EXAMPLES WITH CLINICAL CASES OF PROBLEMS

LEARNING
Pablo Cazau

The cases presented refer to schoolchildren who allegedly have learning problems. In each case the
clinical case is presented, then the multiaxial recording is indicated, and finally some additional
comments are made.

CLINICAL CASE NUMBER 1

Marina is 9 years old, she is in 4th grade at a public school in the province of Buenos Aires, and she is
referred by social work to the Psychopedagogy Service of Hospital H. The Rorschach, Bender and Wisc
tests were administered, which did not indicate the presence of personality disorders or mental
retardation. His intelligence is commensurate with his age.
She suffers from chronic otitis that forces her to undergo treatment in an institution far from her
home, which means that, according to her mother, she must miss school frequently. The treatment
was interrupted several times because they could not arrive due to transportation problems. Marina
lives with her parents and an older sister in Adrogué, and they are from a humble background. They
live in a neighborhood where criminals allegedly live, who threaten the other inhabitants, all working
people.
Her father is currently unemployed and receives a very meager subsidy, and her mother helps support
the home by working as a domestic worker.
Marina is very shy and, according to her mother, it is very difficult for her to interact with the other
students. Marina says she feels inferior to them, and that this sometimes causes her anxiety. The
reason the mother consults is her daughter's "disastrous notebook" and her difficulty doing schoolwork
at home. Warned by the teacher that she was going to repeat a grade, the mother asked for help from
social work and was referred to a psychopedagogue from a hospital service.
Marina's notebooks revealed spelling errors and serious flaws in the grammatical organization of
sentences. The dictation writings reveal unclear handwriting, and no respect for the lines. He
complains and suffers because he cannot make a 'clean' notebook like that of his classmates, of
identical age, education and intelligence, according to the teacher. Some of her classmates 'carry' her
and tend to segregate her from the group, which makes her suffer even more.
For three months she has been undergoing psycho-pedagogical treatment, and the girl, although she
has not yet managed to significantly improve her notebook, gets along better with her classmates and
has even become good friends with one of them. Marina's problem had begun at the beginning of the
year, and, according to her mother, when her father was fired from his job because the company
where he worked as a journeyman bricklayer closed.

MULTIAXIAL DIAGNOSIS OF CLINICAL CASE NUMBER 1

Axis I: Disorder of written expression
Axis II: Without diagnosis
Axis III: Chronic otitis
Axis IV: Conflicts with classmates. Conflicts with neighbors. Insufficient socioeconomic aid. Lack of
transportation to healthcare services.
V axis: 55 (previous year). 62 (current).

CLINICAL CASE NUMBER 2

Rocío is 10 years and 3 months old. His mother says that he attended primary school until last year at
the school in his hometown, and that now that they moved he started fifth grade at a municipal school
in Buenos Aires. Rocío has two other male brothers younger than her, who attend the same school.
Thirty days after starting classes, she was referred to the district's psychopedagogy service, and the

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teacher reported that the girl speaks and reads poorly: "she eats the final s, uses one letter for
another," etc. The mother says that Rocío was always like this, and her husband and she thought that
she would grow out of it when she grew older, because the same thing had happened to another girl
they had known.
The teacher points out that Rocío's difficulty in speaking also causes her to read poorly, although she
writes relatively well and understands much of what she reads. Her difficulty speaking makes her feel
bad at school for not being able to make herself understood by her classmates, and sometimes her
mother caught her crying silently. She was examined by a neurologist two years ago and is perfectly
normal.
In the psychopedagogy service, an intelligence test was performed, resulting in an IQ = 62, and it was
considered that his speech problem could not be attributed to this low IQ. This IQ allows you to explain
your difficulties in understanding arithmetic problems and stories.
Rocío is a physically healthy girl, and her mother says that the move seems to have bothered her a lot
because she doesn't go to school with the same pleasure as before and she always misses her old
classmates. However, she became good friends with a neighbor who lives on the other block, and
whom she goes to visit every afternoon.

