Preview
FILED: NEW YORK COUNTY CLERK 11/12/2019 11:28 AM INDEX NO. 150316/2017
NYSCEF DOC. NO. 24 RECEIVED NYSCEF: 11/12/2019
NEUROPSYCHOLOGICAL EVALUATION REPORT
Patient: LM D
D ate of Birth: W2005
Date of Evaluation: 01/13/2019
Age: 13 years, 7 months
Test Site: Brooklyn, NY
The purpose of thisevaluation was to determine the basic motor, cognitive and behavioral
performance resources ofIM D and their impact on his edücability and ability to execute
activities of daily living. In addition, a detennination was made of the influence of
neuropsychologically significant factors in IWs history upon his current level of fimenosg.
Lmwas accompanied to the evaluation by his mother, Ms. Solenny Sanchez, who provided
information concerning his background and current functioning. The following medical,
educational and administrative records were also reviewed:
1. New York Presbyterian Hospital - Pediatric Medical Records
2. East Naples Medical Center - Pediatric Medical Records
3. Marion E. Fether Medicine - Pediatric Medical Records
Family
4. David Lawrence Center - Psychiatric Medical Records
5. New York Department of Preservation - Lead Inspection Records
City Housing
6. New York Department of Education -School Admission Records
City
7. Collier Public Schools - Achievement Test Results and 504 Records
County Eligibility
History
No or neonatal status records were provided for review. based upon
Iw
labor/dclivery However,
information contained within the available pediatric medical records, itappears that
born in New York City at fullterm via a normal vaginal delivery, following an uneventful
pregnancy with no perinatal or neonatal complications.
Except for occasional upper respiratory infections,being overweight, and experiencing lead
poisoning as described below, I exhibited generally good health throughout his
childhood. His pediatric records indicate thathe developed typhoid fever while the
visiting
Dominican Republic, and hisonly hospitalization occurred when he underwent nasal surgery in
. 2010 to remove a partialbone from his nasal cavity that was apnea. renuja
causing sleep
exhibited age appropriate developmental milestones, although he had difficulty pronouncing
words clearly and received speech therapy to address his disfluency.
L was exposed to lead by the time he was 27 months old, as evidenced by a blood lead level
of 7.8 µg/dl. This represents significant lead poisoning, as blood lead levels as low as 5µg/dl
have been acknowledged by the CDC to be neurotoxic to children of this age, He was not
retested for over two years, by which time his blood lead concentration had fallento less than 1
µg/dl. Itshould be noted that at thetime of his elevated blood lead reading, the NYC
Department of Health identified multiple lead paint violations in Lenny's residence.
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RE: DnpMOf L
Bease I 'sblood lead level had not been monitored for a year prior to his clevated reading,
nor for two years thereafter,the actual onset and duration of his lead poisoning, and the
magnitude of his body's lead burden, are not known and areprobably underestimated by the
available data. I s decamcated history of blood lead test resultsis shown in Table 1.
Table 1. Blood-Lead Levels
03/10/06 0
06/26/06 2
07/20/07 7.8
09/11/09 < 1
IW moved from New York City to Naples, Florida when he was seven years old, where he
attended second grade at Big Cypress elementary school. He was administered the abbreviated
606
Stanford Achievement Test, on which he scored at the perceñtile in reading comprehension.
He was referred for evaluation by his teachers, due to problem behaviors in the classroom that
½dd a limited attention span, difficultymai=+=4ning focus, forgetfulness and aggression. In
addition, he often fought with other students who teased and bullied him, and called him fatand
dumb.
In May 2013, a psychiatric evaluation was conducted to address I persistent and chronic
aggressive outbursts, poor focus and concentration, inattention, low frustration tolerance,
impulsivity, forgetfulness, and temper tantrums. At that time he was diagnosed with Depressive
Disorder - NOS and with Attention Disorder - Eattentive subtype. He was
Deficit/Hyperactivity
initiallyprescribed Focalin, but since that time he has also taken Vyvanse and Adderall.
When he was in third grade, I begin working under a Section 504 Student Accommodation
Plan, which allowed him to have extended time on tasks and tests in order to deal with his
anxiety and frustration in timed situatioñs. Although his behavior improved somewhat in the
third grade, I continued to have problems at home, which included defiance, impulsivity,
and aggression toward his brother.
IW s fourth grade school records indicate that he continued to have difficulty focusing on
tasks, difficulty remembering what he learned, and poor frustrationtoicrañce. At home, he
continued to intimidate his siblings, and exhibit an unhappy mood with negative self-statements.
I evaluated I three years ago, when he was 10;4 years old, at which time his scores on the
Wide Range Intelligence Test indicated a Full-Scale IQ of 115, which was in the high average
range, a Verbal Comprehension Composite Score of 123, in the superior range, and a Visual
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RE: M LW
Score of 102, in the average range. Neuropsychological and neurofanctional testing revealed
deficits in his verbal fluency skills,hand and fingermovementa, immediate memory for design
and immahte and delayed memory for visunspatial material. Evidence of inattention, visual
plùüessing speed deficitsand impulsive behavior were also observed.
No additional medical or school records, nor reports of any subsequent evaluations, for the
period since my previous evaluation were provided for review.
Present Evaluation
LW presented as a well dressed adolescent who was polite and friendly,and appeared well
oriented to time and place. A good rapport was established with the examiner, and his mother
stated that his behavior during the evaluation was typical for him. Accordingly, the present
evaluation should be taken as a valid reflection of L cognitive and neuropsychological
functioning.
