This Report Is to Be Interpreted and Used Only by Individuals Properly Trained and Certified By

School Neuropsychological Evaluation This report is to be interpreted and used only by individuals properly trained and certified by state agencies, and/or by parents or legal guardians of the stated child. This report is confidential and must not be released to persons who do not have a legitimate professional interest in the child. IDENTIFYING INFORMATION Student’s Name: DG Student’s Date of Birth: 11/19/2002 Student’s Age: 14 years 7 months Student’s Gender: F Student’s Ethnicity: Caucasian Student’s School: Benbrook Middle School Student’s Grade: 8th Names of Student’s Parents/Guardians: SA Primary Language Spoken at Home: English Examiner’s Name: ???????, Psy.D. LPA Testing Date(s): 5/30/2017, 5/31/2017, 6/6/2017, 6/20/2017, 6/27/2017, 7/9/2017 Date of Report: 8/8/17 REASON FOR REFERRAL

This evaluation was completed in order to fulfill requirements for the School Neuropsychology training program.

Specific referral questions from the parent include: 1. What neurocognitive processes may be affecting DG’s performance at school and what interventions may be implemented to help improve her functioning? 2. Why does she have excessive anxiety and worry that is hard to control? 3. What are the possible effects of long-term Lithium use on her neurocognitive performance? 4. What are her current levels of academic performance?

Mrs. SA reported that DG’s MRI of 5/12/17, confirmed the presence of her pineal gland cyst and ruled out the absence of a pituitary adenoma that was previously diagnosed on 5/8/16. Further, she was diagnosed with lower lumbar spinal stenosis, has poor bladder control and pain that are managed with medication. She has convergence insufficiency disorder in her left eye and uses glasses for correction. She has had prolactin production as a side effect of Risperidone prescription. Her parents’ concerns are that DG might be receiving psychotropic treatment that is not helpful and expressed their interest for a thorough neuropsychological evaluation for more diagnosis which her neurologist is equally interested in the outcome. During her early childhood, DG was exposed to her grandfather’s suffering from a terminal chronic obstructive pulmonary disorder (COPD) and witnessed the death of her cousin; events which appeared to have traumatized her life. She engaged in suicidal behaviors such as self-mutilation and ingestion of hair which almost suffocated her.

BACKGROUND INFORMATION

Family History DG lives at home with her mother, father, aunt, 16-year-old brother and 10-year-old female cousin. She reportedly gets along well with her siblings. She participates in a variety of activities which include watching TV, engaging in conversations, visiting with relatives, and attending church services. She has the opportunity to visit with her grandparents weekly. When asked what Mrs. SA enjoys the most about her daughter, she said “She is amazing, sweet, helpful and loving.” Furthermore, she stated the most difficult thing raising her as “Nothing really, proper diagnosis.” Mrs. SA admitted she wants DG to be happy and hopes she will complete law, medical, or other advanced studies. At home, DG’s parents are the main disciplinarians who utilize a time out management style of talking with her. Birth and Developmental History Pregnancy with DG reportedly was not planned but under a doctor’s care. Mrs. SA has had two previous pregnancies and one miscarriage. She declined having any complications but admitted using cigarettes during pregnancy. At DG’s birth, her mother was 22-year-old and her father, 21-year-old. At the birth of her first child, her mother was 20-year-old. DG was born in the hospital after a 40 weeks pregnancy and 12-hour labor. At birth, DG weighed 8 pounds 2 ounces and had a broken collar bone. She did not have complications at birth except induced labor. She had a hospital stay of 3 days and was discharged at age 3 days. DG’s developmental milestones revealed she turned over at 2 months, sat alone at 3 months, crawled at 9 months, stood alone at 11 months, walked alone at 14 months, and walked up and downstairs at 24 months-old. She was breast-fed and weaned at 2 weeks, bottled-fed and weaned at 6 months. She was toilet trained, did not soil but wet the bed till age 10 and the medical reason was attributed to spinal stenosis. She was reported to have unclear speech that was assisted through speech therapy, colic complications and has had difficulty learning to catch. She uses her right dominant hand for writing or drawing and eating. Health History Mrs. SA reported at age 2, DG had chicken pox and at 10-year-old, her tonsils were removed. She admitted DG has a history of genitourinary problems urinating in her bed, musculoskeletal clumsy walking, severe skin acne and neurological nail biting, and ADHD diagnosed at age 12 that was controlled with Concerta. At age 12, she was diagnosed with bipolar disorder, had a history of borderline personality disorder and received treatments through Partial Hospitalization Program (PHP), Intensive Outpatient Program (IOP) and Residential Treatment Center (RTC). A likely source of her borderline problems could be associated to her exposure to her grandfather’s sufferings from chronic and terminal illness of COPD and the death of her close cousin. These events apparently presented an adverse childhood experiences (ACE) which could have traumatized her. Her struggle with trauma was evidenced by her self- 2 mutilation and attempts to choke herself by biting and attempting to swallow her hair. She has vision problems that are corrected with eye glasses. She had her last vision exam in May, 2017. She receives medical care through a primary care physician and a neurologist. She had her last medical visit in June, 2017, and currently takes Lithium Carbonate 300 mg, Hydrochlorothiazide 25 mg, Oxybutynin 5 mg, and Vitamin D. Research indicates that Lithium daily use has a negative effect on immediate verbal learning, processing speed and memory (Honig, Arts, Ponds & Riedel, 1999; Wingo, Wingo, Harvey & Baldessarin, 2009). Despite the adverse effect, the individual might not notice any changes in performance. She has had psychological and psychiatric evaluation and counseling. Her psychological evaluation of 7/10/2015 at the Center for Psychological Services, indicated the presence of Major Depressive, Single Episode, Severe without Psychotic Features, Generalized Anxiety Disorder, ADHD, predominantly inattentive presentation (Provisional). Other concerns specified included learning disabilities, death of cousin and grandfather’s illness, limited coping skills, health concerns, weight issues and bullying at school. Mrs. SA admitted a family health history of cancer, diabetes, migraine headache, alcohol and drug use. DG has had a history of suicide attempts but during her clinical interview denied having any suicide ideation of hurting herself or anybody else. However, she admitted having a history of delusion, hallucinations or having bizarre thoughts.

Social History DG has some social difficulties relating to other children; she prefers playing with younger children, has difficulty making friends and prefers to play alone. In a peer group game, she assumes the role of a follower. She does not participate in any sports but expressed her hobbies in arts work. DG exhibits behavior or temperament deficits in which she has a short attention span, hides her feelings and overacts when faced with a problem. Her mother indicated that DG becomes angry when she cannot figure something out.

Educational History She attended a private home daycare 5 day a week, 8 hours a day, from birth till age 2. She attended kindergarten and had difficulties that were not disclosed. She admitted DG’s changing school for mental health reasons that were not related to normal academic progression. She has never been in special education but reportedly has overall poor grade and difficulty in reading and mathematics. She is currently in high school and projected to graduate in 2021. Educational Interventions (Response to Interventions). DG’s records revealed she has never had any special accommodation at school, and consequently no Full and Individual Evaluation (IEP). Previous Testing Results On 7/10/2015, DG had a psychological assessment completed at the Center for Psychological Services. A Kaufman Brief Intelligence Test, Second Edition (K- BIT-2) was administered as a screening tool for her intelligence functioning and provided data for her verbal, nonverbal and composite IQ performance as shown below. Cluster Standard Score Percentile Descriptions IQ Composite 104 61 Average Verbal 106 66 Average Nonverbal 100 50 Average

CURRENT ASSESSMENT INSTRUMENTS AND PROCEDURES

Record Review, Parent Interview, Teacher Reports, Student Interview, and Classroom Observations Behavior Assessment Scale for Children, Third Edition (BASC3) The BASC3 is an integrated system designed to facilitate the differential diagnosis and classification of a variety of emotional and behavioral disorders of children. Conners Continuous Performance Test – Third Edition (CCPT III) A computer-based continuous performance test designed to measure various aspects of visual attention in children ages 6 and older through adults. Dean-Woodcock Sensory Motor Battery (DWSMB) The DWSMB is designed to measure sensory-motor functioning. It comprises tests to measure sensory functioning and motor functions. Delis-Kaplan Executive Function System (D-KEFS) The D-KEFS contains a set of standardized tests for the comprehensive assessment of executive functions, both in children and adults. Minnesota Multiphasic Personality Inventory – Adolescent (MMPI-A), Self-report measure of an individual’s personality. NEPSY-II: A Developmental Test of Neuropsychological Assessment (NEPSY-II) The NEPSY-II is a comprehensive instrument designed to assess neuropsychological functioning in preschool and school-age children. A broad range of subtests included in order to assess neuropsychological development in five functional domains: attention/executive function, language, sensory-motor functions, visuospatial processing, and memory and learning. Neuropsychological Processing Concerns Checklist for School-Aged Children and Youth – Third Edition (NPCC-3) The NPCC includes seven different areas: attention, sensorimotor functions, language functions, memory and language functions, executive functions, cognitive fluency, processing speed, and academic functions (reading, writing, and math). Traumatic Symptoms Checklist for Children – (TSCC) Evaluate acute and chronic posttraumatic symptomatology in children. Wechsler Individual Achievement Test – Third Edition (WIAT-III) The WIAT-III is an individually administered test that evaluates academic achievement in reading, math, and writing, and oral language (expressive and receptive). Wechsler Intelligence Scale for Children – Fifth Edition The WISC-V is an individually administered clinical instrument designed to assess the cognitive ability and problem-solving processes of children aged 6 - 0 through 16 - 11. School Neuropsychology Report Shell v26.1 (December, 2016) Copyright © 2016 by Daniel C. Miller, Ph.D., KIDS, Inc. 3

Wide Range Assessment of Memory and Learning – Second Edition (WRAML-2) The WRAML2 is an individual administered test battery designed to assess learning and memory functions in three separate domains: auditory and verbal memory functions, visual and nonverbal memory functions, and attention and concentration skills. Each domain is further subdivided to compare short-term memory, delayed recall, and general recognition skills. Woodcock-Johnson IV, Tests of Oral Language (WJ IV OL) The WJ IV OL is based on the Cattell-Horn-Carroll (CHC) theory and is designed to measure oral language skills in English or Spanish.

TEST OBSERVATIONS AND RELATED ASSESSMENT VALIDITY The reader is reminded that these results are compiled from tests that were not normed from the same sample; however, test results have been integrated with data from other sources including review of records, interview, observations, other test results and work samples to ensure ecological validity. Standardization was followed for all administrations. No single test or procedure was used as the sole determining criteria for eligibility or educational planning. Unless otherwise noted these results are considered a valid estimate of DG’s demonstrated skills and abilities at this point in time. Observations were made and reported on the WJ IV Classroom Behavior Observation Form by DG’s regular class teacher. She endorsed that “Student prefers to work independently but will still interact with other students.” She noted that during her observation DG wore glasses and took medication for unspecified behavior problems. She denied having observed any serious behavior problem with DG and stated her behavior during her observation was typical of her. Her teacher did not endorse any behaviors related to inattentiveness, overactivity, impulsivity, uncooperativeness, anxiousness or aggression. However, she asserted DG was observed withdrawn and stated “student came in ready to work. Per student request she worked alone on project and was engaged with the assignment and material the whole period.”

EVALUATION RESULTS

The Integrated School Neuropsychological (SNP)/Cattell-Horn-Carroll (CHC) Model (Miller, 2013) serves as the conceptual guide for this school neuropsychological evaluation. The conceptual model states that the basic cognitive processes influence all aspects of acquired knowledge (what we learn in school and through experience). Basic cognitive processes and acquired knowledge are influenced by basic sensorimotor capabilities (e.g., seeing, hearing, touching) and are either helped (facilitated) or hindered (inhibited) by other processes such attentional skills, working memory, and speed and efficiency. All of these processes and functions may be affected by the student’s social-emotional, cultural, and/or environmental factors. The test results are organized into the following sections which follow the Integrated SNP/CHC Model:

I. Classroom Observations II. Basic Sensorimotor Functions III. Cognitive Processes: Visuospatial IV. Cognitive Processes: Auditory/Phonological V. Cognitive Processes: Learning and Memory VI. Cognitive Processes: Executive VII. Facilitators/Inhibitors: Allocating and Maintaining Attention VIII. Facilitators/Inhibitors: Working Memory IX. Facilitators/Inhibitors: Speed, Fluency, and Efficiency of Processing X. Acquired Knowledge: Language Abilities XI. Acquired Knowledge: Reading Achievement 4

XII. Acquired Knowledge: Written Language Achievement XIII. Acquired Knowledge: Mathematics Achievement XIV. Social-Emotional Functioning and Adaptive Behaviors Performance levels for all tests administered will be reported according to the following scale:

NEPSY-II NEPSY-II STANDARD SCALED PERCENTILE NORMATIVE PROFICIENCY SCALED PERCENTILE NORMATIV PROFICIENCY SCORE SCORE RANK CLASSIFICATION CLASSIFICATION SCORE RANK E CLASSIFICATION CLASSIFICA TION > 129 > 15 > 98% Superior Markedly Advanced Very Proficient to 121 – 129 15 92 – 98 Well Above Expected Advanced 13 – 19 > 75 Above Markedly Advanced 111 – 120 13 – 14 76 – 91 Above Expected Very Proficient Expected 26 – 75 or 90 – 110 8 – 12 25 – 75 At Expected Proficient 8 – 12 25-50% or At Expected Proficient 51-75% 80 – 89 6 – 7 9 – 24 Slightly Below Expected Inefficient 6 – 7 11 – 25 Slightly Inefficient Below Expected 4 – 5 3 – 10 or 70 – 79 4 – 5 2 – 8 Below Expected Deficient 6 – 10 or 2 – 5 Below Deficient Expected < 70 1 – 3 < 2 Well Below Expected Markedly Deficient 1 – 3 ≤ 2 Well Below Markedly Deficient Expected

I. Classroom Observations At the time of this report, there was no opportunity to observe DG in the school or classroom environment. However, observations were made during testing. She presented herself as polite, cooperative, patient, resilient and willing to engage in testing. At times, she was fidgety on her seat, in between sessions, she enjoyed engaging in a conversation with the examiner and had to be redirected to continue testing. In all, DG maintained a good eye contact, showed no unusual mannerisms and completed all testing sessions.

II. Basic Sensorimotor Functions Sensory functions encompass our ability to process visual, auditory, kinesthetic, and olfactory information. Dysfunctions in any single sensory system can have a dramatic effect on a child’s learning capabilities and behavioral regulation. Motor functions encompass both fine motor skills (e.g., picking up or manipulating small objects, holding a pencil correctly, buttoning a button) and gross motor skills (e.g., walking in a balanced and coordinated manner, running, jumping, riding a bike). Presenting Concerns. The Neuropsychological Processing Concerns Checklist for School-Aged Children & Youth – Third Edition (NPCC-3) was completed by mother and teacher. The areas of concern from these raters are shown in the table in the table below.

Sensorimotor Functions Mild Moderate Severe Basic Sensory Deficits M  Difficulty with pitch discrimination (tone deaf). M  Difficulty with simple sound discrimination. M  Known or suspected hearing acuity problems. T  Difficulty identifying basic colors (color blind). M  Less sensitive to pain and changes in temperature. M  Complains of loss of sensation (e.g., numbness). Motor Functioning Difficulties Circle right (R), left (L) or both right and left (B) as applicable T M  Clumsy or awkward body movements. (Circle which one) ((R L B) T M  Walking or posture difficulties. Visual Motor Functioning Difficulties T M  Difficulties with drawing or copying. T M  Difficulties with fine motor skills (e.g., using a pencil). Neurologically Related Sensorimotor Symptoms M  Displays odd movements (e.g., hand flapping, toe walking). M  Displays involuntary or repetitive movements. Sensory Sensitivity Issues M, T  Does not like loud noises. M T  Overly sensitive to touch, light, or noise. Legend: M = Mother, T = Teacher School Neuropsychology Report Shell v26.1 (December, 2016) Copyright © 2016 by Daniel C. Miller, Ph.D., KIDS, Inc. 5

Both mother and teacher expressed concerns regarding DG’s difficulties with drawing or copying, clumsy or awkward ambulatory posture, poor fine motor skills, oversensitivity to touch and dislike for loud noise. Further, her teacher noted DG is color blind and her mother specified DG has difficulty with hearing acuity, less sensitivity to pain and acknowledged DG displays odd movements, and involuntary or repetitive movements. Current Levels of Functioning

1. Lateral Preference: Measures the degree of handedness or preference of which side of the body used for fine motor activities.

DG’s performance revealed a high left preference when she responded by showing or mentioning which hand or arm she uses to perform fine motor activities. During her clinical interview, she admitted being ambidextrous but indicated a right-hand predominance when writing and doing most activities both at home and school.

2. Sensory Functions: Measures of auditory and visual acuity (how well can the student hear and see) and measures of tactile sensation and perception (how well the student can respond to touch). Sensory Functions Well Slightly Well Below Below Below At Above Above Instrument – Subtest: Description Expected Expected Expected Expected Expected Expected Superior Level Level Level Level Level Level Auditory Acuity and Visual Perception DWSMB – Auditory Acuity (Right Ear): 0 A basic auditory test. DWSMB – Auditory Acuity (Left Ear): 0 A basic auditory test. DWSMB – Auditory Acuity (Both Ears): 1 A basic auditory test. DWSMB – Near Point Visual Acuity (Right Eye): -79 Measures near-point vision in each eye. DWSMB – Near Point Visual Acuity (Left Eye): -49 Measures near-point vision in each eye. DWSMB – Visual Confrontation (Right Eye): 1 Measures visual field perception. DWSMB – Visual Confrontation (Left Eye): 1 Measures visual field perception. DWSMB – Visual Confrontation (Both Eyes): 1 Measures visual field perception. Tactile Sensation and Perception DWSMB – Finger Identification (Right Hand): -35 While blindfolded, identifying the finger that is touched. DWSMB – Finger Identification (Left Hand): -43 While blindfolded, identifying the finger that is touched. DWSMB – Object Identification (Right Hand): -23 While blindfolded, identifying common objects by touch. DWSMB – Object Identification (Left Hand): -19 While blindfolded, identifying common objects by touch. DWSMB – Palm Writing (Right Hand): -82 While blindfolded, recognizing a number or letter traced on palm by the examiner. DWSMB – Palm Writing (Left Hand): -80 While blindfolded, recognizing a number or letter traced on palm by the examiner. DWSMB – Simultaneous Localization (Right Hand): -56 While blindfolded, identifying the hand, cheek, or both that is touched. DWSMB – Simultaneous Localization (Left Hand): -56 While blindfolded, identifying the hand, cheek, or both that is touched. DWSMB – Simultaneous Localization (Right and Left -40 Hands): While blindfolded, identifying the hand, cheek, or both that is touched. Note: Standard scores appear in normal font. Scaled scores appear in (parentheses). Percentile ranks and cumulative percentile ranks of any kind appear in italics. DG’s used a card to cover her left eye and read numbers on an eye chart held about 14 inches away with her right eye and repeated testing covering her right eye. Her results suggested a severe near point visual acuity impairment for her right and moderate for her left eyes. She commented that her left eye convergence does not affect her left eye vision but admitted that without a new prescription for her eye glasses, she experiences worst right eye vision. She wore eye glasses during the entire testing and her profile is consistent of her previous history visual problems which are likely to affect her academic performance if left unreplaced. Unlike concerns noted by her mother, she did not manifest any difficulties with auditory acuity. With fingers wiggled in front, 6 her performance on visual perception was proficient. As indicated by both her teacher and mother, DG reported her being oversensitive and discomfort by opposite gender to touch, and declined any simultaneous localization testing that included her being touched on the cheek when testing her tactile sensation and perception. Mild to severe impairments were registered when she was blindfolded and requested to identify numbers and letters traced on her hands with a stylus, objects placed on her hands, identify fingers and hands touched. She admitted not feeling any sensations in her hands with light touch except the pressure from heavy objects. Her mother reported concerns that DG complains loss of sensation and is less sensitive to pain and changes in temperature. Her overall performance with tactile sensation was poor and likely to impact her feel and application of school objects that including her pen or pencil when writing.

3. Fine Motor Functions: Measures the student’s ability to move fingers and hands in a coordinated manner. Fine Motor Functions Well Well Below Slightly At Above Above Instrument – Subtest: Description Below Expected Below Expected Expected Expected Superior Expected Level Expected Level Level Level Level Level Above Expected (NEPSY-II) Coordinated Finger/Hand Movements DWSMB – Coordination (Right Finger to Nose): Touching the end of nose with the index finger then 1 touches the examiner’s index finger as it moves across field of vision. DWSMB – Coordination (Left Finger to Nose): Touching the end of nose with the index finger then 1 touches the examiner’s index finger as it moves across field of vision. DWSMB – Coordination (Right Hand to Right Thigh): Touching the back of the hand then the front of the same -1 had to the thigh quickly. DWSMB – Coordination (Left Hand to Right Thigh): Touching the back of the hand then the front of the same -1 had to the thigh quickly. DWSMB – Left-Right Movements: Making purposeful left-right motor movements on -1 command. DWSMB – Mime Movements: Following commands (e.g., “Show me how you would 1 brush your teeth”). NEPSY-II – Fingertip Tapping Dominant Hand Combined: Dominant hand completion time for two fine motor 9 tasks. NEPSY-II – Fingertip Tapping Nondominant Hand Combined: 9 Nondominant hand completion time for two fine motor tasks. Note: Standard scores appear in normal font. Scaled scores appear in (parentheses). Percentile ranks and cumulative Percentile ranks and cumulative percentile ranks of any kind appear in italics. DG manifested at or above adequate skills accomplishing complex maneuvers when she had to perform hand-finger fine motor movements during a variety of activities that included purposeful movements and fingertip tapping. She appeared energetic and maintained a steady speed when completing tasks. In contrast to her mother’s concerns, she did not manifest any fine motor involuntary movements during testing but struggled with consistent and accurate positioning when touching the end of her nose with the index finger and the examiner’s index finger. Her teacher did not indicate any fine motor challenges at school.

4. Visual-Motor Integration Skills: Measures the student’s ability to copy objects on paper.

Visual-Motor Integration Skills Well Well Below Slightly At Above Above Instrument – Subtest: Description Below Expected Below Expected Expected Expected Superior Expected Level Expected Level Level Level Level Level Above Expected (NEPSY-II) Visual-Motor Copying Skills DWSMB – Construction (Cross): -16 Drawing figures. NEPSY-II – Design Copying General Score: >75 Copying simple to complex designs on paper. NEPSY-II – Design Copying Process Total: The fine motor contribution to the overall visual-motor 13 task. 9  Design Copying Process Motor: School Neuropsychology Report Shell v26.1 (December, 2016) Copyright © 2016 by Daniel C. Miller, Ph.D., KIDS, Inc. 7

This score represents the motor output portion of the overall score.  Design Copying Process Global: Ability to recognize the overall configuration of the 7 design.

 Design Copying Process Local: 5 Ability to recognize details of the design. Note: Standard scores appear in normal font. Scaled scores appear in (parentheses). Percentile ranks and cumulative percentile ranks of any kind appear in italics. Although her fine motor skills appeared adequate, she manifested difficulties with some aspects of visual-motor integration. Her overall fine motor contribution to her visual-motor skills was proficient when copying simple to complex designs. However, her figural manipulating skills appeared mildly impaired drawing figures such as a cross. Further, she performed slightly below the typical range when she had to recognize the overall configuration of a design and struggled the most when recording the details. Deficiencies with her vision are likely to interfere with her visual motor integration. She is likely to encounter challenges coping from the blackboard, with the likelihood of registering the overall picture and a highly probability of missing on the details.

5. Qualitative Behaviors for Sensorimotor Functions

Qualitative Behaviors for Sensorimotor Functions Total Age 14 Qualitative Behavior: Description Base Rate NEPSY-II: Fingertip Tapping - Visual Guidance: Looking at fingers during the performance of task. 57% - Incorrect Position: Wrong position of fingers. 15% - Posturing: Finger/hand on opposite side extended stiffly. 10% - Mirroring: Fingers on opposite side move involuntarily. 5% - Overflow: The lips or mouth move involuntarily. 8% Note: A base rate is the percentage of the children in the comparison group (e.g., students the same age, or students in a clinical group).

When performing fine-motor functions, DG engaged in using visual guidance and incorrect positioning of her fingers as much as other children her age with emotional self-regulation difficulties. Some posturing (stiffly extending the finger on the opposite hand and involuntary mouth movements) was below the level manifested by the comparison group. She did not demonstrate any mirroring with her opposite hand while trying to perform a movement with the other hand. The challenges she encounters in drawing are consistent with concerns stated by her teacher and mother. There are chances she might struggle with writing at school.

6. Visual Scanning Skills: Measures the student’s ability to visually scan a horizontal line for information. Visual Scanning / Tracking Well Well Below Slightly At Above Above Instrument – Subtest: Description Below Expected Below Expected Expected Expected Superior Expected Level Expected Level Level Level Level Level Above Expected (NEPSY-II) Direct Measures of Visual Scanning/Tracking D-KEFS – Trail Making Condition 1 (Visual Scanning): All of the number 3s on a page are marked as quickly as 12 possible. Indirect Measures of Visual Scanning/Tracking NEPSY-II – Picture Puzzles Total: A large picture divided by a grid with four smaller pictures taken from sections of the larger picture is 8 presented. The student identifies the location on the grid of the larger picture from which each of the smaller pictures was taken. WISC-V – Cancellation: Marking target pictures within a visual set of pictures in a 9 specified time period. WISC-V – Coding: Symbols that are paired with simple geometric shapes or 4 numbers are copied within a specified time limit. WISC-V – Symbol Search: Visual scanning a group of stimuli to match target 11 symbols. Note: Standard scores appear in normal font. Scaled scores appear in (parentheses). Percentile ranks and cumulative percentile ranks of any kind appear in italics. 8 DG performed adequately when she had to quickly scan and identify numbers and pictures on a page but poorly when drawing geometric shapes and identifying symbols under timed conditions. She is likely to struggle with mathematics that employs the use of geometric structures. Slowing down when performing tasks that require fine motor skills may increase her efficiency. In all, she is likely to struggle with tasks that require both visual-motor output and visual scanning.

7. Gross Motor Functions: Measures a student’s ability to use his/her large muscles in their body in a coordinated manner. Gross Motor Functions Well Slightly Well Below Below Below At Above Above Instrument – Subtest: Description Expected Expected Expected Expected Expected Expected Superior Level Level Level Level Level Level Balance DWSMB – Romberg: -31 Maintaining balance with feet together, standing toe-to heel, and standing on one foot, without visual cues. Coordination DWSMB – Gait and Station: -22 Walking using three gaits — free walking, heel-to-toe, and hopping. Note: Standard scores appear in normal font. Scaled scores appear in (parentheses). Percentile ranks and cumulative percentile ranks of any kind appear in italics. She struggled to maintain her balance and coordination when requested to perform different gross motor activities. When walking freely, she performed slightly better than heel-to-toe, hopping and standing with head up, feet together eyes opened and closed. Participating in school activities that require gross motor coordination and balance could be challenging for her. Summary of Sensorimotor Functioning DG’s teacher and mother reported concerns with sound discrimination, copying or drawing, display of involuntary movements and sensitivity to noise and touch. Her peripheral visual perception, auditory acuity appeared adequate, however, she presented a poor bilateral near point vision. Her vision is adequate with corrective eye glasses. Her performance in the classroom is likely to be impacted by her visual skills which need further evaluation and improvement. Even though, she demonstrated bilateral handedness, she presented herself as a regularly right-hand dominant person both at home and school. She appeared insensitive to touch on her hands and fingers; she was unable to identify objects or drawing in her hands when blindfolded. She copied designs and performed slightly better with the presentation of an overall picture and poorly with the details. She performed inadequately with balance and coordination when she had to perform aforementioned activities with her gross motor skills. In the classroom, her writing, and copying simple to complex designs as well as her participation in extracurricular activities that necessitate gross motor use are likely to be a challenge. III. Cognitive Processes: Visuospatial

For the purposes of this report, visual-spatial processes include visual-spatial perception and visual spatial reasoning. Presenting Concerns. The Neuropsychological Processing Concerns Checklist for School-Aged Children & Youth – Third Edition (NPCC-3) was completed by mother and teacher. The areas of concern from these raters are shown in the table in the table below.

Visuospatial Functioning Mild Moderate Severe T M  Shows right-left confusion or directions (up-down) M  Difficulties with putting puzzles together DG’s mother and teacher endorsed that she exhibits a mild to severe right-left confusion or up and down directions. Further, her mother noted that she has difficulties putting puzzles together. Current Levels of Functioning

1. Visuospatial Perception: Measures a student’s ability to make visual discriminations, locate objects in space, and construct objects. Visuospatial Perception Well Well Below Slightly At Above Above Instrument – Subtest: Description Below Expected Below Expected Expected Expected Superior Expected Level Expected Level Level Level Level Level Above Expected (NEPSY-II) Visual Discrimination and Spatial Localization NEPSY-II – Arrows Total: Two arrows from many are chosen by letter label, which (8) are thought to point to the center of the target.

NEPSY-II – Block Construction Total: Reproducing 3-dimensional constructions from models (5) or 2-dimensional drawings under time constraints. WISC-V – Block Design: (6) School Neuropsychology Report Shell v26.1 (December, 2016) Copyright © 2016 by Daniel C. Miller, Ph.D., KIDS, Inc. 9

Re-creation of a constructed model or a picture of a block design within a specified time limit. Note: Standard scores appear in normal font. Scaled scores appear in (parentheses). Percentile ranks and cumulative percentile ranks of any kind appear in italics. DG’s performance on visual discrimination and spatial localization when she had to choose two labeled arrows from many others that pointed to the center was within the average range. At the beginning of this session, she used her fingers to trace the path of arrows to the center and later continued tracing visually when the presentation became complex. She demonstrated at a typical level choosing arrows that point to the center, however, her ability to accomplish a visual-motor block construction task appeared inadequate, with a performance that ranged from slightly below to below expected levels. Her visual deficits coupled with deficiency in hand/finger feelings capabilities maybe contributing factors to her challenges in blocks construction. Concerns raised by her mother and teacher together her results indicate her likelihood of having difficulties with mathematics and writing.

