Reason for Referral
Ryan was recommended for a psychoeducational assessment by Heather Skippen, registered
Social Worker and Ryan’s primary therapist at the East Calgary Health Centre, to determine
what learning, social, emotional, or behavioural issues may be interfering with Ryan’s ability to
progress in the homeschool setting. Specifically, Ryan’s mother is interested to know if Ryan
has a learning disability and whether or not he meets the criteria for Autism Spectrum Disorder.
Current Situation
Ryan is a nine year old boy who lives on a ranch in Millarville, Alberta with his parents and four
siblings (aged 11, 6, 4, and 2). He was initially referred to the Pediatric Behavioural
Developmental Clinic (PBDC) upon referral by pediatrician Dr.Kelleigh Klym.
Ryan’s mother Lisa expressed concern regarding Ryan’s lack of progress in the homeschool
setting. According to Lisa, Ryan is struggling in all academic areas, including mathematics,
writing, and reading. Of these areas, reading was identified as the primary area of concern.
According to Lisa, despite showing an “early interest” in reading, Ryan is unable to read. When
he is asked to read, he appears to “guess” the words instead of sounding them out phonetically.
In addition to significant academic concerns, Lisa identified some social concerns for Ryan.
Specifically, she expressed that he shows little interest in leaving the home and frequently
withdraws from social situations. Although she accepts these behaviors, Lisa acknowledges that
these behaviors may not typical of someone Ryan’s age and developmental level.
Development
Ryan was born one day before his due date, after what Lisa describes as a “textbook”
pregnancy. Ryan was born with the umbilical cord wrapped around his body, though this did not
result in any post-natal complications. Lisa described Ryan as an easy baby who slept well and
could be put down easily. He was breastfed from birth, but did not gain weight for the first six to
eight weeks of his life due to an undiagnosed milk allergy. After this allergy was discovered at
six weeks of age, Ryan was fed a soy-based milk product and gained weight normally.
According to Lisa, Ryan met all developmental milestones within normal limits. Notably, Ryan
did not crawl, but instead, progressed from a “full body drag” straight to walking at around
thirteen months of age. She describes Ryan as uncoordinated, and recalls that gross-motor
activities such as running and swimming were difficult for Ryan. Ryan did not learn to ride a bike
until the age of seven, and even now, has difficulty performing multiple movements at one time
(ex. talking while riding a bike). Lisa describes Ryan’s speech as progressing at a normal rate.
She remembers Ryan’s first words as “thank you”, which he humorously applied to a variety of
situations. Ryan wore diapers at night until the age of five. Lisa believes this delay was due
more to Ryan’s “stubborn” nature, than to a lack of bladder control.
Family History
Ryan’s parents, Lisa and Steven, have been together since high school, and married since
2002. In addition to their four biological children, Lisa and Steven cared for Steven’s nephew
Tyson, when he was between the ages of 6-17. Both parents believe Tyson has Fetal Alcohol
Spectrum Disorder, though he has not been formally diagnosed with this disorder. Lisa
describes this period of guardianship as difficult, and at times, traumatic. Lisa describes Tyson
as emotionally volatile and at times, physically aggressive. Ryan was involved in one such
incident, when Tyson threw him down onto the couch. Ryan was unharmed in the incident. In
2016, Tyson left the home, as Lisa did not feel she had adequate resources to support him.
Since his departure, Lisa believes the family is functioning in a healthier manner.
Both Lisa and Steven reported difficulties in school. Despite being a strong reader, Lisa had
difficulty with mathematics. Steven struggled with reading and remembers being teased when
reading aloud in elementary school.
Lisa reports a family history of depression, ADHD, and alcoholism. She is no longer in contact
with her father but shares a “good” relationship with her mother, who occasionally cares for the
children. Steven reports a family history of alcoholism, depression and anger issues. He has no
contact with either parent.
