Reason for Evaluation

Marie was referred for a psychoeducational evaluation by Constance Wells, the Director of Special Education. Ms. Wells had recently consulted with Marie’s parents who had questions about why school has been so difficult for their daughter and if she might now need a formal special education designation. Puritan Ridge remains on summer break, but Ms. Wells requested that an evaluation be conducted before school starts, with additional information to be added later as needed.

Background Information

Marie’s educational history is interesting and a bit unusual. According to her parents, she attended an exclusive preparatory school in suburban Boston, Massachusetts from kindergarten to third grade. Here, she enjoyed an extremely favorable student-to-teacher ratio and extensive support from a private tutor twice a week. Even so, she was seen to struggle with work completion, direction following, and especially regarding socialization. Nonetheless, she was promoted each academic year and her parents were pleased that she was mastering basic academic skills.

During the school years from fourth grade to the conclusion of seventh grade (just this past June) Marie attended public school, Sumner Elementary and Middle School, where her parents described her as “not really fitting in.” She reportedly “got by” and generally made academic progress. But, perhaps critically, parents described school personnel as extremely open-minded and flexible. The district as a whole subscribes to a policy of nurturing each student while attempting to avoid labeling. Thus, even though social problems persisted, as did the ongoing difficulties with direction following and work completion, Marie never underwent a special services evaluation. Instead, she received a host of informal accommodations without a formal special education designation. In retrospect, her parents note that her pediatrician mentioned once or twice the prospect of a developmental problem. They never chose to follow up. Her mother told me, “perhaps we’re guilty of burying our head in the sand.” Now that the family has moved to another state and the prospect of high school is only a year away, both parents are eager to better understand their daughter’s developmental and academic status and to formalize plans for any needed services.

Marie’s parents provided extensive school documentation consisting of report cards, group achievement test scores, and summaries of academic probes. Marie’s report cards consistently described problems with work completion and limited socialization. Nonetheless, report card marks over the years remained consistently favorable. In fact, there are numerous comments from teachers about strong academic skills and a pleasant personality. Nonetheless, group achievement test scores were found to be varied. That said, there is no obvious pattern, save for the fact that reading scores were generally strong and math scores a bit lower. Even so, achievement test scores ranged from percentiles in the 90s to the low 20s. School records confirm that she has consistently passed hearing and vision screenings. Marie has had strong attendance, on average missing just one or two days annually.

Marie is the elder of two Koffi children. Her father told me that he came to the United States from Côte d’Ivoire for college. His primary language is French. Subsequent to completing a bachelor’s degree in electrical engineering, Mr. Koffi met his future wife in graduate school where both earned master’s degrees in engineering. She is from Montreal and, like her husband, is fluent in English and French. For the sake of developing their children’s language skills, however, parents spoke English only in their home. There is a nine-year-old brother who reportedly does well in school, is socially adept, and sometimes watches out for his older sister’s welfare. Parents described their relationship as stable, and they disavowed stressors in the home that might contribute to their daughter’s presentation. They indicated that they have ample financial resources. Immediate family history is negative regarding learning, developmental, or psychiatric problems. Nonetheless, there is reportedly is a second-degree relative who is mathematically gifted but a poor reader.

