Question How might the diagnosis of ADHD complement or contradict Carters classification as a child with an emotional or behavioral disorder

A Case Study Carter

Carter was initially referred for possible special education services in a first-grade compensatory classroom at Browning Elementary School. The compensatory class, a district Tier II intervention, served students who had not reached the criterion score for first-grade placement on the district readiness test. This classroom had only 15 students and was served by a teacher and a full-time aide.

Carter was referred by his mother, who had many concerns about her son. She noted that his progress seemed slow and that he not only had problems with academics but also had a lot of trouble paying attention, was impulsive, and had poor motor control. Carters teacher concurred with the mothers concerns. Carter was having very little success in the classroom and was constantly in motion. This had become a problem even in this developmentally appropriate, alternative first-grade program. He was easily distracted and had trouble delaying gratification. He was impatient and gave up easily. He was easily discouraged, and he complained that he did not have any friends. His teacher reported that Carter voiced unusual fears for this age group.

Carter was the younger of two children. He had been a large baby (10 pounds at birth), and the pregnancy had been complicated by high blood pressure and toxemia. However, no adverse effects were noted after the birth. His mother described Carter as a clumsy child, with repeated falls and bumps. Normal developmental milestones were somewhat delayed. He did not crawl until he was 8 months old or walk until he was 2. Speech development was interrupted by a loss of hearing at 18 months due to ear infections. The speech and language evaluation, done at the time of referral, confirmed difficulty with some sound frequencies, and it confirmed deficits in speech and communication skills. Carter was taking Ritalin twice a day, prescribed by his pediatrician for ADHD. Even so, Carters mother described him as a creative, sensitive, and generally happy child.

At age 6, Carter was evaluated by the school psychologist, who noted that Carter was able to concentrate more easily on tasks that involved manipulation of objects but was very distracted in auditory tasks. He needed encouragement and reinforcement to sustain effort during the testing. The results indicated the following:

WISC-IV (measure of intellectual functioning):
Full Scale IQ:	105
Composite Scores:
Verbal Comprehension	102
Perceptual Reasoning	109
Working Memory	95
Processing Speed	110

Carter also achieved a standard score of 105 (63rd percentile) on the Peabody Picture Vocabulary Test, a measure of receptive language ability, which indicated age-appropriate receptive language skills consistent with the WISC-IV results.

Carter was given two measures of academic achievement:

Diagnostic Achievement Battery-3
Reading	109
Math	94
Wide Range Achievement Test (WRAT-4)
Subtest	Standard Score
Reading Composite	112
Word Reading	113
Sentence Comprehension	110
Spelling	108
Math Computation	103

From the evaluation, the multidisciplinary team concluded that Carter was a student of average intelligence who showed no significant strengths and weaknesses. Based on state guidelines, he did not qualify for special education at that time.

Carter went on to second grade, continuing on the Ritalin for his medically diagnosed ADHD. His classroom teacher was very sensitive to Carters needs and monitored the effects of his medication carefully. Carter continued to show signs of problematic socialization behaviors. He had significant trouble getting along with others, often picking on other children.

In third grade, he moved to another school, where he still received all of his education in the regular classroom program. He returned to Browning Elementary School in fourth grade, where he seemed to be in constant trouble. He was still on Ritalin, receiving the highest dose possible. His mother had sought help and advice from other doctors and agencies, and she was in the process of getting him evaluated by a major regional child evaluation clinic. Carters behavior at home continued to cause serious problems. He exhibited a lot of unwarranted fears and was obsessed by violence. He could not seem to complete any tasks given to him. For the first time, his math skills fell below grade level. In January of that year, the school support team placed him in the resource room under the new eligibility of other health impaired because of his ADHD. He was also receiving counseling at the community mental health clinic.

Carters problems with attention were causing him difficulties, specifically during transitions, such as from lunch to recess and from recess back to class. Right before lunch, when his morning medication would wear off and before the noon dose would take effect, he was unable to concentrate and do work and was consistently disruptive in the regular classroom. It was suggested that his resource room services could include having lunch with the resource teacher and spending recess in the resource room. This was done for about 4 months, during which careful anecdotal records were kept on his behavior to determine what would be the best placement for Carter. His mother requested that he be reevaluated. He was also scheduled for a brain scan and other diagnostic testing outside of school.

During this period, Carter was being weaned off the Ritalin because he had to be completely off it for the planned brain scan to be accurate. As he came off the Ritalin, his attention quickly diminished. By the time he was completely off the drug, he could not sustain attention for more than 1 or 2 minutes at a time, even on things that he enjoyed, such as computer games. He was unable to do any academic work at that time.

Problem behaviors toward his classmates, teachers, and other people were still very evident. Those behaviors didnt change whether he was on the Ritalin or not. His reevaluation by the school psychologist included additional tests to try to uncover the real source of Carters problems. The reevaluation and the behavioral records helped clarify the nature and extent of his problems. His new fear of crowds caused him to resist going to the lunchroom and to prefer solitude. He made up stories and talked extensively about violence. He would jump from one thing to another in conversation, not seeming to know whether he was telling true or made-up stories. He seemed not to be able to tell what was real from what was not real. By April of that year, the full team met with his mother to determine how to best meet Carters needs. He had not made any progress during this school year, and the entire experience had been very frustrating for him, his mother, and his teachers. Everyone at the meeting was aware that Carter had ADHD. When the team met, the school psychologist reported that the results of the evaluation indicated that Carters school problems stemmed primarily from his emotional problems, not from the ADHD.The ADHD was a contributing factor, but the primary disability appeared to be the emotional or behavioral disorder. Even when he was on Ritalin, the abnormal behavior continued. The mother and the classroom teacher concurred in this. They saw a special class placement as being the least restrictive environment for Carter at that time, a placement that it was hoped would allow him to resume academic learning and to work on his emotional issues and problem behaviors. However, the teacher of the class for students with emotional or behavioral disorders disagreed, saying that the ADHD was the root problem. The committee took all the evidence and decided that the emotional problems were the central issue. Those concerns were always there, on or off the Ritalin; therefore, they felt that his emotional problems were the primary cause of his lack of academic success. Carter had never had a successful year since he started school, and because of his past history, it was the committees sincere hope that intensive work in the self-contained classroom environment would help him finally begin to make progress.