REASON FOR REFERRAL

Kate was referred for psychological evaluation by Dr. Strauss for differential diagnosis of ADD and to better
understand why Kate is not doing well in school.

BACKGROUND INFORMATION

Background information was obtained through interviews with mother. Current family constellation include Mr.
and Mrs. Dumont. They have three children, Biff (9); Buffy (8); and Blake (4). Father works as a pharmacist.
Mother is a homemaker. Family history is positive for allergies and attentional problems.

Mrs. Dumont remembers Kate's development as being normal. Health and development histories were
unremarkable with the exception of ear infections through first grade.

Psycho-educational evaluation was conducted by Joe Moe, MA, School Psychologist in December 1990 at the
parents' request . The following scores were obtained on the Wechsler Scales (WISC-R) Verbal IQ 106,
Performance IQ 112, and Full Scale IQ 109 This would place her global level of intelligence within the average
range

Educational evaluation disclosed scores ranging from Kindergarten to the fifth grade level. Memory for names
was a particular weakness. Report cards from school disclose attentional difficulties even in the first grade. Kate
is currently in Chapter I reading and math programs, which is a federal program for underprivileged children
working below grade level. Kate has visual tracking concerns and was prescribed eye tracking exercises by Dr.
D. However, Dr. D believed her problem with reading was due to a learning disability more than strictly an
oculomotor problem and referred the parent for further evaluation of an undifferentiated attentional deficit and
learning disability. Recent Occupational Therapy evaluation (11/92) indicated that Kate requires repetition of
instructions and that Kate completes assignments without fully understanding the expectations. Further
Speech/language evaluation was recommended. Kate has a lisp.

TESTS ADMINISTERED

 Wechsler Intelligence Scale for Children III

 Emotional and Behavior Problem Scale
 Conner's Teachers Rating Scale
 Juvenile Sentence Completion
 Diagnostic Interview
 California Test of Personality
 Personality Inventory for Children
 Wechsler Individual Achievement Test

TEST BEHAVIOR AND OBSERVATIONS

Kate was accompanied to this evaluation center by her mother. Kate separated readily and was generally
cooperative and friendly. As the session progressed, Kate became aloof and easily distracted. This behavior was
most prevalent during the administration of the academically related material. Attention span was short and
concentration was limited. She was easily distracted.

TEST SCORES AND CLINICAL INTERPRETATIONS

The following scores were obtained on the Wechsler Intelligence Scale for Children III. Scaled scores of 9-11
would be considered average.
Information 10 Picture Completion 11
Similarities 14 Coding 9
Arithmetic 7 Picture Arrangement 8
Vocabulary 14 Block Design 9
Comprehension 14 Object Assembly 7
 Digit Span (9) Symbol Search 8
Verbal Comprehension 117 (87%) High Average

Perceptual Organization 93 (32%) Average

Freedom From Distractibility 90 (25%) Average

Processing Speed 93 (32%) Average

The Wechsler Intelligence Scale for Children III was administered to assess Kate's cognitive skills and how she
processes information. Her Verbal IQ was 111 (High Average), Performance IQ was 93 (Average), and Full
Scale IQ of 102 (Average). These scores would place her average range. Significant strengths were noted in
Verbal comprehension, crystallized intelligence, and extent of outside reading. Kate's verbal concept formation,
verbal conceptualization, and reasoning skills are in the superior range.

Significant weaknesses were noted in short-term auditory memory, attention, and concentration. Additional
weaknesses were noted in sequential learning, memory, convergent production, auditory memory, simultaneous
processing, nonverbal reasoning, visual motor coordination, trial and error learning, and working under time
pressure. Factor analysis suggests weaknesses in Freedom from Distractibility, perceptual organization, and
processing speed. The WISC-II ACIDS Profile indicate index scores of 90 to 91.

The Emotional and Behavior Problem Scale and Conner's Teacher Rating Scale was completed by Kate's
teachers. The results do not suggest severe overt, aggressive behaviors. Rather Kate presents with organizational
deficits, short term/long-term memory deficits, lack of preparation for assignments and homework, difficulty
with abstract concepts and reading comprehension, as well as the need for drill. Additionally, Kate seems to
display some nervous habits (nail biting, etc.) and is easily upset by constructive criticism. These characteristics
are consistent with the diagnosis of Undifferentiated Attention Deficit Disorder.

