Adventist University of the Philippines

College of Arts and Humanities

Department of Psychology

The Case Study of Luca: An Exceptional Child

Presented to
Dr. Rhalf Jayson F. Guanco, RPsy, RPm, CSDP

In Partial Fulfilment
Of the Requirements for the Course
Psychology for Exceptional Children
By

Cuadra, Don Arturo R.

Delgra, Lorein Kate Y.
Dumas, Kayecelyn B.
Fernandez, Annazehl Claire D.
Ke-e, Mary Mae R.
Laroa, Christine Joan P.
Macasa, Princess Marian G.

November 2021

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 CONFIDENTIAL PSYCHOEDUCATIONAL EVALUATION

Identifying Information
Name: Luca Andres (Pseudonym) Date of Consultation: September 26, 2021
Age: 8 years old Date of Report: November 19, 2021
Gender: Male Date of Birth: January 20, 2013
Grade: 1 Address: B1-4 L8 Zone XI, Brgy. Sampaloc
Primary Language: Filipino IV, Bautista, Dasmariñas City, Cavite
Examiner: Ms. Kayecelyn Dumas

Reason for Referral

The client was referred for a comprehensive evaluation to (a) assess his current level of
academic and cognitive functioning, (b) identify diagnostic impressions and whether he still
qualifies for special education support, and (c) determine appropriate treatment
recommendations that will improve his learning and behavior at home.
Referral Source: The Mother

Assessment Procedures

Assessment Procedure Date Conducted/Administered

Interviews
• Mental Status Examination
• Primary Caregiver September 24, 2021
• Student
Behavioural Observation
• Home September 24, 2021
• Test-taking Behaviour Oct. 3, 31, and Nov. 7, 2021
Projective Tests
• Sack Sentence Completion Test for Boys
and Girls (SSCT) October 3, 2021
• Goodenough Draw a Person Test
(DAPT)
Objective Tests
• Revised Child Anxiety and Depression
Scale - Child version (RCADS-Child)
• Revised Child Anxiety and Depression
Scale – Parent version (RCADS-Parent) October 31, 2021
• Dyslexia Assessment (From Davis
Dyslexia Association International)

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 • IQ Test for kids from 7 to 16 years old
(testometrika.com) November 7, 2021
Review of Psychoeducational Records
• Previous Psychological Consultation June 10, 2019
• Sample handwriting November 12, 2021

Mental Status Examination

Appearance
The client is an eight-year-old boy who looks exactly with his age and in his normal
weight. He was wearing a white sando and shorts when the interviewer met him. He had not yet
taken a bath and exhibits a poor hygiene. He perspires a lot and makes fun of his six-year-old
sister by letting her smell his sweat. It was also noticeable that he is not wearing slippers inside
their house.
Behaviour
The client avoids eye contact and is not completely cooperative with the examination and
interview process. Moreover, he easily gets distracted with the things around him, he has a short-
attention-span—seeming not to listen to the interviewer, missing important details of the
interviewer’s instructions, and doing irrelevant things, thus, forgetting that he is in the middle of
an assessment. He kept moving, jumping, and getting out from his seat from time to time. It was
also evident that he is poor in communication. He can’t speak basic words in a clear and
understandable manner. When he talks, he stutters a lot and speaks in a low volume and slow
rate of speech.
Mood and Affect
The client’s mood is euphoric which is marked by his enthusiastic joyfulness. He also
seemed very hyperactive and loves to keep his body moving.
Perception and Thought Processes
The client did not demonstrate any psychotic symptoms like delusion and hallucinations,
nor reported suicidal ideations. His thoughts are logical but seemed to have difficulty
maintaining attention and focus.
Cognition
The client’s level of alertness was assessed by mere observation. He was tested with a
simple addition and subtraction problems but failed to give the correct answer. Furthermore, he
is not well-oriented to time, date, and place. When asked to count the natural numbers, he was
able to do it but only from numbers 1 to 10. Also, he can no longer recite it backwards. When
asked to follow instructions, it took more time for him to understand, so the interviewer had to
repeat the command for several times.

