School Neuropsychological Evaluation

School Neuropsychological Evaluation

(Sample Draft Case for 2015 -2016 Kidsinc. Cohort Students only-Confidential Example-Teachable Example)

This report is to be interpreted and used only by individuals properly trained and certified by

state agencies, and/or by parents or legal guardians of the stated child. This report is confidential

and must not be released to persons who do not have a legitimate professional interest in the child.

IDENTIFYING INFORMATION

Student’s Name: XXXXXX Student’s Date of Birth: XXXXXX Student’s Age: XXXXX

Student’s Gender: Female Student’s Ethnicity: XXXXX
Student’s School: XXXXXXX Student’s Grade: 9

Names of Student’s Parents/Guardians: XXXXX and XXXXX Primary Language Spoken at Home: English

Examiner’s Name: XXXXXXXXX

Testing Date(s): X/XX/2XXX (9:00 – 11:00) X/XX/2XXX (8:15 – 9:45) X/XX/2XXX (9:15 – 9:45)

X/XX/2XXX (12:00 – 2:00) X/XX/2XXX (12:30 – 2:00) X/XX/2XXX (9:00 – 10:30 & 2:00-2:30)

X/XX/XXXX (10:30 – 11:45) X/XX/2XXX (9:45 – 11:45) X/XX/2XXX (10: 00 – 11:30)

Date of Report: XX/XX/XXXX

REASON FOR REFERRAL

XXXX has been referred for school neuropsychological evaluation as part of her three-year re-evaluation for special needs. She is currently on an Individualized Educational Plan (IEP) under other emotional Impairments, which include: Panic Disorder without Agoraphobia (PD) and Post Traumatic Stress Disorder (PTSD).

She is currently on an Individualized Educational Plan (IEP) under emotional Impairment. Although she has made significant progress, concerns remain in the areas of academics (Math). This past semester she failed Geometry and has yet to receive a passing grade on the statewide competency exam. It is hoped that results from this evaluation will aid in post high school planning. The IEP team is currently pursuing this neuropsychological evaluation to answer the following questions:

1. How do the neurocognitive aspects of XXXX’s anxiety disorders impact her current learning and future plans?

2. How do observed weaknesses in attention, executive functioning and memory skills impact XXXX’s current learning and future plans?

3. Do other learning impairments exist, which contribute to XXXX’s current learning difficulties?

BACKGROUND INFORMATION

Health History

XXXX developed a kidney infection with high fever (>104) at 3 years of age. She was diagnosed with hydronephrosis (swelling of the kidney) and bilateral obstructions of both kidneys, which included urinary tract problems. For more detailed information about hydronephrosis the reader is referred to the website for the National Kidney Foundation (National Kidney Foundation, n.d.). Invasive medical procedures and surgeries were performed between the ages of 4 and 5, which included removal of the left kidney and functional repair of the right kidney. She was prescribed blood pressure medication from 3 years until the age of 11. Kidney functioning continues to be monitored annually. As a result of the illness and subsequent hospitalizations she experienced feeding problems, sleeps problems, eating problems and was underweight. At age 8 years, XXXX’s school closed and she began attending a new school in third grade. She had a difficult transition, particularly making new friends and adjusting to the new school and teachers. That fall XXXX started to have panic attacks before bed coupled with a fear of dying related to her earlier hospitalizations. She also began wearing corrective classes for astigmatism in her right eye. She began therapy in January 2009 with XXXX, XXXXX, LICSW and was diagnosed with Panic Disorder without Agoraphobia (PD) and Post Traumatic Stress Disorder (PTSD) related to her earlier medical procedures. While PTSD symptoms have reduced, panic attacks and anxiety symptoms persist. She continues to attend therapy with XXXX, XXXX. XXXX’s current health issues include: hay fever, itchy skin/frequent rashes, shortness of breath/dizziness from physical exertion, and clumsy walk. Neurological issues include: accident-prone, teeth grinding, tics/twitches. Her latest hearing exam (2013) found no problems; however, her vision exam from (2014) indicated she needed corrective lenses for distance. She had worn glasses to correct for astigmatism from age 8 to 12. Her latest health screening at school indicated hearing was intact. She failed the vision screen, but passed the follow up exam. Family history is positive for XXXXX, XXXXX and XXXXX XXXXX in the XXXX family and XXXXXX issues on the paternal side of the family.

