Behavioral Problems and Dyslexia:

A Case Study
This case illustrates the psychological management of a 9 years old male with reading, writing
difficulties, and behavioral problems of non-compliance by using behavior therapy and
multisensory approach through Individualized Educational Plan (IEP). Informal assessment was
done through Clinical Interview, DSM-5 Checklist, Baseline Chart and informal academic
assessment. Formal Assessment included SIT, WRAT and Bangor Dyslexia Test. Considering
the results of assessment and presenting complaints, M. E (not his true initials) was diagnosed
with specific Learning Disorder. Psychotherapeutic intervention was comprised of behavior
therapy and multisensory approach which showed significant decrease in non-compliance
behavior and moderate improvement in reading writing difficulties. This improvement was also
confirmed by the psychological assessment done at pre and post level of therapy.
Keywords: psychological management, behavior therapy and multisensory approach,
psychological assessment, bangor dyslexia test, dyslexia, non-compliance.
Introduction
In the modern society mastery of basic academic skills i.e. reading, writing is a necessary
pre-requisite for success in school. A large percentage of children suffer from learning
disabilities or learning difficulties and therefore do not master or partially master-these required
academic skills. Not surprisingly, each one learns differently. Most of us have our own “learning
difficulty”, to cope with. Some people don’t do well with numbers, others have difficulty in
writing. Some people feel they have to discuss a new idea before they understand it; others need
to mull it over in privacy. The term ‘learning difficulty’ has been applied to those children who
have significantly greater difficulty in learning than the majority of their age. People with
learning difficulties can have problems with many every day learning activities. Reading,
spelling and numeracy skills are basic to school achievement. Children with specific learning
difficulties may show problems in all three areas or only one or two. Reading and spelling are
closely associated skills and it is rare to find reading disabled children who are not at all
handicapped in spelling. Most children are likely to be behind in all three areas.
At least one in every ten children of school age will have difficulties with one or more
areas of the school curriculum, most commonly reading and spelling. A proportion will
overcome difficulties early, but for the majority, learning difficulties are likely to persist and
have deleterious consequences on their later careers. Learning difficulties occur for a variety of
reasons. One reason is that the child has some inherent cognitive difficulty that makes learning
some skill more difficult than normal. However, some difficulties perhaps the majority are the
result of educational or environmental problems that are unrelated to the child’s cognitive
abilities. Ineffective teaching strategies can seriously affect a child’s level of achievement. Early
school failure can lead to a lack of self-confidence with subsequent detrimental effects on
learning. A variety of variables associated with home background can also contribute to learning
difficulties. Sometimes all of the different factors are interwined. For some children these
problems will result in writing difficulties and intervention will be required for the child to cope
with the demands of the curriculum. There is unanimous agreement among educationist today,
that the quality of primary education in almost all parts of our country is poor. Even though
children progress in primary grades due to the non-detention policy, in practice, little learning is
taking place. Children are pushed from one grade to the next, irrespective of how much they are
learning. Findings from a number of studies reveal that class III to IV children are not able to
read and write even simple sentences. Thus something is surely wrong with the learning
outcomes of children (Batra, 2002; Dewan, 2002 and Ramachandran, 2003). Another factor
contributing to the declining learning levels in schools is the curriculum load at each level, which
makes it difficult for children to cope with the increased quantity of facts and information. This
has encouraged students to go in for private tuitions (Ramachandran, 2002).
Learning difficulties not only present problems in coping with academic requirement but
has serious repercussions. Teachers and parents label children by their behavior without knowing
that reasons are at the root of the problem. Behavioral problems can be caused by learning
difficulties. According to researchers, learning difficulties can cause emotional distress. Children
with learning difficulties are frequently criticized by teachers and parents and they may be
rejected by peers, who are quick to perceive who stands out in the class as being unable to read
and spell. As they fall further and further behind they develop a picture of themselves as
deficient, different, hopeless and unsuccessful, unless special steps are taken to attend to these
