). She consistently misses the ending sounds in words (see nonword repetition especially as well as review of work samples). Her lapse into baby talk, at this testing when she was tired, is probably a way to cope with phonological information since baby talk emphasizes the final sounds of words by repeating them and capitalizes on prosody as way of organizing phonology, i.e., provides a rhythm around which to organize syllable sound). X is a lively conversationalist with a sense of humor and the ability to respond to a topic set by another. She has more difficulty when she is solely responsible for organizing her verbal expression. She will sometimes jump in to make a point without setting the stage well enough such that it takes some time to determine what she is actually talking about. There are syntactic problems in speech production, such as “we do something first beginning” and “the kids been lost stuff.” She sometimes supplies answers using the wrong part of speech or can supply a missing word (in the Woodcock-Johnson passage comprehension test) that creates incorrect syntax. In addition to her phonological confusion, X seems to have some visual confusion with symbolic (letter) forms as well as abstract designs. She also failed to recognize those critical features in a picture that would suggest function (based on pictures, she couldn’t think of what function a vise might serve or a tourniquet). She leaves an increasing left hand margin as she writes and began on the right side as she drew the ROCF figure. All of this is suggestive of difficulties with directed attention/visual scan and possibly visual perception. X does better with form perception despite some distortions of size and shape (see spatial relations test). She wanted to draw a picture of a fish, which although poorly rendered, showed clear recognition of form. She does not like school very much because she has to sit at her desk all day and “work, work, work”. At testing, she also worked, worked, worked. As discussed above, she often exerted more effort than was inherent in the task demands. In part this is due to some difficulty finding an initial organization (see ROCF results). In part it’s due to the need to overcome phonological and speech difficulties. She seems also to be tired when she comes home from school. At home, X likes to play math and science computer games in her room. Of the things that upset her, paramount is when her mother does not believe her. She says her response is to get sad. X uses an awkward pencil grasp, the first two fingers opposed to the thumb. She also had some difficulty turning pages. TEST RESULTS: Woodcock-Johnson standard score* percentile word attack 79 8 letter-word recognition 88 21 spelling 86 17 passage comprehension unprompted 87 19 prompted 112 78 calculations 104 60 applied problems unprompted 104 61 prompted 111 76 incomplete words 82 11 spatial relations 88 21 verbal comprehension unprompted 106 65 prompted 113 80 Scores have a mean of 100, standard deviation of 15 X read the first three pseudowords on the word attack test correctly and then fell prey to a number of phonological confusions. She produced the short i sound for short e (ip for ep). There are quite a few vowel errors (rack for rox, tree for thrept, grew for grawl). She had a difficult time with the r-sound. Sometimes she inserted it where it did not belong (treed for tayed). At other times she could not use it within a vowel-r construction (snirk read as snir-ak). In addition to phonological confusions, there are confusions about letter forms as well. Lower case f and l are often confused such that feap is read as leap, foy is read as loll. The latter error involves a consonant assimilation as well, i.e., carrying a consonant sound into a position where it is not indicated. Phonological confusions dominate high frequency, real word reading as well (letter-word identification). The order of sounds can be transposed (sniss for since). The nasalized n is omitted (aggist for against, dist-as for distance). There are vowel confusions (most for must, git for get). Despite the fact that these are errors, they reveal how painstakingly she accounts for one letter at a time. However laudable this approach is in terms of effort, it also reveals a lack of insight into the orthographic structure of words (i.e., -tance is an integrated syllable in distance as is dis; the t goes with the second syllable). X’s difficulty with phonology is even more apparent in her spelling. Ending sounds are omitted (tabe for table, cook for cooked) or changed (second spelled as seent, rewards spelled as weweres). Note the w/r confusion in the previous example as well. Nasalized n is omitted (uder for under). Sometimes X seems to be lost fairly completely in the phonology of a word: yerly for early, reeog for garage. The passage comprehension test consists of short passages of one, two, or three sentences in length. X was to supply the missing word. Since X chose to read the passages aloud, it was possible to note that her decoding errors in context are similarly phonologically driven. She omits ending sounds and function words (words high in syntactic but low in semantic value), both of which are unstressed in speech (Gulliv for Gulliver, last for lasted; omission of the, substitution of the for a). She continues to have difficulty with the r-sound, reading proud first as ploud but then correcting herself. Decoding errors were a large impediment to comprehension. Even when she did comprehend, X could supply a word that created incorrect syntax (...go to the library, you will find many things to look). Nevertheless, X has a strong ability to comprehend text level language. She