Case Study: Autism, 8 year old male

Associates Names:
Cindy Dawkins, OTR/L, Andrea Pointer, MS/CCC-SLP, Shannon Norris, OTR/L

Name of Organization:
Kids Kount Therapy

Age/Gender of Client:
Male, 8 years, 11 months old

Presenting Problems:
“H” was diagnosed with institutional autism, apraxia, auditory processing and visual processing deficits. He presented with an inability to interact with peers, frequent echolalia, stimming, negative behaviors and difficulty with transitions.  He never participated in pretend play or parallel play.  He could understand questions but would not participate in conversation, only repeat phrases over and over. He did not answer ‘yes’ or ‘no’ to any questions.  He presented with low muscle tone and poor fine motor and gross motor skills. He was hypo-responsive with vestibular and tactile input, and would seek closed spaces prior to purposeful behaviors.   He required deep pressure and used a neoprene vest for calming at home and school.  He was unable to write a sentence with words in the correct order.

Client Background Information:
“H” was adopted at 7.5 months old from Guatemala and immediately diagnosed with failure to thrive, weighing 13.5 lbs.  He received early intervention but a developmental specialist told the family that therapy services would be waste of money. When he was 3 years old, he was enrolled in a special needs preschool.  “H” participated in clinic-based iLs Sensory Motor Program. He was seen 2x weekly for OT and iLs.  He demonstrated improvements with attention and focus in school. His self-regulation improved and self-stimulatory behaviors decreased, but he continued to have behavior problems at school. Transitions from one place to another were very difficult for him. He presented as severely autistic.

iLs Program:
He began using the iLs Sensory Motor program at home 5 days a week for one hour a day with consultative Occupational Therapy once every 3 weeks. He received Speech Therapy services one day a week for the 12-week, 60-session iLs program. His parents incorporated many activities at home, went swimming every day during iLs, and participated in gymnastics.

Summary of Changes During and After the iLs Program:

• After 2 months of iLs, his mother came into the clinic crying because he was participating in pretend play with Toy Story characters for the first time.
• He is now writing paragraphs with full sentences with appropriate syntax (word order).  He is reading more fluently with increased decoding although he still has weakness with auditory comprehension.
• He is initiating social greetings with others unprompted and maintaining conversation with at least 3 circles of communication whereas previously he was unable to complete one circle of communication.  Some language is still scripted and requires redirection, but it is more voluntary.
• During conversation, he is maintaining eye contact and sustaining it throughout the duration of thought and expression.
• He now asks for self-regulatory strategies instead of behaviorally acting out.  His mom reports he will manipulate people to get out of work, demonstrating behaviors to go to resource room but will confess why he is doing it.
• He is categorizing things and recognizing/using humor.  Mom sees more parallel play now, and language has improved to the point they can ask him questions and get responses. He is asking for interaction with friends at home and is communicating with his brother now.  He participates in Boy Scouts, soccer, basketball and church activities with greater participation.

Therapist’s comment:
There was a dramatic difference in the results from receiving iLs 5 days a week at home with therapy support and having iLs 2 days a week during therapy.  Increased frequency and duration made the difference.

Mom’s reported BEST RESULT:
“Before he did not answer questions and now after waiting a few seconds, we get a completely appropriate answer!  There are NO behavioral problems this year at school; he gets a “G” every day.”

Ron Minson, MD, iLs Clinical Director, Comments:
This is not the same child as the one who entered therapy six months earlier.  As noted by the clinician, the positive changes reflect the value of increased frequency and duration of therapy through a home program that followed the clinic program for the markedly improved outcomes. Note the emphasis was on improving subcortical function first. Thus, there are a number of cognitive improvements, such as increased attention, freedom from distractibility, improved writing and communication, increased social engagement, and, incredibly, a sense of humor. The improved eye contact most likely reflects improved auditory processing. There is also a marked improvement in self-awareness as evidenced by requests for help in self-regulation.

These improvements in cognitive function underscore the importance of the Sensory Motor Program to improved sub-cortical processing of the sensory systems (vestibular, motor, proprioceptive) to achieve the gains noted above. These gains will hold and continue to improve, because they are now built upon a stronger subcortical foundation. I am delighted the parents refused the egregious advice of the developmental specialist.

Changes in Sensorimotor Skills:
Postrotary nystagmus moved from off the charts to within normal limits.  He no longer seeks out the swing for self-regulation, although it will always be an activity he enjoys. He showed a mild increase in muscle tone and now can co-contract with wheelbarrow walking. He can catch a ball 75% of the time in a static position.  He showed marked improvement in gross motor skills with hopping on squares and doing hopscotch.  His balance improved on each foot from 1 sec. to 7 sec. on each foot. He could not touch finger to nose, but overshot prior to iLs nor could he reciprocate arm movements.  He is now able to touch finger to nose.  He still has delayed protective reaction backward, but his lateral extensions have improved. “H’ is now able to perform isolated finger touching.  He could not close his eyes by himself, but can now close his eyes independently.   His Dad’s main goal was related to sports. His kick accuracy has improved with a moving ball; before he would kick at a 45 degree angle.  He couldn’t kick with his non-dominant foot, but now can kick with accuracy with each foot.  Note:  His family just donated his neoprene vest to the clinic since he no longer needs it.

Miller Function and Participation Scales (M-FUN)   

The (M-FUN) is a developmental assessment tool designed to assist in “determining how a child’s motor competency affects his or her ability to engage in home and school activities and to participate socially in his or her world.” (Miller, 2006).

	Pretest				Post test¹
	Raw Score	Scaled Score	Interpretation	Progress Score	Raw Score	Scaled Score	Interpretation	Progress Score
Visual Motor	28	1	Average	283	40	1	Average	347
Fine Motor	40	1	Very Low/ Severe	292	37	1	Very Low/ Severe	281
Gross Motor	12	1	Very Low/ Severe	100	65	1	Very Low/ Severe	386
Test Observations	3	NA	Far Below Average	NA	30	NA	Far Below Average	NA
Home Observations (parent report)	99	NA	Far Below Average	NA	143	NA	Below Average	NA

SCAN3:C  

The SCAN-3:C “is an individually administered battery of tests designed to identify auditory processing disorders in children.” (Keith 2009)

	Pre test			Post test
	Raw Score	Scaled Score	Interpretation	Raw Score	Scaled Score	Interpretation
Auditory Figure-Ground +8dB¹	13	1	Disordered	31	4	Borderline
Competing Words-Free Recall	10	5	Borderline	18	8	Normal
Filtered Words¹	13	5	Borderline	19	7	Normal
Competing Words – Directed Ear¹	8	1	Disordered	21	4	Borderline
Competing Sentences¹	10	1	Disordered	26	3	Disordered
Auditory Processing Composite	8	47	Disordered	18	64	Disordered

Test of Auditory Processing Skills (TAPS-3)  The TAPS-3 “is an individually administered assessment of auditory skills necessary for the development, use, and understanding of language commonly utilized in academic and everyday activities.” (Martin & Brownell, 2005).

	Pre test			Post test
	Raw Score	Scaled Score	Interpretation	Raw Score	Scaled Score	Interpretation
Word Discrimination	15	1	Below Average	23	4	Below Average
Phonological Segmentation	2	1	Below Average	5	1	Below Average
Phonological Blending	12	7	Average	16	8	Average
– Phonological	9	65	Below Average	13	72	Below Average
Number Memory Forward	6	1	Below Average	6	1	Below Average
Number Memory Reversed	3	3	Below Average	8	9	Average
Word Memory	8	3	Below Average	12	6	Below Average
Sentence Memory	4	1	Below Average	10	3	Below Average
– Memory	8	60	Below Average	19	74	Below Average
Auditory Comprehension	0	1	Below Average	6	4	Below Average
Auditory Reasoning	0	3	Below Average	2	5	Below Average
– Cohesion	4	60	Below Average	9	73	Below Average
Overall	21	62	Below Average	41	73	Below Average

Sensory Processing Measure (SPM) – Questionnaire completed by parent  The SPM is a measure of a child’s sensory processing issues, praxis and social participation in school aged children.

	Pre test			Post test
	Raw Score	t score	Interpretation	Raw Score	t score	Interpretation
Social	27	67	Some Problems	26	66	Some Problems
Vision	21	68	Some Problems	20	67	Some Problems
Hearing	15	66	Some Problems	13	63	Some Problems
Touch	17	61	Some Problems	16	59	Typical
Body Awareness	14	57	Typical	14	57	Typical
Balance and Movement	20	65	Some Problems	18	63	Some Problems
Planning and Ideas	23	67	Some Problems	20	64	Some Problems
Total Score	96	65	Some Problems	91	63	Some Problems