Case Study ADHD and Dysexecutive Functioning Syndrome Do not use or distribute without written permission.
Initial Concerns - Age 6 years, 9 months • Sensory Seeking behaviors • Self-regulation • Anxious, fearful • Trouble with transitions • Invading personal space • Lack of social awareness • Too rough with people and objects • Loud talker • Rushes through schoolwork • Impulsive • Beginning to see academic difficulties with reading and writing Do not use or distribute without written permission.
Initial Evaluation – 5/19/2016Phase 1: Foundation • Sensory Modulation under-reactivity patterns • Sleep difficulties with enuresis • Balance (vestibular discrimination) below average • Unintegrated reflexes: Moro, Hands Supporting, TLR, Leg Cross Extension, Spinal Galant • Postural Control Difficulties • SCAN-3: Listening challenges in Borderline range • Ear atypicality Do not use or distribute without written permission.
Phase 2: Organization • Jerky ocular pursuits • Saccadic eye difficulty • Mild under convergence of bilateral eyes • Visual-spatial difficulties • VOR reflex difficulties • Bilateral Integration below average • Articulation errors • Praxis Difficulties (Generalized) • Interactive Metronome (timing) severe deficiency – hyper anticipatory profile Do not use or distribute without written permission.
Phase 3: Executive Functions • Atypical reversals for his age group • Difficulties with laterality and directionality • Reverses words in sentences or sounds in words • Difficulty with past tense • Visual motor skills below average • Inefficient handwriting skill: speed, forming his letters, spacing, orienting to line • BRIEF: Inhibition, shifting attention, self monitoring • Difficulty learning to read, write and spell • Timing regulation difficulties • IVA: • Auditory and Visual Response Control: Average • Auditory and Visual Attention Quotient: Below Average (visual more poor) • Sustained Attention Quotient: Below Average Do not use or distribute without written permission.
Social-Emotional • Impulsivity • “Motor is running fast” – own words • “I do not know how to stop myself” • Does make friends fairly easily • Will become shy or avoid new situations • Can become aggressive once over-excited • Social interaction becoming increasingly harder • Requires parent involvement to resolve conflict Do not use or distribute without written permission.
Intensive 1 • 12 days, 2 hours daily (5 days per week) • Tomatis Sound Therapy • Tactile Integration Massage • Rhythmic Movement training - Neural Chassis • Somatosensory activities to increase body registration • Postural control • Upper body weight bearing activities • Active speaking over the microphone using sounds, words, phrases, singing for 4 days at end of program. • Followed by 6 to 8 weeks of 1x weekly OT Do not use or distribute without written permission.
1. Post Consultation – September 7, 2016 • Increased chewing on his shirt and vocal noises • Sleep difficulties persist • Wearing night pull-ups • Still not interested in writing, tends to rush through • More focused when communicating • Increased eye contact • Asking deeper and more abstract questions • Pacing in conversational skill now, will wait for an answer • Listening more efficiently • Connecting past with present now • More active physically • Anxiety was less in transitioning back to school compared to year before • Fear of dark is improving • Asserting more independence • Easier separation from mom • Spatial boundaries still hard • Chooses rough and tumble play with peers • Doing better with sibling • Need for sensory input is subsiding, though increases when fatigued • More regulated overall, impulsivity improving Do not use or distribute without written permission.
DIR/Floortime Progress Session September 7, 2016 • Improved praxis and use of body more fluidly • Improved communication • Less hesitation and anxiety • Discussed his anxiety about school • Told story of “boy who cried wolf” • Showed pride when he was able to problem solve an idea • Increased engagement and joint attention • Handled small moments of frustration well Do not use or distribute without written permission.
2. Intensive • Tomatis Sound Therapy • Tactile Integration Massage • Rhythmic Movement Training: Neural Chassis • Somatosensory activities • Postural control • Upper body weightbearing activities • Pre-Astronaut Training Activities • Learning Breakthrough Program • 6 to 8 weeks of 1x weekly OT after intensive Do not use or distribute without written permission.
2. Post Consultation – November 2, 2016 • Still needs parent to be with him before falls to sleep • Increased hunger • Still enuresis • Increased need for physical input • Improved ability to form letters, still spatial issues • Vocabulary keeps growing • Will grab instead of using words – increased impulsivity • Safety awareness not good • Frustration tolerance decreased • Anxiety continues to improve • Increased need to be independent • Fear of dark has returned • No issues from teachers • Transitions improved • Back to rushing through his self care routine • Gets lost in play while showering • Needs more coaxing to get into homework • Chewing on shirts subsided • Spelling reversals still evident • Activity level up again Do not use or distribute without written permission.
DIR/Floortime - November 2, 2016 • Clear changes in sequencing and motor planning • Needing physical release, likely due to changes • Chose working in sand – themes of anxiety • Tries to resist going back into the past • Theme of attempting to physically control emotional anxiety • Growth stress Do not use or distribute without written permission.
3. Intensive • Tomatis Sound Therapy with Active reading in last half of program • Tactile Integration • Rhythmic movement training – Neural Chassis • Somatosensory activities • Postural control activities • Upper body weightbearing activities • Pre-Astronaut training activities • Learning Breakthrough Program • Break from therapy after intensive Do not use or distribute without written permission.
