iLs Case Summary Report

Associate’s Name:
Susan Tieche OTR/L, Jennifer Bilyew, M.S., CCC-SLP

Name of Organization:
ITS: Developmental Therapy Services

Presenting Problem:
Sensory Processing, Attention, Language Delays

1. OT: “Dillon” presented with a vestibular processing disorder affecting self-regulation (low arousal/ high vestibular threshold), low muscle tone, poor visual efficiency skills, and bilateral integration. He also presented with significant proprioception deficits influencing body awareness, coordination, fine and gross motor abilities. There were also indications of auditory processing deficiencies.

2. Speech: Dillon initially presented with delays in expressive and receptive language skills. He had difficulty with sequencing information, processing directions in a timely manner, and telling about events that took place in a clear and comprehensive manner. His vocabulary base was weak and he appeared to have word finding difficulties.

Therapeutic Goals:

1. OT: normalize vestibular processing, improve visual efficiency skills, improve core strength and balance, improve self-regulation/attention resulting in the ability to engage in social interactions and classroom work with out repetition of instructions and one-on-one support, improve availability for visual motor work and improved visual motor skills.

2. Speech:naming pictures, identify categories, retell a story with 3 steps (without pictures), and describe a picture from memory (2-3 details such as what, color, shape).

Background:
Dillon is a 6 year-old boy who had a history of delays in expressive and receptive language as well as in fine motor and gross motor skills. There was also notable concern regarding inattention. He had PE tubes inserted at 22 months and no other medical problems or diagnoses. He had been receiving weekly OT intervention to address sensory integration dysfunction, handwriting deficits, and visual information processing deficits since (18 months to 5 years 4 months). Dillon did participate in the Therapeutic Listening program at home, which had significant impact on his performance on Kindergarten (in terms of attention and concentration). He began private speech intervention at ITS: DTS in January. This was in addition to speech therapy provided by the school (2x per week in a group).

iLs Program Used:
The iLs Total Focus Sensory Motor Program was initiated in February of 2011 where he listened 1 hour per day, 7 days per week in combination with participating in a sensory diet of core strength, swinging, and ocular motor exercises. He completed the 60 hours of the Sensory Motor Program and is now on the second round of the Sensory Motor Program.

Other Interventions used:
Dillon began private weekly speech-language therapy in January and continued this therapy throughout the iLs intervention.

Summary of Changes:
In January, Dillon was given the Differential Screening Test for Processing before he began the first 60 hours of the iLs program. It was given over 3 sessions by his SLP. There are 3 areas of subtests – Acoustic (Dichotic Digits, Temporal Patterning, Auditory Discrimination), Acoustic-Linguistic (Phonemic Manipulation, Phonic Manipulation), and Linguistic Subtests (Antonyms, Prosodic Interpretation, Language Organization). The screening was administrated via headphones and audio CD. The screening was split up over 3 sessions due to Dillon’s inability to attend to the tasks, fatigue, and delayed processing skills. For each subtest, Dillon required the CD to be stopped between each item to allow him time to process the auditory information. For a 6 year old, he failed all of the subtests, as he could not answer the target questions within the allotted time frame. The scores in the “January” column reflect the raw score he received given time between each item. The numbers in the “Pass/Fail” column shows the score one must have to pass the screen. The final column shows the scores Dillon received when the screen was given in May after the initial 60 hours of the iLs program. It should be noted that during the administration of the screen in May, Dillon was not given any extra time between items. He was able to attend without redirection, did not require the directions to be given a second time, and did not require any movement breaks. He was calm and attentive.

Differential Screening Test for Processing Raw Score January Pass/Fail (6 yrs.) Raw Score May
Dichotic Digits 2 P* 2 6 P
Temporal Patterning 4 P* 3 11 P
Auditory Discrimination 9 F 10 15 P
Phonemic Manipulation 5 F 6 10 P
Phonic Manipulation 3 F 4 6 P
Antonyms 6 P* 6 6 P
Prosodic Interpretation 6 F 7 8 P
Language Organization 8 F 9 13 P

*Dillon would not have passed these sections with out extra time. He would have scored a 0 for each of these subtests.

