גילה קדוש דדון - דוקטורנטית חינוך מיוחד

Case Management Model

Case Management Model – feasibility review of an idiosyncratic treatment plan with children / youth with ADD

Abstract

BY:Gila Kadosh-Dadon
ADHD is a general term encompassing a wide range of symptomatic cognitive and operational impediments. ADD Attention Deficit Disorder is a subtype of ADHD, denoting lacks and difficulties in attentiveness. A child with ADD is required to manage a complicated course of development. In order for him to grow up as a whole and fulfilled human being he/she requires intensive support – scholastic and emotional – throughout his/her development. This paper offers an idiosyncratic model of case management treatment methods for children with special needs.  Within the model we conduct a didactic psychological diagnosis, which serves as a basis for an idiosyncratic treatment plan, tailored to the unique needs of the child, and assuring emotional support, all through care or guidance in relevant content. 
Case management as well includes professional and empathic management by the case manager of all the child’s support circles – parents, teachers and professionals, within and without the education system. 
The present research examined the effectiveness of the model as it was implemented upon three children with a similar learning profile. Utilizing a multi-case research format, data was gathered within a qualitative naturalistic paradigm.
The findings of the research prove that ADD does not disappear with growing up. Still, scholastic as well as emotional support allows children with ADD to cope with the difficulty and to express their abilities. Over the years of working with each child it is possible to see impressive academic, emotional and personal progress. 
ADD is a general term that deals with a wide spectrum of deficiency symptoms, cognitive and operational. Four decades after the term ADD was first coined it still lacks a uniformed and coherent definition but it is widely understood that the disability stems from intrinsic factors and that it leads to gaps between intellectual potential and actual academic functioning (Gumpel & Sharoni, 2007). 
ADD (Attention Deficit Disorder) is a specific deficiency, inclusive of up to nine specific inattentiveness symptoms: lack of attention to details or mistakes stemming from rashness; attention deficits ; flagrant inattentiveness; easy distraction by irrelevant sights, sounds and extraneous stimuli; difficulties in organizing; avoidance of tasks requiring mental effort; loss of materials pertaining to tasks; high distractedness and forgetfulness concerning daily activities. (American Psychiatric Association, 2000).  
A child with ADD encounters a complicated and bumpy development course, experiencing difficulties in almost all aspects of development: cognitive, emotional, social, behavioral etc.
According to current cognitive research, AD(H)D children lack in operative/executive functioning that enable self monitoring/control and regulation (Sergeant et al, 2002). These children have difficulties in organizing and executing tasks; in short and long term focusing and keeping attention; in regulating their alertness; in controlling frustration; in memory usage; and in self monitoring and regulating (Brown, 2005). 
In the emotional domain, there is evidence that these children experience high pressure, anxiety and occasionally depression (Ramirez, 2005; Cohen, 1985). Some of them find it difficult to develop interpersonal interactions; they suffer social rejection and isolation (Bender, 1997; Clegg & Landsall-Welfare, 1995; Hinshaw, 1994). Sometimes they evince behavioral problems such as hyperactivity and aggressiveness (Gadeyne, Ghesquie`re, & Onghena, 2003; Osman, 2000; Willcutt & Pennington, 2000). Often they experience gaps between their abilities and achievements. These find expression in constant difficulties at school, failures and a vicious circle of helplessness (Barkley, 1998; Bender, 1997; Hinshaw, 1994). In these circumstances they cannot develop proper and effective coping skills, therefore reacting to pressure by avoidance or aggression (Young, 2005). Consequently a child fails to develop a proper self image and the resilience necessary for social success and acceptance (Mather & Ofiesh, 2005).
But the child is not alone - he is a part of a social network comprised of parents, siblings and peers, on the one hand, and professionals both within school and without.
The parents comprise the inner circle. Parents of children with AD(H)D face immense challenges. First of all, family life is complicated; the child with special needs shifts the family's center of gravity – influences the climate, the agenda, the financial considerations, etc. (Whalen, Henker, Jamner, Ishikawa, Floro, Swindle, Perwien, & Johnston, 2006). Moreover, being a parent to an AD(H)D child is  not simple – there is always peer and family criticism as well as frustration and anger (Malacrida, 2003). Finally the pressures and stresses involved in the care needed by a child like this, the responsibility for his/her welfare present and future, take their toll.
For an ADD child to grow into a full person, active, fulfilled and a contributor to society, he requires intensive support throughout his development – from his inner circle (parents, siblings), via the professionals that surround him, and finally from his academic environment (school).
Current structured intervention plans are directed mainly at the family and/or classroom. Academic intervention plans include instructional modification and strategy qualification. Intervention plans within peer groups concentrate on providing proper skills such as communication, cooperation and participation. Family intervention plans are directed at changing parental behavior patterns. In addition there is a variety of school and classroom intervention plans aimed at achieving behavioral change and academic improvement (Chronis et al., 2006).
The present research examines a new methodology of working with ADD children, which is the outcome of a personal narrative. A variety of methods were developed by me during the last twenty years. At first they were individually validated in my treatment of my son. Later they were implemented at various working spheres: schools and other educational institutions, at "Nitzan" (the Israeli Association for Children with Learning Disabilities),  at communication workshops and clinically. In fact, this research examines the effectiveness of case management as it is implemented in the AD(H)D domain. 
 
