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Child Neuropsychology: A Journal on Normal

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Pediatric Neuropsychological Reports: Do They Really

Have To Be So Long?
Jacques Donders
Published online: 09 Aug 2010.

To cite this article: Jacques Donders (1999) Pediatric Neuropsychological Reports: Do They Really Have To Be So Long?,
Child Neuropsychology: A Journal on Normal and Abnormal Development in Childhood and Adolescence, 5:1, 70-78

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 Child Neuropsychology 0929-7049/99/0501-070$15.00
1999, Vol. 5, No. 1, pp. 70-78 © Swets & Zeitlinger

THE PEDIATRIC NEUROPSYCHOLOGIST

Pediatric Neuropsychological Reports:

Do They Really Have To Be So Long?*
Jacques Donders
Mary Free Bed Hospital, Grand Rapids, MI
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ABSTRACT

This article offers a proposal to keep reports on pediatric neuropsychological assessments succinct and
specific. A format is recommended that emphasizes interpretation and implications of assessment data, as
opposed to detailed review of numeric test results. Practical applications and ramifications are discussed
and are illustrated with case examples.

Report writing is an important part of the clini-
cal neuropsychological assessment of children.
Reports are the common format for documenting
one’s findings and recommendations in response
to a referral question. Because of differences in
the training of the clinician, differences in the
target audience, and differences in the purpose
of the assessment, there is substantial variability
in how neuropsychological reports are written.
Often, however, neuropsychological reports tend
to be fairly lengthy, sometimes running in ex-
cess of 10 pages. In most instances, a large por-
tion is dedicated to a description of quantitative
test results. I suggest that neuropsychological
reports can be made more meaningful and user-
friendly by making them brief and by focusing
on interpretations and implications of all the
available data, rather than on formal test scores.
BENEFITS OF SHORT REPORTS
Efficiency
Before the advent of managed care, many psy-
chologists may have had the time to write
lengthy reports, and at least some readers may
have had the time to read them. However, most
professionals are under increased time pressure
to obtain and distribute information as effi-
ciently as possible. Shorter reports that do not
sacrifice accuracy, integrity, or clarity may be
helpful in this respect to both the writer and the
reader.
Organization
It could be argued that extended reports force
the writer (particularly if this is a predoctoral
intern or postdoctoral resident) to explain his or
her awareness of patterns or inconsistencies in
the data, and to present an organized framework
that shows how the various conclusions flow
from the findings. However, it could also be ar-
gued that it is not necessary to go into minute
detail for this purpose, let alone to burden the
reader for that reason. Psychologists-in-training
are supposed to work under close supervision,
and the face-to-face discussion with the super-
vising neuropsychologist (as well as subsequent

