Case Study EDS 718

Name: Daniel Date: 06/12/01 D.G.B.: 06/18/98

C.A. 2 years, 11 months Report: Psychological Evaluation

Reason for Evaluation

Daniel is a 2 year, 11 month old boy who currently attends ASP five afternoons a week. In addition to special instruction, Daniel receives speech/language therapy, occupational therapy and family training through Early Intervention. The current psychological evaluation is part of an overall assessment of Daniel's developmental prior to review of his school district's Committee for Preschool Special Education.

Behavioral Observation

Daniel willingly accompanied the examiner to the evaluation room. Daniel communicated using 2-3 word utterances along with several articulation errors. During formal testing, Daniel demonstrated inconsistent attention and concentration skills. He attempted initially to control the situation, preferring to engage in self-selected activities, but was redirected through playful interactions. Daniel's flexibility and acceptance of limits increased with time, though he required moderate redirecting throughout testing. Daniel remained cheerful and verbal throughout the remainder of testing, with a few very brief periods of pouting and avoidance, which were overcome through play tactics. Daniel presented with highly limited persistence in the face of challenge. When tasks appeared challenging to him, Daniel required an excessive amount of coaxing and redirection, as well as occasional promise of activity reinforcement (e.g.: playing with a dinosaur) in order to persist. He frequently responded to tasks by stating, "no" or "no blocks". Daniel typically persisted on request, though seemingly painfully aware of when he performed correctly and when he did not. In fact, Daniel became immensely enthusiastic, including smiling, laughing and clapping his hands when succeeding on a task he initially avoided. When unable to succeed, he became briefly sullen and sometimes notably frustrated. Daniel responded very favorably to all verbal praise, and seemed to crave the positive adult interaction. He was noted to have difficulty at times, transitioning from preferred activities, doing so with extra coaxing and prompting. Daniel's performance on testing is felt to be an accurate reflection on his current functioning ability. Once the evaluation was complete and Daniel was given permission to play, he did so with great enthusiasm. His play skills were appropriate for his age. He carried on elaborate conversations with the toys in a thematical play approach.

Following the evaluation, as the evaluator spoke briefly with his teacher, Daniel was noted to tantrum verbally and physically (crying, demanding and pouting). He was finally responsive to verbal redirection/request to relax and rejoin the class. After a few minutes he repeated the same behaviors during circle time. His teacher reports that such behavior is not uncommon.

Bayley Scales of Infant Development - 2nd Edition (BSID-II) Mental Development Index = 85 normal limits 35 months Psychomotor Dev. Index = 80 mildly delayed 28 months

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Cognitive Development

On the mental scales of the Bayley Scales of Infant Development: 2nd Edition, Daniel achieved a Mental Development Index of85, which reveals that his overall cognitive functioning is within normal limits, Clinical concerns are raised regarding his overall motor functioning, behaviors, expressive language and articulation.

In the area of nonverbal visual motor integration skills, Daniel was able to build a tower and a wall using cubes and imitated a vertical and horizontal crayon stroke. He was unable to build a bridge using cubes or count blocks with a one-to-one correspondence. With regard to expressive language-oriented tasks, Daniel demonstrated the ability to pose' questions, name pictures and produce multiple words in response to a picture book. He was unable to answer gender questions correctly or name four colors. The examiner also noted several articulation errors. Receptively, Daniel was able to display verbal comprehension, understand the concept of one, and compare masses. He was unable to understand two prepositions or discriminate pictures,

On the psychomotor subscale, Daniel's performance reflects functioning at the 28-month level, a delay of 7 months. Both gross motor and fine motor skills were delayed. In the fine motor functioning, Daniel could lace three beads, grasp a pencil and copy a circle. He was unable to copy a square and a plus sign or button one button. In gross motor functioning, Daniel is independently ambulatory and is able to walk up stairs in a step-by-step fashion. He was unable to walk on his tiptoes or walk sideways. It is the examiner's opinion that a low score in his overall motor functioning may be due to his uncooperation with the tasks.

Social Emotional Development

Daniel’s mother describes him as being distractible and having a low frustration tolerance. She states, "Daniel's behavior has improved dramatically since attending ASP. He has been learning to accept limits put on him and is working through his frustration." In the classroom, Daniel continues to have difficulties with transitions and acceptance of limits. His temper tantrums are significantly less severe and he is able to recuperate from his tantrums quicker. His play skills appear to be appropriate for his age. He carries on elaborate conversations with toys in a thematical play approach. However, it is important to note that he does not yet initiate play activities with the other children in his class.

SPEECH AND LANGUAGE EVALUATION

Name: Daniel DOB: 6-13-98 C.A.: 3.1

BACKGROUND INFORMATION:

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Daniel is a three year, one month old boy who attends Genesis five afternoons per week. He has been enrolled in the toddler program since October 2000. He receives speech and language services two times per week as well as occupational therapy twice weekly. The current evaluation is to assess Daniel's overall communication skills and his present needs for the purpose of speech and language recommendations.

Daniel is the product of a full-term, uncomplicated pregnancy, and weighing eight pounds, seven ounces. He was born via Cesarean section. Medical history is significant for frequent and recurring middle ear infections. Daniel also has a history of excessive wax build-up in both ears. Mother has attempted to remove the earwax with over-the counter medication without success. An otolaryngologist saw Daniel on February 21, 2001. Findings from a tympanogram revealed that there was middle ear fluid in both ears. Myringotomy surgery for placement of PE tubes was performed on March 8, 2001 as well as adenoid removal. An audiological evaluation was performed at Good Samaritan Hospital in October 2000 and it was reported that high frequency sounds were within normal limits. Developmental milestones included sitting at six months, standing at eight months, walking at 15 months and producing first word at 12 months of age.

Summary and Recommendations

Daniel is a 2 year, 11 month old undergoing evaluation due to his transition from Early Intervention to his Preschool Special Education. He is currently receiving occupational therapy and speech and language therapy, family training and special instruction provided by the Health Department’s Early Intervention program. Formal testing revealed cognitive functioning within normal limits and overall motor delay. It is the examiner's opinion that his overall motor functioning may be a low estimate due to his behavioral difficulties during formal testing. Clinical concerns exist regarding his expressive language, articulation, peer interaction and behavioral issues.

TESTS ADMINISTERED:

Preschool Language Scale - 3 (PLS-3)

SS % Auditory 83 13 2.6 Comprehension: Expressive 76 5 2.2 Communication: Total Language 77 6 2.5 Score:

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Goldman-Fristoe Test of Articulation - 2 (GFIA-2)

TEST INTERPRETATIONS:

Receptive and Expressive Language Skills:

The Preschool Language Scale - 3 (PLS-3) was administered to assess Daniel's overall language comprehension and use.

Receptively, Daniel attained a standard score of 83, with a percentile rank of 13, and _ age equivalent of two years, six months (C.A., three years, one month). This is seven months' below Daniel's chronological age, indicating a mild delay in receptive language skills. These scores are -1.0 to -1.5 standard deviations below the mean. Daniel demonstrated understanding of action words in pictures (e.g., washing), descriptive concepts (e.g., wet, big), part/whole relationships (e.g., "Show me the nose of the cow."), and pronouns (e.g., he, they). Areas of difficulty included grouping objects (e.g., "Show me all the animals."), understanding negatives (e.g., no, not), identifying colors, comparing objects (e.g., "Which one is heavier - a boot or a shoe?"), and making inferences (e.g., "Charlie played outside and got his shoes all wet. What was it like outside?").

Expressively, Daniel attained a standard score of 76, with a percentile rank of 5, and an age equivalent of two years, two months (C.A., three years, one month). This is 11 months below Daniel's chronological age, indicating a mild to moderate delay in expressive language skills. These scores are -1.5 to -2.0 standard deviations below the mean. Daniel was able to use a question inflection, use three words in a sentence, name pictures, and answer what, where and yes/no questions. Areas of difficulty included using plurals ( e.g., shoes), using present progressive verbs (e.g., eating), producing basic sentences, using possessives, telling how an object is used and answering questions logically.

Articulation:

The Goldman Fristoe Test of Articulation-2 (GFTA-2) was administered to collect a single word example of Daniel's speech. He named pictures to sample each sound in the initial, medial and final positions of words. Speech sounds that were not elicited at the spontaneous level were elicited in imitation. A summary of responses revealed 56 errors. Daniel achieved a standard score of74, with a percentile rank of 10, and an age equivalent of below 24 months of age (C.A., three years, one month). These scores represent a moderate delay in articulation skills. Errors were characterized by omissions and substitutions. The most prevalent phonological processes were medial and final consonant deletion. Errors were as follows:

Initial Position:

Substitution of:

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w/l, w/r, d/dz, f/o, s/z, d/o

Blends: b/bl, b/br, j/dr, f/ft, s/fr, g/gl, g/gr, k/kl, k/kr, w/kw, p/pl, s/sl, p/sp, t/st, f/sw, t/tr

Medial Position:

Substitution of: p/f, f/o

Omission of: p, b, g, k, d, ng, t, S, tS, 1, r, dz, v, s, z, 0

Final Position:

Omission of: m, n, b, g, k, f, d, ng, t, S, tS, 1, dz, 0, v, s

Intelligibility of speech is poor in both known and unknown contexts. Daniel exhibits frustration when not understood by others. He frequently relies on pointing and pouting to achieve his wants/needs. Error sound patterns are inconsistent as Daniel is able to produce a sound in familiar words, but does not use the sound in other words. He exhibits difficulties with sequencing sounds to form words. Multi-syllabic words are reduced in complexity via syllable omissions and final consonant deletion.

Educational Report Name: Daniel

Daniel is the middle child, with an older sister ad a younger brother. He comes from an intact English speaking family and was evaluated due to concerns regarding his speecb/1anguage development. His mother was extremely helpful in providing any necessary information regarding Daniel's Development.

Oral-Motor Examination

Daniel has an open and closed mouth position with no drooling at rest and while moving around the environment. An intermittent open mouth posture is observed during motor tasks. Evaluation of the jaw revealed difficulty with jaw grading and jaw instability. Range of

5 Case Study EDS 718 motion is adequate. There is reduced strength in the jaw.

SUMMARY:

Daniel is a three year, one month old boy who presents with delays in receptive and expressive language skills. Scores from the PLS-3 revealed that receptive language skills fell-La to -1.5 standard deviations below the mean, indicating a mild delay, and expressive language skills fell -1.5 to -2.0 standard deviations below the mean, indicating a mild to moderate delay. Findings from the GFTA-2 indicated scores were moderately delayed and were below the' 24 month age 1_-6ingle word level. Daniel exhibits difficulties with motor sequencing skills as evidenced b.l2"eduction of multi-syllabic words and syllable omission, deletion of medial and final and inconsistent error sound patterns. Intelligibility of speech is poor given known and unknown contexts. Delays in oral-motor skills are also observed characterized by weakness and reduced range of motion of the jaw, lip and tongue musculature.

BEHAVIOR DURING ASSESSMENT

Daniel was tested within his home in an area free from distraction. He was somewhat reticent and required a short warm up period. Daniel's attention was fleeting. He had difficulty attempting some of the tasks and would discard them if he did not achieve immediate success. Daniel was eager to explore this examiner's testing material and had difficulty maintaining focus on one task. Daniel was expressive during the exam; however, his language consisted of babble with minimal gestures. Daniel was observed to pull his mother’s hand in order to lead her to what he wanted. If she did not go immediately Daniel would tantrum. His tantrums were somewhat frequent during the evaluation, however short- lived. 26 20 23

Gross motor skills prove Daniel to be at an age equivalent of 17 months which is in the 1st percentile. This indicates a 33% delay in this area Visual receptive (cognitive) skills appear to be delayed as Daniel is in the 1st percentile, with an age equivalent of 13 months. A 33% delay is noted in this area. Daniel] enjoyed looking for a car covered with a washcloth and attended to pictures in a book. He was able to turn several pages in a book" however, not singly. Daniel’s motor skills need improvement, as he scored an age equivalent of 18 months and is in the 1st percentile. Fine motor skills show that Daniel is exhibiting an overall 33% delay. He is able to use a pincer grasp and two hands together. Daniel did not attempt to imitate crayon strokes. He did stack blocks and attempt to make a train with blocks, however was unsuccessful. Daniel enjoyed putting pennies in a bank. both vertica1ly and horizontally. Social/emotional skills, according to the HELP strands checklist indicate Daniel is able to display independent behavior (24-30 months). and feels strongly possessive of loved ones (24-36 months). He does not use his own name to refer to himself) or use self- centered pronouns (24-30 months). Daniel is able to recognize himself in a photograph and experiences a strong sense of self importance (18-24 months). Taking pride in clothes or distinguishing between sexes has yet to develop (24-30 months). Daniel will comfort others

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in distress and dramatize (22-30 months). Daniel does easily tantrum (18-24 months). He engages in parallel play (18-24 months) Mrs. States that when Daniel p1ays with other children he is initially excited then will become frustrated. Skills range from 18-30 months in this area with existing concerns regarding peer interaction 8Ild associate play.

Daniel's self help ski11s, according to the HELP strands, reveals that he is able to dress and undress with assistance (26-28 months) and feed himself 'with a spoon (24-30 month’s). Daniel's sleep patterns are that he will nap three hours a day and will sleep ten- twelve hours a night (13-18 months). Daniel is able to wash his hands and brush his teeth with assistance (24+ months). At this time, Daniel is not potty trained and shows no interest in this area. Daniel assists with household and fragile items (21-26 months). Daniel enjoys the bath and dry material$ however shows resistance for wet, mushy things. Daniel’s self-help skill range nom 13-30 months.

Summary

Daniel is an active happy child of 26 months, He is somewhat shy with strangers and may requite a warm up period before engaging He is a child who prefers to control his environment and displays a low frustration to1erance if wants are not met. A speech/language delay is evident with an expressive vocabulary of about 10 words. His primary form of communication is babble or leads the listener by the hand. He qualifies for services based On a 33% delay in gross motor skills and a 33% delay in visual perception (cognitive) and fine motor ski11s. His social/emotional skills and self-help skills are scattered with concerns regarding his associative play and peer interaction. A physical and occupational therapy evaluation is recommended to address his overall motor skill's. Although Daniel did not attempt some tasks in these sub-tests, others he displayed much difficulty completing after several attempts. Special education is suggested.

Physical Therapy Evaluation

Name: Daniel. Assessment Tools: Early Intervention Developmental Profile Clinical Observation

History: Daniel is a two year, two month old boy referred for a physical therapy evaluation

due to concerns about "knock knees" and safety awareness. He was seen at home with his mother and sister present. Daniel was reported to be the product of a full term pregnancy, born via c/ section with a birth weight of 8 lb., 7 oz. Developmental milestones were achieved as follows: sitting at 8 months, crawling at 10-11 months, walking at 14-15 months.

Behavior: Daniel was active and distractible throughout the evaluation. He was very interested in getting toys out of the toy bag. Attention span was brief and he required constant refocusing to complete the task at hand. Eye contact was brief. Daniel is noted to

7 Case Study EDS 718 climb all over the furniture with minimal safety awareness. It was difficult to assess visual and auditory responses during today's assessment. Daniel demonstrated a social smile.

Physical Findings: Muscle tone and range of motion are within normal limits throughout. all four extremities. Muscle strength appears adequate throughout trunk and all four extremities. Daniel is noted to be a big boy, appearing older than his stated age: Legs demonstrate a "knock knee" appearance with mildly flat feet noted as well This does not appear to be interfering with his ability to gain motor milestones and develop appropriate balance.

Balance/Equilibrium Reactions: Daniel demonstrates balance responses in both sitting and standing. Balance responses are adequate during walking. He demonstrates mildly decreased balance during running, although this appears to be related to attention. He will look around or become distracted and is not paying attention to where he is going. Parachute response is present and functional.

OCCUPATIONAL THERAPY EVALUATION

Evaluation Methods: . Clinical observations, record review, teacher/parent interview, Peabody Developmental Motor Scales (PDMS).

Standardization of the PDMS could not be utilized due to Daniel's inability to be assessed in a standardized manner. However, overall performance levels were determined through specific tasks of the PDMS.

Background: Daniel is an adorable 29- month old boy who was referred by his child study team in order to determine developmental motor levels. Daniel was born after a full-tern uncomplicated pregnancy via c-section with a birth weight of 8 pounds 7 ounces. With the exception of speech, Daniel is reported to have met developmental motor levels within normal limits, including unsupported sitting at 6-7- months, crawling at 9-months, and independent walking at 15-months. There are no reported concelJ1S regarding sleeping or eating patterns. Mrs. _reports that Daniel is not always attentive when maneuvering through his environment.

Evaluation Behavior/Observations: Daniel initially resisted leaving his classroom to go with this unfamiliar t!1erapist. He continued to require verbal and physical prompting as his teacher accompanied him to the evaluation room. Once seated, Daniel's teacher was able to leave. Initially, Daniel refused to participate in tasks presented. He covered or closed his eyes and repeated "no way." Eventually he was able to be encouraged to participate in several evaluation tasks, When met with a challenge or a task that he was not interested in, Daniel reverted to closing his eyes, saying "no way" or indicating with his hands, no more. Daniel was easy to engage in sensori-motor tasks, especially those that provided him with linear vestibular input. During

8 Case Study EDS 718 this time, increased verbalizations and facial expressions were observed. During both fine and sensori-motor tasks, Daniel was able to follow one-step verbal directions.

Physical Status: Daniel presents with overall active range of motion and muscle within normal limits. Equilibrium and protective responses were grossly assessed and appear to be within normal When seated on a therapy ball, gravitational insecurity was noted and significant increased facial tone was observed during this time. Daniel enjoyed climbing equip_8ne difficulty motor planning novel tasks. When met with such challenges, he used avoidance tactics. Daniel eagerly attempted to hang from suspended rings. He was unable to sustain a grasp on them independently. Daniel will toss a ball, however, he is unable to direct it to a specific area/person. He is unable to catch a ball. Mrs._was interviewed regarding various responses Daniel has to sensory input. It does not appear that Daniel has significant adverse responses to sensory stimuli. During this evaluation, Daniel was observed to really enjoy linear movement as evidenced by changes in affect and behavior. His mother reports that as a baby, Daniel loved the baby swing and the car. He continues to like swings and rides such/as a carousel. Daniel demonstrates inconsistent visual regard to objects and persons. Visual tracking is guided by whole head movements. .

Fine Motor/__Visual Perceptual Skills: Daniel presents with a right hand preference during unilateral hand tasks. He freely crossed midline when reaching for objects. Daniel is able to use his hands bilaterally to separate pop beads (18-23 months) and string 3 beads (18-23 months). When stringing beads, in hand manipulation of the beads was appropriate, however, he demonstrated some mild difficulty when attempting to pull the bead down the length of the string. Daniel is unable to twist open a cap or turn a door-knob (24-29 months), but can remove and replace rings 01llm'-'.4- 29 months). Daniel momentarily grasped a marker using a palmer grasp, but did not demonstrate any interest in scribbling (15-17 months). Daniel would not attempt to grasp scissors (15-1 7 months). Daniel refused to attempt block or puzzle tasks. .

Self-Help: Daniel is reported to be able to remove his unfastened shoes and socks. He is attempting to put on his unfastened shoes. Daniel will remove and put on a pullover shirt and pull-on pants. Daniel is able to drink from a cup and drinks from a bottle at night. He is able to spear with a fork. He has some difficulty keeping food on a spoon while eating, but is able to complete a meal with a spoon. He prefers to finger feed himself, rather than using utensils. Daniel allows his mother to brush his teeth. There are no adverse responses to the bath, hair brushing, or hair washing.

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