Jennifer Niskala Apps l Robert F.

Newby
Laura Weiss Roberts
Editors

Pediatric Neuropsychology
Case Studies
From the Exceptional to the Commonplace
Chapter 15
The Energizer Bunny Meets Shirley Temple:
Attention Deficit Hyperactivity Disorder,
Combined Type

Michael J. Zaccariello

‘‘She will not sit still and be quiet! She just goes and goes nonstop.’’ Jenna’s
exasperated mother moaned during the initial clinical interview. Her voice was
tinged with both frustration and guilt over her reactions to her daughter’s behavior
that occasionally resulted in abrupt, sharp rebukes. In addition, Jenna herself had
begun to realize that something was ‘‘wrong.’’ This previously effervescent and
optimistic child began to remark that she was stupid and dumb and was being
ridiculed by peers at school.
Historically, Jenna was a highly energetic toddler who talked excessively.
Although never significantly or consistently oppositional or argumentative, her
behavior became increasingly more difficult to control as she grew older. Jenna’s
mother noted that she literally played all day long and seemingly never tired. In
addition, it was impossible for her to sit down appropriately for longer than a few
minutes at a time. She constantly fidgeted, kicked her legs, or touched objects.
Cognitively, she had extreme difficulty staying focused and on-task, and needed
frequent redirection or a quiet, nonstimulating environment to complete work. She
had a tendency to be impulsive, rushing through her school assignments, which
resulted in careless mistakes. She had organizational problems in her day-to day-
activities (e.g., frequently losing objects or articles of clothing). Academically, she
had always been an average to above average student, but starting in the second
grade she began to demonstrate some struggles in mathematics, spelling, and
handwriting. Her mother’s perception was that Jenna’s difficulties in these academ-
ic areas were not reflective of a skill deficit but, rather, extreme problems with
sustained focus and impulsivity.
Medically, Jenna was in perfect health, and both language and motor develop-
mental milestones were reached within normal limits. She had no significant
problems with vision, hearing, eating, or sleeping. She was prescribed no medica-
tion at the time of the evaluation.
Socially, Jenna was described as an outgoing and engaging child who enjoyed
horseback riding and any outdoor activities. She lived with her parents and an older

J.N. Apps et al. (eds.), Pediatric Neuropsychology Case Studies: 141

From the Exceptional to the Commonplace.
# Springer Science þ Business Media, LLC 2008
142 M.J. Zaccariello

brother who had been diagnosed with Attention Deficit Hyperactivity Disorder-
Primarily Inattentive Type (ADHD-I) by a pediatric neuropsychologist. The home
environment was described as positive and loving.
Jenna’s parents requested a neuropsychological evaluation to identify her pattern
of cognitive strengths and weaknesses. However, their prime concern was her
increasing restlessness and difficulties with attention. They were also concerned
with the emotional toll of social ridicule because of her high energy behavior. Her
parents questioned if she met formal criteria for Attention Deficit Hyperactivity
Disorder (ADHD) and wished for professional corroboration of their suspicion.
Jenna had never undergone a neuropsychological evaluation, and her mother
was curious about her overall cognitive skill set. Consequently, a broad approach
was taken, with a focus on attention and mental executive function measures.
Measures of attention are thought to assess one’s ability to direct and maintain
focus on a task. Executive functions are considered a related construct and involve
higher-ordered, goal-directed abilities that are organizational or supervisory in
nature. This cluster of abilities allows one to engage in abstract reasoning, prob-
lem-solving, judgment, cognitive flexibility, planning, and organization. Utilizing
feedback to correct responses, inhibit inappropriate behavior, and sustain one’s
attention is also considered in this area. Specific domains that were assessed
included intellectual ability, fine motor functions, attention, executive functions,
language fluency, visual-spatial abilities, and comprehensive academic skills de-
velopment. Behavioral ratings scales completed by both Jenna’s teacher and par-
ents were included as a critical foundation of the assessment.

Conceptual Diagnostic Background

With the introduction of the Diagnostic and Statistical Manual of Mental Disorders,
Third Edition, in 1980, delineation was made between the presence and absence of
hyperactive symptoms in children with attentional difficulties. Current diagnostics
further clarified this distinction into three types: primarily inattentive (ADHD-I),
primarily hyperactive-impulsive (ADHD-H), and combined (ADHD-C). However,
some recent studies have questioned the diagnostic accuracy of the current categor-
ical subtypes of ADHD and propose more of a dimensional model (Frazier, Young-
strom, & Naugle, 2007). Prevalence studies indicate that ADHD (devoid of a
specific subtype) is diagnosed three times as often in boys than girls in community
samples. This discrepancy rises to five to nine times more often in clinic-referred
groups. It is thought that ADHD-C occurs more often in boys and that ADHD-I
tends to be diagnosed more in girls. As children age, hyperactive symptoms
typically dissipate, but inattention symptoms can remain prominent. In a sense,
one does not typically outgrow ADHD.
There has been much debate in the literature concerning the usefulness
and relevance of neuropsychological tests in the diagnosis of ADHD. Although
a comprehensive review of this issue is beyond the scope of this brief case,
15 The Energizer Bunny Meets Shirley Temple 143

indications suggest that the most scientific and powerful diagnostic indicator of
ADHD is a significant level of inattention or hyperactive symptoms as reported on
behavioral rating scales.
So, this begs the question, what is the point of a comprehensive neuropsycho-
logical evaluation of a child with ADHD features? Although not necessarily
diagnostic, a neuropsychological evaluation can provide a snapshot of how signifi-
cantly inattention or hyperactivity interacts with performance in other cognitive and
academic domains. Once such areas have been identified, specific recommenda-
tions beyond those typically given for ADHD can be outlined in the report to
maximize a child’s learning potential (Tables 15.1–15.3).

