NeuroPsych Evalutation Report

We received the evaluation report from Dr. Seibert regarding John's evaluation from Feb-April.
At the time of this test, John is considered 3 years, 2 months old.
Listed below are some of the highlights from the 12 page report:

Areas of concern defined by parents:
1.He needs to be taught certain things that other kids seem to pick up naturally
2. Demonstrates some echolalia (repeats the ends of some questions when asked)
3. Preoccupations with narrow areas of interest and focus (in phases)
examples: clocks, lining up cars, left-turn arrows, train tracks,& reading clothing tags
4. Frustration tantrums -- problems managing anger
5. Craves sensory stimuli (specifically with hands/touch, chew non-food items)
6. Trouble with eating (messy eater, prefers to use hands, overstuffs mouth)

Areas of concern Socially:
1. Limited eye contact
2. Unable to show comfort to others in distress
3. Some pretend play
4. mostly parallel play

Areas of Concern defined by Current Teachers:
1. Little Attention Span
2. Easily Destracted
3. Limited Spontaneous Speech
4. Limited to no interaction with other children
5. Loves sensory activities (finger painting, eating with hands, feet in sand)
6. Limited interest in classroom when given free time (lines up cars or 'reads' a book)
7. Delayed academically
8. No eye contact

Things the teachers did not notice:
1. No strange or odd preoccupations
2. No behavior problems
3. No transition tantrums

Observation In the Clinic over 2 observation days:
1. No tantrums or upsets
2. mild mannered
3. Reduced eye contact
4.quiet most of the time, with only one-word utterances
5. Poor intelligibility of speech
6. Fairly distractible, but was able to maintain focus if sitting on lap, bounced, or squeezed

Observation at School:
1. John did not remain on carpet square during storytime and had to sit on teacher's lap to maintain focus
2. Wandered room
3. Responded to yes/no questions
4. Kids lined up to wash hands, John consistently wandered out of line; needed re-direction
5. Food placed in front of him, told to wait, kept putting hands in spaghetti; needed to be reminded to wait multiple times
6. Facial expression blunted most of the time
7. Complied with verbal instruction but never made eye contact; appeared not to be paying attention, but would respond appropriately
8. Messiest eater in the class
9. After lunch, wandered over to line up cars
10. Wandered to book area, opened book, sat down, and "read" it
11. On playground, rode tricycle alone most of the time
12. Smiled at girl who climbed on "caboose" of tricycle
13. Stopped bike purposely to have 2 other girls crash into him; all giggled; John repeated again
14. Gravitated to outskirts of playground most of time
15. Seemed to be "in his own world"

ADOS test (Austim Diagnostic observation Schedule):
1. John responded to name by turning toward examiner
2. Poor eye contact; used eye contact to get the examiner to do something again
3. Showed some shared enjoyment with examiner, but not consistent; interested mostly in having sole control over a toy; needed to be re-engaged to play with examiner
4. Did not spontaneously give objects to examiner; but would comply after repeated requests
5. Could show functional use of toys when prompted but did not demonstrate any symbolic play on own
6. Did not initiate any social interactions, but did not mind the examiner playing alongside him
7. Produced single word utterances, most not intelligible
8. Showed only occasional, unusaual sensory behavior -- objects in mouth
9. According to ADOS, fell within the spectrum, but not autism, per se

GARS test completed by parents scored an 81 -- meaning "possibly" has autism

Other Tests Administered:

• DAS-II - Differential Ability Scales - Verbal & Non-Verbal Cognitive Development; John scored in the 66th percentile for Verbal Comprehension (average) and 58th percentile for Naming Vocabulary (also average); For the Non_verbal section, he scored in the average for Picture Similarities, but scored mildly impaired on Pattern Contruction; His total scores for this test was a 96, and fell within the average range (39th percentile)
• Although the examiner felt that the scores need to take in account that John had a very low attention span, needed frequent re-direction to the tasks at hand, cues to remind him to persist in his effort, prompting to consider the full range of answer chocies before responding, etc.
• PLS-4 - PreSchool Language Scale - measures comprehension and expressive language skills; John's auditory comprehension scored of that of a 2-year 11 month old child (average range for his age) Most advanced skills he showed was the ability to distinguish activities that were day from activities at night. He could understand picture analogies, identified objects, identified colors and common activities, understood quantitive concepts (one vs. all), and descriptive concepts (big vs. small) Could follow 2 step commands, but COULD NOT show spatial concepts (on, off, in, out of), pronouns (I, me, you) or negatives (show me the baby that is not crying) His scores resulted in that of a 2-year 8 month old, which is on the low average for his age range.
• VABS-II - Vineland Adaptive Behavior Scale - questionnaire filled out by parents; day-to-day functioning;
  
• Communication scored low at 1 year 11 months;
  
• Expressive Language scored at 2 years, 10 months;
  
• Written Language was HIGH at 4 years, 3 months - able to recognize upper and lowercase alphabet, own written name in printed form;
  
