Demographic Data:        Back to Top
 

Client:	Jane Doe *****	Age:	10 year-X months
Parents:	Mr. and Mrs. *****	Birth Date:	********
Address:	**********	School:	**********
	**********	Grade Completed:	4th
Phone:	**********	Date of Testing:	**********
		Examiner:	Sherri Sharp, MS

Reason for Referral:

Jane Doe was referred for a comprehensive psychoeducational evaluation by her great grandparents.  It was reported that she was having difficulties with spelling and reading. Therefore, an evaluation was conducted to determine the level of Jane Doe's ability.

Background Information:

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Jane Doe is a 10-year, 1-month old Caucasian female who resides in *****.  She is enrolled in the 4th grade at *****.  She lives with her great grandparents, Mr. and Mrs. *****, and her younger biological sister, Chelsea.

Mr. and Mrs. *****, Jane Doe's paternal great grandparents, had legal custody of her and her sister, Chelsea.  When Jane Doe was 6 months old, her parents worked and the great grandparents provided childcare for her.  The parents began leaving Jane Doe with Mr. and Mrs. ***** more frequently and for longer periods of time.  Then, the parents moved to *****, leaving Jane Doe to live with her great grandparents.  One year later, the parents called and asked Mr. and Mrs. ***** to come and pick up Chelsea, then two weeks old.  The parents would visit the children occasionally until 1998 when they divorced.  At the time of the evaluation, Jane Doe's biological father called them daily, while her biological mother made little contact.

Jane Doe was a product of a full term delivery weighing 7 pounds, 15 ounces.  A Caesarian section was performed because the mother, Kimberly, was unable to deliver; the reason was unknown.  Mrs. *****, reported that Kimberly smoked marijuana and consumed alcohol during the pregnancy; the amount and frequency was unknown.  Both Kimberly and Jane Doe had staff infections for ten days after delivery.  Medications given were unknown.  It was reported that Jane Doe reached her developmental milestones, such as talking and walking, within normal limits.  When Jane Doe was 6-years old, she was attacked in her backyard by the neighbor's 120-pound dog.  The dog knocked her onto the ground and bit her face and head several times.  Jane Doe's great-grandfather, Mr. *****, pulled the dog off of her.  She was taken to the emergency room and underwent four hours of surgery.  Jane Doe was given rabies shots, pain medications, and antibiotics.  After the attack, Jane Doe was very afraid of all animals and began having nightmares.  She saw a counselor for four months to address these issues.  She no longer has a fear of animals or nightmares.  Children at school teased Jane Doe because of her scars, but this ended as the scars lightened.  When Jane Doe was 8-years old, she received cosmetic surgery for the scars on her face.  Jane Doe began getting severe headaches and vomiting when she was nine.  A doctor was consulted who said that the symptoms may have been due to Jane Doe worrying about the possibility of an up-coming cosmetic surgery.  Mr. and Mrs. ***** decided that Jane Doe did not need the second cosmetic surgery; her headaches and vomiting stopped.

Educationally, Mrs. ***** expressed concern with Jane Doe's reading and spelling difficulties.  She attended both preschool and kindergarten.  The problems were first noticed when Jane Doe was in the second grade by Mr. and Mrs. *****, who discussed their concerns with Jane Doe's teacher.  The teacher told them that it was nothing to be concerned about because it was not affecting her grades.  Classroom modifications were made in order to allow Jane Doe to use a spell checker on the computer.  The problem was again addressed with Jane Doe's third grade teacher.  This teacher also stated that the spelling trouble was not a concern, but continued to implement the previous classroom modification of allowing Jane Doe to use a spell checker on the computer.  No formal assessment was conducted.  The school provided a tutor for Jane Doe during the second half of her third grade year.  Mr. and Mrs. ***** were unsure of what the tutor did with Jane Doe or how often they met.  During second and third grade, Jane Doe received mostly A's on her report cards.  Mr. and Mrs. ***** believed these teachers were too lenient.  They reported that Jane Doe's fourth grade teacher was strict and they were afraid that her grades were going to drop.

Mr. and Mrs. ***** believed that Jane Doe understood why her parents were not together and why they did not see her often, but that she felt sad about it.  Mr. and Mrs. ***** stated that Jane Doe got along with her sister, but often engaged in typical childhood disputes.

Mrs. ***** reported that Jane Doe had a bad temper and would throw tantrums.  When Jane Doe became mad, she would scream, throw things on the ground, and slam the door to her room where she would sit for approximately 15 minutes until she had calmed down.  As a means of discipline, Mr. and Mrs. ***** would put Jane Doe in time-out or take an activity away from her.  Spanking Jane Doe did not help; removing privileges seemed to be the most effective method.  As a way to reward Jane Doe when she behaved appropriately, she would receive praise, hugs, and added privileges.  Mrs. ***** viewed Jane Doe as an outgoing, loving child.  She stated that Jane Doe was involved in many activities such as soccer, basketball, swimming, and piano lessons.  Jane Doe reported that she has many good friends and a great relationship with her great grandparents.
 

