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Psychological Case Study

Reason for Referral

Susan was referred for assessment by Centrelink to determine why she is having

difficulties retaining employment. Susan has been seen three times, once with her mother

present. She has also submitted to a WAIS- III in an effort to establish basic intellectual

ability.

Susan’s mother reports that Susan consistently met normal developmental mile stones

such as speech and language, social skills and cognitive skills late. She has also always

been physically uncoordinated. She has never participated in sports. Her mother reports

that Susan does seem to have normal fine motor coordination. Susan did attend school

from ages eight to fifteen. She frequently achieved below the required standard expected

level in her classes even though she put forth effort to learn and participate in the classes.

She left school at age fifteen seeming unable to keep up with other students. She has

never been formally tested in the educational system. Susan reports that she has worked

primarily as a packer in supermarkets. She has worked only intermittently at this but she

reports that she enjoys the work. Her mother reports she was dismissed from at least one

job because she stocked products in the wrong isles. Susan denies being dismissed but

she does admit that she stocked the shelves incorrectly. Socially, Susan’s mother reports

that Susan had difficulties with friendships in school and was often the child that was

teased by others. She did have one romantic encounter that was serious enough that she

moved from her parent’s home to he boyfriend’s home. The relationship lasted only
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three weeks because Susan was not able to cope with living away from home. Susan’s

parents seem to be providing a great deal of daily living support for Susan.

Centrelink reports that they are having difficulties keeping Susan employed. Susan

seems to think they have just not been able to find her suitable employment and she has

agreed to this assessment for that purpose. Susan’s mother reports that a year ago Susan

was involved in a car accident. The car in which Susan was riding was struck for the side

and Susan hit her head on the wind screen. She did not lose consciousness and the

ambulance attendants and the hospital professionals state that there was no significant

injury to cause harm to Susan. She remained at hospital for only one hour. Currently,

Susan is living with her parents who provide a great deal of daily living support from

doing her laundry to arranging her appointments. Her mother states that she is often

sedentary but she is not depressed. Previous intellectual assessment has not been done.

Centrelink reportedly found her below average in her adaptive behavioral functioning but

the report is not available for details.

Behavioral Observation

Susan presents alert and friendly. She is cooperative but this therapist found it

difficult to develop rapport immediately. Rapport did improve as the interview

progressed. She was neatly dressed in appropriate casual attire. Susan’s speech is slow

but articulate with occasional grammatical mistakes. She was aware of the time date and

place and she seemed to be aware of timely current events. She reports she is generally

content and happy but she would like more freedom at home feeling her parents “control”
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her too much. There was no evidence of delusions, hallucinations or thought disorders

and she reports she does not feel depressed. Her mood and cognition appear consistent.

She appears to lack insight into her employment situation and perhaps her own

limitations in general. She is able to use humor in uncomfortable situations. She also

appeared to show some discomfort in the testing situation especially when she did not

know an answer.

WAIS-III

Susan has a full scale IQ score of 78 with a range of 73-85 with a .95% confidence

interval. This would put Susan in the 7 percentile when compared to the general

population. The full scale IQ is generally considered to be the most reliable and valid

estimate of intellectual ability provided by the Weschler scales. This is a global estimate

of the individual’s ability.

Her Verbal IQ is 84 which is in the 14th percentile of the general population. This

scale provides information about the individual’s ability to understand and utilize

information that is provided to her verbally. She is able to understand and utilize the

amount of information given in verbal form as well as the bottom 14 percent of the

general population. One must be careful to remember she is being compared to the

general population. This figure is not saying that she understands only 14 percent of

what she hears. It is likely that Susan is not understanding an adequate amount of the

directions given to her to do her job. Of what she, understands she can only utilize a

small portion to problem solve. She has a higher information score and a lower
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comprehension score indicating that even though she receives some of the information

she is not able to use all that she receives. It is likely she is not able to figure out where

to put items on a shelf in a grocery store with out being shown where each differing item

belongs. She would have to understand the organization of the store and then figure out

into which category the product she has fits. It is unlikely people in this verbal

comprehension range could do that.

Susan’s performance IQ is 78 with a range of 62-76 in the 95% confidence level. This

is in the lower 7th percentile of the general population. The performance IQ covers

perceptual organizational skills. This is the individual’s ability to view a situation and

use what is there to solve a problem. So, it is unlikely that Susan can observe the

arrangement of a grocery story and figure out the order of items. We have already seen

that her verbal comprehension is likely not high enough to understand instructions as to

the order of the grocery store items in addition she is even less likely to be able to

observe the situation and figure it out from that observation.

The verbal and performance scores are not 15 points apart, therefore, it is unlikely

there needs to be further testing for a learning disability. The fact that her verbal score is

somewhat higher than her performance score would indicate that her auditory-vocal

processing skills are better developed than her visual motor skills. This is important as it

indicates the best way to approach teaching her further skills. Further, her problem

solving skills that come from experience are better developed than immediate problem-

solving skills so it is likely she will improve her performance with repeated experience.

Her strengths do seem to involve her memory as she indicated in the interview.
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An individual’s strengths and weaknesses can sometimes be seen in the subtest

scores or a combination of subtest scores. This is not as accurate as the full scale IQ as it

includes less data but it can give some direction to treatment. Susan’s Digit Span and

information are her strongest scores. This would indicate that she remembers what she

hears; it is reasoning and problem solving that is more difficult for her. Her Verbal

Comprehension is her strength so teaching skills needs to be done verbally. Her

processing speed is slow so one would expect her to need time to complete a task. She is

also easily distractible so work performance is likely a skill that she needs to learn.

