The IDEA (Individuals with Disabilities Education Improvement of 2004) and NCLB (No Child Left Behind of 2001) have been added to the US Federal Laws to provide ample support to schoolchildren through evidence-based general and special education (VanDerHeyden and Burns, 2010). General education is sufficient for most of the children. However at-risk children like Mike will be left behind as they cannot cope with the general education alone.
Special education is for the children at-risk but who cannot be considered to have frank disabilities. It provides individualized education that children like Mike require. The other advantage of special education is the identification of children with disabilities. Children with disabilities have other privileges to support them. In its media release for February 15, 2011, the Alabama State Education Department has decided to provide “project grants and flow through funds to education agencies” for providing good services to the children with disabilities (Alabama State Education Department, 15/2/2011).
The response-to-intervention is a research-based approach of special education to provide additional support for students like Mike. The aim is to start at a very early stage when the difficulties begin to be noticed. VanDerHeyden and Burns (2010) have described RTI as “scientific-based instruction, curriculum and interventions, early identification of learning problems, ongoing monitoring of annual yearly progress, designing and implementing remedial and individualized interventions for those who do not respond to normal general curriculum”.
The idea behind the RTI is that time is not allowed to lapse till a child is found to be in need of intervention. Critical features of RTI include universal screening, continuous monitoring of progress, evidence-based interventions one behind the other, instructional decision-making with solution of problems and efficient and regular documentation as observed by Fox et al (2009).
Response-to-intervention using the Tier or pyramid model for Mike
The service that Mike will be delivered is the response-to-intervention format within a three-tier system. This multiple tier approach would ensure that Mike will be continually supported with varying instructional support.
Tier 1 has set a goal which ensures that all the students learn the maximum. Accepted screening data is utilized for the purpose. Universal screening is the usual one used; it is a fast and low-cost test which is repeatable based on age-wise skills. The usual tests used are the oral fluency test, spelling test, mathematics test including addition, subtraction, multiplication and division, curriculum-based tests and systematic screening tests for behavioral changes. Group and individual performances are evaluated and the success of the curriculum will be understood. The core instructional program will be adjusted to be of the best quality for all the students based on the results.
The most number of students (80-90%) is expected to reach the standards set by the district authorities. Mike has emotional and behavioral problems along with asthma; so Mike will be having a score that puts him in the at-risk group.
Universal promotion of practices which are essential for Mike’s social development will be instituted. Mike will be encouraged to nurture care-giving relationships with his teacher and parents (Fox et al, 2009). A high-quality supportive environment will be produced by collaborative relationships between the parents, Mike’s teacher, members who deliver the intervention and class team members with a singular purpose of supporting Mike and hence contributing to his planned development. Mike would be able to improve social skills and develop peer-bonding. A curriculum that is associated with all areas of development of the child and is culturally and developmentally effective is followed (Fox et al, 2009).
Parents will be guided on the setting up of a routine which is to be explicitly followed by Mike. Social, emotional and social interaction skills will be practiced during playtime. Engaging Mike’s attention for studies and play, providing immediate responses to his queries, promoting communications, helping him to promote skills in running on the track, riding his bicycle and baseball are some areas to be focused upon. He must be encouraged to develop lasting friendships with many. Mike may be unresponsive to these interventions as understood by the two psychologists. Their observations of his behavior in the social studies class and the playfield had enough information to conclude that Mike needed special attention if he were to succeed in his studies and change his behavior and emotional setup.
The second tier of the pyramid model which is secondary prevention is most appropriate for children like Mike who cannot cope with the interventions or instructions of the first tier or benefit from them. Efforts or specific instructions must be utilized for changing Mike’s behavior (Fox et al, 2009). Developing the ability to focus on his immediate activity is a beginning. His activities may be timed for short periods at first where he has no time for ‘wandering’. When he is able to concentrate for the short periods, the time of activity may be lengthened in phases till he can sit attentive for a normal class.
Expression of emotions and being cooperative may need the guidance of parents and peers. For emotional regulation in normal people, “physiological, neurological, cognitive and behavioral” systems are to be simultaneously functioning and continuously (Rosen and Epstein, 2010). Mike may be having a problem anywhere in these systems. He needs to be taught self-regulation of his emotions and avoid angry outbursts (Fox et al, 2009). The peers may pretend to show their anger at Mike and later question him as to whether he appreciated this. Mike should realize that expression of anger is unpleasant for others and spoils his mood too.
A peer can participate in activities Mike is engaged in. A few normal children may be encouraged to join in. Friendship may be stressed upon. The peer must have the same group each time; this may impress upon Mike the value of friendship. He should then be encouraged to invite himself the same group to his activities. Later he may be able to invite others too. He may be asked to solve social problems occasionally; there can be a created situation when Mike is in a group.
Another child may be asked to pretend that he is crying after a fall. Mike must be asked to pacify him. Similar problems may be handled by Mike successfully resolving the issues. Mike will have learnt to solve social problems (Fox et al, 2009). Reading being his strong point, he may be asked to read to the class frequently. The various strategies would help him overcome his anger outbursts, build relationships and help to spend time pleasantly. His skills would be simultaneously developed.
Mike may be expected to behave in a cooperative manner. The relationship with his sister must also be developed in a similar manner: Mike must understand that she is younger and needs his support always. Allowing him to be her leader would definitely promote compassion for her. She must also be primed to stop teasing him. The increase in confidence may lead to Mike turning out to be a better person socially and he may be more receptive to educational instructions. The parents must be taught to promote “targeted social and emotional skills” (Fox et al, 2009).
If Mike is found to need more support, he will be delivered the Tier 3 instruction which provides “sustained support for students not making adequate progress with targeted support” (Fox et al, 2009). Direct, systematic instruction with sufficient opportunities for support is the aim. Small groups are used and frequent monitoring is done. More intensive instructions provide Positive behavior support (Fox et al, 2009). Mike’s daily life activities are to be closely monitored by the parents and teachers. Plans will be exclusively designed for Mike. New skills would be encouraged. The first step is the convening of the team which is supporting the child. This team may consist of the family, teacher and care-givers. Functional assessment of the child is made to understand the precise problems of behavior (Fox et al, 2009). Hypotheses are developed for Mike’s challenging behavior.
A behavior support plan will be developed. This would aim at finding out those triggers for the challenging behavior and incorporate them in the prevention strategies. Replacement skills are developed to oppose the challenging behavior (Fox et al, 2009). The challenging behavior is slowly downplayed by making arrangements not to reinforce it. The home, community and the school environments are all addressed in the plan. The family is especially supported and more ecological factors affecting the family are addressed.
Major hypotheses for Mike’s problems
- The emotional and behavioral problems of Mike are related to Attention Deficit/ Hyperactivity Disorder (ADHD).
- The emotional and behavioral problems of Mike are not related to asthma
- The emotional and behavioral problems of Mike are not related to co-morbidity with conduct disorder.
Mike has symptoms which are characteristic of ADHD. The persistent inattention, impulsiveness with hyperactivity and emotional impulsivity exhibited by Mike could be features of ADHD (Barkley, 2010). The inattention and hyperactivity/impulsivity are due to defects in neuropsychological functioning. The emotional impulsivity that Mike shows could be due to the failure to inhibit emotions (Barkley, 2010). His bursting out in anger for small matters is an example of emotional impulsivity.
The speed of negative reaction is a significant feature but it is more of an expression of lack of self-regulation or emotional inhibition (Barkley, 2010). A later paper by Barkley and Murphy (2010) suggests that emotional impulsiveness and deficient emotional self-regulation are the major components of ADHD. Mike’s emotional problems may be attributed to the ADHD. Children with ADHD have 6 times greater chance of having “emotional, conduct and peer problems” (Strine et al, 2006).
Mike’s level of impairment has affected his home life, social life and friendships, classes at school and his leisure activities; it has been said that these disturbances could be as high as nine times (Strine et al, 2006). Emotional and behavioral problems are seen in one third of children diagnosed with ADHD. The impression is that lack of continued care, ineffective treatment or medical holidays could have increased the behavioral problems associated with ADHD (Strine et al, 2006). Hypothesis 1 is supported as Mike has the problems of emotional dysregulation and behavior.
