Report Template for Children and Adolescents – copyright Carol Oster, Psy.D.
clo_60035@yahoo.com or 847-962-4089 for questions and permissions
Leave room at the top for letterhead. Delete instructional comments in blue and red from
your final report. They are there to help you think about what to write. Blue text is
specific to cognitive assessment courses or basic to all reports. Red text is specific to
objective and projective personality assessment courses. Throughout the report, strive to
describe the child, not the tests. Pay attention to developmental stage: the child is on
their way to peak performance. Where are they on that journey? Maintain a
developmental, hopeful tone and future focus, as appropriate to the situation.
PSYCHOLOGICAL EVALUATION
(Confidential)
Name:
Date of Birth:
Age:
Referred by:
Place of Examination:
Date of Examination:
Date of Report:
Examiner:
Give age in years and months. Spell name of month.
Spell name of month
Spell name of month
Reason for Referral:
Before beginning any assessment, clarify the questions to be answered by the assessment.
Include the child's and parents’ questions, as well as those of third parties. The clearer
the reason for the assessment is, the more helpful you can be to the child. Common
referral questions are to clarify diagnosis, to assist in differential diagnosis, to identify a
learning disability, to understand the child’s academic performance and help them learn
better, to determine whether the child is qualified for a particular academic program, to
assist in treatment planning, and to answer a particular question or set of questions. The
better-delineated the referral question is, the more targeted – and on-target – the
assessment, report, and recommendations will be.
Procedures:
List any procedures completed, in order of administration. In the standard approach to
assessment, procedures are administered in a “peel the onion” order. For assessment
courses in graduate school, include “Clinical Interview” in your list, even though you
may not conduct a formal interview, to reflect your collection of any background
information. There is not really a “standard battery” for assessing children. An
assessment for learning disabilities purposes should include intelligence, achievement,
and emotional components, tailored to assess the components of the possible problem –
and to rule out competing hypotheses. That is, it might be a reading disability – or it
might be depression, anxiety, OCD, and so on… so be sure to adequately gather
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information for and against alternative hypotheses. The traditional “standard battery”
consists of those tests marked with a *. Delete the * in the list below. Answering the
referral question will usually require that the list be altered to include more, fewer, or
different assessment methods.
Clinical Interview (specify interview of parents, child)*
Wechsler Intelligence Scale for Children - IV (WISC-IV)*
Woodcock Johnson Test of Achievement – III
Bender-Gestalt Test*
House-Tree-Child*
Incomplete Sentences Blank*
Minnesota Multiphasic Personality Inventory – Adolescent Version (MMPI-A)*
Thematic Apperception Test (TAT)*
Rorschach Inkblot Method*
Others as needed to answer the referral question, such as review of educational records,
review of prior testing, the Gray Oral Reading Test, Conners’ ADHD scales, Achenbach
Child Behavior Checklist, and so forth.
List contacts with teachers, social workers, pediatricians, etc.
Background Information:
Throughout this template, I am referring to both children and adolescents when I say
“child”.
Include here information regarding the following topics, as relevant to the purposes of the
assessment. This list is given to provoke your thinking and to encourage you to be
thorough, wherever such thoroughness is warranted:
 Identifying information including age, gender, ethno-cultural identity, year in
school.
 Describe the family context. Be careful about reporting that the child is adopted,
or that one parent or another is a stepparent, or that “Mom and Dad” are actually
“Grandma and Grandpa”. If the child has not been told, you might not want to put
it in writing. What is the child’s birth order? Do not name relatives other than
parents. Instead, refer to them by relationship; e.g. “older brother”.
 Presenting complaint and symptoms;
o History of the presenting complaint including onset, duration, course
(times when it’s better or worse);
o Whether the problem seems to be improving or worsening as the child gets
older;
o Prior treatment efforts and success of these;
o The parents’ and child’s (teacher’s, pediatrician’s?) conceptualization of
the problem;
 Relevant personal history
o Critical events in development and timeliness of meeting developmental
milestones
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o Life stressors in the time period preceding the presenting problem and
preceding the referral for evaluation
o Changes in the family situation prior to the onset of the symptoms (birth
of a sibling, older sibling left for college or marriage, family moved, best
friend moved away, finances changed, parent got ill, etc.)
 Academic history
o Grade in school
o School performance a/e/b report cards, teacher’s written comments over
time, GPA, recent work handed in and graded, and similar hard data
o How the child performs in reading and math (basic skills) as well as other
subjects – parent, teacher and child perspectives.
o Best/worst classes. Are those constant? Time of day those classes are
scheduled; teacher characteristics; other factors affecting performance in
those classes (ask the child!).
o What the child recalls about learning to read and do math; what is
hard/easy for them from their perspective; teacher and parent perspective;
evidence in submitted work.
o Whether any special assistance or accommodation has been needed or
granted before this assessment, and effect of that intervention.
o Parental expectations and standards
o Setting effects: study area at home, environmental disruptions, etc.
o Permission to contact school, if relevant and necessary to the evaluation
o Review of previous psycho-educational assessments, including results of
both standardized group achievement tests (E.g., Terra Nova tests) and
any previous individual ability or achievement testing. Look at this
chronologically for clues as to the evolution of the presenting problem or
question.
 Occupational history for adolescents where applicable
o What jobs the adolescent has had
 Functional job analysis – what do they actually DO on a daily,
weekly basis. What knowledge, skills, and attitudes are required
for success and happiness on the job? Make sure you actually
understand what the adolescent is supposed to do when he or she is
at work. Don’t assume. Ask.
