EXAMINEE: Amanda M Tritt REPORT DATE: 4/14/2005

AGE: 16 years 2 months GRADE: 8 th

DATE OF BIRTH: 2/14/1989 ETHNICITY: White Not Hispanic Origin

EXAMINEE ID: Not Specified EXAMINER: Martha Affeld

GENDER Female Age at Testing: WISC-IV (15 years 11 months)

Is this a retest? No

Reason for Referral

Amanda was referred for an evaluation by the School Psychologist, J. Affeld. The reasons for her referral are: academic difficulties, attention difficulties, behavior difficulties, emotional difficulties, family difficulties, learning difficulties, mathematics difficulties, memory difficulties, reading difficulties, required evaluations, and suspected intellectual deficit.

Home

Amanda is a 15-year-old who lives in a Group Home that has a Christian orientation. There are five or more children living in the home with Amanda. Her custodial arrangements have changed several times in the last 3 years. Amanda has been living in her present living arrangement less than two years. The educational background of Amanda's family is not known. Her biological mother is known to have ingested alcohol while pregnant with Amanda and it is also suspected that drug use occurred in the same time frame.

Amanda does not form appropriate relations within a familial unit and this does cause tension in her living environment. Amanda often argues with the other children, and exhibits inappropriate behavior including withholding bowel movements for weeks. She has also smeared her own feces on the bathroom walls. Stories that Amanda highlights about herself are told in extremes, overdramatically and many decibels above average speech. They include inappropriate content and lack of social connection to those being told. In many cases they carry the feeling of “twice-told tales” or myths she developed in place of being able to be fully present in the times and places. The recounting does not bring her peace or additional insight. They may provide insights about her level of functioning and presence in situations.

Amanda does not seem able to capture her surroundings accurately. It is almost as if she has tunnel vision and tunnel memory. . . missing the content and complexity of situations. Being with Amanda feels like being in the room with a young person in a heavy bubble. When the bubble rests on or touches a surface or a person, a tiny amount of content may transfer to the surface tension of the bubble. Amanda is not likely to notice that interchange enough to transfer it to short-term memory. If her attention is directed to the content, she will most likely not attend or be unable to attend to the milieu or adjust her actions or behavior to take in and deal with the surrounding information or content provided by others.

Amanda has had some traumatic occurrences in the past year. Prior to her placement at Love Lost she was living in a foster home. She had developed some evidence of a connection and bond to the female guardian and though she was displaying negative behavioral tendencies, she also appeared to be somewhat happier. This guardian died of cancer in the middle of the school year, which increased Amanda's acting out. She had many tantrums and loud angry outbursts. These have lessened with the structure of Love Lost. Love Lost is a positive placement for her because it is so structured. Amanda needs this structure.

Amanda has had a number of normal vision screenings and hearing screen during her time in school. She has not exhibited any indication that she has difficulty with hearing or vision. Amanda's guardian has not reported sensory or motor difficulties. During testing, Amanda exhibited gross motor difficulties that affected performance, appeared to be having difficulty focusing visually, and inappropriate verbal discussions. Amanda's guardian reports that she is diagnosed with Fetal Alcohol Syndrome and prenatal exposure to drugs. There is no information available regarding Amanda's neurological status. During the assessment, it was observed that Amanda appeared to be in good health. There is no data that suggests that Amanda uses medication or substances.

Amanda has been assigned to several different schools since beginning formal schooling. She currently attends classes full-time, regular classes, and special education classes. She was retained in the 4 th grade. She was retained more than four times. In the past, Amanda had frequent unexcused absences. Amanda had ongoing disciplinary and learning problems. In addition to frequent foster care and private caretaker changes, Amanda has a spotty school attendance record. She has been home schooled, had spotty success in attending and frequent absences while being schooled.

Currently, Amanda has many academic difficulties. Her performances tends to be right at the level of her proximal development, which falls far below the expected performance of a student Amanda's age.

Tests Administered:

WISC-IV (2/1/2005)

PIAT-R

Behavior Observation

Amanda appeared disheveled and nervous when she began the test. Amanda often wears the same outfit many days running. She stated many times that she had prayed before showing up and that many people had reassured her that everything would be okay. Her conversation often strayed to the inappropriate and she had to be redirected to the tests on several occasions. She took one test each day because she was very slow in completing the work. She asked numerous times how much work was left, and how much time was left, and what percentage of the test had she taken. She straightened the workbooks, and made only brief flickers of eye contact.

She kept discussing how angry she was that the evening before the routine had been disrupted. She exhibited numerous symptoms of autism throughout the interview and testing time.

It was observed that Amanda required frequent redirection. Amanda's speech during testing was typically clear, but slurred or mumbled at times. Amanda demonstrated English proficiency.

Wechsler Intelligence Scale for Children (WISC-IV)

SCORES SUMMARY

Interpretation of WISC-IV Results

Amanda performed much better on the verbal than on the nonverbal tasks of the Wechsler Intelligence Scale for Children-Fourth Edition (WISC-IV). Her motor coordination difficulties may have interfered with her opportunity to fully express her nonverbal reasoning abilities because many of the nonverbal tasks require the perception and manipulation of small materials. Amanda's general cognitive ability, therefore, is best estimated by her performance on the verbal tasks.

