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English to Chinese: Identification and Authentication using Liquid Crystal Material Markings General field: Tech/Engineering Detailed field: Physics
Source text - English Identification and Authentication using Liquid Crystal Material Markings
Field of the Invention
The present invention relates to a machine readable marking for the recognition, identification and authentication of individual items. The marking is made of liquid crystal material, which is applied to a substrate by known variable information printing techniques. The marking is detectable and/or identifiable by passive detecting means, e.g. optical filters under unpolarized (ambient) light, as well as by illumination with polarized light. The marking is applied in the form of indicia, such as a one- or two-dimensional bar code, a matrix code, or the like.
Background of the Invention
“Track and Trace” systems are currently used in different fields of industry. Many industries suffer from counterfeit or diverted products, in particular in the field of mass-produced items such as beverages, perfumes, pharmaceutical drugs, cigarettes, CDs/DVDs, as well as other kind of consumables.
Counterfeiting and market diversion are facilitated if the mass products are handled on a lot base, rather than on an individual item base. Counterfeit or diverted products are in such case easily introduced into the supply chain. Producers and retailers would like to be in a position to distinguish their original products from such counterfeit or diverted (parallel imported) products at the level of the individual unit which can be sold.
The underlying technical problem has been addressed in the art through an individual marking of each sellable item introduced into the supply chain. The markings of the prior art were chosen in such a way that they were not susceptible to photocopying, i.e. preferably covert markings were used, which are not visible to the unaided eye or the photocopying machine.
A “Covert” marking, in the context of the present invention, is any marking or security element, which cannot be authenticated by the unaided eye, but which, for authentication, depends on a detecting or reading device of any kind, such as an optical filter or an electronic authentication equipment.
An “Overt” marking, in the context of the present invention, is any marking or security element, which, for authentication, does not depend on a detecting or reading device; i.e. which can be authenticated by the unaided eye.
“Color” in the context of the present invention is used to designate any spectrally selective return of light (electromagnetic radiation) from an illuminated object, be it in the visible, the infrared or in the UV range of the electromagnetic spectrum (i.e. in the whole wavelength range from 200nm to 2500nm).
The term “visible” is used to indicate that a property can be revealed by the unaided eye; “detectable” is used for a property that can be revealed by an optical instrument, though not necessarily by the unaided eye, and “invisible” is used for a property that cannot be detected by the unaided eye. In particular, the term “visible color” means a spectrally selective return of light in the wavelength range from 400nm to 700nm, which is detectable by the unaided eye.
A first type of individual markings, useful to prevent counterfeit and diversion, is disclosed in US 5,569,317, US 5,502,304, US 5,542,971 and US 5,525,798. According to these documents, a bar code is applied onto the item, using an ink which is not detectable under light of the visible spectrum (400-700nm wavelength) but which becomes visible when illuminated with light of the UV spectrum (200-380nm wavelength).
A second type of individual markings is disclosed in US 5,611,958 and US 5,766,324. According to these documents, a marking is applied onto a commercial good, using an ink which is not detectable in the visible spectrum, but which can be detected through illumination with light of the infrared spectrum (800-1600nm wavelength).
Yet another type of individual markings, applied through an ink, is disclosed in US 5,360,628 and US 6,612,494. This marking needs to be illuminated jointly with UV- and IR-light to be revealed.
Still another type of individual marking relies on inks comprising up-converting phosphors such as described in US 5,698,397.
All of the markings mentioned in the cited prior art are covert markings, which are completely invisible to the unaided human eye. The reading of such covert markings depends on a corresponding detecting or reading device, able to detect or read the marking. This can be a disadvantage at the retail center or at the point-of-sale, where an appropriate reading device may not always be available.
Overt markings comprising “optically variable” features, e.g. exhibiting viewing-angle dependent color, have been proposed in the art as authentication means for the “person in the street”. Among these are the holograms (cf. Rudolf L. van Renesse, “Optical Document Security” 2nd ed., 1998, chapter 10), the optical thin film security devices (idem, chapter 13) and the liquid crystal security devices (idem, chapter 14).
Particularly useful as security devices are the cholesteric liquid crystals. When illuminated with white light, the cholesteric liquid crystal structure reflects light of a determined color, which depends on the material in question and generally varies with the angle of observation and the device temperature. The cholesteric material itself is colorless and the observed color is only due to a physical reflection effect at the cholesteric helical structure adopted at a given temperature by the liquid crystal material. (cf. J.L Fergason, Molecular Crystals, Vol. 1, pp. 293-307 (1966)). In particular liquid crystal materials, the cholesteric liquid crystal polymers (CLCPs), the cholesteric helical structure is “frozen” in a determined state through polymerization, and thus rendered temperature-independent.
If the cholesteric liquid crystal material is applied on a dark or black background, its reflection color is highly apparent to the unaided eye, because the light transmitted by the cholesteric material is largely absorbed by the background, so that the residual backscattering from the background does not disturb the perception of the cholesteric material’s own reflection. A careful choice of the background color can thus contribute to the visibility of such an overt marking.
On a clear or white background the reflection color of the cholesteric liquid crystal material is virtually invisible due to the superposition of the cholesteric material’s own reflection with the strong backscattering from the background. The cholesteric liquid crystal material can, however, always be identified with the help of a circular polarization filter because it selectively reflects only one of the two possible circular polarized light components, in accordance with its chiral helical structure.
EP-B1-1 381 520 and EP-A1-1 681 586 refer to a birefringent marking and a method of applying the same in the form of a liquid crystal layer having a non-uniform pattern of regions of different thickness. The applied liquid crystal coating or layer may provide for a hidden image on a reflective substrate, which is invisible when viewed under unpolarized light but rendered visible under polarized light or with the help of a polarization filter.
US 5,678,863 refers to means for the identification of documents of value which include a paper or polymer region, said region having a transparent and translucent characteristic. A liquid crystal material is applied to the region to produce an optical effect, which differs when viewed in transmitted and reflected light. The liquid crystal material is in liquid form at room temperature and must be enclosed in a containing means such as microcapsules, in order to be used in a printing process such as gravure, roller, spray or ink-jet printing. The printed liquid crystal region can be in the form of a pattern, for example a bar code. The pattern can be verified by visual or machine inspection of the polarization states of the areas having left-handed and right-handed liquid crystal forms.
US 5,798,147 refers to coating compositions of polymerizable liquid crystal monomers which can be applied by conventional printing processes, such as letterpress, rotogravure, flexographic, offset, screen, and ink-jet printing. The printing inks can be used to produce markings and security inscriptions which are invisible to the human eye. The markings can be detected by their circular polarization or their angle dependent reflection color.
US 6,899,824 refers to a process for printing or coating a substrate with a multilayer of a liquid-crystalline composition and at least one non-liquid-crystalline coating. The process and the printed substrate are useful for producing a counterfeit-proof marking of articles. Preferred methods for applying such printing or coating are screen printing, planographic printing, flexograhic, and letterpress printing.
None of the markings disclosed in the prior art does, however, provide a solution to the technical problem underlying “track
“可見“一詞是用來"表明可以肉眼來看出的一種性質；“可測”是指可以用光學儀器來顯示，雖不一定能用肉眼看到，而“不可見”則是用來表示不能被肉眼偵查到的特性。特別是,“可見顏色指的是選擇性返回的光譜中，波長的範圍是從400nm 到700nm的顏色， 它能被肉眼偵測到。對防止偽造和轉移有用的第一類的個別標記是被披露於US 5,569,317， US 5,502,304, US 5,542,971 和 US 5,525,798。 根據這些文件,一個條形碼被加在項目上，這個條形碼所使用的油墨是可見光譜(400-700nm波長)測不到的,但經紫外線光譜(200-380nm波長)照射後，就變成可見。
公開標記(具備“光學變數 ” 的特色, 例如，展現的顏色隨觀看的角度而變。這種標記，已在學藝中被建議過，作為辨識“過街人士（person in the street）“的一種方法。包括在這其中的是全息圖（Holograms） (比較 Rudolf L. 和van Renesse的“光學文件安全"第二版,1998年,第10章)、光學薄膜安全裝置(同上,第13章)和液晶安全裝置(同上,第14章)。
特別對安全裝置有用的是氯的液晶。當照以白色光時，氯液晶結構會反射人們決定要的顏色。該顏色決定於疑問中的物質，而且通常會隨不同的觀察角度和裝置的溫度而變。氯材料本身是無色的，而觀察到的顏色完全決定於液晶材料在某一溫度下所采用的氯的螺旋結構(helical structure)之物理反射效應。(比較 L Fergason、Molecular Crystals, 第一卷, 第293-307頁(1966))。有一種特別的液晶材料、是氯液晶聚合物(CLCPs), 它的氯螺旋結構通過聚合被“凍結“ 在決定的狀態, 因而擺脫了溫度的影響。
該液晶高分子色素片最好是氯液晶聚合物。這個氯液晶聚合物能展示在決定波長（幹涉色)的反射,也能作依角度變化的顏色轉換。內行人能在以下文件查到這種顏料色素的訊息：WO 2008/000755 A1(和有關文件), EP 1 213 338 B1; EP 0 685 749 B1; DE 199 22 158 A1; EP 0 601 483 A1; DE 44 18 490 A1; EP 0 887 398 B1, WO2006/063926, US 5,211,877, US 5,362,315, 和 US 6,423,246.
