Associate’s Name:
Danielle Peters, MSOTR/L

Associate’s Discipline:
Occupational Therapy

Name of Organization:
Bluebird Pediatric Therapy Services, Inc.

Age/Gender of Client:
Male, 11 years old

Presenting Problems:
Main diagnoses: dyslexia, ADHD, (Central) auditory processing disorder
Other presenting problems: dysgraphia, visual processing skills deficiency, lack of coordination, poor core strength/balance/body awareness, impulsivity, low self-esteem.

Therapeutic Goals:

  • Improve overall coordination, balance and strength (core, fine motor and shoulder) to improve handwriting & hand/eye coordination
  • Improve body awareness to enhance overall: self-regulation, attention, coordination and balance
  • Improve ability to initiate and plan out multi-step motor planning tasks in order to improve overall problem solving/processing skills
  • Improve visual processing skills (visual motor, visual tracking and visual perceptual) to enhance reading skills

Background:
At the initial evaluation, ‘L’ was 11 years, 2 months old.  He was struggling greatly in the 5th grade with all subjects due to an inability to read fluently and difficulty with focusing.  He attends monthly counseling sessions due to family struggles (parents separated) and his attention difficulties.  He takes Concerta and Clonodine for his attention difficulties.  ‘L’ was born via C-section without any complications, was difficult to comfort and always on the go as an infant and child.  Further, ‘L’ had frequent ear infections, two sets of pressure equalizing (PE) tubes and frequent colds.  ‘L’ receives special accommodations in school that mother feels often inhibit him from learning because he is not challenged with reading assignments.  His tests and all reading assignments are read aloud to him and he answers verbally.  Prior to this assessment, ‘L’ had not received any special services outside of his school accommodations.  Mom would like him to be able to read at a high enough level to survive as an adult.

iLs Program Used:
The iLs Pro System was used for ‘L’’s program with a total of 30 sessions estimated at the beginning.  He began with an Organization Phase with SI BW for 3 sessions, progressing to the Transition Phase for 5 sessions with SIBW>7, then 7 sessions in the Activation Phase >7.  Following a two-week break, he did a 5 session Integration Phase and finished his program with 5 sessions of FSM & SPL and 2 sessions with FSM.  ‘L’ completed a 27 session program using the iLs Pro System, a 3-month break was taken upon which a reevaluation was completed.

Other Interventions used:
The iLs program was completed during occupational therapy treatment sessions with focus on the above areas of deficit.  Each session was 75 minutes in length 2 – 3x’s per week (this varied due to school schedule) with daily home programs provided for the family to carryover; these included the iLs Playbook focusing on visual motor activities, balance and bilateral coordination, as well as visual perceptual activities.

Summary of Changes (tests, observations, feedback, etc.):
Upon re-evaluation, ‘L’ has made improvements in all areas noted initially as deficits.  ‘L’ now demonstrates age appropriate balance, coordination, strength, handwriting, body awareness, visual motor integration skills and attention abilities.  Mom reports improvement in handwriting skills, attention to tasks and independence in completing tasks at home.  She reports decreased impulsivity with task completion and increased attention and self-confidence when attempting new tasks.  She reports continued difficulty with reading but great improvements in mathematics (from a D average to an A average).

TVMS-4 (Test of Visual Motor Skills-4):  This is a standardized assessment tool used to measure visual perceptual skills with a motor component (the client is asked to replicate designs increasing in complexity as the test progresses).  This test is an excellent measure for how well a person’s hands/eyes work together.
Initial Evaluation Results RE-Evaluation Results
Raw Score

42

46

Standard Score

95

104

Percentile Score

37th %

61st %

Age Equivalency

10 years

13 years, 2 months

Comments Major weaknesses in the areas of closure, line quality, add/deleted part and shape overlap. This is an excellent improvement in visual motor skills!  This demonstrates an overall improvement in using his hands/eyes together.  There are some difficulties with line quality and shape overlap but no difficulties in other areas noted from previous evaluation (demonstrate fine motor weakness).

 

The HWT Print Tool:  This is an assessment tool used for handwriting assessment based on the areas of memory, size, placement, orientation, start, sequence and control.
Initial Evaluation Results RE-Evaluation Results

Uppercase

Lowercase

Numbers

Uppercase

Lowercase

Numbers

Memory

96%

96%

100%

100%

92%

100%

Size

0%

0%

0%

100%

96%

100%

Placement

72%

60%

56%

88%

73%

56%

Orientation

100%

90%

100%

100%

100%

100%

Formation

88%

76%

100%

100%

98%

100%

Control

52%

68%

78%

88%

85%

100%

Overall Handwriting Score: 67% Overall Handwriting Score: 93%
Comments ‘L’’s overall score for handwriting is poor for his age. His age equivalency is below 6 years.  He has definite deficits in the areas of placement, size and control with moderate deficits in the formation of the letters. ‘L’’s overall score for handwriting has improved greatly and is now age appropriate.  He now has the ability to write with accurate placement, size and control.  Excellent improvement.

Conclusions and Recommendations:
Re-evaluation results show that ‘L’ made excellent progress during the 27 sessions of occupational therapy with the iLs program. Areas that continue to require improvement are visual perceptual skills without a motor plan, problem solving skills and reading skills.  After consultation with ‘L’’s Mom, it was decided that ~30 more occupational therapy treatment sessions with the use of iLs prior to school starting would be beneficial. The major focus will be on visual perceptual skills (discrimination, memory, spatial awareness and figure ground) and reading skills.  He is currently completing this program using the Reading and Auditory Processing Zones using the iLs Pro System 3x’s per week for 60 minutes each session. Note: Financial resources do not allow the use of a Focus System at home or to enroll him in a reading program.  However, the mother is very conscientious in implementing any recommendations.

Comments from Ron Minson, MD, iLs Clinical Director:
Standing back from the details of this case, a number of ideas come to mind, particularly in regard to the reading and visual processing issues.

Difficulties in visual processing skills (visual motor, visual tracking and visual perceptual) were noted in the goals and remain a problem following the intervention. Therefore, an evaluation by a developmental/behavioral optometrist is indicated to identify significant underlying concerns that may need the special attention of a specialist trained in vision therapy, unless the therapist has special training in this field.

With reading, it is not clear how much the visual versus the auditory system, or both are contributing to this problem. The visual concern has been addressed above. A diagnosis of an Auditory Processing Disorder was noted in the presenting problems. At this point, it would be helpful to have more information. How was the diagnosis made? Was it done by an audiologist? Is there evidence of a weak left ear from the SCAN 3 or similar test? The answers to these questions can suggest the next steps to be taken and particularly how the Interactive Language Program (ILP) may be of help.

Very importantly, it may not be obvious to therapists in general, how valuable the ILP can be in these cases. Reading is a language-based function. The ILP addresses, from bottom up to top down processing, all the neurological and language based components of reading – except some aspects of the visual system. It would have been advantageous to use the ILP beginning with the Integration Phase and to continue through the remainder of the program. By all means, I recommend that it be included in this second round of therapy.

Finally, I was pleasantly surprised at the marked improvements in the motor system; given the history, I would have suggested at least 5 sessions of the Organization Phase. However, this points out the efficacy of combined iLs and OT together to achieve results that may have taken longer with either intervention alone. These findings are supported by evidence from research on the power of movement and multi-sensory input for improving brain function.

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