Profile of an NLD/ASD Child: Part 6

SPEECH EVALUATION

Age: 4-7

REASON FOR TESTING: Kira was seen for a psychological evaluation. Concerns were in the areas of immature behavior and perceptual-motor development, directly related to kindergarten readiness. A complete Child Study Team evaluation inclusive of speech and O.T. evaluations was recommended.

DIAGNOSTIC EVALUATION:

Behavior: Kira, a friendly responsive child, was attentive and cooperative. Kira became anxious when she anticipated difficulty with a task. She became somewhat oppositional and at times silly to avoid responding. Eye contact was elicited but Kira frequently looked away.

Oral-Peripheral: Examination revealed normal structure of the articulators. Dental condition and occlusion were good. The strength, control and coordination of the articulators were adequate for voluntary initiation and imitation of gross non-speech movements, syllables and syllable patterns. No drooling was observed.

Hearing: A pure tone hearing screening administered at 20dB revealed hearing to be within the normal range for speech, bilaterally.

Auditory Memory Span:

Non-Meaningful Language:  7-0 (5 digits)

Meaningful Language: 7-0 (14 words: 18 morphemes)

Receptive Language:

Peabody Picture Vocabulary Test: (Form B) MA: 5-9

Preschool Language Scale Auditory Comprehension Level: 4-0

Vocabulary recognition and understanding of language concepts were above age-level.

Expressive Language:

Expressive One-Word Vocabulary Test: 6-7

Preschool Language Scale Verbal Ability Age: 6-3

Word-finding skills and expression of language concepts were above age-level.

Speech Sample: Expressive efforts were through sentences of adequate length, characterized by very mild structural errors. Semantic usage was good and pragmatic intent, adequate. Speech intelligibility was judged to be good. The rate, pitch, volume, vocal quality and fluency were within the normal range.

Articulation: Responses elicited on the Weiss Comprehensive Articulation Test revealed a mild disorder involving a few sounds consistent with the five to seven year level. The following errors were presented in single words: b/v medial, t/o initial, s/o medial and final, d/j all positions, w/l all positions, d/z initial, w/l in blends and -/s in blends. Similar patterns were presented during conversational speech.

SUMMARY: Kira, a pleasant, responsive child, was attentive and fairly cooperative. She became somewhat oppositional and resistant when she anticipated difficulty with a task. Overall receptive and expressive language abilities were above age-level. Expressive efforts were through sentences of adequate content, form and intent. Although structural errors were presented, they were extremely mild in nature and not atypical for her age.

A mild articulation disorder did not interfere with speech intelligibility. Oral-peripheral structure and function were adequate. Hearing was within the normal range.

Speech therapy for correction of mild articulation errors was recommended should errors not self correct within six months.

 

 

Profile of an NLD/ASD Child: Part 5

Psychological Evaluation

Age: 4 years, 7 months

Reason for Referral: Kira is being evaluated as part of a full child study team assessment. Parental concerns over perceptual-motor development and immature social/play behavior have persisted since Kira was first brought to the attention of Project Child one year ago. Currently there are questions about Kira’s readiness for Kindergarten.

Background Information: Kira was seen for screening by Project Child last year. Results at that time indicated possible deficits in gross and fine motor development, while age appropriate speech/language and cognitive skills were apparent. Kira demonstrates shy behavior in unfamiliar situations. An occupational therapy evaluation noted gross motor abilities within normal limits. However, delays in fine motor ability, including both quality of production and skill achievement were evidenced. Recommendations were made by the occupational therapist which were relevant to home and nursery classroom setting.

Currently behavioral concerns centering around socially reticent behavior, lack of peer relationships and immaturity are being noted by mother and classroom teacher. Delays in the fine motor area also appear to be hampering Kira’s development.

Observations: Kira is a very pretty 4 year 7 month old girl of average height and build. She was unwilling to separate from her mother and therefore Kira’s mother accompanied her throughout this assessment. Initially Kira remained seated on her mother’s lap but spontaneously moved to a nearby chair after approximately five minutes in to the session.

Kira was very interested in the testing materials and was cooperative with all tasks.  No spontaneous speech was apparent. Speech upon demand was sparse and not elaborate but effective in relaying information.

