Brittney Klauser, M.A. 2000 University Dr. Muncie, IN 47306 (217) 243-8159 PSYCHOLOGICAL EVALUATION CONFIDENTIAL Name: Donnie Devil Guardian(s): Darrell Devil Address: Street Address Muncie, IN 47302 Examiner: Brittney Klauser, M.A. Date(s) of Evaluation: 2/12/2014 Date of Birth: 03/22/1996 Age at Testing: 17.5 years Phone: (700) 555-5555 Supervisor: Eric Pierson, PhD Intake: 2/10/2014 Date of Report: 2/20/2014 INFORMED CONSENT Potential risks and benefits, limits of confidentiality, and test procedures were discussed. Following this discussion, the patient’s grandfather, Donnie’s legal guardian, agreed to complete the evaluation. REASON FOR REFERRAL Donnie was referred by his teacher for an evaluation due to behavior problems including fighting with other students and not performing academically to his full potential. Donnie’s grandparents have asked Donnie’s teacher for assistance in handling these behaviors. RELEVANT HISTORY At the time of the evaluation and report Donnie was a seventeen year old hispanic male. He currently is enrolled in the 11th grade at Fillmore High School. He lives with his maternal grandparents. This evaluation was initiated because Donnie has been exhibiting aggressive behavior and has fallen behind in school since his mother left the country due to not being able to control Donnie. Donnie is feeling extreme guilt about his mother leaving and is obsessive about his relationship with her. Mr. Devil, Donnie’s grandfather, reported he is concerned with Donnie’s aggressive behavior and poor level of academic success. Mr. Devil stated Donnie has been very agitated and aggressive at home to the extent that Mr. Devil has had to restrain Donnie. Mr. Devil reported Donnie has been upset recently due to concerns about his relationship with his mother and how he can make it better. Mr. Devil reported he and his wife currently have custody of Donnie. Donnie reported he does not like living with his grandparents because they do not understand him. Donnie reported his grandfather yells at him all of the time. Mr. Devil indicated Donnie’s mother left the country six to seven months ago and it is unclear when she will be returning. Mr. Devil reported Donnie has had increased anger and guilt since his mother left and he has become obsessive. According to Mr. Devil, Donnie believes his mother is out of the country looking for a new job, however, Mr. Devil stated she left due to Donnie’s behavior. Mr. Devil indicated Donnie’s mother left because she could not handle Donnie’s anger outbursts and self-injurious behavior. Mr. Devil said Donnie communicates with his mother via cell phone and Skype. According to Mr. Devil, Donnie has not had contact with his biological father since the age of five years. Donnie reported he talked to his mother three weeks ago and he has not seen her since Christmas. He stated his mother is not here because “she hates him”, he is a “screw up”, and he is a “failure so she does not like him”. Mr. Devil reported Donnie was born in San Jose, Illinois. Mr. Devil indicated Donnie’s mother received good prenatal care, however, she was not aware she was pregnant until after the first trimester. According to Mr. Devil, Donnie’s mother smoked about three cigarettes per day during pregnancy and used the nicotine patch. Mr. Devil said Donnie met all developmental milestones, however, he indicated Donnie has poor penmanship and had difficulty learning how to ride a bike. Mr. Devil denied that Donnie has any current medical conditions and denied Donnie is currently taking any medication. Mr. Devil indicated Donnie received an annual physical six months ago. Mr. Devil stated Donnie broke his left arm when he was ten years old. Mr. Devil denied any further significant medical history. Donnie denied being on any medication, but reported the doctor gave him a shot when he was at his office three weeks ago. Donnie is experiencing auditory hallucinations and paranoia. He is also exhibiting physical aggression, engaging in self-injurious behavior and has suicidal ideation. Mr. Devil denied Donnie previously received counseling or had a psychological evaluation. Donnie stated he sees the school counselor. Mr. Devil reported Donnie talks about suicide two to three times per week. Mr. Devil indicated that Donnie has never had a plan to commit suicide to his knowledge. Mr. Devil reported Donnie engages in self-injurious behavior by superficially cutting himself on his torso. Mr. Devil indicated none of the cuts have been serious, but they do bleed. Mr. Devil reported he is not aware of Donnie having any homicidal thoughts. However, Mr. Devil indicated Donnie gets violent and aggressive with his grandfather when he tells Donnie no. Mr. Devil stated Donnie has said he