Patient Name: John Smith
Examined by: Michelle Patterson, Ph.D.
Dates of Assessment: 3/11/2011; 3/18/2011
Report of Neuropsychological Assessment
CHIEF COMPLAINT, REFERRAL QUESTION
John is an 11-year 7-month old right handed male with a chromosomal abnormality (16p11.2 deletion syndrome). He also has a history of cognitive difficulties. Evaluation has been requested by Dr. Ryan of Developmental Pediatrics to document his current neurobehavioral status in the context of his medical history to assist with intervention planning.
SOURCES OF RELEVANT DATA
Relevant information was obtained from John’s medical record, school records, and interview and feedback discussions with John and his mother.
REVIEW OF NEUROBEHAVIORAL SYSTEMS
General presentations/Interpersonal style: John presents as an endearing and polite youngster. He was cooperative throughout the evaluation and worked hard throughout. He did not become unduly frustrated by difficult talks and remained motivated and persistent throughout the evaluation sessions. Findings are considered to be a valid representation of his current level of functioning.
Social cognition/processing: In the structured one to one testing session, basic social processing skills were grossly intact. Eye contact was age appropriate. John was clearly interested in engaging with others and is generally able to participate in reciprocal conversation. However, appreciation of other aspects of social pragmatics was more vulnerable. He was somewhat socially awkward and at times appeared unsure how to engage with others. In addition, prosody was atypical. He could also struggle to interpret nonverbal aspects of social interaction including humor and sarcasm. Socially y in some aspects he presents as a child somewhat younger than his chronological age.
Affect/mood: John displayed a range of affect that was congruent with the situation. No difficulties with regulation of affect were noted. John’s overall mood was bright and cheerful.
Arousal/attention: Arousal was within normal limits. John was alert and fully oriented. Attention was generally intact. In the highly structured testing environment with minimal distractors, he was able to focus, shift, and sustain attention over time. Parent report on behavioral questionnaires did not endorse significant difficulties with attention, nor did teacher report on behavioral questionnaires.
Performance on a computerized measure of attention and response inhibition identified strong performance. John displayed good sustained attention, intact attentional vigilance and age appropriate inhibitory control on this task.

Executive control processes: In the structured one to one testing session, John displayed good control over this behavior and emotions. Task persistence was strong. Observations of organization in the context of a linear, detail oriented information processing style. Although this information processing style can be quite beneficial for simple, concrete tasks, it is not an efficient approach to processing more complex and larger amounts of information. Thus, while his performance on simple materials is intact, as the complexity of tasks increases or items become more abstract, he had greater difficulties. This was particularly noticeable in the language domain. On the other hand, his ability to generate efficient problem solving strategies on his own was generally adequate and within the expected range for age. Self monitoring of his performance was intact as well. Parent report on executive control skills in daily living on the control skills on the BRIEF did not document any difficulties with metacognitive or regulatory aspects of executive control skills, nor did teacher report on the BRIEF.
On specific tasks of executive control skills, John’s performance was notable for vulnerable working memory capacity. Auditory working memory, the ability to mentally manipulate information held in immediate memory, was slightly reduced. For example, on a digit span task,
John was able to recite five digits forward but only three digits in reverse suggesting difficulties with working memory capacity. Speed of information processing was generally intact. However, on a task of rapid naming and inhibitory control skills, John was able to maintain adequate processing speed; however, he made a high number of errors suggesting that he sacrificed accuracy for speed. This makes him quite vulnerable to making imprecision errors on tasks.
Hypothesis generation and conceptual level thinking skills were generally adequate.
General cognitive abilities: Administration of WISC-IV documented overall cognitive ability in the Average range with slightly better developed nonverbal compared to verbal reasoning skills.
John’s pattern of performance is quite similar to his previous evaluation from August 2006.
Additional details of performance are discussed in relevant sections of this report.
