Sunday, April 1, 2007

3 to 4 Years Old

October 2001: (3yrs) Transitioned from 0-3 to the School District. All therapists and Yale recommended typical preschool since he was doing so well in daycare.

Schedule: MW speech, W Gymboree, TuTh mornings typical prek, F full daycare day. Usually 2 play dates per week. Time
spent with peers per week is 16 to 18 hours per week, depending on play dates.

Issues: Driving concern is perseverance play, narrow interests, and sensory issues will interfer in concentration, learning, and socialization in school. Lack of self-monitorization, low frustration point, low confidence level, wildly fluctuating arousal level characterize his vulnerable areas. Parents fear he’ll get behind in skills again due to the amount of time spent on behaviors. Parents also fear his behaviors will interfere with him to make friends.

In general, Leo seems uncomfortable with himself, needs constant adult interaction to be content. He’s rarely able to tolerate
being alone in a room while mom is in another for more than a few minutes. At approx 2 ½ years, he’d tolerate being with his
therapist or others without mom in the room. He rarely plays independently unless he’s watching a video or doing a behavior. Even then he’ll seek an adult for company. He’ll participate in activites and be social with other kids as long as he’smonitored. We strive to change his en216;stuck’ on something else.

Leo’s turned out to be a very friendly, gentle little guy, that is almost always interested in children. However, Leo often misses
social cues. We are not sure if it’s an age thing or a PDD thing, or a combination. Some of these are; Talking to people out of range, like through a window. Seeking rough-housing play with a friend who CLEARLY isn’t interested, and Leo won’t stop. Asking someone if they’d like a french fry, the person says ‘no’, and he keeps asking. Sometimes he’ll repeat a request over and over, not realizing he must change how he’s asking, speak louder, or perhaps he doesn’t have the intended person’s attention.

Perseveration has always been the largest issue. About once a month it manifests into something different. It’s usually some
object and some type of repetitive movement. Leo is very easily redirected by an adult. It’s just that left to his own devices, he’ll seek these behaviors 50% of the day. He continues to need adult interaction.

Cars & trucks continue to pacify him when he is stressed, tired, bored, or isn’t monitored by an adult. He’ll take matchbox
cars and hypnotically role them back & forth on a table, floor, or on himself. He also will closely examine them, 3 or 4 inches
away from his face. He’ll be in a very low arousal state, appearing tired. Often, he’ll lie on his side while doing this. We’ve
compromised by allowing him only matchbox sized cars, as they tend to not interfere in doing other activities like large toys
do. We also stress playing with them appropriately.

Tapping: Lately, he’s been tapping his hands and feet. He’ll often drum very loudly while chanting Ba Ba Black Sheep, Happy Birthday, or something he makes up. He likes to bang on a ball, tables, and the floor. He also likes to run around the kitchen table, limping, stamping very hard, while chanting. He’ll do this for 10 seconds or 20 minutes, depending on his needs.

Visual discrimination: Leo will often fixate on a certain characteristic. One day he’ll say “you have a neck”, as if he just realized we all have one. For one week he’ll comment about how this person and that person has a neck (belt, nose). He continues to gravitate towards purple items, and will prefer a puzzle with a purple background. Sometimes he’ll notice the smallest detail, and other times he’ll miss something really obvious. He can’t seem to get a game where you hide a toy under one of three cups, move them around and he has to follow and pick the correct cup. It’s like he just can’t follow with his eyes, and it seems like he’s really trying.

Past behaviors include opening and closing doors &cabinets, carrying around and being obsessed with milk cartons, purple
items, and seat belts. Occasionally he’ll perseverate with scripts, repeating something a request 30 times in a row. It was really bad, all day for a long time. Now it’s minimal, but does come up every couple days. Other significant behaviors include
watching water flow from hoses and cups, and loves to put his hands under the water in the sink.

Stimming was reduced to approx. 50% of the time. We carefully monitored vehicles, as he was playing with them appropriately as long as we were present. Once we weren’t, he’d start to stim. Visual discrimination deficits became more apparent. Ex: Realizing that all people have a neck. Checking each person he sees, and amazed at this fact. Talking to people that were outside through a closed window. Obsessions changed every few weeks, becoming more sophisticated. At this point he loved to hold several milk cartons, and tried to snow us into thinking he is pretending with them, when he was actually just staring at them.

Parents rejoice during Leo’s third birthday party, looking back at the long hard year, and see a happy healthy boy bouncing
on his trampoline outside with 5 peers. Laughing, chatting, initiating chase games, Leo is the social butterfly. We look at
each other with tears of happiness rather than sadness like last year.

Leo is re-evaluated at Yale. Even Yale was shocked at the level of progress Leo had made, validating all my time and hard
work with Leo. They again gave us great direction on how to address Leo’s social issues, how to specifically teach him these
skills.

