Case Study #1 Supporting the Use of iLs

DATE: 07/02/2014

ASSOCIATE’S NAME & DISCIPLINE: Mark L. Prohaska, Ph.D. (Director; Licensed Clinical Psychologist, Clinical Neuropsychologist), Heather C. Miller, B.S. (Clinical Coordinator and iLs Associate), Michelle Campbell, B.A. (iLs Associate)

NAME OF ORGANIZATION: Neuropsychology Clinic, P.C.

Background:  H is an 11-year-old, right-handed female in the 5^th grade who has a history of AD/HD (treated with Concerta).  She is an only child and lives with her biological parents.  She likes cats, collects statues, likes art and drawing, and is involved in the girl scouts.  H gets along well with her peers.  H’s mother reports that she was on bed rest for three months during her pregnancy due to preeclampsia; however, the delivery was unremarkable and H was early in reaching her developmental milestones (e.g., crawled at 4 months, walked at 7½ months, talked at 8 months).  H’s medical history is notable for allergies and reflux.  She has not required any surgical procedures and her neurological and psychiatric histories are unremarkable.  Her current medications included Zyrtec, Zantac, and Concerta.  Family medical history includes AD/HD (father and paternal grandmother). 

Presenting Problem: H had been taking Concerta with good results since first diagnosed with AD/HD in kindergarten; however, she required two increases in her dosage over the previous year that were believed to be factors in the her developing facial tics.  Although she typically earned A’s and B’s and there were no behavioral issues in the classroom, H was described as being distractible and as having difficulty staying on task which resulted in her having to take her classroom work with her to complete at home. This, in addition to her other assigned homework, was taking a very long time to complete and her mother was making plans to start home-schooling.  Similar problems were seen at home, where H was observed to be easily distracted and to take a much longer time to get tasks accomplished than she should.  Results of our initial evaluation estimated H’s overall abilities to be in the low average (nonverbal) to average (verbal) range; her performance on screening measures of academic achievement were somewhat above expectations based on her estimated level of overall ability with no evidence of an underlying learning disability.  H’s performance on formal cognitive testing revealed that she was performing below her potential in several aspects of cognitive functioning, most notably in the areas of attention and response control (auditory worse than visual).  This finding, coupled with her mother’s report of symptoms, problems in the classroom, and other evidence of deficits in attention that were significantly impacting her daily functioning, warranted a diagnosis of AD/HD, combined type.  Her mother also commented several times on H’s clumsiness and tendency to sporadically fall into stationary objects. Upon initial observation, it was noted that H exhibited extremely poor vestibular and proprioceptive abilities as well as poor coordination and somewhat awkward gross and fine motor movements.

Therapeutic Goals: Initially, sensory-motor integration and visuo-motor coordination activities; higher order attention, working memory, and executive tasks were later integrated into her therapies.

iLs Program Used: iLs Total Focus Concentration/Attention Program (40 one-hour sessions), three times per week (Monday, Wednesday, and Friday) in clinic; approximately six one-hour sessions were conducted at home due to scheduling conflicts.   

Other Interventions used:Cognitive-Behavioral interventions were utilized in conjunction with iLs to focus on specific functional difficulties and areas of cognitive deficit that were identified on neuropsychological testing and other data collected in the initial evaluation.

Post-treatment evaluation:  At baseline, H obtained an estimated Full Scale IQ of 85 (low average range).  An analysis of her index scores revealed slightly better developed verbal vs. nonverbal abilities (Verbal = 92, average range; Nonverbal = 83; low average range) (all based on mean=100; SD =15), a statistically significant though not uncommon difference that was seen in 25% of the standardization sample.  H’s post-treatment performance on this measure yielded a Full Scale Estimate of 103 (average range), representing an 18-point increase over her baseline performance.  This increase was largely due to a 25-point improvement in her nonverbal index, which reversed the verbal-nonverbal discrepancy that was present at her baseline testing. 