Auditory/linguistic processing: There are no current concerns about hearing. Spontaneous language in the context of conversations is fairly easy to elicit. John communicates fluently and spontaneously and engages in social conversations. Speech was notable for poor articulation characterized by dyspraxia and dysarthria. Overall intelligibility was variable. Voice volume and quality were within normal limits. As stated previously, prosody was somewhat atypical.
Difficulties with verbal formulation and organization were noted, particularly when John was required to convey information with precision using more complex language. Difficulties with word retrieval were noted in casual conversations. Comprehension was generally intact in the conversational setting.
Tasks tapping specific language skills yielded variable performance. On tasks that were more concrete, John’s performance was within expectations. However, difficulties with non-literal language and inferential reasoning were noted. Vocabulary knowledge is intact for age. Verbal reasoning skills are intact for concrete information, Confrontation naming skills are well below the expected range for age; difficulties with word retrieval were prominent. Rapid word generation skills were reduced for both letter and category cues. Immediate repetition of sentence length material was reduced for age as well.

Across the board, John’s performance was generally appropriate when managing simple concrete language tasks. Difficulties were noted, however, when he was asked to apply this knowledge in novel situations that required more abstract or inferential reasoning. Moreover, John’s difficulties with word retrieval likely affect his ability to express the knowledge he does possess.
Overall while John’s basic language and communication skills are generally intact, his higher order language skills are much more vulnerable, which limits his overall linguistic and social competence.
John’s success with verbal learning and memory tasks is variable. Performance varies as a function of the meaning fullness of material to be retained. When material is meaningful and contains a high level of contextualized support such as stories with strong thematic content, his performance is within normal limits. On contrast, the demands of a list learning task proved to be significantly more challenging for John. He had difficulty maintaining his attention across the five learning trails. Upon initial presentation of the word list he encoded an average amount of information, recalling eight out of 15 items. However, he did not benefit from the repeated trials format of the task. He did not appreciate sematic relationships among the list items, failing to utilize semantic strategies to enhance recall, apparently relying on brute or rote memorization.
Recall following a short and longer delay was below the expected range. His poor performance following short and longer delays was reflective of poor initial encoding rather than loss of information over time. Thus, what John was generally able to encode during the five learning trials he was able to retain during a short and longer delay. Recognition of items from the word list was below the expected range as well.
Visual-spatial processing: There are no obvious problems with visual acuity, gaze patterns, or attention to visual fields. John recognizes and locates objects/people in the environment and navigates in topographic space without difficulty.
Analysis of performance on visual-spatial and visual-constructional tasks reveals generally intact performance. Nonverbal reasoning skills are within the expected range for age. John had no difficulty reconstructing geometric configurations from multicolored blocks. Likewise his performance on a task requiring more complex visual analysis and synthesis was within normal limits. Visual-motor integration skills are within normal limits as well. John could, however, struggle to some extent to copy a complex figure with substantial organizational demands. His approach to the task was somewhat poorly planned. His recall of the complex figure was formally scored within the Average range.
Motor/sensory: John is an attractive child. Habitus and facies are unremarkable. Bilateral coordination is available. Fine motor speed and dexterity are impaired bilaterally. John prefers his right hand for writing and drawing. Graphomotor control is lightly reduced.
Emotional/personality: John is a warm and friendly youngster. He has a strong desire to connect socially with others. Despite his eagerness to connect with others, there is a somewhat awkward quality to his ability to engage with others. His is fairly concrete and literal and can struggle at times to understand humor and sarcasm in an age appropriate manner. Nevertheless he is a bright youngster and does pick up on some social cues to recognize that when others are laughing, he

should laugh as well. Overall, John presents as a well adjusted and well behaved youngster. In order to gain more information regarding emotional adjustment in daily situations, Mrs. Smith completed the BASC-2. She did not endorse any clinically significant issues. John’s teacher also completed the BASC-2. She endorsed subclinical levels of somatization, which would be expected given John’s medical issues.
