Comprehensive Evaluations: Case Reports for Psychologists, Diagnosticians, and Special Educators

By Nancy Mather and Lynne E. Jaffe

An invaluable collection of sample case reports from experts in child and adolescent assessment

With contributions from authorities in the fields of psychology and special education-including Dawn Flanagan, Elaine Fletcher-Janzen, Randy Kamphaus, Nadeen Kaufman, George McCloskey, Jack Naglieri, Cecil Reynolds, and Gale Roid—Comprehensive Evaluations provides over fifty sample case reports to help you draft carefully planned, goal-directed, and comprehensive evaluations that clearly explain the reasons for a student's school-related difficulties, from preschool to postsecondary level.

A wellspring of information for educational professionals, Comprehensive Evaluations provides models for writing diagnostic reports to accompany the tests most frequently administered in the evaluation of children, adolescents, and adults, including the BASC-2, KABC-II, WAIS-IV, WISC-IV, and WJ III. The reports reflect various disciplines within psychology and education, different theoretical perspectives and paradigms, and span a broad spectrum of disabilities.

The diagnostic reports found within Comprehensive Evaluations will help:

• Expand your familiarity with widely used test instruments

• Enhance your understanding of the interpretation of test scores

• Improve your ability to tailor written reports to the purposes of the evaluation

• Translate assessment results into meaningful treatment recommendations

• Recognize the differences in what evaluators from various school districts, agencies, and private practices consider to be a comprehensive evaluation

• Appreciate how your theoretical perspective and choice of tests can influence diagnostic conclusions

• Determine a report writing style that meets your needs

Comprehensive Evaluations deftly illustrates how thorough assessments help empirically pinpoint the reasons a student is struggling in school, which then allows an evaluator to select the most appropriate accommodations and interventions to help the student succeed.

• Language: English
• Publisher: Wiley
• Release date: Nov 11, 2010
• ISBN: 9780470881965

Book preview

Case 1

Assessment of Individuals with Autism: Procedures and Pitfalls

Sally Logerquist

The diagnosis of an Autistic Disorder is complicated by many factors, such as variability in interpretation of autistic characteristics among psychologists, and a lack of awareness within the schools as well as the general public as to how autism manifests differently in one case to another. The variability in interpretation of autistic characteristics among psychologists is due to the qualitative nature of the behaviors and a lack of instruments with good psychometric properties to measure autism. The two instruments used in this case, the Autism Diagnostic Inventory-Revised (ADI-R) and the Autism Diagnostic Observation Schedule (ADOS) are considered the gold standard in the field of autism (Klin, Sparrow, Marans, Carter, & Volkmar, 2000). These instruments are being used widely in research studies on autism, but they are not widely used among clinicians due to their cost and the additional training requirements (Klin et al., 2000). The ADOS and ADI-R have standardized procedures for test administration. The ADOS is a series of situations that are developed to elicit behaviors associated with autism. During the administration the evaluator has the opportunity to probe a wide array of behaviors. The evaluator who is not trained in these instruments uses checklists, parent reports, and/or observation. These techniques do not include the probing for autism characteristics that occurs during the ADOS administration or standardized administration. Often, a psychologist is left with his or her own clinical judgment, hence the variability in interpretation.

Autism is not a widely understood diagnosis. Limited understanding of this disorder within the schools may impact how the report is written. This report is written to all of the possible consumers (e.g., schools, state agencies). It is much easier for school personnel to respond to findings of the report when the conclusions are clearly supported by the data. To differentiate between the autism characteristics of Erik and another individual with the same diagnosis, it is helpful to describe specific behaviors (e.g., echolalia) in addition to the category of behaviors (e.g., communication). In addition, parents want to know what specific behaviors resulted in a diagnosis of autism. To aid in their understanding, clinicians should identify the behaviors that the child exhibits that are associated with autism, as well as those that are not. This is also very important for school personnel as they need an accurate description of the child to ensure that the interventions match their needs.

The diagnostic category of Autistic Disorder is more appropriate for Erik than the diagnostic category of Asperger’s Disorder. The criteria for Asperger’s Disorder are similar to Autistic Disorder with regard to impairment in social interactions and restricted repetitive and stereotyped patterns of behavior, interests, and activities. The criteria for these disorders are different with regard to cognition and aspects of communication. Asperger’s Disorder is not associated with either a communication or a cognitive delay, whereas an Autistic Disorder is associated with a communication delay and may be associated with a cognitive delay. Erik did not use oral language until the age of 3. Whereas he compensated effectively with sign language, historically and currently he presents with communication impairments (as measured by the ADI-R and ADOS). Based on a documented communication delay, Autistic Disorder is the appropriate diagnostic category.

MULTIDISCIPLINARY TEAM REPORT

REASON FOR REFERRAL

Erik, a 3-year, 11-month-old boy, was referred by his preschool teacher and his parents for a comprehensive evaluation to rule out an Autism Spectrum Disorder. Erik has been experiencing some difficulty transitioning from his parents’ and grandparents’ homes to the preschool classroom. His reluctance to go to school increases in the beginning of the school year and following school breaks. Erik is awkward in his social approach with peers; however, he has strong language skills and is comfortable with familiar adults. He is typically a happy, caring, cooperative child, but at times has intense tantrums and demonstrates oppositional behavior. Although these tantrums are infrequent, they are of concern to the family. Erik has a supportive family and extended family members who are eager to understand his behavior and provide the appropriate interventions.

BACKGROUND INFORMATION

Erik resides with his biological mother and father; his grandmothers provide his daycare. Mrs. Templeton reported that her pregnancy progressed without complications. During labor, however, because Erik did not drop in the birth canal and pushing decreased his heart rate, he was delivered by cesarean section. His weight and height were 8 pounds, 6 ounces and 20.5 inches, respectively. As an infant, Erik was content, was easy to feed and hold, and slept easily. He met his motor milestones at the usual times; he crawled at 10 months and walked at 12 months. Erik did not use oral language until he was 3 years old and the use of phrases soon followed. He did, however, understand oral language and use sign language effectively to communicate his wants and needs. Sign language was introduced by his mother when oral language did not emerge within the expected time frame. By the age of 18 months he had an American Sign Language (ASL) vocabulary of 175 words. When Erik began to speak, he reversed pronouns (e.g., using I for you and you for I), referred to himself in the third person, and demonstrated echolalia (repetition of what is said by other people as if echoing them). All of these language errors have decreased but have not been eliminated at this time. His only significant medical history was the development of fluid under the skin of his forehead at 8 weeks and croup with a high fever at 32 months. At his last annual checkup with his pediatrician, Dr. Andrew Moore, his vision and hearing were both normal.