issues. Continuing failure and increasing distress further reduce motivation to try and a syndrome
of “learned helplessness” may produce indifference to learning, or in some cases, energetic
avoidance of school work. It has long been known that learning problems and behavior problems
tend to go together i.e., children who have specific learning difficulties are more likely than non-
specific learning difficulties children to have behavioral problems of one sort or another; and
children with behavioral problems are likely to be high risk for the development of specific
learning difficulties. Learning disabilities may negatively affect a child’s social growth. Children
with LD who do not have many friends will feel lonely, sad and misunderstood. These children
will get into fights easily because they will feel disapproved. Behavioral problems may mask
learning disabilities. Because adults may pay attention on the child’s personality and behavior,
they may ignore the child’s learning disabilities. When disabilities are not observed and children
do not get help and support, they will come up with any excuse to avoid doing homework tend to
drop out of school. The association between specific learning disability and behavioral problems
is of great significance over the long time as both behavior problems and academic problems are
likely to persist and both are related to maladjustment, social deviance, unemployment and
unhappiness in later life (Abrams and Maslow, 1976; O’Hara and Levy, 1984). The current study
therefore is an attempt to identify children with learning difficulties and explore the prevalence
of the problem and attempt to study the etiological factors and also the consequences of learning
difficulties and/or disabilities on their behavioral problems and academic achievement. The study
was undertaken with the following objectives:
1. To study the prevalence of learning difficulties/disability
2. To explore the etiological factors affecting learning difficulties.
3. To study the behavioral problems of children with learning difficulties.
4. To know the academic achievement of children with learning difficulties.
Case Study
Participant
Client was born through normal delivery, had low birth weight and achieved all his
developmental milestones at age appropriate level. He developed his early readiness skills at
normal age. He was admitted in play group of mainstream at age of 3 years. Mother reported that
child’s teacher told her that his interest sometimes easily shifted to other activities while she
engaged him in learning. He was promoted to nursery and was able to learn counting and
alphabets easily but faced confusion in recognition of b and d in writing. Mother reported that
being in educated family, study was considered very important so because of his academic issues
she used to give him extra time in teaching at home by sitting aside 3-4 hours daily. After that,
he got able show average performance in class. Afterwards, he passed prep, 1 and 2 grade with
average marks in all subjects except Urdu in which he scored slight less than average marks. In
these years, client faced difficulty in recognizing the words, he used to take time in reading and
writing, Urdu and English. The mother reported that he often forgets the spelling, his writing
expression clarity and organization was poor, and it was like he is not writing but drawing the
words. Client was scolded by his mother for not showing good grades as she was doing too much
work with him. It was reported by the mother that he got irritated because of too much study
duration i.e. 8-9 hours and often did not follow commands of mother and tuition teacher related
to studies.
At the age of 7 years, when client was in grade 3, his behavioral issue of disobeying
mother appeared to be more prominent. At study time, he showed disinterest, focused on
irrelevant things, and did not listen to instructions given by teacher. With the increasing level of
study, mother used to give extra time to teach him and to complete his homework. Client started
to face difficulty in reading Urdu and English sentences, could not read easily and accurately,
could not remember spellings. With constant guidance and support, he passed three class with
almost average grades in all subjects.
At the age of 8 years, when client was in fourth grade he was still having same problems
in reading and writing English and Urdu. As the study level increased, the client’s difficulties in
reading and writing increased. His behavioral problems of less concentration and not to follow
the commands also increased. He used to spend most of his time in playing outside the home,
making drawings during study time, irrelevant talks with mother, going to toilet when say to
study, drink extra water and showing hunger during study time. He was prompted to class 5 but
his grades were below from all his class fellows. Due to his deteriorating performance and
behavioral issues, mother got really worried, discussed his condition with his school teacher and
principle. The school teacher suggested the client’s mother to take him to psychiatrist for his
assessment.
Background Information