answered many middle school level passages correctly when they were read to her (prompted score). She was most engaged and said she was having “fun” while listening to the highest level (8th grade) passages. It should be noted that she did not reach ceiling under the prompted, listening condition and therefore her comprehension ability may be under estimated. Further, her appreciation for the subtleties of the Winnie the Pooh personalities (see observations) suggests a keen interest in and aptitude for literature. X expressed confidence about her math ability. She was able to add with renaming and read the four-digit answer correctly. She cannot operate with two-digit numbers in any further operation. She failed to borrow and instead simply subtracted the greater from the lesser digit, yielding the following solution, 48-19=31. She could multiply with one digit numbers but could not perform simple division. X explained that she could not find the answer to 13 x 7 because she did not know the 7 table. She answered that she did not know 7 x 3 either (apparently failing to understand the commutative property that would allow her to use knowledge of the 3-table). When asked to draw a picture that would allow her to find the answer to 7 x 3, X knew immediately what to do. She drew 3 circles and wrote 7 marks in each. She used an unusual approach to count up her marks, counting all of the marks in the left most circle, only the left hand portion in the middle and last circles and then returned to the middle and last circles to count the remaining marks on the right. Surprisingly, she tracked her counting well enough to come up with an accurate count. X did not know how to proceed from this point to solve 13 x 7. She was then asked how much 2 x 10 and 3 x 10 were and could answer correctly. This did not prompt her to proceed further. She finally understood how she could capitalize on this approach when she was given more direct instruction. She was given examples showing that 4 x 3 was the same as 2 x 3 plus 2 x 3; 5 x 3 could be calculated as 2 x 3 and 3 x 3; 13 x 7 as 3 x 7 plus 10 x 7. X followed these examples and set up the same format to solve 14 x 3 correctly. Although X was allowed to use a calculator to solve the word problems on the applied problems test, she did most of her work mentally. It took X some time to get through complex, indirect and dense problem language, but she did so correctly. She rarely had any trouble at all in conceptualizing the relationships in a problem. Errors involved keeping track of calculator entries, as well as lack of knowledge of advanced skills such as fractions. One error revealed her failure adequately to scan an accompanying picture. When asked to figure out how much change she would get given the amount of money pictured, X noticed the coins but not the dollar bill. When her attention was drawn to it, she could find the correct answer (prompted credit). Problems with calculator entries may involve similar problems with scanning as X had some difficulty in directing her attention alternatively to the number and then the operation keys. The incomplete words test consists of the partial, spoken representation of words. The full word must be inferred, i.e., le-er for letter. No print is involved. X encountered a great deal of difficulty in recognizing the implied word. She often dropped the ending sound (wa-er for water/walker was answered as walk, aper-oy for paperboy was answered as apron, bir-ay for birthday answered as bird). The spatial relations task is to determine which component pieces would go together to form a designated shape. Errors suggest that although X managed a loose appreciation for the needed size and shape, there were mild distortions in both of these qualities. There were also some, albeit fewer, errors in orientation. None of these answers was a result of impulsivity. X pondered her choices and was still unsure of many of them in the end. The verbal comprehension test consists of measures of picture labeling, synonyms, antonyms and analogies. There were phonologically driven word finding delays and aborted attempts (could not find the word stethoscope to label the picture but accurately described it as a “heart checking thing”). There were phonological confusions (pentamid for pyramid). X was given prompted credit for identifying the meaning (heart checking thing) when she could not find the correct word. Of some interest was X’s difficulty examining pictures of a vise and of a tourniquet, neither of which she could label. She said that she thought a vise might be something that goes on the back of a boat but missed the clamping function afforded. Similarly, she thought the tourniquet might be a cast but missed the tightening function of the stick twisted in the fabric. X was most fluid on the analogies portion of the test, working associatively to complete the basic analogies with ease. However, she maintained her associative approach when it was no longer suitable to analogies that required deeper analysis of relationships (water: pipe::electricity:___, X answered run). Comprehensive Test of Phonological Processing (CTOPP) standard score* elision 4 digit memory 7 nonword repetition 5 *standard scores have a mean of 10, standard deviation 3 X had difficulty with almost every level of the elision test which asked her to delete a sound from within a syllable. She had difficulty maintaining ending sounds (bold without /b/ was given as ole). She altered the vowel when she effectively deleted an ending sound (time without /m/ was given as tih, with a short i). Similarly, ending sounds were missed consistently on the nonword repetition test (wudoip repeated as wudoit, nigong as