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 Background Information and Early Developmental History

The following data were provided by the client’s mother during the clinical interview.
Presenting Problem
Luca is an eight-year-old boy who is currently enrolled at a Special Education (SpEd)
Center in Dasmariñas City. He struggles with reading, writing, mathematics, and speech. It was
reported that his speech and communication is not normal unlike children of his age. He has been
undergoing in a speech therapy class for already 3 years but his progress is very slow. Luca is
not currently on any medication to alleviate his impairments in learning, but his mother reported
that he did consult a mental health professional in 2018 at De La Salle Dasma and in 2019 at
Psyche Guide Association, Trece Martires City. Luca is described as a loving child but one who
tends to easily give up on tasks that involve comprehension, writing, and arithmetic.
Furthermore, his speech problem is impairing his social relationships with people.
History of Prenatal, Perinatal, and Early Development
The client’s mother reported that her pregnancy with the client was a complicated one.
The doctor told her that she is having a hydatidiform mole or molar pregnancy. As a result, she
was advised to take medications to protect the baby in her womb. The mother then maintained a
healthy lifestyle by following her physician’s recommendations.
Baby Luca was born on the predicted date for his mother’s delivery. He came out through
a normal delivery and with a normal weight. However, the new born did not cry nor showed any
sign of pulse for about an hour. Later, when he finally had pulse, he immediately experienced
convulsion. This caused him to be brought to a Neonatal Intensive Care Unit (NICU) for a month
and seven days. Fortunately, Luca did not suffer from colic—a physical condition in which a
baby is very uncomfortable and cries for long periods of time.
Growing up, his mother felt happy that Luca was able to reach his developmental
milestones. He was able to crawl on time, stand by himself and walk with his mother’s assistance
during his first birthday. He also learned toilet training at the expected stage. However, baby
Luca did not have the chance to say a syllable nor babbled a word in his infant years. This made
his mother frustrated over her son. So, she thought that baby Luca is not capable of speaking—
thinking that her son is deaf. Fortunately, she was wrong with her assumption when she tried
talking to the baby and calling his name.
The mother noted that it was only during Luca’s 5th birthday that he was able to utter his
first word. He said the word, “ayaw” in furious manner. The mother explained that Luca’s
developmental milestones were met within normal limits except for his speech, and his learning
to count and read.
Medical and Health Background
The client does not have a history of illness, head traumas, and does not need a
medication to maintain. According to his pediatrician, his medical records and physical health

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are normal as consistent with his age. The same is true with his hearing and visual ability. But
the mother noted that whenever Luca is burning with fever, he then experiences seizures.
History of Cognitive, Academic, and Language Functioning
The client’s problem is notable in the issues of reading, spelling, and pronouncing a word
or a phrase. In connection to this, he is also having a difficulty in comprehension. Moreover,
every time he thinks and tries to focus on a certain thing, his eyes changes its direction of vision.
Concerning language, Luca’s primary language is Filipino. He uses it to converse at
home and with other people. His progress in reading was very slow that he can’t even read his
name or spell a basic word. In his conversation, he only uses short and simple phrases. He can
name and recognize letters, but cannot write it down. His cognitive ability was assessed when he
was 6 years old and his kindergarten year. His teacher noticed that he seems to be ineffective
academically and wandered if he may have a learning disability. So, the teacher advised his
parents to seek for professional help to address Luca’s cognitive difficulties.
In the case of learning mathematics, the mother conveyed that Luca had already
improved because back then, he can’t recite natural numbers, even from 1 to 10. Nonetheless, he
is still not able to do a simple addition or subtraction.
Luca is also poor in writing. He writes with big spaces in each letter and sometimes, pens
them in a chaotic manner. Moreover, when he is not in the mood of practicing his handwriting,
he easily gives up and chooses not to finish his task.
The mother noted that Luca’s SpEd center does not incorporate a grading system in class.
When it comes to scores, all students receive an equal academic grade. However, she observed
that Luca is really struggling in the areas of reading, writing, and mathematics. Despite this,
Luca is very good in arts. He loves to draw and build blocks at school. His creativity is shown in
his artworks.
Luca has a problem in dealing with his different subjects at school because he is poor in
comprehension. He can’t do his activities in class unless his mother or teacher sits by his side to
assist and guide him. Luca went to a basic education school for a year; but today, he is taking
modular classes at a school for children with special needs.
History of Social, Emotional, and Behavioral Functioning
The client is capable of following classroom rules and instructions of his teacher. He does
not get into trouble at school except when he is annoyed or being made fun by his classmates.
Nevertheless, he immediately listens to his teacher when he is being corrected and asked to
reconcile with his classmate. Luca has difficulty interacting with other kids and with the older
ones. Yet, the mother shared that Luca loves to play with other children. He displays a normal
mood but sometimes experiences anxiety symptoms. His tantrums are manageable, but there are
times that he exhibits aggressiveness when his wants are not immediately addressed.

