Advocate Illinois Masonic Medical Center XXXX XXXX, M.D., M.S.

Pediatric Developmental Center Medical Director

3040 N Wilton 773-296-7340
Chicago, Illinois 60657

Developmental Disorders Clinic

Psychological Evaluation

Name: Dddd Zzzz Parent’s name: XXX & YYY

Age: 5 year, 7 month Zzzz
Sex: Male Address: XXXXX
DOB: XX/XX/XXXX City/State: Chicago, IL 60645
DOE: XX/XX/08, XX/XX/08, XX/XX/08 Telephone: XXXXX

Psychologist:
Licensed Clinical Psychologist
Speech Pathologist:
Occupational Therapist:
Psychology Intern:

Identifying Information / Presenting Concerns

Dddd is a 5 year, 7 month-old male who was referred to the Developmental Disorders Clinic
by Dr. XXXX XXXX, primary care provider. Concerns included delays in language (both
receptive and expressive), communication, play and social interaction skills. Mother reported
that Dddd plays cooperatively with siblings and relatives, but has difficulty engaging with
unfamiliar children. His elementary school, XXXX Elementary School, also expressed
concerns indicating that Dddd plays alone and frequently talks to himself. Thus, a
multidisciplinary assessment was requested to determine if Dddd’s challenges fall within the
autism spectrum and to make specific recommendations for treatment.

Family Information
Dddd lives with both biological parents along with his twin brother, Gggg, and 15 month old
brother, Pppp. Mother also expressed concerns in regards to the developmental progress of
Dddd’s siblings. Gggg, Dddd’s twin brother, is being evaluated by the Developmental
Disorder Clinic, due to restricted interests and limited communication, as well as problems
with attention. Further, Mother is concerned because Pppp, David’s youngest brother, has not
yet started to crawl. In addition to English being the primary language spoken in the home,
the family speaks Arabic and Asyrian. There were no other spiritual or cultural aspects
reported that need to be considered for evaluation purposes.
Early development
Dddd was reported to be a generally healthy child. He was delivered via C-section at 32
weeks. Dddd was born weighing 6 lbs. No other complications were described.

His mother reported that she became concerned with his development and behaviors at four
years of age. At that time, Dddd’s school was concerned with his play and lack of interaction
with others. Mother reported that Dddd spoke his first word at 18 months of age and began
using word phrases at 3 years of age. Although Dddd did not lose any language skills, he did
not make gains in language acquisition as would be expected. In terms of meeting other
developmental milestones, Dddd walked unaided at the age of 14 months and was
successfully toilet trained at two years of age.

Tests Administered

 ADI-R (Autism Diagnostic Interview-Revised)

Parents were administered the ADI-R, which is a semi-structured interview designed to ask
parents or primary caregivers a variety of questions regarding their child’s performance and
behavior in the areas of communication, social interaction, and restricted and repetitive behavior
patterns.
 ADOS (Autism Diagnostic Observation Schedule)
David was administered Module 2 of the ADOS, which is a standard set of activities designed to
elicit a range of social and communicative situations to aid in the diagnosis of autism or PDD.
 Leiter-R International Performance Scale-Revised, Non-Verbal Screener was administered to
David. This nonverbal battery provides an estimation of a child’s global intellectual ability.
 Vineland Adaptive Behavior Scales II. The Vineland II is a semi-structured interview for assessing
personal and social skills used for everyday living. This assessment provides critical data for the
diagnosis or evaluation of a wide range of disabilities, including mental retardation,
developmental delays, functional skills impairment, and speech/language impairment.
 Communication skills were assessed via clinical observation utilizing the parameters outlined in
the CSBS (Communication and Symbolic Behavior Scales). This test was not formally
administered or scored. This observation targets the function or purpose of communicative acts,
and the means used to accomplish them.
 The Preschool Language Scale-4 (PLS-4) was used to formally assess language comprehension
and expression.
 Peabody Developmental Motor Scale Test
The Peabody Developmental Motor Scale Test examines a child's development in the
areas of reflexes, gross motor skills, object manipulation, grasping, and visual-motor integration.
These areas of development assess a child's ability to use coordinated movements for performing
functional activities.

