Sample Report: Ray B

Psychological Assessment

Ray B.
date of birth:
date of testing:

Examiner: Alvin E. House, Ph.D.

Ray B is a 10-year-old male. Ray lives with his father and brother in Town, State.
Ray attends the 4th grade at School in Town.

Testing

• mental status examination
• Wechsler Intelligence Scale for Children, Third Edition (WISC-III)
• Wide Range Achievement Test, Third Edition (WRAT-3)
• Disruptive Behavior Disorders Rating Scale (father)
• interview (father)
• In addition to my interview, testing, and observation, I have reviewed the following data supplied by DHS: grandmother, Function Report 6 to 12 Years (date); Third Grade Report; IEP Progress Report; Conference Summary Report (date); Educational Achievement Report (date).

General Observations

Ray was brought to his appointment by his father. He separated easily. His gait appeared unremarkable. His posture was erect. He was restless in his chair. He was cooperative and compliant during the testing. His task motivation appeared good once he began an activity but he required cueing to ensure attention. He became inattentive quickly between tasks. He was appropriately dressed in casual clothing and was adequately groomed. His vision, hearing, speech, and fine motor coordination were adequate for testing. He held a pencil in his right hand with a standard grip and placement.

Mental Status:

Ray was alert. His concentration appeared limited. He gave his correct birthdate and age. He reversed two letters in spelling his name. His printed letter formations were large but legible. He failed to capitalize, misspelled, and failed to punctuate a simple, declarative sentence written to dictation. He correctly identified his school and grade. He did not know the date; gave the year as, “April”; and gave the day of the week as, “Thursday.” His picture naming appeared grossly adequate. His spontaneous verbal fluency appeared limited; his oral comprehension appeared adequate. He was able to copy a Greek cross. He was able to copy a Necker (3D) cube with a mild distortion. His thinking appeared unremarkable for his age. There was no evidence of looseness of associations, cognitive or perceptual distortions, or psychotic thought content. His affect was appropriate and his mood normal.

Ray’s Report:

Ray appeared to relax and become comfortable with the testing situation quickly. He was pleasant in interaction with the examiner. Ray reported he liked to, “play outside” and “ride my bike.” He said he had two best friends. He said he liked school. He said he had another home where his mother and “another father” lived, but said he had not visited there for a long time.

Intellectual Functioning:

Ray obtained a WISC-III Full Scale IQ of 86 (18th %ile) which falls in the low average range of intellectual functioning (IQ 80-89); approximately 16 percent of the general population score within the range. His Verbal IQ was 74 (4th %ile) and his Performance IQ was 102 (55th %ile). The 28 point difference between his VIQ and PIQ was significant beyond the .05 significance level. A difference of this magnitude or greater occurred in 2.7 percent of the WISC-III standardization sample. The 95% confidence interval for his VIQ was 69-82, and for his PIQ 94-110.

On the WRAT-3 Ray’s Reading (oral word recognition) grade score was 2.1 for a standard score equivalent of 70 (2nd %ile) and his Spelling grade score was 1.9 for a standard score equivalent of 77 (6th %ile). His printed letter formations were large but legible.

Testing six months previously with the Woodcock-Johnson III Tests of Achievement had yielded the following results:

• Oral Language 97
• Broad Reading 68
• Basic Reading Skills 75
• Reading Comprehension 78
• Math Calc Skills 82
• Academic Fluency 72
• Written Expression 84
• Letter-Word ID 71
• Reading Fluency 69
• Story Recall 103
• Understanding Directions 96
• Calculation 86
• Math Fluency 73
• Writing Fluency 82
• Writing Samples 91
• Passage Comp 80
• Word Attack 83
• Reading Vocabulary 83

Father’s Report

Mr. Dan G., Ray’s father, was interviewed. He reported that his name was listed on Ray’s birth certificate although Ray’s mother had give inconsistent reports regarding whether he was Ray’s father. Mr. G. appeared committed to caring for Ray and his younger brother. Mr. G. reported that the boys had lived with him since Ray was in Preschool. He reported that Ray was doing, “Pretty good.” He reported that Ray took Adderal prescribed by Dr. F. Burns. He said that the Adderal was begun, “last year”, discontinued over the summer, and resumed, “two weeks ago.” Mr. G. reported that the medication, “helps some academically, a lot socially.” Mr. G. reported that in kindergarten Ray had been, “totally unresponsive” and “wouldn’t try anything.” Ray began to receive special services and Mr. G. said this, “did him so much good.” Mr. G. reported that Ray had been prescribed Ritalin in the 1st grade when Dr. Burns diagnosed “ADD.” Mr. G. said that Ray was, “not hyper.” He said that Ray’s brother was, “hyper”: “moves and talks constantly, wears me out”, but is not currently on any medication. Mr. G. said that around other children Ray was, “quiet and reserved.”

Ray, Mr. G., and Ray’s grandmother all reported that he had two best friends that he got along well with and played with frequently.

Mr. G. completed a DBD Rating Scale for Ray. He endorsed clinically significant scores on 9 of the 18 DSM-IV symptoms of ADHD pertaining to Ray’s behavior for the past six months—8 of the 9 inattentive symptoms and 1 of the 9 impulsive/hyperactive symptoms: inattention to details, difficulty sustaining attention, not following through on instructions, difficulty organizing tasks, avoiding tasks requiring sustained effort, losing things, easily distracted, being forgetful, and fidgeting. He endorsed clinically significant scores on 1 of the 8 DSM-IV symptoms of ODD for the past six months: blaming others for his mistakes. He endorsed none of the 15 of the DSM-IV symptoms of Conduct Disorder over the past year.

Ray receives special education services for a qualification of “learning disability.” School records indicate that Ray’s Second and Third grade teachers each reported him to have continuing problems with staying focused on tasks, needing frequent prompts to stay on task, and being unable to work independently. He would occasionally be a distraction to other students when off task, but usually seemed quietly absorbed in daydreaming or doodling. Neither noted any serious behavior or social problems. Both teachers had commented that Ray had great difficulty getting organized for any activity and was easily distracted. The second grade teacher observed to Ray to be somewhat withdrawn from the other children; the third grade teacher noted he was reserved but had made some friends and generally interacted well.

Early childhood social records indicated Ray was removed from his mother for neglect. There was a notation of elevated lead levels found in a blood sample at age 3. He was placed with his father at age 4.5. Mr. G. is listed as the custodial parent.

Impression:

• Axis I:
  • 315.00 Reading Disorder
  • 314.00 Attention-Deficit/Hyperactivity Disorder, Predominantly Inattentive Type, In Partial Remission with medication
• Axis II:
  • V71.09 No disorder on Axis II
  • Borderline verbal intelligence, average visual-spatial skills
• Axis III:
  • Ray’s father reported that high lead levels had been reported in an Early Childhood Intervention medical screening
• Axis IV:
  • Academic difficulties
• Axis V:
  • GAF = 58, moderate difficulty in school functioning

Alvin E. House, Ph.D.
Licensed Clinical Psychologist