 What jobs they have previously had
 Level of accomplishment a/e/b promotions, added responsibilities,
awards, etc.
 The child’s report of how easy or difficult it was to learn the job
 What they feel they do well and not so well
 What they like and dislike about the job
o Quality of interactions with peers, supervisors, and supervisees
o Parental expectations and standards
o Whether any special assistance or accommodation has been needed or
granted before this time
o Permission to speak with employer if relevant and necessary to the
evaluation
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 Social history
o Report in writing only what is 1) relevant to the referral question, and 2)
appropriate to share with a general audience. Some of this is none of a
school’s business. Bear in mind that adolescents between 12 and 18 may
be able to suppress some information they share with you – even from
their parents. Know the law; follow it; consider the good of the child and
need to know before you put something in writing or share it verbally.
o Number and length of friendships; breadth of the group; whether friends
are considered positive influences by parents and teachers; whether the
older child/adolescent has changed friends lately or at the onset of the
problems; any traumas within the friendship group, whether to this child
or others; whether the child is popular, accepted, ostracized, bullied, etc.
o Typical social activities and type and level of involvement in
extracurricular activities (too few, too many, variety, level of commitment,
task and time demands of the activity, etc.)
o Whether the older child or adolescent is “dating” (check idiosyncratic
meaning); who they date; history of break-ups (who, why, coping method,
impact?). Ask a dating adolescent if he/she is sexually active, and if so,
ask about birth control, STD protection, pregnancies/abortions, and so
forth. Consider such information in your assessment, but do not put it in a
written report without a clear, legal, ethical rationale for doing so.
o Success of social activities a/e/b length and persistence of relationships,
cooperation and reliability in group activities (e.g., gets to practice on
time, practices the instrument, etc.)
o Parental expectations and standards (too loose, too lax, high standards,
standards adjusted for child’s ability, temperament, and personality?)
o Satisfaction/dissatisfaction with friendships, community, dating
o Quality and appropriateness of interaction with members of peer group,
family, and community
o Any difficulties – onset, course, duration, patterns, situational analysis
o Capacity to tolerate being alone; demonstration of appropriate judgment
and impulse control in history
 Medical and developmental history
o Age at which major developmental milestones were attained (crawling,
walking, first word, sentences, etc.)
o Physical skills: walking, bike riding, coloring and writing, athletic or
musical skills; comparison with peers, parental expectations
o Congenital or neonatal history, congenital or inherited neuro-muscular
problems such as cerebral palsy, dystonia, and the like
o Childhood illnesses, particularly ear infections, asthma, injuries,
hospitalizations, chronic illnesses, anything that could interfere with
school attendance, either episodically or cumulatively
o Later illnesses, especially…
 Chronic illnesses
 Diabetes
 Thyroid problems
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

Metabolic problems
Fibromyalgia, juvenile or osteoarthritis, carpal tunnel, or other pain
or functional disorder/disease
 MS or other degenerative disease/disorder
 Cerebral palsy, dystonia, “tics” or other neuromuscular disorder
o Any hospitalizations
 What for and when
 Length of hospitalizations
 Any problems, complications, or sequelae?
 Success of treatment
o Hearing, vision, orthotic, or vestibular problems,
 Impact on presenting problem
 Corrective measures or treatment
 Efficacy of corrective measures
 Whether the child is using those corrective measures at the time of
testing
o Medications taken previously or currently;
 Type and dosage
 What for
 Efficacy
 Side effects the child experiences
 How long they’ve been taking it
 Whether they take it regularly as prescribed
 Last time they took it (date and time)
 If today, “Is it working? How long does it take to “kick in”?
o Substance use:
 Alcohol and street drugs the child “has tried”
 When started, largest amount consumed and when; current types
and levels of use in dosage and exact frequency
 Last use
 Effects and impact
 Side effects
 Legal issues (Consider a formal substance abuse history where
indicated.)
 Prior efforts to quit
 Social system’s reactions to use
o Last physical checkup
 Results
 Whether parents have discussed the presenting problem with the
pediatrician
 Parents’ and child’s relationship with medical professionals
o Permission to contact physician if relevant and necessary to the evaluation
 Psychiatric/Psychological history
o Previous psychiatric or psychological treatment
 With whom, what for, when and for how long
 Efficacy
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 What worked, what didn’t
 What the child and parents liked/disliked
 Long-term outcome
 Relationship with treating clinicians
o Prior psychological or psycho-educational assessment or testing
 When? Why?
 Results – get copies if at all possible
 Interventions and efficacy
 Family history
 Adopted or related by blood (careful!)?
 Academic accomplishments and problems in siblings, parents,
grandparents, aunts & uncles (think genetics, familial demands,
social modeling)
 Occupational functioning in parents, grandparents, siblings
(predicts target functioning level or self/other expectancies)
 Relevant medical history, Ps, Gs, Sibs
 Psychiatric history, Ps, Gs, Sibs, As & Us
 Level of acculturation of family
 Length of time in US; child and parent “generation” in US
 English-language fluency
 Conflict or acceptance of US cultural norms relevant to the
referral question or diagnoses under consideration.
 Permission to speak with family members if relevant and necessary
for the assessment
 Note: Do not name family members. Refer to them by relationship only. E.g.,
“Mr. X’s uncle” versus, “John Smith, Mr. X’s uncle”; “older brother” versus
“Tom Smith”, Mr. X’s older brother”.
