Private Therapy

J began attending private speech and occupational therapy in October of 2006 twice a week. Her progress was first measured in November  of 2006.

Her long term occupational therapy goals were:

•  Improve motor performance and neurosensory processing to increase independence with school, play/leisure, and self-help skills
• Improve fine motor/visual motor skills to improve independence with self-care and pre-academic skills
• Improve gross motor skills and coordination
• Improve sensory processing to maintain appropriate energy level; improve attention and participation during tasks; and improve sensory input responses

Short term OT goals were:

• Consistently be able to independently take off shorts and shirt
• Use scissors to snip edges of paper with minimal assistance
• Throw a ball forward 3 feet using an underhand throw
• Imitate drawing a vertical line
• Kick a ball forward 6 feet using opposing arm and leg movements by extending leg back with knee bent

She was able to meet one goal of being able to throw a ball at a target.

Her long term speech therapy goals were:

• Improve functional performance in school, play/leisure, and self-help skills
• Improve expressive language skills to effectively express wants and needs
• Improve receptive language skills in order to be able to follow directions

Short term speech goals were:

• Express "more" and "all done" verbally by using a manual sign or pointing to a picture
• Follow simple one-step directions without physical and verbal cues
• Point to and label age appropriate vocabulary items
• Correctly follow a 4-5 step picture schedule during sessions
• Correctly imitate various consonant-vowel patterns with 80% accuracy

She was able to partially meet a goal of imitating animal, environment and simple consonant sounds during play.

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First full year of "school"

A new Individualized Education Program (IEP) was drawn up in September of 2006. The following sections were included:

Present level(s) of educational performance:

• Follows familiar classroom routines; uses Picture Exchange Communication System (PECS) to request foods at snacktime; occasionally uses words such as "doggie" and "duck"
• Not using words for requests or to answer questions; only able to point to one out of five familiar pictures (but able to match them); not able to verbally express wants and needs; not able to respond to verbal directions in the classroom
• Able to imitate gestures and movements to songs; able to complete a 6-7 piece puzzle; able to nest 4 nesting blocks; able to operate language master independently; able to play one game on computer independently
• Not able to stack rings in order of size; not able to use size words; not able to match animals to their sounds; not able to point to colors; not able to recognize name; unable to independently find cubby in classroom and remove jacket and hang it in cubby
• Separates easily from mom at school; able to follow classroom routine with assistance; stays on task 50-75% of the time; has started using "I want" card to request toys
• Does not engage with other children when playing; only spends 1-2 minutes with toys and in play areas before moving on; needs assistance at clean up time; makes jargon sounds during group time that can be disruptive

Student-based needs: 

• Use more words and demonstrate understanding of more words
• Increase  cognitive and readiness skills
• Increase social, behavioral and attending skills

Annual Goals:

• Move from infrequent communication attempts and limited demonstration of receptive language skills to more frequent communication attempts and increased understanding of simple language
• Move to more consistent demonstration of cognitive skills
• Move from inconsistent demonstration of peer interactions, behavioral and attention skills to more consistent demonstration

Short-term objectives:

• Verbalize requests for food and drink using PECS cards
• Choose named familiar picture out of a display of 5
• Say "hi" and "bye" to familiar adults or peers
• Point to 6 body parts
• Sort 4 colors
• Learn to cut a 3" long x 1" wide piece of paper in half
• Learn to draw a 6" horizontal line
• Point to 2 shapes
• Learn to independently walk to cubby and hang up backpack and jacket
• Play with the same toy for 3 minutes
• Sit in her chair for 4 minutes without making interrupting sounds
• Play with the same toy as a peer for 2 minutes

The following services were included in the IEP:

• Attend class 3 days a week for 3 hours (the other 2 days she was attending private therapy)
• Direct Speech and Language twice a week for 20 minutes
• Indirect Occupational Therapy twice a week for 20 minutes
• Indirect Autism Support once a week for 30 minutes
• Indirect Physical Therapy 3 times a year for 20 minutes

Initial School Assessment

J's first assessment by the Early Childhood Special Education department through the school district was conducted in October of 2005. The team used the following test procedures:

• Preschool Language Scale - 4th Edition
• Receptive-Expressive Emergent Language Test - 3rd Edition
• Observation
• Bayley Scales of Infant Development - 2nd Edition - measures current level of cognitive, language, personal-social, and fine and gross motor development in infants and children 1-42 months of age
• Infant Developmental Inventory (1st 21 months)
• Infant/Toddler Sensory Profile