*
Address correspondence to: Jacques Donders, Psychology Service, Mary Free Bed Hospital, 235 Wealthy S.E.,
Grand Rapids, MI 49503, USA. E-mail: jdonders@mfbrc.com
Accepted for publication: December 5, 1997.
 PEDIATRIC REPORTS
editorial comments on the first draft of the re-
port) may be a more appropriate place to exam-
ine and modify the writer’s thought processes. If
the writer starts with the goal of keeping the re-
port limited to one or two pages, it might force
him or her to be more focused and organized in
the write-up.
Utility
Readers other than fellow psychologists may not
be interested in the amount of detail (particu-
larly when describing test results) that is often
provided in neuropsychological reports. Physi-
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cians, case managers, and other referral sources
often complain that neuropsychological reports
are long on tedious descriptions of findings and
short on new insights or useful recommenda-
tions. A discussion of all the psychometric rea-
sons why a child’s score on Test A is or is not
significantly different from the child’s score on
Test B may be interesting to other psychologists,
but members of an Individual Educational Plan-
ning Committee would most likely rather read
about what the complete pattern of results means
in terms of specific special education support
needs.
CONTENT OF SHORT REPORTS
Making something shorter does not, in and of
itself, make it more user-friendly. Any report
should address the reason for referral, the rele-
vant background history (as obtained from inter-
view as well as from records review), the major
findings (qualitative as well as quantitative), the
answer to the referral question, and the associ-
ated recommendations for further intervention
or follow-up. The APA ethical principles (spe-
cifically, standard 5.03a) suggest that one should
include in reports only information that is ger-
mane to the purpose for which the communica-
tion is made (American Psychological Associa-
tion, 1992). The trick then becomes to decide
what is germane and how to summarize it.
Most reports should include some review of
relevant premorbid history and available re-
cords. However, this can be limited to a concise
but meaningful description of information that is
71
pertinent to the issues involved in the neuropsy-
chological evaluation, in a manner that mini-
mizes not only intrusion on privacy but also re-
dundancy. For example, a prior history of sexual
abuse should probably be mentioned in a work-
up for learning disability but it is not necessary
to include all the specific details or circum-
stances. If it is known in advance that specific
information is already available to the reader
(e.g., a premorbid history that was described in
a previous neuropsychological report), refer-
ences to prior documents may sometimes be
more appropriate than repeating the same infor-
mation.
One way of avoiding lengthy discussions of
test results is to display all quantitative data in
an appendix. The appending of raw neuropsy-
chological test data to reports has been a topic of
considerable debate in recent years (Freides,
1993, 1995; Matarazzo, 1995; Naugle &
McSweeny, 1995, 1996). A particularly contro-
versial issue in this respect is the determination
of who is competent to interpret the raw data.
Indeed, the APA ethical principles (specifically,
standard 2.02b) caution again release of raw test
results to persons who are not qualified to use
such information (American Psychological As-
sociation, 1992). This remains an issue of judge-
ment for the report writer. Should such informa-
tion be available to any referring agent, or only
to other psychologists? If information is limited
to other psychologists, should they be board-
certified in neuropsychology, and if so, is one
board as acceptable as another? Not providing
raw data can also be disadvantageous to the
child in situations where schools or other pro-
viders need immediate access to specific scores
for purposes of academic placement, treatment
planning, or repeat assessments.
One way to address these issues may be to
include in the appendix a clear statement that the
numeric data are presented only for use by ap-
propriately trained professionals and that those
scores should never be interpreted without con-
sideration of all the information that is contained
in the rest of the report (including history, quali-
tative observations, and other findings). Under
such conditions, the quantitative data are avail-
able but the text of the report is clearly identi-
 72 JACQUES DONDERS
fied as the main, authoritative source of infor-
mation. The ‘‘Results’’ section of the report can
then focus on the validity, meaning, and impli-
cations of the data, followed by specific recom-
mendations, the level of detail of which may
need to vary with the level of understanding of
the reader. Of course, this approach does not
eliminate the risk of misinterpretation of the test
data by others who chose to ignore the caution-
ary disclaimer. However, it does strike a balance
between including an extended description of
test results in the report, thereby lengthening it
considerably, and supplying the data, but not
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clarifying that it is only for use by appropriate
professionals.
An alternative solution to the issue of report
length could be to write the customary ‘‘long’’
report but to add a separate cover letter high-
lighting the main points. However, that may not
be time-efficient for most professionals. If the
main findings, implications, and recommenda-
tions can be summarized in a one-page cover
letter, why not make this part of the actual re-
port?
CASE EXAMPLES
I recently had an opportunity to review, at the
request of a school principal, a seven-page re-
port pertaining to the data presented in Table 1.
The data were obtained by a self-proclaimed
neuropsychologist during an examination of an
11-year-old, right-handed girl who had sustained
an infarction (of unclear etiology) of the left
middle cerebral artery 6 weeks earlier. More
than five pages of the report were dedicated to a
description of test findings, whereas the para-
graph-length ‘‘Conclusions & Recommenda-
tions’’ section included little more than that the
child had ‘‘fronto-temporal left cerebral dys-
function’’ and a general endorsement that she
needed ‘‘special education placement’’ with
‘‘nonverbal instruction methods’’. The principal
was exasperated by the report because he al-
ready knew that the child had sustained a left
hemisphere stroke. The school district was more
than willing to provide adapted services for her;
they did just not know (neither before nor after
receiving the seven-page report) how to imple-
ment them. After review of the entire report and
school and medical records, I was able to reword
the available data and the associated implica-
tions for him as follows:
The findings reflect a significant decline from
her apparent average functioning before her
stroke, as documented in the school records.
She is frustrated but not depressed. She has
particular difficulties with both the under-
standing and the expression of spoken lan-
guage, in which areas she is performing at a
level that would typically be exceeded by
about 95% of her peers (best exemplified by
the Token Test, WISC-III Verbal Compre-
hension , and WIAT Oral Expression scores).
Reading is slightly better but still laborious,
and she has problems with getting to the
‘‘gist’’ of complex written information. Be-
cause of the weakness and slowness of her
right hand, and because she has about as
much difficulty expressing herself in writing
as by mouth, note-taking and writing assign-
ments may not be realistic at this time. How-
ever, she can still learn new things under the
right conditions (best exemplified by the
Halstead Category Test score, which is aver-
age for her age). Oral or written instructions
should be very concise and concrete, with
particular avoidance of shifting topics, need
for subtle inferences, or recall of detailed
facts. Simply repeating the same verbal infor-
mation is not going to be helpful. Instead, she
may profit from having the task requirements
demonstrated. She will also need extended
time to complete tasks; rushing her is likely
to lead to more errors. She may do much
better under a format that is interactive (with
ample use of visual reminders such as picture
cards, hands-on experience without concern
about ‘‘neatness’’, and immediate brief redi-
rection as soon as she starts getting ‘‘off-
track’’). It is also important to make sure that
her work space is not cluttered and that im-
portant things are not ‘‘hidden’’ on her far
right side, because she is aware of only about
50% of the visual information there. Evaluat-
ing her learning by having her demonstrate
 PEDIATRIC REPORTS 73

