Organization:
Project CHILLD, Beverly MA

Submitted by:
Kathy Carley, MS OTR/L and Christine King, COTA/L

Presenting Problem:
Diagnosis of Apraxia of Speech, Dyspraxia

Subject:
Robert” was a 3.6-year-old male at intake

Therapy:
iLs combined with occupational therapy and speech therapy

Date:
August 2011

Background:
Robert is a twin, who is the product of a pregnancy complicated by low amniotic fluid and by maternal gestational diabetes, which resulted in bed rest restrictions.  Robert was delivered at 36 weeks and was intubated at birth for two days due to immature lung development. He was in the neonatal intensive care unit for two days and received phototherapy for jaundice. Robert failed the newborn hearing test twice in his left ear.   His medical history is notable for frequent high fevers until age two, frequent colds between six and 18 months, gastrointestinal issues between six and 15 months and one ear infection at six months. His mother reports that Robert met developmental gross motor milestones within typical timeframes. He received Early Intervention services until three years of age for speech and language delays. He is now enrolled in an integrated preschool program where he is receiving occupational, speech and physical therapy.  Robert also is receiving private speech therapy two times per week.

Robert was referred to Project CHILLD due to concerns regarding speech delays, motor incoordination, sensory processing difficulties and decreased social participation at home and in school.

Initial Assessment:
Robert was given the Berry-Buktenica Developmental Test of Visual-Motor Integration (Beery VMI) and theBeery VMI Developmental Test of Visual Perception (Beery DTVP). The Beery VMI is a standardized test assessing a child’s ability to copy geometric designs from a model with paper and pencil. The Beery DTVP is a standardized measure assessing a child’s ability to view a shape and scan through a group of similar shapes to identify its match. On the Beery VMI, Robert received a raw score of 1 placing him in the 0.9th percentile.  On the Beery DTVP, Robert received a raw score of 13 placing him in the 99th percentile.

The Sensory Profile Caregiver Questionnairewas completed by Robert’s parents. The Sensory Profile is a 125-item caregiver questionnaire created to identify sensory processing differences in children between three and 10 years of age.  Scoring of the Sensory Profile is divided into two sections.  The first is the Section Summary, which includes the subcategories of Sensory Processing, Modulation and Behavior and Emotional Responses.  The second is the Factor Summary.

In the Sensory Processing section of the Sensory Profile, Robert scored in the Definite Difference range in the areas of Vestibular Processing, Touch Processing and Oral Sensory processing.  He scored in the Probable Difference range in the areas of Auditory Processing, Visual Processing and Multi-sensory Processing.

In the Modulation section, Robert scored in the Definite Difference range in the areas of Sensory Processing related to Endurance/Tone and Modulation Related to Body Position and Movement.  He scored in the Probable Difference range in the areas of Modulation of Movement Affecting Activity Level, Modulation of Sensory Input Affecting Emotional Responses, and Modulation of Visual Input Affecting Emotional Responses and Activity Leve.

In the Behavior and Emotional Responses section, Robert scored in the Definite Difference range in the area of Behavioral Outcomes of Sensory Processing.  He scored Probable Difference range in the area of Emotional/Social responses.

In the Factor Summary section, Robert scored in the Definite Difference range the factors of Emotionally Reactive, Low Endurance/Tone, Sedentary, Fine Motor/Perceptual.  He scored in the Probable Difference range in the factors of Sensory Seeking and Oral Sensory Sensitivity.

Initial Level of Performance:
Clinical observations at the time of Robert’s initial assessment concluded that Robert presented with moderate difficulty in the areas of postural control, motor planning, bilateral coordination and fine motor skills, and presented with gravitational insecurities. Robert was unable to jump with a two-foot take off, lift his head or upper extremities against gravity from a prone position, or assume supine flexion.  Robert had difficulty with reciprocal crawling and demonstrated strong ATNR and STNR reflex patterns. Robert had moderate difficulties with ideation, and initiation. He was unable to form prewriting shapes, or use functional grasp on scissors or writing tools.

Also at the time of his initial assessment, Robert’s parents reported that Robert had not been successful with toilet training, required moderate assistance for dressing and oral hygiene, and had difficulty socializing with peers.

An evaluation from Robert’s private speech therapist concluded, “[Robert’s] intelligibility remains significantly impaired, Roberts’s sound repertoire is limited; recently, he has seemed to plateau and even regressed.”

In addition, Robert’s school-based speech therapist reported the following information about Robert’s language skills: “Robert has nice receptive language skills, he is able to follow his classroom routine as well as 1-2 step directions. With the use of a communication program, Robert is able to answer some ‘wh’ questions by selecting from a field of 8-12 items, he can identify all peers, teachers and therapists by either their label on his iPod Touch or by pointing in context.

