ALL NAMES AND IDENTIFYING INFORMATION HAVE BEEN CHANGED TO PROTECT PRIVACY IN THIS PUBLICATION.

Demographic Data:      Back to Top
 

Client:	Jane Doe *****	Age:	38 yrs - x mos.
Address:	**********	Birth Date:	*******
	**********	Date of Testing:	*******
Phone:	**********	Examiner:	Sherri Sharp, MS

Reason for Referral:

Jane Doe was self-referred for a comprehensive psychoeducational evaluation.  She indicated that she was having difficulties with spelling and reading.  Specifically, she wanted to know why she could not learn and where she could receive assistance for her difficulties.

Background Information:

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Jane Doe is a thirty-eight year-old Caucasian female who resides in *****.  She is employed as a custodian at two locations.  She reports that she has always had two or more jobs at the same time and that they are necessary to meet her financial obligations.

Jane Doe reported that she was born on her due date.  There were no problems indicated during pregnancy or birth.  However, Jane Doe stated that her mother smoked three cigarettes per day while pregnant.  Jane Doe reported that she reached her developmental milestones, such as talking and walking, within normal limits.  At the age of 11 months, she fell down the basement steps of her home and broke her leg; she wore a cast for several months.  At two years old, Jane Doe put an electric socket to her mouth and was electrocuted; significant damage was caused to her bottom lip.  Subsequently, she had plastic surgery immediately following the incident and then again at three.  Jane Doe also reported that she had the measles at age three and the chicken pox at age four.  She had her hearing and speech tested in second grade; no problems were found.  When Jane Doe was 17 years old, she attempted suicide by overdosing on pills that she found in the medicine cabinet.  At the time of the evaluation, she did not recall any specific events that preceded her suicide attempt, but reported that she had felt depressed for a long time.  Her brother found her and took her to the hospital where she had to stay for a few hours.  A family doctor prescribed anti-depressants for her.  Jane Doe took medication for anxiety attacks for three years starting at age 18.  She said that she learned to control the attacks by making herself calm down when she became short of breath.  Because of this, she stopped taking the medication.  In 1985, Jane Doe was depressed about her husband's affairs and made a second suicide attempt by, again, overdosing on pills that she found in the medicine cabinet.  This time her husband found her and brought her to the hospital where she was hospitalized for four days.  After being released, she was required to attend counseling.  She discontinued her sessions after four months because she felt that they were not helping her.  No medications were prescribed.  Jane Doe reported currently experiencing severe premenstrual syndrome symptoms such as fidgetiness, anger, and depression that was accompanied by suicidal thoughts.  In 1999, Jane Doe was diagnosed with Fibromyalgia.  The doctor told her to regulate her sleep patterns in order to help the sleeplessness and muscle fatigue that accompanies Fibromyalgia; no medication was prescribed.

Educationally, Jane Doe expressed concern with reading and spelling.  She attended both preschool and kindergarten.  The problems with reading were first noticed in second grade, but nothing was done until third grade at which time she began tutoring one time a week.  No formal assessment was conducted.  Jane Doe did not remember how many years she received tutoring.  No other school interventions were made.  Jane Doe learned to sight read and had never tried a phonetic approach.  She reported being able to comprehend what she read.  She said that she had trouble with words that sound alike, as well as silent letters.  Jane Doe was enrolled in regular education classes while at ***** High School, although she did attend general literacy classes in the summers.  In 1989, she attended one semester of classes at ***** University.  She said that she earned a C in her nutrition class and B's in her filing and calculator using classes.  Despite wanting to achieve and do well, Jane Doe had to quit college because she needed insurance; so she began working.

Jane Doe reported having a good relationship with her parents.  She believed that her father might have had trouble spelling because he was always asking how to spell words.  Her mother and brother had no academic troubles.  Her brother engaged in cutting behavior.  She was unable to recall when it started, only that he was placed on medication and was receiving treatment.  Jane Doe reported that her first husband was mentally abusive, telling her that she was crazy.   He cheated on her and then divorced her after five years of marriage.  The couple had two children while married.  At the time of testing, Lisa [real name withheld] was 19 years old and Brandon [real name withheld] was 18 years old.  Jane Doe and her ex-husband have had joint custody since the divorce, but both children reside with their father.  Jane Doe indicated that Lisa had trouble spelling, adding and subtracting, while Jack did not hear consonant sounds clearly.  Jane Doe then had a sporadic relationship for three years with the father of her third child, Terry [real name withheld].  At the time of testing, he was 11 years old.  Terry resided with Jane Doe's mother, who had custody of him, due to Jane Doe's demanding work schedule.  When Terry was five years old, he began saying that he wanted to kill himself by jumping out of a window.  Jane Doe took him to see a counselor.  The counselor told Jane Doe that Terry was reacting to her moods and trying to get attention.  They continued going to family therapy for several months until the counselor told Jane Doe that there was no longer anything to be concerned about with Terry.  Jane Doe married for a second time to a man in the service.  While they were legally married for three years, they were actually only together for 1 year.  Jane Doe indicated that they were too different and that he preferred to be on his own.  Currently, she is single, living on her own, and spends what little free time she has with a small group of friends.
 