Methodology
The leading paradigm of the research is the qualitative naturalist. This kind of research is characterized by a holistic attitude to phenomena. Qualitative researchers aim at understanding phenomena and situations as whole entities, with an emphasis on processes, interactions, reciprocity and meaning (Clandinini, 2000, Shkedy, 2003). Reality is examined and interpreted from the individual's perspective – the subjective world on the subject or subjects. There are no preconceptions concerning an absolute or objective reality (Tsabar, 2001, Shkedy, 2003).
This perspective is compatible with the ethics and philosophy of participatory research (Stalker, 1998). Children with ADD are involved in the research, supported by emphatic professionals; the experience of the child/subject is at the core of the research.   
The present research aims therefore to examine an intervention process designed to promote a child with ADD. The planned intervention was first tested on one ADD child (a pilot – the researcher's son); after further fine tuning, it was implemented on two other children, and systematically evaluated.
An examination of such processes requires in depth examination of the children's personal life stories as well as those of the supporting family members and the professionals. The data gathering method is required to reflect the process, the meanings and experiences of all participants. Therefore we chose the qualitative naturalist method. 
Case research concentrates on gathering and presenting specific data on one or a few subjects. This kind of qualitative research emphasizes subjective experimental aspects and context (Shkedy, 2003).
Multi case researches require time and money. This method leans on the reconstruction principle. Thus, a significant finding from one case is reproduced in the others, thus enhancing the whole research (Yin, 2002).
The three cases of the present research were hand picked to reflect complex ADD and similar learning profiles. The first sample is the researcher's son, and the project grew while trying to find a variety of solutions to his deficiency. The other two, having similar learning profile, are treated by the researcher at her own clinic.
Thus were three cases examined in a model of multi-case research. Each research unit includes a personal narrative as it was told by some significant informants, a specific treatment plan and the relevant circles of support. Data was gathered in accordance with the rules of the qualitative naturalist paradigm, with research tools such as: narrative, interviews, observations, text analysis of vignettes, notebooks, school examinations, diaries, documents etc. 
Narrative analysis was conducted in three consecutive steps: biographical, linguistic and contextual (Rosenthal, 1987 with Bar-On 1994). On a more general level, data analysis was thematic, using categories in order to create meaning (Shkedy,2004). We analyzed each of the three research units for each category, identifying similar patterns without neglecting the uniqueness of each case. The outcome, the "categories three" represents a categorical mapping of the analysis process. 
 
 
 
 
 
Findings
The main findings of the research are presented analogous to the process accompanying its participants and their families – analysis; identification of the difficulty; parents' research after information and solutions; case management within a model that answers to the special needs of children with ADD. 
Analysis as a generating process.
Analysis starts with the appearance of foreboding signs of various abnormality. These preliminary indications can appear during an acute and dramatic incident, such as an illness accompanied by high temperature that causes neurological damage; the indications may include abnormal behavior patterns, or minor impediments that are expressed in underachieving. During childhood, all three subjects suffered from conspicuous social difficulties and low frustration thresholds. Two of them were high temperamental, restive and highly distracted.
 
"Then I found Dan jerking very hard involuntarily and unconscious… I tried to shake him and apply artificial respiration but to no avail, so I ran down the steps…. At the hospital D' was immediately treated to artificial respiration and regained consciousness. D' remained at the hospital for a comprehensive examination…. There were no concrete findings. (An interview with his mother)
Dory cried constantly, did not cling to me like babies do and never were at rest, not a moment of quiet, a crybaby, never slept like other babies or as is written in the books, therefore I became a nervous wreck. (Mother).
 