按照目前發明，確認攜帶一個標記的項目或物件，一般來該，包括以下步驟： a ) 跟據目前發明，提供一個攜帶一個標記的項目或物件, b) 用至少一個光源及至少一個有品質的光，來照明該項目或物件的標記, c)讀代表這個標記的郵戳, 獲得相應的信息.d)將從這個標記的郵戳所獲取的信息與存儲在數據庫之內的信息做關聯e)獲得這個項目和物件的身份的證實或否認。
English to Chinese: PSYCHOLOGICAL ASSESSMENT REPORT
Source text - English
PSYCHOLOGICAL ASSESSMENT REPORT
Name: Caroline Hoang
MR #: 75911500
Age: 7 years
Date of Birth: 8-16-2001
Dates of Evaluation: 6-23-2008, 7-14-2008,
7-21-2008, 8-4-2008,
8-25-2008
Examiner: Andrea Hindes, Ph.D.
Referred by: Robert Horst, M.D.
Cassandra Ariaz, M.F.T.
Evaluation Included:
Interviews:
Clinical Interview with Mother (Lynn Feng)
Collateral Information from Therapist (Cassandra Ariaz, M.F.T.) and Psychiatrists (Robert Horst, M.D., Hong Shen, M.D.) at Visions Unlimited Mental Health Center
Collateral Information from Teachers (Mrs. Diane Farley at Florin Elementary School, Ms. Jennifer Carlisle at Samuel Kennedy Elementary School)
Review of Records
Social Welfare Institution of Feixi County
Visions Unlimited Mental Health Center
Psychological Testing;
Behavior Assessment Scale for Children – Second Edition (BASC-2): teacher and parent forms
Conners’ Parent Rating Scale-Revised: Short Form (CPRS-R)
Conners’ Teacher Rating Scale-Revised: Short Form (CPRS-R)
Roberts Apperception Test for Children
Sentence Completion – for Children
Wechsler Intelligence Scale for Children – Fourth Edition (WISC-IV)
Identifying Information and Reason for Referral
Caroline is a 7-year-old Chinese female who was referred for a psychological assessment by her psychiatrist, Robert Horst, M.D., to address concerns regarding Caroline’s behavior. In particular, Caroline exhibits problems with understanding and following directions, attention, restlessness, and fidgeting. Concerns were also raised that Caroline makes statements that are odd, off-topic, or difficult to understand and that she talks and laughs to herself when she is alone. Finally, it was noted that she engages in oppositional and angry behavior when she does not get her way. Caroline’s mental health providers and mother would like a better understanding of Caroline’s diagnosis in order to implement appropriate interventions.
Background History
Currently Caroline lives with her adoptive mother, Lynn Feng, and adoptive maternal uncle, aunt, and three cousins. Ms. Feng is Chinese and was born in China. She moved to the United States approximately 10 years ago. Her first languages are Mandarin and Cantonese, which she and her family speak at home with Caroline. Ms. Feng speaks some English; however, she employs the use of a translator when attending Caroline’s meetings with mental health providers. For the purpose of the current evaluation, Mary Ninh, an interpreter from Asian Pacific Community Counseling who has worked with Ms. Feng in the past, translated the interview and specific questionnaires for Ms. Feng. According to Ms. Feng, Caroline’s relationships with her family are generally fine. However, Caroline has difficulty getting along with her cousins, who do not like to play with her because she argues and fights with them. Throughout the assessment, Caroline remarked that her 8-year-old male cousin oftentimes teases her, which makes her feel bad. Ms. Feng reportedly has little time to spend with Caroline because of her demanding work schedule and Caroline’s aunt often cares for her at home.
Caroline was adopted by Ms. Feng in China when she was two-and-a-half years old. Documentation from the Social Welfare Institution of Feixi County in China indicates that Caroline was abandoned when she was approximately six weeks old. After two months of unsuccessful attempts to locate her biological parents, Caroline was placed in an orphanage, where she lived until she was adopted by Ms. Feng. After adopting Caroline, Ms. Feng returned with her to Mississippi in the United States where she had been living with her husband. Documents indicate that Ms. Feng divorced her husband shortly thereafter and moved to Sacramento in 2006. Caroline is unaware that she is adopted. When discussing her life during an individual interview, Caroline stated that she was born in China and but does not remember her early childhood there. She stated that she has always lived with her mother and that she does not have a dad.
Developmental History
There is no information regarding Caroline’s prenatal, birth, or early infancy history. Ms. Feng was not provided with any details with respect to Caroline’s developmental milestones, attachment to caregivers, behavior, or physical health during the time that she lived in an orphanage. However, she speculated that Caroline was neglected and malnourished there. When Caroline was first adopted she often bit or hit others and threw things at them. Caroline already knew how to walk at the time of the adoption but she did not begin talking, even in single words or phrases, until she was three years old. Since that time, Caroline has learned to speak English, Cantonese, and Mandarin. Typically, Caroline speaks Cantonese and Mandarin at home, while speaking English, which she prefers, at school. Ms. Feng noted that Caroline’s speech in Cantonese or Mandarin does not “flow” and she must speak more slowly in order for Caroline to understand her. Caroline’s mother, teachers, and mental health providers stated that in either English or Chinese, Caroline oftentimes has difficulty understanding and following instructions, directions, and conversations and appears confused, oblivious, and inattentive. Moreover, it is oftentimes challenging to understand Caroline’s meaning when she speaks because she makes irrelevant, off-topic, or inappropriate statements.
Family History
There is no information regarding Caroline’s biological family history.
Medical History
Ms. Feng reported that Caroline has been healthy since her adoption with no major illnesses, injuries, surgeries, or hospitalizations. She has seasonal allergies for which she has taken medication in the past. She has no history of head injuries, loss of consciousness, or seizures. Ms. Feng did not report any problems with Caroline’s hearing or vision. Caroline reportedly has trouble falling asleep and oftentimes laughs and talks to herself while in bed. Ms. Feng denied that Caroline is afraid of the dark, needs to sleep with someone else, wets the bed, or has any nightmares. She also denied that Caroline has ever been witness to or experienced any physical, emotional, or sexual abuse.
Psychiatric History
Caroline was referred for mental health treatment in April 2007 because of her difficulty with sitting still, following directions, and talking excessively. She was referred to Visions Unlimited Mental Health Center and now works with a therapist and a psychiatrist. Currently, she has a diagnosis of Attention-Deficit/Hyperactivity Disorder, combined type and Disruptive Behavior Disorder NOS. In therapy, Caroline works with Cassandra Ariaz, M.F.T. to improve her inattention, hyperactivity, and emotional expression. Ms. Ariaz also works with Ms. Feng to learn and practice techniques for appropriate limit-setting and behavior management. According to Ms. Ariaz, Caroline and her mother attend therapy inconsistently approximately once or twice per month. Initially, it was difficult to engage in therapy because of the language barrier between Ms. Ariaz and Ms. Feng, who was hesitant to allow an interpreter into the session. However, Ms. Feng now allows Mary Ninh to attend the therapy sessions.
Caroline also began working with a psychiatrist, Robert Horst, M.D. at Visions, in July 2007 to address her problems with inattention and hyperactivity. Currently she is prescribed Adderall XR (10 mg), which she takes in the morning. According to Dr. Horst, Ms. Feng is very concerned that Caroline is disrespectful and misbehaves, especially in comparison to her cousins. After speaking with Caroline’s teachers, however, Dr. Horst speculated that Caroline misbehaves more often with her mother than with her teachers. During her therapy sessions and psychiatry appointments, Caroline reportedly is well mannered and responds well to limit-setting and structure. In September, Caroline transferred to a new psychiatrist, Hong Shen, M.D., because Dr. Horst transitioned out of Visions. Dr. Shen, who is a native speaker in Mandarin and Cantonese, reported that during an interview with Caroline, she had difficulty communicating and expressing herself in English, Mandarin, and Cantonese. He remarked that it was difficult for her to understand Dr. Shen and she often made statements and responses that were irrelevant or off-topic.
Educational History
Caroline is in second grade at Samuel Kennedy Elementary School. Both Caroline’s current teacher, Jennifer Carlisle, and her first grade teacher, Diane Farley, reported that Caroline has significant difficulty in understanding and following conversations and discussions. Oftentimes she makes statements or tells stories that are off-topic and irrelevant to the current situation. Her teachers also remarked that Caroline requires several repetitions of directions and explanations in order to understand classroom assignments and expectations. Despite her difficulty with oral communication, Ms. Farley noted that Caroline’s reading abilities, including fluency and comprehension, are adequate. Caroline also exhibits problems with attention, hyperactivity, and impulsivity at school. She has difficulty maintaining her focus and concentration. She fidgets, cannot sit still, wanders the classroom, interrupts others, talks excessively, and oftentimes bothers her peers. Finally, it was noted that Caroline has had difficulty making and keeping friends at school. Ms. Farley observed that during the beginning of first grade, Caroline often fought with her peers, especially on the playground, where she hit, bit, and pinched them. At times, she had to be removed from the classroom and isolated from everyone else. Over time, Caroline stopped engaging in these behaviors and no longer displays any oppositional or defiant behavior. However, she continues to struggle with friendships as many of her peers are bothered by her inattentive, restless, and hyperactive behavior.
