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Sample Test Report

Peter was referred for testing as part of a special educational reevaluation. Peter had been tested a number of times in the past by various examiners. He is presently identified as being educationally handicapped due to a learning disability.

Mr. Dumont requested that the school consider adding to Peter's current educational identification, the following special education labels: Seriously Emotionally Disturbed (SED), Other Health Impaired due to an Attention Deficit Hyperactive Disorder (ADHD), and Learning Disability due to "dyslexia."

This particular portion of the evaluation was done in an attempt to make differential diagnosis of the disorders raised by Mr. Dumont's letter. A meeting was held prior to testing during which each assessment tool was discussed and explained to Mr. and Mrs. Dumont.

Test behaviors:

Peter came willingly from his classroom to the three testing sessions. Each session varied in length from 45 minutes to 1 hour and 15 minutes. He was administered various tasks of attention and vigilance in one setting, the Test of Memory and Learning (TOMAL) over two sessions, and the Differential Ability Scales in one session. The TOMAL was the only test broken by session. This test has a number of core subtests and delayed recall subtests as well as tests called Supplementary. During one session, Peter was administered the 4 core subtests, followed by their delayed recall. During the second session he was administered the remaining subtests. This examiner had spoken with the test author (Cecil Reynolds, personal communication, 11/93) about the feasibility of such an administration and was told that this approach was "highly acceptable."

Peter typically came to the sessions appearing annoyed at having been called out of his class. Once in the testing room though, he became talkative and willing to try the tests. It was often necessary for the examiner to begin each session with some rapport building conversation. This is very typical of children of Peter's age and should not be viewed as affecting the results. He appeared comfortable during the evaluation, showing no signs of apprehension about the testing or his own performance on the tests with the exception of some comments made about his own ability on the memory tasks. He displayed adequate perseverance on all tasks, even those he found most difficult. He was friendly and cooperative throughout the session, talking openly about himself and school and making jokes about himself.

Some of Peter's behaviors during the session were annoying but it was felt that most were done without any real malicious purpose. For example, during the first session, Peter was administered the Trails A & B tasks which resemble a dot to dot task. Peter was to draw a line from one circle to another following a set rule. After completing this, he was administered subtests of the TOMAL. One showed him a card with black dots placed on a page. He was to watch the examiner point to specific dots and then remember the sequence and location of the dots. Peter took his pencil and drew lines connecting the dots. This was inappropriate but Peter did not seem to realize that he had done it until it was pointed out to him.

Intellectual assessment:

Peter has been assessed a number of times in the past. In 1984, using the McCarthy scale, he was found to have a General Cognitive score of 54. On three successive administrations of the WISC-R (1986, 1987, and 1989) he obtained respective Full Scale Scores of 70, 92, and 87. On a WISC-III short form in 1992 he obtained a score of 84. The Differential Ability Scales (DAS) was used for this evaluation. This tool was chosen for a number of reasons. Besides its excellent technical characteristics, the DAS is made up of three clusters measuring diverse abilities. These clusters, although similar to the WISC scores of Verbal and Performance, also allow for the examination of Nonverbal reasoning skills. Each cluster is examined to assess how Peter is able to demonstrate his intellectual ability.