EDUCATIONAL HISTORY AND SCHOOL BEHAVIOR

Erik currently attends Shadow Rock Preschool 3 to 4 times a week for 6.5 hours per day. His teacher, Ms. Jeanette Spaulding, reported that he will cry and protest when his parents or grandparents drop him off at school, especially at the beginning of each school year and after school breaks. He does not cry for long as Ms. Spaulding quickly redirects his attention to an activity. Ms. Spaulding reports that Erik barks and demonstrates self-stimulating behaviors. Erik demonstrates the self-stimulating motor movements of flapping and the self-stimulating verbal behaviors of echolalia.

Ms. Spaulding reported that Erik possesses language and reasoning skills way beyond his years and that he is often preoccupied by a special interest. His current interest is volcanoes. He draws volcanoes and talks about them at great length every day. He is able to provide information on volcanoes, such as the cause and effect of a volcanic eruption including details, such as the temperature of the lava.

ASSESSMENT FINDINGS

The Autism Diagnostic Inventory-Revised (ADI-R) was administered in an interview format with Erik’s parents. This instrument relies primarily on descriptions of an individual during the early years. The strengths of this approach lie in its objectification of symptoms that are unique to the diagnosis of autism, and the developmental course an individual shows during the early years. The limitations of this approach are that it is primarily interview based, and relies on parental reports. The ADI-R is structured so as to assess the presence or absence of the American Psychiatric Association’s Diagnostic and Statistical Manual’s (DSM-IV) definition of autism. Questions are grouped into three sections addressing: Language and Communication Functions, Social Development and Play, and Interests and Behaviors. Parental responses are coded in each area and cut-off scores are assigned to reliably differentiate the presence or absence of autism.

The Autism Diagnostic Observation Schedule (ADOS) was administered in direct assessment. The ADOS is a comprehensive, semi-structured instrument covering most developmental and behavioral aspects of autism. Information is obtained by presenting activities designed to illicit behaviors associated with autism. The scoring criteria are consistent with DSM-IV criteria for an Autism Disorder. The scoring system is as follows:

0 = behavior (associated with autism) is NOT present

1 = behavior is present but not clear, severe, or frequent

2 = behavior is present and meets criteria for autism

Mr. and Mrs. Templeton report that they have been concerned about Erik’s behavior since he was 2 years old. The behaviors of concern include:

Lining up toys

Tantrums, biting and flapping his arms when frustrated

Referring to himself in the third person

Late acquisition of oral expressive language

Echolalia that began at age 3, when he began to use oral language, which is still present

Reluctance to enter a conversation or play situation with a same-age peer

Not including others in his conversation or play

QUALITATIVE IMPAIRMENTS IN SOCIAL INTERACTIONS

The Templetons noticed impairments in social interactions at age 2 when Erik entered preschool. He was awkward in social situations with same age peers in contrast to his ease in conversing with adults. The Templetons report that he is still awkward in conversing with peers. When he does talk to peers, his interchanges are focused on his interests with little or no awareness of whether the listener is interested. While this is not uncharacteristic for a 3-year, 11-month old child, the lack of awareness of others is also evident in group interactions (not taking turns) and in play (parallel play).

During the direct administration of the ADOS, Erik used eye contact; however, he did not use eye contact to regulate social interactions (i.e., looking in the direction he wants the listener to look). He shared his enjoyment of the activities with his father by directing smiles toward him; he did not indicate shared enjoyment with either smiles or words with the evaluator. He did respond to his name the first time it was used by the evaluator. Erik seldom initiated conversation with the evaluator; when he did, the topics were related to his interests or to gain assistance.

Erik’s ADI-R score of 6 did not meet the cutoff of 10 for autism. Erik’s ADOS score of 10 exceeded the cutoff of 6 for autism. Based on the results of parent interview (ADI-R) and direct assessment (ADOS), Erik meets the DSM-IV criteria for an Autistic Disorder in the area of qualitative impairments in social interactions. Despite his impairment, he demonstrates many positive behaviors in this area that are not characteristic of autism, such as:

He demonstrates appropriate speech fluctuation, rate, and pitch of speech and is capable of modulating the volume to be appropriate to the setting.

He has a full range of facial expressions that are appropriate for a variety of situations.

Erik demonstrates empathy and seems to care about other people and their needs.

He is very thoughtful with regard to his family.

He does initiate sharing, more with adults than peers.

Qualitative Impairments in Communication

Erik did not acquire oral expressive language until he was 3 years old. Prior to that time he understood the oral language of others (receptive language). He also compensated for his expressive language delay by using ASL. By the age of 18 months, he knew 175 ASL signs. Once he developed oral language at age 3, phrase speech soon followed. Language errors were observed as soon as he began speaking, such as reversed pronouns, reference to himself in the third person, and echolalia. All of these language errors have decreased but have not been eliminated at this time. Echolalia is only observed now when he is excited (e.g., a birthday party) or anxious (e.g., entering a new situation).

Currently, he has strong language skills; he uses sentences of five or more words including adverbs, adjectives, prepositions, and proper plurals. This was reported by parents and observed by the evaluator. Erik can maintain a conversation if the topic is of his choice. His communication style is one directional (in which he reports facts) rather than two directional (the back and forth of a reciprocal conversation). His verbal discourses continue without requesting input from the listener. His parents report that he recently began to bring others into his conversations by directing their attention, verbally or by pointing, to something of his interest (joint attention). At this time, the majority of Erik’s interactions are for the purpose of directing others toward things that he wants or areas of his interest rather than socially sharing. The Templetons report that Erik will use the gestures, such as head nodding, head shaking, shrugging, and pointing for nonverbal communication.

During the ADOS administration, Erik did not show an interest in interacting with the evaluator except to share his knowledge about volcanoes. He showed no interest in entering into imaginative play. For example, he was offered toys (e.g., dolls, rocket, dog) to see if he would pretend they were animate and have them interact with each other. He did not. When asked to make up a story, he responded, I don’t know a story. The evaluator initiated imaginative play to see if he would join in but he did not. The only imaginative play that was observed during the ADOS was to load up a toy truck and dump it.

In the category of qualitative impairments in communication, Erik’s ADI-R score of 10 exceeded the cut-off of 8 for autism. Erik’s ADOS score of 7 exceeded the cut-off of 5 for autism. Based on the results of parent interview (ADI-R) and direct assessment (ADOS), Erik meets the DSM-IV criteria for an Autistic Disorder in the area of qualitative impairments in communication. Despite his impairment, he demonstrates many positive behaviors in this area that are not characteristic of autism, such as:

Erik does not engage in use of inappropriate questions or make inappropriate statements (with a few exceptions that are consistent with his developmental level).