Behavioral Observations
Caroline attended four sessions for testing (7-14-2008, 7-21-2008, 8-4-2008, and 8-25-2008) and was accompanied by Ms. Feng. On all occasions, Caroline was well-groomed and appropriately dressed in a t-shirt, pants, and sneakers. She was of small stature, but looked her stated age. She sat in her mother’s lap or hugged her while waiting for each session. She separated easily from her mother and engaged with this psychologist without any difficulty. She displayed warm and cheerful affect, moderate eye contact, and open and spontaneous conversation. Throughout the sessions, she expressed excitement at showing her mother the stickers she “earned” during each session. Overall, Caroline was polite, respectful, and cooperative. She responded well to redirection, praise, and rewards. At times, however, she complained that the tasks were “too hard” and bargained for more rewards to complete what was asked of her.
Caroline was fairly distractible, impulsive, and restless throughout the evaluation. She appeared more attentive during those tasks that did not require detailed understanding or expression of information presented orally. At times, it was difficult to determine whether she understood the directions and questions on specific measures. Further, her responses lacked appropriate details and elaboration and, at times, were unrelated and off-topic. She appeared to compensate for problems with oral expression by getting out of her seat to gesticulate and physically demonstrate her answers and ideas.
Psychological Testing Results and Interpretation
Cognitive and Intellectual Functioning
In order to assess Caroline’s intellectual ability, she was administered the Wechsler Intelligence Scale for Children – Fourth Edition (WISC-IV). The WISC-IV provides an overall estimate of a child’s intellectual abilities. In addition, it provides estimates of a child’s intellectual abilities across four specific domains: verbal comprehension, perceptual organization, processing speed, and working memory. The scores on each of these domains are compared in order to measure the consistency of children’s abilities. Commensurate scores across each of the four domains suggest relatively even development in the areas of verbal and nonverbal reasoning, speed of processing, and working memory. Significant differences in scores may indicate significant strengths and/or weaknesses in children’s cognitive development. The scores for each domain are presented in standard scores with a mean score of 100 and a standard deviation of 15, while the scores of each individual subtest are presented in scaled scores with a mean of 10 and a standard deviation of 3.
Scale Standard Score 95% Confidence
Interval Percentile
Full Scale IQ 101 96-106 53
Verbal Comprehension Index 77 72-85 6
Perceptual Reasoning Index 117 108-123 87
Working Memory Index 102 94-109 55
Processing Speed Index 112 102-120 79
Verbal Comprehension Index Scaled Score Perceptual Reasoning
Index Scaled Score Working
Memory Index Scaled Score Processing
Speed Index
Scaled Score
Similarities
3 Block Design 12 Digit Span 14 Coding 12
Vocabulary 6 Picture Concepts 10 Letter-Number 7 Symbol Search 12
Comprehension 9 Matrix Reasoning 16 (Arithmetic) 10 (Cancellation) 14
(Information) 9 (Picture Completion) 12
(Word Reasoning) 6
Caroline obtained a Full Scale IQ of 101 on the Wechsler Intelligence Scale for Children (WISC-IV), placing her in the average range of overall ability (53rd %ile). However, there were significant discrepancies in her performances across those indices that comprise the Full Scale IQ. As such, Caroline’s Full Scale IQ is not the best estimate of her overall intellectual abilities and her performance across the four indices should be considered separately.
Caroline’s overall performance on measures of verbal concept formation, verbal reasoning, and the amount of general knowledge that she has acquired from her environment fell in the borderline range of functioning (Verbal Comprehension Index, Standard Score = 77, 6th %ile). Her performance varied somewhat across individual subtests comprising the VCI. Across these subtests, Caroline displayed difficulty understanding information presented verbally. In fact, it was difficult to determine whether she understood the directions to tasks. She required that directions be broken down into smaller, simpler sentences and repeated frequently. She also exhibited problems in expressing herself verbally as her responses tended to be vague, muddled, and off-topic. Caroline appeared to compensate for her difficulties in verbal expression by employing physical gestures and pantomimes to get her point across. On specific subtests, Caroline performed in the extremely low range on a measure of verbal abstract reasoning and verbal expression (Similarities, 1st %ile), which represented a significant weakness relative to her own abilities as well as those of same-age peers. During the administration of this measure, it was difficult to determine whether Caroline understood the directions. In particular, she tended to respond to items by saying, “they are not the same,” as though she were asked to determine whether or not the items were similar, rather than the actual task, which was to state why the items were similar. She also demonstrated a weakness relative to her own abilities as well as those of other same-age peers when she performed in the low average range on a subtest assessing her long-term memory and knowledge of words and their meanings (Vocabulary, 9th %ile). On this measure, she had difficulty providing even simple definitions to words. Instead, she attempted to use the item word in a sentence or acted-out the meaning. For example, when asked the definition of “bicycle,” Caroline replied, “you ride a bicycle,” and then got up out of her seat and pretended to peddle a bike around the room. Caroline exhibited low average ability to reason through verbal material and integrate different types of information about a particular concept (Word Reasoning, 9th %ile). Although Caroline has been observed to engage in off-topic or unrelated behavior and speech, she demonstrated average and age-appropriate knowledge of conventional standards of behavior, common sense, and social judgment (Comprehension, 37th %ile). She also performed in the average range on a subtest that measured her knowledge of general facts (Information, 37th %ile). Caroline demonstrates adequate and age-appropriate understanding of general principles, facts, and social judgment, but significant limitations in her ability to perceive, reason through, and express information verbally.
In stark contrast to her verbal reasoning abilities, Caroline displayed high average nonverbal reasoning abilities (Perceptual Reasoning Index, Standard Score = 117, 87th %ile). On a measure of nonverbal abstract reasoning and the ability to process information presented visually, Caroline performed in the very superior range (Matrix Reasoning, 98th %ile), which is a strength relative to her own abilities as well as those of other same-age peers. Her performance on this subtest strongly diverges from her extremely low range performance on the Similarities subtest, which, as mentioned above, also assesses abstract reasoning and processing, but requires a language component. On another measure of nonverbal abstract and categorical reasoning, Caroline performed in the average range (Picture Concepts, 50th %ile). She performed in the high end of the average range on measures of visual recognition and identification, nonverbal concept formation, and the ability to synthesize a whole into its component parts (Picture Completion, 75th %ile; Block Design, 75th %ile). Overall, Caroline exhibits well-developed abilities for perceptual and fluid reasoning, spatial processing, and visual-motor integration. When she is not required to perceive, comprehend, and express information orally, Caroline demonstrates well-developed and advanced intellectual abilities that are higher than 86 percent of other same-age children.
Caroline exhibited average-range ability to sustain attention, concentrate, and exert mental control (Working Memory Index, Standard Score = 102, 55th %ile). Nevertheless, her performance across individual subtests of the WMI was considerably variable. On a measure of short-term auditory memory, she performed in the high average range, which was a strength relative to her own abilities as well as those of her peers (Digit Span, 91st %ile). On a measure of freedom from distractibility, short-term memory, and computational skill she performed significantly lower and in the average range (Arithmetic, 50th %ile). Such a difference in her performance may have been related to this subtest’s verbal demands as it requires an individual to perceive, process, and remember information presented verbally. Caroline performed in the low average range on a measure of sequential processing and short-term memory (Letter-Number Sequencing, 37th %ile). Her performance on this measure was significantly lower than her performance on the other two subtests that comprise the WMI and is a weakness relative to her abilities. Although Caroline’s performance on subtests of the WMI was variable, she demonstrated adequate to advanced abilities to temporarily retain information in memory, process and manipulate this information, and produce a result.
Caroline demonstrated high average abilities to process simple or routine visual material without making errors (Processing Speed Index, Standard Score = 112, 79th %ile). Caroline’s performance was consistent across individual subtests that comprise the PSI. On a measure of visual selective attention and processing speed, she performed in the high average range of functioning (Cancellation, 91st %ile), which significantly higher than same-age children. On this subtest, Caroline’s performance was consistent when the task was structured (Cancellation Structured, Scaled Score = 13) or unstructured (Cancellation Random, Scaled Score = 14), suggesting that Caroline has the ability to structure and organize information without outside assistance in order to solve problems effectively. She performed in the high end of the average range on a measure that required the coordination of fine-motor skills, short-term memory, and learning ability (Coding, 75th %ile). She performed in the high end of the average range on a measure that also assesses visual memory and sequential processing but is more demanding of attention to detail and mental control without a psychomotor component (Symbol Search, 75th %ile). Caroline’s performance on the subtests that comprise the Processing Speed Index indicates that Caroline has well-developed ability to quickly and correctly scan, sequence, discriminate, and remember simple visual information.
In sum, Caroline demonstrated significant differences between her verbal abilities and nonverbal abilities, working memory, and processing speed. While she has developed at or above average ability to nonverbal abilities, processing speed, and working memory, her verbal abilities fall in the borderline range of functioning. She evidences a tremendous difference between her verbal and nonverbal abilities that is very rare and occurs in less than one percent of children. Because of such significant differences in her abilities, the Full Scale IQ is not the best estimate of her intellectual abilities. Rather, her verbal and nonverbal intellectual abilities should be considered separately as they represent extreme differences in her functioning.
