Case Study: ASD, PDD-NOS, Anxiety Disorder, ADHD-NOS, TBI & LD

SSP ASSOCIATE’S NAME & DISCIPLINE:  Joseph Falkner, MST/CCC-SLP, CA

CLIENT BACKGROUND: 12-year-old male with ASD, PDD-NOS, Anxiety Disorder, ADHD-NOS, TBI, and Learning Disorder

Previous Therapies and Programs:

• Speech Therapy
• Occupational Therapy

AE is a 12-year-old male who is currently in the 6th Grade.  AE presents with the following diagnoses:  ASD, PDD-NOS, Anxiety Disorder, ADHD-NOS, TBI, and Learning Disorder. AE’s mother indicated that AE’s functioning prior to and following the TBI were consistent.  AE has a history of ear infections, and has received 2 sets of pressure equalizing tubes. Some high frequency loss was reported in a past evaluation, although AE does not wear hearing aids and it was not determined to be a significant factor at the time of the intervention.

Developmentally, AE’s mother shared that he was born after a healthy, full-term pregnancy, appearing healthy and typical upon delivery. Regardless, she shared that AE was significantly delayed in reaching his early motor and language developmental milestones. AE reportedly crawled independently at 14-months-old, walked independently at 22-months-old, began speaking in single words after his 2nd birthday, and began stringing words together near his 3rd birthday. AE has a reported history of some disordered language patterns, as well, such as asking repetitive questions, as well as speech articulation difficulties. AE also engages in stereotypical motor mannerisms, such as hand flapping and toe walking and often seeks a high level of sensory input.  AE does demonstrate some rigidity in eating (e.g. no foods can be touching each other on his plate, he does not like meats).

AE has attended speech therapy to address receptive and expressive deficits, and occupational therapy to address emotional and sensory regulation, attention, social participation, daily living skills (e.g. shoe tying) and gross and fine-motor skill development.  AE has since been discharged from both of these services both in the private and school settings as it was felt that he met his goals.  AE currently sees an educational therapist who works with AE on skills related to both reading and math.

PRESENTING PROBLEM:

Primary presenting concerns were related to AE’s history of impulsivity, inattention, anger outbursts, meltdowns, social difficulties, and relative weaknesses in aspects of learning.  In addition, his mother indicated that he struggles following directions and providing coherent personal narratives.

At the time of AE’s evaluation (in June and July of 2017), AE’s mother endorsed that he exhibited difficulties with:  taking the perspective of others in a situation, awareness that others’ thoughts, beliefs, etc. may differ from own perspective, compromising or negotiating, understanding context of situations; identifying feeling of self or others, emotional reciprocity, taking into account others’ emotions when acting, overstated emotional reactions to a given situation (with significant blowups and meltdowns);  initiation, planning, sequencing, organization, prioritization, goal-directed persistence, time management, a significant discrepancy between executive functions when calm versus when emotions are involved; and sensory/stimulation-seeking, sensory avoiding, appearing inattentive at times to human speech, use of adaptive coping responses, and ability to self-calm.  These endorsed difficulties do correspond with past and current testing.

GOALS FOR THE SSP PROTOCOL:

• Improve self-regulation (emotional) and calming
• Decrease overall hyperarousal and hyper-reactivity to perceived pain (whether physical or psychosocial)
• Decrease severity of meltdowns/blowups

HOW IMPLEMENTED/OTHER INTERVENTIONS USED: (occupational therapy, speech and language, etc.)

This was AE’s first intervention with this therapist.  He has received both Occupational and Speech Therapy in the past, but has been discharged from both.  AE does currently work with an educational therapist.

SUMMARY OF CHANGES: (pre-post therapy assessments, observations, etc.)

• AE’s mother reports that AE has exhibited the following in the weeks after the SSP intervention:  improved sleep, improved self-calming (which mom also described as “getting over things faster” or exhibiting a decreased time between an event that is dysregulating, such as falling down while playing or discussing a peer who AE has a difficult relationship with, and the time that AE becomes regulated and is able to return to activity), sitting during activities where he is not directly engaged, vocabulary use and coherency of narratives (with use of complete sentences and appropriate narrative structures), and being increasingly “tuned in” to conversations around him.
• On the BBC Sensory Scales, AE’s mother’s overall ratings for Auditory Processing during the pre-test went from 9/15 questions being at the almost always or frequently/often levels, and being very concerned about AE’s Auditory Processing; to having 0/15 questions answered at the almost always or frequently/often levels, and being slightly concerned about AE’s Auditory Processing.
• On the Sound Sensitivity Program:  Caregiver Questionnaire, AE’s mother indicated the following observations (in addition to those previously mentioned):
  • improved self-awareness (particularly of emotions)
  • improved communication about himself (his feelings),
  • participation in someone else’s conversations regarding the other person and their interests
  • improved direction following, and a decrease in a particular fear that AE had in separating from his family and going to another part of the house where he would be alone.

In addition, AE has made a smoother transition from summer to school than his mother previously would have predicted.

ADDITIONAL INFORMATION:

AE’s mom related two anecdotes concerning specific changes that she has noted:

1)  AE was playing tennis with his family.  While trying to chase down a ball, he fell and skinned his knee, ripped his shirt, and hurt his hand.  In the past this type of event (where he became injured whether it be a tiny amount or more significantly) would lead to AE having a meltdown that lasted a significant period of time (over a half hour), and he would need to be calmed by his mother.  AE’s mother reported that he let out a scream and went to the sidelines to stop playing.  She reported that in under 5 minutes (about 3 or so points in the game) AE was able to return to the game after self-calming and self-regulating.

2)   AE’s parents were talking in the next room about a neighbor and her feelings about something that had happened in the neighborhood.  AE was watching television at the time.  His mother reports that AE overheard what they were talking about, and was able to clearly and concisely tell them what he had heard the neighbor saying about the incident.  AE’s mother reported that he seemed much more “tuned in” to what was going on in his social environment, and that both his vocabulary usage and the coherency of his speech were significantly increased over what he was exhibiting prior to the intervention.