Kira’s attention was appropriate although she sometimes seemed to tune out. Kira interacted affectionately with her mother and was socially responsive with the examiners. Kira seemed quite interested in people but hesitance was noted in her interaction with them.

Results of Evaluation:

McCarthy’s Scales of Children’s abilities

Scale                             Scale Index               Scale Age Equivalent          Percentile

Verbal                                 60                                         5-6                                85th

Perceptual Performance  45                                    4-0                                 30th

Quantitative                       52                                   4-6                                  55th-60th

Memory                           55                                    5-0                                   70th

General Cognitive Index  105                            4-10                                  60th-65th

 

Results of this measure indicate overall cognitive development at the average level. Perceptual-Performance scores are an area of relative weakness, with scores at below average levels. Verbal and memory skills are at high average level.

Verbal: The verbal scale measures the child’s ability to express herself verbally and to measure the maturity of her verbal concepts. Age scores for subtests include: Pictorial Memory (4-6); Word Knowledge (4-6); Verbal Memory I: Words and sentences (5-6) Verbal Memory II: Story  (5-0); Verbal Fluency (6-6);  Opposite Analogies (5-6).

Kira recalled four out of six pictures. She identified or named nine out of nine pictures and defined the words “coat” and “tool”. She repeated a series of four unrelated words. Kira correctly completed five opposite analogies.

Perceptual Performance:  Kira achieved these subtest age scores in the perceptual performance area: Block Building (3-0); Puzzle Solving (4-0); Tapping sequence (3-6); Draw-a-design (4-0); Draw-a–child (4-0); Conceptual grouping (5-6). This scale evaluates reasoning ability through manipulation of materials. The child demonstrates skills of imitation, logical classification and visual organization which are generally below age expectations.

Kira copied block structures such as a 6 block tower and a 3 block chair. She correctly put together a three piece puzzle. Kira copied a circle, vertical and horizontal line and a right angle intersection. Her drawing of a person consisted of six scorable parts but the quality of her drawing was immature. Kira used the right hand for drawing tasks and a pincer grasp was inconsistent.

Kira identified the concepts of big/little, square-round and named nine colors. She was able to sort by three attributes.

Quantitative: The quantitative scale is designed to measure Kira’s number aptitude rather than the upper limit of computational skills. Kira’s understanding of quantitative concepts is judged to be at these age equivalents: Number Questions (4-0); Numerical Memory I: Forward Series (8-6);  Counting and Sorting (5-0).

Kira answered number questions such as “how many heads do you have?” to a 4-0 year old level. She repeated six digits, which is a notable strength for her age.

Kira was able to sort four and ten blocks by half. She correctly counted to five with one to one correspondence.

Memory: Visual and auditory memory are assessed by subtests on this scale. The following subtest age equivalents have been achieved: Pictorial Memory (4-6); Tapping Sequence (3-6); Verbal Memory I: Words and Sentences (5-6) ; Verbal Memory II: Story (5-0): Numerical Memory (8-6). Kira’s short and long term memories appear adequately developed.  A strength was noted in short term auditory recall.

Summary of Evaluation: Kira, a pretty and reticent 4 year 7 month year old girl, was cooperative and curious during this evaluation. She was able to maintain attention in a consistent manner for about fifty minutes.

Results of the cognitive assessment indicate functioning at approximately the 4-10 year level, with scatter to the 6-6 level. Perceptual-fine motor skills appear developed to the 4-0 level, which would be considered an area of notable weakness for Kira. Receptive language and expressive language appear well developed and were exhibited to the 5-6 level. Kira’s memory skills were demonstrated to the 5-0 level while qualitative skills appeared average.

These results suggest cognitive development at the average level overall.

Profile of an NLD/ASD Child: Part 4

Initial Neurodevelopmental Evaluation:

Age: 4 years, 6 months

Reason for Referral: Developmental delays, hand flapping, not interacting well

Kira attends a preschool program at a daycare center. The daycare staff report that she does not initiate play, does not interact with other children or adults, does not listen and does not follow directions. They have also noted that she gets easily distracted, talks to herself, flaps her arms and is not functioning well enough to be in a group of 25 children. Mrs. Baker has observed all of these behaviors at home as well. However, she feels that Kira interacts very well with her and her husband and also with other people once she gets to know them well. She finds her too distractible, stubborn and shy. Kira is very affectionate with her mother and looks to her for comfort and security. Mrs. Baker feels that Kira’s social skills have improved over the past year but not to the point where she can function in a regular Kindergarten.