Language and Communication Skills
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Caroline evidences significant limitations in her ability to understand and express verbal information. As noted earlier, multiple reports indicate that Caroline oftentimes appears not to listen to or understand directions, makes irrelevant and off-topic remarks, and requires that directives be broken-down and repeated frequently. In order to understand better adults’ perceptions of Caroline’s functioning across several domains, Caroline’s mother and two teachers were administered standardized questionnaires, including the Behavioral Assessment System for Children – 2nd Edition (BASC-2). The BASC-2 is a paper-and-pencil measure that assesses children’s behavior and mood as well as academic and adaptive skills. Ms. Feng completed the parent report form of the BASC-2. Her overall pattern of responding on the BASC-2 indicates that she answered attentively and consistently to each item and did not rate Caroline in an overly positive or negative light. Caroline’s schoolteacher from last year, Ms. Farley, and her current teacher, Ms. Carlisle completed the teacher report forms of the BASC-2. Overall, their responses on the BASC-2 indicate that they were attentive to the item content and did not attempt to portray Caroline in an overly positive or negative light. However, Ms. Farley’s answers to relatively similar items on the measure were inconsistent, suggesting that her responses should be interpreted with caution. On this measure, Ms. Feng and Ms. Carlisle reported that Caroline demonstrates significant difficulty with understanding and expressing information verbally (BASC-2 Parent Report form, Functional Communication, T = 32, 5th %ile; BASC-2 Teacher Report form, Functional Communication, T = 34, 8th %ile). Such problems with communication typically manifest as problems with communicating ideas, information, or experiences clearly, responding appropriately to questions, and tracking down necessary information.
To more clearly assess Caroline’s ability to understand information presented verbally, she was administered the Peabody Picture Vocabulary Test – Third Edition (PPVT-III). The PPVT-III assesses children’s receptive language abilities by showing an array of four pictures and presenting them with a vocabulary word. Children are asked to point to the picture that matches the vocabulary word. Caroline’s receptive language abilities fall within the moderately low range (SS = 84, 14th %ile) and at a 5 year 7 month age level. Her performance on this measure is significantly below her estimated high average range intellectual abilities as measured by the Perceptual Reasoning Index on the WISC-IV. However, her receptive language skills are commensurate with her borderline verbal reasoning abilities as measured by the Verbal Comprehension Index of the WISC-IV. When coupled with her performance on the VCI, Caroline’s performance on the PPVT-II indicates that she has significant problems in her ability to understand information presented orally. It is not surprising then, that multiple sources report that Caroline oftentimes appears not to listen to or understand directions, makes irrelevant and off-topic remarks, and requires that directives be broken-down and repeated frequently.
Caroline’s difficulty in understanding and responding to information presented verbally was evident throughout the evaluation. In addition, to her aforementioned performance on the WISC-IV as well as the PPVT-II, Caroline made several off-topic or irrelevant comments and responses during both the interview and administration of standardized assessment measures. On one measure, the Rotters’ Sentence Completion – Child Form, which was administered orally because she could not sit down to read the responses, Caroline completed sentence stems with odd or unclear responses that oftentimes required several repetitions and clarification. For example, when presented with the sentence stem, “It isn’t nice to,” she replied, “meet each other.” She completed the sentence stem, “My mother,” with “wish [sic] that she will be a Cinderella.”
Visuo-spatial Skills
In order to assess Caroline’s visual, perceptual, and motor skills, she was administered the Developmental Test of Visual-Motor Integration – Fifth Edition (VMI). The VMI is a paper-and-pencil test in which individuals are instructed to copy a set of increasingly difficult objects. On the VMI, Caroline obtained a standard score of 101 (51st %ile), which falls within the average range. Her performance on this measure suggests that Caroline is able to integrate adequately visual-perceptual abilities with finger and hand motor movement. Nevertheless, her performance is significantly below her estimated high average range intellectual abilities as measured by the Perceptual Reasoning Index on the WISC-IV. This may suggest that Caroline’s visual-perceptual abilities are better developed than are her motor abilities, or, that both are relatively evenly developed, but that Caroline has more difficulty when required to integrate the two.
Socio-emotional Functioning
The following section provides insight into Caroline’s mood and behavior as well as the ways in which she perceives and interacts with the world. It is important to note that given Caroline’s considerable limitations in her capacity to perceive, understand, and respond to information that is presented orally, it was not possible to administer a full battery of standardized assessment measures. In particular, most standardized, self-report measures of a child’s functioning rely heavily on the use of questions and techniques that involve a large language component. In this case, it is likely that these measures would not serve as accurate representations of Caroline’s internal functioning because she has such limitations in articulating her thoughts, ideas, and feelings verbally. As such, Caroline was only administered two assessment measures, which should be interpreted with caution.
There is limited evidence to suggest that Caroline struggles with problems related to her mood or anxiety. Adults who know Caroline well perceive that Caroline sometimes struggles with depressed mood. Specifically, during an interview, Ms. Feng reported that Caroline frequently appears sad and cries. On the BASC-2, she rated Caroline within the at-risk range for problems with depression (BASC-2 Depression, T = 63, 90th %ile). Ms. Farley’s pattern of responding on the BASC-2 indicates that Caroline oftentimes appears withdrawn, pessimistic, and/or sad to a considerably higher degree than other children do (BASC-2 Depression, T = 76, 97th %ile). With respect to anxious behavior, neither Ms. Feng nor Ms. Carlisle reported that Caroline displays anxiety-based behaviors, such as worry, fearfulness, nervousness, or self-deprecation, more often than other same-age children do (BASC-2 Parent Report form Anxiety, T = 41, 20th %ile; Teacher Report form T = 43, 26th %ile). However, Ms. Feng did report that Caroline tends to be overly sensitive and complain about relatively minor physical problems and ailments (BASC-2 Somatization, T = 67, 94th %ile). Such a tendency sometimes represents a physical manifestation of anxious or mood symptoms. Ms. Farley, Caroline’s teacher from last year, did endorse that Caroline exhibits behaviors related to anxiety at an at-risk level (BASC-2 Anxiety, T = 62, 88th %ile). She also commented that Caroline bites her fingernails “constantly,” but did not rate her within the at-risk or clinically significant range for somatic problems (BASC-2 Somatization, T = 57, 82nd %ile).
Caroline’s presentation throughout the evaluation does not suggest that she experiences significant problems related to mood or anxiety. Nevertheless, as noted above, Caroline was only administered one standardized psychological measure because of her problems with oral information. Her responses on this measure may not adequately reflect her functioning as it relies heavily on children’s ability to express themselves verbally. Specifically, Caroline was administered the Roberts Apperception Test – Second Edition (Roberts-2), which is a projective measure in which children and adolescents are presented with illustrations of individuals engaged in various interactions. The children are asked to tell a story about the illustration and describe what happened before, during, and after the situation depicted in the card. They are also asked to describe the individuals’ thoughts and feelings. In general, Caroline’s stories on the Roberts-2 did not contain themes of depression, anxiety, or anger at clinically significant levels. Further, during an interview, Caroline denied that she worries or feels nervous. When asked what she worries about, she replied that her mother will die and she will not see her again.
The results of the evaluation suggest that Caroline has significant problems with hyperactive and impulsive behavior, which are easily evident to Caroline’s mother and teachers. Specifically, reports from Caroline’s mother and teachers as well as observations during testing reveal that Caroline frequently leaves her seat, talks excessively, interrupts others, and fidgets. To capture Caroline’s mother’s and her teachers’ perceptions of her behavior as compared to other same-age children, Caroline’s mother and two teachers were administered the BASC-2 and the Conners’ Parent or Teacher Rating Scale – Revised Edition (Conners’). On both the BASC-2 as well as the Conners’, Ms. Feng perceived that, when compared to other same-age children, her daughter frequently engages in disruptive, impulsive, and uncontrolled behaviors at an extremely high and clinically significant level (BASC-2 Hyperactivity, T = 75, 98th %ile; Conners’ Hyperactivity, T = 84). These behaviors include being overly active, difficulty sitting still, rushing through work and activities, and acting without thinking. Similarly, Caroline’s teachers reported clinically significant elevations in Caroline’s hyperactive and impulsive behavior on both the BASC-2 (Hyperactivity, T = 79, 98th %ile; T = 73, 96th %ile) and the Conners’ (Hyperactivity, T ≥ 90; T = 83).
