CASE CONCEPTUALIZATION SHEET Melissa Martin

Now that you have the background and initial assessment results, it is time to
determine what testing, if any, you want to follow-up with.
Following the system of Hypothesis testing, complete the following:
1.

Identifying information

Students Name:
Reason for
Referral:

David Foster

Age:

Grad 3
e:
Reading, writing, and spelling difficulties; difficulty with peer
relationships

2. Information about strengths and weaknesses based on initial information

(from background, observations, and test data)
Based on presenting problem(s) and initial assessment, the following cognitive
strengths and weaknesses are hypothesized:
Strengths

Supporting evidence

VisualSpatial
Processing
and Visual
Perception

- Performed within the 95th

percentile for Block Design
and 84th percentile for
Matrix Reasoning subtests
in the WISC-IV, which
indicates good experience
in part to whole
relationships in regards to
visual construction and
organization.
- School report indicates
that David does well with
planning and creating
projects using materials
(could indicate a strength
in visual planning,
construction, and
organization).
- Parents report that he has
a strong artistic ability and
likes to make things with
his hands

Areas of
suspected
weakness
Reading

Supporting evidence

- Performed within the 3rd

percentile for Total Reading, 9th
percentile on Basic Reading, and
1st percentile for Reading
Comprehension and Fluency
composite scores.
- 8th percentile on the Early
Reading Skills, 4th percentile on
the Reading Comprehension, 7th
percentile on Word Reading, and
0.5th percentile on Oral Reading
Fluency subtests.
- School report indicates that
David is behind grade level in
reading
- David had difficulties with word
recognition in the WIAT-III. His
decoding of words was slow
- School report indicates that he
has troubles with decoding and
that his reading is choppy. Parents
also identify a major problem with

Nonverbal
reasoning

Vocabulary

th

- 95 percentile for Block

Design and 84th percentile
for Matrix Reasoning. This
demonstrates that he has a
good understanding of how
to process and analyze
visual information and
develop strategies to solve
problems using visual
reasoning.
- 84th percentile on the
Symbol Search subtest in
the WISC-IV. He is able to
visually analyze and
determine relationships
between different symbols,
shapes, and patterns.
-He is also able to visually
discriminate by scanning
symbols for similarities and
differences in their visual
characteristics.
- School report states that
David is strong in higherlevel thinking in regards to
creating original ideas,
formulating problemsolving strategies, using
logic, and forming new
concepts
- 84th percentile on
Vocabulary subtest in the
WISC-IV. He is able to do
well at verbally defining
the meanings of words,
which indicates a good
lexical knowledge as well
as crystallized knowledge.
The Vocabulary subtest is
considered to be an
excellent estimate of
Davids intellectual ability.

Writing
and
Spelling

Executive
Functionin
g

reading.
- 19th percentile on the Written
Expression Composite Score.
- 9th percentile on Spelling subtest
-School report indicates that he is
spelling phonetically.
- Even though he performed within
the 27th percentile on the Essay
Composition subtest, this is on the
lower end of the Average range
and this subtest is easier to score
well on. David has difficulty
generating ideas for the essay
topic.
- School report indicates that
David is behind grade level in
spelling
- School report describes his
printing as being too large.
The observation report during
testing indicated that he would
mix up his d and b letters and
he formed letters starting from the
bottom up.
- Parents reported a major
problem with his written language
output and spelling

- Observational report during

testing indicated that David
experienced frustration during
reading tasks and that he was
aware of his difficulties
- School report also commented
that his motivation and confidence
in reading is declining since the
beginning of the school year. His
resource teacher indicated that he
has a minor problem with
becoming easily frustrated.
- Difficulty with initiating his Essay

Persistence,
Following
Directions,
Checking
Over Work

- Observational report
during testing stated that
he checked his work over
carefully before declaring
that he was finished.
- He was persistent on
tasks that were difficult.
- Had high expectations for
himself to do well, which
seemed to motivate him to
try and do his best (even
though he verbalized that
he felt he could have done
better)
- Was very exact and
compliant when following
directions during testing

Sensorimo
tor Issues

SocialEmotional
Issues

Writing subtest on the WIAT-III. He

started the essay twice after
deciding to switch topics after the
first attempt.
- Slow and methodical in his
response time, which resulted in
testing time that took longer than
usual
- School report indicates that he
likes to take his time and the
accommodation of extra time
seems to work well with him.
- Davids resource teacher
described how he does not always
notice his errors and is not critical
of his own work.
- The school report states that he
is slow to switch tasks and change
activities and that he has a minor
problem in finishing tasks and
following routines.
- School report describes his
printing as being too large.
The observational report during
testing indicated that he would
print large letters and would mix
up his d and b letters
- During writing tasks, David was
observed as forming letters
starting from the bottom up.
- School report rated Davids
hands-on or fine motor skills as
being a minor problem