Zila was a sweet baby but restless, already at that age I discerned that she would scream until I got to her. Not patient and silently crying, but restive." (Mother)
 
                                               
The initiative for the diagnosis is normally external. The family learns from the environment that something is wrong with the child's development. The earlier the initial symptoms are conspicuous, the earlier the initial diagnosis is performed. The initial diagnosis exposes difficulties and gaps in development; however, it explains the picture only partially – the deficiency is not diagnosed at this early stage. 
"The nursery teacher never informed us about any anomalies, therefore on receiving a letter from the municipality, inviting us to a meeting of a placement committee I was greatly surprised… the psychologist opened the meeting with a laconic report of my sons learning profile, then spoke the other members, trying to convince us to place the child in a small diagnostic setting, where "they" would be able to help him to fulfill himself." (Mother)
"One day the psychologist spoke to us outside the kindergarten, saying that although Zila does not belong to her special care group, she would like to draw our attention to a number of problems that she discerns, which justify a diagnosis. So we asked for one."(Mother)
"In the 7th grade her difficulties grew so we decided on a psychological diagnosis. The psychologist said that she is experiencing mental difficulties due to being frustrated at school… nothing about scholastic matters." (Mother)    
 
 
 
The integral diagnosis is not the first diagnosis – it is performed only after likelihood has been established that the scholastic difficulties do not result solely from emotional problems. An integral diagnosis comprises an emotional and an academic evaluation. In all cases – the psychological evaluation focuses on emotional-social difficulties, and the didactic one exposes all aspects of the deficiency. Within the present research the integral diagnosis took place at an early stage in cases of seeming acuteness, as an alternative to a standard diagnosis. In cases of mild seeming the integral diagnosis was conducted at a later stage. 
 
"We arrived at Professor F's clinique in Jerusalem. Prof. F' diagnoses children from different cultural backgrounds, using non verbal tools. The diagnosis took part during several meetings. Dan was cooperative, and eager for each consecutive meeting. At the concluding meeting Prof. F' presented Dan's scholastic profile, emphasizing his high capabilities, as well as his weaknesses, indicating D's learning deficiency."
"Dory was diagnosed after three years of psychological therapy. The emotional aspects were treated and it was time to highlight his scholastic and social profile. D' was in 3rd class and has not yet acquired basic skills: reading and writing, did not conform to writing conventions, and his lettering was very deficient. He did not prepare his homework and did not inform his parents about them." (Diagnostician)
Until junior high we did not think about learning deficiency. Only at the end of junior high did I understand that this was the right time for an integral diagnosis, because there was a window of opportunity…" (Zila's Mother)       
 
2. Learning deficiency does not pass with age.
All three cases in the research represent multi learning deficiency – ADD, memory difficulties and dysgraphia. All children have above average cognitive potential – they all function above the typical norm of their age, but the deficiency hinders and prevents fulfillment of that potential within the educational, social and familial spheres.  
Two of the children were diagnosed as suffering from ADD (Attention Deficit Disorder) – which represents a pure attention and concentration disorder. The term denotes people of all ages who suffer from chronic difficulties in attention and concentration. The third child was diagnosed with ADHD, an attention deficit containing an element of impulsiveness and hyperactivity. Attention deficit may present a difficulty in choosing from a variety of stimuli operating on a person at a given time, those which are relevant to the present situation, and react properly. Other manifestation may include difficulties in vocal choice – inability to separate a meaningful sound from a multiplicity of sounds; and difficulties in transferal of attention – the ability to transfer attention from one stimulus to another, when the old one is not necessary anymore. 
 
"There are acute attention fluctuations, as a function of the attractiveness of the stimuli or the degree of control. His attention span is short, and in a formal setting he tends to disengage and go astray. Constant stimuli changes and an external mediator are necessary to enlist his attention." (From a diagnosis of Dan, 4th grade, Peled)
"Dory most significant impediment is in maintaining a good concentration level."
"In the past there were behavioral difficulties at home and at nursery school, expressed by blowups and tantrums."
"Zila experiences….  Attention deficits and troubles in planning and getting organized for tasks, weak diligence and control."     
 