Caroline also exhibits difficulty with attention and concentration. According to reports from her mother and teachers, Caroline easily distractible, has difficulty maintaining concentration on tasks and homework, and requires repetition of directions and instructions at home and school. As noted above, observations during the current evaluation indicate that Caroline appeared more distractible on measures that required her to perceive, understand, and express verbal information. On the BASC-2 and the Conners’, Ms. Feng’s pattern of responding indicated that Caroline has a significant difficulty maintaining necessary levels of attention and concentration (BASC-2 Attention Problems, T = 70, 97th %ile; Conners’ Cognitive Problems, T ≥ 90). Such difficulty likely manifests as problems with organization, completing tasks and schoolwork, and sustaining concentration especially on tasks that require more mental effort. Caroline’s teachers perceive that she has some difficulty with distractibility and poor concentration but to a lesser degree than her mother does. In particular, on the BASC-2, they rated her within the at-risk range for problems with distractibility and concentration (BASC-2 Attention Problems, T = 69, 98th %ile; T = 64, 88th %ile) while on the Conners’ they did not (Conners’ T = 60; T = 55). Caroline’s teachers also answered questions regarding her academic performance at school. Ms. Farley and Ms. Carlisle did not indicate that Caroline has any problems with academic achievement in the areas of reading, writing, or mathematics (BASC-2 Learning Problems, T = 50, 61st %ile; T = 50, 61st %ile). Nevertheless, Ms. Farley observed that Caroline exhibits behaviors, such as problems with motivation, attention, learning, and/or cognition that interfere with her overall academic success (BASC-2 School Problems, T = 60, 86th %ile). Ms. Carlisle also indicated mild problems with study skills, such as problem solving, note taking, organization, motivation, and completing homework (BASC-2 Study Skills, T = 38, 15th %ile).
Caroline appears to exhibit some oppositional and, at times, aggressive behavior. At home, Caroline reportedly exhibits some oppositional behavior such as not following directives, throwing tantrums, and fighting with her cousins. On the Conners’ Ms. Feng rated her daughter within the clinically significant range for oppositional behaviors, such as breaking rules, problems with authority, and becoming easily irritated and angered (T = 89). However, on the BASC-2, her responses do not indicate that Caroline exhibits rule-breaking or aggressive behavior more often than other children her age (Conduct Problems, T = 56, 76th %ile; Aggression T = 55, 73rd %ile). According to Ms. Farley’s and Ms. Carlisle’s responses, Caroline exhibits at-risk to clinically significant levels of rule-breaking and oppositional behavior at school (BASC-2 Conduct Problems, T = 73, 97th %ile; T = 63, 90th %ile; Conners’ Oppositional, T = 64; T = 64). Ms. Farley also perceived that Caroline acted aggressively towards others last year at levels that place her in the at-risk range (BASC-2 Aggression, T = 67, 93rd %ile). During the current evaluation, Caroline required redirection to remain on task and, at times whined that she did not want to continue with testing because she found it too difficult. However, she responded well to praise and redirection and was able to complete all that was asked of her.
Concerns were raised that Caroline exhibits odd or inappropriate behavior. Ms. Feng is concerned that her daughter talks and laughs to herself, especially at night. Further, her teachers noticed that Caroline oftentimes makes off-topic and unrelated comments during classroom instruction. On the BASC-2 Ms. Feng reported that Caroline exhibits strange or odd behaviors much more often than other children do (Atypicality, T = 74, 96th %ile). Specifically, she endorsed that Caroline sometimes does and says strange things and appears “out of touch” with reality and that she often babbles to herself. Caroline’s teachers also rated her within the at-risk to clinically significant range for odd or strange behavior (BASC-2 Atypicality, T = 79, 97th %ile; T = 66, 92nd %ile). Like Ms. Feng, they also endorsed that Caroline sometimes does and says things that are odd or do not make sense. Neither Caroline’s mother nor her teachers endorsed that she ever sees or hears things that are not there. Throughout the evaluation, Caroline made comments that were off-topic or irrelevant. Nevertheless, these comments appeared more related to her difficulty in expressing herself verbally, rather than representative of disorganized thinking or responding to internal stimuli.
The following paragraphs refer to the manner in which Caroline interprets, understands, and responds to events and experiences in the world. It provides specific information regarding her problem-solving, coping, and interpersonal skills.
Caroline was administered the Roberts-2 to evaluate her problem-solving abilities. Again, the findings from this measure must be interpreted within the context of Caroline’s limited abilities to express herself through verbal language. In assessing problem-solving ability, the Roberts-2 focuses on children’s ability to reason through problems effectively as well as their perceptions of and access to internal and external sources of support. Effective reasoning, involves the ability to recognize, understand, and resolve problems effectively and positively. Caroline exhibited problems in her capacity to perceive and identify problems accurately. Specifically, many of her stories did not identify key elements depicted in the pictures (Popular Pull, T = 38). Further, her stories only contained immature and vague identification of each character’s feelings, behaviors, and problems (Problem Identification 1, T = 77). They lacked more elaborate detail and explanation of the causes of these feelings, behaviors, and problems (Problem Identification 2, T = 32). Such an approach to situations is below her age level and demonstrates that Caroline likely overlooks or misidentifies problems in her day-to-day routine and has significant trouble considering how these problems came about. This is more typical of children who are referred for mental health treatment. Taken as a whole, her performance on the Roberts-2 suggests that Caroline likely has problems picking up on, understanding, and responding to social cues in her environment and likely is unaware of when problems arise. She probably has difficulty figuring out the expectations for appropriate behavior that are required of her in specific situations. As such, she is vulnerable to behavior that is off-topic, irrelevant, or inappropriate. Nevertheless, when Caroline is able to identify and accurately perceive cues and problems, she demonstrates age-appropriate ability to generate solutions to problems. As do most children her age, Caroline resolved the problems in her stories with relatively simple solutions that provided little to no elaboration on the process behind achieving the solution (Resolution 1, T = 40; Resolution 2, T = 56). Two of Caroline’s stories described outcomes to the situations that were detrimental, which is uncommon for children her age (Maladaptive Outcome, T = 75). Specifically, after telling a story in which a little girl breaks a chair and then proudly fixes it on her own, Caroline ended the story by stating, “and then she messed up the chair.” In sum, Caroline’s performance on the Roberts-2 reveals that she lacks age-appropriate and adequate ability to perceive and understand effectively information in her environment regarding social interactions and problems. This predisposes her to off-topic and at times, inappropriate verbalizations and behavior. However, when she is able to perceive accurately information, she is able to respond appropriately and work-through problems effectively.
The Roberts-2 also evaluates children’s perceptions of their internal and external resources to cope with problems. Caroline’s responses on the Roberts-2 suggest that she experiences positive feelings about herself and has an appropriate level of self-esteem (Support Self – Feeling, T =67). She appears to possess adequate internal skills to handle her emotions and resolve problems on her own (Support Self – Advocacy, T = 66). She finds that others in her support system are positive, nurturing, and responsive to her needs and, as such, reaches out to them for support and assurance (Support Other – Feeling, T = 59; Support Other – Help, T = 43; Reliance on Other, T = 51).
Caroline displays limited social skills. According to her mother and teachers, despite her best efforts and desire for friends, Caroline has difficulty initiating and maintaining friendships. She oftentimes disrupts, bothers, and annoys other children to such an extent that they do not enjoy playing with her. On the BASC-2 Ms. Feng and Ms. Carlisle rated Caroline in the at-risk range for problems with social skills (BASC-2 Parent Report form Social Skills, T = 37, 10th %ile; Teacher Report form, Social Skills, T = 34, 5th %ile). Caroline probably has difficulty complementing or encouraging others, offering assistance, and making tactful and socially appropriate statements. Further, Caroline’s teachers perceive that she is in the at-risk range for withdrawn behavior (BASC-2 Withdrawal, T = 66, 92nd %ile; T = 66, 92nd %ile) and they view her as sometimes alone, lonely, and rejected. Caroline herself is aware of her problems in connecting with other children her age. During an individual interview, when asked what things make her mad or sad, she remarked when other children do not play with her.
Caroline’s relationship with her mother merits immediate intervention. In order to better assess how she perceives her interactions and relationship with her daughter, Ms. Feng was administered the Parenting Stress Index/Short Form (PSI/SF). Ms. Feng’s responses to items on the PSI/SF suggest that she answered openly and honestly (PSI/SF DR subscale, > 95th %ile). It appears that Ms. Feng experiences a clinically significant level of distress regarding her role as a mother to Caroline (PSI/SF PD subscale, 95th %ile). Such an elevation may indicate that Ms. Feng lacks confidence in her ability to parent Caroline and/or lacks social support. She also finds it difficult to manage Caroline’s behavior in terms of setting limits and gaining her cooperation (PSI/SF DC subscale, > 95th %ile). She perceives a clinically significant level of negativity in her interactions with Caroline (PSI/SF P-CDI subscale > 95th %ile), which may represent that there is not a strong bond between Ms. Feng and Caroline or that Ms. Feng feel rejected by or alienated from Caroline. Overall, Ms. Feng’s responses reflect that she struggles with a clinically significant level of overall stress as a parent to Caroline (PSI/SF TS > 99th %ile). Throughout the evaluation process, Caroline referred to her relationship with her mother often. Specifically, as noted above, she stated that during those times that she does worry, she worries that her mother will die. On the Rotters’ Caroline brought up her mother several times. For example, she completed the sentence stem, “I worry about,” with “my mom – she’s gonna be mad at me.” She completed the sentence stem, “It makes me sad to,” with “when my mother goes to Sacramento.” Finally, she responded to the sentence stem, “the worst thing that ever happened to me was,” by noting a time when her mother got angry with her.