He does not use made-up words or idiosyncratic language.

Erik imitates the actions of others; for example, when his father sits down to watch TV, he postures himself in a similar manner.

Erik demonstrates appropriate fluctuation in tone to match his emotions, such as louder and faster speech when he is excited.

Restricted, Repetitive, and Stereotyped Patterns of Behavior

Erik’s parents and teacher reported that he is restricted in his play and conversations. His preoccupations have changed over time with his current special interest being volcanoes. This was observed during the ADOS administration. He did not want to talk about any of the topics presented by the evaluator, and he only wanted to talk about volcanoes. Volcanoes came up in other contexts; sometimes it was appropriate; sometimes it was not. For example, in one activity, he was asked to describe what he saw on a pictured map. He focused on areas with volcanoes, which was appropriate, but resisted redirection to any other area on the map. In another activity, the evaluator set up a pretend birthday party and invited Erik to participate. During this activity, he made the play dough into a volcano rather than a cake. The evaluator praised his work and then redirected him to the birthday activity but he informed the evaluator that he was not interested in the birthday party. He did not explore toys that were provided for free play; he used a truck, blocks, and puzzles but his play often included lining up blocks and puzzle pieces.

The Templetons report that in the past, Erik engaged in the repetitive motor movements of flapping his arms; however, these have been greatly reduced. He continues to have temper tantrums in highly anxious situations (e.g., going into a new classroom). These are infrequent (less than once a month), but intense in that they may last for hours. The tantrum behaviors include refusal, withdrawal, and yelling.

In the category of restricted, repetitive, and stereotyped patterns of behavior, Erik’s ADI-R score of 3 matched the cutoff of 3 for autism. Erik scored a 1 on the ADOS but there is not a cutoff score in this area. Based on the results of parent interview (ADI-R) and direct assessment (ADOS), Erik meets the DSM-IV criteria for an Autistic Disorder in the area of restricted, repetitive, and stereotyped patterns of behavior. Despite his impairment he does not demonstrate some of the negative behaviors commonly associated with autism. For example, he is not aggressive to others or himself with the current exception of biting his nails and hitting his arm when he was very young. He does not engage in hyperventilation and has never had a seizure.

SUMMARY

Erik’s scores on the ADI-R indicate that history and present behaviors meet or exceed the diagnostic criteria for Autism in 3 of 4 categories. Erik’s scores on the ADOS indicate that his present behaviors meet or exceed the DSM-IV diagnostic criteria for Autistic Disorder in three of three categories:

1. Qualitative impairments in social interactions

2. Qualitative impairments in communication

3. Restricted, repetitive, and stereotyped patterns of behavior

Erik qualifies for consideration as a child with an Autistic Disorder. In the school setting, the appropriate category of eligibility would be autism. Autism, as defined by IDEA-2004, is a developmental disability that:

Significantly affects verbal and nonverbal communication and social interaction

Is generally evident before the age of 3

Affects educational performance

Evidence is provided in this report to address items 1 and 2. The multidisciplinary team, which includes Erik’s parents, will need to identify the effect on educational performance and make the final determination of eligibility.

RECOMMENDATIONS

Educational Programming

1. Erik’s parents are encouraged to share the current evaluation with the school psychologist at the school he will attend for kindergarten. Initially, it is recommended that a district individual, knowledgeable in the current research and practice in autism, be consulted to assist the team in developing appropriate accommodations. The nature and degree of the appropriate accommodations will depend on: Erik’s age, the task demands of the classroom, and the ability of the general education teacher to provide appropriate accommodations (taking into consideration the composition of the class, teacher’s knowledge in this area, etc.).

2. Children with neurodevelopmental disorders (such as autism) learn best when they are provided with clear and predictable learning environments. Attention should be directed to the physical environment (reduction of distractions, sequencing of activities, and duration of activities) so as to not overwhelm or overstimulate Erik.

3. The National Research Council has endorsed the inclusion of children with neurodevelopmental disorders with age-mates in all areas of educational and non-educational instruction, to the extent that it promotes the ongoing development of educational goals. To this end, Erik’s school team is encouraged to explore the potential for him to continue to be in the mainstream environment, with special education support, as needed. It will be important for Erik’s teachers to receive instruction and education in effective strategies for teaching children with autism.

Qualitative Impairment in Social Interactions

1. Erik appears bright and verbally skilled beyond his years, which may result in his using language that is more mature than that of his peers. He is also interested in concepts and material that may be less interesting to his peers. While his vocabulary and understanding of special interest (volcanoes, for example) are characteristics that appeal to adults, these behaviors will not help him relate to other children. Assist him in being aware of the tone and content of his communication. Currently he is saying, I am sorry, did you think I was talking to you? While this may sound precocious now (at almost 4 years old), as he gets older it may be considered disrespectful. Start now to shape the communication that will serve him well in the future.

2. Erik will need support to facilitate social interactions. Adults in his environment may need to determine first if he understands whether his behavior is appropriate or inappropriate in social situations. As he does not seem to read the facial messages and body language of his peers, he may not gain the feedback in the natural environment that tends to shape our social behavior. In the absence of this feedback, it may be beneficial for adults to teach appropriate behavior explicitly in the form of a social story. See http://www.thegraycenter.org/ for information on the use of social stories to promote social skill development.

3. In the future, Erik would benefit from social skills education, training, and participation in a structured group setting. A social skills group will serve as a safe environment to learn and practice core skills, with supportive feedback from others. Such a setting should also bolster his confidence and increase his willingness to take risks in initiating social contact.

Qualitative Impairments in Communication

Erik does not present with expressive or receptive language impairment at this time. However, he does seem to be impaired in nonverbal communication, specifically sending and receiving nonverbal messages. Parents and teachers are encouraged to promote eye contact as a source of nonverbal information. Suggest to Erik that the information that is provided by the eyes and the mouth are clues to uncovering information about other people. The book Teaching Your Child the Language of Social Success (Nowicki, 1996) is a valuable tool for teaching these skills. Parents and teachers are encouraged to point out to Erik (privately) when he has not correctly detected a social cue. For example, if another child’s body language suggests irritation, pull Erik aside and show him the body posture that indicates I’m irritated.

Restricted, Repetitive, and Stereotyped Patterns of Behavior

1. At times Erik has difficulty transitioning from one activity to another. Adults are encouraged to provide consistent prompts to cue him to move in X amount of time. It will be beneficial if the cues for prompting are consistent at home and school. For example, 5 minutes prior to the end of the activity the adult would provide a prompt. This may be in the form of a verbal prompt (5 minutes to finish) and/or visual prompt (egg timer). At first it may be necessary to provide both verbal and visual prompts. When the time is up, the adult must insist that the activity end. If this results in avoidance, noncompliance, or a meltdown, the adult will need to stay calm and consistent. Continue to provide him with the visual and/or verbal prompt to calm down.

2. Anytime that Erik has a meltdown, it will be necessary for an adult to be available to stay with him until the incidence is resolved. This may take quite awhile at first; however, it is very important that this process be completed prior to moving on to the next activity. While he is angry, adults are encouraged to provide only the prompt to calm down. If he has problems processing words when he is angry, then provide a visual cue of a calm face. An alternative is to take a picture of him when he is calm and use this to prompt him to resume that state. There should be no discussion of any topic while he is upset. Make sure he is calm before attempting to discuss the incidence. Once he is calm, the adult can assist him in problem solving by using the following 3-step process:

a. Stop, take a deep breath, and count to 3

b. Think about your choices and the consequences of each choice

c. Make a decision and act on it

3. Arrange for Erik to be allowed to choose time out when he feels overwhelmed or overstimulated, and arrange for an area to which he can retreat for a short period of time to regroup. Actively teach progressive muscle relaxation, deep breathing, and positive self-statements as positive stress management strategies. Have him practice these skills when he is calm so they may be used in stressful situations.

Thank you for the opportunity to work with your child.

PSYCHOMETRIC SUMMARY

Autism Diagnostic Inventory-Revised

Autism Diagnostic Observation Schedule

The scoring system for the Autism Diagnostic Observation Schedule and Autism Diagnostic Interview-Revised is as follows:

0 = behavior (associated with autism) is NOT present

1 = behavior is present but not clear, severe, or frequent

2 = behavior is present and meets criteria for autism

A score that meets or exceeds the diagnostic cutoff indicates that the individual has met the DSM-IV criteria for Autistic Disorder in that area.

REFERENCES

Duke, M. P., Nowicki, S. Jr., & Martin, E. A. (1996). Teaching your child the language of social success. Atlanta, GA: Peachtree Publishers.

Klin, A., Sparrow, S. S., Marans, W. D., Carter, A., & Volkmar, F. R. (2000). Assessment issues in children and adolescents with Asperger Syndrome. In A. Klin, F. R. Volkmar, & S. S. Sparrow (Eds.), Asperger syndrome (pp. 309–339). New York: Guilford Press.

Case 2

Neuropsychological Evaluation of a Young Child with a Seizure Disorder

Marshall Andrew Glenn

This evaluation of a child with a seizure disorder bears significance for several reasons: the effects of seizure disorders on early neurological development, the long-term effects of antiepileptic drugs (AEDs) and their attendant side effects on neuropsychological functioning, and the need for close monitoring and periodic reevaluation. Sometimes the control of seizures comes with significant consequences on neuropsychological functioning, which may be the case here. This report addresses not only the implications of the effects of seizure disorders on development, but also the possible deleterious (iatrogenic) effects of medications on current functioning. The other issues addressed in this evaluation are the importance of collecting a thorough medical history and adhering to the Lurian principle of documenting supporting qualitative behaviors during assessment and not relying strictly on psychometric results in arriving at a diagnosis.

PSYCHOLOGICAL REPORT

REASON FOR REFERRAL

Susie was referred for an evaluation to assess her current neuropsychological functioning at the request of her epileptologist. Susie was given a developmental screening from the Department of Health on 08/02/2010. The Ages and Stages Questionnaire assessed Susie’s skills in the areas of communication, gross motor, fine motor, problem solving, and personal-social. Suzie fell within the at-risk range in all areas.

Mrs. Waterhouse, Susie’s mother, reported that Susie had more than 200 seizures last year. She described these seizures as being grand mal; however, her medical report indicated a diagnosis of complex partial seizure disorder. Her mother reported that Susie becomes frustrated easily, acts out aggressively, is experiencing some problems with memory recall, and complains of fatigue in her legs. Susie is currently attending Robert F. Kennedy Preschool. Although school has only been in session for 3 weeks, her teachers have already noted problems in learning and behavior.

In an interview, Mrs. Waterhouse described her concerns regarding Susie’s problems in communication.

Susie cannot retain information such as colors, numbers, or letters. One day she asked me to write numbers, so I wrote 1–9. She asked repeatedly for me to draw a 5 then she’d ask me to point to the 5 in the row of numbers. When I asked her to point to the 5, she never could figure out which one the 5 was.

When I take a shower, Susie stays in the bathroom with me. I tell her that if the doorbell rings, she is to stay in the room with me. We go over this at least three times a week. Last week I said, Susie, now what do you do if the doorbell rings while we’re in here? She said, Papa.

She was disruptive in school twice, pushing a child out of line one day and pinching a girl the next. I said, Susie what’s something you can do tomorrow when you are mad instead of pinch? She said, 10.

When people ask her what she did in school she can’t provide an answer until yes or no questions are presented, and then she’ll say, Oh, yeah, I do that to everything you ask her.

She said, Mommy, what’s Megan and Mary (two children she plays with)? I asked, What’s Megan and Mary’s what, Susie? because her question didn’t make sense, and she nodded her head and said, Yeah, you’re right, Mommy.

She asked me what letter her name starts with, so I wrote S’s and practiced with her (she could only draw a line) for 2 days. On the third day at dinner she said, Daddy, my name starts with L. She became extremely frustrated when he corrected her, and she kept yelling, It’s an L, it’s an L repeatedly.

She didn’t know her first name was Susie until this month, and still doesn’t recognize that Waterhouse is her last name.

Susie broke something in her brother’s room. I asked her what she had broken, and she kept saying, I broke Harold’s … Finally I asked her, You broke Harold’s what, Susie? and she said, I just can’t think the name of it, Mommy.

Based on Mrs. Waterhouse’s recent observations, Susie is having symptoms related to aphasia, that is, word retrieval difficulties or problems finding the words she needs to express herself along with memory problems. Thus, her language output is often confused and confusing to her as well. These behaviors describe clinically significant symptoms that should be seriously considered in the context of her results on neuropsychological tests.

BRIEF LITERATURE REVIEW

According to Williams and Sharp (2000), epilepsy is the most common neurological condition of childhood, with higher occurrence in males. Prevalence statistics are 4.3 to 9.3 per 1,000 children. The authors noted that antiepileptic drugs (AEDs) are successful in controlling approximately 70% to 80% of seizures in children.

The authors further noted that remission over 5 years occurs in approximately 70% of children with epilepsy, and approximately 75% who have been seizure-free for at least 2 years can be successfully taken off AEDs.

Susie’s medical reports indicated a diagnosis of complex partial seizures, which involves an alteration of consciousness, accompanied later by confusion, memory loss, and fatigue. Other reports mentioned primary generalized tonic/clonic seizures, suggesting that Susie’s seizures may be complex partial with secondary generalization. In as much as Susie’s presenting concerns are language-related, it is important to note that seizures affecting the language cortex may result in several types of language impairments (Ho-Turner & Bennett, 1999). Children with seizure disorders may exhibit variability in cognitive processes, and periodic reexamination is warranted (Arzimanoglou, Guerrini, & Aicardi, 2004).

BACKGROUND INFORMATION

According to information provided by her parents, Susie’s first seizure occurred in January 2007 at 6 months of age. It was a one-sided seizure involving the right side of her body; the duration was approximately one-and-a-half hours. While she was in the emergency room, efforts to intervene with medication were unsuccessful. She was later given phenobarbital, but it was not entirely successful in controlling her seizures and she continued to have episodes every month or two. Between the ages of 6 months and 3 years, Susie had seizures at varying intervals, from none to several within a month. She has been prescribed Keppra, Trileptal, and Zonegran at different times and in different combinations and dosages. Throughout, EEGs, MRIs, and CT scans have shown normal brain activity.

In September 2009, Susie spent three weeks in the Epilepsy Monitoring Unit (EMU) at Arlington Children’s Hospital. During her stay, she had 12 seizures and her medication was changed to Depakote. Subsequent evaluation with MRI and PET tests again were normal. Her performance on a neuropsychological examination, administered on September 7, 2009, was reportedly affected by an IV splint on her right-dominant hand; additionally, some of the tasks could not be completed. The report noted that the test results may be an underestimate of her abilities due to being in an unfamiliar environment during testing and the immobility caused by her hand splint.… On the Wechsler Preschool and Primary Scale of Intelligence-III (WPPSI-III), Susie earned a Full Scale score of 107, based on a Verbal IQ of 97 and Performance IQ of 117, with no outstanding pattern of strengths or weaknesses. Subtest scores were not reported. Susie was also administered the NEPSY. Results indicated below average memory, poor ability to organize and name body parts, average phonological processing, and ability to follow instructions at the lower end of average. Results of the WPPSI-III suggested average receptive and expressive vocabulary and average to above average visual-spatial abilities. The report noted that although language and nonverbal abilities were average relative to her age, her frequent seizures placed her at risk for developmental delays. Since complex problem solving and memory skills are developing, an annual evaluation was recommended.

Susie is currently taking Topamax, 100 mg in the morning and 125 mg in the evening. A review of the literature on side effects of Topamax included sedation, weight loss, and language disturbance (Williams & Sharp, 2000).

BIRTH AND DEVELOPMENTAL HISTORY

Developmental history indicated that Susie was the product of a full-term pregnancy. She was placed in the neonatal care unit due to fluid in her lungs. Susie accomplished developmental milestones within normal limits. She rolled back-to-front at 3 to 4 months, was able to sit up without support at 5 months, was able to pull herself up at 9 to 10 months, and was able to walk at 13 months. She was able to construct two-word sentences around 1 year of age.

Family Background

Susie lives with her biological mother and father and her 5-year-old brother, Harold. A review of information provided by the parents indicated a family history for depression, anxiety, and bipolar disorder in distant relatives. Mrs. Waterhouse also reported a history of having two seizures, one in infancy and one at 14 years of age.

Temperament and Behavior

With regard to temperament and behavior, it was reported that Susie has some incidents of inappropriate disruptive behaviors. Alistella Grace, RN, has observed Susie in a church program since August 2009. According to Ms. Grace, Susie often engaged in disruptive, nonviolent behavior attributed in part to inattention and hyperactivity caused by the side effects of her medication. During these episodes, Susie has to be removed from the room. Ms. Grace said that Susie’s seizure disorder has had an adverse effect on her education and class participation because she frequently has to be removed from the room. Her mother reported that Susie does not consider the consequences of her actions and often appears unremorseful.

CURRENT ASSESSMENT INSTRUMENTS AND PROCEDURES

Miller Neuropsychological Processing Concerns Checklist (Neuropsychological Checklist) (for baseline qualitative observations of behaviors)

Wechsler Preschool and Primary Scale of Intelligence, Third Edition (WPPSI-III)

NEPSY (a developmental neuropsychological assessment)

Behavior Assessment System for Children, Second Edition (BASC-2), Parent Rating Scale – Child

OBSERVATIONS

Rapport with Susie was established quickly and she seemed to put forth the effort necessary to elicit valid test results. At times she did not seem to understand what was required of her or the nature of a question. She simply remained quiet with a rather vacant stare, at which point she was redirected as allowed by standardization. Overall, she appeared immature relative to her chronological age. Additional test observations are noted below under each cognitive area assessed.

TEST RESULTS

Intellectual Functioning

WPPSI-III

Susie’s scores on the current administration of the WPPSI-III were lower than those on the previous administration (9/09) at Children’s Hospital, despite the restriction of the IV splint at that time. Her current Verbal IQ score was 88 (compared to 97), her Performance IQ score was 98 (compared to 117), and her Full-Scale IQ was 91 (compared to 107).

NEPSY

The NEPSY provides neuropsychological measures in five domains: Attention/Executive Function, Language, Sensorimotor, Visuospatial, and Memory and Learning. The NEPSY addresses diagnosis of primary deficits, those underlying a particular domain (e.g., sensorimotor), and secondary deficits, impairments arising from a primary deficit. The NEPSY is therefore designed to assess subcomponents of complex functioning. For the sake of achieving optimal comparisons for pre-post testing purposes, the NEPSY was readministered in favor of the NEPSY-II. Given that Susie’s performance may have been affected by her limited right-dominant hand mobility due to her IV splint, it is important to see how she performs on the same instrument without this handicap.

Attention

Presenting Concerns

According to the Neuropsychological Checklist, Susie’s parents noted that Susie becomes absorbed in what she’s doing (e.g., playing with puzzles) and has difficulty moving to another task. She is easily frustrated with difficult tasks and often does not attempt to complete them. Problematic behaviors that they attributed to her included the following.

Focused Attention

Becomes easily distracted by sounds, sights, or physical sensations (moderate problem)

Is inattentive to details or makes careless mistakes (moderate problem)

Does not know where to start when given a task (mild problem)

Sustained Attention

Has difficulty paying attention for long periods of time (moderate problem)

Mind appears to go blank or loses train of thought (moderate problem)

Seems to lose place in an academic task (moderate problem)

Shifting Attention

Has difficulty stopping one activity and starting another (severe problem)

Gets stuck on one activity (severe problem)

Applies a different set of rules or skills to an assignment (mild problem)

Divided Attention

Has difficulty attending to more than one thing at a time (moderate problem)

Does not seem to hear anything else while watching TV (moderate problem)

Easily becomes absorbed into one task (severe problem)

Attentional Capacity

Stops performing tasks that contain many details (severe problem)

Seems overwhelmed with difficult tasks (severe problem)

Visual Attention

Susie was given the NEPSY Visual Attention subtest. This is a time-restricted test in which she has to scan multiple rows of pictures to find and mark specific ones. Her performance was in the Average range (SS 9). This test assesses attention to visual detail as well as perceptual speed. She held her pencil with a high, light pencil grip and marked her targets with a light-trace mark. She randomly scanned the pages, rather than systematically proceeding from left to right in pursuing targets. The Neuropsychological Checklist indicated attention problems that may likely manifest on neuropsychological measures when she is older and can be assessed in more depth.

Executive Functions

Presenting Concerns

According to the Neuropsychological Checklist, Susie’s parents noted that she is slow to grasp concepts and learn, but once she understands, she excels. They also reported that Susie does not consider the consequences of her actions and often is unremorseful. She has hit her brother many times. In the first few weeks of preschool, she was removed from class because she threw toys and pushed other children. Problematic behaviors attributed to her regarding executive functioning were as follows.

Problem Solving, Planning, and Organizing

Has difficulty learning new concepts or activities (mild problem)

Has difficulty solving problems that a younger child can do (moderate problem)

Makes the same kinds of errors over and over (severe problem)

Quickly becomes frustrated and gives up easily (severe problem)

Behavioral-Emotional Regulation

Appears to be undermotivated to perform or behave (moderate problem)

Has trouble getting started with tasks (moderate problem)

Demonstrates signs of impulsivity (severe problem)

Has trouble following rules (moderate problem)

Demonstrates signs of irritability (moderate problem)

Lacks common sense judgment (severe problem)

Cannot empathize with feelings of others (moderate problem)

Summary of Executive Functions

Because of Susie’s young age, executive functions are not reliably assessed, but her parents have expressed several concerns regarding her problem-solving, planning, organization, and self-regulation abilities.

Sensory and Motor Functions

Presenting Concerns

On the Neuropsychological Checklist, Susie’s parents noted that she will sit down and say she can’t walk because her legs are too tired; she has trouble with fine motor skills such as copying a line drawn on a paper and using scissors properly.

Motor Functioning

Muscle weakness or paralysis-bilateral (mild problem)

Clumsy or awkward motor movements (mild problem)

Walking posture difficulties (mild problem)

Involuntary or repetitive movements—taps feet while standing (moderate problem)

Poor fine-motor skills (mild problem)

Tactile/Olfaction Functioning

Overly sensitive to touch, light, or noise (mild problem)

Complains of loss of sensation (e.g., numbness) bilaterally in arms and legs (severe problem)

Auditory Functioning

Does not like loud noises (severe problem)

Summary of Sensorimotor Functioning

Susie’s performance on subtests that measure sensorimotor skills was within the Average range. She was able to plan motor activities, reproduce hand positions, and use a pencil to execute a maze-like task under speeded conditions. Notice that her mother has reported bilateral muscle weakness and awkward movements, which may require additional follow-up with her pediatrician. Susie’s pencil grip is rather high and as a result she draws with very light, rather wisp-like marks. Pencil grip is a learned skill and she may need some instruction to give her more control of the pencil and the marks she makes.

Visual-Spatial

Presenting Concerns

The Waterhouses’ response to the Neuropsychological Checklist indicated that Susie experiences the following problems.

Visual-Spatial Functioning

Drawing or copying difficulties (severe problem)

Difficulty with puzzles (mild problem)

Confusion with direction (moderate problem)

Summary of Visual-Spatial Functioning

Susie’s performance on subtests that measure visual-spatial skills showed variability ranging from Below Average to Average. Her overall nonverbal reasoning as reflected by her Performance Index on the WPPSI-III was within the Average range. She showed relative weakness in nonverbal spatial reasoning on the Block Design and Picture Completion subtests. Both subtests of the NEPSY were within the Average range.

Language

Presenting Concerns

In responding to the Neuropsychological Checklist, Susie’s parents noted concerns about Susie’s receptive language.

She has difficulty answering questions. She appears unable to process the meaning of questions at times and her responses do not make sense. For example, if you ask what she did in school, she’ll say ‘yes’ or if you ask who she played with she’ll say ‘blocks’. She recognizes when her answers don’t make sense, but can’t provide the correct information. She is intelligent in that she attempts to compensate for missed information, so people don’t realize that she does not understand. She is still learning to say her first and last name.

Articulation

No problems noted

Phonological Processing

Difficulty blending individual sounds to form words (mild problem)

Receptive Language

Trouble understanding what others are saying (moderate problem)

Does not do well with verbal directions (moderate problem)

Expressive Language

Difficulty finding the right word to say (moderate problem)

Unusual language or vocal sounds (mild problem)

Summary of Language Functioning

Susie’s language scores show uneven development. She has good skills in naming common pictures and describing familiar objects as indicated by her average WPPSI-III Vocabulary score; however, she was rather dysnomic on Body Part Naming. She does not do as well on language tasks that call for more abstract skills such as figuring out the correct word when an object is described. She had great difficulty when asked to retrieve words or to describe the attributes in a picture. She did well on a phonological processing task in which she matched a spoken phoneme to one of three pictures.

Language comprehension was more challenging for her. On the WPPSI-III Comprehension subtest, her score was at the lower end of the Average range (SS 8). On this task, she had to answer an opened-ended question. She looked perplexed and often replied, I don’t know. On the Comprehension of Instructions subtest (NEPSY), she also earned a scaled score of 8. On this task, she was to identify the picture that matched a set of multiple modifiers (e.g., Show me the one that is blue and happy). She was able to do so for sentences with two modifiers but not for three (e.g., Show me the one that is blue, big, and happy).

On the Similarities subtest, she had extreme difficulty answering how two things are alike, such as red and yellow, despite ample training prior to starting this subtest. Taken together, these findings suggest that while she has some fundamental knowledge of word meanings when the words are presented in isolation, she has trouble reasoning with language and engaging in spontaneous expression. Her relative weakness in comprehension of language appears to match the behaviors described by her mother. Mrs. Waterhouse has observed that Susie is sometimes aware that she has expressed herself incorrectly but then she does not know how to correct it. Additionally, Susie has been observed to have significant word finding problems both in the classroom and in the home.