2. Visuospatial Reasoning: Measures the student’s ability to recognize spatial configurations, identify objects with missing parts, and match similar visual patterns. Visuospatial Reasoning Well Well Below Below Slightly At Above Above Instrument – Subtest: Description Expected Expected Below Expected Expected Expected Superior Level Level Expected Level Level Level Level Above Expected (NEPSY-II) Recognizing Spatial Configurations WISC-V - Visual Puzzles: Identify two or more pieces that go together to form a (6) complete target shape.

NEPSY-II – Geometric Puzzles Total: A picture of a large grid containing several shapes is (1) presented, then the student matches two shapes outside of the grid to two shapes within the grid. Note: Standard scores appear in normal font. Scaled scores appear in (parentheses). Percentile ranks and cumulative percentile ranks of any kind appear in italics. DG completed tasks that required visual selection of component parts to mentally construct a puzzle; her performance was reported at an inefficient level. In addition, she performed at a markedly deficient level with geometric puzzle that required matching two shapes outside of a large grid to two inside among several other geometric shapes. Completing these tasks needs an ability to use mental rotation, planning and strategy. In all, her performance to complete these functions appeared inadequate. Her weakness in this area may impact her written language and mathematics related to geometry. Summary of Visuospatial Processes The results of DG’s performance on tasks in this domain suggest inadequate development of these skills. These results are consistent with current and previous classroom performance in academic areas that are heavily dependent on visuospatial processing such as mathematics and written language. Overall, she demonstrated weaknesses in both her visuospatial perception and reasoning. Her weakness in this domain is likely innate to deficiencies related visual perception and are consistent with concerns raised by her teacher and mother. IV. Cognitive Processes: Auditory/Phonological We live in a highly language-rich society where verbal skill are often valued above nonverbal skills. The basic building blocks of language are basic sound discrimination and auditory processing skills. Presenting Concerns. The Neuropsychological Processing Concerns Checklist for School-Aged Children & Youth – Third Edition (NPCC-3) was completed by teacher and mother, however, no areas of concern were indicated in this domain. Current Levels of Functioning Auditory/Phonological Processes: Measures the student’s ability to discriminate differences in sounds and speech and to apply basic auditory and phonological processing skills. Auditory/Phonological Processes Well Well Below Slightly At Above Above Instrument – Subtest: Description Below Expected Below Expected Expected Expected Superior Expected Level Expected Level Level Level Level Level Above Expected (NEPSY-II) NEPSY-II – Phonological Processing: Part 1: Word segment recognition (7) Part 2: Phonological segmentation WJ IV OL – Sound Awareness: 98 Rhyming, deletion, substitution, and reversal of phonemes. WJ IV OL – Segmentation: 95 Ability to break apart speech sounds in words. WJ IV OL – Sound Blending: 83 Blending sounds to form a whole word.

Note: Standard scores appear in normal font. Scaled scores appear in (parentheses). Percentile ranks and cumulative percentile ranks of any kind appear in italics. 10 Summary of Auditory Processes DG’s showed slightly inadequate proficiency performance in her phonological processing when she was required to manipulate phonemes in words and blend sounds to form new words. On the tasks of listening and providing words that rhyme or deleting part of presented word to produce new words, her performance was typical compared to others her age. Challenges in phonological processing are attributed to poor decoding needed for success in reading. She admitted having had speech therapy. V. Cognitive Processes: Learning and Memory Memory is a significant contributor to the learning process. Memory is comprised of multiple interactive systems: immediate memory, working memory, and long-term retrieval. Each of the types of memory may be tested using different modalities; for example, visual immediate memory or auditory immediate memory. Memory and learning will be subdivided into the following categories for this report: 1. Overall Memory Indices: Overall indicators of memory and learning. 2. Rate of Learning: How well the student learns new material over repeated trials. 3. Immediate Memory: How well the student learns new information with one trial using either verbal or visual input with or without context. 4. Delayed Memory: Recall Versus Recognition: How well the student retains verbal or visual information over time. 5. Verbal – Visual Associative Learning and Recall: How well the student learning new verbal-visual associations and remembers those associations over time. Presenting Concerns. The Neuropsychological Processing Concerns Checklist for School-Aged Children & Youth – Third Edition (NPCC-3) was completed by mother and teacher. The areas of concern from these raters are shown in the table in the table below.

Learning and Memory Functions Mild Moderate Severe Long-Term Memory Difficulties M  Forgets where personal items or school work were left. M, T  Forgets to turn in homework assignments. M  Forgets what happens days or weeks ago. T  Does well on daily assignments but does not do well on end of the week quizzes. Legend: M = Mother, T = Teacher Both mother and teacher reported concerns of varying magnitude ranging from mild to severe. Both raters endorsed, DG forgets to turn in her homework assignments. Further, her mother indicated that she forgets the whereabouts of her personal items and what happened days or weeks ago. In addition, her teacher stated she does not perform well on end of week quizzes as she does on daily assignments. Current Levels of Functioning

1. Overall Memory Index Scores: Broad indicators of the student’s learning and memory skills. WRAML2 Memory Indices Well Below Slightly Below Well Expected Level Below Expected Expected Level At Expected Above Expected Above Expected Indices Level Level Level Level Superior Verbal Memory 80 Index Visual Memory 73 Index Working 100 Memory Index Recognition 66 Index Note: Standard scores appear in normal font. Her overall memory indices were generally deficient except her working memory; her ability to maintain information in conscious awareness, appeared typical for her age. Her recognition index reflects her ability to respond effectively to cues; a domain she struggled the most recognizing previously presented information. She performed slightly better with her verbal than visual memory. There is a probability she might encounter difficulty encoding and recognizing visual information. Her classroom effort which depends on different types of memory may vary and consistent with differences found in her memory profile.

2. Rate of Learning: Measures the student’s ability to learn new information over repeated trials. Rate of Learning Well Well Below Slightly At Above Above Instrument – Subtest: Description Below Expected Below Expected Expected Expected Superior Expected Level Expected Level Level Level Level Level Above Expected (NEPSY-II) Verbal Learning WRAML2 – Verbal Learning: (4) School Neuropsychology Report Shell v26.1 (December, 2016) Copyright © 2016 by Daniel C. Miller, Ph.D., KIDS, Inc. 11

Learning a list of words over repeated trials. o Slope: An indicator of the rate of learning. The change in the 1 number correct from the first to the last trials. Retention: o 13 The amount of information retained after a delay. Intrusion Errors: o 5 Words not on the list that are recalled. Note: Standard scores appear in normal font. Scaled scores appear in (parentheses). Percentile ranks and cumulative percentile ranks of any kind appear in italics.

Using WRAML2, DG was presented with a list of words over 4 trials she had to learn the words quickly and retain them. Her overall result on this test appeared below expected levels. Results of her graph above indicate an overall lower performance relative to the mean age scores of others her age, with a deep decline observed in her delay recall. As indicated by her graph, the rate of change from first to fourth trials was poor and attributed to fluctuations in the recall of her responses. She introduced new words when asked to recall previously learned ones. Her results are consistent with concerns raised at home and school about her forgetfulness. Deficiency in rate of learning, retaining and recalling learned information is consistent with difficulties raised by her teacher at school and mother at home. 3. Verbal Immediate versus Visual Immediate Memory: Measures the student’s ability to immediately recall information presented either verbally or visually in a variety of formats. Immediate Verbal Memory Well Well Below Slightly At Above Above Instrument – Subtest: Description Below Expected Below Expected Expected Expected Superior Expected Level Expected Level Level Level Level Level Above Expected (NEPSY-II) Number Recall (No Contextual Cues) WRAML2 – Number/Letter: Repeating auditorily presented number/letter strings of (6) increasing length. Sentence Recall (with Contextual Cues) WRAML2 – Sentence Memory: Memory for sentences of increasing length and (13) complexity. WIAT-III – Sentence Repetition: Memory for sentences of increasing length and 104 complexity. Story Recall (with Contextual Cues) WRAML2 – Story Memory: (9) Details recalled from verbally presented stories.

 Verbatim Total: (8) Exact story details recalled.

 Gist Total: (5) General ideas of story details recalled. Note: Standard scores appear in normal font. Scaled scores appear in (parentheses). Percentile ranks and cumulative percentile ranks of any kind appear in italics. Immediate Visual Memory Well Well Below Slightly At Above Above Instrument – Subtest: Description Below Expected Below Expected Expected Expected Superior Expected Level Expected Level Level Level Level Level Above Expected (NEPSY-II) Abstract Designs with Motor Response (No Contextual Cues) NEPSY-II – Memory for Designs Total: Placing elements of an abstract design into a grid after briefly (5) looking at an abstract design.

 Memory for Designs Content: (5) Correctly identifying design elements.

 Memory for Designs Spatial: (4) Correctly identifying spatial location of design elements. WRAML2 – Design Memory: Redraw geometric shapes in proper locations after brief visual (2) exposure. Spatial Locations with Motor Response (No Contextual Cues) WRAML2 – Finger Windows: (1) Using a finger to repeat a visual pattern of increasing length. 12

Picture or Symbolic (With Contextual Cues) WRAML2 – Picture Memory: Detecting changes in specific features or details within four (9) scenes after brief visual exposure to original scenes. Note: Standard scores appear in normal font. Scaled scores appear in (parentheses). Percentile ranks and cumulative percentile ranks of any kind appear in italics.

Although she demonstrated deficiencies in her immediate verbal memory when asked to listen and repeat mixed numbers and letters after the examiner, she was highly proficient when she had to repeat sentences of increasing length and complexity. Further, her performance was within the typical range when she recalled details from verbally presented stories with a high degree of exactitude. Contrary to challenges with recalling abstract letter and numbers, adding content or details highly improves her immediate verbal recall. She was generally deficient with her visual memory after being cued and directed to identify and place abstract designs in a grid or use her finger to repeat a pattern after the examiner. Her immediate visual memory profile which ranged from well below to below expected levels appeared extremely poor but improved significantly when contextual cues were provided for her to detect changes after she was briefly exposed to previously presented visual scenes.

3. Delayed Memory: Recall Versus Recognition: Measures the student’s ability to recall or recognize information that was presented verbally of visually after a 20–30-minute delay.

Delayed Verbal Memory Well Well Below Below Expected Slightly Below At Expected Above Expected Above Expected Instrument – Expected Level Level Expected Level Level Level Level Superior Subtest: Description Above Expected (NEPSY-II) Delayed Verbal Recall Without Contextual Cues WRAML2 – Verbal Learning Delayed Recall: Number of (5) correct words recalled from list after delay. Delayed Verbal Recall With Contextual Cues WRAML2 – Story Memory Delayed Recall: Number of (8) correct story details recalled after delay. Delayed Verbal Recognition Without Contextual Cues WRAML2 – Verbal Learning Recognition: Number of words correctly recognized as (1) being on the original learned list of words selected from a broad list of words. Delayed Verbal Recognition With Contextual Cues WRAML2 – Story Memory Delayed Recognition: Number of (10) story details recalled with additional multiple-choice cues. Note: Standard scores appear in normal font. Scaled scores appear in (parentheses). Percentile ranks and cumulative percentile ranks of any kind appear in italics.

Well Well Below Slightly At Above Above Instrument – Subtest: Description Below Expected Below Expected Expected Expected Superior Expected Level Expected Level Level Level Level Level Above Expected (NEPSY-II) NEPSY-II – Memory for Designs Delayed Total: (5) Delayed recall of the abstract designs.

 Delayed Content: (5) Delayed recall of design elements.

 Delayed Spatial: (4) Delayed recall of spatial location of design elements. Delayed Visual Recognition Without Contextual Cues WRAML2 – Design Memory Recognition: (5) Correctly identifying designs that appeared in the original stimuli. Delayed Visual Recognition with Contextual Cues WRAML2 – Picture Memory Recognition: Correctly identifying portions of pictures that appeared in the (5) original stimuli. Note: Standard scores appear in normal font. Scaled scores appear in (parentheses). Percentile ranks and cumulative percentile ranks of any kind appear in italics. DG demonstrated an unevenly distributed performance on delayed verbal recall. She demonstrated a higher level of proficiency in her story memory recall and recognition; she could recall correct story details after delayed memory and when presented with multiple choice of items from previous stories. She performed better recalling stories than singly presented words presented from a broad list of words. Contrarily to her verbal performance which improved with context, her overall visual recall was deficient in all categories that ranged from difficulty recalling design elements or previously presented design stimuli. Even when cues were provided, she failed to recall or recognize abstract designs content, spatial location or portions of pictures that were previously presented to her; indicating that she might be having difficulty with visual encoding and retrieval. Summary of Learning and Memory Processes DG demonstrated below expected levels in her overall rate of learning. She struggled more in areas that demanded visual recall than verbal. She displayed higher proficiencies in her verbal immediate and delay recall that included prompting and cuing. She performed slightly better with visual immediate memory when presented with a brief exposure to previously presented pictures. Her overall performance with visual memory processing was deficient compared to her higher proficiency in verbal memory which is highly improved when presented with contextual cues. She might excel in class when presented information verbally than visually and may be characterized as a verbal learner. Her results revealed challenges with her long-term memory that are consistent with concerns raised by her teacher and mother. A summary of her memory profile is presented below. Summary of Learning and Memory Functions Well Below Slightly Below Well Expected Level Below Expected Expected Level At Expected Above Expected Above Expected Instrument: Level Level Level Level Superior Subtest Rate of learning x across trials Immediate Memory Verbal Immediate Memory x (without contextual cues) Verbal Immediate Memory (with x contextual cues) Visual Immediate Memory x (without contextual cues) Visual Immediate Memory (with x contextual cues) Delayed Memory (Free Recall Versus Recognition) Verbal Delayed Recall (without x context) Verbal Delayed x Recall (with 14

context) Verbal Delayed Recognition x (without context) Verbal Delayed Recognition x (with context) Visual Delayed x Recall (content) Visual Delayed x Recall (spatial) Visual Delayed Recognition x (without context) Visual Delayed Recognition x (with context)

VI. Cognitive Processes: Executive Functions

Executive functioning can be conceptualized into two broad areas: cognitive and behavioral/emotional control. Each of these broad areas has some relationship to the frontal lobes of the brain. The cognitive aspects of executive functioning include concept generation and problem solving. The behavioral/emotional aspects of executive functioning relate to the inhibitory controls of behavior (e.g., impulsivity, regulation of emotional tone, etc.). Presenting Concerns. Presenting Concerns. The Neuropsychological Processing Concerns Checklist for School-Aged Children & Youth – Third Edition (NPCC-3) was completed by teacher and mother. The areas of concern from these raters are shown in the table below.

