Name of Organization: Therapy Solutions, Wolverine, MI
Associates Name & Discipline: Amy Dubey, OTR/L, CBIS, iLsP, CIMP, SIPT
Age/Gender of Client: 6 ½ year old female
Date: November 1, 2016
Background Information:
Mary is a 6 ½ year old female. She is currently diagnosed with ADHD, anxiety and Sensory Processing Disorder. She attended speech and occupational therapy from June 2015 until approximately April 2016 at a hospital outpatient clinic.
Mary had chronic ear infections as an infant and had tubes put in her ears at 2 years old. She has also had a lot of dental problems and has approximately 17 cavities filled. She was still given a bottle until about the age 2. Per parent report, the following are difficulties or weaknesses they notice with Mary:
- difficulty problem solving
- difficulty determining cause and effect
- lack of motivation to take care of self needs
- toe walking
- “w” sitting
- rigid and does not adapt
- inappropriate responses to sensory stimuli
- understanding social cues
Presenting Problems: Speech Delay, Sensory Processing, ADHD, toe walking, and “W” sitting.
Therapeutic Goals:
- Reflexes Integration
- Body Awareness – copy motor movements and/or positions using a photograph or other person
- Gross Motor Skills – perform bilateral lower extremity activities for balance and coordination without loss of balance
- Attention/Arousal/Modulation/Posture – maintain focused attention for 20 minutes following sensory input, provided or directed by caregiver, and sit with upright posture on floor/chair.
Parent Goals:
- Help her sensory issues
- Learn to self-regulate better
- Learn strategies to encourage self responsibility
- Help her learn to be a bit more adaptable
iLs Program used: SSP was used 5 consecutive days in one week.
Mary was seen on Day 1, Day 3, and Day 5 in the clinic with this program. She performed Day 2 and Day 4 at home with parents.
Other Interventions Used:
Occupational Therapy – brushing and joint compressions performed throughout the day
She is seen 2 times a week for 1-hour durations in outpatient clinic
Summary of Changes:
This therapist noted that on Day 1 Mary choose 4 activities (Tanagrams, connecting beads, coloring, and Thera-putty with hidden beads) and performed them quickly. She moved through them before therapy time was finished. By Day 5 she choose 2 activities (Legos and connecting beads) and played with the Legos 80% of the time before moving on to the connecting beads. She completed building a complete Lego set of a miniature airport before moving on to the next task.
Mary worked on the floor or at a table. While sitting on the floor during the activities she often “w” sits and requires verbal cues to correct her positioning. The following are the results of verbal cues used for asking her to sit “criss-cross” style: Day 1 – 7 verbal cues, Day 3 – 3 verbal cues, and Day 5 – 2 verbal cues.
Another observation noted by therapist is that by Day 5, Mary did not seem to protrude her tongue as much as she had been observed during previous therapy sessions.
Post intervention based on the SSP Caregiver questionnaire parent reports improvement in:
Prior to intervention, my child used verbal language appropriately. NO was circled.
Description of spontaneously verbal language not previously observed, but used following the intervention.
Parent wrote: “Before intervention, Mary would occasionally offer up information without prompting but normally we would have to have to ask and we normally wouldn’t get much information.”
Parent marked: a lot better after treatment
Prior to intervention, my child talked to others in an appropriate manner: NO was circled.
Description of reciprocal conversations not previously observed, but used following the intervention.
Parent wrote: “If prompted she could reciprocate more than twice but we would have to keep asking questions to get her to respond. In the last few days she has engaged more.”
Parent marked: a little better after treatment
Prior to intervention, my child initiated social interactions for the sake of social pleasure: NO was circled.
Description of initiating behavior not previously observed, but used following the intervention.
Parent wrote: “She very rarely would initiate conversations unless she was asking for something. She seems to be doing it more freely now.”
Parent marked: a little better after treatment.
Prior to the intervention, my child read social situations appropriately: NO was circled.
Description of reading social cues not previously observed, but used following the intervention.
Parent wrote: “Mary really struggles with reading social cues. She continues to need a lot of direction with this. She does tend to take her cues from other children, for example she will copy what they are doing whether it is appropriately or not.”
Parent marked: the same and a little better after treatment.
Prior to the intervention, my child listened in an appropriate manner: NO was circled.
Description of listening not previously observed, but noticed following the intervention.
Parent wrote: “Mary still struggles with following these types of directions. She often needs to come back a few times to get the instructions again. Before the intervention she would often go to get it but then would just stay in the other room without the item or doing what she was asked to do without coming to ask for help.”
Parent marked: a little better after treatment.
Prior to the intervention, my child regulated emotions in an appropriate manner: NO was circled.
Description of emotional control not previously observed, but observed following the intervention.
Parent wrote: “She had trouble controlling her excitement when it is at an inappropriate level. This has resulted in tantrums in the past but she can control it better now.”
Parent marked: a little better after treatment.
Conclusions and Recommendations:
She will begin using the iLs system at home and in the clinic to address her above mentioned presenting problems.
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