Case Study: Mood Disorder

Organization: Lowry Occupational Therapy, Denver, CO

Client: Madeline, 6-year old girl

Clinical Diagnosis/Presenting Problem:
Madeline had just turned 6 years old when she was referred for Occupational Therapy by her psychologist, whom she and her mother had been seeing for 6 months with little improvement. There was concern she may have had a bipolar mood disorder, but her parents were reluctant to consider the need for medication and wanted to try a more holistic approach first. Madeline’s mother reported that the primary concerns for her daughter were her volatility and rage at home. She particularly directed her anger toward her mother, but also lashed out at her father and younger brother.

Summary of Changes: (tests, observations, feedback, etc.)
Follow up testing at the end of a 32-session program (over 4 months) showed the following:

• Madeline’s balance improved significantly, increasing balance on each foot from 4 to 30 seconds.

• Oculomotor skills for visual pursuits went from below average to near typical for her age, with smooth horizontal and vertical pursuits, and moderately smooth circular pursuits.

• She no longer showed signs of retained Moro or ATNR reflexes, and was able to sit still in her chair for greater than 20 minutes at a time.

• On the SCAN-C test for auditory processing, Madeline had improved her ear advantage for right-ear directed words to +1, well within the normal range. Her left-ear directed score did not change.

• Beery Motor Coordination score improved from 65 to 104, and she was proud to show off her improved writing abilities.

• Teacher reported she had improved significantly in reading comprehension and was at grade level. She was independently choosing to read more at home.

• By the end of the iLs program, Madeline’s outbursts were considered by her parents to be in the normal range for a 6-year old, and she was even displaying mature self-regulation skills at times, e.g. announcing she needed a break and going off to her room before becoming upset. For Madeline’s mother, the most meaningful improvement was her own ability to relax around her daughter and enjoy being with her without the dread of saying or doing the “wrong” thing.

Presenting issues per parent report:

• inflexible, angry, and defiant verbal interactions with parents

• tendency to talk and act like a baby; depended on her mother for soothing when upset

• 1-2 incidents per day of biting, hitting, spitting, throwing objects, and screaming at parents, ~ 5 days per week

• perfectionist tendencies; blamed other people or objects for her mistakes, clumsiness, failures

• poor initiation of independent play

• did not like athletic competition or people watching her play

• lacked desire for completing her school work

Clinical assessment results:

• One foot stance:  left foot – 30 seconds; right foot – 4 seconds

• cross-dominance of right hand and left eye

• oculomotor skills were immature: poor quality visual pursuits in horizontal; unable to pursue in vertical or circular planes; unable to converge both eyes (turned head to use left eye to track the object)

• mild to moderate signs of a retained ATNR (asymmetrical tonic neck reflex) on her right, normal on her left.

• strong presence of a retained Moro reflex

• poor postural control when seated at a desk

• high threshold for tone perception of the lower frequencies in her right ear

• normal score for all subtests of the SCAN-C, but an atypical switch in ear advantage on the Competing Words subtest: +8 with directed right-ear, -2 with directed left ear

• Beery VMI: standard score of 98

• Beery Visual Perception: standard score of 104

• Beery Motor Coordination: standard score of 65

• below grade level in letter formation and legibility

• Sensory Profile scores showed a “definite difference” for: Auditory, Vestibular, Touch, and Multisensory Processing

Therapeutic Goals:
Madeline’s poor emotional and behavioral self-regulation, along with her poor postural control, retained infantile reflexes, and sensory processing profile indicated a globally immature nervous system. Her atypical Ear Advantage scores on the SCAN-C was an indicator of a potential language-based learning disability, and her poor play skills indicated difficulty with ideation, sequencing, and feed-forward planning. Issues with postural control and oculomotor skills also had the potential to significantly interfere with her ability to be successful in the classroom as she grew older.

The initial treatment goals were:

• normalize the physiological foundations contributing to her low threshold for triggering a sympathetic response, i.e. the “fight or flight” system, including:

• vestibular and auditory sensitivities

• body awareness and spatial perception

• integration of the primitive reflexes

• postural control and motor planning

• self-awareness of arousal and emotional states

• improvement of imagination and play skills

• improve fine motor control for writing

• increase enjoyment of, and desire for, reading books

iLs Program Used: (program name, frequency, length, etc.)

Due to Madeline’s primary presentation of poor arousal/emotional control, her iLs protocol was customized to include a longer period of focus on the lower, Body Zone frequencies was chosen. She was not transitioned into the filtration phase until evidence of improvement in her foundational skills was noted. Due to her auditory sensitivity and difficulty with multisensory processing, Madeline’s first three sessions consisted of a mix of the narrow band-width frequencies: SI 250-1000, SI 125-1500, and SI 0-2000. Once she had adapted to the combination of iLs and traditional Sensory Integration therapy, Full Spectrum was also included for sessions 4-12.

An attempt was made to transition Madeline into the Filtration stage after the first 6 sessions. She had made solid improvements in behavior at home and postural control/motor planning in the clinic. She tolerated the first session of filtration, up to FM 500, but had a return of severe outbursts with physical attacks after the second session of FM 500 and FM 750. She was immediately returned to the Body Zone frequencies and was able to regain her behavioral improvements right away. A second attempt to begin filtration was attempted after 12 sessions (6 weeks of therapy), and this time she was able to tolerate filtration up to FM 4000. During the filtration phase, Madeline had occasional meltdowns but at only half the previous frequency and of much less intensity. She began to acknowledge her behaviors and be able to talk about the triggers. She gradually was able to accept strategies for preventing or recovering from emotional upset, such as receiving deep hugs or joint compressions from her mother.

Madeline was given a 3 week break from therapy after 20 sessions, before beginning the Defiltration phase. Over the break she initially displayed emotionally immature behaviors such as desiring to be cuddled like a toddler, but her raging outbursts continued to decrease in frequency and intensity. By the time she returned to therapy, Madeline was behaving age-appropriately and only having one meltdown per week. She appeared happier and more confident, and was reported to be cooperating and completing all her work in school as required.

During the Defiltration stage, Madeline sought activities in therapy with a cognitive component rather than purely movement based play. She began to play pretend games with planned story-line sequences. She was able to play board games and tolerate periods of “losing,” something she was incapable of in the past. She began to be interested in drawing pictures and in the quality of her printing, although these were not directly addressed in therapy. By the end of Defiltration, Madeline’s outbursts were considered by her parents to be in the normal range for a 6 year old, and she was even displaying mature self-regulation skills at times, e.g. announcing she needed a break and going off to her room before becoming upset.

Madeline completed Defiltration in 5 sessions, then received 5 sessions of Full Spectrum/Speech and Language, with 20 minutes of Actives during each session. She was initially resistant to the sound of her own voice, but improved quickly after repeating the therapist line-by-line as they read Dr. Seuss books. She was then able to tolerate the repeating words and poems, but still did not like singing.

Other Interventions used: (occupational therapy, speech and language, etc.)
Madeline’s treatment program was based on a traditional Sensory Integration approach with simultaneous use of a customized iLs program. She was seen two times per week, for one hour each session. Madeline was seen a total of 32 times over a period of 4 months.