Asthma is a chronic disease of childhood producing several associated problems which impair the quality of life of the child. Frequent hospitalizations which are costly with regular emergency room visits, absenteeism and a poor quality of life are the regular associations of asthmatic children like Mike (Halterman, 2006). Reduced quality of life has been reported by some researchers (Juniper et al, 1996 in Halterman, 2006). Absenteeism is another feature where schoolchildren are involved. (NIAID, 1996 in Halterman, 2006).
Behavioral problems have been found to be common among children who are asthmatic; this was reported in a meta-analysis of community children (McQuaid, 2001 in Halterman, 2006). Inner city children have a greater morbidity (McQuaid, 2001 in Halterman, 2006). Urban children are least likely to receive preventive care (Warman et al, 1999 in Halterman, 2006). Treatment recommendations are also less adhered to in urban life with its psychosocial stresses hence the chances of more behavioral problems among the urban children (Fehrenbach, 1989 in Halterman, 2006).
Four behaviors assessed in the Halterman study (2006) were positive and negative social skills, task orientation and shy anxious behavior. The “negative peer social skills” and inattention were seen more in the children who had severe asthma. Where Mike is concerned, his mother considers him to be of good health and his asthma does not appear to be of intense proportions with absenteeism and frequent hospital or emergency department visits. So the chances of his asthma leading to his behavioral problems of inattention and emotional outbursts are less. The Hypothesis 2 would stand correct.
Comorbidity is common with ADHD. Externalizing psychopathology is seen. Children who had ADHD had other disorders like ODD and CD (Adler, 2009). Conduct disorder is characterized by emotional and behavioral problems and these children have difficulty in accepting rules and regulations (Adler, 2009). Anti-social behavior is expected. Aggressiveness is a feature of conduct disorder.
Initiating fights is another relevant symptom (Adler, 2009). Having a co-morbid disorder would not change the medicines required for the major condition. A combination of behavioral therapy and medicines provide fairly good treatment (Adler, 2009). From the observations of the mother and the teacher, it is difficult to include conduct disorder as a co-morbid situation where Mike is concerned. Hypothesis 3 is supported.
Comprehensive psychological assessment plan for each hypothesis
Interviews conducted with Mr. John, the teacher, Mike’s mother and Mike revealed some precise observations which are noted below against the 3 major hypotheses.
The teacher has noted behavioral problems in class and otherwise. Impulsiveness causes Mike to burst out in anger for trivial matters but otherwise he is a normal pleasant person. His aggressiveness, anger and extreme frustration at times are behaviors different from the others in class and Mike is unable to control these behaviors. The teacher described an incident where Mike punched another student for teasing him.
He cannot bear anyone teasing him. The teacher is unhappy that Mike does not apply himself in academics and cannot focus for long in any activity; these behaviors may be included under inattention. He presented reports of Mike’s academic performance the previous year; they showed only an average performance in all subjects. Having observed Mike for one and a half years, the teacher, Mr. John has made observations which have stood for a long time. The teacher is worried about Mike’s reaction to the separation of his parents.
His mother is worried that he gets close to a new person very fast and “monopolizes the friendship”. At any time, he would be having only one friend. School friends have been at the butt of his unpleasant behavior and are surprised by him trying to have his way. He cannot maintain a sportsman spirit. His sister is also treated in a similar manner though she is younger and plays with him a lot.
Mike himself is aware that he is a little different from other children. He realizes that his memory power is defective. The science class is a favorite as he loves experiments. Running the track, playing baseball during the weekends and riding his bicycle with his friends are his favorite pastimes. Echoing his mother when he says that he has only one friend Jake, he does not realize that this is not normal. The relationship with his sister is good but he hates her teasing him. He has no difficulty in talking about his frequent bouts of anger. His incessant talking in class evokes his teacher’s punishment. Though he is aware of his parents’ separation, he is not disturbed as he feels they love him a lot. He believes that many of his friends come from such homes.
Only the mother’s observations noted that Mike has asthma and uses an inhaler for it. No mention has been made of heavy absenteeism or frequent hospitalizations by the teacher or the mother or Mike himself (Halterman, 2006). Reduced quality of life has not been noted anywhere. Negative peer social skills, behavioral problems and inattention have been reported only for children with persistent asthma so these symptoms of Mike could not be due to asthma which does not affect Mike to a great extent (Halterman, 2006). The hypothesis 2 is thus supported.