Intelligence Assessment
The Wechsler Intelligence Scale for Children -Fifth Edition (WISC-V) was ad ±rd, and
14 attained a Full Scale IQ of 102
(555
percentile)
(58*
which is inthe average range, a Verbal
Comprch==ian Composite Score of 103 in the average a Visual Spatial
percentile) range,
(876
Composite Score of 117 percentile) in the high average range, a Fluid Reasoning
(73"'
Composite Score of 109 percentile) in the average range, a Working Memory Composite
(27*
Score of 91 percentile) in the average range and a Processing Speed Composite score of 98
(45$
perceñtile) in the average range. Lenny's Composite Score -=7 ispresented in Table
2, and his subtest summaries and percentiles are presented in Table 3.
Table 2. WISC-V Composite Score Summary
Scale Composite Score . Percentile_
Verbal Comprehension 103 58
Visual Spatial 107 87
Fluid Reasoning 109 73
Working Memory 91 27
Processing Speed 98 45
Full Scale 102 55
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RE: 16ms M
Table 3. WISC-V Subtest S-==s y
Verbal Comprehensien Scaled Score Percentile
Similarities 11 63
Vocabulary 10 50
Visual Spatial Scaled Score Percentile
Block Design 12 75
Fluid Reasoning Scaled Score Percentile
Matrix Reasaning 9 37
Figure Weights
Working Memory Sealed Score Percentile
Digit Span
Picture Span 8 25
Processing Speed Scaled Score Percentile
Coding 7 16
Symbol Search 12
Neuropsychological Assessment
A. Language
L verbal fluency was assessed using the Controlled Oral Word Association Test from the
Multilingual Aphasia Examination (MAE), and he achicycd a score in the high avciage range
(Controlled One Word Association Test - 85d'percentile). L was assessed
naming ability
using the Visual Naming subtest from the MAE, which fellwithin the low average range (Visual
-24d'
Naming percentile).
LWwas achhed the Comprehension of Instnerinna subtest from the NEPSY-IL This
testrequires one toperform specific tasks according to verbal instractiõñs, thus assessing his
comprehension of spoken language. L performance on the Compreheiision of Insti-Gctions
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- 25*
testwas in the average range (Comprehension of Instructions percentile).
IW's ability to define words was assessed using the Vocabulary subtest from the WISC V,
which indicated that his knowledge of word meanings was in the average range -
(Vocabulary
50*
percentile).
These results indicate that LWis exhibiting deficitsin his mming abilityand inhis ability to
comprehend instmctions. He isdisplayed relative strengths in his ability to access vocabü1ary
words from his mental lexicon and inhis ability to define vocabulary words.
B. Sensory-Motor Functioning
LW was admidstered three assessmento to evaluate his sensory-motor functioning: the Purdue
Pegboard test,the Rey Osterrieth Complex Figure Test, and the Arrows test.
The Purdue Pegboard testis used to assess dexterity and visuomotor abilitiesby requiring
individuals to quickly fitpegs into holes in a board. L performance on the Purdue
Pegboard indicated that hand and finger mavcments with his dominant righthand were within
-455
the average range (Right Hand percentile), and movements with his lefthand were within
- 23"I
the low average range (LeftHand percentile). L use of both hands together in simple
- 32ªd
symmetrical movements was within the average range (Both Hands percentile), and his
ability toasserable multi-component objects was within the intellectually deficient range
- 2"d percentile).
(Assembly
LWs visuospatial constr uctional ability was assessed using the Rey Osterrieth Complex
Figure Test, which requires one to copy a complicated geometric design. Lenny's ability to
- > 16*
reproduce this complex design was within the average range (Osterrieth: Copy
percentile).
L visuospatial was also assessed the Arrows subtest from the -
piecessing using NEPSY-II,
which requires one tolook at an arrayof arrows arranged around a target and to indicate which
arrows point to the center of the target. Igs performance on this test was in the average
range (Arrows - 25 percentile).
These results indicate that IW is displaying deficitsin his hand and finger movements and in
his visuospatial processing abilities.
C. Learning and Memory
Storage of verbal, auditory and visual information ismcdiated in different ways and, to some
extent, by different parts of the brain. Accordingly, to testmemory functioning itis necessary to
use differenttests thatare 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 was used to assess for .
Memory Learning (WRAML-2) memory
narration, memory forwords, memory for design and memory for pictures. immsliate working
memory was assessed using two subtests of the WISC-V, the Digit Span and Picture Span tests.
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RE: DS,
The recall trialof the Rey Osterrieth Complex Figure Test and Recognition Trialwas used to
assess visuospatial memory and recognition.
LMwas administered the Story Memory subtests from the WRAML 2 to assess his immediate,
delayed and recognition memory for narration. LWs performance on this test indicated that
his immediate recall for narration was in the average range Memory: hnmediate Recall -
(Story
63d
percentile), hisdelayed recall for narration was in the high average range (Story Memory:
- 75*
Delayed Recall percentile) and his recognition memory for narration was within the
-50S
average range (Story Memory: Recognition percentile).
L was administered the Verbal Learning subtest from the WRAMI 2, which assessed his
immediate, delayed and recognition memory for listsof words. L perfonnance on this test
indicated thathis immediate recall for words was in the average range (Verbal Learning:
- 25S
Immediate Recall percentile), his delayed recall forlistsof words was inthe average range
-50*
(Verbal Learning Msmory: Delayed Recall percentile) and his recognition memory for
-16*
listsof words was within the low average range (Verbal Learñiñg: Recognition percentile).
Igwas administered the Design Memory subtest from the WRAML-2, which assessed his
immediate and recognition memory forabstract designs. L performance on this test
indicated that his immediate recall for abstract designs was in the average range (Design
- 256
Memory: Immediate Recall percentile) and his recognition memory for abstract designs
was within the average range (Design Memory: Recognition - 25* percentile).
