340 ESSENTIALS OF NEPSY-II ASSESSMENT

page attached to the back of the report. Interpretations should be straightforward and readable without too much technical lingo. The authors find that designating the primary, secondary, and co-occurring deficits is a helpful device to help parents and professionals understand the influence of deficit areas on the subcomponents of complex functions and how that impacts the child’s performance in specific areas. Discuss the influence of deficits across domains so your reader can understand how a primary deficit in one domain can influence performance in several other domains. Verify your interpretation by relating findings to the referral question, and to developmental, educational, or medical factors that are impacting the child’s functioning in everyday life. Your interpretation should speak directly to the interventions that you recommend. There is no point in interpreting findings and then attaching interventions that have little or no connection to interpreted findings. It is hoped that the following illustrative case reports will help you understand the use of NEPSY-II Referral Batteries and different approaches to compiling and interpreting test results that will lead to meaningful interventions.

The first case study is a brief report of an evaluation with a General Assessment Battery due to a vague referral question. It reveals how important diagnostic information can be gleaned from such an assessment, and the results can be used to build a further assessment, if necessary, and to design a treatment plan. It is also a demonstration of how subtests can be used clinically when scoring them would be misleading.

The second case is the report of a child with math difficulties who is not responding to interventions, and his parents question whether or not he is receiving appropriate remediation. He was assessed with the focused Learning DifferenceMathematics Referral Battery.

The third case is the report of a child with high-functioning autism who was re-evaluated with the Social/Interpersonal Referral Battery in order to help with the decision whether or not to place him in a regular classroom. It also demonstrates how subtests not needed can be eliminated from the Referral Battery and more pertinent subtests can be substituted.

CASE STUDY #1: GENERAL REFERRAL BATTERY

Neuropsychological Report

Text in italics and enclosed by brackets ([ ]) is intended to be interpretive for the reader of this volume and is not a part of the assessment report.

ILLUSTRATIVE CASE REPORTS 341

Referral Statement

Julianne D. is a 6.5-year-old girl who resides with both parents. She has no siblings. Julianne is presently in kindergarten at Sunshine Elementary School. Julianne was brought for evaluation by her parents because they and Julianne’s teacher are confused by her learning profile. She is very verbal and expressive, but has marked difficulty with any type of spatial activities (puzzles, copying, etc.). Julianne’s teacher, Ms. N., referred Julianne for assessment through the school, and the school psychometrist administered a brief cognitive screening (see following) that revealed an intellectual deficit. The psychometrist felt that developmental immaturity might have negatively affected Julianne’s results, because her vocabulary level was average. The psychometrist noted, however, that Julianne should have a full evaluation, but reported that it would be several months before she would be able to undertake any further testing for Julianne. The D. family feared that Julianne would fall further behind in school in that amount of time; therefore, they sought an outside evaluation through this clinic. (See Rapid Reference 7.1 concerning information to include in referral section.)

Rapid Reference 7.1

Information for Referral Section

•Identify the child by full name, age, and gender (nickname can be put in quotation marks)

•Brief description of child’s family and with whom the child lives

•Referral source(s)

•Brief description of presenting problem (this focuses the report immediately on the referral question(s) to be answered)

Relevant History

History was obtained from a review of the history form filled out by Julianne’s parents and the parent interview prior to Julianne’s assessment, as well as a review of school records, and a telephone conference with the school psychometrist and Julianne’s teacher.

342 ESSENTIALS OF NEPSY-II ASSESSMENT

Julianne is an only child born to apparently caring parents in an intact family. Mr. D. is a draftsman for an engineering firm and Mrs. D. works as a baker in a local grocery store. Both parents report that they were average students and are high school graduates. Father had an additional year of technical training. Mother’s family history is unremarkable for any neurodevelopmental disorders, but Julianne’s father was adopted and he has no biological family medical history.