Kira has mild developmental delays for which she was evaluated by Project Child. At that time, hearing and vision were found to be normal. An occupational therapy evaluation revealed some delays in perceptual fine motor abilities. Occupational therapy was recommended.

Kira is the older of two children to her parents.  This was the first pregnancy for Mrs. Baker who was in good health prior to and during the pregnancy. She had onset of premature labor at 28 weeks and was hospitalized for a week. She was placed on Ritodrine and magnesium sulfate. She had a non-stress test every week and was then placed on oral Ritodrine. She also had decreased amniotic fluid. Kira was born at 37 1/2 weeks gestation by cesarean section due to breech presentation. Birth weight was 6 lbs, 6 1/2 oz. Apgar scores were 8 probably at the first minute.  No resuscitation was required. At birth she was noted to have congenital torticollis which resolved following some physical therapy. She did get evaluated at the Children’s Hospital of Philadelphia for the torticollis. X-rays of the cervical spine were done, which were normal.

Kira was breast fed. There were no feeding difficulties. She was not a colicky infant. Mrs. Baker recalls that she was never really a good sleeper.

Gross motor delays were noted early on. She did not lift her head up until 4 months of age. She rolled over at 5 months, sat alone at 8 months and crawled at 10 1/2 months. She walked alone at 11 1/2 months. She started riding a tricycle at 3 years. Initially she was clumsy and would trip frequently but this is much less now.

Her language milestones were achieved early. By her first birthday she was saying 5-10 words. By 15 months she had a vocabulary of 15-20 words. Before her second birthday she was speaking in short sentences.  She can narrate a story. She conducts a conversation, at least with her mother. She does not have any nonsense words. She does not speak out of context.  There is no history of echolalia.

Her fine motor skills have been of some concern. She is a little sloppy when it comes to handling a cup, spoon or pencils and crayons. She drooled until the age of 2 years.

She was toilet trained at 2 1/2 years.

Kira has had 2-3 ear infections per year.  She also gets frequent colds. She is on prophylactic antibiotics. She also has a history of eczema. There are no known allergies. She has had one episode of urinary tract infection.

Kira lives with her parents and younger brother Michael. Michael is 3 years old and developing well.  He is reported to be shy. Mrs, Baker, age 33 is in good health. She has B.S. and M.S. degrees and is a medical copywriter in an advertising agency. Dr. Baker, age 52, is in good health.  He is an M.D, , Ph.d and is the executive director of microbiology in a biotech company. There is no history of developmental problems on either side of the family.

Physical Examination: Kira was a pretty little girl. Her left eye was slightly smaller than the right, otherwise there were no dysmorphic features. Examination of the head and neck area was normal, including both ears.  Dentition was normal. Auscultation of the heart and lungs were normal.  The abdomen was soft, there was no hepatosplenomegaly. There was no scoliosis or midline defects. Genitalia were prepubertal female. There were no neurocutaneous lesions. Sidney crease was present on the right side. There was no major asymmetry of the extremities.

Neurological Examination: Kira was alert and active. As soon as the examiner entered the room she became suspicious and ran to her mother. She did not move away from her mother until she was ignored for a length of time and felt reassured. When she warmed up she became more sociable. She had a high activity level once she felt at ease.  She made good eye contact but it was not sustained. For each task requested she would cooperate briefly, then become oppositional again. She was whiny and her first response to any task was “No, I don’t want to do it.” During this entire session she was not heard talking to herself but she did flap her hands for a few minutes while jumping in place. She also twirled her hair for a minute or so.  She did not do any repetitive task such as turning the light off and on or turning the water off and on.  She did not hum to herself. She did not laugh or cry inappropriately. Although her social interaction was not normal, she was not in a world of her own.  She frequently asked her mother to read her a storybook and followed the story carefully, correcting her mother at intervals.

She did not initiate much speech except when asking her mother to read her a book but when she spoke she was fluent, appropriate and intelligible. Her sentences were 4-5 words long.