 
All children's disorders include deficiencies in various perceptual channels. These deficiencies impede acquiring basic skills – reading and writing. Dysgraphia as well distorts their writing style which is characterized by large and faulty hand writing, defective lettering, writing between lines, anagrammatic writing, unequal spacing of letters, many writing mistakes due to homophonic replacements and ignorance of grammatical and writing rules.  
As aforesaid, the intelligence levels of these children are at the top of the norms for their age groups. However, due to their objective difficulties, often their academic achievements do not reflect their potentials. There is a significant variance in their personal traits. Externally, Dan is the most quite and calm. Dory is the most volatile (ADHD), and Zila' is calmer but still rather active.  
"Dan is every teacher's dream – quiet, organized and diligent." (Dan)
"In the past there were behavioral problems, at home and nursery school, tantrums and difficulties in coping with hardships and losing in children's games." (Dory)
"According to the teachers she was an insolent student, having difficulties in postponing gratifications, spiteful, all of which was understood as non-conformism directed at them."  (Zila's Mather)
All three share a desire to succeed, but differ in the prices that they are willing to pay for success. Whereas Dan is willing to immerse himself in his studies and pay a social price and in mental pressure, the other two are more forgiving.
 
"Tends to perfectionism and very self demanding, greatly frustrated when facing a mistake or a failure." (Dan) 
"Dory was cooperative all through the diagnosis and was highly motivated."
"Zila seemed to be ambitious but not enough self demanding to fulfill these wishes." (Daniela & Gila Kadosh Dadon).
 
Identification of a deficiency is significant to the life of the individual, and its timing has crucial importance to his development. The three subjects of the present research represent three ages of identification. Their personal stories reveal the crucial importance of that age.  
Dan was diagnosed while in nursery school, Dory at elementary school, Zila just before high school. All were treated immediately. Therefore Dan has benefited from support circles since he can remember; Dory experienced considerable difficulties in acquiring basic skills, but after identifying the deficiency and with the right treatment, means were found to evince his potential. Zila wasted many years while amassing scholastic gaps as well as many frustrations. 
 
"Dan was three and a half years old. We arrived for a systematic didactic diagnosis in Jerusalem, were we heard the term 'learning deficiency' for the first time."
"Actually, only at 3rd grade, after a systematic diagnosis, was the problem defined. And we had to cope with  the difficulties." (Dory's father).
"The diagnosis exposed us for the first time to Zila's difficulties and I felt frustrated that she has been living so long with the deficiency without getting proper treatment."(Mother)  
 
 
The present research findings prove that the identification age projects on many life aspects, such as self image, awareness of the learning deficiency and its inner meaning. The self image evolves from a set of self expectations, and is influenced by gaps between these and actual achievements. As aforesaid, children with learning deficiencies often experience the gap between their potential and achievements.  Difficulties in acquiring basic skills, social seclusion and frustration at being under achievers, all these cause lowering of self expectations and self image.     
 
"I remember my first years at school: I was mostly alone, in class and at intermissions. It was hard for me to communicate with other children, and everything was scary and threatening…" (Dan)
"At the nursery school… the teacher willed me to sit and be quite…. She used to send me to the kitchen to help her assistant… I hated being there' wanted home, to mum and dad. I felt horribly lonely." (Dory)
"at elementary school, they kept punishing me, because I did not prepare my homework, I kept forgetting books and notebooks. My diary was full of reprimands intended for my parents…. Neither the teachers nor the other girls liked me." (Zila)
 
Awareness is relevant to the child's own attitudes to his deficiency. Awareness is shaped by the difficulties and the feelings of being different compared to the peer group. These sensations may evolve from social comparisons, family tales and personal experiences. 
Dan was diagnosed while being young – he developed as a person in the shadow of his deficiency. Dory grew up feeling different – with seeds of awareness to his potential versus objective difficulties; the diagnosis of his deficiency actually brought relief. Zila was perceived as lazy and antagonistic. The earlier in the child's life an integral diagnosis is carried; the higher is the awareness to the deficiency. Moreover, the younger is the age of identifying the deficiency; the stronger are its inner implications.
Thus for Dan it is a part of his narrative, his identity, perhaps of his destiny. Dory's deficiency as well is inherent to his personality. While Zila does not relate to it; she does not see it as a part of her personality. It is a part of her life – but apparently not an inherent aspect.  
 
