Nicohwilliam

NEUROPSYCHOLOGICAL EVALUATION REPORT

(CONFIDENTIAL-DO NOT COPY WITHOUT PERMISSION)

NAME: PATIENT REFERRED BY: X

DATE OF INTERVIEW: DATE OF BIRTH:

DATE(S) OF TESTING: AGE AT EVALUATION: 16 y, 2 m

HANDEDNESS: Right DATE OF REPORT:

EVALUATION BY: EVALUATOR

NEUROBEHAVIORAL STATUS EXAMINATION/INTERVIEW:

Informed consent was obtained after a review/discussion of reasons for this evaluation, evaluation procedures, risks/benefits, costs/payment issues, and issues regarding professional records and confidentiality. The following information was obtained through an interview with Patient and his father, Mr. Father, as well as a review of available records.

Reason for Evaluation:

Patient was a 16-year-old young man who was referred for a neuropsychological evaluation by Practitioner, CNFP, due to ongoing concerns regarding inattention, poor concentration, and academic performance. Ms. Practitioner was interested in obtaining information regarding Patient’s current level of neurocognitive functioning, as well as diagnostic impressions and treatment recommendations.

Current Concerns:

When asked his understanding of why he was referred for this evaluation, Patient stated, “I can't concentrate.” He reported that he is sometimes easily distractible, especially when reading. He reported losing interest when reading, necessitating re-reading the material. He reported better focus with short stories than with books. Patient reported he is able to pay attention in class, though it takes effort. Mr. Father stated that Patient has the most trouble with sustained attention, and agreed this is most pronounced when reading. Both father and son reported that Patient functions better with structure, which he doesn't appear to be able to impose himself. Patient denied problems with daydreaming, organization, planning, or multitasking (though he stated multitasking was never a strength). Patient reported he is frequently forgetful, usually forgetting boring tasks like chores. He stated interesting tasks and conversations were easier to remember. Mr. Father reported Patient sometimes has trouble with language comprehension, stating he will tell Patient things that “go in one ear and out the other.” Both Patient and his father reported that Patient has trouble sitting still and will wiggle in his chair or crack his knuckles frequently. This has reportedly improved over time, as both father and son reported Patient had trouble staying seated in kindergarten and would get up and walk around during class.

On a questionnaire format, Mr. Father endorsed the following current symptoms as problematic for Patient: distractibility; poor frustration tolerance; concentration problems; and poor judgment. Ms. Mother endorsed the following additional current systems as problematic for Patient: short term memory problems; temper control; impulse control; and alcohol/drug abuse (specifying that Patient has tried alcohol once and marijuana four to five times).

Past Psychiatric History:

Mr. Father reported a history of psychological counseling for Patient, which he stated lasted only a few sessions during Patient's parents' divorce in 1999. History of psychiatric hospitalization, and/or psychopharmacological intervention was denied. Records indicate that Patient was evaluated at the age of five for oppositional and aggressive behavior (see evaluation by Doctor, M.D., dated September 7, 2000). Dr. Doctor's impressions at that time were as follows: oppositional defiant disorder related to family issues; probably gifted child; denied a diagnosis of ADHD.

Developmental/Medical History:

Patient's parents denied problems with the patient’s gestation or birth. Patient reportedly met developmental milestones appropriately, and there were no concerns about his childhood or adolescent development. His father noted that Patient had some classroom behavior issues of concern when he was four or five years old. Mr. Father reported that Patient was easily distractible as a child, and had trouble sitting still, but denied history of hyperactivity. According to his father, Patient’s medical history is remarkable only for allergies. The only prescription medication use reported was Claritin PRN.

Family History:

Ms. Mother reported that family history was remarkable for bipolar disorder (father diagnosed in adolescence) and anxiety (mother). Mr. Father was reportedly adopted, and little is known regarding family history of his birth parents.