how to do a certain task is going to be more
informative than asking her to describe facts
or details. A combination of teacher-consul-
tant and resource room interventions might
allow some limited mainstreaming. These
special education supports could be consid-
ered under the ‘‘Physical & Otherwise Health
Impaired’’ qualification because her physical
and mental difficulties are the direct result of
a brain infarction. For further information
about classroom accommodations for chil-
dren with stroke, one might consider the book
‘‘Educational dimensions of acquired brain
injury’’ by Savage and Wolcott (published by
Pro-Ed in Austin in 1994).
The school principal found this feedback very
useful. The purpose of this illustration is not to
argue the ‘‘best’’ interpretation of the available
test scores, but to offer an alternative and more
user-friendly way of communicating the results
of a neuropsychological evaluation. This half-

Table 1. Test Scores of an 11-Year-Old Girl with Left-Hemisphere Stroke (TS).

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Age-based norms

Measure TS M (SD)
WISC-III Full Scale IQ 74 100 (15)
WISC-III Verbal IQ 72 100 (15)
WISC-III Performance IQ 80 100 (15)
WISC-III Verbal Comprehension 73 100 (15)
WISC-III Perceptual Organization 87 100 (15)
WISC-III Freedom from Distractibility 78 100 (15)
WISC-III Processing Speed 67 100 (15)
WIAT Reading Comprehension 81 100 (15)
WIAT Numerical Operations 89 100 (15)
WIAT Listening Comprehension 75 100 (15)
WIAT Oral Expression 75 100 (15)
WIAT Written Expression 70 100 (15)
WRAML Verbal Learning 5 10 (3)
WRAML Visual Learning 9 10 (3)
Token Test for Children (total correct)a 486 500 (5)
Aphasia Screening Test (total errors)b 5 2.50 (1.00)
Halstead Category Test (total errors)b 37 43.50 (14.55)
Trail Making Test – A (sec)b 30 17.00 (6.50)
Trail Making Test – B (sec)b 92 35.71 (15.00)
Finger tapping – right (average # taps)b 21.20 38.52 (4.50)
Finger tapping – left (average # taps)b 32.00 35.45 (5.43)
Grip strength – right (kg)b 2.50 10.31 (4.10)
Grip strength – left (kg)b 9.00 10.00 (4.10)
Finger agnosia – right (errors)b 4 0.20 (0.50)
Finger agnosia – left (errors)b 1 0.30 (0.50)
Visual imperception – right (suppressions)b 7 0.20 (0.20)
Visual imperception – left (suppressions)b 0 0.10 (0.20)
CBC Total Problems 44 50 (10)
CBC Total Competence 48 50 (10)
YSR Total Problems 42 50 (10)
YSR Total Competence 44 50 (10)

Note. CBC = Child Behavior Checklist (Achenbach, 1991a); WIAT = Wechsler Individual Achievement Test
(Wechsler, 1992); WISC-III = Wechsler Intelligence Scale for Children – Third Edition (Wechsler, 1991);
WRAML = Wide Range Assessment of Memory and Learning (Sheslow & Adams, 1990); YSR = Youth Self-
Report (Achenbach, 1991b).
a
DiSimoni (1978)
b
Knights & Norwood (1980) and Reitan & Wolfson (1992)
 74 JACQUES DONDERS

page narrative could have taken the place of five
single-spaced pages of text, and could probably
have fit (with a proper succinct description of
history, interview, observations, outpatient treat-
ment recommendations and follow-up) into a
report of less than two pages. An appendix in-
cluding the raw data would have allowed the
school to use the required scores for their docu-
mentation and certification purposes, and such a
summary sheet would also be of benefit in a fu-
ture repeat evaluation. By focusing on the inter-
pretation of the data, not every single test needs
to be referenced, although pointing out some
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port) are presented in Table 2. The evaluation
was done about 18 months post injury at the re-
quest of a physiatrist to assist with school place-
ment. The complete report is presented with in-
formed consent from the foster parents but a few
identifying characteristics have been altered to
protect confidentiality. Note that the majority of
the report concerns the meaning and implica-
tions of the findings. Information is also summa-
rized to avoid redundancy, whenever possible.
For example, because the premorbid history did
not contain major contributing information, it is
described in the report as ‘‘unremarkable’’,

scores that may be particularly relevant to the
referral question (such as those needed for spe-
cial education certification, or those highlighting
strengths and weaknesses) can often be helpful.
Of course, reports are most often prepared on
the basis of one’s own evaluation, which typi-
cally includes review of the relevant history,
interview findings, behavioral and other qualita-
tive observations, and specific recommendations
for intervention and follow-up. This does not
necessarily have to result in lengthy reports. As
an example, the complete report on a neuropsy-
chological evaluation that I performed recently
is presented in the Appendix. For purposes of
clarity and consistency, the test scores (which
were originally a one-page addendum to the re-
rather than describing every Apgar score, devel-
opmental milestone, or kindergarten experience.
A few clarifications may be in order to put this
report in proper perspective.
The report does not discuss in detail the psy-
chosocial reasons why the biological mother
(who had a number of problems of her own) de-
cided that she could not take the child home
with her. This information was considered to be
sufficiently sensitive (and not relevant to the
referral question) that it was decided that the
privacy of the biological mother would be better
served by not going into minute detail. The re-
port also does not discuss the concerns that the
foster mother had about the school program in
which the child was enrolled (e.g., not enough

Table 2. Test Scores of an 8-Year-Old Boy with Traumatic Brain Injury (TS).

Age-based norms

Measure TS M (SD)
KABC Nonverbal Composite index 54 100 (15)
KABC Hand Movements subtest 12 110 (13)
KABC Triangles subtest 13 110 (13)
KABC Matrix Analogies subtest 14 110 (13)
KABC Spatial Memory subtest 12 110 (13)
KABC Photo Series subtest 13 110 (13)
VABS Adaptive Behavior Composite index 56 100 (15)
VABS Communication subdomain 63 100 (15)
VABS Daily Living Skills subdomain 50 100 (15)
VABS Socialization domain 69 100 (15)
CCT Total score 33 150 (10)
CVLT-C Total score 21 150 (10)