"Learning deficiency is a difficulty that you arrive to the world with – a hardship that accompanies me since I know myself, nothing comes easily… everything should be reprocessed, many times with assistance… searching all the times for ways to bypass the weakness so as to better express myself" (Dan).
"I have always known that something is fucked up with me, but did not know what…" arriving at school I saw that all the young children can read and I don’t, even my younger sister could read before me. It drove me crazy…" (Dory, vignette)
"Being deficient in learning has never interfered with being me. I was always loyal to myself and never let it influence my life or who I am." (Zila, vignette)  
 
3. Parents in search.
After diagnosis the parents are flooded with a variety of feelings – from fear and anxiety, through helplessness and anger, to disappointment and pain. The fear relates to their child's fate, the anxiety to his unclear future; the anger turns at the messenger, the diagnostician. Later on disappointment appears – an awakening of sort from the "perfect child" fantasy and pain due to is future confrontations and disappointments.   
 
"During that scene at the placing committee…. I felt cheated, angry, nearly losing control over myself, speaking irrationally. I have never felt so betrayed and helpless" (Dan's father)
"I was afraid of social ostracism, because we, his parents, can contain him, but with children, you never can know their reaction…." (Dory's father)
"I was very sad… my pain was his pain, the things he will have to cope with, I was sorry for his struggles…. My sadness, pity, I was sorry for him…"     
 
Behavioral response to the diagnosis/indications of difference varies from case to case.  Motivating the parents to take action is normally related to the diagnostic course. If it is dramatic and stormy, immediate action is a must; if it is slow – the parents may gradually adapt. Finally, if the indications are minor and the family unaware, nothing will be done until a later stage.
 
"We had to act rapidly because the school year was about to end. We thought, as parents, of moving to another city, to allow Dan a fresh start" (Dan’s father)
"We started treatment, she saw the gaps and focused on the emotional aspect, but missed the larger picture – the involvement of the deficiency with everything." (Dory's parents)
"Every day after school Zila was assisted in all disciplines, homework was done, not willingly, but done, because it was important to us." (Zila's mother)
 
After acknowledging the new reality the parents start searching – for information on the one hand, and for solutions and treatment on the other. First of all the parents need to understand the nature of the deficiency and to internalize its existence. They may acquire formal or informal/experiential information.
 
"On that day, I told my husband that I intend to study special education at the university, he was very excited and encouraging. It was very important for me, as a tool in helping my son, and other parents who had the same misfortune as we did." (Dan's mother)
"We participated in parents’ workshops, where we learnedt how to cope with Dory as parents. Our instructor was fantastic and we learned a lot from her." (Dory's father)
"I can perfectly understand the deficiency, because my sister-in-law and children have it and have learnt to cope wonderfully." (Zila's mother)
 
Next, the parents are required to choose professionals and treatment methods in accordance with the deficiency of their child. At first they lack the knowledge necessary to evaluate the quality of the treatment. During that process they often become care givers, as they improve their skills as empathic and supportive parents of children with learning deficiencies.  
 
"We went from one diagnosis to the next; from one expert to the next… each presented his own world view, his own perspective. We were exposed to an enormous amount of information, not always knowing how to interpret it." (Dan's father)
"As frustrated and helpless parents at that stage, we followed all advice, every tip we've got." (Dory's father)
"We believed that was an emotional or social difficulty, and turned for help in that direction. We went to meetings – us and the girls." (Zila's mother)
 
4. Case management as a comprehensive solution.  
The best treatment plan for a child/adolescent with a learning deficiency comprises of the devising and implementation of a patient treatment plan, as well as managing the supporting circles – creating and maintaining professional ties with all significant persons in the child's proximity, who operate on his behalf.
The entire process is the outcome of a systematic diagnosis – didactic and psychological, through which the deficiency is entirely formulated. This forms the basis of a comprehensive treatment plan for the child/adolescent.
The treatment plan is mainly didactic, tailored to patient needs and comprises of corrective teaching methods and learning strategies. A strategy is a number of skills directed at a specified end; a set of thinking processes and learning skills operated by the patient to enhance the effectiveness of his learning. In other words, students with learning deficiencies often lack effective learning strategies. Therefore a main component of the treatment plan is dedicated to the impartation of learning strategies, some of which are tailor made with regard to a specific deficiency. Strategies are therefore learning how to learn. They are concerned with cognitive aspects, and develop the awareness of thinking processes.
Strategies are designed to circumvent specific difficulties. Some of them are intended to enhance attentiveness, other are directed at improving memory processing, reading comprehension, or mitigating dysgraphia.    
 