Test Results

On formal testing, Jenna presented as an absolutely delightful and pleasant young

girl. She readily engaged in conversation and expressed an appropriate range of
emotion throughout the evaluation. Her social interactions were appropriate, and
she spontaneously demonstrated a very kind and helpful attitude (e.g., picking up
dropped items).
In terms of her approach to testing, there was significant evidence of motor
restlessness throughout the evaluation, coupled with moderate levels of distracti-
bility, inattentiveness, and impulsivity. She had extreme difficulty sitting upright
and still in her seat. She frequently fidgeted, got out of her chair, rubbed the walls,
and looked at herself in an one-way mirror. Rather frequently, she reached for test
stimuli before being told to do so and/or blurted out answers before receiving

Table 15.1 Intellectual

Wechsler Intelligence Scale for Children – Fourth Edition Scorea Percentile
Full Scale IQ 113 81st
General Ability Index 111 77th
Verbal Comprehension Index 99 47th
Similarities (10)
Vocabulary (8)
Comprehension (12)
Perceptual Reasoning Index 121 92nd
Block Design (12)
Picture Concepts (14)
Matrix Reasoning (14)
Working Memory Index 110 75th
Digit Span (11)
Letter-Number Sequencing (13)
Processing Speed Index 109 73rd
Coding (12)
Symbol Search (11)
a
Standard score, (scaled score), [T-score], {z-score}.
144 M.J. Zaccariello

Table 15.2 Academic achievement

Woodcock Johnson Tests of Achievement – Third Edition Score Percentile
Broad reading 108 71st
Letter-word identification 110 75th
Passage comprehension 100 51st
Reading fluency 108 70th
Basic reading skills 109 73rd
Letter-word identification 110 75th
Word attack 106 66th
Broad math 120 91st
Calculation 113 80th
Applied problems 126 96th
Math fluency 103 59th
Broad written language 104 60th
Spelling 103 58th
Writing samples 104 60th
Writing fluency 102 55th
Academic skills 110 75th
Academic applications 112 78th
Academic fluency 106 65th

Table 15.3 Other cognitive functions

Tests Scorea Percentile
Attention-Deficit Hyperactivity Disorder Rating
Scale – Fourth Edition
Home Version
Total >99th
Hyperactivity-impulsivity 97th–98th
Inattention 98th–99th
School Version
Total 95th–96th
Hyperactivity-impulsivity 94th–95th
Inattention 94th–95th
Achenbach Child Behavior Checklist
Parent Form
Anxious/depressed [63] 90th
Withdrawn/depressed [50] 50th
Somatic complaints [53] 62nd
Social problems [50] 50th
Thought problems [58] 79th
Attention problems [80] >97th
Rule-breaking behavior [55] 69th
Aggressive behavior [60] 84th
Teacher’s Report Form
Anxious/depressed [50] 50th
Withdrawn/depressed [50] 50th
Somatic complaints [50] 50th
(continued)
15 The Energizer Bunny Meets Shirley Temple 145

Table 15.3 (continued)

Tests Scorea Percentile
Social problems [54] 65th
Thought problems [50] 50th
Attention problems [71] >97th
Rule-breaking behavior [59] 81st
Aggressive behavior [60] 84th
Gordon Diagnostic System
Vigilance task (9 minutes)
Correct 100 50th
Commission errors <1 <1st
NEPSY
Auditory Attention and Response Set (10) 50th
Attention Task (12) 75th
Response set task (10) 50th
Wisconsin Card Sorting Test
Categories >16th
Total errors 96 39th
Perseverative responses 98 45th
Perseverative errors 98 45th
Nonperseverative errors 92 30th
Conceptual level responses 100 50th
Failure to maintain set 2nd–5th
Learning to learn 2nd–5th
The Tower of London 72 3rd
Behavior Rating Inventory of Executive Function
Parent Form
Behavioral regulation index [61] 86th
Inhibit scale [80] 96th
Shift scale [45] 38th
Emotional control scale [48] 50th
Metacognition index [74] 97th
Initiate scale [67] 95th
Working memory scale [70] 94th
Plan/organize scale [69] 94th
Organization of materials scale [59] 83rd
Monitor scale [87] 99th
Global executive composite [70] 96th

instructions. Despite these behaviors, she was relatively easy to redirect but did
require constant prompting throughout the test session.
Consistent with Jenna’s test session behavior, both her parents and teacher were
observing a significant level of inattentive and hyperactive symptoms. Her mother
also noted marked problems with impulse control, general organizational skills, and
the ability to self-monitor behavior. Her cognitive and behavioral difficulties were
leading to mild to moderate compliance issues at home and school.
146 M.J. Zaccariello

A quick glance at Jenna’s neuropsychological profile revealed that most of her

scores were average to above average. Overall intellectual ability was high average
with a significant strength in nonverbal intellectual ability relative to her solidly
average verbal intellectual ability. She had little difficulty on specific tests of
language, visual-spatial processing, or fine motor dexterity. Her academic skills
development was progressing at the expected rate with no evidence of deficit in any
academic domain.
A different picture emerged on tests of attention and mental executive function.
Her test scores ranged from average to impaired. Jenna had difficulty on most tasks
where she had to rely on self-regulation strategies to successfully negotiate the
measure and did not have the examiner encouraging her to remain attentive. She
was impulsive, which resulted in a high number of mistakes. In addition, she
displayed a weakness in being able to change problem solving strategies efficiently.

Formulation and Recommendations

On the basis of the responses to behavioral questionnaires and test session behavior,
Jenna had significant inattention, distractibility, impulsivity, and motor restless-
ness, which were consistent with individuals diagnosed with ADHD-C. She could
not sit appropriately for longer than 10–15 min at a time and frequently reached for
test stimuli or blurted out answers.
Jenna was subsequently diagnosed with ADHD-C, which includes a mixture of
problems with behavioral inhibition, sustained attention, organization, consistency
of performance, and/or goal-directed behavior. ADHD-C is the most common form
of ADHD that arises in childhood in 3–7% of the population (American Psychiatric
Association, 2000). The symptoms of ADHD do not spontaneously disappear in the
majority of cases but can be treated to some extent with behavior management and/
or medication. Jenna’s combination of ADHD-C features included average intel-
lectual ability and average to above average underlying academic skills. Therefore
it would be realistic for her to attain average to above average performance in
school most of the time.
Although not directly assessed, another important finding concerned is the
Jenna’s emotional functioning. During the assessment, she acknowledged strug-
gles in school and admitted self-esteem issues related to her attentional prob-
lems. Studies have shown that 40% of children with ADHD show signs of either
depression and/or anxiety (Spencer, Biederman, & Wilens, 1999). It is vitally
important to address the behavioral and cognitive difficulties that children with
ADHD typically experience. However, professionals, caretakers, and school per-
sonnel should also be acutely aware of the impact and range that ADHD can have
on a child’s emotional and social well-being. Her parents were provided with
psychotherapy referrals, which they could use if her distress continued or worsened.
At least 75% of children with ADHD benefit from stimulant medication. Jenna’s
behavioral and cognitive presentation of ADHD symptoms make an evaluation for
stimulant medication routinely recommended. If she continues using the medica-
15 The Energizer Bunny Meets Shirley Temple 147

tion over a long period of time, observation trials off medication for a week at a time
approximately twice during each school year would be useful to monitor her
ongoing benefit or need for the medication.
Standard suggestions for managing attention and organization problems in the
classroom included obtaining eye contact with Jenna prior to delivering directions.
It may be helpful to place a hand on her shoulder or arm and to be sure that
directions are clear, simply stated, and given one at a time. Delivering more com-
plex directions in brief, simple, numbered steps (e.g., ‘‘First, read pages 1–10;
second, answer questions 1–5; and third, check answers in the back of the book’’)
would also be helpful. If Jenna continues to have difficulty, writing down key
instructions and taping them to her desk may help cue her.
Presenting material in small, successive units that can be mastered hierarchically
would allow Jenna to maximize her attentional capacity, assist in organizing the
material to be learned, reduce the feeling of being overwhelmed by the material,
and develop greater self-confidence as she progresses through the material.
Jenna would need distractions minimized to the greatest extent possible in the
classroom (e.g., seating her at the front of the class and increased one-to-one contact
with the teacher), as well as regular feedback provided with concrete suggestions for
appropriate behaviors. It would also be helpful to provide consistency and structure
through daily schedules; standard seating arrangements; clearly defined class-
room expectations, rules and consequences; and clear places for necessary materi-
als, such as color-coded subject folders, and reinforcement for using organizers.
Jenna needs guided practice in planning how to complete assigned tasks (what
is needed, how to break tasks into manageable parts, estimating time needed for
each part) and to be assigned tasks or classroom duties that she can successfully
complete.
It would be helpful to provide other organizational checklists, such as steps to
get ready to go home after school, and to remind Jenna at the end of the day about
what she needs for home and the next day. Also, Jenna would benefit from pacing
her work and changing the pace or task frequently and from opportunities for
controlled movement.
Given Jenna’s inattentive and hyperactive tendencies, she would not always be
expected to perform at top efficiency level on timed tasks. Extra time can be given
strategically when needed, and curriculum requirements such as timed math tests
might be loosened or modified for her, but not omitted.
At home, Jenna needs more frequent attentional cueing. Adults should help her
break complex tasks into smaller steps. Commands should be given one or two at a
time, and longer sets of commands should be repeated, rehearsed, or written down.
More frequent attentional cueing (e.g., ‘‘look at this now’’; ‘‘this is important to pay
attention to’’) in everyday life will be needed in the long run, and adults should try
to avoid becoming frustrated with this need. She should be given extra instruction in
organizational skills such as outlining, diagramming, planning a sequence of steps
in complex tasks, and taking strategic breaks during extended study time.
Jenna and her family would benefit from ongoing consultation with a psycholo-
gist who is knowledgeable about behavior management approaches for children
148 M.J. Zaccariello

with ADHD symptoms. Family psychotherapy could also provide an opportunity to

work on family interaction issues, emotional issues, and/or peer interaction issues
that often accompany ADHD.
Jenna’s difficulties with abstract reasoning and logical problem-solving tasks
suggest that she may have difficulty with some complex, novel tasks. Specifically,
she may find it difficult to analyze the requirements of a task and apply effective
strategies toward a solution. As a result, she may get frustrated with the acquisition
of novel cognitive skills such as higher level academics.
Although not indicated at this time given her average to above average academic
skills development, with a diagnosis of ADHD, Jenna may be eligible to have an
Accommodation Plan prepared for her as mandated under Section 504 of the
Rehabilitation Act of 1973. This could be particularly important if her academic
performance begins to suffer due to her ADHD presentation as she progresses to
higher grades with greater requirements for attention and self-control. Many of the
specific attention and organization suggestions outlined could be incorporated into
an Accommodation Plan.

Additional Resources

Key Concepts and Terms

Attention The cognitive process of selectively concentrating on one aspect of the

environment while ignoring other things.
Executive functions Processes that are most involved in giving organization and
order to actions and behavior. Executive functions involve (1) strategic thinking
and future planning, (2) the ability to inhibit or delay responding, (3) initiating
behavior, and (4) shifting between activities flexibly.

References

Resources for Clinicians

American Psychiatric Association. (2004). Diagnostic and statistical manual of mental disorders
(4th ed., Text revision). Washington, DC: American Psychiatric Association.
Barkley, R. A. (2006). Attention-deficit hyperactivity disorder. (3rd ed.). New York: Guilford
Press.
Cutting, L. E., & Denckla, M. B. (2003). Attention: Relationships between attention-deficit
hyperactivity disorder and learning disabilities. In H. L. Swanson, K. R. Harris, & S. Graham
(2003), Handbook of learning disabilities (pp. 125–139). New York: Guilford Press.
Ellison, P. (2005). School neuropsychology of attention-deficit/hyperactivity disorder. In R. C.
D’Amato, E. Fletcher-Janzen, & C. R. Reynolds (Eds.), Handbook of school neuropsychology
(pp. 460–486). New Jersey: Wiley
15 The Energizer Bunny Meets Shirley Temple 149

Frazier, T. W., Youngstrom, E. A., & Naugle, R. I. (2007). The latent structure of attention-deficit/
hyperactivity disorder in a clinic-referred sample. Neuropsychology, 21, 45–64.
Spencer, T., Biederman, J., & Wilens, T. (1999). Attention-deficit/hyperactivity disorder and
comorbidity. Pediatric Clinics of North America, 46, 915–927.
U.S. Department of Education, Office of Special Education Programs’ (OSEP), Individuals with
Disabilities Education Act (IDEA) web site: http://www.idea.ed.gov/explore/home

Resources for Families

A.D.D. Warehouse, www.addwarehouse.com/shopsite_sc/store/html/index.html. Provides general

information on Attention Deficit Hyperactivity Disorder and a comprehensive catalog of
books, tapes, and training materials.
Barkley, R. A. (2000). Taking charge of ADHD: The complete, authoritative guide for parents.
(2nd ed.) New York: Guilford Press.
Children with Attention Deficit Disorders (CHADD), http://www.chadd.org. Lecture programs,
parent support groups, and valuable information for parents and teachers.
Dawson, P., & Guare R. (2003). Executive skills in children and adolescents: A practical guide to
assessment and intervention. New York: Guilford Press.
Flick, G. L. (1996). Power parenting for children with ADD/ADHD: A practical parent’s guide for
managing difficult behaviors. Hoboken, New Jersey: Jossey-Bass.
Learning Disabilities Association of America, http://www.ldanatl.org
National Center for Learning Disabilities, http://www.ncld.org, www.schwablearning.org and
http://www.ldonline.org/.
Chapter 16
‘‘He is not Working up to Potential’’:
Atypical Attention Deficit Hyperactivity
Disorder with Executive Weaknesses

Jennifer Niskala Apps and Dawn Pflugradt

Robert was referred for neuropsychological evaluation because of concerns regard-

ing his academic achievement. In fact, he had reportedly demonstrated inconsistent
motivation in school for quite some time. In early elementary school, he had not
shown any difficulty acquiring basic academic skills. However, he was occasionally
distractible or inattentive. In fifth grade, his parents become concerned about his
relationship with his teacher. They said Robert clashed with his teacher, developed
more negative emotions about school, and struggled with classroom performance.
He began therapy with a social worker, which appeared to enhance his coping skills,
and he showed some improvement in the classroom, but his academic performances
continued to be variable. He would ‘‘freeze’’ on certain tests, and his mother
described him as learning faster when things were presented in a song or pattern.
As Robert progressed through school, he appeared smart but did not seem to care
about school, was nonchalant, and would not work to his potential. He had difficulty
attending at times, inconsistently turned in assignments (even if he completed
them), and would not complete work even if he was able to do it. In the year before
he was referred for an evaluation, Robert completed ninth grade in a new school.
The transition to the new school was difficult for him, as he had to make new friends
while also adjusting to the high school environment. He did well initially, but his
grades declined over the course of the year. As a result, he failed two math classes
and was placed in summer school. The summer school teacher quickly indicated
that Robert knew all of the mathematical content of the class, and the teacher
reported being confused as to why he had not passed the class in the first place.
Robert’s mother became increasingly concerned about his academic difficulties.
She began to realize how much assistance with structure she gave him in the home
environment, including help with planning and lists. She decided that it was time
for a professional opinion about his development.
When Robert’s mother met with the neuropsychologist, she described him as a
good kid who was generally happy but had some difficulty expressing his emotions.
While she highlighted his difficulties with organization, she also described him as

J.N. Apps et al. (eds.), Pediatric Neuropsychology Case Studies: 151

From the Exceptional to the Commonplace.
# Springer Science þ Business Media, LLC 2008
152 J.N. Apps, D. Pflugradt

laid back, with no overt anxiety or depression (other than situational and generally
related to normal adolescent issues). Robert had never been defiant with his parents
or had any problems with his conduct. He also had no sleep problems. Reportedly,
he had recently become interested in his physical health, and he was active in
exercising and remaining fit in hopes of joining his high school football team. His
interest in football had also driven his decision not to use alcohol or other drugs.
Robert’s mother described her pregnancy and delivery with him as normal and
without complication; however, he was delivered 2 weeks late. He was described as
an ‘‘easy-going and funny’’ infant, who developed into a good kid. He met all of his
developmental milestones within normal limits. Starting at approximately 4 years
of age, he developed chronic ear infections, which were treated with adenoidect-
omy and tonsillectomy, as well as placement of ear tubes. At this time, he was
diagnosed with asthma and prescribed an inhaler to use on an as-needed basis,
which he continued to use at the time of evaluation. He also had seasonal and
environmental allergies, for which he was prescribed medications. Robert experi-
enced a concussion while playing football last year, following helmet-on-helmet
contact. He did not lose consciousness and was able to walk off the field by himself.
Following the game, he experienced a severe headache for several days, although
no memory loss or vomiting was involved. He was taken to the hospital, and cranial
magnetic resonance imaging (MRI) and a computed tomography (CT) scan were
normal. He remained out of practice for several weeks, following which he returned
with no subsequent complications. His additional medical history consisted of only
minor injuries throughout his lifetime.
At the time of evaluation, Robert was living with his mother. His parents
divorced when he was approximately 3½-years of age. He spent every other
weekend with his father. Maternal family history was described as remarkable for
mild depressive symptoms in his mother upon the deaths of her parents and learning
difficulties in a nephew. Paternal family history was remarkable for alcohol pro-
blems and depressive symptoms. Family stressors were significant; when Robert
was 2½-years old, the family experienced the loss of his infant brother. Approxi-
mately a year later, his parents divorced, and he and his mother moved in with his
maternal grandparents. When Robert was around 6½-years of age, he and his
mother moved into their own apartment; however, he remained close with his
grandparents. At age 13, Robert experienced the death of his grandfather. Over
the subsequent year, his grandmother became quite ill, and he and his mother were
actively involved in her care. Robert was with her when she died the following
summer. Following her death, he and his mother relocated, and he enrolled in his
new high school and started ninth grade.

Test Results

Given Robert’s past difficulties with distractibility, attention, and possible emotional
challenges, these areas were the focus of assessment.
16 He is not Working up to Potential 153

Robert was presented as a pubescent adolescent male dressed in khakis, a T-

shirt, and a baseball cap. His initial reaction to the examiner was appropriate, and
rapport was established quickly. He was extremely polite throughout the evaluation
day, and had good awareness of social cues. Although he did not initiate spontane-
ous social conversation, he was able to carry appropriate conversation when the
examiner began it. Robert’s sustained attention appeared good, and he was not
overly distractible in the one-to-one testing situation. However, his attention and
motivation appeared to vary on certain tasks. At times, he would make silly
mistakes, answer too quickly, or lose track of an item or thought. However, he
was easily reorientated to task, and this did not appear to negatively impact testing.
His mood was euthymic, and his affect was appropriate. Overall, Robert was very
cooperative with the entire testing process. He appeared self-motivated and wanted
to perform well. He worked persistently on items, although he was more inclined to
say he did not know an answer when asked verbal questions. On visual items, he
worked persistently until given the option to stop.
In reviewing Robert’s evaluation results, his intellectual abilities were in the
overall average range (Table 16.1). He demonstrated average verbal and nonverbal
intellectual abilities. His current level of academic skill acquisition was in the
average to above average range (Table 16.2). This was consistent with, or higher
than, what would be expected given his overall intellectual abilities. Robert did not
appear to be demonstrating any overt indications of a learning disability.
However, Robert demonstrated variable attention and executive function skills
(Table 16.3). His working memory was in the low average range, which was slightly
lower than would be expected given his overall intellectual abilities. He demonstrated
a statistically significant difference (p < 0.05) of 16 points between Verbal Compre-
hension and Working Memory Indices. Additionally, he had greater difficulty on

Table 16.1 Intellectual

Wechsler Intelligence Scale for Children – Fourth Edition Scorea Percentile
Verbal Comprehension Index 104 61st
Perceptual Reasoning Index 104 61st
Working Memory Index 88 21st
Processing Speed Index 97 42nd
Full Scale IQ 100 50th
Similarities (9)
Vocabulary (13)
Comprehension (11)
Digit Span (8)
Letter-Number (8)
Block Design (13)
Picture Concepts (10)
Matrix Reasoning (9)
Coding (10)
Symbol Search (9)
a
Standard score, (scaled score), [T-score], {z-score}.
154 J.N. Apps, D. Pflugradt

Table 16.2 Academic achievement

Woodcock Johnson Tests of Achievement – Score Percentile Grade
Third Edition, Form A equivalent
Broad reading 119 90th 13.5
Letter-word 106 65th 10.6
Reading fluency 122 93rd 14.1
Passage comprehension 116 85th 18.0
Broad math 104 62nd 10.5
Calculation 109 72nd 12.1
Math fluency 100 50th 8.9
Applied problems 102 54th 10.3
Broad written language 117 87th 13.0
Spelling 127 96th 16.0
Writing fluency 98 45th 8.4
Writing samples 118 88th 17.7