The May screening revealed a significant difference in both scores and observable behaviors. Dillon was able to sit and calmly attend with out break and without stopping the CD. His raw scores changed in all subtest except for Antonyms. In his speech-language therapy, the areas that were being addressed fell in the Linguistic Subtests (Antonyms, Prosodic Interpretation, and Language Organization). We primarily worked on vocabulary and Language Organizations. We did not formally address Prosodic Interpretation. We would have expected a certain amount of change for this section of the screening. He was not getting intervention (other than the iLs program) that was targeting the Acoustic or Acoustic-Linguistic sections of the screen. It was felt that Dillon had much greater access to his auditory skills and linguistic skills after the 60 hours of the iLs program. His attention was improved and his impulsivity had diminished.

In speech therapy, his ability to use the correct vocabulary and sequence events (in life and in books) was greatly improved. All visual cues could be taken away and Dillon was still able to recall and sequence stories. He had become more animated and had much more direction in his conversations. He had specific ideas about what we should do and took the time to explain how to do it. These abilities had not been seen in January.

Parent observations: (after 27 hours of the initial 60 hours): Dillon’s mother was an excellent observer of her son and gave us weekly updates of the changes she saw and the changes the school reported. She noted, “Within the first week of iLs he demonstrated better pragmatic language and increased social interactions with peers in unstructured settings and in classroom group activities. He was quicker in following directions and quicker processing information. He demonstrated better conversation skills and staying on-topic with less prompting across all settings.” He was more confident moving through his school day (by teacher report). He was showing more resilience with unexpected events (i.e., no more tears over seemingly trivial events at school). In the third week, he demonstrated better focus, attentiveness to daily routines, was “spacing out” less often, and participated in more self-initiated productive play. During their daily OT home program, his mom noted that he had better visual functioning.

OT Changes: In terms of self regulation and attention (iLs stimulates the vestibular system which has an influence over the Reticular Activating System in the brainstem which is our “thermostat” for sleep/wake, hunger/thirst, and bowel/bladder function), Dillon initially spent most of his time seeking input from his environment (jumping and crashing/swinging) with a poor adaptive response for adjusting his arousal level. When required to attend auditorally, he would need directions repeated and the “wait time” for him to respond could be up to 15 seconds (or no response) and then what he said would be segmented and disorganized. For table top tasks, he would look at the visual information on a page briefly then look away. His sustained visual attention was poor. Now, Dillon is able to visually attend to table top work for up to 45 minutes and able to initiate independent work in school with minimal redirection from the teacher and minimal to no verbal cue to prompt initiation of an activity. While he continues to enjoy movement and gets it regularly, he is not obligated to it demonstrating improved availability and initiation with social engagement with peers consistently. He has demonstrated dramatic improvement in self-regulation and his ability to attend to academic tasks, process language and respond and, conclusively, he can learn in school with very minimal support versus maximal support. He repeated Kindergarten and is now a rising first grader in a public school with a class of 25-28 students. Dillon continues to receive group speech therapy 2x/week to address expanded language goals such as answering critical thinking questions about events or stories, and in-class support from the special education “team,” (typically the general education teacher or a paraprofessional) to address attention, comprehension, and written expression. Additionally he receives several classroom supports including a picture schedule and repetition of directions as needed, lined paper for writing tasks, and preferential seating to help with focus, processing speed, and work focus.

In terms of visual efficiency skills (iLs stimulates the vestibular-visual neurological pathway), Dillon initially struggled 100% of the time (indicated by brow furrowing) to team both eyes for saccades, ocular motor pursuits, and visual fixation. He demonstrated significant improvement in visual attention moving from 10 seconds of visual fixation to 30 seconds of visual fixation, 10 seconds of ocular motor skills (with 3 jumps off the target) to solidly tracking for 30 seconds (each eye then both eyes together). The end ranges of ocular motor skills remain a struggle. He was able to move from 10 seconds of saccades (with over and undershooting) to a solid 30 seconds with only slight instability. Congruently, his reading and visual attention for academics has dramatically improved and his engagement in near point activities/table top visual motor activities have significantly improved. His mother continues with a home program of end range ocular motor pursuits and using the Brock String to train eye teaming abilities as his endurance for eye teaming is still deficient.

