Pediatric Services Pediatric Services: An intervention team serving children with developmental delays.

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Case in Progress

Mickey

Mickey was born on April 1, the second child in the home. His parents came to this country from Israel for job purposes three months prior to his birth. His parents were both tested for Tay-Sachs Disease, Galactocemia, and Gaucher's Disease, diseases, which are more prevalent in the Israeli community. It was determined that they are not carriers of any of these.

Mom's pregnancy was remarkable for hypertension and she was taking 60 milligrams of aspirin per day. Because hypertension remained a problem, labor was induced at 38 weeks gestation. Mickey weighed 7 pounds and his Apgar scores were 6 at one minute and 8 at five minutes. He had respiratory distress and was transferred to the NICU, where he stayed for 12 days. He also had hypvolemia and jaundice with a peak bilirubin of 18 on his seventh day of life.

The day after his discharge from the NICU, Mickey was found to have congenital hypothyroidism on the screening test. He was started on Synthroid, eventually evening out at a dose of 50 milligrams daily. He was noted to be hypotonic throughout, which was attributed to his hypothyroidism. His mother contacted the Magic Foundation, a parent support group in Pennsylvania, and was given the information about Early Start services and advised to call her local regional center.

Upon referral to Pediatric Services, at the age of 17 weeks (15 weeks adjusted), his development was assessed for the first time. He was found to be functioning at approximately a 12 week level, with some skills scattered to16 weeks. Goals were set for the next six months- primarily in the areas of gross motors skills and feeding, which were most affected by his hypotonia. It was determined that Mickey would benefit from physical therapy and child education to address his skill deficits in the areas of gross motor, cognition, fine motor, self-care, and communication.

When therapy first began Mickey was somewhat resistant to the work. At this time he weighed 17 pounds, which is somewhat large for a child of that age. He was slow to want to be moved or involved in motor activities, especially resisting sitting in an upright position. Eventually he became used to us, and loved to sit. He rolled for mobility before he crawled, and rolled throughout the house.

Feeding remained an issue, as he would resist any new foods that were introduced. His mother was very patient and keep reintroducing the food, and eventually he would tolerate it. Mickey is a happy and very handsome boy, and got so that he liked having therapy and made good developmental progress.

At 10 months of age, Mickey was seen my a developmental pediatrician. His motor skills were at the 7-8 month level for gross motor, and 8-9 months for fine motor. Self care development were clustered at 8 months, language at 7-8 months, cognitive skills at 8-9 months, and social development is his strength at 9-10 months.

Also prior to his first birthday it was decided that an Occupational Therapist would begin to provide services to Mickey, and his child education therapist would phase out for awhile. This is something that our team often does, as a child's needs change from month to month and it becomes apparent that something should be looked at closely.

In Mickey's case, it was feeding concerns and also his fine motor control - particularly in the area of self-feeding that needed expert advice and therapy. Mickey was not only resistant to different textures orally but tactually too. He did learn to feed himself and liked to do it so well that he didn't want anyone else to feed him!

At the age of one year (54 weeks - 52 weeks adjusted) Mickey's skills were again formally assessed and found to be as follows:

Gross Motor: skills were solid at 44 weeks - Mickey would pivot in sitting, cruise along the furniture, and walk with two hands held.

Perceptual/Fine Motor: skills were solid at 44 weeks and emerging at 48 weeks. Mickey would use a pincer grasp, poke with his index finger, and remove three pegs eventually.

Cognition: skills were solid at 48 weeks, emerging at 52 weeks. Mickey could release two cubes into a cup, pick up a cup to discover a toy underneath, and insert a round block after demonstration.

Communication:

Receptive: 48 weeks - Mickey would follow one command, understand simple questions, and participate in repetitive speech games.

Expressive: 44 weeks - Mickey had two or more gestures with meaning, vocalized with intent frequently, and said Mama with meaning.

Social-Emotional Skills: were at 48 weeks - Mickey gave a toy upon request, performed for social attention, and responded differently to young children.

Self-Care Skills: also at 48 weeks. Mickey fed himself with his fingers, chewed a cracker well, and cooperated with dressing.

It was noted that Mickey still presented with low tone throughout. He had had three episodes of increased low tone that lasted a few days, where he became like a sack of potatoes when you picked him up. These episodes included increased drooling, falling, tongue protrusion, and decreased coordination. These episodes also preceded a major developmental and/or growth spurt. Mickey's pediatrician and neurologist were kept abreast of these developments.

As Mickey became more mobile, his weight became more stable and his thyroid medication stayed at an even level. Our largest concern at this time was his communication development. Mickey had had several ear infections and there was concern that they were having an impact on his hearing. The occupational therapist felt that it would be in Mickey's best interest for the child education therapist to return to address cognitive skills, along with a speech/language therapist to consultation. Mickey also walked very well by the age of 14 months, along with squatting, climbing and other gross motor skills, so the job of the physical therapist was done.

Mickey's speech was evaluated at the age of 15 months. The most important things noted were that Mickey's parents, while fluent in English, predominantly spoke Hebrew in the home. Mickey received all of his therapy in English, although we learned some key words in Hebrew. Mickey's increasing frustration at being unable to communication was noted. His mother felt that he understood a lot but had trouble expressing himself. Mickey would shake his head for no, use the expression ta-da in many contexts (although in Hebrew there is a similar word for thank you), and said Dada and Ema (mama in Hebrew). The speech therapist noted that his Receptive Language (what he understands) was at 14 months (one month below chronological age) and his Expressive Language (what he said) was at 7 months (an 8 month delay). Speech/language began on a weekly basis at this time. Mickey's hearing was tested and it was discovered that he did have a mild hearing loss. His ear/nose/throat doctor felt that this would be corrected with the placement of PE tubes.

When Mickey was 18 months old he was assessed once again. At this time he weighed 32 pounds and was 35 inches tall. He continued to take Synthyroid for his hypothyroidism. His developmental skills were as follows:

Gross Motor: 18 months. Mickey was able to walk upstairs with one hand held, kick a ball after demonstration, and climb onto a chair to reach something.

Fine Motor: at 15 months, with 75% of skills at 18 months. Mickey could tower 4 cubes, turn the pages of a book, and insert one of three puzzle pieces.

Cognitive: 14 months, scattered to 18 months. Mickey could use an adult to solve a problem, insert three puzzle pieces after demonstration, and pull a cloth to reach an object.

Social/Emotional Development: 15 months. Mickey moved out of caregivers sight momentarily, sought help in doing things, and made choices.

Self-Help: 15 months, scattered to 18 months. Mickey was able to remove loose clothing, scoop food from a dish with a spoon, and cooperated with toothbrushing.

Speech/language development: Mickey had finally begun to use signs for more, finished, turn, and all done. He also began to use more consonant sounds.

When Mickey was 20 months old, he and his family moved out of our area. His mother had the necessary information to transfer Mickey's services to the new regional center and early intervention in their new town. Mickey and his family have been a delight to get to know and we have every confidence that Mickey will continue to grow and achieve his goals. Now that the family is settled in their new home, the family let us know that Mickey is attending an Early Start school based program. He is enjoying the other children and receiving speech and language services in this setting.

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Last modified: January 26, 2013