Dr Henry Peterson, Ph.D.

Clinical Neuropsychologist
Neuropsychological Evaluation

NAME: Smith, Zachary

DOB: 04/19/2010
DOE: 12/01 & 12/03/2015
AGE: 5 years, 7 months
Referral and Background Information
Zachary Smith (Zach) is a five year old, right handed boy who is a kindergarten student in the
Therapeutic Learning Center, a separate, special education classroom at the Shirly Hills
Elementary School, MN. He lives at home in Chaska with his mother, Heather, who completed high
school and attended some college; his father, Mark, who completed an engineering degree at
University of Minnesota and who works as a director of technology for Autotrader; and his three
year old brother, Zander. Zach’s step-siblings, Tracy (17) and John (22) are Heather’s biological
children from a previous marriage and live separately.

Zachary was a planned, uncomplicated pregnancy. He was born full term via vaginal delivery
and there were no postnatal complications. He weighed six pounds and twelve ounces. For the
first three to four months, he required continuous holding and would scream if put down. Gross
motor skills developed within normal limits. Speech and language and fine motor skills were
delayed. Parents also note that Zach had a number of sensory sensitivities. Medical history is
unremarkable. Extended family history is significant for depression, anxiety, alcoholism and Autistic
Spectrum Disorder.

Zachary remained with his mother at their home in Chaska following his birth until the age of
eighteen months. He began daycare twice a week at the Burroghs School in Waconia, MN. He had
difficulty with cognitive rigidity and aggression. He remained there for two years. In May, 2014,
family moved to Brainer. Zachary was at home for the summer and, in September, began pre-K at
Next Generation in Baxter. He was in a class of twenty children and lasted one month, leaving due
to his aggression. In October, 2014, he began in an integrated preschool class of ten children and
three teachers at the Boutwell School in Baxter. He left there in April, 2015 due to repeated
aggressive episodes against peers and teachers, property destruction, tantrums, non-compliance,
bolting, spitting as well as incidents in which he disrobed and urinated and/or defecate Shirly Hills
School with a one to one staff member for a forty five day assessment. The TLC employs an
Applied Behavioral Analysis approach and over the forty five days, while Zachary’s dysregulation
continued, it diminished in frequency and intensity. In addition to the behavioral approach, Zach
also receives Occupational Therapy two to three times a week. Currently, according to his teacher,
Amber Larson, Zach continues to respond aggressively to a variety of triggers (decreased
structure, large groups, changes in routine, not being first in line, losing a game, not catching a
ball, loud noises) and will also spit, urinate, disrobe, destroy property, bolt or throw his body on the
ground. She further notes that he shows no remorse after engaging in aggressive behaviors. When
highly dysregulated, staff will either hold him or place him in a safe room in the classroom.

Previous assessments include the BASC2 and the Battle Developmental Inventory- Second
Edition at four years of age. On the Battle, concerns were raised in the areas of social, gross motor
and sensory, communication, and cognitive development. Results on the BASC2 indicated that, at
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home, most of his behaviors were scored in the average range excepting adaptability and social
skills. At school, however, virtually all of the scales were scored at the clinically significant level.
Zach has also been receiving weekly OT intervention at Brainer Integrated Therapies and works
there with Amanda Carson, who has diagnosed him with a Sensory Processing Disorder.

Parents sought the current evaluation to better understand his current cognitive, academic,
behavioral and social/emotional needs. They are very concerned about his behavior and are
seeking help to plan for the next steps. They note that he can be very endearing but that he can
still become dysregulated at home. They describe Zach as very bright, affectionate and articulate
with a great memory for details. His interests include building with Legos, pretend play, fascination
with super heroes and playing video games such as Minecraft.

Tests Administered
Wechsler Preschool and Primary Scale of Intelligence- Fourth Edition (WPPSI-IV)
Beery-Buktenica Developmental Test of Visual Motor Integration (VMI)
Children’s Memory Scale (Dot Locations, Stories)
Behavior Rating Inventory of Executive Function- Second Edition (BRIEF2)
Woodcock Johnson IV- Tests of Achievement (WJ IV - Ach)
The Rorschach Inkblot Test
The Children’s Apperception Test (CAT)
House-Tree-Person
Behavior Assessment System for Children, Second Edition (BASC-2)- teacher report and parent
rating scales.
Review of records

Mental Status and Behavioral Observation

On the first day of testing, Zachary responded to my greeting with appropriate eye contact
and reciprocated my handshake. He complied with his mother’s request to put some toys away in
the waiting room and proceeded with her and myself to my office. Once there, he was immediately
distracted by the toys on the shelf and explored them without sustaining his attention on any one
toy for more than seconds at a time. He was particularly drawn to a number of superhero figures
and displayed a vast knowledge about these and additional superhero characters and their
nemeses. Despite his mother’s requests, he was driven to continue with the toys and there was a
considerable latency for him to even acknowledge what she was saying. After he exhausted most
of the toys on the shelves, he was attracted to some of the board games. He then requested that
we play chess and insisted we try it in spite of my cautioning that it was a complicated game with
many rules. As I began setting up the board and explaining some of the pieces and their moves,
Zach used a Superman figure to joyfully crash into the pieces and requested that we repeat this
sequence several times. We did so with his understanding that after a few repeats, we would move
to the table across the room to begin the testing.

Zachary was initially engaged with the first task on the WPPSI-IV, a test on which he was
required to construct designs with blocks to recreate a model I had constructed. As the designs
became more complicated, however, he became anxious and requested that I not time him. Once
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the models shifted to a two dimensional representation, he abruptly announced “I quit. This is too
hard” and refused to continue. This pattern of his cooperation up to the point where he felt a task
was too difficult continued throughout the evaluation. At those points, he either announced that he
would not go on or, often, he would suddenly scream “NO”, bolt across the room and attempt to
leave. His mother would then bring him back and attempt to calm him. While this behavior could be
precipitated by difficult tasks, it could also result from my saying something he did not like. For
example, hoping to encourage him and reassure him that he was doing well, I attempted to
reinforce his efforts by connecting him to his interest in superheroes and called him “Super
Zachary”. He objected strongly by screaming “NO” and bolting. At other times, however, he could
accept my joking. Whether or not he would react negatively was unpredictable.

Zach’s reactivity to incidents that impinged on his sense of control was also evident. For
example, when about to eat a snack, he dropped a plastic spoon and immediately became very
distressed and dysregulated. His mother quickly reassured him that she could rapidly wash the
spoon and return it. In addition, over the course of the day, Zach became anxious about having to
defecate and attempted to do so three times, without success, instead urinating and explaining “It
hurts when that happens”. In this way, it appeared that his bladder sensation was confusing him,
making him anxious and resulting in some dysregulation. His dysregulation was also apparent in
his need to be constantly moving. He had significant difficulty remaining seated and preferred to be
walking around the room. He continued to be easily distracted, and it was possible to engage him
in tasks if I made them appear to be very interesting, thus providing him with a more salient
distractor.

As Zachary’s distress about being challenged by the materials accumulated, he became

increasingly agitated, oppositional and emotionally labile. After one of the incidents in which he
exclaimed “I hate you. I hate this place”, I asked him if he was reacting because I was asking him
to do things that were too difficult. He nodded his head “yes” and, with my apology for making him
feel badly, he was able to continue. I processed this further with him during one of our many breaks
and after he hit me for something I said. At his mother’s insistence, he said “sorry” rather
grudgingly. I then took the opportunity to apologize again for hurting his feelings and explained that
I wasn’t trying to make him feel that way and that sometimes it feels so bad he has to blame the
other person. He accepted my apology and then became much more related and began playing
with me in a more reciprocal manner. In this way, it seemed that we began repairing our
relationship. This understanding between us also appeared to begin to mitigate his reactivity to
challenging materials. He began using some of the toys, such as the Superman figure or a wind-up
toy robot, to answer difficult questions, using them as a buffer against feeling inadequate and thus
enabling him to take more risk. He was also able to comply with my request to draw, despite his
comments that “I can’t draw” and “I’m not good at it”.

The repair in our relationship was evident on the second day of testing when he was happy to
return. He had also spoken with his mother and told her that he wanted to apologize for hitting me
because he felt badly about having done it. He then proceeded to do so quite sincerely without any
prompt from his mother. Furthermore, over the course of the day, he was much more able to
tolerate my requests related to testing. He screamed at me only once on this day and did not run
away at all. He was more responsive to my suggestion that he can tell me when something is too
difficult. He also related a story about his great grandfather whose death he had recently learned
about and acknowledged that he felt sad about his father’s loss. He later asked me questions
about myself, wondering if I had children and how old they were. Upon leaving on the second day,
he cheerily said good-bye, gave a hug and added “See you next week”.
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 Thus, although it was clearly challenging for Zach to sustain his attention and effort, filter
distractions, manage his anxiety, and channel his motor overflow, when engaged, he appeared to
work hard at the tasks presented. Therefore, within the context of the above discussion, the results
reflect Zach’s functional abilities at this time. However, some findings may underestimate his
potential due to the fact that his performance was likely impacted by anxiety, his rigidity and his
difficulty sustaining his concentration and effort.

Assessment Results
General Cognitive Functioning
Zachary’s current level of cognitive functioning was assessed with the WPPSI-IV. On this
administration of the WPPSI-IV, because of the variability in the subtest scores contributing to the
Full Scale score, the Full Scale IQ is rendered meaningless and should not be considered an
accurate measure of Zach’s overall intelligence and, therefore, is not reported here. In addition, for
his age group, Zach’s verbal abilities fell at the upper end of the Average range (VCI = 108; 70th
percentile), his Visual Spatial abilities fell in the Average range (VSI = 97; 42nd percentile), his
Fluid Reasoning skills fell in the High Average range (FRI = 114; 82nd percentile), his Working
Memory was in the Low Average range (WMI = 87; 19th percentile) and his Processing Speed was
in the Borderline range (PSI = 75; 5th percentile).

