Download: Model Eval: Psych Evaluation 2;9- Autism Spectrum Disorder
This evaluation was done by David Usdan, PhD for a 2-9 month old boy diagnosed with Autism Spectrum Disorder. As the boy, George, is a culturally and linguistically diverse (CLD) child, Dr. Usdan does not use any standard scores. Although he uses portions of standardized tests, any information obtained from those tasks is presented in a descriptive manner. Dr. Usdan determined George’s percentage of delay through clinical judgment/ informed clinical opinion and milestones indicated by Early Intervention policy and procedures.
Reason for Referral
George is a two-year nine month-old boy who was referred for this evaluation by his parents, Mary Smith and John Smith, for an assessment of George’s cognitive and adaptive functioning to determine eligibility for special preschool services as he will be aging out of Early Intervention in April 2012.
Background Information
George was diagnosed with an Autism Spectrum Disorder and began receiving Early Intervention services in June 2011, just after turning age 2. George is currently receiving home-based ABA 25 hours per week (recently increased from 20 to 25), speech therapy 3 times per week and occupational therapy 1 hour per week. George’s mother reported that when he was 18 months of age George was not talking or socializing. He did not seem interested in playing with other children and was unusually passive, letting other children take his toys. She said that he seemed very different than her older children were at his age and by then they were already talking clearly. His mother reports that George has made progress in therapies, but she remains very concerned that George still does not initiate or engage in social contact. She reports that ABA seems to have help George to the extent that now is able to do some puzzles and responds to modeling. He uses many single words for labeling pictures, colors and body parts when directed but has not able to start using words spontaneously for communicative purposes. In addition, George engages in some seemingly repetitive and stereotyped behavior such as rubbing his mother’s ears, flapping his hands and walking on his toes.
Family Background
George lives with his parents and two older siblings in their apartment in New York City. George’s mother, Mary Rogers, 37, graduated from high school. His father, John Smith, 42, is also a high school graduate. Ms. Rogers is a fulltime homemaker and Mr. Smith is employed as a handyman. George’s 19 year-old sister Sara is attending Mercy College and is working part-time. George’s 13 year-old brother John was evaluated at age 12, after having struggled in elementary school, and diagnosed with ADHD. He has a classification of Emotionally Disturbed and is in a 12:1:1 class setting with a paraprofessional due to aggressive behaviors. He takes the medication Concerta. Ms. Smith was not aware of any other speech and language or academic problems in the family history.
Language Acquisition History
Ms. Rogers reported that she and George’s father were born and raised in New York City. Mr. Smith is African American and only speaks English. Ms. Rogers was born in New York. She was raised in a bilingual Puerto Rican household and can read and write in both Spanish and English. Ms. Rogers speaks Spanish with her mother, but she only speaks with her approximately once a week and George is not around during those conversations. Only English is used in the home and with George. George is a monolingual/English speaking child with no exposure to any other language.
Medical History
George was born at St. Luke’s Roosevelt Hospital Center via natural delivery following a full-term pregnancy. George’s birth weight was 8 pounds 15 ounces. Ms. Smith reported that the prenatal, birth and postnatal periods were unremarkable. George has been in good physical health with no history of significant medical problems.
Developmental History
George’s mother reported that George’s development seemed normal until about 18 months when he was still not talking. In retrospect, Ms. Rogers noted that he was rather passive before that but had considered it to be within the normal range. George first sat up unassisted at 6 months. He crawled at 78 months, and first walked at 14 months. George did not use any words until about 34 months after starting Early Intervention services.
Evaluation Conditions
George was evaluated at Kennedy Child Study Center in a quiet office with age appropriate furniture and toys. George’s mother was present throughout the evaluation, and Dr. Catherine Crowley of Teachers College Columbia University was also in attendance as an observer.
