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Case in Progress

Danny at 13 months

Danny began early start services at the age of 9 months. He benefited immediately and made good gains. His family and therapist were all pleased.

When Danny was 13 months old he had some seizure activity that necessitated a visit to the hospital. At first it was difficult to tell what had caused the seizures because Danny had had a high fever following a bout with bronchitis. There was some question as to whether the seizure was febrile (caused by fever), and that is why the neurologist was called in. At that time he saw a pediatric neurologist, who prescribed Tegretol to stop the seizures. The seizure were diagnosed as being caused by status epilepticus (epilepsy). It took a few weeks for Danny to adjust to the Tegretol, and in the beginning he was somewhat groggy and sleepy. His mom was diligent about getting his blood levels checked to make sure the Tegretol was helping, not hurting. See note by Suzanne Berman, M.D.

At the age of 14 months Danny was assessed by a speech/language therapist to get a baseline on his speech abilities to that time. The speech therapist found that Danny's expressive language was at 7 months and his receptive language at 11 months. Danny's hearing had been tested and appeared to be within normal limits.

He was always a very quiet child, although quite friendly. He is a child who is curious about toys and interacts well with his mother and other adults, once he gets to know them. It was also noted that he did not fuss or tantrum at all. His mom stated that he rarely cried, even when he should be hungry, and that was one of her biggest concerns - that he never exhibited hunger. Another concern was Danny's teeth, which were very slow to erupt. He had begun to drink through a straw without any difficulty, and tried and enjoyed various textures. Due to his lack of teeth, he would chew with a munching motion, rather than an adult rotary type chewing motion.

In terms of parent education, as Danny's parents were quite young and he was their first child, the therapist worked closely with his mother on parenting skills, behavior, and issues of separation, and typical developmental milestones. Danny's mother was very connected to Danny, and did not like to be apart from him for even a brief time. This was sometimes difficult as she had resumed her college education. Danny would participate in therapy well when his mother was present, but if his grandma was babysitting, he would not participate at all. In order for Danny to continue to benefit from therapy this area was addressed.

By the time Danny was 18 months old, it was noted that he had not only gone from sitting independently and crawling but also to walking. Danny generally has low tone, and is flatfooted when he stands. He has a tendency to roll over on his foot, putting abnormal pressure on the insides of his knees, and ankles (pronates at the ankles). He and his parents received physical therapy consultation for this. The easy answer being, that Danny wear high top, tennis shoes, with a good arch support to help his not pronate.

By this time also, his health had improved greatly. The seizures were now controlled and the medication was stabilized. At his assessment his skills were as follows:

Gross Motor: 15 - 18 months.
Fine Motor: 15 months, emerging at 16 - 18 months.
Cognitive: 11 months, scattered to 15 months.
Self-Care: 15 months, emerging at 18 months.
Communication: 8 - 11 months, emerging at 13 - 14 months.
Social/Emotional: 18 months, emerging at 21 months.

You will note, that in many areas of development he was beginning to perform almost at his age. This is particularly true in the area of social/emotional development. Also, his gross and fine motor skills had grown amazingly strong, yet his communication skills were continuing to lag behind. Based on his developmental assessment and parental concerns, it was decided to target speech and cognitive development for his intervention program and move parent education to a consult basis.

Shortly after Danny reached the age of 18 months, his mother discovered he was going to be a big brother. This added a new dimension and complexity to what she wanted him to accomplish. This also stressed the family's ability to maintain all of the myriad of schedules working cohesively, including his mother continuing her college education.

In the next six months until his second birthday Danny made some good strides. He had begun to build upon his abilities to perform self-care tasks for himself, particularly in feeding. Physically he had grown a great deal and was quite tall and had put on some weight. His behavior remained quite placid, and he was still quite attached to his mother, although he was getting somewhat more independent and making solid choices for himself.

At Danny's second birthday IFSP we saw the following skill levels:

Gross Motor: solid at 21 months, emerging at 24 months.
Cognitive: solid at 18 months, emerging at 21 months.
Fine Motor: solid at 18 months, emerging at 21 months.
Self-Care: solid at 21 months, emerging at 24 months.
Social-Emotional: solid at 24 months (age appropriate).
Communication: 16 months (receptive) and 10 months (expressive).

At the age of two, our primary concerns remained Danny's cognitive and communication skills. A new emphasis was encouraging his mother to put him in a setting where he could play with other children his age for brief periods of time. He was greatly in need of learning to model from his peers, as he was surrounding mainly by adults. Overall though, we were all pleased with his development.

The plan for his next year included weekly speech and language therapy, and weekly child education. Physical therapy and parent education would remain available on a consultation basis to make sure that no areas of need were missed.

Next month we will show you how much growth and change await in Danny, and his family, including the addition of a sibling. This next year is also a time for many decisions for the family regarding what type and amount of education they would like Danny to receive when he turns three years old.

Comment by Suzanne Berman, M.D.

Enjoyed browsing your web site. It seems you are having both fun and success treating the "small humans" of your community, and I congratulate you on your good work. I only wish multidisciplinary services provided by pediatric-trained therapists were available in all communities!

If I may, I wish to comment on your current case in progress ("Danny"). You write, "The seizures were diagnosed as being caused by status epilepticus (epilepsy)." This is implies that status epilepticus is equivalent to epilepsy. Status epilepticus is *not* the same thing as epilepsy, and I think this is an important distinction to make.

Epilepsy is the disorder of recurrent seizures, for which a cause can never be found (i.e. not febrile seizures, not seizures due to low sodium, a brain tumor, meningitis, etc.) Epilepsy necessitates treatment with anticonvulsant drugs. A person can have epilepsy but, because of taking appropriate medicine, be seizure-free for years and years, and have a completely normal life. Having a single seizure, without knowing the cause, is NOT adequate to make a diagnosis of epilepsy.

Status epilepticus, on the other hand, is prolonged, continuous, uncontrolled seizures for 30 minutes or more. The unremitting seizures of status epilepticus can be caused by *anything* that causes seizures: epilepsy, OR febrile seizures, electrolyte imbalances, brain trauma, meningitis, poisoning, etc. Treatment of status epilepticus obviously involves stopping the seizures, but also is directed at the root cause of the seizures (e.g. correcting electrolyte imbalances, antibiotics for meningitis, de-toxification) Many children who had status epilepticus whose original cause for seizures was self limited and curable never require anticonvulsant treatment again.

As seen by your current question (a 15 month old with a first time seizure), there's definitely a lot of confusion among parents as to what sorts of things cause seizures, what the prognosis is, etc. Just trying to help clarify!

Again, thank you for your excellent web site, and for your contributions to the development & progress of children in the central California area.

Sincerely,

Suzanne Berman, M.D.
SIU Pediatrics
Springfield, Illinois

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Last modified: January 26, 2013