MULTIAXIAL DIAGNOSIS OF CLINICAL CASE NUMBER 2

Axis I: Phonological disorder
Axis II: Mental retardation
Axis III: Without diagnosis
Axis IV: Change of home
V axis: 60 (current)

CLINICAL CASE NUMBER 3

Nicolás left school two years ago, is currently 12 years old and lives with his mother and siblings. The
mother works all day and does not have time to accompany her son to school. Her behavioral problems
began around the time her parents actually separated, a year and a half ago, an event that forced the
mother to work even harder and neglect her children. His mother has sent him to his maternal uncle to
help him in his task and to learn the shoemaker's trade from him. However, Nicolás does not always go
with his uncle, and stays on the street with a bar.
Nicolás's family belongs to the lower middle class, and lives in a humble neighborhood in the suburbs,
although it is not a "village." The parents of the other children have told him several times that Nicolás
fights very often and "bullies" some boys, some of whom he has even hit with a rock. Also, he has
been seen on several occasions breaking the glass of cars to steal any object he saw inside. This has
caused various disputes with the neighbors, and the mother says that she no longer knows what to do
and that is why she took him to the hospital, referring him to the pediatric service, from where they
referred him to a psychologist.
The mother states that the child never had medical problems, and says that the teacher had told her
that, although he had good intelligence, Nicolás had, in addition to bad behavior, serious difficulties
adding two-digit figures, and that when he read out loud Alta replaced some letters with others and did
not pronounce others, at times becoming unintelligible. For these reasons, he was at serious risk of
repeating a grade, although his dropout had nothing to do with these difficulties.

MULTIAXIAL DIAGNOSIS OF CLINICAL CASE NUMBER 3

Axis I: Conduct disorder
Axis II: Without diagnosis
Axis III: Without diagnosis
Axis IV: Family disturbance due to separation
V axis: 48
CLINICAL CASE NUMBER 4

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Consultation in November 1984, at 2 years and 9 months, referred by a psychologist due to lack of
language development, hyperactive and aggressive behavior. According to his parents, Gustavo began
to have such symptoms at the age of one and a half, coinciding with the birth of a cousin and the
mother's pregnancy; They accept that he was a hyperactive baby.
Father with sequelae of poliomyelitis. Born of normal pregnancy and childbirth, normal neonate. He
walked at 16 months and still had no sphincter control and only babbled some monosyllables or
unintelligible sounds. Normal neurological examination, normal skull X-ray, normal fundus. normal
EEG. Normal auditory evoked potentials. He had been medicated by a neurologist with CMZ, which had
a paradoxical effect.
Due to his behavior, lack of language and play difficulties, the psychologist's impression was that of a
psychotic child; however, during our consultation the child behaved more like a DCM. Given the
suspicion of the referring professional, no medication was instituted.
At 3 years and 2 months he controls his sphincters and develops gestural language. The suggestion for
speech support is postponed by the primary psychotherapist. 3-year-old kindergarten begins, where
according to the teacher report, correct integration occurs. Deficiencies remain in language and motor
clumsiness becomes evident in the neurological examination, while hyperactivity decreases slightly.
In 1986 he began working with a speech therapist who considered language delay as simple, with a
good prognosis; However, in that year, his difficulties in the garden became evident, with severe
attention and motor problems. Thinking of a DCM, he is medicated with Deanol.
In 1987, he studied again in a 4-year-old group, his graphics and language improved. Although the
latter passes into the speech therapy diagnosis of simple delay, it appears to be a cortical-type
phonological programming deficit. He continues in psychotherapy and psychopedagogical support is
suggested.
In 1988, preschool began; In April, following a comment from the mother, what until now was a
jealously guarded secret became evident: the existence of other delays in the family. A genetic study
is requested that reports the fragility of the X chromosome. Observing the family's genealogical tree,
one notices the randomness of the distribution of retardation, with variable mental disorders, all males.
In this case the transmission seems to originate via the maternal grandfather, which indicates the
confusing way in which this syndrome appears.
This tree is unfinished, since efforts are being made to carry out genetic studies on direct and indirect
relatives in order to finally reveal this jealously and unjustifiably kept secret.
The child continues to slowly improve in his hyperactivity, attention, motor skills and language.
Provides psychotherapy, speech therapy and psychopedagogy. He is promoted to 1st grade, currently
looking for the right school for him.

