(8-16-13)
Ruthie is a 36-year-old, single female who lives in a an apartment complex owned and managed by a not-for-profit organization devoted to serving individuals with developmental disabilities. She is employed at a local restaurant busing tables and doing some kitchen work; she has support from a job coach. Ruth comes to your attention because her psychological assessment needs to be updated to continue to qualify her for services. Her records indicate that Ruth has a medical diagnosis of Down’s Syndrome, confirmed by genetic analysis. She completed school through special education. Ruth is active in her church, where she sings in the choir; and she participates in Special Olympics. She visits her parents and sister on a regular basis. She is able to use the public transportation system. Ruth was able to complete driver’s education in school and pass her driver’s examination but she never drove independently and did not renewed her license. Past psychological evaluations have reported IQ scores in the mild to moderate ranges of mental retardation. There is not history of emotional or behavioral problems. Ruth takes no psychotropic medication.
You evaluation finds a Wechsler Adult Intelligence Test, Third Edition (WAIS-III) Full Scale IQ of 45 with little variation among subscales. Academic skill assessments finds impaired scores in reading, spelling, and arithmetic. Adaptive behavior assessment with the Scales of Independent Behavior-Revised (SIB-R), using her mother as an informant, yields impaired scores for Social Interaction and Communication Skills, Personal Living Skills, and Community Living Skills. Ruth appears happy and reports no problems; no problems are reported by her parents or the social worker who manages the apartment building.
Impression
DSM-IV-TR Impression:
- Axis I: V71.09 No disorder on Axis I
- Axis II: 318.0 Moderate Mental Retardation, Reason For Visit
- As manifested by a WAIS-III FSIQ of 45; impaired adaptive functioning in academic skills, fully independent living, work; limitations evident since childhood
- Axis III: Trisomy 21 documented in chart records
- Axis IV: Difficulties in social integration, occupational functioning, and housing associated with cognitive limitations
- Axis V: 55–moderate difficulty in social functioning
DSM 5 Impression:
318.0 Moderate Mental Retardation, Reason For Visit, as manifested by a WAIS-III FSIQ of 45; impaired adaptive functioning in academic skills, fully independent living, work; limitations evident since childhood; Trisomy 21 documented in medical records.