Muscle tone and strength were normal. Deep tendon reflexes were 2+ and symmetrical bilaterally. Plantar responses were flexor bilaterally. Her gait was normal. She walked on her heels and toes satisfactorily. She could not walk in tandem. She could not skip, hopping was limited. She stood on each foot for 2 seconds. She picked up a cheerio with a neat pincer grasp. No tremors were noted during fine motor tasks. She used her right hand predominantly , including writing, but used her left hand for building with blocks. She did not like to be touched, although she permitted the entire physical examination over a period of time.

Pupils were equal and reactive to light. Extraocular movements were full. Red reflexes were present bilaterally but discs were not visualized. There was no drooling. Other cranial nerve functions seemed normal.

On developmental assessment, delays were noted predominantly in the fine motor adaptive and personal/social areas. She built a tower of 8 cubes but could not imitate a bridge. She imitated vertical and horizontal lines and correctly picked the longer of two lines. She drew a person with three parts. She could not copy a circle or a cross. She recognized several colors. She comprehended prepositions and followed directions appropriately. She named opposites and defined words. She named the composition of a few items. She comprehended cold, tired and hungry.  She used plurals and gave her first and last name. She jumped in place and did a broad jump satisfactorily. She threw a ball overhand and kicked a ball forward.  She hopped on one foot for a few seconds. She could balance on one foot for only 2 seconds. By history she cannot dress herself completely and does not yet button her clothing. Kira correctly identified three letters of the alphabet.

Summary: Kira is a 4 1/2 year old girl with a history of poor social skills and mild developmental delays. She does not interact well with others, has a high activity level and is oppositional. Perinatal history is positive for premature labor at 28 weeks suppressed with medications, oligohydraminos, breech presentation and cesarean section delivery. Gestation was 37 1/2 weeks. Congenital torticollis was noted at birth and resolved with physical therapy. X-rays of the cervical spine done at the Children’s Hospital of Philadelphia were normal. Early motor milestones were slightly delayed, although she was walking without assistance by one year of age. Fine and gross motor coordination difficulties have been noted. Language milestones were achieved in the normal range, if not early. Family history is negative.

Growth parameters are in the normal range, including head circumference. Mild facial asymmetry is noted, the left eye being smaller than the right. General physical examination otherwise is normal. Neurological examination does not show any focal or lateralizing findings. Fine motor difficulties are noted. Behavioral observations include slow to warm up, lack of initiation of interaction, short attention span, easy distractibility, oppositional behavior and poor motivation to perform tasks. She makes good eye contact, though not sustained. There is no echolalia, no repetitive activities and no tuning out. She does show some self stimulatory behaviors in the form of jumping in place, flapping her arms and twirling her hair. Hand functions are purposeful. While she has impairment of social skills, they do not appear to be to a degree where a diagnosis of pervasive developmental disorder can be made at this time.

Developmental delays are noted in the fine motor adaptive areas but not in the language area.

Impressions:

1. Developmental delays in fine motor adaptive and personal/social areas.

2. Impairment of social skills.

3. Language skills tested are age appropriate.

4. Self stimulatory behaviors in the form of hand flapping and twirling of hair.

Recommendations:

1. Since Kira is not able to function in a regular preschool setting, she should be evaluated for placement into a preschool handicapped program. In the interim she may benefit from group play therapy and/or social skills program.

2.No neuroinvestigative studies are indicated at this time.

3. Neurodevelopmental re-evaluation in 6 months.

:

 

Profile of an NLD/ASD Child: Part 3

Occupational Therapy Evaluation

Child’s age: 4 years, 6 months

Reason for referral: Kira was referred for an occupational therapy evaluation as part of a full child study team evaluation. Kira was previously evaluated by this therapist last year. Concerns at that time centered around her social development and attention to task. Kira has attended preschool this year. While growth has been noted, concerns persist in the aforementioned areas.

Behavioral Observations: Kira entered the evaluation room with this tester, by herself, as her mother completed an interview with the social worker.  She was pleasant and friendly but announced that she did not want to play. Nonetheless, she was cooperative when asked to perform a variety of gross and fine motor activity.  While she preceded her performances with “I don’t want to” she could be encouraged to participate. This was Kira’s second evaluation on this morning.