hears voices other people do not hear over the last three weeks. Mr. Devil also indicated Donnie is concerned his grandparents have been talking about him when they have not been engaging in any conversation. Mr. Devil reported that over the past six months Donnie has been very particular about what he eats and drinks because Donnie thinks people are going to do something to his food to make him sick. Mr. Devil said Donnie has an overall perception that he is a burden to everyone and Donnie feels guilty about this. Mr. Devil reported Donnie is failing most of his classes. Donnie reported he does not care about his grades. Donnie reported he fails at school because the teachers and students “hate” him and do not understand him. Donnie says he tries “very hard” at school. Mr. Devil stated that Donnie was retained in the seventh grade and that he did “ok” after that, but has struggled since third grade. Mr. Devil said Donnie has a hard time staying in school without getting upset. Mr. Devil indicated he gets a call from the school to pick Donnie up about three times per week. Mr. Devil said since the assessment process has started he and his wife have decided to keep Donnie at home. Mr. Devil reported Donnie is bullied and teased by other kids at school. Done reported he does not have any friends. Donnie reported people will not leave him alone and they “pick on him”. Mr. Devil reported Donnie lacks warm relationships with other students. Mr. Devil indicated Donnie spends time alone in his room listening to tape of political speeches. Mr. Devil stated Donnie enjoys hearing how the crowd reacts to the speeches. Mr. Devil reported the family and Donnie’s primary language is Spanish, but they are fluent in English. Donnie denied that he has ever used any illicit substances, alcohol, or tobacco. Mr. Devil denied Donnie has ever been physically, emotionally, or sexually abused or neglected. BEHAVIORAL OBSERVATIONS AND MENTAL STATUS EXAM Donnie’s appearance and hygiene were age appropriate. He was wearing jeans and a sweater on the date of testing. Donnie was oriented to person, place, and date appropriate to age. He exhibited difficulty in sustaining attention and focusing on the tasks at hand as evidenced by being unresponsive to questions at time and answering questions with relevant information. Donnie exhibited irritable and agitated affect throughout the diagnostic interview. He showed extreme emotions of anger and being upset that were unexpected for the situation. Donnie’s visual acuity was reported to be normal. He was able to understand and follow verbal commands at typical levels of conversational volume. His speech was fluid and coherent; however he exhibited repetitive language at times. He was capable of maintaining social conversation and used both nonverbal and verbal language skills. Donnie avoided eye contact at times, particularly at the beginning of the interview. Donnie appears to have mature gross motor and fine motor skills. His gait appeared to be within normal limits. He was able to pick up and manipulate objects such as pencils without difficulty. He is right-handed. Donnie was physically shaking throughout the interview and rubbed his hands, legs, and head excessively. He denied any current or thoughts of homicidal ideation. Donnie reported a history of suicidal ideation, but he reported he does not want to commit suicide because he thinks it is wrong. Donnie reported he has thoughts of harming himself all of the time. He stated he cuts himself, generally on his chest, “as often as necessary”. Donnie is experiencing auditory hallucinations. He hears his family talking when they are not present. He stated the voices tell him to cut himself and that he has heard the voices for the past six months. His thought processes were disorganized and obsessive around the topic of his mother. Additionally, he expressed feelings of others trying to keep him and his mother apart. Given Donnie’s level of cooperation, attention, consistency of the results, and his effort during the course of the evaluation, the results of this report should be considered an accurate representation of his cognitive, academic, and psychological functioning. ASSESSMENT RESULTS AND CLINICAL IMPRESSIONS Behavioral Assessment System for Children – 2nd Edition (Parent Form) Classroom Observation Conner’s Continuous Performance Test – 2nd Edition Controlled Oral Word Association Test Minnesota Multiphasic Personality Inventory - Adolescent Rey-Osterreith Complex Figure Test Woodcock Johnson Test of Achievement – 3rd Edition Woodcock Johnson Test of Cognitive Abilities – 3rd Edition Wechsler Memory Scale – 3rd Edition Assessment Results: Cognitive Abilities Estimates of Donnie’s level of cognitive