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 In Case Studies, Sensory Processing Disorder (SPD)

Author
H’s Mother, RN, BSN, CAPA at St. John Medical Center, Tulsa OK

Abstract
H was a five-year-old with sensory processing difficulties, poor fine motor, coordination and muscle strength. He scored 104 on the iLs Checklist before starting iLs; after a year of listening, he made a 72 point improvement. Listening at home, he has completed Sensory Motor Program, Concentration and Attention Program and is halfway through the Reading & Auditory Processing Program. 

Background
H was born after a difficult birth and had ear tubes placed at 10 months, after which he stopped napping and would not sleep alone. He did not sleep through the night until he was 3-½-years old due to night terrors. As a toddler he would have violent outbursts at school.  H had sensorial sensitivity, making bath time, getting dressed and haircuts a battle ending in screaming and tears. He always met his milestones, but not through practice; he just woke up one day and started crawling, then walking and did the same with potty training.  He was accident prone and learning new things was very frustrating for him. He had very low self-esteem.  We tried traditional therapy with a psychiatrist, but it didn’t go well. When H was five we found The Tulsa Sunshine Center and with behavior therapy and occupational therapy we saw some improvement, but he still had quite a way to go.  I was very excited when our OT, Kassie, suggested the iLs Home Rental Program.

Presenting Problems:

  • Lack of fine motor skills
  • Poor coordination and muscle strength
  • Difficulty recognizing sounds of letters
  • Difficulty following strings of instructions
  • Inability to remember things in the short term
  • Low frustration threshold
  • Sensory Processing difficulties

Therapeutic Goals

  • Improve coordination and fine motor skills
  • Improve ability to focus and follow multiple commands
  • Encourage sensory processing through play

iLs Programs Used

  • Sensory Motor (approximately 3 week break), Concentration and Attention (approximately 5 week break), Reading & Auditory Processing, 3-5 times a week with Playbook activities
  • Home Program overseen by therapist and administered mainly by H’s mother

Summary of Changes

ils-checklist-chart

Lower scores indicate improvement

iLs Checklist: Expanded

Sensory & Sensory Motor 7/1/2013 12/1/2013 7/10/2014
bothered by background noise, loud, unexpected sounds 2 0 0
avoids eye contact 3 1 0
constantly on the move, seeks intense crashing or rough play 2 1 1
has difficulty sitting still, wiggles a lot, especially if trying to pay attention 2 1 1
struggles with fine motor skills, like handwriting 3 1 0
cannot follow directions in a noisy environment 2 1 1
bothered by textures on body, face or hands, having nails cut, hair combed 3 1 0
unaware of body sensations such as hunger, hot or cold or need to use toilet 0 0 0
makes disruptive noises or sounds 0 0 0
difficulty leaning new motor skills or those that require more than one step 3 2 1
difficulty organizing personal spaces or takes a long time to perform daily life tasks 3 2 1
dislikes or avoids group sports 3 2 2
difficult wit visual pursuits; often loses place, eyes skip one or three lies 3 1 1
has difficult completing puzzles 2 1 0
difficulty finding number or words on a page especially during math or reading tasks 2 1 1
clumsy, awkward, or accident prone, tripping or bumping into people or objects 3 1 0
has difficulty identifying and distinguishing between different sounds of letters 3 2 1
has difficulty judging force required for a task 1 0 0
cannot find pictures hidden in background 1 0 0
Totals 41 18 10
Auditory/Language
difficulty with spelling 3 3 2
poor grammar doesn’t speak in complete sentences 0 0 0
needs to be given directions repeatedly before responding 2 2 1
seems to not understand what is said, i.e., poor comprehension, needs explanations 1 1 0
difficulty following what others are saying 1 0 0
says, “What?” or “Huh?”, needs instructions repeated, needs visual cues 0 0 0
slow to react to speech 0 0 0
misuses or confuses words and sounds 2 2 1
is difficult to understand due to poor enunciation, can’t speak clearly 0 0 0
unable to recognize or repeat rhymes or songs 3 2 0
does not like to sing or hum 3 2 1
difficulty interpreting tone of voice – e.g. angry vs joking 1 1 1
Totals 16 13 6
Social/Emotional
does not transition smoothly from one activity to another 2 1 1
is not affectionate, not touching or hugging 0 0 0
lack of tactfulness, acts impulsively 2 1 1
response to situations appears immature for age 3 2 1
anxious, bites nails, face and body are not relaxed 1 0 0
easily overwhelmed, frustrated by daily life activities 3 1 0
lacks confidence with new environments and new tasks 3 2 1
“needy” – lacks independence, low self-reliance, low-self esteem 3 2 2
irritable, short-tempered 3 1 0
has difficulty making and keeping friends 3 2 2
does not sleep well, can’t get enough rest 3 1 0
has frequent mood fluctuations 3 1 0
Totals 29 14 8
Organization/Attention/Cognition
is distracted easily, not able to stay on task 3 2 1
has poor short term memory 3 1 1
must re-read schoolwork several times to comprehend 3 2 2
has difficulty getting, finding clothes, getting dressed in the morning 2 2 1
planning ahead is difficult, prefers to avoid planning at all 1 1 1
disorganized with school assignments, belongings, and schedule 1 0 0
can’t remember sequential tasks – e.g. do A, then B, then C 2 1 1
often fails to begin or to complete tasks or projects unless helped 3 2 1
Totals 18 11 8

