sample case study for special child

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Description of Assignment

During your time at Manor, you will need to conduct a child case study. To do well, you will need to plan ahead and keep a schedule for observing the child. A case study at Manor typically includes the following components: 

• Three observations of the child: one qualitative, one quantitative, and one of your choice. 
• Three artifact collections and review: one qualitative, one quantitative, and one of your choice. 
• A Narrative

Within this tab, we will discuss how to complete all portions of the case study.  A copy of the rubric for the assignment is attached. 

• Case Study Rubric (Online)
• Case Study Rubric (Hybrid/F2F)

Qualitative and Quantitative Observation Tips

Remember your observation notes should provide the following detailed information about the child:

• child’s age,
• physical appearance,
• the setting, and
• any other important background information.

You should observe the child a minimum of 5 hours. Make sure you DO NOT use the child's real name in your observations. Always use a pseudo name for course assignments. 

You will use your observations to help write your narrative. When submitting your observations for the course please make sure they are typed so that they are legible for your instructor. This will help them provide feedback to you. 

Qualitative Observations

A qualitative observation is one in which you simply write down what you see using the anecdotal note format listed below. 

Quantitative Observations

A quantitative observation is one in which you will use some type of checklist to assess a child's skills. This can be a checklist that you create and/or one that you find on the web. A great choice of a checklist would be an Ounce Assessment and/or work sampling assessment depending on the age of the child. Below you will find some resources on finding checklists for this portion of the case study. If you are interested in using Ounce or Work Sampling, please see your program director for a copy. 

Remaining Objective 

For both qualitative and quantitative observations, you will only write down what your see and hear. Do not interpret your observation notes. Remain objective versus being subjective.

An example of an objective statement would be the following: "Johnny stacked three blocks vertically on top of a classroom table." or "When prompted by his teacher Johnny wrote his name but omitted the two N's in his name." 

An example of a subjective statement would be the following: "Johnny is happy because he was able to play with the block." or "Johnny omitted the two N's in his name on purpose." 

• Anecdotal Notes Form Form to use to record your observations.
• Guidelines for Writing Your Observations
• Tips for Writing Objective Observations
• Objective vs. Subjective

Qualitative and Quantitative Artifact Collection and Review Tips

For this section, you will collect artifacts from and/or on the child during the time you observe the child. Here is a list of the different types of artifacts you might collect: 

Potential Qualitative Artifacts 

• Photos of a child completing a task, during free play, and/or outdoors. 
• Samples of Artwork 
• Samples of writing 
• Products of child-led activities 

Potential Quantitative Artifacts 

• Checklist 
• Rating Scales
• Product Teacher-led activities 

Examples of Components of the Case Study

Here you will find a number of examples of components of the Case Study. Please use them as a guide as best practice for completing your Case Study assignment. 

• Qualitatitive Example 1
• Qualitatitive Example 2
• Quantitative Photo 1
• Qualitatitive Photo 1
• Quantitative Observation Example 1
• Artifact Photo 1
• Artifact Photo 2
• Artifact Photo 3
• Artifact Photo 4
• Artifact Sample Write-Up
• Case Study Narrative Example Although we do not expect you to have this many pages for your case study, pay close attention to how this case study is organized and written. The is an example of best practice.

Narrative Tips

The Narrative portion of your case study assignment should be written in APA style, double-spaced, and follow the format below:

• Introduction : Background information about the child (if any is known), setting, age, physical appearance, and other relevant details. There should be an overall feel for what this child and his/her family is like. Remember that the child’s neighborhood, school, community, etc all play a role in development, so make sure you accurately and fully describe this setting! --- 1 page
• Observations of Development :   The main body of your observations coupled with course material supporting whether or not the observed behavior was typical of the child’s age or not. Report behaviors and statements from both the child observation and from the parent/guardian interview— 1.5  pages
• Comment on Development: This is the portion of the paper where your professional analysis of your observations are shared. Based on your evidence, what can you generally state regarding the cognitive, social and emotional, and physical development of this child? Include both information from your observations and from your interview— 1.5 pages
• Conclusion: What are the relative strengths and weaknesses of the family, the child? What could this child benefit from? Make any final remarks regarding the child’s overall development in this section.— 1page
• Your Case Study Narrative should be a minimum of 5 pages.

Make sure to NOT to use the child’s real name in the Narrative Report. You should make reference to course material, information from your textbook, and class supplemental materials throughout the paper . 

Same rules apply in terms of writing in objective language and only using subjective minimally. REMEMBER to CHECK your grammar, spelling, and APA formatting before submitting to your instructor. It is imperative that you review the rubric of this assignment as well before completing it. 

Biggest Mistakes Students Make on this Assignment

Here is a list of the biggest mistakes that students make on this assignment: 

• Failing to start early . The case study assignment is one that you will submit in parts throughout the semester. It is important that you begin your observations on the case study before the first assignment is due. Waiting to the last minute will lead to a poor grade on this assignment, which historically has been the case for students who have completed this assignment. 
• Failing to utilize the rubrics. The rubrics provide students with guidelines on what components are necessary for the assignment. Often students will lose points because they simply read the descriptions of the assignment but did not pay attention to rubric portions of the assignment. 
• Failing to use APA formatting and proper grammar and spelling. It is imperative that you use spell check and/or other grammar checking software to ensure that your narrative is written well. Remember it must be in APA formatting so make sure that you review the tutorials available for you on our Lib Guide that will assess you in this area. 
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Case study: ‘He’s a 10-year-old child with disabilities . . . I can’t see how isolating helps’

Debbie kennedy says the regular use of seclusion has worsened her son’s behaviour.

Dylan Kennedy (10) with his mother Debbie Kennedy at home in Dublin. Photograph: The Irish Times

Debbie Kennedy accepts her 10-year-old son can be difficult to handle on occasion.

He’s autistic and has been diagnosed with attention deficit hyperactivity disorder.

There are times when he gets frustrated, angry and stressed. Equally, she says, he can be calmed down quickly with simple interventions.

“He’s very intelligent,” says Kennedy.”He could tell you anything about any car. He loves Top Gear . . . when he does act out, I can control him with one hand or distract him.”

But she says the past past two years have been marked by a sharp deterioration in his behaviour. She puts much of this down to what she says was the overuse of seclusion at school to control his behaviour.

In all, she estimates he was placed in a seclusion or “time-out” room on more than 30 occasions over a two-year period.

While in most cases she was told they were for short periods of time, she maintains that on a several occasions he was placed there for up to two hours at a time.

“In order to help a vulnerable child like Dylan manage his emotions and control his behaviour, he needs support, guidance and explanation,” she says.

“If he’s isolated from others, without guidance or support, I can’t see how that helps. In fact, it’s a more frightening experience – especially for a child with disabilities.”

Benincasa Special School in Blackrock, Co Dublin, said that while it was not in a position to comment on Dylan's individual case, the school had always acted "properly and in accordance with good practice at all times".

In line with its policies, seclusion was only ever used as a measure of last resort and where a child was disruptive to the point of posing an imminent danger to themselves or others.

Kennedy, however, feels the school was too quick to seclude her son and says he regularly came home in tears after being placed in the room, or isolated from the wider class.

“He would spend hours crying, saying how much he wanted to die and felt he wasn’t good enough.”

She also feels he was placed in the room on foot of relatively minor incidents, like throwing a pencil against a blackboard or refusing to do work.

School records, however, show there were occasions when he kicked or punched staff. On one occasion, he is said to have raised a chair in the air, before it was taken from him.

The seclusion room – based on photographs taken by Dylan’s mother – is a small bare room with no furniture.

There is a window with metal bars on the outside. The door has no handle on the inside and there is a peephole for staff.

The school said a staff member was present outside the seclusion room, monitoring the student, at all times.

“The seclusion room is designed with regards to the health and safety of the student in question. The room does not contain certain furniture as such items are often considered safety hazards to both the student or staff members,” it said.

Kennedy ended up withdrawing permission for her son to be placed in the room. Afterwards, she says she would receive phone calls from 9.10am onwards asking her to collect him.

He ended up being taught at home by his mother for long periods and resumed school on a limited basis.

She is careful to say Dylan enjoyed several successful years at his special school prior to this and many staff went out of their way to help and support him. “I couldn’t speak highly enough of them.”

But she feels the use of seclusion has left a damaging legacy which Dylan is still coming to terms with.

“He needs therapy after all that’s happened. We can be out having fun and he’ll mention what happened to him,” she says.

“He is the most caring and affectionate boy. He’s clever and funny and has a huge obsession with cars. I wouldn’t change him for anything.”

Carl O'Brien

Carl O'Brien is Education Editor of The Irish Times. He was previously chief reporter and social affairs correspondent

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Case Study of a Child with Intellectual Disability

In this intellectual disability case study, the author looks at designing an education curriculum for Meagan, a 14-year-old student.

Introduction

There are numerous interventions that have been designed to enable students with intellectual disability better cope with their condition. Most of these interventions have been hinged on the principle that respective educational programs should be tailored to complement the students’ strengths, and to supplement their weaknesses.

This is the same principle underlying the functioning of the K12 educational principle because it is centered on meeting individual student needs (K12 Inc. 2011, p. 1). The K12 educational paradigm mostly works through online communication but it has been seen to offer a lot of advantages to students with unique disabilities.

For instance, the educational methodology is known to provide rich, challenging and engaging content; an individualized learning plan; a learning coach; and cutting-edge technology in the provision of the best learning outcomes for intellectually disabled students (K12 Inc. 2011, p. 1).

When educating students with intellectual disabilities, it should be understood that, students are bound to have trouble in learning, retaining information and understanding information (Pearson Education Inc. 2011, p. 2).

Educators have often experienced such challenges, but comprehensively, there is a consensus among most stakeholders that it is vital to make accommodations for certain groups of students, and it is also crucial to make curriculum modifications for other students. In this regard, there seems to be a lack of consensus in coming up with one formula for handling students with intellectual disability.

This is the main framework for the advancement of this paper because this paper focuses on developing curriculum adjustments for a young man, Meagan. Meagan is 14 years old and has had a history of intellectual disability. This paper analyzes various dynamics of Meagan’s life, with the intention of making curriculum adjustments to provide an effective framework for learning.

To provide a good backdrop for the development of a good framework for learning, several aspects of Meagan’s life will be analyzed. These aspects include his family background, personal history, personal skills and personal abilities.

These factors will be analyzed systematically. Comprehensively, this analysis will be done with the aim of identifying one long-term aim or objective of the learning outcome and two short-term aims or objectives of the learning outcome.

Family Background

Meagan is the eldest child in a family of three children. His younger sibling is a girl, Sophia, aged nine years old. The youngest child is also a girl and she is three years old. Among his siblings, Meagan is deemed to be the child who has experienced most difficulty in learning. Meagan’s family hails from a middle-class society in Melbourne, Australia. His father works as a retired engineer in a local factory.

The mother works as a librarian in a local university. There has been no vivid or confirmed reports of intellectual disability among any of Meagan’s family members, though there have been unconfirmed reports of mental illness among some of Meagan’s relatives hailing from his father’s side of the family.

His aunt is said to experience occasional episodes of mental instability. However, there have been no confirmed reports of mental illnesses or cognitive disability from any of the family members of Megan’s mother.

Megan’s family professes the Christian faith, though they are not committed in their religion. However, Christianity has had an influence on Meagan’s life because he strongly identifies with his Christian faith. In the past couple of months, Meagan was baptized and currently devotes most of his time to his religious duties. None of Meagan’s family members pay much attention to religion.

His family also hails from a background of child neglect, with many of Meagan’s relatives having been abandoned by their parents at an early age. Meagan’s parents are no exception. The degree of attention they give Meagan is inadequate because little attention is paid to Meagan’s slow intellectual development. This has been going on since his parents confirmed that he was suffering from intellectual disability.

There is also an almost non-existent family support structure for Meagan to cope with his condition. Moreover, there is very little evidence of family cohesion among Megan’s family members, starting from his parents to his siblings. In this regard, Meagan is left to live with his condition, alone.

Personal History

Meagan hails from the aboriginal community of Australia. He was prematurely born because he was birthed at only seven months into his mother’s pregnancy. During his infant life, Meagan was abandoned by his mother, even before he was completely weaned from her. This forced his father to look for a baby sitter.

Nonetheless, despite these challenges, Meagan lived to have a vibrant childhood, with no signs of failing to cope with his playmates or friends. To a large extent, Meagan has been deemed a “normal” child. In his teen years, he used to participate in church activities (for the young) and also took part in school activities including extracurricular games.

He was a vibrant member of the school choir and an active member of the school soccer club. However, Meagan’s repeated the seventh grade level (twice) because he failed to meet the minimum threshold for admission into the eighth grade.

For a long time, he experienced a lot of difficulty trying to meet the minimum threshold for admission into sequential class grades because he always trailed among the last five candidates in any class. This was witnessed from his admission into the first grade.

However, Meagan’s academic background was characterized by exemplary performance in various academic writing competitions. His teachers termed him as a very creative writer and he never disappointed in his English creative writing assignments.

However, this was as far as his academic excellence stretched. Currently, Meagan undertakes blue collar jobs on minimum wage but there is increasing pressure among his peers for him to continue with his studies.

Personal Skills and Abilities

Meagan has a creative mind. He has shown interest in creative writing from his younger years but as he grew older, his interest changed. However, as explained in earlier sections of this study, in his young years, Meagan used to write exemplary creative works. His interest however shifted into music when he grew a little older.

So far, he has been able to record music in a local music company but his talents have never been fully exploited because of the lack of adequate finances to bankroll his musical ambitions. Moreover, there has been limited support from most of his family members in his quest to pursue music. However, due to his strong religious background, Meagan hopes to produce music for his local church.

The main aim of undertaking a curriculum adjustment for Meagan is to enable him to earnest his abilities and use them to the optimum benefit of his talents.

To enable Meagan to be independent and able to communicate his needs in effective and acceptable ways.

To assist Meagan to excel in personal growth and compete with other students in varying levels of excellence.

Curriculum Adjustments

Making the best curriculum adjustments for Meagan entirely depends on the nature of his disability. From previous sections of this paper, we have affirmed that Meagan suffers from a slow comprehension of academic disciplines, but he has a stronger grasp on creative works.

Here, there are several curriculum adjustments that can be done to ensure Meagan lives to his full potential. In this regard, this paper proposes several curriculum adjustments, based on the K12 teaching model which aims to provide individualized learning for students with intellectual disability. They are outlined below:

Interest and Student Ability

To ensure Meagan lives to his full potential, it is crucial to make curriculum adjustments to suit individual needs, abilities and preferences. A uniform curriculum which is meant to work for the majority student population is bound to fail for Meagan because it will not be specific to Meagan’s abilities and potential.

In this regard, it is therefore crucial for the curriculum to be designed to emphasize on creative works, as opposed to academic excellence, to enable Meagan to succeed in arts (Queensland Government 2011). Emphasis should be further made to ensure the school grading criteria focuses the same level of attention it gives to sciences (and other disciplines) as it does with art subjects.

Such a grading criterion would ensure students are assessed on all fronts, and not just academic. When adjusting the learning curriculum, it is also crucial for teachers to structure the curriculum in a manner that guarantees the grouping of students into different ability groups.

Not all students have the same type of abilities and therefore, it would be beneficial for teachers to group Meagan into the “creative works” group, so that he can share his creative ideas with his peers (Foreman 2009, p. 170).

Adjusting the Learning Outcomes

Adjusting the learning outcomes is an important adjustment to the learning curriculum if the school grading process is to be fair. Here, “fair” means to accommodate intellectually disabled students (Snowman 2011).

Accommodation of Diverse learning Styles

Intellectually disabled students are normally faced with the challenge of failing to comprehend learning instructions as fast as other students do. However, research studies affirm that some of these students prefer certain learning styles in place of others (Queensland Government 2011). Moreover, educationists have shown that certain learning styles are more effective for intellectually disabled students, while others are not.

Such dynamics withstanding, it is crucial to make curriculum adjustments that allow for the accommodation of diverse learning styles for improved efficacy in learning. For instance, conventional or online lessons can be administered using various learning materials such as DVDs, CDs, Books, videos and such materials (Browder 2011, p. 332).

The inclusion of such diverse strategies is set to improve the level of interaction between the students and the teachers because an appropriate learning style would motivate the students to pay more interest in the learning process. This improves the students’ level of engagement. Moreover, such curriculum changes ensure the learning process is rich in its contents.

Integrating a Learning Coach (Parent Involvement)

It is crucial to integrate the input of a learning coach into the school curriculum to encourage the participation of Meagan’s parents in his educational endeavors. The parents will be the learning support team.

Already, we have established that Meagan hails from a family that pays little attention to his educational needs. Here, there is a strong need to integrate the parents’ input into Meagan’s educational projects to ensure he enjoys a support structure, aside from the traditional teacher-student framework.

Though an integration of the role of the learning coach into the school curriculum may not necessarily be confined in the parent-student framework, it is crucial for this integration to be developed in this framework, if Meagan has to develop better learning skills (National Parent Teacher Association 2009, p. 1 ) .

