Preview
FILED: NEW YORK COUNTY CLERK 11/12/2019 11:28 AM INDEX NO. 150316/2017
NYSCEF DOC. NO. 23 RECEIVED NYSCEF: 11/12/2019
NEUROPSYCHOLOGICAL EVALUATION REPORT
Patient: H D
Date of Birth: M006
Date of Evaluation: 10/4/2015
Age: 9 years, 2 months
Test Site: Brooklyn, NY
The purpose of this evaluation was to determine the basic motor, cognitive and behavioral
performance resources of H4gg IWand their impact on her educability and abilityto
execute activities of daily living. In addition, a determination was made of the influence of
neuropsychologically significant factors in H 'shistory upon her current level of
functioning. H was accompanied to the evaluation by her mother, Solenny Sanchez, who
provided information concerning her background and current functioning. The following
medical, educational and administrative records were also reviewed:
1. New York Presbyterian Hospital - Prenatal and Labor Records
/Delivery
2. New York Presbyterian Hospital - Neonatal and Pediatric Medical Records
3. Physicians Regional Medical - Pediatric Medical Records
Group
4. East Naples Medical Center - Pediatric Medical Records
5. David Lawrence Center - Psychiatric Medical Records
6. New York State Department of Health - WIC Medical Referral Forms
7. New York Department of Preservation - Lead Inspection Records
City Housing
8. Williamsbridge NAACP Care Center - School and Health Records
Day
9. Collier Public Schools - School Performance and IEP Records
County
History j
Ih was born at New York Presbyterian Hospital in New York City. Her mother received
regular prenatal care, and denies any use of alcohol or drugs.
illicit Prenatal medical records
indicate that she was seen in the ER for a falltwo months prior to Hemands birth, but no injury
to mother or fetus was identified at that time. She was noted to be positive for B
Group
Streptococcus at the time of delively.
H medical records describe a normal spontañecus vaginal delivery at fullterm. Her birth
weight was 6 lbs 8 oz (2963 grams), and she received Apgar scores of 9 and 9 atone and five
minutes, respectively. At birth,Helenny was active and alert,with spontañcous respiration and
good cry, muscle tone and reflexes, No prenatal or peripartum complications, nor any
indications of fetalor neonatal distress, were reported. H was admitted to the regular
nursery for routine newborn care, and was discharged with her mother after two days.
HM has a history of occasional upper respiratory and ear infections,and asthma. When she
was six years old, she developed obstructive sleep apnea, which worsened over the following
year, prompting the surgical removal of her adenoids and resection of her inferiorturbinates.
Otherwise, except for lead poisening as described below, I has experienced good health
with no serious illnesses or injuries, and with age appropriate physical growth and dcyclopment.
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RE: 1 H
H was diagnosed with CDC Class IIa lead poisoning when she was one year old, at which
time her blood.1ead level was found to be lil µg/dl. No subsequent blood lead test reports were
provided, although her pediatric medical records refer to her having had a blood lead level as
high as 13 µg/dl. Because H s blood lead levelhad not been monitored prior to her initial
elevated reading, and no follow-up blood test resultsare available, the actual onset and duration
of her lead poisoning, and the magnitudc ofher body's lead burden, are not known. Itshould be
noted that at the time of her elevated blood lead reading, the NYC Department of Health
identified multiple lead paint violations in her family's residence.
H dopumented history of blood lead testresults isshown in Table 1.
Table 1. Blood-Lead Level
Date IIµg/dl
07/20/07 11 1
H began attending the Williamsbridge NAACP Day Care Center when she was three years
old, and isreported to have performed at an age-appropriate level at that time.
IM moved from New York City to Naples, Florida when she was six yeañ old, where she
attended firstgrade at Big Cypress elementary school. She was described by her teachers as a
sweet girl who coñtributed to class discussions, but who was easily distracted and had difficulty
listening and following directions. She also exhibited difficultbehaviors at home, where she was
reported to be very active,unable to sitstill,and overly aggressive. She did not follow directions
and often fought with her siblings. She was diagnosed with ADHD - Combined Subtype (with
inattention, hyperactivity and impulsivity) as well as with Oppositional Defiant Disorder. She
was prescribed
-initially Metadate, and has subsequently taken Focalin, Vyyanse, Concerta and [
hituniv.
H was observed to have difficulty speaking clearly in class. For example, she would
repeat phrases and sentences, and became embarrassed when she was unable toget the words
out. She was administered a speech and language evaluation, which found sound repetitions, as
well as many word and phrase repetitions and circumlocutions, and ratedher stuttering as
Moderate to Severe according to the Stuttering Severity Instrument-4. She was diagnosed with
Expressive Language Disorder, and entered second grade with an Individualized Education
Program (IEP) with the disability classification of Speech Impaired. H participated in
general education academics and activities,but received small group speech therapy 30 minutes
weekly to improve her fluency.
From October 2013 to November 2014, H eceived psychological services from the David
Lawrence Center foranxiety and ADHD. Her most recent therapy notes refer to such behaviors
as excessive talking, constantly moving and fidgeting, being forgetful, being easily distracted,
and having difficulty completing tasks.
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RE: 1 He
This ispresumed to represent H 'sfirstñearapsychological evaluation.
Present Evaluation
H presented as a well dressed child who was polite and friendly, and appeared well
oriented to time and place. A good rapport was echhliaed with the examiner, and her mother
stated that her behavior during the evaluation was typical for her. At the time of testing,
was taking Concerta and Vyvanse, =dinins enabling her to contro1her attention and impüisive
responding. Accordingly, the present evaluation should be taken as a valid reflection of
H s cognitive and neuropsychological functioning.
Intelligence Assessment
The Wide Range Intelligence Test (WRIT) was ah·idstered and H attained a Full Scale IQ
(776
of 111 percentile) which isin the high average range, a Verbal Comprehension Composite . .
(68* (79*
Score of 107 percentile), in the average range, and a Visual Score of 112 percentile),
in the high average range.