IM was administered the Picture Memory subtest from the WRAMI,2, which assessed his
immediate and recognition memory for pictures. L performance on this testindicated that
his immediate recall for pictures was in the high average range (Picture Memory: Immediate
-84*
Recall percentile) and his recognition memory for pictures was within the low average
- 95
range (Picture Memory: Recognition percentile).
LSwas administered the Digit Span and Picture Span subtests from the WISC-V, to assess
his imm~Uate memory for number and for pictures, respectively.
375
LW s immediate memory
for numbers was in the average range (Digit Span - and hisimmediate
percentile) memory
for pictures was in the average (Picture Span - 25* percentile).
Visuospatial memory was also assessed by examining the recall and recognition trials of the Rey
Osterrieth Complex Figure Test. LW s immediate free recall
-165
for visuospatial material was in
the low average range (Osterrieth: Immediate Free Recall percentile). His delayed free
recall for visuospatial material fellwithin the deficient - borderline range
intellectually
-3d
(Osterrieth: Delayed Free Recall percentile), and his recognition for visuospatial material
- 92"d
fellwithin the superior range (Osterrieth: Recognition Memory percentile).
These results indicate that IW is exhibiting deficitsin his memory forvisuospatial material,
in his immediate and delayed recognition for wor is,in his recognition for pictures and inhis
immediate and recognition for designs, He displayed relative strength in his imm -m ate
memory
memory forpictures, in his recognition memory for visuospatial material and inhis immediate,
delayed and recognition memory for narrative material.
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RE: , L
D. Attention
a++ætinna1 Conners'
A detailed analysis of L visual fimetinnino was performed using the
Continuous Performance Test-E (CPT-E). The CPT-E 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 rateof letter presentation, the CPT-E allows a close
examination of the multiple processes thattogether underlie one's visual attention.
LARM pattern of performance of the CPT-E included scores that ranged from low to average
% Omissions - T = 52 % Commissions - T = 44 Hit RT - T= 48 - T = 50
( ; ; ;Detectability ;
RT SD - = - T = 3 8; - = RT -
Hit T 40 ; Variability Perseverations T 44 ; Hit Block Change T
= 56 and Hit RT ISI Change - T = . Lenny's performance profile on the CP T-E indicated
53)
difficulty with sustaining attention.
The Conners CP T IIIperforms a validitycheck based on thenumber of hitsand omission errors
commated, as well as a self-diagnostic check of the accuracy of the timing of each
administration. If there is an insufficient number of hitsto compute scores, and/or ifthe
omission error rate exceeds 25%, the program issues a warning reessage noting that the
administration was invalid. There was no indication of any validlty issues in this case, and the
cunent adm%tration should be considered valid.
E. Executive Functioning
Executive functions of the brain include higher levelcognitive processes that allow adaptive
thought to be used to solve novel problems and toplan adaptive and goal directed behavier.
Among the more salient processes subsumed under the mbric of executive fnnctioning are
planning, verbal concept formation, and visual spatial processing.
The Mazes subtest from the WISC-E, and theTower of London (TOL) were used to assess
Lenny's planrdng abilityand impulse control. In order to complete the Mazes test, IWhad to
successfully indicate the route an individual would take to exita maze without turning into any
- 63"I
blind alleys, and hisperformance on the Mazes task was within the average range (Mazes
percentile).
In order to correctly complete the Tower of London one must reproduce a pattern compnsed of
colored balls placed on pegs, using a second pegboard and setof colored balls. Several scores
are derived from one's performance on the TOL, including the ñümbct of correct complefiene,
the totalnumber of moves taken, the number of role violations, and the time taken to comploto
the task. LW's performance on the TOL yielded mixed results. His totalnumber of correct
completions was within the low average range (TOL: Number Correct - 7"1 and the
percentile),
number of moves needed to complctc the entire test fellwithin the average range (TOL: Total
Move Score - 50* percentile). the time ittook to complete the task was with
However, Lenny
-76*
the high average range (TOL: Total Execution Time percentile). These results show that
LM sacrificed accuracy forspeed.
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RE: Daun9, I
The Similarities subtest of the WISC requires one tosupply an appropriate word in an orally
presented analogy, thereby
aeman*atine
competency in verbal concept formation. Le
- 63"1
verbal concept formation skillswere shown to be in the average range (Similarities
percentile).
IAAAmh abilities to easily change from one format to another (set shifting),to inhibita prepotent
response (iñhibitory control), and to efficiently scan a visual field,were assessed through his
performance on the Compichcñsive Trail-Making Test (CTMT). In order to c0mplete the
CTMT, one simply has to connect numbers, words and numbers, or numbers and letters.
Competency in each of these areas is measured by the time required to perfonn the various tasks.
(CTMT- 1862
TGAIEs performance on the CTMT was in the low average range percentile),
which reflects his difficulty changing sets,controlling his impulses, and efficientlyscanning the
visual field.
These results indicate that I has visual processing speed deficits (asreflected in the length
of time it took him to complete the and in ph=ni as demon¤trated his performance
CTMT), g by
on the TOL. However he was able to complete tasks in a timely fashion, demonstrated
compctcñcy in verbal concept formation and inthe completion of the maze task.
Summary
IMDMpresented with an IQ inthe average range. Neuropsychological and
neurofhnctional testing of Is DEevealed strengths in the areas of accessing vocabulary
words from his mental lexicon and defining vocabulary words. Additionally he displayed
strengths in his immediate memory for pictures, in his recognition memory for visuospatial
material and inhis immediate, delayed and recognition memory for narrative material. L
was able to perform the Maze task well and displayed verbal concept formation skills.