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 Before the pandemic began, when Luca is still able to attend a face-to-face class, his
teacher reported that he feels afraid if he has to talk in front of the class. In addition, he feels
scared when taking a test. There are also periods in class in which Luca cannot think clearly.
Luca does not show any signs of harming himself or others. To communicate his needs,
he uses basic words. When it comes to school activities, Luca is always on the go. His behavior
had improved over the past school year. However, according to his mom, Luca tends to be hot-
tempered, especially when he is being made fun of in the dark—since this is one of his
weaknesses. He cannot control himself but to bite the one who keeps annoying him. Lastly, Luca
had mastered the fundamental classroom routine in his special education school and can already
follow simple instructions given by his teacher.
History of Adaptive Functioning
To help Luca become motivated to finish his class activities and tasks, his teacher would
always apply operant conditioning—giving him a reward after he completes a certain task.
Specifically, his teacher rewards him with Php 5.00 for each completed task. Nonetheless, when
Luca observes that his classmates are doing the same activity as his, he is also eager to do it.
Sometimes, when Luca gets bored in the classroom, he tries to copy and imitate his classmates’
actions.
Luca’s teacher reported that he is obedient and hardworking especially when it comes to
learning household chores. When the pandemic did not yet emerge, Luca can prepare himself to
go to class even without his mother’s assistance. He can do everyday activities for self-care on
his own. These activities include eating, brushing his teeth, taking a bath, and getting dressed.
When often repeated and reminded, Luca can understand and distinguish the wrong from
the right things. He also knows what is safe and what is dangerous. However, there seems to be a
problem in his social interaction with other children. He struggles to communicate with them
because he tends to stutter when speaking. When playing with other kids, he is having a hard
time understanding his playmates, especially when the game has a specific rule that needs to be
followed. He cannot easily catch-up with the instructions that the other kids are saying. His
comprehension and communication were truly a problem. Thus, even if his interest to join in the
game is obvious, he ends up feeling out of place in the group.
People who are conversing with him cannot understand the words he is saying. Luca
needs to repeat his words for them to understand him. But according to the mother, Luca’s
communication at home is not a problem since the members of their household are already
familiar with the child’s manner of talking.
Strengths and Interests
Luca is a sweet, loving, hardworking, obedient, and cheerful boy. He loves to observe
and appreciate things. He honestly confides to his mother when things go wrong and expresses
himself freely. His relationship towards other people can be described well. Whenever he
establishes trust to others, he easily gets to interact with them. He is creative and is excellent in

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arts and drawing. Moreover, he is fond of pets and insects. It is also one of his core strengths to
participate in activities that involves hands-on tasks, especially those that comes with a reward.
Luca is a child whose eagerness to pursue a goal in life prevails. His ultimate dream is to
become a soldier or a police officer someday. Lastly, he loves to watch ASMR (Autonomous
Sensory Meridian Response) food-eating videos because of its tingling sensation.

Assessment Results

Interview Results
• Primary Caregiver Interview. Luca’s mother was interviewed to explore her son’s
cognitive, academic, social, and behavioural development. According to her, Luca shows
interest in arts and drawing but struggles with reading, writing, and mathematics. She
then explained that Luca enjoys any other things as a kid except that he can’t
communicate properly with his friends at school. She also reported that in their family
history, she has a sister who showed symptoms of intellectual disability. Her sister can’t
function on its own. Her daily activities require the assistance of her family members.
However, the latter died when she was 9 years old.

• Student Interview. Luca was interviewed to verify his speech problems and to have a
deeper understanding of his academic progress through his perspective. He confessed that
he experiences difficulty in reading and writing and expressed concerns such as that he is
afraid being in the dark. There was only a limited information gathered from the student
due to speech problems that even the interviewer cannot understand his words.

Results of Observation
• Home Observation. The client was active, happy, and comfortable at home, playing with
his toys. He is also behaving when watching TV. Sometimes, he mimics the words he
hears and keeps on repeating it. He just speaks when wants to.

• Assessment Observation. Throughout the assessment process, Luca is easy-going, and

keeps moving his body. During the Draw a Person Test, he seemed to be confused
because he does not know what to draw first—the hands or the feet. He was carefree and
does not care if he follows the assessor’s instructions or not. He has a poor eye contact
and his eyes cannot focus on what he is doing when he is thinking hard. Moreover, he is
having difficulty pronouncing words. He keeps on stuttering. Nonetheless, Luca was
responsive to the evaluator’s questions to him and was engaged in the tasks given to him.
Thus, the results appear to be a valid representation of his abilities.

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Projective Tests
• Sack Sentence Completion Test for Boys and Girls
Description Rating Interpretation
Attitude toward mother 0 Expresses only
4. Kung minsan ang kanyang nanay mabait. positive feelings
11. Dahil sa kanyang nanay mabait. toward his mother.
31. Karamihan ng mga ina nagbibigay.
34. Ang kanyang nanay ay laging nakain.
Attitude toward father X His relationship
14. Dahil sa kanyang ama tinda. with his father has
24. Marami sa mga tatay matanda. insufficient
39. Ang tatay niya ay laging cp at tv. evidence.
Attitude toward family unit 3 The client shows
12. Kapag ayaw syang pasamahin ng kanyang mga magulang sa sentiments toward
kanyang barkada nalabas. the family and
26. Kapag sya ay malayo sa kanyang pamilya miss. appears to be
28. Ang mga magulang niya ay madalas na nagsasabi na ang conformed with
kanyang mga kaibigan away-away/awat-awat. them.
32. Kung ang pamilya lamang niya bata.
35. Kung siya ay nasasangkot sa gulo ang pamilya nya ay aawat.
37. Kung siya ay sinasabihan ng kanyang pamilya kung ano ang
gagawin, wawalis.
Attitude toward other children/friends 3 Feels superior over
2. Karamihan sa ibang mga batang lalaki na kaidad nya ay his peers but is
kumikilos na parang tatayaan. also one who is
3. Nakakainis ang mga batang lalaki dahil di sasali. being rejected
13. Ang kanyang matalik na kaibigan ay mabuti dahil peheram at during playtime.
tatayaan.
16. Karamihan sa mga batang lalaki ay dapat pogi.
19. Kung itutulad sa ibang batang lalaki siya ay iba dahil bossing.
25. Kapag sya ay hinamon ng away nagsasapak.
33. Kung sya ay kasama ng kanyang mga kabarkada naglalaro.
38. Kapag ang ibang bata lalaki/babae ay ayaw syang isali sa laro,
nag ccp.
Attitude toward people supervised/superior at school 0 Expresses only
7. Kung minsan nagagalit sya sa kanyang guro kasi lagi nag sulat. good things at
23. Kapag tinataong siyang maging lider nagsusulat. school.
29. Siya ay madalas na nagtataka kung bakit sya kasi sa kaibigan
ko.
30. Kahit kalian na siya ay maatasang mamahala sa klase (n/a)
Goals 0 Expresses only
1. Kung minsan gusto niyang tatawagan si mama. positive things
6. Higit sa lahat gusto niyang mabait. towards his goals.
8. Kapag sya ay tumanda police.
20. Kapag siya ay lumaki gusto niyang maging police.

