Case Study: Pervasive Developmental Disorder – Not Otherwise Specified

Organization:
Family Achievement Center

Associates Name & Discipline:
Rachel Kuenzli, SLP & Shawna DeHaan, OTR/L

Presenting Problem:
PDD-NOS (Pervasive Developmental Disorder – Not Otherwise Specified, or PDD-NOS, for short, is a condition on the spectrum that exhibits some, but not all, of the symptoms associated with classic autism.)

Client Background:
3-year-old male “W” diagnosed with PDD-NOS. W met all his developmental milestones earlier than normal limits. At the time of his evaluation he presented with speech, language, gross motor, fine motor, and auditory processing delays.

Therapeutic Goals:

Speech Therapy:

1. W will follow simple, routine 1-2 step directions (sit down, stand up, etc) with 80% accuracy without cues over three consecutive sessions.
2. W will verbally request objects and actions in his environment with 80% accuracy with minimal cues.
3. W will use the Picture exchange communication system (PECS) to describe objects and answer simple wh-questions with 80% accuracy with minimal cues.
4. W will demonstrate understanding of and use of age appropriate verbs, pronouns, and adjectives while describing pictures with 80% accuracy when provided with minimal cues.
5. W will choose between 2-4 real objects or activities using real words or gestures in 8 out of 10 trails with minimal cues.
6. W will complete simple 3-step picture sequences with 80% accuracy with moderate cues.
7. W will answer simple wh- questions (what, where, who) given 3 picture choices with 80% accuracy with minimal cues.

Occupational Therapy:

1. W will demonstrate improved bilateral integration skills by button/unbutton ½” buttons donned on self with minimal assistance 75% of trials. (Goal modified and increased due to progress while participating in iLs)
2. W will cut within a ½” of a straight line with adapted scissors (loop) with minimal assistance 75% of trials.(Goal modified and increase due to progress while participating in iLs)
3. W will engage in functional tasks that involve crossing midline to promote consistent hand use when engaging in age appropriate coloring tasks. (Goal written prior to participating in iLs)
4. W will consistently imitate pre-writing strokes (horizontal/vertical lines, cross, and circle) with minimal assistance in 75% of trials. (Goal revised from initial evaluation and prior to participating in iLs)
5. W will demonstrate improved fine motor and grasping skills by using a mature quadropod grasp on a writing tool with minimal assistance 75% of trials. (Goal written while participating in iLs)

iLs Program Used:
Sensory Motor Program, 4.5 hours per week (two days a week he listened to 1.75 hours (7 songs total) and a third day was 1 hour). 12 weeks total.

Other Interventions Used:
Continued OT and ST during the program

Summary of Changes:
Potty Training: Mom commented that two of the biggest changes from iLs were that he potty trained and began communicating his wants and needs.  W had never been interested in potty training and the family had not pushed it.  During the first few weeks of iLs, he began showing interest and was potty trained within weeks.

Expressive Language & Emotional Regulation: She also stated that he began articulating his wants and needs, which he had never done before.  It may have been only 1 word, but she finally knew what it was that was upsetting him.  This resulted in a decreased number of tantrums and an increase in engagement with his family.

Transitions: Another major change was W’s ability to transition between environments and various activities.  Previously, W was easily brought to tears and meltdowns with any slight changes or transitions, such as going through a different door leading to the same place.  During the iLs program, he was able to make these transitions with familiar people but continues to have difficulty with unfamiliar individuals.

Pretend Play: Finally, mom was excited about an increase in pretend play.  Being a former early-education teacher, mom had worked on pretend play constantly  but to no avail.   Toward the end of the 60 sessions, W began creatively playing with toys and showed the desire to be social with peers but did not know how to.

Speech Therapy:

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Prior to starting iLs, W displayed difficulty answering yes/no questions, understanding and following routine one-step directions (e.g., throw it away, stand up), transitioning between activities, completing simple sentences with nouns and verbs, and understand simple spatial concepts (e.g., in, on, off). When transitioning, he typically required a visual schedule, timer, and moderate cues. If something new was being introduced, he became confused and nervous, running away from the activity and crying.

During and after iLs, W began answering yes/no questions, understanding simple spatial concepts, labeling and using verbs, following 2-step related commands, and completing sentences. His MLU increased slightly, but the most drastic change was with transitions. He was able to transition between activities with minimal cues and no longer became frustrated and nervous when something new was introduced. He stayed with the activity and allowed the therapist to model.

Occupational Therapy:

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W demonstrated improvements in grasping and visual motor integration skills since the implementation and completion of the Sensory Motor iLs program.

Grasping Area:

Prior to iLs, W frequently switched hands, demonstrated an inconsistent grasp pattern and had difficulty crossing his midline. After iLs, W demonstrated consistent use of his right with a consistent grasp pattern and demonstrated increased ability with crossing his midline. Prior to iLs, W was unable to manipulate buttons and after was able to unbutton.

Visual Motor Integration Area:

Prior to iLs, W was unable to imitate pre-writing strokes and shapes, cut paper in half or on a designated line, and lace holes on a strip. After iLs, W was able to imitate pre-writing stokes (horizontal and vertical lines), copy a cross and circle and attempted to copy a square. He was also able to cut paper in half and on a straight line, but was unable to cut out a circle or square. W was also able to motor plan the ability to lace 3 holes on a lacing strip.

Conclusions and Recommendations:
Discharged from OT one month after completion of iLs program. Recommended parent continue to work on pre-school readiness skills of coloring, cutting, shape imitation, grasping skills, and puzzles. Continue one-on-one ST as well as iLs Attention and Concentration program after 2-3 month break.