However, this same testing revealed that IW is exhibiting deficits in his naming ability and in
his abilityto comprehend instructions. He demonstrated deficits in his hand and finger
movements and inhis visnospatial processing ability.He had difficulty sustaining attention over
time and in his visual speed deficits (as reflected inthe length of time ittook him to .
processing
complete the CTMT), and in planning as demonstrated by hisperformance on the TOL. And
finally,L exhibited deficitsin his memory for visuospatial material, in his immediate and
delayed recognition for words, in hisrecognition for pictures and in his immediate and
recognition memory fordesigns.
Interpretation
LWs observed deficiencies, in association with expected to greater than expected functioning
in other neurocognitive domains and interpreted within the context of his history, are indicative
of pediatric brain injury. Furthennore, such impairmcats have been described as sequella of
early childhood exposure to lead. Lead is a known environmental toxin whose effects on the
developing nervous system have been well documented, and oftenlead to such cognitive and
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behavioral conseqüences as language disorders, hyperactivity, attention deficits and mental
impairment. Elevated lead levels in young children have also been associated with poor
performance on standardized assessments of emotional regulation and orientation-engagement.
A review of IW available medical history indicates that he experienced clinically significant
lead poisoning, and reveals no other factors or lifeevents that would be expected to exert such a
negative impact on his neuropsychological functioning.
The severity of brain damage caused by lead poisoning isrelated to a child'sage at the time of
exposure, the duration of his exposure, and the magnitude of the body's lead burden. L was
shown to have a significantly elevated blood lead concentration as early as 27 months, which
places his lead exposure well within the period of nervous system development during which
many areas of the human brain undergo a complex seriesof anatomical and functional
transformations. Exposure to an established neumtoxin 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 the brain. 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
concentrations, the lead that has previously been deposited in the brain ecñtinues to exert its
neurotoxic influence for years thereafter.
Although 10 µg/dl was formerly considered the clinical threshold for childhood lead poisoning,
considerable research has been published which indicates that children with much lower levels of
lead experience reduced as well as deficits in executive visual-
IQ, attention,language, function,
motor integration, social behavior and motor skills. In fact,there isnow compelling scientific
evidence that there is no safe level of lead exposure. The Centers for Disease Control (CDC) has
acknowledged that lead's neurotoxicity ismuch greater than was previansly believed, and ithas
Level"
established a blood lead "Reference of 5 µg/dl as the triggerfor clinicai reporting and
intervention, effectively redefining lead poisoning to thislower threshold.
In addition to his observed deficits, ImI s injuries are likely to have deleterious effects upon .
his future social/behavioral development because, as important skillsfailto develop, his inability
to keep up with his peers would be expected to leadto problems with self-esteem and impaired
social development. This problem is often compounded by the fact thatthe areas of the brain
thatunderlie behavioral control and socialjudgmcñt, and aretherefore criticalto acquiring
interpersonal skills,are the same areas that are typically affected by lead poisoning.
Brain injury of thistype ispermanent, and significantrecovery cannot be expected. Indeed, the
neural systems implicated in such cognitive domains as working memory and executive function
enntin= to lateinto the teen and behavioral indices of dydmainn in these parts
develop years,
of the brain typically emerge as the demands for higher level cognitive processes increase with
age. Thus, in addition to the evident impact of these neuropsychological impairments upon
IWs current academic performance, we can expect to see an increasingly greater impact upon
his performance as he progresses to the higher grades wherein more conceptually difficult
material will be encountered.
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In summary, based upon condderation of L s ncürobchavioraland neuro-
paydek.gice his
deficits, medicalhistoryand the currentmedical I conclude
literatre, thatbrain
damage f om leadpoisoning has can;
significantly ould to sd~-en±d cognitive,
socialand behavioralimpairments.
I certify
that evs!üated
I personally L D , employingage-appropriateinstruments and
procedures as wellas lñfeatied
clinicalopinion. I further that
certify the findingscontainedin
thisreportdecuratelyrepresenthislevelof b g at the time
ofmy assessment. I holdthis
opinion and all
others in this
reportwith ar ^=Ma degree ofpsychological certainty.
Vic d Ph.D.
alter,
Licensed sychologist
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NEUROPSYCHOL OGICAL EVALUATION REPORT
Patient: I
Date of Birth: 4005
Date of Evaluation: 10/4/2015
Age: 10 years,.4 months
Test Site: Brooklyn, NY
The purpose of thisevaluation was to determine the basic.motor, cognitive and behavioral
performance resources of I DWand their impact on his educability and ability to execute
activities of daily living. In addition, a determination was made ofthe influence of
neuropsychologically significant factors in L history upon his current level of functioñg.
