Provides a draft report of a cognitive assessment for a child. This template is useful for clinicians who have used the “Developmental History Interview – Child Cognitive Assessment” template to summarise an interview with a parent, caregiver, or teacher as part of providing a cognitive assessment report.
It is recommended that clinicians add files of any relevant assessment results (e.g., WISC, WPPSI, Stanford-Binet, Kaufman, Woodcock-Johnson, ABAS, Vineland, SIB-R, Adaptive Behavior Composite from the Bayley Scales, etc.) before generating the report, in order to obtain complete coverage of all results.
Confidential
Psychological Assessment Report
Name:
Date Of Birth:
Age at Assessment:
Client’s Address:
Assessor:
Measures Used:
Assessment Date:
Report Date:
Documents Reviewed:
Referral Information:
Background Information / Personal History:
Previous Assessments:
Medical and Mental Health History:
Current Concerns:
ASSESSMENT
Behavioural Observations:
Assessments Administered:
Diagnostic Impression:
Summary:
Recommendations:
Conclusion:
Confidential
Psychological Assessment Report
Name: Sarah Mitchell
Date of Birth: 8 June 2017
Age at Assessment: 7 years, 9 months
Client’s Address: 42 Avenue Avenue, Melbourne, VIC 3000
Assessor: Dr. Emma Taylor, Clinical Psychologist
Measures Used:
Assessment Date: 18 March 2024
Report Date: 25 March 2024
Documents Reviewed:
Referral Information:
Sarah was referred for cognitive assessment by her parents, Helen and Robert Mitchell, following concerns about her academic progress in reading and spelling. According to parental report, Sarah has struggled with literacy tasks since commencing Prep despite receiving regular support at school. Mrs. Mitchell reported that Sarah becomes frustrated during homework, often stating “the words are too hard” and requiring extensive assistance to complete tasks. The difficulties became more pronounced in Year 1 when phonics-based reading instruction was introduced. Sarah’s teacher noted that she has difficulty retaining letter-sound correspondences and frequently guesses words based on initial letters. These challenges are impacting Sarah’s confidence at school, with her parents reporting increased reluctance to attend school and complaints of stomach aches on school mornings.
Background Information / Personal History:
According to parental report, Sarah’s pregnancy and birth were uncomplicated with normal developmental milestones achieved within expected timeframes. Sarah’s parents noted she was somewhat later than her peers in developing speech clarity, with some articulation difficulties persisting until age 5. Sarah has attended Brighton Primary School since Prep and is currently in Year 2. Family circumstances have been stable with no significant disruptions. Sarah has a positive relationship with her younger brother and maintains several close friendships at school. Sarah’s strengths include her creativity in art, her empathy towards others, and her love of animals and nature.
Previous Assessments:
A speech pathology assessment was completed by Ms. Lucy Chen, Speech Pathologist, in March 2022 when Sarah was 4 years old. This assessment identified mild articulation difficulties affecting /r/ and /th/ sounds. Speech therapy was recommended but not pursued by the family at that time as the difficulties resolved naturally.
Medical and Mental Health History:
According to parental report, Sarah has experienced good general health with no chronic medical conditions or hospitalisations. She had a hearing assessment in 2023 which showed normal hearing bilaterally. There is a family history of reading difficulties, with Sarah’s father reporting that he struggled with reading in primary school and was eventually diagnosed with dyslexia in Year 4. Sarah has not received any formal mental health diagnoses or psychological interventions. No medications are currently prescribed.
Current Concerns:
Sarah’s parents report that their primary concerns relate to her slow progress in reading and spelling despite consistent support at home and school. Mrs. Mitchell noted that Sarah requires significantly more time than peers to decode simple words and often avoids reading activities. Sarah’s teacher reported concerns about her phonological awareness skills and her difficulty with sound blending and segmentation. From Sarah’s perspective, she expressed that reading is “really tricky” and that she feels worried when asked to read aloud. Her parents’ goals include improving Sarah’s literacy skills, building her confidence in reading, and ensuring she receives appropriate educational support to prevent her falling further behind her peers.
ASSESSMENT
Behavioural Observations:
Sarah presented as a well-groomed child who separated easily from her parents and established good rapport with the examiner. She maintained appropriate eye contact throughout the assessment sessions and was cooperative with all tasks. Sarah demonstrated good effort and persistence even when tasks became challenging, though she required encouragement when faced with reading and spelling activities. Her communication was clear and age-appropriate, with no difficulties noted in receptive or expressive language during conversation. Sarah showed some anxiety when presented with word reading tasks, requiring reassurance before proceeding. Attention and concentration were appropriate for her age throughout the assessment sessions. These observations suggest that the assessment results provide a reliable indication of Sarah’s current cognitive and academic abilities.
