**9. Development of a programme directed at areas of language weakness, basic skills deficits and areas of lack of automaticity**

It will be evident from the above that the conceptual framework suggested by Luria [206] not only underpins the functional nature of the assessment process used in the author's practice but also guides how indications from assessment are operationalised into specific activities to address areas of language weakness, areas of basic skill deficit as well as areas in which automaticity still needs to develop. How a child's needs are related to different areas and components within a programme of intervention will be evident from the following case study.

### **9.1. Child 1: A Grade 3 child in a South African Government School**

*9.1.1. Problems highlighted in initial interview (February 2014)*

Auditory processing difficulties.

analysis of neurological symptoms and a series of additional objective tests. Luria suggests that the examination needs to be relatively short and involves methods of experimental psy-

The methods of examination used in the initial sessions spent working with the child also include pragmatic assessment of repetitive and spontaneous speech, writing, reading, comprehension of texts and the solution of problems, in order to establish how reading, writing and spelling are used by the child as a functional system. This informal evidence is then combined with more formal testing of reading, writing and spelling skills and interpreted, as Luria suggests, against a framework of knowledge of the types of difficulties normally associated with the functional system under investigation, based on current literature (for example [104, 170]). Assessment leads to a functional description of deficits sufficient for diagnosis of learning

labelling of the child as dyslexic. The standpoint adopted by the author would accord with the suggestions made by Elliott and Grigorenko [204] and Elliott [205], namely that adding a label adds little of clarity to a functional description of deficits in reading, writing and spelling for purposes of intervention. Similarly, the pattern of scores on subtests of an IQ test is used functionally to indicate areas of cognitive and language strength and weakness, as well as areas in

The majority of children referred into the author's practice have had developmental difficulties at school, manifesting in problems with language, reading, writing and spelling, as well as associated difficulties with focus, attention and working memory. A number of the children have had previous assessments or have been referred by either their teachers or medical professionals. These difficulties form the focus of discussion in the preliminary interview with the child's parents, as well as preliminary conversation conducted during an initial session with the child. Following Luria [1], the aim is to move from assessment to statement of areas of deficit and from this to specific suggestions for programmatic intervention. During the initial session with the child, evidence is collected on how the child uses a pencil for drawing and copying, how the child uses language in conversation and in writing and how the child works with integrated picture-based tasks involving comprehension and interpretation. Evidence collected during the second initial session includes indicators of one word reading ability, sentence reading ability, one word spelling ability and sequential spelling ability as tapped by two short tests of dictation. Besides assessment of basic skills in reading, writing and spelling, the evidence collected in the two initial sessions also enables assessment to be made concerning handedness, eye movements and visual tracking, as well as the potential influences of focus, attention and fatigue on rate of work. This evidence is then interpreted against a framework of additional

At time of writing, the ICD DSM IV criteria are being phased out by South African medical aid societies and replaced by the ICD DSM V criteria. This may affect the codings used in the author's practice [202, 203] in the future, but has not

affected the codings used with the children whose results are reported in this and the next chapter.

sequencing and working memory which may need to be worked with in therapy.

**8. From assessment to statement of areas of deficit**

as opposed to an attempt to link this to possible

chological investigation applied to clinical practice.

128 Learning Disabilities - An International Perspective

disability to meet medical aid requirements,<sup>9</sup>

9

Delayed milestones affecting speech and walking.

Has had occupational therapy.

Phonological weaknesses.

<sup>10</sup>The author has worked with children under the care of a number of paediatricians and neurologists, but particularly closely with Dr W.G. Maxwell, neurologist, of Sandton Clinic. The stabilisation of focus and attentional difficulties as well as attendant attentional lapses and symptoms of cortical irritability has been an essential feature of the fluencybased interventions provided in the author's practice. Behavioural, emotional, parental as well as chemical interventions are likely to have contributed to the gains made by the children whose results are reported in this chapter.

<sup>11</sup>The DSM V criteria were published in May 2013, with both ICD-9-CM and ICD-10-CM codes assigned to each of the DSM V diagnoses. South African medical aids have continued to use DSM IV criteria up to this point in time. At time of writing, the shift to use of the DSM V criteria is in process of taking place. All children referred to in this and the next chapter were assessed against the ICD DSM IV criteria [194, 199].

b/d Reversals; n/m confusion.

High anxiety levels.

Familial difficulty (dad also had learning difficulties as child).

*9.1.2. Strengths highlighted in initial interview*

Social abilities and friendships at school.

Good visualisation abilities.

Interest in lego and computers.

Spatially competent child.

*9.1.3. Results from initial sessions of observation of performance on tests of basic skills combined with analysis of performance on pragmatic language tasks*

The following tests were administered in the initial sessions with Child 1:

Buck's House Tree Person Test, the Bender Gestalt Test, the Peabody Picture-Language Vocabulary Test, the Schonell One Word Spelling Test, the Holborn Reading Scale, the Daniels and Diack Sentence Reading Test (as performance on the Holborn was low), the Schonell One Word Spelling Test and the Schonell Graded Dictation Tests (Tests A and B). The test-based evidence was supplemented by pragmatic language tasks involving (a) analysis of a spontaneous writing sample, (b) analysis of school books and (c) analysis and comprehension of a picture story.

Child 1 presented with one word reading difficulties, sentence reading difficulties, one word spelling difficulties, sequential spelling difficulties and problems with sound/letter associations indicating difficulties with phonics. There were a number of reversals in writing (b/d) as well as confusion of n/m. Observation indicated that Child 1 had attentional and focus difficulties and was very active. Emotional indicators were also present both in Child 1's drawings and in the Bender Gestalt test.

As there were a number of indicators of potential learning disability in the case history as well as in the evidence from the two initial sessions conducted with Child 1, a diagnosis of learning disability with attendant difficulties in reading, writing and spelling was made. As there was evidence of fluency-based difficulties affecting accuracy and rate of reading, as well as evidence of difficulties with rate and spelling of written work, recommendations were made for more in-depth testing to establish Child 1's cognitive profile, ongoing assessment by the family's neurologist,<sup>12</sup> as well as testing using the phonic inventories [207–209] to establish Child 1's pattern of phonic errors.

These results are reported below.

<sup>12</sup>Child 1 had symptoms of focus and attentional difficulties due to immaturity in the myelinisation process, as well as accompanying attentional lapses and cortical irritability. He was treated for each of these symptoms by Dr W.G. Maxwell, neurologist, of Sandton Clinic, who assessed Child 1 on a six monthly basis throughout the period the fluencybased intervention programme was implemented.