MULTIAXIAL DIAGNOSIS OF CLINICAL CASE NUMBER 4

Axis I: Attention deficit hyperactivity disorder.
Phonological disorder (it is not due to mental retardation as it later progresses)
Axis II: Mental retardation.
Axis III: None.
Axis IV: No data.
V axis: EEAG=0
COMMENTS ON CLINICAL CASE NUMBER 4.- Tallis presents this condition as mental retardation. "The variability of
the presentation of the condition can be illustrated in Gustavo's story with initial symptoms of language impairment,
and psychotic behaviors, to later appear as a MCD (Minimal Brain Dysfunction), with hyperkinetic behaviors and a
slightly affected mental level.
Source: Tallis J. and Soprano A., "Neuropediatrics, neuropsychology and learning", Nueva Visión, Bs. As., 1991.

CLINICAL CASE NUMBER 5

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Luis is a child with no significant personal history, whose father is an epileptic who presents
generalized tonic-clonic and absence seizures. Both the paternal aunt and the grandfather are type G
epileptics. Evil.
He consulted in August 1983, at the age of 9, due to a state of absence for which he was admitted to
our service. His illness began when he was two years old, and his attacks were never completely
suppressed. He received Ethosuximide and Clonazepam. Near the consultation, he had been prescribed
Phenobarbital (FB), which apparently had precipitated the status crisis. The FB is suspended and the
patient is left on Ethosuximide and Valproic acid (VA), yielding the absence status.
This medication is continued and his seizures decrease from four to five attacks a day until they
completely disappear after 8 months of treatment. EEGs show typical spike-wave discharges during
hyperventilation up to a year after the disappearance of clinical seizures, although small absences not
detected by parents and teachers cannot be ruled out. The dosages of Ethosuximide and AV are in
therapeutic ranges.
In the period of disappearance of the crises, in the 4th grade, a teacher report indicates elements of
learning commitment and emotional: "regular learning, sometimes almost deficient with low
performance. He is a very distracted child which harms him considerably. "Cordial relationship with his
colleagues, very shy, cries when his mistakes are pointed out to him."
The normalization of the EEG, achieved in 5th grade, coincides with an improvement in their academic
performance; at this time the AV is suspended.
In 6th and 7th grade there is no crisis and there is good learning.
In 1987 he began industrial school with 3 years without clinical seizures and 2 with normal EEG. After
a good start, in June there is a deterioration in performance that coincides with separation from the
parents and the reappearance of typical spike-wave discharges during hyperventilation, without
apparent clinical manifestations. Repeat the year.
In March 1988, with the reconstitution of the couple, they returned to the consultation, Ethosuximide
was replaced by AV. The last control was carried out in August 1988, there were no absences, his
school performance was satisfactory and the EGG only showed slow waves during hyperventilation.