nigonn, chaseedoolid as chaseedoo). X called these tongue twisters. For the most part, X was attentive enough to capture the digits in many of the digit strings but she could not support phonologically driven rehearsal of the strings and therefore could not maintain the order of digits (84239 repeated as 84329). Lindamood Auditory Conceptualization Test (LAC) The LAC requires the child first to listen to a sequence of isolated phonemes and to represent the number and order of sounds using colored blocks. Same sounds are represented with the same color. The second level of task is to use the colored blocks to represent the number and order of sounds within a syllable. X did remarkably well on this test, especially given her difficulty with phonological processing in all other contexts. On this test, X could use the colored blocks correctly for all but two items. She represented /f/ and unvoiced /th/ as the same sound. Although she correctly manipulated within syllable changes (shifts in medial vowels, shift in the order of consonants), she could not segment a consonant blend (changed asp to sasp by moving the block representing the sound of p to the front of the word). X’s score of 93 places her above grade level, at a level equivalent to the first half of the sixth grade year. THE PHONOLOGICAL AWARENESS TEST (PAT) raw score standard score* GRAPHEMES consonants 20 110 long and short vowels 8 98 consonant blends 2 <45 consonant digraphs 4 106 r-controlled vowels 1 <53 vowel digraphs 5 114 diphthongs 0 <82 TOTAL 75 DECODING vc words 5 75 cvc words 4 65 consonant digraphs 6 85 consonant blends 0 <53 vowel digraphs 8 100 r-controlled vowels 4 77 CVCe words 4 86 diphthongs 0 <62 TOTAL 70 *standard scores have a mean of 100, standard deviation 15 Errors in giving sounds for graphemes are consistent with other phonologically based errors. X could not differentiate between the sounds for short e and i, giving the short i sound for both vowels. She did not blend consonant combinations but rather placed a vowel between them, producing a full syllable (gr read as ger, str as stir or star). She gave the sound of ar for all vowel-r constructions and the long o sound to all diphthongs (ou, oi, ow, oy). Reading whole, one-syllable pseudowords on the decoding test introduced orthographic issues in addition to basic grapheme-sound correspondences. X continued to make vowel differentiation errors (oob for ob, oom for um, in for en, kib for keb, hun for hin, lip for lep) and in addition, failed to recognize those orthographic patterns that determined the vowel sound (eek for ek, shome for shom, rik for rike, puzz for puze). Consistent with previous errors, X introduced an r-sound where it was not indicated (crun for croan, troop for tupe). Vowel-r constructions were confusing for her (tarb read as terb, forf as farf), She read curf as carf and then said that the word sounded as if it had no vowel in it, suggesting that X assigns the sound of vowel-r completely to the r. X worked hard and long at this test despite the fact that she was jittery throughout. Rime-Onset Instruction X was asked to read words color coded as rime (vowel through the end of the syllable) and onset (initial sound or sounds) to see if she could be sensitized to orthographic patterns (the rime in this case) and use orthography to determine the vowel sound. She was able to maintain correct short-long vowel shifts and correct short vowel differentiation for rime patterns using a and i: sat sate rag rage flat flate tag tage. She began making errors when asked to maintain the short e sound in the context of shifts to long e (ep vs epe). As a further probe, X was asked to read the word bed which she could do correctly. We had to work long and hard for her to be able to isolate the sound made by the e in bed and then for her to maintain it as she applied it in syllables using the ep rime pattern. Gray Oral Reading Test standard score* percentile rate 8 25 accuracy 7 16 comprehension 9 39 standard scores have a mean of 10, standard deviation of 3 The Gray uses paragraphs of 7 or 8 sentences in length. They were read aloud and then summarized. The comprehension score is based on answers to multiple choice questions. The passage score is a combined measure of rate and accuracy. Decoding errors continued to be in function words (the/a omitted or substituted for each other) and word endings (you for you’ll, childrens for children, only for one, children for child, jar for jay). X does not recognize when her decoding errors have created an incorrect syntax. In connected text with high frequency words, X could establish baseline for rate and accuracy at the 1.3 grade level. She passed the next passage at the 1.7 level and then failed criterion on the next, at the 4.4. grade level. Comprehension was stopped by the fact that she could no longer read accurately. Even when she had fairly serious decoding problems, X managed to get a good deal out of the passage, told accurate and well structured summaries and never actually failed criterion for multiple choice testing. Comprehension probes had to be stopped only because X could no longer manage the passage decoding. Syntactic errors not withstanding, X’s summaries are quite good. Following is a linguistically flawed but conceptually accurate summary: getting ready for school and the kids been lost stuff like their red shoes, their blue book. At the end the father lost his car keys and mother said good by and gave them all a kiss. When her summaries fail to include information it is because she hasn’t read that portion of the passage correctly due to decoding errors. In the passage about the jay who dropped stones into a jar to make the water