Lisa describes her family as close and targets humour as a primary source of connection within
the home. In regards to physical affection, Lisa describes Ryan as more “standoffish” than the
other children, though he frequently picks up and cuddles with his youngest sister. Lisa
describes herself as emotive and says she frequently communicates her moods to the children.
In contrast, Steven considers himself quiet and introverted. When asked about parenting roles,
Lisa describes herself as the disciplinarian. She believes strongly in natural consequences for
behavior, and prides herself in being more hands-off in helping her children solve their
problems.
Ryan was interviewed informally during the assessment process. He shared about his daily
routines at home, his likes/dislikes, and current challenges he may be facing. Like Lisa, Ryan
described his daily routine as unstructured. According to Ryan, his home responsibilities include
preparing food and helping to care for his younger siblings. In terms of his academic
expectations, Ryan is asked to read each day. Otherwise, he spends time playing on his i-Pad,
looking for insects, and building things outside. He shared that reading is his least favourite
subject, since it is difficult for him and “boring”. Ryan identified math as his favourite subject, as
it was easier for him than reading. He explained that he often creates and solves his own math
questions in his head. Ryan expressed a strong interest in insects, and stated that he would like
to one day become an entomologist. In terms of learning preferences, Ryan said he prefers a
quiet place, though he acknowledges this can be hard to find in a busy household. Although
Ryan spoke freely during the interview, a number of speech anomalies were noted. For
example, Ryan used the word “goed” instead of went, the word “swinged” instead of swung,
“churkey” in place of turkey, and “frew” instead of threw. In 2015, Ryan was assessed by a
Speech-Language Pathologist. Results of this assessment are discussed later in the report.
Medical History
Ryan’s parents report no current medical concerns, aside from an allergy to dairy. There are no
concerns regarding his vision or hearing. Ryan was diagnosed in 2015 with ADHD- inattentive
type, by Dr. Kelleigh Klym. Ryan is not currently medicated for this disorder. No issues with
sleep and concentration were reported.
Lisa describes Ryan as extremely picky eater. He has a small list of foods which he will eat
including tofu, sushi, steak, and peanut butter and honey sandwiches. Ryan is averse to a
number of foods, including some pasta shapes and cooked vegetables. Despite these
aversions, and eating very little, Lisa believes Ryan’s diet to be well-balanced and able to meet
his nutritional needs.
No sensory issues were reported. According to Lisa, Ryan is generally unphased by changes in
noise, light, or temperature.
Education
Ryan has been homeschooled by Lisa since Kindergarten. Lisa follows an “unschooling”
approach to homeschooling. According to Lisa, this child-led approach allows children to learn
at their own pace, guided by their own interests. Included in this philosophy is the child’s choice
whether or not to attend a formal school setting. According to Lisa, she chose homeschooling as
a way to tailor the children’s education and encourage in them a love of learning. The family is
enrolled in the Wisdom program, a program that supports homeschooling environments.
Through this program, the family has signed up for extra-curricular activities such as drama,
kayaking and forest rangers. Lisa is aware of the curriculum standards, but reportedly, does not
follow a set educational program. According to Lisa, there is “no typical day” in their homeschool
setting and instead, the children independently engage in learning activities. For example,
mathematics may take the form of online math games, and science may involve studying
insects outside. Ryan reported also spending time playing Minecraft and watching YouTube
videos on his i-Pad. According to Lisa, Ryan does not routinely engage in writing activities.
In order to develop reading skills, Lisa reads with the children. Lisa describes her family as a
“family of readers” and shared that Ryan’s sister taught herself to read within a few weeks. Lisa
approximates that Ryan is reading at a grade 2 level, though no formal assessments have been
conducted until now. According to Lisa, Ryan struggles with all basic reading skills. When Ryan
reads, he seems to guess at words, instead of sounding them out phonetically. Consequently,
Ryan’s reading fluency is poor. Because of these challenges, Ryan avoids reading, becoming
“stiff” or “weepy” when asked by his mother to read aloud. Lisa is unsure what is causing these
difficulties, but is interested to learn how to best help him progress.