Academic/Social History:

Patient reported that English was his first language. Mr. Father reported that Patient attended Blank Elementary through third grade, then transferred to Elsewhere Elementary for the fourth and fifth grades. Patient reportedly attended Random Middle School and then Some Other High School, where he is currently a junior. He reported a grade point average of 3.0. Mr. Father reported that Patient has received tutoring in reading, geometry, physics, and algebra. Patient reported current difficulties in physics, and stated he is a “bad test taker,” especially when the tests are administered on scantron sheets. He reported feeling considerable anxiety when taking tests, though he denied panic attacks. Patient reported having trouble studying for tests, stating he gets bored and will take a break, and will sometimes not return to studying. He reported that he reads more slowly than his classmates, and often has to reread material. He reported that it takes him a long time to write essays, and that his teachers and peers have commented that he repeats himself in his writing. He stated that he lives with both his parents part-time, as they are divorced, and one older sister. Patient reported ongoing conflict in his relationship with his mother in the last year.

Previous Testing:

None available.

Records Reviewed:

Mystery Clinic evaluation dated September 7, 2000 performed by Dr. Doctor, M.D. of Healthcare Group.

NEUROPSYCHOLOGICAL TESTING:

Procedures/Tests Administered:

After informed consent was obtained and a clinical interview was conducted, the following measures were administered according to standardized procedures: Wechsler Adult Intelligence Scale-Fourth Edition (WAIS-IV), Woodcock Johnson III (WJ-III): Tests of Achievement, Conners’ Continuous Performance Test II (CPT-II), Trail Making Test: Parts A & B, California Verbal Learning Test – Second Edition (CVLT-II), Boston Naming Test (BNT), Nelson-Denny Reading Test, Wechsler Memory Scale-Third Edition, visual reproduction subtests (WMS-III), Controlled Oral Word Association (COWA) FAS and Animals, Wisconsin Card Sort Test (WCST), Behavior Assessment System for Children-Second Edition (BASC-2): Parent, Teacher, and Self-Reports, Behavior Rating Inventory of Executive Function (BRIEF): Parent, Teacher, and Self-Reports.

Behavioral Observations:

Patient was a right-handed boy who appeared his stated age of 16 years. He arrived on time and accompanied by his father for his evaluation. She was casually dressed and well groomed. Eye contact was appropriate. He was friendly, easily engaged, and cooperative throughout the interview and evaluation, and had an active interpersonal style. Spontaneous speech was fluent and without articulation difficulties. Thought process was logical with no evidence of referential thinking. No evidence of delusions or hallucinations was present. Mood was reported to be “good,” and full range of affect was exhibited, which was appropriate to context. He denied current suicidal ideation, intent, or plan. He ambulated independently, and by observation only, gross motor functioning was unremarkable. No difficulty in comprehending test instructions was noted, and he attempted every item without prompting. Some difficulty with inattention was noted during the evaluation, particularly during tasks Patient found less interesting. Overall, the results reported below are considered to be a valid estimate of current neurocognitive functioning.

Test Results:

Intellectual Function:

Patient was administered the WAIS-IV to measure his current intellectual function. On the WAIS-IV, Patient obtained a Verbal Comprehension Index score (VCI) of 96 (39th percentile; average range), a Perceptual Reasoning Index (PRI) score of 100 (50th percentile; average range), a Working Memory Index score (WMI) of 97 (42nd percentile; average range), and a Processing Speed Index (PSI) score of 97 (42nd percentile; average range). Patient’s Full-Scale Intelligence Quotient (FSIQ, SS=97, 42nd percentile) was in the average range.

Academic Achievement:

Patient was administered subtests of the Woodcock Johnson-Third Edition, Tests of Achievement (WJ-III) in order to assess select academic achievement skills. His performance was compared to grade-related peers. His performances were in the average range on a task of letter recognition and single word reading skills (Letter-Word Identification SS=92, 8.0 grade level) and on a task of reading comprehension skills (Passage Comprehension SS=95, 8.9 grade level). Patient’s performance was also in the average range on a test of speeded reading, (Reading Fluency SS=94, 9.2 grade level). Overall, Broad Reading was in the average range (SS=94, 33rd percentile).