level rise so she could drink it, X read the pertinent sentence incorrectly. The actual sentence is The jay gathered a pile of stones and began dropping them the jar. X read it as The jar gruntly was pulled of stones and began dropping the jar. Needless to say her comprehension was hampered by mistakes such as these. Her summary of the jay passage was as follows: a blue jay flying north. It was a hot day. She was thirsty. Then she found a jar. She somehow made water into it and she dranked the water little by little. The above summary shows something of how hard X must work to fill in what has been missed at the decoding level. X ad libbed the points about going north, about being hot and skimmed over the fact that she could not figure out how the jay actually got to drink water from the jar. Nevertheless, she does the work and because of her intelligence and background knowledge manages to fill in a good deal of what she misses. The caution here is that when she is reading in areas about which she has little background knowledge (i.e., one of the primary functions of reading), this strategy can no longer work. Furthermore, guessing at words is a very poor substitute for accurate reading and can only distort passage intent as well as make critical analysis impossible. Raven prompted unprompted raw score 40 32 percentile (1986 norms) 90 60 standard score equivalent* 120 104 standard score equivalents have a mean of 100, standard deviation 15 The Raven is a test of abstract reasoning that uses pictured patterns,considered the “best measure” of general intelligence, “Whatever g (general intelligence) may be, at least we know how to measure it. The accepted best measure is a (usually untimed) test of visual reasoning called Raven’s Progressive Matrices.” (Neisser, http://americanscientist.org/template/AssetDetail/assetid24612/page/2) Despite the fact that X was engaged in this task and spent considerable time with it, she was rarely right in her first attempt. She monitored herself carefully and often corrected herself. When she did not, prompts were extremely effective in getting her to a second, correct answer. Prompts asked her to justify her first choice such that she had to put language to her thinking and become explicit about it. The difference in performance level is large, moving her from an average to a superior level of reasoning and intellectually ability. It is important to emphasize that no substantive support was given. Her need for a second, more explicit pass through the material seems to be based in some perceptual confusion. Nearly all of her first, wrong attempts reflected a loose awareness of form but failed to account for more carefully scanned information and failed to account for those visual characteristics that have differentiating value only in a symbol system (directionality, orientation). In the first case of vagueness about form and composition, X made errors such as picking a square formed by four corner dots rather than one marked off in a 3 x 3 grid. In the second case, she disregarded issues of orientation (as in b/d confusion) and mild differences in form (as in f/l confusion). California Verbal Learning Test - C (CVLT-C) The California Verbal Learning Test measures a number of memorial, verbal, organizational and attentional functions. There are 5 consecutive exposures to a list of words which fall into 3 categories. This is followed by the learning of a second list, also with 3 categories. One of the List B categories overlaps with one on List A although the items are different (i.e., pears on list B, peaches on list A). This trial is followed by a series of short-delay and long-delay recall trials concerning the list A items. Most scores are reported as z scores, measures of standard deviation. As usual, X began slowly, with a below average score for learning at the first trial (z=-1, 4 items repeated). By the fifth trial, however, X had diligently worked herself up to a solidly average score (11 items repeated, z=.5). She was working extra hard primarily because she never exploited the essential, meaningful underlying categorical structure of the list (semantic cluster score, z=-1.5). Instead, she worked randomly through the list with only minor adjustment to the order in which the list was presented, itself random (serial cluster score, z=.5). Due to her essential lack of access to the underlying and essential structure, she again found herself floundering with her first and only trial with List B, z=-1. Nevertheless, sheer diligence allowed her to avoid perseverations and intrusions as well as to have solid scores at all recall and recognition probes. Rey Osterrieth Complex Figure Test (ROCF) (Taylor Scoring) standard deviation increase/decrease from average copy -3.86 immediate recall - .84 X, as is often the case with her, had a difficult and disorganized beginning. She tried to organize her efforts by finding a semantic basis for the completely abstract, meaningless drawing. She labeled it a fish with a diamond. Since neither captured the right form nor the extensive internal detail, it was not especially helpful, however motivated it was. X did draw a fish later that demonstrated how she had incorporated the broad contour of the ROCF figure into her depiction of a fish. She began the copy drawing on the right, an unusual approach for someone who is right handed, suggestive of some difficulty directing attention to the left visual field (see also her tendency to leave wide left margins). From this point she tried to outline the contour first but in so doing missed the more essential structural features (central rectangle, diagonal and cross). She dutifully referenced the model, trying to