Executive Functions Mild Moderate Severe Flexibility in Thinking Difficulties M  Does not seem to hear anything else while watching TV. M  Difficulty transitioning from one activity to another. Planning Difficulties M  Quickly becomes frustrated and gives up easily. M  Difficulty figuring out how to start a complex task. M  Difficulty sticking to a plan of action. Problem Solving and Organizing Difficulties M  Difficulty solving problems that a younger child can do. M  Makes the same kinds of errors over and over, even after corrections. Behavioral/Emotional Regulation Difficulties M  Does not seem to think before acting. T  Difficulty following rules. M  Demonstrates signs of irritability. M  Lacks common sense or judgment. Legend: M = Mother, T = Teacher Both mother and teacher endorsed mild to severe challenges at home and in school. Her teacher raised concerns that DG has difficulty following rules. Further, her mother noted several areas where she struggles with among which are not being flexible and being unable to transition from one thing to another, figuring out to start a complex task, becoming quickly frustrated and giving up easily when attempting a task, being irritable and acting before thinking. Current Levels of Functioning Cognitive Flexibility (Set Shifting): Measures the student’s ability to stop focusing on one activity and start focusing on another activity. Cognitive Flexibility Well Well Below Slightly At Above Above Instrument – Subtest: Description Below Expected Below Expected Expected Expected Superior Expected Level Expected Level Level Level Level Level Above Expected (NEPSY-II) Verbal Cognitive Flexibility D-KEFS – Color-Word Interference Condition 4 (Inhibition/Switching): Completion time as the child rapidly switches back and (12) forth between naming the dissonant ink colors and reading the words. School Neuropsychology Report Shell v26.1 (December, 2016) Copyright © 2016 by Daniel C. Miller, Ph.D., KIDS, Inc. 15

. Total Errors: (11) Total uncorrected and corrected errors. D-KEFS – Verbal Fluency Condition 3 (Category Switching Total Correct Responses): (6) Total number of correct responses when switching between verbalizing fruits and pieces of furniture. NEPSY-II – Inhibition Switching Combined: Rapidly and accurately name shapes while switching (10) cognitive sets.  Switching Total Completion Time: How quickly the task was completed (slower time = (9) lower scaled score).  Switching Total Errors: Total errors made on the task (more errors = lower % 51-75 rank).  Switching Uncorrected Errors: Errors with no attempt to correct (more errors = >75 lower % rank).  Switching Self-Corrected Errors: Errors that were self-corrected (more self-corrections 11-25 = lower % rank). Visual Cognitive Flexibility D-KEFS – Design Fluency Condition 3 (Switching): Switching between connecting solid dots and empty (2) dots. D-KEFS – Trail Making Condition 4 (Number-Letter Switching): (10) A psychomotor task that requires switching between number and letter sequences (e.g., 1-A-2-B…). . Trail-Making Condition 1 (Visual Scanning): All of the number 3s on a page are marked as quickly (12) as possible. o Trail-Making Condition 2 (Number Sequencing): (5) Quickly connecting lines between consecutive numbers. Trail-Making Condition 3 (Letter Sequencing): o (5) Quickly connecting lines between sequential letters. o Trail-Making Conditions 2 & 3 Combined (Sequential Processing): (5) Time taken across number and letter trials. Trail-Making Condition 5 (Motor Speed): o (1) Tracing a dotted line as quickly as possible.

NEPSY-II – Response Set Combined Score: Added shifting of attention while selectively responding (12) to auditory target words and ignoring auditory non- target words over time.  Total Commission Errors: Responding to non-target words that were to be >75 ignored (more errors = lower % rank).  Total Correct: Responding correctly to target words (more correct = 51-75 higher scaled score). Total Omission Errors: o 6-10 Missing target words (more errors = lower % rank). o Total Inhibitory Errors: Ignoring distracter words (more errors = lower % 2-5 rank). Note: Standard scores appear in normal font. Scaled scores appear in (parentheses). Percentile ranks and cumulative percentile ranks of any kind appear in italics. Inhibition switching involves processing speed and sequential processing. DG’s responses related to cognitive flexibility varied and ranged from well below to highly proficient levels. She was aware of the challenges that could arise from inhibition switching; her ability to rapidly switch back and forth between naming patches in ink color and reading words, and performed at a typical level in this domain without committing many errors. However, she struggled at a slightly below typical level in her verbal fluency test; ability to switch between verbalizing fruits and pieces of furniture under timed conditions. Her poor performance demonstrated difficulty with delayed verbal recall under timed conditions. She was proficient at quickly naming and switching shapes; when 16 presented with a visual array of circles and squares, or up and down arrows. With the exception of her verbal fluency, she performed at a typical level with her verbal cognitive flexibility. She made a great amount of effort towards monitoring and self-correction. Visual cognitive flexibility employs scanning, visual motor speed and processing speed. Her performance in this domain appeared unevenly distributed. When asked to switch between connecting solid and empty dots, she demonstrated her ability at an extremely deficit level. She can quickly scan through a page at a normal range but is likely to encounter challenges with sequencing that engages both visual perception and motor speed indicating that her visual cognitive flexibility is highly influenced by her motor capability. She performed more poorly at quickly connecting number or letter sequencing than switching between them. This could be attributed her ability put more effort in completing more complex than simple tasks. Given the order in which she had to complete the tasks, she could have improved her understanding and perfection from completing simpler tasks so she could improve on completing the complex tasks. When she had to shift her attention while listening and responding to target and non-target words, her attention shifting ability appeared typical compared to other children her age. She did not respond to many non-target words but committed several omission errors when she failed to attend correctly to target words. She was observed to fidget and did not sustain to listening and attending. However, she admitted the need to bend and scratch her legs which she said were itching. Her profile revealed likely struggles with visual cognitive flexibility attributed to her motor speed and distraction than her verbal cognitive flexibility. Her psychomotor slowness and inattention may adversely impact her flexibility both in the classroom and at home.

Concept Recognition and Generation: Measures the student’s abilities to recognize or generate multiple ways of classifying or categorizing objects, pictures, or words. Concept Recognition and Generation Well Well Below Below Expected Slightly Below At Expected Above Expected Above Expected Instrument – Expected Level Level Expected Level Level Level Level Superior Subtest: Description Above Expected (NEPSY-II) Concept Recognition D-KEFS – Twenty Questions Initial Abstraction: (11) Level of abstract reasoning in the first questions asked. D-KEFS – Twenty Questions Total Questions (15) Asked: The fewer the questions asked the better. D-KEFS – Twenty Questions Total Weighted Achievement: (12) This score used if the child guesses the correct answer quickly. WISC-V– Similarities: Describing how two words that represent (5) common objects or concepts are similar. Concept Generation D-KEFS – (9) Sorting Test Condition 1 School Neuropsychology Report Shell v26.1 (December, 2016) Copyright © 2016 by Daniel C. Miller, Ph.D., KIDS, Inc. 17

(Free Sorting) Confirmed Correct Sorts (Card Set 1 + 2): The number of confirmed correct sorts made on the two card sets.  Condition 1 Free Sorting Description (Card Set 1 + 2): Ability to (5) describe sorting concepts or rules used in sorting the cards. NEPSY-II – Animal Sorting Combined: A combination of the number of correct sorts and the number of errors. (6) Measures initiation, cognitive flexibility, self- monitoring, and conceptual knowledge.  Animal Sorting Total Correct Sorts: A high score suggests good (8) initiation or sustained effort, good conceptual reasoning or semantic knowledge.  Animal Sorting Total Errors: A low number of errors 2-5 suggests good self- monitoring (More errors = lower % rank). oAnimal 51-75 Sorting Total Novel Sort Errors: A high score suggests 18

idiosyncra tic or immature reasoning (more errors = lower % rank). oAnimal Sorting Total Repeated Sort Errors: A high score suggests 11-25 poor cognitive flexibility and self- monitorin g (more errors = lower % rank). Note: Standard scores appear in normal font. Scaled scores appear in (parentheses). Percentile ranks and cumulative percentile ranks of any kind appear in italics. When DG was required to use the least number of simple questions to guess correct answer when presented with visual cues, her performance on this test was at a proficient level. Without cues her abstract reasoning when she had to demonstrate how two words or concepts were alike, her performance appeared significantly deficit. Her concept generation results were unevenly distributed with performance ranging from below to typical levels. In concept generation she utilized initiation, cognitive flexibility, self-monitoring and conceptual knowledge abilities to sort and categorize cards. Her sustained effort measured by the total correct sort made was within typical limits, however, her self-monitoring and cognitive flexibility were inadequate. She presented several repeats suggestive poor cognitive flexibility which are consistent with observations made by both her mother and teacher. She is likely to do the same things over and over suggestive of challenges with transitioning. Problem Solving, Fluid Reasoning, and Planning: Measures the student’s ability to solve problems, apply reasoning skills, and use planning strategies. Problem Solving, Fluid Reasoning, and Planning Well Well Below Below Expected Slightly Below At Expected Above Expected Above Expected Instrument – Expected Level Level Expected Level Level Level Level Superior Subtest: Description Above Expected (NEPSY-II) Verbal Deductive and Inductive Reasoning D-KEFS – Word Context Total Consecutively Correct: (10) Verbal abstract deductive reasoning. WISC-V– Comprehension : Answering questions based on (8) understanding of general principles and social situations. Visual Deductive and Inductive Reasoning D-KEFS – Tower Total Achievement: Overall quality (17) of tower building within time limits. WISC-V – (5) School Neuropsychology Report Shell v26.1 (December, 2016) Copyright © 2016 by Daniel C. Miller, Ph.D., KIDS, Inc. 19

Matrix Reasoning: Completing a missing portion of a picture matrix. WISC-V – Picture Concepts: Choosing one picture from among two or (7) three rows of pictures to form a group with a common characteristic. Quantitative Reasoning WISC-V - Figure Weights: Ability to determine what (10) weight is needed to balance a scale. WISC-V – Arithmetic: Mentally solving orally presented (8) arithmetic problems within time limits. Note: Standard scores appear in normal font. Scaled scores appear in (parentheses). Percentile ranks and cumulative percentile ranks of any kind appear in italics. DG manifested normal limits with her verbal deductive and inductive reasoning when she had to figure out specific words using abstract contextual cues or from answering questions based on understanding general principles and social situations. However, her visual deductive and inductive reasoning abilities varied significantly. When she employed visual spatial application with motor processing using blocks to build a tower, she performed at a superior level. Contrarily, when faced with challenges of visualizing and mentally completing missing portions of a picture matrix she performed at below to slightly below the typical level compared to other children her age. She is likely to be pragmatic when presented with visual and practical task than utilizing mental orientation and manipulation of visual concepts. When asked to employ quantitative reasoning to solve problems, her performance was within normal limits. Response Inhibition: Measures the student’s ability to learn and demonstrate a new response to a stimulus instead of producing a typical response. Response Inhibition Well Well Below Below Expected Slightly Below At Expected Above Expected Above Expected Instrument – Expected Level Level Expected Level Level Level Level Superior Subtest: Description Above Expected (NEPSY-II) Verbal Response Inhibition D-KEFS – Color- Word Interference Condition 3 (Inhibition): Time to rapidly (11) naming the color of the ink a color word (“red”) is printed in. An inhibitory task. . Color-Word Interference Inhibition Total Errors: (5) Total uncorrected and corrected errors. NEPSY-II – (5) 20

Inhibition (Condition 2) Combined: Rapidly and accurately naming the opposite names of shapes (e.g., “circle” for “square”).  Inhibition Total Completion Time: How quickly (8) the task was completed. (slower time = lower scaled score)  Inhibition Total Errors: Total errors made on the 2-5 task. (more errors = lower % rank) o Inhib ition Uncorrect ed Errors: Errors with no 26-50 attempt to correct (more errors = lower % rank). o Inhib ition Self- Corrected Errors: Errors that were self- <2 corrected (more self- correction s = lower % rank). Note: Standard scores appear in normal font. Scaled scores appear in (parentheses). Percentile ranks and cumulative percentile ranks of any kind appear in italics. DG’s response inhibition profile appeared unevenly distributed. When a new stimulus is presented to her, she performed at a typical level when she had to name the color of the ink the word is printed in but below the expected level when naming the opposite of shapes. She completed the task on time but with many errors. In the classroom or home situation, she is likely to become frustrated and give up when she makes errors or gets confused or has difficulty when she has to provide a new response instead of the typical one when the stimulus changes. Qualitative Behaviors for Executive Functions: Qualitative Behaviors Well Well Below Below Expected Slightly Below At Expected Above Expected Above Expected Instrument: Expected Level Level Expected Level Level Level Level Superior Subtest Above Expected (NEPSY-II) Set-Loss Errors (Failure to Maintain the Directions) D-KEFS: Design Fluency: Total (1) Set-Loss Designs Repetition Errors (Close Together = perseveration, Far Apart = memory weakness) School Neuropsychology Report Shell v26.1 (December, 2016) Copyright © 2016 by Daniel C. Miller, Ph.D., KIDS, Inc. 21

D-KEFS: Design Fluency: Total (13) Repeated Designs Rule Violations During Task Performance (Impulsive Response Style or Oppositional Response Style) D-KEFS: Tower Total Rule 40 Violations Total Attempted Items D-KEFS: Design Fluency: Total (10) Attempted Designs DG exhibited significant repetition errors in her design fluency that appeared to be memory related. Her rule violation and attempted designs performance were typical, however, she failed significantly to maintain cognitive set measured by her inability to adequately follow directions. Likewise, she might encounter difficulties with following through when demanded to complete a task. Summary of Executive Functioning DG presented behavior problems consistent with concerns raised by her teacher and mother with regards to her executive functioning. She presented limited strengths with her visual than verbal cognitive flexibility. Her concept recognition with cuing appears stronger than concept generation which appeared unevenly distributed. Her verbal abstract, deductive, inductive and fluid reasoning abilities appeared within the typical range. She exhibited a high level of set loss error suggestive of losing track of what she is supposed to do, and having an increased number of repetition errors. Both her mother and teacher expressed concerns with following rules and cognitive flexibility. She made adequate effort towards self-monitoring and self-correction, a strength she can employ at school to improve on her academic performance. VII. Facilitators/Inhibitors: Allocating and Maintaining Attention Attention is a complex and multifaceted construct used when an individual must focus on certain stimuli for information processing. In order to regulate thinking and to complete tasks of daily living such as schoolwork, it is necessary to be able to attend to both auditory and visual stimuli in the environment. Attention can be viewed as the foundation of all other higher-order processing. In other words, if attention is compromised it can adversely affect other cognitive processes of language, memory, visuospatial skills, etc. Attention can be divided into four subareas: selective/focused attention, sustained attention, and attentional capacity. The test results will be reported broken down into those subtypes of attentional processing. Selective/Focused attention refers to the ability to pay attention to relevant information while ignoring irrelevant information. An example of selective/focused attention would be the child’s ability to pay attention to only the classroom teacher when there is the noise and the visual distracters of the classroom to ignore. Sustained attention refers to the ability to maintain an attention span over a prolonged period of time. Attentional capacity refers to the child’s ability to recall information ranging from small chunks (e.g., a string of numbers or letters), to larger chunks of information (e.g., list of unrelated words or sentences of increasing length and complexity), and to even larger semantically complex chunks of information (e.g., memory for stories). Presenting Concerns. The Neuropsychological Processing Concerns Checklist for School-Aged Children & Youth – Third Edition (NPCC-3) was completed by teacher and mother. The areas of concern from these raters are shown in the table in the appendix.

Attention Problems Mild Moderate Severe Selective or Sustained Attention Difficulties M  Seems to get overwhelmed with difficult tasks. M, T  Difficulty paying attention for a long period of time. M  Mind appears to go blank or loses train of thought. M  Inattentive to details or makes careless mistakes. Legend: M = Mother, T = Teacher Both mother and teacher stated selective or sustained attention problems that are observed both at home and school. DG has attention problems related to sustaining attention for extended period of time and appearing overwhelmed with difficult task and being inattentive to details or making careless mistakes. Current Levels of Functioning

1. Selective/Focused and Sustained Attention: Measures the student’s ability to find designated targets (visual or auditory) that are embedded in many targets (how well the student can filter extraneous information), and measures the student’s ability to pay attention over prolonged periods of time. Selective/Focused and Sustained Attention S S Well e u Well Below Slightly At Above Above Instrument – Subtest: Description l s Below Expected Below Expected Expected Expected Superior e t Level Level Level Level 22

c a Expected Expected Above Expected (NEPSY-II) t i Level Level i n v e e d Auditory Selective/Focused and Sustained Attention NEPSY-II – Auditory Attention Combined: Selectively responding to auditory target words while X X (5) ignoring auditory non-target words over time.

