Name: Pickering, Samuel J Sex: Male

Nickname: Sammy ID Number:

Address: 11358 S. Gardner St.
Mother: Melissa Pickering Father: Bradley Pickering
Phone Number: 555-1111 Primary Language: English

Test Date: 09/18/2001 Examiner: M. Montrose

Birth date: 05/13/2000 School/Clinic: Abbott Clinic
Chronological Age: 16 Months Adjusted Age: 14 months

Number of Weeks Gestation: 30 Birth Weight: 2 lbs 3 oz

Apgar Score 1 Minute: 6 Vision Problems: No
Apgar Score 5 Minutes: 7 Hearing Problems: No
Hospital: Hughes Memorial

Personal or Physical Characteristics:

-------------------------------------
Weight 20 lbs (10th percentile); Height 29 inches (10th percentile)

Medication: None

Reason for Referral:

--------------------
Suspected developmental delay

Additional Information/Comments:
--------------------------------
History is positive for two bouts of sepsis and an inguinal hernia.

--------------------------------------------------------------------------------

Name: Pickering, Samuel J Sex: Male

Test Date: 09/18/2001 Mother: Melissa Pickering
Birth date: 05/13/2000 Father: Bradley Pickering
Chronological Age: 16 Months School/Clinic: Abbott Clinic
Adjusted Age: 14 months Examiner: M. Montrose

SCORE SUMMARY

90%
Raw T Confidence %ile Devel Age Descriptive
Scales Score Score Interval Rank Stage Equiv Category
------------------- ----- ----- -------- ---- ----- ------ -------------
Gross Motor 14 28 22 - 34 1 4 11 mos Very Low
Visual Reception 15 37 29 - 45 10 4 12 mos Below Average
Fine Motor 12 22 13 - 31 1 3 10 mos Very Low
Receptive Language 15 44 37 - 51 27 4 14 mos Average
Expressive Language 12 39 33 - 45 14 4 12 mos Below Average

90%
Standard Confidence Percentile Descriptive
Composite Score Interval Rank Category
------------------------ -------- --------- ---------- -------------
Early Learning Composite 73 66 - 80 3 Below Average

T SCORE PROFILE
 90% Confidence Interval

|------------------- T SCORE (Mean=50, SD=10) ---------------|

| |
Scales |20 30 40 50 60 70 80
================|+----+----+----+----+----+----+----+----+----+----+----+----+
Gross Motor | ******X******
T Score: 28 |
----------------|+----+----+----+----+----+----+----+----+----+----+----+----+
Visual Reception| ********X********
T Score: 37 |
----------------|+----+----+----+----+----+----+----+----+----+----+----+----+
Fine Motor |**X*********
T Score: 22 |
----------------|+----+----+----+----+----+----+----+----+----+----+----+----+
Receptive Lang | *******X*******
T Score: 44 |
----------------|+----+----+----+----+----+----+----+----+----+----+----+----+
Expressive Lang | ******X******
T Score: 39 |
================|+----+----+----+----+----+----+----+----+----+----+----+----+
Percentile Rank | 2 16 50 84 98
-3 SD -2 SD -1 SD Mean +1 SD +2 SD +3 SD

--------------------------------------------------------------------------------

Name: Pickering, Samuel J Sex: Male

Test Date: 09/18/2001 Adjusted Age: 14 months

NARRATIVE REPORT

Samuel Pickering is a 1 year 4 month old male who was referred by Dr.
Ramirez for the following reason: Suspected developmental delay. Samuel
weighed 2 pounds 3 ounces at birth after a 30-week gestation. His one
minute Apgar was 6 and his five minute Apgar was 7. Personal and
physical characteristics include: Weight 20 lbs (10th percentile);
Height 29 inches (10th percentile).

He was examined by M. Montrose on September 18, 2001, and administered

the Mullen Scales of Early Learning: AGS Edition, an assessment of
learning styles, strengths, and needs. Because of a 30-week gestation,
an adjusted age of 14 months was used in comparing Samuel's performance
to other children's.

Samuel was assessed in the areas of Gross Motor, Visual Reception, Fine
Motor, Receptive Language, and Expressive Language.

GROSS MOTOR SCALE

Samuel is functioning Very Low for his adjusted age on the Gross Motor
Scale. His T score is 28 and his percentile rank is 1. His skills are at
the 11-month level, which is in developmental stage 4. Typical skills in
this stage include developing balance, controlling upper/lower
extremities, and gaining upright mobility.