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Test / Behavioral Observations:

Jane Doe was observed within a one-to-one testing situation over the course of three 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 often refused breaks when offered.

At the beginning of the cognitive and achievement measures, Jane Doe would not try to figure out words that she did not know.  On her own, she gradually began breaking up and sounding out words, although not always correctly.  She often read out loud in a whispered tone, correcting her mispronunciations along the way.  If she was unsure about the answer, Jane Doe usually reread the problem or worked it out on paper.  While trying to spell unfamiliar words, she often stated that she did not know what various phonetic phrases sounded like (e.g., ph).  She enjoyed the writing sample portion of the measure because it allowed her to use words that she knew.  This appeared to be an example of her compensation strategies.

During a measure of reading and spelling, Jane Doe would again repeat the words over and over again as she tried to spell them, but as she did this the words began to change to something slightly different (e.g., insignificant changed to insignifant).  Also, she would guess at words that were very similar to or had similar letters of the word that she was trying to read (e.g., bureau was said as brochure).  Jane Doe maintained a good attitude through the last day of testing.
 

Instruments Administered and Methods Used:

• Client Interview
• Woodcock-Johnson-Revised Tests of Cognitive Ability
• Woodcock-Johnson-Revised Tests of Achievement
• Boder Test of Reading-Spelling Patterns
• Minnesota Multiphasic Personality Inventory-2
• Thematic Apperception Test
• Developmental Questionnaire

 

Cognitive Ability Measure:

Woodcock-Johnson Tests of Cognitive Ability (WJ-R)
(Mean = 100, Standard Deviation = 15)

Achievement Measure:     Back to Top

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

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Boder Test of Reading-Spelling Patterns

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Personality/Socio-emotional Measures:

Minnesota Multiphasic Personality Inventory-2

Thematic Apperception Test
(See text of report for discussion)

ASSESSMENT RESULTS AND CLINICAL IMPRESSIONS              Back to Top

Cognitive Measure

Woodcock-Johnson-Revised Tests of Cognitive Ability (WJ-R Cognitive) includes a series of subtests, which are used to estimate an individual’s intellectual ability.  Jane Doe's Broad Cognitive Ability (Extended) was found to be in the Low Average range.  A relative weakness was found in her ability to work quickly, particularly when required to maintain focused attention.  This means that she will have trouble maintaining focused and steady concentration during most tasks.  Jane Doe exhibited some difficulty with tests measuring direct school performance such as reading and writing.  A measure of Jane Doe's ability to scan and compare visual information quickly was a relative strength.  She was also good at recognizing a subset of previously presented pictures within a field of distracting pictures.  Jane Doe deals well with visual novelty, matching shapes, and identifying concept rules illustrated in pictures.  She is able to analyze the presented components of an incomplete logic puzzle and determine the missing components, as well as discover essential relations of novel tasks and draw inferences that could not have been worked out before.

Achievement

Woodcock-Johnson-Revised Tests of Achievement (WJ-R Achievement) includes a series of subtests, which are used to estimate an individual’s achievement functioning.  Jane Doe was found to be performing within the Low Average range on school-related tasks, with the exception of written expression, which was in the Average range.  This performance is commensurate with her general cognitive ability.  Jane Doe was also administered a measure to more specifically assess her reading and spelling aptitude.  The reading tasks included reading lists of words with increasing difficulty.  Jane Doe’s reading age was found to be at a 14 year old (9th grade) level, with a reading quotient of 37%.  A reading quotient expresses the percent of expected reading achievement attained by the reader.  The spelling tasks included writing words presented orally by the examiner.  The spelling words were comprised of two lists: one list of words that were previously read successfully, and the second was a list of words that were not read successfully.  Jane Doe correctly spelled 10% of the known words, one of which was phonetic.  Her total good phonetic equivalents (GFE) score for the unknown words was 20%, with two being GFE misspellings.  GFE's are phonetically accurate misspellings in which the word is written the way that it sounds.