Behavioral Observations:
This section should describe what the child brings to the testing. It reports your general
observations of the child. Observations are what a video recorder would pick up. Thus,
they are a form of objective data. Keep this section descriptive, not evaluative or
conclusive. This not the place for diagnostic statements. This section also does not
include the child's response to specific test stimuli. That belongs under "results". To
clarify, “John became increasingly anxious as testing progressed and refused to
complete the some tasks” does belong here, as it describes the child’s ongoing anxious
state. “Mary laughed upon being presented with set 4 of the Picture Arrangement
subtest, saying it reminded her of her mother” does not belong here (if, indeed, it is
useful at all!) because it is a response to a specific test item. In addition, “John appeared
to be using a kinesthetic approach to Matrix Reasoning,” belongs under test results
because it indicates not a state, but an approach to the particular task. Finally, “Mary
appeared to be suffering from a generalized anxiety,” is a diagnostic conclusion, and
belongs at the end of the report, after test results (the data that informs the conclusion)
have been presented.
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DO include here the following: Setting constraints on testing (e.g., two or more sessions,
background noise, interruptions in the testing, interference, etc.). Generally, you want to
relate any environmental conditions that might have made it difficult for the child to put
forth his/her best effort, or that might have affected the validity of testing.
The parts of the Mental Status Exam that are readily observable belong here. For
example, discuss the child’s appearance if it is noteworthy or related to referral question.
Note his or her orientation to person, place and time, especially in settings where that
might be in question, such as psychiatric, forensic, or rehabilitation/neurological settings.
Observe speech quality, e.g., intonation, modulation, pressure, fluidity, speech problems,
as well as reticence or garrulousness. Describe the child’s affect (visible display of
emotion) in regard to feelings displayed, range of expressiveness (flat, labile,
animated/normal), and appropriateness to content during the interview and formal testing.
List any reported or observed handicaps to sensory-motor functioning: glasses or contacts
(to correct what?), hearing aid, gait or motor problems, hand tremors, etc.
Report on the child’s ideation evident in behavior, such as overtly anxious statements,
suicidal/ homicidal comments, evidence of delusional or hallucinatory thinking evident in
behavior (as opposed to evident in test results).
Report on the child’s ability to separate from parents, and his/her apparent attention and
concentration, cooperation, persistence, and effort – the conative factors involved in
performance. Then make a statement about your sense of the validity of results, based on
the full collection of behavioral observations and the child’s history. For example, you
could say, "Based on John’s behavior, and his apparent effort and cooperation, test
results are likely to be an (accurate, underestimate) assessment of his (typical
functioning, functioning at this time, or potential)".
Note the parentheses. Throughout this teaching template, parentheses suggest
alternatives. Note especially the last set in the above paragraph. “Typical functioning”
means you think this is the way the child functions generally, and that the test results are
not unduly influenced by situational factors. “Current functioning” means this is the way
the child is functioning NOW, but the results may not indicate prior functioning or
predict future functioning. This is appropriate when, for example, you are testing a child
who is recovering from brain injury, or who is severely depressed. “Potential” indicates
you are trying to predict how the child will function in the future, such as on the job, or in
school. For example, you might be evaluating a child for accommodation on the job, and
the test results may reflect about how well the child can be expected to perform at his/her
best, provided you were able to motivate him/her to perform well, and there were no
situational or other constraints.
Some examples:
“Based upon John’s obvious cooperation, persistence, and effort, these tests results are
likely to accurately reflect his true potential.”
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“Based on the clear and persistent discrepancy between John’s test responses and his
behavior during breaks from the testing, the test scores are likely to reflect his attempt to
manipulate the outcome of the assessment rather than the “truth” about his
capabilities.” (Such as happened in one personal injury assessment I observed.)
“Based upon John’s lack of cooperation and his difficulty with concentration and
persistence, these results likely underestimate his true potential. However, they may
accurately reflect his functioning under the current stress of family disruption.”
“Based upon Mary’s effort, concentration, and cooperation, these results likely
accurately reflect her functioning under the influence of her depression.”
“Based upon the number of interruptions and the less than optimal testing conditions,
these results likely underestimate Mary’s true ability, despite her cooperation, effort, and
obvious desire to succeed.”
“These test results may slightly overestimate Mary’s true abilities, particularly on
Performance tasks, due to her familiarity with the test materials.”
“John’s history and his cooperation with the testing procedure suggest that the results
reflect his typical functioning.”
Cognitive Functioning:
Select appropriate phrases. Note: here and throughout, underlines are space holders. Do
not use underlining in the report itself. Consider using subheadings: General Ability,
Academic Skills and Achievement, Reading Problems, and so forth, as appropriate to the
referral question, rather than the general heading above.
(Child’s name)'s performance on the WISC-IV places (him/her) within the (average/
above average/ superior/ borderline/ extremely low) range of intellectual functioning.
(His/Her) general intelligence of ___ is higher than that of ____% of
(children/adolescents) (his/her) age. This last statistic is called a percentile rank.
Don’t confuse it with being “95% sure of your results.” An IQ of 90 to 109 is average.
Were (s/he) tested again under similar circumstances, there is a 95% chance that (his/her)
score would fall between ___ and ___. The last phrase is the “confidence interval.”
You are 95% confident that the child’s “true score” falls within the given interval of
scores. Contextualize the child’s general ability by referring to those things in the child’s
life that fit with their overall ability. Discuss the implications of the child’s general
ability for the referral question.