Findings

Autism Diagnostic Interview-Revised (ADI-R)

Based on interview data, Dddd’s communication skills seem to be somewhat impaired.
Mother reports that Dddd “understands everything in English.” He uses phrases to
communicate his needs on a regular basis, in addition to delayed echolalia and scripted
language. Dddd will sometimes talk just to chat, saying something like, “Mom it’s getting
late. The sun is going down.” He will answer questions in a limited way but does not expand
on them. It is difficult to engage in reciprocal conversation with him. At times Dddd will use
his own name in place of “I” or “me” such as saying “It’s for Dddd” instead of “It’s for me.”
Dddd does not engage in verbal rituals or use language in odd ways, such as making up his
own words.

Dddd’s social skills, as reported by his mother and school officials, are also an important area
of difficulty. The school expressed concern due to Dddd’s lack of interaction with peers in the
classroom. Mother reported that he has difficulty establishing eye contact with others. In
addition, mother reported that during play, Dddd reenacts movie scenes and lacks imaginative
play. Nonetheless, based on mother’s report, it seems that Dddd shows interest in children and
responds appropriately to the approaches of other children. Based on interview data, Dddd has
the capacity to share his enjoyment with others and can direct his attention appropriately.
Mother indicated that she has been working with him and that there has been significant
improvement in his behaviors over the past four months.

Mother described Dddd’s behavior as mild, with rare occasions of an outburst. In the past he
displayed some stereotypical behaviors such as hand-flapping; however, he no longer engages
in this type of behavior. Mom denies the presence of unusual preoccupations, ritualistic
behavior or unusual sensory interests. He does display some sensitivity to loud noises. For
example, at a fireworks show Dddd covered his ears and became distressed, wanting to leave
the area. Dddd is generally able to transition easily and does not seem to mind minor changes
in his routine. He does like to always be holding an item in his hand, although there is not one
particular item that he must always hold. Dddd does seem to have an intense interest in
“Thomas the train” but will also play with many other toys appropriately.

Autism Diagnostic Observation Schedule (ADOS)

Dddd’s language and communication patterns during the ADOS evaluation were similar to
those reported by his parents in the home. Dddd used phrase speech with occasional echoing
to communicate during the evaluation. He made frequent attempts to get both the examiner’s
and his mother’s attention to show and request items of interest. He used appropriate
intonation with any vocalization. Dddd was observed to point distally to items that he
wanted. He used a variety of gestures throughout testing, including clapping during the
birthday party, pretending to eat and pretending to brush his teeth with his finger in order to
“teach” the examiner how to brush her teeth. Dddd was able to engage in reciprocal
conversation in a limited way. His answers were not always complete or accurate, but he did
reciprocate and offer some leads for the examiner to follow.

During the ADOS evaluation, his overall quality of social interactions was inconsistent. Dddd
presented with limited eye contact. He was observed to use facial expressions to
communicate affect for a variety of communicative purposes, although eye contact was not
always well coordinated. However, he showed appropriate responsiveness to social bids by
the examiner. For example, Dddd was able to respond to his name immediately when called
by the examiner; he followed the examiner’s gaze to an item across the room on the first
press; and was observed to play functionally with a variety of toys. He did attempt to engage
in interactive play; however, it was limited and difficult to follow.
Dddd was highly active during the evaluation, sitting when expected to do so but very fidgety
and moving about in his seat. He was not observed to engage in unusual sensory interests of
the play materials or his person. In general, his sensory and motor responses were appropriate
to the context at hand. He did not display hand or finger mannerisms or other complex
movements of his body. He seems to have several favorite topics, such as Sponge Bob and
Thomas the train, that he raised many times throughout the evaluation. He was able to shift
from these topics easily but seemed to focus on them more than would be expected.