Diagnostic Impressions
Caroline is a 7-year-old Chinese female who was referred for a psychological assessment by her psychiatrist, Robert Horst, M.D., to address concerns regarding her difficulty with inattentive, hyperactive, and oppositional behavior. Concerns that Caroline exhibits odd, irrelevant, or off-topic behavior were also raised. Caroline’s mother and mental health providers would like a better understanding of her presentation in order to implement appropriate interventions.
Caroline evidences considerable delays in her language development to such an extent that she meets criteria for a diagnosis of Mixed Receptive-Expressive Language Disorder. As demonstrated by her scores on the WISC-IV, PPVT-III, and VMI, Caroline’s performance on measures of expressive and receptive language and verbal intellectual abilities was significantly below her performance on measures of nonverbal intellectual ability. Specifically, on the WISC-IV she performed in the borderline range on subtests assessing verbal concept formation, verbal reasoning, and general fund of knowledge. Similarly, on the PPVT-III, she demonstrated extremely low receptive language skills. In contrast, Caroline displayed high average nonverbal reasoning ability and processing speed on the WISC-IV and average range visual, perceptual, and motor skills on the VMI. Because English is a second language for Caroline, it would be reasonable to wonder whether her delays in language are because she has not yet mastered the English language. It is beyond the scope of the current evaluation to assess Caroline’s language and communication skills in Chinese. However, her mother and current psychiatrist, both of whom are native speakers of Chinese, stated that Caroline exhibits problems in understanding and expressing herself with oral language. Although it is not possible to provide a definitive statement concerning her communication in Chinese, there is sufficient evidence to suggest that Caroline’s problems with communication are likely the result of a disorder of language and communication rather than learning English as a second language. It is also important to note that because Caroline evidences such high nonverbal abilities and processing speed as well as average range attention, others may not perceive that how taxing it is for her to understand and employ oral language. As a consequence, she is at risk for the misperception that she is an odd, oppositional, or intentionally disruptive girl.
Such problems with receptive and expressive language have far-reaching implications for Caroline’s functioning across a variety of domains including attention and behavior, problem-solving, and social skills.
Caroline has a long-standing history of problems with attention, concentration, hyperactivity, and impulsivity. Currently, she is diagnosed with Attention-Deficit/Hyperactivity Disorder, combined type and Disruptive Behavior NOS. Reports indicate that she is easily distracted, has difficulty maintaining concentration on tasks and homework, and requires repetition of directions and instructions at home and school. Moreover, Caroline reportedly frequently leaves her seat, talks excessively, interrupts others, fidgets, and is impulsive. Throughout the evaluation, Caroline exhibited mild distractibility and moderate hyperactivity and impulsivity, all of which varied with the demands of the task. On those tasks that did not require a verbal language component, Caroline exhibited mild, if any, inattention. Indeed, on the WISC-IV she displayed adequate to advanced abilities to sustain attention, concentrate, and retain and manipulate information in short-term memory. This is not typical for children who are diagnosed with Attention-Deficit/Hyperactivity Disorder. Caroline appeared more distractible, hyperactive, and restless on measures that required her to listen to, process, and respond to verbal information. Therefore, although Caroline demonstrates some problems with inattention, hyperactivity, and impulsivity, it is not possible to determine whether these problems represent a true diagnosis of ADHD. There is such a significant overlap between symptoms related to a diagnosis of Mixed Receptive-Expressive Language Disorder and Attention-Deficit/Hyperactivity Disorder that it is not possible to determine whether Caroline’s symptoms of ADHD may be subsumed under the diagnosis of Mixed Receptive-Expressive Language Disorder. For that reason, it will be important to continue to monitor Caroline’s symptoms to rule out a diagnosis of Attention-Deficit/Hyperactivity Disorder.
Although concerns were raised regarding Caroline’s tendency to make irrelevant or off-topic comments and to engage in inappropriate behavior, the findings from the current evaluation do not suggest that Caroline functions at a psychotic level. Specifically, multiple sources denied any evidence that Caroline responds to internal stimuli, such as auditory or visual hallucinations, or engages in any form of delusional thinking. Rather, it is likely that, as with her symptoms of ADHD, Caroline’s limited language and communication skills dramatically affect her speech, behavior, and interpersonal interactions to such an extent that others may perceive her as odd or strange. Caroline’s language disorder makes it extremely challenging for her to determine when, where, why, and with whom communication should occur. She has problems in understanding and following oral directions as well as with initiating, maintaining, or terminating a conversation. Consequently, she likely appears confused, inattentive, or oblivious. She has the potential to interrupt conversations, talk excessively, or confuse listeners by switching from one unrelated subject to another. Further, Caroline probably overlooks the subtleties of conversation, such as facial expressions, gestures, posture, tone of voice, and personal space. As such, she may not be able to interpret the tone of conversation and may miss the main point of social interactions. She may make comments that appear arbitrary or insensitive even though she does not intend to hurt anyone’s feelings. She may also miss important situational and environmental cues like day-to-day rules and routines, which can lead others to perceive her as oppositional or defiant. Taken as a whole, Caroline’s speech and behavior are likely a manifestation of her language disorder rather than a true psychotic process.
Recommendations
1. The following recommendations are made to address Caroline’s delays in language and communication:
a. Caroline should receive a thorough hearing evaluation to rule out the presence of any underlying problems with hearing that may affect her language and communication.
b. Caroline should receive an extensive speech and language evaluation by a qualified professional to determine the nature and extent of her language disorder.
c. It is critical that Caroline receive speech and language therapy with a qualified language pathologist.
d. Caroline should be re-evaluated in one year to assess her progress in speech and language.
e. Caroline’s teachers may find the following strategies helpful in supporting Caroline within the classroom:
• BE PATIENT: Allow Caroline at least 10 to 15 seconds to process what is said as well as additional time for her to formulate a response.
• Employ a multi-modal approach to encourage Caroline’s encoding and understanding of information.
o Pair visual cues (i.e. pictures, graphs, charts) and nonverbal gestures with verbal communication in the classroom.
o Supplement verbal instructions with visual guides whenever possible.
o Use picture dictionaries that illustrate the meaning of the words and ideas.
o Whenever possible, use mechanical aids such as videotapes, books on tape, and computer programs, to supplement verbal instruction and assignments.
o Use materials and objects (i.e. clay, drawings, pictures, models) whenever possible to make abstract learning more concrete.
• When giving verbal instructions:
o Break them down into smaller, simpler phrases and concepts.
o Repeat directions.
o Ask Caroline to repeat instructions in order to ensure that she understands.
• Limit the demands on Caroline to express herself orally:
o Allow her to read prepared work rather than speak from memory.
o Ask questions that do not require detailed elaboration. Instead, use questions that allow for yes or no answers, the use of demonstration, or visual/physical responses (i.e. pointing to a map or a picture, gesturing).
• Caroline will likely benefit from accommodations such as seating near the teacher, extended time on tests and assignments, and modified homework and class work.
f. Caroline’s mother may find the following strategies helpful in supporting Caroline at home:
• She may find the American Speech-Language Hearing Association to be helpful in providing her with additional information regarding Caroline’s diagnosis:
ASHS National Office
2200 Research Boulevard
Rockville, MD 20850-3289
Phone: 301-296-5700
Website: www.asha.org
• BE PATIENT: Allow Caroline at least 10 to 15 seconds to process what is said as well as additional time for her to respond.
• Use visual cues, such as pictures, graphs, charts, and nonverbal gestures to help explain things to Caroline (please refer to attached handouts for ideas).
• Ask questions that do not require detailed elaboration. Instead, use questions that allow for yes or no answers, the use of demonstration, or visual/physical responses (i.e. pointing to a map or a picture, gesturing, or enacting concepts).
• When giving verbal instructions:
o Break them down into smaller, simpler phrases and concepts.
o Repeat directions.
o Ask Caroline to repeat instructions in order to ensure that she understands.
2. Caroline and her mother are encouraged to remain in therapy. Through therapy, Caroline’s therapist can help Caroline and her mother learn, practice, and employ
a. Helpful strategies for better language and communication skills:
• Develop and employ scripts to set a structured format for Caroline to practice and follow. For example, to help Caroline initiate conversations with her peers, it may be helpful her to rehearse a script such as:
o “Hello, my name is Caroline. What is your name?”
o “My name is .”
o “Would you like to play with me?”
o “Sure.”
o “Do you want to draw a picture with me?”
o “No.”
o “How about we play with the ball?”
• Role play and model acceptable and appropriate responses in specific situations (i.e. in class, on the playground, during a serious conversation). It may be important for Caroline to:
o Take the perspective of someone else in the situation. For example, in discussing the illness of a peer’s grandmother, encourage Caroline to think about how she would feel if placed in a similar situation. What words, facial expressions, and gestures might she choose to relate her feelings?
o Discuss the words, facial expressions, and gestures that are appropriate in different contexts. For example, brainstorm the appropriate responses for situations, such as during classroom instruction (i.e. children are expected to sit in their seats, make eye contact, and remain quiet). Make sure when brainstorming to make a list that is both verbal as well as visual. Draw pictures or make models next to ideas on the list.
o Practice talking to different types of people such as authority figures (teachers, principals), strangers (clerks, waitresses), relatives, and peers.
o Build responsiveness to nonverbal cues.
Use charts or pictures with faces showing different feelings.