Marie was born following a term pregnancy without perinatal complications. She had normal Apgar scores. She came home from the hospital on time. Linguistic and motor milestones were reportedly met on time, although Marie has always been described as displaying quite limited social drive. Her mother remembers her as a baby who would spend hours without either fussing or seeking either parents’ attention. As a preschooler, she seemed to prefer parallel play or solitary amusement much more often than interacting meaningfully with age-mates. Nonetheless, Marie reportedly professed interest in acquiring friends and she engaged in social activities (e.g., birthday parties) even if she routinely felt anxious about attending and socially awkward once at an event. She has not routinely participated in sports or other age-appropriate social groups (e.g., scouting, church). Consistent efforts to involve her in soccer (a sport her father loves) failed. Her parents candidly described her as motorically clumsy on the one hand and perhaps unable to understand the intentions of teammates (maybe even the precise rules of the game) on the other hand. Looking back, parents also noted peculiarities. They described her as a child who seemed to incessantly wring her hands as if anxious or unsure. As a preschooler, she was apt to investigate the world around her by tasting, smelling, or feeling objects to detect their texture. She has always expressed strong culinary preferences, with an extremely restricted set of items that is willing to eat (or even try). A food’s texture is a prime complaint and seemingly the basis for her limited diet. Perhaps even more striking is Marie’s long been and intense fascination with the weather. For example, she reportedly is always alert to the portion of the evening news devoted to weather, she commonly asks her mother to check the status of the local weather on her cell phone. She sometimes watches the Weather Channel alone for an hour or more. In fact, parents sometimes have to prompt her to stop watching this channel or even themselves change the television to another channel. Marie is apt to protest, occasionally having a tantrum.

Now, as a 12-year-old, Marie is seen by her parents as quite socially isolated. She reportedly has no friends, although sometimes she is invited to social events as part of her membership in her parents’ network of acquaintances. Both parents described her as shy and afraid to talk. For example, she has rarely spoken up in class. Oral reports have routinely been accommodated by allowing Marie either to make a one-on-one presentation with her teacher or to submit a written document (that parents have invariably helped prepare).

Assessment Procedures

• Wechsler Intelligence Scale for Children-Fifth Edition (9 subtests)
• NEPSY-II (3 subtests)
• Kaufman Test of Educational Achievement-Third Edition (6 subtests)
• Autism Spectrum Rating Scale (ASRS)
• Behavior Assessment System for Children-Second Edition (BASC-3; Parent Report and Teacher Report)
• Parent Interview
• Child Interview

Findings

Because school is currently on summer recess, there was no opportunity to conduct classroom observations. Nonetheless, observation during testing is relevant because of social limitations noted. Marie is a somewhat unusual appearing 13-year-old female with light brown skin and fine facial features. She is tall, thin, and socially remote, an interaction style evident from the very outset of the evaluation. Even as the evaluation proceeded there was little evidence of warm-up. During psychometric testing, she initiated absolutely no conversation and even conversational pauses and changes in voice tone on my part (presses to engage in conversation) failed to get her to say much. When she did speak, there was limited prosody and poor eye contact. No echolalia or pronoun reversals were noted, however. This changed during a clinical interview, when Marie turned quite loquacious on the topic of weather (see below).

The observations above notwithstanding, she was quite cooperative, well-focused, and persistent during cognitive and academic testing. There was no motor restlessness noted nor was she ever seen to be distractible. Similarly, I never saw evidence of a hurried or careless response style. Many children, especially those who are initially anxious or shy during testing, warm up noticeably during a second session. Not so with Marie. In fact, there was no change in her presentation during testing session number two; she showed no more spontaneous language, eye contact, or responsiveness to words or gestures on day two. During both sessions, her affect was quite constricted. There was little evidence of smiling or change of voice tone. I noticed her to sniff the fingers on her left hand three or four times during testing, ostensibly in the midst of transitions or when she appeared anxious. Later, her parents confirmed that they frequently see the same behavior and concur that these actions seem anxiety mediated.

A clinical interview produced noteworthy observations, including much more talking. Still, Marie expressed marked problems engaging in a reasonable two-way conversation. For example, she appeared to miss obvious cues to respond to a topic I raised on the one hand. On the other hand, once the discussion moved to a topic of her interest (i.e., a potential career in meteorology) she proceeded with obsessive detailedness, reflecting quite poor management of the common rules for conversations. The number of facts that she provided on the topic of meteorology is reminiscent of the savantism sometimes associated with ASD. Favorably, during the interview she disconfirmed feelings of depression. On a scale from 1 (lowest) to 10 (highest), she described her mood most days as seven. She specifically disavowed suicidal ideation or intention. Even though this is true, her comments suggest an element of demoralization, which makes sense given the situation that she finds herself in interpersonally and academically. Her goal of becoming a meteorologist certainly matches her current interests. Moreover, there is nothing indicative of a thought disorder. She denied hallucinations or delusions. There was nothing grandiose or expansive about her speech.

Background information and observations are strongly suggestive of a youngster with autism spectrum disorder or, in educational terms, “autism.” This is true even though most youngsters with this condition are identified before age 12. Autism-specific ratings, specifically the Autism Spectrum Rating Scale, concur (see it accompanying psychometric summary for scores). The ratings of Marie’s parents are strongly indicative of the presence of autism spectrum disorder (ASD). This is true for the composite score, the most trustworthy indicator, and especially true when one considers items endorsed that correspond to recognize nomenclature (i.e., Diagnostic and Statistical Manual of Mental Disorders, DSM). The scores alone are strongly suggestive of ASD, but their unambiguous clinical range coupled with the history and observed behavior described above prove even more strongly diagnostic.

Sometimes ASD is mistakenly assumed to be present because it mimics other disorders (and sometimes other disorders co-occur with genuine ASD). For example, many individuals with ASD suffer co-occurring anxiety disorders. Although Marie struggles with self-disclosure, during the clinical interview she did confirm feelings of nervousness, especially during transitions or in anticipation of situations where she must socialize. She showed a degree of self-insight, confirming that she doesn’t always know what to do in new situations. She described having to joke with others or talk about herself as universally prompting emotional distress. Anxiety appears to be expressed both as anticipatory worry and somatically, such as by feelings in the pit of her stomach or sweaty hands.

General purpose rating scales seem entirely consistent with the emerging picture of Marie. Marie’s parents completed the BASC-3, a broadband rating scale able to assess Marie’s behavior, adjustment, and adaptive skills across many domains. One of Marie’s former teachers from Sumner Elementary and Middle School (Leticia London) did the same after she was contacted. Although not specific to concerns about autism, the BASC-3 completed by both raters indeed evidenced score elevations on precisely those dimensions related to autism. Specifically, the Atypicality scale, the Developmental Social Disorder Scale as well as the Autism Probability Index was elevated (see accompanying psychometric summary for scores). As might also be expected, scales related to social withdrawal, and to a less extent anxiety, were also elevated. The two raters produced quite consistent profiles on the BASC-3. It is also noteworthy that both raters appeared to produce trustworthy ratings based on formal BASC-3 validity indicators. These ratings, Marie’s characteristics found via observation and interview, and her history fail to point toward a better explanation for her presentation than ASD. For example, her symptoms are not really explainable by anxiety alone nor does the set of OCD and tic-spectrum behaviors that sometimes co-occur seem to be present as an alternative to ASD.

Cognitive-Intellectual

Many individuals with ASD encounter general cognitive limitations (low IQ). Favorably, this is not at all the case with Marie. She is quite bright, as best referenced by Verbal Comprehension and Visual Spatial composite scores above 120 on the WISC-5 (see accompanying psychometric summary). Research suggests that IQ is one of the best predictors of long-term outcome for individuals with autism spectrum disorder. Consequently, these scores are hopeful.

Furthermore, Marie evidenced no pervasive linguistic deficits, another important prognostic sign. In fact, she enjoys a very large vocabulary, good ability to reason abstractly with words on the WISC-5, and (by observation) she was quite capable of understanding what was said to her and expressing herself orally (problems with social communication aside).

The positive above aside, Marie does not possess across-the-board cognitive strengths. Speedy processing of information (that includes a fine-motor component) was markedly inferior to her outstanding general cognitive capability (WISC-5 Processing Speed = 83). Also, working memory, especially for auditory information, was not as well developed as many of her other cognitive abilities. Her mother has observed difficulty following multi-stage directions. However, in a quiet laboratory environment where she worked without distractions and with her attention secured problems with verbal working memory or understanding lengthy directions were not apparent. Perhaps over-focus or self-preoccupation explain trouble with direction following in day-to-day life.