Language Evaluation:
Standardized testing was conducted using the Preschool language Scale-4. Testing was
conducted in English. Parent noted that English, Arabic, and Syrian are spoke in the home,
although Dddd’s dominant language is English. Informal observation and parent interview
was also utilized.

Preschool Language Scale – 4 (PLS-4)

Raw Score Standard Score Age Equivalent

Auditory Comprehension 52 75 4-7
Expressive Communication 53 81 4-4
Total Language Score 83 76 4-5

Receptive Language:
Dddd achieved a receptive language standard score of 75 on the PLS-4 (average range is
between 85-115) indicating mild-moderate impairments receptive language skills. He
understood expanded sentences and descriptions containing a noun + 2 modifying adjectives.
Dddd understood qualitative concepts, eg. longest, pointed, temporal concepts, eg. day, night
and quantitative concepts, eg. 3, 5. Dddd showed difficulty with understanding of more
complex statements, eg. passive voice (The dog was chased by the chicken). He did not
understand some higher level language concepts, eg. quantity- half, whole, temporal- first,
last.

Within conversation, Dddd showed impairments in question comprehension, eg. ‘How are
you?’ ---5, ‘Who is Gaby?’ –Gaby hurt his feet. He was able to answer some simple ‘yes/no’
questions and answered some forced choice questions with inconsistent accuracy. Parent
stated that Dddd sometimes doesn’t answer right away and is a slower learner (than his
brother).

Expressive Language/Social Communication:

Dddd achieved an expressive language standard score of 81 on the PLS-4 (average range is
between 85-115) indicating mild impairments in expressive language skills. Dddd named
categories and was able to repeat sentences, showing appropriate use of syntax. He used
qualitative concepts (long, short), adjectives to describe, and morphological use of –er
(painter). He showed difficulty with describing similarities and formulating meaningful,
grammatically correct questions, which reflects impairments in pragmatic language and
integrative language skills.
Within conversation, Dddd was noted to only answer portions of a question or produce a
related response. Parent reported that he has difficulty with telling stories and often uses
more visuals (eg. gestures) than words to describe. He will at times repeat lines from movies
and TV.

Oral Motor/Speech:
A cursory examination revealed structures and functions within normal limits to support
speech and feeding. Dddd eats a variety of foods and is able to chew and drink without
difficulty. No concerns regarding choking or gagging noted. Dddd was observed to produce
an interdental lisp for /s/ and /z/ phonemes in all word positions. He produced substitution of
f/θ (voiceless ‘th’), which may be an influence of other languages spoken in the home.

 Occupational Therapy Evaluation

Sensory Integration and Processing:
Attention and Activity Level: Dddd demonstrated age-appropriate attention to seated work,
however was noted to be more easily distracted during language based tasks. He was observed
to have some difficulty attending after a prolonged period of table tasks. He was able to
complete all seated testing, however preferred gross motor activity and was noted to move
quickly between activities during unstructured play.

Ability to Transition: Dddd was able to transition into the evaluation room, warm to
evaluators, and move somewhat fluidly between activities. Parent reports that transitions used
to be a problem, but this has been an area of improvement.

Tolerance of Sensory Input: Dddd has some resolving hypersensitivities. He continues to have
a poor tolerance to loud noises and requires his hands be washed immediately when soiled.
Otherwise, Dddd does a nice job interacting with his environment. Mother stated he’s great in
public places and has a generous food repertoire. Eye contact was decreased.

Sensory Seeking: Dddd displays minimal repetitive and sensory seeking behaviors. He will
run in circles, turn lights on and off, and jump from the sofa to the floor. Mother reports he
loves to go to the park and will play on all the different equipment.

Summary: Dddd has a history of difficulties with sensory regulation. However, it appears he
has made great gains in this area and performed nicely today. David continues to struggle
with attention to language-based activities.