Zachary’s Verbal Comprehension and Fluid Reasoning Indices were not statistically different
from each other, suggesting that his ability to access verbal reasoning skills (VCI) and his ability to
think logically and solve novel problems (FRI) were equivalent. These two domains represent
significant relative strengths. His his ability to process visual spatial information (VSI) and to hold
auditory information in his head when required to perform an operation on it (WMI) were no
different from each other. However, his ability to scan and discriminate simple visual information
and organize a motor response (PSI) was significantly lower than three of the four indices and, as
such, represents a significant relative vulnerability.

IQ and Index Scores have a mean of 100 and a standard deviation of 15; scores at 90, 100
and 110 represent levels of performance at the 25th, 50th, and 75th percentile for age,
respectively. Subtest Scores have a mean of 10 and a standard deviation of 3; scores at 8, 10 and
12 represent levels of performance at the 25th, 50th, and 75th percentile for age, respectively. The
findings are summarized in the table below:

Score Percentile
Verbal Comprehension Index 108 70
Visual Spatial Index 97 42
Fluid Reasoning Index 114 82
Working Memory Index 87 19
Processing Speed Index 75 5

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 Subtest Scores Summary

Verbal Comprehension Scales Visual Spatial Scales Fluid Reasoning Scales

Information 12 Block Design 9 Matrix Reasoning 13
Similarities 11 Object Assembly 10 Picture Concepts 12

Working Memory Scales Processing Speed Scales

Picture Memory 9 Bug Search 8
Zoo Locations 7 Cancellation 3

Verbal Functioning
Zach’s Verbal Comprehension Index of 108 on the WPPSI-IV placed him at the upper end
of the Average range for verbal functioning. There was no significant variability between subtest
scores in this area, suggesting his abilities in this area are even. On Information, a subtest
measuring his ability to acquire, retain and retrieve a general fund of knowledge, Zachary’s
answers were concise and precise. He was able to acknowledge when he did not know an answer.

Similarities is a subtest measuring his ability to reason through and articulate how two words
were alike and is considered a measure of verbal concept formation and abstract reasoning. On
this test, Zach was again able to answer concisely and precisely and, while he provided abstract
responses when familiar with the underlying relationship between words, as the underlying concept
became less familiar, his responses tended to be based in his experience and he became
frustrated and began answering all of the questions with the word “poop” or “stupid”.

Thus, on tests assessing his language skills, Zach’s performance was average. He
demonstrated an average ability in the understanding of familiar abstract language concepts. His
general fund of knowledge was also average, indicating that he is acquiring and retaining
information from his environment at a rate commensurate with his peers.

Visual-Spatial-Organizational and Fluid Reasoning (Nonverbal Functioning)

Zachary’s performance on tasks of Visual Spatial reasoning on the WPPSI-IV gave him an
overall score of 97, in the Average range for perceptual organizational skills. There was no
significant degree of variability between subtests in this area. Block Design, a timed test in which
one uses blocks to copy an abstract pattern from both three dimensional and two dimensional
models, is designed to measure one’s ability to analyze and synthesize abstract visual stimuli and
organize spatial information. On this subtest, Zach’s performance was average. He used a trial and
error approach and did best when the overall design was relatively simpler and salient. As the
designs became more complex, he became reluctant to attempt them and eventually said “I quit,
it’s too hard”. He also evidenced some anxiety about being timed and requested that I not use a
stopwatch.

He did only slightly better and in the Average range on Object Assembly, a subtest on which
one assembles the pieces of a puzzle to create a picture of an identified object. It is designed to
measure visual perceptual organization, integration of part to whole relationships and nonverbal
reasoning. On this test, Zach performed consistently and accurately until the puzzles became too

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difficult and, as they became more complex, he resorted to a trial and error approach as a means
to solve them but refused to attempt the last two.

Fluid Reasoning is the ability to think logically and solve novel problems independent of
acquired knowledge. The Fluid Reasoning Index is a composite derived from two subtests of the
WPPSI-IV. On this measure, Zach received a score of 114, in the High Average range. There was
no significant difference between the two subtests in this area. On Picture Concepts, a test on
which he had to formulate a category by which various everyday objects were organized, Zach’s
performance was variable and dropped off as the underlying relationships between visual stimuli
became more abstract and he tended to fall back on more concrete and idiosyncratic associations.
At times, he required scaffolding to help him maintain organizational set. For example, he tended
to forget that he had to pick an item from separate rows and was occasionally distracted by items
that went together within a row. With redirection, however, he was able to make an effort to
appropriately associate items across rows. On Matrix Reasoning, a test on which he had to match
the missing visual portion of a grid with one of a number of options below the grid, Zach’s
performance was more consistent and his performance dropped off as the models became more
visually complex and abstract.