The Juvenile Sentence Completion was administered as a projective device. Kate's responses had themes low
self-esteem, a need to move on from her current class/grade, normal sibling rivalry (brother), and a pervasive
feeling that if she were smarter she would do better in school.

During the Diagnostic Interview Kate's responses were very brief. She wanted nothing more than to be free. She
fears being hated or shunned by others. When asked for three wishes, Kate wanted a lifetime supply of candy
and a mansion (spelled mengen). The rest of her spelling was so poor her writing was illegible. Her favorite age
was 11, so she could play soccer at school.

The California Test of Personality was administered to assess Kate's overall life adjustment which is a balance
between social and personal security. Kate's personal adjustment is at the 60th percentile, meaning she perceives
her adjustment as being average. Kate's social adjustment is at the 40th percentile, and her overall adjustment at
the 50th percentile. These scores suggest Kate perceives her social and personal adjustment to be average.

Subtests %ile Subtests %ile

Self-reliance 20% Social Standards 20%
Personal Worth 80% Social Skills 50%
Personal Freedom 40% Anti-social Tendencies 90%
Feeling of Belonging 40% Family Relations 40%
Withdrawal Tendencies 90% School Relations 50%
Nervous Symptoms 90% Community Relations 10%

Strengths were noted in feelings of self-esteem, denial of withdrawal tendencies, and freedom from nervous
symptoms or anti-social tendencies. Weaknesses were noted in community relations, self-reliance, and social
standards. Meaning that she is dependent on others and has difficulty subordinating her needs to the desires of
the group.
The Personality Inventory for Children was completed by her mother. (See the attached print-out.) The
following profile is suggested: Parents and teachers are likely to be concerned about the child's limited academic
achievement. Classroom performance reflects poor study skills, distractibility, and difficulty completing
assignments. As preadolescents the majority of these children receive special education services and are likely
to be classified as learning disabled. Diagnostic criteria suggest specific developmental disorders and adjustment
disorder.

The Wechsler Individual Achievement Test was administered to assess Kate's achievement levels. The
following scores were obtained.

Subtests Standard Score Percentile

Basic Reading 109 73%
Mathematics Reasoning 105 63%
Spelling 99 47%
Reading Comprehension 105 63%
Numerical Operations 102 55%
Listening Comprehension 100 50%
Oral Expression 85 16%
Written Language 84 14%

These scores suggest weaknesses in oral expression and written language. When compared to her FSIQ of 102,
written language is a significant weakness at the .05 level of significance.

SUMMARY AND FORMULATION

Kate is a nine year old youngster who was referred for evaluation by her physician to evaluate for differential
diagnosis of ADD as well as to assess her current abilities.

Psychometric evaluation disclosed average intellectual ability with strengths in verbal concept formation, verbal
comprehension, reasoning, and conceptualization. Weaknesses were noted in short-term auditory memory,
attention, and concentration. Additional weaknesses were not in working under time pressure, sequential
learning, visual motor coordination, trial and error learning, retention ability, simultaneous processing, and
memory. The ACIDS profile was at the 25%ile (Index 90). Factor analysis suggests weaknesses in Freedom
from Distractibility, Perceptual Organization, and Processing Speed. Academic testing suggests weaknesses in
oral expression and written language.

Personality testing suggest adequate personality development with mild, transitory, reactive stressors such as
change of classroom teacher, although they function well within their families and within special education
programs. Cognitive deficits, hyperactivity, poor school achievement, and immature .social skills manifest
during elementary school. Problems may be associated with genetic influences. Basically these findings are
consistent with Attention Deficit Disorder and Specific Developmental Disorders.

Diagnosis:

 Undifferentiated Attention Deficit Disorder

 Adjustment Disorder with Conduct
 Specific Developmental Disorder NOS (organization and planning, written language, and oral
expression)

RECOMMENDATIONS

1. These. results should be shared with the school personnel in designing a special education program. Hence,
this report should be shared with the school to insure a comprehensive treatment plan.