render each detail. However, since the structural elements were not in place, the contour was distorted and therefore provided an inadequate framework for positioning the rest of the detail. Despite the distortions in the original drawing, X seems to have overcome a good deal of her confusion at recall. When the model was no longer present so that she could not be disorganized by the large amount of detail, and following some methodical exploration of each aspect of the figure, X developed a far more integrated understanding of it. She drew a central rectangle, represented the diagonal as integrated unit and placed individual elements in far better relationship to each other and the framework of the figure. This is seen in her improved score at recall. Graphomotor problems manifest as shaky lines and poorly formed angles. Test of Written Language - 2 standard score* percentile thematic maturity 8 25 contextual vocabulary 7 16 syntactic maturity 7 16 contextual spelling 6 9 contextual style 7 16 Test of Written Language - 3 contextual conventions 8 25 contextual language 10 50 story construction 11 63 standard scores have a mean of 10, standard deviation 3 The TOWL-2 scoring credits each instance of a correct response. Short passages are therefore penalized, longer passages may have inflated scores. The TOWL-3 is a more qualitative scoring system. Since X’s passage was short, she was especially penalized by the TOWL-2 scoring. X uses fairly simple sentence construction and in so doing avoids some of the syntactic errors made in more spontaneous speech. Her passage, with spelling errors, spacing issues and left margin increments is repeated below: I visted a plonet. It was ones knon as the moon. I thout it was a big ball of cheese. I t was ik sonding (exciting) I went to the moon because I was having a test. It was fun and I had the most because I found someting I had never seen. X maintained phonological order much better in most her spellings on this test, due most probably to her selection of very simple, one syllable vocabulary. When she did try to represent the sounds in a multisyllable word, she began losing track of the phonological structure: ik sonding for exciting. ANALYSIS Cognition As her teachers have indicated, X is intellectually quite capable. The prompted Raven places her intelligence in the superior range (120) which is reasonably consistent with other prompted scores (verbal comprehension, 113; passage comprehension 112). Prompted scores should be taken as valid measures of her ability because in each case they allow her to bypass distinct processing problems without providing substantive supports. Even these scores may be under estimates of her ability since X is constantly struggling with diffuse processing difficulties including: 1) phonological deficits, 2) oral and other fine motor problems; and 3) problems with directed attention that affect visual perception. Phonological deficits are linked with oral motor difficulties. Since phonemes sounds are determined by how they are articulated, lack of articulatory clarity is a substantial impediment in differentiating among sounds and segmenting one phoneme level sound from the next, as in X’s difficulty in recognizing that er is two phonemes, the short e and the r, that gr is meant to be two phonemes and not three (ger) and that the sound of x has two phonemes and not one as in her pronunciation of rox as rak. Problems with analyzing phonemes are apparent when she tries to articulate words (hurdy for hurried, pentamid for pyramid), when she tries to spell (ik sonding for exciting, weweres for rewards) and when she reads (rak for rox, sniss for since). Perceiving ending sounds is particularly hard since they are unstressed (nonword repetition, spelling with ending sound omissions, ending sound errors in reading). The same is true for function words. When she misses endings and function words, X is often missing critical syntactic information (noun-verb agreement, conjunctions, tense indicators). Since decoding is dependent on mapping letters to the sounds that they represent, the inability to isolate phoneme level sounds is a problem of great magnitude when trying to read. X’s ability to segment individual phoneme level sounds from the speech stream is significantly below average (elision). In rather extreme contrast, however, when she is given an explicit means by which she can track her phonological analysis, she manages very well (use of colored blocks on the LAC). Directed Attention and Perceptual Deficits interfere with X’s ability to perform a systematic visual scan. Although form perception seems fully in tact, failure to direct attention to all aspects of the visual field results in X’s difficulty with full analysis of more structurally critical forms (orients to contour of ROCF but not structural features, Raven errors, more subtle discriminations on the spatial relations test, correctly understands that b and d have the same form but not aware of directionality, vague sense of form similarity in f and l without examining extra-form detail). Her difficulty in directing attention to all aspects of the visual field is seen in her unusual way of tracking herself through counting up (drawing sets for 3 x 7 and counting them up). Since directed attention is part of a system with input from the right hemisphere to frontal areas, i.e., frontal eye fields, the left visual field is most dramatically affected (starts right on the ROCF, leaves wide left margins when writing). It is important to note that directed attention is more than the simple issue of what X looks at. It is based in an intention, which in turn is based in awareness that certain features are in