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Positive things 0 There is no
5. And pinakamagandang bagay tungkol sa kanya maganda. significant
18. Maging maligaya siya kung tatayaan. disturbance noted
27. Kadalasan iniisip ng mga tao na sya ay mabuti dahil in this area.
nagtatayaan.
40. Siya ay madalas magkaroon pera.

Negative things 2 Shows awareness

9. Ang hirap/problema sa kanya ay hindi salita. of his weaknesses,
10. Kapag ang iba ay umaasa sa kanya siya nagagalit. particularly his
15. Naiisip nyang maglayas kung minsan dahil uuwi. speech problem
17. Ang pinakamasamang bagay natapakan. and
21. Nagagalit sya kapag sasapak. aggressiveness.
22. Kapag nalaman niyang siya ay hindi magtatagumpay hindi niya
alam.
36. Siya ay hindi gusto ng ibang tao dahil (n/a)

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 • Goodenough Draw a Person Test
Details Total-7
Mental age: 4 ¾ years old
IQ- (4 ¾/8 x 100) = 61.25
The Goodenough Draw a Person Test supports the child’s records with some observation
on his drawing. He was shown to be striving for independence as he draws a full figure and face
without profile suggestion that reflects in his history of adaptive and behavioural functioning.
He was shown to be rigid and has the determination to face life directly, as he is obedient
and receptive to his mother. He can also ensure that he will prepare himself for everyday
activities without his mother’s assistance. In addition, he had mastered some fundamental
classroom routines and strives to follow simple instructions given by his teacher.
Luca's drawing has shown social withdrawal tendencies that are characterized by lack and
omitted face features which are evident in his social and emotional history. According to his
account, he experiences difficulty interacting with other kids and other adults. This may be
caused by his communication problems particularly, in speaking and expressing. In addition, his
feelings of inadequacy and ineffectiveness was distinct through his drawing of frail, thin, small,
or shrunken arms. This indicates that he felt weak, not confident, and has difficulty establishing
interpersonal relationships. This observation further supports his confession that struggles in
reading, writing, and with his expressed concerns such as being afraid in the dark.
Luca’s feeling of inadequacy was also evident in his Sack Sentence Completion Test
result and adaptive functioning. It was mentioned that he has been struggling to communicate to
his playmate as he tends to stutter when speaking. Lastly, this concept was reflected during his
playtime with other kids. Because he cannot understand the mechanics of the game being played,
his playmates tend not to exclude him in the group. Thus, he ends up being rejected or feeling
left out in the group, and later feeling anxious.

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Objective Tests
• Revised Child Anxiety and Depression Scale - Child version (RCADS-Child)
Raw Community Percentile Description
Score 8-12 years
Total Internalizing Scale Score (Range 0-141) 27 -
Total Anxiety Scale Score (Range 0-111) 24 -
Separation Anxiety (Range 0-21) 6 65.8 Average
Social Phobia (Range 0-27) 9 48.6 Average
Generalized Anxiety (Range 0-18) 3 20.2 Very Low
Panic Disorder (Range 0-27) 2 26.5 Average
Obsessive-Compulsive (Range 0-18) 4 41.1 Average
Major Depression (Range 0-30) 3 18.8 Very Low

The RCADS-Child test results showed that the client’s percentile scores represent
Average levels of symptoms compared to age-related peers. However, his scores in
Generalized Anxiety and Major Depression both indicate a Very Low level. Thus, it is
recommended to make further examination and evaluation that may discover other
underlying factors of the said result.
RCADS-Child scale test is a 47-item self-report questionnaire that measures
symptoms of depression and anxiety in children and adolescents aged 8-18. This test is
validated with a sample of 1641 children and adolescents in the community and showed
six factors that were yielded from DSM-IV disorders of anxiety and depression. Results
indicate that the RCADS is a reliable and valid instrument. The original 6-factor structure
was replicated to a fair extent in the present study (RMSEA = 0.048) and internal
consistency was good (αs = 0.70-0.96). It has demonstrated good structural validity,
reliability, and convergent and discriminant validity.