Note. CCT = Children’s Category Test (Boll, 1993); CVLT-C = California Verbal Learning Test – Children’s
Version (Delis, Kramer, Kaplan, & Ober, 1994); KABC = Kaufman Assessment Battery for Children (Kaufman
& Kaufman, 1983); VABS = Vineland Adaptive Behavior Scales (Sparrow, Galla, & Cicchetti, 1984).
 PEDIATRIC REPORTS
positive reinforcement, transportation time too
long). Because she was considering moving the
child to a different school and because it was
unclear who in the child’s school district would
have access to the report (and what their reac-
tions might be), it was agreed with the foster
mother that these issues would be addressed in-
directly (i.e., by describing the needs of the
child, instead of criticizing the failure to provide
the most appropriate services). These are exam-
ples of how even short reports often need to be
tailored to the individual child and his or her
unique social and environmental circumstances.
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Telephone follow-up 6 weeks after the assess-
ment revealed that this particular child had been
moved successfully to another school program
that appeared to meet his needs better.
CONCLUSIONS
I am not suggesting that shorter reports are nec-
essarily better than extended reports, or that it is
impossible to include useful recommendations
in long documents. I am only suggesting that it
is not necessary to review in detail numeric
scores in neuropsychological test reports.
Whether brief or long, the report must be based
on (1) a solid knowledge base of developmental
and psychometric issues, (2) a sufficiently com-
prehensive assessment, (3) a thorough under-
standing of brain-behavior relationships, and (4)
an integration of all available data (including
medical and school records, observations, his-
tory, and test scores). However, writing succinct
reports that focus on the most relevant issues in
a pragmatic, specific manner that is intelligible
to the reader and that forgo the common lengthy
description of test results may increase user-
friendliness for both the writer and the reader.
In the future, researchers should investigate
the extent to which anyone other than psycholo-
gists actually read the body of the text of tradi-
tional extended reports. If the vast majority of
readers just flip to the last page for the summary
and recommendations anyway, one should con-
sider what there is to gain by writing extensively
for one’s self or for fellow psychologists. I have
had virtually unanimously positive feedback on
75
my decision to change to this type of brief report
format (usually 1 to 2 pages plus test score ap-
pendix) about 2 years ago, from sources as di-
verse as physicians, case managers, school pro-
fessionals, and trial lawyers. I also suspect that
other neuropsychologists who consider more
user-friendly, shorter reports will have as little
difficulty as I had in finding constructive things
to do with the time that can be saved in this con-
text.
I would welcome comments from readers
about the proposed report format. As others
have suggested, there is no definitive model for
writing a specific, intelligible, and useful report
(Baron, Fennell, & Voeller, 1995). There may
also be occasional instances where longer re-
ports are clearly indicated (e.g., with extremely
complicated cases). My hope is that constructive
peer discussion about report preparation may
help to improve the clinical practice of child
neuropsychology.
REFERENCES
Achenbach, T.M. (1991a). Manual for the Child Be-
havior Checklist / 4-18 and 1991 Profile. Bur-
lington, VT: University of Vermont.
Achenbach, T.M. (1991b). Manual for the Youth Self-
Report and 1991 Profile. Burlington, VT: Univer-
sity of Vermont.
American Psychological Association (1992). Ethical
principles of psychologists and code of conduct.
American Psychologist, 47, 1597-1611.
Boll, T. (1993). Children’s Category Test. San Anto-
nio, TX: Psychological Corporation.
Delis, D.C, Kramer, J.H., Kaplan, E., & Ober, B.A.
(1994). California Verbal Learning Test – Chil-
dren’s Version. San Antonio, TX: Psychological
Corporation.
DiSimoni, F. (1978). The Token Test for Children.
Allen, TX: DLM Teaching Resources.
Baron, I.S., Fennell, E.B., & Voeller, K.K.S. (1995).
Pediatric neuropsychology in the medical setting.
New York: Oxford.
Freides, D. (1993). Proposed standard of professional
practice: Neuropsychological reports display all
quantitative data. The Clinical Neuropsychologist,
7, 234-235.
Freides, D. (1995). Interpretations are more benign
than data? The Clinical Neuropsychologist, 9, 248.
Kaufman, A.S., & Kaufman, N.L. (1983). Kaufman
Assessment Battery for Children. Circle Pines,
MN: American Guidance Service.
 76 JACQUES DONDERS