functioning were determined by his performance on the Woodcock-Johnson Test of Cognitive Abiltiies-3rd Edition Normative Update. The best representation of his broad overall level of cognitive functioning is the General Intellectual Ability estimate. The Average range of performance is between 85 and 115. His level of performance is in the Average range (87- 96). His performance on tasks of phonemic awareness and working memory were consistent with his broad estimate of cognitive functioning. Typically students with this level of ability will be capable of earning average grades with typical amounts of effort. His pattern of cognitive abilities is not consistent with someone with a learning disability. Attention An assessment of Donnie’s abilities in areas of attention included data from multiple sources including direct observation, performance on specific tasks of attention, and ratings by third parties. His performance on the Conners’ Continuous Performance Test-2nd Edition is best summarized by the Confidence Index. This index indicates the probability that someone has a problem with attention that requires clinical intervention. The probability of Donnie’s performance coming from someone with such a difficulty in attention is 22 out of 100. Classroom observations revealed that Donnie was only on task 55 percent of the time during Algebra II as compared to his peers whom were on task 85 percent of the time. Donnie exhibited minor motor movements ten percent of the time and major minor movements two percent of the time in comparison to his peers whom exhibited a lower rate of minor and major motor movement, five and zero percent respectively. Additionally, Donnie was making noise 33 percent of the time, which is a rate three times higher than that of his peers. This indicates that although Donnie did not have difficulties sustaining attention in the controlled testing environment he is struggling to pay attention in the classroom environment. Ratings completed by his parents suggest that Donnie has difficulty paying attention at home. This may reflect an increased difficulty completing tasks at home, such as homework Visual Spatial Skills Donnie’s performance on tasks of Visual Motor Integration are in the range to be expected of someone with his broad level of cognitive ability and achievement levels. On tasks of both simple and complex copying Donnie performed in the below average range. Memory Donnie’s memory on tasks of both working and delayed memory fall in the range expected of someone with his levels of cognitive abilities. Donnie’s general memory performance falls in the range of (110-126) which is in the high average range. On tasks of working memory his level of performance falls in the range of (104-122). This is in the average to above average range. On tasks of delayed memory his level of performance was in the range of (100-119). This is in the average range. Achievement Donnie’s level of academic achievement in the areas of reading, mathematics, and written language are consistent with his cognitive abilities. His estimated level of achievement in tasks of Broad Reading falls in the range of (90-99). His estimated level of achievement in Broad Math falls in the range of (99-108). His estimated level of performance in Broad Written Language falls in the range of (92-106). All of these levels of performance are in the average range. Persons with this level of achievement are expected to be earning typical grades in school. These individuals are likely to have to work extremely hard and long to earn superior grades in school. Personality An assessment of Donnie’s personality and mood was the product of an integration of his personal history, third party reports, standardized assessments, and behavioral observations. It is important to note that Donnie’s previous pattern and style of interacting with others greatly influences and shapes his current behavior and interpersonal style. Donnie’s difficulties at school and failing grades are likely not a result of cognitive problems, but a result of in ability to concentrate due to his other symptoms. It is likely that if these underlying symptoms are managed, then Donnie’s academic achievement will return to its normal level after a period of remediation. Donnie exhibits a persistent pattern of obsessive thoughts and ruminations, particularly around the topic of his mother, his inferiority, and the guilt he feels about not living up to his and his mother’s standards. In addition, he is exhibiting atypical behavior that is exemplified by his auditory hallucinations and delusions that people are trying to poison his food. These patterns are likely to lead to poor judgment and difficulties focusing on tasks leading to a