Today H will look you in the eye when he talks to you. His diet has greatly expanded and he told me a couple months ago to no longer send the same thing to school every day for lunch. He is able to focus and concentrate more. We spend less time arguing over textures of clothing. He is getting his face wet and says he is ready to take swim lessons. He no longer feels like his brain is not working. Most importantly his confidence has greatly improved.

Listening at Home – Lessons Learned

  • Put it on the schedule

There were some challenges with doing the therapy at home. I work full time and like any mom, my responsibilities do not end when I get home. We planned out certain days and times to do the therapy, and stuck to the schedule. It allowed us to not overbook, because nothing works well when he is tired.

  • Discuss who will help with the therapy

My husband and I decided that I would be the main person to complete therapy with H and he only filled in when I was not available.

  • Read all the materials

I read the manual, but skipped a few things during the first phase that I later went back and read. Read the entire manual – it is worth it!

  • Let your child have (some) control

I sat down with H and explained that he could pick which Playbook set of exercises he wanted to do each day. After he did those we could choose other things to do that he preferred. I was firm with the things that were off limits.

  • Modify the Playbook Activities for success

H couldn’t do many of the Playbook activities on his own when we started, and there are still things in the sets he cannot do completely independently.   I broke down the more difficult things into steps for him to master before doing it all on his own. Throwing the ball and catching it is hard, so I throw it and he catches it whether off the wall or ground. We first started with just catching, then catching one handed, then added catching after a bounce and, finally catching off the wall. I modified other exercises to help increase his success and build his confidence, The look on his face the first time he accomplishes the next step is worth it.

As he mastered some of the activities we added skip counting, simple addition and similar cognitive activities to increase the difficulty. I push him to do more than he thinks he can do, though not to the point of frustration. We set goals for this summer and I am anxious to help him reach those goals.

Conclusions & Recommendations
I was so excited after reading the progress that children had with this therapy. As a parent I want the best for my child and hearing my son say, “mom my brain just does not work right” broke my heart. The child we had a year ago is not the child we have today. iLs did not fix the normal things we deal with in our children. We still continue to guide him in our expectations of his behavior; however it has decreased some of the daily frustration for us and him.

We are in the last phase of his therapy, I still cannot think of his journey without getting tears of joy in my eyes, because what we have been able to accomplish. Doing his therapy at home has given us more freedom. I am able to work it into our weekly schedule; we can even do it while traveling. Communicating with our therapist through google docs has been so easy. I tell her how he is doing and she gives us feedback and ways to help him when he is in the regression phase.

Comments from the Therapist, Kassie Peck OTR/L
H had significant sensory and anxiety issues when he first came to see me.  He wasn’t able to communicate or express his feelings.  After a year of traditional OT, we started a trial graduation from OT and started iLs at home. Thanks to the consistency of his home listening, and the gains he was making, I graduated him completely.

This family has been wonderful to work with.  Their consistency and follow-through have allowed wonderful gains. Using the Google docs has been great; it is really easy to use, H’s mom and I “talk” on it three to four times a week.

H is a wonderful child.  He is now much less anxious, much more willing to try new things and his confidence and interpersonal skills have improved quite a bit.  H is able to stay regulated and his social-emotional skills have improved dramatically.  He can now express his emotions instead of just melting down. His biggest struggle now is with higher level cognitive tasks: reading, processing, handling stressors while doing other activities, though we have seen gains in those areas.  After completing the Reading and Auditory Processing Program, we’ll take a break and then plan to do boosters every few months as he continues through school.

Comments by Ron Minson, MD, iLs Clinical Director
Looking at the marked improvements in the Sensory Motor area of the iLs checklist, we can assume that the significant improvements in the other categories – Auditory/Language, Social/Emotional and Organization/Attention/Cognition – are a direct result of improved body and motor integration. Research has demonstrated that there is a strong correlation between the degree of body/motor organization and higher level emotional and cognitive organization.

Although it may seem precocious, it is not, in fact, desirable for a child to skip all the practice involved in learning to crawl and to walk. It is through practice that the neural pathways are solidified. His being accident prone and having poor fine motor skills is evidence of incomplete body/motor integration. Thus, the Playbook activities combined with the iLs Sensory Motor Program, well supervised and administered by his mother, improved the following two presenting problems that are fundamental to other improvements:

  • Poor coordination and muscle strength
  • Lack of fine motor skills

Improving body coordination, balance, muscle tone and motor skills is the most direct route to improving cognitive and emotional skills, as well.

This case, submitted by a parent, underscores how effectively a program may be done at home with the support and supervision of the therapist.

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