Other Health Impaired

Abstract

The category of Other Health Impaired (OHI) is unique to IDEA. It is neither in the DSM nor in any other classification taxonomy. OHI encompasses both medical and mental health conditions that are not included under the other IDEA categories. A multidisciplinary team must consider the definition of OHI, in combination with state policies, when making an eligibility decision. OHI is the third most prevalent special education classification comprising approximately 10.6 % of all special education classifications (Scull & Winkler, 2011). This feature makes it an important category for the psychologist in the school to understand.

Appendices

Appendix: Sample Report 1—Qualify Without Outside Diagnosis of ADHD

1.1 Assessment Methods

Reynolds Intellectual Assessment Scale (RIAS)

Woodcock–Johnson Tests of Achievement, Fourth Edition (WJ-IV)

Bender Visual Motor Gestalt, Second Edition (Bender-2)

Behavior Assessment System for Children, Second Edition (BASC-2)

• Ms. Carol Jones (First Grade Teacher)

ADHD Rating Scale IV

• Ms. Carol Jones (First Grade Teacher)

Teacher Interview

• Ms. Carol Jones (First Grade Teacher)

Parent Interview

• Ms. Daisy White (Mother)

Student Interview

• Tina White

Classroom Observations (5/16/16; 5/24/16)

Review of Academic Grade Reports

Review of School Records

Background Information

Tina White is a 7-year-old child in the first grade at the Smith Public School (SPS). Tina received early intervention services but was exited from them during her last year in preschool. Ms. White expressed concern that Tina might still be suffering from the adverse effects of extreme prematurity. Background reports indicate that Tina struggles with attention, distractibility, impulsivity, and loss of focus. She also struggles with conflict resolution and sometimes disregards teacher and classroom rules. Tina’s academic performance is considered low in reading comprehension and written expression. Her progress in other core academic areas is reported to be grade appropriate. Teacher reports also indicate concern about Tina’s behavioral and social progress.

Prenatal, Perinatal, and Early Developmental History: Tina was born with very low birth weight (1 lb., 6 oz) due to extreme prematurity (26 weeks gestation). She had a 3-month stay in the neonatal intensive care unit. Tina’s language was delayed compared to that of her siblings. Ms. Jones noted that Tina faced delays in learning to walk and did not walk until 14 months. All other developmental milestones were attained within normal limits.

Medical: Tina suffered from many ear infections as a child and required ear tubes. Tina wears glasses. Her hearing is within normal limits. She is not currently taking any medications. She is presently under the care of an endocrinologist out of concern that she might be entering puberty early.

Cognitive, Academic, and Language Functioning: Tina struggles with academic subjects that require sustained attention. When given independent work, Tina will start the assignment without reading instructions. This leads to incorrect work and performance below what she is capable of completing when the assignments are structured. Tina is able to fluently decode words and understands basic mathematics facts. However, she struggles with more complex academic activities such as written expression and reading comprehension. When Tina focuses, she is better able to accurately complete classwork. Ms. Jones reports that Tina struggles with homework and is easily frustrated by homework.

Social-Emotional and Behavioral Functioning: Ms. Jones indicates that she is concerned with Tina’s social and behavioral functioning. Tina frequently misperceives other children’s social cues. She was reported to have pushed a classmate who accidentally bumped into her desk. Tina insisted that the classmate did it on purpose. Tina can be impulsive and likes to be the center of attention in class. Ms. White reports that this is also an issue at home. She is constantly getting into arguments with her siblings over their shared attention with Ms. White.

Strengths: Tina’s strengths include potential leadership ability and an interest in doing well. When given the leadership role, Tina rises to the occasion and performs her duties appropriately.

Summary: Tina struggles with academic subjects that require sustained attention. This includes reading comprehension and written expression. Tina also experiences conflict with peers when she misinterprets social cues.

