The document summarizes a case study of a 17-year-old girl named Ashley who was referred for reevaluation of her diagnoses of autism, intellectual disability, and recently diagnosed Kleefstra syndrome. It outlines the psychological evaluation process that will be used, including a clinical interview, mental status exam, intellectual assessment using the SB5, observations, and assessments for autism including the DISCO and ADOS. It discusses the importance of gathering data from multiple sources and using clinical judgment along with diagnostic tools and assessments.

1. In your initial post, begin with a paragraph briefly summarizing
the main information about the case you selected.
The following case was chosen from the DSM-5 Clinical Cases
by Barnhill (2014):
After being diagnosed with autism and mental retardation for
most of her life, 17-year old Ashley was referred for a
reevaluation. Ashly has been recently diagnosed with Kleefstra
syndrome, thus her family feels it is important to confirm her
diagnosis of autism, mental retardation, and Kleefstra syndrome
and the genetic risk for her sisters. In order to focus on
functioning skills, Ashley attended a special school as she could
not be left alone due to causing self-harm and was unable to
perform certain tasks such as bathing. An informal IQ testing
was done at the time of reevaluation. Beginning at 9 months of
age, Ashely’s parents began noticing developmental delays.
During the evaluation, there was a possible diagnosis of facial
dysmorphology. Her vocabulary consisted of hundreds of single
words and several simple phrases and was interested in license
plates from different states, and would spend many hours
drawing. She had a strong attachment to her parents and sisters,
but very little interest in other individuals her age. A family
history of Asperger’s syndrome, epilepsy, and dyslexia runs in
her family. While being examined, Ashley made inconsistent
eye contact, minimally laughed, often ignored others talking to
her, and spoke many words and few simple phrases in a high
pitched tone. When requesting an object, Ashley would rock her
foot. When given an object, Ashley would examine it with her
nose and lips. Her recent medical examination indicated urinary
tract infections in which was believed to cause Ashley to
become apathetic. During the medical examination, Ashley was
diagnosed with Kleefstra syndrome, which is a rare genetic

2. defect correlated with several medical issues. The parents both
tested negative for this disorder.
Evaluate and describe the ethical and professional interpretation
of any assessment information presented in the case study.
Based on the information provided, it appears a proper
interpretation of the assessment information has been presented.
Pertinent information within the case study was presented while
maintaining privacy and confidentiality. For example, Ashley’s
first name was stated, but not her last. The use of the
assessment was deemed appropriate and useful in order to make
a diagnosis of the patient. The variety of information gathered
such as the patient’s history, family medical history, medical
evaluation, and an observation of the patient were collected in
which is essential and will contribute to making a diagnosis. A
better understanding of the patient assists in interpreting
assessment results as several factors are taken into
consideration.
Psychological evaluation
When conducting a psychological evaluation, it is essential to
collect data using a variety of techniques in order to ensure the
professional has a wealth of information to complete a detailed
evaluation.
Clinical Interview
The first step when devising an assessment battery is
conducting a clinical interview. The clinical interview is
essential in order to gain a better understanding about the
individual and assists the psychologist making a diagnosis and
creating a treatment path. The first step would be to have
Ashley’s parents fill out a simple questionnaire about Ashley.
Although there are many types of clinical interviews, using the

3. information presented in the case study as background
knowledge and guidance, this interview would contain open-
ended questions related to Ashley’s mental and physical health.
The interview would be conducted in a safe and confidential
environment. Even though some background knowledge about
Ashley has been received, it is essential that I get to know her
and her parents personally by engaging in conversations and
observing her behaviors. It is essential that there is trust built
between the psychologist, patient, and her parents. Since Ashley
only uses simple words and phrases, it may be essential for
Ashley’s parents to be in the room during some of the interview
process as they may be able to provide some first-hand
knowledge related to Ashley. It would also be essential to
collect medical records, school reports, and all prior
assessments that have been conducted.
Mental Status Exam
Since Ashley is a new patient, a mental status exam (MSE) will
be conducted. Observing Ashley will assist in gaining answers
to interview questions as it appears Ashley will not be able to
communicate about her behaviors. The MSE will allow the
psychologist to review the personal and intellectual functioning
and watch for signs and symptoms that will assist in making a
diagnosis (Gregory, 2014). There is some flexibility when
conducting a MSE, but there are some common areas that are
examined. The areas that will be examined include appearance
and behavior, processes related to speech and communication,
thought content, insight and judgement, orientation, as well as
cognitive, memory, and emotional functioning (Gregory, 2014).
Observing and careful interviewing skills are essential during
this process.
Intellectual Assessment
An intellectual assessment is a vital part of the evaluation

4. process. The purpose of the intellectual assessment is to
examine Ashley’s general intellectual functioning and cognitive
abilities. The Stanford-Binet: Fifth Edition (SB5) Intelligence
Test is one of the most common types of intelligence tests that
will be used. The SB5 measures five factors of intelligence
including fluid reasoning, knowledge, quantitative reasoning,
visual-spatial reasoning, and working memory (Gregory, 2014).
In addition, these five factors are assessed under two domains;
verbal and nonverbal. Using this assessment will provide a
better understanding of Ashley’s IQ and cognitive abilities,
which will assist in making a diagnosis.
Observations
Client observations are another critical part of the evaluation
process. Observing the client’s behavior and emotions is an
important process that provides the psychologist additional
information that may not have been obtained otherwise.
Observing the client in a variety of areas including social
interaction as well as repetition of behaviors is important
((Volkmar et al., 2014)). Observational data will assist in
making a diagnosis and developing a treatment plan that will
meet the client’s needs.
Assessment Instruments
Although Ashley was diagnosed with severe intellectual
disability and Autism Spectrum Disorder (ASD) when she was
younger, it is essential to continue assessing as individuals
change along with their needs changing. ASD is a broad
category and requires gathering information from a variety of
sources. Although there are a variety of assessments to use
when diagnosing ASD, two assessment instruments that are
recommended include the Diagnostic Interview for Social and
Communication Disorders (DISCO) as well as the Autism
Diagnostic Observation (ADOS). The DISCO can be used for a

5. variety of ages ranging from children through adulthood. The
DISCO is a semi-structured interview that collects a variety of
information related to skills, weaknesses, and behavior without
focusing on ASD alone, but relates to other disorders as well.
The ADOS is also a semi-structured assessment focusing on
social interaction, imagination, and communication. This is a
useful instrument that can be used for assessing autism as well
as other developmental disorders. In addition, the Leiter
International Performance Scale-Revised (LIPS-R) would also
be an important assessment tool. This instrument can be used to
assess adolescents with suspected autism and may provide
useful in order to assess characteristics such as speech delay
associated with Kleefstra syndrome.
Pros and cons of instruments
Gathering a variety of data is essential when conducting a
psychological assessment. While the use of instruments are
tools that assist in the assessment process, clinical judgement
should not be replaced (Volkmar et al., 2014). The DSM-5 used
by the referring professional is used to classify mental health
disorders. While this diagnostic instrument is helpful, it is
necessary to obtain information from a variety of sources. In
addition to interviews, observations, intake forms, history of
patient and family, medical history, results of prior assessments
and tests, it is essential to conduct assessments using
assessment instruments as well. The SB5 is a good intelligence
test to conduct as it covers 5 domains that measures general
cognitive ability. In addition, the LIPS-R is helpful when
conducting an intellectual assessment of individuals when their
language skills are weak (Gregory, 2014). Measuring cognitive
ability and adaptive skills is an essential part of the assessment
process as it helps create a treatment plan and is relative to
overall development (Volkmar et al., 2014). The DISCO
assessment will assist in providing a variety of information
including adaptive skills. Adaptive skills can also be measured

6. using the ADOS as it related to social interaction and
communication, which is an essential part of every day
functioning. ASD has a broad range of syndrome expressions
and is challenging for clinicians to manage (Volkmar et al.,
2014). While these assessments provide valuable information
amongst a broad range of categories and are essential when
evaluating disorders, no single assessment or test should be
used to diagnose a disorder, but rather a wide range of
assessments should be conducted.
References
Barnhill, J. W. (Ed.). (2014).
DSM-5 Clinical Cases
. Washington, D.C.: American Psychiatric Association.
Gregory, R. J. (2014).
Psychological testing: History, principles, and applications
(7th ed.). Boston, MA: Pearson.
Volkmar, F., Siegel, M., Woodbury-Smith, M. King, B.,
McCracken, J., State, M., & the American Academy of Child
and Adolescent Psychiatry (AACAP) Committee on Quality
Issues (CQI). (2014).
Practice parameter for the assessment and treatment of children
and adolescents with autism spectrum disorder (Links to an
external site.)Links to an external site. (Links to an external
site.)Links to an external site.
[PDF].
Journal of the American Academy of Child & Adolescent
Psychiatry, 53(2),
237-257. doi:10.1016/j.jaac.2013.10.013
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