This is because a great degree of the deterioration of his intellectual ability comes from a lack of effective support structure that enables him to improve his learning skills (Queensland Government 2011).

For long, this need has been ignored, and as a result, Meagan has continually performed poorly in his academic endeavors. Nonetheless, the learning coach framework can be designed in various ways. For instance, the school curriculum can be designed to include the participation of parents in the student’s projects, at least once or twice a semester.

Parents may be required to give consent, provide counsel or similar activities on the student’s tasks, thereby encouraging him to better develop with his learning activities. The inclusion of this principle into the school curriculum may be indirectly beneficial to Meagan because it is bound to have a motivating effect on him. This is the first strategy that can be adopted in encouraging parent participation.

The second strategy that can be adopted by the school is implementing a family-school partnership policy where parents and teachers agree on a common framework where parental involvement is assessed, and the parents’ progress is measured (Westwood 2011, p. 15).

This recommendation emanates from research studies which have shown that schools which have an efficient family-school partnership perform better than schools which lack this policy (Queensland Government 2011).

Finally, the school should make adjustments to the curriculum to ensure that parents take part in the decision making process of activities affecting student achievement. Here, parents should be allowed to be part of advisory committees which affect student achievement.

This paper proposes that, adjustments in the school curriculum which have to be made to accommodate Meagan’s skills and abilities have to be done within the confines of earnesting his skills and abilities (to use them for the benefit of his personal growth). In this regard, this paper proposes that the school curriculum should be tailored to accommodate Meagan’s artistic skills.

Moreover, the learning outcome should be adjusted to accommodate the same skills and abilities. From a holistic perspective, this paper also proposes that diverse learning styles should be accommodated into the learning curriculum to ensure students with intellectual disability learn in an efficient way.

These recommendations are carved from the K12program. Nonetheless, this paper also puts a lot of emphasis on the importance of incorporating parent input in the school curriculum. Integrating these principles will go a long way in enabling Meagan to earnest his strengths and use them to the optimum benefit of his talents.

Browder, D. (2011) Teaching Students with Moderate and Severe Disabilities . New York, Guilford Press.

Foreman, P. (2009) Education of Students with an Intellectual Disability: Research and Practice (PB). New York, IAP.

K12 Inc. (2011) How a K12 Education Works . Web.

National Parent Teacher Association. (2009 ) Enhancing Parent Involvement. Web.

Pearson Education Inc. (2011) Teaching Students with Special Needs . Web.

Queensland Government. (2011) Intellectual Impairment – Educational Adjustments. Web.

Snowman, J. (2011) Psychology Applied to Teaching . London, Cengage Learning.

Westwood, P. (2011) Commonsense Methods for Children with Special Educational Needs . London, Taylor & Francis.

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IvyPanda. (2023, October 29). Case Study of a Child with Intellectual Disability. https://ivypanda.com/essays/case-study-of-a-student-with-intellectual-disabilities-essay/

"Case Study of a Child with Intellectual Disability." IvyPanda , 29 Oct. 2023, ivypanda.com/essays/case-study-of-a-student-with-intellectual-disabilities-essay/.

IvyPanda . (2023) 'Case Study of a Child with Intellectual Disability'. 29 October.

IvyPanda . 2023. "Case Study of a Child with Intellectual Disability." October 29, 2023. https://ivypanda.com/essays/case-study-of-a-student-with-intellectual-disabilities-essay/.

1. IvyPanda . "Case Study of a Child with Intellectual Disability." October 29, 2023. https://ivypanda.com/essays/case-study-of-a-student-with-intellectual-disabilities-essay/.

Bibliography

IvyPanda . "Case Study of a Child with Intellectual Disability." October 29, 2023. https://ivypanda.com/essays/case-study-of-a-student-with-intellectual-disabilities-essay/.

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Explore the experiences of children and families with these interdisciplinary case studies. Designed to help professionals and students explore the strengths and needs of children and their families, each case presents a detailed situation, related research, problem-solving questions and feedback for the user. Use these cases on your own or in classes and training events

Each case study:

• Explores the experiences of a child and family over time.
• Introduces theories, research and practice ideas about children's mental health.
• Shows the needs of a child at specific stages of development.
• Invites users to “try on the hat” of different specific professionals.

By completing a case study participants will:

• Examine the needs of children from an interdisciplinary perspective.
• Recognize the importance of prevention/early intervention in children’s mental health.
• Apply ecological and developmental perspectives to children’s mental health.
• Predict probable outcomes for children based on services they receive.

Case studies prompt users to practice making decisions that are:

• Research-based.
• Practice-based.
• Best to meet a child and family's needs in that moment.

Children’s mental health service delivery systems often face significant challenges.

• Services can be disconnected and hard to access.
• Stigma can prevent people from seeking help.
• Parents, teachers and other direct providers can become overwhelmed with piecing together a system of care that meets the needs of an individual child.
• Professionals can be unaware of the theories and perspectives under which others serving the same family work
• Professionals may face challenges doing interdisciplinary work.
• Limited funding promotes competition between organizations trying to serve families.

These case studies help explore life-like mental health situations and decision-making. Case studies introduce characters with history, relationships and real-life problems. They offer users the opportunity to:

• Examine all these details, as well as pertinent research.
• Make informed decisions about intervention based on the available information.

The case study also allows users to see how preventive decisions can change outcomes later on. At every step, the case content and learning format encourages users to review the research to inform their decisions.

Each case study emphasizes the need to consider a growing child within ecological, developmental, and interdisciplinary frameworks.

• Ecological approaches consider all the levels of influence on a child.
• Developmental approaches recognize that children are constantly growing and developing. They may learn some things before other things.
• Interdisciplinary perspectives recognize that the needs of children will not be met within the perspectives and theories of a single discipline.

There are currently two different case students available. Each case study reflects a set of themes that the child and family experience.

The About Steven case study addresses:

• Adolescent depression.
• School mental health.
• Rural mental health services.
• Social/emotional development.

The Brianna and Tanya case study reflects themes of:

• Infant and early childhood mental health.
• Educational disparities.
• Trauma and toxic stress.
• Financial insecurity.
• Intergenerational issues.

The case studies are designed with many audiences in mind:

Practitioners from a variety of fields. This includes social work, education, nursing, public health, mental health, and others.

Professionals in training, including those attending graduate or undergraduate classes.

The broader community.

Each case is based on the research, theories, practices and perspectives of people in all these areas. The case studies emphasize the importance of considering an interdisciplinary framework. Children’s needs cannot be met within the perspective of a single discipline.

The complex problems children face need solutions that integrate many and diverse ways of knowing. The case studies also help everyone better understand the mental health needs of children. We all have a role to play.

These case has been piloted within:

Graduate and undergraduate courses.

Discipline-specific and interdisciplinary settings.

Professional organizations.

Currently, the case studies are being offered to instructors and their staff and students in graduate and undergraduate level courses. They are designed to supplement existing course curricula.

Instructors have used the case study effectively by:

• Assigning the entire case at one time as homework. This is followed by in-class discussion or a reflective writing assignment relevant to a course.
• Assigning sections of the case throughout the course. Instructors then require students to prepare for in-class discussion pertinent to that section.
• Creating writing, research or presentation assignments based on specific sections of course content.
• Focusing on a specific theme present in the case that is pertinent to the course. Instructors use this as a launching point for deeper study.
• Constructing other in-class creative experiences with the case.
• Collaborating with other instructors to hold interdisciplinary discussions about the case.

To get started with a particular case, visit the related web page and follow the instructions to register. Once you register as an instructor, you will receive information for your co-instructors, teaching assistants and students. Get more information on the following web pages.

• Brianna and Tanya: A case study about infant and early childhood mental health
• About Steven: A children’s mental health case study about depression

Cari Michaels, Extension educator

Reviewed in 2023

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Home > Books > Learning Disabilities - Neurological Bases, Clinical Features and Strategies of Intervention

The Child with Learning Difficulties and His Writing: A Study of Case

Submitted: 30 May 2019 Reviewed: 16 August 2019 Published: 20 November 2019

DOI: 10.5772/intechopen.89194

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The purpose of this paper is to present one child with learning difficulties writing process in multigrade rural elementary school in México. It presents Alejandro’s case. This boy lives in a rural area. He shows special educational needs about learning. He never had specialized attention because he lives in a marginalized rural area. He was integrated into regular school, but he faced some learning difficulties. He was always considered as a student who did not learn. He has coursed 2 years of preschool and 1 year of elementary school. Therefore, this text describes how child writes a list of words with and without image as support. Analysis consists to identify the child’s conceptualizations about writing, his ways of approaching, and difficulties or mistakes he makes. The results show that Alejandro identifies letters and number by using pseudo-letters and conventional letter. These letters are in an unconventional position. There is no relationship grapheme and phoneme yet, and he uses different writing rules. We consider his mistakes as indicators of the learning process.