Social
Ryan spends most of his time at home with his family. He was able to identify a few close
friendships outside of his family, though according to Ryan, he does not see these friends
regularly. According to Lisa, Ryan prefers to stay at home and avoid socializing with others
outside of the family. However, when Ryan was asked what he would change if he had three
wishes, he identified “having more friends to play with” as a wish. When Ryan is in a social
situation, he reportedly prefers to stand back and observe others at a distance. Ryan does not
appear to have any difficulty separating or being away from his parents and enjoys the
occasional sleepover at a friend’s house.
Despite frequent emotional sharing within the home, Lisa characterized Ryan as having a
limited emotional vocabulary and explained that many of his emotions (e.g., happiness,
sadness, excitement) are expressed in a muted manner. Lisa describes Ryan as calm, level,
and easygoing most of the time. However, when he is upset or angry, Ryan’s body typically
stiffens and becomes tense. When this occurs, he avoids eye contact and prefers to escape to
his bedroom. According to Lisa, Ryan has a hard time “letting go” when angered, and tends to
dwell on the event or talk about it incessantly.
Ryan was also interviewed informally using the Kiddie-Sads-Present and Lifetime Version
(KSADS-PL), a semi-structured interview used to gain more insight into Ryan’s feelings and
behaviours. Ryan described experiencing significant anxiety when speaking in front of others,
eating in front of others, writing in front of others, performing in front of others, changing clothes
when others are present, and attending parties and social events. When asked what made him
most anxious in these events, he expressed a general fear of others “making fun” of and “being
mean” to him. Ryan also expressed a fear of being on a train. Although he could not identify
what aspect of riding the train scared him the most, he does not like being surrounded by “all of
the people”.
Previous Assessments
In the fall of 2015, Ryan was referred to Physiotherapy, Occupational Therapy and Speech
Language Pathology by his pediatrician, Dr. Klym, based on concerns regarding Ryan’s
articulation, inattention, decreased muscle tone/strength and fine motor skills.
In August, 2015, Ryan was assessed by Jennifer Collett, Occupational Therapist, based on
concerns regarding Ryan’s decreased core strength, his inability to tie shoelaces, left/right
confusion, fine-motor delays, and possible Autism Spectrum Disorder. Overall, Ryan’s visual
motor skills were found to be in the below average range, with noted deficits in printing, letter
sizing, and correct spacing when writing. Developmental Coordination Disorder was discussed
as a potential diagnosis for Ryan, though this diagnosis has not been pursued. Some sensory
concerns were also noted, including sucking or chewing on his clothing, tapping his fingers, and
becoming overwhelmed in loud environments.
Also in August, 2015, Ryan was also assessed by Physiotherapist Carolyn Fuss to address
Ryan’s gross motor delays (e.g., balance and dexterity). During this assessment, Ryan met the
criteria for mild overall gross motor delay for his age. Deficits in motor planning (coordination
and sequencing), poor endurance and decreased overall strength were noted.
In September, 2015, Ryan was assessed by Carmen Kurtz, Speech-Language Pathologist to
address articulation and verbal expression concerns. Based on this assessment, Ryan met the
criteria for a moderate to severe receptive language delay and a severe expressive
language delay.
COGNITIVE FUNCTIONING
Wechsler Intelligence Scale for Children- Fifth Edition (WISC-V)
The WISC-V is an individually administered test battery used for assessing the intelligence of
children ages 6 years 0 months through 16 years 11 months. It consists of a maximum of 21
subtests, which are used to assess the general thinking and reasoning skills of children between
the ages of 6 and 16 years. This tests has 5 index scores that represent intellectual functioning
in the following areas: Verbal Comprehension Index, Visual Spatial Index, Fluid Reasoning
Index, Working Memory Index, and Processing Speed Index. Under most circumstances,
together the subtests provide a good summary of a child’s functioning in each of these areas.