The client’s mother reported that she was divorced by the client’s father in 2009 after 4
months of arranged marriage. The client’s mother was pregnant at that time and the client’s
father was aware of that pregnancy but he never showed any concern towards the client.
According to mother, client’s father had aggressive and harsh personality. He often used to abuse
client’s mother after taking alcohol. Their relationship was ended due to client’s father extra
marital affair and alcohol addiction. The client’s mother used to live with her parents until the
client reached the age of 3 years. In 2013, client’s mother was again married to client’s
stepfather.
The client was currently living in his stepfather’s home. He was a 35 years old, an
engineer. His attitude towards client was caring and loving apparently. But when the thing comes
to afford the client’s expenses, he used to neglect client. Although from the start of their
marriage, the client’s expenses were done by the client’s grandparents. The client’s mother
reported that he has calm temperament but got irritated when used to give extra time and
attention to the client. He said his wife not to take too much tension about the client’s study, and
asked to give more attention to their daughter.
The client’s mother was 34 years old housewife. She had done Masters in Political
Science. She had kind and cooperative nature. Her attitude towards the target child was very
loving and caring. General health of mother was good as reported. She was very concerned about
his child’s condition. She got worried and tensed when the client does not comply her and could
not get good grades in academics. She also get frustrated due to the child’s deteriorating grades
with advanced study level. Both parents had a satisfactory relationship with each other
irrespective of client issues.
The client had two younger step siblings. 2nd born, step brother was passed away after 3
weeks of his birth due to high grade fever. 3rd born was a 3 and half years old sister. Client used
to care and love her lot. General home atmosphere was reported to be calm and satisfactory, but
got disturbed and uncongenial at times due to arguments between parents on matter of client’s
education. The client belonged to a middle socio-economic status and lived in nuclear family.
The authoritative figure in the family was client’s stepfather. As per mother’s reporting, one of
the child’s paternal aunt was diagnosed with reading problems. Apart from that there was no
family history of any psychiatric or medical illness.
The client was born through normal delivery at a private hospital in 2010. Mother
suffered from nutritional deficiency during gestation period and was prescribed medications.
After birth, client first cry was present, he did not suffer from any birth complications. Although
his birth weight was low. He achieved all his developmental milestones at age appropriate level.
No neurotic traits and traumatic injury were reported by the mother.
According to mother, client had problems of inattention since his early school years, he
had difficulty maintaining attention while doing his study related work. He faced difficulty in
reading and writing sentences (Urdu and English) but easily grasped and comprehend the
abstract concepts, relationships, numerical concepts etc. He did not comply with commands both
at home and school, did not follow instructions related to study or other tasks and spend most of
time in playing and with mobile. He had adequate problem solving and socialization skills. He
remained confident in class and took part in extracurricular activities. His hobbies including
watching videos from tik tok, Youtube, playing cricket, painting, spending time alone and to
manipulate the old things to make new ones. His gross motor, fine motor and self-help skills
were developed properly. His memory was intact but had some problems when it came to writing
the memorized things, because writing seems difficult to him. His daily routine was scheduled by
his mother but client frequently try not to follow the schedule. His study hours were not fixed
due to that reason. His playing and eating time patterns were also irregular, he insisted frequently
to play and eat during study hours. His bed time routine was scheduled and his sleep patterns
were normal. If his demands did not get fulfilled he became non-compliant and misbehaved with
mother and grandparents.
Assessment
For Informal and Formal Assessment following scales were administered at pre and post
level of therapy. Informal assessment was done by Clinical Interview, Behavioral Observation,
DSM-5 Checklist, Student Reinforcement Survey, Baseline Chart and informal academic
assessment. Formal Assessment was done by administering Slosson Intelligence Test (SIT),
Wide Range Achievement Test (WRAT) and Bangor Dyslexia Test.
Table 1
Showing Average frequency, intensity and duration of the non-compliance behavior of the client
as reported by his mother
Non-compliance Behavior Pre Assessment Ratings
Average intensity of behavior 7.6
Average duration of behavior 22.5 minutes
Average frequency of behavior 3 times a day