L was accompanied tothe evaluenon by his mother, Solenny Sanchez, who provided
information concerning his background and current functioning. The following medical, [
educational and administrative records were als o reviewed:
1. New York Presbyterian Hospital - Pediatric Medical Records
2. East Naples Medical Center - Pediatric Medical Records
3. Marion E. Fether Medicine - Pediatric Medical Reconis
Family
4. David Lawrence Center - Psychiatric Medical Records
5. New York Department of Preservation - Lead Inspectien Records
City Housing
Preview
FILED: NEW YORK COUNTY CLERK 11/12/2019 11:28 AM INDEX NO. 150316/2017 NYSCEF DOC. NO. 24 RECEIVED NYSCEF: 11/12/2019 NEUROPSYCHOLOGICAL EVALUATION REPORT Patient: LM D D ate of Birth: W2005 Date of Evaluation: 01/13/2019 Age: 13 years, 7 months Test Site: Brooklyn, NY The purpose of thisevaluation was to determine the basic motor, cognitive and behavioral performance resources ofIM D and their impact on his edücability and ability to execute activities of daily living. In addition, a detennination was made of the influence of neuropsychologically significant factors in IWs history upon his current level of fimenosg. Lmwas accompanied to the evaluation by his mother, Ms. Solenny Sanchez, who provided information concerning his background and current functioning. The following medical, educational and administrative records were also reviewed: 1. New York Presbyterian Hospital - Pediatric Medical Records 2. East Naples Medical Center - Pediatric Medical Records 3. Marion E. Fether Medicine - Pediatric Medical Records Family 4. David Lawrence Center - Psychiatric Medical Records 5. New York Department of Preservation - Lead Inspection Records City Housing 6. New York Department of Education -School Admission Records City 7. Collier Public Schools - Achievement Test Results and 504 Records County Eligibility History No or neonatal status records were provided for review. based upon Iw labor/dclivery However, information contained within the available pediatric medical records, itappears that born in New York City at fullterm via a normal vaginal delivery, following an uneventful pregnancy with no perinatal or neonatal complications. Except for occasional upper respiratory infections,being overweight, and experiencing lead poisoning as described below, I exhibited generally good health throughout his childhood. His pediatric records indicate thathe developed typhoid fever while the visiting Dominican Republic, and hisonly hospitalization occurred when he underwent nasal surgery in . 2010 to remove a partialbone from his nasal cavity that was apnea. renuja causing sleep exhibited age appropriate developmental milestones, although he had difficulty pronouncing words clearly and received speech therapy to address his disfluency. L was exposed to lead by the time he was 27 months old, as evidenced by a blood lead level of 7.8 µg/dl. This represents significant lead poisoning, as blood lead levels as low as 5µg/dl have been acknowledged by the CDC to be neurotoxic to children of this age, He was not retested for over two years, by which time his blood lead concentration had fallento less than 1 µg/dl. Itshould be noted that at thetime of his elevated blood lead reading, the NYC Department of Health identified multiple lead paint violations in Lenny's residence. Page 1 of 10 1 of 20 FILED: NEW YORK COUNTY CLERK 11/12/2019 11:28 AM INDEX NO. 150316/2017 NYSCEF DOC. NO. 24 RECEIVED NYSCEF: 11/12/2019 RE: DnpMOf L Bease I 'sblood lead level had not been monitored for a year prior to his clevated reading, nor for two years thereafter,the actual onset and duration of his lead poisoning, and the magnitude of his body's lead burden, are not known and areprobably underestimated by the available data. I s decamcated history of blood lead test resultsis shown in Table 1. Table 1. Blood-Lead Levels 03/10/06 0 06/26/06 2 07/20/07 7.8 09/11/09 < 1 IW moved from New York City to Naples, Florida when he was seven years old, where he attended second grade at Big Cypress elementary school. He was administered the abbreviated 606 Stanford Achievement Test, on which he scored at the perceñtile in reading comprehension. He was referred for evaluation by his teachers, due to problem behaviors in the classroom that ½dd a limited attention span, difficultymai=+=4ning focus, forgetfulness and aggression. In addition, he often fought with other students who teased and bullied him, and called him fatand dumb. In May 2013, a psychiatric evaluation was conducted to address I persistent and chronic aggressive outbursts, poor focus and concentration, inattention, low frustration tolerance, impulsivity, forgetfulness, and temper tantrums. At that time he was diagnosed with Depressive Disorder - NOS and with Attention Disorder - Eattentive subtype. He was Deficit/Hyperactivity initiallyprescribed Focalin, but since that time he has also taken Vyvanse and Adderall. When he was in third grade, I begin working under a Section 504 Student Accommodation Plan, which allowed him to have extended time on tasks and tests in order to deal with his anxiety and frustration in timed situatioñs. Although his behavior improved somewhat in the third grade, I continued to have problems at home, which included defiance, impulsivity, and aggression toward his brother. IW s fourth grade school records indicate that he continued to have difficulty focusing on tasks, difficulty remembering what he learned, and poor frustrationtoicrañce. At home, he continued to intimidate his siblings, and exhibit an unhappy mood with negative self-statements. I evaluated I three years ago, when he was 10;4 years old, at which time his scores on the Wide Range Intelligence Test indicated a Full-Scale IQ of 115, which was in the high average range, a Verbal Comprehension Composite Score of 123, in the superior range, and a Visual Page 2 of 10 2 of 20 FILED: NEW YORK COUNTY CLERK 11/12/2019 11:28 AM INDEX NO. 150316/2017 NYSCEF DOC. NO. 24 RECEIVED NYSCEF: 11/12/2019 RE: M LW Score of 102, in the average range. Neuropsychological and neurofanctional testing revealed deficits in his verbal fluency skills,hand and fingermovementa, immediate memory for design and immahte and delayed memory for visunspatial material. Evidence of inattention, visual plùüessing speed deficitsand impulsive behavior were also observed. No additional medical or school records, nor reports of any subsequent evaluations, for the period since my previous evaluation were provided for review. Present Evaluation LW presented as a well dressed adolescent who was polite and friendly,and appeared well oriented to time and place. A good rapport was