disruption in his school and home life. Donnie is shy and introverted. He is likely to not function well in social situations; which is exemplified by his report of not having any friends. These difficulties are likely to be worsened by Donnie’s deficits in functional communication. Donnie’s emotional turmoil is more likely to be exhibited through externalizing problems than internalizing problems. When Donnie becomes very upset he is likely to become aggressive and hyperactive rather than becoming anxious or complaining of somatic symptoms. Summary The results of this current multi-method, multi-informant evaluation indicate that Donnie is a 17year Hispanic male experiencing difficulty with school achievement, aggression, hallucinations, and obsessions. While there has been a history of difficulty in school the result of the current evaluation does not suggest that there is a learning disability present DIAGNOSTIC IMPRESSIONS The following multi-axial diagnostic impressions are made based upon the extent of the information made available to the examiner through a multi-method, multi-informant approach to assessment. In the case where information has been withheld, the impression may vary considerably from other professional’s perspective and/or clinical diagnosis of this individual. Axis I: 295.70 Schizoaffective Disorder (provisional) Axis III: deferred to primary physician Axis IV: Problems with primary support group, educational problems, problems related to social environment Axis V: GAF Current: 31 DSM 5: 295.70 Schizoaffective Disorder (provisional) It was a pleasure working with Donnie and his family. If you have any further questions or concerns regarding the content of the report please contact Brittney Klauser M.A. or Eric Pierson, Ph.D., NCSP, HSPP at the Center for Psychological Development. Signature: __________________________________________ Brittney Klauser, MA Practicum Student in School Psychology Ball State University ________________ Date __________________________________________ Dr. Eric Pierson, Ph.D., HSPP, NCSP Licensed Psychologist #5551212 Licensed School Psychologist #51515151 ________________ Date Recommendations 1. It is recommended that Donnie have his self-inflicted wounds checked out by a medical professional immediately. 2. It is recommended that this report be shared with Donnie’s primary care physician. 3. Donnie and his guardians may want to discuss medication options with his primary care physician or ask for a referral to a psychiatrist to address his depression, hallucinations, and paranoia. 4. Donnie’s guardians should lock up all sharp objects and monitor Donnie’s behavior at home as closely as possible to deter him from engaging in further self-injurious behavior. 5. It is recommended that Donnie begin individual to address his depression and maladaptive thought patterns. 6. It is recommended Donnie and his grandparents, or mother upon her return, engage in family therapy to address problems in the family system. 7. It is recommended that Donnie’s mother join a support group to help her learn to help Donnie manage his behaviors and emotions and help her cope with the difficult situation. 8. If difficulties in school achievement and attendance persist, it is recommended that Donnie be considered for special education under other health impairments or a 504 plan with appropriate accommodations to allow Donnie to have full access to educational opportunities. 9. It is recommended that Donnie go see the school counselor when he is upset at school, so that she can help calm him down and help him be able to return to the classroom. This should be tried before Donnie has a guardian come pick him up to avoid any more missed school. 10. It is recommended that Donnie be provided with an aid to help redirect and focus him in the classroom. Test Results Behavioral Assessment System for Children – 2nd Edition (parent) (T-Scores have a mean of 50 and a standard deviation of 10) Scale Classification F Acceptable Response Pattern Acceptable Consistency Acceptable Scale Confidence Interval Hyperactivity 79-83 Aggression 60-74 Conduct Problems 59-73 Externalizing problems 71-81 Anxiety 49-63 Depression 43-55 Somatization 49-60 Internalizing Problems 48-58 Atypicality 80-96 Withdrawal 34-48 Attention Problems 73-85 Behavioral Symptoms Index 70-78 Adaptability 22-36 Social Skills 29-41 Leadership 25-37 Activities of Daily Living 20-36 Functional Communications 15-27 Adaptive Skills 21-29 Conner’s Continuous Performance Test-2nd Edition Domain T-Score Discriminant Function 22% (clinical) # Omissions 53 # Commissions 48 Hit RT 32 Hit RT Std. Error 36 Variability 41 Detectability 59 Response Style 48 Perseverations 51 Hit RT Block Change 48 Hit SE Block Change 54 