“Aggression to people and animals, destruction of property, deceitfulness or theft and serious violations of rules”, features of conduct disorder as mentioned by Adler, are behaviors not observed by the teacher or mother or Mike himself (Adler, 2009). These extreme behaviors not having been exhibited, the chances of conduct disorder being responsible for the emotional and behavioral problems are less. Hypothesis 3 is supported.
Vision and Hearing test
Mike was screened and found to have normal vision and hearing.
The first psychologist found that Mike was focused on his Social Studies class for some time when his penchant for talking showed up. Mike attempts to concentrate when the teacher starts talking about the reasons for the World Wars. However he drops a pencil probably just to get up; this distraction technique was noticed and he was asked to sit back. Then he plays with two pencils as drumsticks on his book. Again he is caught and asked to stop. His inattention and lack of focus on his activity is obvious. He goes off-task very fast. Teacher scolded him but he was none the worse. He continued with his side-tracking tactics.
The second psychologist assessed him in the Physical Education class. During the soccer game, Mike shouted at his team-mate and then someone from the opposite side on two occasions. Each time he walks off and then returns. For the remaining ten minutes, he is focused on his game. Both findings support hypothesis 1
Previous psychological assessment 2 years back
The WISC-IV Intelligence test showed a score of 103 out of 126 (full score) and all other scores for verbal comprehension, perceptual reasoning, working memory, and processing speed showed only average scores for Mike. The Woodcock Johnson III Achievement test also showed an average score of 90-96 where a score more than 131 is classified as very superior. These indicate the average intelligence and achievement of Mike.
Review of records
Mike exhibited excessive talking and blurting out at inappropriate times. He found it difficult to organize his activities and showed a poor concentration in his tasks. Close attention to details was also not his forte. Tasks were not completed and he did not follow instructions. Probably unable to focus mentally for a long time or having an attention deficit, he would be distracted and have emotional outbursts of anger or become aggressive. The observations of his teacher which covered a period of more than a year may be deemed appropriate for a diagnosis of ADHD. The interviews have pointed to the diagnosis of ADHD for Mike.
The records of the two psychologists confirm further the emotional and behavioral problems of Mike. Mike is of average intellect and average in the various tests of achievement. He has asthma which troubles him only occasionally. The chances of him having conduct disorder are small. The next step is to subject Mike to a comprehensive psychological assessment. Hence all the 3 major hypotheses are considered supported.
The interviews may be conducted in the school environment and the records maintained. Collection may be assisted by the school authorities and teachers. The scales may also be distributed to the parents and teachers and the completed forms be collected by the teachers and handed over to the support team. The observations of the clinical psychologists are similarly collected. The school statistician may feed the data into the computer and maintain the data. Considering frequent repetition of the tests and immense data, it would be easier to store it and maintain for future purposes.
Assessments to be made
Intelligence testing would reveal strengths and weakness on the cognitive side (Psychological assessment service, Yale School of Medicine). Intellectual strengths or giftedness and weaknesses or disabilities will be revealed. Non-verbal reasoning skills and speed of tasks will be assessed.
Academic achievement will be assessed to understand the skills in reading, mathematics and writing (Psychological assessment service, Yale School of Medicine). Learning disabilities like dyslexia will be discovered.
Memory and attention skills are tested using Neuropsychological tests. Planning and organizational skills which constitute executive functioning are tested to. In addition tests for ADHD are also done.
The Disruptive Behavior Disorders Rating scale may be used for Mike to confirm ADHD and rule out Conduct Disorder at one go. Two major hypotheses, hypothesis 1 and 3, can be proved using the DBDR scale. The Disruptive Behavior Disorders Rating scale meant for use by the parents and teachers is sufficient to identify the symptoms of ADHD in children. This scale is also meant for diagnosing Oppositional Defiant Disorder and Conduct disorder.