When reviewing Ryan’s scores, remember that no test is perfectly accurate. Any child might
score slightly higher or lower if tested again on a different day. Although the WISC-V is a test of
thinking and reasoning abilities, a person’s scores on this test can be also be influenced by
motivation, attention, interest, and opportunities for learning. Please keep in mind that a few test
scores cannot assess all of the skills that a child might be capable of using to assist him in
achieving success.
WISC-V Composite Scores Summary
Index
% Rank
Verbal Comprehension (VCI)
Visual Spatial (VSI)
Fluid Reasoning (FRI)
Working Memory (WMI)
Processing Speed (PSI)
25th
50th
84th
32nd
1st
95% Confidence
Interval
83-98
92-108
107-121
86-101
61-79
Qualitative Range
Average
Average
High Average
Average
Extremely Low
Ten subtests from the WISC-V were administered to Ryan. There was significant variability in
some of his scores, both at the Index and the subtest level. For example, there was a sizeable
and significant difference between his Fluid Reasoning Index score and his Processing Speed
Index score, a difference that is not commonly seen in the standardized population (BD 1.3%).
Because of these differences, Ryan’s Full-Scale IQ is not likely the best indicator of his cognitive
abilities and will not be reported. Instead, a breakdown of his performance on each Index will be
given below.
The Verbal Comprehension Index measures the ability to access and apply acquired word
knowledge. This involves verbal concept formation, reasoning, and expression. Ryan’s overall
Verbal ability was found to be within the Average range (25th percentile). He scored at the 16th
percentile on the Similarities subtest, which required him to verbalize similarities between
various words and concepts. Ryan performed at the 50th percentile on the Vocabulary subtest,
which asked him to define an object or concept in words. He performed in the Low range on the
Information subtest (5th percentile). Ryan had difficulty with many of the fact-based questions.
For example, when asked “what day comes after Thursday?” Ryan responded, “Tuesday”.
Overall, Ryan’s scores on this Index suggest that though his vocabulary may be in line with his
peers, he may have difficulty with verbal reasoning. His scores also indicate a lower level of
acquired knowledge than would be expected of someone his age.
The Visual Spatial Index measures a child’s ability to evaluate visual details and understand
visual spatial relationships. Overall, Ryan’s score on this Index fell within the Average range
(50th percentile). There was little variability in his performance on the two timed subtests. He
performed in the Average range (63rd percentile) on the Block Design subtest, which required
him to recreate designs from a model using blocks. On this subtest, Ryan worked in an
organized and systematic manner, and was able to complete most designs within the given time
limit. The Visual Puzzles subtest required Ryan to determine which shapes fit together to
complete a given design. Again, he performed within the Average range (50th percentile).
Overall, Ryan’s performance on this Index indicates evenly developed and age-appropriate
visual-spatial skills.
The Fluid Reasoning Index measures a child’s ability to pick up on relationships between
pictured objects, and use reasoning to identify and apply rules for those relationships. Overall,
Ryan’s performance on the Fluid Reasoning Index fell within the High Average range (84th
percentile). There was little variability in his performance on the two subtests. The Matrix
Reasoning subtest tapped Ryan’s abstract and analogical reasoning skills. On this subtest, he
performed in the Average range (75th percentile). Ryan’s performance fell in the High Average
range on the Figure Weights subtest, which required him to use quantitative reasoning to solve
problems (84th percentile). Overall, Ryan’s performance on this Index indicates that his inductive
and quantitative skills may be better developed that the other cognitive skills reviewed this far.