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• Revised Child Anxiety and Depression Scale - Parent version (RCADS-Parent)
Raw Community Description
Score Percentile Male
Total Internalizing Scale Score (Range 0-141) 27 66.7 Average
Total Anxiety Scale Score (Range 0-111) 24 73.3 Average
Separation Anxiety (Range 0-21) 3 58.3 Average
Social Phobia (Range 0-27) 9 60.8 Average
Generalized Anxiety (Range 0-18) 2 27.4 Average
Panic Disorder (Range 0-27) 5 95.6 Very High
Obsessive-Compulsive (Range 0-18) 5 90.5 High Average
Major Depression (Range 0-30) 3 38.4 Average

The client’s RCADS-Parent Version test results showed an Average level for each
of the subscales except for the Panic Disorder and Obsessive-Compulsive with a score of
95.6 and 90.5 respectively. The former indicates a Very High level of symptoms while
the latter is High Average. The results imply the client’s tendency to be anxious.
Consequently, it requires a more comprehensive psychological examination.

RCADS-Parent scale test is a 47-item parent-report questionnaire that measures

symptoms of depression and anxiety in children and adolescents aged 8-18. It was
validated in a community sample of 967 parents of children and adolescents. The tests
demonstrated high internal consistency, test-retest reliability, and good convergent and
divergent validity. It was also supported by factor analysis to have 6 factor structure of
RCADS-Child.

Incongruently, this test result showed some difference compared to the RCADS-
Child result. As indicated by the child, his Panic Disorder and Obsessive Compulsive are
both in the Average level. However, in RCADS-Parent, the parent reported that the client
has a Very High and High Average level of Panic Disorder and Obsessive Compulsive,
respectively.

This inconsistency may be rooted from the child’s cognitive and attention
problems. This means that he may not have well-understood the interviewer’s instruction
and questions during the assessment. Despite the observed discrepancy, the RCADS-
Parent can be utilized as a basis for impression since its results are aligned with the
client’s background information.

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• Dyslexia Assessment (From Davis Dyslexia Association International

The chart above implies the key areas of learning that addresses the client’s
tendency for Dyslexia Disorder. As shown, his scores fall in the Moderate level. In detail,
the client may have moderate difficulties in General Academic, Listening and/or Speech,
Math and/or Time Management, and Behavior, Health, Development and/or Personality.
His biggest problem areas seem to be in Vision, Reading, and/or Spelling, Writing and/or
Motor Skills, and Memory and/or Cognition. Nevertheless, the dyslexia assessment
results also show that the client is talented in the areas of Art and Building.
This assessment was designed primarily as an educational tool. The results
provide a better understanding of the client who completed the survey. The broad scope
of questions helps identify learning patterns that are commonly associated with dyslexia.
It also helps parents and teachers appreciate that symptoms of dyslexia extend beyond
difficulties with reading or spelling. This short online assessment cannot provide a formal
diagnosis of dyslexia, as that would require in-person testing by a qualified professional,
such as an educational psychologist. However, awareness of symptoms and patterns can
give individuals information that will help determine whether formal testing is
appropriate or necessary.

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• IQ Test for kids from 7 to 16 years old
IQ result Interpretation Correct Answers Test-taking time
60 Below Average 3 out of 30 19 mins 18 seconds

The client’s IQ test result is 60 which corresponds to a Below Average level IQ. In this
test, the client was only able to correctly answer 3 out of 30 items. Moreover, it took 19 minutes
and 18 seconds for the client to complete the test. The client’s test-taking time is 9 minutes
behind compared to the average population which only takes them for around 10 minutes. The
test result implies that this is not a very good result to his age of 8.