Table 16.3 Other cognitive functions

Tests Score
Delis-Kaplan Executive Function System
Verbal Fluency Test
Letter fluency (8)
Category fluency (6)
Category switching
Total (7)
Accuracy (8)
Design Fluency Test
Condition 1 total (12)
Condition 2 total (10)
Condition 3 total (11)
Color-Word Interference Test
Color naming (8)
Inhibition (6)
Inhibition/switching (9)
Tower Test
Achievement (14)
Move accuracy ratio (9)
Conners’ Continuous Performance Test
Omissions [53.71]
Variability [74.28]
Standard error by block [84.84]

both verbal and visual tasks requiring the greatest amount of abstract thought.
Further, he demonstrated mild relative weaknesses in executive skills including
verbal fluency, the inhibition of behaviors, vigilance, and attention. He demon-
strated average visual fluency, overall processing speed, and problem-solving
16 He is not Working up to Potential 155

skills. This pattern of mild executive dysfunction does not formally fall within the
diagnostic category for Attention Deficit Hyperactivity Disorder (ADHD). How-
ever, the conceptualization of ADHD as a neuropsychiatric disorder of executive
functions leaves open for interpretation how to categorize those children with mild
executive difficulties.

Formulation and Recommendations

The lack of specific diagnostic categories for various types of executive deficits
often results in ADHD becoming the default diagnosis. Often these children exhibit
symptoms that meet formal DSM-IV-TR criteria for the disorder, although in
Robert’s case, his symptoms met formal criteria only minimally. He was qualified
as inattentive because of his difficulties with attention to detail, sustained attention,
follow-through, organization, and forgetfulness. However, these symptoms were
not clear enough to teachers and caregivers for Robert to appear as ‘‘classically
ADHD.’’ In cases like Robert’s, the clinician must help those living and working
with the child to understand how relative weaknesses in verbal fluency, impulsive
verbal behaviors, variable attention, mild distractibility, and lower relative abstract
reasoning skills can be conceptualized as a variant of ADHD and result in impaired
functioning.
Individuals who experience fundamental weaknesses in executive functioning
generally demonstrate a host of difficulties with their behaviors. Executive func-
tions allow a person to solve problems, think abstractly and flexibly, plan and
organize behavior, and alter behaviors based on experience and feedback. Problems
in these areas can result in difficulties organizing information and efficiently
managing large amounts of information. Individuals may not use prompts well
and may have trouble thinking flexibly, often becoming stuck responding in ineffi-
cient manners. Formal testing offers a window into a person’s executive skills but
does not comprehensively measure such a complex construct. Indeed, the introduc-
tion of executive function measures is still relatively new in the field of neuropsy-
chology, with some areas having a greater predominance of research available.
Measures of fluency, verbal working memory, inhibition, and planning have rela-
tively significant bodies of research contributing to overall validity. However, many
of these measures are not available at all ages. Further, our understanding of how all
aspects of executive skills develop in children continues to be an area requiring
further research. Therefore, while measures in these areas can inform, they are not
all inclusive in their explanation of a child’s functioning. Robert appeared to
struggle with some of these skills, particularly relative to his overall average
intellectual abilities. These relative weaknesses were likely to impact his ability
to acquire adequate study skills. However, his additional cognitive strengths were
areas from which he could build upon in order to learn to compensate for his
relative weaknesses.
156 J.N. Apps, D. Pflugradt

Robert’s emotional development appeared age-appropriate. However, he was

struggling to reconcile his known abilities with his apparent weakness in remaining
organized and studying successfully. Robert had become stuck in a pattern of
expecting himself to somehow try harder. Intervening with Robert and his family
to help them understand how to compensate for his weaknesses became an impor-
tant step in his emotional growth and self-esteem.
Robert’s family was informed that he would likely function best in a structured,
consistent environment free of relative distractions. Although his executive weak-
nesses did not appear significant enough to qualify him for special education
assistance through an Individualized Educational Program (IEP), his parents were
strongly encouraged to help him learn appropriate study skills and environmental
controls in order to help him compensate for his difficulties (some environmental
compensations in the home environment are listed in Box 16.1).
Robert was likely to experience some difficulty organizing materials and
keeping track of multiple classes and assignments. More abstract assignments and
concepts might be harder for him, and he might have difficulty acquiring effective
study strategies, particularly compared with other young men of his age. A tutor or
academic mentor was strongly encouraged to provide the structure, guidance, and
assistance Robert may need to organize, synthesize, and manage the amount of
information involved in high school courses. This tutor should be someone whom
he can get along well with, who is less like a parent and more like a coach. The tutor

Box 16.1 Recommendations for the environment

l Keep rules clear and brief, and keep task lists short.
l Provide organizational structure, including using lists, calendars, and structured routines.
l Provide a distraction-free environment for the completion of homework or other chores,
including turning off the TV, video games, and/or music, closing windows, and reducing
noise.
l Assist Robert in getting started with assignments or projects, if he requires this, by ensuring
that he understands all of the instructions and expectations.
l Build in breaks, planned interspersed times of sustained attention for longer assignments or
projects.
l Establish a regular routine for homework with a specific time, place, and schedule.
l Monitor and give feedback, while not doing all of the work together, by praising positive
effort and hard work.

Box 16.2 Where do I find a tutor?

Parents often find tutors in a wide variety of places. A few places to start inquiring might
include the following:
l Family members with a background in education
l Past and current teachers
l Local universities and colleges
l Neighbors
l Pastors or church members
16 He is not Working up to Potential 157

or mentor should have experience working with children with mild attention and
executive problems (Box 16.2). Robert and the tutor should meet as necessary,
probably two to three times a week, and the tutor could provide structured study
skills. Such a relationship will also allow for additional presentations of material as
needed, guidance in organizing and keeping track of classes and assignments,
structure and discipline in study skills, and alternative explanations for more
difficult abstract concepts. Further, the tutor would be encouraged to help Robert
learn how to recognize hints or cues in assignments that describe what output is
expected and could model and help Robert learn how to break larger tasks into
logical steps. An overall goal for Robert would be to learn better self-evaluation
skills, so that he can more effectively monitor and alter his own behavior and
actions academically.
Robert’s tutor and his parents were encouraged to work closely with each of his
teachers to encourage assistance, such as additional visual study aids or written
handouts of any lectures. Robert was likely to have greater difficulty than other
students in taking notes in a timely fashion and remaining orientated to longer
auditory lectures. Utilizing multimedia formats in the classroom may be helpful,
such as tape recording lectures.
If Robert’s school were to need a formal document to provide him with these
recommendations, his parents were encouraged to share the neuropsychologist’s
report with his school’s special education director and to request that Robert be
evaluated for a 504 plan to assist him with his academic weaknesses. Section 504
ensures that children with disabilities who do not qualify for formal assistance
through the special education department still have access to accommodations that
they may require.
Robert’s family was advised to continue to monitor his academic and emotional
development. Returning to a mental health care professional was recommended
should any further emotional or cognitive struggles develop. However, it was
anticipated that with the improved understanding both Robert and his family now
had about his executive weaknesses, he would be able to develop compensatory
strategies and experience increased academic success and improved self-esteem.