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Test / Behavioral Observations:

Jane Doe was observed within a one-to-one testing situation over the course of two sessions. The sessions took place in a quiet, well-lit room.  When the evaluation began, Jane Doe was friendly and ready to get started.  She spoke at a casual pace and was easily understood. She sustained logical, appropriate conversation with the examiner.  Jane Doe was very cooperative during testing and accepted breaks when offered.

When questions were presented verbally, Jane Doe would repeat them to herself.  She would also sound out words that she was attempting to spell.  Jane Doe was very definite about the words that she did not know and did not attempt to guess.  She appeared not to be bothered by the questions that she did not know.  During the second session, Jane Doe appeared tired, yawning and requiring more breaks.  She was also more hesitant with sounding out tasks.  She would attempt questions that she was unsure about, but would give up easily.
 

Instruments Administered and Methods Used:

• Parent Interview
• Child Interview
• Wechsler Intelligence Scale for Children - Third Edition
• Wechsler Individual Achievement Test
• California Verbal Learning Test - Child Edition
• Developmental Test of Visual-Motor Integration
• Woodcock Diagnostic Reading Battery
• Behavioral Assessment System for Children-Parent Rating Scales
• Behavioral Assessment System for Children-Teacher Rating Scales
• Behavioral Assessment System for Children-Self Report
• Children’s Self-Report and Projective Inventory
• House-Tree-Person
• Kinetic Family Drawing
• Developmental Questionnaire

Cognitive Ability Measure

Wechsler Intelligence Scale for Children - Third Edition (WISC-III)
(Mean = 100, Standard Deviation = 15)

Achievement Measure       Back to Top

Woodcock-Johnson III Tests of Achievement (WJ III A)
 (Mean = 100, Standard Deviation = 15)

Reading:       Back to Top

Woodcock Diagnostic Reading Battery (WDRB)
(Mean = 100, Standard Deviation = 15)

Memory/Learning:    Back to Top

California Verbal Learning Test - Children’s Version
(Mean = 50, Standard Deviation = 10)
(Scaled and Difference Score Mean = 0, Standard Deviation = 1)

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Visual-Motor Measure:

Developmental Test of Visual-Motor Integration (VMI)
(Mean = 100, Standard Deviation = 15 )

Personality/Socio-emotional Measures:    Back to Top

Behavioral Assessment System for Children  - Parent Reports (BASC PRS-C)
                                                                        - Teacher Report (BSAC TRS)
(Mean = 50, Standard Deviation = 10, Norming Group = Female)

*    At Risk
**  Clinically Significant

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Behavioral Assessment System for Children  - Self Reports (BASC SRP)
(Mean = 50, Standard Deviation = 10, Norming Group = Female)

*    At Risk
**  Clinically Significant

Children’s Self-Report and Projective Inventory
(See text of report for discussion)

House-Tree-Person (H-T-P)
(See text of report for discussion)

Kinetic Family Drawing
(See text of report for discussion)

ASSESSMENT RESULTS AND CLINICAL IMPRESSIONS                Back to Top

Cognitive Measure

The Wechsler Intelligence Scale for Children - Third Edition (WISC-III) includes a series of subtests, which are used to estimate an individual’s intellectual ability.  Overall, Jane Doe performed in the High Average range.  Her ability to sustain attention and her short-term memory were found to be within the Average range.  In addition, a relative strength was found in Jane Doe's ability to process information, and her reaction time and decision speed.  Based on this, she would be expected to think through information and respond as quickly as her same aged peers.

Achievement

The Wechsler Individual Achievement Test (WIAT) includes a series of subtests, which were used to estimate an individual’s achievement.  Jane Doe was found to be performing within the Average range on school-related tasks, with the exception of the language composite, which was within the Superior range. This performance is commensurate with her general cognitive ability.  Strengths of Jane Doe seemed to be her language ability, both receptive and expressive.  A score of Jane Doe’s understanding of information presented verbally was found to be within the High Average range.  Similarly, tasks that required oral expression of ideas were found to be within the Superior range.

Jane Doe was also administered a measure to more specifically assess her reading achievement.  This battery measured the two prerequisites for successful reading achievement: phonological awareness and comprehension of oral language.  Jane Doe's score on measures of reading identification, phonic and structural analysis skills, reading vocabulary, and comprehension fell in the Average range.  A strength for Jane Doe was her ability to understand and remember information presented verbally.  Jane Doe's ability to analyze and produce the basic sounds of speech fell in the Low range of scores obtained by others at her age level.  Due to this, Jane Doe may find the phonological demands of such tasks difficult.  This difficulty with basic speech sounds could be effecting her spelling.

Memory

Jane Doe was administered a test that assessed auditory memory and verbal learning.  Her performance indicated that her recall ability was High Average over the course of the initial five trials.  On both short-delay (several minutes) and long-delay (20-minutes) recall, Jane Doe performed in the Average range.  Although, with the benefit of category cues, her recall was in the Superior range for those in her age group.  This suggests that Jane Doe had some difficulty, although still within the Average range, retrieving information from short-term memory and that the cues helped her.  The findings suggest that Jane Doe exhibited adequate encoding and retrieval skills in learning verbal information.