Table 2. WRIT Competite Score Summary
Scale empsits Score Percentile
Verbal 107 68
Visual 112 79
General 111 77
Table 3. WRIT Subtest Summary
Verbal Subtests Standard Score Perceñtile
Verbal Analogies 96 34
Vocabulary 117 87
Visual Subtests Standard Score Percentile
Matrices 119 90
Diamonds 101 53
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Neuropsychological Assessment
A. Language
H s verbal fluency was assessed using the Controlled Oral Word Association Test from
the Multilingual Aphasia Examination (MAE), and she achieved a score in the average range
- 70*
(Controlled One %rd Association Test percentile). H naming ability was asscsscd
using the Visual Naming subtest from the MAE, which fellwithin the borderline range (Visual
- < 4*
Naming percentile).
H as administered the Comprehension of Instructions subtest from the NEP SY-IL This
testrequires one toperform specific tasks according to verbal instructions, thus a Mg her
comprehensics of spoken language. Helenny's perferreañce on the Comprchension of
- 25*
Instructions testwas in the average range (Comprehension of Instructions percentile).
H s abilityto defme words was assessed using the Vocabulary subtest from the WRIT,
which indicated thather knowledge of word meanings was in the high average range
- 87*
(Vocabulary percentile).
These results indicate that H is exhibiting deficits in her naming abilityand inher ability
to comprehend instructions.
B. Sensory-Motor Functioning
H as administered three accacements to evaluate her sensory-motor functioning: the
Purdue Pegboard test, the Rey Osterrieth Complex Figure Test, and the Arrows test.
The Purdue Pegboard test isused to assess dexterity and visacmotor abilities by requiring
individuals to quickly fitpegs into holes in a board. H performance on the Padue
Pegboard indicated thathand and finger movements with her dominant right hand were within
- 49*
the average range (Right Hand percentile), and movcmcñts with her lefthand were within
the average range (Left Hand - 47* percentile). H use ofboth hands together in simple
- 46*
symmetrical movements was within the average range (Both Hands percentile), and her
- 35*
ability to assemble multi-component objects was within the average range (Assembly
percentile).
H 'svisuospatial constructional abilitywas assessed using the Rey Osterrieth Complex
Figure Test, which requires one tocopy a complicated geometric design. Helenny's abilityto
- > 165
reproduce thiscomplex design was within the average range (Osterrieth: Copy
percentile).
H 'svisuospatial was also assecsed the Arrows subtest from the NEPSY-
processing using
which requires one tolook at an of arrows arranged around a targetand toindicam which
II, array
arrows point to the center of the target. H performance on this testwas in the high
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RE: 1 ,
- 846
average range (Arrows percentile),
These results indicate that I is notdisplaying deficitswithin her sensory motor
functioning at thistime.
C. Learning and Memory
Storage of verbal, auditory and visualinformation is mediated in different ways and, to some
extent, by different parts of the brain. Accordingly, to testmemory functioning itis necessary to
use differenttests that are sensitive to specific components of verbal and non-verbal memory,
and which may reflect the functioning of different brain systems. The Wide Range Assessment
of and - Second Edition vias used to assess for
Memory Learning (WRAML-2) memory
narration, memory for words, memory for design and memory for pictures. The recall trialof
the Rey Osterrieth Complex Figure Test and Recognition Trial was used to assess visuospatial
memory and recognition.
H was admin_istered the Story Memory subtests from the WRAML 2 to assess her
immediate, delayed and recogniticñ memory for narration. H performance on this test
indicated that her immediate recall fornarration was in the average range (StoryMemory:
Immediate Recall - 50th his delaycd recall for narration was in the average range
percentile),
-50th
(Story Memoq: Delayed Recall percentile) and his recognition memory for narration was
- 50*
within the average range (Story Memory: Recognition percentile). j
H was âdministered the Verbal Learning subtest from the WRAML-2, which assessed her
immediate, delayed and recognition memory for listsof words. HWs performance on this
test indicated that her immediate recallfor words was in the intellectually deficient range (Verbal
Learning: Immediate Recall - 2"d her delayed recall for listsof words was.in the
percentile),
- 256
average range (Verbal Learning Memory: Delayed Recall percentile) and her recognition
- 5*
memory for listsof words was within the borderline range (Verbal Learning: Recognition
percentile).
H was administered the Design Memory subtest from the WRAML-2, which assessed her
imme lateand recognition memory for abstract designs. H performance on this test
indicated thather immediate recall forabstract designs was in the low average range (Design
- 16*
Memory: Immediate Recall percentile) and her recognition memory for abstract designs
was within the high average range (Design Memory: Recognition - 75'h
phl
H as administered the Picture Memory subtest from the WRAML-2, which assessed her
immediate and recognition memory for pictures. H performance on this test indicated
that her immediate recall for pictures was in the average range (Picture Memory: Immediate
- 50*
Recall percentile) and her recognition memory for pictures was within the average range
(Picture Memory: Recognition - 25* percentile).
Visuospatial memory was also assessed by avambing the recalland recognition trialsof the Rey
Osterrieth Complex Figure Test. H irarnediata fme recall forvisuospatial material was
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RE: M H
in the high average range (Osterrieth: hnmediate Free Recall - 84th
percentM He d d h
recallfor visuospatial material fellwithin the superior range (Osterrieth: Delayed Free Recall -
92nd
percentile), and her recognition for visuospatial material fellwithin the average range
- 66*
(Osterrieth: Recognition Memory percentile).
These results indicate that H is exhibiting deficits for her memory for words, in her
recognition of pictures and in her immediate memory for design.
D. Attention
Conners'
A detailed analysis of H visual attentional functioning was performed using the
Continuous Perfonnance Test-H (CPT-II). The CPT-H requires one todetect and respond to the
visual presentation of certain letterson a computer screen. By varying the duration of exposure,
as well as the pattern and rate of letterpresentanon the CPT-H allows a close examination of the
multiple processes that together underlie one's visual attention. Itmust be remembered that
H as taldng Concerta and Vyvanse at the time of the administration to help her control
her attention and impulsive responding.