- School and home reports both

comment that he can be anxious
and nervous, particularly around
his academic difficulties in
reading.
- Complaints about aches and

pains reported by parents (that he

has occasional headaches), could
be symptomatic to his anxiety and
nervousness
- Is self-conscious about receiving
help in class
- Frustration during reading tasks
while being tested and was
reported as having a minor
problem in becoming easily
frustrating according to his
resource teacher
- David would indicate that he
should have done better after
completing some subtests during
testing. This may indicate a low
self-esteem towards his own
awareness of his abilities.
- Difficulties getting along with
peers as well as making and
keeping friends (as indicated on
both the home and school reports)

Primary Hypothesis:
Specific Learning Disability (SLD) in Reading (Phonological Awareness and
Processing Difficulties)
Rationale:
David shows significant deficits in all areas of his reading as indicated by
being placed within the 3rd percentile in his Total Reading composite. Since he
performed poorly on his Basic Reading composite in the WIAT-III (within the 9 th
percentile) and in the Early Reading Skills subtest (8 th percentile). These results
would suggest that he is experiencing difficulty in his lower level reading skills that
are affecting his higher level reading skills (as demonstrated by his difficulty on the

Reading Comprehension and Fluency composite in the WIAT-III). Word recognition

skills and the ability to decode words are strong predictors of higher level reading
skills such as reading comprehension and fluency. Phonological processing is one
basic reading skill that is required to help the reader detect the different sounds
(phonemes) and to be able to segment and blend these sounds together in order to
read fluently. David was observed as having problems with his recognition of words.
He was slow at decoding words when reading out loud. This could suggest that he
is having difficulty recognizing the phonemes and struggles with trying to blend
them together to create a recognizable word. That would create significant
difficulty when trying to read words together in sentences and paragraphs.
David is also spelling words phonetically and is not always aware of his
errors. One example of this is that David is mixing up the letters b and d in his
spelling and seems unaware of this mistake. This method indicates that he is
associating incorrect phonemes with certain word sounds to create spelling errors
as well as combining similar letter shapes (i.e. b and d) and using them at
inappropriate times.
In regards to Davids performance on the WISC-IV, Prifitera, Saklofske, and
Weiss (2008) identified that children with the phonological subtype in SLD in reading
were characterized with relative weaknesses on Information, Digit Span (especially
Digits Backwards), Arithmetic, Matrix Reasoning, and Coding subtests as well as
deficits in Word Reasoning. Davids results on the Information and Coding subtests
were relatively weaker in comparison to his results on the Matrix Reasoning subtest.
These differences could indicate that he is having greater difficulty with verbal
reasoning and comprehension from the Information subtest in comparison to
nonverbal reasoning and comprehension in the Matrix Reasoning subtest. His
results on the Coding subtest could be mimicking what he is doing when he mixes
up the letters b and d. He could be confusing similar looking symbols with each
other.
Overall, Prifitera et al. (2008) state that the WISC-IV does not adequately
measure phonological processes so it would be beneficial to further test Davids
phonological awareness and processing to determine if it could be a factor in his
difficulties in reading.

Alternative Hypotheses:
1. SLD in Reading (Orthographic Awareness and Processing Difficulties)

Another basic reading skill that is important in developing reading fluency is

orthographic processing. This type of processing involves the recognition of
patterns, phonemes, and sequences of letters in words. These orthographic skills
require the ability to decode graphemes into phonemes as well as encode
phonemes into graphemes to enable adequate reading fluency and to be able to
store the letter and phonetic formations of words into memory. This also allows
readers to develop increased recognition in sight words, where they can determine
the word as a whole when reading instead of having to break it down by decoding.
Davids reading was slow and he experienced difficulties with word recognition.
This could also indicate that he is having difficulty remembering the appropriate
phonetic breakdown of words through memory. Also, he may not be able to
recognize common sight words that he may have been exposed to before. Davids
difficulties with incorrect spelling using phonetics also gives a strong indication that
he has not memorized the appropriate phonetic rules associated with different
types of words.
Prifitera et al. (2008) identified the orthographic subtype as having lower
scores on the Coding, Symbol Search, Cancellation, and Arithmetic subtests in the
WISC-IV that were consistent with visual attention, symbolic representation, and
processing speed deficits in children with reading SLD. Davids score on Coding was
relatively weaker than his score on Symbol Search. His difficulties in Coding could
be due to possible struggles with remembering the symbolic associations between
the pairings of the geometric shapes and numbers. This could be similar to his
difficulty at remembering phonemic rules within the pairings of word sounds to
specific phonemes that inhibit his ability to spell and read. Sattler (2008) also
identified the Coding subtest as possibly involving a verbal-encoding process if the
child attaches verbal descriptions to the symbols. David may have incorporated
this strategy, which may have caused him to score lower in comparison to his other
scores in the Processing Speed Index since he may have trouble with verbal
encoding. His higher result in Symbol Search involves a simpler recognition task
where he has to match a target symbol within a search group. The symbols in this
task are difficult to encode verbally so it is likely that David used his more
developed visual-perception skills rather than his reading skills of encoding to
complete this task.
2. Difficulties in Expressive Language
David has a strong vocabulary as evidenced by his significantly higher
Vocabulary subtest score on the WISC-IV. This would indicate that he has the
appropriate tools for effective verbal communication. However, his struggles with
writing could demonstrate a difficulty for him to be able to express himself through
written language. David had trouble generating ideas for the Essay Writing subtest
on the WIAT-III. This may be a sign that he found it difficult to come up with a topic
to expressively write about on his own.

Davids score on the Comprehension and Similarities subtests are relatively

weaker than the score on his Vocabulary subtest. The Vocabulary subtest is a
primary measure of a childs language skills through concrete word knowledge and
verbal concept formation. This suggests that David has an appropriate background
in lexical and semantic comprehension. The Comprehension and Similarities
subtests measure beyond basic vocabulary skills to include the use of verbal
expression. David may have found the task of having to elaborate verbally about
the association between items (Similarities) and describing general principles and
social situations (Comprehension) to be a more challenging task since it requires
him to express beyond concrete, memorized knowledge and use his own words.
3. Sensorimotor Difficulties
Davids resource teacher observed that Davids fine motor skills were a minor
problem. During testing, his writing was slow and laborious where he formed large
letters and would write from the bottom-up. His confusion between the letters b
and d could be a sign of a mechanical problem with his writing. Davids lower
score in Coding in comparison to Symbol Search could be explained by the fact that
he was required to copy out the symbol shapes within a specific amount of time. In
Symbol Search, which is also timed, he only had to draw a slash over the correct
response to indicate whether or not the target symbol is in the array. The writing
requirement for Coding is more demanding than Symbol Search, which may indicate
that it was more difficult due to his difficulty with handwriting.
The Block Design subtest does require sensorimotor coordination to move the
blocks into the indicated two-dimensional design. Prifitera et al. (2008) describes
Coding as requiring more constructional praxis or graphomotor skills than Symbol
Search or Cancellation, which may suggest difficulty with the primary or secondary
motor cortex, the motor executive circuit or cerebellum. Graphomotor skills are a
combination of motor, perceptual, and cognitive skills that allow a person to write.
Any difficulty in these skills could cause a detachment between their thoughts and
the physical act of writing them down with their hand and fingers. David did
demonstrate a good pencil grip during his writing tasks on the WIAT-III and WISC-IV.
However, there could be problems with coordinating his thoughts with the
appropriate muscle movements needed to write them down.
4. ADHD (Due to Executive Functioning and Behavioral Difficulties)
Prifitera et al. (2008) identified Attention-Deficit Hyperactivity Disorder
(ADHD) as a fundamental deficit in behavioral inhibition, which is manifested most
clearly in deficits of working memory and in regulation of motivation and motor
control. Difficulties with executive functioning (EF) also appear to be a fundamental
symptom of ADHD, as evidenced through problems with cognitive flexibility,
initiation, interference control, planning and organization, response inhibition, selfmonitoring, and working memory (Prifitera et al, 2008).