The test results were converted into a standard deviation score (SD) as follows:

• +1.51 - +2.33 = Above Average
• -1.50 - +1.50 = Average
• -1.51 - -2.04 = Moderate Delay
• -2.05 - -2.33 = Significant Delay

J's results were as follows:

Preschool Language Scale - 4th Edition

Auditory Comprehension - 1st %tile; Standard Score of 64; Standard Deviation of -2.40

Expressive Communication - 7th %tile; Standard Score of 78; Standard Deviation of -1.47

Total - 2nd %tile; Standard Score of 68; Standard Deviation of -2.13

During the auditory comprehension section of the test it was difficult engaging J in the tasks. She did not use the objects in play appropriately; follow directions with cues; or identify pictures of familiar objects. She did not look at things when they were pointed out. She did respond to no-no; use more than 1 object; and understand when I asked her to "come with me".

During the expressive communication section of the test J was able to initiate a turn-taking game; imitate one word; and play with another person for 1-2 minutes. She was not able to use 5-10 words; vocalize and gesture to request toys or food; or produce consonant vowel combinations.

Receptive-Expressive Emergent Language Test - 3rd Edition

Receptive Language - <1st %tile; Standard Score of <55; Standard Deviation of <-3.0

Expressive Language - <1st %tile; Standard Score of 60; Standard Deviation of -2.67

Total Language Ability - <1st %tile; Standard Score of 49; Standard Deviation of -3.4

Bayley Scales of Infant Development - 2nd Edition

J was unable to demonstrate any imitation skills or respond to spoken requests. Her performance on the cognitive section was less than 50, which was more than 2 standard deviations below the mean. On the motor section she was not able to imitate demonstrated movements or hold a pencil or crayon. Her performance on the motor section was 55, which was more than 2 standard deviations below the mean (more based on her inability to imitate actions and follow directions than on her motor ability).

Infant Developmental Inventory (1st 21 months)

This is a checklist divided into 5 areas:

Social (11 of 17) - She didn't wave bye-bye or greet people.

Self-help (11 of 13) - She could not completely feed herself or eat with a fork.

Gross Motor (18 of 19) - She could run, climb on furniture, and had good balance and coordination. She could not kick a ball forward.

Fine Motor (15 of 17) - She could build a tower with 2 or more blocks, manage small objects, and turn a few pages of a book at a time. She could not mark with a pencil or crayon or use them to scribble.

Language (14 of 22) - She did not respond to  her name, use consonant/vowel sounds, or shake her head for no. She was not able to follow simple directions. She could say "mama", but no other words.

Infant/Toddler Sensory Profile

The results of this assessment tool are as follows:

General Processing - At Risk

Auditory Processing - between At Risk and Typical Performance

Tactile Processing - Typical Performance

Vestibular Processing - Typical Performance

Oral Sensory Processing  - Typical Performance

Based on the results of this assessment an Individual Family Service Plan (IFSP) was drafted. The following goals were included in the IFSP:

• learn to play with a variety of toys in functional ways
• be more interactive with adults and children at home and in early childhood settings
• learn to use a formal system of communication (picture symbols)
• learn to process and/or tolerate different types of sensory input

J started attending Early Childhood Special Education classes 5 days a week in January of 2006. She started receiving direct speech therapy twice a week for 30 minutes, indirect occupational therapy once a week for 15 minutes, and indirect autism support once a week for 30 minutes. She also attended summer school that year.

First Signs of Autism

J was screened at 18 months by an early intervention agency. Her receptive and expressive language skills were placed at a 6-9  month level. 2 months later another screening was done and she was referred for Early Childhood Special Education services. At 23 months J was given an educational autism assessment. The sections of the assessment included the following:

• Modified Checklist for Autism in Toddlers (M-CHAT) - helps to identify children with characteristics of autism
• Childhood Autism Rating Scale (CARS) - rates behaviors that typically manifest in autism. Consists of 15 subscales including: Relating to people; Imitation; Emotional Response; Body Use; Adaptation to Change; Visual Response; Listening Response; Taste/Smell/Touch Response and Use; Fear or Nervousness; Verbal Communication; Nonverbal Communication; Activity Level; Level and Consistency of Intellectual Response; and General Impressions. The subscale scores are combined to give an overall rating.
• Early Coping Inventory - observation instrument to assess coping related behaviors for everyday living. Provides information about the following: level of coping effectiveness; coping style; and specific coping strengths and vulnerabilities. Divides 48 items into 3 categories: Sensorimotor Organization; Reactive Behavior; and Self-Initiated Behavior.
• Observations
• State Criteria for Autism - includes: Qualitative impairment of reciprocal social interactions (2 or more out of 8); Qualitative impairment in communication (1 or more out of 8); and Restricted, repetitive or stereotyped patterns of behavior, interests and activities (1 or more out of 7)
• Developmental Interview

M-CHAT
J did not pass the M-CHAT. Concerns included: not taking an interest in other children; not using index finger to point; not imitating; and difficulty following a point.

CARS
For CARS, J's scores were as follows:

1. Relating to people (2.0) - avoids looking people in the eye and gets mad if encouraged to relate to someone
2. Imitation (3.0) - rarely imitates sounds or words despite prodding from an adult
3. Emotional Response (2.0) - occasionally displays emotional responses
4. Body Use (1.0) - shows typical coordination
5. Object Use (3.0) - shows little interest in toys and gets preoccupied with repetitively touching certain parts of toys
6. Adaptation to Change (3.0) - tries to continue same activity when an adult tries to change tasks
7. Visual Response (2.0) - avoids looking people in the eye
8. Listening Response (3.0) - covers ears to certain sounds and sometimes ignores sounds the first time they are made
9. Taste, Smell, and Touch Response and Use (2.0) - tastes inedible objects
10. Fear or Nervousness (2.0) - not enough fear
11. Verbal Communication (4.0) - absence of meaningful speech
12. Nonverbal Communication (2.5) - difficulty pointing or gesturing to indicate wants or needs and unable to pick up on facial expressions
13. Activity Level (3.0) - very active and endless energy
14. Level and Consistency of Intellectual Response (1.0)
15. General Impressions (2.0) - symptoms of autism are present

Overall CARS score is 35.5 which falls in the moderate range of autism.

Early Coping Inventory
J scored 3.4 in Sensorimotor Organization; 2.8 in Reactive Behavior; and 3.1 in Self-Initiated Behavior. Adaptive Behavior Index was 3.1, which means her behavior is situationally effective.
Her most adaptive behaviors include:

• demonstrates coordinated movements
• tolerates being in a variety of positions
• energy level that is forceful and vigorous
• accepts warmth and support from familiar persons
• reacts to different types of touch by caregiver
• accepts help when necessary
• demonstrates happy disposition
• demonstrates persistence during activities

Least adaptive behaviors include:

• difficulty maintaining visual attention to people and objects
• difficulty reacting to feelings and moods of others
• difficulty adjusting to irrelevant sounds
• difficulty engaging in reciprocal social interactions
• difficulty with actively participating in situations
• difficulty changing behavior to solve problems or achieve goals

State Criteria for Autism
Qualitative impairment of reciprocal social interactions

• limited use of facial expressions toward others
• prefers isolated or solitary activities
• difficulty relating to people

Qualitative impairment in communication

• not using finger to point or request
• absence or delay of spoken language
• inability to initiate or maintain conversation
• lack of spontaneous imitations and lack of varied imaginative play
• limited understanding of nonverbal communication skills (gestures, facial expressions, voicetone)
• using others' hand or body as a tool

Restricted, repetitive or stereotyped patterns of behavior, interests and activities

• lack of true imaginative play vs. reenactment
• over-reaction or under-reaction to sensory stimuli
• intense focused preoccupation with a limited range, interest or conversation topics

Based on the results of the educational autism assessment J was referred for special education services through the school district.

My Story

I gave birth to twin girls via c-section in October 2003 at 30 weeks gestation. They spent 6 weeks in the hospital. I decided to stay home with them to avoid putting their health in jeopardy. Every 3 months we would have home visits from a public health program to follow the babies' development. At the last visit, when the babies were 23 months, the nurses saw some behavior from one of the girls (J) that raised some red flags and led to a recommendation to have her assessed for autism. She was then given an educational diagnosis of mild/moderate autism. This blog will be a documentation of our journey from birth to now.