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Name: ….         Age: 11 years         Sex: Male
Education: 5th standard Handedness: Right DOB: 16/02/2006
School: ..........................
Informants: Parents and Self
Information: Reliable and adequate

Referred by: ......

Reason for Referral: For the assessment of current level of intellectual functioning and learning disability

Duration: Since four years of age

Chief Complaints:

Poor academic performance
Problems in reading
Spelling errors
Problems in pronunciation

History of Present Illness:

Client’s father reported that he has poor academic performance in school. He finds it extremely difficult to read both Hindi and English. The client has had these problems since the time he started formal schooling. The client mentions that he specifically finds it difficult to read big words. Even though he can’t read most of the words, he can make sense of the paragraphs and understand most of what is written. He also reports that he can memorize most of the material, thus being able to score average grades in class.

The client also reports that it is difficult for him to write, not because he doesn’t have information to elaborate on, but because he doesn’t know how to write a lot of words. He mentions that he gets confused with spellings and therefore, is unable to express in a clear manner.

The client also has a problem of mispronunciation, which has been present since his childhood (two years of age). Over the year multiple medical opinions were sought but the doctors usually said that the condition will go away on its own. Speech therapy was given four years ago. Informants report significant improvement, yet the difficulty in speech persists.


Family history

The client lives in a nuclear family with his parents and younger sister. His father, 41 years old is a businessman and his mother, 35, is a homemaker. His sister, 10 years old will now start 5th standard.
The family environment is congenial; yet there are comparisons between the client and his younger sister, who scores above average in her class. The client does report feeling less favored by his father as compared to his sister. The client is attached to his mother the most in the family.
Consanguinity is absent between the parents and there is no history of psychiatric illness in the family.

Family genogram 


family genogram
family genogram

Personal history

Birth and Early Development

Client was born pre term by normal delivery in a hospital. The mother reports that it was a complicated pregnancy, with bleeding at multiple times and her inability to consume solid foods. The mother also was diagnosed with thyroid when she was pregnant with the client. Birth cry was present. Client had low birth weight of just 1.25 kgs and he suffered from jaundice a week later. No other post-natal complications were reported. Client’s developmental milestones, apart from talking were achieved on time. However, he only started talking at the age of 2 years, which was also not very clear. Client had a habit of thumb sucking till the age of 6 years, which then went away on its own.

Childhood history

According to the informants, the client has always been very social and friendly. He is involved in various group activities with his friends. Although he is reported to be a little stubborn and aggressive at times, he has cordial relationships with his peers and his family. There is no history of stealing, sleep disorders, enuresis, encopresis, tics and unusual habits.

Scholastic History and Extracurricular activities

The client started formal schooling at the age of 4 years. He reports being interested in his studies, but feels that he can’t cope in the class with the pace of the teachers. He has been an average student throughout due to his ability to memorize the content, even when he doesn’t understand it. He is excellent in sports and reports an active interest in various games like cricket, basketball and cycling in school as well as with friends at home. He is also a keen artist and indulges in painting, drawing and model making for leisure.

Mental Status Examination: 

The client was well kempt, well dressed and groomed. During the test administration he was friendly, talkative but cooperative towards the examiner. Eye contact was present. Rapport was easily established and maintained. He spoke audibly but with tendency to mispronounce. He was well oriented to time place and person. His attention was easily aroused and sustained.  His immediate, recent and remote memories were intact.

Tested On: Date and time

Tested in: Hindi and English

Test duration: 2 sessions - 4hours

Tests administered:
Binet Kamat Test for Intelligence
NIMHANS Battery for Learning Disability

Behavioral Observation:

Rapport was easily established with the client. The client was able to maintain eye contact. Attention was aroused and sustained. He was motivated for the assessment. He could comprehend the test instructions and followed them correctly.

Test Findings:
Binet Kamat Test for Intelligence

On Binet Kamat Test for Intelligence, his basal age was found to be 10 years and terminal age was found to be 19 years. His Intelligence quotient came out to be 114, i.e. average level of intellectual functioning.


NIMHANS assessment battery for Specific Learning Disability 

On NIMHANS Assessment Battery for Specific Learning Disability, he had been tested for Reading, Comprehension, Writing, Mathematics, Spellings.

Reading and Comprehension

Assessment of reading ability was done by asking the child to read out a given passage. There was confusion between words like him/her, push/pull etc. A lot of letters were omitted and words were guessed if found difficult to read. He was unable to read many words like crocodile, crowded and begged. He mispronounced even simpler words like hay, afraid, bite and official. His reading ability was found to be adequate at grade 2, indicating disability in reading. Skills for comprehension were assessed by asking questions about the read passage. He could easily answer questions adequately till grade 4, indicating difficulty in comprehension, which could be due to problems in reading instead of ability to understand.

Writing and Spellings

In written expression, his handwriting was neat and legible. When asked to write a paragraph on ‘My School’, he made small and simple sentences with various grammatical and spelling errors. Capitalization and punctuation errors were also present. Even when asked to copy a passage, he made capitalization and punctuation errors. Substitutions of letters like writing ‘wauld’ instead of ‘would’ was also present. His writing and spelling ability was found to be adequate at grade 1 level. Reversals between ‘I’ and ‘e’ was seen in words like ‘sep’ for ‘sip’, addition of letters in writing ‘children’ for ‘child’, ‘traind’ for ‘train’, ‘entred’ for ‘enter’ and ‘banted’ for ‘bath’ was observed. Error of substitution such as in ‘sets’ for ‘said’, ‘sheet’ for ‘sheep’, ‘shout’ for ‘short’, ‘doy’ for ‘dog’ and ‘down’ for ‘done’ was also present.

Arithmetic

In Arithmetic, he has a well formed concept of graded addition, subtraction, multiplication and division. He can do double digit calculations but is yet to develop working concept of fractions. His level of performance was adequate at grade 4 level.

Summary of Findings:

The client’s IQ on Binet Kamat Test of Intelligence was found out to be 114, which indicates an average level of intellectual functioning.

On NIMHANS Index for Specific Learning Disability, the client was found to have disability in the areas of Reading, Writing and Spelling.

Impression:

Mixed Learning Disabilities (Reading, Writing and Spelling)

Suggestions:

Child is eligible for Exemption Certificate and other benefits given by Government as per the rule for learning disability
Parental counseling
Assisted learning with the help of teachers/parents
Exercises that increase phonological awareness, to help him to learn and understand sound patterns associated with words
Using audio-visual modalities to enhance learning of spellings
Using mnemonics and cued-spelling techniques to memorize spellings
Pre-teaching vocabulary using analogies, synonyms or visual aids
Reading understanding instructions, fractions and word problems


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