On this particular administration of the DAS, Peter obtained a Verbal cluster score in the range of 74 to 94, a Nonverbal Reasoning score in the range of 58 to 77, and a Spatial cluster score in the 82 to 99 range, which resulted in an obtained General Conceptual Ability score (GCA) of 76. Scoring better than approximately 5% of the children his own age, Peter's true ability is most likely (95% chance) in the range of 70 to 83. Using the DAS classification system, this would identify Peter's present level of cognitive ability as being in the Very Low to Below average range. The scores that he obtained on this administration of the DAS are very consistent with the scores he obtained on the earlier administration of the WISC-R and the WISC-III Short form. Because the DAS assesses ability across many different domains or clusters, each must be compared to the overall score to determine if they better describe individual skills than does the overall GCA. On this administration of the DAS a significant difference was found between the Nonverbal Reasoning Cluster, and the Spatial cluster score when they are compared to the GCA. This suggests that Peter is able to demonstrate his intelligence differently, depending upon the demands of the task presented. Peter was able to demonstrate his abilities best through complex visual spatial processing rather than when asked to demonstrate ability through acquired verbal concepts and knowledge or nonverbal inductive reasoning. The differences between the global scores on the DAS are found to occur in between 10 and 25% of the population. They are not, in and of themselves, indicative of pathology or disability, but may help to understand how Peter processes and learns information. Because of the significant differences between Peter's ability, the overall GCA is considered an inaccurate representation of Peter's ability. Although when compared to others his own age, the GCA is an accurate measure, within Peter there are such differences in ability that the focus of attention should be on the individual cluster scores. They probably best describe how Peter functions, and they help to determine the current strengths and weaknesses that Peter displays.

Cluster analysis

Most of Peter's subtest scores grouped about his own mean with a few exceptions. There was a statistical strength on the Recall of Designs subtest while weaknesses on the Matrices and the Recall of Digits subtests.

The Verbal cluster is made up of the Word Definitions and Similarities subtests. Peter was found to be functioning in the Low to Average range on the cluster. There was no significant difference between Peter's scores on this cluster. The cluster itself is a measure of complex, verbal mental processing which includes acquired concepts, verbal knowledge, and reasoning. Peter's expressive language skills appeared to be evenly developed in that he was able to utilize his verbal skills to describe word meanings in long descriptive sentences as well as to correctly assign 3 different words into one meaningful classification or category using typically a single word.

The Nonverbal Reasoning cluster is made up of the Matrices and Sequential & Quantitative Reasoning subtests. The cluster is a measure of nonverbal, inductive reasoning requiring complex mental processing. It required Peter to identify elements in a stimuli, to form and test hypotheses about relationships and to apply the relationship to new material. Here Peter was found to be functioning in the Very low to low range. Peter demonstrated a significant difference between the two subtests. He had most difficulty on the abstract problems of the Matrices subtest. The use of multiple choice answers on the Matrices subtest did not appear to be very helpful for Peter. He seemed not to grasp the patterns required of the problem because of the very abstract nature of the visual patterns. He did do slightly better on the Sequential and Quantitative Reasoning subtest. Here he was able to recognize patterns that involved simple number concepts. In fact, the errors that he made were logical. Although he understood the math process (for example: add, subtract, multiply), his errors were in computation. On a problem in which the correct answer is obtained by subtracting a certain number, Peter was able to discover the number difference, but when he gave his answer, he added the number instead of subtracting it.

Peter did best on the Spatial cluster. This cluster is made up of Recall of Designs and Pattern Construction scores. This cluster is a measure of complex visual spatial processing. It requires the ability to perceive and to remember spatial relationships. The first subtest is a paper and pencil task that involves a short term memory component while the second has no memory aspect but involved timed performance. For Peter, the scores showed no significant difference, but overall, his Recall of Designs score was his best. On these simple designs, Peter aided himself in his recall by trying to name each item. This form of verbal compensation, helped him to remember the designs. On other tests administered to him, he used this form of compensation to help himself.

Peter was also administered two diagnostic subtests to assess his memory for both meaningful and non meaningful stimuli. On the Recall of Digits subtest he was read a series of increasingly longer non related numbers and asked to repeat them back to the examiner. Read at a rate of 2 per second so that he could not compensate by repeating the numbers to himself, he was able to remember easily a string of up to 4 numbers but became inconsistent on any longer string. He was able to correctly remember only 1 out of 5 number string for items involving 5 numbers. He either simply forgot (could not encode) the numbers, or when he did remember them, they were out of sequence. For example, 23746 became 23764. On the meaningful, visual memory task of Recall of Objects, he was shown a page with 20 objects and asked to remember all that he could. Given 3 trials, he was able to correctly recall 27 items (8, 10, 9 items on each trial) and after a 15 minute delay was able to recall 6 items. His scores on these subtest suggested that his memory skills are aided when a visual component is added, and, like most, his memory skills are best when the information to remember has some meaning or is placed in some meaningful concept. The lower Recall of Digits also may suggest some difficulty with the sequential nature of the task. Having to remember something, but also to keep the items in the proper sequence was more difficult for Peter.

To assess Peter's memory, the Test of Memory and Learning (TOMAL) was chosen. This tool assesses a number of memory domains and allows for quantitative as well as qualitative analysis. Both immediate and delayed memory is measured.

Test of Memory and Learning (TOMAL):

On the TOMAL, Peter obtained a Composite Memory Index (CMI) of 79, which, when placed at 95% confidence, has a range of 74 to 84. This would identify Peter's overall memory skills as being in the Deficient to Below Average range. This description of Peter's abilities should be viewed with caution, since the individual memory scales of the TOMAL showed diverse abilities. The TOMAL measures memory not only globally, but in two more distinct realms, Verbal and Nonverbal memory. For Peter, the Verbal memory index (VMI) was significantly below that of his Nonverbal memory index (NMI). His VMI was found to be in the Very Deficient to Deficient range while his NMI was in the Below Average to Average range. Although many people show differences in their particular memory abilities, the size of the difference shown by Peter (30 points) is considered abnormal since it is expected in only about 4% of the population. Rather than focus on the global score (CMI), analysis of memory should focus on the diversity of Peter's ability.

Overall, Peter had average ability on all those memory tasks that presented material, both meaningful and abstract, with a visual format. On some of the nonmeaningful stimuli, Peter introduced meaning by verbally naming the abstract design. On those tasks that involved memory for things presented orally without some visual cueing, Peter did much worse. Only one verbal subtest, Word Selective Reminding, was in the average range. Within the Verbal Memory grouping, this subtest was a strength for Peter. He was read a list of words and asked to repeat the list to the examiner. He could repeat them in any order that he wanted, and at the end of his repeating he was told each item he had missed. He used his memory to categorize the items into certain groups and to repeat them back within the group. He remembered things as groups of fruits, groups of table items, and groups of animals. Peter was aware of his method, noting to the examiner "I'm doing them in categories." In contrast to his skill on this task, he was also shown pictures of 15 items and asked to remember them. After each trial, he was shown the pictures again, but each trial presents them in a different order. He is not reminded of errors. He had trouble with this task since each time he was presented with the pictures they had changed in the order he remembered them.

Peter's Delayed recall index (DRI) was also within the average range but also offers some clues to how Peter encodes and remembers. This index is made up of 4 subtests that are repeated after a 30 minute delay. When administered a second time they are not retaught, Peter is asked to simply recall all that he could remember. Two of the subtests, Memory for Stories Delayed and Facial Recognition Delayed were below average while the other two, Word and Visual Selective Reminding Delayed were average or above. He appeared to have stored into retrievable memory much more data on those two subtests that had repeated trials. This repetition of stimuli aided in both the storage and later retrieval of that material. On a subtest (Memory for Stories) in which he is read a short story and asked to repeat back all that he could remember, Peter showed the ability to recall only small bits of the verbal information and most importantly, when he tried to recall the material, he did so in a very random and haphazard manner. Although aspects of the story were encoded, his retrieval of the information was badly mis-sequenced.