Memory and Learning

Presenting Concerns

According to the Neuropsychological Checklist, Susie’s parents expressed concerns about her lack of retention of information, poor comprehension, and limited recall. They reported that she answers questions incorrectly, such as ‘How was your day?’ or ‘What did you do?’ and if you ask her about an upcoming activity or event, she will say she has already done it.

Short-Term Memory

Frequently asks for repetitions of instructions/explanations (moderate problem)

Seems not to know things right after they are presented (moderate problem)

Has trouble following multiple step directions (severe problem)

Active Working Memory

Loses track of steps/forgets what they are doing amid tasks (moderate problem)

Long-Term Memory

Has difficulty answering questions quickly (severe problem)

Forgets what happened days or weeks ago (moderate problem)

General Learning

Has difficulty with verbal, visual, and integrating both (moderate problem)

Current Levels of Functioning

SUMMARY OF MEMORY FUNCTIONING

According to the subtests measuring memory, Susie’s long-term recall of basic facts was Below Average. Note that her mother reported that Susie still struggles with the recall of her own first and last name, a task that is within expectations for her age. She is also struggling with learning and recalling the names of colors, letters, and numbers. Her performance on Narrative Memory (NEPSY), which requires her to listen to a short story and recall the essential details, was within the lower limits of the Average range. Short-term auditory memory, assessed by listening to sentences and repeating them verbatim, was Average, an improvement from her previous score. When one examines her mother’s observations of her memory problems, however, along with the fact that memory functions are frequently adversely impacted for children with severe seizure disorders, her current scores may belie a more serious and emerging memory deficit. One must consider also the implications of memory on language. Susie appears to do better on rote memory tasks such as sentence repetition. She has considerably more difficulty attending to and performing a mental operation on information she has been given, such as listening to a story and answering questions, a complex task requiring integration of language.

Social-Emotional Functioning

Behavior Assessment System for Children-2

The BASC-2 assesses emotional and behavioral disorders in children and can be used to develop intervention plans. Susie’s overall Behavior Symptom Index of 72 fell within the Clinically Significant range, indicating serious problems in socio-emotional functioning that require intervention. Please refer to the separate report in her confidential file for more detailed information.

SUMMARY OF FINDINGS

According to the results of this evaluation, although Susie is functioning within the Average range of intellectual functioning, the effects of her seizure disorder appear to have adversely impacted neuropsychological functioning, particularly manifested in areas of language and memory.

RECOMMENDATIONS

Further Evaluation and Monitoring

1. Susie has symptoms of a subclinical mixed receptive-expressive language disorder that should be evaluated by a pediatric speech-language pathologist. Diagnostically, the difficulties in language processing described by Mrs. Waterhouse are equal in importance to the scores and help to put them in context. Susie would benefit from intensive speech/language therapy focusing on word retrieval and receptive and expressive language abilities.

2. It would also be advisable to have an occupational therapist conduct further fine-motor assessment to design a program to help Susie develop her fine-motor and visual-spatial skills.

3. The complexity of Susie’s medical condition warrants close and frequent monitoring by her pediatric neurologist and by periodic neuropsychological reevaluation. Side effects of AEDs should be thoroughly researched and carefully observed. Also, her mother has reported bilateral muscle weakness and awkward movements, which should be disclosed to Susie’s pediatrician.

For School

1. Refer Susie for special education under the category of Developmental Delay.

2. Keep in close contact with Susie’s parents to facilitate a coordinated support system for Susie’s learning.

3. To improve selective/focused attention:

a. Reduce auditory and visual distracters that may unnecessarily compete with her attention.

b. Teach Susie how to keep her desk organized and free of unnecessary objects that could distract her.

c. Maximize the high interest material and visual cues in assignments. She may profit from having a visual depiction of what she is expected to do.

d. Make sure you have Susie’s attention before giving her oral instructions.

e. Allow for breaks throughout the day as needed to reduce fatigue, and divide large assignments into manageable units.

4. To alleviate memory difficulties:

a. Deliver oral instructions at a slow pace in a brief and concrete format, and accompanied by visual reinforcement when possible.

b. When giving brief instructions, keep in close physical proximity while maintaining eye contact. Then have her repeat what she is expected to know.

c. As Susie grows older, teach memory strategies such as using daily schedules, organizers, and hand-held recorders.

d. When introducing new skills, provide Susie with pictures to visualize and form associations regarding what is being learned.

5. To alleviate behavior problems:

a. Susie may benefit from behavioral therapy to alleviate problems she is having with getting along with peers.

b. Provide positive feedback on instructions and assignments. Given her sensitivity, she should be reinforced for her effort along with the quality of her work.

REFERENCES

Arzimanoglou, A., Guerrini, R., & Aicardi, J. (2004). Aicardi’s epilepsy in children (3rd ed.). Philadelphia, PA: Lippincott, Williams & Wilkins.

Ho-Turner, M., & Bennett, T. (1999). Seizure disorders. In S. Goldstein & C. Reynolds (Eds.), Handbook of neurodevelopmental and genetic disorders in children (pp. 499–524). New York: Guilford.

Williams, J., & Sharp, G. (2000). Epilepsy. In K. Yeates, M. Ris, & H. Taylor (Eds.), Pediatric neuropsychology: Research, theory, practice (pp. 47–73). New York: Guilford.

Case 3

Language Assessment of a Sibling of a Child with Autism

Dale Bailey

Given the increase in the incidence of autism over the last decade, much attention has been given to comprehensive language assessment during a youngster’s early years of life (age 5 and younger). Likewise, an increase in the incidence of autism has resulted in a greater number of assessment instruments being developed for this population. Most notable is the increase in the number of assessment instruments available to evaluate language pragmatics.

Comprehensive assessment of language and greater resources devoted to early childhood language assessment have resulted in two significant outcomes. First, children with autism have benefited significantly because instruments that are more sensitive to language differences caused by autism and/or pervasive developmental delays are more readily available and used. This results in a more accurate diagnosis, as well as the provision of early intervention.

Second, children without autism have benefited because these same instruments are also used with children without autism. Some of the children evaluated do not carry an autism diagnosis, but they are the siblings of children with autism.

This is the case of Anthony Oscar who was referred for a speech-language evaluation prior to the age of 2. Anthony has an older brother who has autism (diagnosed before the age of 3). Anthony’s parents, who learned about autism through their older son’s diagnosis, became concerned when Anthony was demonstrating delayed receptive oral language skills (i.e., listening) and delayed expressive oral language skills (i.e., speaking).

The speech-language evaluation report that follows details Anthony’s developmental history, including his speech-language evaluation history to age 5 years. Significant throughout the years is that Anthony demonstrated a fairly stable language profile over the course of 3 years. That is, with minimal intervention provided (i.e., language therapy at a frequency of 1x/week), Anthony’s language delay did not markedly increase over time, as would be likely with a child with autism. Review of Anthony’s receptive oral language skills, in fact, shows that progress occurred during the 3-year time frame.