fact relevant. She has most consistent difficulty with those features that become relevant only within a symbol system such as precise size, directionality, orientation, minor details. Fine Motor development delays are evident both in speech difficulties as well as in awkward pencil grasp, shaky lines while drawing, distortions in drawing and writing. Reading/Writing X has difficulty with all aspects of phonological processing. Her problems are pervasive and deep enough to continue to affect speech. During her preschool years it appears that phonological deficits interfered with the development of speech and language manifesting as a prolonged period of unintelligible babbling. Problems with isolating parts of a word surfaced during kindergarten in X’s difficulty with rhyming. Phonological processing, and in particular phoneme awareness, are critical to learning how to read and spell. In order to map letters to the phoneme level sounds that they represent, X must first be able to segment the speech stream into phoneme level sounds. Not only does X have trouble segmenting phoneme sounds from within a syllable (severely below average score for elision), she does not always perceive all of the sounds in a word or syllable (nonword repetition, spelling and reading errors). In fact, X manifests each of the problems associated with those phonological deficits that undermine reading: Problems with word endings and function words, i.e., forms that are unstressed in speech incorrect ending sounds in speech (constituting grammatical errors as in lost for losing in the phrase, “the kids been lost stuff.” incorrect ending sounds in word repetition (nonword repetition) omission of ending sounds in speech (incomplete words) incorrect ending sounds in writing, “Scott and Tim has 7 dog. How many dog are there?”; spelling green as gree; potato as potat Problems with the order of sounds omission and transposition of syllables in speech and in writing as in saying hurdy for hurried or writing begging for beginning and reeog for garage consonant assimilations, i.e., carrying a consonant sound through a syllable into positions where it is not indicated as in mistaking f for l and then reading foy as loll. Problems perceiving phoneme level sounds omitting or inserting the r-sound as in reading tayed as treed, spelling crack as cack. omitting nasalized n in reading against as aggist, spelling sound as soud. omitting parts of a consonant combination as in empty spelled as emty, crack as cack failure to elide vowel portion of a consonant sound when blending (snirk read as snirak, training spelled as turaning Problems discriminating between sounds confusion among short vowel sounds (ep/ip, rack/rox) inability to discriminate between similarly articulated sounds: t/d as in spelling seent for second; w/r as in spelling weweres for rewards. X does best with phoneme segmentation when the fact that she should be dealing in discrete sounds is made evident by the use of blocks (LAC). The blocks also allow her to keep a constant representation of her work to which she can refer, thus alleviating working memory while obviating any need for specific letter-sound knowledge. Even under this ideal condition, however, X cannot manage consonant combinations. She can detect that there are differences among short vowel sounds but this does not make it possible for her to produce those differences correctly (isolating the short e sound from bed, decoding, spelling). Because she has not been able to detect, discriminate and maintain the order of sounds within a syllable, X has not been able to map the print code to those speech sounds it is meant to represent. Her well below average score for the Woodcock-Johnson word attack test, many below average scores on the PAT and low average total grapheme and decoding scores on the PAT all indicate X’s failure to learn the reading/spelling code. At this point, X has not mastered any syllable type with the possible exception of vowel digraphs. She inserts sounds where they are not indicated, in part it seems as an unconscious way of reducing motor demands (treed requires a lesser degree of diadochokinetic shifting than tayed). Whenever she distorts sounds in this way, X also distorts clear letter-sound associations. Further, without a clear grasp of how adjacent sounds are distinguished from each other (consonant combinations) and without a clear grasp of how similarly made sounds are distinguished from each other (short vowel confusion), it is difficult to recognize that patterns of letters indicate the vowel sound (ob vs obe, puzz vs puze) and signal phonological breaks (dis-tance vs dist-ance). X can take advantage of orthographic (spelling) patterns, especially when they are clearly marked for her as in the color coded rime-onset instruction. When the pattern is made clear she can detect shifts from long to short vowels and hard to soft consonants. However, the short e sound remained very difficult for her to manage. As discussed above in the cognition section, there are minor issues with those aspects of directed attention and analysis of symbol features that have some impact on letter recognition (not evident in writing). These can be handled through motor feedback (see recommendations). X’s writing is affected by her lack of knowledge of the code and its phonological underpinnings (ik sonding for exciting). This does not stop her writing from being lively and fluid. Since she has to allocate resources to analyzing sounds in words and then inventing spelling to depict them, there are occasional word omissions and a tendency to shift topics abruptly. Topic shifts occur in speech as well and may be a reflection of difficulty