What's Wrong with Kevin?

"Sharon, don't forget about the child study meeting this afternoon at 2:30," said Fran, the learning specialist. "We're discussing Kevin Smith's case again today. He's first on the docket because the psychologist has another appontment and has to leave by 3:15.  Do you think that your aide can get the kids on the bus for you?  We need to start at 2:30 sharp.".

"I'll see what I can do, Fran," Sharon replied as she passed through the school office on her way to the copy room. "Are Mr. and Mrs. Smith going to be there?"

"Yes but Kevin will have to stay at school till we're finished. Do you have any ideas how we can entertain him while we talk with his parents?" Fran asked tentatively as she followed Sharon into the copy room.

"I'll ask Ms. Stevens to take Kevin back to my room after she gets the other kids on the bus. He'll enjoy having the computer all to himself for a change.  He loves it so much," said Sharon as she hurried to copy some vocabulary practice sheets.

"Great!" said Fran in her typically cheerful manner. "I really appreciate your help. It's important that we arrive at some consensus about Kevin today. This process has already taken so long."

"I agree," Sharon responded as she inserted more copy paper into the machine. "I want to organize my thoughts on Kevin before the meeting," she said as she ran her copies.

"Yes, we want to represent Kevin accurately without upsetting his parents more than they already are," Fran agreed. Maybe  you can highlight some of the observations you have noted since he joined your class last fall," Fran suggested as she headed back to her office. Sharon had already given a lot of thought to what she should say about Kevin this afternoon. She considered all the previous child study team meetings she had attended to discuss her concern's about him. Her mind returned to last fall and she tried to remember when she first realized there was something different about Kevin.

Sharon Williams had been a kindergarten teacher at Oak Bend Elementary School for 13 years and this class was no different from previous ones. Sam, a high functioning child with autism, was included with her other kindergarten students this year. That did not concern her though, because children with special needs were often successfully included into general education classrooms at Oak Bend.

Sharon expected it to take several weeks before all of the children learned the routine and began to feel comfortable. After a month, most of her children were settled in and getting the hang of her classroom activities -- all except for Sam and Kevin.

She understood why Sam took longer to learn the routines; that was expected for children with autism. But what was the problem with Kevin? He was a cute, normal looking little boy who was very verbal and visually alert. He appeared to be intelligent and well prepared for kindergarten, but he never seemed to know what was going on in class.

She had mentioned Kevin to Mr. Robinson, the principal at Oak Bend, who knew Kevin's family well. He assured Sharon that Kevin was a perfectly normal, perhaps even precocious, child. Sharon agreed that, in many ways he was, but he always lagged behind the other children, watching to see what they did before he acted. He often looked confused or gave odd or inappropriate responses to questions. One day when his nose began to bleed, he made no attempt to let her know and by the time the other children alerted her, his face, shirt, and desk were covered with blood.

Sometimes when Sharon called his name or gave him oral instructions, Kevin didn't respond at all, as if he didn't hear her. On the rare occasions when he did try to tell her something, he had a difficult time getting the words out. His speech was hesitant and choppy as if he had to continually search for the words he wanted to say.

"Maybe he has a hearing problem," she thought at the beginning of the year. After sharing her concerns with his mother, Kevin was taken for a hearing evaluation. Although many of his responses were inconsistent, the audiologist determined that Kevin's hearing was within normal limits. She accounted for the inconsistencies by suggesting that Kevin had difficulties understanding and concentrating on the task of raising his hand when he heard the sound.

"Well, maybe he is just having adjustment problems," his mother had suggested when she informed Sharon about the results of the hearing evaluation. Then, there was the coat incident. That was probably the moment when Sharon knew something more serious was amiss. She had entered the room after lunch to discover many of the children's jackets on the floor. After directing the children to the reading circle for their afternoon story, she gathered up the jackets and brought them with her to the circle. "Whose jacket is this?" she called as she held the jackets up one by one. As the children claimed their jackets, they were directed to go to the back of the room and hang them up. When she held up the last jacket, no one raised his or her hand to claim it. She repeated the question "Whose jacket is this?" several times.

Finally, several children called out, "It's Kevin's jacket," as they pointed to Kevin sitting with them on the floor.