Overall, in terms of memory storage and retrieval, this and other tests, suggests that Peter has difficulty with storing information that is purely verbal in its presentation and which requires him to retain large amounts of data in a sequential way. Under these circumstances, he retains information in bits and pieces and for those portions that he has remembered, he is only able to recall correctly smaller parts of the data. In contrast, Peter remembers (encodes) best when information is logically sequenced; when it is visual presented either alone or in concert with oral presentation; when the remembering task involves repetition as opposed to a "one shot" presentation; and when the information to remember is meaningful or has been placed into some meaningful context. These memory skills are fairly common to most. The difference for Peter is that while others may also be able to remember data that is unstructured, has little meaning, and is presented through many different channels, Peter can not do so on a level commensurate with his other skills. Retrieval of information may also appear difficult for Peter, but this too was enhanced by aids, both visual and verbal. Having "learned" a number of items by having them repeated to him over a number of trials, when he was asked to remember them after a delay, his recall was enhanced by presenting him with both verbal and visual cues. Although at first he could not remember certain items, prompted with the first sound of a missing item ("br" for bread) he was able to recall the items. Similarly, when shown pictures of 3 items, one of which he had not remembered freely, the addition of the visual cueing resulted in his remembering every item. Retrieval was also best when the demand for sequence was not added. Asked to recall items in any order he wished, he performed in the average range. Asked to recall items in the same sequence in which they were presented, he performed well below average.

Attention and vigilance:

To aid in the assessment of attention and vigilance, a number of laboratory measures was used. Trails A & B, the Stroop Color Word Task, and the Mesulam Continuous Performance task were used. These were chosen because of the way they assessed the various skills. Teachers were also asked to complete the Conners rating scale.

Trails A: This task, with the teaching sample shown below, asked Peter to draw a line from one circle to another by connecting the circles depending on the number in each one. He was able to quickly, easily, and correctly trace the path from 1 to 15.

Trails B: This task is much like the first but forces Peter to alternate between the numbers and letters in each circle. Instead of simply tracing the path from 1 to 2 to 3, he much cognitively shift his attentions from 1 to A to 2 to B, etc..

Trails B: Peter had great difficulty making the cognitive shift and maintaining the correct sequence. He was able to complete all items but only after self correcting a number of mental lapses and taking a considerable amount of time. The difference between his success on the first part and his difficulty on the second part may imply some difficulty on sequential tasks that are multi-stepped and complex. He has difficulty making quick and accurate shifts in mental process.

Stroop Color/Word Task: This task asked Peter to do three things: First read a list on words (green, blue, red) as quickly and accurately as he could. Second, name a list of colored XXXX's as quickly and accurately as he could. Finally, shown a word (RED) printed in a different color (Green) he was to suppress the urge to read the word and to simply name the color of the word. From the scores on the first two trials, a prediction is made about how many 'color-words' he should name, and an 'interference' score is calculated. When his results are calculated using age corrected scores, there was no significant difference found between his scores. He obtained an interference score of 1 (mean 0, sd ±10). This suggests that Peter's ability to make a cognitive shift was heightened when he did not have some time imposition. Adding the pressure of time, as in the Trails task, may lead to some internal anxiety that adversely effects Peter's ability. Although his scores are nonsignificant, he did have difficulty maintaining proper sequence while "reading" on each trial. He would often jump ahead of himself when he made a mistake and need to return to the proper place in the list.

Mesulam Continuous Performance task: These tasks consists of two pages with the letters of the alphabet printed in uppercase. On one page (Ordered), the letters are placed in neat, orderly rows and columns, while on the second page (Random), the letters are placed in a haphazard fashion, with no order imposed. On both pages, 60 A's are placed among the other letters. Regardless of the page, the A's are in the same location, with approximately 15 in each of the 4 quadrants. Children are asked to simply scan the page and "find all the A's." This is an untimed task and Peter was asked to do it until he felt he had discovered all items. He was administered the ordered page first and the random second. Below is a sample from the ordered page. The circles are the A's that Peter circled, while the black marks are the A's Peter missed and were marked by the examiner for scoring.

His approach to this task was consistent, no matter what page. He scanned the page quickly, but without imposing any order to the search. He went from left to right, and top to bottom, but not in any real order. Consequently, when he said he was through, he had missed 6 A's on the ordered page and 3 on the random. Compared to 502 children similar his own age (11 to 15), the total number of errors (9) was significantly high (Total Error mean 1.5 sd 2.3). He performed like only about 4 percent of the standardizing population. This would imply some deficit in visual, sequential scanning and in proper organization of tasks.