"at the beginning of the school year Dan asked his teacher to be seated in the first row, so as not to be distracted by any noises…. In order to cope with his attention problem, he wrote down everything that was said. (Dan, vignette)
"For language learning he used a primer, writing every new word and its meaning. Soon he understood that in order to remember a word, it should be put in context, therefore he constructed short sentences. Thus his vocabulary expanded." (Dan, corrective teacher)  
"I am summarizing each paragraph and while preparing for examinations I practice memorizing everything. I focus on these. Everything I learn I write down in the form of a question and after answering all I reread everything." (Zila, vignette)
"Having to summarize a paragraph I use different color markers. With one I mark the subject matter, with the other the personalities. Thus I manage to summarize large amounts of material." (Zila, vignette) 
"Due to his high capabilities we were greatly assisted by illustrations and external clues to the texts. Prior to reading and he had to lean on pre knowledge… after acquiring reading skills, we concentrated our efforts on text comprehension skills, such as identifying key sentences and words, and organizing information in flow charts which greatly helped him." (Dory's case manager)
"We started with writing skills. In order to facilitate his hold, lighten the pressure exerted and improve his writing flow we used triangle shaped pens and pencils. We exchanged normal children's notebooks for smart notebooks. And re-learnt lettering, rigorously attending to writing direction and conventions." (Zila, case manager)
"I had to help him to rewrite, because he often failed to read his handwriting. Later on I started typing everything, so he would be able to read… when he grew up he learned to type, thus everything became clearer to him." (???)   
 
Corrective teaching is a part of the treatment plan. Since the children suffer from attention deficits, we normally precede the class. When the child has a foreknowledge of the subjects that are taught in class, his anxiety is mitigated and he is able to master attention from strength.   
 
"We prepared for high school; bought the textbooks and learnt some of the subjects during the summer." (Dan's mother) 
"I am always trying to keep Dory ahead of class. That is, we prepare beforehand, so arriving in class he has some foreknowledge, and is ready to pay attention. Thus we are gaining from his active participation." (Dory's case manager)
"I asked Zila's parents to buy the textbooks during the summer vacation; to be able to teach Zila from them, and prepare her for high school. The idea was that if she would arrive prepared, having some foreknowledge of the material, her anxiety would diminish. And that’s how it was." (Zila's case manager) 
 
Correspondingly, we work with each child on the emotional level. The children experienced objective pressure, stemming from uncertainty in transitional states and frustrations due to the gaps between input and achievements. Stress was processed in all cases by playing and/or discussions all through psychological treatment, guidance and coaching. 
Socially, all three children had difficulties functioning with their peers, and needed support and mediation which were supplied by coaching and guidance in present content and challenges.
 
"During the summer vacation before starting high school I was in great stress… it was very hard having to live in a state of uncertainty. I tend to be very anxious when not knowing how things will happen, how I shall cope with my studies and friends, therefore I asked my parents to arrange for me some meetings with my therapist whom I appreciate very much. In those sessions I focused on the stress causing situations, we devised simulations by which to plan future behavior patterns. Those sessions reduced the stress considerably." (Dan, Vignette)
"The failures started in 9th grade. For a long time I failed in math even after dedicating many hours. But the main downfall occurred in 10th grade…. I cried a lot. I let everything out at my therapist’s, but her treatment helped me refuel my batteries, I started afresh, on a road made of successes only, no more downfalls." (Zila, vignette)
"The social sphere was more difficult since he is shy. Because he lacked initiative, I would invite boys and girls from his class, organizing party games; slowly he eased and started inviting friends on his own." (Dan's mother)
"I devised a social plan for Dory intended to promote the idea of not rejecting the other because he is slower or thinks differently ,of accepting the other. It was a workshop aimed at improving interpersonal communication. I moderated the workshop with the aim of creating a dynamic process whereby children present their problems, we discuss them and offer solutions and small assignments. Returning back the child presented the group with a new dialog. Slowly we were able to see improvement in his relations and interactions with others." (Dory's case manager)
 
A testimony of learning and internalizing skills is their implementations in new learning environments. Generally we may say that our patients use the skills acquired at the clinique in other learning environments.
 