with phonologically based function words including those conjunctions which support transitions (because, then, if, so, and, but...). Math As her teacher and mother appreciate, X has a strong understanding of math concepts, reflective of her general intellectual ability. Her processing problems interfere with some aspects of math functioning. She has to make some accommodation when visual scanning is required using a calculator, viewing graphic material). Although X usually manages the accommodation, it comes at the cost of time, effort and ultimately fatigue. One outcome of fatigue seems to be her lack of adventure in experimenting with new calculations and problems of a completely novel form. It would be important to give this kind of experience some priority since it is likely to be an opportunity for X to express and develop her competence. Special Education Eligibility X has a learning disability. Because of her disability, intelligence testing is best done under an untimed, language reduced condition. Further, she may need support in scanning the visual field. With those provisions in place, X’s ability as measured by the Raven is 120. Even if the unprompted Raven score of 104 is used as a highly conservative measure of ability, there are a number of achievement discrepancies exceeding 1.5 standard deviations (scores of 82 or 8 or lower): word attack, PAT graphemes and decoding as well as many of the individual subscale scores, all TOWL-2 scores, TOWL-3 contextual conventions. There are discrepancies among processing abilities as well. X manages verbal comprehension at the 106 level but incomplete words only at 82, spatial relations 88. Her phonological processing disorder is measured well into the below average range on the CTOPP elision and nonword test and has documented effects on working memory as measured by the CTOPP digit memory and CVLT-C scores for initial learning, i.e., List B and List A, trial 1. Deficits in directed attention are seen on the spatial relations test, the copy drawing of the ROCF, in Raven errors and work samples. RECOMMENDATIONS 1. X will need a highly structured, highly individualized reading-spelling program with support for articulation interwoven with it. The following elements are needed: X will need to recognize and produce short vowel sounds as well as differentiate them from each other both perceptually and in speech production. This will need to be done by showing her (possibly with mirrors) the difference in how vowels are articulated. The LIPS program can be used as a guideline to explain the articulatory gestures used to make individual sounds. Given X’s word finding and working memory problems, it is NOT recommended that she use the LIPS terminology for how sounds are produced. She can formulate her own descriptions and these can be the standard terminology used by her speech and language therapist as well as her reading teacher. Phoneme discrimination based in articulation will need to be extended to similarly made consonant sounds as well (t/d), to understanding the nature of consonant blends and to recognizing when a sound has been added, omitted or transposed. The above two objectives will need to be worked on in isolation, perhaps as speech therapy. They will also have to be worked on in the context of reading and spelling activities. When X makes a reading or spelling error involving sound discrimination/production problems, omission of sounds, insertions or transpositions, she will need to be helped to use her knowledge of how the sounds are articulated, how to isolate them from the speech stream in order to correct her errors. For example, if X has read the word tayed as treed, she can be told that she has introduced a sound. She can listen to the word treed, write lines to designate the number of sounds, __ __ ___ ___. This can be compared to the original word. She then can be helped to write letters in the appropriate position to represent each sound (using one e or ea, or ie would be acceptable in the third position). If she spells empty as emty, the same procedure might be used in reverse, i.e., how many sounds in empty, what’s the missing sound, where does it go. X needs to work through a highly structured decoding program that lays out all orthographic patterns systematically. She should use Let’s Read as the basic text, starting at the very beginning, and can practice skill and achieve some fluency by synchronizing Wilson program stories with Let’s Read skills. To start with, once she has finished Book 4 in Let’s Read (cvc words using all short vowels), X could begin with step 1 of Wilson which provides stories controlled for cvc vocabulary. It is critical that X can read and spell each word family (-at, -an...) with efficiency and at least 85% accuracy before moving on to the next word family. All words need to be attacked as first rime and then onset (cat is read as at-cat, flat as at-flat). This serves two major functions. First, it makes it possible to know the vowel sound before starting the consonant and thus to avoid coarticulating the consonant with the wrong vowel as in buh-a-guh for bag. Second, it preserves the rime as an integrated unit and emphasizes the fact that knowledge of the vowel sound and some consonant sounds comes from syllabic context and not from isolated phonetic rules. Color coding will help to emphasize the rime as an integrated unit. If letter form discrimination becomes a problem, X can use kinesthetic feedback to support systematic scan. She can trace letters, write them, feel them while blindfolded all as a way of using motor feedback as way to notice critical features. X’s reading program will need to be conducted by a highly knowledgeable teacher with training in linguistic reading including phonology, orthography and morphology. 