established with the examiner, and his mother stated that his behavior during the evaluation was typical for him. Accordingly, the present evaluation should be taken as a valid reflection of L cognitive and neuropsychological functioning. Intelligence Assessment The Wechsler Intelligence Scale for Children -Fifth Edition (WISC-V) was ad ±rd, and 14 attained a Full Scale IQ of 102 (555 percentile) (58* which is inthe average range, a Verbal Comprch==ian Composite Score of 103 in the average a Visual Spatial percentile) range, (876 Composite Score of 117 percentile) in the high average range, a Fluid Reasoning (73"' Composite Score of 109 percentile) in the average range, a Working Memory Composite (27* Score of 91 percentile) in the average range and a Processing Speed Composite score of 98 (45$ perceñtile) in the average range. Lenny's Composite Score -=7 ispresented in Table 2, and his subtest summaries and percentiles are presented in Table 3. Table 2. WISC-V Composite Score Summary Scale Composite Score . Percentile_ Verbal Comprehension 103 58 Visual Spatial 107 87 Fluid Reasoning 109 73 Working Memory 91 27 Processing Speed 98 45 Full Scale 102 55 Page 3 of 10 3 of 20 FILED: NEW YORK COUNTY CLERK 11/12/2019 11:28 AM INDEX NO. 150316/2017 NYSCEF DOC. NO. 24 RECEIVED NYSCEF: 11/12/2019 RE: 16ms M Table 3. WISC-V Subtest S-==s y Verbal Comprehensien Scaled Score Percentile Similarities 11 63 Vocabulary 10 50 Visual Spatial Scaled Score Percentile Block Design 12 75 Fluid Reasoning Scaled Score Percentile Matrix Reasaning 9 37 Figure Weights Working Memory Sealed Score Percentile Digit Span Picture Span 8 25 Processing Speed Scaled Score Percentile Coding 7 16 Symbol Search 12 Neuropsychological Assessment A. Language L verbal fluency was assessed using the Controlled Oral Word Association Test from the Multilingual Aphasia Examination (MAE), and he achicycd a score in the high avciage range (Controlled One Word Association Test - 85d'percentile). L was assessed naming ability using the Visual Naming subtest from the MAE, which fellwithin the low average range (Visual -24d' Naming percentile). LWwas achhed the Comprehension of Instnerinna subtest from the NEPSY-IL This testrequires one toperform specific tasks according to verbal instractiõñs, thus assessing his comprehension of spoken language. L performance on the Compreheiision of Insti-Gctions Page 4 of 10 4 of 20 FILED: NEW YORK COUNTY CLERK 11/12/2019 11:28 AM INDEX NO. 150316/2017 NYSCEF DOC. NO. 24 RECEIVED NYSCEF: 11/12/2019 - 25* testwas in the average range (Comprehension of Instructions percentile). IW's ability to define words was assessed using the Vocabulary subtest from the WISC V, which indicated that his knowledge of word meanings was in the average range - (Vocabulary 50* percentile). These results indicate that LWis exhibiting deficitsin his mming abilityand inhis ability to comprehend instmctions. He isdisplayed relative strengths in his ability to access vocabü1ary words from his mental lexicon and inhis ability to define vocabulary words. B. Sensory-Motor Functioning LW was admidstered three assessmento to evaluate his sensory-motor functioning: the Purdue Pegboard test,the Rey Osterrieth Complex Figure Test, and the Arrows test. The Purdue Pegboard testis used to assess dexterity and visuomotor abilitiesby requiring individuals to quickly fitpegs into holes in a board. L performance on the Purdue Pegboard indicated that hand and finger mavcments with his dominant righthand were within -455 the average range (Right Hand percentile), and movements with his lefthand were within - 23"I the low average range (LeftHand percentile). L use of both hands together in simple - 32ªd symmetrical movements was within the average range (Both Hands percentile), and his ability toasserable multi-component objects was within the intellectually deficient range - 2"d percentile). (Assembly LWs visuospatial constr uctional ability was assessed using the Rey Osterrieth Complex Figure Test, which requires one to copy a complicated geometric design. Lenny's ability to - > 16* reproduce this complex design was within the average range (Osterrieth: Copy percentile). L visuospatial was also assessed the Arrows subtest from the - piecessing using NEPSY-II, which requires one tolook at an arrayof arrows arranged around a target and to indicate which arrows point to the center of the target. Igs performance on this test was in the average range (Arrows - 25 percentile). These results indicate that IW is displaying deficitsin his hand and finger movements and in his visuospatial processing abilities. C. Learning and Memory Storage of verbal, auditory and visual information ismcdiated in different ways and, to some extent, by different parts of the brain. Accordingly, to testmemory functioning itis necessary to use differenttests thatare 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 was used to assess for . Memory Learning (WRAML-2) memory narration, memory forwords, memory for design and memory for pictures. immsliate working memory was assessed using two subtests of the WISC-V, the Digit Span and Picture Span tests. Page 5 of 10 5 of 20 FILED: NEW YORK COUNTY CLERK 11/12/2019 11:28 AM INDEX NO. 150316/2017 NYSCEF DOC. NO. 24 RECEIVED NYSCEF: 11/12/2019 RE: DS, The recall trialof the Rey Osterrieth Complex Figure Test and Recognition Trialwas used to assess visuospatial memory and recognition. LMwas administered the Story Memory subtests from the WRAML 2 to assess his immediate, delayed and recognition memory for narration. LWs performance on this test indicated that his immediate recall for narration was in the average range Memory: hnmediate Recall - (Story 63d percentile), hisdelayed recall for narration was in the high average range (Story Memory: - 75* Delayed Recall percentile) and his recognition memory for narration was within the -50S average range (Story Memory: Recognition percentile). L was administered the Verbal Learning subtest from the WRAMI 2, which assessed his immediate, delayed and recognition memory for listsof words. L perfonnance on this test indicated thathis immediate recall for words was in the average range (Verbal Learning: - 25S Immediate Recall percentile), his delayed recall forlistsof words was inthe average range -50* (Verbal Learning Msmory: Delayed Recall percentile) and his recognition memory for -16* listsof words was within the low average range (Verbal Learñiñg: Recognition percentile). Igwas administered the Design Memory subtest from the WRAML-2, which assessed his immediate and recognition memory forabstract designs. L performance on this test indicated that his immediate recall for abstract designs was in the average range (Design - 256 Memory: Immediate Recall percentile) and his recognition memory for abstract designs was within the average range (Design Memory: Recognition - 25* percentile). IM was administered the Picture Memory subtest from the WRAMI,2, which assessed his immediate and recognition memory for pictures. L performance on this testindicated that his immediate recall for pictures was in the high average range (Picture Memory: Immediate -84* Recall percentile) and his recognition memory for pictures was within the low average - 95 range (Picture Memory: Recognition percentile). LSwas administered the Digit Span and Picture Span subtests from the WISC-V, to assess his imm~Uate memory for number and for pictures, respectively. 375 LW s immediate memory for numbers was in the average range (Digit Span - and hisimmediate percentile) memory for pictures was in the average (Picture Span - 25* percentile). Visuospatial memory was also assessed by examining the recall and recognition trials of the Rey Osterrieth Complex Figure Test. LW s immediate free recall -165 for visuospatial material was in the low average range (Osterrieth: Immediate Free Recall percentile). His delayed free recall for visuospatial material fellwithin the deficient - borderline range intellectually -3d (Osterrieth: Delayed Free Recall percentile), and his recognition for visuospatial material - 92"d fellwithin the superior range (Osterrieth: Recognition Memory percentile). These results indicate that IW is exhibiting deficitsin his memory forvisuospatial material, in his immediate and delayed recognition for wor is,in his recognition for pictures and inhis immediate and recognition for designs, He displayed relative strength in his imm -m ate memory memory forpictures, in his recognition memory for visuospatial material and inhis immediate, delayed and recognition memory for narrative material. Page 6 of 10 6 of 20 FILED: NEW YORK COUNTY CLERK 11/12/2019 11:28 AM INDEX NO. 150316/2017 NYSCEF DOC. NO. 24 RECEIVED NYSCEF: 11/12/2019 RE: , L D. Attention a++ætinna1 Conners' A detailed analysis of L visual fimetinnino was performed using the Continuous Performance Test-E (CPT-E). The CPT-E 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 rateof letter presentation, the CPT-E allows a close examination of the multiple processes thattogether underlie one's visual attention. LARM pattern of performance of the CPT-E included scores that ranged from low to average % Omissions - T = 52 % Commissions - T = 44 Hit RT - T= 48 - T = 50 ( ; ; ;Detectability ; RT SD - = - T = 3 8; - = RT - Hit T 40 ; Variability Perseverations T 44 ; Hit Block Change T = 56 and Hit RT ISI Change - T = . Lenny's performance profile on the CP T-E indicated 53) difficulty with sustaining attention. The Conners CP T IIIperforms a validitycheck based on thenumber of hitsand omission errors commated, as well as a self-diagnostic check of the accuracy of the timing of each administration. If there is an insufficient number of hitsto compute scores, and/or ifthe omission error rate exceeds 25%, the program issues a warning reessage noting that the administration was invalid. There was no indication of any validlty issues in this case, and the cunent adm%tration should be considered valid. E. Executive Functioning Executive functions of the brain include higher levelcognitive processes that allow adaptive thought to be used to solve novel problems and toplan adaptive and goal directed behavier. Among the more salient processes subsumed under the mbric of executive fnnctioning are planning, verbal concept formation, and visual spatial processing. The Mazes subtest from the WISC-E, and theTower of London (TOL) were used to assess Lenny's planrdng abilityand impulse control. In order to complete the Mazes test, IWhad to successfully indicate the route an individual would take to exita maze without turning into any - 63"I blind alleys, and hisperformance on the Mazes task was within the average range (Mazes percentile). In order to correctly complete the Tower of London one must reproduce a pattern compnsed of colored balls placed on pegs, using a second pegboard and setof colored balls. Several scores are derived from one's performance on the TOL, including the ñümbct of correct complefiene, the totalnumber of moves taken, the number of role violations, and the time taken to comploto the task. LW's performance on the TOL yielded mixed results. His totalnumber of correct completions was within the low average range (TOL: Number Correct - 7"1 and the percentile), number of moves needed to complctc the entire test fellwithin the average range (TOL: Total Move Score - 50* percentile). the time ittook to complete the task was with However, Lenny -76* the high average range (TOL: Total Execution Time percentile). These results show that LM sacrificed accuracy forspeed. Page 7 of 10 7 of 20 FILED: NEW YORK COUNTY CLERK 11/12/2019 11:28 AM INDEX NO. 150316/2017 NYSCEF DOC. NO. 24 RECEIVED NYSCEF: 11/12/2019 RE: Daun9, I The Similarities subtest of the WISC requires one tosupply an appropriate word in an orally presented analogy, thereby aeman*atine competency in verbal concept formation. Le - 63"1 verbal concept formation skillswere shown to be in the average range (Similarities percentile). IAAAmh abilities to easily change from one format to another (set shifting),to inhibita prepotent response (iñhibitory control), and to efficiently scan a visual field,were assessed through his performance on the Compichcñsive Trail-Making Test (CTMT). In order to c0mplete the CTMT, one simply has to connect numbers, words and numbers, or numbers and letters. Competency in each of these areas is measured by the time required to perfonn the various tasks. (CTMT- 1862 TGAIEs performance on the CTMT was in the low average range percentile), which reflects his difficulty changing sets,controlling his impulses, and efficientlyscanning the visual field. These results indicate that I has visual processing speed deficits (asreflected in the length of time it took him to complete the and in ph=ni as demon¤trated his performance CTMT), g by on the TOL. However he was able to complete tasks in a timely fashion, demonstrated compctcñcy in verbal concept formation and inthe completion of the maze task. Summary IMDMpresented with an IQ inthe average range. Neuropsychological and neurofhnctional testing of Is DEevealed strengths in the areas of accessing vocabulary words from his mental lexicon and defining vocabulary words. Additionally he displayed strengths in his immediate memory for pictures, in his recognition memory for visuospatial material and