Use a mirror and have Caroline demonstrate different facial expressions related to feelings.
Ask Caroline to look at pictures from magazines and books to describe how the people are feeling.
Use videos of TV shows or movies and stop the program periodically and ask Caroline to identify the characters’ feelings and why the character is feeling that way.
Model and practice different postures that relay feelings (clenched fists for anger, head down for sadness).
Discuss and practice tones of voice for different feelings (i.e. loud and fast means angry).
b. Because of Caroline’s difficulty in effective communication, she is at risk for becoming easily frustrated and engaging in angry outbursts. Therapy can provide Caroline and her mother practice with employing nonverbal means of emotional expression.
• Caroline’s therapist may find it beneficial to first devote time to helping her develop concrete and simple strategies for acknowledging, processing, and communicating her internal experience. She may find the following strategies easier modes to figure out how she is feeling, rather than typical questions, such as, “how are you doing?” or “what are you feeling?”
o At first, Caroline may find it helpful to practice attending to and identifying physical perceptions (heart rate, shallow breathing, muscle tension, stomachaches, lump in throat, tight chest, etc.).
o Next, encouraging her to relate physical perceptions to psychological experiences will be important (i.e. “When my heart is racing, I feel anxious.”).
o Finally, once she has demonstrated the ability to identify physical perceptions and psychological experiences, Caroline can engage in tasks that foster recognition of how these perceptions and experiences relate to her behavior. For example, she can practice filling in the blanks to sentences such as, “When I feel anxious, I scream, yell, fight.”
• Caroline should be provided with practice aimed at increasing her emotional vocabulary. For example, she should be encouraged to learn several words that describe a particular feeling (i.e. mad: angry, irritable, irate, frustrated, etc.) as well as learn to differentiate the different degrees of intensity of each feeling (i.e. irritated is less intense than angry, which is less intense than enraged).
• Caroline will likely find it helpful to develop a variety of practical, specific, and concrete ways to express his emotions (i.e. stomping feet = anger). Please refer to attached sheets for specific ideas.
3. It is strongly recommended that Ms. Feng set aside at least 15 to 20 minutes each day to spend alone with Caroline to participate in a fun activity(ies) of Caroline’s choosing. This time should be dedicated to increasing both Caroline’s and her mother’s pleasure in interacting with each other as well as their bond to each other. Ms. Feng should continue to make efforts to reaffirm Caroline and provide her with affectionate and nurturing demonstrations of love.
4. It will be important that Caroline continue to be seen by a psychiatrist to monitor the need for psychotropic medication to address her difficulty with inattentive and hyperactive behaviors.
5. Because Caroline is an energetic and active girl, she may find enrollment in classes that focus physical energy into positive and healthy outlet, such as sports, enjoyable. She may also find art classes or activities like pottery, finger painting, or sculpture engaging and fun.
Caroline has several strengths that will continue to serve as assets to her overall development. She is a bright, charming, and warm child who demonstrates a strong interest in connecting with and pleasing others.
I appreciated the opportunity to meet with Caroline and hope that this information will be helpful in guiding your work with her. If you have any questions regarding the results of this evaluation or recommendations, please feel free to contact me at (916) 875-1183.
Andrea Hindes, Ph.D.
Licensed Clinical Psychologist (License #PSY 21725)
与她口头推理能力成鲜明对比的是、Caroline 展示高于平均的非口头推理能力(感性推理指数、标准分数=117,第87次%Ile)。 On a measure of nonverbal abstract reasoning and the ability to process information presented visually, Caroline performed in the very superior range (Matrix Reasoning, 98th %ile), which is a strength relative to her own abilities as well as those of other same-age peers 在一个非口头抽象推理能力及视觉信息处理测验中,Caroline的表现属非常优异的范围(矩阵推理,98%Ile次),这是相对于她自己的能力以及其他同龄学生的能力。她在这个次测试的成绩与她的极为低水平的相似次测试表现形成了强烈的对比。相似次测试，上面提到过,也评估抽象推理和处理,但需要一个语言部分。在另一个非口头抽象及明确推理的测试中,Caroline的表现属平均范围(图片概念,50次%Ile) 在鉴定图像识别和确认时， 非口头概念的形成，和将整体分成组成部分的能力方面，她的表现属平均的高端(图片完成,75次%ile;模具方块设计、75次%Ile)总的来说,在感性和多向推理、空间处理和视觉机动整合方面 Caroline展示出发展得很好的能力。 当不被要求去察觉和用口头表示信息时,Caroline表现出发展得很好的和先进的智慧能力，高于86%的其他同龄儿童。
为了评估Caroline的视觉感性和机工技能，她被安排用Developmental Test of Visual-Motor Integration – Fifth Edition (VMI).（视觉移动整合发展测试第五版）来做评定。VMI是一个纸和笔的侧试,被试者被指示去复制一组越来越难的物件。在VMI，Caroline获得了一个标准分数的101(51%勒), 可归类为平均范围。她在这个测试中的表现显示出她有能力用手指和手的动作与接受视觉的能力作足够的整合。不过,她这里的表现是远低于Perceptual Reasoning Index on the WISC-IV给她估计的高平均范围知识能力。这表明,Caroline的视觉-感性能力比她的机动能力发展得较好。或是说两者是相当均衡地发展。但是,当需要结合的时候，卡洛琳有较多的困难。
社会情感运作
下面的一节洞察Caroline的情绪和行为以及她如何来看这个世界， 她如何和这个世界交流互动。
重要需注意的是，由于Caroline的口头提出的感知，理解，回应信息的能力有很大的限制、做一个全面的标准评估措施是不可能的。尤其特别的是，大多数标准化的儿童运作的自我报告鉴定，重重地仰赖使用有大量语文成分的问题和技术。在这一个情况，很有可能的是,这些措施不能当作Caroline的内部运作的准确表述。原因是, 她在口头阐述想法、关念和感受的能力上受到限制。因此, Caroline只有两个评价被执行, 它们应该被慎重地诠释。
有限的证据显示，Caroline遇到与她的心情或焦虑有关的问题时，颇有挣扎。知道Caroline的成人们认为 Caroline有时与抑郁情绪挣扎，特别是在接受采访时。Ms. Feng说,Caroline经常看来伤心及想哭。
在On the BASC-2, 的认定指出， Caroline在抑郁症的问题上属危险范围(BASC-2 抑郁, T = 63, 90th %ile).
Farley女士在BASC-2 的反应模式指出， Caroline经常出现退缩，悲观,和/或难过。其程度远超过其他儿童(BASC-2 抑郁症,T =76、97次%Ile)。就焦虑行为来说，Ms. Feng 和 Ms. Carlisle都没有报告说 Caroline显示有焦虑行为，比方说就担心,害怕、紧张、或自我抑郁等来说，Caroline并不比她同龄的儿童来得严重焦虑。不过,Ms. Feng确实报告说Caroline往往过于敏感和抱怨相当轻微的身体问题和疾病(BASC-2焦虑 T = 67, 94th %ile) 这种趋势有时是一种焦虑或情绪症状的身体表现。Caroline去年的老师Farley女士确是同意，Caroline表现的行为关联到危险层次的焦虑(BASC-2 焦虑, T = 62, 88th %ile). 她还表示Caroline“不断地”咬自己的手指，但并没有将Caroline评鉴为危险或躯体问题上有临床症状的范围(BASC-2 躯体, T = 57, 82nd %ile)..