The Working Memory Index provides a measure of a child’s working memory abilities. Unlike
short-term memory, working memory tasks require the child to retain information in the memory,
perform some operation or manipulation of it, and produce a result. Ryan’s overall performance
on this Index fell within the Average range (32nd percentile). However, there was a significant
difference in his performance on the two subtests. The Digit Span subtest required Ryan to
remember and later, mentally manipulate, progressively longer number strings. He performed in
the Low Average range (16th percentile) on this subtest. During this subtest, Ryan frequently
repeated the numbers aloud, presumably, to hold the numbers in his memory until he produced
a response. In contrast, Ryan performed in the Average range on the Picture Span subtest (63rd
percentile). This subtest required him to remember and order target pictures in a field of visual
distractions. Overall, Ryan’s performance on this Index suggests that his visual and auditory
memory skills are unevenly developed. This information may have important implications for
understanding Ryan’s learning process, as it may be challenging for him to learn and retain
information and/or instructions told to him orally.
Finally, the Processing Speed Index provides a measure of a child’s ability to quickly and
correctly scan, sequence, or discriminate simple visual information. A cognitive decision-making
or learning component is also involved in these tasks. Overall, Ryan’s score on the Processing
Speed Index was within the Extremely Low range (1st percentile). However, his performance on
the two Processing Speed subtests varied significantly. Ryan performed within the Extremely
Low range (<1st percentile) on the Coding subtest, which required him to quickly write symbols,
using a code for reference. On this subtest, Ryan worked slowly and often referenced the
coding key. The act of writing appeared effortful for Ryan, given his odd pencil grasp. In
contrast, he performed in the Low Average range on the Symbol Search subtest (9th percentile),
which required him to visually scan rows of symbols to identify whether or not a target object
was present. WJ III comment….
This weakness may have important implications for his learning. Specifically, Ryan may struggle
with integrating and processing new information; this makes learning a more time-consuming,
effortful, and stressful process than it would be for others. Consequently, this may make Ryan
want to avoid learning new skills and view learning at times, as a frustrating and unrewarding
experience.
Wechsler Intelligence Scale for Children- Fifth Edition (WISC-V Integrated)
The WISC-V Integrated is an individually administered test battery used to assess the cognitive
processes of children ages 6:0-16:11. The subtests and scores extent the clinical information
about the cognitive processes and test-taking behaviours that may affect performance on the
WISC-V and permits additional understanding of the cognitive abilities measured with the
WISC-V in specific areas of intellectual functioning.
In an effort to better understand Ryan’s cognitive inconsistencies and weaknesses, he was
administered subtests from the WISC-V Integrated assessment. The WISC-V integrated
includes alternate presentation modes and response formats to the WISC-V. He was
administered three subtests from the Verbal Comprehension domain, one from the Working
Memory domain, and one from the Processing Speed domain.
To begin, the Similarities Multiple Choice (SIMC) subtest is designed to measure verbal
reasoning and concept formation. On this subtest, Ryan was asked to choose the response that
best represents how objects or concepts presented to him are similar. On this subtest, the
examiner read five response options to Ryan. He was then asked to pick the response that best
captured how the two concepts are similar. On this subtest, Ryan performed in the Average
range (37th percentile). This was not significantly different from his performance on the
Similarities subtest on the WISC-V.
To further explore Ryan’s language comprehension skills, the Vocabulary Multiple Choice
(VCMC) subtest was administered. Similarly, Ryan was asked to pick the best description for a
word given five response options. On this subtest, he performed in the Average range (63rd
percentile). Again, this was not significantly different from his performance on the WISC-V
Vocabulary subtest.
Finally, the Picture Vocabulary Multiple Choice (PVMC) was administered. The child is asked
to pick the best depiction of a given word out of four picture choices. On this subtest, Ryan
performed in the Average range (37th percentile). Again, when compared to his performance on
the WISC-V Vocabulary subtest, there was not a significant difference.
Overall, results of the Multiple Choice Verbal Comprehension Index indicate that Ryan does
not perform significantly better when expressive language demands are reduced.