The WISC-IV also yields the following Index Scores and subtest scales scores. Index
scores of 90 to 109 and scaled scores of 8 to 12 are average. (Child) obtained the
following scores. The following table should appear on one page in your final report,
with no break. If necessary, include a page break before the table. In your report, cell
boundaries of the table will not print. If you TAB over to each cell, you will be able to
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replace the data below with your child’s data. More data might appear in your table if
you are using the WISC-IV Integrated.
Index
Verbal
Comprehension
Similarities
Vocabulary
Comprehension
Information
Word Reasoning
Working Memory
Score
108
%-ile
70
Index
Perceptual Reasoning
(101-114)
12
13
10
11
14
75
84
50
63
91
Block Design
Picture Concepts
Matrix Reasoning
Picture Completion
Block Design w/o time
bonus
107
68
Processing Speed
(99-114)
Digit Span
Letter-Number
Sequencing
Arithmetic
12
11
75
63
Symbol Search
Cancellation
13
84
Coding
CA Random/Structured
Cued/Free Recall
Score
127
(117-132)
14
12
17
10
15
%-ile
96
97
(88-106)
11
11
42
8
10/11
25
50/63
>25%
91
75
99
50
95
63
63
In interpreting results of intelligence tests – or any other test that has subscores – you can
take a top-down or bottom-up approach to interpretation. The best approach is to do both
simultaneously. Think about the aggregate scores as most reliable, but also attend to the
component scores that contribute to that aggregate in interpreting it. So… the FSIQ is the
best predictor of a child’s general ability, but the score accurately reflects his or her
overall ability only insofar as it reflects a unified construct.
Be careful here. Any difference between index scores or subtests that is not statistically
significant is not clinically significant, under most circumstances. If the difference is too
small to reach statistical significance, it is unlikely to be detectable to the observer or to
the child themselves, or to make a difference in the child’s functioning, and thus will not
have any meaning in describing the child’s behavior. Let me make this clear: if there is
no statistical difference, you treat the scores as identical, and do not discuss the (illusory)
difference in the report. Also, there is no such thing as “almost” statistically significant.
It either is or is not. Do not interpret as useful, distinguishing, or relevant a difference
that approaches but does not equal or surpass the cut off for significance! These cautions
are necessary both because our tests are not perfectly precise tools, and because people
are not perfectly consistent over time.
When discussing each “index area”, first identify where the child’s ability is relative to
the general population (normative range). A score that is significantly different from
average (<90 or >109 for IQ and index scores) are strengths or weaknesses relative to the
general population, regardless of how they compare to the child’s overall ability. When
discussing significant discrepancies between index scores, consider the child’s overall
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ability the “baseline”. Index scores significantly different from that baseline represent
relative strengths if higher, or relative weaknesses if lower. “Relative” means relative to
the child’s own average – the “local norm”. For example, if the child’s FSIQ is 140, and
Processing Speed is 120, PSI may be a relative weakness compared to the child’s other
scores, but it is still significantly stronger than the score for the average individual the
child’s age. If you only say it is a weakness, the reader assumes the child can’t do things
as well as the average child his/her age. You must include the term “relative,” or some
other verbal indication that this is a within-child comparison, when describing differences
from the child’s overall ability, rather than differences from the normal population
(between-persons comparison).
In the next sections, “drill down” from larger pools of data – index scores - to individual
data points (individual items) to reveal patterns in the child’s performance. VCI and PRI
are relatively “pure” measures of verbal and non-verbal reasoning, compared to the VIQ
and PIQ found in the WAIS and previous editions of the WISC. Compare VCI and PRI
as you would VIQ and PIQ. It is likely that most of the research on VIQ-PIQ differences
applies fairly well to VCI-PRI differences, and that much of the research on the WISC-III
and its predecessors applies to the WISC-IV, but be careful, and do not assume. In some
ways, the WISC-IV is a very different animal from the WISC-III.
Working down the hierarchy, each index score meaningfully assesses a unified construct
or aspect of intellectual functioning only if the subtests that make up that measure “hang
together” statistically. Discuss the meaning of the child's index scores individually, and
their comparisons from the discrepancy analysis page of the WISC-IV record form using
that hierarchy. Discuss both which scores are statistically high, low or average compared
to the general population (nomothetic comparison), and which scores are strengths or
weaknesses when compared to the child’s overall functioning (ipsitive comparison).
Discuss whether the constructs assessed by each index area operate as unified wholes.
That is, do the subtests that make up the index area co-vary, or are they discrepant? If
discrepant, what accounts for that? Consider the sensory-motor stimulus-response
demands of the task, whether the child displayed different levels of anxiety, whether
scores fell as time went on (a fatigue effect), whether scores rose or fell depending on
whether there were time limits, how the cognitive demands of stronger and weaker tests
varied, and so on, in looking to understand differences in the child’s performance on
different subtests within the same index. Address any other important patterns or
discrepancies. For example, you might consider whether the child’s scores vary
according to Bannatyne’s factors, according to the CHC theory of intelligence, according
to whether the task requires more simultaneous or more sequential processing, and so on.
At the bottom of the hierarchy, each subtest accurately assesses performance on its
construct to the extent that intra-subtest scatter is minimal. Discuss any scatter. Look for
patterns in “hits and misses.” E.g., does the child miss all geography questions on the
Information subtest? All division problems on Arithmetic? Discuss the implications of
any such patterns.