On a timed test of vocabulary based on a multiple-choice format, Patient performed in the average range (NDRT; Vocabulary at 55th percentile, 11.6 grade equivalent). On a timed test of reading comprehension, his performance was also in the average range (NDRT; Comprehension at 47th percentile, 11.3 grade equivalent). Patient did not complete either the above vocabulary subtest or the comprehension subtest within the standard time allotted (Vocabulary: completed 75/80 items with 44 correct responses; Comprehension: completed 28/38 items with 22 correct). Thus, the extended-time administration of both the vocabulary and reading comprehension subtests were administered. The provision of additional time resulted in his completing all of of the items on both subtests, but performance was not improved (Vocabulary at 35th percentile, 9.7 grade equivalent; Comprehension at 45th percentile, 10.1 grade equivalent). It should be noted that with extended time Patient answered 41/80 questions correctly on the Vocabulary subtest and 28/38 questions correctly on the Comprehension subtest. Overall, Patient’s vocabulary and reading comprehension were in the average range. The grade equivalents and percentile scores are based on education norms. These scores are not available based on age only.

Attention/Concentration and Executive Functions:

Patient was administered a computerized test of sustained visual attention (CPT-II). His overall performance had inconclusive results, with a 50% chance that a clinically significant attention problem exists. These results suggest Patient was experiencing some difficulty with sustained visual attention. On a brief test of visual attention, scanning and sequencing (Trails A), he performed in the high average range (82nd percentile). On second test of visual scanning and sequencing requiring cognitive flexibility (Trails B), he performed in the average range (50th percentile). He performed in the high average range on a test of nonverbal, inductive reasoning that relied on visual stimuli without corrective feedback (WAIS-IV: Matrix Reasoning at 84th percentile).

Patient’s performances on tasks from the WAIS-IV that assessed working memory were in the average range (Working Memory Index, SS=97; 42nd percentile). His ability to repeat digits verbatim (simple attention) was in the mildly to moderately impaired range (Digit Span; Longest Digits Forward, 5 digits, 3rd percentile), his ability to repeat digits in reverse order was in the low average range (Digit Span; Longest Digits Backward, 4 digits, 11th percentile), and a function of both simple auditory attention and working memory, was in the average range (Digit Span; Longest Digits Sequencing, 6 digits, 29th percentile).

Patient obtained a WAIS-IV Processing Speed Index score of 97 (42nd percentile), placing him in the average range. Patient’s performance was in the average range on a task involving visual scanning, incidental learning and grapho-motor speed (Digit Symbol Coding: 50th percentile), as was his performance on a task of visual scanning and speeded decision making (Symbol Search: 37th percentile). Thus, cognitive processing speed performances were in the average range.

Taken together, results suggested that brief auditory attention and sustained visual attention were somewhat impaired, while brief visual attention and scanning were generally intact. Cognitive flexibility and non-verbal reasoning abilities were also grossly intact.

Learning and Memory:

Patient was administered a test of verbal learning and memory where he was asked to learn a list of words over repeated trials (CVLT-II). His performance across the five learning trials (6, 13, 14, 15, 14) was in the high average range (88th percentile). His immediate recall after the first learning trial, often considered a measure of attention, was in the average range (31st percentile). Learning slope across the remaining trials was in the average range (as he made age-expected gains in performance over repeated trials: 50th percentile). This suggested that his encoding was somewhat aided by repetition. An interference word list was presented to Patient after 5 trials of the initial list. His recall for this second list of words was in the low average range (5 of 16 words recalled: 16th percentile). Immediate free recall of the original list of words post-interference was average (50th percentile, 12 words), and the provision of cues did not improve performance significantly (average range, 69th percentile, 13 words). Following a 20-minute delay, Patient’s free recall of the initial word list was in the average range (69th percentile, 13 words). The provision of cues resulted in no change in performance (69th percentile, 13 words). This suggested that Patient did not particularly benefit from the provision of semantic categories following the delay. Patient was able to recognize the word list and discriminate learned words from distractors (CVLT-II: Discriminability, average range, 69th percentile) with no false negative errors and no false positive errors.

Learning of visual geometric designs was in the superior range (WMS-III Visual Reproduction I at 91st percentile). Delayed recall of the same information was in the very superior range (WMS-III Visual Reproduction II at 98th percentile) and percent retained after a delay was at the upper end of the high average range (91st percentile). Delayed recognition of the designs was also in the high average range (WMS-III Visual Reproduction Recognition at 84th percentile).

Overall, the pattern of results reflected intact immediate encoding of both visual and abstract verbal information with increased learning observed with repetition. Retention, retrieval, and discrimination of this same information were intact. Immediate encoding of geometric designs and recall of those designs were relative strengths.