H pattern of perfonnance of the CPT-H included scores that ranged from good to average
- 696 -386 - 56*
(% Omissions percentile; % Commissions percentile; Hit RT percentile;
- 24* Response Style - 59 Hit RT SE - 34*
Detectability percentile; percentile; percentile;
- 28* Perseverations - 29* Hit RT Block Change - 91"
Variability percentile; percentile;
- 88* -54*
percentile; Hit SE Block Change percentile; Hit RT ISI Change percentile; and Hit SE
- 61"
ISI Change percentile). H s performance profile on the CPT-H was considered to be
reflective of a nonclinical profile with a 59% confidence interval.
Itshould be noted that the CPT-II performs a self-diagnostic check of the accuracy of the timing
of each administration, There was no indication of difficultiesor respondent non-
any timing
compliance, and therefore the current administration should be considered valid.
E. Executive Functioning
Executive fimctions of the brain include higher level cognitive processes that allow adaptive j
thought to be used to solve novel problems and toplan adaptive and goal directed behavior.
Among the more salient processes subsumed under the rubric of executive functioning are
planning, concept formation, and cognitive flexibility.
The Mazes subtest from the WISC-III, and the Tower of London (TOL) were used to assess
H s nbnning ability and impulse control. In order to complete the Mazes test, H
had to successfully indicate the route an individual would take to exita maze without tuming into
blind and her performance on the Mazes task was within the average range (Mazes -
any alleys,
50*
percentile). In order to correctly complete the Tower of London one must reproduce a
pattern composed of colored ballsplaced on pegs, using a second psgboard and set of colored
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balls. Several scores are derived from one's perforraancc on the TOL, including the number of
correct completions, the totalnumber of moves taken, the number of rule violations, and the time
taken to complete the task. IM's performance on the TOL yielded mixed results. Her total
- 62d
number of correct completions was within the average range (TOL: Number Correct
percentile), and the number of moves needed to complete the entire test fellwithin the high
- 81't
average range (TOL: Total Move Score percentile). However, H s number of rule
vicktions, which indicates impulsive and perseverative responding, was within the bordctliñe
- 3d
range (TOL: Total Rule Violadon percentile), and the time ittook her to complete the task
-69*
was with the average range (TOL: Total Èxecution Time percentile).
The Verbal Analogies subtest of the WRIT requires one tosupply an appropriate word in an
orally presented analogy, thereby demonstrating competency in verbal concept formation.
H verbal concept formation skills were shown to be in the average range (Verbal
Analogies - 396 percentile).
H s abilitiesto easily change from one format to another (set shifting),to inhibit a
prepotent response (inhibitory control), and toefficiently scan a visual fleld, were assessed
through her performance on the Comprehensive Trail-Making Test (CTMT). In order to
completc the CTMT, one simply has to connect numbers, words and numbers, or numbers and
letters. Cornpetcacy in each of these areas ismeasured by the time required to perfonn the
(CTMT- 13*
various tasks. H performance on the CTMT was in the low average range
percentile), which reflects her difficulty nging sets, controlling her impulses, and efficiently
scanning the visual field.
These results indim» that Hammeshas visual speed deficits (as reflected in the length
processing
of time ittook her to complete the CTMT), and that she has difficultycontrolling impulsive
responding, even while on Concerta and Vyyanse, as seen in her rule violations she mmmitted
on the TOL.
Summary
H presented with an IQ inthe high average range. However, in order for I to
perform well, she has tobe taking Concerta and Vyyanse, medicines designed to help the
individual control her attention and impulsive responding. Neuropsychological and
neurofunctional testing of Helenny revealed impaiñnsts in naming abilityand inher abilityto
comprehend instructions. Additionally, testing revealed thatHelenny displays deficits in her
scraory forwords, recognition of pictures and inher immediate memory for design. She
displayed visual processing speed deficits (as reflected in the length of time ittook her to
complete the CTMT), and in difficultycontrolling impulsive responding as seen in her rule
violations on the TOL. .
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Interpretation
HM's observed deficiencies, in association with expected to greater than expected
functioning in other neurocognitive domiñs and interpreted within the context of her history, are
indicative of pediatric brain injury. Furthermore, such impairments have been described as
sequella of early childhood exposure to lead. Lead is a latown environmental toxin whose effects
on the developing nervous system have been well documented, and often lead to such cognitive
and behavioral consequences as language disorders, hyperactivity, attention deficitsand mental
retardation. Elevated lead levels in young children have also been associated with poor
performance on standardized assessments of emotional regulation and orientation-engagersent.
A review of I s available medical history indicates that she experienced clinically
significant lead poisoning, and reveals no other factors or lifeevents thatwould be expected to
exert such a negative impact on her neuropsychological functioning.
The severity of brain damage caused by lead poisoning isrelated to a child's age at the time of
exposure, the duration of her exposure, and the magnitude of the body's lead burden. H
was shown to have a significantly elevated blood lead concentration as early as one yearof age
which places her lead exposure well within the period of nervous system development during
which many areas of the human brain undergo a complex series of anatomical and functional
transfonnations. Exposure to an established neurotoxin at such an early age would be expected
to disrupt this criticaldevelopment.
Itis also important to recognize that the duration of an elevated blood lead level under-
greatly
represents the duration of the toxic effects of that exposure on thebrain. Once present in the
central nervous system, lead is eliminated very slowly, with a biological half lifein the brain of
about two years. Thus, even when lead levels in the blood decrease to seemingly insignificant
concentations, the lead that has previously been deposited in the brain continues to exert its
neurotoxic influence for years thereafter. Although in 1991 the CDC established 10 µg/dl as the
clinical threshold for lead poisoning, considerable research has been published since that time
"sub-clinical"
which indicates thatchildren with elevated but levels of lead experience lower IQ,
as well as deficits in attention, langüãge, executive function, visual-motor integration, social
behavior and motor skills. In fact,there is now compelling scientific evidence that there is no
safe level of lead exposure. The CDChas recently acknowledged that lead levels less than 10 I
µg/dl are asseciated with numerous adverse health effects in children, and ithas estahM~1 a
Level"
new blood lead "Reference of 5 µg/dI as the triggerfor clinical reporting and intervention,
effectively redefining lead poisoning to this lower threshold.