Assessment Procedures
● Bayley Scales of Infant and Toddler Development – Third Edition (BayleyIII)*
● VinelandII Adaptive Behavior Scales, Survey Interview Form (VinelandII)*
● The Childhood Autism Rating Scale, Second Edition (CARS2ST)*
● Clinical Practice Guideline, Communication Disorders, NYSDOH Early Intervention
● Clinical Practice Guideline, Autism/Pervasive Developmental Disorders, NYSDOH Early
Intervention Program**
● Clinical Practice Guideline, Motor Disorders, NYSDOH Early Intervention Program**
● Playbased Assessment
● Informed Clinical Opinion
* George has been receiving 25 hours of ABA that focuses on the many skills assessed by the Bayley-III and Vineland-II such as colors, shapes, body parts, puzzles, block building, reading a book and naming pictures. His performance on these items, therefore, would be expected to be somewhat inflated. In addition, these norm referenced assessment tools were not standardized for children of diverse cultural and linguistic backgrounds. Because of these issues, the use of standard scores would be inaccurate and misleading, and results are presented in a descriptive manner.
**Neither validity nor reliability has been determined for these assessment instruments. They provide criterion referenced information. Appropriate applicability to populations of diverse cultural and linguistic backgrounds has not been considered by these instruments.
Ms. Rogers indicated that George’s performance during the evaluation was representative of how he typically behaves. She did say that he was tired toward the end of the evaluation, but that she felt that this did not affect his performance significantly.
Behavioral Observations
George is an adorable two-year nine month-old boy that was well-groomed and dressed. George presented as a very sweet although variably to poorly related boy with evidence of some repetitive and stereotyped behaviors and a lack of spontaneous language. George was clearly quite attached to his mother and also visibly anxious about being in a new setting; George clung to his mother’s side and did not want to separate from her.
George more readily, although still warily, accompanied his mother into the office. Once inside the office, George remained initially wary. He sat on his mother’s lap sucking his thumb and rubbing his mother’s ear and her earring. Gradually after the evaluator spent some time talking with his mother, George was able to start to explore objects in the room. George did not make eye contact with the evaluator or his mother, nor did he seek joint attention. George was observed to flap his hands on occasion when he was frustrated. During the course of the evaluation George was able to engage intermittently in ways that suggested more social/emotional potential. He was able to smile and laugh with some eye contact during a game of catch with a ball. George was able to respond well to structure, and he participated in a variety of activities when directed and provided with modeling. George followed some simple oral directions although often needing visual cues. He used single words to label but did not produce any spontaneous words.
Cognitive Functioning
Cognition
George seemed comfortable and confident when given different types of puzzles. George was able to work with 9-piece puzzle boards and placed shape pieces in their spaces with ease. George easily put together free standing two piece puzzles of familiar objects. He was able to match colored disks with pictures of colored crayons. George was able to match pictures when asked to point to a picture among an array of four to match a target picture. George’s ability to perform this task was impressive and demonstrated beginning ability to process oral directions, but at the same time it should be noted that this may be an over learned skill that has picked up from ABA and may not generalize to processing other types of directions.
Dynamic assessment demonstrated that George is intelligent and learns quickly. The evaluator showed George how to make a rubber duck fly into the air by placing the duck on the flat end of a spoon placed on the table and hitting the round end. George smiled and laughed and searched for the duck, although he did not make eye contact with the evaluator. George tried and had difficulty the first time, but after a second demonstration George was able to make the duck fly and seemed happy he made it happen.
George demonstrated some functional and relational play skills. When directed, George was able to feed the doll with a spoon and give the doll a drink with a cup, although he did not produce such play spontaneously. George did engage in spontaneous functional play such as holding a toy airplane and making it fly. However, George never sought to engage others in his play nor seemed to respond to efforts to create a reciprocal play scenario. Based on George’s performance on the assessment materials administered and this evaluator’s informed clinical opinion, George’s cognitive skills are at least within normal limits.
Language Skills
Receptive Language
In the receptive domain, George was able to understand part/whole relationships by pointing to objects such as the nose of a dog. He identified a few pictured actions and followed a two part direction with a doll. Some of these may be similar to what George has learned in ABA.
George was not able to show understanding consistently of the use objects. When asked to point to what people “cut” with George made a cutting motion with his fingers but did not point to the appropriate picture. He did not understand pronouns or label for sizes. With directions presented in a social context, George needed repetitions along with visual, auditory and some physical prompts. For example, George’s mother asked him to put a toy container away and he did not respond. He responded only when she repeated the direction in a firmer voice while pointing to where she wanted him to put the container. When the evaluator asked George to start to clean up some toys, George did not respond but when the evaluator picked up the bin, started to clean up and to sing the clean-up song George was able to help.