 Total Commission Errors: Responding to non-target words that were to be 6-10 ignored (more errors = lower % rank).  Total Correct: Responding correctly to target words (more 51-75 correct = higher scaled score). o Total Omission Errors: Missing target words (more errors = lower % 6-10 rank). o Total Inhibitory Errors: Ignoring distracter words. (More errors = lower 26-50 % rank). Note: Standard scores appear in normal font. Scaled scores appear in (parentheses). Percentile ranks of any kind appear in italics. DG’s scores on attributes that measure her selective and sustained attention indicated that she responded at an adequate level of ignoring distracters and accurately focusing on target words but committed some errors by responding to some non-targets and omitting some target words. In a classroom environment, she may ignore distracters, and make an endeavor to sustain her attention but is likely to commit mistakes when completing an academic task. Her continuous performance testing revealed deficiency with sustained attention.

Connors Continuous Performance Test – Third Edition (CCPT III)

Measure T- Scores Interpretation Validity Measures Check one: ____ Valid Administration ____ Invalid Administration Response Style (Check on): ___ Conservative style ____ Liberal Style ____ Balanced Style Measures of Inattentiveness Detectability: 53 Average Measure of difference between signal and noise distributions. # Omissions: Failure to respond to target letters. 52 Average # Commissions: Responses given to non-targets 48 Average Hit Reaction Time: The mean response time, measured in milliseconds, for all non-perseverative responses made 60 Slow during the entire administration. Hit Reaction Time Standard Error: Measure of response speed consistency across test items. 64 Elevated Variability: Measure of response speed consistency within student’s responses. 61 Elevated Measures of Impulsivity Hit Reaction Time (same score from the section above): The mean response time, measured in milliseconds, for all non-perseverative responses made 60 Slow during the entire administration. # Commissions (same score from the section above): Responses given to non-targets 48 Average Perseverations: Reaction times less than 100 milliseconds. 50 Average Measures of Sustained Attention Hit Reaction Time Block Change: The change in mean response time across blocks. 63 Elevated Measures of Vigilance Hit Rate Inter-Stimulus Interval Change: 60 Elevated The slope of change in reaction time across the three inter-stimulus intervals.

The Conners Continuous Performance Test – III (CCPT III), a computer software tool, was also administered to measures visual levels of inattentiveness, impulsivity, and vigilance. Use the classifications labels for the test (e.g., good performance, a little fast, mildly atypical, etc.). DG’s profile showed strong indication of challenges with inattentiveness, sustained attention and vigilance. When performing the test, she easily got bored and continuously asked when the computer testing will be over. In the classroom, she is likely to become easily bored and exhibit difficulties with sustained attention needed for prolonged and sustained effort to accomplishing academic task.

2. Attentional Capacity: Measures the student’s ability to learn information with increased content and meaning. School Neuropsychology Report Shell v26.1 (December, 2016) Copyright © 2016 by Daniel C. Miller, Ph.D., KIDS, Inc. 23

3. Attentional Capacity Slightly Well Well Below Below At Above Above Instrument – Subtest: Description Below Expected Expected Expected Expected Expected Superior Expected Level Level Level Level Level Level Above Expected (NEPSY-II) Attentional Capacity for Numbers or Letters with Verbal Response WRAML2 – Number/Letter: Repeating auditorily presented number/letter strings of (2) increasing length. Attentional Capacity for Visual Sequential Patterns with Motor Response WRAML2 – Finger Windows: Using a finger to repeat a visual pattern of increasing (1) length. Attentional Capacity for Words and Sentences (Increased Meaning) with Verbal Response WRAML2 – Sentence Memory: (13) Repeating sentences of increased length and complexity. Attentional Capacity for Stories (Even more Contextual Meaning) with Verbal Response WRAML2 – Story Memory: (9) Recalling verbally presented story details. Note: Standard scores appear in normal font. Scaled scores appear in (parentheses). Percentile ranks and cumulative percentile ranks of any kind appear in italics. DG’s results demonstrated a vast range of performance from well below to highly proficient levels. She appeared deficient when presented with number/letter strings of increasing length but proficient when repeating sentences of increased length and complexity or recalling verbally presented story details which appeared as a strength to her. Compared to other children her age, she has a high attentional capacity when learning stories with increased contextual content and meaning.

4. Qualitative Behaviors of Attention Qualitative Behaviors for Attentional Processes Total ADHD Clinical Sample Age Sample Test/Qualitative Behavior Base Rate Base Rate NEPSY-II: Auditory Attention and Response Set 3-10% of children this age 26-75% of children with ADHD who exhibited who exhibited - Inattentive/Distracted Off-Task Behaviors inattentive/distracted or inattentive/distracted or off-task off-task behaviors behaviors - Out of Seat/Physical Movement in Seat Off-Task 3-10% 26-75% Behaviors Note: A base rate is the percentage of the children in the comparison group (e.g., students the same age, or students in a clinical group). Although DG made endeavors to be focused and sustained her attention during attention testing, she often attempted to engage the examiner in a conversation, shifted on her seat and complained of having pain and being dizzy. She was encouraged to be steady, listen and continue testing. It should be noted that 3-10% of children her age are likely to be inattentive or distracted when performing a task and 3-10% are likely to perform some physical movements in the seat. Compared with other children with ADHD, the percentage of children with similar clinical problems rose to 26-75%. During testing DG engaged in verbal and physical fidgeting by attending to itches on her leg. 4. Behavioral Ratings for Attention and Hyperactivity The Behavior Assessment System for Children – Third Edition (BASC3) is an integrated system designed to facilitate the differential diagnosis and classification of a variety of emotional and behavioral disorders of children. Any score on the BASC3 in the clinically significant range (T = 70+) suggests a high level of maladjustment in that area. Scores in the at-risk range (T = 60–69) identify either a significant problem that may not be severe enough to require formal treatment or a potential of developing a problem that needs careful monitoring. The chart below shows the BASC3 results from the Parent and Teacher forms for the Hyperactivity and Attention Problems scales. The norms were calculated using a normative comparison based just on females/girls DG’s age. Behavioral Ratings Norm Group Comparison Percentile BASC3 Ratings T-Score Rank Classification Parent Rating - Hyperactivity All females her age 57 78 Average Teacher Rating – Hyperactivity All females her age 47 54 Average Student Rating - Hyperactivity All Females her age 37 7 Average Parent Rating – Attention Problems All females her age 57 68 Average Teacher Rating – Attention Problems All females her age 47 38 Average Student Rating- Attention Problems All females her age 37 7 Average

ADHD Hyperactivity All females her age 67 97 At Risk Probability Index – Parent ADHD Hyperactivity All females her age 48 45 Average Probability Index – Teacher 24 Her mother’s ratings indicated DG exhibits chances of displaying a hyperactive behavior. All her other attentional ratings on the BASC 3 appeared at an average range. Further testing with Conners Continuous Performance Testing, revealed DG has difficulties with inattentiveness and sustained attention. The absence of any risk of displaying any attentional profile registered by the teacher are suggestive of the presence of a structured setting at school. Summary of Attentional Processing DG manifested limited fidgeting during testing and made an adequate effort to remain focused and complete testing. She has difficulties with sustain attention and demonstrates a high probability of making mistakes. Her difficulty in this domain is likely to impact her ability to sustain attention without losing her train of thought with increased academic content that is presented for a prolonged duration of instruction and learning as remarked by her teacher and mother. Her attentional capacity for stories and sentences appears more significant than that for numbers and letters sequencing which do not have context. She committed omission errors, but continued to sustain her visual and auditory attention to complete the tasks. When reminded to pay attention, she made an effort to minimize fidgeting during testing. Her mother endorsed her being at risk with hyperactivity problems, a condition that was not reported by her teacher. In the classroom, she might benefit from narrative strategy of instruction, her performance and interest using this modality may improve her ability to pay more attention and do even better. VIII. Facilitators/Inhibitors: Working Memory

Working memory is a memory system that underpins our capacity to keep things in mind when performing complex tasks. Information placed in working memory may come from sensory memory, short-term memory, or from long-term memory. The key component of a working memory task is the requirement for active manipulation of the information. Working memory has been shown to be a required cognitive process for components of reading, mathematics, and writing achievement in children. Presenting Concerns. The Neuropsychological Processing Concerns Checklist for School-Aged Children & Youth – Third Edition (NPCC-3) was completed by teacher and mother. The areas of concern from these raters are shown in the table below.

Working Memory Difficulties Mild Moderate Severe M  Trouble summarizing narrative or text material. M  Trouble remembering facts or procedures in mathematics. Legend: M = Mother, T = Teacher DG’s mother reported concerns related to working memory. She rated DG as having trouble summarizing narrative or remembering facts. Working Memory Well Well .Below Below Expected Slightly Below At Expected Above Expected Above Expected Instrument – Expected Level Level Expected Level Level Level Level Superior Subtest: Description Above Expected (NEPSY-II) Verbal Working Memory

WISC-V – Arithmetic: Mentally solving orally presented (8) arithmetic problems within time limits. WISC-V – Letter-Number Sequencing: Recalling numbers in ascending order and letters in alphabetical (11) order after listening to a sequence of numbers and letters spoken by the examiner. Note: Standard scores appear in normal font. Scaled scores appear in (parentheses). Percentile ranks and cumulative percentile ranks of any kind appear in italics. Summary of Working Memory DG’s verbal working memory appeared typical compared to other girls her age. She was able to demonstrate an average level of mental proficiency in solving problems and recalling numbers and letters after listening and repeating a sequence presented by the examiner. Working memory is needed in mathematical computation, and comprehension. Concerns raised by her mother and teacher were not consistent with results from this evaluation; differences could be attributed to the degree of complexity and processing speed at which the material can be retrieved and manipulated. School Neuropsychology Report Shell v26.1 (December, 2016) Copyright © 2016 by Daniel C. Miller, Ph.D., KIDS, Inc. 25

IX. Facilitators/Inhibitors: Speed, Fluency, and Efficiency of Processing

The facilitators/inhibitors of speed, fluency, and efficiency of processing are conceptualized to be composed of four second sub classifications: performance fluency, retrieval fluency, acquired knowledge fluency, and fluency and accuracy. Performance fluency is defined as the ability to quickly perform simple, repetitive tasks. Retrieval fluency is defined as how quickly information can be retrieved from long-term memory. Performance fluency tasks do not require accessing previously learned or stored information; whereas, retrieval fluency requires quick access to long-term memory. Acquired knowledge fluency relates to the automaticity of academic achievement including: reading fluency, writing fluency, and mathematics fluency. The final second order classification within the speed and efficiency of processing areas is fluency as it relates to accuracy. Processing speed must be interpreted with the context of performance accuracy. Presenting Concerns. The Neuropsychological Processing Concerns Checklist for School-Aged Children & Youth – Third Edition (NPCC-3) was completed by teacher and mother. The areas of concern from these raters are shown in the table below.

Speed, Fluency, and Efficiency of Mild Moderate Severe Cognitive Processing Processing Speed and Fluency Difficulties M  Takes longer to complete tasks than others the same age. T M  Homework takes too long to complete. T M  Requires extra time to complete tests. M  Responds slowly when asked questions. Processing Speed With Accuracy Difficulties M, T  Does not do well on timed tests. M  Difficulty recalling information accurately and quickly. Legend: M = Mother, T = Teacher DG’s mother and teacher noted severe concerns in different areas. Concerns reported by both raters pertained to DG’s taking longer time to complete tasks compared to other children her age, requiring extra time to complete tasks and difficulty recalling information accurately and quickly. Current Levels of Functioning

1. Performance Fluency: Measures the student’s ability to quickly perform simple repetitive tasks. Performance Fluency Well Well Below Below Expected Slightly Below At Expected Above Expected Above Expected Instrument – Expected Level Level Expected Level Level Level Level Superior Subtest: Description Above Expected (NEPSY-II) Psychomotor Fluency D-KEFS: - Trail Making Condition 5 – Motor Speed: (1) Tracing a dotted line as quickly as possible. Perceptual Fluency WISC-V – Cancellation: Marking target pictures within (9) a visual set of pictures in a specified time period. WISC-V – (4) Coding: Copying symbols paired with geometric shapes or 26

numbers within a time limit. WISC-V – Symbol Search: Scanning a search group and marking the presence or (11) absence of a target symbol or symbols within a time limit. Figural Fluency D-KEFS – Design Fluency Total Correct Condition 1 + 2: The total (5) number correct across Conditions 1 & 2. . Condition 1 (Filled Dots) Total Correct: Connects filled dots (8) to create as many different designs as possible in 60 seconds. . Condition 2 (Empty Dots) Total Correct: Connects empty dots to (2) create as many different designs as possible in 60 seconds. Naming Fluency D-KEFS – Color- Word - Condition 1 (Color Naming): (5) Time to name the color of colored squares rapidly. D-KEFS – Color- Word Interference Condition 2 (Word (4) Reading): Time to name color words (e.g., “red”) rapidly. D-KEFS – Color- (5) Word Naming and Reading Completion School Neuropsychology Report Shell v26.1 (December, 2016) Copyright © 2016 by Daniel C. Miller, Ph.D., KIDS, Inc. 27

Time Combined: Total time needed to name both the name of the colors and the color words combined. NEPSY-II – Inhibition: Naming Combined: (5) Rapidly and accurately name shapes.  Naming Total Completio n Time: How quickly the task was (4) completed . (slower time = lower scaled score)  Naming Total Errors Total errors made on 11-25 the task. (more errors = lower % rank) oNaming Uncorre cted Errors: Errors with no attempt 26-50 to correct (more errors = lower % rank). oNaming Self- Correct ed Errors: Errors that were self- 11-25 correct ed (more self- correcti ons = lower % rank). Note: Standard scores appear in normal font. Scaled scores appear in (parentheses). Percentile ranks and cumulative percentile ranks of any kind appear in italics. 28 DG demonstrated fluctuations in her performance fluency scores, she attained adequate levels in some areas and low in others. Her performance in the areas that demanded motor manipulation by tracing dotted lines, coping geometric shapes, connecting filled and empty dots was deficient. Without engaging motor functioning, she out-performed at typical levels with activities that engaged visual scanning and quickly marking target symbols without motor manipulation such as drawing symbols. When connecting dots to create differently designs under timed conditions, she encountered difficulties following instructions and transitioning from connecting filled dots to empty. In completing the next sequence of designs, she got confused and connected both filled and empty dots and consequently made many errors. These are indications to show she might struggle with transitioning. Her naming fluency measured as her ability to quickly name colored squares, and words was below expected levels. She was fast, made many errors with poor self-monitoring.

2. Retrieval Fluency: Measures the student’s ability to quickly assess information from long-term memory.

3. Retrieval Fluency Well Well Below Below Expected Slightly Below At Expected Above Expected Above Expected Instrument – Expected Level Level Expected Level Level Level Level Superior Subtest Above Expected (NEPSY-II) Word Fluency D-KEFS – Verbal Fluency – Condition 1 (Letter Fluency): Naming as (5) many words within a time limit that start with a specific letter. NEPSY-II – Word Generation Initial Letter Total: (5) Words recalled quickly that start with a particular letter. Semantic Fluency D-KEFS – Verbal Fluency – Condition 2 (Category Fluency): Naming as (8) many words within a time limit that all fall in the same category (e.g., fruits). NEPSY-II – Word Generation Semantic Total: (3) Words recalled quickly that fit into a category. WIAT-III – Oral Word Fluency: Name as many words within a 89 time limit that fit within a category. Note: Standard scores appear in normal font. Scaled scores appear in (parentheses). Percentile ranks and cumulative percentile ranks of any kind appear in italics. 1 The Word Generation subtest scores were previously reported in the Language Processes section of the report, but need to be considered in this section as well. Word Generation is the verbal analog to the nonverbal Design Fluency subtest. Both subtests require retrieval fluency, which is an executive function. DG’s performance revealed unevenly distributed scores in her word and semantic fluency with test scores that ranged from extremely low to average levels when operating under timed conditions. Her worst performance occurred when she had to quickly recall words or facts that fitted into a given category such as words starting with a particular letter. She was more proficient at quickly recalling fruits due to her higher knowledge base than words starting with specified letters. Retrieval fluency is important in taking tests and examinations at school. Item analysis in her social-emotional profile reveals she has test anxiety, a likely consequence of poor retrieval word and semantic fluency needed during test taking. School Neuropsychology Report Shell v26.1 (December, 2016) Copyright © 2016 by Daniel C. Miller, Ph.D., KIDS, Inc. 29

Acquired Knowledge Fluency: Measures the degree to which reading, writing, and math is fairly automatic for a student. Presenting Concerns. The Neuropsychological Processing Concerns Checklist for School-Aged Children & Youth – Third Edition (NPCC-3) was completed by mother and teacher. The areas of concern from these raters are shown in the table below.

Acquired Knowledge Fluency Mild Moderate Severe Reading Fluency Difficulties T M  Slow reading that makes comprehension difficult. T M  Difficulty reading quickly and accurately. T M  Slow and deliberate reader. M  Difficulty using appropriate phrasing and expression while reading. Writing Fluency Difficulties T M  Takes a long time to write even simple sentences. T M  Develops an organized sequence in writing that is easy to follow T M  Maintains a clear and sustained focus on the main writing topic Mathematics Fluency Difficulties M  Difficulty pulling basic math facts out of memory quickly. Legend: M = Mother, T = Teacher DG’s teacher and mother noted concerns with her reading, writing and mathematical fluency. She encounters difficulties with slow reading, reading quickly and accurately, developing an organized sequence in writing that is easy to follow, maintain a clear and sustained focus on the main writing topic. In addition, she takes longer to solve simple math problems and pulling basic math facts out of memory quickly. Current Levels of Functioning

Acquired Knowledge Fluency Well Below Expected Slightly Well Level Below Below At Above Above Instrument – Subtest: Description Expected Expected Expected Expected Expected Superior Level Level Level Level Level Reading Fluency: Rapid Phonological Decoding WIAT-III – Oral Reading Fluency: Reading passages aloud and then orally responds to 82 comprehension questions. Oral Reading Accuracy: o 81 Number of correctly read words. Oral Reading Rate: o 81 How quickly passages were read. Mathematical Fluency WIAT-III – Math Fluency-Addition: 90 Solving simple addition problems quickly. WIAT-III – Math Fluency – Subtraction: 88 Solving simple subtraction problems quickly. WIAT-III – Math Fluency – Multiplication: 72 Solving simple multiplication problems quickly. 1Note that the PAL-II scores are based on grade norms not age norms. DG demonstrated slightly below expected levels when requested to read passages and answer questions. Her oral accuracy and reading rate appeared below average. Her achievement was registered within the typical limit when solving simple addition but below average doing simple subtraction and multiplication. Her performance in these areas is consistent with concerns raised by both her mother and teacher. Concerns about her writing fluency were not examined; the test available was to access basic skills for children younger her age.

4. Assessing Fluency with Accuracy: Measures the interaction between completion time on a task and accuracy. Some students slow down on tasks to be more accurate. Other students are very fast but make many errors. DG tended to have average completion times for simple tasks, but when tasks became more complex, she slowed down to improve accuracy.

Average to Low Number of Errors High Number of Errors Tests Fast Average Slow Fast Average Slow Completion Time Completion Completion Completi Completion Time Completion Time Time Time on Time D-KEFS Color-Word Interference Test: x 30

Color Naming D-KEFS Color-Word Interference Test: x Word Reading D-KEFS Color-Word Interference Test: x Inhibition Condition D-KEFS Color-Word Interference Test: x Inhibition/Switching Condition NEPSY-II Speeded Naming x NEPSY-II Inhibition: Naming x NEPSY-II Inhibition: Inhibition x NEPSY-II Inhibition: Switching X 5. Qualitative Behaviors for Processing Speed DG exhibited a pattern within the slow completion time with a high number of errors suggesting poor inhibitory skills. She performed inadequate self- correction indicating that she was not able to perform self-monitoring. Her teacher and mother indicated she encounters difficulties with her reading, writing and mathematics fluency which is consistent with her poor performance in these areas during testing. In the classroom, emphasis on performance could be placed both on qualitative and quantitative productivity in which self-monitoring is highly recommended. Summary of Speed, Fluency, and Efficiency of Cognitive Processing DG’s speed, fluency and efficiency of cognitive processing varies between well below to at expected levels. Some aspects of her processing speed are consistent with concerns noted by both her mother and teacher that she takes slower than other children her age to complete simple academic tasks. She demonstrated adequate strength with perceptual fluency that did not engage copying and likely to indicate difficulties with writing. She could benefit from graphical or pictorial representation of educational material. Figural manipulation essential in mathematics could be a problem for DG. Her performance on this evaluation revealed some difficulties with psychomotor, naming, figural, retrieval and acquired knowledge fluency. X. Acquired Knowledge: Language Abilities

We all live in a highly verbal society; therefore, language skills are necessary for successful academic and behavioral functioning in school-aged children. The language domain is categorized into oral expression and listening comprehension (receptive language). Presenting Concerns. The Neuropsychological Processing Concerns Checklist for School-Aged Children & Youth – Third Edition (NPCC-3) was completed by mother and teacher. The areas of concern from these raters are shown in the table below. School Neuropsychology Report Shell v26.1 (December, 2016) Copyright © 2016 by Daniel C. Miller, Ph.D., KIDS, Inc. 31

Language Functions Mild Moderate Severe Receptive Language Difficulties M  Loses track of what she was told to do. Legend: M = Mother, T = Teacher DG’s mother reported a concern of her losing track of what she was told to do. Current Levels of Functioning

1. Oral Expression – Vocabulary Knowledge: Measures the student’s knowledge of word meanings. Oral Expression Well Well Below Slightly At Above Above Instrument – Subtest: Description Below Expected Below Expected Expected Expected Superior Expected Level Expected Level Level Level Level Level Above Expected (NEPSY-II) Vocabulary Knowledge and Oral Expression WIAT-III – Oral Expression (Expressive Vocabulary): Naming the concept shown in a picture or saying words 103 from a given category and repeating sentences.  WIAT-III – Expressive Vocabulary: Ability to name objects, actions, or concepts 116 illustrated in pictures. WISC-V – Vocabulary: Ability to name pictured objects or define word (13) meanings. Note: Standard scores appear in normal font. Scaled scores appear in (parentheses). Percentile ranks and cumulative percentile ranks of any kind appear in italics. DG demonstrated a proficient performance in her vocabulary knowledge and oral expression that was registered at and above typical levels. She was able to name concepts in pictures, repeat sentences, say words from different categories and define their meaning with ease. 2. Qualitative Behaviors of Oral Expression Qualitative Behaviors of Oral Expression Slightly Below Well Well Below Below Expected Expected Level At Expected Above Expected Above Expected Instrument: Expected Level Level Level Level Level Superior Subtest Above Expected (NEPSY-II) Spatial Questions D-KEFS: Twenty Questions: 100 Spatial Questions Without time limits imposed, she was markedly proficient at posing the least number of simple deductive questions to identify objects on a page with different pictures when provided cues. The number of questions posed decreased significantly from the first trial of 6 questions to 3 in the fourth and final trial. Qualitatively, she displayed indications of improving her learning by posing questions for enhanced comprehension. She is likely to improve her oral expression and comprehension when encouraged to pose questions on things she does not understand. 3. Receptive Language (Listening Comprehension): Measures the student’s ability to understand spoken language. Receptive Language (Listening Comprehension) Well Well Below Slightly At Above Above Instrument – Subtest: Description Below Expected Below Expected Expected Expected Superior Expected Level Expected Level Level Level Level Level Above Expected (NEPSY-II) Receptive Language With Verbal Response WIAT-III – Listening Comprehension: Listening to a word and pointing to a picture that 101 illustrates the word, then listening to passages and answering questions about each one. oOral Discourse Comprehension: Listening to verbal content and then answering 94 questions about that content. Receptive Language With Nonverbal Motor Response WIAT-III – Receptive Vocabulary: Pointing to one of four pictures that corresponded to a 108 spoken word. Note: Standard scores appear in normal font. Scaled scores appear in (parentheses). Percentile ranks and cumulative percentile ranks of any kind appear in italics. 32 DG’s performance on listening comprehension appeared within the average compared to other children her age. She demonstrated a strong ability to listen to recorded passages and answer correctly to the content of what she heard. She performed equally well when asked to provide either verbal or nonverbal response by pointing to response items. However, she was deficit with her attentional or receptive language pertaining to phonological processing.

5. Qualitative Behaviors of Receptive Language Qualitative Behaviors for Asking for Repetitions Well Below Slightly Below Well Expected Level Below Expected Expected Level At Expected Above Expected Above Expected Instrument – Level Level Level Level Superior Subtest Possible Attentional or Receptive Language Deficits NEPSY-II: Phonological (7) Processing Percentile ranks and cumulative percentile ranks of any kind appear in italics. Summary of Acquired Knowledge Language Functioning DG performed equally well with both her oral expression and receptive language abilities. She was efficient at utilizing the least number of questions in her verbal deductive reasoning. There are indications she can improve her learning through posing questions to improve comprehension. She is apt at providing both verbal and nonverbal motor responses to indicate her proficiency in receptive language. Her results revealed challenges with her phonological processing. XI. Acquired Knowledge: Reading Achievement

Presenting Concerns. The Neuropsychological Processing Concerns Checklist for School-Aged Children & Youth – Third Edition (NPCC-3) was completed by teacher and mother. The areas of concern from these raters are shown in the table below.

Academic Functions: Reading Mild Moderate Severe Reading Comprehension Difficulties T M  Difficulty understanding what is read. M  Difficulty identifying main elements of a story. M  Never appears distracted while reading. M  Misses important details while reading. Legend: M = Mother, T = Teacher A number of concerns on the NPCC were reported both by DG’s mother and teacher. They both noted that she has difficulty understanding what she read or identify the main element of a story. Her mother noted that she never appears distracted while reading but appears to miss important details when reading. Current Levels of Functioning Reading Achievement Scores Well Below Expected Slightly Well Level Below Below At Above Above Instrument – Subtest: Description Expected Expected Expected Expected Expected Superior Level Level Level Level Level Basic Reading Skills: Phonological Decoding WIAT-III – Pseudoword Decoding: 71 Ability to phonologically decode pseudowords. WIAT-III – Word Reading: 78 Reading words in isolation. Reading Comprehension Skills WIAT-III – Reading Comprehension: Reading passages aloud or silently under untimed conditions, 74 then answering open-ended questions about each one. Note: Standard scores appear in normal font. Scaled scores appear in (parentheses). Percentile ranks and cumulative percentile ranks of any kind appear in italics. DG’s result profile indicated that she performed below expected level on phonological decoding when asked to decode pseudowords or read isolated words. Her reading comprehension skills appeared below expected level when reading under untimed conditions and answering open-ended questions from what she read. Her test results are on par with concerns noted by her teacher and mother regarding her understanding of what she read. She is likely to counter challenges in the classroom with reading comprehension and phonological decoding. Summary of Reading Achievement DG demonstrated reading achievement skills at below expected levels. She lacks basic reading and comprehension skills required to enhance performance in school. Her deficiencies are consistent with concerns specified by her teacher and mother. She is likely to struggle acquiring these basic skills which are needed for further education and a successful career. She may benefit from using compensatory strategies such as digital text books. XII. Acquired Knowledge: Written Language Achievement

Presenting Concerns. The Neuropsychological Processing Concerns Checklist for School-Aged Children & Youth – Third Edition (NPCC-3) was completed by mother and teacher. The areas of concern from these raters are shown in the table below. School Neuropsychology Report Shell v26.1 (December, 2016) Copyright © 2016 by Daniel C. Miller, Ph.D., KIDS, Inc. 33

Academic Functions: Writing Mild Moderate Severe Writing: Spatial Production Functions M T  Demonstrates uneven spacing between words and letters. M T  Trouble staying on the horizontal lines. M, T  Others have difficulty reading what the child has written. T  Trouble forming letters and words M T  Writes overly large letters and words. Writing: Expressive Language Functions T  Uses simple sentence structure and lacks variety. T M  Produces poor spelling in writing. M T  Poor grammar in writing. Writing: Graphomotor Output Functions T  Difficulty holding the pencil or pen correctly T M  Presses too hard with the pencil/pen while writing. T  Shows preference for printing over cursive writing Legend: M = Mother, T = Teacher DG’s mother and teacher presented several concerns regarding her writing skills. They noted severe difficulties in her ability to space out between words or letters, write in ways others can read, often writes overly large letters or words, produces poor spelling in her writing and presses too hard with her pen or pencil when writing. Current Levels of Functioning Written Language Achievement Scores Well Below Expected Slightly Well Level Below Below At Above Above Instrument – Subtest: Description Expected Expected Expected Expected Expected Superior Level Level Level Level Level Expository Composition WIAT-III – Sentence Composition: Combining information from two or three sentences into single 69 sentences that mean the same thing, then writing meaningful sentences that use specific words.

 Sentence Combining: 63 Combining two sentences into a single sentence.

 Sentence Building: 78 Building a sentence that incorporates a certain word. WIAT-III – Essay Composition: 58 Writing an essay within a 10-minute time limit.

 Word Count: 69 The number of words produced in the essay.

 Theme Development and Text Organization: 60 The quality of the essay. WIAT-III – Spelling: Writing single words that are dictated within the context of a 73 sentence. Orthographic Spelling WIAT-III – Spelling: Writing single words that are dictated within the context of a 73 sentence. Note: Standard scores appear in normal font. Scaled scores appear in (parentheses). Percentile ranks and cumulative percentile ranks of any kind appear in italics. 1Note that the PAL-II scores are based on grade norms not age norms. DG demonstrated written language achievement performance that was markedly deficient and consistent with concerns reported by her teacher and mother. Her ability to combine two or more sentences to produce a single sentence or incorporate certain words into a sentence was below the average. With regards her essay, she lacked the ability to develop a theme, did not space out her words or use appropriate punctuation and grammar. Her word characters were large in size. She demonstrated an extremely low level of written expression when timed to write a 10-minute essay which was very brief and confusing to understand. She did not exhaust all the time limit allocated. Her orthographic spelling was poor. Qualitative Behaviors of Writing Although difficult to read, she limited her writings to a concrete level and abstained from any abstract structures and mastering of written expression. Summary of Written Language Achievement 34 DG demonstrated weaknesses in her ability to combine simple and concrete sentences into a single sentence or build a sentence that incorporates certain words. She used simple words to compose her essay and abstained from sentences that demanded abstract reasoning. Difficulties with concept generation , complex reasoning and acquired language is likely to limit her performance in classroom situations that demand elaborate or abstract writing suggesting that her ability to learn advanced concepts is limited.

XIII. Acquired Knowledge: Mathematics Achievement

Presenting Concerns. The Neuropsychological Processing Concerns Checklist for School-Aged Children & Youth – Third Edition (NPCC-3) was completed by mother and teacher. The areas of concern from these raters are shown in the table below.

Academic Functions: Mathematics Mild Moderate Severe Mathematics: Computational and Procedural Difficulties Makes computational errors. M, T Slow in solving math problems. M Makes careless mistakes while solving math problems. M Mathematics: Visual-Spatial Difficulties Difficulty aligning a column of numbers. M, T Difficulty understanding spatial attributes such as size and location of numbers. M Mathematics: Verbal Difficulties Difficulty with retrieval of basic math facts. M Difficulty solving story problems. M Legend: M = Mother DG’s mother and teacher noted performance concerns in mathematics pertaining to making computational errors and difficulty aligning a column of numbers. In addition, her mother indicated she is slow at solving math problems, makes mistakes and has difficulty retrieving math facts and solving story problems. Current Levels of Functioning Mathematics Achievement Scores Well Below Expected Slightly Well Level Below Below At Above Above Instrument – Subtest: Description Expected Expected Expected Expected Expected Superior Level Level Level Level Level Mathematical Calculations WIAT-III – Numerical Operations: 78 Performing a variety of math calculations. Mathematical Reasoning WIAT-III – Math Problem Solving: 100 Analyzing and solving practical math problems. Note: Standard scores appear in normal font. Scaled scores appear in (parentheses). Percentile ranks of any kind appear in italics DG’s performance in mathematical calculation was within the borderline range. However, her ability to analyze and solve practical math problems was typical when compared to other children her age. Her performance in mathematics was unevenly distributed and is likely to fluctuate. These results are partly consistent with concerns endorsed but indicate room for improvement with an appropriate intervention.

Qualitative Behaviors of Math DG’s level of automaticity solving math problems was easier when timed to complete simple addition than subtraction and multiplication. She did not exhibit any advanced computational skills. Summary of Math Achievement DG’s performance in mathematics is likely to fluctuate evidenced by the uneven distributions of her result profile. Certain aspects of her struggles in math are consistent with concerns noted by her mother and teacher. She demonstrated significant difficulties when performing a variety of mathematical calculations. In a classroom environment, there is a likelihood of her experiencing difficulties when requested to compute complex numerical operations. XIV. Social-Emotional Functioning and Adaptive Behaviors

Presenting Concerns. DG is a pleasant girl who has some social, emotional and behavior struggles. Her mother indicated she has a short attention span, hides her feelings, overacts when faced with a problem and becomes angry when she cannot figure out something. Current Levels of Functioning

1. Social-Emotional Rating Scales The BASC-Third Edition (BASC3) is an integrated system designed to facilitate the differential diagnosis and classification of a variety of emotional and behavioral disorders in children and to aid in the design of treatment plans. The BASC3 is divided into Clinical Scales and Adaptive Scales. There is a separate form for parents (BASC3 Parent Rating Scale) that her mother completed and a form for teachers (BASC3 Teacher Rating Form) that was completed by the student’s 8th grade regular education teacher. For each rater, mother, teacher and student, DG’s scores were compared to all females her age and to a School Neuropsychology Report Shell v26.1 (December, 2016) Copyright © 2016 by Daniel C. Miller, Ph.D., KIDS, Inc. 35 clinical group of girls with attention-deficit/hyperactivity disorder (ADHD). The Clinical Scales are displayed on the graph below. T-scores between 60 and 69 are considered at-risk behaviors and T-scores at and above 70 are considered clinically significant behaviors.

BASC3 Domain Parents Classification Teacher Classification Self-Report Classification

Externalizing Problems 56 Average 50 Average

Hyperactivity 57 Average 47 Average 37 Average

Aggression 55 Average 49 Average

Conduct Problems 53 Average 53 Average

Internalizing Problems 81 Clinically Significant 57 Average 59 Average

Anxiety 81 Clinically Significant 56 Average 74 Clinically Significant

Depression 71 Clinically Significant 53 Average 58 Average

Somatization 75 Clinically Significant 58 Average 56 Average

Behavioral Symptoms Index 70 Clinically Significant 58 Average

Attention Problems 57 Average 47 Average 37 Average

Learning Problems 51 Average

School Problems 49 Average 37 Average

Atypicality 69 At Risk 60 At Risk 70 Clinically Significant

Withdrawal 80 Clinically Significant 79 Clinically Significant

Adaptive Skills 35 Average 50 Average

Adaptability 33 Average 49 Average

Social Skills 42 Average 50 Average

Leadership 38 Average 52 Average

Study Skills 46 Average

Functional Communication 37 Average 53 Average

DG, her mother and teacher’s scores fall within an acceptable range and suggest they understood and responded to form items in a consistent manner. Compared to other girls with ED, her mother endorsed responses in DG’s profile that were clinically significant with internalizing problems. Both DG and her mother endorsed clinically significant anxiety problems. Further, her mother’s responses were indicative of clinically significant depression. Her mother’s representation for DG’s profile, indicated clinically significant behavior symptom index challenges. Furthermore, both mother and teacher endorsed DG’s withdrawal tendencies that were observed both at home and school. In her self-report, DG’s responses asserted clinically significant atypicality levels. In her atypical item analysis, she endorsed “Almost Always” endorsement of responses “I hear things that others cannot hear”, “Even when alone, I feel someone is watching me”, “I hear voices in my head that no one else can hear”, and “People think I’m strange.” In her “True” response, she admitted “Sometimes, when alone, I hear my name.” Traumatic Symptoms Checklist for Children (TSCC) is a measure of posttraumatic stress and related psychological symptoms in children ages 8-16. This test was chosen to objectively validate her early childhood traumatic experiences. It assesses traumatic events such as major loss, adverse childhood experiences (ACE), physical or sexual abuse, exposure to natural disasters or witness to violence. Validity scores are related to the tendency of a child either under responding or over-responding to test items. T-scores on validity scales that are 70 or higher are considered invalid. Clinical scales with T=65 or higher are significant; 60- 65 are suggestive of difficulty. T-scores 70 and higher for sexual concerns and subscales are considered clinically significant.

Trauma Symptom Checklist for Children (TSCC)

Clinical Scales T-Score Interpretation

Validity Underresponse 42 Valid Hyperresponse 82 Valid Anxiety 75 Clinically Significant Depression 63 Difficult but not significant Anger 51 Average Posttraumatic Stress 52 Average Dissociation 47 Average Overt Dissociation 48 Average Fantasy Dissociation 47 Average Sexual Concerns 50 Average Sexual Preoccupation 54 Average Sexual Distress 41 Average 36

Based on her responses, DG endorsed some degree of validity in her responses, however, some might have been over or understated. She endorsed responses that were clinically significant for anxiety. Although she manifested some difficulty with depression it did not appear clinically significant, however, her mother endorsed her being depressed in her BASC 3 profile and self-report in her MMPI-A. In addition, both her teacher and mother asserted clinically significant withdrawal symptoms. In all, her profile presents anxiety and depressive symptoms.

Minnesota Multiphasic Personality Inventory – Adolescent (MMPI-A), a 478-item self-report measure of an individual’s personality. With her previous diagnosis of bipolar disorder, the MMPI was chosen to objectively rule out any personality issues she might be experiencing. DG responded to each of the items on the measure (Cannot Say = 14) which were not high enough to invalidate her test results. She endorsed items in a consistent manner, and results suggest she may be conventional, unassuming, and unpretentious. In addition, other indicators suggest DG answered in a consistent fashion throughout the administration of the instrument (VRIN = 47, TRIN = 60T). While the Lie scale was above normal limits (L = 80T), indicating she did attempt to portray herself in a positive light, her profile suggests slight underreporting. Despite this, validity scales indicated her results were valid and omitted items were discussed with the examiner. Her clinical presentation below, revealed a 2-3/3-2 configuration characterized of depression based brooding or unhappy racing thoughts, and hysteria based somatization and need for affection. Her interpersonal relations revealed the need to be alone and being away from the crowd, evidenced by significantly high levels of shyness, introversion and low self-esteem based on self-doubt. A clinical interview pertaining to omitted items indicated attempts to kill herself by cutting her skin and biting to swallow her hair because she could not stand to see her grandfather being terminally ill from COPD and being devastated by her cousin’s death to whom she was strongly attached; all happened in 2014. She reportedly almost choked herself with stuffed hair in her throat. She continued cutting and hair biting from 2014 and stopped in 2015. When stressed, she bites her fingernails. In addition, she was bullied and had death threats at school from individuals who revenged on her because of her brother’s social challenges with other school children. After her cousin’s death, she became terrified with heights, darkness, detested being lonely from her family members and continues to have disturbing nightmares. Her symptoms are suggestive of adverse childhood experiences (ACE) which are considered to be traumatic which can be expressed through somatic complaints and the need for affection.

F L K 1 2 3 4 5 6 7 8 9 0 56 80 58 56 61 65 46 40 54 50 51 45 70

Validity and clinical scales: VRIN (variable response inconsistency), TRIN (true response inconsistency), F (infrequency), L (lie), 1 (hypochondriasis), 2 (depression), 3 (hysteria), 4 (psychopathic), 5 (masculinity-femininity), 6 (paranoia), 7 (psychastenia), 8 (schizophrenia), 9 (hypomania), 0 (social introversion)

4. Social-Emotional Test Results Social Perception Slightly Below Well Well Below Below Expected Expected Level At Expected Above Expected Above Expected Instrument – Expected Level Level Level Level Level Superior Subtest: Description Above Expected (NEPSY-II) NEPSY-II – Affect Recognition Total: Ability to (9) recognize emotions in pictures of faces.

 Total Happy 2-5 Errors

 Total Sad >75 Errors

 Total Neutral 6-10 Errors

 Total Fear 26-50 Errors

 Total Angry 26-50 Errors

 Total Disgust 51-75 Errors NEPSY-II – Theory of Mind Total: 11-25 Ability to tale the perspective of others. . Theory of 26-50 Mind Verbal School Neuropsychology Report Shell v26.1 (December, 2016) Copyright © 2016 by Daniel C. Miller, Ph.D., KIDS, Inc. 37

Score: Verbal items related to perspective taking. Note: Standard scores appear in normal font. Scaled scores appear in (parentheses). Percentile ranks and cumulative percentile ranks of any kind appear in italics. DG’s profile demonstrated her ability to recognize other people’s emotions when presented with pictures of faces, which she performed at a typical level. She had difficulties recognizing faces that presented happiness and neutrality. She performed at typical levels when identifying faces that showed fear, anger and disgust. She committed the least errors when recognizing sad faces. Her ability to tell the perspective of others was slightly below expected range and did not indicate any challenging understanding the verbal perspective of others. Social-Emotional Qualitative Behaviors Qualitative Behaviors of Spontaneous Comments Well Well Below Below Expected Slightly Below At Expected Above Expected Above Expected Instrument: Expected Level Level Expected Level Level Level Level Superior Subtest Above Expected (NEPSY-II) Possible Impulsive or Socially Inappropriate Extraneous Comments NEPSY-II: Memory for Faces and Memory for >75 Faces Delayed – Spontaneous Comments NEPSY-II: Affect Recognition – >75 Spontaneous Comments Percentile ranks and cumulative percentile ranks of any kind appear in italics. During the completion of responses related to social and emotional understanding, DG did not make any spontaneous comments suggesting the absence of any challenges with inhibition. Summary of Social-Emotional Functioning and Adaptive Behaviors DG’s mother raised pertinent concerns that were consistent with DG’s emotional/behavioral performance recorded during this testing. Her profile revealed clinically significant manifestation of internalizing difficulties that include anxiety, depression and atypical psychotic features. Although highly attached to her family, she struggles socializing with others and often finds herself solitary and withdrawn in the classroom environment. Her history of adverse childhood experiences indicated by the presence of trauma related anxiety in her profile. A likely source of her trauma is based on early childhood exposure to her grandfather’s suffering from terminal illness and the death of her beloved cousin in the same year. These adverse effects led to her manifestation of borderline-like features of body cutting which started in 2014 and ended in 2015. Her personality profile presented challenges with depression and hysteria- related somatization. Further, she struggles with attention problems of inattentiveness, sustained attention and vigilance. Although, her ability to tell the perspective of others was slightly impaired, she did not demonstrate any challenges in understanding the verbal perspective of others. Her social-emotional challenges are likely to impact her higher cognitive processing and consequently, adversely affect her academic performance, her inflexibility, frustration and anger when faced with a situation she cannot figure out and sustaining her attention to complete a task. SUMMARY DG is a 14-years 7-months old obese student, who is attending 8th grade in the middle school. She was referred for a school neuropsychological evaluation for the examiner to fulfill training course requirements. DG’s previous diagnosis of bipolar and borderline personality disorders may have been a result of her adverse childhood experiences. She demonstrated positive results of childhood trauma and personality inventory in the domains of anxiety, depression and hysteria based on somatic complaints and need for affection. Her result also showed difficulties with introversion, shyness and low self-esteem based on self- doubt. Her profile did not present any maladaptive behaviors related to bipolar or borderline personality. Her emotional disturbance (ED) that includes her struggles with anxiety, depression and social introversion, as well as her ADHD present a high probability of interfering with her academic performance and could be addressed through intervention provided below. Results from this evaluation and her history revealed difficulties with motor sensory and bladder control challenges which could be a result of poor integration of these neurocognitive processes which could have failed to properly integrate with maturity and will need further evaluation and therapy as indicated below. During her interview, she did not raise any sleep-wake irregularities that could have been attributed to complications that may arise from her pineal cyst. Any difficulties with sleep deprivation are likely to adversely affect her academic performance and need to be monitored. Strengths DG’s results revealed proficient performance on her bilateral auditory acuity and visual field perception. Although her near point visual acuity appeared impaired, she admitted her left eye convergence problems had less impact on her vision but reported her right eye has the worse problem. She indicated the need for new prescription glasses that might be helpful. She can visually scan and track simple concepts like numbers, letters or pictures but struggles with visual motor copying of symbols and other geometric patterns. With regards to her cognitive flexibility, her verbal abstract, deductive, inductive and fluid reasoning abilities appeared within the typical range. She made adequate effort towards self-monitoring and self-correction, a strength she can employ at school to improve on her academic performance. She demonstrated higher proficiencies in her verbal immediate and delay recall, that include prompting and cuing. She performed slightly better with visual immediate memory when presented with multiple choice of previously observed pictures. Her 38 attentional capacity for stories and sentences appears more significant than that for numbers and letter sequencing. In the classroom, she might benefit from narrative strategy of instruction. She could benefit from graphical or pictorial representation of educational material. She was efficient in utilizing the least number of questions in her verbal deductive reasoning and is likely to improve her learning through posing questions to improve comprehension. She is apt at providing both verbal and nonverbal motor responses to indicate her proficiency in receptive language. Weaknesses She presented a poor bilateral near point vision processing. Her performance in the classroom is likely to be impacted by her visual skills which need further evaluation and improvement. Her tactile sensation was highly deficit, she was insensitive to touch on her hands and fingers; she was unable to identify objects or drawing in her hands when blindfolded. She copied designs and performed slightly better with the presentation of an overall picture and poorly with the details. Her gross motor processing equally appeared deficient and greatly affects her psychomotor ambulation. She performed inadequately with balance and coordination when she had to perform activities with her gross motor skills. In the classroom, her writing, and coping abilities as well as her participation in extracurricular activities that necessitate gross motor use are likely to be a challenge. Her sensory motor integration is essential for higher cognitive functioning that include mathematics and written language. Overall, she demonstrated weaknesses in both her visuospatial perception and reasoning. DG demonstrated below expected levels in her overall rate of learning. She struggled more in areas that demanded visual recall than verbal. She has difficulties sustaining attention and demonstrates a high probability of making mistakes. Her difficulty in this domain is likely to impact her ability to sustain attention without losing her train of thought with increased academic content that is presented for a prolonged duration of instruction and learning. Her working memory ranges from slightly below expected to a typical level, suggesting that she could have difficulty with academic performance demanding skills such as copying information from the board, taking notes, following directions, and completing multi-step instructions. Working memory is needed in mathematical computation, and comprehension. However, some aspects of figural manipulation essential in mathematics could be a problem for DG. Her performance on this evaluation revealed some difficulties with psychomotor, naming, figural, retrieval and acquired knowledge fluency. DG demonstrated reading achievement skills at below expected levels. She lacks basic reading and comprehension skills required to enhance performance in school. Her deficiencies are consistent with concerns raised by her teacher and mother. She is likely to struggle acquiring these basic skills which are needed for further education and a successful career and could benefit from compensatory digital text books. DG demonstrated weaknesses in her ability to combine simple and concrete sentences into a single sentence or build a sentence that incorporates certain words. She demonstrated significant difficulties in mathematical calculations. In a classroom environment, there is a likelihood of her experiencing difficulties when requested to compute complex numerical operations. Her social-emotional processing reasoning revealed difficulties with depression, anxiety, somatization, inattention, poor sustain attention, vigilance, social introversion and low self-esteem. If left unattended, these struggles are likely to manifest negatively on her academic performance by impairing other neurocognitive processes.

