Case Study: Sensory Processing, Speech and Language Delays

Associate’s Name:
Doreen Hunt MA, OTR/L

Associate’s Discipline:
Pediatric Occupational Therapy

Name of Organization:
Children’s Therapy of Woodinville (CTW)

Client Background Information:
“E” is a 6-year, 3-month old girl with no medical diagnosis; She is currently finishing up her kindergarten year of school in a typical classroom. Birth history and developmental milestones were all within normal limits except for Speech and Language delays. E began Speech Therapy services at the age of 4 years, 11 months and began receiving Occupational Therapy (OT) services a few months later. The family switched therapy clinics and began OT combined with iLs at CTW at the age of 5 years, 9 months.

Initial Presenting Problems:

• Low self-confidence: appears to be disinterested with a flat affect
• Poor auditory processing: needs directions repeated, broken down, visual cues to help her understand; delayed verbal response of 1-3 seconds (poor auditory processing speed)
• Quiet, shy personality: minimal verbal output with low volume; clings to her mother; speaks more at home than in public, however parents often did not understand what she was trying to communicate (language-based problem, not articulation)
• Chews or grasps onto the neckline of her shirt frequently (to self-regulate, decrease anxiety)
• “Potty accidents” are frequent
• Vestibular hypersensitivity (sensory over-responsive)
• Sensory under-responsive (SUR) with poor registration of tactile, auditory, and visual input
• Dyspraxia
• Deficient visual tracking, especially of fast moving objects (i.e. catching a ball)
• Poor Directionality/Spatial Awareness (gets lost, confused easily)
• Deficient Visual Perceptual skills

Therapeutic Goals: 

• Improve the integrity and function of the vestibular system and the integration of visual-auditory-vestibular information to promote appropriate adaptive responses to sensory stimuli to allow E to interact in an organized, purposeful, increasingly complex way.
• Improve ideation and motor planning (praxis) abilities for greater independence and success in planning and executing self-care, play and P.E./recreation activities.
• Improve oculomotor and visual perceptual skills for improved play skills (i.e. ball games) as well as reading and handwriting development.
• Improve distal finger strength for greater success in fine motor, handwriting and self-care activities (i.e. buttons and snaps on clothes).

iLs Program Used:
The iLs Focus Sensory Motor and Concentration & Attention Programs were completed. E averaged 5 hours per week: 2 hours of OT + iLs in clinic and 3 hours of iLs at home). The programs were completed within 6 months’ time.

Other Interventions Used:
E received OT services twice a week for one hour each session and speech therapy services one time per week for 45 min. per week.

Summary of Changes:
E is more confident socially and is more verbally outgoing with adequate voice volume. She now likes to tell stories of events and she asks “why” and other “wh-” questions. She has been able to make new friends at school and appears happy now instead of having a flat affect.

E’s auditory figure-ground filtering ability improved significantly (from 5% (AFG +8) on her initial OT evaluation to 95% (AFG 0)) after the iLs programs were completed. Her motor planning/praxis and balance have improved greatly as well as her comfort with moving her body in space. Her oculomotor and eye-hand coordination skills have improved significantly.

Follow-up testing at the end of iLs’ Sensory Motor Program:
Improved modulation/tolerance of vestibular input: E now seeks out vestibular input and tolerates swinging to high heights or climbing up ladders

Improved motor planning/praxis: alternates feet climbing stairs 100%; rides a two wheeled stand-up scooter; able to complete variety of bilateral motor tasks (i.e. cross-lateral march, opposite arm-leg scissor jumps, skipping); able to pump a swing with long endurance and ability to swing very high; able to learn new motor sequences more quickly, with less repetition.

Visual tracking skills are much improved: able to separate head from eye movements; good endurance and smooth tracking of slow objects; normal saccades and convergence. Still struggles tracking fast moving objects but has improved her ability to catch balls. Improved handwriting skills/legibility and reading skills are developing.

Comments from E’s SLP:
E is making very good progress in therapy. Particular improvement has been noted during the past three months with regards to her response speed to many different tasks (verbal responses to questions and motor responses with pencill/paper or computer mouse tasks) and in terms of her social language skills development. While previously E was extremely quiet during most therapy sessions and rarely initiated conversation, over the past three months she has become quite talkative, initiates conversations, comments and elaborates frequently throughout each session.

Pre-Post testing with TVPS-3, before and after 60 hours of SM and 40 hours of Concentration & Attention Program:

TEST	Raw Score	Scaled Score	Percentile Rank		Raw Score	Scaled Score	Percentile Rank
Visual Discrimination	4	8	25%		6	10	50%
Visual Memory	8	12	75%
V-Spatial Relations	0	<4	1%		9	12	75%
Form Constancy	5	10	50%
V-Sequential Memory	1	5	5%		3	7	16%
V-Figure Ground	10	18	99%
Visual Closure	1	5	5%		4	9	37%

Pre-Post testing with SCAN-3 C, before and after 40 hours Concentration & Attention Program:

TEST	Raw Score	Scaled Score	Percentile Rank		Raw Score	Scaled Score	Percentile Rank
AFG +8	34	8	25%
AFG 0					32	15	95%
Filtered Words					20	8	25%
Competing Sentences	27	6	9%		29	6	9%
Competing Words-FR	11	6	9%		11	6	9%
Time Compressed Sentences	27	1	0.1%		36	5	5%

Conclusions and Recommendations:
E continues to have significant auditory processing difficulties, especially with inter-hemispheric/di-chotic listening situations and with processing speed.  Reading & Auditory Processing Program on the iLs Focus is recommended, at least 3 hours per week with continued core-strengthening, balance, praxis and eye-hand coordination, iLs Playbook activities and OT services.