iLs Case Summary Report
Date: 9/25/10
Associate’s Name: Melissa Nilsen, MS, OTR/L
Associate’s Discipline: Pediatric Occupational Therapy
Name of Organization: Children’s Therapy of Woodinville (WA)
Presenting Problem: “John,” a 5 ½ year-old boy was referred to occupational therapy one year ago due to delays in fine and gross motor skills, sensory sensitivities, and emotional lability.
His evaluation revealed his motor skills to be in the 5th percentile in comparison to his same age peers (Peabody Developmental Motor Scales (PDMS-2). On the Sensory Profile, he scored in the definite difference category (>2.0 SD from the mean) in auditory processing, modulation of input affecting emotional responses, emotional responses and sensory avoiding behaviors.
Outside psychological testing indicated he demonstrated severe impulsivity, emotional lability, and social interaction difficulties. He was termed “at risk” for Asperger’s Syndrome, ADHD, Opposition Defiant Disorder and Mood Disorder.
Therapeutic Goals: Goals focused on organizing his sensory system, emotional regulation and improving balance, trunk control and motor skills.
iLs Program Used (program name, frequency, length, etc.): The 60-session Sensory Motor Program was used. John averaged 3 times per week. The family moved during this time, which made listening a little less consistent, but the family persevered. Also, the Calming Program was used – without headphones – in the evening to assist in going to sleep.
Other Interventions Used (occupational therapy, speech and language, etc.): John participated in weekly Occupational Therapy sessions and in a summer Friendship Club run by an OT and a Speech Therapist. He is tracked by a developmental optometrist and wears a bifocal glasses to address accommodative dysfunction, convergence insufficiency, deficiencies of smooth eye pursuits and saccadic eye movements, and decreased depth perception.
Summary of Changes (tests, observations, feedback, etc.):
Post tests included the PDMS-2, Sensory Profile, the iLs Checklist, and reports from Neena Gabrielle, OD, FCOVD.
PDMS-2: John gained ground in comparison to his same age peers in all categories. Given his vision challenges, ball handling skills tested in the Object Manipulation category have not been a focus of therapy or home activities.
Sensory Profile: John made point improvements in 12/14 categories (in the other two categories he already obtained the top possible score) He now scores solidly within the “Typical Performance” category in all Sensory Processing, Sensory Modulation and Behavioral and Emotional Responses categories.
iLs Checklist: Unfortunately only the Sensory/Sensory Motor portion pretest was completed. However, the change was significant. Total point score improved from 34 points to 10 in this category. In the post-test, John’s mother scored a “0” (Never) in all Auditory/Language and Organization/Attention/Cognitive categories. He had an average score of “1” (Rarely) in the Social/Emotional Category.
Optometrist Report: In her most recent report, Dr. Gabrielle reported improvements in accommodative dysfunction and convergence insufficiency. She reported significant improvement in smooth eye pursuits, saccadic eye movements and depth perception.
Conclusions and Recommendations: John has made significant improvements in all areas. His emotional well being has significantly improved. He is adjusting well to his new school. His motor skills are on track and his visual skills are improving. His mother reports, “he is now the little boy I knew he was capable of being.”