“Expressively, Robert can independently produce the following sounds; ma, na, ba, pa, ta, da, ha, rrr, wa, sss, zzz, ka, ga. He is beginning to produce the /i/ sound in single syllables (i.e., hi, by, tie, pie). He consistently uses the following approximations, “ma”/more, a da/ all done, baba/ bye bye, ma/ mom, hi/ help.”

Intervention Used:
Robert completed 31clinic-based iLs sessions, each 90 minutes in length.  Robert attended three to four listening sessions per week, with a three to four week integration break after the 15th session and then again after the 23rd session.  Robert was seen for occupational therapy one time per week during these breaks.

Each of the 31 sessions included a strong oral motor component, incorporating varied sensory input to Robert’s mouth, such as vibration, massage, taste and texture, as well as oral motor exercise, a variety of whistles, blowing and sucking activities, as well as oral imitation exercises.

Additionally, each session included movement-based activities that were targeted at reflex integration, visual, auditory and ocular integration, body awareness, postural control, motor planning and bilateral coordination.

Greater independence with ADLs and improved play skills were also a focus of Robert’s sessions.

Summary of chronological changes reported by home and school:

December 

* Robert’s mother reports that Robert is independently looking at books and naming items, saying, “It is as if he is reading to himself.”

* Increased eye contact, and increased energy are reported.

* Increased independence with his iPod Touch program is reported.

January 

* Robert’s speech therapist reports that Robert is starting to approximate words with vowel sounds and consonant transition: “No ta-ta” for “no tiger,” and making approximations with closing sounds: “hap” for “help.”

February

* Robert begins to use new sounds during play such as “choo-choo” when playing with trains, and siren sounds when playing with fire trucks.

* Robert demonstrates an increase in his number of sounds and signs in combination.

* Robert begins to join in when others are humming or singing.

* Mom also reports that Robert is responding to questions more quickly and joining in family conversations.

* Robert makes progress dressing himself and begins initiating the dressing process in the morning.

March

* Robert’s speech therapist reports, “Robert’s articulation skills are taking off”

* Robert is now approximating the names of his peers.

* He is singing along with songs at school and home

* Robert is using consistently blended consonant and vowels

* Robert Counts to 10.

* Demonstrates more vocal control, using “no” instead of “na na na.”

* Shows an increased ability to modulate the volume of his voice.

* Robert is dressing himself

* Washes himself in the tub

* Robert is completely potty trained.

* Mom also reports that Robert is choosing to spend less time with his mother and       preferring to spend time with his father and grandfather.

April

*Robert begins approximating short sentence structures. “I hear a______________, I see a _______________.”

* Robert is labeling letters.

May

*Robert begins communicating verbally at circle time

* He can name all of his classmates

* He is able to answer “wh” questions.

* His language becomes natural and spontaneous

June

* Robert begins consistently speaking in short structured sentences, asking questions and offering information independently.

Conclusions and Recommendations:
Robert showed dramatic improvement is the area of speech and language.  His private SLP, who has been with us since the end of April 2011, has rewritten his goals three times since May because he is progressing so quickly. He is no longer using any assistive device for communication.

Dramatic changes in other goal areas have also been noted.  Robert demonstrates improvement is vestibular processing.  He currently seeks out a variety of types of suspended equipment in the clinic, and demonstrates improved balance. He is able to jump with a two-footed take off, and his ability to balance on one foot is emerging. Robert demonstrates improved strength and endurance; he is able to hold his upper body against gravity in prone. Robert’s mother states the following changes in endurance, “Prior to iLs, Robert would tire after sitting up for twenty minutes while engaging in an activity. He would often continue playing while lying down on the floor. He was difficult to rouse out of bed in the morning. Since the first phase of listening iLs, Robert wakes spontaneously in the morning and maintains an aroused energy level throughout the day”.

Robert’s improvement in the area of fine motor skills can be measured through the increase in his score on the Beery VMI, where he improved from the 0.9th percentile during the initial assessment to the 18th percentile during post testing.

Robert now is able to demonstrate reciprocal crawling.  He has improved in ideation, as he can plan a 3-step obstacle course using preferred equipment, and now approaches his therapy sessions with specific ideas and plans for activities. He is able to engage in turn-taking activities with peers; however, he still is not initiating play. Robert has made gains in the area of ADLs. He is dressing himself, washing himself in the tub and is completely potty trained.

In summary:
Robert’s parents offer this statement, “Beginning approximately six weeks after the end of iLs, Robert had a ‘language explosion.’ The gradual progress he has been showing suddenly grew exponentially every day. Now three months later, he talks constantly, saying almost anything he wants to say and speaking in full sentences (with developing articulation).  For a long time, Robert’s thoughts were trapped inside of him. Now they flow from mouth. He is still difficult to understand, but with speech therapy, he is improving every day.”

Videos:
Robert after 15 iLs sessions:

Robert after 31 iLs sessions: