Illustrative Case Report

A sample psychological case report follows: Walt H., a 21-year-old Caucasian male who suffered brain damage following a car accident at age 14. Walt has a striking V > P pattern, suggestive of damage that is exclusively or primarily confined to the right cerebral hemisphere. (This is an ac tual case, although the name and other identifying information have been altered to preserve anonymity.) We have modified the test interpretation sections of these reports (and of the other case reports that follow Chapters 9, 12, and 13) to conform to the specific interpretive procedures advocated in this book; however, these modifications affect only how the test results are communicated, not the basic findings themselves.

As is evident from the case reports in this book, report writing is as individual an endeavor as test administration. Competent interpretation of the WAIS-III depends on the examiner's ability to integrate the test data with data from other relevant tests, cognitive and otherwise. Further, test scores are interpretable only in the context of the person's specific background and clinically observed behaviors. The interpretive rules and guidelines elaborated throughout this text are useful to a point; however, competent interpretation often demands modifying the suggested procedures to fit a specific case.

Consequently, we are opposed to the computerized case reports that are so prevalent and easily available to clinicians. Some computerized techniques are available that simplify clerical procedures, such as determining significant strengths and weaknesses; we see no problem with that type of shortcut. However, we strongly oppose those computerized techniques that offer specific interpretations of IQ and subtest profiles and that generate canned reports. Nothing is more individual than the report that communicates the results of a psychological, neuropsychological, or psychoeducational evaluation to those who will potentially use the results for the person's benefit.

WALT H., AGE 21, HEAD INJURY

Referral and Background Information

Walt H. was referred to determine the current levels of his abilities and to make appropriate vocational suggestions for him. Walt is currently unemployed and lives at home with his mother and one younger sister. He has one older sister who no longer lives at home. He enjoys a good relationship with his stepfather, who is currently separated from his mother. Walt was involved in a car accident a few months before his 15th birthday. The accident resulted in partial paralysis of his left side and in a significant loss of vision. Vision in his right eye is limited to gross form discrimination peripherally and to light/dark awareness in his central vision. Central vision in his left eye is normal but peripheral vision is severely limited. Difficulties with both short-term and long-term memory were noted after the accident.

Prior to his accident, Walt was enrolled in public school and was placed in a learning disabilities resource room. Difficulties were noted in reading, spelling, and behavior. Both before and after the accident, Walt was taking Cylert for diagnosed hyperactivity. He is currently taking no medications.

Subsequent to the accident, Walt enrolled in a new public high school following his family's move to another state. Placement in a learning disabilities resource room was continued. During this period, presenting problems included severe motor deficits and limited vision. Partial paralysis continued to affect his left side, and his balance was tenuous. Walt was naturally left-handed and, consequently, was forced to learn to use his right hand for writing activities. His remaining vision permitted him to do most academic tasks; however, he experienced significant difficulties in tracking across a page or across the blackboard. Cognitively, Walt evidenced similar deficits to those noted prior to the accident. In addition, short-term memory was inconsistent and periods of confusion and disorientation were noted. Walt progressed steadily and was able to graduate from high school at age 19. During high school and subsequent to graduation, he received training through state vocational rehabilitation services. Training included job skills and a period of training at a nearby school for the deaf and blind.

He was administered a WISC-R at age 12, prior to his accident, and obtained a Full Scale IQ of 101 (Verbal and Performance IQs were not available). After his accident, Walt was administered a WAIS-R at age 17. That testing yielded a Verbal IQ of 91, a Performance IQ of 66, and a Full Scale IQ of 77. The large difference in favor of Verbal IQ over Performance IQ (25 points), the motor damage to the left side of Walt's body, and the precise nature of his visual problems all suggest that he suffered right cerebral damage—either primarily or exclusively— from his accident. This current testing was initiated in an effort to establish Walt's level of functioning and to isolate specific skill abilities and deficits. Walt has expressed a desire to determine career areas for which he is best suited.

Appearance and Behavioral Characteristics

Walt is a 21-year, 7-month-old Caucasian male with blond curly hair; he is heavyset and below average height. Walt was tested over the course of three sessions. The first session was in a psychologist's office at a high school; testing conditions were good. Subsequent sessions were at the University of Alabama under adequate testing conditions. Walt appeared to be at ease with all examiners and rapport was easily established and maintained throughout the testing. It is felt that these results represent a valid and reliable indication of his current level of functioning.