DIAGNOSTIC IMPRESSIONS

Results of DG’s evaluation suggests the following DSM-V psychological disorders:

1. Major Depressive Disorder with psychotic features DG demonstrated following Symptoms:

 Has irritable mood most of the day, almost every day

 Often exhibits greatly decreased interest or pleasure in all, or almost all, activities most of the day, almost every day

 Has feelings of worthlessness or excessive/inappropriate guilt almost every day.

 Observed behavior in one setting (home)

 Has difficulty thinking, concentrating, or making decisions almost every day

 Recurrent thoughts about death or suicide

 Hears voices other people do not hear and thinks people are watching her

2. Persistent Depressive Disorder (Dysthymia) Symptoms associated with Depressed Mood:

 Has difficulty making decisions or concentrating

 Often has feelings of hopelessness

 Poor self-esteem

 Has a depressed mood

 Duration at least a year for children and adolescents

DG demonstrated following Symptoms:

 Difficulty to control, excessive anxiety and worry about a number of events/activities

 Has feelings of restlessness, being keyed up or on edge

 Has test anxiety

 Symptoms only present at home

4. Attention-Deficit Hyperactivity Disorder, Predominantly inattentive presentation Inattention Symptoms

 Has difficulty sustaining attention

 Often does not seem to listen when spoken to

 Is careless and does not give close attention to details

 Has difficulty organizing task and activities

 Forgetful in daily activities

 Is often easily distracted by extraneous stimuli Hyperactive-Impulsive Symptoms:

 Often Fidgets or squirms excessively

 Behavior observed only at home

5. Disruptive Mood Dysregulation Disorder (Provisional) DG demonstrated following Symptoms:

 Has verbally or physically aggressive temper outbursts

 Often persistently irritable or angry mood between temper outbursts

 Observed behavior in one setting (home)

 Symptoms started before age 10

 She is at least 6-year-old

Results of DG’s evaluation suggests the following Educational Disability Impressions 1. Other Health Impairment Other Health Impairment (OHI) is determined due to chronic or acute health problems. OHI has the vitality to adversely affect the child's educational performance. Results of this evaluation demonstrate that DG meets this criteria ADHD inattentive presentation, persistent and major depressive disorders with psychotic features and chronic anxiety disorder related to childhood trauma The following referral questions are answered in this section Specific referral questions from the parent

1. What neurocognitive processes may be affecting DG’s performance at school and what interventions may be implemented to help improve her functioning?

Neurocognitive processes likely to affect DG’s performance at school have been elaborated in the summary section above and intervention to be implemented are in the intervention section below.

2. Why does she have excessive anxiety and worry that is hard to control? 40 Results from this evaluation indicate that DG has chronic anxiety due to childhood trauma events she could not control. She has made attempts in the past to commit suicide by means of cutting, biting and swallowing hair that almost suffocated her, because she did not have the audacity and resilience when exposed to suffering from her grandfather’s terminal illness and the death of her cousin who was born on her birthday. Results from her trauma profile revealed the presence of clinically significant anxiety. She continues to have horrifying nightmares as a result of her exposure to adverse childhood experiences. Her traumatic events coupled with other poor sensory integration and psychotic experiences appear to exacerbate her uncontrollable anxiety problems. Her bladder control problems could be associated with trauma-related reversal of primitive reflexes she cannot control.

3. What are the possible long-term Lithium use on her neurocognitive performance?

Research indicates that Lithium daily use has a negative effect on immediate verbal learning, processing speed and memory (Honig, Arts, Ponds & Riedel, 1999; Wingo, Wingo, Harvey & Baldessarin, 2009). Despite this adverse effect, the individual might not notice any changes in performance.

4. What are her current levels of academic performance?

Although she performed at or above typical levels in her expressive and receptive language, her reading, written and mathematic achievement are deficient. Her poor performance is likely impacted by weaknesses in her neurocognitive processes that have been presented above.

INTERVENTION STRATEGIES AND RECOMMENDATIONS

Recommendations for Instruction at School: Strategies to improve attention

1. To improve attention and consolidate memory, she would benefit from lessons that emphasize an auditory and visual modality. 2. Memorize small chunks of verbally presented material rather than learning everything at once. 3. Participate in school activity that emphasize yoga, rhythmic movement and mindfulness training to enhance attention 4. Reinforce student for remembering details 5. Teacher recall salient details at the end of period or class as a way of redirecting attention to what is important 6. Break down lengthy assignments in small manageable chunks

Strategies to improve academics

1. Role play of social stories to enhance her social skills and encourage verbal learning 2. Employ strategic intervention for Reading Fluency (AIMSweb, Read Naturally) 3. Emphasize reading comprehension through repeated reading, discussions, analysis while noting new vocabulary. 4. Encourage the use of audio books. May use headphone to reduce distractions. (www.learningally.org) 5. Present a graphical representation of information where she can visualize and easily interpret information. 6. Establish a conversational, collaborative and participatory instruction approach that is facilitated with cuing. 7. A contingency management system; providing rewards for incremental achievements. 8. Encourage the practice of self-monitoring after she completes her work.

Recommendations for Instruction at Home: Strategies to improve social emotional, sensory integration and attention

1. She could benefit from integrated psychotherapy and medication treatment for her trauma, depression, anxiety and ADHD 2. Engage her in and out of school social skill activities or clubs (eg. Girls scot). Further, she could benefit from social skill training to enhance her ability to integrate and socialize with others 3. She could benefit from developmental vision and optometry therapy 4. She could benefit from further evaluation and occupational therapy for sensory integration 5. She could benefit from in-home and/or clinic integrated auditory, movement, visual entrainment for attention training program with parental/therapist couching

Strategies to improve academics

1. Obtain, encourage audio visual material for home use. 2. Help to start a flashcard system. Encourage verbatim copying of salient concepts and details. 3. In order to optimize consolidation of information into memory, locate a specific study area and times to study and complete assignment. 4. Parents could advocate for her to receive special accommodation/education at school. School Neuropsychology Report Shell v26.1 (December, 2016) Copyright © 2016 by Daniel C. Miller, Ph.D., KIDS, Inc. 41

Recommendations for the Student:

1. She could benefit from using audio books as alternative to reading (www.learningally.org) 2. She could benefit from flashcard system to improve memorization and recall through repetition. 3. DG is encouraged to practice basic math skills (https://www.ixl.com) 4. She is encouraged to pose questions in class to improve concept comprehension 5. She could benefit from reading aloud to her caregiver. 6. She may benefit from using a calculator and use of assistive technology such as tape recorder, typing

______?????, Psy.D. LPA Post-Doctoral Fellow

References

Honig A., Arts, B.M.G., Ponds, R.W.H.W., & Riedel, W.J. (1999). Lithium induced cognitive side-effects in bipolar disorder: a qualitative analysis and implications for daily practice. International Clinical Psychopharmacology. (14), 167-171 Wingo, A.P., Wingo, T.S., Harvey, P.D., & Baldessarini, R.J. (2009). Effects of lithium on cognitive performance: a meta-analysis. Journal of Clinical Psychiatry. 70(11), 1588-97. doi: 10.4088/JCP.08r04972 School Neuropsychology Report Shell v26.1 (December, 2016) Copyright © 2016 by Daniel C. Miller, Ph.D., KIDS, Inc. 42

School Neuropsychological Assessment Summary Form – Abilities and Skills At or Above Expected Levels Speed Student’s name: and DG Efficienc y of Student’s age: 14 years 7 months Cognitiv Student’s grade: 8th e Processin Student’s school: g Benbrook Middle School  Perfor Student’s DOB: 11/19/2002 Allocating and Maintain Attention mance Working Memory  Selective attention (auditory / visual) Fluen Examiner’s name: Facilitators/  Verbal cy Mathias Ngwa, Psy.D. LPA Inhibitors:  Selective attention (auditory / visual) o Psy  Attentional capacity (small chunks / semantic cues)  Visual Date of report: 7/9/2017 cho mot or flue ncy o Per cept ual flue ncy o Fig ural flue ncy o Na min g flue ncy o Ora l mot or flue ncy  Retrie val Fluen cy o Wo rd flue ncy School Neuropsychology Report Shell v26.1 (December, 2016) Copyright © 2016 by Daniel C. Miller, Ph.D., KIDS, Inc. 43

/ sem anti c flue ncy  Acqui red Knowl edge Fluen cy o Rea din g flue ncy (ph ono logi cal / mor pho logi cal) o Wri ting flue ncy o Mat h flue ncy

Acquired Knowledge  Semantic Memory Cognitive Processes: o Verbal comprehension  Visuospatial o General information o Perception o Domain specific knowledge o Reasoning  Language Abilities  Sound Discrimination and Auditory/Phonological o Oral expression (vocabulary knowledge) o Sound discrimination o Receptive language (listening comprehension) o Auditory/phonological  Reading Achievement  Learning and Memory o Phonological / orthographic / morphological decoding o Immediate memory (verbal / visual / associative) o Reading comprehension o Delayed memory (verbal / visual / associative)  Written Language Achievement  Executive Functions School Neuropsychology Report Shell v26.1 (December, 2016) Copyright © 2016 by Daniel C. Miller, Ph.D., KIDS, Inc. 44

o Cognitive flexibility (verbal / visual) o Written expression o Concept recognition / concept generation o Expository composition o Problem solving / fluid reasoning / planning o Spelling o Response inhibition (verbal / motoric) o Handwriting skills  Mathematics Achievement o Mathematical calculations o Mathematical reasoning Color code each of the assessment Basic Sensory Functions Fine Motor Functions Visual-Motor Integration Skills Visual Scanning Gross Motor areas according to this legend: Sensorimotor  Auditory acuity  Coordinated finger/ hand  Visual-motor copying skills  Direct measure Functions  Above Expected Level Capabilities:  Visual acuity movements  Indirect measure  Balance  At Expected Level  Tactile sensation and  Coordination  Slightly Below Expected Level perception  Below Expected Level Limiting factors (Physical / Speech or language / Environmental / Cultural / Social-Emotional) If yes, specify:

School Neuropsychological Assessment Summary Form – Abilities and Skills Slightly Below Expected to Well Below Expected Levels Speed Student’s name: and DG Efficienc y of Student’s age: 14 years 1 month Cognitiv Student’s grade: 4th e Processin Student’s school: g JL Boren Elementary  Perfor Student’s DOB:2/20/2006 Allocating and Maintain Attention mance  Selective attention (auditory / visual) Working Memory Fluen Examiner’s name: Facilitators/  Verbal cy Mathias Ngwa, Psy.D. LPA Inhibitors:  Selective attention (auditory / visual) o Psy  Attentional capacity (small chunks / semantic cues)  Visual Date of report: 8/8/2017 cho mot or flue ncy o Per cept ual flue ncy o Fig ural School Neuropsychology Report Shell v26.1 (December, 2016) Copyright © 2016 by Daniel C. Miller, Ph.D., KIDS, Inc. 45

flue ncy o Na min g flue ncy o Ora l mot or flue ncy  Retrie val Fluen cy o Wo rd flue ncy / sem anti c flue ncy  Acqui red Knowl edge Fluen cy o Rea din g flue ncy (ph ono logi cal / mor pho logi cal) o Wri ting flue School Neuropsychology Report Shell v26.1 (December, 2016) Copyright © 2016 by Daniel C. Miller, Ph.D., KIDS, Inc. 46

ncy o Mat h flue ncy

Acquired Knowledge  Semantic Memory Cognitive Processes: o Verbal comprehension  Visuospatial o General information o Perception o Domain specific knowledge o Reasoning  Language Abilities  Sound Discrimination and Auditory/Phonological o Oral expression (vocabulary knowledge) o Sound discrimination o Receptive language (listening comprehension) o Auditory/phonological  Reading Achievement  Learning and Memory o Phonological / orthographic / morphological decoding o Immediate memory (verbal / visual / associative) o Reading comprehension o Delayed memory (verbal / visual / associative)  Written Language Achievement  Executive Functions o Written expression o Cognitive flexibility (verbal / visual) o Expository composition o Concept recognition / concept generation o Spelling o Problem solving / fluid reasoning / planning o Handwriting skills o Response inhibition (verbal / motoric)  Mathematics Achievement o Mathematical calculations o Mathematical reasoning Color code each of the assessment Basic Sensory Functions Fine Motor Functions Visual-Motor Integration Skills Visual Scanning Gross Motor areas according to this legend: Sensorimotor  Auditory acuity  Coordinated finger/ hand  Visual-motor copying skills  Direct measure Functions  Above Expected Level Capabilities:  Visual acuity movements  Indirect measure  Balance  At Expected Level  Tactile sensation and  Coordination  Slightly Below Expected Level perception  Below Expected Level Limiting factors (Physical / Speech or language / Environmental / Cultural / Social-Emotional) If yes, specify: