Reportedly, Sam’s natural parents raised Sam, his older and his younger brother. Information shared by Sam’s
mother, Jill Martin within a previous evaluation (03/31/2003) indicated that during preschool and the first grade
Sam displayed difficulty with attention. Moreover, the report data indicated that by the second grade Sam was
not doing his work.
Referral Question:
Sam’s mother referred him for psychological testing to assist in evaluating the need for accommodations
related to her son’s academic plans for the upcoming year. The referral questions are: 1) Does Sam have
emotional and academic problems that may affect his performance in the gifted program at school this year? 2)
What accommodations will benefit Sam this year?
Current Symptoms:
Currently, Sam’s mother reported a concern about her son’s attention, auditory processing, attention to detail
and overall mental processing of information. Sam’s mother reported that her son had displayed fluctuations in
academic functioning throughout his childhood. She explained that previously, her son enrolled in advanced
classes and data from a previous evaluation (03/31/03) suggested a superior level of intellectual functioning.
Nevertheless, Ms. Martin explained that historically her son performance at school was variable as were his
grades. Sam acknowledged that a teacher previously suggested that he might have symptoms of attention
deficit disorder. She hoped that the current psychological evaluation would provide information relevant to her
son’s current academic difficulties and provide remedial suggestions for enhanced cognitive functioning other
than the prescribed medication.
Current Stressors: Reportedly, Sam’s girlfriend just broke up with Sam, and she stated that he was not fun
enough and would not try new things. Sam reports a change in his mental functioning to include dizziness,
strange thoughts and feelings, anger, apathy, and depression with mood swings. He acknowledged that he is
losing weight, is more inattentive, and lacks coordination and feels weak. Ms. Martin stated that she has noted
that he is showing impaired judgment.
Relevant History:
Developmental/Medical/Social:
Sam’s mother explained that Sam’s developmental and medical history was unremarkable. Ms. Martin
explained that her son was a quiet and bright child, achieved his developmental milestones early. Reportedly,
he walked at eight months and used complete sentences at 17 months. Moreover, Ms. Martin, Sam’s mother
acknowledged that her son learned to tie his shoes as expected; however, he took “forever” to learn to ride his
bike. Ms. Martin reported two significant life events that occurred after her son’s previous evaluation at age 12.
First, reportedly during the 8th grade, Sam had plastic surgery on his ears during which time he had significant
academic difficulties, which resulted in below average grades. Secondly, Sam stated that at age 12 he was hit
“head on” in a car accident. He explained that he “blanked out” after hitting his head on the window although he
acknowledged that he did not pass out. Reportedly, although Ms. Martin acknowledged that her son had a
concussion; Sam did not receive skull or neck x rays to check for bone fractures or injury nor does his mother
recall any ratings reported from the Glasgow coma scale that could help assess the head injury. Ms. Martin did
not disclose a family history of seizure disorder although she acknowledged close relatives with attention deficit
disorder, affective disorder, and substance abuse difficulties. Reportedly, Sam has had numerous friends and
various interests throughout his childhood. He was involved in the band, on the soccer team, learned
taekwondo, and participated in a problem-solving club. Moreover, reported that he has had numerous
girlfriends.
Educational/Occupational:
Ms. Martin explained that her son was an early reader and began to read during kindergarten at a private
school, Saint John’s Elementary school. Ms. Martin stated that, during the first grade, Sam’s teacher
acknowledged that Sam might have attention deficit disorder because he was very active. However reportedly,
although not on medication, Sam performed quite well academically from the second through the fifth grade.
Sam stated that he had difficulties with handwriting and therefore he never used cursive and has always
printed. Ms. Martin stated that during the 6th grade, Sam changed schools. Reportedly, his difficulties ensued
and continued through the 8th grade although he continued placement within advanced classes. Currently,
Sam acknowledged that he does well writing essays but exhibits significant difficulties when trying to learn
foreign languages. Sam has a part-time job helping his uncle at his paint supply store. Moreover, reportedly
Sam has a talent for painting murals. His mother reported quite proudly that he has quite a talent but always
smells like paint.
Alcohol Substance Abuse:
Sam denied use of any illegal drugs, any prescription drugs, or any alcohol.
Conduct and Legal:
Reportedly, Sam recently took his mother’s car out for a “joy ride” and although they had called the police
about the missing car, they dropped the charges when they found out their son had the car. Ms. Martin
acknowledged this was an example of his poor judgment lately.
Observations:
Sam is a fourteen- year old, white, male of above average height and sizable athletic frame. He appeared his
stated age, arrived at the evaluation casually and neatly dressed. He was cooperative throughout the
evaluation. Sam is right-handed. He appeared alert and responsive during the evaluation and his attention and
concentration were not impaired. Sam’s thought processes were connected and coherent. Sam conveyed no
delusions and his judgment, reasoning, and insight were adequate. Sam’s eye contact during the evaluation
was adequate.
Regarding his motor functioning, there are no apparent abnormalities during testing. No evidence of impaired
vision or hearing was present during this evaluation. Sam frequently asked permission before starting a task.
Sam’s speech was logical, coherent and of appropriate rate and rhythm unless he was stuttering. Sam did not
demonstrate any additional difficulties with speech and appeared to demonstrate the ability to both understand
and express the English language without notable exceptions. The content of his thought was not tangential
and was relevant to the content. He did not report hallucinations or delusions. His affect was appropriate to the
content. Sam’s gait and pace were unremarkable, and he did not express suicidal/ homicidal ideation.
Sam was not easily distracted from his tasks although he worked relatively slowly on timed tasks. Sam
reported that he felt frustrated with a task requiring him to copy designs onto paper and cracked his knuckles
frequently while admitting great discomfort with the task. Moreover, when asked to reproduce the figures from
memory he at first denied that he could remember any because he did not want to draw anymore.