Language Functions:

On the WAIS-IV, expressive vocabulary skills were in the average range (Vocabulary, 63rd percentile), as was general fund of information (Information, 37th percentile). Verbal abstract reasoning was at the upper end of the low average range (Similarities, 25th percentile). Thus, as stated above, his Verbal Comprehension index score was in the average range (SS = 96, 39th percentile). Phonemic-cued fluency was in low average range (COWAT; FAS raw = 26, 16th percentile), and semantic fluency was average (COWAT; Animals raw = 22, 70th percentile), suggesting a benefit from increased structure. Patient’s performance on a visual confrontation-naming task was in the average range (BNT-2 raw = 50, 38th percentile) compared to similarly aged and educated peers.

Visuospatial Functions:

Patient’s WAIS-IV Perceptual Reasoning Index score of 100 (50th percentile) was in the average range. His fluid non-verbal reasoning (Matrix Reasoning) ability was in the high average range (84th percentile), while his performance on a task measuring visual-spatial analysis, synthesis, and construction was at the upper end of the low average range (Block Design at 25th percentile). Ability to mentally match and rotate figures to form complete designs was in the average range (Visual Puzzles, 37th percentile).

Executive Functions

As previously mentioned, Patient’s performance on a complex measure of mental set-shifting abilities was in the average range (Trails B at 50th percentile). Nonverbal concept formation/problem solving was evaluated using a measure that emphasizes discrimination of relevant features of non-verbal stimuli across learning trials (WCST). Performance was within expectation for the number of categories completed (raw = 6, greater than 16th percentile). Percent of errors was in the high average range (i.e., he committed fewer errors than expected; 77th percentile), as was percent of perseverative errors (90th percentile).

Motor Functions:

Patient was right-hand dominant. He was administered a test of speeded manual dexterity (Grooved Pegboard). His performance on this test was in the average range for his dominant hand (DH=66th percentile) and in the high average range for his non-dominant hand (NDH=82nd percentile).

Behavioral Functions:

Patient, his teacher, and his father independently completed questionnaires regarding Patient’s emotions, behaviors, and adaptive functioning. Mr. Father’ endorsement of items indicated no current concerns regarding his executive function exhibited in every day behavior, with no clinically significant elevations. Patient’s endorsement of items indicated mild (at risk) elevation on the Sensation Seeking scale. His teacher’s responses indicated mild (at risk) elevations on the Conduct Problems, School Problems, and Behavioral Symptoms Index scales, with clinically significant elevations on the Hyperactivity, Externalizing Problems, and Attention Problems scales.

Mr. Father also completed the Brief Rating Inventory of Executive Functioning (BRIEF). Both his and Patient’s responses on the BRIEF indicated no clinically significant elevations. However, Patient’s teacher’s endorsement of items indicated current concerns regarding Patient’s ability to regulate his own behavior as well as his ability to initiate, plan, organize, self-monitor and sustain working memory. Additionally, the teacher noted concerns with Patient’s ability to inhibit impulsive responses, adjust to change, initiate problem solving, and plan and organize problem solving approaches.

Taken together, the results of these ratings scales suggested that Patient was experiencing difficulty with symptoms of hyperactivity, inattention, and maladaptive behavior, particularly while at school.

Summary/Impressions:

Patient was a 16-year-old boy who was referred for a neuropsychological evaluation by Practitioner, CNFP, due to ongoing concerns regarding inattention, poor concentration, and academic performance. Ms. Romero was interested in obtaining information regarding Patient’s current level of neurocognitive functioning, as well as diagnostic impressions and treatment recommendations.

Overall, intellectual testing demonstrated average verbal reasoning abilities, non-verbal reasoning abilities, working memory and processing speed abilities. Patient’s Full-Scale Intelligence Quotient (FSIQ, SS=97, 42nd percentile) was in the average range.

Academic achievement test findings indicated that Patient was within the average range with regard to the acquisition of specific age/grade appropriate academic skills (i.e., reading). However, while additional time was required to complete some of these tests, extra time did not appear to improve his accuracy of responding. Patient does not meet criteria for a learning disorder at this time. Reduced reading skills may be related to an attention problem.