Thus, on a measure of visual spatial organization, Zachary’s skills are average. As visual
spatial information becomes more complex, he relies on a trial and error approach and has
difficulty managing his frustration. Zach demonstrates a strength in the area of fluid reasoning but
his performance can be compromised by difficulties with executive functions.

Motor Functioning and Processing Speed

Zachary’s visual-motor abilities, as measured by an untimed paper and pencil task of visual
motor integration (i.e., copying progressively more complex designs), fell in the Average range
(VMI Raw Score = 15/30; Scaled Score = 10; 50th percentile; Age Equivalent = 5 years, 6 months).
While in the Average range, his performance on this test was impacted by his difficulties with
pacing, modulation of size and motor precision. He segmented two of the more complex figures at
the midline, and was reluctant to attempt both, aware that he would have difficulty executing them.
On all of the figures, he used a right handed, mature tripod grip.

Zach’s Processing Speed Index on the WPPSI-IV of 75 fell in the Borderline range. There
was, however, a significant difference between subtest scores. On Bug Search, a timed test on
which one must mark with an ink dauber the bug in the search group that matches the target bug,
Zach accurately scanned the visual arrays but, at times, became distracted by the marks the
dauber made and would repeatedly daub the target stimulus to, for example, cover it completely.
On Cancellation, also a timed task on which one must scan separate random and structured arrays
of objects and mark target objects with an ink dauber, Zach took a disorganized approach on both
tasks, an approach characterized by frequent pulls to and distractions by any target in his field of
vision rather than a sustained and organized effort. He was also slowed considerably by his
tendency to become distracted by the complex visual array.

Together, results from tests of motor functioning and processing speed suggest that Zach is
able to organize visual motor output for simple figures to an average degree but evidences relative
difficulty with fine motor precision, modulation, crossing the midline and pacing. His processing of
complex visual information is below average and is vulnerable to his difficulty mounting an
organized response and distractibility.
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Attention, Working Memory and Executive Functions

The term Executive Functions encompasses a constellation of skills that allows one to set a
goal and work towards completion of that goal. The most important of those skills include deploying
attention, filtering out distractions, sustaining effort and attention, self monitoring, maintaining or
switching cognitive set, inhibiting impulsivity, regulating emotional reactivity, and holding
information in one’s head when required to perform an operation on it (working memory).

Zachary’s performance on the WPPSI-IV tasks of Working Memory, the ability to hold visual
information in his head when required to perform an operation on it, fell in the Low Average range.
There was no significant difference between the two subtests in this area. On Picture Memory, a
task in which he had to view a visual stimulus page of one or more pictures for a specified amount
of time and then select the pictures from options on a response page, Zach scored in the Average
range. His performance was variable and was subject to his variable attention and, as the number
of objects that he had to recall increased, he became upset, screamed “NO” and refused to
continue. On Zoo Locations, a subtest requiring that he view one or more animal cards on a zoo
layout for a specified amount of time and then place each card in the previously viewed locations,
he did less well and scored below average. On this task, his performance dropped off as he had to
recall more complex combinations of spatial locations and different animal cards, an executive
function requiring him to hold more than one visual modality at a time in working memory.

Results from the BRIEF2, a questionnaire given to parents and teachers that is designed to
access information about executive functions, are shown below. T scores of 60 to 65 are Mildly
Elevated, scores from 65 to 70 are Potentially Clinically Elevated and scores of 70 and above are
Clinically Elevated. Scores falling within these three ranges are in bold in the table below.

Scale/Index/Composite Parent Report (T Scores) Teacher Report (T Scores)

Inhibit 63 75

Self Monitor 58 58

Behavior Regulation Index (BRI) 62 69

Shift 76 85

Emotional Control 74 88

Emotional Regulation Index (ERI) 77 88

Initiate 46 56

Working Memory 52 59

Plan/Organize 47 58

Task-Monitor 39 51

Organization of Materials 45 44

Cognitive Regulation Index (CRI) 46 56

Global Executive Composite (GEC) 60 65

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 Thus, results from current observation, tests of working memory and from the BRIEF2
indicate that Zach is struggling with a significant number of executive functions. Of greatest
concern is his difficulty regulating his emotions, a finding in the Clinically Elevated range on the
parent form. His profile in school highlights the same areas of concern but at a significantly higher
level.

Memory Functioning
An evaluation of Zachary’s learning and recall for both verbal and visual modalities was
attempted using selected subtests of the Children’s Memory Scale. Because he refused to try a
number of subtests, scores for a measure of visual spatial recall and verbal recall for a story are
reported.

CMS Core Subtest Scores- Standard Scores (percentiles)

Visual Memory
Dot Locations Stories
Learning 10 (50) Immediate 8 (25)
Total Score 10 (50) Delayed Refused
Long Delay 10 (50)

Thus, Zach was able to learn and retrieve visual spatial information to an average degree on
tasks of both immediate and delayed recall. His recall for contextualized auditory information was
at the low end of the average range. As both visual and auditory information becomes lengthier
and more complex, he has significant difficulty both sustaining his attention, tolerating his
frustration and maintaining his effort.