Based on George’s performance on the assessment materials administered and this evaluator’s informed clinical opinion, George’s receptive language skills appeared mildly to moderately delayed indicating at least a 25% delay. George understood simple, context embedded commands, but George needed visual or physical prompts and directions also need to be repeated.
Expressive Language
In the expressive domain, George was able to name many pictured objects as well as objects presented to him. During the evaluation George used approximately 30 words mostly to label objects or pictures. He answered “Yes ” and “No ” appropriately in at least two responses George used a small number of two-word combinations that were generally to label parts of pictures such as “nose dog,” “tail dog,” and “wheels car.” George spontaneously said “yellow duck” when looking at a picture on the wall. Most words he used were nouns. George used a small number of other words such as “up,” and “help” when trying to unscrew the lid on a piggy bank. However, George typically does not use words for communicating and he did not produce any multiple-word combinations. George vocalizes and often coos. George shows very little interest in engaging in communication with others. His mother confirmed that this is consistent with her observations of George’s communication behaviors. For example, George does not seek joint attention or engage in shared pleasure. He has never had an interest in playing peekaboo.
Based on George’s performance on the assessment materials administered, this evaluator’s informed clinical opinion, George’s expressive language skills were in the moderately severe to severely delayed range indicating at least a 33% delay.According to the Early Intervention Clinical Practice Guideline for Communication Disorders, a child at his age would be expected to produce multi-word utterances, engage in short dialogues, use verbal attention getting strategies and use multi-syllabic words.
Motor Skills
In the fine motor domain, George was able to stack blocks and to put coins into a piggy bank slot. George was not able to imitate the evaluator’s construction of a train with four blocks. George grew tired toward the end of the evaluation and avoided using a crayon and paper. His mother reported that George can scribble with a crayon although he has a fist grip and has no control over the direction of his crayon strokes. George also avoided playing with the connecting blocks. Based on George’s performance and the evaluator’s informed clinical opinion, George’s fine motor skills were in the moderately severe to severely delayed range indicating at least a 33% delay. According to the Early Intervention Clinical Practice Guideline for Motor Disorders, a child of George’s age should be able to be starting to use scissors. Children between 2429 months should be stringing beads and controlling direction of scribbling, and George has not reached these milestones.
In the gross motor domain, George was able to jump forward several inches on a path, and he was able to walk forward following a path. George runs with coordination. He was able to walk up and down stairs putting both feet on each step with support. However, George was not able to balance on one foot. He was not able to jump to the floor from a bottom step or to kick a ball. Based on George’s performance and the evaluator’s informed clinical opinion, George’s gross motor skills were in the moderately severe to severely delayed range indicating at least a 33% delay. According to the Early Intervention Clinical Practice Guideline for Motor Disorders, a child of George’s age should be able to ride a tricycle. A child between 2429 months of age should be walking down steps with alternating feet, and a child between 1824 months of age should be able to stand on one foot and kick a ball.
Adaptive Functioning
In order to assess George’s level of adaptive development the examiner employed the Vineland-II Adaptive Behavior Scales Survey Interview Form, with George’s mother, Mary Rogers, serving as respondent in English. The Vineland scores are calculated based upon the respondent’s report of the child’s day-to-day functioning in the areas of communication, daily living skills, socialization and motor skills. Since the Vineland-II was not standardized for culturally and linguistically diverse populations, the use of standard scores would be inaccurate and misleading so the results reported are presented in a descriptive form.
On the Vineland-II, George obtained an Adaptive Behavior Composite within the Low range for his age. Based on his mother’s report, George’s overall adaptive functioning is in moderately severe to severely delayed range indicating at least a 33% delay in all domains.
Communication
In the receptive domain, George can sometimes follow a two-step direction. He is able to point to many body parts when asked and to pictured objects. George can listen to stories for 5-10 minutes at a time. As stated earlier George often needs repetitions with visual and physical prompts to follow certain directions. In the expressive domain, George’s mother reported he has between 1520 words with which he usually names objects and pictures when asked. He is able to repeat words and responds well to modeling although he can imitate only up to two-word combinations. His mother felt that George does not usually use words for communicative purposes although he can label. George does not point to objects that he wants. He does not use names for his siblings or state his own name when asked. However, George also has some well developed isolated skills such as counting aloud from 19 and identifying many letters.