"Kevin, is this your jacket? Please go hang it up," Sharon instructed as she handed Kevin his jacket. Kevin, looking confused, took the jacket meekly, rolled it up, and with both hands, pushed it into the floor as if he were trying to hide it. He did not appear to understand Sharon's request even after watching the other children claim their jackets and hang them up.

"What a peculiar response," thought Sharon as she began to read the story she had selected for that day. "If it's not his hearing, then maybe he has a processing disorder."

After school that day, Sharon visited Fran Myers, the learning specialist, who coordinated all the services for the children with special needs at Oak Bend. "Fran, I have a little boy in my class who is really beginning to worry me. He already recognizes all of his letters and numbers but he can't count past 12 or say the alphabet in order. He still hasn't learned the class routine and he usually doesn't have a clue what's going on. His mom had his hearing checked but nothing unusual showed up. He also has a peculiar speech pattern, kind of monotone with hesitations, like he can't think of the words he wants to say. I think he might have a problem with comprehension or processing. What should I do?"

"Well, we should probably start by referring him to Megan Marks, our speech pathologist," Fran replied as she bent down to open the bottom drawer of her file cabinet. "Get his parents to sign this notification and permission form and we'll bring him up at the child study meeting next week. In the mean time, I'll come observe him so that we can both give Megan input. Megan can screen his speech and language and test further if she feels it's necessary."

"Okay, but we need to act fast because Kevin is already showing signs of frustration," Sharon continued as she shared some of her other concerns. "He's starting to withdraw from the rest of the class and yesterday he pushed another child down on the playground. Several children have complained to me that he has hurt them recently."

"What do his parents say about all this? Have you talked to them?" Fran asked as she made notes on a sheet of paper.

Sharon replied, "They came in on conference day and we discussed it but I didn't want to alarm them unnecessarily. They've noticed some of this behavior at home too, but they think he is just perfectionistic and shy. He really does have a lot of readiness skills; he has a good vocabulary and he already reads a little. He's a whiz on the computer so it's hard to explain to the Smiths why I'm so concerned. I'm sure they don't realize how poorly he is doing or how inappropriate his behavior is at times."

"Well, we'll do the best we can," Fran reassured her. "Voice your concerns to Mrs. Smith again when you ask her to sign the permission form and I'll talk to Megan about the urgency of testing Kevin soon."

Within two weeks, Megan gave Kevin a complete language evaluation that revealed average language functioning both receptively and expressively (report attached). She remarked that Kevin demonstrated a delayed response time when answering questions and that his expressive vocabulary scores were significantly better than his receptive vocabulary scores. Even though this pattern was atypical for a kindergarten child, Kevin did not meet criteria for enrollment in speech and language therapy.

"Now what?" thought Sharon. Kevin's behavior was becoming more bizarre. He was aloof with the other children, displayed ritualistic patterns of behavior, became agitated and upset when routines were disrupted, and appeared to be in a world of his own. She began to see similarities between Kevin's behavior and Sam's. In fact, Sam was making more progress and getting along better with the other children than Kevin.

In February, Kevin was evaluated by the school psychologist, Alan Moore (report attached). Kevin achieved average to above average scores on a number of intelligence measures, both verbal and nonverbal. However, the evaluation revealed considerable difficulties with processing, retaining, and retrieving information. In addition, Kevin was noted to perserverate on certain tasks and to have many characteristics of Attention Deficit/Hyperactivity Disorder. It was recommended that Mr. and Mrs. Smith consult Kevin's physician about managing his problems with attention and concentration. It was also recommended, in light of Kevin's processing and memory deficits, that he be retested by the speech therapist in a year to see if he would then qualify for language therapy.

At the parents’ request, the hearing evaluation was repeated in March and a mild, conductive hearing loss was detected in both ears. Because of the concerns noted by Kevin's teacher and parents, the audiologist recommended that Kevin use a phonic ear. This device, consisting of a microphone worn by the teacher and an earpiece worn by the student, was often used to amplify the teacher’s voice for children with mild hearing problems. At the same time, Kevin's doctor put him on a trial dose of Ritalin to improve his focus and concentration. Everyone was hopeful that these interventions would solve many of Kevin's problems.

Unfortunately, Kevin resisted wearing the earpieces and did not respond any better even when he did wear them. After two months on the medication, Sharon did not see any improvement in his ability to attend or concentrate. By this time, June was approaching and school would soon be out for the summer.

Mr. Robinson, the principal at Oak Bend, had for some time been encouraging Sharon to move to first grade next year. After much deliberation, Sharon decided to give it a try. Everyone involved with Kevin agreed it would be best for him to move up to first grade with her in order to maintain consistency, even though he had not mastered the kindergarten curriculum. Sam was also going to continue in her first grade class for similar reasons. Sharon was hopeful that over the summer the doctors could regulate Kevin's medication and by August he would return in better shape to learn.

When Kevin returned for first grade, his behavior, if anything, was worse. Because of the increasing demands of the first grade curriculum, he was less able to function and showed more aggression and "autistic-like behaviors." His doctors increased his medication but Kevin began to show signs of an adverse reaction known as a "speech push" (excessive talking) so the Ritalin was discontinued. They tried another medication called Depakote, but Kevin was so sleepy that he could barely keep his eyes open.

Kevin was now able to count only to 15 and still could not recite the alphabet in order. When shown a list of words in alphabetical order and asked to find the "b" word, or the "g" word, he would search the entire list, apparently not realizing that they had any particular order, even when it was pointed out to him. He was eligible for a reading improvement program, and was receiving a half-hour of individual instruction every day. According to the reading specialist, Kevin was making some appropriate gains but needed continual reminders to use visual cues while reading. She reported having a difficult time keeping Kevin on task.

Kevin's mom came in one day to help out in the classroom and Kevin, as if on cue, demonstrated some of his typically rigid behaviors. He refused to participate when the classroom routine was altered for a special activity. Sharon could tell that Mrs. Smith was shocked and disturbed by Kevin's inappropriate and immature behavior. The Smiths were also expressing concern because Kevin's four-year-old sister was now surpassing him academically.

"So that brings us to the present," thought Sharon as she considered what she should say on Kevin's behalf at the meeting this afternoon. "I have taught kindergarten for 13 years and I have never known another child like Kevin," she rehearsed. Well, that wasn't entirely true. She had known others with similar behaviors, but they were diagnosed as being autistic and had shown indications of the disorder from an early age. Kevin, to the best of everyone’s knowledge, had developed normally up until the age of five. "I hope the psychologist and the other specialists can shed some light on this case or give us some direction because I am simply out of ideas," she thought to herself as she prepared to greet her class.

We recommend that the following information is not shared until the conclusion of the case discussion.

More About the Case

Shortly after the meeting, Kevin was diagnosed with Laudau-Kleffner Syndrome, a rare seizure disorder causing severe language disturbances, which typically occurs after a period of normal language development (see attached). After Christmas, everyone was encouraged when Kevin went into a period of remission and began to make progress academically and socially. Then, unfortunately, the seizures reappeared over the summer and he again lost ground, becoming almost entirely nonverbal. Now, as Kevin's family and teachers struggle to support him during the periods when the seizures are active, they also search for answers to the baffling disorder as well as treatment options for Kevin's future. A new form of brain surgery has recently been considered. If Kevin is determined to be a good candidate for this surgery he will be one of a very few to have received it.

In this surgical technique, the doctor slices the brain with a tool that looks like a dental pick.  Those vertical cuts, 5 millimeters apart, interrupt the horizontal flow of abnormal brain activity.  Doctors report that the surgery has helped, to some degree, most of the children who have undergone it.

1. List what you learned/know about each of the characters in the case.
2. What do you think is motivating the thoughts/actions of each of the characters?
3. What are the issues/problems in the case?

1. What were some of the key indicators that caused Sharon to be concerned about Kevin’s progress?
2. Do you think that the referral mechanism in place at Kevin’s school served him well?
3. After reading Kevin’s test results, what would you have considered his weakest areas? His strengths? What patterns do you see in the test data?
4. Is there any correlation between the test data and how Kevin is performing/behaving in class?
5. Considering all of the information in the case and the assessment reports, what do you think is going on with Kevin?

Major Areas:

Characteristics of normal, delayed, and disordered communication patterns of exceptional individuals.

Typical procedures used for screening, prereferral, referral, and classification.

Appropriate application and interpretation of scores.

For more information on Landau Kleffner Syndrome

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