In terms of coordination (iLs stimulates the vestibular-cerebellar neurological pathways), he is now more available to attempt novel motor coordination tasks. After months of swimming lessons and only putting about 3 strokes together at a time and never going in deep water, Dillon surprised everyone at his swim team “safety check” by swimming a full length of the pool using a solid though slow freestyle stroke, even turning his head to the side to breathe. When Mom asked Dillon about his swimming afterwards, he told her his legs were tired but he knew he had to make it to the end without stopping if he was going to be able to join the swim team. After a few weeks of daily practices, Dillon now swims numerous laps on both his front and back. He struggles with stroke formation, for example occasionally forgetting to kick when focused on his arms and vice versa. He also has more trouble stroking with his right arm than his left, presumably because as a left-hand dominant child, he is breathing on his left side so that arm comes out of the water more easily when he is turned to breathe and when his face is in the water, he has difficulty lifting and fully extending his right arm in the same manner. Also, he has overcome his fear of the “bounciness” of the diving board and now jumps off with glee, whenever he has the opportunity. Bilateral Integration remains a struggle for Dillon; however, he is much more willing to take risks and attempt novel motor tasks as compared to previously.

In terms of core strength, he showed improvement in his upper back and neck muscles for prone extension moving from 10 seconds to 40 seconds. He still is unable to co-contract his lower back to lift his lower extremities (Mom is now doing this as a part of his exercise for his sensory diet at home). He improved from supine flexion from 10 seconds to 36 seconds (still below average for his age but improved). From January to June he completed Ball Explosion from the Core Concepts book every day as part of his sensory diet to address core strength.

In terms of balance (iLs stimulates the vestibular system which is our center for balance/righting/equilibrium reactions), Dillon has improved in maintaining his balance for 10 seconds on the right foot with eyes open and 9 seconds on the left foot with eyes open. He has improved with his understanding of his vestibular midline and can hold a heel to toe position for 10 seconds with eyes open. With eyes closed, he is able to hold this heel to toe position for 3 seconds at best and stand on either leg for 2 seconds at best. His visual system is now very supportive of balance as he now owns and understands a visual midline where as he did not previously. With his eyes closed, his vestibular system still struggles to register gravity and so he would continue to benefit from more sensory integration around utricle functioning.

Emotionally, Dillon exhibits a significant improvement in coping skills for changes in routines, transitions, and motor challenges. This is most evident to his mother at the loud, busy swim meets in which Dillon now excitedly takes part. He stays calm, asserts himself when necessary, and remembers which stroke to swim when the race begins. He also has several friends with whom he runs around when not swimming. This independence and enjoyment of peers is a new development as well.

Conclusions and Recommendations:
It was clear to Dillon’s mother, teachers, and therapists, that the iLs program had a large impact on him beginning after the first week of intervention. Each week he arrived in the office, his mother would report the improvements in pragmatic interactions, direction following, and emotional regulation. In speech therapy, the sessions needed to become more challenging (in leaps and bounds) from week to week. His ability was often under-estimated as he would be able to perform a previously challenging task easily. He seemed to have better access to his vocabulary (as word finding errors decreased) and he was able to make connections between concepts easily. His attention improved and his engagement in conversations was more on-topic. He could recall events and tell the sequence with few word errors and little prompting. It was felt that the iLs program seemed to fill in the gaps in his foundational skills and allow him greater access to language and higher-level cognitive skills.

In terms of OT, it is recommended for Dillon to continue the iLs Sensory Motor Program combined with his sensory diet until we can remove it and his level of function continues without regression. At that time, we will move to the higher frequency program to continue to refine attention and auditory processing skills. In terms of SPLT, he is undergoing a summer home program addressing language processing and will reconvene in the fall with Ms. Bilyew to determine the next steps.

As therapists, we have been fortunate to work with this Mom, a seasoned special education teacher who comes to us with a good framework and knowledge of what we do. Due to this, she has been an excellent observer, able to give us exact feedback about the changes Dillon has made. She has also understands the importance of following through with a home program and is the largest reason of why Dillon has made significant progress. Thank you to all of the Mom’s and Dad’s who follow through with our home programs as we are simply your guide!!! It makes THE difference! Susan and Jennifer

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