In addition to her observed deficits,H s injuries are likely to have deleterious effects upon
her future social/behavioral development becane, as important skillsfailto develop, her inability
to keep up with her peers would be expected to lead to problems with self-esteem and impaired
social development. This problem is often compounded by the factthat the areas of the brain
that underlie behavioral control and socialjudgment, and are therefore criticalto acquiring
interpersonal skills,are the same areas that are typically damaged by lead poisoning.
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I
Unforkmately bmin damageof this typeis pmment.
andsignificant recoverycannothe
expected. Indeed, the neural systemsimplicated in such cognitive domainsas working memory .
-
andexecutive Smctioning continueto develop late into the teen yena, andbehavioralindices of
dysfunctionin thesepartsof the brain typically emergeasthe demandsfor higher level cognitive
processesincreasewith age. Thus, in addition to the evidentimpact of these==:py
'±legical
impairmentsupon Helenny's cartent perfbrmanes,we canexpect to sonan increasingly greater
impactupon her perfonnanceassheprogressesto the higher gradeswhereinmore conceptually
difficult material will be encountenxL
In surmnary,basedupon considerationof I neurobehavioraland neuro-
pghelededl deficits, her medical history andthe currentreedical literature, 1 concludethat
bein damagefrom lead poisoning has significantly contdbuted to Helenny's d~==e±d
cognitive, social andbehavioralimpairments.
I certify that I personally evaluated ploying age-appropriateinstrumentsand
preceduresaswell as inforznedclinical opinion. I finther certify that the findings containedin
this report accuratelyrepreseatherlevel of F--±:dng
at the time of my assessment.t hold this
opinina and all othersiñ this report with a reasonabledegreeof psychological certainty.
Vicki u er, Ph.D.
Licensed sychologist
5
B
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NEUROPSYCHOLOGICAL EVALUATION REPORT
Patient:
Date of Birth:
H M
2006
Date of Evaluation: 01/13/2019
Age: 12 years, 5 months
Test Site: Brooklyn, NY
The purpose of this evaluation was to determine the basic motor, cognitive and behavioral
performance resources of H I and theirimpact on her educability and abilityto
excente activitiesof daily living In addition, a determhadon was made of the influence of
neuropsychologically significant factors in Helenny's history upon her current level of
functioning HM was accompanied to the evaluation by her mother, Ms. Solenny Sanchez,
who provided information conceming her background and current functioning. The following
medical, educational and administrative records were also reviewed:
1. New York Presbyterian Hospital - Prenatal and Labor Records
/Delivery
2. New York Presbyterian Hospital - Neonatal and Pediatric Medical Records
3. Physicians Regional Medical - Pediatric Medical Records
Group
4. East Naples Medical Center - Pediatric Medical Records
5. David Lawrence Center - Psychiatric Medical Records
6. New York State Department of Health - WIC Medical Referral Forms
7. New York Department of Preservation - Lead Inspection Records
City Housing
8. Williamsbridge NAACP Care Center - School and Health Records
Day
9. Collier Public Schools - School Performance and IEP Records
County
History
I y was born at New York Presbyterian Hospital in New York City. Her mother received
regular prenatal care, and denies use of Menhn1 or recreational drugs. Prenatal medical
any
records indicate thatshe was seen in the ER for a falltwo months prior to 'sbirth, but no
injury to eithermother or fetus was identified at thattime. She was noted to be positive for
Group B Streptococcus at the time of delivery.
H 's medical records describe a normal spontaneous vaginal delivery at fullterm. Her birth
weight was 6 lbs 8 oz (2963 grams), and she received Apgar scores of 9 and 9 atone and five
minutes, respectively. At birth,Helenny was active and alert,with spontaneous respiration and
good cry,muscle tone and reflexes. No preñatal or peripartum complications, nor any
indications of fetal or neonatal distress, were reported. HMwas admitted to the regular
nursery for routine newborn care,and she was discharged with her mother aftertwo days.
H has a history of occasional upper respiratory and ear infections,and asthma. When she
was six years old,she developed obstructive sleep apnea, which womened over the following
year, prompting the surgical removal of her adenoids and resceuen of her inferiorturbinates.
Otherwise, except for lead poisoning as described below, I has experienced good health,
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with no serious Wesses or injuries, and with age appropriate physical growth and development.
H as diagñósed with lead pokening when she was one year old, at which time her blood
lead level was found to be 1L1 µg/dL No subsequent blood lead testreports were provided,
although her pediatric medical records refer to her having had a blood lead level as high as 13
µg/dL Because Hansnuns blood lead level had not been monitored priorto her initialelevated
reading, and no follow-up blood test resultsare available, the actual onset and duration of her
lead poisoning, and themagnitude of her body's lead burden, are not Imown. Itshould be noted
that at the time of her elevated blood lead reading, the NYC Department of Health identified
multiple lead paint violations in her family's residence.
H 'sdocumented history of blood lead testresults isshown in Table 1.
Table 1. Blood-Lead Level
07/20/07 11.1
H began attending the Williamsbridge NAACP Day Care Center when she was three years
old, and she isreported to have performed at an age-appropriate level at thattime.
HM moved from New York City to Naples, Florida when she was six years old, where she
atten
Preview
FILED: NEW YORK COUNTY CLERK 11/12/2019 11:28 AM INDEX NO. 150316/2017 NYSCEF DOC. NO. 23 RECEIVED NYSCEF: 11/12/2019 NEUROPSYCHOLOGICAL EVALUATION REPORT Patient: H D Date of Birth: M006 Date of Evaluation: 10/4/2015 Age: 9 years, 2 months Test Site: Brooklyn, NY The purpose of this evaluation was to determine the basic motor, cognitive and behavioral performance resources of H4gg IWand their impact on her educability and abilityto execute activities of daily living. In addition, a determination was made of the influence of neuropsychologically significant factors in H 'shistory upon her current level of functioning. H was accompanied to the evaluation by her mother, Solenny Sanchez, who provided information concerning her background and current functioning. The following medical, educational and administrative records were also reviewed: 1. New York Presbyterian Hospital - Prenatal and Labor Records /Delivery 2. New York Presbyterian Hospital - Neonatal and Pediatric Medical Records 3. Physicians Regional Medical - Pediatric Medical Records Group 4. East Naples Medical Center - Pediatric Medical Records 5. David Lawrence Center - Psychiatric Medical Records 6. New York State Department of Health - WIC Medical Referral Forms 7. New York Department of Preservation - Lead Inspection Records City Housing 8. Williamsbridge NAACP Care Center - School and Health Records Day 9. Collier Public Schools - School Performance and IEP Records County History j Ih was born at New York Presbyterian Hospital in New York City. Her mother received regular prenatal care, and denies any use of alcohol or drugs. illicit Prenatal medical records indicate that she was seen in the ER for a falltwo months prior to Hemands birth, but no injury to mother or fetus was identified at that time. She was noted to be positive for B Group Streptococcus at the time of delively. H medical records describe a normal spontañecus vaginal delivery at fullterm. Her birth weight was 6 lbs 8 oz (2963 grams), and she received Apgar scores of 9 and 9 atone and five minutes, respectively. At birth,Helenny was active and alert,with spontañcous respiration and good cry, muscle tone and reflexes, No prenatal or peripartum complications, nor any indications of fetalor neonatal distress, were reported. H was admitted to the regular nursery for routine newborn care, and was discharged with her mother after two days. HM has a history of occasional upper respiratory and ear infections,and asthma. When she was six years old, she developed obstructive sleep apnea, which worsened over the following year, prompting the surgical removal of her adenoids and resection of her inferiorturbinates. Otherwise, except for lead poisening as described below, I has experienced good health with no serious illnesses or injuries, and with age appropriate physical growth and dcyclopment. Page 1 of 9 1 of 19 FILED: NEW YORK COUNTY CLERK 11/12/2019 11:28 AM INDEX NO. 150316/2017 NYSCEF DOC. NO. 23 RECEIVED NYSCEF: 11/12/2019 RE: 1 H H was diagnosed with CDC Class IIa lead poisoning when she was one year old, at which time her blood.1ead level was found to be lil µg/dl. No subsequent blood lead test reports were provided, although her pediatric medical records refer to her having had a blood lead level as high as 13 µg/dl. Because H s blood lead levelhad not been monitored prior to her initial elevated reading, and no follow-up blood test resultsare available, the actual onset and duration of her lead poisoning, and the magnitudc ofher body's lead burden, are not known. Itshould be noted that at the time of her elevated blood lead reading, the NYC Department of Health identified multiple lead paint violations in her family's residence. H dopumented history of blood lead testresults isshown in Table 1. Table 1. Blood-Lead Level Date IIµg/dl 07/20/07 11 1 H began attending the Williamsbridge NAACP Day Care Center when she was three years old, and isreported to have performed at an age-appropriate level at that time. IM moved from New York City to Naples, Florida when she was six yeañ old, where she attended firstgrade at Big Cypress elementary school. She was described by her teachers as a sweet girl who coñtributed to class discussions, but who was easily distracted and had difficulty listening and following directions. She also exhibited difficultbehaviors at home, where she was reported to be very active,unable to sitstill,and overly aggressive. She did not follow directions and often fought with her siblings. She was diagnosed with ADHD - Combined Subtype (with inattention, hyperactivity and impulsivity) as well as with Oppositional Defiant Disorder. She was prescribed -initially Metadate, and has subsequently taken Focalin, Vyyanse, Concerta and [ hituniv. H was observed to have difficulty speaking clearly in class. For example, she would repeat phrases and sentences, and became embarrassed when she was unable toget the words out. She was administered a speech and language evaluation, which found sound repetitions, as well as many word and phrase repetitions and circumlocutions, and ratedher stuttering as Moderate to Severe according to the Stuttering Severity Instrument-4. She was diagnosed with Expressive Language Disorder, and entered second grade with an Individualized Education Program (IEP) with the disability classification of Speech Impaired. H participated in general education academics and activities,but received small group speech therapy 30 minutes weekly to improve her fluency. From October 2013 to November 2014, H eceived psychological services from the David Lawrence Center foranxiety and ADHD. Her most recent therapy notes refer to such behaviors as excessive talking, constantly moving and fidgeting, being forgetful, being easily distracted, and having difficulty completing tasks. Page 2 of 9 2 of 19 FILED: NEW YORK COUNTY CLERK 11/12/2019 11:28 AM INDEX NO. 150316/2017 NYSCEF DOC. NO. 23 RECEIVED NYSCEF: 11/12/2019 RE: 1 He This ispresumed to represent H 'sfirstñearapsychological evaluation. Present Evaluation H presented as a well dressed child who was polite and friendly, and appeared well oriented to time and place. A good rapport was echhliaed with the examiner, and her mother stated that her behavior during the evaluation was typical for her. At the time of testing, was taking Concerta and Vyvanse, =dinins enabling her to contro1her attention and impüisive responding. Accordingly, the present evaluation should be taken as a valid reflection of H s cognitive and neuropsychological functioning. Intelligence Assessment The Wide Range Intelligence Test (WRIT) was ah·idstered and H attained a Full Scale IQ (776 of 111 percentile) which isin the high average range, a Verbal Comprehension Composite . . (68* (79* Score of 107 percentile), in the average range, and a Visual Score of 112 percentile), in the high average range. Table 2. WRIT Competite Score Summary Scale empsits Score Percentile Verbal 107 68 Visual 112 79 General 111 77 Table 3. WRIT Subtest Summary Verbal Subtests Standard Score Perceñtile Verbal Analogies 96 34 Vocabulary 117 87 Visual Subtests Standard Score Percentile Matrices 119 90 Diamonds 101 53 Page 3 of 9 3 of 19 FILED: NEW YORK COUNTY CLERK 11/12/2019 11:28 AM INDEX NO. 150316/2017 NYSCEF DOC. NO. 23 RECEIVED NYSCEF: 11/12/2019 Neuropsychological Assessment A. Language H s verbal fluency was assessed using the Controlled Oral Word Association Test from the Multilingual Aphasia Examination (MAE), and she achieved a score in the average range - 70* (Controlled One %rd Association Test percentile). H naming ability was asscsscd using the Visual Naming subtest from the MAE, which fellwithin the borderline range (Visual - < 4* Naming percentile). H as administered the Comprehension of Instructions subtest from the NEP SY-IL This testrequires one toperform specific tasks according to verbal instructions, thus a Mg her comprehensics of spoken language. Helenny's perferreañce on the Comprchension of - 25* Instructions testwas in the average range (Comprehension of Instructions percentile). H s abilityto defme words was assessed using the Vocabulary subtest from the WRIT, which indicated thather knowledge of word meanings was in the high average range - 87* (Vocabulary percentile). These results indicate that H is exhibiting deficits in her naming abilityand inher ability to comprehend instructions. B. Sensory-Motor Functioning H as administered three accacements to evaluate her sensory-motor functioning: the Purdue Pegboard test, the Rey Osterrieth Complex Figure Test, and the Arrows test. The Purdue Pegboard test isused to assess dexterity and visacmotor abilities by requiring individuals to quickly fitpegs into holes in a board. H performance on the Padue Pegboard indicated thathand and finger movements with her dominant right hand were within - 49* the average range (Right Hand percentile), and movcmcñts with her lefthand were within the average range (Left Hand - 47* percentile). H use ofboth hands together in simple - 46* symmetrical movements was within the average range (Both Hands percentile), and her - 35* ability to assemble multi-component objects was within the average range (Assembly percentile). H 'svisuospatial constructional abilitywas assessed using the Rey Osterrieth Complex Figure Test, which requires one tocopy a complicated geometric design. Helenny's abilityto - > 165 reproduce thiscomplex design was within the average range (Osterrieth: Copy percentile). H 'svisuospatial was also assecsed the Arrows subtest from the NEPSY- processing using which requires one tolook at an of arrows arranged around a targetand toindicam which II, array arrows point to the center of the target. H performance on this testwas in the high Page 4 of 9 4 of 19 FILED: NEW YORK COUNTY CLERK 11/12/2019 11:28 AM INDEX NO. 150316/2017 NYSCEF DOC. NO. 23 RECEIVED NYSCEF: 11/12/2019 RE: 1 , - 846 average range (Arrows percentile), These results indicate that I is notdisplaying deficitswithin her sensory motor functioning at thistime. C. Learning and Memory Storage of verbal, auditory and visualinformation is mediated in different ways and, to some extent, by different parts of the brain. Accordingly, to testmemory functioning itis necessary to use differenttests that are sensitive to specific components of verbal and non-verbal memory, and which may reflect the functioning of different brain systems. The Wide Range Assessment of and - Second Edition vias used to assess for Memory Learning (WRAML-2) memory narration, memory for words, memory for design and memory for pictures. The recall trialof the Rey Osterrieth Complex Figure Test and Recognition Trial was used to assess visuospatial memory and recognition. H was admin_istered the Story Memory subtests from the WRAML 2 to assess her immediate, delayed and recogniticñ memory for narration. H performance on this test indicated that her immediate recall fornarration was in the average range (StoryMemory: Immediate Recall - 50th his delaycd recall for narration was in the average range percentile), -50th (Story Memoq: Delayed Recall percentile) and his recognition memory for narration was - 50* within the average range (Story Memory: Recognition percentile). j H was âdministered the Verbal Learning subtest from the WRAML-2, which assessed her immediate, delayed and recognition memory for listsof words. HWs performance on this test indicated that her immediate recallfor words was in the intellectually deficient range (Verbal Learning: Immediate Recall - 2"d her delayed recall for listsof words was.in the percentile), - 256 average range (Verbal Learning Memory: Delayed Recall percentile) and her recognition - 5* memory for listsof words was within the borderline range (Verbal Learning: Recognition percentile). H was administered the Design Memory subtest from the WRAML-2, which assessed her imme lateand recognition memory for abstract designs. H performance on this test indicated thather immediate recall forabstract designs was in the low average range (Design - 16* Memory: Immediate Recall percentile) and her recognition memory for abstract designs was within the high average range (Design Memory: Recognition - 75'h phl H as administered the Picture Memory subtest from the WRAML-2, which assessed her immediate and recognition memory for pictures. H performance on this test indicated that her immediate recall for pictures was in the average range (Picture Memory: Immediate - 50* Recall percentile) and her recognition memory for pictures was within the average range (Picture Memory: Recognition - 25* percentile). Visuospatial memory was also assessed by avambing the recalland recognition trialsof the Rey Osterrieth Complex Figure Test. H irarnediata fme recall forvisuospatial material was Page 5 of 9 5 of 19 FILED: NEW YORK COUNTY CLERK 11/12/2019 11:28 AM INDEX NO. 150316/2017 NYSCEF DOC. NO. 23 RECEIVED NYSCEF: 11/12/2019 RE: M H in the high average range (Osterrieth: hnmediate Free Recall - 84th percentM He d d h recallfor visuospatial material fellwithin the superior range (Osterrieth: Delayed Free Recall - 92nd percentile), and her recognition for visuospatial material fellwithin the average range - 66* (Osterrieth: Recognition Memory percentile). These results indicate that H is exhibiting deficits for her memory for words, in her recognition of pictures and in her immediate memory for design. D. Attention Conners' A detailed analysis of H visual attentional functioning was performed using the Continuous Perfonnance Test-H (CPT-II). The CPT-H requires one todetect and respond to the visual presentation of certain letterson a computer screen. By varying the duration of exposure, as well as the pattern and rate of letterpresentanon the CPT-H allows a close examination of the multiple processes that together underlie one's visual attention. Itmust be remembered that H as taldng Concerta and Vyvanse at the time of the administration to help her control her attention and impulsive responding. H pattern of perfonnance of the CPT-H included scores that ranged from good to average - 696 -386 - 56* (% Omissions percentile; % Commissions percentile; Hit RT percentile; - 24* Response Style - 59 Hit RT SE - 34* Detectability percentile; percentile; percentile; - 28* Perseverations - 29* Hit RT Block Change - 91" Variability percentile; percentile; - 88* -54* percentile; Hit SE Block Change percentile; Hit RT ISI Change percentile; and Hit SE - 61" ISI Change percentile). H s performance profile on the CPT-H was considered to be reflective of a nonclinical profile with a 59% confidence interval. Itshould be noted that the CPT-II performs a self-diagnostic check of the accuracy of the timing of each administration, There was no indication of difficultiesor respondent non- any timing compliance, and therefore the current administration should be considered valid. E. Executive Functioning Executive fimctions of the brain include higher level cognitive processes that allow adaptive j thought to be used to solve novel problems and toplan adaptive and goal directed behavior. Among the more salient processes subsumed under the rubric of executive functioning are planning, concept formation, and cognitive flexibility. The Mazes subtest from the WISC-III, and the Tower of London (TOL) were used to assess H s nbnning ability and impulse control. In order to complete the Mazes test, H had to successfully indicate the route an individual would take to exita maze without tuming into blind and her performance on the Mazes task was within the average range (Mazes - any alleys, 50* percentile). In order to correctly complete the Tower of London one must reproduce a pattern composed of colored ballsplaced on pegs, using a second psgboard and set of colored Page 6 of 9 6 of 19 FILED: NEW YORK COUNTY CLERK 11/12/2019 11:28 AM INDEX NO. 150316/2017 NYSCEF DOC. NO. 23 RECEIVED NYSCEF: 11/12/2019 balls. Several scores are derived from one's perforraancc on the TOL, including the number of correct completions, the totalnumber of moves taken, the number of rule violations, and the time taken to complete the task. IM's performance on the TOL yielded mixed results. Her total - 62d number of correct completions was within the average range (TOL: Number Correct percentile), and the number of moves needed to complete the entire test fellwithin the high - 81't average range (TOL: Total Move Score percentile). However, H s number of rule vicktions, which indicates impulsive and perseverative responding, was within the bordctliñe - 3d range (TOL: Total Rule Violadon percentile), and the time ittook her to complete the task -69* was with the average range (TOL: Total Èxecution Time percentile). The Verbal Analogies subtest of the WRIT requires one tosupply an appropriate word in an orally presented analogy, thereby demonstrating competency in verbal concept formation. H verbal concept formation skills were shown to be in the average range (Verbal Analogies - 396 percentile). H s abilitiesto easily change from one format to another (set shifting),to inhibit a prepotent response (inhibitory control), and toefficiently scan a visual fleld, were assessed through her performance on the Comprehensive Trail-Making Test (CTMT). In order to completc the CTMT, one simply has to connect numbers, words and numbers, or numbers and letters. Cornpetcacy in each of these areas ismeasured by the time required to perfonn the (CTMT- 13* various tasks. H performance on the CTMT was in the low average range percentile), which reflects her difficulty nging sets, controlling her impulses, and efficiently scanning the visual field. These results indim» that Hammeshas visual speed deficits (as reflected in the length processing of time ittook her to complete the CTMT), and that she has difficultycontrolling impulsive responding, even while on Concerta and Vyyanse, as seen in her rule violations she mmmitted on the TOL. Summary H presented with an IQ inthe high average range. However, in order for I to perform well, she has tobe taking Concerta and Vyyanse, medicines designed to help the individual control her attention and impulsive responding. Neuropsychological and neurofunctional testing of Helenny revealed impaiñnsts in naming abilityand inher abilityto comprehend instructions. Additionally, testing revealed thatHelenny displays deficits in her scraory forwords, recognition of pictures and inher immediate memory for design. She displayed visual processing speed deficits (as reflected in the length of time ittook her to complete the CTMT), and in difficultycontrolling impulsive responding as seen in her rule violations on the TOL. . Page 7 of 9 7 of 19 FILED: NEW YORK COUNTY CLERK 11/12/2019 11:28 AM INDEX NO. 150316/2017 NYSCEF DOC. NO. 23 RECEIVED NYSCEF: 11/12/2019 Interpretation HM's observed deficiencies, in association with expected to greater than expected functioning in other neurocognitive domiñs and interpreted within the context of her history, are indicative of pediatric brain injury. Furthermore, such impairments have been described as sequella of early childhood exposure to lead. Lead is a latown environmental toxin whose effects on the developing nervous system have been well documented, and often lead to such cognitive and behavioral consequences as language disorders, hyperactivity, attention deficitsand mental retardation. Elevated lead levels in young children have also been associated with poor performance on standardized assessments of emotional regulation and orientation-engagersent. A review of I s available medical history indicates that she experienced clinically significant lead poisoning, and reveals no other factors or lifeevents thatwould be expected to exert such a negative impact on her neuropsychological functioning. The severity of brain damage caused by lead poisoning isrelated to a child's age at the time of exposure, the duration of her exposure, and the magnitude of the body's lead burden. H was shown to have a significantly elevated blood lead concentration as early as one yearof age which places her lead exposure well within the period of nervous system development during which many areas of the human brain undergo a complex series of anatomical and functional transfonnations. Exposure to an established neurotoxin at such an early age would be expected to disrupt this criticaldevelopment. Itis also important to recognize that the duration of an elevated blood lead level under- greatly represents the duration of the toxic effects of that exposure on thebrain. Once present in the central nervous system, lead is eliminated very slowly, with a biological half lifein the brain of about two years. Thus, even when lead levels in the blood decrease to seemingly insignificant concentations, the lead that has previously been deposited