Daily Living Skills
George is able to eat using a fork by stabbing his food. He uses a spoon although he still spills. George is able to suck from a straw and drink from an open cup with a small amount of liquid without spilling. George does not communicate when his diaper is wet or soiled. He needs assistance to take off a front-opened coat. George cooperates with bathing and sleeps well. George is able to help with putting toys away given appropriate cues. He does not show care around hot objects and mother feels he should show a little more fear than he does. George is liable to run into the street without appropriate supervision. George does not show understanding of the function of a telephone.
Socialization
George is affectionate with his family members, particularly so with his mother. George often likes to sit in his mother’s lap, sucking his thumb and touching his mother’s ear and earring. George is able to imitate simple actions like clapping and waving and he is imitating words, but he has difficulty initiating these and does not seek joint attention or shared enjoyment. George makes very little eye contact and cannot imitate facial expressions. George does not show awareness of other people’s feelings or show a desire to share. He has not shown interest in playing peekaboo. George does not show interest in other children. Despite George’s social deficits he generally cooperates with transitions between activities.
Motor Skills
In the gross motor domain, George can throw a ball in a specified direction and jump with both feet off the floor. He is able to walk up and down stairs putting both feet on each step with support. He does not yet kick a ball and needs help in order to catch a ball. George does not alternate feet on stairs or know how to pedal a tricycle. In the fine motor domain, George can put together non-inset two-piece puzzles and he can stack blocks. George is not able to turn pages of books one by one, open doors by turning doorknobs or unwrap small objects.
Social-Emotional Functioning
The Childhood Autism Rating Scale Second Edition (CARS2) is a 15-item rating scale used to identify children with autism and distinguishing them from those with developmental disabilities. It is empirically validated and provides concise, objective, and quantifiable ratings based on direct behavioral observation. However, the CARS2 may not have been standardized for use with individuals from culturally and linguistically diverse backgrounds. Therefore scores will be presented in a descriptive rather than quantitative manner.
On the Childhood Autism Rating Scale, Second Edition (CARS2ST), George’s constellation of behaviors described in detail below indicate the presence of Mild to Moderate symptoms of an Autism Spectrum Disorder.
Relating to People
George has moderately abnormal relationships in that he often appears aloof. Persistent attempts were necessary to obtain George’s attention. He never really initiated social contact.
Imitation
George had generally normal imitation skills for simple words and actions.
Emotional Response
George has mildly abnormal emotional responses. George tends to be somewhat overly passive and has a lack of spontaneous and varied facial expressions.
Body Use
George has moderately abnormal body use. George has some motor coordination delays and was observed to flap his hands at times when he was excited or frustrated.
Object Use
George has mildly delayed use of toys and objects. George has some functional play skills but then begins to use toys inappropriately at times such as his moving a toy staircase through the roof of a house.
Adaptation to Change
George was generally cooperative with transitions between activities.
Visual Response
George has moderately abnormal visual responses. George often fails to make eye contact and often needs visual prompting to engage in activities and follow directions.
Listening Response
George has mildly abnormal listening responses. George sometimes does not respond or responds after a delay and repetitions.
Taste, Smell, and Touch Response and Use
George displays moderately abnormal responses in this area. George seems preoccupied with tactile sensory experiences, for example frequently rubbing his mother’s ear and earring while sucking his thumb.
Fear or Nervousness
George has moderately abnormal development in this area. George shows quite a bit less than fear than is appropriate. At other times he may show too much fear.
Verbal Communication
George has mildly abnormal verbal communication. George does not engage in echolalia but he does not produce any multiple-word utterances.
Nonverbal Communication
George has mildly abnormal use of nonverbal communication. George does not point to objects but reaches for what he wants.
Activity Level
George’s activity level is mildly abnormal. He may be generally more passive and slow moving than is typical for a boy his age.
Level and Consistency of Intellectual Response
George has moderately abnormal intellectual response. George has strong nonverbal cognitive skills with severe verbal reasoning and language delays.