Tests of Achievement
Zach was given selected subtests of the WJ IV - Ach to assess his academic skills. The
following are his scores in the specific areas measured for his age.

Skill Areas
Reading- The Reading cluster provides a measure of reading achievement including reading
decoding and the ability to comprehend connected discourse while reading. It is a combination of
Letter-Word Identification and Passage Comprehension. On this measure of reading ability, Zach
received a Standard Score of 95, in the Limited to Average range.
Mathematics- The Mathematics cluster is an aggregate measure of problem solving and
computational skills and provides a measure of math achievement. It is comprised of the Applied
Problems and Calculation tests. On this measure of basic math skills, Zach received a Standard
Score of 101, in the Average range.
Written Language- The Written Language cluster is a comprehensive measure of written
language achievement. This cluster is a combination of Spelling and Writing Samples. On this
measure of written expression, Zach received a Standard Score of 89, in the Limited range.

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 Academic Skills- The Academic Skills cluster is an aggregate measure of reading decoding,
math calculation and spelling of single-word responses providing an overall score of basic
achievement skills. It is a combination of Letter-Word Identification, Calculation and Spelling. On
this overall measure of achievement, Zach received a Standard Score of 97, in the Average
range.
Academic Applications- The Academic Application cluster is a combination of Applied
Problems, Passage Comprehension and Writing Samples. These tests require one to apply
academic skills to academic problems. On this measure, Zach received a Standard Score of 91,
in the Limited range.

Brief Achievement- The Brief Achievement cluster is a combination of Letter-Word

Identification, Applied Problems and Spelling. It screens for performance across reading, writing
and math. On this measure, Zach received a Standard Score of 100, in the Average range.

Individual Achievement Tests

Letter-Word Identification- This test measures an individual’s letter and word identification
skills and requires the correct pronunciation of increasingly difficult words. On this measure, Zach
received a Standard Score of 97, in the Average range.
Applied Problems- This test measures one’s ability to analyze and solve math problems. On
this measure, Zach received a Standard Score of 107, in the Average range.
Spelling- This test measures knowledge of spelling and requires the individual to produce
letters and words in response to oral prompts. On this measure, Zach received a Standard Score
of 100, in the Average range.

Passage Comprehension- This test is a measure of reading comprehension and lexical

knowledge and requires the ability to use syntactic and semantic cues. Initially, it requires one to
match a rebus with a picture and then match a picture to a phrase. On this measure, Zach
received a Standard Score of 94, in the Limited to Average range.

Calculation- This test measures the ability to perform mathematical computations and
requires an individual to perform a variety of calculations ranging from writing simple numbers,
simple calculations, etc. On this measure, Zach received a Standard Score of 96, in the Average
range.
Writing Samples- This test measures the ability to convey ideas in writing and requires the
production of meaningful written sentences in response to a variety of task criteria. It begins with
the writing of one’s name and one word identification of objects. On this measure, Zach received a
Standard Score of 85, in the Limited range.

Thus, Zachary’s math skills are average while his reading skills fall in the lower average
range and his written expression is on the borderline between average and below average. His
strength lies in the area of mathematical reasoning while he demonstrates a relative vulnerability in
written output.

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Behavioral Functioning
Zachary’s parents completed the Parent Rating Scales on the BASC2 as a means to describe
his behavior at home. His teacher, Amber Larson, completed a Teacher Rating Scale as a means
to describe his behavior in school. Scores in the At Risk range (AR) are considered a problem
requiring careful monitoring while those in the Clinically Significant range (CS) suggest a high level
of maladjustment. Scores designated neither AR or CS are considered to be within the Average
range (AVG). The table below presents the results from the parent and teacher scales.

Scale Parent Teacher Composite Scores Parent Teacher

Hyperactivity AVG CS Externalizing Problems AR CS
Aggression AR CS Internalizing Problems AVG AR
Anxiety AVG AR Behavioral Symptoms AR CS
Depression AVG CS Adaptive Skills AR AR
Somatization AVG AVG Content Scales
Atypicality AVG AR Anger Control CS CS
Withdrawal AVG CS Bullying AR CS
Attention Problems AR AR Developmental Social Disorder AR CS
Adaptability CS CS Emotional Self-Control AR CS
Social Skills CS AR Executive Functioning AR CS
Activities of Daily Living AVG NA Negative Emotionality AR CS
Functional Commun. AVG AVG Resiliency CS CS

Based on the above results, Zach’s parents expressed concerns at a moderate level
regarding his Externalizing Problems, Behavioral Symptoms and Adaptive Skills with the latter
category including Clinically Significant levels of concern regarding Adaptability and Social Skills.
In addition, all of the Content Scales were either At Risk or Clinically Significant. In respect to
school, Zach’s teacher reports Externalizing Problems and Behavioral Symptoms at a Clinically
Significant level while Internalizing Problems and Adaptive Skills were At Risk. Nearly all of the
scales making up those composites were either At Risk or Clinically Significant while all of the
Content Scales were Clinically Significant. Thus, Zach’s behavior is more concerning within the
school environment. Of further note, relative to results from a BASC2 completed one year ago,
Zach’s reported behavior has worsened significantly at home and has largely remained the same
at school.