Motor:
 Gross Motor: Strength, tone, and range of motion are all within functional limits; with
tone in the low-normal range. Motor milestones were achieved within normal limits
(walking at 14 months). Dddd ambulates using a heel-to-toe foot pattern. He
frequently maintains a w-sitting posture when seated on the floor. He was observed to
walk, run, stoop to retrieve objects, and jump from raised surfaces. He can throw and
catch a ball back-and-forth +5 times. Dddd negotiates stairs safely and independently.
 Parent reports that he rides a bike with training wheels. Gross motor skills appear
functional and not a concern at this time.

 Fine Motor: The Beer-Buktenica Developmental Test of Visual-Motor Integration was

used to assess the degree to which visual perceptual and finger-hand movements are
well coordinated. Dddd achieved a standard score of 84; a standard score between 85-
115 is considered average. This score places Dddd just below average. However,
Dddd was more impulsive during the end of testing, which likely impacted test
performance. He was able to imitate one written design that was at a 7 year level. In
addition, parent reports that Dddd is writing in complete sentences. He used a mature
tripod grasp for writing and efficiently cut out a circle. Dddd constructed his name and
age with appropriate size, formation, and orientation of letters. Fine-motor abilities
appear to be at age-level and are not a concern at this time.

Self-Help Skills:
Sleeping: Dddd sleeps well. There are no sleep concerns.
Eating: Dddd is independent in age-appropriate eating tasks.
Toileting: Independent
Dressing: Dddd is mostly independent in dressing tasks. He is still mastering zipping and
tying.

Standardized Cognitive Testing

Dddd was administered the Leiter-R, Brief IQ Screener, which is a non-verbal battery of tests
that provides an estimate of global intellectual level.

Dddd was accompanied to this appointment by his mother. Dddd was mostly compliant
throughout the evaluation. He followed directions to remain seated and displayed an
appropriate level of attention and effort. Dddd did show some signs of impatience at times,
for example, asking multiple times if he could get toys and, at one point, he continued to
throw instead of hand cards to the examiner despite repeated requests to hand over the cards.
His throwing seemed impulsive, but was not aggressive. Dddd asked many questions, at
times repetitively, and sometimes repeated the examiner’s phrases and gestures. He engaged
in social interactions with the examiner, but had some difficulty answering questions and
maintaining a conversation. During a break, he became engrossed with a Thomas the Train
board game and was difficult to engage with. He did not want to play with the game
correctly, but instead kept repeating Gggg (his brother) “will be so proud of me.” When
asked who Gggg was, Dddd had difficulty answering, even with prompts from his mother.
When asked what his favorite Thomas toy at home was, Dddd replied that the game he was
currently playing with was his favorite, although his mother reported that he does not have
that particular toy. Dddd also repeatedly asked the examiner to take him to ToysRus.
Nonetheless, Dddd was eventually able to follow directions to put the game away and return
to testing. He was observed to make eye contact with the examiner and to use gestures, such
as “high-five.”

Based on Dddd’s performance during the evaluation, his estimated intellectual level falls
within the average range, with a score of 103. Overall, Dddd demonstrated strongly
average nonverbal cognitive abilities, including visual scanning skills, short-term visual
memory, perception of wholes from fragments, and nonverbal reasoning. Given that Dddd
displayed age-appropriate levels of attention and effort, his performance appears to be an
accurate estimate of his current cognitive functioning.

