Fatima Cortes Brainworks
This clinical report presents a comprehensive neuropsychological and autism evaluation conducted for Fatima Cortes, a 23‑year‑old Hispanic female, on March 25, 2025. Referred by her primary care manager to clarify concerns about attention, executive functioning, social communication, and mood, the evaluation employed a battery of standardized instruments (ADOS‑2, WAIS‑IV, CPT‑3, BAARS‑IV, BDI‑II, BAI, MDQ, PCL‑5, OCI‑R, SRS‑2) alongside behavioral observation and collateral information. Fatima exhibits high‑average to superior general intellectual ability (FSIQ 116, GAI 124) with notably slowed verbal processing and reduced processing speed. Self‑report and performance‑based measures reveal moderate inattention, high sluggish cognitive tempo, and mild hyperactivity/impulsivity. Autism‑specific assessments (ADOS‑2 total 14; SRS‑2 social communication T‑score 84) meet criteria for Autism Spectrum Disorder, Level 1, characterized by deficits in reciprocal conversation, eye‑contact avoidance, and restricted, repetitive internal preoccupations. Mood inventories indicate severe depressive symptoms (BDI‑II 40) and moderate anxiety (BAI 16), with elevated scores on trauma (PCL‑5 40) and obsessive‑compulsive measures (OCI‑R 41). The diagnostic formulation concludes co‑occurring ASD and recurrent moderate Major Depressive Disorder, with depressive symptomatology likely exacerbated by social isolation and executive dysfunction. Recommendations include autism‑informed individual psychotherapy, cautious psychiatric medication evaluation, possible transcranial magnetic stimulation for treatment‑resistant depression, psychoeducation for Fatima and her family, coordinated care management, academic and vocational accommodations, structured daily routines, and lifestyle modifications to improve sleep, caffeine use, and physical activity. The report concludes with contact information for further assistance.
Topics
Referral Rationale and Clinical Questions
Outlines the reason for the evaluation, including concerns about social, emotional, cognitive, and adaptive functioning, and specifies the key diagnostic questions regarding ASD, ADHD, and other possible conditions.
Presenting Symptom Profile and Functional Impact
Details Fatima's self‑reported difficulties with attention, cognitive fog, low energy, overthinking, emotional detachment, and how these impair academic, occupational, and social domains.
Behavioral Observations During Assessment
Describes observed eye‑contact avoidance, minimal spontaneous speech, flat affect, slowed verbal processing, repeated request for clarification, and overall low engagement throughout testing.
Cognitive Assessment Findings (WAIS‑IV)
Presents WAIS‑IV index scores: Verbal Comprehension 118 (high average), Perceptual Reasoning 123 (superior), Working Memory 108 (average), Processing Speed 97 (average), Full Scale IQ 116 (high average), General Ability Index 124 (superior), highlighting slowed verbal processing.
Attention and ADHD‑Related Measures
Reports BAARS‑IV self‑ratings (moderate inattention and sluggish cognitive tempo, mild hyperactivity) and CPT‑3 performance metrics indicating attentional inefficiency and variability.
Autism Spectrum Assessment Results
Provides ADOS‑2 Module 4 total score (14) consistent with ASD, and SRS‑2 subscale T‑scores (severe social communication, moderate social motivation, restricted/repetitive behavior), supporting a Level 1 ASD diagnosis.
Mood, Anxiety, Trauma, and Obsessive‑Compulsive Symptom Measures
Summarizes BDI‑II (40, severe depression), BAI (16, moderate anxiety), PCL‑5 (40, above clinical threshold), MDQ (7, positive), OCI‑R (41, above cutoff), and Y‑BOCS (14, mild), indicating significant affective and trauma‑related distress.
Integrated Diagnostic Impressions
Synthesizes test data and observations to conclude co‑occurring Autism Spectrum Disorder, Level 1, and Major Depressive Disorder, Recurrent, Moderate, discussing the bidirectional influence of each condition on functional impairment.