Mr. and Mrs. D. report that Julianne’s general health is good. She was the product of a full-term, uneventful pregnancy, and an uncomplicated natural birth. She weighed 6 lbs 1 oz. Parents are of average size, but Julianne has always been petite. Mr. and Mrs. D. have assumed that one of Mr. D’s biological parents had a short stature. Parents reported that developmental landmarks were attained within normal limits for the most part, but these landmarks were not documented medically. Little health history is available for Julianne, as she has not been seen by a doctor since her birth, with the exception of three visits in as many years to the emergency room of the local hospital for fever and earache. Julianne’s parents explained that they do not have health insurance. This clinic has sliding scale fees, so Mr. and Mrs. D. were able to make payment arrangements for her evaluation.

Julianne’s parents characterized her as an “easy, very social” infant. She has always been sensitive to noises in the environment, however. Sometimes, these seem to be noises that other children do not mind (e.g. a small bell ringing). Julianne will also comment on an airplane coming before the sound is audible to others in the family. Mother reported that Julianne was a little slow in talking at first, but became very talkative and expressive by the time she was 18 months. She loves to tell stories, and her parents feel that these are quite advanced for Julianne’s age. The one developmental area that has caused Mr. and Mrs. D. concern is Julianne’s inability to assemble puzzles, to build constructions from a picture, and to copy a picture, or do craft activities at a level that they would expect for her age. For this reason, and because Julianne’s maternal grandmother was able to continue taking care of her on the three days that Mrs. D. worked, her parents delayed Julianne’s entry into kindergarten for an extra year. They felt that this extra time might allow her to “catch up.” Julianne’s vision was tested just before school began, because Mr. and Mrs. D. thought that Julianne’s vision might be causing her problems in working with shapes, puzzles, and constructional tasks. Her vision was within normal limits, however.

A month after school began, the kindergarten teacher requested a meeting with Julianne’s parents because their daughter was already experiencing marked learning problems. The teacher reports that despite her well-developed expressive language, Julianne is having trouble learning basic concepts, such as above/below, inside/outside, over/under, and she becomes confused when trying to follow oral directions that include spatial concepts. Although she can say the names of the four

ILLUSTRATIVE CASE REPORTS 343

basic shapes, Julianne cannot identify them if she is given the oral label, nor can she attach the correct names to the correct shapes. Likewise, Julianne can sing the “Alphabet Song” but she has trouble identifying the symbols A, B, and C, because she confuses the shapes. The same is true for numbers. Julianne can count to eight correctly, but mixes up the visual symbols. Mr. & Mrs. D state that Julianne is a year older than her classmates, so her parents feel she should be mastering these concepts easily. Instead, she is falling further and further behind them in learning. Parents have wondered if Julianne might be dyslexic.

Julianne has always been well-liked by children in the neighborhood, according to Mr. and Mrs. D. They have noticed, however, that she prefers to play with children who are younger than she is. They feel that that may be partly because she is petite and feels more confident with them. The teacher reports that she socializes well at school and loves to play in the puppet center where she can make up puppet plays. She is very imaginative in doing this, and the other children enjoy doing the plays with her. The teacher and Julianne’s parents feel, however, that a significant gap is opening up between Julianne’s spatial abilities and those of her peers, yet she converses easily with them and with adults.

Previous Testing

On 09-01-08, the Wechsler Abbreviated Scale of Intelligence (WASI), a brief cognitive measure, was administered to Julianne by M. S., MA, the psychometrist at Julianne’s school. The two subtests (Vocabulary and Matrix Reasoning) version was chosen. It yielded an estimated FSIQ of 68 (2nd percentile), with a significant difference between verbal and nonverbal reasoning. The psychometrist noted that this cognitive ability level seemed to be at variance with Julianne’s good language development, since vocabulary is usually a good general estimate of cognitive ability.

Behavioral Observations

Julianne is a right-handed young girl with blonde hair, blue eyes, and elfin features. She was well-groomed, and appeared well-nourished, though small-for-age. Julianne was very friendly and talkative as she entered the testing session. She separated easily from her mother and settled quickly at the testing table, chatting with the examiner happily. Eye contact was good. When chatting with this clinician, Julianne was verbally and affectively expressive, using very nicely crafted phrases spontaneously. Despite her good language skills, however, Julianne appeared immature for chronological age. For instance, in the waiting area and in this examiner’s office during the break, she chose to play with the toddler toys, rather than toys usually chosen by 6 year-olds.