• Daily Living Skills ---
  
• Personal Care-2 years 9 months,
  
• Domestic Care - 2 years, 2 months;
  
• Community Functioining HIGH at 4 years 5 months
  
• SOCIAL skills - low at 1 year, 7 months;
  
• Play behaviors -1 year, 10 months
• Coping - 2 years, 7 months
• Fine Motor - 3 years, 5 months

DIAGNOSTIC IMPRESSIONS:

• Basic Language skills have caught up to low average-average range, he still shows delays in speech intelligibility, as well as in pragmatic use of language in social/communicative ways
• Delays in age-appropriate social and play behaviors
• Shows some atypical restricted and repetitive behaviors
• Falls short of Autism Diagnosis at this time
• However, meets criteria for PDD-NOS, Pervasive Developmental Delay, Not Otherwise Specified, otherwise known as "atypical autism"
• He has shown signs that intervention boosts his progress

RECOMMENDATIONS:
1. Parents should request an IEP (Individulaized Educational Plan) from Bonita Unified School District based on this second opinion requesting:

• Placement in a classroom with a better teacher-to-student ratio than a typical educational classroom; Should have curriculum appropriate for average-range overall intellectual level, but with resources that meets his needs for supervision, assistance, difficulties for sustained attention, and facilitation for social activities OR in a regular classroom with a one-on-one aide
• John clearly needs speech therapy to address intelligibility and language pragmatics
• John should receive an OT evaluation to address sensory issues and motor skills concerns

2. Parents should re-apply through regional center for services that may benefit them in the community based programs
3. Parents should seek additional play and social opportunities and instruction for John with peers close in age; John needs facilitation to initiate and sustain engagement with other children and verbal cues to help him play
4. Seek parent education and support services

Signs to look For

I received an email with a question regarding someone who believed a family member might have a child with autism. She was interested in learning more about autism and things you could look for to see if the issues that were being observed could be related to autism. So, I thought I'd take a portion of the email I wrote to her and discuss some of the signs or red flags one might notice in a child as he/she are developing.

Some signs to look for (every autistic kid does not have every one of these -- the severity of the autism has to do with how much, how often and how many of them):

Age Appropriate Toys -- does the child play with age appropriate toys or still hold on to baby toys or cause and effect toys (by 3, children should move on to more imaginary play toys like cars, dolls, action figures, drawing, etc)
Tip toe walking --- some do, some don't, but it is a sign of autism
Hand flapping --- some do, some don't, but another sign of autism (often referred to as "self stimulating behavior" -- if over stimulated, the child may wave his hands up by his face to show excitement or nervousness)
Eye Contact --- many children with autism have no eye contact issues with family and close friends/relatives, but can't look strangers or acquaintances in the eyes -- they may glance, but nothing sustained
Joint attention -- does the child point to objects when asked (whether in a book or out on a walk, like point to the tree, or fire hydrant or stop sign) they look for finger pointing -- actual single finger pointing to an object - autistic children often do not point out things and have "poor joint attention", only picking and choosing what to draw their attention to
Interest in things that spin --- many children will spin themselves (another form of self stimulating behavior, but do not get dizzy); others like objects that spin and will stare at it for unusually long periods of time
Appropriate use of everyday objects -- does the child know how to use a hair brush on a doll or self, or know that a spoon is used to stir, -- autistic kids often need to be taught about what an object is used for and these kids do not learn by imitation; how do they play with cars -- line them up & stare at the pattern or spinning the tires are 2 signs that they look for
Interest in shiny objects --- many kids will stare for unusually long periods to shiny objects
Attention span- many autistic kids have a very short attention span; many can't sit through the reading of a book or show no interest in books as infants/toddlers
Chewing/Mouthing objects -- many autistic kids chew or mouth objects as tiny babies without teeth would do; these kids have shirt collars constantly in their mouths, seatbelt straps, toys, etc.
Interest in new toys - does the child have a hard time wanting or knowing what to do with a new toy; does the child show interest in the new toy or pick it up and then move on
Attention to task - this one has to do with two extremes --- either the child bounces from one task to another without long attention or the child is sooo attentive to the task that they can't move away from it or won't do anything else -- both extremes are signs of autism like behavior
Response to own name - a majority of the time will ignore their own name when called
Speech/Language - Most autistic kids have some sort of language or speech delay; extreme cases never gain speech; some have cognitive/receptive issues; others have pronunciation; many/most have both; almost all are late talkers
Dietary Concerns - many kids are "sickly"; have food allergies, bowel issues, stomach problems; weight loss/weight gain; picky eaters; many hate textured foods; many need food purified -- each need is different but there is usually some sort of "feeding" issue one way or another; some are messy eaters and don't know how to use utensils correctly, others can, but prefer to use hands,
**Sensory Issues - Most kids have some sort of Sensory Integration issues which is the source of the manifestation of some of the above listed behaviors -- the brain processing the sensory information received through the senses incorrectly -- some are "sensory seekers", constantly looking for sensory input -- these kids are "crashing into" things like furniture and people's legs; they might spin and not get dizzy; they love "messy" play like paint and glue and might put it all over their hands and arms -- others "avoid" all the sensory input -- they might hate touching certain textures, glue, sand, etc. --- then on the auditory side, they may fear loud noises, including hair dryers or toilets flushing, while the other extreme is that they don't even notice sound and seem like they might have 'hearing' issues, but test within range for hearing (hence not reacting to own name);
on the sensory issues -- there are a ton -- other issues may be poor gross motor skills -- may walk unstably, may have a hard time avoiding obstacles, may avoid or seek swinging for long periods of time, may feel more "grounded" with feet always touching the floor, so can't sit still at a chair with feet up or on a toilet without feet touching a stool