Different items are used for the 3 disorders as required by the criteria of DSM-IV. The scale may be filled by the parent and teacher separately. Nine each of the items provide criteria for the diagnosis for inattention and hyperactivity, symptoms of ADHD. If both the parent and teacher have “pretty much” or “very much” for six or more of the nine items for each of the two symptoms, the criteria for diagnosis would be met. Here the points would be mostly in favor of the hypothesis 1 which says that the emotional and behavioral problems of Mike are related to the Attention Deficit/ Hyperactivity Disorder (ADHD).
The Disruptive Behavior Disorders Parent-Teacher Rating Scale may be used to rule out conduct disorder. There are items which pertain to symptoms of conduct disorder like aggression to people and animals, destruction of property, deceitfulness or theft and serious violations of rules (DBD Parent /Teacher rating scale, University of Buffalo). If 3 or more items in one category or more receive a response of ‘pretty much’ or ‘very much’, the diagnosis may be made.
The Conner’s rating scale is also used by parents and teachers and older children to report on criteria that correspond to ADHD (Conner’s rating scale, Articles.Base.com). For the diagnosis to be correct, the child is to show at least six symptoms of ADHD for the last six months.
Both the DBDR and Conner’s scales do provide information on the severity of the condition from the information by the parents and the teachers. There is concurrence between the two scales and an index of severity may be obtained (Silva et al, 2005). However a diagnosis cannot be made for certain as co-morbidity has been reported by many. Thus the validity of the parent-teacher rating scales is questionable for diagnosis by the DSM-IV rules. For this a physician or neuro- physician may be needed.
Assessment of the asthma
A referral to the chest specialist is made to check the status of asthma and to confirm that Mike does not have a persistent asthmatic condition. Information must be collected as to the medicine used in the inhaler and whether it can produce emotional or behavioral problems. Hypothesis 2 will be supported here.
The three interviews and the psychologists’ findings together indicate that the symptoms of inattention and emotional dysregulation both support the possibility of Mike having the neurobiological disorder ADHD. Hypothesis 1 is supported by these findings. DBD rating scale will also show a positive range. If the symptoms elaborated did not fall into the two groups of symptoms of inattention and emotional dysregulation, this hypothesis will not be supported.
Hypothesis 2 if supported, the asthma will be of a minor proportion with symptoms not persistent and there will be absence of associated complications like frequent hospitalization, absenteeism or reduced quality of life. If it is not supported, Mike’s asthma will be persistent and the associated complications mentioned will be present.
If co-morbid conduct disorder is affecting Mike, the DBD rating scale would have been positive in that range and the emotional and behavioral problems would have been extreme; the hypothesis 3 would not have been supported. If the DBD rating scale is negative in the required range, then conduct disorder would not be affecting Mike and his emotional and behavioral problems would not be due to the conduct disorder. Then hypothesis 3 would be supported.
DSM-IV criteria for ADHD
If six or more of the following symptoms of inattention have persisted for at least six months to a degree that causes maladaptation and inconsistency with the developmental level, ADHD may be diagnosed. The child has a tendency not to focus on details and to make mistakes (APA, 2000). Attention will not be sustained during activities or playing. Inattentive while being spoken to, the child will not follow the directions exactly resulting in the incompletion of chores. Difficulty in organizing tasks is noted. Having likes and dislikes, the child cannot sustain mental efforts (APA, 2000). Losing books, pencils and other things required for class activity is a habit. Poor memory, forgetfulness and distraction by small and unimportant stimuli are other characteristics (APA, 2000).
If six or more of the following features of hyperactivity-impulsivity have remained persistent for six months or more, AHDH can be diagnosed. Frequent fidgeting is a feature. The child finds it difficult to remain seated if expected to be so (APA, 2000). Frequent running around and general restlessness is an indicator of ADHD. Quiet engagement of activities is almost impossible (APA, 2000). Talking without stopping and restlessly moving around indicate hyperactivity. Impulsivity is indicated by the difficulty in waiting for one’s turn or rapidly answering questions even before they are completely asked and interrupting others’ activities.
Knowledge of the criteria of DSM-IV helps in looking out for these features while examining a patient like Mike who has been found to have suspicious symptoms. An accurate diagnosis will allow the preparation of a plan of interventions for Mike, which would help him become more acceptable socially and improve him academically.
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