Social History

Her teachers and parents describe XXXX as an outgoing, friendly and social child. However, she has had times when she has struggled with her peers and making friends. As mentioned previously her parents’ separation was difficult. In addition to stressful interactions with her parents, XXXX also struggled at school with her social relationships. She became involved with a social group who she describes as “Goth and depressed” and she took on that persona. She dated a boy whose father had died from Cancer and spent a lot of the relationship worried about him and trying to support him through his emotional struggles. After ending this relationship, she describes being pressured into a relationship with a girl by her social group. Once the relationship ended the group shunned her, especially when she started dating her current boyfriend. During this time she disclosed that she had been hearing a voice (named XXXXX) instructing her to do mean things (yell or slap) to people when she was angry. She never acted on the voice’s instructions and has not heard the voice in over a year. She relates this too both the stress she was experiencing at home and with peers. She admits this was a difficult period for her, but states now that she surrounds herself with friends who let her be herself, don’t try to change her and about whom she doesn’t have to worry. Her mother notes that XXXX does not have problems relating to her peers. She does not have difficulty making friends and likes to socialize. She can act both as a leader and follower with her friends.

Educational History

Prior to attending XXXXX School, XXXX attended the XXX Pre-School for one year, the XXXX kindergarten through second grade and the XXXX Elementary School third through sixth grade. She has attended XXXX School since seventh grade. Her early educational experiences are well documented (Frankel-Fein, 2012; Geiling, 2012; Etheridge, 2009; Frankel-Fein, 2009; Gallagher, 2009). She has documented disabilities in the area of emotional functioning (PTSD, PD). XXXX was placed on an Individual Student Success Plan in first grade and received support in reading and math. She continued to receive academic support in second and third grade. As discussed above her school closed at the end of second grade and she began attending a new school in third grade. This was a difficult transition for her that was notable for difficulty paying attention during class, completing assignments, disorganization and making new friends. By the middle of the school year she began having panic attacks at home and was diagnosed with PTSD and PD. On the advice of her therapist, she was referred for an initial evaluation of special needs in the spring. She was identified with an emotional disability and placed on an individual education plan (IEP). At the time her classroom teacher (XXXXXXX) described her having “a lot of anxiety about school and social situations…difficulty attending in class and lot’s of confusions and misunderstandings about concepts – which lead to more anxiety.” Her initial IEP included goals in the areas of reading, writing, mathematics and self-regulation/social skills. IEP services provided included 15 minutes a week of consultation to classroom teachers, in class support for written language (2 times a week for 30 minutes) and mathematics (5 times a week for 30 minutes), out of class support for reading (3 times a week for 30 minutes), written language (3 times a week for 30 minutes), and social skills (1 time a week for 45 minutes). She demonstrated significant improvement in her academic and social functioning by the end of sixth grade.

XXXX entered XXXXX in seventh grade, which proved a difficult transition. As discussed above her stressors included: her parent’ divorce, her father’s new relationship, his depression, financial concerns and social difficulties. She often came to school and had difficulty attending in class, as she was preoccupied and worried about these issues. Often she would take a break from class and write down her worries in a journal, which she would later share in a counseling session. This was effective in reducing her anxiety, however, limits needed to be placed on the duration and frequency of the journal writing as she could often write for most of class period. During middle school she struggled academically and needed to attend summer school to make-up for failed classes in Math and Science.

Previous Testing Results

Cognitive Testing

WISC-IV – 2009 / WISC-IV - 2012
Verbal Comprehension Index / 99 / 104
Perceptual Reasoning Index / 100 / 90
Working Memory Index / 74 / 83
Processing Speed Index / 78 / 83

Note: Index scores have a mean of 100 and a standard deviation of 15.

Memory Testing

WRAML – 2009 / WRAML2 – 2012
Verbal Memory Index / 74 / 88*
Visual Memory Index / 77 / 91*
Learning Index / 111 / -
General Memory Index / 84 / -
Screening Memory / - / 91*

Note: Index scores have a mean of 100 and a standard deviation of 15.

* Extrapolated from reported scaled scores

Educational Testing

WIAT-II – 2009 / WIAT-III – 2012
Reading Composite / 90 * / 108
Mathematics Composite / 100* / 108
Written Expression Composite / 81* / 111
Oral Language Composite / - / 98
Math Fluency Composite / - / 76

Note: Note: Index scores have a mean of 100 and a standard deviation of 15.

* Extrapolated from reported percentiles

Phonological Processing

CTOPP- 2009
Elision / 63rd
Blended Words / 37th
Memory for Digits / 5th
Rapid Digit Naming / 16th
Nonword Repetition / 9th
Rapid Letter Naming / 16th

Note: Percentiles appear in italics.

* Extrapolated from reported percentiles

Speech and Language Testing

CELF4 – 2009
Core Language Score / 102
Receptive Language Index / 109
Expressive Language Index / 98
Language Content Index / 104
Language Memory Index / 103
Working Memory Index / 88

Note: Index scores have a mean of 100 and a standard deviation of 15.

A psychological evaluation was available for review by Dr. XXXXXXX (6/17/2009). The Wechsler Intelligence Scale for Children – Fourth Edition (WISC-IV) was administered. Index scores of verbal comprehension (99) and perceptual reasoning (100) were reported in the average ranges. Working memory (74) and processing speed (78) in the borderline ranges were also reported. The Wide Range Assessment of Learning and Memory (WRAML) was also administered. Index scores for general memory (84) in the low average range, Verbal Memory (74) and Visual Memory (77) in the borderline ranges learning index in the high average range and were reported. Additionally the Jordan Left-Right Reversal Test, Rapid Automatized Naming and Rapid Alternating Stimulus Tests, The Rey Complex Figure Test (unscored) were administered. The following ratings scales were administered; Multi-Dimensional Anxiety Scale for Children, Behavior Assessment System for Children – 2 (BASC2), and the Behavior Rating Inventory of Executive Function (BRIEF). Difficulties in memory, processing speed, self-regulation, attention and anxiety were noted. A “loop-like connection” between these issues impacting her in the classroom was proposed. Her distractibility, and focus on non-essential details was noted to contribute to her missing instruction. An observation of her looking around the room while talking, being drawn to an object on the wall, asking an off-topic question about the object, and then trying to return to conversation resulting in confusion for the examiner and XXXX was described. She did well on tasks, which required multiple learning trials and was described as a details oriented learner. Also noted was that “at times (XXXX) may be so focused on strong thoughts or feelings that are meaningful for her that it may be difficult for her to shift her attention to a current social interaction, problem solving task, or focus on information attached to new learning.”

A speech and language evaluation was available for review by Ms. XXXXXX, MA, CCC-SLP (5/29/2009). The Clinical Evaluation of Language Function – 4th edition (CELF-4) was administered with scores as follows: core language (102) receptive language (109), expressive language (98), language content (104), language memory (103) and working memory (88). The pragmatic profile was deemed to meet the criterion for her age group. Additional testing included the Comprehensive Assessment of Spoken Language, and an informal story re-telling. Most of her scores were within the average ranges. Two areas were noted as weaknesses her phonological awareness and working memory.

An academic evaluation was available for review by Ms. XXXXX, Special Education Teacher. The Wechsler Individual Achievement Test-second edition (WIAT-II) was administered. Scores were reported by percentile and included the following: reading comprehension (55th), numerical operations (53rd), math reasoning (45th), pseudoword decoding (30th), spelling (25th), word reading (13th), and written expression (5th). The Comprehensive Test of Phonological Processing was also administered with scores similarly reported by percentile: elision (63rd), blending words (37th), memory for digits (5th), rapid digit naming (16th), nonword repetition (9th), rapid letter naming (16th). XXXX’s ability to attend was noted as a contributing factor to her lower scores.

A second psychological evaluation was available for review by Dr. XXXXXX (4/2/2012). The Wechsler Intelligence Scale for Children – Fourth Edition (WISC-IV) was administered. Index scores of verbal comprehension (104) perceptual reasoning (90) were reported in the average ranges and working memory (83) and processing speed (83) in the low average ranges were also reported. Selected subtests on the WRAML-2 were administered. Scores story memory, story memory delay recall, story memory recognition, verbal learning, design memory, picture memory, were reported in the average ranges. Number letter was reported in the low average range. Rating scales administered included the BASC2, BRIEF, and Brown ADD Scales. Her cognitive scores remained the same, although there was improvement in her processing speed and working memory. Improvement occurred on verbal and visual memory. Attention, distractibility, anxiety and executive functioning were noted as contributing factors her learning difficulties.