344 ESSENTIALS OF NEPSY-II ASSESSMENT

It was notable during the testing that when a task required visuospatial skills or even when the stimuli on a task from a different domain were spatial, Julianne’s performance would slow and she would become confused. This was first evident on the Inhibition subtest that has circles, squares, and directional arrows as stimuli. With just a little reassurance, however, Julianne was ready to try the task. Julianne used a fragmented piecemeal approach to Design Copying. She rarely was able to produce the correct overall configuration. She tended to focus on producing the inner details, but even then they were not integrated. She attempted to talk her way through visuospatial tasks, but was rarely successful, even with verbal mediation. Julianne attended well for the most part, but would become confused with visuospatial stimuli. She was extremely cooperative, and gave very good effort to the assessment. Even when she knew a task would be difficult, she did not become upset, and was willing to try her best. Therefore, this assessment is felt to be a reliable reflection of Julianne’s abilities, given the caveats on certain subtest results presented in this report.

Test Battery Administered

NEPSY-II, General Assessment Battery.

[Because the referral question was vague and time was of the essence, the clinician selected the NEPSY-II General Assessment Battery, knowing that she could get a quick overview of skills in that way, but that, if needed, she could then add any subtests that she felt were necessary in order to delineate Julianne’s primary and secondary defi cits more fully.]

Test Results

Attention and Executive Functioning Domain

Julianne’s performance on the Auditory Attention subtest showed an AA Total Correct Scaled Score of 9 in relation to the NEPSY-II subtest mean of 10 + 3. This performance was At Expected Level for age. Julianne was required to listen for the word red among many other distracter words. When she heard the word red, she was to touch the correct color on an array with a yellow, a blue, a black, and a red circle.

The AA Combined Score integrated her AA Total Correct Scaled Score and the AA Total Commission Errors Percentile Rank (26th–50th percentile), both At Expected Level. A commission error occurs when the child touches the wrong color or touches the correct one more than 2 seconds after hearing the word. Julianne made 3 commission errors, which is average for age. Therefore, her AA Combined Scaled Score (9) was also At Expected Level.

Julianne displayed two instances of inattention on the Behavioral Observations for AA Inattentive Off-Task Behavior Total, which fell At Expected Level

ILLUSTRATIVE CASE REPORTS 345

(Cumulative Percentage of 26–75) when compared to the normative sample for age. Response Set is the second task in this subtest and a part of the General Assessment Battery, but it is intended for ages 7–16, so it was not administered to Julianne.

On the Inhibition subtest, the Naming condition assesses the ability to name shapes and directions from visual stimuli (circles and squares and arrows pointing up and down) quickly, while the Inhibition condition assesses the ability to inhibit a welllearned response in order to say the opposite. Upon seeing the first stimulus picture of circles and squares, Julianne commented that she sometimes gets “mixed up on shapes.” This examiner wanted to proceed with the task in order to observe how Julianne performed with spatial stimuli on a task that was not in the Visuospatial domain. In other words, would she have difficulty with spatial material only on a visuospatial task, or would she also have problems with spatial stimuli in other domains? This clinician reassured her by explaining that the task might be a little difficult, but she should just do her best so that the examiner could see how to help her. She was willing to try and did not appear tearful or anxious, so testing proceeded. Despite her good humor and effort, Julianne displayed marked difficulty, especially on the second section of the test where she had to name the opposite shape for the one shown and the opposite direction for an arrow pointing up or down. Even on the first part, the Inhibition Naming trial, however, Julianne had a difficult time because she was not always sure if she was looking at a circle or a square. Based on a subtest mean (average) scaled score of 10 + 3 and a mean (average) percentile rank of 50, Julianne’s Primary Scores, including Combined Scores, were all deficient:

IN Naming Total Completion SS: 1 (<2nd percentile) INN Total Errors Percentile Rank: <2nd percentile INN Combined SS: 1 (<2nd percentile)

IN Inhibition Total Completion Time SS: 3 (2nd percentile) INI Total Errors Percentile Rank: <2nd percentile

INI Combined SS: 1 (2nd percentile)

IN Total Error (both shapes and arrows) SS: 2 (2nd percentile) INN vs. INI Contrast Scaled Score: 3 (2nd percentile)

Process scores for Julianne on the Inhibition subtest were also Well Below Expected Level for Uncorrected Errors, Self-Corrected Errors, and Total Errors. The clinician felt that because of Julianne’s significant visuospatial problems with the stimuli, this test could not be used as an assessment of either naming or inhibition. Therefore, this was noted on the Record Form, but results were interpreted clinically to demonstrate that even on a task in another domain, visuospatial stimuli caused significant problems for Julianne. She showed marked difficulty with the visuospatial concepts of shape and direction, especially under time constraints,

346 ESSENTIALS OF NEPSY-II ASSESSMENT

and most especially when she had to alternate concepts of which she was unsure in the first place.

Because the Statue subtest had no visuospatial stimuli, it was used to assess inhibition, instead of the Inhibition subtest. Statue is designed to assess the ability to inhibit motor response to intruding auditory stimuli. Julianne performed At Expected Level (Statue SS: 9). On the Statue Process Score Percentile Ranks for Body Movement (51st–75th percentile) and Eye Opening (26th–50th percentile); therefore, Julianne performed At Expected Level in inhibiting body movement, and not opening her eyes when there was an interfering noise. She did startle and open her eyes when this examiner knocked on the table and later coughed as distracters, but her 2 errors on Eye Opening were within normal limits at her age. Predictably, because of her talkative nature, she had difficulty inhibiting vocalizations (3 errors, 11th–25th percentile), but even this area was Borderline. It would not meet the stringent cutoff at the 10th percentile for significant abnormalities. Julianne’s ability to inhibit response appeared to be within normal limits for age, except for mildly distracting herself with talking.

Language Domain

On assessment of language skills, Julianne’s performance revealed Comprehension of Instructions At Expected Level (scaled score of 9 at the 37th percentile in relation to the NEPSY-II Test Mean of 10 + 3). These results indicated that Julianne’s receptive language understanding was within normal limits for age, despite the fact that it was necessary to start her on Item 1, the level for age 5, because she failed one of the prerequisite items when she had to point to a cross. Julianne made no errors on the “bunny” items (e.g. “Show me a yellow bunny;” “Show me a big blue bunny.”). The second section with circles and crosses as stimuli has such items as “Point to the white one and a circle,” and “Point to the blue cross and the yellow cross.” By the time Julianne reached the items that had circles and crosses for stimuli again, she had made the connection between the cross that she saw at church and the stimulus cross, so she passed enough items to score in the average range.

On the Speeded Naming (SN) subtest, Julianne showed an interesting pattern. Again, because she had to confront circles and squares, she had difficulty. Her SN Total Completion Time Scaled Score (7) was Borderline (11th–25th percentile), but the clinician noted that her performance would have been faster if she had not experienced marked difficulty handling Item 4, which involved size/color/shape naming. Julianne’s performance slowed very significantly as she began Item 4. Interestingly, she made no errors on the colors on either Item 3 (color/shape) or Item 4, but she did not seem to be able to label the spatial words well. Even on Item 3, Julianne named only six shapes correctly and

ILLUSTRATIVE CASE REPORTS 347

self-corrected only two errors. In other words, she was still confusing circles and squares. On Item 4, although all of the colors were correct, she named only six shapes correctly and eight sizes. She self-corrected an additional three size words and one shape word. Thus, of a possible 84 points on the two items, Julianne scored only 58 points, and 32 of those were for correct colors. This performance did not appear to be a problem in naming, because Julianne had no trouble accessing color names. Rather, it appeared to be a visuospatial deficit that prevented her from developing automaticity in naming shapes and sizes.

Julianne’s SN Total Correct Percentile Rank was at less than the 2nd percentile for age. She made only six self-corrections, suggesting that she did not always realize that she had identified a shape or size incorrectly. Her SN Self-Corrected Errors Percentile Rank was also at the < 2nd for age. These results were Well Below Expected Level for Julianne’s age.

Memory and Learning Domain

On Narrative Memory (NM), in relation to the NEPSY-II subtest mean of 10 + 3, Julianne performed At Expected Level (26th–75th percentile) on the NM Free Recall Scaled Score (8) and the NM Free and Cued Recall (9) In relation to the subtest mean percentile of 50, Julianne’s NM Recognition performance was also At Expected Level (51st–75th percentile). Therefore, the NM Free and Cued Recall vs. Recognition Contrast Scaled Score (8) was At Expected Level, as well. In other words, Julianne showed average story memory for age in freely recalling the story details, responding to questions about the story, and recognizing story details when she heard them.

Julianne’s performance on Memory for Faces was exceptional in relation to the NEPSY-II mean of 10 + 3 and to Julianne’s own mean (10.7) on the memory subtests scores overall, with Julianne selecting 13 out of 16 faces correctly. This placed her performance Above Expected Level at an MF scaled score of 15 at the 95th percentile for immediate memory, and Memory for Faces Delayed was also Above Expected Level with Julianne selecting 15 out of 16 faces correctly (SS: 17; 99th percentile). Interestingly, Julianne’s facial recognition skills appeared to be dissociated from her significant visuospatial deficits.

The Word List Interference subtest is also a part of the General Assessment Battery, but it is given to children ages 7–16, so it was not appropriate for Julianne.

Sensorimotor Domain

On the Visuomotor Precision (VP) subtest, Julianne showed a VP Time to Completion Scaled Score of 8, At Expected Level (26th–75th percentile), again

348 ESSENTIALS OF NEPSY-II ASSESSMENT

pointing to motor speed within normal limits, though at the bottom of that classification. On the other hand, she displayed a VP Total Error Percentile Rank of 2nd–5th percentile (average is 50th percentile). The clinician noted that Julianne did not seem to perceive or anticipate the curves in the track as she was drawing pencil lines between the winding tracks, so her pencil tracing frequently strayed outside the tracks, causing errors. The integration of the VP Time to Completion and VP Total Error scores produced a VP Combination Scaled Score of 3, Well Below Expected Level. Again, the problem appeared to be visuospatial rather than motoric.

Social Perception Domain

[The General Referral Battery of the NEPSY-II does not include either of the subtests on the Social Perception Domain unless the child is displaying social/interpersonal defi cits, which was not the case for Julianne.]

Visuospatial Processing Domain

As expected, Julianne performed poorly on the Visuospatial Processing domain subtests. In relation to the NEPSY-II subtest mean of 10 + 3, she displayed a Design Copying Process Total Scaled Score of 4 at the 2nd percentile with a classification Well Below Expected Level in relation to other children of her age.

DC Motor Scaled Score (SS): 8, At Expected Level (26th–75th percentile) DC Global Scaled Score: 2, Well Below Expected Level (<2nd percentile) DC Local Scaled Score: 6, Below Expected Level (3rd–10th percentile)

Julianne’s fine motor skills for copying were acceptable, but she performed poorly in reproducing the global configuration of the designs. While her DC Local SS was significantly better than the Global SS, it still indicated that Julianne had significant difficulty in reproducing the design details. Her copy designs showed better reproduction of details than of the outside configuration of the design, but even then the details were poorly integrated and randomly placed.

Julianne’s Global vs. Local Contrast Scaled Score was at a scaled score of 11, At Expected Level (26th–75th percentile). This does not mean that her performance on both tasks was average. Rather, it means that given her very poor performance in reproducing the configuration of the design (Global), the poor level of her ability to reproduce small features within the design is approximately what one would expect. In other words, Julianne has marked difficulties reproducing both global and local elements of a design, though her motor control was within normal limits for age. Thus, it appeared that the deficits lay in Julianne’s visuospatial perception rather than in her fine motor control.