Case study 1 - Steven's story

Steven* was a 14-year-old boy with low self-esteem who was under-achieving at school, and becoming increasingly negative about his future prospects when he came for assessment. His poor self-image stemmed partly from difficulties he had been experiencing with schoolwork, and he described himself as “dumb”. It is a real indictment on our education system that so many children leave feeling that they are unintelligent, hopeless at learning, no good at anything, or losers.  In Steven’s case his negative feelings led to school avoidance, staying home and spending time watching TV and playing on his computer. Steven had problems concentrating in class, had difficulty making friends and was uncoordinated at sport and unwilling to participate in it. His co-ordination problems were such that at 14  he still could not tie his shoelaces.

His parents had not noticed any delay in his acquisition of language, possibly because Steven was their first child, however, speech problems were noticed by Steven’s pre-school teacher. No therapy or formal assessment was organized, as Steven seemed to catch up as the year progressed. The pre-school teacher also noted that Steven would not join in with other children in activities on the mat.

In Grade 1 Steven was reading well above his year level, and he continued to do well with reading throughout primary school. However, with regard to Mathematics his Grade 1 teacher commented: “Steven has the basic knowledge but makes many mistakes because he does not listen to directions. Steven finds it difficult to follow directions and tends to become confused.”  Subsequent teachers each year commented on his difficulty concentrating and remaining on task, his difficulties organizing himself, his need to listen more and the need for constant reminders to keep him working, yet this was not followed up, and it is only in retrospect that these comments jump out of the pages of his reports.

What eventually happened was that in Grade 6, Steven was seen by a paediatrician who diagnosed him as having Attention Deficit Disorder and prescribed Ritalin. This was despite the fact that throughout his primary school years Steven had been described by teachers as accepting responsibility, being punctual, having courtesy and consideration, respecting authority and the rights of others, but as having difficulty working in a group and mixing with peers.  He was described as taking pride in his work and having the ability to persist in the face of difficulties but being poor in self-organization and his use of time.

When  assessed at 14, Steven’s attention and decision making were indeed below the level expected for his age, but the major discrepancy was with his language abilities. He did poorly on a task requiring auditory attention, but well on one for visual attention. In doing the former task, Steven appeared to “fade out” in patches, seeming to forget parts of the instructions. On this task he appeared not so much impulsive as “foggy”, or unable to hold both parts of the complex instructions in mind at the same time. And indeed, when Steven was specifically tested for comprehension of instructions, he had considerable difficulty. A child who has difficulties of this sort may have problems processing and comprehending verbal messages that are complex. The impression Steven gave was of not considering a problem and working out a strategy to achieve the task. He seemed impulsive, but his comprehension difficulties were more likely to be responsible as Steven was capable of accurate and efficient attention to visual tasks.

Steven performed well on memory tests, particularly those involving visual processing. He did less well in his ability to recall verbal information, particularly more complex sentences. List learning revealed that although Steven took a little longer to encode information into memory, he was able to retain what he had learned.

This case illustrates how important it is that where children are experiencing significant difficulties, the nature of these difficulties be clarified because some learning problems are not obvious and children’s needs and their behaviour can be misunderstood. This is particularly true of children with attention problems, since lack of attention is not a simple issue and has many causes. In particular, we believe that children should never be given a diagnosis of ADHD and prescribed stimulant drugs without a comprehensive assessment. The inability to listen and to follow instructions, and difficulties with organization may, for example, be due to a nonverbal learning disability, with problems with attention arising secondary to an inability to process complex information.Fortunately, the CAN DO Program can address all these issues.

School Issues

Unfortunately, it is often thought that these children have motivational difficulties, and they are constantly being urged to try harder. This can compound problems they already have with self-esteem. Our concern for children like Steven is that failure to understand the nature of their real strengths and weaknesses will lead to further emotional adjustment problems with anxiety, depression and poor self-esteem. Another concern is that they will face increasing academic difficulty as the degree of complexity of school work increases in later secondary classes and they will become discouraged and drop out of school, when what they need is to be explicitly taught how to manage and organize information to enhance their ability to learn. Placing children in separate special education classes sometimes poses real problems from the child’s point of view as they can be teased unmercifully.

Children with nonverbal learning disabilities can face additional problems simply because the nature of their difficulties may go unrecognised. Their apparent strength in the language realm including superficially adequate verbal expression and age-appropriate or superior word recognition and spelling skills, can mask their underlying problems which may only emerge as demands become more complex in later years at school. These children typically have a tendency towards clumsiness, delayed self-help skills, poor friendships, and may be excessively active, impulsive and have problems with sustained attention when younger. As they approach adolescence there may be a shift towards personality problems as they become increasingly anxious and feel out of place in many situations. While at school, these children typically have difficulty with arithmetic and other forms of mathematics, printing and handwriting difficulties, poor reading comprehension as contrasted with their excellent word-recognition skills, and general organizational difficulties. Mistakes may be ignored because when children are fully stretched by cognitive demands, they may have little energy left for monitoring their performance. They may show considerable variability and quickly fatigue in cognitive tasks.

They may also be unruly or disruptive in class and unwilling to participate in group discussion, especially if they find that they cannot follow group instructions. As they become aware of differences between their own ability to absorb and generate information and those of their peers, they may become aggressive or withdrawn, and may rebel against their teachers or against the school system in general.

Parenting issues

Parents may need to be particularly patient and to understand that these children will do better at home and at school when requirements are clearly spelled out for them and they have practised several times how to do a task e.g., they may need to be shown several times how to change a tyre and to be supervised closely in their initial attempts but should be able to do it adequately on their own thereafter. Setting them a task such as “tidy up your room” may place too great a demand on their organizational skills, and they will need to be shown several times how to manage the separate tasks needed to accomplish the job successfully. This does not mean that they are less intelligent than other children, but that information processing will be better in smaller chunks initially. It is rather like having a narrow inlet into a reservoir. It may take more time for the water to flow in and it can only get there in smaller amounts, but the capacity of the reservoir is the same.

It is very important to look for and cultivate the genuine talents of these children. Finding an activity at which they can excel is the most effective way of improving a child’s self-esteem. Reassurance rarely helps as the child is only too well aware of his or her difficulties. Genuine achievement promotes self-esteem which in turn helps a person to grow and further display his natural talents.

* Name has been changed for privacy.