3. Post Consultation – January 4, 2017 • Appetite down • Difficulty falling asleep, enuresis still • No longer w-sitting • Letter formation continue to improve, though still having visual-spatial difficulties • No communication issues any longer, vocabulary continues to grow • Starting to “lie” • Anxiety increased currently going back to school after winter break • Anxiety over time lapsing • Started seeing guidance counselor • Before Christmas had some really good calm moments – still periods of good regulation • His sister reported that he was being better with her – “does not hit her so much” • Increased awareness of own behavior • Loves being social, though still misses social cues • Independent ADL’s • Can read 3 to 4 sentences per page – still wanting to rush • Concerns with coin recognition in math • “My body does not feel good” “I have to get my wiggles out” Do not use or distribute without written permission.
DIR/Floortime January 4, 2017 • Laced with tinges of anxiety • Still evidence of visual-spatial disorganization • Expresses not feeling in control dealing with chaos • Oppositional themes evident: conflict between having ability and not having ability • Showing a need to want to be constructive, to feel in control Plan: • 8 weeks of 1x weekly DIR/Floortime sessions Do not use or distribute without written permission.
4. Post Consultation – April 10, 2017 • Has made huge strides • Will own his behavior now, instead of making excuses • Mostly irritated after school • Teacher conference noted him on par with his peers; largest concern is around impulsivity • Still enuresis, though sleeping through the night • Appetite good • Making good progress in handwriting club • During writing stories; erases frequently – self monitoring • Social still impacted by needs of his body Do not use or distribute without written permission.
4. Intensive • 1 hour Tomatis Sound Therapy • Tactile Integration • Learning Breakthrough Program • 1 hour of Interactive Metronome • Followed by 10 weeks of 1x weekly OT Do not use or distribute without written permission.
5. Post Consultation – July 19, 2017 • Ended school year well, good report from teacher, though some slight academic concerns still • General performance anxiety with atypical errors • Shirts are wet, bitten clear through • Sleeping well; still wakes up wet every morning • Some leaking throughout the day that he does not feel • No appetite in am • Seeking outdoor activity 24/7; no sedentary activity • Beautiful handwriting in summer school • Will initiate communication with strangers • Taught 3 “novel” kids how to fish with sequence and good vocabulary • Handles initial frustration; only shows frustration when pushed too far • Doing well with play dates; one incident of becoming upset; understood that it was wrong • Vowel sounds difficult in reading and spelling Do not use or distribute without written permission.
Interactive Metronome Comparison of Long Form Test Do not use or distribute without written permission.
Interactive MetronomeComparison of Averages Do not use or distribute without written permission.
5. Intensive • 10 days, 2 hours daily – 5 days per week • 1 hour of Active Work through Integrated Learning Systems (ILS) • Working on recognition of sounds, auditory memory, blended sounds and dichotic listening • 1 hour of DIR/Floortime Do not use or distribute without written permission.
6. Post Consultation – October 3, 2017 • Opthalmologist pleased with progress in vision • Still destroying shirts through chewing • Social anxiety • Writing samples still improving, though showing spelling difficulties • Comments on how his work compares with his peers • Continued enuresis • No appetite at breakfast • No more leaking throughout the day • Needing to be more “quiet” at school Do not use or distribute without written permission.
DIR/Floortime Highlights • Relational themes • Constructive sequence game choices • Wanting to engage in ”winning and losing” • Verbal expressing themes of “things being hard” • Spontaneous successful attempts at problem solving • During facilitation told the therapist to “relax, lady”! • Discussion about cheating • Fear for therapy dog at center decreasing • Displaying sense of humor on multiple occasions • ”Bad and good” themes • Increased empathy • Decrease of anxiety as days progressed • Initiated taking on responsibility Do not use or distribute without written permission.
Pre-Testing for ReadON – 11/11/2017Post Testing for ReadON – 06/26/2018 WOLD: • Letters per minute was 32.4, now 34.8 (norm 39.8 / 2 grade) • Time to complete was 204 seconds, now 184 seconds (norm 166 sec) IVA: • Response Control Quotient: • Auditory: was 94, now 108, both average • Visual: 74, now 80; both below average • Attention Quotient: • Auditory: was 77 (below average); now 98 (average) • Visual: was 96, now 85; both average • Sustained Attention Quotient: • Auditory: was 71 (below average); now 97 (average) • Visual: was 104, now 91 (both average) • 3 minute reading video: remarkable difference between pre and post video. Do not use or distribute without written permission.
Further Recommendations • Continue Interactive Metronome Training • Advanced ReadON training • SLP for written expression • Monitor emotional expression Do not use or distribute without written permission.
Maude Le Roux, OTR/L, SIPT, IMC Websites • https://maudeleroux.com/ • www.atotalapproach.com Facebook https://www.facebook.com/ATAMaudeLerouxOT/ LinkedIn https://www.linkedin.com/company/a-total-approach Blog http://www.maude-leroux.com/