Additional Resources

Key Concepts and Terms

Attention Deficit Hyperactivity Disorder A disorder defined by the Diagnostic and

Statistical Manual of Mental Disorders (2000) that encompasses problems with
inattention, distractibility, and at times hyperactivity and impulsivity, which reach a
level of impairment across environments.
Executive Functions A cluster of cognitive abilities including but not limited to
working memory, attention, planning, set-shifting, and problem solving associated
with prefrontal-subcortical brain systems.
158 J.N. Apps, D. Pflugradt

504 Plan Part of the civil rights act, Rehabilitation Act of 1973, which protects
the rights of people with various forms of disabilities to ensure that they are not
denied access to any program that receives federal funding.

References

Resources for Clinicians

American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders
(4th ed., text revised). Washington, DC: American Psychiatric Association.
Barkley, R. A. (2005). ADHD and the nature of self-control. New York: Guilford Press.
Dawson, P., & Guare, R. (2004). Executive skills in children and adolescents: A practical guide to
assessment and intervention. New York: Guilford Press.
Furman, L. (2005). What is attention-deficit hyperactivity disorder (ADHD)? Journal of Child
Neurology, 20, 994–1002.
Nigg, J. T. (2006). What causes ADHD: Understanding what goes wrong and why. New York:
Guilford Press.
Pliszka, S. R. (2003). Neuroscience for the mental health clinician. New York: Guilford Press.
Shallice, T., Marzocchi, G. M., Coser, S., Meuter, R. F., & Rumiati, R. (2002). Executive function
profile of children with attention deficit hyperactivity disorder. Developmental Neuropsychol-
ogy, 21, 43–71.
Voeller, K. K. S. (2004). Attention-Deficit Hyperactivity Disorder (ADHD). Journal of Child
Neurology, 19(10), 798–814.

Resources for Families

Children and adults with attention deficit/ Hyperactivity disorder: http://www.chadd.org

Edward M. Hallowell. (1994). Driven to distraction: Recognizing and coping with attention deficit
disorder from childhood through adulthood. Random House, New York, USA: Pantheon
Books.
Michael Gordon. (1990). ADHD/Hyperactivity: A consumer’s guide for parents and teachers.
New York: GSI Publications.
Mountain Plains Regional Resource Center. A parent and educator guide to section 504: Another
service option for children with disabilities. http://www.rrfcnetwork.org/images/stories/
MPRRC/Products/Generic/Section504/504parentguide.pdf.
National Resource Center on ADHD: http://www.help4adhd.org.
Parent Advocacy Coalition for Educational Rights: http://www.pacer.org/index.htm
Russell Barkley. (2000). Taking Charge of ADHD: The Complete, Authoritative Guide for Parent.
(2nd ed.,) New York, USA: Guilford Press.
Russell Barkley. (2005). ADHD and the nature of self-control. NY, USA: Guilford Press.
The San Diego ADHD Project: http://www.sandiegoadhd.org.
Chapter 17
Sorting Sounds: Reading Disability
with Phonological Awareness Deficit

Robert F. Newby

As Angie’s father was reading to her one evening near the end of junior kindergar-
ten, he paused in the story to play a game with her of matching letters to their
sounds. Angie had been slow in learning to recognize printed letters earlier that
year, and he thought it would be good to practice some more advanced alphabet
skills now. He was dismayed to discover during the game that she was bafflingly
inconsistent at recognizing even the /a/ sound that began her own name. Had
Angie’s teacher not commented recently that the class was working on this for
the past several weeks?
After bedtime, Angie’s father called his sister, who was a reading specialist in
the next town. ‘‘Classic sign,’’ she burst out immediately, ‘‘particularly since Angie
has talked up a storm since the first words came out of her mouth!’’ Classic sign of
what? How could Angie’s aunt detect something with such clarity after her dad’s
brief phone description? In fact, her aunt was right: Angie turned out to have
a classic case of emerging word reading disability, and catching it early was a
good thing.
On her aunt’s suggestion, Angie’s parents next requested testing by an
Individualized Education Program (IEP) team at school, who documented her
strong general intelligence, with robust verbal comprehension skills in particular.
Angie also was whizzing ahead in early math development, drew with artistic flair,
and wrote numbers with amazing precision, but she meandered through most attempts
to write letters as if she were drawing abstract expressionism. She simply could not do
the oral language tests that asked her to put together sounds like n-e-t into one word
(even though she was an avid fisherwoman) or to take out a single sound like the /c/
from the word cart to come up with the word for her favorite subject at school. She
also was very slow in saying the names of simple color spots on a page, even though
she already was choosing paint for her room with names like fuchsia.
The IEP team concluded that Angie was at risk for the emergence of a reading
disability and offered to pull her out of some class time during senior kindergarten

J.N. Apps et al. (eds.), Pediatric Neuropsychology Case Studies: 159

From the Exceptional to the Commonplace.
# Springer Science þ Business Media, LLC 2008
160 R.F. Newby

the next fall for extra training in phonemic awareness (like the test tasks just
illustrated), beginning phonics skills (the association of sounds and printed letters),
and early literacy conventions (such as scanning from left to right and handling
basic punctuation like periods).
Angie’s parents were stunned. Reading disability in such a bright girl? What
were they to do? They decided to invite Angie’s aunt for a coffee conference the
next day to try to put the puzzle together.
At coffee, Angie’s mom added an interesting twist to the story: ‘‘Ever since we
decided to pursue this testing, I have had this sinking déjà vu that I couldn’t quite
pinpoint, but it just came to me this morning. Remember when I spent that summer
after first grade at the college department of education clinic, being a guinea pig for
those graduate students practicing their teaching methods? And how hard reading
was for me all the way through grade school? Well, it is flashback time now: Angie
is me all over again.’’ Angie’s mom needed some support from both family
members and professionals to get around her fear that Angie was doomed to
struggle throughout her school career. At this point, Angie’s aunt felt that it
would be best for the family to have some additional expert consultation outside
of school, so she referred Angie for a neuropsychological evaluation to clarify the
apparent emerging reading disability and to add other relevant recommendations
for intervention.

