Lily is a fourteen-year-old, year 9 student at Mannum Community College, South Australia. Lily was removed from her biological parents initially at three days of age after they were assessed to be unable to provide her with adequate care. Lily’s biological mother has significant developmental delays and her father is diagnosed with bipolar disorder. At age four Lily was reunited with her father for five months until an emergency removal was ordered. She was then placed into the care of her current foster parents, with an order determining that Lily remain under the Guardianship of the Minister until she reaches eighteen years of age.

Academic performance and attendance
Lily has performed below year level standard since beginning kindergarten, with delays in speech and language since infancy. She participated in the National Assessment Program – Literacy and Numeracy (NAPLAN) in year 3, falling into band 2 (national minimum standard for the year level) for reading and language conventions and band 1 (below standard) for persuasive writing and numeracy. She was withdrawn from the year 5 NAPLAN and exempt from the year 7 NAPLAN. Lily has received grades of C and D in all subjects from year 3 to 8. A formal assessment of Lily’s reading, numerical and spelling skills was conducted in September 2018, at which time Lily was in year 8. Her reading performance was equivalent to that expected of a year 4, and her numerical and spelling skills equivalent to that expected of a year 3. This assessment of Lily’s current level is supported by her home class teacher.
Lily has a significant rate of non-attendance, with between 14 and 27 days absent each year from year 3 to 8. While none of these non-attendances were unexplained, being for illness or appointments, this represents an important loss of learning time (120 days over 6 years, approximately four weeks per year).

Diagnoses
Lily was diagnosed with an auditory processing disorder (APD) in early 2015. She had difficulty identifying subtle differences in pitch, affecting her comprehension of communication such as questioning and sarcasm. She also had difficulties focussing her listening in the presence of noise and recalling verbal instructions.
Lily’s psychological assessment, conducted in 2018, concluded that she has a mild intellectual disability. This affects her academic achievement, reasoning, working memory, communication, self-direction and interpersonal skills. Lily’s teachers report that her memory is deteriorating over time.

Behaviour with adults and peers
Lily is a compliant and willing student who is eager to please, though she has several behavioural reports in her file for repeated refusals to work. Her teachers’ assessments of her effort were partial to satisfactory in primary school, with a notable improvement in middle school (good to excellent). Her positive attitude and pleasant demeanour is a major strength. Lily is easily distracted from assigned tasks and does not seek help.
Lily is quiet in class, works alone and has no close friends, avoiding social interactions during breaks by staying in class to work. Lily has previously had issues maintaining personal hygiene, including managing her menstruation, and a recent assessment of her self-care ability indicated that her skills are equivalent to those of a child under seven years of age.

Interests
Lily has a number of extra-curricular interests including horse riding, calisthenics, dancing, choir and music. When interviewed, Lily indicates that she enjoys attending school, that her favourite subject is maths (especially times tables) and that she finds reading boring.

Implications for learning
Lily is unable to access the curriculum at her year level standard and has been provided modified content throughout her school career. Although her rate of progress is slow, Lily is capable of achieving academic success. Lily’s poor working memory and APD cause her difficulty in recalling instructions, especially verbal instructions, and focussing in class. Her memory problems also impact her ability to grasp larger ideas and likely contribute to her feeling that reading is boring as she cannot recall contextual information across a longer text. She remains a concrete thinker and thus finds problem solving, inferencing and predicting very challenging. Lily’s intellectual disability limits her ability to understand open ended or minimally scaffolded tasks; when presented with these she becomes overwhelmed, stubborn and refuses to work. Lily’s lack of social skills impacts her ability to construct understanding with her peers, impacts on her wellbeing and may subsequently reduce her desire to attend school.

The specialists treating Lily have made a number of suggestions including a focus on life skills such as financial maths and time, one-to-one classroom support, short breaks during lessons and the use of simple instructions with minimal steps. Lily also uses a frequency modulation (FM) device in class to assist her to hear her teachers (Reynolds, Kuhaneck, & Pfeiffer, 2016). The interventions suggested below are in addition to those already in place.

Music-based cognitive training
Learning to play a musical instrument induces neuroplastic changes including increased grey matter and strengthened white matter connectivity, with a particularly positive effect on the auditory and motor networks (Francois, Grau-Sanchez, Duarte, & Rodriguez-Fornells, 2015; Huotilainen & Tervaniemi, 2018). Musicians have enhanced auditory processing, and music and speech share neural resources, suggesting that musical practice may strengthen language competency (Francois et al., 2015; Huotilainen & Tervaniemi, 2018). Research has demonstrated that musical training can result in improvements in auditory attention, phonological awareness and perception of temporal components of speech, with improvements persisting after short untrained periods (Habib et al., 2016). Further, students in a musical education program perform better in English, maths and tests of executive function and short-term memory (Holochwost et al., 2017; Huotilainen & Tervaniemi, 2018).
In light of this information and Lily’s existing interest in music, the evidence suggests that Lily is likely to benefit from commencing lessons with an instrument of her choice as soon as possible. The Department for Education instrumental music staff attend the school once per week and thus formal lesson time is limited. However, Lily should practice for a minimum of three hours per week (Habib et al., 2016). An assessment of Lily’s intellectual function was conducted in late 2018. This assessment may be a useful baseline against which Lily’s progress can be measured, to be compared with her next assessment. Based on her history, aspects of Lily’s function are assessed regularly. The goal of this activity is to improve Lily’s auditory memory or at a minimum halt its deterioration and improve her pitch detection.