Cognitive and Academic Functioning

3.1 Reynolds Intellectual Assessment Scale (RIAS)

Tina was administered the Reynolds Intellectual Assessment Scales (RIAS). The RIAS is an individually administered measure of intellectual functioning normed for individuals between the ages of 3 and 94 years. The RIAS contains several individual tests of intellectual problem solving and reasoning ability that are combined to form a Verbal Intelligence Index (VIX) and a Nonverbal Intelligence Index (NIX). The subtests that compose the VIX assess verbal reasoning ability along with the ability to access and apply prior learning in solving language-related tasks. Although labeled the Verbal Intelligence Index, the VIX is also a reasonable approximation of crystallized intelligence. The NIX comprises subtests that assess nonverbal reasoning and spatial ability. Although labeled the Nonverbal Intelligence Index, the NIX also provides a reasonable approximation of fluid intelligence and spatial ability. These two indexes of intellectual functioning are then combined to form an overall Composite Intelligence Index (CIX). By combining the VIX and the NIX into the CIX, a strong, reliable assessment of general intelligence (g) is obtained. The CIX measures the two most important aspects of general intelligence according to recent theories and research findings: reasoning or fluid abilities and verbal or crystallized abilities.

The RIAS also contains subtests designed to assess verbal memory and nonverbal memory. Depending upon the age of the individual being evaluated, the verbal memory subtest consists of a series of sentences, age-appropriate stories, or both, read aloud to the examinee. The examinee is then asked to recall these sentences or stories as precisely as possible. The nonverbal memory subtest consists of the presentation of pictures of various objects or abstract designs for a period of 5 s. The examinee is then shown a page containing six similar objects or figures and must discern which object or figure has previously been shown. The scores from the verbal memory and nonverbal memory subtests are combined to form a Composite Memory Index (CMX), which provides a strong, reliable assessment of working memory and may also provide indications as to whether or not a more detailed assessment of memory functions may be required. In addition, the high reliability of the verbal and nonverbal memory subtests allows them to be compared directly to each other.

Each of these indexes is expressed as an age-corrected standard score that is scaled to a mean of 100 and a standard deviation of 15. These scores are normally distributed and can be converted to a variety of other metrics if desired.

Following are the results of Tina’s performance on the RIAS.

	Composite IQ	Verbal IQ	Nonverbal IQ	Memory index
RIAS index	104	109	98	93
Percentile	61	73	45	32
Confidence interval (95 %)	98–109	102–115	92–103	87–100

On testing with the RIAS, Tina attained a Composite Intelligence Index of 104. On the RIAS, this level of performance falls within the range of scores designated as average and exceeded the performance of 61 % of individuals at Tina's age. Her Verbal IQ (Standard Score = 109; 73rd percentile) was in the average range and exceeded 73 of individuals Tina’s age. Tina’s Nonverbal IQ (Standard Score = 98; 45th percentile) was in the average range, exceeding 45 % of individuals Tina’s age. Tina earned a Composite Memory Index (CMX) of 93, which falls within the average range of working memory skills and exceeds the performance of 32 out of 100 individuals Tina’s age.

3.2 Woodcock–Johnson Tests of Achievement-IV (WJ-IV)

The WJ-IV is an achievement test used to measure basic reading, writing, and mathematics skills. The Reading composite includes letter and word identification, vocabulary, and comprehension skills. The Writing composite includes spelling, writing fluency, and simple sentence writing. The Mathematics composite includes calculation, practical problems, and knowledge of mathematical concepts and vocabulary.

Tina obtained the following scores in each of the areas of measurement:

	Standard score	Percentile	Descriptive classification
Broad reading	81	11	Low average
Letter-word ID	92	38	Average
Sentence reading fluency	92	38	Average
Passage comprehension	78	7	Below Average
Broad writing	86	20	Low average
Writing samples	77	6	Below average
Sentence writing fluency	81	9	Low average
Spelling	92	27	Average
Broad mathematics	96	48	Average
Math facts fluency	98	49	Average
Applied problems	94	45	Average
Calculation	92	29	Average

Standardized achievement test results revealed low average performance across broad reading and writing clusters. Tina scored in the average range on the broad mathematics clusters. Tina scored in the below average range on the passage comprehension and writing samples subtests.

3.3 Bender Visual-Motor Gestalt Test, Second Edition (Bender-II)

The Bender-II measures visual-motor integration skills, or the ability to see and copy figures accurately. A quantitative and qualitative analysis of Tina’s drawings suggests that her visual-motor integration abilities (e.g., fine motor skills for paper and pencil tasks) are below average (Copy Standard Score = 75; 7th percentile). However, Tina also quickly completed the drawings and was less concerned about her performance on this test.