Neuropsychological test findings indicated that cognitive flexibility, non-verbal reasoning abilities, and brief visual attention and scanning were generally intact. However, brief auditory attention and sustained visual attention were somewhat impaired. Additionally, performances were variable on tests of attention, ranging from mildly to moderately impaired to high average, and indicated, at minimum, mild to moderate impairment of functioning. Immediate encoding of visual and abstract verbal information was intact with increased learning observed with repetition. Retention, retrieval, and discrimination of this same information were intact. Visual perceptual skills, fine motor coordination, non-verbal categorization and concept formation abilities, and non-verbal reasoning were intact. Phonemic and semantic-cued verbal fluency were also intact, though his improved performance on semantic-cued verbal fluency is suggestive of a need for structure. Behavioral ratings scales suggested that Patient was experiencing difficulty with symptoms of hyperactivity, inattention, and maladaptive behavior, particularly while at school.

Overall, test findings were consistent with parent report of long standing inattention, distractibility, and poor concentration on clinical interview. Relative deficits in sustained visual attention and brief auditory attention as well as teacher behavioral ratings were consistent with symptoms Attention Deficit/Hyperactivity Disorder (ADHD).

As noted, Dr. Doctor had previously dismissed the possibility of ADHD, and suggested Patient's behavioral issues may have been the result of Oppositional Defiant Disorder (313.81). There is currently no evidence to support this diagnosis, but there is sufficient evidence to support the diagnosis of ADHD.

Diagnosis:

Results of this evaluation are consistent with the diagnoses of:

Attention Deficit/Hyperactivity Disorder, Combined Type (314.01)

Recommendations:

It is recommended that Patient receive Special Education Services to assist in the acquisition of his academic skills. He qualifies for Special Education Services under the category of Other Health Impaired (OHI). In view of Patient’s cognitive strengths and weaknesses, curriculum modification is a prerequisite for academic progress, as well as for gains in socialization, self-esteem, and independence. Curricula, teaching methods, and expectations should be adjusted to optimize academic progress. Some other general guidelines that might be helpful in the development and refinement of his individualized educational program (IEP) include:

Patient is likely to perform best in environments that are structured and predictable. Providing clear and specific rules and consistent daily routines will be beneficial.

Patient requires double time extension for all standardized and unstandardized examinations. In addition, he should be given the option of taking examinations in a distraction free environment.

It is recommended that Patient receive preferential seating close to his teacher so that proximity control procedures can be easily implemented that will help him maintain on-task performance. This includes placement in a position away from distraction (e.g. away from students who tend to be disruptive, away from visual and auditory extraneous stimuli).

It is recommended that, if needed, his teachers and/or parents implement well-designed behavioral management systems utilizing positive behavioral interventions and contingency management strategies. Suggestions include:

i. Positive attention or praise should be provided frequently.

ii. Parents and teachers should model expected behaviors whenever possible.

iii. A clearly stated system of positive and negative consequences for specific behaviors is important. ADHD children require clear, strong, immediate, and frequent feedback regarding their behavior. It is extremely important to ensure that positive reinforcement is given as often as negative. Be sure to use punishment sparingly. The classroom needs to be a positive environment for the child.

iv. At home, it may be useful to utilize a contingency management system whereby negative or positive consequences are applied contingent on the appropriateness of the behaviors. A point system is one example of this system. Points are awarded for positive behaviors and can be exchanged for privileges, favored items, etc. Points are lost (removed) for negative behaviors.

It is recommended that teachers give simple directions and avoid multi-step commands. Short, brief work periods interspersed with breaks are likely to be more beneficial than a long, extended work period.

Use brief, precise, and concrete instructions and make sure that Patient understands them and has not gotten lost during provision of verbal instruction.

Patient should be provided with copies of class notes from his teacher to minimize the impact of divided attention during instructional periods.

Patient’s parents, teachers, and educational team may find the following texts helpful: Taking Charge of ADHD: The Complete Authoritative Guide for Parents by Russell A Barkley, ADHD and the Nature of Self-Control by Russell A. Barkley, and Interventions for ADHD: Treatment in Development Context by Phyllis Anne Teeter and Sam Goldstein.

For math specifically, work should concentrate on developing math concepts and include use of “hands-on” material, estimation strategies, discussion of complex computations and word problems, and review of the practical application of mathematics to everyday life.

Use of a calculator to aid with math facts is recommended.

Continuous communication between home and school regarding Patient’s progress is also recommended. Specific attention should be paid to his educational progress as well as his social progress.