Test Results

The evaluators considered all Angie’s results from the school’s testing valid and
reliable, because her effort, cooperation, attention, stamina, self-control, mood, and
social response were positive throughout all sessions. She was aged 5 years and 6
months at the time.
Angie’s overall intelligence was in the high average range, with no significant
difference between verbal and nonverbal reasoning abilities, including some
strongly above average subskills in each domain. Although none of the academic
skills tested at school were below average, indicators of alphabet knowledge,
beginning visual cue word recognition, and letter-sound awareness were in the
lower half of the average range. Graphomotor (paper and pencil) skills were
average, and math reasoning was high average to above average. In contrast, both
phonological awareness and rapid naming were mildly impaired and significantly
discrepant from verbal reasoning (Tables 17.1–17.3).
Some children have had enough relevant testing prior to referral for pediatric
neuropsychological evaluation, so that little or no further testing is necessary. In
these cases, the pediatric neuropsychologist assumes the role of a consultant,
explaining results coherently to parents and helping to flesh out an optimal treat-
ment plan. This is what happened with Angie.
Several other domains of neuropsychological functioning could have been
assessed for thoroughness, including manual dexterity, other basic sensory and
17 Sorting Sounds: Reading Disability with Phonological Awareness Deficit 161

Table 17.1 Intellectual

Differential Abilities Scale Scorea Percentile
Verbal cluster 112 79th
Nonverbal cluster 107 68th
General cognitive ability 110 75th
Verbal comprehension [49] 46th
Naming vocabulary [65] 93rd
Picture similarities [68] 96th
Pattern construction [43] 24th
Copying [51] 54th
Early number concepts [55] 69th
a
Standard score, (scaled score), [T-score], {z-score}.

Table 17.2 Academic achievement

Woodcock Johnson Tests of Score Percentile Grade Equivalent
Achievement – Third Edition, Form A
Letter-word 93 33rd K.1
Passage comprehension 101 53rd K.8
Word attack 92 30th <K.8
Spelling 98 45th K.2
Writing samples 95 38th <K.8
Applied problems 119 90th 1.4

Table 17.3 Other cognitive functions

Tests Score Percentile
Comprehensive Test of Phonological Processing
Phonological awareness 76 5th
Phonological memory 91 27th
Rapid naming 76 5th
Elision (6)
Blending words (6)
Sound matching (7)
Memory for digits (9)
Nonword repetition (8)
Rapid color naming (5)
Rapid object naming (7)
Beery-Buktenica Developmental Test of Visual-Motor Integration 106 66th

motor skills, memory, receptive and expressive language, attention, executive

mental functions, and other categories of academic skill included in the federal
guidelines for learning disability in the Individuals with Disabilities in Education
Improvement Act (Table 17.4). In addition, from a psychometric perspective, zero
162 R.F. Newby

Table 17.4 Categories of learning disability in federal special education law

l Oral expression
l Listening comprehension
l Written expression
l Basic reading skill
l Reading fluency
l Reading comprehension
l Mathematics calculation
l Mathematics problem solving

or very low raw scores on several subtests raised questions about whether those
skills were being sampled with adequate range of item difficulty.
The decision was made against further testing in this case for three main reasons:
First, neither Angie’s history nor the testing already completed raised concerns in any
of these other domains. Second, there is something to be said for pragmatic focus to
conserve health care and rehabilitation resources. For instance, what if Angie’s
parents wanted to consider marshalling family funds to buy out-of-school tutoring
services more than exhaustive testing? Third, the psychometric considerations were
outweighed by the consistency of the pattern in data from all available resources.

Formulation and Recommendations

In this relatively basic neuropsychological profile, a clear pattern of solid, roughly

equivalent core verbal reasoning and visual-spatial problem-solving is seen, con-
trasting subtly but not convincingly with some low average early academic skills.
Clinicians commonly observe that formal academic achievement test scores
obtained at kindergarten or early elementary age often do not capture the emerging
struggles of many students who eventually have learning disabilities. Early testing
also often fails to find a large aptitude-achievement discrepancy that comprises a
cornerstone of the traditional and legal definitions of LD, which have been seriously
questioned in recent research and scholarly discussion. Keeping these caveats in
mind, the most salient aspects of Angie’s profile consisted of her difficulties in
phonological awareness and rapid naming. These red flags triggered the recom-
mendations by the IEP team outlined earlier. Without formally classifying Angie
into special education services, the team was advising a trial to determine her
response to intervention as a prestep to special education.
Angie was considered at risk for word reading disability or developmental
dyslexia, which is the most common type of learning disability. The pattern can
range from mild to severe, so even highly qualified professionals sometimes
disagree about when to apply the diagnosis. The main learning difficulty in word
17 Sorting Sounds: Reading Disability with Phonological Awareness Deficit 163

reading disability involves recognizing or decoding words in reading, but secondary

difficulties in spelling, written expression, reading comprehension, memorizing
math facts, or math word problems often accompany the key word recognition
deficit.
Early problems in learning the alphabet, writing letters and numbers, associating
letters with their sounds, or rhyming can place a child at risk for dyslexia, but many
children outgrow these problems and become normal readers. For this reason,
reading disability is often not diagnosed until at least second grade and often not
until the child has been exposed to an appropriate form of extra help in reading
beyond the regular classroom.
The underlying cognitive processing cause in almost all cases is a core deficit in
phonological awareness, including segmenting words into component sounds,
blending sounds together, and associating letters and letter clusters with their
appropriate sounds. Some children with reading disability also show reduced
speed in reading symbols (letters and numbers) and/or naming commonly recog-
nized items (colors and pictures of objects); this type of rapid naming deficit often is
associated with slow reading fluency or speed, as discussed more thoroughly in the
Chaps. 19 and 20.
Because a subtle difficulty in specific aspects of language processing in the brain
is implied in a diagnosis of reading disability, it is important to rule out environ-
mental causes such as inappropriate instruction when making the diagnosis. Al-
though a growing body of research is beginning to clarify what this brain processing
problem may be, no reliable medical tests have been developed yet to establish the
diagnosis. Many children with reading disability have immediate or extended
family members with similar problems, and there is strong scientific evidence
that the phonological processing problems underlying this pattern can be genetic.
Myths about dyslexia can mislead families who are trying to get appropriate help
for their children, especially the idea that the learning problem is caused by a
detectable basic vision difficulty, such as eye tracking.
In light of an ample body of outcome research in reading interventions, built on
the knowledge base outlined in the previous paragraph, the following recommenda-
tions were made for specific instructional techniques for Angie.
Children with phonological awareness deficits are at risk for reading disabilities
and usually need extra training in segmenting and relating sounds in oral speech.
This is called phonemic awareness training. Phonemic awareness is a more basic
process than traditional phonics training, which focuses on the correspondence
between written letters and sounds in speech. Recent research suggests that most
children in kindergarten or first grade can learn these prephonics skills through
regular exercises in which they carefully listen for and articulate phonemes in oral
speech, break words into sound components or phonemes, match similar sounds in
words, and detect or produce rhyming words. Older children who already have
diagnosed reading disabilities also may benefit from this type of training, but it
takes a lot more time to achieve the benefit.
Work on traditional phonics skills should be emphasized in Angie’s reading
program. The most effective phonological development components in reading
164 R.F. Newby