In regards to observational data, David does exhibit behavioral issues such as

frustration in completion of reading tasks, anxiety, and nervousness, which could
indicate poor behavioral control in certain academic and social situations. He also
wants to do things his way when playing with others and does not always get along
with his peers, which could be a symptom of impulsivity or poor self-control.
Children with ADHD will often become impatient when they do not get to play a
game according to their own rules or when they have to wait their turn. This can
create difficulty for them to be able to make friends. Prifitera et al. (2008) also
describe how children with ADHD may have difficulty in abstract reasoning (i.e.
thinking concretely, not being able to understand a joke, etc.), which may lead to
atypical social behaviors. Davids resource teacher has observed that he typically
will play on his own, which may be an indicator that he has some different social
behaviors in comparison to his peers. His teacher also sees a decline in his selfesteem and motivation, which can be a regulatory issue with ADHD.
In regards to Davids performance in school, he fails to complete some of his
tasks, which may be a sign that he is too distracted or requires more self-discipline
to complete them on time. His resource teacher also identified that he does not
always notice his errors and is not critical of his own work. This could be an
indicator of the inattentive subtype of ADHD where a child may fail to give close
attention to details or make careless mistakes in schoolwork. Prifitera et al. (2008)
described how a disorganized and impulsive child with EF impairment may have
problems with coping with changes in their environment and may become agitated
or upset when something interferes in their routine. Problems with cognitive
flexibility are observed in children who have difficulty coping with planned or
unplanned changes in their surroundings. Davids resource teacher made the
observation that he does have difficulty transitioning on to new tasks.
Prifitera et al. (2008) identified EF and working memory as important skills
associated with reading disorders. Children with ADHD typically have more
difficulty in tasks involving working memory (WM) and processing speed (PS).
Davids PS subtests are significantly different from one another. PS measures
cognitive flexibility, which is found to be an area of weakness for most children with
ADHD. The Coding subtest, where David scored lower than Symbol Search, is
considered to be a cognitively complex test (Sattler, 2008). It is possible that David
found it to be problematic due to struggles with cognitive flexibility associated with
EF difficulties. Prifitera et al., (2008) also reported that children who are found to
have a Writing Disorder, typically have lower scores on initiation and set shift tasks
(Prifitera et al., 2008). David had difficulty beginning his Essay Writing subtest in
the WIAT-III. This could indicate poor planning skills as well as a difficulty in
initiation of new tasks in regards to writing.
Prifitera et al. (2008) acknowledge that some students have a mixture of EF
deficits that do not result in a specific behavioral syndrome. However, these EF
issues do affect their cognitive abilities that can result in poor mental flexibility,

poor frustration tolerance, mild language problems, possible conduct problems,

academic concerns, poor planning and execution, comprehension difficulties, and
poor judgment. Even if David does not demonstrate some of the symptoms of
ADHD, there appears to be issues with EF that should be explored further.

Follow-up plan: What tests would you administer to test your

hypothesis/hypotheses?
Follow-up test (s)
CTOPP-2
(Comprehensive Test of Phonological
Processing Second Edition)

TOC
(Test of Orthographic Competence)

WISC-IV Supplementary Subtests

Rationale
The WISC-IV does not adequately
measure phonological awareness and
processing skills. The CTOPP-2
provides a standardized,
comprehensive analysis of the
strengths and weaknesses of an
individuals phonological processes.
This can be used to help clarify if
David is struggling in reading due to
phonological processing difficulties.
The TOC is a comprehensive,
standardized test that specifically
assesses the orthographical aspects
of reading and writing in terms of
letters, spelling, punctuation,
abbreviations, and special symbols.
This test can help determine if David
is experiencing difficulty with
orthographical process in regards to
his issues with reading.
Davids PSI has two subtests that are
significantly different from one
another (Coding and Symbol Search).
Cancellation is a supplemental PSI
subtest that may provide more

WISC-IV Integrated

Beery VMI
(Beery Visual-Motor Integration
Sixth Edition)

NEPSY-II
(Neuropsychological Assessment
Second Edition)

complete insight into Davids true PS.

There is less handwriting involved so
it may be a better indicator of his
visual-processing abilities.
The Similarities Multiple Choice,
Information Multiple Choice, and
the Comprehension Multiple
Choice subtests on the WISC-IV
Integrated reduces the demand for
verbal expression and memory
retrieval from the Similarities,
Information, and Comprehension
subtests in the WISC-IV. These
multiple choice subtests can be used
to determine Davids true ability on
these subtests in relation to his
higher score on the Vocabulary
subtest within the VCI. This would be
beneficial if David does have an issue
with expressive language.
Coding Copy is a subtest on the
WISC-IV Integrated that can be used
to measure graphomotor ability,
which may be an area of weakness
for David in terms of his writing.
The Beery VMI can measure Davids
motor coordination in regards to
handwriting as well as visual-motor
integration where his visual
processing and handwriting must
coordinate and work together on
handwriting tasks. This may help
determine if there is a sensorimotor
issue with his handwriting.
The NEPSY-II can be used to assess
Davids executive functioning,
attention skills, and social perception
in regards to his alternative
hypothesis of ADHD. His academic
difficulties surrounding language
(especially in regards to expressive
language difficulty and phonology),
memory, and learning can also be

assessed. There are also

sensorimotor and visuospatial
domains that can be evaluated in
regards to his possible motor
difficulties.
NOTE: Testing in regards to Davids social-emotional and behavioral
issues would also be beneficial, such as a BASC-2.

References
Prifitera, A., Saklofske, D.H., & Weiss, L.G. (2008). WISC-IV Clinical Assessment and
Intervention (2nd Edition). San Diego, CA: Elsevier Inc.

Sattler, J.M. (2008). Assessment of Children: Cognitive Foundations (5 th Edition).

San Diego, CA: Jerome M. Sattler, Publisher, Inc.