Table 2
Showing Score on WRAT at Pre Treatment Phase
Raw Score Standard Score Grade Score Percentile
Reading 61 109 4.7 73
Spelling 35 100 3.7 50
Arithmetic 55 125 5.2 80

Table 3
Showing Score on Bangor Dyslexia Test at Pre Treatment Phase
Subtests Indicators
Left- Right (body parts) +
Polysyllables -
Subtraction 0
Tables 0
Months forward +
Months reversed +
Digits forward +
Digits reversed +
b-d confusion +
Familial incidence +
Total no. of positive indicators 07
Diagnosis
315.00 (F81.0) Specific Learning Disorder (Moderate) with impairment in reading (in
word reading accuracy, reading rate or fluency)
315.2 (F81.81) with impairment in written expression (spelling, grammar, punctuation
accuracy and organization of written expression)
Case Formulation
After complete assessment, client was diagnosed as having specific learning disorder
with impairment in reading and with impairment in written expression. DSM-V defined this
disorder as: difficulties in reading and in written expression, despite the provision of intervention
for these difficulties and affected academic skills were quantifiable below those expected for
individual’s age and grade level (APA, 2013). Similarly in this case, client’s had poor reading
and writing skills that were quantifiably below than required for his age and grade level; and
symptoms manifested when demands of skills exceeded his limited capacities i.e. at age of 8
years fulfilled criteria of this disorder.
Intellectual disability had been ruled out because of presence of normal level of
intellectual functioning i.e. IQ of client was in average range according to SIT. Despite presence
of concentration difficulties, attention deficit hyperactivity disorder could not be diagnosed
because the criteria was not fulfilled as hyperactivity was absent. Since symptoms manifested
during developmental period and did not represent marked decline from former state so
neurological disorders were ruled out.
Hereditary factors as a cause of learning disability were studied by various researchers, it
was reported that learning disorders run in the family so it’s not uncommon to find that people
with learning disabilities have parents or other relatives with similar difficulties (Horowitz &
Cortiella, 2014). Problems during pregnancy like low birth weight, drug and alcohol use during
pregnancy also contributed to development of this disorder (Haworth, Dale, & Plomin, 2010). As
in the present case, client’s paternal aunt was diagnosed with learning disorder. Further client’s
father had alcohol addiction and client had low birth weight which may also work as
predisposing factors. While there was an indication of neurological deficit by the scores obtained
from the Bangor dyslexia test which may predispose individual with dyslexia (predisposing
factors).
Manifestation of learning disability may be some time behavioral in the form of
noncompliance i.e. reluctance to engage in learning and following commands because of skills
deficit in relevant domains, difficulty in comprehend concepts and getting overwhelmed so, may
not be able to organize himself to begin the task (APA, 2013). Similarly in present case, client
disobeyed mother’s instructions of studying because he had difficulty in reading and writing
hence in order to avoid mental stress, he did not comply with mother’s commands (precipitating
factors). However, it is also clear that if discouragement of certain behaviors is not firmly
consistent, meaning that sometimes there is a positive outcome, then the child will continue the
‘’bad’’ behavior in hopes of hitting this positive outcome again (Lee and Sondrage, 2013).
Similarly in the present case, whenever the client did not follow the commands, family either
attend to his undesirable acts and dealt with that by fulfilling his demands or ignored him by
allowing him do, whatever he wanted. Hence his behavior was reinforced and he learned
disobedience to achieve desired outcomes (perpetuating factors).
Management Plan
For the present case, a management plan was devised on the basis of Behavior Therapy to deal
with the idiosyncratic needs of the client.
Mirroring, reciprocity and commonality were used to indulge client in therapeutic process
and to develop warm, trustworthy and understanding relationship between therapist and client. In
order to aware client’s mother about nature, severity level, cause and etiological factor of
diagnosis and to guide her about mode of therapy and prognosis, psychoeducation was provided
to the mother. To teach client’s mother basic principles, teaching techniques and skills of therapy
so that his academic skills and problematic behavior of non-compliance can be managed at
home. IEP was established on the basis of Behavior modification techniques i.e. prompting,
modeling and positive reinforcement to establish the behaviors and then fading was used to
maintain his behaviors. Different multisensory methods were used to better client’s reading and
writing skills. Behavioral Contract, Response Cost, Token Economy (star chart) and Differential
reinforcement of incompatible behavior were used to deal with client’s disobedience and non-
compliance behavior during session and at home.
Ten therapeutic sessions were conducted with the client during the course of therapy. Per
week three structured sessions were conducted.
Session Summary
Below is given a bird eye view of therapeutic sessions.
In first session, history of client’s problem and background information was taken. In this
session, nature and severity levels of the problem were explored. Baseline chart regarding non-
compliance was given to client’s mother to be filled for five days. Therapist also explained the
client’s mother how therapy will be preceded and the importance of her active participation in
the therapy was emphasized.
In second session, firstly informal academic assessment was done and then DSM-V
checklist was administered. The baseline chart given in first session was analyzed by the
therapist. The antecedent and consequences were discussed with the client’s mother.
In third and fourth session, formal assessment was done and results of assessment were
explained to the mother. Client’s diagnosis was revealed to client’s mother and she was informed
about this disorder, its specific symptoms, its causes and etiological factors (psychoeducation).
She was also explained about the therapy process and the importance of management strategies.
Mother was also provided with emotional support; and told that client’s problem is manageable,
and with her cooperation, effort and guidance; the client’s condition could get better. It was also
explained that the client will need an individualized educational plan to learn reading and writing
skills. Importance of homework exercises, family role and mother’s guidance and training in
managing client’s undesirable behaviors was highlighted. Moreover, mother was also instructed
not to burden client with too much academic work, expectations for high grades and not to scold
him for his low performance. Concerns of the mother regarding diagnosis and management
procedure were also addressed and she was also given a written sheet for psychoeducation
material. In order to deal; with client’s non-compliance, an agreement was signed between him,
mother and therapist during session. In contract it was stated that if he complied with mother’s
request of coming home at 7pm after playing 2 hours and then study for 2 hours during a week,
he will be allowed to play games on mobile for one hour on Monday and for one hour on
Tuesday; that contract was fulfilled by client appropriately.
In fifth session, multisensory methods in IEP to better the reading skills of the client were
implemented to him by behavior therapy techniques i.e. modeling, prompting and positive
reinforcement and were also taught to mother. The baseline chart was fully analyzed and the
mother was told that how the client’s behaviors were reinforced by the family. Response Cost
was introduced and mother was instructed that if he disobey her, his favorite toy or game would
be taken from him. Client was also explained the consequences of engaging in positive and cost
he had to pay for his undesirable behaviors.
In sixth and seventh session, multisensory approach was implemented to better the
client’s writing skills by use of sight, touch and hearing senses. This technique was used to teach
letters, sounds formation and word recognition and in making sentences. Say-Trace and Write
model was used with the client in following steps by use of oral language to assist him with the
learning of motor scripts