Other Neuropsychological Functioning

Marie’s scores on the NEPSY-II Memory for Names subtest, at least on the face, suggest declarative memory problems. Her ability to immediately memorize names associated with faces was poor and retention was even poorer after a half-hour delay (compared to age-mates). Whether there is a social basis for this poor score (facial recognition and recall are “social” in nature) is uncertain. It is interesting that parents reported noteworthy problems learning and remembering math facts.

It is thought that failure to recognize emotions-affect may plague children with autism spectrum disorder and that those with ASD lack the ability to understand others’ thinking and perspective. But when these two constructs were tested psychometrically, glaring problems were not detected (see NEPSY-II Affect Recognition and Theory of Mind subtests). Like her general cognitive strengths, these might be viewed as positive prognostic signs.

Academics

Academics appears to represent a relative strength. Specifically, Marie showed well-developed reading and reading comprehension skills as well as excellent writing skills (see KTEA-3 scores in accompanying psychometric summary). The latter included writing a story in a coherent manner. Perhaps even more favorably, she revealed some ability to take perspective and to assume a role on the writing task. This might imply a bit of social competence that not entirely evident in her day-to-day behavior as reported by parents or witnessed during this assessment. That said, regarding writing Marie’s penmanship (manuscript letter production) appeared a bit labored, and her printing was sometimes hard to read (i.e., poor legibility).

Also on a positive note, even in academic subjects of greater parental concern that Marie’s  father and mother, KTEA-3 Math Concepts & Application and Math Computation scores were found to be average or better. In light of her outstanding cognitive capability and her complement of strong academic skills, one might anticipate that she could ultimately head toward college. This outcome, however, would seem to hinge on ameliorating social-emotional and other barriers

Adaptive Functioning

It is unfortunate that raters (on the BASC-3) characterize Marie’s adaptive functioning as sub-standard. Statistically poor scores (most of these scores are at or below the 5th percentile) were found on the following dimensions: Adaptability, Social Skills, Leadership, Activities of Daily Living, Functional Communication, and Adaptive Skills. More specifically, her father and mother endorsed rating scale items implying at least some difficulty in: group situations, independent preparation for school in the morning, getting organized for chores, selecting clothing to match the weather, appropriate responding when asked questions, telephone skills, on-the-spot decision making, planning and “self-starting,” time management regarding eating, dressing, and showering. The cumulative information suggests that as Marie progresses through adolescence that she may continue to encounter adaptive difficulty because of limitations in social communication and lack of flexibility. Moreover, given her ASD symptoms and her current limited array of adaptive functioning, she is at risk for adaptive deficits during adulthood. These aggregated limitations, coupled with pragmatic communication problems, might ultimately constrain her regarding college and independent adult living.

Diagnostic note

Observations during testing are quite consistent with parents’ reports. In fact, using parent reports and current observations, Marie satisfies all DSM-5 ASD criteria: criterion A (persistent deficits in social communication and social interaction) and criterion B (restricted, repetitive patterns of behavior, interests or activities). These include deficits in social-emotional reciprocity; deficits in nonverbal communication used in social interaction; deficits in developing, maintaining, and understanding relationships; stereotyped or repetitive movements (stereotypies), use of objects, or speech; insistence on sameness and inflexibility of routines; highly restricted fixated interests that are abnormal in intensity or focus; hyper-reactivity or hypo-reactivity to sensory input or unusual interest in sensory aspects of the environment. Moreover, the symptoms have been present early in development (criterion C), cause clinically significant impairment (criterion D), and are not better explained by intellectual disability or global delay (criterion E, as described below).

The somewhat less stringent IDEA criteria for “autism” that would create special education service eligibility are also satisfied.