Emotional Functioning
Zachary is a troubled young boy who, nevertheless, has a number of significant strengths.
These include his language, fluid reasoning and math reasoning skills as well as his ability to think
logically and coherently and his interest in engaging in relationships. His vulnerabilities include his
difficulty with processing and executive functions with the latter including his rigidity, difficulty
sustaining his effort and attention, distractibility and his behavioral and emotional dysregulation.
Zach’s difficulty regulating his behavior and emotional reactivity have a neurological basis but have
been exacerbated over time as he has confronted the ordinary demands placed on him by his

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environment both at home and at school. Because he has the capacity for self awareness, his
dysregulation has also negatively impacted his self image. Furthermore, his behavior is alienating
his peers and making it difficult for him to make good use of and sustain relationships. Despite this,
he continues to have the capacity to relate in a meaningful way and, when not dysregulated, can
benefit from such relationships.
On current tests of emotional functioning, findings indicate that Zach is experiencing a
significantly heightened level of chronic stimulus overload due to his difficulty drawing on adequate
psychological and emotional resources. Because his capacity to adapt to environmental demands
is below average for a child his age, he is vulnerable to becoming overwhelmed by the ordinary
stresses of everyday life. This can contribute to his feeling anxious, tense, reactive and irritable.
Furthermore, his ability to tolerate frustration is severely compromised and can result in frequent
outbursts and impulsive behavior. Thus, when challenged in this manner, Zach is likely to respond
in a fight or flight manner, resulting in aggressive outbursts or a tendency to bolt.

Zach has particular difficulty managing challenges when they are of a more complex or
ambiguous nature. He therefore benefits from clearly defined, structured and less complex
situations in which expectations are unambiguous. In more emotionally complex situations, he is
therefore at risk for becoming confused, overwhelmed and reactive. Furthermore, while his ability
to distinguish between fantasy and reality is normally adequate, when he is emotionally
overwhelmed and disoriented, he can have a tendency to misperceive events and the intentions of
others. This confusion of reality and fantasy can then result in his exercising poor judgement and
contribute to his impulsive behavior and emotional reactivity, further confusing his perceptions. In
addition, his cognitive rigidity can further contribute to his difficulty reconsidering and taking
another’s perspective.

Despite his capacity for introspection, Zach is currently avoiding self focusing as doing so
makes him aware of the difficulties he is experiencing and results in his comparing himself
unfavorably to others. He observes others as being better able to manage themselves and to
better meet the demands placed on them. His confidence in himself has been undermined and he
is experiencing low self esteem. His tendency to judge himself negatively is contributing to feelings
of anxiety and depression. The latter is being exacerbated by his difficulty expressing his emotional
experience and his tendency to internalize his feelings rather than articulate them. Nevertheless,
he remains very responsive to someone being able to articulate what he is experiencing and
making a connection with them on this basis. Thus, his ability to make good use of a relational
approach in which he is given language to organize his emotional experience is a significant
strength and one that contributes to a good prognosis. A strictly behavioral approach to managing
his behavior, while having been helpful in the past, is not recommended going forward, as it will not
deal with the processing of his affective experience and social difficulties within the context of an
ongoing and developing relationship.

Summary and Recommendations

Zachary Smith is a five year old boy who has been evaluated at the request of his parents to
better understand his current cognitive, academic, behavioral and social/emotional needs. They
are very concerned about his behavior and are seeking help to plan for the next steps. Previous
assessments include the BASC2 and the Battle Developmental Inventory- Second Edition at four
years of age. On the Battle, concerns were raised in the areas of social, gross motor and sensory,
communication, and cognitive development. Results on the BASC2 indicated that, at home, most
11
of his behaviors were scored in the average range excepting adaptability and social skills. At
school, however, virtually all of the scales were scored at the clinically significant level. Zach has
also been receiving weekly OT intervention at Baxter Integrated Therapies and works there with
Amanda Carson, who has diagnosed him with a Sensory Processing Disorder.

On current testing, although it was clearly challenging for Zach to sustain his attention and
effort, filter distractions, manage his anxiety, and channel his motor overflow, when engaged, he
appeared to work hard at the tasks presented and made good use of the relationship he developed
with myself. Therefore, within the context of the above discussion, the results reflect Zach’s
functional abilities at this time. However, some findings may underestimate his potential due to the
fact that his performance was likely impacted by anxiety, his rigidity and his difficulty sustaining his
concentration and effort.