Kira’s attentional behavior appeared to be diminished. Eye contact could be elicited but was fleeting in length and not offered frequently on her own initiative. Response time appeared to be notably delayed. Kira often appeared to be staring in to space. Sometimes she seemed to forget what she was supposed to do. On other occasions after a long delay, she would say “I don’t know how to do that.” While performing many gross and fine motor activities, Kira failed to watch what she was doing, which interfered with the accuracy of her work. Kira talked freely throughout the evaluation period: conversations were not always topical. Also noted was that Kira tended to hold her breath while concentrating, letting it out suddenly.

Gross Motor:  Kira displayed a full repertoire of primary movement patterns, with a fairly complete range of secondary, more integrated movement patterns. Active range of motion and muscle tone appeared to be generally within normal limits. Overflow observed last year (arms in midguard posture and hand flapping) seemed to have lessened. The quality of her movements in terms of speed and agility appeared to be within normal limits. Kira tended to move spontaneously, without careful regard to motor planning other directed movements.

According to the Michigan Preschool Profile, Kira functioned on a 4 year to 4 year 6 month level in gross motor development, with scattering of skills in the 3 year 6 month to 4 year 6 month level. Kira walked with heel to toe articulation.  She was able to walk backwards and in a heel to toe fashion.  She stood on one foot for one to two seconds. She jumped in a forward direction a distance of about twelve inches. By report, she pedals a riding toy, and uses the slide and swing, although she does not yet pump a swing. She was able to toss a ball, with inconsistent control.  Inattention interfered with her ability to catch the ball.

Perceptual/Fine Motor: Kira used her hands in a fairly coordinated, assistive fashion, displaying a preference for her right hand. Mild hypermobility of the joints of the hands was noted. Manipulation was usually performed in the fingertips, although when inattentive, palmar control was used. She displayed a wide range of grasp patterns with pincer grasps occasionally being lateral. Release appeared to be immaturely developed in both control and precision in placement, again being modified by inattention to task.

According to the Michigan Preschool Profile, Kira functioned on a 3 year 6 month level, with skills widely scattered in the 2 years 6 months to 4 year 6 month range. She stacked eight one inch cubes and duplicated building a four cube train and a three cube bridge using trial and error but did not build the five cube gate or six cube pyramid. She did not complete the rotated two piece puzzle but did complete the simple five piece puzzle. Again, Kira’s approach was not well organized, and she tended to retry the same piece in the improper place repeatedly. She placed six pegs in a pegboard in ten seconds.

Kira held a pencil in her right hand, in a digital supinated grasp. She copied a vertical and horizontal line and a circle and attempted to copy a cross.  She printed her name with some assistance. She drew a seven part man upon request. She attempted to trace within a square template. Kira attempted to cut on a line, with some success.

On the Ernhardt Developmental prehensile assessment, she functioned on a 3 year 6 month to 4 year level. On the design copying test from the SCSTI she achieved a standardized score of – 0.1 (where scores above + 1.0 SD and below -1.0 are considered increasing significant.)

Self Care: Mrs. Baker reported that Kira is completely toilet trained, including at night. She dresses and undresses herself. She can undo snaps and zippers. For feeding she uses a fork and spoon and can pour from a small pitcher.

Summary:  Kira was referred for an occupational therapy evaluation as part of a full Child Study Team evaluation. Her behavior was marked by inattentiveness and difficulty planning and organizing herself for movements and activities. Gross motor functioning was essentially within normal limits, although movements were spontaneous and not well planned. Perceptual/fine motor development was judged to be mildly to moderately delayed, with a wide scattering of skills up to age level. Inattention hampered her performance in all areas tested.

Profile of an NLD/ASD kid: Part 2

Occupational Therapy Evaluation

Child’s age:  3 years, 8 months

Background: Kira was referred for an occupational therapy evaluation by staff from Project Child’s Assessment service because of concerns with gross and fine motor development. Mrs. Baker originally brought Kira to Project Child because of concerns about her social abilities and questionable attention to task.

Kira is the product of a full term pregnancy, with delivery achieved through Cesarian section due to a breech positioning. Mrs. Baker reported her recollections of gross motor milestones being mildly delayed, although independent ambulation was achieved by one year. Medical history was remarkable in that Kira was born with congenital torticollis, which has since resolved. Health has been generally good. Kira attends nursery school.