• writing difficulties
• learning difficulties
• writing learning
• writing process
• special education

Author Information

Edgardo domitilo gerardo morales *.

• Faculty of Philosophy and Letters, National Autonomous University of Mexico, México City, México

*Address all correspondence to: [email protected]

1. Introduction

One of the purposes of Mexican education system is that students acquire conventional writing during first grades in elementary school [ 1 ]. This purpose consists of students to understand the alphabetical code, its meaning, and functionality. In this way, they can integrate into a discursive community.

The elementary school teacher teaches a heterogeneous group of children [ 1 ,  2 ]. Some students show different acquisition levels of the writing. This is due to literacy environment that the family and society provide. Thus, some children have had great opportunities to interact with reading and writing practices than others. Therefore, some students do not learn the alphabetical principle of writing at the end of the scholar year. They show characteristics of initial or intermediate acquisition level of the writing. In this way, it is difficult for children to acquire writing at the same time, at the term indicated by educational system or teachers.

In addition, there may be children with learning difficulties in the classroom. Department of Special Education teaches some children. Students with special educational needs show more difficulties to learn than their classmates [ 3 ]. They require more resources to achieve the educational objectives. These authors point out that special educational needs are relative. These needs arise between students’ personal characteristics and their environment. Therefore, any child may have special educational needs, even if he/she does not have any physical disability. However, some students with learning difficulties do not have a complete assessment about their special educational needs. On the one hand, their school is far from urban areas; on the other hand, there are not enough teachers of special education for every school. In consequence, school teachers do not know their students’ educational needs and teach in the same way. Thereby, students with learning difficulties do not have the necessary support in the classroom.

Learning difficulties of writing may be identified easily. Children with special educational needs do not learn the alphabetical principle of writing easily; that is, they do not relate phoneme with grapheme. Therefore, children show their conceptualizations about writing in different ways. Sometimes, teachers censor their students’ written productions because they do not write in a conventional way. Children with special educational needs are stigmatized in the classroom. They are considered as less favored. At the end of the scholar year, children do not pass.

Therefore, the purpose of this paper is to present one child with special educational needs writing process in a Mexican multigrade rural school. This text describes how the child writes a list of words with and without image as support. Analysis consists to identify the child’s conceptualizations about writing [ 4 ], his ways of approaching, and difficulties or mistakes he makes. These mistakes are the indicators of learning process [ 5 ].

This paper presents Alejandro’s case. This boy lives in a rural area. He shows special educational needs about learning. He never had specialized attention because he lives in a marginalized rural area. He was integrated into regular school, but he faced some learning difficulties. He was always considered as a student who does not learn. Therefore, this text describes Alejandro’s writing, what he does after 2 years of preschool and 1 year of elementary school.

2. Children with learning difficulties and their diagnosis

According to the National Institute for the Evaluation of Education [ 6 ], Mexican education system provides basic education (preschool, elementary, and secondary school) for students with special educational needs. There are two types of special attention: Center of Multiple Attention (CAM, in Spanish) and Units of Service and Support to Regular Education (USAER, in Spanish). In the first one, children with special educational needs go to this Center. These children receive attention according to basic education and their educational needs. In the second, specialized teachers on special education go to school and provide support to students. These teachers provide information to school teachers too. In this way, there is educational equity and inclusion in Mexican school [ 7 ].

Physical appearance : Teacher describes the child’s physical characteristics. These features indicate the type of food the student eats, care his or her person, the parents’ attention, among other elements.

Behavior observed during the assessment : In this section, the teacher should record the conditions in which the assessment was carried out: child’s attitude, behavior, and interest.

Child’s development history : This section presents conditions in which pregnancy developed, physical development (ages in which child held his/her head, sat, crawled, walked, etc.), language development (verbal response to sounds and voices, age in which said his/her first words and phrases, etc.), family (characteristics of their family and social environment, frequent activities, etc.), hetero-family history (vision, hearing, etc.), medical history (health conditions, diseases, etc.), and scholar history (age at which he/she started school, type of school, difficulties, etc.).

Present condition : In this, there are four aspects:

It refers to student’s general aspects: intellectual area (information processing, attention, memory, understanding, etc.), motor development area (functional skills to move, take objects, position of his/her body, etc.), communicative-linguistic area (phonological, semantic, syntactic and pragmatic levels), adaptation and social interaction area (the child’s skills to initiate or maintain relationships with others), and emotional area (the way of perceiving the world and people). In each one, it mentions the instruments he suggests, although there is not enough information about them [ 3 ].

The second aspect is the curricular competence level. Teacher identifies what the student is capable of doing in relation to established purposes and contents by official curriculum.

The third aspect is about the learning style and motivation to learn. It presents physical-environmental conditions where the child works, their interests, level attention, strategies to solve a task, and the incentives he receives.

The fourth aspect is information about the student’s environment: factors of the school, family, and social context that influence the child’s learning.

Psycho-pedagogical assessment allows to identify children’s general educational needs. In this way, the school teacher could have information about the students’ difficulties. However, it is a general assessment. It contains several aspects and does not go deeper into one.

Therefore, this paper does not propose a new assessment. It consists of presenting one child’s writing difficulties, his ways of conceptualizing writing, and some mistakes he gets to make.

3. Students with learning difficulties and their scholar integration

Since 1993, Mexican system education has tried to offer special education services to students with special educational needs in basic education [ 8 ]. The first step was to promote the integration of these children in regular education classrooms. However, only insertion of the student in the school was achieved. Therefore, the system of education searched for mechanisms to provide advice to teacher. In this way, student with learning difficulties can be attended at the same time in the classroom [ 8 ].

Educational integration has been directly associated with attention of students with learning difficulties, with or without physical disabilities [ 8 ]. However, this process implies a change in the school. For this, it is necessary to provide information and to create awareness to the educational community, permanent updating of teachers, joint work between teacher, family, and specialized teachers.

At present, Mexican education system looks at educational integration as process in which every student with learning difficulties is supported individually [ 9 ]. Adapting the curriculum to the child is the purpose of educational integration.

Curricular adequacy is one of the actions to support students with learning difficulties [ 10 , 11 ]. This is an individualized curriculum proposal. Its purpose is to attend the students’ special educational needs [ 3 ]. At present, Mexican education system indicates that there should be a curricular flexibility to promote learning processes. However, it is important to consider what the child knows about particular knowledge.

Regarding the subject of the acquisition of written language, it is necessary to know how the children build their knowledge about written. It is not possible to make a curricular adequacy if teachers do not have enough information about their students. However, children are considered as knowledge builders. Therefore, there are learning difficulties at the process.

4. Alejandro’s case

This section presents Alejandro’s personal information. We met him when we visited to his school for other research purposes. We focused on him because the boy was silent in class. He was always in a corner of the work table and did not do the activities. For this, we talked with his teacher and his mother to know more about him.

Alejandro is a student of an elementary multigrade rural school. He was 7 years old at the time of the study. He was in the second grade of the elementary school. His school is located in the region of the “Great Mountains” of the state of Veracruz, Mexico. It is a rural area, marginalized. To get to this town from the municipal head, it is necessary to take a rural taxi for half an hour. Then, you have to walk on a dirt road for approximately 50 min.

Alejandro’s family is integrated by six people. He is the third of the four sons. He lives with his parents. His house is made of wood. His father works in the field: farming of corn, beans, and raising of sheep. His mother is a housewife and also works in the field. They have a low economic income. Therefore, they receive a scholarship. One of his older brothers also showed learning difficulties at school. His mother says both children have a learning problem. But, they do not have any money for attending their sons’ learning difficulties. In addition, there are no special institutes near their house.

The boy has always shown learning difficulties. He went to preschool for 2 years. However, he did not develop the necessary skills at this level. At classes, this child was silent, without speaking. Preschool teachers believed that he was mute. Nevertheless, at scholar recess, he talked with his classmates. Alejandro was slow to communicate with words in the classroom.

When he started elementary school, Alejandro continued to show learning difficulties. At classes, he was silent too. He just watched what his classmates did. He did not do anything in the class. He took his notebook out of his backpack and just made some lines. Occasionally, he talked with his classmates. When the teacher asked him something, Alejandro did not answer. He looked down and did not answer. He just ducked his head and stayed for several minutes.