By age 5, through both observation and language sampling, it became clear that Anthony enjoyed playing and interacting with others and was developing relatively good pragmatic language skills.

Through standardized assessments, however, Anthony’s specific language deficits became clear as well. By the age of 5, it was clear that Anthony’s receptive language skills were low average to mildly delayed and that his expressive syntax was most problematic.

Following this evaluation, Anthony went off to kindergarten in September and was referred by the school for a psychological evaluation to identify possible Attention-Deficit/Hyperactivity Disorder of unknown type and to obtain assistance in developing a plan to help Anthony succeed and focus/stay on task. He was 5 years, 1 month at the time of the psychological evaluation. A Child Symptom Inventory (CSI), ADHD Rating Scale-IV, BASC-2, IVA+, and WISC-IV (selected subtests) were administered and the diagnostic impressions were a provisional diagnosis of ADHD-Predominantly Inattentive Type, problems with primary support group, and academic problems. The evaluator explained for better future comparisons, test selection included two tests that were beyond Anthony’s age range by two months.

Several recommendations for improving behavior(s) were made in the psychological evaluation report. There was also discussion of environmental disconnection that is common in the siblings of special needs children. The evaluator went on to say that Anthony does demonstrate an immature level of ability suggesting that he will likely be able to develop proficiency in the right environment, given effective modeling. In contrast to the conclusions of the school evaluation, the results of the following evaluation suggest that Anthony’s behavioral and attentional challenges may be more attributable to his language delays.

SPEECH-LANGUAGE PATHOLOGY REEVALUATION REPORT

SIGNIFICANT INFORMATION

Anthony is a 5-year, 1-month-old boy who lives with his parents and older brother in Parker, Idaho, and attends the pre-kindergarten program at Parker Elementary School. Anthony was originally referred for a speech-language evaluation just prior to turning 2 years old. There were no significant pre- or postnatal challenges. Labor was induced at 40 weeks’ gestation and Anthony’s birth weight was 7 pounds, 1 ounce. There is no history of frequent middle ear infections. This reevaluation is occurring at this time to determine Anthony’s progress in language therapy.

A history of speech-language delays exists on both sides of the family. In addition, Anthony’s older brother, Matthew, was diagnosed with autism after an interdisciplinary evaluation, when he was 2½ years of age. Matthew is currently a fifth grader and requires the services of a 1:1 aide throughout his school day. Although he is verbal, he is considered to have severe autism.

Mr. and Mrs. Oscar are both high school graduates. Mrs. Oscar remains home to care for the family and Mr. Oscar owns an air-conditioning business. Anthony’s parents have consistently attended his speech-language sessions, as has his maternal grandmother who is also active in the treatment plan. English is the only language spoken in the home.

Anthony’s initial evaluation indicated mildly delayed receptive oral language, mildly delayed expressive oral language, and moderately delayed overall oral language. Regular/weekly speech-language therapy was recommended (at a frequency of 1–2x/week) and was provided, but mostly at a frequency of 1x/week.

Anthony’s speech and language were reevaluated in January of 2008 (at age 3 years, 1 month). Results of that evaluation indicated moderately delayed receptive language, mildly delayed expressive language, and moderately delayed overall language. An attempt was made to assess oral vocabulary; however, this was unsuccessful because Anthony’s responses were considered unreliable and inconsistent. Continued speech-language therapy was recommended and subsequently provided at a frequency of 1x/week. Given that Anthony’s receptive language was more delayed than his expressive language, more emphasis was placed on the development of receptive language in therapy. Anthony made good progress on his speech-language goals through June of 2008 so extended school year (ESY) services were not recommended. Anthony did not receive speech-language therapy during the summer of 2008 and therapy commenced in September of 2008; he also began participating in a Head Start program in the fall of 2008.

A speech-language reevaluation was conducted in January of 2009. Results of that evaluation indicated at least average receptive and expressive vocabulary, mildly delayed receptive language, moderately delayed expressive language, and moderately delayed overall language. Continued speech-language therapy was recommended and subsequently provided at a frequency of 1x/week. ESY services were provided during the summer of 2009 that included speech-language therapy. Services continued into the fall of 2009 at a frequency of 1x/week. The current reevaluation is being conducted to determine Anthony’s present status and progress, as well as to address Anthony’s parents’ concern that his slow language development may be indicative of autism.

TESTS ADMINISTERED/METHODS USED

Test of Language Development-Primary, Fourth Edition (TOLD-P:4)

Comprehensive Assessment of Spoken Language (CASL)

Language Sample/Observation of Play

File Review

TESTS/RESULTS

General Behavior

Although Anthony was mostly cooperative and compliant throughout the course of this evaluation, completion of standardized tests typically successfully used with 5-year-old children was challenging. Specifically, Anthony repeatedly attempted to turn the tasks into a game. Although reinforcing activities were used intermittently (between tests) to increase participation, Anthony did not appear to enjoy more structured tasks, such as naming pictures. As such, his somewhat limited engagement should be taken into account when considering whether the results are representative of his actual level of speech-language functioning.

Oral-Peripheral, Speech/Articulation, and Voice and Speech Fluency

No significant deviations were present in the structure or function of the oral-peripheral area and mechanism. Anthony’s oral-peripheral mechanism is considered structurally and functionally adequate for speech production purposes. Speech articulation is considered to be within normal limits. Anthony’s speech is easily understood. For this reason, speech articulation was not assessed. Voice and speech fluency characteristics observed during this evaluation were judged to be within normal limits. No speech fluency behaviors were noted or suspected.

Language

The Test of Language Development-Primary, Fourth Edition (TOLD-P:4) was administered in order to evaluate Anthony’s oral language skills. The TOLD-P:4 is a standardized assessment instrument consisting of six subtests that are combined into composites. These composites provide information about an individual’s receptive, expressive, and overall oral language skills, language organization, language form (grammar), and language content (semantics). Only five of the six subtests of the TOLD-P:4 were administered because only the listening, speaking, and grammar composites were warranted. Information about Anthony’s performance on the TOLD-P:4 follows. Descriptions of the TOLD-P:4 subtests are found in the Appendix. The following table illustrates the verbal descriptors used in this report to describe the score ranges:

TOLD-P:4 Performance

A review of Anthony’s performance on the TOLD-P:4 indicates that his receptive language skills are in the low average to mildly delayed range and that his expressive language skills are mildly delayed. The Picture Vocabulary and Syntactic Understanding subtests