2. Consultation with Kate's pediatrician regarding treatment of an attention deficit. In view of her parent's
objection to medication, other treatment modalities should be evaluated first (e.g.. Cognitive Behavioral).
3. Continued individual counseling focusing on low self-esteem, understanding her learning disability, and
problem solving skills.

4. The following educational modifications may aid Kate's teachers to better deal with her attentional problems
in school:

a. Preferential seating within close proximity of where the teacher provides most of the class lessons.

b. Peer tutoring and/or the Buddy system within the classroom.

c. A behavioral system should be implemented to reward completion of classroom work within allotted time
periods. Classroom rules and expectations should be clearly defined and consequences should be immediate and
reasonable.

d. Time management and other organizational strategies should be implemented in her classroom regime.

e. Timing and pacing of activities of varying length and difficulty.

f. Homework notebook should be used.

g. Reinforcers for completion of assignments at home. Due to her low self esteem participation in
extracurricular activities should not be made contingent on completion of homework.

h. Praise and encouragement for work completed.

i. Praise and encouragement for work completed.

j. Do not criticize erasures or spelling/grammar errors.

k. Cueing Kate before presentation of new information will ensure that she is receiving the information
committing it to long-term memory. Cues could be auditory or touch or maintaining eye contact.

1. Social reinforcers for on-task behaviors will increase Faith's attention span.

m. Quiet, contemplative activities such as chess, checkers, reading, card or board games will improve her
attention span.

n. Independent reading will reap benefits in the areas of vocabulary and sustained attention, at home and in
school.

o. Learning carrel or quiet area will help in cutting down on extraneous stimuli interfering with Kate's learning
style.

p. Fatigue is likely to increase versus decrease activity level, hence, Kate should be well rested.

Certified Psychologist

Addendum Page

While the PIC program has selected the child's most characteristic type using a branching tree procedure, other
profile types may also be similar. Similarity indexes matching the child's clinical T-score profile to all types for
which similarity can be computed are provided below. Type showing similarity values close to or higher than
the one given for this child's selected type should be considered in diagnostic hypotheses. Brief descriptions of
all types are given on the sheet provided with the PIC program disk.

Similarity

Type 3 .22 ............. Type 8 .08

Type 4 .35 ............. Type 9 - .24
Type 5 .66 ............. Type 10 - .22
Type 6 .69 ............. Type 11 - .28
Type 7 - .27 ............Type 12 .12

CLASSROOM PLACEMENT ANALYSIS

PLACEMENT/INTERVENTION PROGRAM SIMILARITY INDEX

 Regular Classroom -.32

 Regular Classroom with Counseling -.30

SPECIAL EDUCATION

Emotionally Impaired .07

 Learning Disabled, Mainstreamed with Teacher Consultant .42

 Learning Disability Self-contained classroom .75
 Educable Mentally Impaired .88
 Trainable Mentally Impaired .85

In this analysis the child's profile is compared for similarity to seven average profiles obtained from groups of
elementary school children found in regular classrooms, receiving counseling, or placed into one of five special
education classifications. The index of similarity calculated is comparable to a correlation coefficient, in that
larger values indicate those groups with whom this child has the greatest similarity. The table above may be of
value in suggesting those educational placements that are the most and the least appropriate.

PSYCHOLOGICAL  EVALUATION
(FACILITY NAME HERE)

Jane Smith                                                                                 Dates of Evaluation: 9/12/96 

Case No.: 111,111                                                                                                   9/13/96 
Building No.: 11  
Admission Date: 9/2/96                                                                Date of Report: 9/14/96 

PURPOSE FOR EVALUATION:  Rather than "Reason for Referral" the first section for
the report is better called "PURPOSE FOR EVALUATION."  This gives you a lot more
flexibility.  If you use "Reason for Referral", you pretty much have to copy whatever the
consult says.  Unfortunately, many consults ask questions which tests can't answer (or else
they don't ask any question at all). 

Use this section to briefly introduce the patient and the problem.  Begin with a concise
"demographic picture" of the patient. (e.g., This is the third inpatient admission for this 32
year old, single, white female who has 13 years of formal education and is employed as a
beautician.  She was admitted due to symptoms of major depression with possible psychotic
features.) 
Use this section to tell your reader what issues you will address in the body of the report.  In
this way, he won't get to the end of your report, then have to think back to decide whether
your conclusions were supported by your data.  He'll know on what issues to focus, and he
can be forming his own impressions while he's reading. (e.g., The purpose for the current
evaluation was to screen for evidence of psychosis and clarify the nature of the underlying
depressive disorder.)  In sum, use this section to "pose a question," which you will answer in
the "SUMMARY" section. 

Finally, if the evaluation takes more than 5 days to complete, you should put a progress note
in the patient's chart giving preliminary test results. For example, you might conclude the
"PURPOSE FOR EVALUATION" section of your report with, "Preliminary results were
reported in the patient's progress notes on 9/13/96.  The current report will supplement and
elaborate upon those preliminary findings." 

ASSESSMENT PROCEDURES:  Refer to this section as "ASSESSMENT

PROCEDURES" rather than "TESTS ADMINISTERED."  This allows you to include the
Mental Status Exam and the Clinical Interview as two of your procedures.  This also helps
communicate to referral sources that you do more than give some tests and copy interpretive
statements out of a manual.  It lets them know that your evaluation is a professional
integration of information from a variety of sources.  Be sure to also note who gave the tests
and how long it took.  These issues are important if a case ever goes to court. 

e.g.: Millon Clinical Multiaxial Inventory-III (MCMI-III) 

       Minnesota Multiphasic Personality Inventory-2 (MMPI-2) 
       Mental Status Examination 
       Review of Prior Psychological Assessment 
       Review of Prior Medical Records 
       Clinical Interview 

      This patient participated in 3 hours of testing and a 1 hour diagnostic 

       interview.  Tests were administered by Jim Smith, M.S. and interpreted by 
       John Jones, M.A.. 

BACKGROUND INFORMATION:  In this section present paragraphs dealing with family,

social, legal, medical, family mental health, etc. issues, if needed.  Only include those issues
that are relevant to the "questions" posed under "PURPOSE FOR EVALUATION." 
Excessive, unnecessary details will distract the reader from the case you are trying to build in
support of your conclusions!  Whenever possible, MAINTAIN CHRONOLOGICAL
ORDER when presenting background information. 

Next describe the patient's history of substance abuse/mental problems, and mental health
care in CHRONOLOGICAL order.  Where possible, provide enough details of prior
intervention efforts to clarify what was attempted and whether it was successful.  Your goal is
to encourage replication of prior successes and/or avoid duplication of prior treatment
failures.  Also, be sure to describe the patient's behavior and level of adaptive functioning
BETWEEN prior interventions.  These details will help give the treatment team an idea of
what "target level" of adaptive functioning to shoot for in the current intervention.  Follow
with a paragraph describing the onset and development of the present illness/ exacerbation. 
Let the reader get an idea of how the current admission compares to prior admissions and
what specific events precipitated the current admission.  End this section with a brief
paragraph summarizing staff observations, patient behavior, level of motivation, etc. during
the current admission.  Keep in mind that objective observations by professional staff are one
of your best sources of data. Conclude with a sentence indicating medications being taken at
the time of testing. 

MENTAL STATUS EXAMINATION:  Focus on YOUR observations and impressions. 

This section of the report should focus on your objective evaluation.  Avoid quoting the
patient's opinion of his own mood, affect, etc. It's also best to avoid mixing in background
information or test information with this section.  A typical MSE for a 'normal' patient might
read: 

Results of mental status examination revealed an alert, attentive individual who

showed no evidence of excessive distractibility and tracked conversation well. The
patient was casually dressed and groomed. Orientation was intact for person, time and
place. Eye contact was appropriate. There was no abnormality of gait, posture or
deportment. Speech functions were appropriate for rate, volume, prosody, and
fluency, with no evidence of paraphasic errors. Vocabulary and grammar skills were
suggestive of intellectual functioning within the average range. 

The patient's attitude was open and cooperative. His mood was euthymic. Affect was
appropriate to verbal content and showed broad range. Memory functions were
grossly intact with respect to immediate and remote recall of events and factual
information. His thought process was intact, goal oriented, and well organized.
Thought content revealed no evidence of delusions, paranoia, or suicidal/homicidal
ideation. There was no evidence of perceptual disorder. His level of personal insight
appeared to be good, as evidenced by ability to state his current diagnosis and by
ability to identify specific stressors with precipitated the current exacerbation. Social
judgment appeared good, as evidenced by appropriate interactions with staff and other
patients on the ward and by cooperative efforts to achieve treatment goals required for
discharge.