Review of Psychoeducational Record

• Previous Psychological Evaluation
On June 10, 2019, Luca had an Intelligence Evaluation with a Psychologist at Trece
Martires City, Cavite for SpED requirement purposes. The intelligence results indicated that
current intellectual functioning falls into Profound Level, with intellectual quotient of 10%.
Obtained results are considered as true representation of his innate skills, abilities, and potentials.
• Sample Handwriting
The first line shows the mother’s writing sample for the child to copy. The second line
pertains to the child’s handwriting. It is notable that some of the letters are not written properly
and spaces for each word cannot be appropriately identified. There are also crooked lines and
sketches after the name.

Conceptualization and Classification

A list of data sources and assessment methods were used to conceptualize the client’s
cognitive, academic, social-emotional, and behavioral functioning, as well as his eligibility for
special education support. The sections below provide details to validate these findings:
Academic and Cognitive Functioning
The client’s academic and cognitive functioning were reflected on the tests, interviews,
and observations made. As reported by the client’s mother, he experiences difficulty in reading,
writing, and mathematics, which caused him to be enrolled in a Special Education Center. This
claim is consistent with his results in Mental Status Examination for Children. In the specific
area of mathematics, the client was not able to accurately answer a simple addition and
subtraction problem. In writing, it was also evident that when he wrote his name, some of its
letters are reversed. In reading, he could not read a basic word.
Aside from MSE for Children, these findings were also supported by the client’s IQ test
result (Intelligence Quotient = 60%). This is 50% higher as compared to his previous intellectual
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evaluation (IQ=10%) with a psychologist last June 2019. Despite the increase, his IQ is still
below the average population. Furthermore, his dyslexia assessment showed a moderate score in
each of the learning areas.
The client’s below average IQ test result is also an evidence of his observed cognitive
functioning at home and school. The notable manifestation is his short-attention span—missing
important details of the interviewer’s instructions, and doing unnecessary things, thus, forgetting
that he is in the middle of an assessment; needing more time to complete a task, like taking a test;
and his difficulty in language and speech. He mispronounces words and stutters when
conversing. Likewise, it is backed up by his results in IQ test and dyslexia assessment.
The client’s art creativity as imaged in his artworks is seen as one of his core strengths
under cognitive ability. This is according to his mother’s report and as verified by his dyslexia
assessment result. Moreover, his awareness of his weaknesses, particularly his speech problem
and aggressiveness can be considered as part of his strengths. This statement is supported by his
result in Sack Sentence Completion Test.

Functioning on a Social, Emotional, and Behavioral Level

Social Functioning. Luca is active and loves to play with kids of his age. However, he struggles to
make proper interaction and communication them because of his speech problem—he stutters all
the time. This specific report is maintained by his results in Goodenough Draw a Person Test which
projects his difficulty in communicating with other children and adults.
In addition, he often feels weak, exhibits low confidence, and has trouble forming
interpersonal relationships. This is further supported by his Sack Sentence Completion Test which
indicates that he may feel superior over his peers but also goes through rejections during playtime.
Nonetheless, he can easily interact to people familiar to him. Moreover, despite his communication
problems, his RCADS-Parent test result indicates that his social phobia is in the Average level.
Emotional Functioning. There are times that Luca tends to be hot-tempered when annoyed or when
other children are making fun of him. This is because he is also struggling in making conversations
with them. He also gets aggressive when his wants are not immediately attended. In contrast, his
test results in Sack Sentence Completion Test suggest that he expresses positive feelings towards
his mother and his goals. Furthermore, he shows sentiments towards his family and appears to be
conformed to them.
Lastly, he exhibits anxiety symptoms as reported by his teacher. He feels afraid if he is
asked to talk in front of the class. He also feels scared when taking a test; and there are periods in
class in which Luca cannot think clearly. This account is reinforced by his test results in RCADS-
Parent, implying that his tendency of panic disorder is Very High. Fortunately, depressive
symptoms are not present, according to the result.
Behavioral Functioning. Based on Luca’s result in Mental Status Examination for Children, he
easily gets distracted and is not very cooperative with the interview and examination process. He
was also described as active, playful, and carefree. Luca is usually unmindful of the things around