Game-based cognitive training
Training of cognitive functions, including auditory functions and phonological memory, has been effective in young people with intellectual disabilities (Brzdek, 2018; Delavarian, Bokharaeian, Towhidkhah, & Gharibzadeh, 2015; Homer, Plass, Raffaele, Ober, & Ali, 2018; Kerns, Macoun, MacSween, Pei, & Hutchison, 2017; Zhang, Chang, Chen, Ma, & Zhou, 2018). Although some studies have reported no significant effects of interventions using brain training, it has been suggested that this is due to a lack of game elements such as a robust reward system and “levelling up” to provide consistent challenge (Delavarian et al., 2015; Homer et al., 2018; Kirk, Gray, Riby, & Cornish, 2015). Therefore, it is important to select carefully designed programs that integrate game mechanics and explicitly target cognitive function. Examples of such games include the Alien Game (Homer et al., 2018) and Caribbean Quest (Kerns et al., 2017). Research suggests that such training should be conducted at school under the supervision of a trained staff member and the level of complexity carefully matched to the student; activities that are too easy or too difficult will fail to motivate the student (Delavarian et al., 2015; Kirk et al., 2015).
If an appropriate game can be found in a cost-effective way, this may be an alternate method of therapy for Lily. Such an intervention may be effective in as little as 20 minutes per week over six weeks (Homer et al., 2018). Homer et al. (2018) and Kerns et al. (2017) describe a variety of tests of executive function that could be used in the short term to assess the effectiveness of such a program. For example, the dimensional change card sort task, in which children sort cards first on one dimension (e.g. colour) and then re-sort on another (e.g. shape) tests cognitive flexibility (Zelazo et al., 2013). The flanker test assesses a child’s ability to focus on a stimulus in the presence of competing stimuli (executive attention) by asking them to indicate whether a particular item fits a given criteria when surrounded by either congruent or incongruent items (Zelazo et al., 2013).

Assistive technologies
Lily’s occupational therapist is investigating the use of alarms on Lily’s watch to remind her to change her sanitary napkin while menstruating. Further to this, Lily may find benefit from other prospective memory aids designed to guide a user through multi-step tasks (LoPresti, Mihailidis, & Kirsch, 2004). Such technology may be computer or mobile phone based and be used to support Lily in tasks such as cooking and cleaning, life skills which will be of increasing importance to Lily in coming years (LoPresti et al., 2004).
Lily has previously stated that she finds reading boring, and this may be due to her difficulties with working memory. Two technological solutions may ameliorate this problem; firstly, online summary tools which provide an automatic synopsis of a text and, secondly, concept mapping software such as Inspiration (Inspiration Software Inc, Portland, OR) which allow the user to categorise information in graphic form (LoPresti et al., 2004). Both of these tools reduce the cognitive load of the user, which may offer significant benefit to Lily. Lily’s teachers should attempt to integrate these into her learning where ever possible and appropriate.

References

Brzdek, E. (2018). The Warnke method as a support in education of children with mild intellectual disabilities. International Journal of Education and Information Technologies, 12, 64-68
Delavarian, M., Bokharaeian, B., Towhidkhah, F., & Gharibzadeh, S. (2015). Computer-based working memory training in children with mild intellectual disability. Early Child Development and Care, 185(1), 66-74. 
Francois, C., Grau-Sanchez, J., Duarte, E., & Rodriguez-Fornells, A. (2015). Musical training as an alternative and effective method for neuro-education and neuro-rehabilitation. Frontiers in Psychology, 6, 15. 
Habib, M., Lardy, C., Desiles, T., Commeiras, C., Chobert, J., & Besson, M. (2016). Music and dyslexia: A new musical training method to improve reading and related disorders. Frontiers in Psychology, 7, 15. 
Holochwost, S. J., Propper, C. B., Wolf, D. P., Willoughby, M. T., Fisher, K. R., Kolacz, J., . . . Jaffee, S. R. (2017). Music education, academic achievement, and executive functions. Psychology of Aesthetics Creativity and the Arts, 11(2), 147-166. 
Homer, B. D., Plass, J. L., Raffaele, C., Ober, T. M., & Ali, A. (2018). Improving high school students' executive functions through digital game play. Computers & Education, 117, 50-58. 
Huotilainen, M., & Tervaniemi, M. (2018). Planning music-based amelioration and training in infancy and childhood based on neural evidence. Annals of the New York Academy of Sciences, 1423(1), 146-154.
Kerns, K. A., Macoun, S., MacSween, J., Pei, J., & Hutchison, M. (2017). Attention and working memory training: A feasibility study in children with neurodevelopmental disorders. Applied Neuropsychology-Child, 6(2), 120-137. 
Kirk, H. E., Gray, K., Riby, D. M., & Cornish, K. M. (2015). Cognitive training as a resolution for early executive function difficulties in children with intellectual disabilities. Research in Developmental Disabilities, 38, 145-160. 
LoPresti, E. F., Mihailidis, A., & Kirsch, N. (2004). Assistive technology for cognitive rehabilitation: State of the art. Neuropsychological Rehabilitation, 14(1-2), 5-39.
Reynolds, S., Kuhaneck, H. M., & Pfeiffer, B. (2016). Systematic review of the effectiveness of frequency modulation devices in improving academic outcomes in children with auditory processing difficulties. American Journal of Occupational Therapy, 70(1), 11. 
Zelazo, P. D., Anderson, J. E., Richler, J., Wallner-Allen, K., Beaumont, J. L., & Weintraub, S. (2013). II. NIH toolbox cognition battery (CB): measuring executive function and attention. Monographs of the Society for Research in Child Development, 78(4), 16-33. 
Zhang, H. X., Chang, L., Chen, X. Y., Ma, L., & Zhou, R. L. (2018). Working memory updating training improves mathematics performance in middle school students with learning difficulties. Frontiers in Human Neuroscience, 12, 12.