Communication: Leo’s communication problems contribute to his social and emotional difficulties. Has a hard time integratingall social elements together (ex: asking a question but not looking at the listener). Has a tough time shifting attention betweenobjects and people, which provides a foundation for interpreting intents, perspectives, emotional expressions. His language strength is misleading in that his grammatical morphemes & sentence structures are constrained given his language stage. His use of over-generalizedword forms (from word retrieval difficulties) compromise the clarity of Leo’s messages, likely to lead to frequent communication breakdowns, especially with peers. Uses scripted language. Decreased sense of himself as an effective communicator. Decreased rate of self-initiated communication. Leo has sentence formulation difficulties and trouble monitoring interests and intents of conversational partner. These vulnerabilities need to be aggressively addressed in order to prevent behavioral difficulties, frustration, and to foster social and communication development, to establish social relationships and benefit from an academic setting.

Examples are:
1) Leo has a hard time sharing since he can’t expressive himself efficiently in the heat of the moment (word retrieval). (ex:
easily yells and grabs during a dispute over a toy)
2) Leo often can’t effectively explain something or “read” his listener. (ex: Still tickles a friend after friend frowns and backs
away)
3) One-on-one we can see frustration or anxiety and diffuse or help him, in less controlled situations it’s difficult (ex: kids all
doing same activity)
4) Can become overly focused or rigid on toys and materials, less able to utilize context to correct erroneous impressions (ex:
seeks and covets all purple crayons while coloring with others, misses out socially)
5) Seeks out adults to navigate the social environment, using adults to clarify things for which he has less of an intuitive
understanding. (ex: uses lots of questions to show anxiety, requires lots of explanation – we are his eyes and ears to the
world.
6) Likes topics in immediate context rather than past events. This is due to word retrieval, and lack of awareness about what
the listener knows and doesn’t know. (ex: he doesn’t realize Mommy didn’t go to the museum, so Mommy can’t comment or
explain things)
7) Tough maintaining a simple conversational exchange beyond 3 to 4 conversational turns. (ex: If he can’t “say what he
wants to say”, will back out by changing the subject, using humor, or other distractions that he knows will please the listener
(ex: “let’s color!” when we know his dislikes it)

Integration: Sometimes imitates without fully understanding the entire context. He’s vulnerable given he may reproduce an action or respond adequately to a social demand by modeling only part of the action. He responds appropriately without necessarily understanding the full context. He may pick one cue to respond to, say “That’s funny” without any facial gestures that would show he really thinks it is funny.

Novelty: Leo performs at a higher level, is more comfortable, speaks more fluently in familiar situations. If adults not present, will revert to more self-isolating style, more primitive play. Distracted by minor details, structure & familiarity will continue to be needed until a more solid sense of imaginative play is internalized. When modeling scripted/language isn’t available, as in novel contexts, his own rule system compromises his ability to form even simple sentences. This is why Leo compensates by copying others very well.

Associative Learning: He can’t take his knowledge of a concept and apply it to a novel instance very well. Has difficulty getting the context of a situation (defined by cues; changing facial expressions, variable tone of voice, posture, gestures). Learns by “chunks”, the way things occur rather than how they integrate with his internalized body of knowledge and experiences, making him particularly vulnerable to decontextualized copying of others.

Fine motor
Below average, at 31 month level. Ex: holding crayon effectively, drawing, imitating basic shapes. Can’t copy a 3 piece tower
(visual integration).

Baby is happy in bouncy chair or on my lap while I work with Leo. She can even nurse while I do this.

Holidays are spent as opportunities to have parties at our house, Leo learns to share well, tolerates the activities well,
although quite an overstimulating and exhausting time. Forms even more solid relationships with other family members, talks
on phone well.

January 2002:3yrs 3 months
Baby Sydney (8 mos) has been crawling for a couple months now, and is more demanding. Leo seems to have plateaued, seeing more of a gap socially during playdates. Frustration level starts to increase as Mom’s attention is diverted to baby. It was quite depressing to see Leo stimming more. Mom doesn’t have as much opportunity to work with Leo one-on-one. Very challenging to fit in that table time. Panicked, I discuss my concerns with the SLP and Guidance Counselor at the school, seeing if there are ways we can address his social issues better. They felt comfortable with his current services.
Waiting for Yales’ re-eval written report.

March 2002: 3yrs 5 months Although Leo seemed happy and still progressing in some areas, socially Leo continued to stay at the same level. The social gap seemed to be more apparent yet again. He began to hang back like he used to with children. Leo continued to demonstrate he can imitate well, although decontextualized. Showed he was a quick learner, responded well to direction and structure. Sought help again from school to no avail, sought private help, educated myself about how to best address Leo’s needs.

June-July 2002: 3yrs 8-9 months Completely burned-out, Mother found an ABA provider that specialized in social skills training for high functioning children like Leo. They started, saw immediate results (carryover). I felt tremendous relief that these two experienced therapists were working with Leo one-on-one, “putting the screws to him” just like I do, but even better since they are so experienced with these kids. Finally, professionals that address issues other than negative behaviors or academic issues.

September 2002: 3yrs 11 months After 8 months of very little intervention, Leo has an excellent program in place for this new school year. Leo was ecstatic at his preschool’s open house. He was excited to see his friends and teachers.