Conners Teacher Rating Scales: This widely used rating scale provides measures for identifying a variety of behavioral problems in children. This particular version contains 6 factors: Hyperactivity, Conduct problems, Emotional overindulgence, Anxious/Passive, Asocial, and Daydreaming-attendance problem. Symptoms are rated on a 4 point scale (0-3) and raw scores are transformed into T scores (mean 50 sd 10). T scores 2 or more standard deviations above the mean may be considered problem areas.

Six teachers completed the scales. Of the six areas assessed, only 1, the Hyperactivity index, was rated as being elevated, and with only 2 raters approaching the 2 standard deviation score, while 3 found some elevation and 1 found none. The second highest rated areas for Peter, although not rated high enough to be considered a true problem area, was that of Asocial problems.

Visual Spatial task:

The Rey Osterrieth Complex Figure task was administered to Peter. Here he shown a picture of a fairly complex design and asked to copy it from the model After he has completed his drawing, he again draws the figure, this time simply from memory. Scores are dependent on accurately and placement of the distinct portions of the design. Analysis of organization and approach to the task are noted.

Rey Osterrieth Complex Figure: Peter's approach to this tasks was similar in nature to his approach on the other tasks of visual scanning and planning. He drew the image by breaking it down into smaller component parts, but did non impose any successful organization to the design. His final result was a close reproduction of the original but one in which his lack of organization resulted in disjointed and misplaced lines. Peter was also asked to reproduce the complex design from memory. When he did, his recall showed many forgotten parts. It suggests that complex visual material does not become encoded well by Peter possibly because of a lack of self imposed organization.

Original Recall

Social Emotional issues:

Peter's father had raised the issue of whether Peter currently fits the educational handicapping category of Seriously Emotionally Disturbed (SED). Peter had first had that label applied to him in 1986, although at that time Mr. Dumont felt that it was an inappropriate label for Peter's difficulties. The school district in 1989, after a recommendation by this examiner, and with agreement from Mr. and Mrs. Dumont, removed the SED label because it was felt to be inappropriate for Peter at that time. In order for a child to be SED, a 'condition' of emotional disturbance must be present and that condition must meet at least one of 6 characteristics. Once those qualifying conditions are present, they must also meet the requirement of being "to a marked degree", "over a long period of time", and "adversely effect education." To assess the appropriateness of this label, Peter's teachers and parents were asked to fill out behavior checklists. A parent interview and home visit was done, and Peter was interviewed at school.

Behavioral assessment: As noted above, teachers had rated Peter using the Conners rating scale and found the area called Asocial to be slightly higher than others. Peter's teachers completed the Burks' Behavior rating scales. Here, 110 descriptions of behavior are rated on a scale of 1 to 5 for their presence and severity. The items are then grouped together into 19 areas of behavior and the results are compared to children his own age. When the teachers ratings were compared for agreement, 11 were rated as Nonsignificant, while 7 were Significant and 1 Very Significant. The areas most typically rated as being Significant to Very significant were: Poor ego strength, Poor intellectuality, Poor academics, Poor attention, Excessive aggressiveness and Excessive resistance. There was little variation in how the individual teachers saw Peter, with most rating the same areas as places of concern. These results seem to be consistent with those found on the Conners scale. These results are also fairly consistent with the levels of concerned rated by teachers using this same scale in 1989. They suggest some concerns with Peter's behavior, but not to a level that this examiner would consider pathological or necessarily indicative of an emotional disturbance.