When Alejandro was in second grade, he did different activities than his classmates. His teacher drew some drawings for him and he painted these drawings. Other occasions, the teacher wrote some letters for him to paint. The child did every exercise during several hours. He did not finish his exercises quickly. Sometimes he painted some drawings during 2 h.

Although Alejandro requires specialized attention, he has not received it. He has not had a full psycho-pedagogical assessment at school by specialized teachers. His school does not have these teachers. Also, the child was not submitted to neurological structural examination or neurophysiological studies to exclude an organic origin of his learning difficulties. His parents do not have enough financial resources to do this type of study for him. In addition, one specialized institution that can do this type of study for free is in Mexico City. It is so far from child’s house. It would be expensive for the child’s parents. Therefore, he is only attended as a regular school student.

For this reason, this paper is interested in the boy’s writing process. This is because Alejandro coursed 2 years of preschool and 1 year of elementary school; however, he does not show a conventional writing yet. In this way, it is interesting to analyze his conceptualizations about writing and difficulties he experiences.

5. Methodology

The purpose of this paper is to know the child’s ways to approach writing spontaneously and his knowledge about the writing system. For this, the author used a clinical interview. He took into account the research interview guide “Analysis of Disturbances in the Learning Process of Reading and Writing” [ 12 ].

The clinical interview was conducted individually. We explored four points, but we only present two in this text: to write words and to write for image.

Interviewer took the child to the library room at school. There were no other students. First, the interviewer gave the child a sheet and asked to write his name. Alejandro wrote his name during long time. Interviewer only asked what it says there. He answered his name: “Alejandro.” Next, the interviewer asked the child to write some letters and numbers he knew. Alejandro wrote them. The interviewer asked about every letter and number. The child answered “letter” or “number,” and its name.

To write words : The interviewer asked the child to write a group of words from the same semantic field in Spanish (because Alejandro is from Mexico) and one sentence. Order of words was from highest to lowest number of syllables. In this case, interviewer used semantic field of animals. Therefore, he used following words: GATO (cat), MARIPOSA (butterfly), CABALLO (horse), PERRO (dog), and PEZ (fish). The sentence was: EL GATO BEBE LECHE (The cat drinks milk). The interviewer questioned every written word. He asked the child to show with his finger how he says in every written production.

To write for image : This task was divided into two parts. The first analyzed the size and second analyzed the number.

Interviewer used the following image cards: horse-bird and giraffe-worm ( Figure 1 ). Every pair of cards represents a large animal and a small animal.

Cards with large and small animals.

The purpose of this first task was to explore how the child writes when he looks at two images of animals with different size. The animal names have three syllables in Spanish: CA-BA-LLO (horse), PA-JA-RO (bird), etc. In this way, we can see how the child writes.

The interviewer used the following pair of cards for second task ( Figure 2 ).

Cards for singular and plural.

First card shows one animal (singular) and the second shows some animals (plural). In this way, we search to explore how the child produces his writings when he observes one or more objects, if there are similarities or differences to write.

The interviewer asked what was in every card. Next, he asked the child to write something. Alejandro wrote something in every picture. Afterward, the interviewer asked the child to read every word that he wrote. Child pointed with his finger what he wrote.

After, the interview was transcribed for analysis. We read the transcription. The author analyzed every written production. He identified the child’s conceptualizations about writing. He compared the written production and what the child said. In this way, the analysis did not only consist to identify the level of writing development. This text describes the child’s writing, the ways in which he conceptualizes the writing, the difficulties he experienced to write, and his interpretations about writing.

6. Alejandro’s writing

This section describes Alejandro’s writing process. As we already mentioned, Alejandro is 7 years old and he studies in the second grade of the elementary school. His teacher says the child should have a conventional writing, because he has already coursed 1 year of elementary school, but it is not like that. Most of his classmates write a conventional way, but he does not.

We organized this section in three parts. The first part presents how Alejandro wrote his name and how he identifies letters and numbers; the second part refers to the writing of words; and the third part is writing for picture.

6.1 Alejandro writes his name and some letters and numbers

The first part of the task consisted of Alejandro writing his name and some letters and numbers he knows. His name was requested for two reasons. The first reason is to identify the sheet, because the interviewer interviewed other children in the same school. Also, it was necessary to identify every written productions of the group of students. The second reason was to observe the way he wrote his name and how he identified letters and numbers.

The interviewer asked the child to write his name at the top of the sheet. When the interviewer said the instructions, Alejandro was thoughtful during a long time. He was not pressed or interrupted. He did not do anything for several seconds. The child looked at the sheet and looked at everywhere. After time, he took the pencil and wrote the following on the sheet ( Figure 3 ).

Alejandro’s name.

The interviewer looked at Alejandro’s writing. He asked if something was lacking. The interviewer was sure that Alejandro knew his name and his writing was not complete. However, Alejandro was thoughtful, and looked at the sheet for a long time. The interviewer asked if his name was already complete. The child answered “no.” The interviewer asked the child if he remembered his name. Alejandro denied with his head. So, they continued with another task.

Alejandro has built the notion of his name. We believe that he has had some opportunities to write his name. Perhaps, his teacher has asked him to write his name on his notebooks, as part of scholar work in the classroom. We observed that Alejandro used letters with conventional sound value. This is because he wrote three initial letters of his name: ALJ (Alejandro). The first two letters correspond to the beginning of his name. Then, he omits “E” (ALE-), and writes “J” (ALJ). However, Alejandro mentions that he does not remember the others. This may show that he has memorized his name, but at that moment he failed to remember the others, or, these letters are what he remembers.

Subsequently, the interviewer asked Alejandro to write some letters and numbers he knew. The sequence was: a letter, a number, a letter, another letter, and number. In every Alejandro’ writing, the interviewer asked the child what he wrote. In this way, Alejandro wrote the following ( Figure 4 ).

Letters and numbers written by Alejandro.

For this task, Alejandro wrote for a long time. He did not hurry to write. He looked at sheet and wrote. The child looked at the interviewer, looked at the sheet again and after a few seconds he wrote. The interviewer asked about every letter or number.

We can observe that Alejandro differentiates between letter and number. He wrote correctly in every indication. That is, when the interviewer asked him to write a letter or number, he did so, respectively. In this way, Alejandro knows what he needs to write a word and what is not, what is for reading and what is not.

Also, we can observe that the child shows a limited repertoire of letters. He did not write consonants. He used only vowels: A (capital and lower) and E (lower). It shows us that he differentiates between capital and lower letter. Also, he identifies what vowels and letters are because the child answered which they were when the interviewer asked about them.

6.2 Writing words from the same semantic field

Asking the child to write words spontaneously is a way to know what he knows or has built about the writing system [ 12 ]. Although we know Alejandro presents learning difficulties and has not consolidated a conventional writing, it is necessary to ask him to write some words. This is for observing and analyzing what he is capable of writing, what knowledge he has built, as well as the difficulties he experiences.

The next picture presents what Alejandro wrote ( Figure 5 ). We wrote the conventional form in Spanish next to every word. We wrote these words in English in the parentheses too.

List of words written by Alejandro.

At the beginning of the interview, Alejandro did not want to do the task. He was silent for several seconds. He did not write anything. He looked at the sheet and the window. The interviewer insisted several times and suspended the recording to encourage the child to write. Alejandro mentioned he could not write, because he did not know the letters and so he would not do it. However, the interviewer insisted him. After several minutes, Alejandro took the pencil and started to write.

Alejandro wrote every word for 1 or 2 min. He required more seconds or minutes sometimes. He looked at the sheet and his around. He was in silence and looking at the sheet other times. We identified that he needs time to write. This shows that he feels insecure and does not know something for writing. He feels insecure because he was afraid of being wrong and that he was punished by the interviewer for it. It may be that in class he is penalized when he makes a mistake. There is ignorance because he does not know some letters, and he has a low repertoire of the writing system. Thus, Alejandro needs to think about writing and look for representing it. Therefore, this is why the child needs more time to write.

We identified that the child does not establish a phoneme-grapheme relationship. He only shows with his finger from left to right when he read every word. He does not establish a relationship with the letters he used. In each word, there is no correspondence with the number of letters. The child also does not establish a constant because there is variation in number and variety of letters sometimes.

Alejandro used letters unrelated to the conventional writing of the words. For example, when he wrote GATO (cat), Alejandro used the following letters: inpnAS. It is possible to identify that no letter corresponds to the word. Perhaps, Alejandro wrote those letters because they are recognized or remembered by him.

Alejandro shows a limited repertoire of conventional letters. This is observed when he uses four vowels: A, E, I, O. The child used these vowels less frequently. There is one vowel in every word at least. When Alejandro wrote PEZ (fish), he used two vowels. We observed that he writes these vowels at the beginning or end of the word. However, we do not know why he places them that way. Maybe this is a differentiating principle by him.