On tests of cognitive functioning using the WPPSI-IV, Zach’s verbal abilities fell at the upper
end of the Average range, his Visual Spatial abilities fell in the Average range, his Fluid Reasoning
skills fell in the High Average range, his Working Memory was in the Low Average range and his
Processing Speed was in the Borderline range. His Verbal Comprehension and Fluid Reasoning
Indices were not statistically different from each other, suggesting that his ability to access verbal
reasoning skills (VCI) and his ability to think logically and solve novel problems (FRI) were
equivalent. These two domains represent significant relative strengths. His his ability to process
visual spatial information (VSI) to hold auditory information in his head when required to perform
an operation on it (WMI) were no different from each other. However, his ability to scan and
discriminate simple visual information and organize a motor response (PSI) was significantly lower
than three of the four indices and, as such, represents a significant relative vulnerability.

In the verbal area, on tests assessing his language skills, Zach’s performance was average.
He demonstrated an average ability in the understanding of familiar abstract language concepts.
His general fund of knowledge was also average, indicating that he is acquiring and retaining
information from his environment at a rate commensurate with his peers.

In the area of visual spatial organization, Zach’s skills are average. As visual spatial
information becomes more complex, he relies on a trial and error approach and has difficulty
managing his frustration. Zach demonstrates a strength in the area of fluid reasoning but his
performance can be compromised by difficulties with executive functions.

Results from tests of motor functioning and processing speed suggest that Zach is able to
organize visual motor output for simple figures to an average degree but evidences relative
difficulty with fine motor precision, modulation and pacing. His processing of complex visual
information is below average and is vulnerable to his difficulty mounting an organized response
and distractibility.

In regard to his attentional and executive functioning abilities, results from current
observation, tests of working memory and from the BRIEF2 indicate that Zach is struggling with a
significant number of executive functions. Of greatest concern is his difficulty regulating his
emotions, a finding in the Clinically Elevated range. His profile in school highlights the same areas
of concern but at a significantly higher level.

On tests of memory functioning, Zach was able to learn and retrieve visual spatial information
to an average degree on tasks of both immediate and delayed recall. His recall for contextualized
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auditory information was at the low end of the average range. As both visual and auditory
information becomes lengthier and more complex, he has significant difficulty both sustaining his
attention, tolerating his frustration and maintaining his effort.

Regarding tests of achievement, Zach’s math skills are average while his reading skills fall in
the lower average range and his written expression is on the borderline between average and
below average. His strength lies in the area of mathematical reasoning while he demonstrates a
relative vulnerability in written output.

On the BASC2, Zach’s parents expressed concerns at a moderate level regarding his
Externalizing Problems, Behavioral Symptoms and Adaptive Skills with the latter category including
Clinically Significant levels of concern regarding Adaptability and Social Skills. In addition, all of the
Content Scales were either At Risk or Clinically Significant. In respect to school, Zach’s teacher
reports Externalizing Problems and Behavioral Symptoms at a Clinically Significant level while
Internalizing Problems and Adaptive Skills were At Risk. Nearly all of the scales making up those
composites were either At Risk or Clinically Significant while all of the Content Scales were
Clinically Significant. Thus, Zach’s behavior is more concerning within the school environment. Of
further note, relative to results from a BASC2 completed one year ago, Zach’s reported behavior
has worsened significantly at home and has largely remained the same at school.

In respect to emotional functioning, Zach is a very troubled young boy who, nevertheless, has
a number of significant strengths. These include his language, fluid reasoning and math reasoning
skills as well as his ability to think logically and coherently and his interest in engaging in
relationships. His vulnerabilities include his difficulty with processing and executive functions with
the latter including his rigidity, difficulty sustaining his effort and attention, distractibility and his
behavioral and emotional dysregulation. Zach’s difficulty regulating his behavior and emotional
reactivity have a neurological basis but have been exacerbated over time as he has confronted the
ordinary demands placed on him by his environment both at home and at school. Because he has
the capacity for self awareness, his dysregulation has also negatively impacted his self image.
Furthermore, his behavior is alienating his peers and making it difficult for him to make good use of
and sustain relationships. Despite this, he continues to have the capacity to relate in a meaningful
way and, when not dysregulated, can benefit from such relationships. Thus, his ability to make
good use of a relational approach in which he is given language to organize his emotional
experience is a significant strength and one that contributes to a good prognosis. A strictly
behavioral approach to managing his behavior, while having been helpful in the past, is not
recommended going forward, as it will not deal with the processing of his affective experience and
social difficulties within the context of an ongoing and developing relationship.

In light of these findings, the following recommendations are made.

• Parents are encouraged to review some of the results of this assessment with Zach. It would be
helpful for him to appreciate his strengths and to understand his vulnerabilities within the context
of these strengths. Being very specific about both his vulnerabilities and strengths would
potentially help him develop a more balanced perception of himself.

1)Regarding school programs:

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• Parents are encouraged to share the details of this report with Zach’s teachers. A better
understanding of his relative strengths and vulnerabilities on the part of school personnel will help
them support him more effectively. This report could be used as a basis to provide additional
support and integrated into his Individualized Educational Program to address his academic,
behavioral, social and emotional needs.