inhis immediate, delayed and recognition memory for narrative material. L was able to perform the Maze task well and displayed verbal concept formation skills. However, this same testing revealed that IW is exhibiting deficits in his naming ability and in his abilityto comprehend instructions. He demonstrated deficits in his hand and finger movements and inhis visnospatial processing ability.He had difficulty sustaining attention over time and in his visual speed deficits (as reflected inthe length of time ittook him to . processing complete the CTMT), and in planning as demonstrated by hisperformance on the TOL. And finally,L exhibited deficitsin his memory for visuospatial material, in his immediate and delayed recognition for words, in hisrecognition for pictures and in his immediate and recognition memory fordesigns. Interpretation LWs observed deficiencies, in association with expected to greater than expected functioning in other neurocognitive domains and interpreted within the context of his history, are indicative of pediatric brain injury. Furthennore, such impairmcats have been described as sequella of early childhood exposure to lead. Lead is a known environmental toxin whose effects on the developing nervous system have been well documented, and oftenlead to such cognitive and Page 8 of 10 8 of 20 FILED: NEW YORK COUNTY CLERK 11/12/2019 11:28 AM INDEX NO. 150316/2017 NYSCEF DOC. NO. 24 RECEIVED NYSCEF: 11/12/2019 behavioral conseqüences as language disorders, hyperactivity, attention deficits and mental impairment. Elevated lead levels in young children have also been associated with poor performance on standardized assessments of emotional regulation and orientation-engagement. A review of IW available medical history indicates that he experienced clinically significant lead poisoning, and reveals no other factors or lifeevents that would be expected to exert such a negative impact on his neuropsychological functioning. The severity of brain damage caused by lead poisoning isrelated to a child'sage at the time of exposure, the duration of his exposure, and the magnitude of the body's lead burden. L was shown to have a significantly elevated blood lead concentration as early as 27 months, which places his lead exposure well within the period of nervous system development during which many areas of the human brain undergo a complex seriesof anatomical and functional transformations. Exposure to an established neumtoxin 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 the brain. 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 concentrations, the lead that has previously been deposited in the brain ecñtinues to exert its neurotoxic influence for years thereafter. Although 10 µg/dl was formerly considered the clinical threshold for childhood lead poisoning, considerable research has been published which indicates that children with much lower levels of lead experience reduced as well as deficits in executive visual- IQ, attention,language, function, motor integration, social behavior and motor skills. In fact,there isnow compelling scientific evidence that there is no safe level of lead exposure. The Centers for Disease Control (CDC) has acknowledged that lead's neurotoxicity ismuch greater than was previansly believed, and ithas Level" established a blood lead "Reference of 5 µg/dl as the triggerfor clinicai reporting and intervention, effectively redefining lead poisoning to thislower threshold. In addition to his observed deficits, ImI s injuries are likely to have deleterious effects upon . his future social/behavioral development because, as important skillsfailto develop, his inability to keep up with his peers would be expected to leadto problems with self-esteem and impaired social development. This problem is often compounded by the fact thatthe areas of the brain thatunderlie behavioral control and socialjudgmcñt, and aretherefore criticalto acquiring interpersonal skills,are the same areas that are typically affected by lead poisoning. Brain injury of thistype ispermanent, and significantrecovery cannot be expected. Indeed, the neural systems implicated in such cognitive domains as working memory and executive function enntin= to lateinto the teen and behavioral indices of dydmainn in these parts develop years, of the brain typically emerge as the demands for higher level cognitive processes increase with age. Thus, in addition to the evident impact of these neuropsychological impairments upon IWs current academic performance, we can expect to see an increasingly greater impact upon his performance as he progresses to the higher grades wherein more conceptually difficult material will be encountered. Page 9 of 10 9 of 20 FILED: NEW YORK COUNTY CLERK 11/12/2019 11:28 AM INDEX NO. 150316/2017 NYSCEF DOC. NO. 24 RECEIVED NYSCEF: 11/12/2019 In summary, based upon condderation of L s ncürobchavioraland neuro- paydek.gice his deficits, medicalhistoryand the currentmedical I conclude literatre, thatbrain damage f om leadpoisoning has can; significantly ould to sd~-en±d cognitive, socialand behavioralimpairments. I certify that evs!üated I personally L D , employingage-appropriateinstruments and procedures as wellas lñfeatied clinicalopinion. I further that certify the findingscontainedin thisreportdecuratelyrepresenthislevelof b g at the time ofmy assessment. I holdthis opinion and all others in this reportwith ar ^=Ma degree ofpsychological certainty. Vic d Ph.D. alter, Licensed sychologist Page 10 of 10 10 of 20 FILED: NEW YORK COUNTY CLERK 11/12/2019 11:28 AM INDEX NO. 150316/2017 NYSCEF DOC. NO. 24 RECEIVED NYSCEF: 11/12/2019 NEUROPSYCHOL OGICAL EVALUATION REPORT Patient: I Date of Birth: 4005 Date of Evaluation: 10/4/2015 Age: 10 years,.4 months Test Site: Brooklyn, NY The purpose of thisevaluation was to determine the basic.motor, cognitive and behavioral performance resources of I DWand their impact on his educability and ability to execute activities of daily living. In addition, a determination was made ofthe influence of neuropsychologically significant factors in L history upon his current level of functioñg. L was accompanied tothe evaluenon by his mother, Solenny Sanchez, who provided information concerning his background and current functioning. The following medical, [ educational and administrative records were als o reviewed: 1. New York Presbyterian Hospital - Pediatric Medical Records 2. East Naples Medical Center - Pediatric Medical Records 3. Marion E. Fether Medicine - Pediatric Medical Reconis Family 4. David Lawrence Center - Psychiatric Medical Records 5. New York Department of Preservation - Lead Inspectien Records City Housing