in the brain continues to exert its neurotoxic influence for years thereafter. Although in 1991 the CDC established 10 µg/dl as the clinical threshold for lead poisoning, considerable research has been published since that time "sub-clinical" which indicates thatchildren with elevated but levels of lead experience lower IQ, as well as deficits in attention, langüãge, executive function, visual-motor integration, social behavior and motor skills. In fact,there is now compelling scientific evidence that there is no safe level of lead exposure. The CDChas recently acknowledged that lead levels less than 10 I µg/dl are asseciated with numerous adverse health effects in children, and ithas estahM~1 a Level" new blood lead "Reference of 5 µg/dI as the triggerfor clinical reporting and intervention, effectively redefining lead poisoning to this lower threshold. In addition to her observed deficits,H s injuries are likely to have deleterious effects upon her future social/behavioral development becane, as important skillsfailto develop, her inability to keep up with her peers would be expected to lead to problems with self-esteem and impaired social development. This problem is often compounded by the factthat the areas of the brain that underlie behavioral control and socialjudgment, and are therefore criticalto acquiring interpersonal skills,are the same areas that are typically damaged by lead poisoning. Page 8 of 9 8 of 19 FILED: NEW YORK COUNTY CLERK 11/12/2019 11:28 AM INDEX NO. 150316/2017 NYSCEF DOC. NO. 23 RECEIVED NYSCEF: 11/12/2019 I Unforkmately bmin damageof this typeis pmment. andsignificant recoverycannothe expected. Indeed, the neural systemsimplicated in such cognitive domainsas working memory . - andexecutive Smctioning continueto develop late into the teen yena, andbehavioralindices of dysfunctionin thesepartsof the brain typically emergeasthe demandsfor higher level cognitive processesincreasewith age. Thus, in addition to the evidentimpact of these==:py '±legical impairmentsupon Helenny's cartent perfbrmanes,we canexpect to sonan increasingly greater impactupon her perfonnanceassheprogressesto the higher gradeswhereinmore conceptually difficult material will be encountenxL In surmnary,basedupon considerationof I neurobehavioraland neuro- pghelededl deficits, her medical history andthe currentreedical literature, 1 concludethat bein damagefrom lead poisoning has significantly contdbuted to Helenny's d~==e±d cognitive, social andbehavioralimpairments. I certify that I personally evaluated ploying age-appropriateinstrumentsand preceduresaswell as inforznedclinical opinion. I finther certify that the findings containedin this report accuratelyrepreseatherlevel of F--±:dng at the time of my assessment.t hold this opinina and all othersiñ this report with a reasonabledegreeof psychological certainty. Vicki u er, Ph.D. Licensed sychologist 5 B Page9 of 9 9 of 19 FILED: NEW YORK COUNTY CLERK 11/12/2019 11:28 AM INDEX NO. 150316/2017 NYSCEF DOC. NO. 23 RECEIVED NYSCEF: 11/12/2019 NEUROPSYCHOLOGICAL EVALUATION REPORT Patient: Date of Birth: H M 2006 Date of Evaluation: 01/13/2019 Age: 12 years, 5 months Test Site: Brooklyn, NY The purpose of this evaluation was to determine the basic motor, cognitive and behavioral performance resources of H I and theirimpact on her educability and abilityto excente activitiesof daily living In addition, a determhadon was made of the influence of neuropsychologically significant factors in Helenny's history upon her current level of functioning HM was accompanied to the evaluation by her mother, Ms. Solenny Sanchez, who provided information conceming her background and current functioning. The following medical, educational and administrative records were also reviewed: 1. New York Presbyterian Hospital - Prenatal and Labor Records /Delivery 2. New York Presbyterian Hospital - Neonatal and Pediatric Medical Records 3. Physicians Regional Medical - Pediatric Medical Records Group 4. East Naples Medical Center - Pediatric Medical Records 5. David Lawrence Center - Psychiatric Medical Records 6. New York State Department of Health - WIC Medical Referral Forms 7. New York Department of Preservation - Lead Inspection Records City Housing 8. Williamsbridge NAACP Care Center - School and Health Records Day 9. Collier Public Schools - School Performance and IEP Records County History I y was born at New York Presbyterian Hospital in New York City. Her mother received regular prenatal care, and denies use of Menhn1 or recreational drugs. Prenatal medical any records indicate thatshe was seen in the ER for a falltwo months prior to 'sbirth, but no injury to eithermother or fetus was identified at thattime. She was noted to be positive for Group B Streptococcus at the time of delivery. H 's medical records describe a normal spontaneous vaginal delivery at fullterm. Her birth weight was 6 lbs 8 oz (2963 grams), and she received Apgar scores of 9 and 9 atone and five minutes, respectively. At birth,Helenny was active and alert,with spontaneous respiration and good cry,muscle tone and reflexes. No preñatal or peripartum complications, nor any indications of fetal or neonatal distress, were reported. HMwas admitted to the regular nursery for routine newborn care,and she was discharged with her mother aftertwo days. H has a history of occasional upper respiratory and ear infections,and asthma. When she was six years old,she developed obstructive sleep apnea, which womened over the following year, prompting the surgical removal of her adenoids and resceuen of her inferiorturbinates. Otherwise, except for lead poisoning as described below, I has experienced good health, Page 1 of 10 10 of 19 FILED: NEW YORK COUNTY CLERK 11/12/2019 11:28 AM INDEX NO. 150316/2017 NYSCEF DOC. NO. 23 RECEIVED NYSCEF: 11/12/2019 with no serious Wesses or injuries, and with age appropriate physical growth and development. H as diagñósed with lead pokening when she was one year old, at which time her blood lead level was found to be 1L1 µg/dL No subsequent blood lead testreports were provided, although her pediatric medical records refer to her having had a blood lead level as high as 13 µg/dL Because Hansnuns blood lead level had not been monitored priorto her initialelevated reading, and no follow-up blood test resultsare available, the actual onset and duration of her lead poisoning, and themagnitude of her body's lead burden, are not Imown. Itshould be noted that at the time of her elevated blood lead reading, the NYC Department of Health identified multiple lead paint violations in her family's residence. H 'sdocumented history of blood lead testresults isshown in Table 1. Table 1. Blood-Lead Level 07/20/07 11.1 H began attending the Williamsbridge NAACP Day Care Center when she was three years old, and she isreported to have performed at an age-appropriate level at thattime. HM moved from New York City to Naples, Florida when she was six years old, where she atten