 

WASI – II
Subtest	Raw	T-score	Scale		Sum of T-scores	Composite Score	%ile Rank	Confidence Interval (95%)
Block Design	(17)30	(40)50	Verbal		(90)   97	(92)  98	30 (45)	(86-99)  91-105
Vocabulary	(25)30	(44)51	Nonverbal		(79)  110	(83) 108	13 (70)	(77-92) 100-115
Matrix Reasoning	(12)22	(39)60	Full Scale		(169) 207	(85) 103	16 (58)	(80-91)   97-109
Similarities	(22)23	(46)46
Confidence Level (IQ =(103  )			Difference	Raw	Significance	Base Rate
90%	68%		VCI>PRI	10	.15	20%
(85-87) 103-104	(85-86) 103-104		VCI<PRI

*pre-treatment scores are in parentheses

With the exception of psychomotor speed, H’s post-treatment performance on cognitive measures reflected an improvement to the average range of functioning in all cognitive domains, which correlates with the improvement of her estimated overall level of ability from the low average to the average range. 

 

Patient Profile	Percentile Range				> 74	25 - 74	9 - 24	2 - 8	< 2
	Standard Score Range				> 109	90 - 109	80 - 89	70 - 79	< 70
Domain Scores	Subject Score	Standard Score	Percentile	Valid Score	Above	Average	Low Average	Low	Very Low
Neurocognitive Index (NCI)	N/A		37	Yes		X	O
Composite Memory	100		47	Yes		XO
Verbal Memory	51		32	Yes		X
Visual Memory	49		63	Yes		XO
Psychomotor Speed	133		19	Yes		O	X
Reaction Time	677		55	Yes		X	O
Complex Attention	22		30	Yes		X		O
Cognitive Flexibility	25		40	Yes		X	O
Processing Speed	38		19	Yes		X	O
Executive Function	33		55	Yes		XO

X = Post-Treatment; O = Pre-treatment

 

In the area of attention, H’s baseline performance revealed significant deficits in auditory (though not visual) response control and low average abilities to sustain her attention over extended periods of time for both auditory and visual information.  H’s post-treatment performance in this arena revealed a significant improvement in auditory response control as well as in both auditory and visual sustained attention, both of which improved to the average range.

 

IVA Continuous Performance Test
Response Control			Attention
	Baseline	Post Rx		Baseline	Post-iLs Rx
Full Scale Quotient	73	88	Full Scale Quotient	90	105
Auditory	55	75	Auditory	92	106
Visual	93	99	Visual	88	103

Lower scores reflect greater deficits

 

H’s parents completed the iLs checklist at baseline and post-treatment.  Their observations revealed no significant differences between baseline and post treatment ratings. 

 

iLs Checklist
	Baseline	Post Rx	% Improvement
Sensory and Sensory Motor	37	37	0
Auditory/Language	14	15	0
Social/Emotional	15	13	0
Organization/Attention/Cognitive	19	14	0

Higher scores reflect greater deficits

 

At baseline, H’s parent’s ratings of her executive abilities on the Comprehension Executive Functioning Inventory (CEFI) resulted in an overall classification that fell in the low average range with lower scores in the area of initiation and significant relative weaknesses in attention (2^nd percentile) and working memory (2^nd percentile).  Post-treatment, H’s full scale score significantly improved from the low average to average range with statistically significant improvements being seen in the areas of attention, emotional regulation, flexibility, and working memory. 

 

Comprehensive Executive Function Inventory (CEFI)
	Baseline	Post Rx	Significance
Full Scale	83	96	Significant
Attention	70	93	Significant
Emotional Regulation	80	95	Significant
Flexibility	106	124	Significant
Inhibitory Control	102	109	No Change
Initiation	78	90	No Change
Organization	80	85	No Change
Planning	98	105	No Change
Self-Monitoring	93	93	No Change
Working Memory	68	84	Significant

Lower scores reflect greater deficits

Summary of Changes: H’s full scale IQ estimate increased by 18 points (from the low average to the average range), mostly due to a significant 25-point improvement in her nonverbal index, which reversed the verbal-nonverbal discrepancy that was present at her baseline testing.  H’s performance on screening measures of academic achievement revealed no significant differences between baseline and post-treatment assessment, with her results being most notable for an unusual decline in word reading performance that is of uncertain etiology or significance.  H’s performance on formal cognitive testing revealed significant improvements on measures of complex attention, reaction time, cognitive flexibility, and processing speed, as well as significant improvements in auditory response control and both auditory and visual sustained attention.  Although her parent’s rating on measures of executive functioning suggested significant improvement in attention, emotional regulation, flexibility, and working memory, a comparison of baseline to post-treatment rating on other behavioral measures completed by H’s parents revealed no significant differences in symptom ratings that correlated with the improvements seen on formal cognitive testing and their functional ratings on the CEFI.