There is qualitative and quantitative differentiation in Alejandro’s writing. That is, he did not write any words in the same way. All the words written by him are different. Every word has different number and variety of letters. When two words contain the same number of letter, they contain different letters.

When Alejandro wrote MARIPOSA (butterfly), he used five letters. The number of letters is less than what he used for GATO (cat). Maybe he wrote that because the interviewer said “butterfly is a small animal.” This is because the cat is bigger than the butterfly. Therefore, it may be possible that he used lesser letters for butterfly.

In Spanish, PERRO (dog) contains five letters. Alejandro wrote five letters. In this case, Alejandro’s writing corresponds to the necessary number of letters. However, it seems that there is no writing rules for him. This is for two reasons: first, because there is no correspondence with the animal size. Horse is larger than dog and Alejandro required lesser letters for horse than for dog. Second, CABALLO (horse) is composed by three syllables and PERRO (dog) by two. Alejandro used more letters to represent two syllables. In addition, it is observed that there is a pseudo-letter. It looks like an inverted F, as well as D and B, horizontally.

When Alejandro wrote PEZ (fish), the interviewer first asked how many letters he needed to write that word. The child did not answer. Interviewer asked for this again and student said that he did not know. Then, interviewer said to write PEZ (fish). For several minutes, Alejandro just looked the sheet and did not say anything. The interviewer questioned several times, but he did not answer. After several minutes, Alejandro wrote: E. The interviewer asked the child if he has finished. He denied with his head. After 1 min, he started to write. We observed that his writing contains six letters. Capital letters are predominated.

Alejandro used inverted letters in three words. They may be considered as pseudo-letters. However, if we observe carefully they are similar to conventional letters. The child has written them in different positions: inverted.

May be there is a writing rule by Alejandro. His words have a minimum of four letters and a maximum of six letters. This rule has been established by him. There is no relation to the length of orality or the object it represents.

We can identify that Alejandro shows a primitive writing [ 4 ]. He is still in writing system learning process. The phoneticization process is not present yet. The child has not achieved this level yet. He only uses letters without a conventional sound value. There is no correspondence to phoneme-grapheme, and he uses pseudo-letters sometimes.

6.3 To write for image

Write for image allows us to know what happens when the child writes something in front of an image [ 12 ]. It is identified if there is the same rules used by the child, number of letters, or if there is any change when he writes a new word. It may happen that the length of the words is related to the size of the image or the number of objects presented. In this way, we can identify the child’s knowledge and difficulties when he writes some words.

6.3.1 The image size variable

The first task is about observing how the child writes when he is in front of two different sized images. That is, we want to identify if the image size influences on his writings. Therefore, two pairs of cards were presented to Alejandro. Every pair of cards contained two animals, one small and one large. The interviewer asked Alejandro to write the name on each one ( Figure 6 ).

Horse and bird writing.

Based on the writing produced by Alejandro, we mentioned the following:

Alejandro delimits his space to write. When he wrote for first pair of words, the child drew a wide rectangle and he made an oval and several squares for the second pair of words. The child wrote some letters to fill those drawn spaces. It seems that Alejandro’s rule is to fill the space and not only represent the word.

When Alejandro writes the words, we identified that he presents difficulty in the conventional directionality of writing. He wrote most of words from left to right (conventional directionality), but he wrote some words from right to left (no conventional). For example, the child started to write the second word on the left. He wrote seven letters. He looked at the sheet for some seconds. After, he continued to write other letters on the right. He wrote and completed the space he had left, from right to left.

Alejandro shows two ways to write: left–right (conventional) and right–left (no conventional). When he wrote the last word, the child wrote one letter under another. There was no limited space on the sheet. Alejandro wrote it there. The child has not learned the writing directionality.

When we compared Alejandro’s writings, we identified that the number of letters used by him does not correspond to the image size. Although the images were present and he looked them when he wrote, the child took into account other rules to write. The six names of animals had three syllables in Spanish and Alejandro used nine letters for CABALLO (horse) and eleven for PÁJARO (bird). The letters used by him are similar to the conventional ones. However, these are in different positions. There are no phonetic correspondences with the words. The child shows a primitive writing. Alejandro has not started the level of relation between phoneme and grapheme yet. We can believe that the boy wrote some letters to cover the space on the sheet. Alejandro takes into account the card size instead of the image size.

After writing a list of words, the interviewer asked Alejandro to read and point out every word he wrote. The purpose of this task is to observe how the child relates his writing to the sound length of the word. When Alejandro read CABALLO (horse), he pointed out as follows ( Figure 7 ).

Alejandro reads “caballo” (horse).

Alejandro reads every word and points out what he reads. In this way, he justifies what he has written. In the previous example, Alejandro reads the first syllable and points out the first letter, second syllable with the second letter. At this moment, he gets in conflict when he tries to read the third syllable. It would correspond to the third letter. However, “there are more letters than he needs.” When he reads the word, he shows the beginning of phoneticization: relation between one syllable with one letter. This is the syllabic writing principle [ 4 ]. Nevertheless, he has written more letters. Therefore, Alejandro says “o” in the other letters. In this way, we can point out that Alejandro justifies every letters and there is a correspondence between what he reads and what he writes.

When Alejandro reads the second word, the child pointed out as follows ( Figure 8 ).

Alejandro reads “pájaro” (bird).

Alejandro makes a different correspondence syllable-letter than the first word. Although his writing was in two ways, his reading is only one direction: from left to right. The first syllable is related to first three letters he wrote. The second syllable is related to the fourth letter. But, he faces the same problem as in the previous word: “there are many letters.” So he justifies the other letters as follows. He reads the third syllable in relation to the sixth and seventh letter. And, reads “o” for the other letters.

When interviewer showed the next pair of cards, Alejandro wrote as following ( Figure 9 ).

Giraffe and worm writing by Alejandro.

When the interviewer shows the pair of cards to Alejandro, the child said “It’s a zebra.” So, the interviewer said “It’s a giraffe and it’s a worm” and pointed out every card. The interviewer asked Alejandro to write the name of every animal. First, the child draws a rectangle across the width of the sheet. Next, he started to write on the left side inside the rectangle. He said the first syllable “JI” while writing the first letter. After, he said “ra,” he wrote a hyphen. Then, he said “e” and wrote another letter. At that moment, he looked at the sheet and filled the space he left with some letters ( Figure 10 ).

Giraffe writing.

Alejandro shows different rules of writing. These rules are not the same as previous. He delimited the space to write and filled the space with some letters. The child tries to relate the syllable with one letter, but he writes others. There is a limited repertoire of letters too. In this case, it seems that he used the same letters: C capital and lower letter, A capital and lower letter, and O. We believe that he uses hyphens to separate every letter. However, when he wrote the first hyphen, it reads the second syllable. We do not know why he reads there. Alejandro had tried to use conventional letters. He uses signs without sound value. In addition, there is no relation phoneme and grapheme.

When Alejandro wrote GUSANO (worm), he drew a rectangle and divided it into three small squares. Then, he drew other squares below the previous ones. After, he began to write some letters inside the squares, as seen in the following picture ( Figure 11 ).

Worm writing.

Alejandro used other rules to write. They are different than the previous. Alejandro has written one or two letters into every box. At the end, he writes some letters under the last box. There is no correspondence between what he reads and writes. There are also no fixed rules of writing for him. Rather, it is intuited that he draws the boxes to delimit his space to write.

6.3.2 Singular and plural writing

The next task consists to write singular and plural. For this, the interviewer showed Alejandro the following images ( Figure 12 ).

Cards with one cat and four cats.

Alejandro drew an oval for first card. This oval is on the left half of the sheet. He wrote the following ( Figure 13 ).

Alejandro writes GATO (cat).

Next, the interviewer asked Alejandro to write for the second card, in plural. For this, Alejandro draws another oval from the middle of the sheet, on the right side. The child did not do anything for 1 h 30 min. After this time, he wrote some different letters inside the oval ( Figure 14 ). He wrote from right to left (unconventional direction).

Alejandro writes GATOS (cats).

Alejandro wrote in the opposite conventional direction: from right to left. He tried to cover the delimited space by him. His letters are similar to the conventional ones. Also, there are differences between the first and the second word. He used lesser letters for first word than the second. That is, there are lesser letters for singular and more letters for plural. Perhaps, the child took into account the number of objects in the card.

The writing directionality may have been influenced by the image of the animals: cats look at the left side. Alejandro could have thought he was going to write from right to left, as well as images of the cards. Therefore, it is necessary to research how he writes when objects look at the right side. In this way, we can know if this influences the directionality of Alejandro’s writing.

With the next pair of images ( Figure 15 ), the interviewer asked Alejandro to write CONEJO (rabbit) and CONEJOS (rabbits).

Cards with one rabbit and three rabbits.

Alejandro draws a rectangle in the middle of the sheet for the first card (rabbit). He said “cone” (rab-) and wrote the first letter on the left of the sheet. Then, he said “jo” (bit) and wrote the second letter. He said “jo” again and wrote the third letter. He was thoughtful for some seconds. He started to write other letters. His writing is as follows ( Figure 16 ).

Alejandro writes CONEJO (rabbit).

At the beginning, Alejandro tries to relate the syllables of the word with first two letters. However, he justifies the other letters when he read the word. There is no exact correspondence between the syllable and the letter. As well as his writing is to fill the space he delimited.

Alejandro takes into account other rules for plural writing. He drew a rectangle across the width of the sheet. Starting on the left, he said “CO” and wrote one letter. Then, he said “NE” and drew a vertical line. After, he said “JO” and wrote other letters. His writing is as follows ( Figure 17 ).

Alejandro writes CONEJOS (rabbits).

Alejandro writes both words differently. He reads CONEJO (rabbit) for first word and CONEJOS (rabbits) for the second. Both words are different from each other. But, he wrote them with different rules. This is confusing for us because there are vertical lines between every two letters in the second word. We believe that the child tried to represent every object, although he did not explain it.

In summary, Alejandro shows different writings. He used pseudo-letters and conventional letter. These letters are in unconventional positions. There is no relationship between grapheme and phoneme yet; and, he uses different writing rules.

7. Conclusions

We described Alejandro’s writing process. According to this description, we can note the following:

Alejandro is a student of an elementary regular school. He presents learning difficulties. He could not write “correctly.” However, he did not have a full assessment by specialized teachers. His school is so far from urban areas and his parents could not take him to a special institution. Therefore, he has not received special support. Also, there is not a favorable literacy environment in his home. His teacher teaches him like his classmates. Usually, he has been marginalized and stigmatized because “he does not know or work in class.”

We focused on Alejandro because he was a child who was always distracted in class. We did not want to show his writing mistakes as negative aspects, but as part of his learning process. Errors are indicators of a process [ 5 ]. They inform the person’s skills. They allow to identify the knowledge that is being used [ 13 ]. In this way, errors can be considered as elements with a didactic value.

Alejandro showed some knowledge and also some difficulties to write. The child identifies and distinguishes letters and numbers. We do not know if he conceptualizes their use in every one. When he wrote, he shows his knowledge: letters are for reading, because he did not use any number in the words.

The writing directionality is a difficulty for Alejandro. He writes from left to right and also from right to left. We do not know why he did that. We did not research his reasons. But, it is important to know if there are any factors that influence the child to write like this.

The student does not establish a phoneme-grapheme relationship yet. He is still in an initial level to writing acquisition. He uses conventional letters and pseudo-letters to write. There are no fixed rules to write: number and variety of letters. However, we observed student’s thought about writing. He justifies his writings when he reads them and invents letters to represent some words.

There is still a limited repertoire of letters. He used a few letters of the alphabet. Therefore, Alejandro needs to interact with different texts, rather than teaching him letter by letter. Even if “he does not know those letters.” In this way, he is going to appropriate other elements and resources of the writing system.

Time he takes to write is an important element for us. He refused to write for several minutes at the beginning. After, he wrote during 1 or 2 min every word. As we mentioned previously, we believe that Alejandro did not feel sure to do the task. Perhaps, he thought that the interviewer is going to penalize for his writing “incorrectly.” He felt unable to write. Therefore, it is important that children’s mistakes are not censored in the classroom. Mistakes let us to know the child’s knowledge and their learning needs.

We considered that class work was not favorable for Alejandro. He painted letters, drawings, among others. These were to keep him busy. Therefore, it is important for the child to participate in reading and writing practices. In this way, he can be integrated into the scholar activities and is not segregated by his classmates.

About children with learning difficulties, it is important that these children write as they believe. Do not censor their writings. They are not considered as people incapable. It is necessary to consider that learning is a slow process. Those children will require more time than their classmates.

Special education plays an important role in Mexico. However, rather than attending to the student with learning difficulties in isolation, it is necessary that the teacher should be provided with information and the presence of specialized teachers in the classroom. In this way, the student with learning difficulties can be integrated into class, scholar activities, and reading and writing practices.

We presented Alejandro’s writing process in this paper. Although he was considered as a child with learning difficulties, we identified he shows some difficulties, but he knows some elements of the writing system too.

Acknowledgments

I thank Alejandro, his parents, and his teacher for the information they provided to me about him.

Conflict of interest

The authors declare no conflict of interest.

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A case of a four-year-old child adopted at eight months with unusual mood patterns and significant polypharmacy

• Magdalena Romanowicz   ORCID: orcid.org/0000-0002-4916-0625 1 ,
• Alastair J. McKean 1 &
• Jennifer Vande Voort 1  

BMC Psychiatry volume  17 , Article number:  330 ( 2017 ) Cite this article

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Long-term effects of neglect in early life are still widely unknown. Diversity of outcomes can be explained by differences in genetic risk, epigenetics, prenatal factors, exposure to stress and/or substances, and parent-child interactions. Very common sub-threshold presentations of children with history of early trauma are challenging not only to diagnose but also in treatment.

Case presentation

A Caucasian 4-year-old, adopted at 8 months, male patient with early history of neglect presented to pediatrician with symptoms of behavioral dyscontrol, emotional dysregulation, anxiety, hyperactivity and inattention, obsessions with food, and attachment issues. He was subsequently seen by two different child psychiatrists. Pharmacotherapy treatment attempted included guanfacine, fluoxetine and amphetamine salts as well as quetiapine, aripiprazole and thioridazine without much improvement. Risperidone initiated by primary care seemed to help with his symptoms of dyscontrol initially but later the dose had to be escalated to 6 mg total for the same result. After an episode of significant aggression, the patient was admitted to inpatient child psychiatric unit for stabilization and taper of the medicine.

Conclusions

The case illustrates difficulties in management of children with early history of neglect. A particular danger in this patient population is polypharmacy, which is often used to manage transdiagnostic symptoms that significantly impacts functioning with long term consequences.

Peer Review reports

There is a paucity of studies that address long-term effects of deprivation, trauma and neglect in early life, with what little data is available coming from institutionalized children [ 1 ]. Rutter [ 2 ], who studied formerly-institutionalized Romanian children adopted into UK families, found that this group exhibited prominent attachment disturbances, attention-deficit/hyperactivity disorder (ADHD), quasi-autistic features and cognitive delays. Interestingly, no other increases in psychopathology were noted [ 2 ].

Even more challenging to properly diagnose and treat are so called sub-threshold presentations of children with histories of early trauma [ 3 ]. Pincus, McQueen, & Elinson [ 4 ] described a group of children who presented with a combination of co-morbid symptoms of various diagnoses such as conduct disorder, ADHD, post-traumatic stress disorder (PTSD), depression and anxiety. As per Shankman et al. [ 5 ], these patients may escalate to fulfill the criteria for these disorders. The lack of proper diagnosis imposes significant challenges in terms of management [ 3 ].

J is a 4-year-old adopted Caucasian male who at the age of 2 years and 4 months was brought by his adoptive mother to primary care with symptoms of behavioral dyscontrol, emotional dysregulation, anxiety, hyperactivity and inattention, obsessions with food, and attachment issues. J was given diagnoses of reactive attachment disorder (RAD) and ADHD. No medications were recommended at that time and a referral was made for behavioral therapy.

She subsequently took him to two different child psychiatrists who diagnosed disruptive mood dysregulation disorder (DMDD), PTSD, anxiety and a mood disorder. To help with mood and inattention symptoms, guanfacine, fluoxetine, methylphenidate and amphetamine salts were all prescribed without significant improvement. Later quetiapine, aripiprazole and thioridazine were tried consecutively without behavioral improvement (please see Table  1 for details).

No significant drug/substance interactions were noted (Table 1 ). There were no concerns regarding adherence and serum drug concentrations were not ordered. On review of patient’s history of medication trials guanfacine and methylphenidate seemed to have no effect on J’s hyperactive and impulsive behavior as well as his lack of focus. Amphetamine salts that were initiated during hospitalization were stopped by the patient’s mother due to significant increase in aggressive behaviors and irritability. Aripiprazole was tried for a brief period of time and seemed to have no effect. Quetiapine was initially helpful at 150 mg (50 mg three times a day), unfortunately its effects wore off quickly and increase in dose to 300 mg (100 mg three times a day) did not seem to make a difference. Fluoxetine that was tried for anxiety did not seem to improve the behaviors and was stopped after less than a month on mother’s request.