Diagnosis and Conclusion

This writer can not diagnose this individual at this time. While her IQ is low it is in

the low normal range so mental retardation can not be diagnosed. There are no

compelling indications that a learning disability is likely, so further testing in that area is

not recommended. This examiner has also ruled out damage from possible head trauma

from the accident the individual was in one year earlier. The symptoms of concern, the

inability to function well in a work setting (previous difficulties in a school setting),

difficulties in relationships and difficulty with daily living skills appear to be continuous

over this individual’s like span and no changes have been noted over the last year since

the accident.

Susan is a 26-year old woman who has lived with her parents all but three weeks of

her life. Her parents care for her doing everything from her laundry to scheduling he

appointments. Susan was slow in attaining developmental mile stones. She started
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school at age eight and attended until she was fifteen. She did poorly in many classes and

finally dropped out of school. The pattern continued in the work place and she has had

difficulty maintaining a job. She has now been referred by Centrelink for assessment

since they can not find a good job fit for her. Susan has also had difficulties with

relationships. She was picked on in school, does not maintain friendships. She had one

serious romantic relationship where she moved in with a man. That lasted only three

weeks due to Susan’s inability to live on her own without her parent’s support.

Recommendations

It is likely in this case that the parents in trying to protect Susan have actually added to

the problem. Susan has not received any behavioral treatment known to this examiner.

Susan is in the low normal IQ range. She has difficulties with perceptual problem

solving and slightly less difficulty with verbal problem solving. Susan would likely

benefit from attending a school that will work on behavioral issues. She needs to learn

how to take care of herself physically. She needs to learn scheduling skills, financial

skills and housekeeping skills. At the same time, she needs work training skills and

social skills training. It is very likely that Susan can learn to maintain herself in

minimally a group home setting and perhaps eventually function with little support.

Susan does not seem to be aware of her situations and she needs to be educated about her

strengths and deficits. Along with Susan, her parents also need to be educated and given

guidance as to how to proceed.

Susan should also have a complete medical assessment as little is known about her

physical health. It is important to alert her doctor to her learning and performance

difficulties. Her lack of coordination should also be mentioned. Susan should also be

assessed for co-morbid mental health disorders. She appears to have little energy so both

medical and mental health issues that could be affecting that should be considered.

Depression often accompanies low functioning symptoms so continuing with a mental

health assessment is important.

Susan has proven she can learn and that she wants to learn. Helping her understand

the situation and providing her with skills training that utilizes her verbal strengths and

memory strengths should be quite helpful.

Appendix 1

Issues for further exploration

My first concern as the general mental health practitioner is to find any co-morbid

conditions. The problem with assessment instruments at this point is that Susan’s verbal

skills are quit low so one can not be sure how much or what she is reading she

understands. Because of her low energy level this examiner would use the Beck

Depression Scale along with an interview to rule out depression. A further interview

process with Susan and her Parents would be used to identify other issues. This examiner

would particularly be looking for changes in behaviors, attitudes and abilities between the

present and her school years.

This examiner would also like a complete school record and possibly and interview

with a teacher or school official who knew Susan well. It is interesting that the school

did no testing and little special programming for Susan. That should be better

understood. Also the school may have insight into a behavioral skills program that would

fit Susan well.

Medically, the lack of coordination and the low spatial ability are a concern. The

questions is, is there a neurological problem that may be getting worse since Susan does

not seem to be advancing as a result of world experience?

This examiner would also be interested in a good family history. At this point, little is

know about her history or the family’s history. If this is generally a low functioning

family insight into what has worked for others could be helpful. If parents and
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grandparents are low function then has Susan then been deprived of stimuli in her

environment which may be provided at this point?

Question #1

This examiner is not feeling unsure about the diagnosis. At this point, no diagnosis

can be made due to the fact the Susan’s IQ is just slightly about 70 which is required for a

mental retardation diagnosis. There are the above issues that need to be ruled out but it

seems likely that this individual is a very low average functioning individual. The fact

that she is so close to the 70 IQ cut off raises care issues. Government funding is often

dependant on a diagnosis as is entrance into group housing and supervised work

positions. This examiner may consider retesting Susan with the Standford-Binet

Intelligence Scales. They correlate nicely with the Weschler Scales in the middle ranges

but tend to be more sensitive in the low and high ranges. I could be that she would score

a bit lower on these scales and there by qualify for a diagnosis of high functioning mental

retardation and they would have a greater number of options for care and treatment.

An interview with Susan’s parents would be helpful. First, I would be interested in

her parent’s and other family member’s level of functioning. It is very strange that no

testing has been done until the age of 26. The genetics of the problem is not as valuable

at this point as is the environment in which Susan has been living. She may not have

been in an environment that allowed her to reach her greatest potential.

It would be very valuable to see school records. I would also like to interview a

school official that knew Susan, if that would be possible. A fairly long time have passed
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since Susan was in school. The schools view of the issue would be helpful for her

functioning level at that time and their expectations of her ability level. It seems very

strange that the school did not follow up with testing or recommendations for testing. If

they did why did the parents not follow through? If they did not then has her functioning

regressed? If that is the case, that regression would need to be addressed immediately.

School and any other records available may help in learning what help Susan has had

so far and how does she learn best. All of this would make the treatment plan better.