Samuel was able to move from a sitting position to hands and knees and
stand alone for 1 to 2 seconds. He could not walk several steps without
help or throw a ball underhand from a standing position.
 VISUAL RECEPTION SCALE

Samuel's Visual Reception Scale accomplishments place him at the

12-month level and in developmental stage 4. Milestones at this stage
include understanding the concept of object permanence, associating
objects with their functions, and demonstrating early spatial awareness
and visual memory. He has a T score of 37 and a percentile rank of 10
for this Scale and is functioning in the Below Average range for his
adjusted age.

Samuel opened and closed a book and attended to a picture by vocalizing,

pointing to, or patting it. However, he did not yet look for a toy that
was covered and then displaced or place at least one shape in a
formboard.

FINE MOTOR SCALE

Samuel has a T score of 22 and a percentile rank of 1 on the Fine Motor

Scale. He is functioning in the Very Low range for this Scale. He

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Name: Pickering, Samuel J Test Date: 09/18/2001

Adjusted Age: 14 months

performed at a 10-month level, developmental stage 3, which focuses on

refinement of grasping and manipulating objects, and use of a partial
pincer grasp.

Samuel could not turn pages in a book singly or a few at a time or draw
a vertical or horizontal line (imitating a model). But he could take
blocks out or put blocks in a container and use both hands together when
playing with a toy.

RECEPTIVE LANGUAGE SCALE

Samuel is functioning in the Average range on the Receptive Language

Scale at a 14-month level, in developmental stage 4. At this level,
children typically identify objects that have labels and give objects on
verbal request. His T score on this Scale is 44 and his percentile rank
is 27.

Samuel accomplished tasks such as: understanding a simple question such

as "Where's the door" and pointing to named body parts such as nose and
hair. He had difficulty touching or pointing to a picture of an object
after hearing it named and following related commands such as "Stand up
and get the ball".

EXPRESSIVE LANGUAGE SCALE

Samuel's Expressive Language Scale T score is 39 and his percentile rank

is 14. He is functioning in the Below Average range on skills for his
age. At the 12-month level, developmental stage 4, expressive language
abilities include the spontaneous use of single words and words or
sounds with gestures.

On his last two successful activities, Samuel said first words such as
"mama" and jabbered with inflection. Samuel could not communicate
 intentions by using jargon combined with gestures or combine a word and
a gesture to make a request.

SCALE SUMMARY

Samuel's strengths are in Visual Reception, Receptive Language, and

Expressive Language. Samuel showed a weakness in Gross Motor and Fine
Motor. He may benefit from parental or caretaker activities in these
areas.

EARLY LEARNING COMPOSITE

The Early Learning Composite is a measure of general cognitive ability

and includes scores from the four cognitive Scales. Samuel's Early
Learning Composite standard score is 73 and his percentile rank is 3,
which falls in the Below Average range.

--------------------------------------------------------------------------------

Name: Pickering, Samuel J Sex: Male

Test Date: 09/18/2001 Adjusted Age: 14 months

RECOMMENDED ACTIVITIES

"You and Your Small Wonder" activities were designed to encourage physical,
intellectual, and emotional growth as well as language development in
children. The activities referred to in this report are further explained
in the "You and Your Small Wonder" books. If your child does not respond
well, or appears to be bored, try some of the many other activities
appropriate for his age level. Before beginning an activity, read the
entire passage to be sure it is appropriate for the child you are working
with and to familiarize yourself with what you will be doing.

NOTE: Certain activities may not be physically or otherwise possible for

some children. A trained professional should be consulted about ways to
modify these activities to fit your child.

GROSS MOTOR SCALE

Activity: You and Your Small Wonder - Book One

Just for the Two of You
13. Dancing Together
With music playing, pick up your baby and dance to the rhythm.

Activity: You and Your Small Wonder - Book One

Teaching--Family Style
13. Batting a Balloon
Show your baby how to bat at a balloon.

Activity: You and Your Small Wonder - Book One

Growing with the Grass
12. Running Errands
Give an object to your baby and ask him to bring it to someone
nearby.

Activity: You and Your Small Wonder - Book One

Chore-time Chums
14. Playing Catch
 Roll a sock ball to your baby; encourage him to roll or throw it
back to you.

Activity: You and Your Small Wonder - Book One

Bathtime Business
11. Putting Things into a Container
Have your baby practice putting objects into a container while in
the bathtub.

--------------------------------------------------------------------------------

Name: Pickering, Samuel J Test Date: 09/18/2001

Adjusted Age: 14 months

Activity: You and Your Small Wonder - Book One

Teaching--Family Style
8. Stopping a Ball and Picking It Up
Sit with your legs spread apart and your baby in between while
someone rolls a ball to your baby.

Activity: You and Your Small Wonder - Book One

Teaching--Family Style
12. Retrieving Bean Bags
Have your baby take bean bags out of a basket and hand them to
you.

VISUAL RECEPTION SCALE

Activity: You and Your Small Wonder - Book One

Just for the Two of You
18. Solving Simple Problems
Show your baby an object and then hide it under a washcloth for
your baby to find.

Activity: You and Your Small Wonder - Book One

Bathtime Business
12. Uncovering a Hidden Toy
While your baby is in the tub, cover a toy with the washcloth and
then uncover it.

Activity: You and Your Small Wonder - Book One

Chore-time Chums
12. Hide-and-Seek with Objects
Hide a toy while your baby is watching you; help him to find the
toy.

Activity: You and Your Small Wonder - Book Two

Shop, Look, and Listen
12. Shape Shopping
Take your child on a shopping trip to find objects that are
shaped like circles, squares, or triangles.

Activity: You and Your Small Wonder - Book One

A Classroom in the Kitchen
16. Nesting Bowls
Show your baby how to place different sized bowls or measuring
cups together.
 Activity: You and Your Small Wonder - Book Two
Just for the Fun of It
2. Inserting "Pegs" into Holes
Show your child how to insert a straw into a spool.

--------------------------------------------------------------------------------

Name: Pickering, Samuel J Test Date: 09/18/2001

Adjusted Age: 14 months

Activity: You and Your Small Wonder - Book Two

A Classroom in the Kitchen
10. Form Puzzles
Teach your child how to complete a puzzle that has different
shaped pieces.

FINE MOTOR SCALE

Activity: You and Your Small Wonder - Book One

Just for the Two of You
17. Enjoying a Book
Show your baby books with simple stories and colorful pictures.

Activity: You and Your Small Wonder - Book One

Teaching--Family Style
9. Looking at a Book
Sit with your baby in your lap and page through a picture book
while naming the objects.

Activity: You and Your Small Wonder - Book One

Just for the Fun of It
18. Finger-Painting
Teach your baby how to paint with his fingers.

RECEPTIVE LANGUAGE SCALE

Activity: You and Your Small Wonder - Book One

Just for the Two of You
17. Enjoying a Book
Show your baby books with simple stories and colorful pictures.

Activity: You and Your Small Wonder - Book One

Bathtime Business
12. Uncovering a Hidden Toy
While your baby is in the tub, cover a toy with the washcloth and
then uncover it.

Activity: You and Your Small Wonder - Book One

Bathtime Business
13. Learning to Follow Directions
Ask your baby to hand you objects while you are giving him a
bath.

Activity: You and Your Small Wonder - Book One

Bathtime Business
16. Selecting an Object
While your baby is in the bathtub, have him pick up the objects
you ask for.
--------------------------------------------------------------------------------

Name: Pickering, Samuel J Test Date: 09/18/2001

Adjusted Age: 14 months

Activity: You and Your Small Wonder - Book One

A Classroom in the Kitchen
18. Setting the Table
Talk to your baby as you show him how to set the table.

Activity: You and Your Small Wonder - Book Two

Shop, Look, and Listen
2. Finding Foods
When you go grocery shopping, ask your child to point out the
items you need.

EXPRESSIVE LANGUAGE SCALE

Activity: You and Your Small Wonder - Book One

A Classroom in the Kitchen
8. Making Sounds
Repeat the sounds your baby makes and make some new sounds for
him to imitate.

Activity: You and Your Small Wonder - Book One

Changing Time
9. Learning Hand Movements for a Song
Teach your baby how to make gestures to a song.

Activity: You and Your Small Wonder - Book One

Changing Time
8. Gesturing
Teach your baby how to gesture to be picked up.

Activity: You and Your Small Wonder - Book One

Teaching--Family Style
11. Follow the Leader
Have your baby imitate you while you clap your hands or blow a
kiss.

Activity: You and Your Small Wonder - Book One

Bathtime Business
18. Getting Undressed
Teach your baby how to undress at bathtime by showing him how to
pull socks off, or lift his arms up to remove a shirt.