Social-Emotional and Behavioral Functioning

4.1 Behavior Assessment System for Children, Second Edition (BASC-2)

The Behavior Assessment System for Children, Second Edition (BASC-2) is an integrated system designed to facilitate the differential diagnosis and classification of a variety of emotional and behavioral conditions in children. It possesses validity scales and several clinical scales, which reflect different dimensions of a child’s personality. T-scores between 40 and 60 are considered average. Scores greater than 70 (T > 70) are in the Clinically Significant range and suggest a high level of difficulty. Scores in the At-Risk range (T-Score 65–69) identify either a significant problem that may not be severe enough to require formal treatment or a potential of developing a problem that needs careful monitoring. On the Adaptive Scales, scores below 30 are considered clinically significant while scores between 31 and 35 are considered at-risk.

Clinical scales	Ms. Jones
	T-score	Percentile
Hyperactivity	67*	93
Aggression	74**	98
Conduct problems	71**	97
Anxiety	50	50
Depression	62	88
Somatization	69*	94
Attention problems	62	88
Learning problems	42	23
Atypicality	66*	93
Withdrawal	66*	93
Adaptability	30*	3
Social skills	40	15
Leadership	43	23
Study skills	40	15
Functional communication	49	49
Externalizing problems	72**	98
Internalizing problems	63	89
Behavioral symptoms index	70**	98
Adaptive skills	39*	15
School problems	52	53

*At-risk

**Clinically significant

BASC-2 ratings suggest a clinically significant rating on the overall behavior symptoms index and on the externalizing problems composite. She was rated as at-risk on the adaptive skills composite. Tina was also rated as clinically significant on the aggression and conduct problems scales. She was in the at-risk range on the hyperactivity, somatization, withdrawal, atypicality, and adaptability scales.

4.2 ADHD Rating Scale IV

The ADHD Rating Scale IV is a rating scale consisting of ADHD symptoms based on the DSM V diagnostic criteria. In general, scores between the 85th and 93rd percentile are considered above average or “at-risk” for symptom cluster compared to the normative sample. Scores above the 93rd percentile are generally considered clinically significant. Tina received the following scores:

Scale	Teacher percentile	Parent percentile
Hyperactivity/impulsivity	95th (clinically significant)	95th (clinically significant)
Inattention	94th (Clinically significant)	95th (clinically significant)
Combined	97th (Clinically significant)	97th (clinically significant)

Interview Results

Parent Interview (May 16, 2016): Ms. Sharon White was interviewed regarding her impressions of Tina’s progress at school. Ms. White explained that Tina is experiencing behavioral issues at school explaining that Tina is “very touchy and tactile” with other children. Ms. White continued, “over the past few weeks, things have gone downhill. I’m getting frequent phone calls.” Ms. White indicated that Tina needs constant redirection. She noted that Tina is “very impulsive and does much before thinking.” Ms. White explained that this is having an effect on her schoolwork because Tina is being sent out every day and is beginning to dislike school as a result. Ms. White explained that Tina also has a low frustration tolerance and is very easy to agitate. Ms. White noted that Tina was born at 26 weeks weighing 1 lb, 6 oz. Tina had a 3 month stay in the NICU at the Hospital of the University of Pennsylvania. She received early intervention and the gap narrowed. Ms. White explained that in kindergarten, there were no academic issues present, but Tina struggled with social issues and relating to other children. Ms. White stated that Tina’s kindergarten report card indicated a wide range of grades. Ms. White stated that she wants to know whether Tina is struggling in any area before it becomes a bigger problem. Ms. White commented on one other medical issue that Tina is facing and noted that this issue is related to her prematurity. Ms. White explained that Tina is under the care of an endocrinologist because she may be entering puberty early. Ms. White noted that Tina’s strengths include being a leader and taking pride in doing jobs assigned to her.

