CASE REPORT 1: JENNA

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Table 6.1 Overview of Case Studies

Reason for Evaluation

Jenna Bronson is a 9-year-old girl who lives with her parents and her 12-year-old brother. Jenna is entering the third grade at a special education school in a major metropolitan city. Jenna was tested by this examiner at age 6. The results of this prior evaluation indicated developmental111111111 reading disorder, mathematics disorder, and mixed receptive-expressive language disorder, along with possible attention-deficit/hyperactivity disorder (ADHD). Mr. and Mrs. Bronson requested this current evaluation in order to obtain an updated assessment of Jenna’s neurocognitive and psychological functioning.

Background Information

Jenna is the product of a high-risk pregnancy complicated by preeclampsia. Jenna was delivered at 34 weeks and she weighed 7 lbs. She remained in the NICU for 21∕2 weeks due to breathing di culties. All motor milestones were reached within appropriate limits. Surgeries and hospitalizations include ear tubes at age 2. Jenna’s vision and hearing are described as intact.

She struggles with ongoing sensory integration issues, including sensitivity to sounds and food textures. Jenna is a picky eater who eats mainly carbohydrates. She was treated with occupational therapy and physical therapy from ages 3 to 6 to address these struggles. She also participated in speech therapy due to a lisp. Jenna evidenced a tic in the form of a head jerk last school year.

Jenna is a very athletic girl with a tall and skinny build who loves sports and is a gifted baseball player. She also excels in soccer and basketball. She falls asleep easily at night and sleeps well.

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Regarding her academic history, Jenna evidenced di culties with attention and response control at age 3 and di culties with phonics at age 4. She struggled with increasing academic di culties in kindergarten and was diagnosed with significant learning, language, and anxiety struggles, as well as possible attentional deficits.

Behavioral Observations

Jenna presented as a happy and friendly young girl. Her cute smile was contagious and rapport was very easily established. Jenna separated easily from her mother. She never complained about tasks, and for the most part, even when it was clear that Jenna was fatigued or challenged, she persevered. Jenna was a little reluctant to attempt more challenging math computation problems involving two-digit addition. However, with the promise that she would be able to choose one sports trading card for each problem she attempted, Jenna was a little more willing to persist with the task. Her mood and a ect were normal although some tasks were somewhat frustrating for her. At no time was Jenna observed to be anxious or overtly upset by the testing.

Jenna was talkative, and no expressive or receptive language deficits were noted. Jenna’s attentional stamina and endurance were somewhat poor for her age. Although

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she was alert both mornings as testing began, she became fatigued after working for a short period of time. Nonetheless, with support from the examiner, Jenna was able to work for at least an hour before needing a short break. Jenna was not observed to be restless or distractible. However, at times Jenna appeared to rush through tasks, and she was reminded to slow down and respond carefully. Her rushing was most evident on reading comprehension tasks.

Jenna took one or two breaks on each day of testing. During her breaks she played with Legos but refused snacks. She transitioned back to structured testing with no di culty. Testing results, along with these behavioral observations, indicate that the test results appear to be valid measures of Jenna’s current functioning.

For this evaluation, Jenna was assessed without stimulant medication on the first day of testing but with stimulant medication (Focalin XR) on the second day to assess the e ects of her medication on neurocognitive symptoms related to attention and learning.

Assessment Procedures and Tests Administered111111111

Clinical interviews with Mr. and Mrs. Bronson and Jenna Bronson Exchange of information with Jenna’s tutor and psychiatrist

Intellectual Functioning and Executive Functions

California Verbal Learning Test–Children Version (CVLT-C) Comprehensive Test of Phonological Processing–Second Edition (CTOPP-2) Integrated Visual & Auditory Continuous Performance Test (IVA+Plus CPT) Medical Symptom Validity Test (MSVT)

NEPSY: A Developmental Neuropsychological Assessment–Second Edition (NEPSY-II), Selected Subtests

Test of Everyday Attention for Children (TEA-Ch), Selected Subtests