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Verbal tasks on the WISC-IV are of two types: those measuring verbal comprehension
and those measuring working memory. Verbal Comprehension tasks include defining
words, answering questions requiring common sense or common knowledge, identifying
similarities between two concepts or words, and using verbal clues to “construct” a
concept. Verbal comprehension is strongly related to overall ability and academic
performance. On these tasks, (Child) scored in the (name the range using Wechsler’s
terminology) range, (higher/lower) than about NN% of children (his/her) age.
In the paragraph on Verbal Comprehension, discuss how the child’s abilities or
difficulties, as assessed by VCI alone, function in his/her life. Contextualize and
individualize this description. Talk about the child, not the test. Point out any
discrepancies between specific abilities the subtests identify and what the differences
imply, by analyzing how the tasks in subtests with higher and lower scores differ in terms
of needed skills, stimulus and response modalities, and theoretical constructs being
measured. How do these relative strengths and weaknesses function in the child’s life?
How do they relate to the referral question? Discuss any noteworthy response patterns or
behaviors the child demonstrated when presented with these tasks. Speech patterns,
response latencies, word-finding difficulties, Spartan or verbose responses, need for
repetition or encouragement could all be discussed, especially if persistent. Idiosyncratic
responses to items or idiosyncratic problem solving methods that may be relevant to
diagnosis or referral question should be addressed. Emotional response, concentration,
and so forth could be discussed here, if different from what was displayed on other tasks.
The subtests that make up the construct Working Memory measure the ability to hold
information active in mind while solving a problem with it, selectively attend to some
information while ignoring other information, and perform mental tasks using a step-bystep logical approach. Child’s Working Memory score is (name the range),
(higher/lower) than NN% of children (his/her) age. Working memory is engaged when,
for example, Child (here include some examples of working memory as it might show up
in the child’s life, such as using math knowledge to solve longer problems, adding long
rows of numbers, keeping track of what he/she reads sufficient for comprehension,
remembering complex or multi-step instructions, taking organized notes during a lecture,
performing mental math, and so on. Use examples that fit the child’s context.) Discuss
the implications of the score given the referral question. Discuss any significant
differences between subtests. Both immediate auditory recall of meaningless information
(Digit Span and Letter-Number Sequencing) and recall and processing of meaningful
information (Arithmetic) are assessed in this area. Discuss the meaning of a difference
between Digits Forward and Digits Backward, if significant or relevant. Address the
assessment of incidental memory from Digit Symbol - and later relate this to the recall
portion of Bender. Add observations as appropriate, as described in the section above.
Compare and contrast the child’s abilities as assessed by VCI and WMI areas. Discuss
the implications of any significant difference or lack thereof, in light of the referral
question, the child’s history, the context to which you are predicting, and so forth.
Discuss how the abilities assessed by VCI and WMI affect each other. Note, for
example, whether retrieval difficulties or problems with incidental learning appeared to
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impact Information, or whether language processing affected the Arithmetic subtest.
Identify any relevant commonalities in the child’s approach to these tasks, in light of
stimulus factors (auditory) and response factors (verbal), or other relevant patterns.
Non-verbal problem solving tasks on the WISC-IV are of two types. The first of these,
Perceptual Reasoning, required Child to construct visual models using a visual guide,
perform hands-on problem solving, understand complex ideas presented visually, solve
abstract visual problems, and identify important missing visual details. Child’s ability in
this area is (name the range), higher than NN% of (children/adolescents his/her) age.
Continue discussing as above. Discuss the implications of the child’s perceptual
reasoning for academic functioning – given this specific child. For example, it might
affect the child’s handwriting, discrimination between similar letters, ability to track
across and down a page when reading, copy from the board, set up math problems in
columns, read maps, understand graphs, make sense of geometry, follow demonstrations
in science, read social cues, or find his/her way around the school.
Since POI and VCI are the most “pure” measures of reasoning, subtracting out WMI and
PSI, compare and contrast the child’s verbal and non-verbal reasoning abilities next.
That is, compare and contrast their abilities as reflected in PRI and VCI. What are the
implications? Talk about the child and their relative abilities, not the scores.
Processing Speed tasks assessed the speed with which (Child) learns material presented
visually, (his/her) visual alertness, and the speed with which (he/she) makes decisions,
given visual information. (Child)’s abilities in this area were (name the range),
(higher/lower) than NN% of children (his/her) age. Continue discussing as above.
Differentiate poor performance on Coding due to motor vs. incidental learning problems,
and relate this to the “recall” portion of the Bender, if you administered it, as well as any
other incidental learning issues. Discuss the meaning of any difference between
Cancellation Structured and Random. Comment on any problems with retrieval speed or
response latencies observed on subtests other than those directly assessing processing
speed. For example, did the child lose points on Block Design due to slow speed? Were
his/her responses to verbal subtests delayed? Compare and contrast the child’s abilities
as reflected in PRI and PSI.
Overall, Child’s intelligence test results indicate that (he/she) thinks at a (name the range)
level. Briefly reiterate areas of absolute and relative strength and weakness, and any
critical patterns and observations.
Continue your report by discussing the results of any other achievement or cognitive
testing. I’ve provided one way to set up Woodcock Johnson test results at the end of
this report, which is where I include them. I’ve given set-ups for both cognitive and
achievement results, using all – or nearly all -subtests available for each. If you
administer only the basic subtests, some of the general indices will not be computed,
and you may need to alter the table.
Child Name
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If additional or other academic tests were administered, such as Key Math, the GORT,
the WRAT-III, and so on, report results and what they mean about the child’s abilities
here. Discuss the implications of such results. Compare with WISC-IV results, and
discuss the implications of the differences. Learning disability assessment is shifting
from solely an ability-achievement discrepancy to include an assessment of strengths and
weaknesses in cognitive processes thought to underlie learning. Pay attention, therefore,
to the underlying processes assessed in all instruments, as, for example, the index scores
on the Wechsler. Is the child performing as would be expected from his/her intelligence
test results? If not, what seems to be the problem? How does that explain actual
academic performance in the classroom?
Include relevant findings from the MSE, Bender, House-Tree-Person, and Sentence
Completion, TAT, Rorschach, etc. (Koppitz’s and/or Lacks’ criteria, construction
complexity on HTP and/or results of DAP scoring of person drawing; presence of
cognitive, motor, or perceptual problems on the Bender, HTP; vocabulary usage, fluency
of language, evidence of learning disabilities or higher intelligence in content, grammar,
spelling, punctuation, on Sentence Completion; complexity, coherence, orderliness, and
language skills evident in TAT, number and intactness of responses on the Rorschach,
and so forth.)
Resolve any discrepancies in the data by identifying the differences or similarities in the
constructs being measured, setting or child characteristics, or task demands. For
example, memory tested using sentences, numbers, words, mixed stimuli, or spatial
location; visual vs. auditory stimuli; familiar/contextual vs. nonsense/out-of-context
stimuli; and free versus cued recall may differ. What are the implications of these
differences for the child’s ability to perform as expected in his/her context?
Note the child’s behavioral responses to test stimuli, or to the testing situation itself,
particularly unusual responses. Alternately, note normal responses when the unusual
would be expected. For example, an allegedly hyperactive child attends, persists,
concentrates, and so forth (might be effect of medication, misdiagnosis, or…) An
adolescent claims not to be able to do a task on the test, yet performs a similar task during
breaks without difficulty. Describe any information gained or performance differences
observed from “testing the limits” (and describe the method of testing of the limits –
which did not violate test security, did it?).
Translate all of this into terms relevant to the child’s life. What do strengths and
weaknesses in the above areas look like in this child’s everyday life and the contexts in
which he or she lives? How are they connected to the presenting problem or other reason
for referral?
Sum up this section by discussing the implications of the results. What do they say about
the child’s overall cognitive functioning and cognitive style?
Social-Emotional Functioning
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Consider a different heading than the above. For example, in reporting results for a child
with ADHD, it might say, “Behavior” or “Behavioral Problems and Strengths”. For an
anxious child, it might say, “John’s Ability to Cope with Anxiety”
Caveat: I conceptualize clients from a multi-theoretical perspective, but my core
approach is CBT. Alter all of the below to fit your theoretical orientation. But talk about
the child, not their “mirroring transference”, “oral fixation”, “incongruence”, or
whatever. Describe the child so that their grandmother and best friend would recognize
them from your description.
In describing children through college aged individuals, it is critical to take a
developmental perspective. Personality is in the process of being created, not hard-set, in
children, and is more plastic in young adulthood than in older years. Describe the child,
adolescent, and young adult as in development, rather than set in stone. Talk about the
social and self-skills they have or have not developed YET, about how far they have
come and where they are going next. While this is important for all clients, it’s especially
important when describing children, adolescents, and young adults.
In addition, on the whole, children do not select their environments, and it is therefore
much more critical to consider social environment effects on their performance and
behavior (family, neighborhood, SES, global level of education in the neighborhood, this
year’s teacher, the school as a whole, the unique combination of personalities in the
child’s peer group, and so forth) than for adults. While staying true to the data that
emerged from the assessment, carefully consider the reciprocal influence of
child/adolescent and environment in describing the child/adolescent.
Start by discussing the implications of the child's cognitive strengths, weaknesses, and
style (as reported in the prior section) for daily functioning. Address the child's capacity
for self-control. Address his/her ability to appreciate reality and control irrationality,
his/her judgment and empathic ability, his/her ability to initiate and maintain friendships,
and likely areas of difficulty in solving social-emotional problems based simply on
cognitive strengths and weaknesses.
Identify the child's primary psychological symptoms, if any. If you could identify a basic
direction of movement (a developing personality style, if you will) or diagnostic
characteristic, what would it be? If this is the core of the child, or the core of his or her
problem, how do the rest of the characteristics or symptoms relate to, contribute to,
maintain, or emanate from this core? What environmental factors might be contributing
to, modifying, or maintaining the problem cognition, emotion, or behavior, or keeping the
child stuck in development?
Identify the child's predominant affect and mood. Discuss the child’s degree of
responsiveness to affective stimuli, his/her range of affect, and its appropriateness to the
situation. What is his/her capacity to delay gratification, to delay action, to cope with
frustration? Again, contextualize this in terms of social learning theory and other
environmental factors.
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What is the nature of the child's anxiety? I.e., under what circumstances does the child
manifest anxiety? How is the anxiety manifested? How does the child attempt to cope
with anxiety, stress, and the current situation? How effective are these methods for
him/her? Discuss the child's capacity for appropriate (not too lax, not too harsh) impulse
control.
Identify the cognitive, social-emotional, situational (and biological, if applicable) factors
that underlie the presenting problem, if any, or that relate to the referral question.
Relate the above to the child's presenting problems, and social, academic/occupational,
peer-group, and family functioning. Identify the child's emerging view of self, world,
others, future – and describing these as in the process of development, rather than fixed.
Relate these to the life tasks of work, love, community/friendship, self and spirituality.