2. X has lost valuable time in learning to read. To prevent further regression and to prevent being further locked out of grade level curriculum, it will be important for X to begin the above reading/spelling instruction as soon as possible and continue through the summer. Since very few children her age have X’s degree of phonological impairment and her lag in reading skill, she will need to have one-to-one instruction. This is necessitated further by the fact that she must move at her own rate, one that will ensure mastery of each step before moving on to the next and one that will allow her time to work through her errors while developing phonologic/articulatory skill. During the school year, X should receive 45 minutes of reading/spelling skill instruction daily. This is to the exclusion of all other reading and writing activities, i.e., comprehension and composition. 3. At the same time as she is learning basic reading skill, X needs challenging, above grade level reading material for comprehension and vocabulary development. Since she cannot read it, it will have to be read to her by an adult or using an electronic reading device. It is unlikely that X will have enough and fluent enough reading skill to keep up with curriculum demands in the fourth and middle school grades. By that time she will need to have an assistive technology evaluation with the goal of identifying the appropriate electronic reading assistance. 4. X is likely to need lo tech handwriting supports such as a pencil grip, supports for positioning, possible support for keyboarding. Consultation with an occupational therapist and/or an assistive technology consultant would be helpful in instituting this immediately. 5. X’s grammatical problems can be explained in large part by her phonological deficits and will need to be supported accordingly. This might be done in speech and language therapy where morphological endings and function words receive extra emphasis in speech so that X can make the correct grammatical distinctions (Tim has/ Tim and Scott have; 7 dog/dogs). This can be applied to reading/spelling instruction as she develops the appropriate decoding skill. When she begins to read the Wilson stories, X can highlight word endings and function words before beginning to read so that they become more salient to her. Editing of X’s writing at this point ought to emphasize effective use of function words, i.e., conjunctions, to make clear and smooth transitions. Spelling corrections should not be emphasized with the exception of those words which conform to orthographic principles she has learned in her reading program. 6. Complete speech and language evaluation will be needed in order to develop the kinds of recommendations suggested here. Central auditory processing disorder (CAPD) evaluation is indicated as well. Until such time as CAPD evaluation is completed, it will be important to modify X’s speech environment so that all speech is delivered at a slow rate, there are periodic pauses to allow her to process speech information, check-ins to ensure that she has captured what has been said and opportunities for repetition. 7. As part of her difficulty with directed attention, X at first does not always grasp the essential organizing structures in an information field, especially a visual information field. She is likely to need more time to begin awkwardly and then to revise her approach (as with the ROCF, as with all prompted vs unprompted conditions). This means more time and patience during instruction. At no time should instruction interfere with X’s own attempts to find organization in the material. It also means extended time for tests of all kinds. 8. X is coping with her learning disabilities nearly all day long, even at home if she is in a normally paced speech environment. This may explain why she likes playing alone in her room. Her fatigue (feeling that 6:00 is right after school) might be managed somewhat through periodic rest/break periods. 9. X might partake in any of the math enrichment programs in her school. In addition, math should be used as the basis for developing independence in thinking and working, trying new approaches on her own, using feedback about errors to refine them. This should be part of an IEP objective targeting greater independence in doing her work. 10. In school and at home, it will be important to monitor visual scanning to ensure that X notices all of the relevant material. This could be built into her assignments so that she can be optimally independent by using color to draw her attention, by ensuring that she can position herself and materials to minimize any possibility of left visual field neglect. When using a calculator, it might be helpful to place different colored electrical tape over the operation and equals keys and to mark them accordingly. 11. If the PPT would like further intelligence testing, it is critical that any instrument used does not involve timed responding, cumulative speech perception(WISC digit span or arithmetic tests) or unsupported visual scan (nearly all WISC performance tests, rendered especially detrimental due to their timed quality). 12. It seems important to X that she be believed and trusted (the issue of whether she is lying or not seems very much on the surface). During this testing session it became apparent that X’s perception (quite literally) of events might be in fact different than those of others. At the very least, it would be important to try to understand the viewpoint from which she is coming and consider it before assuming that her distortions are intentional.