MULTIAXIAL DIAGNOSIS OF CLINICAL CASE NUMBER 5

Axis I: No data.
Axis II: None.
Axis III: Epilepsy. (Petit Mal)
Axis IV: Family disturbance due to separation.
V axis: EEAG=0.
COMMENTS ON CLINICAL CASE NUMBER 5.- Tallis presents this condition as epilepsy. "The discussion arises not
regarding the presence of attentional disorders during absence seizures, but rather their persistence outside of
them, either due to sub-clinical spike-wave discharges or secondary inhibitions of processes related to the attention.
The clinical history shows the intricacy of this discussion.
There is no doubt that while this child had frequent seizures or absence status, his learning difficulties were
correlatable with an attentional alteration resulting from his illness: this is pointed out by the teacher, although her
report also indicates the presence of an altered emotional constitution. . It is not clear whether the subsequent drop
in performance is due to undetected absences, electrical crises or emotional disorders resulting from the breakup of
the parental couple, although we cannot rule out that this emotional alteration precipitates the EEG exacerbation.
The recovery of their learning raises the same questions: is it the medication, the improvement of the EEG or the
reconstitution of the couple? And what is the influence of the latter on the improvement of the disease?
As we see in this story, and in others, a global approach to the child and his environment is necessary before
assigning problems to specific aspects of the disease. On the other hand, our case history shows us that the
majority of well-controlled Petit Mal patients have satisfactory learning."
Source: Tallis J. and Soprano A., "Neuropediatrics, neuropsychology and learning", Nueva Visión, Bs. As., 1991.

CLINICAL CASE NUMBER 6

José Manuel is a boy of eleven years and nine months who comes to the consultation because he is

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two grades behind. He began school at the age of five in a bilingual school where he had difficulty
learning to read. At seven years old he was just a very ordinary student. Then he suffered a choreic
condition that kept him in bed for three months and which became chronic. The choreic movements,
according to the parents, evolved in the form of chronic tics, of which there are many family histories.
Currently the child has the greatest problem with mathematics and is self-conscious. His hobbies are
painting, drawing, reading history, mineralogy, etc. His humanistic knowledge contrasts with his
difficulty in mathematics. In character, he is a child adapted to the family environment, perhaps a little
aggressive. He has few friends for his age, "because he retires rather than looking for them," and he
feels more comfortable with older people.
He is an only child. He grew up very healthy until Korea. He has always been clumsy in psychomotor
activities; Today it still inverts words and syllables. He is, like his father, left-handed. The parents are
both painters and, as artists, have given him a liberal education. The father identifies with the son
because, in addition to being left-handed, he considers himself slow in learning things; For
mathematics it was a real disaster. "Then I learned in seven days what I haven't learned in seven
years." José Manuel is very fond of drawing and painting, where he shows brilliant results.
During the psychological examination we found a cooperative child. His verbal expression is not very
fluid; It lacks rhythm and speaks like blows. He has multiple tics that are accentuated when we discuss
conflictive topics or he has to perform tasks that require concentration. Regarding his school failures,
they accentuate his difficulties in mathematics and his poor relationship with teachers, for all of which
he feels very guilty. What he likes least is mathematics and language. It narrates dreams with frankly
persecutory content. His behavior is very unstable.
His drawings are balanced and of great artistic quality. In his projections, a castrating relationship with
the maternal figure and identification difficulties with the paternal figure stand out.
On the WISC he obtains a total IQ of 115, with 101 on the verbal and 124 on the manipulative. There
is difficulty expressing oneself verbally. Their lowest scores are "comprehension", "arithmetic", and
"keys", with large discrepancies of up to 13 points between the various subtests.
In psychoneurological tests, Bender estimates visual-motor maturation, still slow, appropriate for his
age. The Galifret-Granjon laterality tests, even within the limits of ambidextrism, estimate a left-
handed predominance of the eye and hand, and a right-handed predominance of the foot. In the
Piaget-Head spatial orientation test, he found difficulties in recognizing the position of objects in space
relative to each other, reversing the left-right position. Mira-Stamback rhythm tests show no
abnormalities.
The Rorschach assesses an intratensive, rationalizing, oppositional attitude and psychological conflicts
with parental figures. All this together with a strong self with a good capacity to adapt.

