Triennial Review to Determine Whether Client Is Still Applicable for Services

Identifying Information

Name: Jesse James

Date of Birth: February 2nd, 2002

Age: 9 years 4 months

Date of Testing: June 15, 2011

Date of Report: June 24, 2011

Examiner’s Name: Naydine Johney

Referral Question

Triennial review to determine whether client is still applicable for services.

Measures Used

Wechsler Intelligence Scale for Children-Fourth Edition (WISC-IV)

History

        Jesse’s mother suffered from drug addiction and Jesse was prenatally exposed to cocaine. Subsequently, she was born prematurely and cocaine dependent. Her mother abandoned her before the age of one and Jesse was raised by her grandmother. Jesse showed signs of failure to thrive during her first few years which was attributed to her birth circumstances. She was on medication from the age of 4 to regulate and minimize the consequences of being born cocaine dependent. When Jesse was prekindergarten her behavior slightly disruptive but manageable. In 2008, Jesse was administered the Wechsler Preschool and Primary Scale of Intelligence (WPPSI). Her scores were relatively average to other children of the same age. Her Verbal IQ (VIQ) was 98, Performance IQ (PIQ) was 108 and Full-Scale IQ (FSIQ) 100. At the age of 5, Jesse was delayed in attaining milestones that were typical to children within her age group. She seemed to be slower than her peers but her academic performance was not significantly poor; however, it was obvious that she was beginning to struggle. In addition, she had difficulty being attentive, behaving appropriately and socially interacting. Her behavior was becoming increasingly unmanageable. At the age of 5 it was suggested by her social worker and teacher that she be transferred to a therapeutic school where she would receive better services that would cater to her circumstances. She was transferred from the public school system to begin kindergarten at the age of 6 because of her behavioral and academic difficulties that required this additional support. Prior to beginning at the Ruby Therapeutic School, Jesse was administered the Wechsler Intelligence Scale for Children-Fourth Edition (WISC-IV) in 2008 and at the time she was 6 years old. She performed relatively average in comparison to others her age with scores of 99 in Verbal Comprehension index (VCI), 108 in Perceptual Reasoning Index (PRI), 65 in Processing Speed Index (PSI) and 83 in Working Memory Index (WMI). Jesse has been at the Ruby Therapeutic School for the past 3 years. She has been diagnosed with Attention Deficit Hyperactivity Disorder (ADHD) and Anxiety Disorder NOS (Not Otherwise Specified). Her Individual Education Program (IEP) includes Physical Therapy, Occupational Therapy, speech, social, emotional and organizational goals. Her current medications include Seroquel, Concerta, Trazodone and Clonidine. Jesse’s grandmother has been her guardian and primary caregiver since she was abandoned by her mother. Recently her grandmother passed away.