General Impressions
George presented as an adorable, very sweet although variably to poorly related boy with evidence of some repetitive and stereotyped behaviors and a lack of spontaneous language. George sat on his mother’s lap sucking his thumb and rubbing his mother’s ear and her earring. George did not make eye contact with the evaluator or his mother, nor did he seek joint attention. George was observed to flap his hands on occasion when he was frustrated. George was able to engage intermittently in ways that suggested more social/emotional potential. He was able to smile and laugh with some eye contact during a game of catch with a ball. George followed some simple oral directions although often needing visual cues. He used single words to label but did not produce any spontaneous words.
Summary/Impressions and Recommendations
George is a two-year nine month-old boy who was referred for this evaluation by his parents, Mary Rogers and George Smith, for an assessment of George’s cognitive and adaptive functioning to determine eligibility for special preschool services as he will be aging out of Early Intervention in April 2012. George was diagnosed with an Autism Spectrum Disorder and began receiving Early Intervention services in June 2011, just after turning age 2. George is currently receiving home-based ABA 25 hours per week (recently increased from 20 to 25), speech therapy 3 times per week and occupational therapy 1 hour per week. George’s mother reported that when he was 18 months of age George was not talking or socializing. His mother reports that George has made progress in therapies, but she remains very concerned that George still does not initiate or engage in social contact. George lives with his parents and two older siblings in their apartment in the Bronx. George is a monolingual/English speaking child with no exposure to any other language. George was born at St. Luke’s Roosevelt Hospital Center via natural delivery following a full-term pregnancy with no complications. George has been in good physical health with no history of significant medical problems.
George seemed comfortable and confident when given different types of puzzles. Dynamic assessment demonstrated that George is intelligent and learns quickly. Based on George’s performance on the assessment materials administered and this evaluator’s clinical opinion, George’s cognitive skills are at least within normal limits. Based on George’s performance on the assessment materials administered and this evaluator’s clinical opinion, George’s receptive language skills appeared mildly to moderately delayed indicating at least a 25% delay. Brian understood simple, context-embedded commands, but George needed visual or physical prompts and directions also need to be repeated. George’s expressive language skills were in the moderately severe to severely delayed range indicating at least a 33% delay.George has not met expected milestones for child at his age such as producing multi- word utterances, engaging in short dialogues, using verbal attention getting strategies and multi-syllabic words. Ms. Rogers indicated that George’s performance during the evaluation was representative of how he typically behaves. She did say that he was tired toward the end of the evaluation, but that she felt that this did not affect his performance significantly.
George obtained an Adaptive Behavior Composite within the Low range for his age. Based on his mother’s report, George’s overall adaptive functioning is in moderately severe to severely delayed range indicating at least a 33% delay in all domains. On the Childhood Autism Rating Scale, Second Edition (CARS2ST), George’s constellation of behaviors indicates the presence of Mild to Moderate symptoms of an Autism Spectrum Disorder. Clinically, George presented as an adorable, very sweet although variably to poorly related boy with evidence of some repetitive and stereotyped behaviors and a lack of spontaneous language. He sat on his mother’s lap sucking his thumb and rubbing his mother’s ear and her earring. George did not make eye contact with the evaluator or his mother, nor did he seek joint attention. He was observed to flap his hands on occasion when he was frustrated. George was able to engage intermittently in ways that suggested more social/emotional potential. He was able to smile and laugh with some eye contact during a game of catch with a ball. George followed some simple oral directions although often needing visual cues. He used single words to label but did not produce any spontaneous words. In the clinical opinion of this evaluator, the results of this evaluation represent a true reflection of George’s current levels of functioning.
Taking into consideration George’s performance in the evaluation, parental report, clinical observations and this psychologist’s informed clinical opinion, George’s behavior is consistent with a DSMIVTR diagnosis of Pervasive Developmental Disorder NOS (299.80).
Based on the current evaluation, the following recommendations are offered:
1. Speech evaluation to assess further George’s receptive and expressive language skills.
2. Occupational therapy evaluation to assess George’s fine motor and sensory processing skills.
3. Physical therapy evaluation to assess George’s gross motor skills.
4. George would benefit from individualized preschool services geared for children with developmental delays and Autism Spectrum Disorders in order to facilitate George’s development of expressive language, motor and socialization skills.
5. George would benefit from the addition of Floor Time therapy in order to promote development of joint attention, shared enjoyment and reciprocal interactions.
6. Further specific educational recommendations and therapeutic modalities will be discussed upon review by the Department of Education.
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