Amanda's verbal reasoning abilities as measured by the Verbal Comprehension Index are in the Average range and above those of approximately 27% of her peers (VCI = 91; 95% confidence interval = 85-98). The Verbal Comprehension Index is designed to measure verbal reasoning and concept formation. Amanda performed comparably on verbal subtests contributing to the VCI, suggesting that these verbal cognitive abilities are similarly developed.

Amanda's nonverbal reasoning abilities as measured by the Perceptual Reasoning Index are in the Borderline range and above those of only 5% of her peers (PRI = 75; 95% confidence interval = 69-85). The Perceptual Reasoning Index is designed to measure fluid reasoning in the perceptual domain with tasks that primarily assess nonverbal fluid reasoning and perceptual organization abilities. Amanda performed comparably on the perceptual reasoning subtests contributing to the PRI, suggesting that her visual-spatial reasoning and perceptual-organizational skills are similarly developed.

Amanda's ability to sustain attention, concentrate, and exert mental control is in the Extremely Low range. She performed better than approximately 0.1% of her age-mates in this area (Working Memory Index = 52; 95% confidence interval 48-63).

Amanda was referred for this evaluation in part because she has attention difficulties. Her score profile is consistent with this possibility. The pattern of weaker performance on mental control and processing speed tasks than on reasoning tasks occurs more often among students with attention deficits and hyperactive behavior than among children without these difficulties.

Amanda's ability in processing simple or routine visual material without making errors is in the Borderline range when compared to her peers. She performed better than approximately 4% of her peers on the processing speed tasks (Processing Speed Index = 73; 95% confidence interval 67-85).

Amanda's performance on the subtests that comprise the PSI is quite variable; therefore, the PSI score should be interpreted with caution. She performed much better on Symbol Search (Scaled Score = 7), which is more demanding of attention to detail and mental control, than on Coding (Scaled Score = 3), which is more demanding of fine-motor skills, short-term memory, and learning.

Processing visual material quickly is an ability that Amanda performs poorly as compared to her verbal reasoning ability. Processing speed is an indication of the rapidity with which Amanda can mentally process simple or routine information without making errors. Performance on this task may be influenced by visual discrimination and visual-motor coordination. Her motor skill difficulties may have hampered her in demonstrating her true ability on this task.

The academic difficulties, attention difficulties, behavior difficulties, emotional difficulties, social interaction difficulties, learning difficulties, mathematics difficulties, memory difficulties, reading difficulties and suspected intellectual difficulty noticed by Amanda's psychologist may be related to her lower mental control and processing speed abilities.

This pattern of mental control and visual processing speed abilities are both less developed than the student's ability and is more common among students with learning disabilities than among those without such disabilities. It also is suggestive of lack of ability to attend to current content with consistency. Amanda has a history of academic difficulties is school and is experiencing many academic difficulties in her current classes. She is slow to recognize a connection between herself and social, verbal or work expectations directed her way. Her scores suggest that this lack of ability to focus and draw expected information from a situation may be a limitation rather than a choice.

Personal Strengths and Weaknesses

Amanda achieved her best performance among the verbal reasoning tasks on the Vocabulary and Similarities subtests. The Vocabulary subtest required Amanda to explain the meaning of words presented in isolation. As a direct assessment of word knowledge, the subtest is one indication of her overall verbal comprehension.

Performance on this subtest also requires abilities to verbalize meaningful concepts as well as to retrieve information from long-term memory; (Vocabulary scaled score = 9). On the Similarities subtest Amanda was required to respond orally to a series of word pairs by explaining how the words of each pair are alike. This subtest examines her ability to abstract meaningful concepts and relationships from verbally presented material; (Similarities scaled score = 9).

Peabody Individual Achievement Test (PIAT-R)

Scores

Raw Grade Equivalents Age Equivalents

General Information 78 8.0 13.4

Reading Recognition 46 3.0 8.7

Reading Comprehension 58 3.8 9.5

Total Reading 104 3.3 8.11

Mathematics 38 3.5 9.0

Spelling 54 3.6 10.5

Total Test 274 4.1 9.6

Amanda falls far below her age level in every category except General Information. This indicates a pattern that is very common in youngsters with prenatal exposure to alcohol. Though she can pick up incidental information it is very difficult for her to build strong permanent memory traces. This is a positive and a deficit. It means that Amanda “presents well” in limited contexts and brief encounters. She keeps a patter of information flowing, and provides the appearance or façade of being connected to the social situation and engaging with others. It is a deficit because she relies on this incidental information and superficial connections rather than making solid constructs and knowledge based models.

Amanda engaged in a lot of repetitive motion throughout the test. She also wrung her watch, and had to be distracted numerous times because she continually began conversations with no context to the testing situation. If papers were not straight she tidied them over and over again which distracted her and kept her from being able to complete her own work. Amanda is exhibiting symptoms of high functioning Autism.

Amanda scored at statistically significant low levels in all academic subjects. She is receiving Special Education services at this juncture and should continue to receive these services. Amanda has no areas beyond general knowledge that indicate a proclivity.

Summary

Amanda is a 15-year-old young woman who completed the WISC-IV and the PIAT-R. She was referred by her psychologist due to academic difficulties, attention difficulties, behavior difficulties, emotional difficulties, family difficulties, learning difficulties, mathematics difficulties, memory difficulties, reading difficulties, required evaluations, and suspected intellectual difficulty.

Her motor difficulties may have impeded her performance on the nonverbal tasks, and thus her verbal abilities may be the best estimate of her overall intellectual functioning. They may also give additional evidence of the fetal alcohol syndrome diagnosis, since it is consistent with the pattern of neurological deficits noted. Amanda's verbal reasoning abilities are in the average range when compared to her peers but are an isolated peak with no concomitant strengths to help her utilize the surface information she gleens.

Amanda exhibits very specific symptoms of High Functioning Autism or Aspberger's Syndrome. Amanda's routine must be set, and she must be warned of any changes. If a change is not instituted as she would like she becomes hostile and angry. She cannot be taught through traditional means and needs a great deal of one-to-one teaching and support. Amanda throws many temper tantrums in her daily regimen, though there has been a marked decrease with the structure of joining the special education classroom and getting more one-on-one attention.

Amanda does not have appropriate peer relations and cannot seem to understand personal boundaries or appropriate versus inappropriate topics. Amanda can change emotional status for no apparent reason and may again, rapidly cycle out of the emotional status.

Efforts to help her make sense of her moods, her needs, her verbal patterns do not seem to connect beyond an intellectual exercise. During her emotional outbursts that is no way to reason with her to help her discontinue her behavior. She appears to self soothe by talking and may as rapidly move to another mood and seem unclear of the emotional content of moments ago.

Amanda begins to form inappropriate bonds with most adults. She attempts to build a verbally close relationship, disclosing things that may or may not be true and begins to use terms of endearment. One example is calling her teachers “Mom. If she is asked not to do this she refuses to discontinue. Amanda will continue to exhibit this behavior until the individual who is the object of her esteem reciprocates, which immediately leads to Amanda becoming angry and engaging in behaviors that might be seen as “punishing” the person who is trying to build relationship with her.

In this manner her behavior mimics Reactive Attachment Disorder. Amanda often initiates a pretend hug where she may touch her fingertips to your back, but wants no further contact. Amanda can initiate eye contact but cannot maintain any eye contact for more then a brief flicker.

Amanda runs back and forth across the parking lot by herself during unstructured play-time, or refuses to stop her drawings or stories about fairies and witchcraft, which she has assured everyone she is very accomplished in. Amanda does seem to have at least limited difficulties with reality testing. She is not tolerated by same age peers, but finds connections with youngsters who approach her social and emotional age so this lack of connection to real world teen content does not seem to impair her significantly in the realms of home or school. As she gets older, it will show greater impact among adults who will be likely to misunderstand the content as well as the context of her verbalizations.

Transition: It is difficult to determine which of the many behaviors that Amanda exhibits disrupt her social functioning. There are times when age mates try to connect with her, but it is on a surface level. None of the students or adults appears to be able to establish an acquaintanceship with Amanda and there is a history to this point that shows Amanda has not been able to get anyone to maintain a friendship or closeness. Her inability to mitigate her moods and to genuinely connect with others makes it unlikely that she will be successful in work situations that require connection with the public, unless closely supervised. This does not provide a positive outlook for a work environment.

A multi-disciplinary conference is recommended to evaluate Amanda's current level of functioning and plan appropriate educational programs, placement, or services. It is recommended that the focus of this team be the manner in which Amanda's autism and FAS will inform her education.

Recommendations

1. Amanda needs to be placed on and IEP and remain in an inclusive environment at least 60% of the time.
2. The IEP process should include attention to transitioning, though it is recommended that Amanda remain in school until age 22.
3. Amanda needs to be evaluated periodically to ensure that her difficulty with reality testing does not develop into a psychiatric disorder, especially during stressful life periods.
4. She needs to be evaluated at 18 because this age tends to be the most common time of onset for many psychotic disorders that are characterized by difficulty with reality testing.
5. Amanda needs to have support in developing her reading skills.
6. Amanda needs support in developing her writing skills.
7. Amanda needs to have social direction and specific help in gaining social skills, including immediate help in understanding the difference between what is and isn't shared.
8. Amanda needs a set and structured routine that does not change.
9. Amanda also needs to be directed toward a course of vocational work in an area where her intellectual and social deficiencies do not put her or the public at risk.

Multiaxial Diagnosis_

Axis 1: 299.0 Autistic Disorder

313.89 Reactive Attachment (possibly)

Axis 2: 317 Mild mental retardation

Axis 3: Possible super colon, fetal alcohol syndrome, prenatal exposure to drugs

Axis 4: Living in Group Home; recent death of female guardian

Axis 5: GAF: 31

Composite Scores Summary

__________________________ ________________________

J'Anne D. Ellsworth Ph.D. Martha Affeld, M.S.
Licensed Psychologist, State of Arizona Psychometric support
Peak Education Peak Education