RESULTS OF EVALUATION:  There are several "models" for writing test reports.  For
most MSH evaluations the Hypothesis Testing Model is recommended.  In this model results
are focused on possible answers to the referral question(s).  The idea is to present a
hypothesis in the "PURPOSE FOR EVALUATION" section, then present data systematically
to support or refute the hypothesis.  Separate paragraphs in the "RESULTS OF
EVALUATION" section address theoretical/ conceptual issues by integrating data from the
history, mental status exam and behavioral observations with data from all the tests. 

Specific tests are rarely mentioned by name.  For example, information from scale 2 on the
MMPI-2 may be combined with interpretive data from the MCMI-III dysthymia scale.  If the
integration of this information is consistent with the history and the mental status exam, it is
included in a paragraph dealing with depression. 

The strength of this model lies in its efficiency and concise focus on the referral problem. The
reader isn't distracted by unrelated details.  The primary weakness of the model is that you
don't report some of the information which is unrelated to the "PURPOSE FOR
EVALUATION" but which could potentially be useful to other disciplines. 
SUMMARY/RECOMMENDATIONS:  Begin by specifically answering the questions you
posed under "PURPOSE FOR EVALUATION."  Then elaborate as much as needed to
present your conceptualization of the case.  It's fine to include DSM diagnostic impressions,
but your summary of the patient's psychological makeup is far more important.  If you do
include DSM labels, be sure you've provided enough detail in the body of the report to
support the diagnostic criteria as described in DSM.  Any recommendations for treatment can
also go here.  For example: 

Results of psychological evaluation reveal an extended history of alcohol abuse and a

psychotic disorder characterized primarily by disturbance of thought content, with
relative integrity of thought process and no clear indication of perceptual disturbance.
The current clinical presentation appears to represent an acute exacerbation of a
chronic psychotic disturbance which had its onset approximately 8 years ago.
Currently, Mr. Jones appears to remain extremely distressed, anxious, paranoid, and
delusional, despite self-reports to the contrary. He lacks sufficient capacity/
motivation to rely on external supports and lacks sufficient personal insight to cope
independently at present. The patient appears to be attempting to cope with his illness
using extreme guardedness and withdrawal. During recent months he has shown no
signs of aggressive ideation and is not believed to be a physical risk to himself or
others at present. 

It is recommended that efforts to establish a trusting relationship with this patient be

continued, in order to help him cultivate a more adaptive coping/defensive pattern.
Individual therapy will be more productive than group interventions. Once his
guardedness has been relaxed, it will likely be beneficial to explore psychosocial
issues present at the time Mr. Jones lost his job, as these appear to have partially
precipitated the current psychotic exacerbation. Additionally, the patient will benefit
from encouragement to explore the social and adaptive significance of his substance
abuse history.

SUMMARY OF TEST RESULTS:

Otis-Lennon School Ability Tests (OLSAT):
The OLSAT is designed to give the respondent and the test-givers an idea of the respondent's
academic capabilities. The OLSAT can be used to predict future academic performance, or to
compare the level of current academic performance with the level of capability. The OLSAT is divided
into two parts: verbal and nonverbal. The scores on these parts are expressed as raw scores,
percentile ranks (in comparison to norms by age), and Stanine scores. For Stanine scores, mean=5
and SD=2.

Kyle's scores on the OLSAT are as follows, with raw scores in bold type, percentile rank in italics, and
Stanine scores underlined:
Total Scores- 64,98th percentile, 9
Verbal Scores- 33, 95th percentile, 9
Nonverbal Scores- 31, 95th percentile, 8

Big-5 Personality Inventory:

The Big-5 is an internet personality inventory survey, which measures five basic dimensions of
personality: Extraversion, Emotional Stability, Agreeableness, Conscientiousness, and Openness to
Experience. Standard deviations and means were not reported, but the respondent's scores are
compared to a mean, and the percentile rank for the scores is reported.