Hit RT ISI Change 43 Hit SE ISI Change 42 Z +0.27 -0.20 -1.80 -1.40 -0.93 +0.87 -0.20 +0.07 -0.20 +0.40 -0.73 -0.80 Minnesota Multiphasic Personality Inventory-Adolescent Welsh Code 780`2+3-159/64;K`LF+ Mean Profile Elevation: 59.9 Controlled Oral Word Associations Test Trial Letter 1 Letter 2 Letter 3 Category (Animal) Raw Score 15 12 17 18 Z +0.22 -0.26 +0.25 -0.43 Woodcock-Johnson III-Tests of Academic Achievement (WJTA-III-NU) (Mean = 100, Standard Deviation = 15) Cluster Standard Score Z 95% Confidence Interval Broad Reading 95 -0.33 90-99 Broad Math 103 +0.20 99-108 Broad Written Language 99 -0.07 92-106 Woodcock-Johnson III-Tests of Cognitive Abilities (WJIII-COG) (Mean = 100, Standard Deviation = 15) Cluster Standard Score Z GIA 92 -0.53 Verbal Ability 98 -0.13 Thinking Ability 90 -0.67 Cognitive Efficiency 103 +0.20 Phonemic Awareness 86 -0.96 Working Memory 110 +0.67 Wechsler Memory Scale-3rd Edition Scale Standard Score Auditory Immediate 99 Visual Immediate 94 Immediate memory 96 Auditory Delayed 111 Visual Delayed 91 Auditory Recognition 110 Delayed General Memory 120 Working Memory 115 95% Confidence Interval 87-96 90-105 85-96 97-110 77-95 103-117 Z -0.07 -0.40 -0.27 +0.73 -0.60 +0.67 95% Confidence Interval 92-106 88-105 88-104 100-119 83-103 96-118 +1.33 +1.00 110-126 104-122 Rey-Osterreith Complex Figure Test Condition Raw Score Copy 32 Recall 28 Time on Task Algebra II Class Z-Score -1.26 +0.57 Group On Task mm MM Noise Target Peer 55% 85% 10% 5% 2% 0% 33% 10% 11 Personality Report Grading Rubric Report Introduction 10 points 7 – 6 points 5 – 4 points < 4 points Identifying infor- Identifying infor- Identifying infor- One of the Two or more mation, statement mation, statement mation, statement sections (identifying of the sections of purpose, client of purpose, client infor- history, behavioral history, behavioral mation, (identifying infor- observations, and observations, and statement diagnostic interview diagnostic interview of purpose, are present, how- are present, how- ever one or more ever one or more are lacking precise are lacking precise description OR description AND sufficient comprehensiveness. sufficient comprehensiveness. of purpose, client history, behavioral observations, and diagnostic interview are complete, precisely described, and sufficiently 9 – 8 points comprehensive to depict the child/ adolescent. client history, behavioral observations, and of purpose, client history, behavioral observations, and diagnostic interview) diagnostic interview) may be missing and/or several are lacking precise are not present. description AND sufficient comprehensiveness. 10 points = Distinguished 9 – 8 points = Proficient 7 – 6 points = Basic 5 and below = Unsatisfactory mation, statement Introduction Score 10_________ 12 13 Data Presentation/Interpretation 10 points 9 – 8 points 7 – 6 points 5 – 4 points < 4 points Presented data is Presented data Presented data accompanied includes inter- includes inter- Presented data Presented data by statement pretation, but pretation, but is either un- is not reliable of confidence one of the two or more of reliable or and does not and confidence following is the following does not include inter- intervals when possible, includes missing: is missing: include inter- pretation. statement of statement of confidence and confidence and confidence confidence protects the intervals, accurate intervals, accurate confidentiality identification of identification of of test items. data, or confiden- data, or confiden- tiality of test tiality of test items. items. an interpretation, is accurately identified, and pretation. 10 points = Distinguished 9 – 8 points = Proficient 7 – 6 points = Basic 5 and below = Unsatisfactory Data/Interpretation Score __10_______ 14 Inferences based upon behavioral and/or personality assessment data 10 points 9 – 8 points 7 – 6 points 5 – 4 points < 4 points Inferences draw Inferences include Inferences include Inferences are Inferences based not based upon upon behavioral all but one of the at least two of information and/or personality together information from all sources, are supported by following: data, are related information from to the statement all sources, of purpose, and support by explain possible contradiction. data, relationship to the statement of purpose, and lack of contradic- the following: information from all sources, support by data, relationship gathered through- assessment data out the testing are not included (multiple sources, in the report. data gathered, to the statement statement of pur- of purpose, and pose) and may lack of contradic- contradict one another. tion. tion. 10 points = Distinguished 9 – 8 points = Proficient 7 – 6 points = Basic 5 and below = Unsatisfactory