Knights, R.M., & Norwood, J.A. (1980). Revised
smoothed normative data on the neuropsychologi-
cal test battery for older children. Ottawa, ON:
Author.
Matarazzo, R.G. (1995). Psychological report stan-
dards in neuropsychology. The Clinical Neuropsy-
chologist, 9, 249-250.
Naugle, R.I., & McSweeny, A.J. (1995). On the prac-
tice of routinely appending neuropsychological
data to reports. The Clinical Neuropsychologist, 9,
245-247.
Naugle, R.I., & McSweeny, A.J. (1996). More
thoughts on the practice of routinely appending
raw data to reports: Response to Freides and Mata-
razzo. The Clinical Neuropsychologist, 10, 313-
314.
Downloaded by [Ams/Girona*barri Lib] at 00:39 10 October 2014
Reitan, R.M., & Wolfson, D. (1992). Neuropsycho-
logical evaluation of older children. South Tucson,
AZ: Neuropsychology Press.
Sheslow, D., & Adams, W. (1990). Wide Range As-
sessment of Memory and Learning. Los Angeles,
CA: Western Psychological Services.
Sparrow, S.S., Balla, D.A., & Cicchetti, D.V. (1984).
Vineland Adaptive Behavior Scales. Circle Pines,
MN: American Guidance Service.
Wechsler, D. (1991). Wechsler Intelligence Test for
Children – Third Edition. San Antonio, TX: Psy-
chological Corporation.
Wechsler, D. (1992). Wechsler Individual Achieve-
ment Test. San Antonio, TX: Psychological Corpo-
ration.
 PEDIATRIC REPORTS
APPENDIX
SAMPLE NEUROPSYCHOLOGICAL
REPORT
Background Information
John is an eight-year-old, right-handed, Cauca-
sian boy who sustained a severe traumatic brain
injury (coma at least 9 days; multiple bilateral
subcortical hemorrhages) as the unrestrained
passenger in a motor vehicle accident on 3/4/96,
after a relatively unremarkable prior develop-
ment. Since discharge from an extended care
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facility last January, he has been living with new
foster parents. His biological, single mother was
not capable of taking care of him in her own
home, and voluntarily gave him up for adoption.
John attends a special education program (no
previous psychological assessment) and also
receives a variety of outpatient therapies.
Interview
John denied major distress. He did not mention
his biological mother (whom he still sees about
twice per month) and he appeared to have
bonded well to his foster mother (who is also his
guardian). John is on Depakene (which is being
weaned) for seizures, and on Dantrium for spas-
ticity (abnormal muscle tone). The three biologi-
cal children of the Doe’s have reportedly ac-
cepted him well. His sleep is unremarkable. He
eats soft and blenderized foods but hydration is
done by a gastrostomy tube. He is continent at
home during the day but wears Attends at night,
and he is not continent at school. The latter may
be due to either fatigue, distractibility, or behav-
ioral issues (or a combination of these). His be-
havior is reportedly manageable at home. Coor-
dination of toileting strategies between home
and school might need to be looked at, though.
Observations
John was appropriately dressed and groomed.
He presented in a wheelchair and he was wear-
ing glasses. He had impaired motor control in
both arms: spasticity, tremor, as well as apraxia
(motor planning problems). These were worse
on the left and he also appeared to have some
slight inattention of the left side of space. Drool-
77
ing was frequent and his speech was dysarthric
(impaired articulation because of motor plan-
ning / coordination problems). His affect was
broad in range and generally appropriate. He
was cooperative and appeared to perform to the
best of his abilities, yielding valid results. How-
ever, he needed frequent redirection because he
either tended to perseverate (i.e., could not dis-
engage from a particular verbal or motor re-
sponse pattern), or became careless when his
attention started to ‘‘run out of gas’’ (which was
accommodated by including some brief extra
breaks). I noticed that his elbows got quite red
when resting on his lapboard, and I suggested to
Mrs. Doe that she might want to consider some
elbow pads. John also worked with his eyes very
close to the surface when working with visual or
tangible materials and I am not sure if anything
can be done about that with different prescrip-
tion lenses.
Assessment Results
The formal test scores are appended. Measures
were selected to minimize the need for elaborate
verbal responses or speed of motor performance
(because those would have put John at an undue
disadvantage). Informally, it was evident that he
knew his age and the number of siblings in his
family. He was inconsistent with shape and
color discrimination, and he had problems with
following two-step commands. His overall level
of psychometric intelligence (KABC) was about