research at this time involve systematic review of basic phonics elements, such as
letter sounds when needed; practice in segmenting short words in print; blending
methods, such as orally stretching out the sounds in words; contextual application
of analytic phonics methods, such as word families; and an integration of reading
and writing activities. Reading decoding work should focus on reading material that
is at Angie’s instructional level for word recognition at any given time.
Angie probably will need extra instruction in some aspects of written language,
particularly spelling. It is often most helpful to have children focus on spelling words
that are integrated with their reading curriculum and/or words that are grouped together
in phonologically related word families. The use of a ‘‘word wall’’ would be helpful for
Angie. In classroom application, this consists of a list of words on the wall, grouped
according to their beginning letters alphabetically, to which children can refer when
doing written work. Children are expected to spell correctly all words on the word wall
in their written work, and words are gradually added as they are taught in the curricu-
lum. Easily confusable similar words (e.g. what, when) are printed on different
colored paper and cut out with the outline shape closely following the configuration
of the letters in the word. This type of system can be individualized with a chart on
the child’s desk if the child is working at a lower level than the overall class or if
this type of system is not usable in the whole class format. In the long run, if
Angie’s spelling development does not fully normalize, the goal may be for Angie
to spell reliably a circumscribed list of commonly used words.
Parents and school staff should monitor Angie’s progress closely in the related
areas of reading fluency, reading comprehension, sentence construction, paragraph
structure, and organization of longer written products, in case extra instruction in
these areas becomes necessary.

Update

The end of Angie’s story? Taking advantage of the extra instruction available at
school during kindergarten and first grade, her aunt’s expertise in after-school
tutoring during weekends and summers, a semester in the small-group reading
program at the very same college clinic her mother had attended, and the wonderful
additional knowledge they gained by reading Dr. Sally Shaywitz’s book for parents
and teachers, Overcoming Dyslexia, Angie and the adults working with her accom-
plished just what the title of Shaywitz’s book says. Now in second grade, Angie
reads just above the average range in all three of the key areas of word decoding,
fluency or speed, and comprehension. Her spelling is still a little below average, but
in her free time she is already composing clever plays for her friends to act out.
Researchers in reading intervention now estimate that the majority of cases (with
numbers ranging from 75% to as high as a perhaps overoptimistic 95%) of ongoing
reading disabilities essentially could be prevented by the type of early identification
and intervention that Angie received.
Three other case examples, which illustrate variations that deserve the keen eye
of the sophisticated clinician, will be considered in the next chapters to further
17 Sorting Sounds: Reading Disability with Phonological Awareness Deficit 165

elaborate on Angie’s case, which represents a prototype of a well-assessed and

properly treated positive outcome in a young child with the most common kind of
phonological processing deficit.

Additional Resources

Key Concepts and Terms

Dyslexia The International Dyslexia Association IDA Board of Directors, on

November 12, 2002, adopted the following definition, which is also used by the
National Institute of Child Health and Human Development (NICHD):
Dyslexia is a specific learning disability that is neurological in origin. It is characterized
by difficulties with accurate and/or fluent word recognition and by poor spelling and
decoding abilities. These difficulties typically result from a deficit in the phonological
component of language that is often unexpected in relation to other cognitive abilities and
the provision of effective classroom instruction. Secondary consequences may include
problems in reading comprehension and reduced reading experience that can impede
growth of vocabulary and background knowledge.

Individualized Education Program (IEP) Defined by federal law, an IEP means a

written statement for each child with a disability that is developed, reviewed, and
revised in a meeting including school staff and parents. Each IEP must include
statements of the child’s present levels of academic achievement and functional
performance, measurable annual goals, how the child’s progress toward meeting
the annual goals will be measured, the special education and related services and
supplementary aids and services to be provided, and any individually appropriate
accommodations necessary to measure the academic achievement and functional
performance of the child on state and district-wide assessments.
Phonological Awareness An individual’s awareness of and access to the sound
structure of his or her oral language. Overlaps with or is sometimes used synony-
mously with phonemic awareness.

References

Resources for Clinicians

Adams, M. J., Foorman, B. R., Lundberg, I., & Beeler, T. (1998). Phonemic awareness in young
children: A classroom curriculum. Baltimore, MD: P. H. Brooks Publishing.
Blachman, B. A., Ball, E. W., Black, R., & Tangel, D. M. (2000). Road to the code: A phonologi-
cal awareness program for young children. Baltimore, MD: P. H. Brooks Publishing.
Fletcher, J. M., Lyon, G. R., Fuchs, L. S., & Barnes, M. A. (2007). Learning disabilities: From
identification to intervention. New York: Guilford Press.
166 R.F. Newby

Harris, K. H., & Graham, S. (2005). Handbook of learning disabilities. The Guilford Press.
Pennington, B. F. (1991). Diagnosing learning disorders: A neuropsychological framework. New
York: Guilford Press.
Spear-Swerling, L., & Sternberg, R. J. (1994). The road not taken: An integrative theoretical model
of reading disability. Journal of Learning Disabilities, 27(2), 91–103, 122.
United States Department of Education, Office of Special Education Programs. IDEA – Building
the legacy of IDEA 2004. Retrieved November 21, 2007, from http://idea.ed.gov/explore/home
Wagner, R. K., Torgesen, J. K., & Rashotte, C. A. (1999). Comprehensive test of phonological
processing (CTOPP). Austin, TX: Pro-Ed.

Resources for Families

International Dyslexia Association, http://www.interdys.org

LD OnLine, http://www.ldonline.org/
Shaywitz, S. E. (2003). Overcoming dyslexia: A new and complete science-based program for
reading problems at any level. New York: A. A. Knopf.
 Erratum

FM (Page No. ix, Contents)

10 Pathological Left-Handedness: Stroke and Seizures . . . . . . 87
Elizabeth N. Adams and Mariellen Fischer

FM (Page No. xiii, Contributors Page)

Mariellen Fischer, Ph.D.
Professor, Department of Neurology, Medical College of Wisconsin, Milwaukee, WI

Chapter 10 (Page No. 87)

Pathological Left-Handedness: Stroke and Seizures
Elizabeth N. Adams and Mariellen Fischer

In the print and online version of the original chapter, the second author’s name was
omitted. The correct authors line is Elizabeth N. Adams and Mariellen Fischer.

DOI 10.1007/978-0-387-78965-1