Tests Administered: 

Michigan Early Intervention Developmental Profile

Michigan Preschool Profile

Ernhardt Prehensile Profile

Parent Report

Observation

Behavioral Observations: Kira entered the evaluation room with her mother, appearing fairly comfortable and interested in her environment. She sat at the table when directed to do so.  Eye contact could be elicited but was fleeting, particularly as language or task demands became more persistent. Kira was generally cooperative and happy, although she seemed to need to be encouraged to participate in dialogue. Mrs. Baker reported concerns that she needs to direct Kira’s play and that she frequently reverts to hand flapping episodes. Occasional episodes of hand flapping were observed during this assessment, but not in an uncontrollable fashion. She also held one hand in the air, while manipulating with the other hand.

Kira benefited from focusing prompters to direct and maintain her attention to task. She occasionally became fidgety in her chair. She seemed more distracted by her own movements and thoughts than by external stimuli.

Gross Motor: Kira displayed a full repertoire of primary movement patterns, with a fully complete repertoire of secondary more integrated movements. Active range of motion and muscle tone appeared to be within normal limits as well. Overflow was observed on occasion as noted previously, with shaking of the arms, as well as occasional fisting, and oral overflow. The quality of her movements was judged to be age appropriate.

According to the Michigan Preschool Profile, Kira functioned on a 3 year 6 month level. She walked with heel strike, and ran fairly smoothly. Mrs. Baker reported that Kira ascends and descends stairs in a reciprocal fashion. She was able to jump twelve inches in a forward direction and repetitively. She stood two to three seconds on one foot. By report, Kira uses the slide, climbing bars and swings on the playground. She pedals a riding toy as well.

Perceptual/Fine Motor: Kira could use her hands in a coordinated, assistive fashion, displaying a preference for her right hand. She manipulated objects comfortably in her fingertips. A very mild tremor was occasionally evident in the hands in unstable postures. Release appeared immaturely developed in both control and precision in placement. Kira had difficulty isolating the movements of her thumb and individual fingers imitatively.

According to the Michigan Preschool Profile and EDP, Kira functioned on a 30 to 32 month level in perceptual/fine motor development, achieving a basal score of 28 months and displaying a scattering of skills up to 3 years 6 months. She was able to stack 6 one inch cubes, and aligned the blocks. She did not actually duplicate building a 4 cube train. She completed the three piece formboard in a forward and reversed presentation. She did not complete the rotated two piece puzzle. She placed six pegs in a six holed pegboard in 19 seconds.

Kira held a marker in a static tripod grasp. She was able to copy a vertical, horizontal and diagonal line, and a circle. She drew an eye, an ear and some hair on a complete-a-man drawing. Kira held scissors in both hands, and is mastering snipping. Kira achieved a 3 year level on the Erhardt Prehensile Profile.

Self Care: Kira is toilet trained during the day, but not at night. She eats using a spoon, and occasionally fork. She spreads very little. She can take off her socks, shoes and underwear, and put on her underwear, and sweatshirts.  She is cooperative in dressing and not yet handling fasteners.

Summary:  Kira was referred for an occupational therapy evaluation because of concerns about hand flapping, difficulty involving herself in play, and delays in gross and fine motor development. Gross motor abilities were judged to be within normal limits. Perceptual/fine motor abilities are judged to be moderately delayed in both quality and skill achievement. Overflow, as noted by Mrs. Baker, was also observed. She will probably gradually outgrow this behavior.

Recommendations:

  1. Kira has been referred to the Perceptual/Motor Clinic. If vacancies are not available, she will be placed on the waiting list.
  2. Mrs. Baker may be able to gradually lead Kira to making her own decisions about play by providing two or three choices, start her on the activity, then encouraging her to play independently for increasing periods of time.
  3. Kira should be encouraged to give and maintain eye contact, by using the directive “Look” (point to eye) and delay speaking to her until she does look at speaker.
  4. Games that encourage Kira to follow directions, move slowly, or sit quietly may also help (i.e.-Giant Steps, Follow the Leader, Simon Says, etc,)