What are the emerging core beliefs that are affecting the child’s functioning, especially
those relevant to the referral question?
Identify the areas in which the child demonstrates psychological strength and positive
qualities. How does the child use these strengths in his/her life? How do they mitigate
the presenting problem or add to an understanding of the referral question? How might
the child’s strengths be used in therapy or in the situation to which you are “predicting”
to improve the child’s functioning? How will those strengths continue to affect the
child’s development.
Summary:
Briefly summarize the report as a whole. Some audiences (judges, busy psychiatrists)
read only the summary, so you must be succinct, clear, and direct. What was the referral
question? What is the child’s general level of intelligence, and any noteworthy strengths,
weaknesses, or stylistic patterns observed. Then summarize overall social/emotional
assessment results, highlighting the more central and salient aspects of the child’s
developing self, and his/her current functioning.
Clearly and simply relate the results to the referral question, and ANSWER THE
QUESTION/S in as straightforward and clear a manner as possible. Make sure your
answer is clearly supported by the test data. Give MUCH more weight to the data and to
actuarial interpretation of results than to your “clinical judgments,” as research says the
former is likely to be more accurate. Where there is conflict between clinical impression
and data, say so, identify which is which, describe your conclusions and rationale for
them, and help the reader know how to handle the discrepancies.
NOTE: Information and hypotheses listed in the summary should reflect PREVIOUSLY
DISCUSSED information and hypotheses. No new information or hypotheses should be
presented here.
Check to make sure you have CLEARLY ANSWERED the referral question.
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Diagnosis: Note that for some referral questions, diagnosis is not the issue, and no
diagnosis should be given. For example, pre-employment screening does not require a
diagnosis. For doctoral students in assessment courses and preparing competency
examinations, full 5-axis diagnoses must be given.
Axis I: XXX.XX (Write out diagnosis and modifiers for Axes I and II
Axis II: XXX.XX in addition to their codes. If there is no diagnosis on either of these
axes, the code is “V71.09 No Diagnosis”.
Axis III: (Medical conditions that impact on the referral question, if any. Note the
source of the information, such as medical file, patient report, or pediatrician, or
“per DSM-IV criteria”. Failure to cite the source can leave you open to charges
of practicing medicine without a license, because you are not qualified to make
medical diagnoses. )
Axis IV: (Psychosocial stressors: list category of stressors and the specific stressors, and
identify them as mild, moderate, severe or extreme. Note that the rating is by
objective criteria. Adjusting to a new school is usually a mild stressor, but may
become moderate is preceded by a move at a vulnerable age or by a complication
such as coping with peer reaction to a physical disability, or may be more severe
if it comes as a result of some trauma.)
Axis V: GAF Current:
__
GAF Highest in past year: __
(Note that a child’s current level of adaptive functioning cannot exceed his/her
highest level of functioning in the past year, since the day you assessed him/her is
a part of the past year!)
Recommendations: Use whichever apply of those below, and/or additional or
alternative ones pertinent to the referral questions. Group recommendations according to
the major findings of the report. Place major recommendations first, and less critical
recommendations later in each numbered point. Present recommendations in numbered
outline format, for easy digestion and referral.
1. Your first point, when needed, should be anything urgent or emergent: the need to
hospitalize, to take action to protect the child or others from the child’s
dangerousness, to protect the child due to extremely poor reality testing, to urgently
have the child assessed for medical or neurological problems. If it’s serious, say so
clearly. Further, if something needs to be done emergently, don’t wait for the report
to be written to get in touch with the child, their family, the referrer, etc., so that
emergency needs can be met immediately.
2. Identify any educational interventions needed, arranging them by problem area.
Consider interventions that need to be done at school, that can be implemented at
home, that a therapist should help with, or that the child/adolescent can work on
themselves, with support. My recommendations start with a numbered statement of
the problem (E.g., 2. John does indeed have a reading disability, characterized
primarily by problems in comprehension due to severe difficulties with working
Child Name
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memory. Suggestions to improve, his comprehension are:) and then several ways to
help improve or accommodate the difficulty.
3. Identify whether psychological treatment is warranted. If so, related to what specific
issues? What mode? What kind? What frequency, intensity, setting, and urgency?
To achieve what goals? Of what expected duration? If this is an inpatient
assessment, is continued hospitalization warranted? Based on what?
Example:
“Continued inpatient hospitalization is warranted due to John’s suicidal ideation and
plan, concurrent severe anxiety, lack of social support, and refusal to participate in
outpatient therapy.”
“John’s therapist should help him cope with the learned and habitual behavior patterns
that accompany his ADHD, and specifically should focus on helping him develop impulse
control, the capacity to delay gratification, and frustration tolerance.”
“Individual, outpatient, cognitive-behavioral therapy, once weekly, to address Mary’s
adjustment to high school and separation anxiety is recommended. Mary should begin
working with the high school counselor this week if possible, as she is considering
dropping out of school.”
“Mary should be referred to Kinheart for participation in “coming out” groups to help
her identify and cope with the issues related to her decision to reveal her sexual
orientation to her family, and to receive support from others after having been “outed”
at school.” (If making a specific referral, give contact information.)
3. Consider medical evaluation? To alleviate what symptoms?
Example:
“If Mary’s anxiety does not abate within two weeks of starting treatment, her parents
should consult with her pediatrician or an adolescent psychiatrist to determine whether
anti-anxiety mediation would help her calm down enough to attend classes while she is
beginning therapy. Specific attention should be paid to evaluating her sleep pattern,
since she reports she stays up “all night” worrying.”
