Using the case of Jenni from the end of Chapter 12 of Psychopathology of Childhood and Adolescence, appraise the treatment plan offered for Jenni. What role do physical, behavioral, academic, and cognitive interventions play in the treatment process? What value does this bring to the treatment of Jenni? Is there anything missing from the assessment and intervention given all that you have learned though the assigned materials this week?
Paper must be 2-4 pages of text and must include title page and references, APA format! Use appropriate resources as well as the one attached.
REASON FOR REFERRAL AND DEMOGRAPHIC INFORMATION
Jenni (fictional name) is an 8-year-old female whose parents presented with major concerns regarding her recent academic difficulties as well as social struggles. Jenni has started to fall behind in her schoolwork based on standardized testing reports and teacher comments. Jennis teacher recently reported that Jenni was forgetting about homework assignments, failing to turn in her homework, and rushing through her work too quickly, making careless mistakes.
Jenni struggles with paying attention to and remembering instructions. She requires frequent reminders from the teacher to stay on task. Parents report that although Jenni enjoys extracur- ricular activities, she often has difficulty with them. For example, it is hard for her to remem- ber or follow the rules during soccer practice. Jenni also has problems keeping friends. She has difficulty adhering to social boundaries, often acting impulsively, grabbing items from peers, or saying inappropriate things. Although Jenni is perceived as exciting and fun by her peers at first, they tend to eventually become annoyed and frustrated with her impulsive behavior. In addition to having trouble waiting for her turn to speak in social situations, Jenni also struggles with this issue in classroom situations. Teachers report that Jenni has difficulty staying in her seat, often getting up to sharpen her pencil or wander around the room when she is supposed to be seated. At home, Jennis parents experience some frustration with Jennis behavior. For example, helping Jenni with her homework can be extremely trying because of her impaired attentional and organizational abilities. Jenni has recently become more aware of the social problems she experiences and has mentioned feelings of sadness over these difficulties.
A review of developmental history revealed that Jennis mothers pregnancy was uncompli- cated and she had regular obstetric care. Jennis sensory, motor, and language development were typical. She has not experienced any notable medical problems.
Jenni is in second grade and has not received any special education services. Although her academic performance in kindergarten and first grade was Low Average to Average, her parents have noticed recent academic difficulties as the material has become more complex. Current and previous teachers report that Jenni misses much of the material presented in the classroom because of her attentional lapses. A previous intelligence test placed her Full Scale IQ (FSIQ) in the Average range (Standard Score of 92).
Jenni is the oldest of three children. She has a 6-year-old brother who struggles academically and who has some speech-language difficulties. She also has a 3-year-old sister who is in preschool and doing well. Although never formally diagnosed, Jennis father suspects that he has Attention-Deficit/Hyperactivity Disorder (ADHD) and recalls experiencing learning difficulties as a child.
NEUROPSYCHOLOGICAL ASSESSMENT RESULTS
Wechsler Intelligence Scale for ChildrenFourth Edition (WISC-IV) Working Memory Index (WMI; Wechsler, 2003)
The WISC-IV WMI measures the recall of strings of letters and numbers, and computing oral arithmetic word problems. On the WMI, Jenni obtained a standard score of 91 (Average range), with a percentile rank of 27. A table of Jennis performance on the WISC-IV WMI is included below in Table 12.1.
Conners Continuous Performance Test (CPT; Conners, 1995)
The CPT is a measure of attention and response inhibition that requires the participant to press a key when a target letter appears on a computer screen and not press the key when the letter does not appear. Jenni made an exceptionally large number of errors of commission (T-Score of 70; 50 is average) and a slightly more-than-average number of errors of omission (T-score = 60). She was atypically fast but also often inaccurate at responding and exhibited an atypical percentage of perseverations.
Delis-Kaplan Executive Function System (D-KEFS; Delis, Kaplan, & Kramer, 2001)
Jenni was administered three of the eight D-KEFS subtests. The D-KEFS Tower Test assesses motor planning, problem solving, reasoning, and speed. Jennis scores on this test all fell within the Low Average range, and she had a relatively low Move Accuracy Ratio score, indicating that she made many more moves than needed to create the accurate tower. This pattern suggests that she may have had difficulty planning ahead and instead haphazardly attempted to solve problems without a concrete plan. On the D-KEFS Sorting subtest, which assesses abstract reasoning, Jenni also performed within the Low Average range. She had dif- ficulty sorting the cards into appropriate groups and recognizing the sorting strategy. Finally,
TABLE 12.1 WISC-IV Working Memory Subtest Scores
WISC-IV WORKING MEMORY SUBTESTS
Digit Span Letter-Number Sequencing Arithmetic WMI Standard Score (mean = 100)
SCALED SCORE (MEAN = 10)
9 34 8 21 8 21
Jenni was administered the D-KEFS Color-Word Interference Test, which measures inhibi- tory control and cognitive flexibility. Jennis ability to name colors and read words was in the Average range. However, her ability to inhibit the automatic tendency to read words when asked to name the colors in which the words were printed (Inhibition condition) was in the Low Average range. She also struggled in the domain of cognitive flexibility, demonstrated by her Low Average performance when asked to switch between naming colors and reading words (Inhibition/Switching condition). Scaled Scores are included below in Table 12.2.
Trail Making Test for Children (Reitan & Wolfson, 1992)
The Trail Making Test (parts A and B) is a measure of visual processing, attention, and cog- nitive flexibility that requires the participant to draw lines to connect numbered circles in numerical order (Part A) and draw lines to connect alternating numbered and lettered circles in numerical and alphabetical order (Part B). Jenni completed Part A of the Trail Making Test in 24 seconds and made no errors. She completed Part B in 43 seconds and made one error. These scores put Jennis speed of performance within the Low Average range.
Rey-Osterrieth Complex Figure Test (RCFT; Meyers & Meyers, 1995)
The RCFT is a test of design copying, visual memory, planning, and sustained attention. Jennis time needed to copy the design was in the Average range. However, her copy score was less than or equal to first percentile, indicating significant impairment in the ability to accurately copy this complex design. When asked to draw the design from memory after a three-minute delay, she achieved a percentile ranking of 14, indicating that she was relatively
TABLE 12.2 D-KEFS Subtest Scores
Total Achievement Score Mean First Move Time Time-Per-Move-Ratio Move Accuracy Ratio Rule-Violations-Per-Item Ratio
Free Sorting Correct Sorts Free Sorting Description Sort Recognition Description
Color-Word Interference Test
Color Naming Word Reading Inhibition Completion Time Inhibition/Switching Completion Time
TABLE 12.3 Rey-Osterrieth Complex Figure Test Scores
SCALED SCORES (MEAN = 10)
8 10 11 7 8
7 8 8
9 8 7 6
?1% >16% 14% 14% <1%
REY COMPLEX FIGURE TEST
Copy of Design Time Needed to Copy Design Immediate Recall Delayed Recall Recognition
T-SCORE (MEAN = 50)
Below Normal Limits Within Normal Limits 39
weak in the Immediate Recall and reproduction of a complex abstract design. Jennis Delayed Recall also resulted in a percentile ranking of 14. On the Recognition subtest, Jennis T-Score was 22 with a percentile rank of less than 1, indicating that her visual recognition scores were far below normal limits (Table 12.3).
Behavior Rating Inventory of Executive Function (BRIEF; Gioia, Isquith, Guy, & Kenworthy, 2000)
The BRIEF is a questionnaire for parents of school-age children that allows for the assess- ment of executive function in the home environment. Results are presented in Table 12.4 as T-scores; scores above 65 are potentially clinically significant. Ratings were obtained from Jennis mother.
The results indicate that Jenni demonstrates significant levels of difficulty in the areas of inhibiting inappropriate behavior, controlling emotions, initiating tasks, holding and manip- ulating information in her memory, and planning and organizing tasks and materials. She was at risk for developing significant impairment in the ability to fluidly shift from one activ- ity to another and monitoring her performance and the impact of her behaviors on others. Such difficulties are bound to make it hard for Jenni to succeed in self-directed tasks, in the classroom, and with peers.
Wisconsin Card Sorting Test (WCST; Heaton, Chelune, Talley, Kay, & Curtiss, 1993)
This test required Jenni to sort cards according to different rules. It measures higher level problem solving, hypothesis testing, and cognitive flexibility. Jennis percentile scores for the components of the test ranged from 2 to 55, suggesting that she had difficulty in certain areas of this test, particularly in maintaining set (Table 12.5). She had some trouble changing sort- ing principles as well as maintaining set.
TABLE 12.4 BRIEF Scores
Behavioral Regulation Index (BRI)
Inhibit Shift Emotional Control Metacognition Index (MI) Initiate Working Memory Plan/Organize Organization of Materials Monitor Global Executive Composite (GEC; BRI + MI)
TABLE 12.5 Wisconsin Card Sorting Test Scores
T-SCORE (MEAN = 50)
70 68 65 76 75 70 81 77 75 65 75
Significant Significant At Risk Significant Significant Significant Significant Significant Significant At Risk Significant
Failures to Maintain Set Perseverative Errors % Perseverative Errors Nonperseverative Errors % Nonperseverative Errors
11% 18 25%
T-SCORE (MEAN = 50)
25% 49 47% 53 55% 35 7% 36 8%
RATIONALE FOR DIAGNOSIS
A primary diagnosis of Attention-Deficit/Hyperactivity Disorder (ADHD) Combined Type is warranted, based on DSM-IV criteria, parent and teacher Conners attention checklists (not discussed fully in the limited space available herein), family history of attention difficulties, observations and interviews of Jenni, and patterns of test results strongly suggestive of inatten- tion and impulsivity (see scores on the Conners CPT and the other neuropsychological tests).
1. Medication. Medication treatment, involving the use of psychostimulants, may be benefi- cial. Such medications may improve Jennis ADHD-related symptoms, thereby having a positive impact on functional impairments across settings. Medications should be mon- itored carefully to establish an optimal dosage. Because the effects of medications only persist as long as they are ingested and because they obviously cannot teach skills, other interventions may also be warranted.
2. Behavior Therapy: Child-Focused. Given Jennis social difficulties, social skills interventions would likely be relevant. Additionally, treatment programs utilizing combinations of pos- itive and aversive contingencies could yield important benefits. Supplementation of these behavioral reinforcement programs with cognitive strategies skills could be considered, including a focus on self-evaluation procedures, particularly when Jenni is entering the teen years.
3. Behavior Therapy: Parent-Focused. Parents could benefit from consultation from a behavior- ist to learn how to target problems for intervention, develop a reinforcement menu and token reward program, measure behavior, and utilize consistent (nonphysical) punish- ment procedures. Parents should also focus on coordinating programs between home and school in order to maintain consistent use of behavioral strategies.
4. Academic Interventions. Jennis teachers should be trained in the implementation of behav- ior modification including developing a clear reward system in the classroom. A daily report card program would enhance consistency across home and school settings. Certain accommodations based on Jennis difficulties may also be crucial, such as extra time on tests and assignments, to support Jennis academic progress.
5. Cognitive Training. Cognitive training paradigms have yielded some promising prelimi- nary results in the research literature in terms of improving aspects of executive func- tion such as working memory. However, the long-term clinical utility of such programs is not yet established and they should be considered supplementary to primary, established treatments like medication and behavioral therapy.
Work on this chapter was supported, in part, by National Institute of Mental Health Grant R01 45064, awarded to Stephen P. Hinshaw.
Conners, C.K. (1995). Conners continuous performance test computer program: Users manual. Toronto, Canada: Multi-Health Systems.
Delis, D., Kaplan, E., & Kramer, J. (2001). Delis-Kaplan executive function scale. San Antonio, TX: The Psychological Corporation.