I have a good book that talks about sensory issues that is a good introduction into children that just seem to be a bit different -- not necessarily autistic, but have Sensory Processing Disorder. It's called The Out of Sync Child by Carol Stock Kranowitz. She also wrote a companion book called The Out of Sync Child has fun, which is a workbook that teaches parents tips to practice in the home to help your child overcome the sensory issues. The good news is that if it's Sensory Processing Disorder by itself, then there are things that you can do that helps the child and makes it go away. Many kids with autism have Sensory Processing Disorder, but not every child with it has Autism. It is a good resource for a parent to read who has just begun to understood their child is a bit "different".

Autism

I thought I'd take the time in today's blog to concentrate on Autism, the diagnosis John has received.

Autism (defined here by regional center) is a developmental disorder defined as a syndrome causing significant and sustained impairment in social interaction and communication, with restricted and stereotypic patterns of interests, behavior, and activities which appear before age three. Since Autism is a syndrome, all people who have the disorder will not have all of the different behaviors associated with the disorder. Autism is a lifelong disability.

Children with autism are slow developing self-care, communication, social or learning skills. These skills are often uneven, having good skills in one area and poor skills in another. The person will have limitations in understanding words and ideas, and may be inappropriate responses in sight, hearing, touch, pain or balance. Relationships with people and objects may be abnormal.


Here are a list of behaviors that are Characteristic of Autistic Children: (though a child may not show all of these, showing a significant amount of them could lead to a diagnosis of an Autistic Disorder)

• Difficulty expressing needs; severe language deficits
• difficulty mixing with other children (parallel play)
  
• Repeats words or phrases in place of normal responsive language
• Acts deaf at times. Tests in normal range of hearing, but not always responsive to verbal cues (doesn't respond to name when called, for example)
• Resists learning
• No fear or danger
• Resists change in routine
• Indicates needs through gesture (may lead adult by the hand, instead of pointing)
• inappropriate laughing
• resists cuddling
• physical over activity
• avoids eye contact
• inappropriate attachment to objects
• spins objects
• sustained odd play
• standoffish manner
• uneven gross/fine motor skills
• laugh, cries, or shows distress for no apparent reason
• unresponsive to normal teaching methods

John's Autistic Characteristics
I took John in for a speech delay, but had also noticed these things:

• would make eye contact for only brief periods of time - nothing sustained
• Abnormal behavior of touch (wanting his hands in my mouth or armpits all the time)
• Difficult time with pointing out objects
• Communication issues (would lead my hand to what he wanted)
• Scattered skills (on a development chart he would have some advanced skills and lack basic skills like stacking blocks)
• Didn't always respond to his name when called
• always in constant movement

I did not notice: problems with cuddling, social skills, interacting with other kids (although he did not have a lot of opportunity), spinning objects, odd play, inappropriate laughing, attachments to objects, etc.

Characteristics seen in his evaluation

• tip toe walk
• "W" sit on the floor
• did not respond to his name
• reduced eye contact
• low joint attention (ability to point or look at an object one is directed to)
• Could representational play (imaginary play -- pick up a phone and say hello)
• short attention span
• Difficulty with imitation (this one surprised me because at home,he imitates everything Katie does)
• Could hold crayon appropriately
• Completed peg board quickly in only 25 seconds
• Could retrieve hidden toys quickly
• Easily distracted
• Could follow directions in imaginary play (feed the baby, put the baby to bed)
• needed to be reminded to "watch where he was going"
• words used were not recognizable
• Difficulty in sensory processing
• preference for mother
• engaged in non-functional activity (turning lights on and off repeatedly)

The areas of concern were:
Social Skills : Tested at a 10-17 month level (he was 30 months the day of the test)
Language Skills: tested at a 6-9 month level
Problem Solving: tested at a 21 month level

An "area of concern" is determined when a child tests at 1/3 his age in any category. He was 30 months old when he was tested. Any category where he tested at 20 months or lower was labeled an "area of concern".

The pattern of development shows "at risk" behaviors for an Autistic Disorder. At this time, he has not been "officially" diagnosed with Autism. The pattern meets the criteria for an Autistic Spectrum Disorder. Early Intervention was recommended, as well as a re-test when John is 4 or 5. We are also going to be seeing an Autistic Specialist in October for a second opinion.