I think we cracked the case. After 5 hours of diagnostic testing, I think my co-clinician and I have figured out what’s going on with our client.  He exhibited difficulties in several aspects of language processing, like word-finding and sentence repetition, but had completely normal vocabulary scores.  His reading was poor, despite normal phonemic awareness and phonics skills.  His phonological processing was normal except some scores that were skewed due to poor phonological memory.  This made us think that maybe all of the issues were memory-related.  If you don’t have a good working memory, you won’t be able to do things like repeat sentences, or nonwords, or digit strings (three areas that were especially challenging for him).  Working memory could also affect reading: if you’ve already forgotten the words at the beginning of the line, you’re going to have a shaky grasp on the material, resulting in extremely low comprehension, even if you have a vocabulary that would allow you to understand all the words. Tests administered: KBIT (Kaufman Brief Intelligence Test)CTOPP (Comprehensive Test of Phonological Processing)CELF-4 (Clinical Evaluation of Language Fundamentals)TOWRE (Test of Word Reading Ability)TERA-3 (Test of Early Reading Ability-3)TOSWRF (Test of Silent Word Reading Fluency)TAPS-3 (Test of Auditory Processing Skills-3)TORC-4 (Test of Reading Comprehension-4)DIBELS (Dynamic Indicators of Early Literacy Skills)PPVT (Peabody Picture Vocabulary Test)EVT (Expressive Vocabulary Test) I like my diagnostic clinic.  Actually, it might be the clinic that I like the most: fitting together scraps of evidence, and putting together a puzzle.  The bad part is that the puzzle is a living, breathing person, and at the end, we have to tell the parents that there is a piece missing.  In this case, it appears to be a cognitive piece.  Parents don’t want to hear this.  They want their child to have 10 fingers, and 10 toes, the right number of chromosomes, and a functional working memory.  They don’t want to hear that their kid has a problem, let alone one that is beyond the clinician’s scope. I don’t know how to fix a working memory problem; it’s unclear that anyone can.  If it was an attention problem, then maybe we could work on that, or get the kid some meds that would help.  But his attention is fine: he’s not ADD, he’s not spaced out.  He just doesn’t have the cognitive desk space available to hold things he’s hearing and seeing in his mind long enough to work on them.  Other than teaching a kid strategies to compensate for the deficit, there really isn’t anything that can be done. I can make your kid segment and blend the sounds in words, I can get him to read, and spell, and I can get him to produce all of the sounds of the English language.  I can help kids who stutter and kids who have poor eye contact and kids with swallowing disorders.  But I can’t change this kid’s brain, and that makes me feel shitty.

I think we cracked the case.

After 5 hours of diagnostic testing, I think my co-clinician and I have figured out what’s going on with our client.  He exhibited difficulties in several aspects of language processing, like word-finding and sentence repetition, but had completely normal vocabulary scores.  His reading was poor, despite normal phonemic awareness and phonics skills.  His phonological processing was normal except some scores that were skewed due to poor phonological memory.  This made us think that maybe all of the issues were memory-related.  If you don’t have a good working memory, you won’t be able to do things like repeat sentences, or nonwords, or digit strings (three areas that were especially challenging for him).  Working memory could also affect reading: if you’ve already forgotten the words at the beginning of the line, you’re going to have a shaky grasp on the material, resulting in extremely low comprehension, even if you have a vocabulary that would allow you to understand all the words.

Tests administered:

KBIT (Kaufman Brief Intelligence Test)
CTOPP (Comprehensive Test of Phonological Processing)
CELF-4 (Clinical Evaluation of Language Fundamentals)
TOWRE (Test of Word Reading Ability)
TERA-3 (Test of Early Reading Ability-3)
TOSWRF (Test of Silent Word Reading Fluency)
TAPS-3 (Test of Auditory Processing Skills-3)
TORC-4 (Test of Reading Comprehension-4)
DIBELS (Dynamic Indicators of Early Literacy Skills)
PPVT (Peabody Picture Vocabulary Test)
EVT (Expressive Vocabulary Test)

I like my diagnostic clinic.  Actually, it might be the clinic that I like the most: fitting together scraps of evidence, and putting together a puzzle.  The bad part is that the puzzle is a living, breathing person, and at the end, we have to tell the parents that there is a piece missing.  In this case, it appears to be a cognitive piece.  Parents don’t want to hear this.  They want their child to have 10 fingers, and 10 toes, the right number of chromosomes, and a functional working memory.  They don’t want to hear that their kid has a problem, let alone one that is beyond the clinician’s scope.

I don’t know how to fix a working memory problem; it’s unclear that anyone can.  If it was an attention problem, then maybe we could work on that, or get the kid some meds that would help.  But his attention is fine: he’s not ADD, he’s not spaced out.  He just doesn’t have the cognitive desk space available to hold things he’s hearing and seeing in his mind long enough to work on them.  Other than teaching a kid strategies to compensate for the deficit, there really isn’t anything that can be done.

I can make your kid segment and blend the sounds in words, I can get him to read, and spell, and I can get him to produce all of the sounds of the English language.  I can help kids who stutter and kids who have poor eye contact and kids with swallowing disorders.  But I can’t change this kid’s brain, and that makes me feel shitty.