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him and prefers to keep running, jumping, and moving his body. His behaviour at home seems not
to be problematic as his tantrums are manageable, according to his mother. He is also able to do
simple activities for self-care by his own. At school, his behaviour also seems not to be bothering
since he was able to adapt with the rules set by his teacher. This account is further strengthened by
his drawing in Draw a Person Test, projecting that he is rigid and has the determination to face life
directly.

Conclusion
Upon combining the multiple data sources, projective and objective assessment
instruments, and clinical judgment, the client has the tendency to meet the criteria of Language
Disorder, Childhood-Onset Fluency Disorder, and Dsycalculia—a Specific Learning Disorder
with an impairment in Mathematics. However, the latter does not have a substantial test result as
support, only the information background reported by the client’s mother.
Luca's differential diagnosis is Attention-deficit/hyperactivity disorder. This is evident in
his mental status examination, he has also a very short attention span and is easily distracted by
extraneous stimuli. Furthermore, he seems not to listen, does irrelevant things, and misses
important details on the interviewer's instructions. He kept moving, jumping, and getting out of
his seat from time to time and has some difficulty organizing tasks and activities. A specific
learning disorder is distinguished from the poor academic performance associated with ADHD,
because in the latter condition, the problems may not necessarily reflect specific difficulties in
learning academic skills but rather may reflect difficulties in performing those skills. However,
the co-occurrence of specific learning disorder and ADHD is more frequent than expected by
chance.
The client has persistent difficulties in the acquisition and use of language in speaking
and writing. This is because he has deficits in understanding words. His word knowledge is very
limited which is also the reason why he struggles communicating with others. Moreover, his
stuttering makes him disturbed in the normal fluency and time patterning of speech that are
inappropriate for his age and language skills. This is marked by his broken words and sound and
syllable repetitions.

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 Recommendations

Considering the client’s performance on measures of intelligence and cognitive ability,

combined with parent interviews and behaviour observations, he continues to be eligible for
special education support. The following recommendations may benefit the client based on the
evaluation's findings:
1. Continue to attend Speech Therapy classes to improve the client’s language and
communication. Interact through talking and playing, and using books, pictures other
objects as part of language intervention to help stimulate language development.

2. Provide strategies and homework for the child and parent or caregiver on how to do
speech therapy at home.

3. Give direct instructions designed for verbal activities. This will aid the client’s
difficulties in reading, writing, spelling and pronunciation of words and phrases.

4. Provide effective reading instruction that will focus on phonemic awareness and
phonemic decoding skills, fluency in word recognition, construction of meaning,
vocabulary, spelling, and writing.

5. Offer cognitive-behavioral approaches to teach the client monitor his own thought
processes.

6. Encourage the client’s strength and interest in arts and animal science. Allow him to
engage in activities that will help him explore and hone the skills he enjoys.

7. Let the client experience Computer-Assisted Learning. It can provide more academic
engagement and achievement than traditional pencil-and-paper methods. Computer
programs slow down grammatical sounds allowing young children to process them more
slowly and carefully.

8. Continue to visit and consult a mental health specialist for a clearer diagnosis.

Prepared by:
Cuadra, Delgra, Dumas, Fernandez, Ke-e, Laroa, and Macasa
4th year Psychology students

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 Appendices
A. Informed Consent

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B. Goodenough Draw A Person Test

C. Sample Handwriting

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D. Revised Child Anxiety and Depression Scale - Parent Version (RCADS-Parent)

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E. Revised Child Anxiety and Depression Scale - Child version (RCADS-Child)

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F. Previous Psychological Evaluation

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