In order to further examine Ryan’s auditory working memory abilities, the Sentence Recall
subtest was administered. This subtest required Ryan to recall a sentence after answering a
simple, and unrelated “Yes” or “No” question. On this subtest, Ryan performed in the Average
range (37th) percentile. This was not a significant difference between his performance on the
WISC-V working memory subtest.
The last subtest administered was Coding Copy. This subtest is similar to the Coding subtest,
but decreases visual scanning demands. Like his performance on Coding on the WISC-V,
Ryan’s performance on Coding Copy fell within the Extremely Low range (<1st percentile).
Removing the visual scanning demands did not appear to improve his performance. It is likely,
then, that poor visual motor skills are responsible for his lower scores on processing speed
subtests.
ACADEMIC FUNCTIONING
Wechsler Individual Achievement Test- Third Edition (WIAT-III)
The WIAT-III is a test battery that includes 14 subtests measuring achievement in reading,
mathematics, written expression, and oral language (as described in the table below).
Composite scores are obtained for each of the four areas of performance, along with a Total
Composite score, indicative of Ryan’s current level of performance. WIAT-III scores do not
reflect the Alberta curriculum or age/grade placement relative to that curriculum.ll
Since Ryan’s homeschooling has not followed a structured curriculum, it is not possible to
determine the academic content he has been exposed to until now, and the opportunities he
has had to develop academic skills. His performance on the WIAT-III should therefore be
considered in light of this important fact.
Not all subtests on the WIAT-III were administered to Ryan due his significant reading and
writing challenges. The following subtests were administered in their entirety: Math Problem
Solving, Word Reading, Pseudoword Decoding, Numerical Operations, Spelling, and Math
Fluency. The Early Reading Skills subtest was also given to gain insight into his literacy
development.
On the Early Reading Skills subtest, Ryan was able to: identify the names of most letters;
identify beginning and ending sounds in a word; and, match a word (or words) to a picture. In
contrast, Ryan had difficulty identifying rhyming words and correctly identifying the letters “b”
and “d”. His performance indicates that Ryan’s has not yet mastered the phonetic and decoding
skills required to read. This finding is in line with Lisa’s report that Ryan simply “guesses” at a
word when asked to read. Reading skills must be explicitly taught before they are applied
automatically. It seems imperative, then, that Ryan is given the opportunity to master basic
literacy skills in an explicit and structured manner, before being expected to read independently.
As expected, Ryan’s performance on the Word Reading and Pseudoword subtests fell within
the Extremely Low range (<1st percentile; 3rd percentile, respectively). His makes sense in light
of the fact that he has not yet mastered the basic literacy skills required to read. Similarly, Ryan
performed in the Extremely Low range (<1st percentile) on the Spelling subtest. As Ryan’s
literacy skills develop, his ability to remember and/or sound out how a word is spelled is also
likely to improve.
Ryan’s Mathematics and Math Fluency Composite scores placed him within the Below
Average range (8th percentile; 10th percentile, respectively). Though his mathematics abilities
are well below the expected levels for his age, they represent a relative strength for Ryan. For
example, Ryan’s strongest performance, on the Math Fluency subtest, indicate that he is able
to solve basic addition, subtraction, and multiplication problems.
WIAT-IIICDN Results
Subtest/Composites
Word Reading
Pseudoword Decoding
Basic Reading Composite
Spelling
Numerical Operations
Math Problem Solving
Mathematics Composite
Math Fluency- Addition
Math Fluency-Subtraction
Math Fluency- Multiplication
Math Fluency Composite
Standard
Score
58
72
65
60
85
76
79
89
81
80
81
95%
Confidence
Range
54-62
67-77
62-68
53-67
76-94
68-84
73-85
78-100
72-90
71-89
75-87
% Rank
Qualitative
Descriptor
<1st
3rd
1st
<1st
16th
5th
8th
23rd
10th
9th
10th
Extremely Low
Below Average
Low
Extremely Low
Low Average
Low
Below Average
Low Average
Below Average
Below Average
Below Average