• Zach would function best within a small, contained, language based classroom with a low student
to teacher ratio. It should be a classroom that could accommodate his sensory, executive
functioning, social and emotional needs. It should be populated by peers with similar issues so
that material is geared to his learning level, he can participate as a full member of the classroom
and he would have a consistent peer group that was not fragmented by a shifting population
throughout the day. Children in the classroom should be at a similar cognitive level and have the
capacity for social skills roughly equal to Zach’s abilities. Because he does not present as a child
with a profile consistent with children on the Autistic Spectrum, placement in a classroom
specifically designed for that population would not be appropriate. Furthermore, while he has
made significant gains using an Applied Behavioral Analysis (ABA) approach, he now requires an
approach that emphasizes the development of relationships, the processing of emotions and the
provision of language to help him better understand his emotional experience and modify his
behavior. Therefore, an ABA approach is not recommended.

• While Zach has clear cognitive strengths, his educational program, at this point, requires that he
be provided a highly individualized curriculum; one that can be oriented to his interests and draw
on his knowledge base as a means to help him connect new learning with familiar material.

• Zach will require a daily therapy/social skills group as a means to develop strategies to develop
better social pragmatic skills. This group should be conducted by either a psychologist or
licensed mental health clinician who has been trained in social skill development and therapeutic
approaches.

• Adaptations within the classroom that are useful to children with attentional issues would be
appropriate for Zach. Placement of his seat near the teacher would optimize his engagement. In
addition, he would benefit from the availability of fidget toys to help him displace or focus his
motor overflow as well as scheduled sensory breaks to reset his sensory and motor thresholds.
In addition, a quiet place in the classroom to which he could retreat when overwhelmed would
help him better manage the classroom environment. Weekly consultation from an OT would
support this program.

• Zach will require continued support in addressing his graphomotor vulnerabilities through OT
services. Demands for increased production will amplify the fatigue and frustration resulting from
such effort. Eventually, in later grades, the use of an alpha smart or computer may be the most
efficient means of written expression. Programs such as Type To Learn would help him develop
his keyboarding skills.

• Zach will continue to require direct OT intervention to address his sensory processing issues. He
should receive twice weekly sensory integration therapy to develop better body awareness and
modulation. This should be reinforced with weekly therapy at Baxter Integrated Therapies.

• Zach would eventually benefit from the use of a computer with graphic organizer software to
complete written assignments of any length as he progresses through upper grade levels. A
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 program such as Kidspiration would enable him to circumvent his graphomotor weakness while
also being able to more easily edit his work. In addition, such a program could provide the
scaffolding and organizational support that he needs, enabling him to more easily provide details
and interrelate them.

• Zach will need support in the development of organizational skills. Particularly as the demands of
school increase regarding independence, he will need explicit strategies to organize his
homework and use of time. He will also need support understanding and maintaining
organizational sets, i.e., keeping his eye on the bigger picture. The teaching of these
organizational strategies would be done with the goal of Zach becoming an independent learner.

• Specific organizational strategies that would support Zach’s progress as an independent learner
would include; 1) previewing of material, 2) the development of frameworks into which material
can be organized to prevent him from losing set or the “big picture”, 3) learning to structure new
learning and problem solving, particularly within the context of familiar and favored internal
templates, 4) learning to rehearse material verbally and within the context of narratives and 5)
learning to develop a summary of expectations of written work.

• The school should provide staff for active liaison with parents and allocate staff time for planning
which develops and maintains a consistent approach across the school day and between home
and school.

• Zach should be monitored for signs of difficulty in making educational progress as expectations
for more complex work increase in the classroom, such as increased emotionality, difficulty
understanding or completing assignments, or increased distress associated with school. If such
events occur, further interventions and support may be appropriate.

2) Regarding therapeutic services;

• Zach would benefit from an individual play therapy that would serve to help him gain a better
understanding of himself and his emotional response to his relative strengths and vulnerabilities.
One goal would be, with time, to integrate his understanding of these feelings into his experience.
This, ultimately, would enable him to access his affective experience in making sense of his
world. This could be done through play and the utilization of narratives that could give him a
context for his emotional experience.

• This therapy could also address his learning and processing issues. He will need ongoing
support to better understand his processing style and develop better coping strategies. He will
eventually need to be able to embrace his learning differences and begin to advocate for himself
through a clear understanding of his needs.

• Zach’s therapist would be in an advantageous position to consult, as needed, with school

personnel in their efforts coordinating an integrated approach to meet his social, emotional and
behavioral needs.

• Zach’s parents would benefit from receiving help in their ongoing efforts to support him. This
could take the form of child guidance consultations with his therapist.

3) Further considerations
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• Given Zach’s pattern of explosive behavior and feelings of remorse, parents should seek a
consultation with a neurologist to rule out any underlying neurological factor.

It was a great pleasure to meet and work with Zachary and his very caring parents. If you
have any further questions, please contact me at the number listed above.

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