Case Study #1:

BRIAN

Brian is a 13-year-old male who sustained a severe closed head injury in a bicycle accident.  He suffered a left fronto-parietal skull fracture and subdural hematoma with lacerations of the underlying brain tissue in the left fronto-orbital area.  Brian experienced an extended intensive care course with multiple neurosurgical interventions (e.g., left frontoparietal craniotomy to relieve subdural hematoma, left parietal craniotomy for removal of epidural hematoma, and left pariatal craniotomy for reconstruction of bone flap and replacement).   He remained on the intensive care unit for approximately one month and was then transferred to the inpatient rehabilitation unit for one month.  Upon discharge from the hospital, Brian received daily outpatient speech, occupational, and physical therapies for four months, decreasing to three times a week (occupational and speech therapies) for three months until he returned to school in the fall.

Prior to the accident, Brian was a 7^th grader at a middle school.  Pre-injury developmental and medical history was unremarkable.  Brian was an excellent student receiving straight A’s.  ISTEP+ scores taken one year prior were above standard for both English/language arts and mathematics (571 and 600, respectively).   There was no history of behavioral disturbances prior to the accident.  Brian was an outstanding soccer player prior to the accident, participating in state and regional competitions.  He planned to play soccer in high school and college with aspirations of playing soccer at a professional level.  

            Brian underwent a complete multidisciplinary assessment prior to planning for his reintegration back into school.  Specific findings from this diagnostic workup included:

Cognitive:

q       Cognitive: Slowed with moderate processing deficits

q       Language: Moderate to severe receptive and expressive knowledge, social, and spontaneous language impairment; weak and slow word retrieval; disorganization in communication; limited appropriateness of spontaneous language; misinterprets social cues and body language (i.e., gestures, facial expressions, tone of voice)

q       Memory: Moderate to severe impairment in new learning as such relates to retrieval ability; weak verbal memory

q       Attention: Moderate to severe impairment in attention control related to distractibility

q       Reasoning: Moderate impairment

q       Abstract Thinking: Moderate impairment

q       Judgment: Moderate impairment

q       Problem Solving: Moderate impairment

q       Information Processing: Slowed with moderate to severe deficits in simultaneous processing and mental manipulation

q       Visual-Spatial:  Difficulty interpreting position or direction and orienting oneself to the surroundings; weak simultaneous processing of visual-spatial information; poor spatial planning and visual organization for writing and drawing and organizing spatially on a page

q       Visual-Motor Integration: Slow, uncoordinated and imprecise copying, writing or drawing; poor mechanical and construction skills for arts or building or fixing things

Physical:

q       Gross Motor: Skills are functional; gait normal and independently ambulatory

q       Fine Motor: Skills are functional but mild deficits in mechanics

Academic:

q       Reading: Word recognition commensurate with a 1.8 grade level; comprehension commensurate with at 1.5 grade level

q       Writing: Spelling words to dictation commensurate with a 1.1 grade level; Written formulation of sentences commensurate with a 1.5 grade levels

q       Math:  Basic calculation skills commensurate with a 3.8 grade level; functional math skills at a 5.2 grade level

Behavior:

q       Strong work ethic; cooperative, pleasant; friendly; polite

q       Social maturity is impaired

q       Perceptual disabilities leave Brian feeling confused, anxious and frustrated

q       Situational distress and performance anxiety noted; reacts with more frustration and anxiety when he feels incapable of performing some task well

q       Social impulsivity and disinhibition has been reported

q       Brian is capable of focusing and sustained attention as long as he is allowed to focus on one task at a time; when he is forced to focus on two or more tasks simultaneously and/or when he has to shift his attention between competing tasks, his ability to focus and sustain attention diminishes quickly

q       Brian’s frustration about his language impairment exacerbates the impairment

q       Brian has recently evidenced increased frustration and anger regarding his deficits secondary to improvements in his awareness of deficits

INSTRUCTIONAL EVALUATION:

Brian will be returning to school in the fall and you have been asked to anticipate and plan for Brian’s return to the classroom. The chart below is offered as a tool to illustrate specific behavioral deficits that may influence academic achievement and social competence in the classroom.  Using the multidisciplinary test findings stated above, you are asked to complete the chart below with (1) the specific behavior impairments displayed by Brian, (2) how these impairments might affect classroom performance, and (3) possible intervention strategies to consider implementing when he returns to school.  The chart has been started for you. 

 ASSESSMENT RUBRIC