"I used to arrive at the army office very early in the morning; I needed the silence to fulfill my daily missions. When everybody arrived I finished the officers' schedules, and planned all guard duties and other tasks." (Dan, vignette)
"In time I was functioning automatically and implementing what I had learned. Before examinations I classify and categorize the material, then work on each domain according to the paragraph model in which I have become an expert. I mark the essential information, thus having to cope with much less, and I am ready. I employ that scheme in class as well, so things are much easier. (Zila, vignette)
 
In a parallel process the case manager coordinates all support agencies. The parents, major change agents, receive guidance and coaching; than there is the learning environment (kindergarten, school, and army); there is an ongoing professional dialog with colleagues – therapists and other professional teachers outside the education system; occasionally with other significant agents.   
The contact with the parents is established around the comprehensive, didactic diagnosis. The preliminary session is pre-diagnostic, however all participants are aware that a learning plan is being scheduled. These preliminary meetings are crucial, because they lay the foundations of the relations between the case manager and the parents as well as for the future plan and ongoing relations, which will exist all through the coming years. The parents are encouraged to follow the child's progress; they are regularly updated regarding his scholastic-emotional state, current and future priorities and future goals.
 
"Three weeks after Dory's diagnosis I invited his parents for a meeting. For them it was the time of having to cope with a new term, learning deficiency. We decided that I should manage all aspects of therapy: a treatment plan, coaching the team, identifying and removing obstacles, in fact escorting the parents." (Dory's case manager)
"Zila was present at the room, with me and the psychologist and diagnostician. The last explained the essence of the deficiency, its sources and implications to her, and described the ways to by-pass the weakness. She said that she would manage the case; I asked for the meaning of the term, and received a detailed explanation of the model and of her part in it." (Zila's mother)
"I meet Dory's parents once a week. Each time I describe those elements of our treatment which I would like them to monitor. Sometimes I guide them concerning what they should or should not demand of him. We arrange coaching as well as learning and cognitive priorities." (Dory's case manager)
"Gila informs me regarding her findings, the situation at school, and Zila's attitudes in every domain. In fact all is transparent, I know everything about my child." (Zila's mother)   
 
The learning environment may be each of those that the child/adolescent/adult may be in, and is dependent on his age at the first diagnosis. In all three cases of the present research, a close contact was maintained with the learning environment. The first meeting is crucial. All agencies which participate in the therapy should take part. In it we present the diagnosis' findings, their implication regarding school, a proposed treatment plan, examinations adjustment etc. After establishing the groundwork in school, communication is regularly maintained, including follow up of the plan's progress. Still, the initiative is external – the case manager is the driving force behind all processes. Communication is maintained in periodical multi participants meetings, or through the phone with key agents such as teachers school consultants, etc.   
 
"At the first meeting we presented Dory's diagnosis and the proposed treatment plan emphasizing Dory's stronger points. The psychologist spoke about the need to support him, to relate to his strong point as well as to his functioning. We proposed that he would take further examinations, orally if possible, to enhance his chances of success. If found compatible we proposed to send him once a week to a school for gifted children, and on the other days to his neighborhood school." (Dory's case manager)
"At the beginning of the school year I met with Zila's teaching staff at school. I presented her diagnosis, and its scholastic implications. Together we devised learning plans and agreed on all adjustments needed in internal and external examinations."
"I guided the staff at the regional high school, because not all have the knowledge and orientation about learning disabilities. More than once they interpret difficulties as manifestations of laziness, or evasion of assignments." (Zila's case manager)
"Once every four or six weeks I would meet with or speak on the phone with staff members who were in contact with Dory, and the principal of the school for the gifted. Once a month I was in touch with his classroom teacher, regarding his progress, his grades, changes in his reading and writing skills etc. (Dory's case manager)
"Once every four or six weeks, depending on the urgency of the problems, I visit Zila's school. I have initiated think tank meetings regarding Zila as a full and creative human being. Present at these meetings are the school psychologist and counselor; the classroom and psychology teachers, a history teacher who is very active at school and learning disabled himself, and therefore sensitive to the subject, and I. We discuss Zila's progress towards her main goals, the A levels."(Zila's case manager)  
 