Dddd’s adaptive daily functioning was assessed using the Vineland Adaptive Behavior
Scale 2nd edition, which yields standardized composite scores (average = 100, standard
deviation = 15). The classification of “adequate” indicates age-appropriate adaptive
functioning.
Domain Subdomain V-Scale/Domain %ile Age Adaptive
Standard Score Rank Equivalent Level
Communication Receptive 15 5:6 Adequate
Expressive 14 4:6 Adequate
Written 19 6:10 Moderately
High
Composite 104 61 Adequate
Communication
Daily Living Skills Personal 17 6:1 Adequate
Domestic 17 7:6 Adequate
Community 17 6:2 Adequate
Composite Daily 111 77 Adequate
Living Skills
Socialization Interpersonal Skills 11 2:7 Moderately
Low
Play and Leisure 11 3:5 Moderately
Time Low
Coping Skills 13 3:11 Adequate
Composite 81 10 Moderately
Socialization Low
Motor Skills (Est) Gross Motor Skills 13 4:5 Adequate
Fine Motor Skills 13 4:7 Adequate
Composite Motor 88 21 Adequate
Skills
Overall Adaptive Behavior Composite 384 37 Adequate

Dddd’s overall adaptive functioning fell within the adequate range, indicating that his
adaptive skills are on par with the majority of his peers. However, there was some variability
in his adaptive functioning in different subdomains. Within the Communication domain,
Dddd’s Receptive Language fell at an age-appropriate level, but his Expressive Language
skills, while still within the adequate range, were over one year behind his current age. For
example, he was noted to have some difficulty with correct pronoun usage and answering
“when” questions. In contrast, Dddd’s Written Language skills were over one year above his
actual age, in the moderately high range. For example, Dddd was noted to be able to read
simple stories aloud and print simple sentences of three or four words. Dddd displayed the
most difficulty in the area of Socialization, scoring in the moderately low range. In fact,
Dddd’s functioning in all three subdomains of Socialization was over one year below his
current age. His lowest level of functioning was in the area of Interpersonal Skills. Dddd was
noted to have difficulty imitating relatively complex actions, answering when familiar adults
make small talk, and using words to express happiness or concern for others. In addition,
Dddd displayed difficulties in the area of Play and Leisure Time. In particular, he sometimes
does not choose to play with other children, does not use common household objects for
make-believe activities, and does not play simple make-believe games with others. Lastly,
while Dddd fell within the average range for Maladaptive Behaviors overall, his internalizing
problems score fell within the elevated range. Problems noted were being overly dependent,
avoiding others, and having poor eye contact. Additionally, Dddd is sometimes obsessed with
objects or activities, has strange habits or ways, prefers objects to people, and is unaware of
what is happening around him. All findings will be placed in the context of the overall results
of the test battery in the section below.

Summary and Formulation

Dddd is a 5 year, 7 month old child who presents with a pattern of social, communication, and
behavioral challenges that is NOT consistent with autistic spectrum disorder. Dddd is able to
initiate and coordinate social interactions and behavior. His eye contact is inconsistent;
however, he is able to use his gaze to regulate social interaction. He shows interest in sharing
his enjoyment and interests with others, continuously engaging his mother or the examiners
with the activities at hand. The language evaluation also showed that Dddd’s language is
limited in conversational abilities with difficulties in question comprehension and topic
initiation and extension. He shows functionally appropriate play skills and interests, with the
use of make-believe or imaginative play. He is able to use toys to play imaginatively, for
example setting up a tea party, but has a more difficult time using an object other than what it
was intended for in a more abstract fashion. The occupational therapy and sensory evaluation
revealed that Dddd has made great gains in improving his overall sensory regulation and
presents with age-level motor skills. He continues to be more distracted during language-
based activity. During the cognitive testing, Dddd presented as a child with solid average
non-verbal cognitive abilities. Although verbal performance was not formally assessed, it is
suspected that his performance would have been lower and possibly in the deficient range
given the extent of his language disorder.

Although Dddd does not meet the criteria for autistic disorder, he continues to have
significant difficulties in communication and socialization that cannot be fully explained by a
simple language disorder. The current testing suggests that Dddd currently functions within
the average levels of cognitive abilities for non-verbal skills. However, these tasks do not
require generative and flexible language use. Therefore, as mentioned earlier, his
performance on an overall verbal and non-verbal cognitive measure may present a more
deficient picture. He shows strengths in visual scanning skills, short-term visual memory,
perception of wholes from fragments, and nonverbal reasoning skills. The pattern of Dddd’s
difficulties in communication and social interaction is consistent with a diagnosis of semantic
pragmatic language disorder. Despite his ability to demonstrate understanding and use of
grammar and syntax, Dddd shows significant communication difficulties. While his social
communication skills are communicative in nature, they reflect poor initiation of
conversations, incoherence of expressive language, difficulty with recognition and use of
contextual/non-verbal cues, and use of stereotyped speech. These difficulties were observed
throughout testing, but particularly when asked questions that required he extend responses
with further related details or questions.

Dddd’s difficulties were most pronounced in a conversational context. When given open-
ended questions or prompted to expand his responses to simple queries, he often had a
difficult time and responded inappropriately despite a large vocabulary. While he may have a
large vocabulary, he demonstrated difficulty combining words in novel ways for interacting
and conversing.

Dddd’s difficulty with semantic and pragmatic aspects of language has many implications for
his learning and social-emotional development. The typical classroom environment is likely
to be confusing and overwhelming for him, as it can often be unstructured and requires the
rapid processing of verbal material for input and output, areas of deficit for him. Nonetheless,
his current school appears to be providing the supports he may need in the classroom
environment in order to be successful. Therefore, we do not necessarily suggest a change in
placement, but rather continued visual supports and structure that will help him actively
participate with his peers, as his cognitive abilities seem to be intact. It is important to note
that in group interactions and on the playground, Dddd is also likely to become overwhelmed
and withdraw, as these interactions often require not only processing of verbal information,
but also the processing and rapid responding to nonverbal social contextual cues, which are
very abstract and difficult for him as well. A socialization group may be useful for Dddd to
develop and rehearse skills with peers in a more controlled setting in order to then be able to
generalize these skills with peers.

Per parent report, Dddd has made significant progress in the past 4-5 months, both at home
and at school, suggesting a positive prognosis. With speech therapy and well-implemented
environmental supports, Dddd is likely to continue making progress in his pragmatic
communication skills and improve the quality of his social interactions. In addition, he
presented as a sweet and mild-tempered child which will only be an asset for him moving
forward with his educational and developmental supports.

Diagnostic Impression:
Semantic-Pragmatic Language Disorder

Recommendations:
 Provide Dddd concrete expectations and rules. Because Dddd has difficulty ascertaining
intentions and “unspoken” rules in various social contexts, he would benefit from having
 everything including plans “explained” to him with visual cues. Structure and visual
support are likely to reduce his anxiety, which has a further debilitating and disorganizing
effect on him as it increases.
 Dddd’s classroom performance is likely to improve if he is given clear, concrete,
written/visual instructions free of extraneous comments and jokes so that he can
understand them without confusion. He would benefit from completing work in a smaller
group so that the amount of social interaction will not overwhelm him.
 Dddd is likely to learn better when presented with visual cues (paper-and-pencil format);
he will need assistance in translating oral questions (e.g., if you have three candies and
you get two more, how many do you have all together?) into the format he can understand
and solve (i.e., 2 + 3 = 5).
 Dddd is likely to benefit from structured peer interaction. Rules and expectations should
be clearly explained to him. He may gain an understanding of other children’s thoughts
and social intentions through the use of visually supported social stories. These stories
may also help him with sequencing of social events. A structured socialization group is
recommended for Dddd to rehearse social skills in a more controlled setting.
 Providing him with a structured and predictable environment will reduce his anxiety.
 School based speech therapy with a focus on development of skills within conversational
contexts, such as answering questions, story retell, verbal sequencing tasks, question
formulation, and expanding responses with appropriate details.
 Short term outpatient speech therapy to help Dddd and his family supplement school
services and provide home program visual supports and practice activities.