4. Non-psychological, non-psychiatric interventions needed? What kind? By whom?
Other agencies need to be involved?
Example:
“Given the nature of Mary’s cultural and religious beliefs and their impact on her
parents’ willingness to seek therapy, consultation with their rabbi is recommended. This
consultation should identify whether the rabbi is capable of helping Mary with her
Child Name
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depression, or whether the rabbi can assist her and her parents in accepting the
professional help she clearly needs.”
6. Environmental interventions (e.g., stimulus control) needed?
Example:
“Johnny needs to be seated at the front of each classroom, so that he is able to see the
board.”
“At work, Johnny should be switched to a position that minimizes interaction with
customers. He should have the opportunity to socialize with a small group of fellow
workers, to reduce his anxiety and provide him with opportunities to check out his
interpretation of his experiences.”
7. Issues that might interfere with treatment and how to address them?
Example:
“Mary’s parents see her as a victim of “the high school’s impersonal, uncaring
environment.” They repeatedly sympathize with and encourage her distress. Unless her
parents can be helped to adopt a supportive yet adaptive approach, this otherwise
capable student may continue to struggle with the transition to high school. It is
recommended that her counselor arrange to meet with her parents and that they be
encouraged to participate in the Parents-in-Transition outreach program.”
8. Further assessment? What kind? By whom (what specialty)? To resolve what
questions?
Example:
“Neuropsychological assessment is recommended to assess the extent and nature of
brain damage John has suffered as a result of his substance abuse. Rehabilitation
evaluation is recommended to identify interventions that may help him cope with his
impairments.”
“Given the nature of John’s learning disability and his slow progress despite the special
education services he is receiving, reassessment is recommended in one year to assess
the efficacy of the new Individual Education Plan and to determine whether an
alternative educational placement should be considered.”
Finally, include a formal signature block, which looks like this:
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Respectfully submitted,
________________________________
Your name, highest EARNED and RELEVANT degree
Examiner (or Psychology Intern, if you are one)
________________________
First Last, Degree
Supervisor
Ethical guidelines specify that you should list only your highest, relevant degree (or two
if both are relevant, such as J.D., Psy.D. if you practice mental health law). That is, you
cannot load your signature to make your credentials look more impressive. Do not list
your Ph.D. in economics, English, or even education (unless it’s school psychology).
Your M.D. or R.N. are irrelevant and not to be listed, because that education did not train
you to perform psychological testing/assessment. Do not list a bachelor’s degree. You
can list masters’ level training in a related mental health field if you have not completed
your doctorate in psychology. If you are a diplomat (i.e., have passed advanced
competency board exams), you may add these initials to your degree initials, e.g., “John
Smith, Psy.D., ABPP”.
In addition, if you are a doctoral student in a program where I teach, it is expressly
prohibited to list yourself as “Psy.D. Candidate”. Psy.D. programs generally do not
recognize or use the term. Traditionally, the term is reserved for persons who have
completed everything for the doctoral degree except for the dissertation, and whose
dissertation proposals have been accepted. Because the path to the Psy.D. varies from the
path to the Ph.D., most programs do not use or endorse the term. Do not use it!
Similarly, do not list A.B.D.. The public thinks this is a credential. It is not. It is the
absence of a credential.
See the next pages for WJ-III results tables I use in my reports.
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Woodcock Johnson – III Cognitive Test Results
Cluster/Test
Thinking Ability
Verbal Ability
Comprehension-Knowledge
General Information
Verbal Comprehension
Cognitive Efficiency
Processing Speed
Visual Matching
Decision Speed
Pair Cancellation
Retrieval Fluency
Working Memory
Numbers Reversed
Memory for Words
Auditory Working Memory
Long-Term Retrieval
Visual-Auditory Learning
Visual-Auditory Learning Delayed
Retrieval Fluency
Rapid Picture Naming
Fluid Reasoning
Concept Formation
Analysis-Synthesis
Cognitive Fluency
Broad Attention
Numbers Reversed
Auditory Working Memory
Pair Cancellation
Executive Processes
Concept Formation
Pair Cancellation
Visual-Spatial Processing
Spatial Relations
Picture Recognition
Phonemic Awareness
Sound Blending
Incomplete Words
%ile
Standard
Score
Functioning Level
Name the range
Z = .nn
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Woodcock-Johnson III Achievement Test Results
Cluster/Test
A. Broad Reading
1. Basic Reading Skills
a. Letter/Word Identification
b. Word Attack
2. Reading Fluency
3. Reading Comprehension
a. Passage Comprehension
b. Reading Vocabulary
B. Oral Language
4. Oral Expression
a. Story Recall
b. Story Recall – delayed
c. Picture Vocabulary
5. Listening Comprehension
a. Understanding Directions
b. Oral Comprehension
C. Broad Written Language
6. Basic Writing Skills
a. Spelling
b. Spelling of Sounds
c. Editing
d. Punctuation & Capitals
7. Written Expression
a. Writing Fluency
b. Writing Samples
D. Broad Math
8. Calculation
9. Math Fluency
10. Math Reasoning
a. Applied Problems
b. Quantitative Concepts
Academic Skills (A1a, C6a, D8)
Academic Fluency (A2, C7a, D9)
Academic Applications (A3a,C7b,
D9)
Academic Knowledge
Phonemic/Graphemic Knowledge
Total Achievement
%ile
Standard
Score
Functioning Level
Name the range
Z = .nn