Discussion
The present research examines a new treatment method for children/youth with ADD, a method which is an outcome of a personal narrative. The seeds of it were sown twenty years ago when my son was diagnosed as having ADD. That initiated a long search for information, tools and methods for treating ADD. All these became the infrastructure for a unique treatment plan intended for children with ADD.
The present research examines the efficacy of the plan as it was implemented on three children having similar learning profiles – a complex learning deficiency comprised off AD(H)D, memory and reading comprehension difficulties and dysgraphia. Within a multi-case research pattern three cases were examined. Each contains a personal narrative that was gathered from significant informants, an idiosyncratic treatment plan, and relevant support circles. The existence of variety among subjects should be noted: in age of diagnosis and duration of treatment. Thus Dan was diagnosed at nursery school and has been treated ever since; Dory was diagnosed in elementary school and has been treated with the present plan for the last six years. Zila was diagnosed before starting high school, and has been treated for three years.
From our findings we conclude that ADD does not disappear over time. Attention deficits, distractedness, memory deficiencies, and dysgraphia, all persist well into adulthood. However, looking from the point of departure to the present, we can conclude that rationally assisted by strategies which were instilled in them through the plan, they manage to cope successfully with their learning assignments. Consistently, these difficulty by-passing, compensatory strategies that are based on their own strengths assist the children in achieving their goals: acquiring basic skills, achieving progress in reading and writing, memory improvement etc.   
In other words, corrective teaching and learning strategies assist in narrowing the gaps resulting from the deficiency. Children/youth with a learning deficiency are required to develop by-passing, compensatory methods to acquire some skills that come easily to normative children. From this aspect we may see that even with a lasting deficiency, they learn to cope. By internalizing useful strategies and through implementation, they are able to maximize their faculties, thereby narrowing the frustrating gap between their potential and actual academic achievements.
The learning plan is personally designed; it is idiosyncratic. Still academic efforts are not enough by themselves. Emotional treatment is an important a tier as is the continuous didactic work. As above mentioned, these children are loaded with stress and feelings of frustration. They need to constantly ventilate these feelings.
The emotional treatment is continuous and multi-form: therapy, guidance and coaching. The mental aspect needs to be dynamically processed to assist the child in developing resistibility to all kinds of pressure (Mather & Ofiesh, 2005), coping skills, self confidence and a proper self image (Marsh, Craven, & Debus, 1998). At times of intensified emotional pressure (transition periods, physical growth periods), it is imperative to pay closer attention to the mental aspect. When the academic aspects are more important (latency periods, after high school, during academic studies) – we emphasize skills acquirement and goals achievement.   
As an outcome of the implementation of the model, all three subjects of the present research are experiencing academic success. All three are socially successful; they experience an ego growth expressed in growing motivation, as well as a better self image, manifested in their future aspirations. As a result of their ongoing therapy – they develop enhanced self consciousness.
Development hindering factors may be unexpected events (such as Dan's fevers). Lack of control and periods of uncertainty may stimulate extreme stress among the participants of the research. Finally, an additional hindering factor may be late diagnosis. Defense mechanisms of the parents – denial and repression of the deficiency – may delay the diagnosis for many years. The child remains behind his peers, accumulates frustrations and develops antagonism toward the system.
The professional literature describes many forms of interventions in school and in class – designed to achieve behavioral changes in children with learning deficiencies, and enhance their academic success. But there are no intervention plans designed to treat learning deficiency, perhaps because these belong in the domain of teachers training (Chronis et al., 2006), which is an underdeveloped one (Arcia et al., 2000). Discussions on the benefits of peer coachingcan be found, but their content is not relevant to learning difficulty (Arnau et al, 2004).
There is therefore a variety of intervention plans - directed at children and their parents – that take place at different locations – at home, school, nature etc. Ever since the late 1990s there has been a growing consensus that treating ADHD requires a comprehensive effort of medical, mental and educational professionals – a Multi Modal Intervention, that combines family training, effective behavioral treatment, personal and family counseling, and pharmaceutical treatment if necessary (Barkley, 1998).
However, these programs do not necessitate professional coordination of all treatment forms by one professional, as is offered in our model. In the Case Management model one professional diagnoses, defines needs, shapes a didactic plan, trains and coaches in the emotional domain, coordinates all interventions and keeps in touch with all those who are involved with helping the child. This model is accepted within the medical, nursing and social work domains, but not yet in the educational one. Its implementation in the learning deficiency environment is innovative and answers the existing necessities in the special education domain, parents as well as systemic necessities (Gumpel & Sharoni, 2007) 
 


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