2. Children with ADHD often show difficulties with: 1) understanding and following instructions for completing tests and assignments, 2) planning ahead and organizing their time and the materials necessary for completing assignments and tests, 3) maintaining attentional focus and resist distractions, for example, while reading or during lectures, and 4) checking their work for careless errors before turning in. It is recommended that Patient be included in the development of an intervention plan to address his attention and executive function weaknesses and that this plan be implemented within positive, meaningful everyday routines and have real-world relevance when possible. The following suggestions may be helpful for difficulties arising in a variety of areas:

a. Organization: These difficulties can result in problems with getting assignments done on time, forgetting to turn them in, or losing the assignment. Organizational difficulties can be addressed by the use of a monitoring system (e.g., daily check-ins for assignments), use of organizational aids (e.g., checklists, reminders, routines), use of a computer for written assignments, and other classroom modifications.

b. Planning: There are a number of steps that should be taught to adolescents to improve their planning skills including: prioritizing, breaking tasks down into simpler steps, setting goals for themselves, recognizing their abilities to accomplish goals, planning the execution of the steps, using flexible problem solving when obstacles arise, reviewing goals, plans, and accomplishments at end, and teaching time management and self-monitoring skills ("What should I be doing now?").

c. Remembering: Possible interventions for helping remember to complete tasks, include incentive systems, memory aids (e.g., lists, appointment books), use of calculators to aid with math facts, take breaks and allow physical movement while memorizing, or a reduction in demands/expectations.

d. Following Directions: Patient may benefit from repeating directions individually, highlighting directions and written instructions, and use of a check-in system to ensure comprehension.

e. Written Production: Possible interventions include dictating responses, use of digital recorders, access to computers for written assignments, reduced written assignments, opportunities to respond orally, assistance with prewriting activities (e.g., outlining), jotting down ideas then organizing into an outline, close-ended writing assignments, use of a spellchecker, use of other students to proofread written assignments, and a proofreading checklist.

f. Problems with Test Taking: Possible interventions include to allow test re-takes, double time extension for tests, break testing into several sessions, oral exams, short-answer/multiple choice formats, allow test taking in a quiet room with minimal distractions, teach test-taking strategies, use open book test formats, provide sample items/templates, and use cues to aid retrieval during test taking.

3. Patient would likely benefit from pharmacological treatment of his ADHD symptoms, as indicated by research. If the effects of stimulant-based medication are of concern to Patient and his parents, he may benefit from a trial of non-stimulant based medication (i.e., Strattera or Wellbutrin). It is recommended that Patient and his parents consult his primary care physician for medication recommendations and management. Additional consultation with a pediatric psychiatrist may also prove helpful. Recommended psychiatrists in private practice would include Leah Rudnick, M.D. at 842.5300. If Dr. Rudnick is not available, psychiatric services can also be obtained through UNMH Programs for Children and Adolescents (505) 272-2190 or Presbyterian Healthplan at 291-5300. In addition, to pharmacotherapy, meeting with a behavior therapist is also highly recommended. Current research literature has shown that children/adolescents who receive combined therapy have the best outcome in treating ADHD. Patient’s parents would also likely benefit from participating in these therapy sessions to ensure adequate structuring of responsibilities, rules, rewards, and consequences at home. These services can be obtained through UNMH Programs for Children and Adolescents (505) 272-2190 or through the Presbyterian Healthplan. Recommended private practice therapists would include Rene Silleroy, Ph.D. (255-5522) and Helen Jackson, Ph.D. (266-4226). Additional, resources can be provided upon request.

4. Additional information regarding research advances, medications, and treatments for individuals with ADHD is available through Children and Adults with Attention-Deficit/Hyperactivity Disorder (CHADD), a national non-profit organization. (http://www.chadd.org/).

As Patient advances to higher academic levels, he may require additional academic accommodations. It is recommended that he receive a follow-up neuropsychological evaluation in 1-2 years to monitor his progress and refine his educational planning needs.

If you have any questions regarding the evaluation or this report, please feel free to contact me at ###-###-####. Thank you for this evaluation. It was a pleasure to work with Patient and his parents.

__________________________________

Neuropsychologist

CC: Practitioner, referring clinician

Patient

Parents