评定的结果表明，Caroline有严重的过动和冲动行为，这从Caroline的母亲和老师那边很容易得到证明。具体来说，Caroline的母亲，老师以及其他在测试中的观察者们的报告都指出，她经常离开座位，话讲得特别多，还打断别人的谈话。她也经常坐立不安。为了获得Caroline的母亲和老师们就她的行为和其他同学的行为做比较的看法，他们接受了BASC-2 和 the Conners’ 父母和老师评分 修订版 (Conners’)这个鉴定。 在BASC-2 以及Conners这两项结果上，Ms. Feng 的看法是 相比於其他同龄儿童，她的女儿经常从事破坏、冲动,和不受控制的行为，其程度达到极高和临床严重的级别(BASC-2 过动, T = 75, 98th %ile; Conners’ 过动, T = 84)。这些行为包括过于活跃,坐不定，工作和活动草率,行动不加思考等 。同样,在BASC-2 (过动, T = 79, 98th %ile; T = 73, 96th %ile) ，the Conners’ (过动, T ≥ 90; T = 83)两个测试中，Caroline的老师报告都认为她的过动和冲动行为达到临床问题相当的高峰。Caroline还展示出注意力和集中的困难。根据来自她的母亲和老师的报告,Caroline容易分心,很难维持集中一项任务和功课,在家和在学校都需要重复方向的指示。如上所述，目前的评价表明Caroline在感知，理解和表达口头讯息方面似乎较易分心。根据the BASC-2 和 the Conners’, 这两项结果，Ms. Feng’s 答复的模式表示Caroline在维持必要程度的集中上有相当程度的困难。(BASC-2 注意力问题, T = 70, 97th %ile; Conners’ 认知问题, T ≥ 90). 这种困难导致了组织，完成任务和功课，以及保持集中的问题，尤其是需要很多思考的做业。Caroline的老师认为,Caroline 有分心和无法集中的困难，但是其程度比她母亲要来得轻。特别是，在BASC-2，他们把她的分心和无法专心列入危险区(BASC-2 注意力问题, T = 69, 98th %ile; T = 64, 88th %ile) 。而在the Conners’ ，他们并没这样做(Conners’ T = 60; T = 55). Caroline的老师也就其在学校的学术表现回答问题。Ms. Farley 和 Ms. Carlisle 并没有指出她在学业上的读，写，和数学有任何问题。(BASC-2 学习问题, T = 50, 61st %ile; T = 50, 61st %ile). 虽然如此,Farley指出Caroline呈现的行为， 比方说，动机，注意力，学习和/或认知等方面，影响到她的总体学业表现（BASC-2 学校问题, T = 60, 86th %ile). Ms. Carlisle 也表示她在学习的技能，比方说，解答问题，写笔记，组织，动机和完成作业方面有轻度问题(BASC-2 学习技能, T = 38, 15th %ile)。
Caroline看来有一些对抗和,有时候，侵略的行为。在家里，据说她展现一些反对行为，如坏脾气，和与她表兄弟打架。在the Conners’， Ms. Feng 将她的女儿鉴定为有相当程度的对抗行为，比方说，破坏规则，不受管束，很易恼火和愤怒(T = 89).。不过，在 BASC-2上，她的反应并未显示 Caroline 所出现的破坏规则或侵略行为会比其他同龄孩子严重 行为问题, T = 56, 76th %ile; 侵略性 T = 55, 73rd %ile).。根据Ms. Farley’s 和 Ms. Carlisle’s 的反应，她在学校的违规行为达到临床危险的程度（BASC-2 行为问题, T = 73, 97th %ile; T = 63, 90th %ile; Conners’ 反抗性, T = 64; T = 64). Farley女士还认为，Caroline在去年对其他同学有侵略性，其程度达到了危险范围(BASC-2 侵略性, T = 67, 93rd %ile). 在目前的评审中，Caroline 要求换题目才肯留下来，有时他会大嚷不想继续了，因为题目太难了。不过,她对赞扬和换方向，反应良好， 她能完成所有要她做的事。有人担心,Caroline呈现奇怪或不当的行为。Ms. Feng关心的是她的女儿会和自己谈笑,特别是在夜里。此外,老师注意到,在课堂教学上，Caroline往往做离题和无关的评论。在BASC-2 上Ms. Feng 报告说Caroline展现奇怪和离奇的行为，其程度远超过其他同学。（具体地说，同意，Caroline有时说及做的一些事情，看来与现实完全脱轨， 她有时还对自己做孩语。
Caroline的老师也将她在怪异行为上评定为临床危险。BASC-2 不正常, T = 79, 97th %ile; T = 66, 92nd %ile).
Like Ms. Feng, they also endorsed that Caroline sometimes does and says things that are odd or do not make sense.
像Ms. Feng一样,他们也同意Caroline有时说些奇怪和没意义的话。Caroline的母亲和老师都不认为 Caroline曾看到或听到并不存在的东西。在整个评估中，Caroline 做一些离题或无关紧要的评论。虽让如 此， 这些评论似乎较多相关到她口头表达的困难，而不代表思想混乱或对内部刺激的反应。 以下的段 落指出的是 Caroline对这个世界上的事情和经验所做的解释，了解和反应。它对她的解题，应对和 人际关系等提供具体的讯息。
1. 以下建议是为了表述Caroline的迟缓的语言和交流
a. Caroline应做彻底的听觉评估，来排除任何存在的潜在的听的问题，因为听的障碍可以导致语言和沟通问题。
b. Caroline也应受到一个合格的专业人员来做广泛讲话和语言评估以确定她语言失序的性质和程度。
c. 非常关键是,Caroline应获得一个合格的语言病理学者来做讲话和语言的治疗。
d. Caroline在一年内应重新评估,来获知她在讲话和语言取得的进展。
e. Caroline的老师可能会发现以下的战略有助于维持Caroline在课堂内。
• 有耐心：允许Caroline至少10至15秒来处理听到的话以及较长的时间来拟订一个反应。
• 雇用多模式的方法,鼓励Caroline的编码和了解信息。
o 在教室内，将视觉启示 (i.e. 图片, 图画, 图表) 和 非口语姿势 与口头交流配对.
o 只要有可能时，用视觉引导来补助口语指示
o .
o 只要有可能，采用机械辅助例如录影带，影带上的书, 和电脑程式 , 来补助口头的知识及作业.
o 用材料和物件 (比方说. 泥土, 图画,模型等) pictures, models) 使抽象的学习变得较实在 .
• 当给她口头指示时：
o 将其分为较小、较简单的片语和概念
o 重复指示：
o 让Caroline重复所收到的指示,以确定她弄清楚了。
• 限制要Caroline口头表达自己的那种要求。
o 让她读准备好的稿子,而不是从记忆中发言。
o 问些比较不需细细琢磨的问题。问的问题容许是或不是的答案，使用示范,或视觉/生理反应(比如， 指向一个地图或图画或做手势)
f. Caroline的母亲可能会发现以下的战略有助于维持Caroline在家里。
• 她可能会发现美国说话语言听力协会有所帮助。它能提供给她更多的有关Caroline诊断的资讯
ASHS 的国内办公室
2200 Research Boulevard
Rockville, MD 20850-3289
电话： 301-296-5700
网址：www.asha.org
• 有耐心：给Caroline至少10到15秒的时间来处理听到的话，以及较多的时间来做回应。
• 使用视觉线索，诸如图画，图片、图表、和非口语手势来帮助对Caroline解释（请看附带的讲义来获得一些观念）。
• 问些比较不需细细琢磨的问题。问的问题只要求是或不是的答案，使用示范,或视觉/生理反应(比方， 指向一个地图或图画，或做手势，或扮演观念)。
• 当给她口头指示时：
o 将其分为较小、较简单的片语和概念
o 重复指示：
o 让Caroline重复所收到的指示,以确定她弄清楚了。
2. Caroline 和她的母亲应被鼓励继续接受治疗.经由治疗, Caroline 的治疗师可以协助 Caroline 和她母亲学习，练习即现用（现买现卖）
a. 以下是一些加强语言和沟通技巧的有用策略:
• 发展和使用现有剧本来定一个设计好的格式，让Caroline练习和实际采用。比方说, 帮助 Caroline 打开话腔，与同学谈话。 让她预读一些写好的剧本，例如:
o “喂，你好？我的名字是Caroline“。“请问你叫什么名字？“
o “我的名字是 .”
o 你愿意和我玩吗？
o “好的“
o “你要不要和我一同画画呢？“
o “不“
o “那么玩球怎样？“
• 舞台演练模拟特定场合的可被接受及适当的反应 (比方说，在教室内，在操场, 在一个正式会话场合等.可能重要的是,Caroline要：
o 站在另一个人的立场来看这个情况：比方说，在讨论一个同学的祖母的病情时,鼓励Caroline去想，如果放在一个类似的情况，她会如何做。让她选择，用什么字，什么面部表情来显示她的感觉？
o 讨论在不同状况，适当时候的用字，面部表情和手势。比方说，洗脑似地灌输 适当的反应，诸如在课堂上的指示（例如，小孩应该坐在座位上，做视力接触和保持安静等等）。 确定做洗脑时，列一个单子，包括口头的和视觉的。在列出观念的地方画个图或做个模型。
o 练习和不同的人讲话，诸如权威人物（老师，校长），陌生人（店员，侍者），亲寂，和同学。
o 对非口语的线索建立反应。
用图表或画来呈现不同感觉的脸部表情。
使用镜子让她表演这些感觉的不同面部表情。
让Caroline 从扎志或书本的图片去看人们是怎么表示感觉的。
用电视的影带或电影，不断停住节目来让认出角色的感觉和为什么角色会有哪个感觉。
建立和练习不同与感情有关的 姿势 (生气时握拳, 低头表示伤心。).
讨论和练习不同感觉的声调（比方说，大声和速度快，表示生气）
b. 由于 Caroline 有效交流的困难, 她很可能变成易于恼怒以至于爆发怒气。治疗能提供 Caroline 和她的母亲练习用非口头的方法来表达情绪。.
• Caroline 的治疗师会发现开始时投资一些时间与帮助她来发展实在的及简单的策略来获知处理机交流他的内在经验是很有用的。她可能发现以下的策略很容易拿来找出她的感觉。 这比问一些典型的问题，比方说“你在做什么，或者是”你感觉怎样？“ 要来的有用。
o 开始时, Caroline 可能发现去练习 和去体会身体知觉 (心跳速率，呼吸短促,肌肉紧张, 肚子痛, 喉咙生块，紧绷的胸口，等等) 是很有用的。
o 下一步，鼓励她将身体知觉 和心理经验做关联。 这一点是非常重要的 (比方说 “当我的心跳加速时，我感到愤怒。).
o 最后, 一旦她展现了能力将身体知觉 和心理经验做关联，她就能做一些努力来培养对这些感受的认知， 知道这些感受经验与她的行为有什么样的关系。例如, 她能练习句子填空，比如,“当我感到紧张时，我尖叫，大喊，我想打架”
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