Academic skills: Assessment of academic achievement reveals performance levels generally below the expected range for grade placement. John’s single word reading decoding skills are at the early 3 rd
grade level while his reading comprehension skills are at the late 3 rd
grade level.
Overall reading fluency is significantly reduced and at the mid to late 3 rd
grade level. Basic math calculation skills are emerged as an area of relative strength and are at the late 5 th
grade level.
Adaptive skills: Adaptive behavior was assessed by Mrs. Smith’s responses on the SIB-R. Johns’ overall functional independence is reduced for age. Within specific domains of adaptive behavior, social interaction skills emerged as an area of relative strength.
IMPRESSION
John is an 11-year-old , right-handed male with a history of chromosomal abnormality (16p11.2 deletion syndrome). He also has a history of cognitive difficulties. Neuropsychological assessment was requested to document his current neurocognitive status and develop recommendations for intervention planning. John presents as a warm, polite, and pleasant youngster. He was cooperative and compliant with testing tasks and put forth excellent effort throughout the evaluation. Thus the results are thought to provide an accurate reflection of his current level of functioning.
Overall cognitive ability is in the Average range on the basis of a standardized intellectual battery. Verbal and nonverbal reasoning skills are both in the Average range. This pattern of performance is consistent with testing from August 2006.
John’s neuropsychological profile is marked by his concrete cognitive style. Concrete, literal cognitive style can render his quite vulnerable to complexity. Although he is able to recite facts n details about more complex information, he can at times fail to appreciate the coherent conceptual context within which these isolated elements are related to one another. Because he can fail to appreciate how to integrate details into a prior context or framework for more efficient processing, he can easily become entangled by details, undermining his ability to efficiently and comfortably meet contextual demands. Moreover, his awareness and understanding of social pragmatics is somewhat vulnerable which can limit his ability to apply his skills in a meaningful and effective way.
John displays subtle language processing issues. He has difficulties with word retrieval and frequently makes paraphasic errors. As stated previously, he also displays difficulties with verbal formulation and organization. In addition, he continues to display significant articulation difficulties characterized by dyspraxia and dysarthria. He also struggles with aspects of higher order language skills including more complex, abstract verbal reasoning, interpretation of ambiguous material, and inferential reasoning. He has clearly made significant progress is his

speech and language skills as his language processing issues are more subtle. Nevertheless, these vulnerabilities can affect his language and social competence.
Secondary to John’s vulnerabilities with aspects of executive control skills, particularly combined with his language processing vulnerabilities, he will require a longer time to process information. It may take him longer to acquire and master new information, complete basic mental reasoning tasks, and to formulate meaningful oral and written responses to communicate his thoughts.
John’s neurocognitive profile places his at risk for academic struggles. Like all individuals with language processing deficits, he is at risk is situations with high verbal demand. Or in situations that require him to comprehend and integrate complex information independently. His vulnerabilities in processing verbal material may be manifest in partial processing of information which may lead to misconstruing what is expected and/or what others may understand in the same situation. He may miss key concepts presented orally and may accurately understand directions. His verbal formulation difficulties can affect his ability to participate in discussions or rapidly respond to questions. He will continue to require targeted supports to address his subtle language processing vulnerability so as to minimize the risk of him missing key information from his academic lessons, falling behind on assignments, and experiencing difficulties managing the academic load.
John has previously been diagnosed with Attention Deficit Hyperactivity Disorder. At this time he DOES NOT manifest clinically significant levels of attentional difficulties. He has no difficulty focusing, shifting, and sustaining his attention over time.
John’s difficulties are seen in the context of many appropriately developed skills. Verbal and nonverbal reasoning skills are within the expected range for age. Speed of information processing is intact. Memory performance is enhanced by contextual support. In addition, John is a hard working and motivated youngster with strong relationships with his parents.
DSM-TR DIAGNOSES
Axis I
Axis II
Axis III
Cognitive Disorder Secondary to a Medical Condition
Mixed Expressive and Receptive Language Disorder
No diagnosis
16p11.2 deletion syndrome