Intellectual Disabilities

Abstract

Intellectual disability, formerly mental retardation, is defined fairly consistently across most psychiatric (e.g., DSM, ICD), special education (e.g., IDEA) and organization-based (e.g., AAIDD) systems of classification. The definition generally shares three common core features: (1) deficits in intellectual functioning such as reasoning, problem solving, judgment, and abstract thinking; (2) deficits in adaptive behavior (conceptual, social, and practical) such as communication, daily living skills, and self-care; and (3) occurrence during the developmental period (i.e., before age 18). Each of the major taxonomies (e.g., IDEA, DSM, ICD) also have at the core of their definition and classification approach the requirement for a “dual deficit” in IQ and adaptive behavior. Psychologists working in the schools, where the preponderance of ID classification are offered, must work within the constraints of their respective state codes. State codes are generally aligned with the definition found within IDEA.

Appendices

Appendix: Sample Report

1.1 Intellectual Disability

1.2 Assessment Methods and Sources of Data

Stanford–Binet Intelligence Scales—Fifth Edition (SB5)

Woodcock–Johnson Tests of Achievement, Fourth Edition (WJ-IV)

Bender Visual Motor Gestalt, Second Edition (Bender-2)

Behavior Assessment System for Children, Second Edition (BASC-2)

• Ms. Jennifer Lincoln (Second Grade Teacher)

Vineland Adaptive Behavior Scales, Second Edition (Vineland-II)

• Ms. Jennifer Lincoln (Second Grade Teacher)

• Ms. Jessie Miller (Special Education Teacher)

Teacher Interview

• Ms. Jennifer Lincoln (Second Grade Teacher)

• Ms. Jessie Miller (Special Education Teacher)

Parent Interview

• Cher Haley (Mother)

Student Interview

• Keith Smith

Classroom Observations

Review of Academic Grade Reports

Review of School Records

Background Information and Developmental History

Keith Smith is an 8 year, 11 month-old child in the second grade at the Smith Public School (SPS). Keith experiences moderate delays in cognitive ability, functional academics, and functional communication. These delays are sufficiently severe that Keith will qualify for a classification of intellectual disability (formerly mental retardation). This classification reflects a revision to the diagnosis from January 2014 where a classification of mental retardation was deferred in favor of a classification of learning disabilities and speech language delay. In 2014, Keith experienced cognitive delays and functional communication deficits, but his academic skills were in the below/low average range. He also just entered kindergarten and other indicators at that time (e.g., standardized achievement test scores; parental input; socialization skills) suggested that the classification of intellectual disability be deferred. At the present time, Keith’s moderate delays in cognitive ability, functional academics, and functional communication are sufficiently severe that a classification of intellectual disability is now clinically indicated.

Prenatal, Perinatal, and Early Developmental History: Ms. Haley noted that Keith was born prematurely at 32 weeks weighing 5 lb. He spent 1 week in the NICU but experienced little to no medical concerns. Ms. Haley also reported suffering from the flu during her first trimester with Keith. Keith experienced delays in walking and talking. He did not say his first word until 13 months of age and walked at 15 months. Ms. Haley reports that all other developmental milestones were attained within normal limits.

Medical: Ms. Haley that Keith is in good health and has no medical concerns. She indicated that his hearing and vision are intact. Keith has never experienced a head injury or major infection.

Cognitive, Academic, and Language Functioning: Keith faces significant struggles with his academic progress. He can only recognize a few letters of the alphabet and struggles with counting up through 100. Keith’s language ability is low. He struggles with verbal expression. Keith’s prior performance on a measure of cognitive ability was in the delayed range (RIAS Composite IQ = 50; 0.04 percentile; Verbal IQ = 44; <0.01 percentile; Nonverbal IQ = 74; 4th percentile). Keith’s performance on the WJ-III Achievement was also in the delayed range across all academic areas. His language ability is low for his age and he struggles with verbal expression. Ms. Haley noted that Kevin’s math ability is improving.

Social-Emotional and Behavioral Functioning: Both Ms. Haley and Ms. Lincoln noted that Keith struggles socially. He frequently misinterprets social cues and gets teased in class. He also struggles with following classroom rules because he sometimes is unaware of his lack of compliance. Keith demonstrates a strength in his ability to emulate other students’ behavior and adapt to situations. He struggles with expressing himself at an age expected manner and is often difficult to understand when he speaks.

Strengths: Ms. Haley indicated that Keith’s strengths include his helpfulness, his sociability, and his concern for others. Kevin is able to emulate other children in school.

Summary: Keith continues to experience significant deficits in the academic and communication arena. He struggles with all academic subjects and faces considerable difficulties with expressing himself orally and in writing.

Cognitive and Academic Functioning

3.1 Stanford–Binet Intelligence Scales—Fifth Edition (SB5)

Keith was administered the Stanford–Binet Intelligence Scales—Fifth Edition (SB5). The SB5 is an individually administered measure of intellectual functioning normed for individuals between the ages of 2 and 85+ years. The SB contains several individual tests of intellectual problem solving and reasoning ability that are combined to form a Verbal Intelligence Quotient (VIQ) and a Nonverbal Intelligence Quotient (NVIQ). These two indexes of intellectual functioning are then combined to form an overall Full Scale Intelligence Quotient (FSIQ). By combining the VIQ and the NVIQ into the FSIQ, a strong, reliable assessment of general intelligence (g) is obtained. The FSIQ measures the two most important aspects of general intelligence according to recent theories and research findings: reasoning or fluid abilities and verbal or crystallized abilities.

The SB5 contains five factor indexes for each the VIQ and NVIQ: Fluid Reasoning, Knowledge, Quantitative Reasoning, Visual Spatial, and Working Memory. Fluid reasoning represents an individual’s ability to solve verbal and nonverbal problems and reason inductively and deductively. Knowledge represents the accumulated fund of general information acquired at home, school, work, or in life. Quantitative reasoning reflects facility with numbers and numerical problem solving, whether with word problems or figural relationships. Quantitative reasoning emphasizes problem solving more than mathematical knowledge. Visual-spatial processing reflects the ability to see patterns, relationships, spatial orientation, and the connection among diverse pieces of a visual display. Working memory is a measure of short-term memory processing of information whether verbal or visual, emphasizing the brief manipulation of diverse information.

Each of these indexes is expressed as an age-corrected standard score that is scaled to a mean of 100 and a standard deviation of 15. These scores are normally distributed and can be converted to a variety of other metrics if desired.

The SB5 provides three intelligence score composites and five factor indices with a mean of 100 and a Standard deviation of 15. Scores between 90 and 110 are considered average.

	Standard score	Percentile	Conf. interval (95 %)	Descriptive classification
Full scale IQ (FSIQ)	48	0.03	44–56	Delayed
Nonverbal IQ (NVIQ)	62	1	58–70	Below Avg
Verbal IQ (VIQ)	49	0.03	45–59	Below Avg
Factor index scores
Fluid reasoning (FR)	63	1	57–70	Below Avg
Knowledge (KN)	50	0.05	45–55	Delayed
Quantitative reasoning (QR)	68	2	63–72	Below Avg
Visual spatial (VS)	57	0.14	52–63	Delayed
Working memory (WM)	45	0.02	40–50	Delayed

The above table may be referenced to obtain Keith’s performance in each of these areas while the following is a description of each of the factor index scores. Fluid reasoning represents an individual’s ability to solve verbal and nonverbal problems and reason inductively and deductively. Knowledge represents the accumulated fund of general information acquired at home, school, work, or in life. Quantitative reasoning reflects facility with numbers and numerical problem solving, whether with word problems or figural relationships. Quantitative reasoning emphasizes problem solving more than mathematical knowledge. Visual-spatial processing reflects the ability to see patterns, relationships, spatial orientation, and the connection among diverse pieces of a visual display. Working memory is a measure of short-term memory processing of information whether verbal or visual, emphasizing the brief manipulation of diverse information.

The SB5 includes ten subtest scores with a mean of 10 and a Standard deviation of 3. Scores between 8 and 12 are considered average. Keith’s individual subtest scores were as follows:

Nonverbal tests		Verbal tests
Fluid reasoning	3	Fluid reasoning	2
Knowledge	2	Knowledge	3
Quant. reasoning	4	Quant. reasoning	3
Visual spatial	1	Visual spatial	2
Working memory	2	Working memory	1

As noted above, Keith’s scores were all in the below average to delayed range. Primary interpretative emphasis should be placed upon the full scale scores with secondary placed upon index level scores. It is generally not indicated to interpret at the level of the subtest.

On testing with the SB5, Keith earned a Full Scale IQ of 48. On the SB5, this level of performance falls within the range of scores designated as delayed and exceeded the performance of 0.03 % of individuals at Keith’s age. His Verbal IQ (Standard Score = 49; 0.03rd percentile) was in the delayed range and exceeded 0.03 % of individuals Keith’s age. Keith’s Nonverbal IQ (Standard Score = 62; 1st percentile) was in the delayed range, exceeding 1 % of individuals Keith’s age.

3.2 Woodcock–Johnson Tests of Achievement-IV (WJ-IV)

The WJ-IV is an achievement test used to measure basic reading, writing, oral language, and mathematics skills. The Reading subtest includes letter and word identification, vocabulary, and comprehension skills. The Writing subtest includes spelling, writing fluency, and simple sentence writing. The Mathematics subtest includes calculation, practical problems, and knowledge of mathematical concepts and vocabulary. Keith obtained the following scores in each of the areas of measurement:

	Standard score	Descriptive percentile	Classification
Broad reading	44	<0.1	Delayed
Letter-word ID	66	1	Delayed
Sentence reading fluency	58	0.3	Delayed
Passage comprehension	37	<0.1	Delayed
Sentence writing fluency	60	0.4	Delayed
Spelling	51	<0.1	Delayed
Broad mathematics	44	<0.1	Delayed
Math facts fluency	57	0.2	Delayed
Applied Problems	64	1	Delayed
Calculation	30	<0.4	Delayed

Standardized achievement test results revealed considerable deficits across all academic domains. Keith will require an intensive, restrictive environment that will focus on functional academic skills.

3.3 Bender Visual-Motor Gestalt Test, Second Edition (Bender-II)

The Bender-II measures visual-motor integration skills, or the ability to see and copy figures accurately. A quantitative and qualitative analysis of Keith’s drawings suggests that his visual-motor integration abilities (e.g., fine motor skills for paper and pencil tasks) are below average (Copy Standard Score = 70; 2nd percentile).

3.4 Behavior Assessment System for Children, Second Edition (BASC-2)

The Behavior Assessment System for Children, Second Edition (BASC-2) is an integrated system designed to facilitate the differential diagnosis and classification of a variety of emotional and behavioral conditions in children. It possesses validity scales and several clinical scales, which reflect different dimensions of a child’s personality. T-scores between 40 and 60 are considered average. Scores greater than 70 (T > 70) are in the Clinically Significant range and suggest a high level of difficulty. Scores in the At-Risk range (T-Score 60–69) identify either a significant problem that may not be severe enough to require formal treatment or a potential of developing a problem that needs careful monitoring. On the Adaptive Scales, scores 30 and below are considered clinically significant while scores between 31 and 39 are considered at-risk.

Clinical scales	Ms. Lincoln
	T-Score	Percentile
Hyperactivity	67*	93
Aggression	72**	98
Conduct problems	62*	86
Anxiety	48	47
Depression	74**	98
Somatization	84**	99
Attention problems	62*	86
Learning problems	80**	98
Atypicality	69*	94
Withdrawal	66*	93
Adaptability	41	21
Social skills	52	53
Leadership	39*	19
Study skills	30**	3
Functional communication	21**	2
Externalizing problems	68*	93
Internalizing problems	73**	98
Behavioral symptoms index	73**	98
Adaptive skills	35*	7
School problems	73**	98

*At-risk

**Clinically significant

BASC-2 ratings suggested a clinically significant elevation on the behavioral symptoms, internalizing problems, and school composites with an at risk score on the adaptive skills composite. Specific scales in the clinically significant range include aggression, depression, somatization, learning problems, study skills, and functional communication. BASC-2 results also revealed scores in the at-risk range on the attention, hyperactivity, conduct problems, leadership, atypicality, and withdrawal clinical scales.

3.5 Vineland II Adaptive Behavior Scales

The Vineland measures a student’s performance of the daily activities necessary for taking care of oneself, socializing, and getting along with others. Ms. Jessie Miller and Jenny Lincoln completed the teacher rating form that assesses Keith’s functioning in the areas of Communication (receptive, expressive, and written), Daily Living Skills (personal, academic, school community), and Socialization (Interpersonal relationships, Play and leisure time, coping skills).

Following are the results on the Vineland-II:

Domain	Ms. Miller		Ms. Lincoln
	Std. Scr	Percentile	Std. Scr	Percentile
Communication	65	1	67	1
Daily Living Skills	80	9	84	14
Socialization	76	5	86	18
Adaptive behavior composite	72	3	77	6

Results indicate that Keith experiences delays in the area of communication (Receptive and expressive). His socialization skills are in the below average/low average range while his Daily Living Skills (e.g., Academic, School Community, Personal) are low average. Keith’s Adaptive Behavior Composite scores of 72 (3rd percentile; Ms. Miller) and 77 (6th percentile; Ms. Lincoln) are below average.

Interview Results

Parent Interview (May 6, 2016): Ms. Cher Haley, Keith’s mother, was interviewed on May 6, 2016 to ascertain impressions of Keith’s progress at school. Ms. Haley noted a positive change in Keith’s math ability. She explained that there is much more structure in math and as long as Keith knows what he is dealing with, then he knows what to do. Ms. Haley explained that Keith still struggles, but he has also improved. Ms. Haley indicated that Keith’s memory issues stand out. “To be able to remember what word is what is very difficult for him,” she noted. His writing is also low. Ms. Haley asked, “if [Keith] has a learning issue that causes him difficulty with remembering words, then how can we expect him to write it?” She continued, “he needs someone assisting him and guiding him so that he can express himself.” Ms. Haley indicated that he is doing okay socially, but he tends to get teased by other children since he is beginning to stand out in terms of academics and considering that he is bigger than other children. Ms. Haley noted that it is difficult for him to keep up with other children. He always attempts to participate and raise his hand, but generally does not know the answer. Ms. Haley continued, “it is not that he’s having a hard time, it is that the other children are shunning him.” She stated that other children tend to call him “dumb” or “stupid.” Socially, when outside of school settings he gets along fine. In a school setting he tends to get teased. Behaviorally he’s okay. Ms. Haley indicated, “I noticed that his frustration from his learning difference tends to make him angry. He tends to want help. If he’s not given the answer, he tends to shut down.” She also explained that if Keith has something to look forward to, he will persist without getting upset. Ms. Haley stated that Keith needs more structure than what he is presently receiving. When he does work and it is incorrect, he needs to be corrected; otherwise, he’ll actually think it is correct. When he does get things correct on his own then he needs to be praised. She concluded by stating that she does not believe Keith is “mentally retarded.” She is concerned that if Keith is placed into a program for children with intellectual disabilities then this will be harmful to Keith’s progress. Ms. Haley explained that “Keith may just shut down” if placed in such a program because he will realize that there is something wrong with him.

Student Interview (April 27, 2016): Keith was interviewed to ascertain impressions of his progress at SPS. When asked whether he enjoys SPS Keith stated “yes.” When asked what he likes about SPS, Keith stated that he likes homework, reading and recess. Keith was asked what he does best at school and he stated, “listening to the teachers.” Keith also stated that he enjoys playing outside. Keith indicated that he does not get into trouble at school. He mentioned that his strengths include math and homework. Keith explained that his needs include homework. Throughout the student interview, Keith was difficult to understand and had difficulty with answering questions posed to him. It was quite apparent that Keith faces considerable communication delays and struggles with answering questions that are abstract.

Teacher Interview (May 4, 2016): Ms. Jenny Lincoln, Keith’s second grade teacher, was interviewed regarding Keith’s academic, behavioral, emotional, adaptive, and social functioning. Ms. Lincoln first discussed Keith’s issue with communication noting that he struggles with both expressing and understanding language. She mentioned that Keith struggles to understand the distinction between friendly and unfriendly intent. She noted that Keith often misinterprets social cues. Ms. Lincoln noted that Keith is both oversensitive and undersensitive to social stimuli. She mentioned that other children sometimes try to provoke Keith. Ms. Lincoln explained that Keith is aware of his own deficit and employs strategies to try to hide them. Some of these strategies can be functional in one way (e.g., get him out of work; have him be a leader at something in school) but maladaptive in another (e.g., alienate him from other children). For instance, Ms. Lincoln commented that Keith attempts to frequently be first in line and will bump into and push other children. Ms. Lincoln noted that Keith tries to engage socially with other children, but other children often have difficulty understanding what he is saying. Ms. Lincoln explained that Keith is a friendly child and knows how to approach a group of children, but struggles with sustaining social contact with them. Ms. Lincoln explained that Keith is very good at emulating other children’s behavior, which allows him to blend in with them to some degree. Regarding academics, Ms. Lincoln explained that Keith cannot read or write. She noted that sometimes he struggles with letter recognition and he cannot blend sounds. Ms. Lincoln indicated that Keith knows his one and two digit numbers and can count by fives and tens. Ms. Lincoln explained that Keith is skilled at trying to appear like his peers. She also mentioned that Keith is a friendly child who likes to draw and do art. Ms. Lincoln explained that Keith requires support for difficulties with academics, social progress, and speech.

Teacher Interview (May 6, 2016): Ms. Jessie Miller, Keith’s special education teacher, was interviewed regarding Keith’s academic, behavioral, emotional, adaptive, and social functioning. Ms. Miller noted that Keith really struggles in school. She explained, “he spends most of his day really trying hard to access the curriculum.” Ms. Miller indicated that Keith’s teachers also try really hard to assist him. Ms. Miller indicated that Keith’s ability to retain and express language is low. Keith is still writing with imaginative spelling which is reminiscent of beginning of kindergarten level. Still, Ms. Miller explained that Keith has worked extremely hard to get where he is. She continued, he gets exhausted even to accomplish this. Ms. Miller noted that Keith can only match about 30 % of the letters to their beginning sounds. He can recognize, mostly, his letters but still gets confused on the “b,” the “q,” and the “t.” He can count to 100 with teacher cues, though he might skip numbers along the way. Ms. Miller indicated that his ability to count to 100 is not consistent. He’s about 80 % accurate with that. Ms. Miller stated that keeping track of verbal instructions is difficult for Keith. Ms. Miller was next asked about Keith’s social progress. She explained that Keith has a very difficult time reading social situations. For example, Keith does not recognize his role in incidents with other children. He always wants to be first in line, and he’ll push other kids and not recognize that this behavior makes children angry. Ms. Miller explained that children are resentful of him pushing to get to the front of the line. Another child will push back and Keith does not recognize why the other child pushed him back. Ms. Miller noted that Keith really wants to connect with other children, but tends to do so in an assertive and aggressive way. Ms. Miller indicated that Keith is a fairly assertive child and getting him to recognize reciprocal (give and take) interaction has been a struggle for him. He is able to emulate other children’s behaviors to look fairly typical for his age. This is strength. Ms. Miller indicated that Keith’s primary focus is on blending in with other children. She also noted that he is becoming extremely aware of the fact that he is different. As a result, when extra support is offered to him, he does not want it. Ms. Miller explained that this may be a signal to him that he is different. Ms. Miller explained that Keith’s needs include comprehension of everyday routines (e.g., classroom; social) and academics across all areas. Ms. Miller indicated that Keith’s pace of growth is very slow, and his receptive and expressive language skills are very low. Keith’s strengths include his capacity to emulate other children his age, and his strong social motivation which inspires his ability to emulate and engage with other children socially.

Observations

Classroom Observation (May 4, 2016): Keith was observed for 15 min during Ms. Lincoln’s class. The class was engaged in a reading workshop activity. Throughout the 15 min observation, Keith did not appear to read a comic book he had selected. Keith talked with another student in his group. He playfully tapped another student. On several occasions, Keith attempted to talk with students in his group, but what he attempted to communicate with them was unintelligible. Toward the end of the class, when Ms. Lincoln rang the chime to signal a need to be quiet, Keith told other children to be quiet thereby violating Ms. Lincoln’s directive to be quiet. Impressions of the observation were that Keith was not involved in the reading activity.

Observation during Assessment: Keith eagerly engaged in the assessment process and seemed to enjoy the one-on-one attention he received. He struggled with all tasks but persisted despite his difficulty. The present test results are a valid representation of Keith’s abilities.

Conceptualization and Classification

Multiple data sources and methods of assessment inform the conceptualization of Kevin’s cognitive, academic, social-emotional, and behavioral functioning include whether he qualifies for special education support. Details in support of these findings are offered below.

Cognitive and Academic Functioning: Keith’s present performance on a measure of cognitive ability was in the delayed range (SB5 FSIQ = 48; 0.03 percentile; VIQ = 49, 0.03 percentile; NIQ = 62, 1st percentile). This is consistent with his prior performance (January, 2014) in the delayed range on a measure of cognitive ability (SB5 FSIQ = 50; 0.04 percentile; Verbal IQ = 44; <0.01 percentile; Nonverbal IQ = 74; 4th percentile). Keith’s performance on the WJ-IV Achievement was also in the delayed range across all academic areas. When previously assessed in 2014, Keith experienced cognitive delays and functional communication deficits, but his academic skills were in the below/low average range. He also just entered kindergarten and other indicators at that time (e.g., standardized achievement test scores; parental input; socialization skills) suggested that the classification of intellectual disability should be deferred. Keith’s present performance in the delayed range on measures of cognitive ability and two adaptive behavior areas (e.g., functional academics and communication) suggest that Keith will qualify, with a reasonable degree of clinical certainty, for a classification of intellectual disability (formerly mental retardation). This classification reflects a revision to the diagnosis from January 2009 where a classification of mental retardation was deferred in favor of a classification of learning disabilities and speech language delay. Keith’s present performance in the moderately delayed range on a measure of cognitive ability and academic achievement suggests a need for intensive supports in a more restrictive environment.

Social, Emotional, and Adaptive Functioning: Keith faces considerable difficulty in his communication with other children and adults in the classroom. He also tends to misperceive social stimuli. This results in social skills difficulties. Still, Keith displays areas of strength in his social-emotional and behavioral functioning. He has a capacity to emulate other children’s behavior, which helps him to blend in with them. However, when Keith attempts to engage in reciprocal interaction, other children struggle to understand what he is saying. Although Keith can be charming and will often smile at or tease other children in an endearing way, he can be overly assertive, if not aggressive, in his interaction with them. For instance, in his attempt to be first in line, Keith will push others out of his way. This tends to alienate Keith from other children. Keith also struggles with reading and interpreting social cues. And, although he may successfully enter into a conversation or social interaction with other children in the classroom, he struggles to maintain that interaction. Keith will require more intensive social and communication intervention.

Strengths: Background information and interview results indicate that Keith is a friendly child who is good at emulating the behavior of other children which helps him meld in with them. He also has developed strategies that help him hide his academic difficulties. This includes acting like other children when they are engaged in classwork such as pretending to read a book or work on written work. He also understands how to enter into a group of children to engage with them socially. These are all very adaptive social skills.

Summary: Keith experiences delays in cognitive ability, functional academics, and functional communication. These delays are sufficiently severe that Keith will qualify for a classification of intellectual disability.

Summary and Recommendations

Keith faces significant delays in two functional areas: communication and academics. Because of these significant delays, in combination with Keith’s delayed performance on a measure of cognitive ability, Keith will require a restrictive environment that can focus on functional academic, communication, socialization, and daily living skills. Keith demonstrates a relative strength in his ability to emulate, and blend in with, other children. However, Keith still faces struggles in the social arena and will require guidance and support for reciprocal interaction and other basic socialization skills. Part of this struggle is related to his inability to communicate at an age-expected level. The other part of this difficulty appears related to Keith’s moderate intellectual disability where he struggles with reading and interpreting social cues and situations. Keith displays a strength in his ability to emulate other children’s behavior which helps him blend in with them. He experiences delayed communication abilities.

Considering multiple data sources and methods of assessment, Keith will benefit from a more intensive program in a different setting that focuses on functional academic, communication, daily living skills, and social skills. Keith will also benefit from exposure to age-typical peers. The IEP team will convene to discuss additional, specific goals and objectives that will benefit Keith. Meanwhile, the following are a few generalized recommendations for Keith.

• 1. Functional Curriculum: Keith will benefit from greater exposure to a functional academic curriculum that will assist him learn basic reading, writing and mathematics concepts.

• 2. Social Skills Support: Keith will benefit from guidance and support regarding entering into and sustaining social interaction. He will also benefit from appropriate social problem solving skills where he can learn to better read and interpret social cues. Modeling, coaching, and behavioral rehearsal will benefit Keith in the acquisition of appropriate social skills. Peer mediated interventions along with cuing and prompting of acquired social skills will enhance skill performance. Training and practice in diverse settings at school and home will help to generalize and maintain skill acquisition.

• 3. Communication: Keith struggles with oral expression and communicating at an age-expected level. He will benefit from continued support from the speech language pathologist for his communication deficits.

Stefan C. Dombrowski, Ph.D.

Licensed Psychologist (PA and NJ)

Certified School Psychologist (PA and NJ)