Among the descriptors that Peter's teachers rated as highest were:

• Satisfied with inferior job
• Little self confidence
• Depreciates and distrusts
• Trouble remembering
• Is sarcastic
• Does things his own way

Peter's parents were also asked to complete the Achenbach's Child Behavior Checklist. Here, 113 behavioral descriptions are ranked and placed into 1 of 9 behavioral domains. These are then compared to normative data. Peter's parents rated Peter's behavior to be significantly elevated in the 6 of the 9 areas: Withdrawn; Anxious/Depressed; Social Problems; Thought Problems; Attention Problems; and Aggressive Behaviors. Of the 113 descriptions, Mr. and Mrs. Dumont rated 35% as being Very True to Often true, the highest rating. This is a very high level of response for these descriptions and suggests some overriding concerns of the parents about Peter's behaviors.

Learning disability: Peter has been identified as a learning disabled child by his school for some time. Given the difficulties he displayed on this evaluation in the areas of Nonverbal Reasoning (DAS), visual perceptual organization (Rey Osterrieth), and memory, in particular memory unaided by repetition, and memory that requires sequential responses (TOMAL Verbal memory), it is felt that, coupled with the low achievement in at least one area (Mathematics), Peter continues to manifest the symptoms of a learning disabled child.

Speech and Language Disorder (Auditory perception): There was nothing on this evaluation to suggest any difficulties in the areas of auditory perception. While some subtle issues were highlighted in the behavioral observations of past evaluations, there was never any "recurrent theme." On the present evaluation, Peter showed no errors in his ability to adequately perceive any oral stimuli. When errors were made in oral presentation it appeared to be the result of inattention as opposed to language processing.

Attention Deficit Hyperactive Disorder (ADHD): Peter has had a history of being identified as Attention Deficit with Hyperactivity Disorder (ADHD). Although the definition and understanding of this disorder has changed over the years, Peter still continues to have a number of symptoms of the disorder, although the classic signs of hyperactivity have decreased. He often fails to give close attention to details and makes careless mistakes; he has difficulty sustaining attention in tasks; he has difficulty organizing tasks; and he avoids tasks that require sustained mental effort. It is extremely difficult to determine where one's frustration caused by a learning disability leads to inattention and activity. For Peter, the two disorders seem inextricably entwined. Given that he was diagnosed previously, that symptoms are reported as being present both in school and at home, and that the disorder causes significant distress in social and academic functioning, it is this examiner's opinion that the diagnosis of Attention Deficit/Hyperactivity Disorder, Predominately Inattentive Type (DSM-IV 314.00) is an appropriate classification.

Serious Emotional Disturbance (SED): Although Peter may present with many symptoms of a behavior disorder, the etiology of his symptoms seem based most appropriately in the learning, memory, and attentional disturbances that Peter has. His father mentioned, during the home visit and interview, that Peter was a very disturbing child. This examiner agrees, but makes a distinction between a disturbing and a disturbed child. Peter's behaviors, feelings about himself and others, and his ability to cope with his settings, are very closely tied to his other difficulties. The Diagnostic and Statistical Manual (DSM) makes a point to psychologists to differentiate between disorders so that a clear case can be made for each. Under each definition of disorder (ADHD, Mood, Anxiety, and Personality Disorders), the psychologist is cautioned to make a distinction about what does and does not account for each disturbance. If Peter was found to be emotionally disturbed, that may account for his attentional issues. If he is found to have an Attention deficit, that might account for his 'emotional' disturbance. This examiner believes that only a very weak case can be made for a true mental disturbance. No evidence of any thought or mood disorders was noted during the evaluations. None of Peter's behaviors were considered bizarre or unprovoked. Although there is no doubt that Peter has behavioral difficulties, these have typically been dealt with differently than those created by an emotional disturbance. The laws and definitions created by the federal government asks schools to make a clear distinction between an emotional and a behavioral disorder. In Peter's case, most of his behavioral/social problems are better accounted for by his history of learning and attentional difficulties. This examiner suggests that the code of SED is still an inappropriate label for Peter.

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L P Farr Ed.D.; NCSP

Director of Psychological Services