Summary

Marie is a 13-year-old girl whose history appears to include long-standing symptoms of autism spectrum disorder. These are associated with significant educational impact. Obvious school problems, however, have been somewhat avoided, likely because of the protective and accepting environment that Marie has experienced during most of her school career. Nonetheless, without additional supports and interventions, there may be increasing problems as Marie advances in grades. Symptoms of autism spectrum disorder may eventually threaten employment, independent living, and college success. This is true despite above average general intellectual ability and generally well-developed academic skills.

Diagnostic Impression

According to the Individuals with Disabilities Education Act (IDEA)-autism

According to DSM-5 Autism Spectrum Disorder

• Without accompanying intellectual impairment
• Without accompanying language impairment (excluding pragmatic language)
• Severity-Social communication: Level 1
• Severity-Restricted, repetitive behavior: Level 1

Recommendations

1. Because Marie seems to be eligible for services in the special education category of autism, there are two options. The first is to now convene a eligibility team meeting. The second is to postpone such a meeting while immediately launching a functional behavior analysis with the goal of creating a (unofficial) behavior intervention plan to boost work completion and social acceptance. If the latter option is exercised, a classroom observation and teacher-completed rating scales should be first completed (immediately after school reconvenes in the fall). Special education services could be later revisited based on the success of Marie’s behavior intervention plan. All of these options will be discussed with parents in detail during the parent feedback conference.
2. Consider a consultation with a speech-language pathologist. Follow-up speech language therapy are likely to be needed to bolster pragmatics and conversational skills. If these skills were better developed, they may enhance the chances for social and academic success during high school, during the college years, and in later life.
3. Consider a detailed hearing examination at the start of the fall semester.
4. Consider behavioral therapy. This might be provided by a behaviorally-oriented psychologist or behavior analyst. Goals might include: (a.) developing socialization, flexibility, and potentially disrupting habitual talk about meteorology, and (b) developing adaptive skills via task analysis as well as devising a plan for shaping desired skills. This might be offered as a “related service” if Marie receives an IEP based on this evaluation.
5. Consider physical fitness training. Marie has previously expressed interest in physical training and potentially team sports. In fact, this may enhance physical appearance, promote participation in sports and even indirectly aid social acceptance.
6. Related to Recommendation #1, familiarize parents with the prospect of receiving services from the New Hampshire Department of Developmental Disabilities, although it appears criteria have recently changed regarding autism spectrum disorder. See the following link for more information. https://www.nhdes.gov/ddd/
7. Promote parent awareness and knowledge of autism spectrum disorder. The following link may help: http://www.ninds.nih.gov/disorders/autism/detail_autism.htm
8. Share assessment results with Marie. She is a bright young lady who has already started to envision her future and to conceptualize potential adult roles. Thus, informing her about these assessment findings will be appropriate (at a point selected by parents). I will be happy to meet with her then.
9. Share these findings with Marie’s primary care physician. That professional (cc’d here) may choose to address additional non-educational considerations such as a neurologic exam, genetic studies, or consideration of other health factors (consistent with suggestions for multi-disciplinary assessment and management of children with autism spectrum disorder). In addition, her pediatrician could make judgments about whether there is a role for medication regarding symptoms of anxiety or inflexibility. Finally, there appear to be eating problems (i.e., restricted range of foods eaten) that might be addressed by her health care team. Again, this set of recommendations are optional for parents to consider; they are unrelated to questions of special education eligibility and are not part of this educational evaluation process.
10. Follow-up with parents and school psychologist as needed regarding implementation of 1-9 above.

Sally A. Thompson, PsyD, EdS,

School Psychologist, Puritan Ridge and Algonquin Special Education Consortium

cc        Parents

  Primary care physician

Psychometric Summary

This summary of confidential scores is prepared for psychologists and others with specific training in individual psychometric test score interpretation. These scores should never be used independent of the written Psychological Evaluation that they accompany.