Assessments Administered:
Wechsler Intelligence Scale for Children – Fifth Edition (WISC-V):
The WISC-V is a standardised assessment of cognitive abilities designed for children aged 6 to 16 years. It provides a Full Scale IQ score representing overall intellectual functioning, along with five index scores measuring specific cognitive domains: Verbal Comprehension, Visual Spatial, Fluid Reasoning, Working Memory, and Processing Speed. Scores are standardised with a mean of 100 and standard deviation of 15, with scores between 85 and 115 considered within the average range.
Sarah achieved a Full Scale IQ score of 102, placing her in the average range of intellectual functioning (55th percentile). Her Verbal Comprehension Index score of 108 (average range, 70th percentile) indicates strong verbal reasoning and concept formation abilities. Visual Spatial reasoning was solidly in the average range at 105 (63rd percentile), suggesting intact visual processing and spatial reasoning skills. Fluid Reasoning yielded a score of 98 (average range, 45th percentile), indicating age-appropriate novel problem-solving abilities. Working Memory was measured at 96 (average range, 39th percentile), suggesting adequate short-term memory and mental manipulation skills. Processing Speed was 94 (average range, 34th percentile), indicating appropriate speed of information processing. Sarah’s cognitive profile shows relatively uniform abilities across all domains, with a particular strength in verbal reasoning.
Wechsler Individual Achievement Test – Third Edition (WIAT-III):
The WIAT-III is a comprehensive assessment of academic achievement measuring reading, mathematics, and written language skills. Standard scores have a mean of 100 and standard deviation of 15, with scores between 85 and 115 considered within the average range.
Sarah’s Word Reading standard score of 78 (7th percentile) falls in the borderline range, significantly below expectations based on her cognitive abilities. Her Reading Comprehension score of 85 (16th percentile) is in the low average range, suggesting she can understand text better than her decoding skills would predict. Pseudoword Decoding yielded a standard score of 75 (5th percentile), falling in the borderline range and indicating significant difficulty with phonological decoding of unfamiliar words. Her Spelling score of 80 (9th percentile) was in the low average to borderline range. In contrast, Sarah’s Mathematics Problem Solving score of 105 (63rd percentile) and Numerical Operations score of 102 (55th percentile) were both solidly in the average range, demonstrating age-appropriate mathematical abilities. These results confirm significant difficulties specifically in reading accuracy and phonological processing, while other academic areas remain age-appropriate.
Diagnostic Impression:
Based on the assessment results, clinical observations, and reported history, Sarah presents with a profile consistent with Specific Learning Disorder with Impairment in Reading (DSM-5). Her performance in word reading and pseudoword decoding is significantly below expectations based on her average intellectual abilities and age. The discrepancy between her strong verbal reasoning abilities and her poor phonological decoding skills is characteristic of dyslexia. Sarah’s difficulties with reading accuracy, fluency, and spelling, combined with her preserved reading comprehension and mathematics skills, support this diagnostic impression. The family history of dyslexia provides additional support for this diagnosis.
Summary:
Sarah was referred for cognitive assessment due to persistent difficulties with reading and spelling despite adequate educational opportunities and support. Assessment results revealed average intellectual abilities with particular strength in verbal reasoning. However, her academic achievement in reading and spelling is significantly below expectations, with word reading and pseudoword decoding skills in the borderline range. Mathematics skills remain age-appropriate. Sarah’s cognitive and achievement profile is consistent with Specific Learning Disorder with Impairment in Reading. Her strong verbal comprehension abilities and positive attitude towards learning represent important strengths that can support intervention efforts.
Recommendations:
Conclusion:
Sarah’s assessment confirms a specific learning disorder affecting reading despite average intellectual abilities. With appropriate evidence-based literacy intervention and educational support, Sarah has good potential to improve her reading skills and develop strategies to support her academic success.
While this report identifies areas where Sarah may benefit from additional support, it is important to recognise that she possesses strengths in areas not measured by these particular assessments. Building on these strengths may enhance her self-confidence, engagement, and overall well-being.
Additionally, performance on cognitive assessments can be influenced by various factors including motivation, attention, fatigue, anxiety, and circumstances on the day of testing. The results should therefore be interpreted as one component of a comprehensive understanding of Sarah’s abilities.
If you have any questions or would like to discuss any aspect of this report, please do not hesitate to contact me.
Yours sincerely,
Dr. Emma Taylor
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