J’s condition continued to deteriorate and his primary care provider started risperidone. While initially helpful, escalating doses were required until he was on 6 mg daily. In spite of this treatment, J attempted to stab a girl at preschool with scissors necessitating emergent evaluation, whereupon he was admitted to inpatient care for safety and observation. Risperidone was discontinued and J was referred to outpatient psychiatry for continuing medical monitoring and therapy.

Little is known about J’s early history. There is suspicion that his mother was neglectful with feeding and frequently left him crying, unattended or with strangers. He was taken away from his mother’s care at 7 months due to neglect and placed with his aunt. After 1 month, his aunt declined to collect him from daycare, deciding she was unable to manage him. The owner of the daycare called Child Services and offered to care for J, eventually becoming his present adoptive parent.

J was a very needy baby who would wake screaming and was hard to console. More recently he wakes in the mornings anxious and agitated. He is often indiscriminate and inappropriate interpersonally, unable to play with other children. When in significant distress he regresses, and behaves as a cat, meowing and scratching the floor. Though J bonded with his adoptive mother well and was able to express affection towards her, his affection is frequently indiscriminate and he rarely shows any signs of separation anxiety.

At the age of 2 years and 8 months there was a suspicion for speech delay and J was evaluated by a speech pathologist who concluded that J was exhibiting speech and language skills that were solidly in the average range for age, with developmental speech errors that should be monitored over time. They did not think that issues with communication contributed significantly to his behavioral difficulties. Assessment of intellectual functioning was performed at the age of 2 years and 5 months by a special education teacher. Based on Bailey Infant and Toddler Development Scale, fine and gross motor, cognitive and social communication were all within normal range.

J’s adoptive mother and in-home therapist expressed significant concerns in regards to his appetite. She reports that J’s biological father would come and visit him infrequently, but always with food and sweets. J often eats to the point of throwing up and there have been occasions where he has eaten his own vomit and dog feces. Mother noticed there is an association between his mood and eating behaviors. J’s episodes of insatiable and indiscriminate hunger frequently co-occur with increased energy, diminished need for sleep, and increased speech. This typically lasts a few days to a week and is followed by a period of reduced appetite, low energy, hypersomnia, tearfulness, sadness, rocking behavior and slurred speech. Those episodes last for one to 3 days. Additionally, there are times when his symptomatology seems to be more manageable with fewer outbursts and less difficulty regarding food behaviors.

J’s family history is poorly understood, with his biological mother having a personality disorder and ADHD, and a biological father with substance abuse. Both maternally and paternally there is concern for bipolar disorder.

J has a clear history of disrupted attachment. He is somewhat indiscriminate in his relationship to strangers and struggles with impulsivity, aggression, sleep and feeding issues. In addition to early life neglect and possible trauma, J has a strong family history of psychiatric illness. His mood, anxiety and sleep issues might suggest underlying PTSD. His prominent hyperactivity could be due to trauma or related to ADHD. With his history of neglect, indiscrimination towards strangers, mood liability, attention difficulties, and heightened emotional state, the possibility of Disinhibited Social Engagement Disorder (DSED) is likely. J’s prominent mood lability, irritability and family history of bipolar disorder, are concerning for what future mood diagnosis this portends.

As evidenced above, J presents as a diagnostic conundrum suffering from a combination of transdiagnostic symptoms that broadly impact his functioning. Unfortunately, although various diagnoses such as ADHD, PTSD, Depression, DMDD or DSED may be entertained, the patient does not fall neatly into any of the categories.

This is a case report that describes a diagnostic conundrum in a young boy with prominent early life deprivation who presented with multidimensional symptoms managed with polypharmacy.

A sub-threshold presentation in this patient partially explains difficulties with diagnosis. There is no doubt that negative effects of early childhood deprivation had significant impact on developmental outcomes in this patient, but the mechanisms that could explain the associations are still widely unknown. Significant family history of mental illness also predisposes him to early challenges. The clinical picture is further complicated by the potential dynamic factors that could explain some of the patient’s behaviors. Careful examination of J’s early life history would suggest such a pattern of being able to engage with his biological caregivers, being given food, being tended to; followed by periods of neglect where he would withdraw, regress and engage in rocking as a self-soothing behavior. His adoptive mother observed that visitations with his biological father were accompanied by being given a lot of food. It is also possible that when he was under the care of his biological mother, he was either attended to with access to food or neglected, left hungry and screaming for hours.

The current healthcare model, being centered on obtaining accurate diagnosis, poses difficulties for treatment in these patients. Given the complicated transdiagnostic symptomatology, clear guidelines surrounding treatment are unavailable. To date, there have been no psychopharmacological intervention trials for attachment issues. In patients with disordered attachment, pharmacologic treatment is typically focused on co-morbid disorders, even with sub-threshold presentations, with the goal of symptom reduction [ 6 ]. A study by dosReis [ 7 ] found that psychotropic usage in community foster care patients ranged from 14% to 30%, going to 67% in therapeutic foster care and as high as 77% in group homes. Another study by Breland-Noble [ 8 ] showed that many children receive more than one psychotropic medication, with 22% using two medications from the same class.

It is important to note that our patient received four different neuroleptic medications (quetiapine, aripiprazole, risperidone and thioridazine) for disruptive behaviors and impulsivity at a very young age. Olfson et al. [ 9 ] noted that between 1999 and 2007 there has been a significant increase in the use of neuroleptics for very young children who present with difficult behaviors. A preliminary study by Ercan et al. [ 10 ] showed promising results with the use of risperidone in preschool children with behavioral dyscontrol. Review by Memarzia et al. [ 11 ] suggested that risperidone decreased behavioral problems and improved cognitive-motor functions in preschoolers. The study also raised concerns in regards to side effects from neuroleptic medications in such a vulnerable patient population. Younger children seemed to be much more susceptible to side effects in comparison to older children and adults with weight gain being the most common. Weight gain associated with risperidone was most pronounced in pre-adolescents (Safer) [ 12 ]. Quetiapine and aripiprazole were also associated with higher rates of weight gain (Correll et al.) [ 13 ].

Pharmacokinetics of medications is difficult to assess in very young children with ongoing development of the liver and the kidneys. It has been observed that psychotropic medications in children have shorter half-lives (Kearns et al.) [ 14 ], which would require use of higher doses for body weight in comparison to adults for same plasma level. Unfortunately, that in turn significantly increases the likelihood and severity of potential side effects.

There is also a question on effects of early exposure to antipsychotics on neurodevelopment. In particular in the first 3 years of life there are many changes in developing brains, such as increase in synaptic density, pruning and increase in neuronal myelination to list just a few [ 11 ]. Unfortunately at this point in time there is a significant paucity of data that would allow drawing any conclusions.

Our case report presents a preschool patient with history of adoption, early life abuse and neglect who exhibited significant behavioral challenges and was treated with various psychotropic medications with limited results. It is important to emphasize that subthreshold presentation and poor diagnostic clarity leads to dangerous and excessive medication regimens that, as evidenced above is fairly common in this patient population.

Neglect and/or abuse experienced early in life is a risk factor for mental health problems even after adoption. Differences in genetic risk, epigenetics, prenatal factors (e.g., malnutrition or poor nutrition), exposure to stress and/or substances, and parent-child interactions may explain the diversity of outcomes among these individuals, both in terms of mood and behavioral patterns [ 15 , 16 , 17 ]. Considering that these children often present with significant functional impairment and a wide variety of symptoms, further studies are needed regarding diagnosis and treatment.

Abbreviations

Attention-Deficit/Hyperactivity Disorder

Disruptive Mood Dysregulation Disorder

Disinhibited Social Engagement Disorder

Post-Traumatic Stress Disorder

Reactive Attachment disorder

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MR, AJM, JVV conceptualized and followed up the patient. MR, AJM, JVV did literature survey and wrote the report and took part in the scientific discussion and in finalizing the manuscript. All the authors read and approved the final document.

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Romanowicz, M., McKean, A.J. & Vande Voort, J. A case of a four-year-old child adopted at eight months with unusual mood patterns and significant polypharmacy. BMC Psychiatry 17 , 330 (2017). https://doi.org/10.1186/s12888-017-1492-y

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Case Study SPED105 Sample for Special Education

Case Study Sample I. Basic Information II. Reason for Referral III. Background History IV. Behavioral Observations V. Tests and Procedures Administered VI. Test Results VII. Conclusion VIII. Recommendations

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