On both measures, Jane Doe often omitted syllables and made guesses at pronunciations.  When reading unfamiliar words, Jane Doe often said words that started with same letter and had similar letters (e.g., "harass" for "hesitating", "significant" for "significance").  In addition, she added or deleted letters on made-up words (e.g., "freap" for "feap", "qantic" for "quantric").  Jane Doe utilized proper sentence structure, but made mistakes in punctuation and the plural forms of words.  Jane Doe's limited vocabulary hindered her knowledge of synonyms and antonyms.  She uses several words to explain what she is talking about instead of the one word that says it directly (e.g., "is being born" instead of "hatching").  Jane Doe was able to add, subtract, and multiply two-digit numbers, as well as decimals.  She was also able to add basic fractions.  However, she was unable to add mixed fractions, divide basic fractions, or solve algebraic equations.  Despite this, Jane Doe was competent at solving one step applied story problems.

Personality/Socioemotional

Jane Doe’s overall behavior, emotional adjustment and personality dynamics were measured with objective and projective measures.  After examination of these measures, several conclusions were made.  The personality assessments indicated an individual who displayed depressive tendencies that were affecting Jane Doe’s social/emotional life.  The Minnesota Multiphasic Personality Inventory for adults indicated that Jane Doe was experiencing mild to moderate emotional distress characterized by apprehensiveness, dysphoria, worrying, and anxiety.  As a chronic worrier, she brooded and ruminated about her problems.  She felt that she was more sensitive than most people and that life was a strain for her.  Jane Doe was experiencing a number of significant life stressors, such as a demanding work schedule, two divorces, and her children not living with her.  She did not seem to have the necessary skills to cope with these stressors, which led to overwhelming feelings of depression and low self-esteem.  She wished that she could be as happy as others seem to be.  She regreted things that she has done and felt disappointment so acutely that she could not stop thinking about it.  Although she was irritable, impatient, and grouchy, Jane Doe was unlikely to express anger overtly or to be aggressive toward others.  Despite this, her feelings have lead to recurrent suicidal ideation and two suicide attempts.

Summary

Jane Doe was a 38-year, 11-month-old, Caucasian, female.  Overall, indications from current testing suggest that Jane Doe’s general cognitive ability was commensurate with her achievement ability.  Her reading and spelling difficulty were caused by her Low Average cognitive ability.  A weakness was found in her ability to work quickly, particularly when measured under pressure to maintain focused attention.  Overall strengths were displayed in her ability to scan and compare visual information quickly, as well as her ability to recognize a subset of previously presented pictures within a field of distracting pictures.  On tests of achievement, Jane Doe scored in the Low Average range.  Her reading and spelling skills were at the 9th grade level.   Personality assessment results indicate that Jane Doe was displaying depressive tendencies.  Her feelings of depression were expressed through worry and anxiety, and, in turn, have lead to recurrent suicidal ideation and two suicide attempts.
 
 

DIAGNOSTIC IMPRESSIONS

DSM-IV Diagnosis
 

Axis I:	296.33 Major Depressive Disorder, Recurrent, Severe Without Psychotic Features
Axis II:	V71.09 No diagnosis
Axis III:	Fibromyalgia
Axis IV:	Problems with stressful work schedule and inadequate finances
Axis V:	GAF  = 50 (Current)

Recommendations:               Back to Top

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

1. Jane Doe may benefit from receiving individual counseling services for her depression and self-esteem.  Cognitive-behavioral psychotherapy focusing on her negative cognitive style may be beneficial to her.  Caution should be taken if medication is prescribed because of her suicidal history of overdosing on pills.

2. Jane Doe may benefit from receiving family counseling services for her and her children.  The therapist may want to facilitate effective communication and work to build the parent-child bond.  An improved family relationship may help to provide Jane Doe with support and increase feelings of self-worth, which may alleviate feelings of loneliness.

3. It is recommended that Jane Doe make flashcards of words that she frequently has trouble with.  This will help her to learn the words by sight and make them more recognizable.  As Jane Doe finds new words that she has difficulty with, a flashcard should be made and studied.  A phonetic spelling should be written on one side of the flashcard, while the appropriate spelling is written on the other.

4. Jane Doe may benefit from using a dictionary that would allow her to look up words by sounding them out, such as the Morrison's Sound-It-Out Speller.  This type of resource would allow her to find a word that sounds like "sapena" by first, sounding it out (e.g., "sa-pe-na"), then, omitting the vowels (e.g., S_P_N_), and finally, looking up "SPN" to find the word "subpoena".

5. Jane Doe may benefit from reading books while listening to it being read on tape.  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.  Such books can be found at most local libraries.

6. Jane Doe may want to consider enrolling 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.

7. It may be beneficial for Jane Doe to continue to engage in extracurricular activities of interest.  Involvement in a local community group or program may allow her to develop some positive social relationships and, in turn, improve her self-concept.

8.  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.
 
 
 

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