three standard deviations below the mean. This
was accompanied by similar deficits in func-
tional independence although he did have rela-
tively better interpersonal skills. Simply repeat-
ing or drilling the same information did not im-
prove John’s performance; he appeared to have
very limited information-processing capacity
(i.e., he could typically consider or remember
less than half of what most of his peers would be
able to handle). He did relatively better when the
task involved frequent interaction and corrective
redirection, although this remained limited to
only fairly concrete concepts.
Considering a 90% confidence interval, likely
regression-toward-the-mean effects, and the fact
that I was new to him, John’s ‘‘true’’ ability lev-
els may be slightly higher than suggested by the
 78 JACQUES DONDERS
current scores. However, I strongly doubt that
they would be above the fifth percentile rank
compared to his age peers. These findings are
therefore not inconsistent with those of various
speech pathologists who had worked with John
for a long time and who recently came up with
standard scores in the upper 60s and low 70s on
tests of fairly overlearned language skills. All
the current results suggest is that when faced
with a new, challenging task where he can not
rely on routinized information, and where he has
to figure things out all by himself, John is likely
to perform at a level that would typically be ex-
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ceeded by about 95 to 99% of his peers. It is im-
portant to realize that this does not mean that he
is incapable of any new learning. However, such
learning will be slower, less efficient, and less
complete than that of most of his peers. It will
also likely remain at a fairly concrete and do-
main-specific level (without much spontaneous
generalization to different tasks).
Impression and Recommendations
John presents with significant physical and cog-
nitive impairments as the result of his traumatic
brain injury. It is likely that many of these will
be permanent and that they will continue to in-
terfere with his academic career and with his
adaptive behavior. The most appropriate special
education certification for a child like John is
probably ‘‘Physical and Otherwise Health Im-
paired’’, but I am less concerned about the ac-
tual label than I am about making sure that he is
in the right learning environment (which tends
to vary from school to school).
John will likely do and learn relatively best in
a classroom that meets the following conditions:
(1) as few students per teacher as possible; (2)
frequent opportunities for individualized feed-
back about his performance, and redirection as
soon as he starts getting ‘‘off track’’; (3) learn-
ing sessions that are brief and spaced apart, with
breaks and subsequent review in between (i.e.,
he will learn more from three 30-minute ses-
sions with 5-10 minute breaks in between than
from one 2-hour session); and (4) utilization of
a ‘‘show and tell’’ approach that offers concise,
concrete instruction while the task requirements
or processes are actively demonstrated to him.
When John starts to perseverate or lets his
attention wander, then a brief, gentle tactile cue
might help (I had reasonable success with touch-
ing his cheek and then redirecting him to the
task at hand). His work space should be kept
free of unnecessary distractors, and placing im-
portant things to his far left should be avoided
(because he may not pick up on things on that
side consistently). It is also crucial to realize
that this is a child who is craving for positive
regard, so appropriate efforts should be fre-
quently verbally reinforced. The ‘‘fresher’’ he
can be for school (by having sufficient sleep,
avoiding prolonged transportation, and possibly
even considering a reduced school schedule), the
better.
At this time, John appears to have integrated
well into his new family. Mrs. Doe clearly ap-
pears to have his best interests at heart. I would
maintain visitation with his biological mother as
long as both parties continue to show consistent
interest. It must be realized that children with
brain injuries at an early age are likely to experi-
ence more academic and adjustment difficulties
when they grow older. I am not suggesting that
he needs a neuropsychological evaluation every
6 or 12 months, but he does need to be followed
regularly (e.g., though the Pediatric Brain Injury
Clinic).
Follow-Up
I have discussed these findings and recommen-
dations with the foster mother. She can share her
copy of this report with the school and with
John’s therapists, as she sees fit. For any further
questions, I can be contacted directly at the
above telephone number.