The effects of the accident were noted in his measured, somewhat rigid movement patterns. Physical posturing was used as an apparently effective accommodation to his limited vision. Walt presented himself as a friendly, highly verbal young man. He conversed freely with the examiners and did not seem to be intimidated by the situation. At times, he seemed to "search for words," but he nonetheless communicated his thoughts and feelings effectively. He appeared to be relaxed and frequently demonstrated a good sense of humor. When discussing the progress he had made, Walt appeared to be self-confident and seemed genuinely proud of what he had accomplished. He expressed a strong determination to continue his progress and indicated that he hoped some day to be able to help other people.

During the initial portions of the testing at the university, Walt evidenced a degree of disorientation. When asked to name the current date (April 15 th), his response was delayed. After some thought, he responded, "I'm not sure. It's not January...April?" He was also uncertain as to what city or university he was in, even though this had been a frequent topic of conversation.

In general, Walt experienced difficulty on tasks that were abstract. When he encountered difficulty, he tended to persist and did not frustrate easily. Walt evidenced the ability to learn on tasks that were initially difficult for him. He tended to approach such problems with a trial-and-error method of problem solving and was most successful when accompanying instructions were ordered and step-by-step. Throughout the testing, Walt's processing skills appeared to be slow, and his answers tended to be measured and deliberate.

Tests Administered

• Bender-Gestalt Test of Visual-Motor Integration

• Peabody Picture Vocabulary Test—Third Edition (PPVT-III)

• Vineland Adaptive Behavior Scales (Expanded Form)

• Wechsler Adult Intelligence Scale—Third Edition (WAIS-III)1

Test Results and Interpretation

Walt H. earned a Full Scale IQ of 79 (8th percentile) on the WAIS-III, which classifies him in the Borderline range of intellectual functioning, ranking him at about the 8th percentile when compared to individuals his age. On the Peabody Picture Vocabulary Test-Third Edition (PPVT-III), Walt earned a standard score of 82, which ranks him at about the 13th percentile. These scores are consistent in categorizing Walt's cognitive functioning at the juncture of the Borderline and Low Average classifications of intelligence (a summary of all of Walt's scores is provided in Table 8.25).

Walt's Full Scale IQ does not provide the most meaningful estimate of his cognitive abilities because his verbal and nonverbal skills were highly discrepant. Specifically, a significant difference exists between his WAIS-III Verbal IQ of 93 (between 89-97 with 90% confidence; 32nd percentile; Average) and Performance IQ of 67 (between 63-75 with 90% confidence; 1st percentile; Extremely Low). This 26-point difference is significant at the .01 level and is abnormal, occurring very rarely (less than 1% of the time) among adults with IQs comparable to Walt's. The Verbal IQ, when compared to the other global scores, is less affected by Walt's brain damage because his accident seems to have primarily affected his right cerebral hemisphere. As such, it is felt that Walt's Verbal IQ of 93 (32nd percentile), is more representative of Walt's true intellectual functioning than other obtained scores. His low Performance IQ (1st percentile) undoubtedly reflects the impact of right cerebral damage suffered in the car accident. His high Verbal-low Performance profile was evident on the Woodcock-Johnson-III as well: Good performance on tests of verbal memory, concept formation, and reasoning; very deficient performance on visual-spatial, nonverbal reasoning, and timed tests.

Walt's WAIS-III Indexes paralleled the findings from his IQs. He had significantly more difficulty in the areas of visual-motor coordination and processing speed (Perceptual Organization Index of 72 and Processing Speed Index of 66) than in the areas of verbal conceptualization, memory, and sequencing (Verbal Comprehension Index of 91 and Working Memory Index of 88). The two indexes that comprise the Verbal IQ, Verbal Comprehension and Working Memory, were not significantly different from one another, and neither were the two indexes that comprise the Performance IQ, Perceptual Organization and Processing Speed. Thus, the Verbal IQ and Performance IQ provide meaningful estimates of his overall verbal and nonverbal abilities.

'This case originally included administration of a WAIS-R and PPVT-R in the first edition of this book. We decided to modify and update the scores from WAIS-R to WAIS-III in order to provide more valuable examples of how to interpret the most recent Wechsler test. However, the major findings from the original report remain unchanged.

TABLE 8.25 Psychometric summary of Walt H.'s test scores

Wechsler Adult Intelligence Scale—Third Edition (WAIS-III)

Wechsler Adult Intelligence Scale—Third Edition (WAIS-III)

TABLE 8.25 Psychometric summary of Walt H.'s test scores

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