Student Interview (May 24, 2016): Tina was interviewed to ascertain impressions of her progress at SPS. Tina indicated that she does not like SPS, noting that “the people at the school are mean.” Tina stated that she “hates Mr. Jeff. My grandma came down and cursed him out.” Tina was unclear in her description of the incident. Tina was asked about her friendships at school. She stated that she “does not have friends; well, maybe one friend.” Tina explained that she prefers to play by herself at home. Tina was next asked about her behavior at school. Tina indicated that she sometimes gets into trouble for no apparent reason. Tina stated that she should not get into trouble at school because she “has not harmed anyone.” Tina explained that her strengths/interests include playing card games.

Teacher Interview (May 16, 2016): Ms. Carol Jones, Tina’s first grade teacher, was interviewed regarding Tina’s academic, behavioral, emotional, and social functioning. Ms. Jones noted that Tina is progressing toward the bottom quarter of the class. She notes that Tina is capable of completing work, but is rarely able to focus. As a result, Tina’s academic performance suffers. She explained that Tina is reading at a guided reading of J. Ms. Jones stated that Tina faces difficulties with her behavioral and social progress. She indicated that Tina struggles with social interaction. Ms. Jones stated that Tina tends to misperceive other children’s intent and interprets ambiguous and even benign intent as hostile. In turn, Tina tends to overreact, which creates an escalation of the incident. Ms. Jones also explained that Tina pushes in line and prefers to be the center of attention in the classroom. When she does not get it, she sometimes will start pouting. Ms. Jones indicated that Tina tends to be impulsive and will often begin an assignment or answer a question before the directions were offered. Ms. Jones explained that Tina believes she understands what she needs to do and will begin the assignment without fully listening to directions. Ms. Jones explained that Tina’s needs include learning how to resolve conflicts and interact with other children in an appropriate way. Tina also needs to improve her listening skills and her tendency to act before thinking.

Observations

Classroom Observation (May 16 and 24, 2016): Tina was observed for 15 min in Ms. Jones’s class on two occasions. During the first occasion, Tina was working on an in-class assignment at her desk. She was observed to be on task and following classroom rules. During the second observation, Tina was working in a small group facilitated by Ms. Jones. Ms. Jones was assisting another student on a worksheet. Tina interrupted Ms. Jones during her instruction with another student. Tina was told to wait a few minutes until she was finished with the other student. Tina waited and was furnished with guidance regarding one of the problems. Approximately 7 min into this observation, Tina was asked to report to the Discovery Room where she was tested for reading glasses. Impressions of the observation were that Tina was generally compliant with classroom rules, but was impulsive on one occasion when she sought Ms. Jones’ help.

Observation During Assessment: Tina was attentive and compliant during the cognitive assessment. She appeared to enjoy the one on one attention with the examiner. During the achievement portion of the assessment, Tina became inattentive. Several times she asked the examiner if the assessment was almost done. The assessment results are considered a valid representation of Tina’s abilities.

Conceptualization and Classification

Multiple data sources and methods of assessment inform the conceptualization of Tina’s cognitive, academic, social-emotional, and behavioral functioning including whether she qualifies for special education support. Details in support of these findings are offered below.

Cognitive and Academic Functioning: Tina’s present performance on measures of cognitive ability was in the average range (Composite IQ = 104; 61st percentile; VIQ = 109, 73rd percentile; NIQ = 98, 45th percentile). Tina’s performance on the WJ-IV Achievement was low average and writing. Tina was average in mathematics. Her attentional difficulties appear to impact her performance on tasks that require sustained attention. For example, Tina scored in the average range on measures of word decoding, spelling and reading fluency, but in the below average range on measures of reading comprehension (passage comprehension) and written expression (writing samples).

Social-Emotional and Behavioral Functioning: Tina struggles with impulsivity, inattentiveness, disorganization, and following directions. She also struggles in her interaction with other children in the classroom. Tina tends to misperceive the intent of others and considers even benign interaction as hostile. On occasion, Tina will disregard teacher and classroom rules, but this is related to not attending to the teacher’s request. She will benefit from teacher guidance and support for her social and behavioral difficulties.

Summary: Tina struggles with reading comprehension and written expression as a result of her documented difficulties with inattentiveness, distractibility, and hyperactivity. Tina also experiences difficulty getting along with other children in the classroom.