MULTIAXIAL DIAGNOSIS OF CLINICAL CASE NUMBER 6

Axis I: Disorder of reading, calculation and written expression.
Axis II: None.
Axis III: Korea.
Axis IV: No information.
V axis: EEAG=60.
COMMENTS ON CLINICAL CASE NUMBER 6.- Monedero comments: "Here we can see a child with difficulties in
school practically from the moment he enters school. The role played by Korea is difficult to define, although it is
surely secondary. There are difficulties in the area of language, motor coordination - instability and tics -, laterality
and failure, in addition to arithmetic, in keys, which would be related to immediate visual memory and motor speed.
There are also emotional problems that, accentuating all these dysfunctions, seem to cause a rejection of schooling.
The child tries to escape from the school world, which so values the verbal, to take refuge in the world of his home,
in which the figurative prevails. "We must not forget the family incidence of certain symptoms."
Source: Monedero C., "Evolutionary Psychopathology", Labor Universitaria, Barcelona, 1982.
CLINICAL CASE NUMBER 7
Macarena is seven years and ten months old and comes to the consultation due to insufficient
academic performance. Her parents describe her as a normal girl, perhaps somewhat childish for her
age. He presents with primary nocturnal enuresis and, from time to time, tics.

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She was born after an 8-month pregnancy and weighed 2500 g. Psychomotor patterns developed
normally. When he was three years old, his next sister was born: she reacted with jealousy, envy and
aggressive attitudes.
At school they say he has some signs of dyslexia. He is doing worse in English, although before that
was what he was better at, and in writing. If parents force her to pay attention, she does better. In
any case, he seems to be behind in school in almost everything. She is a very overprotected and self-
centered girl who has had a hard time adapting to schooling. The parents emphasize that the girl
shows great intelligence for life, which contrasts with her clumsy schooling. The mother is an unstable
personality who has been on antidepressant treatment and experiences the anorexia of another of her
children with great anxiety.
During the psychological examination, we found a harmonious and active girl, who seemed appropriate
to the situation, although somewhat childish for her age. Language is correctly developed and reading
is correct for his age. The writing shows dysgraphic signs such as directional reversals and phonetic
changes. His motor coordination is correct, but he becomes disorganized when he writes more quickly.
He explains the tics in his nose by saying that he does it because his nose is itchy and because he
doesn't scratch it.
His drawings are well structured and proportioned for his age, with no conflicting elements evident in
his projections. In the projective tests - Duss, Three Wishes and CAT-H - he projects his fraternal
rivalry, the experience of loss or inner emptiness and the desire for compensation.
The WISC estimates a total IQ of 108, with a 109 on the verbal scale and a 104 on the manipulative
scale. Its highest scores are in "similarities", from which a capacity for abstract-logical reasoning at a
ten-year-old level can be deduced, and the lowest in "incomplete figures", which place it at a six-year-
old level, which which could be pointing towards the existence of a perceptual, concentration and
attention problem.
In psychoneurological tests, ambidextrism and crossed eye-hand laterality (Galifret-Granjon) are
estimated. His right-left orientation -Piaget-Head- is slightly below his age. His motor speed is higher
than the average limits for his age and the rhythm tests - Mira - Stamback - show irregularities in
terms of excessive speed and abruptness. The Bender places her at the lower limit of the average
range of her age, corresponding to a visual-motor maturation of six years and six months.
The Rorschach shows an average intellectual level and some conflicts in relation to the maternal figure.

MULTIAXIAL DIAGNOSIS OF CLINICAL CASE NUMBER 7

Axis I: Writing disorders
Axis II: None
Axis III: Primary nocturnal enuresis
Axis IV: Overprotected girl in the family environment
V axis: EEAG=0
COMMENTS ON CLINICAL CASE NUMBER 7.- Monedero comments: "Macarena's case seems to fit the diagnosis of
dysgraphia. Their verbal and manipulative IQs are analogous, but there are discrepancies between the subtests that
point us to perceptual difficulties. Psychoneurological tests also point to immaturity. There are also psychomotor
control difficulties, as shown by his tics. "The same as in the previous case, there is a whole conflict that helps in
establishing the picture."
Source: Monedero C., "Evolutionary Psychopathology", Labor Universitaria, Barcelona, 1982.

CLINICAL CASE NUMBER 8

Federico is ten years and four months old and comes to the consultation due to language disorders and
insufficient school performance. He developed language very late. Around the age of five he began to
have difficulty breaking into speech. At six years old he was already reading well, but he has always
been very clumsy at writing and drawing. He is very bad at manual things and is very happy when he
obtains some results in this area.

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Parents describe him as an independent, irascible child and, in general, well adapted to the family and
school environment. It seems she suffered from labor anoxia. He had daytime enuresis until he was
five years old and nocturnal enuresis until he was seven. He was undergoing dyslexia re-education
treatment.
At school he gets better grades in mathematics and worse in natural sciences and language.
During the psychological examination we found a child who seemed friendly, smiling and cooperative.
In language it presents tonic-clonic arrests, which interrupt its course; Sometimes the arrests are so
intense that we have difficulty understanding what he is saying. It is a stutter. Its verbal expression is,
however, correct from a phonetic and grammatical point of view.
A lack of coordination is observed in the writing, remains of a dysgraphic picture. His reading level is
appropriate for his age. He does not express conflicting psychological themes, except those created by
his language difficulties.
The drawings he makes are very childish for his age and not very coordinated. Obsessive and
perfectionist traits can be seen in Corman's family. Those who relate best, according to their
projections, are the father and the son. He also projects fears in relation to the maternal figure, which,
in another drawing, he renders without arms.
The conflicts with the maternal figure also seem to be confirmed in the fables of Duss and the CAT-H.
He experiences his mother as not providing him with the emotional support he demands, which gives
rise to aggressive and self-destructive experiences.
On the WISC he has an IQ of 82, with a verbal score of 88 and a manipulative score of 79. In an
intertest analysis, significant differences are seen, with achievement levels ranging between 6 and 14
years. Their best score is in "arithmetic" and their worst, already below average, in "information",
"vocabulary", "comics" and "puzzles". In this last test, which measures shape memory, spatial
orientation and structuring, their performances correspond to those of six years old. His language
difficulties place him in a conflictive situation when faced with verbal tests, showing signs of insecurity,
anxiety and negativity. Their slowness and psychomotor clumsiness when organizing the tests in a
limited time undoubtedly negatively influence the results of the manipulative scale. The Raven General
Scale placed him in the 50th percentile.
In psychoneurological tests we found visual-motor maturation appropriate to his age -Bender-; a right-
left orientation -Piaget-Head- corresponding to a nine-year-old level, a consequence of a deficient
lateralization of the body scheme that is not intellectually compensated; In the laterality tests -
Galifret-Granjon - eye-hand ambidextrism and a right-handed predominance in lower limbs with great
clumsiness are observed; Their movements, within the ambidextrous category, correspond to 7 years;
In the rhythm tests -Mira- Stamback- a level corresponding to 7 years is estimated.
The psychomotor tests -Pic-Vayer- offer an 8-year level in manual coordination, being more precise
when performed with the left hand than with the right. General dynamic coordination is also at an 8-
year level. In postural control and balance it can reach a level of 9 years; However, he does the 8-
year-old level with difficulty, since this level requires staying on the balls of his feet.
The Rorschach shows a neurotic inhibition of thought and a tendency to escape into fantasies. Their
experiential type is limited and their adaptation to the environment is very reduced. There are also
depressive type traits, insecurity and anxiety.

MULTIAXIAL DIAGNOSIS OF CLINICAL CASE NUMBER 8

Axis I: Stuttering
Axis II: None
Axis III: None
Axis IV: No information
V axis: EEAG=0
COMMENTS ON CLINICAL CASE NUMBER 8.- Monedero comments: "Federico presents a rich symptomatology. We