Visual-Motor

Jane Doe was administered a test to examine her copying ability.  Her ability to copy geometric designs was within the Average range, although significantly below her overall cognitive ability.

Personality/Socioemotional

 Jane Doe’s overall behavior, emotional adjustment, and personality dynamics were measured with several objective and projective measures.  After examination of all these measures, several conclusions were made.  The personality assessments indicated that Jane Doe was experiencing a number of life stressors, such as having infrequent contact with her parents, her great grandmother going to the hospital, and not doing well in spelling.  However, she displayed successful coping skills to effectively deal with these stressors.  Her mild levels of anxiety were expressed through worry, nervousness, aggression, and lack of adaptability.  She displayed her aggression by losing her temper, arguing with her great grandparents, refusing to comply with their requests, and throwing things on the floor when denied her own way.  She would also sometimes threaten and hit other children.  These behaviors occurred more frequently with Jane Doe than in other children her age and developmental level, thus she meets the criteria for Oppositional Defiant Disorder.   Jane Doe expressed concerns about doing well in school and pleasing her great grandparents.  Due to this, she was having a hard time keeping her mind on schoolwork, would often get sick before tests, and bit her nails.  The anxiety and worry have resulted in her giving up easily when learning new things, being forgetful, and not wanting to follow the rules.

Summary

Jane Doe was a 10-year 1-month-old, Caucasian, female.  Overall, indications from current testing suggest that Jane Doe’s general cognitive ability was commensurate with her achievement ability.  Her general cognitive ability was found to be within the High Average range.  Jane Doe's ability to sustain attention and her short-term memory was found to be within the Average range.  A relative strength was found in Jane Doe's ability to process information and her reaction time and decision speed.  On tests of achievement, Jane Doe scored in the Average range, with the exception of the language composite, which was within the Superior range.  A measure of Jane Doe’s ability to understand information presented verbally was found to be within the High Average range.  Similarly, tasks that required oral expression of ideas was found to be within the Superior range.  Jane Doe's reading identification, phonic and structural analysis skills, reading vocabulary, and comprehension skills were average.  Jane Doe's ability to analyze and produce the basic sounds of speech fell in the Low range of scores obtained by others at her age level.  Personality assessment results indicate that Jane Doe was displaying anxious tendencies.  Her feelings of anxiety were expressed through worry, nervousness, aggression, and lack of adaptability.
 

DIAGNOSTIC IMPRESSIONS

DSM-IV Diagnosis
 

Axis I:	Rule out 315.39 Phonological Disorder  313.81 Oppositional Defiant Disorder
Axis II:	V71.09 No diagnosis
Axis III:	none
Axis IV:	Disruption of family by divorce, academic problems
Axis V:	GAF  = 80 (Current)

Recommendations:                  Back to Top

Considering background information, behavioral observations and past and present testing, the following recommendations are made:

1. Mr. and Mrs. ***** may want to consider placing Jane Doe in a program such as those offered at Sylvan Learning Center to work on phonetic awareness proficiency.  The program may help to build her phonic and structural analysis skills.

2. It is recommended that Jane Doe meet with a Speech Language Pathologist to further evaluate her phonetic skills.

3. Jane Doe may benefit from utilizing a computer-spelling program.  This may make studying words more enjoyable, in turn, easier to learn.

4. Mr. and Mrs. ***** may want to verbally quiz Jane Doe on her spelling words.  Mr. or Mrs. ***** would orally present a spelling word and Jane Doe would then spell it out-loud, followed by writing the word on her paper.

5. Jane Doe may benefit from bouncing a basketball as she orally spells the words from the week's spelling list (one bounce per letter).  This may help to develop a rhythm in the spelling of the words, in turn, making them easier to remember.  A variation of this method would be to snap her fingers or clap her hands with each letter.

6. Jane Doe may benefit from reading books out-loud to Mr. or Mrs. *****.  This will expose her to the written form of words paired with the auditory form of the same words, helping to familiarize her with unknown words.  Mr. or Mrs. ***** would provide guidance as Jane Doe comes across difficult words.  The subject matter of the books should be appealing to Jane Doe to maintain her interest in the task.

7. It is recommended that Mr. and Mrs. ***** provided Jane Doe with praise for her performance both on studying her spelling words, as well as her test performance, placing an emphasis effort being more important than the end result.  This may aid in elevating test anxiety, as well as her worry of disappointing Mr. and Mrs. *****.

8. Jane Doe may benefit from individual counseling to address her anxiety and aggression.  This may provide her with the opportunity to discuss her feeling and concerns about family and school.

9. Mr. and Mrs. ***** may want to consider parent training to assist them with anger management and disciplining Jane Doe.  Such training may offer more appropriate methods of addressing Jane Doe’s specific needs.

10. If there are any questions about the material in this report or if further consultation is necessary, please do not hesitate to contact the clinic directly at (XXX) XXX-XXXX.

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_____________________________________
Sherri A. Sharp, M.S. Date
Student Clinician