Summary and Recommendations

Considering multiple data sources and methods of assessment, Tina will qualify for specially designed instruction under a classification of Other Health Impaired since her documented difficulties with Attention-Deficit/Hyperactivity Disorder are adversely impacting her progress in the classroom. The team concludes that specially designed instruction is called for in this case. The following recommendations might benefit her.

• 1. Strategies for difficulties with Attention, Distractibility, Hyperactivity, and Loss of Focus: Background reports indicate that Tina experiences difficulty with attention, impulsivity, distractibility, and loss of focus. As such, the following recommendations might be beneficial for her:

  • (a) Check In, Check Out, and Behavior Report Card: Tina should have his behavioral expectations reviewed at the beginning of the school day. He should check in with an adult periodically throughout the day to determine whether his goals are being met. At the end of the day, Tina should check out with that same adult and receive a behavior report card that acknowledges his behavioral performance and is sent home to his caregivers.

  • (b) Provision of Directions by Teacher: When Tina’s teachers interact with him, he should be encouraged to repeat and explain instructions to ensure understanding. The provision of directions to Tina will be most effective when the teacher makes eye contact, avoids multiple commands, is clear and to the point, and permits repetition of directions when needed or asked for.

  • (c) Positive Reinforcement and Praise for Successful Task Completion: Tina’s teachers should provide positive reinforcement and immediate feedback for completion of desired behaviors or tasks. Initially, praise and reinforcement should be offered for successful effort on a task or behavior regardless of quality of performance.

  • (d) Time on Task: Communicate to Tina how long he will need to engage in or pay attention on a particular task. Open ended expectations can be distressing to any child, let alone one with attentional difficulties.

  • (e) Prepare Student Discreetly for Transitions: Furnish Tina with verbal prompts and visual cues that a new activity or task is about to start. This should be accomplished discreetly so as to avoid student embarrassment.

  • (f) Recess Time: Tina should be permitted to participate in recess. Recess should not be a time to complete unfinished classwork or homework.

  • (g) Extended Time, Teacher Check In’s, Assignment Adjustment, and Frequent Breaks: Tina should be permitted additional time to complete academic tasks and projects. Tina’s teachers should also consider review of classwork as Tina progresses on an assignment or project to assist Tina in avoiding careless mistakes. He may benefit from chunking assignments or assignment reduction. More frequent breaks than what is typical may also reduce careless mistakes and help to maintain focus.

• 2. Social Problem Solving Skills: Tina would benefit from support and guidance regarding conflict resolution with peers. She has a tendency to misperceive the intentions of others which can escalate into a conflict. Social problems solving skills may be taught to her by her teachers as a conflict occurs or within an individual or group counseling session by the school counselor.

• 3. Reading Comprehension: Tina struggles with the comprehension of written text and will benefit from pre-reading and organizational strategies that attempt to improve skills in this area. Following are a few suggestions that will likely benefit Tina:

  • (a) Before reading, preview the text by looking at the title and illustrations.

  • (b) Encourage the creation of a possible story from the illustrations.

  • (c) Make predictions about the story based on story features prior to reading the story.

  • (d) During reading, generate questions about the story that are directly related to the text and that require thinking beyond the text.

  • (e) After reading, spend time reflecting upon the material and relating it to experiences and events the child has encountered.

  • (f) After reading, have Tina engage in the reading material using text summarizing.

• 4. Difficulties with Writing: Tina struggles with expressing her ideas in written form. The following recommendations may be appropriate for her:

  • (a) Assist Tina in generating ideas about a topic and then show her how to put the ideas in an outline.

  • (b) Demonstrate for Tina outlining principles. Have her practice what you just demonstrated so that she can distinguish between main ideas and supporting ideas.

  • (c) Assist Tina in creating a paragraph and then show her that that paragraphs require an introduction, a middle, and a conclusion. Require that Tina generate her own paragraph and offer corrective feedback.

  • (d) Require Tina to proofread her written work and provide corrective feedback when appropriate.

Stefan C. Dombrowski, Ph.D.

Licensed Psychologist (PA and NJ)

Certified School Psychologist (PA and NJ)