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found alterations in the verbal area -stuttering- and psychomotor areas important enough to justify his school
difficulties. The IQ estimated by the WISC does not correspond to their true intellectual possibilities, since both their
verbal and manipulative difficulties greatly increase their completion time; Hence, in another test like the Raven, in
which the incidence of these factors is limited, their score is average.
Stuttering, as in this case, usually coincides with poor lateralization, spatial organization and poor sense of rhythm.
Their better performance in mathematics is clearly reflected in the tests. The low scores in "information" and
"vocabulary" respond, without a doubt, both to their verbal difficulties and to the conflictive experiences involved in
any communication process. The low scores in "comics" and "puzzles", in addition to their poor understanding of
social situations, reveal their imperfect spatial organization. Both the psychoneurological and psychomotor tests
strikingly reflect the alterations in spatial organization, psychomotor and rhythm, which justify the dysgraphic
picture and the motor clumsiness that he always showed.
The condition, as a whole, could be diagnosed as minimal brain dysfunction, because although we do not know the
existence of any certain brain insult, there are antecedents compatible with it and, above all, the symptoms found
are those of a child with brain damage.
There is also a whole emotional conflict, we do not know if it is a condition of some aspects of the condition or just
a result of it, which further reduces the child's performance."
Source: Monedero C., "Evolutionary Psychopathology", Labor Universitaria, Barcelona, 1982.

CLINICAL CASE NUMBER 9

Fernando is a child who is seven years and ten months old, who comes to the consultation due to
behavioral disorders and poor school performance. Parents describe him as an unstable, egocentric and
maladaptive personality. He has always shown a certain intellectual delay, although, at the same time,
he surprises with his sharp or inappropriate observations for his age. He has bad relationships with the
other children because he does not accept their rules of play. He is affectionate with older people and
has always shown a predilection for his father.
The pregnancy and delivery were normal. Around seven months he began to have a serious case of
bronchitis that took a year to cure. Until he was three years old, when he had surgery for tonsillitis, he
only ate milk and cookies. Although he could stand on his feet at 9 months, he did not walk until he
was 16 months old, because, according to his parents, he was afraid of the hits he gave himself. The
first words appeared at the age of two, but it wasn't until he was four that he didn't say complete
sentences. He has not passed the first EGB.
The mother considers herself a normal personality although, as she has five children, she frequently
loses her patience. The father is a very self-controlled personality, who becomes very distressed by the
problems that his children pose.
During the psychological examination we found an unstable child, who spoke spontaneously and tried
to take the initiative. His emotional attunement, although changeable, is good and with hypomanic
features. You become depressed and anxious easily when you encounter difficulties in completing a
task. There is a perseverance in the topics he deals with and his general behavior, even with traits of
timely acuity, cannot be described as intelligent. Language is correctly developed and reading is
appropriate for his age. In writing, multiple dysgraphic signs can be seen, such as inversions, joining
words, combining uppercase and lowercase letters, and, in general, a great lack of coordination and
uniformity. Poor coordination and disproportion can also be seen in the drawings. Valued as a test of
intelligence, it estimates a mental age of five years and nine months.
In Duss's Fables he projects his desire to be cared for, the difficulty of developing fraternal rivalry, and
his desire to compensate for his feelings of abandonment, which become more evident in CAT-H.
On the WISC he obtains a total IQ of 81, with a 90 on the verbal and a 75 on the manipulative. Their
poor performance in manipulative tests seems to be due to poor visual-motor coordination and
inadequate perceptual organization. In "cubes" and "keys" their scores correspond approximately to
five years. In "information" and "vocabulary" he obtains scores appropriate to his age.
Various alterations are observed in psychoneurological tests. On the Bender you obtain a score
corresponding to the visual-motor maturation of a 5 and a half year old child. There are signs of
impulsivity and anxiety, as well as indicators of possible brain injury. In the Galifret-Granjon laterality
tests, it shows an index of manual predominance within the limits of left-handedness, with a right-
handed ocular predominance, therefore possessing crossed laterality. At the level of the lower limbs,
the predominance is right-handed. In the Piaget-Head right-left orientation battery, he obtained a
score specific to 6 years of age without discrepancies within the various subtests.
The electroencephalographic recording was normal.

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In the Rorschach, a type of personality is found with a low level of structuring and control, which
prevents better contact with the outside world, with a predominance of hypomanic mechanisms and
instability factors.