1. Have the student say the word out loud

2. Student writes the word
3. Student checks his word against a model to determine accuracy
4. Student traces the model and says the word aloud
5. Student writes the word from memory
6. Student checks their word against the model to determine accuracy

In eighth and ninth session, worksheets for clarity and organization of written expression
were provided and completed by the client. Client was reinforced on the completion of every
worksheet. The mother and teacher of the client were provided with the teaching strategies in
written form. Parental training was done in every session. Token economy through star chart was
taught to mother in order to strengthen client’s desirable behavior i.e. compliance, following
commands, brushing his teeth regularly, washing face in morning, to put the dustbin outside and
to decrease undesirable behavior i.e. stubbornness, non-compliance, standing from seat and
eating without permission during study etc. Star chart was made during session with client and
he was told that whenever he performed the seven desired behaviors in a day, he would be given
a star for each desired behavior. He was also told that these stars would be used for earning his
favorite things at night, written on the sheet. Feedback was also taken from mother from
previous sessions. The concept of follow-up session was introduced to the client.in ninth session,
post assessment was started.

In tenth session, post assessment was completed. Client’s mother was encouraged to come up
for follow up session for better progress. Therapy blueprint was provided to client’s mother.

Result and Discussion

 At the end of therapy, post assessment was done informally to check the client’s reading and
writing skills taught during therapy, his attentional span duration and his behavioral issue of non-
compliance. A test was devised on the basis of learning in sessions. Client showed 70%
improvement in the test scores, during test his attention used to shift to other things less and
feedback from mother revealed that he became very compliant. Post Treatment Assessment of
M.E has showed marked significant improvement in his non-compliance behavior. Behavioral
Contract, Token Economy and Differential reinforcement of incompatible behavior proved
helpful in dealing with the client’s behavioral complaints. This was clear from the following
table showing comparison of pre and post assessment ratings of non-compliance behavior.
Table 4
Pre and Post Treatment ratings of average frequency, intensity and duration of non-compliance
behavior of the client as reported by his mother
Non-compliance Behavior Pre Assessment Ratings Post Assessment Ratings
Average intensity of behavior 7.6 0
Average duration of behavior 22.5 min 0
Average frequency of 3 times a day 0
behavior

Table 5
Skills, Pre and Post Mastery Level on IEP’s tasks
Skills Mastery Level
Pre Post
Concentration Ability 40% 75%
Related to Reading (English)
Word Reading Accuracy 30% 60%
Reading Rate or Fluency 35% 70%
Reading Comprehension 25% 50%
Related to Reading (Urdu)
Word Reading Accuracy 25% 60%
Reading Rate or Fluency 30% 65%
Reading Comprehension 25% 55%
Related to Written Expression (English)
Spelling Accuracy 35% 65%
Clarity or Organization of Written Expression 50% 80 %
Related to Written Expression (Urdu)
Spelling Accuracy 25% 50%
Clarity or Organization of Written Expression 25% 50%

Non-compliance is a common and considerable behavioral concern in children with

learning disability. When parents fail to adopt disciplinary practices that are not consistent, the
child can develop bad behaviors in adolescence and as adult. It is brought about by the family
either by attending to child’s undesirable acts and dealt with that by fulfilling his/her demands or
ignored him/her by allowing to do, whatever he/she wanted. Hence child’s behavior got
reinforced and he/she learned disobedience to achieve desired outcomes (Lee and Sondrage,
2013). Behavior Therapy (BT) tackles these perpetuating factors and has become known as best
treatment choice for dealing behavioral issues of non-compliance associated with learning
disability (Alberto & Troutman, 1999; Haworth, Dale, & Plomin, 2010). The efficacy of
Behavior Therapy has been established for treating undesirable behaviors associated with
learning disability with the help of different well-designed studies. The collective findings of
different studies (Brennan, 2019; Jedlicka, 2017; Miltenberger, 1997; Spiegler & Guevremont,
1998) have suggested that BT improves the reading and writing skills associated with dyslexia
when associated with multisensory teaching approach and is successful in dealing with the
behavioral issues of non-compliance in association with learning disability. Some empirical
findings imply that four structured therapeutic sessions conducted weekly may increase the
clinical benefit for the individual with learning disability (Horowitz & Cortiella, 2014).
The Behavioral Therapy (BT) and multisensory teaching procedures has produced
improvements in client’s behavioral complaints, reading and writing skills that have been
evaluated subjectively and objectively. There are certain limitations of this case study. Due to the
reopening of school after summer vacations and client’s stepfather issues regarding his
treatment, the client was not able to maintain follow up sessions. So follow up is recommended
for maintaining improvement gains. Large sample size and follow up sessions would help to
establish the validity of the findings.

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