Inferences Personality/Behavioral Score __9_______ 15 Recommendations 10 points 9 – 8 points 7 – 6 points 5 – 4 points < 4 points Pertinent rec- Recommendations Recommendations Recommendations ommendations address the re- are not precisely are not precisely Highly inappropriate are provided that ferral question, described and lack described and lack are supported by one of the two or more are provided OR no data and interpreting following components: of the recommendations inferences, and address the following components: are included. relate to the referral question, address the conclusions, however are precisely referral question, described, are are precisely supported by described, are data and interpreting supported by address the referral question, are precisely described, are supported by data and interpreting inferences, and they are not precisely described. are appropriate and inferences, and related to the are appropriate and conclusion. data and interpreting inferences, and related to the are appropriate and conclusions. related to the conclusions. 10 points = Distinguished 9 – 8 points = Proficient recommendations 16 7 – 6 points = Basic 5 and below = Unsatisfactory Recommendations Score ___9______ 17 Errors of Communication 10 points 9 – 8 points 7 – 6 points 5 – 4 points < 4 points Report is free Report includes Report lacks of communication minimal (1-5) past tense verb Report lacks past tense verb Report has clearly not been edited for errors including: communication consistency and misspelling, errors including: use of jargon instead misspelling, of more precise use of jargon instead consistency and includes several includes many (9 (6-9) communication or more) comm- errors. unication errors descriptions, run on of more precise or incomplete descriptions, run on of several different sentences, paragraphs or incomplete types. without topical sentences, paragraphs themes and/or without topical statements, ambiguous themes and/or sentences, and lack statements, ambiguous of past tense verb sentences, and lack consistency (except of past tense verb for summary section consistency (except and recommendations). for summary section and recommendations). 10 points = Distinguished communi-cation errors. 18 9 – 8 points = Proficient 7 – 6 points = Basic 5 and below = Unsatisfactory Errors of Communication Score ___10______ Consideration of Ethnicity and Diversity Issues 10 Points 9-8 6-7 4-5 <4 Report shows evidence that the report evaluated, considered, and placed the findings of the report into the context of family, school, and community culture. Report shows evidence that the report evaluated, considered, and placed the findings of the report into the context of family, school, and community culture but one was limited. Report shows evidence that the report evaluated, considered, and placed the findings of the report into the context of family, school, and community culture but both areas limited. Report shows evidence that the report evaluated, considered, or placed the findings of the report into the context of family, school, and community culture. Culture was not considered. 10 points = Distinguished 9 – 8 points = Proficient 7 – 6 points = Basic 5 and below = Unsatisfactory Considerations of Ethnicity and Diversity Score ___10______ 19 Errors of interpretation 10 points 9 – 8 points 7- 6 points 5 – 4 points < 4 points Interpretations Interpretations Interpretations Interpretations Failure to Reflect consideration and use of a multi-method multiinformant approach and are free from are generally include a few include several based upon ( up to 5) (6 or more) interpret data errors in the errors in the represented in insufficient reliable, sufficient following following the report/ data, erroneous data, however areas: unreliable areas: unreliable assumptions an erroneous data, data, reflecting in- assumption has insufficient insufficient been made. data, erroneous data, erroneous ledge of the data/ assumptions assumptions instruments, and reflecting in- reflecting in- recommendations sufficient know- sufficient know- that can not be ledge of the data/ ledge of the data/ implemented. instruments, and instruments, and sufficient know- recommendations recommendations that can not be that can not be implemented. implemented. 10 points = Distinguished 9 – 8 points = Proficient 7 – 6 points = Basic 5 and below = Unsatisfactory Errors of Interpretation Score ____9_____ protocol. 20 Overall Grade 65 – 70 points = Distinguished = 95-100% 60 – 64 points = Proficient = 85-95% <60 = Unsatisfactory <85% Report Number __1 revision_________ Semester _Spring___________ Date _3/31/14____________ _____________________________ Personality Student Signature Overall Score __67______