MULTIAXIAL DIAGNOSIS OF CLINICAL CASE NUMBER 9

Axis I: Dysgraphia
Axis II: None
Axis III: Possible brain injury
Axis IV: Conflicts with colleagues.
V axis: EEAG=0
COMMENTS ON CLINICAL CASE NUMBER 9.- Monedero comments: "This case fits within the diagnosis of minimal
brain dysfunction, and shows poor development of language and psychomotor functions. Currently the results are
lower in the manipulative and psychoneurological areas, which translates into difficulty in writing and drawing. The
relatively high scores on verbal tests cause parents to emphasize their "acuity" in this area. His verbal deficit seems
to have been largely compensated, and both his linguistic expression and his reading ability do not appear to be
altered.
"This child's behavioral alterations make the school environment even more reject his integration."
Source: Monedero C., "Evolutionary Psychopathology", Labor Universitaria, Barcelona, 1982.
CLINICAL CASE NUMBER 10
Daniel is close to turning 17 when he arrives at the clinic because he has repeated his fourth year and
is not doing well in his studies. He left in six subjects in December and in two in March. In December
he approves only one, which brings him to seven by March. He fails the first two, and does not pass
the rest because he was already repeating the year.
Regarding his school history, during primary school he was a regular student. In 4th, 5th and 6th
grades, subjects were taken to March, especially Language. In the first, second and third year of high
school he failed in many subjects, and always had to take prior exams.
Daniel says that the subjects he likes the most are those that "don't have to be studied", such as
mathematics, physics or chemistry, because he understands them in class. On the other hand, he does
not like history, language, literature, civic instruction, etc., in which he has greater difficulties.
His parents separated about three years ago. His two older siblings who study and work (a 24-year-old
woman and a 22-year-old man) went to live with his father. Daniel went to live with his mother in his
maternal grandmother's house. Because Daniel did not get along with his grandmother, his mother
decided to rent an apartment, where she and Daniel have lived for two and a half years.
The mother is an only child and has a university education; The father has secondary school. Both
currently have a partner, although the mother does not live with hers.
The operative diagnostic tests reveal that Daniel achieved formal thinking, although he has problems
verbally substantiating his answers due to language difficulties (poor vocabulary, syntax problems,
errors in verbal conjugation, etc.). The Weschler resulted in an IQ = 111 (96 on the verbal scale and
119 on the execution scale).
Significant facts from her story.- The mother became pregnant with her son Daniel when she was
going through a difficult economic situation and had to care for her father with cancer, who died five
months into her pregnancy. In the context of these difficulties, Daniel was born, and was very well
received.
The child was not sought but it was accepted and there was never any doubt about having it or not.
The birth was normal, although the mother reports that he was born "half purple" but he quickly got
out of the situation thanks to timely medical intervention.
Daniel was always allergic. At the age of one and a half he had pneumonia, and since then he has had
breathing difficulties (bronchospasms and fatigue).
When he enters kindergarten he has no difficulties in adapting, being very loved for being very
sociable.
According to what they told his mother, he was a little immature to enter first grade, despite which
they made him start. Precisely in the first grade, difficulties appear, and he is referred for a psycho-

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pedagogical diagnosis. He didn't repeat it but he "scraped by." The neurological studies revealed
nothing although, according to the mother, they spoke to her of a certain degree of immaturity. They
recommended treatment but he stopped because improvements occurred after 2 or 3 months.
He continued well until fourth grade, when he began to have to take exams. He always had a private
teacher. It was difficult for him to learn to read and his difficulties always appeared in the area of
Language.
He never had problems with social integration at school, he was very talkative although, according to
the teacher, somewhat distracted and reluctant to do his homework.

MULTIAXIAL DIAGNOSIS OF CLINICAL CASE NUMBER 10

Axis I: Calculation disorder
Axis II: No diagnosis
Axis III: No diagnosis
Axis IV: New marriage of one of the parents. Physical abuse
V axis: EEAG = 65.

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