Kyle's scores on the Big-5 are listed below, with his score in bold type, and his percentile rank score
in italics:
Extraversion-2.4, 2nd percentile
Agreeableness- 4.8, 92nd percentile
Conscientiousness- 5.5,

98th percentile
Emotional Stability- 3.4, 27th percentile
Openness- 5.2, 95th percentile

Interpersonal Functioning:
Kyle's previously mentioned scores have indicated that he is introverted, and keeps to himself. Kyle
also has a strong need for social relationships, but is still considered a loner. Although he has a set of
close friends, and many dates, Kyle does not feel comfortable in social situations. This is evidenced
by his low scores on the Social Presence Scale and Sociability Scale of the SPI. Because Kyle is
constantly seeking outside approval, he has a strong need for interpersonal contact. Kyle needs
contact with his family, and his mother provides much-needed warmth and stability in his life. Kyle
also dates regularly, for companionship and entertainment. Kyle's combination of the need for
approval and the drive for success make him very competitive, and he tends to seek competition in all
aspects of his life. Kyle has a good group of friends who are intellectually compatible with him, and he
surrounds himself by these people to be stimulated and challenged constantly.

When confronted with difficult situations, Kyle might tend to withdraw and blame himself, as indicated
by his "Beta" personality type, and the Self-Acceptance Scale of the CPI. This has historically been
the

 case for Kyle, as he mentioned several occasions in which he felt defeated, blamed himself for the
defeat, and then withdrew from the situation. One such occasion was when his first real girlfriend
broke up with him. Kyle said that he became very depressed and kept to himself for awhile. However,
on a positive note, Kyle seems to bounce back and recover from these situations. Although he was
depressed when his girlfriend broke up with him, the depression did not last long and Kyle was soon
dating a lot again.

Kyle appears to be very responsible and committed in all of his endeavors. His scores on the CPI and
Big-5 all indicate that he takes responsibility for his actions. His history of excelling in athletics and
school are also strong evidence of his ability to commit. While playing ball, Kyle must commit to
practice and his team, and to achieve good grades, Kyle must commit to his schoolwork. Kyle is also
a very capable student. He has high academic marks in high school, and he scored very high on the
OLSAT. His extremely high scores on the OLSAT indicate that he would be very successful in college.
His past academic achievements also indicate future success in furthering his education.

CONCLUSIONS AND RECOMMENDATIONS:

Kyle Smith is a 17 year old high school student, living in a small town. Although he has high hopes
and plans for continuing his education after high school, Kyle is not sure what career he is most
interested in. The purpose of this psychological testing was to provide guidance for Kyle as to what
type of career he might be most satisfied and successful in. Recommendations for Kyle's college
major and future career are as follows:

a) Kyle should strive to continue his education.

Kyle's historic academic achievements and OLSAT scores have proven him to be very capable of
college-level work. His high Conscientiousness score on the Big-5 indicates that he would pursue a
higher education with determination. Scales from the CPI have also indicated that Kyle would be
persistent in his studies; leading to a high probability of success in college. Kyle's Strong Inventory
also suggests that he is interested in education.

b) Kyle should not pursue an occupation that requires strong leadership skills.
Kyle's scores on scales of the CPI indicate that Kyle is unsure of himself, and lacks the self-
confidence necessary to maintain a leadership role.

c) Kyle should consider a profession that involves helping others.

Kyle's Strong Interest Inventory shoes that he has interests similar to those of college professors,
speech pathologists, psychologists, teachers and social workers. These are all careers which require
the high levels of openness and tolerance that Kyle displayed in his Big-5 Inventory, and on the
Tolerance Scale of the CPI. A career that requires frequent contact with others would also satisfy
Kyle's need for interpersonal contact.

d) Kyle should consider a profession that is highly competitive.

Kyle's love of sports, as indicated in his biography, interviews, and Strong Inventory, show that he is
very competitive. His desire for social approval, as indicated in the Independence Scale of the SPI,
drives him to be competitive in other aspects of his life. Kyle's academic record and statements about
his academics indicate that his is highly competitive academically as well. These indications make a
highly competitive career an ideal suggestion for Kyle. Careers suggested by the Strong Inventory
that are highly competitive include college professor and psychologist.